Psychiatry - H.T. Sonnyk 2003

Drug addiction and substance abuse

Drug addiction is a disease resulting from the systematic use of substances included on the official list of narcotics, characterized by psychological and physical dependence on these substances.

Substance abuse (toxicomania) is a condition characterized by psychological and physical dependence similar to drug addiction, but caused by substances not included on the official list of narcotics.

A narcotic (drug) is a substance whose abuse, considering its social hazard, is legally recognized as such due to its property of inducing a pleasant mental state upon single use, and both psychological and physical dependence upon systematic use.

A substance is officially recognized as narcotic when it is added to the drug schedule by order of the Minister of Healthcare. This schedule is compiled on The basis of international conventions on narcotic drugs and psychotropic substances.

A psychoactive toxic substance may share the same properties as a narcotic, but its social hazard is not as high. Over time, certain substances have alternately been classified as narcotics or excluded from this category, such as barbamyl and ephedrine.

ETIOPATHOGENESIS.

Drug addictions and substance abuse are multi-etiological disorders whose development is influenced by numerous factors:

✵ social factors (availability of the drug, "trends," peer pressure, traditions);

✵ personal and psychological factors, which have recently been assigned a decisive role (character accentuations and personality disorders, the appeal of the drug's effects);

✵ hedonistic orientation, understood as the pursuit of pleasure;

✵ biological factors (age of onset of drug use, initial tolerance, heredity, organic lesions of the Brain and Liver). However, the most critical factor is the type of substance being consumed.

The mechanisms underlying the narcotic effect and dependence on psychoactive substances remain largely unknown. Over recent decades, researchers have studied the action of drugs on synaptic structures and Functions, investigated disruptions in acetylcholine and other neurotransmitter METABOLISM in the Central Nervous system (CNS), and explored potential treatments for drug addictions by targeting neurotransmitter systems.

A milestone in The Study of the Pathogenesis of drug addiction was the discovery in the mid-1950s by Olds and Milner of the self-stimulation effect, which suggested that drug use creates a positive reinforcement loop, driving The Need for constant reinforcement and repetition.

Classification of Psychoactive Substances (WHO, 1990)

1. Opiates (opioids).

2. Depressants: sedatives, hypnotics, tranquilizers.

3. Stimulants: cocaine, amphetamine, caffeine, khat (a plant containing an ephedrine-like substance).

4. Hallucinogens: LSD, mescaline, cyclodol, atropine.

5. Other substances: cannabis (marijuana, hashish), inhalants, coffee, betel (plants native to Oceania), phencyclidine.

In Ukraine, the illicit trafficking of opiates is the most widespread.

SYNDROMOLOGY.

The primary syndromes encountered in the Clinical presentation of drug addictions and substance abuse are:

1) Syndrome of altered reactivity:

a) change in the pattern of use—systematic consumption of the psychoactive substance without significant intervals.

b) Change in tolerance—a person with drug dependence can tolerate higher doses than a healthy individual. Over time, There is a need to increase the dose of the psychoactive substance to achieve the desired effect. At the height of the disease, tolerance varies depending on the specific psychoactive substance. For instance, in barbiturate abuse, it increases 5–10 fold, whereas in opiate addiction, it increases 100–200 fold. There is also so-called behavioral tolerance, meaning that an individual who has used drugs for a long time is able to mask the state of intoxication.

c) Disappearance of defense reactions to overdose (mithridatism) – in individuals with substance dependence, the body's usual reactions to an overdose (itching, nausea, vomiting, profuse sweating, facial flushing) are mild or completely absent. Life-threatening poisoning may present with surprisingly few clinical signs.

d) Alteration of the intoxication pattern – as addiction becomes established, the Physiological Effect of the drug changes. While morphine exerts a sedative effect on a healthy person, it produces a stimulating effect in an individual with opioid dependence. A similar pattern is observed in barbiturate abuse.

2) Psychological dependence syndrome:

a) Psychological craving – manifested by an obsession with the drug, elevated mood prior to consumption, and irritability or dissatisfaction in the absence of the substance.

b) Ability to achieve psychological comfort in a state of intoxication – stems directly from psychological craving. While a healthy person finds joy in various life events, a person with addiction experiences joy solely through drug use. Only in a state of intoxication do they feel a surge of energy, increased productivity, and the disappearance of worries and anxieties. It should be noted that the risk of developing substance dependence is particularly high in individuals with emotional instability who are dissatisfied with themselves and their social status.

