Psychiatry - O. K. Napryeyenko 2001

Clinical Psychiatry
Drug Addiction and Substance Abuse

Definition of Basic Concepts

The term "drug" has various interpretations.

In a medical sense, it is a substance capable of causing chemical dependence; in a legal sense, it is a substance recognized as such under international conventions or national legislation. The Circulation of narcotic substances is strictly regulated by laws and bylaws.

In the West, drugs are commonly classified into hard drugs (heroin, LSD, cocaine) and soft drugs (marijuana). Illegal trafficking or consumption carries criminal liability.

Drug addiction (substance addiction) refers to the systematic use of narcotic drugs. The Development of drug addiction involves two stages:

✵ psychological dependence;

✵ physical dependence on the drug.

Substance abuse (toxicomania) is the systematic use of psychoactive substances that are not included in official drug schedules.

Polydrug addiction (polysubstance abuse) is the systematic use of two or more psychoactive substances. When formulating a Diagnosis, the primary substance is specified.

Physical dependence is a reliance on any chemical agent (drug, alcohol, tobacco) caused by its incorporation into metabolic processes. Physical dependence leads to increased tolerance and withdrawal syndrome.

Psychological dependence is a continuous or recurring desire to consume a psychoactive substance. At the behavioral level, it manifests as an inability to control the intake of the substance. Such dependence is characteristic of the Cytology/cytology/16.html">Early stages of drug addiction.

Withdrawal syndrome is a complex of symptoms that occur when the administration of a psychoactive substance is ceased. This is one of the manifestations of physical dependence. The Nature of the withdrawal syndrome is determined by the type of psychoactive substance. The most severe withdrawal syndromes occur in opioid addicts, while they are somewhat milder in those who abuse cannabinoids and stimulants.

Tolerance is a diminished response to a dose of a psychoactive substance resulting from its systematic use.

A psychoactive substance is any substance that, when consumed, affects emotional responses or cognitive Functions. Psychoactive substances also include drugs, alcohol, tobacco, and psychotropic medications used in psychiatry. This term refers to substances that do not necessarily cause dependence.

Exploratory polydrug use refers to the consumption of various psychoactive substances by adolescents, usually without The formation of dependence. It is a manifestation of typical adolescent psychological reactions, which may potentially lead to the development of chemical dependence.

Epidemiology

Studying the epidemiology of Drug addiction and substance abuse is even more complex than that of alcoholism. This is due to the illicit nature of drug trafficking. Currently, it is estimated that for every registered drug addict or substance abuser, there are 8—10 unregistered ones.

According to the Ministry of Health of Ukraine, in 1998 there were nearly 70,000 registered drug addicts and substance abusers, with numbers increasing by 10—12% annually. Given that drug addiction has a higher latency rate than alcoholism, some researchers suggest multiplying these figures by 10.

Cannabinoid addiction and substance abuse exhibit a higher latency rate than so-called hard drug addiction (opiates and stimulants). According to a 1995 survey of school youth in Ukraine, nearly 15—18% of respondents had used cannabinoids. The proportion of "hard drug" and toxic substance users ranged between 0.5—1.5%.

ADDICTION TYPES

According to modern Classification, there are 3 Major Groups of drugs:

✵ depressants (opiates, heroin);

✵ stimulants (amphetamines, cocaine, ecstasy);

✵ hallucinogens (LSD, cannabinoids, mescaline).

All of them cause psychological and physical dependence, as well as a range of mental, neurological, and somatic disorders. The medical use of drugs is strictly controlled based on joint resolutions of the Ministry of Health and the Ministry of Internal Affairs. Illicit operations involving them (production, storage, transportation, sale) fall under Articles 229 and 230 of the Criminal Code of Ukraine.

Let us consider specific types of drug addiction.

Opioid addiction

This group includes The Use of heroin, pharmaceutical opioids, and homemade extracts from the opium poppy (Papaver somniferum and Papaver rhoeas).

Form. Heroin appears as a brown or light-gray powder or liquid. In Afghanistan, heroin is produced in the form of cellophane-wrapped bricks, often stamped with an emblem of two crossed swords and Arabic lettering. The pharmaceutical form of heroin is occasionally encountered in ampoules or tablets bearing the corresponding name.

Opium (the dried juice of poppy capsules) is a viscous white fluid resembling PVA glue. Sometimes, scraps of fabric or bandages are soaked in opium or heroin.

Pharmaceutical opioids (such as promedol, codeine, thebaine, and pentyl) are used very rarely.

Administration. The powder is dissolved in warm Water (soaked bandages are boiled). The resulting solution is administered intravenously, and less frequently intramuscularly (by inexperienced users or those with thrombosed Veins). Extremely rare practices include smoking heroin or poppy straw, ophiophagy (eating fresh poppy heads and stems), or drinking dissolved heroin (known as 'kok-naru'). It should be noted that the majority of drug users consume heroin alongside sleeping pills, barbiturates, or diphenhydramine.

Classification

According to the traditional domestic approach, substance addictions and toxicomanias are classified either by the specific types of psychoactive substances abused by the patient (e.g., opioid addiction, hashish addiction), or by the Physiological Effect of the substances on the body (euphoriogenic, dyspeptogenic, analgesic, hypnotic, ataractogenic, and poly-narcotoxicomania).

According to DSM-IV

304.00 — Opioid dependence

305.50 — Opioid abuse

292.89 — Opioid intoxication (including with perceptual disturbance):

292 — Opioid withdrawal

292.81 — Opioid intoxication delirium

292 — Opioid-induced psychotic disorders

.11 — With delusions

.12 — With hallucinations

292.84 — Opioid-induced mood disorders

292.89 — Opioid-induced anxiety disorders

292.89 — Opioid-induced sexual dysfunctions

292.89 — Opioid-induced Sleep disorders

292.9 — Unspecified opioid-related disorder.

According to ICD-10

Opioid-related disorders

F 11.0 Acute intoxication

F 11.1 Harmful use

F 11.2 Dependence syndrome

F 11.3 Withdrawal state

F 11.4 Withdrawal state with delirium

F 11.5 Psychotic disorders

F 11.6 Amnestic syndrome

F 11.7 Residual state (incl. F 11.73 — dementia)

F 11.8 Other psychoactive substance-induced psychotic and behavioral disorders

F 11.9 Unspecified psychoactive substance-induced psychotic and behavioral disorders.

Clinical Features

Upon drug consumption, the addict experiences a "rush" of warmth felt around the solar plexus, which then seems to spread throughout the entire body. This "rush" may be accompanied by unpleasant sensations: chills, nausea, vomiting urges, Skin itching; and in some cases, even Swelling of the face and torso. This frequently occurs During the first instance of drug use or when the substance is of poor quality. Such a negative reaction can also be idiosyncratic.

Within 10–20 minutes after drug use, an intoxication-like state develops ("high", "craving"), lasting approximately 2–6 hours depending on the dosage and the stage of addiction. During intoxication, drug users are typically inactive and euphoric. Sudden transitions from a state of calm to aggression are possible if anyone interferes with their experience. Pupils are markedly constricted, bradycardia is present, and Blood pressure is decreased. Instances of low mood and aggressiveness have also been documented, which are associated with poor drug quality.

