Nicotine, Alcohol & Drug Abuse - October 2024 PDF

Professor ; Muhammad Saeed. Professor Of Internal Medicine And Gastroenterology Head Of Internal Medicine Department Professor Muhammad Saeed 1 1) Nicotine And Tobacco Professor Muhammad Saeed 2  Every year, more than 480,000 Americans die because of...

Professor ; Muhammad Saeed. Professor Of Internal Medicine And Gastroenterology Head Of Internal Medicine Department Professor Muhammad Saeed 1 1) Nicotine And Tobacco Professor Muhammad Saeed 2  Every year, more than 480,000 Americans die because of smoking tobacco – that’s nearly one in every five deaths. Tobacco has caused more deaths in the US than all the American wars combined. According to a CDC fact sheet, more deaths are caused by tobacco every single year than combined deaths caused by illicit drug abuse, alcohol use, HIV, road accidents, and gunshots. According to cancer.org, more than 6 million people die around the globe annually, with 30% dying from cancer and other diseases caused because of smoking side effects. Professor Muhammad Saeed 3 Professor Muhammad Saeed 4 Global Prevalence Of Smoking Professor Muhammad Saeed 5  Cigarette smoking is the most common (>90%) method of tobacco use, although other forms of tobacco use, including pipe tobacco, cigars, and smokeless tobacco, are common. Nicotine is the active ingredient in tobacco. Cigarette smoking is the most preventable cause of morbidity and mortality in the Western world. In the United States, approximately 20% of the general population currently uses tobacco compared with 47% in 1965. Since the release of the U.S. Surgeon General’s report in 1965, smoking prevalence has been substantially reduced Professor Muhammad Saeed 6 Professor Muhammad Saeed 7 Professor Muhammad Saeed 8 Professor Muhammad Saeed 9 Professor Muhammad Saeed 10  Tobacco smoking is increasing rapidly throughout the developing world, and it is estimated that cigarette smoking will cause about 450 million deaths worldwide in the next 50 years. In particular, the onset of smoking occurs at a younger age, the rates of smoking in women are increasing, and more smokers are of a lower socioeconomic status. Reducing smoking prevalence by 50% would prevent 20 to 30 million premature deaths in the first quarter of this century and 150 million in the second quarter. Professor Muhammad Saeed 11 What does the cigarette contain? Professor Muhammad Saeed 12 Harmful Constituents Of Tobacco Professor Muhammad Saeed 13  Tobacco smoke is an aerosol of droplets (particulates) containing water, nicotine and other alkaloids, and tar. Tobacco smoke contains several thousand different chemicals, many of which may contribute to human disease. Major toxic chemicals in the PARTICULATE PHASE of tobacco include nicotine, benzo(a)pyrene and other polycyclic hydrocarbons, N′-nitrosonornicotine, β-naphthylamine, polonium 210, nickel, cadmium, arsenic, and lead. The GASEOUS PHASE contains carbon monoxide, acetaldehyde, acetone, methanol, nitrogen oxides, hydrogen cyanide, acrolein, ammonia, benzene, formaldehyde, nitrosamines, and vinyl chloride. Professor Muhammad Saeed 14 Professor Muhammad Saeed 15 Professor Muhammad Saeed 16 Is It Only Cigarettes? Professor Muhammad Saeed 17 Shisha Professor Muhammad Saeed 18 Professor Muhammad Saeed 19 Professor Muhammad Saeed 20 Professor Muhammad Saeed 21 Harmful Effects Of Smoking Professor Muhammad Saeed 22  CANCER Lungs- larynx-oral cavity-esophagus-pancreas. CARDIOVASCULAR DISEASE Sudden death - Acute myocardial infarction - Unstable angina Stroke Peripheral arterial occlusive disease (including thromboangiitis obliterans) - Aortic aneurysm PULMONARY DISEASE Lung cancer - Chronic bronchitis - Emphysema - Asthma Increased susceptibility to pneumonia Increased susceptibility to pulmonary tuberculosis and desquamative interstitial pneumonitis Increased morbidity from viral respiratory infection GASTROINTESTINAL DISEASE Peptic ulcer - Gastroesophageal reflux Crohn's disease REPRODUCTIVE DISTURBANCES Reduced fertility - Premature birth - Lower birth weight - Spontaneous abortion Premature rupture of membranes -Increased perinatal mortality ORAL DISEASE Oral cancer - Leukoplakia - Gingivitis - Gingival recession - Tooth staining OTHER Type 2 diabetes mellitus Earlier menopause Osteoporosis Cataract Professor Muhammad Saeed 23  The Diagnostic and Statistical Manual, 5th edition (DSM-5), which was released in 2013 by the American Psychiatric Association, has changed the diagnostic terminology for nicotine and tobacco, eliminating the term dependence and instead using the term Tobacco Use Disorder. Tobacco use disorder is established clinically by historical documentation of 2 of the following