3) Physical dependence syndrome:

a) Compulsive craving – an irresistible urge to use drugs, reaching the intensity of vital drives such as hunger or thirst. It dictates the patient's mood and behavior, and overrides self-control. Unlike psychological craving, compulsive craving is accompanied by autonomic disorders: mydriasis, hyperhidrosis, dry Mouth, and tremors. This craving is an indicator of a physical need for a dose of the drug.

b) Ability to achieve physical comfort in a state of intoxication – once physical dependence is established, the patient becomes convinced that feeling comfortable is only possible while intoxicated. Without the drug, they cannot concentrate, their work capacity drops sharply, their well-being is extremely poor, and only the next dose can relieve these symptoms.

c) Abstinence syndrome (withdrawal syndrome) – the most striking manifestation of physical dependence. It is a cluster of somatic, neuro-autonomic, and psychological disorders that occurs when drug use is abruptly stopped in a dependent individual. The general signs of withdrawal syndrome (WS) are similar across Various Forms of addiction, dominated clinically by psychiatric and neuro-autonomic symptoms. The distinctness of these manifestations depends on the duration of the disease (long-term users experience less acute WS symptoms, but their overall physical condition is considerably worse); psychopathological symptoms incorporate the individual personality traits of the patient; and WS symptoms are alleviated or eliminated by taking a dose of the drug. It is worth noting that patients subjectively endure withdrawal very poorly, whereas objectively their condition is not critically severe. Therefore, one should not pander excessively to the whims of patients in this state; the only crucial consideration is the potential exacerbation of comorbid conditions.

4) Psychotoxic drug action syndrome:

a) Alterations in mental activity following a single drug dose.

b) Personality changes resulting from chronic use.

5) Somato-neurological function alteration syndrome: comprises a diverse range of somatic-autonomic and neurological disorders.

COURSE OF ADDICTION DISORDERS.

The course of substance dependence and abuse involves the following stages:

1) Stage of prenosological drug use. Literature features numerous terms for drug use without dependence: narcotism, episodic use, addictive behavior, problematic use, and substance abuse. This Diagnosis is made when drug use causes problems for the patient at work, in studies, or within the family; occurs in prohibited situations (such as driving); or leads to legal trouble or health deterioration. The essential condition for this stage is the absence of dependence.

2) Stage of psychological dependence (Stage I addiction) is characterized by The Emergence of the psychological dependence syndrome. Defense reactions to overdose diminish, tolerance increases, and social maladjustment appears, which is particularly pronounced in adolescents.

3) The physical dependence stage (Stage II addiction) is characterized by The formation of the physical dependence syndrome, signs of chronic intoxication, an altered intoxication pattern, high tolerance, progressive social maladjustment, and anosognosia (lack of insight into one's own illness). In Stages I and II, anosognosia is primarily driven by socio-psychological factors. At this point, especially among adolescents and individuals with accentuations or psychopathy, anosognosia involves a glorification of drug use (a desire to stand out in a peer group); later on, it takes the form of a psychological defense mechanism (rationalizing drug use, believing that many other people use drugs as well); and only in Stage III of the disease does developed encephalopathy become the underlying cause of anosognosia.

4) Stage of encephalopathy (Stage III addiction)

is characterized by an altered intoxication pattern (instead of a euphoric and stimulating effect, the drug produces a normalizing effect), declining tolerance, prolonged WS, signs of chronic intoxication and cachexia, apathy, and evidence of organic central nervous system damage. This stage is relatively rare, as most individuals with severe addiction do not survive to reach it.

CLINICAL PICTURE.

Opioid dependence.

For drug use, homemade extracts derived from dried opium poppy seed pods ("shyrka") are utilized. 1 ml of this extract corresponds roughly to 10–60 ml of a 1% morphine solution. Opioid poppies contain A number of Alkaloids – such as morphine and codeine – and synthetic opiates (promedol, omnopon, heroin, and others) are obtained through specific chemical Processing. Chemically, these substances belong to the phenanthrene group.

The MECHANISM OF ACTION of opiates is as follows. Opiate receptors (mu, kappa, delta, and sigma) have been identified in The Human Body, located within the central nervous system, gastrointestinal tract, hematopoietic system, and immune system. Morphine-group drugs stimulate mu-receptors exclusively, which triggers the narcotic effect. Stimulation of other receptors does not produce euphoria, but does result in analgesia, respiratory depression, and other effects characteristic of opiates.

The clinical picture of opioid intoxication comprises four distinct phases.

The first phase begins a few seconds after intravenous administration (it is absent with other routes of use) and lasts up to five minutes. It produces a warm, pleasantly tingling sensation that spreads upward from the back, which is subjectively perceived as intensely pleasurable. The individual experiences euphoria and a sense of sudden insight; the HEAD feels light, and the surrounding environment becomes vivid and bright. In drug subculture, this sensation is known as the "rush" or "kick." Over time, this feeling gradually weakens and eventually disappears altogether.

The second phase is characterized by a deep sense of calm, lethargy, physical immobility, and warmth. Any anxiety related to everyday problems vanishes, and the patient becomes absorbed in daydreams. In the second stage of opioid addiction, the intense euphoria fades, giving way to increased physical activity and a strong desire to move, socialize, and engage in tasks. This phase typically lasts from two to six hours.