When a mixture of heroin with barbiturates or diphenhydramine is used, the state of euphoria lasts longer, but a characteristic drowsiness emerges.

In cases of overdose, drowsiness develops, and speech slows down and becomes slurred. Blood pressure gradually drops, breathing slows, and the individual loses consciousness (initially lapsing into sopor, then coma), requiring immediate medical attention.

Based on their reaction to the first injection, substance users can be divided into three groups:

✵ those who experience the negative effects of the "rush" (the majority);

✵ those who experience no sensations at all;

✵ those who experience euphoria from the very first trial (a minor fraction).

The third group of patients is drawn into the cycle the fastest.

The rate at which chemical dependence develops is also related to the method of administration and the quality of the opioids. For instance, heroin addiction develops more rapidly, and distinct euphoria is sometimes felt after just 1–2 injections. It occurs faster with intravenous administration compared to inhalation or oral ingestion of opioids.

In Stage I of addiction, individual chemical dependence is formed, and tolerance to the substances gradually increases. Symptoms of so-called group dependence (social/contact high) appear. This state resembles drug intoxication and arises through conditioned Reflexes triggered by memories of drug use, encounters with so-called friends, The process of preparing drugs, and similar situations. Stage I is marked by an aversion to alcohol, along with an increased craving for sweets and fats. Withdrawal symptoms at this stage are subdued and most commonly manifest as a depressive-hypochondriacal syndrome with hysterical reactions. Somatovegetative components join in: rhinitis, perspiration, mild tachycardia, and a slight rise in blood pressure. Dreams are quite vivid (eidetic). They primarily consist of episodes related to acquiring, Processing, and preparing drugs for consumption. However, they typically have an unpleasant ending (the syringe breaks in their hands, the police confiscate the substance, etc.) or the person wakes up with an overwhelming craving for the drug. In Stage I, the withdrawal state can be partially alleviated using tranquilizers, cannabinoids, tea, or coffee.

Stage II of opioid addiction is characterized by the development of physical dependence on the drug, necessitating significantly larger doses and regular consumption throughout the 24-hour period. The Nature of the intoxication changes, and a fully developed withdrawal syndrome emerges.

Intoxication at this stage is characterized by the absence of a "rush" and reduced euphoria during the second phase of intoxication. Addicts attempt to compensate for this by progressively increasing the dose (at the peak of Stage II, the dose is increased 20–30 fold compared to The First stage). Some individuals take a more concentrated heroin solution: instead of 4–6 ml of solution made from a Glass of poppy heads, they prepare 2 ml. Yet even this fails to restore the initial sensations. When examining such patients, the dose of consumed opioids should be determined by the dry substance weight. Thus, when using poppy straw extract, the dose is established by the quantity and quality of the poppy straw. If heroin was used, it is measured in quarters ("decks"). Typically, 20–30 "decks" are made from 1 g of heroin.

In Stage II, the period of euphoria gradually diminishes. Instead, addicts experience a surge of energy, improved well-being, and a desire to work and socialize. The motives for drug use also change significantly: the urge to prevent withdrawal comes to the fore. For this purpose, drugs are consumed 2–4 times a day.

Some drug users intentionally experience withdrawal symptoms or seek medical help to reset the nature of their intoxication. Temporarily reducing the dose allows them to regain a state of euphoria for a brief period.

Withdrawal syndrome in stage II heroin addiction reaches its peak intensity. Its manifestations include mood deterioration, irritability, chills, and tremors. These symptoms appear 6–8 hours after the last dose is administered. Gradually, the mucous membranes swell, accompanied by lacrimation, salivation, and similar signs. Clinically, this state resembles acute respiratory viral infection (rhinitis). Symptoms intensify by the 2nd to 4th day. At the height of withdrawal, patients experience tremors, joint and Muscle pain, diarrhea with gastrointestinal spasms, vomiting, numbness in the extremities, and tonic spasms across various muscle groups. This can lead to opisthotonos (where the body arches backward sharply, resting only on the heels and the back of the HEAD). It is important to bear in mind that withdrawal exacerbates chronic conditions, particularly cardiovascular diseases. Lasting 1.5–2 weeks without Treatment, the acute phase is followed by a prolonged period of asthenia and insomnia.

Depending on the manifestation of mental, somatic, and neurological disorders, four Clinical forms of opioid withdrawal are distinguished:

1) explosive with dysphoric components;

2) asthenic with a predominance of somatic and neurological manifestations;

3) dysthymic with an anxiety-depressive component;

4) "productive" — characterized by productive Disorders of Consciousness (predominantly delirium).

To alleviate and suppress withdrawal symptoms, some addicts use stimulants (ephedrone, chifir, coffee) or tranquilizers. All their thoughts revolve around drugs. They become deceitful and cynical, stopping at nothing to secure money for a fix. They lose situational and quantitative control, which frequently leads to overdose.

Stage II addiction is marked by somatic disorders resulting from chronic drug use. These primarily manifest as asthenia, weight loss, and muscle atrophy. The skin becomes flabby and gray, often covered in boils. Immunity is severely compromised, rendering patients vulnerable to various illnesses that may not be accompanied by elevated body Temperature. The Cardiovascular system and digestive Organs (especially The Stomach) also suffer. Most patients develop impotence accompanied by feminization (due to hormonal imbalances), while women experience menstrual irregularities. Vascular sclerosis also occurs. Initially, this affects the veins on the anterior surface of the left forearm (or the right, in left-handed individuals). Subsequently, injections are administered into the Blood Vessels of the back of the hands, shoulders, armpits, legs, groin area, and jugular veins.

Some researchers identify a Stage III of opioid addiction, characterized by profound dementia, numerous somatoneurological complications, and a slight decrease in opioid dosages. However, the majority of patients die during stage II from overdoses and concomitant illnesses.

Atypical forms of opioid use

Aware of the aforementioned negative consequences of regular opioid use, some addicts abstain for extended periods. This typically occurs at the boundary between stages I and II, when dosages begin to escalate and the initial components of withdrawal syndrome take shape. After a time, moderate drug use resumes in the form of "binges" lasting 2–4 days, 2–3 times a month. Such individuals lead isolated lives, desperately trying to conceal their destructive addiction from others.

Under this pattern of use, stage II does not develop due to strict self-control: at the first sign of altered intoxication, the patients cease using any narcotic or toxic substances for prolonged periods.

Simultaneous use of heroin and stimulants

In the early and mid-1980s, opioid addicts used ephedrone to mitigate withdrawal symptoms. Some of them subsequently transitioned to ephedrone addiction, others switched back to opioids, while a small group began combining heroin and ephedrone (known as "black-and-whites").

In this scenario, heroin is administered first, followed by ephedrone In the second phase of intoxication. Occasionally, both substances are injected using the same syringe. The course of intoxication is determined by the combination of both drugs. In cases of polydrug use, the process of personality degradation is drastically accelerated.

Methadone

Synonyms: phenadon, adanon, algidon, algil, algolysin, amidon, amidosan, anadon, butalgin, depridol, diaminon, dianon, dolafin, dolamid, dolesone, dolophine, dorexsol, heptadone, heptanal, ketalgine, mecodine, mephenon, miadone, polamidon, sintalgon.

Form: golden or brown syrup in a labeled bottle, or insoluble tablets. Illicitly manufactured methadone appears as a crystalline powder.