criteria: Professor Muhammad Saeed 24  Tobacco often taken in larger amounts or over a longer period than was intended. Persistent desire or unsuccessful efforts to cut down or control tobacco use. A great deal of time spent in activities necessary to obtain or use tobacco. Presence of craving, or a strong desire or urge to use tobacco. Recurrent tobacco use resulting in failure to fulfill major obligations at work, school, or home. Continued tobacco use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco. Professor Muhammad Saeed 25  Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking in bed) Continued tobacco use despite persistent or recurrent physical or psychological problems that are caused or exacerbated by tobacco use Tolerance, as defined by either a need for markedly increased amounts of tobacco to achieve desired effects, or markedly diminished effects with continued use of the same amount of tobacco Withdrawal, manifested by the presence of the characteristic tobacco abstinence syndrome (e.g., four of the following: irritability, anxiety, difficulty concentrating, increased appetite, restlessness, dysphoric mood, insomnia), or tobacco (or nicotine) taken to relieve or avoid tobacco withdrawal symptoms. Professor Muhammad Saeed 26  Therapy includes behavioral modification and drugs. Currently, three medications have been approved for smoking cessation: Nicotine, Bupropion, And Varenicline. All types of smoking cessation medications, if used properly, double smoking cessation rates compared with placebo treatments. Professor Muhammad Saeed 27 2) Alcohol Abuse And Dependence Professor Muhammad Saeed 28  A variety of terms have been used to describe the spectrum of Medical, Psychological, Behavioral, And Social Problems associated with excessive consumption of alcohol (alcohol problems). Alcoholism is perhaps the most widely used term to describe patients with alcohol problems Professor Muhammad Saeed 29  Abstainers are individuals who consume no alcohol. Moderate Drinking is defined by the National Institute on Alcohol Abuse and Alcoholism as the average number of drinks consumed daily that places an adult at low risk for alcohol problems. At-risk Drinking is a level of alcohol consumption that imparts health risks. Professor Muhammad Saeed 30 Terms And Criteria For Patterns Of Alcohol Use Professor Muhammad Saeed 31 Professor Muhammad Saeed 32 Professor Muhammad Saeed 33 Pathobiology Professor Muhammad Saeed 34  Beverage alcohol contains ETHANOL, which acts as a sedative- hypnotic drug. Alcohol is absorbed rapidly into the blood stream from the stomach and intestinal tract. Alcohol is metabolized mainly in the cytosol by alcohol dehydrogenase (ADH) to produce ACETALDEHYDE. Acetaldehyde is further metabolized to acetate in the mitochondria. Alcohol metabolism results in the formation of NADH and thus changes the redox state of hepatocytes (i.e., increases the ratio of NADH/NAD+). The end result is formation of REACTIVE OXYGEN SPECIES (ROS). Professor Muhammad Saeed 35  Although the BRAIN is the primary target of alcohol's actions, a variety of other tissues have a major role in how alcohol affects the human body. DIRECT LIVER TOXICITY may be among the most important consequences of acute and chronic alcohol use. Alcohol also has substantial negative effects on the heart and CARDIOVASCULAR SYSTEM. Direct toxicity to myocardial cells frequently results in heart failure , and chronic heavy alcohol consumption is considered to be a major contributor to hypertension. Professor Muhammad Saeed 36  Other organ systems that experience significant direct toxicity from alcohol include the Gastrointestinal Tract (esophagus, stomach), Immune System (bone marrow, immune cell function), and Endocrine System (pancreas, gonads). Professor Muhammad Saeed 37 Professor Muhammad Saeed 38 Professor Muhammad Saeed 39  Alcohol has a variety of specific acute and chronic effects. The acute effects seen most commonly are alcohol Intoxication And Alcohol Withdrawal. Chronic clinical effects of alcohol include almost every organ system. Professor Muhammad Saeed 40  Intoxication Acute Alcohol Withdrawal Effects Various Body Chronic Systems Professor Muhammad Saeed 41 Alcohol Intoxication Professor Muhammad Saeed 42  After entering the blood stream, alcohol rapidly passes through the blood-brain barrier. The clinical manifestations of alcohol intoxication are related directly to the blood level of alcohol. Because of tolerance, individuals chronically exposed to alcohol generally experience less severe effects at a given blood alcohol level than do individuals who are not chronically exposed to alcohol. The symptoms of mild alcohol intoxication