The third phase manifests as a superficial, fragmented Sleep lasting two to three hours.

The fourth phase, or the after-effect phase, is variable. It is marked by malaise, headaches, unmotivated restlessness, and occasional nausea or vomiting.

Intoxication presents with the following disturbances: somatic (Skin pallor, dryness of the mucous membranes, bradycardia, hypotension, respiratory depression); neurological (pronounced miosis with unresponsiveness to light, rapid speech, and slurring at the peak of intoxication); and psychiatric (phenomena of figurative mentism, accelerated thought processes, and mood swings).

Overdose leads to the rapid onset of progressive drowsiness and lethargy, which can quickly progress to stupor or coma. Death results from asphyxia due to paralysis of the respiratory center.

The course of opioid addiction is malignant in nature: physical dependence develops within just 1 to 2 months, and tolerance increases rapidly.

When such individuals fail to obtain the drug, they experience severe affective disturbances within the first 24 hours (tension, irritability, and a tendency toward explosive reactions over minor triggers). Suicidal attempts may occur, aimed at compelling relatives to provide money for the next dose. Typical symptoms include insomnia, decreased appetite, and various autonomic disorders.

In Stage II opioid addiction, a more pronounced withdrawal syndrome (WS) is observed. Its signs appear 6 to 8 hours after the last injection, manifesting as general discomfort, anxiety, dysphoria, and an overwhelming craving for the drug. The symptoms of WS escalate rapidly, peaking by the end of the second day: runny Nose, spasmodic abdominal pain, toothache, tachycardia with normal Blood pressure, lacrimation, hypersalivation, nausea, vomiting, diarrhea, and weight loss. Characteristic features include Muscle and joint aches, fever, anorexia, and muscle tremor. Neurological status reveals muscle hypertonia, enhanced tendon and periostial Reflexes, abdominal reflex lability, and a positive Marinesco-Radovici sign.

The appearance of patients during an acute withdrawal crisis is exhausted; the face is pale with sharp features and sunken eyes. The acute period lasts approximately 10 days, after which the symptoms gradually subside and may resolve even without medical intervention. Muscle pain begins to ease by the fifth or sixth day, appetite is the first to return—often accompanied by temporary bulimia—and long-term sleep disturbances remain common.

At this stage, the clinical picture of intoxication changes. The initial autonomic response to intravenous drug administration (the "rush") is diminished or entirely absent, though it may reappear if various adulterants are used. The distinct euphoria accompanied by relaxed pleasure and inactivity is no longer observed. Instead, patients exhibit increased activity alongside a strong urge for socialization and manual labor.

Signs of chronic intoxication appear early and are highly prominent. Physical exhaustion develops; Hair and Nails become brittle, and the skin turns unusually pale with a yellowish tint. Patients appear significantly older than their chronological age, Teeth become fragile and fall out, and hypochromic anemia and visual disturbances develop. Even mild cold is tolerated with extreme difficulty. Libido drops sharply, accompanied by erectile, ejaculatory, and orgasmic dysfunctions. A drastic decrease in working capacity, loss of interest in routine activities, and impaired mental functions requiring cognitive effort are typical.

Only a rare few patients survive to Stage III opioid addiction. A decline in tolerance occurs, and the stimulating effect of the drug disappears entirely—patients now use it solely to stave off withdrawal symptoms. Following an episode of withdrawal, the physiological state no longer normalizes.

Cannabis addiction (Hashishism).

This is the most widespread form of substance dependence, though, unfortunately, a great deal of contradictory literature surrounds the topic.

In Ukraine, the abuse of wild-growing hemp products is common, utilizing dried flowering tops of female plants, dried leaves, and pollen. Common street names for the drug include "ganja," "onasha," "drap," "trava," and "plan."

The active substance is 9-delta-tetrahydrocannabinol. A synthetic variant also exists, which possesses a higher potency compared to the naturally occurring compound.

Hashish is typically smoked, and less frequently ingested orally in the form of decoctions or added as a seasoning to food.

More so than with other psychoactive substances, the effects of cannabinoids depend heavily on psychological set and expectations. The first phase of action occurs 3 to 10 minutes after consumption. It is characterized by suspicion, anxiety, and a sense of impending doom (colloquially referred to as "paranoia" or "freaking out"). This phase lasts 5 to 10 minutes and is frequently absent, or the episode of fear may be amnesized by the patient.

The second phase sets in 8 to 20 minutes after smoking, bringing a sensation of lightness, relaxation, and complacency. Various perceptual disturbances emerge: alterations in the perception of space, lighting, object size, colors, sound intensity and character, and taste. Reality may be perceived discretely as a series of disconnected photographic frames. Thinking is emotionally charged and slowed in tempo, with a noticeable enhancement in attentiveness-switching. Consciousness gradually becomes impaired. A characteristic feature is the emotional contagion within a group of users: the state of one individual (whether mirth, confusion, or fear) is transmitted non-verbally to others.