This synthetic analgesic is utilized to relieve smooth muscle spasms. Once its euphoric properties were identified, the drug began to be used for easing opioid withdrawal and as a long-term heroin substitute (for up to 3–6 years).

It differs from other opioids in that intoxication occurs without the initial phase (the "rush"). The consequences are identical to those of other opioids, though they develop more slowly. This is attributed to the higher purity of the preparation compared to other substances.

Treatment

In cases of opiate overdose, antagonists must be administered immediately — 2.0 to 0.5% nalorphine solution (Narcan). If the patient is unconscious, repeat the administration after 15 minutes. The total dose must not exceed 8.0.

CNS stimulants (amphetamines) and central analeptics (lobeline, cytiton, caffeine) should also be prescribed.

Since opiates enter the stomach via osmotic gradients and are reabsorbed, gastric lavage using a tube must be performed. It should be borne in mind that due to suppressed cough reflexes, the tube may enter the Trachea. Therefore, prior to lavage, a small amount of air is blown into the tube (with Auscultation of the epigastric region). When the tube reaches the stomach, a bubbling sound will be heard; if it remains in the trachea, a blowing sound will be audible.

It is also essential to conduct intensive detoxification therapy.

The treatment of opioid addiction begins with the management of withdrawal syndrome. This requires aggressive detoxification utilizing hemosorption. To alleviate psychiatric disorders, high doses of tranquilizers (such as radedorm, rudotel, seduxen, etc.) are prescribed, while non-narcotic analgesics and anticonvulsants are used to relieve pain and spastic symptoms.

Once the acute manifestations of withdrawal subside, patients face issues of asthenia and insomnia. Typically, numerous underlying disorders become exacerbated during this period. In such cases, it is advisable to focus efforts on normalizing sleep and eliminating affective disturbances using tranquilizers (in cases of anxiety) or antidepressants (in cases of depression). Sedatives and hypnotics should be prescribed with extreme caution, as addicts frequently misuse them to potentiate the effects of opiates. Furthermore, they can heighten cravings for psychotropic substances.

Psychotherapy should aim to overcome anosognosia and achieve complete abstinence from drug use. To prevent relapses, it should be conducted in courses spanning 1–2 years.

Substitution therapy. This approach is based on replacing opiates with methadone or buprenorphine. The goal is to remove the addict from a criminal environment, increase supervision, and prevent the spread of HIV. Such therapy is an integral component of harm reduction programs. It is primarily utilized in two ways:

1) to mitigate withdrawal symptoms with a subsequent tapering of the dose over 0.5–1 month. In this scenario, withdrawal symptoms are milder, though they last longer;

2) the "Methadone maintenance treatment" program involves supplying the addict with methadone for life. Its drawbacks include a high relapse rate, dose escalation, and other Problems associated with systematic opioid use.

Prognosis

Opiate use leads to rapid social, moral, and ethical degradation of the personality. Causes of death among patients often include overdose and acute Heart Failure during withdrawal. A large percentage of HIV-infected individuals are intravenous drug users.

CANNABIS ADDICTION

The raw Materials for producing cannabinoids are the sap, pollen, and inflorescences of female hemp plants (Cannabis indica, sativa, and vulgaris) growing in Ukraine. They are used in folk medicine for pain relief.

The active substance is tetrahydrocannabinol (THC).

Form (based on THC content): dark oil; a dark-colored plastic mass (hashish); dark compressed bricks interspersed with crushed inflorescences, stems, and green leaves (ganja); a black, viscous liquid with an unpleasant chemical odor ("khimka"); thermally processed, crushed brownish-black plant matter ("zharekha"); and crushed green plant matter.

Routes of administration: smoked mixed with tobacco (cigarettes, less commonly in pipes); swallowed or mixed with alcohol; boiled in milk.

Classification

According to DSM-IV

304.30 — Cannabis dependence

305.20 — Cannabis abuse (including perceptual disturbances)

292.81 — Cannabis-induced intoxication delirium

292. — Cannabis-induced psychotic disorders

.11 — with delusions

.12 — with hallucinations

292.84 — Cannabis-induced mood disorders

292.89 — Cannabis-induced anxiety disorders

292.89 — Cannabis-induced sexual dysfunctions

292.89 — cannabinoid-induced sleep disorders

292.9 — cannabinoid-induced disorder, unspecified

According to ICD-10, disorders:

F 12.0 Acute intoxication

F 12.1 Harmful use

F 12.2 Dependence syndrome

F 12.3 Withdrawal state

F 12.4 Withdrawal state with delirium

F 12.5 Psychotic disorders

F 12.6 Amnestic syndrome

F 12.7 Residual state (incl. F 11.73 — dementia)

F 12.8 Other psychotic and behavioral disorders

F 12.9 Unspecified psychotic and behavioral disorders

Clinical presentation

THC has relaxant properties. It is highly lipid-soluble, particularly in Cell membranes. It is metabolized in The Liver and excreted via the biliary system. Its concentration peaks within an hour of use and then declines over the next hour. Subjective effects subside after 6 hours.

It should be noted that there may be no reaction at all to the initial use. It typically emerges after 3–4 administrations. In individuals who smoke and have underlying organic Nervous system lesions, seizures—predominantly tonic—may occur. The earliest sign of these is unmotivated persistent erection.

Intoxication progresses through several stages:

1) immediately after smoking, anxiety and agitation appear;

2) consciousness gradually narrows. Patients easily absorb each other's emotions and can amplify them using music or video. Synesthesia may occur ("colored Hearing", etc.);

3) euphoria. Patients are passive and fully satisfied. Paranoid ideas occasionally occur;

4) coming down from intoxication. Asthenia and insatiable hunger predominate. Individuals eat heavily and, after eating, experience restless sleep.

During intoxication, everything appears brighter and more appealing. Patients are hyperactive, but their activity lacks a systematic nature. During this period, they feel weightless, and self-esteem is inflated. They are amiable, talkative, and prone to forced laughter. Derealization with elements of macro- and micropsia, as well as emotional hyperesthesia, may occur. Occasionally, depersonalization is observed with a sense of split personality: the person seems to observe themselves from the outside, or sometimes—as if dissolving into the Universe. Aggression is not typical, but it is easily provoked. Outwardly, patients resemble individuals in a state of mild alcohol intoxication. The face is flushed, and the pupils are dilated. Tachycardia is observed, and blood glucose levels decrease. The oral and nasal mucosa are dry.

Overdose may present with confusion, aggressive behavior, oneiric or delirious states, and occasionally paranoid ideas of persecution.

Cannabinoid dependence develops slowly. Some researchers even argue that physical dependence does not exist. In our view, it does exist and manifests as increased tolerance and The Emergence of withdrawal symptoms. The rate at which dependence develops is determined by the regularity of use and the quality of the substance. It forms most rapidly with the use of hashish or chemically processed cannabis, somewhat more slowly with Indian, Chuya, and Manchurian hemp, and least rapidly with hemp grown in Ukraine.

The initial signs of dependence appear one year after regular hashish smoking. They manifest as a shortened duration and decreased intensity of euphoria. Patients are forced to increase the THC dose or intensify its delivery to the body by increasing the depth, speed, and frequency of inhalations.

The withdrawal syndrome resembles that of opiates, though it is extremely mild. It is primarily characterized by weakness, asthenia, tremors, edema, headaches, and a depressed mood with episodes of aggressiveness. The hallmark symptom is an irresistible psychological craving for drugs.

Systemic use of THC leads to psychopathic personality changes, where egocentrism and a decline in moral-and-ethical standards come to the forefront. Patients are physically exhausted; men experience feminization due to hormonal disruptions, and impotence develops. The Immune System is suppressed, leading to various infectious diseases.

It is extremely rare for stage II substance dependence to progress to stage III, accompanied by the development of anpathetic or moriatic dementia.

Pure cannabinoid addiction is a rare phenomenon in Ukraine. In most cases, these substances are used for short-term "binges" or as a Supplement to alcohol. The main danger lies in the fact that a portion of THC consumers eventually transition to opioids.

Psychoses during Cannabinoid Intoxication

Cannabinoid oneirism — patients are hypoactive. Facial expressions shift rapidly to polar extremes and appear somewhat exaggerated. Occasionally, patients shout out isolated words and sentences.

Cannabinoid delirium predominantly occurs in individuals with organic CNS pathology. It resembles alcoholic delirium. The delusions are threatening in nature and frequently provoke aggression with violent actions. Typically, patients act alone rather than in a group. It differs from alcoholic delirium by the absence of tremors.

Cannabinoid confusion may arise against the Background of delirium or oneirism. Patients are disoriented in time and space, resulting in hypoactivity. Isolated paranoid statements are possible.

Cannabinoid paranoid syndrome most commonly manifests as ideas of persecution (for instance, by law enforcement officers or fellow drug users), which can lead to violent actions. Patients are suspicious, tense, and anxious.

Treatment

First and foremost, complete cessation of drug use is required. During withdrawal, detoxification therapy can be administered, though not as intensive as in cases of opioid withdrawal syndrome. If depression is present, small doses of antidepressants, adaptogens, and nootropics are prescribed. For psychoses, tranquilizers are primarily recommended, while carbamazepine (finlepsin) is indicated for dysphoria.

Once acute symptoms subside, psychotherapy becomes the mainstay of treatment.

Prognosis

In cases of chronic cannabinoid use, social and moral-ethical personality degradation with the development of dementia is possible. Among comorbid conditions, unreactive inflammation and other lung pathologies (including Cancer) should be highlighted first and foremost.

STIMULANT ABUSE

This category of substance dependencies includes ephedrone and pervitin addiction, as well as the abuse of amphetamines, cocaine, and caffeine.

Classification

According to DSM-IV

304.40 — Amphetamine dependence; 305.20 — Amphetamine abuse

292.89 — Amphetamine intoxication, including with perceptual disturbance

292.00 — Amphetamine withdrawal

292.81 — Amphetamine intoxication delirium

292. — Amphetamine-induced psychotic disorders

.11 — With delusions

.12 — With hallucinations

292.84 — Amphetamine-induced mood disorders

292.89 — Amphetamine-induced anxiety

292.89 — Amphetamine-induced sleep disorders

292.9 — Unspecified amphetamine-related disorder

According to ICD-10

Disorders due to amphetamine use

F 15.0 Acute intoxication

F 15.1 Harmful use

F 15.2 Dependence syndrome

F 15.3 Withdrawal state

F 15.4 Withdrawal state with delirium

F 15.5 Psychotic disorders

F 15.6 Amnesic syndrome

F 15.7 Residual state (incl. F 11.73 — dementia)

F 15.8 Other psychotic and behavioral disorders

F 15.9 Unspecified psychotic and behavioral disorders

Ephedrone and Pervitin addiction

Ephedrone is produced illicitly from medications containing ephedrine (nasal drops, bronchodilators, Solutan, etc.) using potassium permanganate. To produce Pervitin, red phosphorus and crystalline iodine are additionally used. Sometimes, joint-pine grass (Ephedra distachya), also known as steppe raspberry, is used; it is widely applied in traditional medicine as a stimulant of The Nervous System, blood pressure raiser, antipyretic, and expectorant.

Route of administration: most commonly by injection; in rare cases, Ephedra distachya herb is brewed as tea or consumed fresh.

During intravascular administration, even "on the needle", a person feels a warm wave spreading throughout the body, causing a sensation of weightlessness. Addicts who seek a "rush" from the initial stage of the high try to administer the drug in a "push" using a large-gauge needle. Those who enjoy the sensation of weightlessness, conversely, prolong the administration time as much as possible. This is followed by a significant elevation in mood and a drive to activity. This state is very reminiscent of cannabis intoxication, but unlike the latter, the patient's activity is purposeful. Aggression during intoxication is practically nonexistent, although easily provoked.

The use of high doses of stimulants can lead to confusion. Patients are completely disoriented and experience hallucinations. They are restless, fidgety, and unmotivated aggression is possible. Their statements are incoherent yet emotionally charged.

Somatic and neurological signs: mydriasis, diaphoresis, tremor, elevated blood pressure, and occasionally nystagmus. Potency increases sharply during intoxication, which is why group sexual excesses are common among groups of drug users. The intoxication lasts 4–6 hours in the early stages, shortening quite rapidly with systematic use down to 10–15 minutes in stage II addiction.

Upon coming down from intoxication, asthenia, weakness, headache, and occasionally cenesthesia are observed. Patients are exhausted, drowsy, and apathetic. Emotional reactions are polarized, with irritability predominating. They are haunted by thoughts of using the drug.

Pervitin intoxication shares similar features, but is more intense and prolonged in duration and stimulating effect.

Occasionally, primarily in cases of overdose, ideas of reference and persecution develop. These may be reinforced by isolated auditory hallucinations. A characteristic feature of this paranoia is the relatively low motor activity of the patients. Typically, they hide in ambush and watch from there to see if the police or perpetrators have come for them. Such states can also occur in the first few days after drug cessation.

A characteristic symptom is the sensation of insects crawling under the skin, accompanied by intense itching. As a result, drug users constantly scratch themselves, leading to secondary skin infections.

The use of ephedrone and methamphetamine leads to rapid addiction. Within a few months, the duration of the euphoria significantly decreases, while the required dose and injection frequency correspondingly increase. The severity of post-intoxication states also intensifies.

Ephedrone is typically used in binges lasting from 2 to 7 days, during which users practically neither eat nor sleep. The daily dose reaches 80–120 ml (10–20 injections). The concentrated drug provides only a short-lived effect. A "binge" ends either due to a lack of the drug or complete physical exhaustion of the patient. Frequent intravascular injections cause vascular sclerosis and phlebitis. Immunosuppression leads to various infectious diseases. Toxic encephalopathy and polyneuritis develop rapidly, which is attributed to insufficient purification of the preparations. Patients undergo severe personality degradation and frequently die.

Amphetamine Dependence

Form: tablets of Aktedrine, Benzedrine, psychedrinum, psychoton, desoxyn, methedrine, tonedrone, sydnophenum, sydnocarbum, etc.

Amphetamines (phenylalkylamines) are nervous system stimulants prescribed to enhance performance and relieve fatigue. Their pharmacological effects are similar to those of adrenaline, triggering the release of dopamine from the presynaptic membrane.