The third phase of hashish action manifests as a psychotic state characterized by confusion and delusions. Thought processes acquire fragmented qualities, and hallucinations frequently occur. Obsessive imitation of surrounding behavior is typical: the patient laughs when someone else laughs, without experiencing actual joy. Echlalia and echopraxia may also appear. Somato-vegetative symptoms include pupil dilation, flushing of the face and sclerae, dryness of the mucous membranes, potential tremor of the extremities, and paresthesias. Blood pressure and Heart rate increase. Coordination is impaired, accompanied by hyperreflexia, lateral nystagmus, thirst, and an intensification of appetite and libido.

The fourth phase is the comedown phase. Agitation subsides into hypoergia, accompanied by lethargy, weakness, and a drop in blood pressure. Patients develop a voracious appetite (often referred to as "the munchies"). This is followed by prolonged, albeit restless, sleep. Upon waking, patients continue to consume large amounts of food and fluids.

Overdose presents with marked mydriasis, unresponsiveness of pupils to light, facial hyperemia, noticeable dryness of the Lips and nasal mucosa, hoarseness, tachycardia ranging from 120 to 130 beats per minute, elevated blood pressure, severe coordination deficits, and hyperreflexia. Alterations of consciousness ranging from stupor to coma may occur, alongside psychotic presentations (delirium, hallucinatory confusion, amnesia).

It should be noted that the very possibility of developing true cannabis addiction is far from universally accepted among researchers.

Patients suffering from this type of addiction typically exhibit psychological dependence, whereas physical dependence on cannabinoids is relatively mild. The Development of addiction takes a prolonged period, spanning several years of regular smoking. Cravings are formed through habituation rather than emotional reinforcement, unlike the patterns seen in opioid, barbiturate, or stimulant addictions.

The First stage of hashish addiction is characterized by the disappearance of symptoms typically present at the onset (affective reactions), a shortened or completely absent sleep phase during withdrawal, and a decrease in the intensity of intoxication manifestations. Without the drug, patients become restless and experience psychological discomfort. The duration of this stage ranges from two to five years.

At the Second Stage, the pattern of intoxication changes—the first and fourth phases disappear, and consciousness remains unimpaired. The duration of the drug's effect is significantly reduced, forcing the patient to smoke repeatedly to maintain the effect. A mild compulsive drug craving may develop. Withdrawal syndrome appears 4–5 hours after the last cigarette: mydriasis, yawning, lethargy, weakness, dysphoria, loss of appetite, and insomnia. By the end of the first day, these symptoms intensify and are accompanied by tremor, elevated BP, facial hyperemia, salivation, and lacrimation. On the second day, cenestopathic Complaints emerge (sensations of heaviness and tightness in the chest, paresthesia). Patients are restless and irritable. The duration of the withdrawal syndrome is three to four weeks. On days three to five, abstinence psychosis may develop.

The Third Stage develops over several decades of continuous drug use; such observations are rare. At this stage, a compulsive craving for the drug appears, the stimulating effect of the drug is replaced by a tonic effect, and the withdrawal syndrome takes on a protracted character. Psycho-organic syndrome develops.

Some authors attribute disorders associated with hashish use to significant psychopathization, the development of encephalopathy, personality changes of an athetoid-abulic type, the onset of myocardial dystrophy, Upper Respiratory Tract tumors, and retinal angiopathy.

Addictions caused by The Use of stimulants.

The group of stimulants includes psychoactive substances capable of inducing an unusual elevation of mood, a drive for activity, and the avoidance of fatigue, while creating a sense of vigor, unusual mental clarity, ease of movement, and self-confidence. Representatives of this group include amphetamine, ephedrine, pervitin, cocaine, caffeine, ecstasy, and others.

Pervitin (ephedrone) addiction is quite widespread in Ukraine, as the narcotic substance ("vint") is relatively easy to obtain at home and is inexpensive.

Upon oral administration of the drug, euphoria with peculiar psychosensory disturbances develops within ten to fifteen minutes: an unusual lightness in the body appears, colors seem brighter, and characteristic feelings of inner kindness, love for people, and mental clarity emerge. With intravenous administration, the symptoms develop much faster. The first phase of intoxication (the "rush") is manifested by mild chills accompanied by a tingling sensation in the hands and feet, with patients feeling as though their hair is "standing on end" and "starting to grow."