The effects of amphetamines are similar to those of ephedrone, albeit milder, and lack the initial phase of euphoria. Within 10–15 minutes after administration, mood improves, a desire to work emerges, and sleep disappears. Overdose manifests as talkativeness, stereotypy, restlessness, tremor, tachycardia, and occasionally fragmentary ideas of reference and persecution, illusions, and delusions (predominantly auditory).

With chronic use, sleep disappears entirely, and patients attempt to normalize it using medications. The consequences are identical to those of ephedrone addiction.

A distinction should be made between amphetamine addiction and the episodic use of these substances during periods of intense work. In such cases, they are prescribed in moderate doses, preferably with sustained-release agents (sydnocarb, sydnophen), and are discontinued once the work is completed.

Ecstasy

Ecstasy (methylenedioxymethamphetamine) appeared in the West relatively recently.

Form: tablets or capsules of 75–100 mg.

The drug produces an amphetamine-like effect accompanied by short-term relaxation and mood elevation, lasting for several hours. Characteristic signs of intoxication include nasal congestion, dryness of the mucous membranes, loss of appetite, tachycardia, and elevated blood pressure.

Systematic use of this drug disrupts sleep, causing patients to become anxious and irritable. The liver and heart are damaged, immunity is compromised, and the body becomes exhausted.

Cases of convulsions and death resulting from exhaustion and dehydration have been documented.

Caffeine Abuse

Disorders resulting from caffeine use are classified as follows:

According to DSM-IV

305.90 — Caffeine Intoxication

292.89 — Caffeine-Induced Anxiety Disorder

292.89 — Caffeine-Induced Sleep Disorder

292.9 — Caffeine-Related Disorder Unspecified

According to ICD-10, caffeine is included in the amphetamine group (see below).

In Ukraine, the excessive consumption of caffeine has become widespread, particularly among anti-social and criminal youth groups.

Method of consumption: tea (50 g or more of loose tea per 1 liter of water). Sometimes they prepare excessively strong coffee ("coffee jelly"), eat coffee grounds, or smoke tea leaves.

Intoxication resembles a manic state. If the tea is brewed excessively strong (chifir), patients experience a sensation akin to an ephedrone "rush." This is followed by excitement and a surge of energy, with intellectual and physical spheres becoming hyperactive. Appetite increases, and stomach pain may occur. Overdose leads to tachycardia, tremor, and an inability to sustain concentration. In individuals with organic Brain lesions, seizures may develop.

Very often, chifir is consumed concurrently with alcohol (while intoxicated).

The consequences of chronic use are similar to those of amphetamine addiction. Hyperacid gastritis and PEPTIC ULCER DISEASE are added to the clinical picture.

Cocaine Addiction

Cocaine is an alkaloid derived from the leaves of the Erythroxylon coca bush, which grows in South America. Indigenous peoples used it as a stimulant, while in medicine it has been used for local anesthesia.

Clinical Psychiatry

Cocaine-related disorders are classified as follows:

According to DSM-IV

304.20 — Cocaine dependence
305.60 — Cocaine abuse

292.89 — Cocaine intoxication, incl. with perceptual disturbance

292.0 — Cocaine withdrawal

292.81 — Cocaine intoxication delirium

292. — Cocaine-induced psychotic disorders

.11 — With delusions

.12 — With hallucinations

292.84 — Cocaine-induced mood disorders

292.89 — Cocaine-induced anxiety disorders

292.89 — Cocaine-induced sexual dysfunctions

292.89 — Cocaine-induced sleep disorders

292.9 — Unspecified cocaine-related disorder

According to ICD-10

F14.0 Acute intoxication

F14.1 Harmful use

F14.2 Dependence syndrome

F14.3 Withdrawal state

F 14.4 Withdrawal state with delirium

F 14.5 Psychotic disorders

F 14.6 Amnestic syndrome

F 14.7 Residual state (incl. F 11.73 — dementia)

F 14.8 Other psychotic and behavioural disorders

F 14.9 Unspecified psychotic and behavioural disorders Appearance: fine snow-white powder (resembling talcum powder); ampoules.

Route of administration: snorting the powder; adding to alcohol; via injection.

The Effect of intravascular administration resembles that of methcathinone. 5–10 minutes after snorting the powder, mood and self-esteem improve, a sense of bodily lightness emerges, and potency increases. Somatic signs include tachycardia, elevated blood pressure, mydriasis, and tremor of the extremities. Overdose may cause nausea, vomiting, and occasionally persecutory delusions accompanied by episodic auditory hallucinations. A characteristic sensation is formication (the feeling of insects and worms crawling under the skin). In cases of severe overdose, cardiac pain and arrhythmia, as well as delirious and oneiric disturbances of consciousness, may occur.

The clinical course of uncomplicated cocaine addiction resembles a milder form of methcathinone addiction. Somatic and neurological consequences are similar, with The addition of nasal mucosal ulceration and, occasionally, nasal septal perforation.

Crack cocaine

Appearance: small lumps resembling crushed sugar.

Route of administration: injection (dissolved in warm water); smoking (added to tobacco).

The effects of crack cocaine are similar to those of cocaine, but more intense and shorter-lived. It induces dependence more rapidly than cocaine. Due to its high price, it is used less frequently.

Prognosis

With regular stimulant use, patients experience decreased immunity, cardiovascular dysfunction, and generalized asthenia. When drugs are administered via injection (pervitin, methcathinone, amphetamines), There is a high risk of contracting injection-related infections, particularly HIV/AIDS. Most fatalities result from acute heart failure and strokes caused by overdose. Individuals with organic CNS damage may experience seizures. Those who regularly use illicitly manufactured stimulants exhibit neurological complications such as paresis, hyperkinesia, and polyneuritis.

Treatment

Treatment for stimulant addiction should begin with intensive detoxification. In cases of psychomotor agitation, seduxen or relanium is prescribed. Neuroleptic medications in such patients may trigger circulatory collapse.

Following recovery from the acute state, it is advisable to prescribe anxiolytics and low doses of antidepressants. Symptomatic treatments include nootropics, Vitamins AND MINERALS, adaptogens,

and vascular medications. If sleep is severely disrupted, hypnotics, particularly barbiturates, should be used with caution.

The primary goal of psychotherapy is the patient's complete cessation of drug use.

HALLUCINOGEN ABUSE

Hallucinogens include psychodysleptics (LSD, mescaline, psilocybin), certain prescription drugs (taren, cyclodol, seduxen), and plant-derived hallucinogens.

Disorders associated with hallucinogen use are classified as follows:

Per DSM-IV

304.50 — Hallucinogen dependence 305.30 — Hallucinogen abuse

292.89 — Hallucinogen intoxication

292.89 — Hallucinogen persisting perception disorder

292.81 — Hallucinogen intoxication delirium

292. — Hallucinogen-induced psychotic disorders

11 — With paranoid features

12 — With hallucinations

292.84 — Hallucinogen-induced mood disorders

292.89 — Hallucinogen-induced anxiety

292.89 — Hallucinogen-induced sexual dysfunction

292.89 — Hallucinogen-induced sleep disorder

292.9 — Unspecified hallucinogen-related disorder according to ICD-10

F 16.0 Acute intoxication

F 16.1 Harmful use

F 16.2 Dependence syndrome

F 16.3 Withdrawal state

F 16.4 Withdrawal state with delirium

F 16.5 Psychotic disorder

F 16.6 Amnestic syndrome

F 16.7 Residual state (incl. F 11.73 — dementia)

F 16.8 Other psychotic and behavioral disorders

F 16.9 Unspecified psychotic and behavioral disorders

LSD abuse

LSD (lysergic acid diethylamide) is a semisynthetic compound derived from lysergic acid found in ergot Fungi. LSD acts as a competitive serotonin antagonist.

Form: a white, highly soluble powder resembling sugar; sheets of hygroscopic paper with various prints (Donald Duck, Batman, etc.) known as "tabs"; tablets or capsules.

LSD is sometimes adulterated with phencyclidine, methamphetamine, or strychnine (to stimulate sexual activity).

The drug begins to take effect within 10–30 minutes after administration. The effect depends on the user's intent, psychological characteristics, and dosage. Initially, intoxication manifests as heightened sensitivity across all sensory channels: colors become vivid, sounds start to irritate, and skin sensitivity increases. This is followed by illusions and hallucinations. The emotional state fluctuates from euphoria to profound depression with suicidal ideation. Ecstatic-religious experiences are also frequently observed.

According to S. Grof, the wide range of individual reactions is associated with the activation of systems of condensed experience (SCE). SCEs are memories of events that share common features and, most importantly, the same emotional coloring (positive or negative). Euphoria is induced by positive SCEs, whereas negative ones lead to terrifying and threatening delusions.

During intoxication, patients may remain passive or, conversely, rush around the room trying to escape hallucinatory imagery. Among somatic and neurological symptoms, sweating, hypersalivation, tachycardia, and elevated blood pressure are notable. Stomach pain, nausea, vomiting, localized cramps, and hyperreflexia may also occur.

To intensify and, to some extent, control hallucinatory experiences, patients use LSD in darkened rooms accompanied by appropriate music.

Systematic use of LSD and other hallucinogens occurs only among those who experience positive effects. They develop psychological dependence and tolerance quite rapidly.

Abuse of plant-derived hallucinogens (psychodysleptics)

To achieve an LSD-like effect, certain mushrooms and cacti are used. Fungi with hallucinogenic properties also grow in Ukraine. These include toadstools such as Psilocybe spadicea, Psilocybe semilanceata (the active substance is psilocybin), and the quite widespread fly agaric (Amanita muscaria). Its active ingredient is muscarine.

Mushrooms are typically gathered and dried, then swallowed or chewed for a long time. Sometimes a decoction is prepared from fly agarics.

Plant-derived hallucinogens cause vivid, dream-like visions. The consumption of fly agaric may be accompanied by stomach pain, nausea, vomiting, and severe muscular tension that, in cases of overdose, progresses to generalized seizures.

Sometimes drug users consume cacti containing mescaline (Lophophora williamsii). The cactus is stripped of its spines and eaten fresh or dried, or a decoction is made from it. Its effects are similar to those of LSD.

Ketamine abuse

Ketamine is a non-narcotic analgesic used for short-term surgical Procedures.

Form: tablets or capsules; fast-dissolving white powder; scraps of absorbent paper.

It induces euphoria and oneiric hallucinations. The duration of intoxication is up to 3 hours. It elevates blood pressure and accelerates heart rate. Aggressive behavior and self-injury are possible during intoxication. Only psychological dependence develops.

PHENCYCLIDINE (PCP) ABUSE

Phencyclidine hydrochloride (PCP, angel dust).

According to DSM-IV

304.90 — Phencyclidine dependence

305.90 — Phencyclidine abuse

292.89 — Phencyclidine intoxication (including perceptual disorders)

292.81 — Phencyclidine-induced intoxication delirium

292. — Phencyclidine-induced psychotic disorders

11 — With paranoid features

12 — With hallucinations

292.84 — Phencyclidine-induced mood disorders

292.89 — Phencyclidine-induced anxiety disorder

292.9 — Phencyclidine-induced disorder, unspecified

Form: crystalline fast-dissolving powder.

Route of administration: intramuscular injections; snorting, smoking; oral ingestion, including with food.

It induces euphoria and vivid, scenelike hallucinations. PCP intoxication significantly increases aggressiveness, often predisposing individuals to criminal behavior. Somatoneurological symptoms are dominated by nausea and vomiting, with possible generalized seizures.

Rarely used due to its high cost.

ANTICHOLINERGIC ABUSE

Central anticholinergic agents misused for substance abuse include taren, asthmatol, and belladonna tincture (Folium belladonnę).

Form: taren — small tablets; asthmatol — unfiltered cigarettes; leaves and fruits of Jimson weed (Datura stramonium and innoxia), henbane (Hyoscyamus pallidus and niger), and deadly nightshade (Atropa belladonna).

Ingestion of these preparations leads to hallucinations. Very often, to enhance the hallucinogenic experience, individuals watch videos in genres such as erotica (most commonly), mysticism, or action. The nature of the delusions is pleasant. Consumers appear lethargic during this time, with dilated pupils, tachycardia, and elevated blood pressure.

CYCLODOL ABUSE

Cyclodol (tablets) is an antiparkinsonian correction agent with pronounced anticholinergic activity. It differs from other anticholinergics in having a milder effect.

For substance abuse purposes, it is taken in doses significantly exceeding therapeutic levels. Intoxication consists of 4 phases: euphoria (20–30 min); narrowing of consciousness (2–3 hours); hallucination; and emergence from intoxication. Cyclodol-induced hallucinations are characterized by a clear detachment from everyday reality and plots tied to past events. Patients resemble intoxicated individuals: unsteady gait, uncoordinated movements, and dilated pupils.

Physical dependence develops approximately after six months of systematic drug use, evidenced by increased tolerance and the onset of withdrawal symptoms.

Withdrawal begins 10–12 hours after the last dose of cyclodol. It manifests as an irresistible (compulsive) craving for the drug, anxiety, and irritability. Flushes with sudden facial redness occur. Muscle tone increases, accompanied by limb pain, hyperreflexia, and spasms in isolated muscle groups.

Patients rapidly deteriorate. Memory and work capacity decline. Interpersonal conflicts increase. The face becomes flushed. Hyperkinesia is very frequent. The gait becomes characteristic: an arched back, and arms and legs spread wide apart without bending at the joints.

Prognosis

With systematic hallucinogen use, the primary danger stems from the patient's hallucinatory spatial disorientation and overestimation of their own capabilities, potentially leading to self-harm or injury to others. Aggressive (including self-destructive) behaviors are characteristic of phencyclidine users. Plant-based hallucinogens are dangerous because an overdose can result in patient death (comatose state).

Treatment

If the patient is experiencing hallucinatory-paranoid agitation, neuroleptics are prescribed. In cases involving hallucinogenic mushrooms, the treatment regimen should include massive detoxification, along with the administration of hepatoprotectants and nootropics.

Psychotherapy should be aimed at achieving complete abstinence from any narcotic or toxic substances.