The second phase begins 10–20 minutes later. Elevated mood and spiritual elevation arise with heightened activity; the desire for communication and restlessness reach a frenzy, with patients talking incessantly, jumping from one topic to another, repeating themselves, and becoming intrusive. They gesture intensely, and their facial expressions may range into grimaces. Ideas of grandeur, boasting, and confidence in The ability to accomplish even impossible plans predominate in their speech. This may be accompanied by fairly productive activity (poetry, drawings). Sometimes, sexual desire is enhanced and sexual arousal increases. Neurological disorders include mydriasis with weakened pupillary reflex, spontaneous nystagmus, and numerous microsymptoms.

The formation of pervitin addiction occurs quite rapidly (especially under conditions of intravenous administration). Signs of psychological dependence manifest after just 2–3 injections, creating an irresistible desire to experience the intoxication again. Over time, coming down from the state of intoxication leads to severe post-intoxication states: gripping pains in the back and heart, urinary retention, bouts of chills alternating with profuse sweating; sleep becomes restless, with frequent awakenings and terrifying dreams, and hyperacusis and photophobia develop. After 1–2 days, this state gives way to asthenia and drowsiness.

A compulsive craving forms quite rapidly and is particularly pronounced when coming down from pervitin intoxication. Use becomes periodic: the patient continuously uses the drug for 2 to 5 days, staying awake and fasting, driving themselves to complete exhaustion. At this point, the craving for the drug practically disappears, giving way to a state of sharp asthenia accompanied by severe insomnia and dizziness. After 6–12 hours, patients fall asleep, and upon waking, they experience a voracious appetite. After a few days, the craving for pervitin returns with renewed vigor, and the cycle repeats. As the addiction progresses, the intervals between cycles shorten from 5–10 to 2–3 days.

Increased tolerance is manifested by an increasing frequency of use throughout the day. Since a single dose rarely increases by more than 2 times, administrations follow one another every 2–4 hours, and the daily dose of the psychoactive substance increases from 2–3 ml to 30–80 ml.

The withdrawal syndrome is characterized primarily by severe dysphoria. Drowsiness alternates with hyperactivity; tremor and fibrillary twitches of the facial and Tongue Muscles are observed. Spontaneous nystagmus may occur. Persistent red dermographism and facial seborrhea are frequently noted. BP fluctuates, with a tendency toward collapse-like reactions. Patients feel a general malaise and experience headaches. The duration of WS is 1–2 weeks.

Social degradation occurs very rapidly. Previous interests are lost, and patients abandon work and studies. They gradually become indifferent to others, yet intolerant of criticism directed at them. An inability to perform any kind of labor emerges.

Somatic disorders manifest as myocardial dystrophy, Chronic gastritis, and spastic enterocolitis. When consuming low-quality narcotics with an excess of manganese and phosphorus (which are used in the chemical Processing of the raw Materials), specific signs of intoxication are observed: choreiform hyperkinesia, paresis of the soft palate (resulting in characteristic nasal speech), tongue, and facial muscles. In established addiction, a psychoorganic syndrome develops.

In addictions caused by the use of pervitin and amphetamine, the development of specific psychoses is possible, which can be divided into 2 groups:

1) psychoses arising from single or short-term use of psychostimulants;

2) psychoses against the Background of psychostimulant dependence.

Psychoses of the first group typically occur when using large doses. They more often proceed as acute paranoid states that arise instantaneously. Fear, anxiety, and suspicion appear; patients develop a feeling that they "understand everything" and can guess the ill-intentioned plans of those around them. Patients actively express delusions of reference and persecution, and Affective Disorders may manifest as anger and aggression. At the height of the paranoid state, auditory hallucinations may occur. The duration of the psychosis is 1–2 days, and it follows a benign course.

In established dependence, hallucinatory-paranoid syndrome most commonly develops. Typically, against a background of fearful mood, irritability, and depression, delusions of reference and persecution emerge. Patients believe they are being watched and that attempts are being made to destroy them. These ideas are accompanied and reinforced by prominent hallucinatory symptoms. Most commonly, these are auditory hallucinations whose thematic content aligns with the delusional ideas. The hallucinatory-paranoid syndrome develops against a background of clear or clouded consciousness. In the motor sphere, phenomena of both agitation and stupor-level retardation may be observed. There are Variants of the psychotic course accompanied by significant Thought Disorders (thought blocking, "made" phenomena, paralogical reasoning, incoherence, etc.). If such psychosis takes a protracted course—which happens quite frequently—differentiating it from Schizophrenia is extremely difficult.

Caffeine abuse is accompanied by the excessive consumption of beverages containing it—tea and coffee.

Caffeine facilitates the formation of associations and memory processes. Mood is elevated, motor activity is intensified, and both insomnia and drowsiness may occur, depending to some extent on the individual's mood. Caffeine acts more noticeably on a tired person.

In small doses, caffeine is capable of potentiating the action of psychotropic drugs.

The emergence of caffeine dependence is a rather controversial fact. When coffee and tea are consumed in normal quantities, dependence does not form. Those who exhibit caffeine dependence abuse "chifir," which contains more than 1 g of caffeine. In these cases, dependence forms within 1–2 years.

The clinical picture of caffeine intoxication has certain specific features. In addition to the signs mentioned above, a wave-like course of intoxication is observed—periods of elevated mood lasting 1–2 hours alternate with periods of exhaustion of equal duration. The duration of intoxication ranges from 2 to 8 hours. A number of autonomic symptoms are characteristic: tachycardia, extrasystoles, elevated BP, epigastric pain, sensation of hunger, sometimes vomiting, and increased diuresis.

With prolonged abuse of "chifir", the clinical picture of intoxication changes: its stimulating effect decreases, as do the somatic symptoms. The disorder begins to resemble an excited-type psychopathy.

Caffeine abuse is frequently observed among individuals dependent on other psychoactive substances, who typically consume "chifir" during periods of withdrawal.

Cocaine addiction is a widespread phenomenon in the United States, South American countries (the "homeland" of cocaine), and Western Europe. In Ukraine, however, cases of cocaine abuse are much rarer due to the high cost of this drug.

Cocaine is used in the following forms:

1) Chewing coca leaves (Erythroxylon coca), which is a traditional method for the population of South America. The leaves contain 0.5-1.5% cocaine, and chewing them produces only a tonic effect. No harmful consequences of chewing coca have been described.

2) Smoking coca paste, which contains 40-90% cocaine sulfate.

3) Inhaling cocaine hydrochloride powder or intravenous administration.

4) Smoking crystals of cocaine hydrochloride free base ("crack") or intravenous administration.

In its properties, cocaine is the most potent of all known psychostimulants; the intensity of its psychostimulatory action is several thousand times greater than that of other preparations, though this effect lasts for only a few seconds.

When smoking coca paste, euphoria is quickly replaced by severe anxiety, fear, apathy, depression, and dysphoria, which can be temporarily relieved by another dose of smoking.

When using "crack" and inhaling cocaine hydrochloride, the effects—alongside euphoria—manifest as inflated self-confidence, agitation, talkativeness, increased libido, delusions, and hallucinations.

During a state of cocaine intoxication, individuals experience dry mouth, hyperhidrosis, tremors, muscle cramps, and the urge to defecate. Psychologically, there is apathy, impaired Memory and Attention, anxiety, illusions and hallucinations, suicidal thoughts, and impulsivity.

Cocaine overdose may lead to Cardiac Arrhythmias, acute Heart Failure, and suppression of the respiratory center's activity when taken in combination with other psychoactive substances.

Cocaine withdrawal is manifested by severe dysphoria, affective attacks, motor agitation, and alternating periods of somnolence and insomnia. Delusional ideas and suicidal tendencies may also emerge. Somatic manifestations are minor.

Substance abuse caused by the use of hypnotics (sleeping pills).

These occur less frequently than the aforementioned forms of addiction, but their consequences are significantly more severe.

Abuse most commonly involves short-acting agents (barbamyl, bromural, glutethimide/noxiron, nitrazepam).

Narcotic intoxication occurs upon taking a double or triple dose. A prerequisite is the psychological set to achieve a euphoric effect—a substance taken accidentally merely causes drowsiness.

The first phase occurs immediately after intravenous administration (or upon oral intake only in "novices"). The patient experiences blurred Vision, a "soft hit to the head", along withacoasms and photopsias. These sensations are subjectively pleasant. Characteristic features include mydriasis (pupillary dilation), flushing of the upper half of the torso, and sudden muscular weakness.

In the second phase, motor activity increases. Patients experience motiveless joy and hyperbulic drives. Their movements are uncoordinated, although subjectively they believe their actions are purposeful. Attention is extremely scattered, and significant emotional lability and dysphoric manifestations are noted. Pronounced neurological dysfunctions arise: lateral nystagmus, diplopia, dysarthria, dysmetria, coordination disorders, and diminished reflexes. Blood pressure is lowered, pulse is slowed, and sweating is increased. This state lasts for 2-3 hours.

The third phase is characterized by deep sleep.

The fourth phase exhibits lethargy, inability to concentrate, and a feeling of being washed out. Headaches, nausea, and vomiting occur.

In case of an overdose, the second phase is absent, leading directly to immobility, deep sleep, Cheyne-Stokes Respiration, and hypothermia. Death occurs due to the Development of Respiratory center paralysis.

Physical dependence on hypnotics develops quite rapidly—within 3-4 months. Withdrawal syndrome develops During the first 24 hours after the last use of the toxic substance. Various autonomic disturbances appear; by the end of the first day, calf muscle cramps, hyperreflexia, and muscular hypertonia emerge. On the second day, epigastric pain, vomiting, diarrhea, and pain in large joints occur. By the end of the third day, the majority of patients experience convulsive seizures. Psychosis may develop. The duration of the withdrawal syndrome is 4-5 weeks.