SUBSTANCE ABUSE (TOXICOMANIA)

Tranquilizer abuse

Classification of disorders associated with the use of sedatives and hypnotics:

According to DSM-IV

304.10 — Sedative, hypnotic, or anxiolytic-related disorder, dependence

305.40 — Sedative, hypnotic, or anxiolytic abuse

292.89 — Sedative-, hypnotic-, or anxiolytic-induced intoxication

292.0 — Sedative, hypnotic, or anxiolytic withdrawal, including perceptual disturbances

292.81 — Sedative-, hypnotic-, or anxiolytic-induced intoxication delirium

292.81 — Sedative, hypnotic, or anxiolytic withdrawal, including perceptual disturbances and delirium

292.82 — Sedative-, hypnotic-, or anxiolytic-induced persisting dementia

292.83 — Sedative-, hypnotic-, or anxiolytic-induced persisting amnestic disorder

292.0 — Sedative-, hypnotic-, or anxiolytic-induced psychotic disorder

11 — With delusions

12 — With hallucinations

292.84 — Sedative-, hypnotic-, or anxiolytic-induced mood disorder

292.89 — Sedative-, hypnotic-, or anxiolytic-induced anxiety disorder

292.89 — Sedative-, hypnotic-, or anxiolytic-induced sexual dysfunction

292.89 — Sedative-, hypnotic-, or anxiolytic-induced sleep disorder

292.9 — Sedative-, hypnotic-, or anxiolytic-related disorder, unspecified

According to ICD-10

F 13.0 Acute intoxication

F 13.1 Harmful use

F 13.2 Dependence syndrome

F 13.3 Withdrawal state

F 13.4 Withdrawal state with delirium

F 13.5 Psychotic disorder

F 13.6 Amnestic syndrome

F 13.7 Residual state (incl. F 11.73 — dementia)

F 13.8 Other psychotic and behavioral disorders

F 13.9 Unspecified psychotic and behavioral disorders

When considering tranquilizer abuse, only cases involving their use for euphoriant purposes should be taken into account, rather than symptomatic use for chronic stress.

In substance abuse involving tranquilizers, doses are typically high (most commonly taken in tablet form, less frequently intramuscularly). When administered orally, they are rapidly absorbed and remain present in the bloodstream for 4–18 hours (depending on the specific drug's properties). Patients move restlessly to avoid falling asleep. This is followed by a sense of calm, gratification, and euphoria. Gait becomes unsteady, reflexes are diminished, heart rate decreases, and blood pressure drops. Sleep sets in fairly quickly and can progress to a coma in cases of overdose. Characteristic symptoms of overdose include hypersalivation and increased bronchial secretion. In addition, Respiration and heart rate are suppressed, and cardiac cycle irregularities may occur. If tranquilizers are combined with alcohol, the effect is potentiated.

Physical dependence on tranquilizers can be diagnosed based on a rapid increase in tolerance and the emergence of a withdrawal syndrome resembling that of alcohol. This is accompanied by fairly rapid moral and ethical degradation characterized by a specific psycho-organic syndrome. Patients become overly familiar and cynical. Somato-neurological changes also appear, primarily involving vestibular dysfunction (unsteady gait) and a significant decline in immune function.

Situational dependence is likewise accompanied by some increase in tolerance, though dosages do not exceed therapeutic levels.

Prognosis

Systematic barbiturate use leads to the relatively rapid development of organic dementia accompanied by brutality. Liver and Kidney pathology, among others, is frequently observed.

Treatment

In cases of overdose, the stomach must be evacuated first, followed by detoxification. Maintaining cardiovascular and respiratory function is of paramount importance.

Treatment begins with intensive detoxification therapy. When planning the therapeutic regimen, somatic disorders—particularly damage to the liver, Kidneys, and Lungs—must be taken into account. Psychotherapy should target lower vital needs and emotions, given the profound personality changes and dementia present in patients.

INHALANT ABUSE

Inhalant-related disorders are classified as follows:

Per DSM-IV

304.60 — Inhalant dependence

305.90 — Inhalant abuse

292.89 — Inhalant intoxication

292.81 — Inhalant-induced intoxication delirium

292.82 — Inhalant-induced dementia

292. — Inhalant-induced psychotic disorders

11 — With paranoid features

12 — With hallucinations

292.84 — Inhalant-induced mood disorders

292.89 — Inhalant-induced anxiety disorders

292.9 — Unspecified inhalant-related disorder

According to ICD-10

F 18.0 Acute intoxication

F 18.1 Harmful use

F 18.2 Dependence syndrome

F 18.3 Withdrawal state

F 18.4 Withdrawal state with delirium

F 18.5 Psychotic disorder

F 18.6 Amnesic syndrome

F 18.7 Residual state (incl. F 11.73 — dementia)

F 18.8 Other psychoactive substance-related disorders

F 18.9 Unspecified mental and behavioral disorder

Ether abuse

Form: 100 ml dark glass bottles.

Route of administration: inhalation of ether vapor. Isolated cases of oral ingestion, mixing with alcoholic beverages, and even intramuscular injections have been documented.

Ether intoxication is characterized by excitation and euphoria. It is short-lived, with sobriety returning 10—15 min after inhalation. Occasionally, the patient becomes aggressive, and seizures may occur. Intoxication ends in a sound sleep. Overdose may lead to coma, respiratory arrest, and severe Cardiac Arrhythmias. Among somatic symptoms, increased bronchial secretion is also notable, which can lead to Pneumonia and Bronchitis.

With regular use, tolerance and frequency of administration increase rapidly. The patient's personality changes: they become brutal and irritable. Intelligence declines, and chronic infectious processes develop in the lungs and digestive organs.

Nitrous oxide abuse

Nitrous oxide is a substance used for inhalation anesthesia. It is a colorless liquid that evaporates rapidly. Its abuse is a rare phenomenon.

Inhalation of nitrous oxide rapidly induces euphoria. The individual becomes groundlessly cheerful, accompanied by a brief narrowing of consciousness. The gas is usually inhaled in company. The intoxication is short-lived and passes quickly.

Dependence on nitrous oxide is exclusively psychological.

Abuse of household chemicals

The active ingredients of inhalants are aliphatic, aromatic, halogenated, or fluorinated Hydrocarbons. They are rapidly absorbed in the lungs and accumulate in lipid-rich Cells, damaging their membranes.

Route of administration: inhalation from a rag or plastic bag.

Initially, gasoline irritates the respiratory tract, causing facial flushing and tachycardia. Patients then enter a state of euphoria, accompanied by scenic, suggested, or personal experience-related hallucinations. Sometimes the delusions are threatening in nature. The patient typically perceives everything as if watching a horror movie. In case of overdose, the delusions acquire features of true delirium, which is transient in nature and subsides 10—20 min after inhalation.

During the recovery phase from intoxication, patients are asthenic and frequently complain of headaches. A smell of gasoline emanates from their clothing and breath.

Stain removers cause greater euphoria with the visualization of fantasies. Overdose leads to an oneiric state with a "custom-made" theme, yet with an unexpected plot progression.

Hallucinations induced by the use of Solvents and glue resemble comical cartoons.

Besides inhalation, acetone is also applied topically to the head or torso. For this purpose, the skin is scratched, followed by an acetone compress.

The patient's symptoms and behavior mirror those observed after alcohol consumption.

Physical dependence is indicated by a progressive increase in tolerance and a transition to solitary use. Patients experience rapid intellectual degradation, which is a manifestation of toxic encephalopathy. Polyneuropathy is frequently observed, seizure susceptibility increases, and the liver and kidneys become damaged. An overdose can be fatal.