The consequences of this substance abuse appear very early. Such patients are pale; their skin acquires a dirty, earthy tint and is prone to pustular rashes. Blood pressure is lowered, and ECG shows signs of myocardial dystrophy. The range of interests narrows drastically. Noticeable dementia can develop within 4-5 years.

Hallucinogenic substance abuse occurs when individuals misuse substances that, even in relatively small doses, almost invariably trigger short-term psychotic episodes. Such agents include mescaline (an alkaloid derived from the peyote cactus), psilocybin (a toadstool alkaloid), LSD, atropine, cyclodol, and many others.

Psychoses induced by various hallucinogens differ in duration, depth of altered consciousness, presence of insight, and distinctness of somatic-neurological disorders; nevertheless, their psychopathological symptoms share a significant number of common features.

Patients experience hypo- and hyperesthesias, synesthesias, illusions, hallucinations, body schema distortions, as well as derealization and depersonalization phenomena. Short-term memory is impaired, thought processes are disrupted in tempo and coherence, delusions may arise, and attention is compromised. Affective and motor disturbances also occur. Consciousness is altered in the form of stupor, delirium, or an oneiroid state, accompanied by impairments in various types of orientation.

In Ukraine, the abuse of atropine, cyclodol, and diphenhydramine is widespread, particularly among adolescents.

Atropine abuse typically involves the oral ingestion of belladonna extract tablets, atropine eye drops, or seed pods of the belladonna plant.

At the peak of intoxication, a delirious state emerges. Affected individuals are virtually inaccessible to contact, and amentiform phenomena are observed. Autonomic disturbances include facial flushing, pronounced pupil dilation (mydriasis), and tachycardia.

The post-delirious state is characterized by adynamia, lethargy, and rapid fatiguability.

Cyclodol abuse involves taking a large single dose of the medication, often washed down with beer or wine.

Initially, a phase of euphoria occurs, accompanied by derealization phenomena and isolated auditory and visual hallucinations, toward which critical judgment is preserved. Autonomic symptoms are present, such as facial flushing, tachycardia, decreased blood pressure, mydriasis, and accommodation paralysis.

The delirious phase sets in after 1–2 hours and lasts up to 12 hours, featuring vivid, situational hallucinations—predominantly visual. Relapses may occur in the following days.

Following LSD use (even a single instance), relapses can occur even years later ("flashbacks").

Hallucinogens are predominantly used on an episodic basis; therefore, dependence specifically caused by their use is a very rare phenomenon.

Substance abuse caused by the use of inhalants.

This category encompasses volatile substances containing aromatic Hydrocarbons, ethers, alcohols, ketones, and Other Compounds.

Inhaling these substances leads to toxic intoxication. This may involve breathing in the fumes of adhesives, gasoline, acetone, organic Solvents, varnishes, paints, or heated plastics.

Acute gasoline vapor poisoning initially causes upper respiratory tract irritation within 5–10 minutes, followed by flushing of the face and sclera, dysarthria, and impaired motor coordination, accompanied by a state of euphoria. If inhalation ceases, the euphoria persists for 15–30 minutes before giving way to lethargy, irritability, and headaches. However, if inhalation continues, mild stupor develops alongside a delirious syndrome featuring visual hallucinosis lasting about 10–30 minutes. This is followed by prolonged asthenia, apathy, lethargy, headaches, and nausea.

Inhaling acetone vapors induces oneiroid experiences with vivid, scenelike fantasies against a backdrop of mild euphoria. Severe poisoning may progress to sopor and coma.

Intoxication from inhaling glue fumes begins with euphoria unaccompanied by motor agitation, which transitions into an oneiroid state followed by a period of stupor. This state is characterized by the predominance of whimsical, cartoon-like visual hallucinations.

The risk of developing addiction from inhalant abuse is estimated at 5–10%. An encephalopathic stage may occur without the formation of physical dependence, manifesting as a decline in intellectual-mnestic functions, sleep disturbances, and asthenic complaints.

Treatment.

There are general guidelines regarding the hospitalization of patients with substance use disorders:

a) inpatient treatment is indicated in all cases of established dependence;

b) adolescents under the age of 16 are hospitalized with parental consent, whereas those 16 and older must provide their own consent;

c) emergency hospitalization without the patient's consent is indicated in the presence of acute psychotic symptoms; once the psychosis resolves, the patient's consent must be obtained for continued treatment.

To treat psychoactive substance poisoning when reliable information regarding the substance type is available, specific antidotes are employed: bemegride for barbiturate poisoning, nalorphine and naltrexone for opiate poisoning, physostigmine for anticholinergic poisoning, and the differentiated use of neuroleptics and tranquilizers in cases of psychostimulant overdose.

In all cases, a comprehensive set of measures aimed at detoxification and the maintenance of vital functions is carried out:

✵ gastric emptying and lavage in cases of oral ingestion of drugs, as well as in opioid poisoning regardless of the route of administration;

✵ relief of psychomotor agitation by administration of 2–4 ml of a 0.5% diazepam solution;

✵ management of respiratory disorders: restoration of airway patency, use of respiratory stimulants (lobeline, mesaton), and mechanical ventilation;

✵ management of cerebral edema: administration of Lasix, glucocorticoids, and magnesium sulfate;

✵ in cases of dehydration, rehydration therapy (15% glucose solution, rheopolyglucukin) is administered; for hypertensive syndrome, fast-acting antihypertensive agents are used; for vascular insufficiency, plasma-substituting therapy, and in severe cases, glucocorticoids (25–50 mg of prednisolone). Noradrenaline and mesaton are used only after correcting circulating blood volume deficits;

✵ for hyperthermic syndrome, antipyretics (aspirin, paracetamol, lytic mixtures) are employed.

Virtually all forms of Drug Addiction and substance abuse require the radical and complete cessation of the substance causing the dependence (only in barbiturate abuse is the drug withdrawn gradually [lytic withdrawal] due to the risk of status epilepticus—phenobarbital is prescribed at 0.1 mg twice daily).

In the treatment of withdrawal syndrome, detoxification therapy is performed to eliminate the drug from the body, and vitamin supplements are prescribed.

To correct mental disorders, the following are used: for depressive states, amitriptyline; for dysphoric symptoms, carbamazepine, neuleptil, sonapax; for acute fear and anxiety, diazepam, chlordiazepoxide; for sleep disturbances, nitrazepam, levomepromazine at bedtime.

Autonomic disorders are eliminated using central alpha-blockers—pirroxan at 15–30 mg 2–3 times a day, anticholinergics, and tranquilizers. In recent years, clonidine (clophelin) has been used to treat opioid withdrawal syndrome. In the post-withdrawal period, nonspecific general tonics are employed.

Suppression of drug craving is the most pressing challenge in the treatment of addictions. Such an effect (not always persistent) is observed with conditioned reflex and aversion therapies, in which patients develop a conditioned reflex response in the form of vomiting and other unpleasant experiences at the sight or smell of a psychoactive substance, or a corresponding fear is induced through "coding" Methods.

However, the main therapeutic and rehabilitation method should be the Study of the patient's problems that drive them to drug use, and finding ways to resolve them. Psychotherapy plays a major role in this approach. Through it, the patient's anosognosia is overcome, the sources of internal tension and conflict are identified, and ways to resolve them are sought. A necessary condition for successful treatment is the patient's acknowledgment of the illness, the desire to rid themselves of the pathological dependence, and the establishment of a trusting relationship between doctor and patient.

EXPERT ASSESSMENT.

A Conclusion regarding drug intoxication based solely on clinical manifestations can only be preliminary. Confirmation via biochemical analysis of blood, urine, and saliva for the presence of the narcotic substance is required.

Medical and Occupational Expertise. In drug addictions and substance abuse at the stage of pronounced encephalopathy accompanied by disabling chronic somatic diseases, the assessment of working capacity should be based on the severity of these conditions. The presence of these ailments does not preclude the assignment of disability, but individuals abusing psychoactive substances must not be permitted to drive vehicles.

Military Medical Expertise. Drug addiction and substance abuse are not grounds for exemption from military service. However, in the presence of sharply pronounced corresponding chronic mental changes, and even more so of dementia of the same origin, a conclusion of unfitness for military service with removal from military registration is made.

Forensic Psychiatric Expertise. Patients with drug addiction and substance abuse are recognized as legally insane (not accountable) only in cases where the incriminated acts were committed in a state of psychosis, meaning they were unable to control and comprehend their actions. In such cases, the forensic psychiatric examination must conclude on the necessity of compulsory treatment. Most often, criminal offenses are related to the acquisition of drugs (theft, fraud involving forged prescriptions, clandestine drug manufacturing, etc.). All these crimes are committed in a capable and sane state.

CONTROL QUESTIONS.

1. Structure/97.html">Definitions of The concepts of drug addiction and substance abuse.

2. Cytology/cytology/25.html">General characteristics and Classification of psychoactive substances.

3. Syndromology of addictions. Withdrawal syndrome.

4. Clinical picture and course features of opioid addiction.

5. Clinical picture and course features of cannabis (hashish) addiction.

6. Clinical picture and course features of pervitin addiction.

7. Clinical picture and Specific features of cocaine addiction.

8. Clinical picture and specific features of depressant-induced substance use disorders.

9. Clinical picture and specific features of hallucinogen-induced substance use disorders.

10. Substance abuse and its clinical characteristics.

11. Treatment methods for drug addiction and substance abuse.

12. Prevention of drug addiction and substance abuse, and forensic/medical evaluation issues.