ORGANOPHOSPHATE ABUSE

Organophosphate insecticide preparations, such as dichlorvos and others (OPs), are frequently consumed alongside alcohol. They may also be used independently or with a very low dose of alcohol (a bottle of beer shared among 5–7 people). They produce muscarinic-nicotinic-curariform effects and act primarily on cell membranes.

Method of use: added to alcoholic beverages; inhaled using a plastic bag; compressed onto scratched skin (predominantly the crown of the head).

Because OPs are highly toxic, overdose cases (including fatal ones) are frequently observed.

Intoxication consists of three phases (based on the level of toxicity). Phase I is characterized by agitation and a peculiar euphoria accompanied by irritability and aggressiveness. Stomach pain, nausea, and vomiting may also occur.

If intoxication persists, Phase II ensues, characterized by altered consciousness followed by fainting. Bronchorrhea, salivation, elevated blood pressure, and myofibrillation are observed. Pulmonary edema may also develop.

Phase III of intoxication involves collapse, seizures, and depression of the respiratory center, potentially leading to respiratory arrest. These substances are typically abused by individuals with a criminal background or adolescents engaging in so-called exploratory polyaddiction. Systematic use rapidly leads to a psycho-organic syndrome accompanied by significant moral and ethical degradation. The liver and kidneys are severely damaged.

Prognosis

In cases of systematic organophosphate abuse, patients frequently die from an overdose or injuries sustained while intoxicated. Pulmonary diseases, notably cancer, develop over time. Toxic dementia forms within 1–1.5 years, resulting in disability.

Treatment

In the event of an overdose, detoxification is prescribed, and vital functions are supported.

Treatment for dependence begins with detoxification. The comprehensive management plan includes symptomatic therapy, nootropic medications, adaptogens, and psychotherapy.

SMOKING

Nicotine-related disorders are classified as follows:

According to DSM-IV

305.10 — Nicotine dependence

292.0 — Nicotine withdrawal

292.9 — Nicotine-related disorder, unspecified

According to ICD-10

F17.0 Acute intoxication

F 17.1 Harmful use

F 17.2 Dependence syndrome

F 17.3 Withdrawal state

F 17.8 Other mental and behavioural disorders

F 17.9 Unspecified mental and behavioural disorders Tobacco dependence is caused by its nicotine content. Tobacco smoking is widespread in Ukraine. Nicotine is absorbed in the lungs and reaches the brain within 8–10 seconds. Nearly 2/3 of this substance is neutralized by the liver. The concentration of nicotine in the Central Nervous System begins to decline 20–30 minutes after smoking ceases.

The pharmacological action of nicotine is biphasic: initially stimulatory, followed by sedative.

Treatment

First and foremost — psychotherapy. Treatment is complicated by the fact that smoking is embedded in communicative and occupational routines.

Prognosis

Smoking causes a wide range of diseases affecting the respiratory and cardiovascular systems, and triggers gastritis and peptic ulcer disease.

Specific features of substance use disorders in adolescents

Psychoactive substance use typically begins at the age of 13–17, most frequently among adolescents with an amorphous personality Structure. The initial motivation is often a desire to fit in with peers, thereby demonstrating "maturity" and "courage". Typical adolescent reactions of emancipation and cliquishness play a role in developing the craving.

During initial experimentation, adolescents do not always commit to a specific substance. This stage is known as adolescent exploratory polysubstance use. It eventually culminates in choosing a single drug, a trajectory followed by the majority of substance-dependent individuals.

It should be noted that the earlier drug use begins, the higher the progression rate of the disorder.

REMISSIONS AND RELAPSES IN DRUG ADDICTION AND SUBSTANCE ABUSE

Approximately 1–1.5 months after recovering from the withdrawal syndrome, substance users develop a so-called pseudo-abstinence syndrome ("dry withdrawal"). The craving for the drug increases significantly. Somato-neurological symptoms resemble a mild, attenuated form of withdrawal. If the drug is not consumed, the frequency and intensity of these episodes gradually decrease. Drug-related dreams persist the longest. Sometimes, predominantly in polysubstance users, pseudo-abstinence manifests as episodes of irritability, aggressiveness, and conflictiveness, without a somato-neurological component. Patients usually fail to recognize The connection between these states and their past drug use.

Such states may occur even after several years of sobriety, serving as one of the causes of relapse.

Drug cravings are sometimes triggered by encounters with former drug-using peers, the use of sleeping pills and sedatives previously employed to enhance the state of intoxication, or occasionally even by the sight of needles and syringes. These mechanisms frequently operate at a subconscious level.

General Principles of treatment

Treatment for drug addiction or substance abuse requires complete abstinence from psychoactive substances. It begins with the management of withdrawal symptoms and detoxification. Symptomatic therapy is also necessary. In most cases, adaptogens and nootropics are prescribed. Psychotherapy should ideally involve not only the patient but also their family members. Once acute symptoms are resolved, courses of anti-relapse treatment must be administered.

Prevention

Primary: countering the spread of drugs; promoting a healthy lifestyle; identifying high-risk groups.

Secondary: detection and timely treatment of substance users and addicts in the early Stages of the disorder.

Tertiary: prevention of "syringe-borne infections" through advocacy and "Harm Reduction" and "Decriminalization" programs. These programs provide free distribution of syringes and condoms to prevent HIV infection. Under the so-called Dutch model, cannabinoids have been partially legalized to prevent severe forms of drug addiction. Global attitudes toward this program remain mixed.

Tobacco dependence is indicated by an increase in the number of cigarettes smoked and a preference for stronger brands.

The development of tolerance to tobacco has certain specific features. For instance, it noticeably decreases over a period of 6–8 hours. Consequently, many smokers experience a stronger subjective effect from their first cigarette of the morning. Throughout the day, tolerance builds up again, accompanied by an increase in the number of cigarettes smoked and a preference for stronger tobacco. At this stage, the urge to smoke takes on a compulsive character.

Withdrawal symptoms manifest primarily as irritability, nervousness, a strong craving to smoke, and headaches. Typically, these symptoms disappear within 2 weeks. However, dreams related to smoking may still occur even several years later.

Expert Evaluation

Medical and social evaluation. During treatment, patients are temporarily unable to work and are issued sick leave certificates. In cases of dementia or severe somatic complications (persistent disability), they may be referred for disability status.

Military service evaluation. Individuals registered at narcological dispensaries are unfit for military service in peacetime and fit only for restricted service during wartime (Article 19, paragraphs b, v). In cases of significant mental disorders, they are completely exempted from military registration (Article 19, paragraph a).

Forensic psychiatric evaluation. If a crime is committed in a psychotic state, patients are deemed not guilty by reason of insanity (non-accountable). Patients suffering from dementia may also be declared non-accountable.

Review Questions

1. Definition and prevalence of substance abuse and drug addiction.

2. General characteristics of drug addiction. Withdrawal syndrome.

3. Clinical picture of morphinism and opioid addiction.

4. Hashish addiction.

5. Cocaine addiction.

6. Addictions resulting from the abuse of hypnotics (barbiturates).

7. Prescription drug dependence.

8. Polydrug addiction.

9. Tobacco smoking.

10. Principles, Methods of treatment, and prevention of substance abuse and drug addiction.