in nontolerant individuals typically occur at blood alcohol levels of 20 to 100 mg/dL and include euphoria, mild muscle incoordination, and mild cognitive impairment. Professor Muhammad Saeed 43  At higher blood alcohol levels (100 to 200 mg/dL), more substantial neurologic dysfunction occurs, including more severe mental impairment, ataxia, and prolonged reaction time. Individuals with blood alcohol levels in these ranges can be obviously intoxicated with slurred speech and lack of coordination. Professor Muhammad Saeed 44  Alcohol withdrawal can occur when individuals decrease their alcohol use or stop using alcohol altogether. The severity of symptoms can vary greatly. Many individuals experience alcohol withdrawal without seeking medical attention, whereas others require hospitalization for severe illness. Professor Muhammad Saeed 45 Chronic Toxic Effects Of Alcohol Professor Muhammad Saeed 46  SYSTEM COMPLICATIONS Nervous system Intoxication- Withdrawal Cognitive impairment- Cerebellar degeneration Peripheral neuropathy Cardiovascular system Cardiac arrhythmias-Chronic cardiomyopathy Hypertension Liver Fatty liver Alcoholic hepatitis Cirrhosis Gastrointestinal tract, esophagus Chronic inflammation-Malignant neoplasms Mallory-Weiss tears-Esophageal varices Stomach Gastritis Peptic ulcer disease Pancreas Acute pancreatitis Chronic pancreatitis Other medical problems Cancers: mouth, oropharynx, esophagus, colorectal, breast, hepatocellular carcinoma Pneumonia-Tuberculosis Psychiatric Depression-Anxiety-Suicide Behavioral and psychosocial Injuries-Violence-Crime Child or partner abuse Tobacco, other drug abuse Unemployment-Legal problems Professor Muhammad Saeed 47 Professor Muhammad Saeed 48 3) Drug Abuse ,Dependence and addiction Professor Muhammad Saeed 49  What is Addiction Addiction is not limited to drugs and alcohol. People can be addicted to many things, such as food, gambling, shopping, or most anything that gets in the way of a healthy lifestyle. When things get out of hand, and People Behave Compulsively, Regardless Of The Consequences. The addiction can take over a person’s entire life. Nothing else matters. Professor Muhammad Saeed 50 Professor Muhammad Saeed 51 Professor Muhammad Saeed 52  Dangers Professor Muhammad Saeed 53  Drug addiction and abuse costs the country a great deal of money. This is related to lost job wages, healthcare costs, crime, traffic accidents and associated costs of the criminal justice system. Drug addiction and abuse can be linked to at least ½ of all major crimes committed in Egypt. In USA, 100 people die every day from drug overdoses. This rate has tripled in the past 20 years. 6.8 million people with an addiction have a mental illness. Over 90% of those with an addiction began drinking, smoking or using illicit drugs before the age of 18. Professor Muhammad Saeed 54 Situation in Egypt Professor Muhammad Saeed 55 Professor Muhammad Saeed 56  The geographical positioning of Egypt has contributed to the nation's growing drug issue. Egypt is considered a main transit country for the most important drugs in the world, as it lies between the Mediterranean Sea, the Red Sea and the Suez Canal. Egypt is therefore in the middle of the world’s main routes for drug trafficking. Professor Muhammad Saeed 57  Opiates and heroin comes through Egypt from Afghanistan to supply the European market. Amphetamines produced in Eastern Europe travels via Egypt to the region and on to South Asia. Additionally, opiates and cannabis are grown in areas in the Sinai Peninsula and Upper Egypt, with most being locally consumed. Professor Muhammad Saeed 58  Estimates on how many people are addicted to opiates, cannabis, amphetamine-type stimulants or heroin vary greatly, but range between 600,000 and 800,000, according to a 2007 study. The slums of Cairo and Giza are hotbeds of addiction. These slums are among the largest in the world, and are home to hundreds of thousands of street children. More than 12 percent of Egyptian students are dependent on drugs. Professor Muhammad Saeed 59  A 2007 report stated that 8.5 percent of Egyptians - or six million people - are addicted to drugs. The majority of them are between 15 and 25 years of age. Rising rates of unemployment are said to contribute to increases in addiction. Professor Muhammad Saeed 60  Substance abuse treatment falls within the province of Psychiatrists. In Egypt, a Small Handful Are Trained to specialize in addiction recovery. So most cases are treated by general psychiatrists without special education or experience. The number of inpatient beds assigned to addiction treatment is only about 600, about half administered by the government and the other half by non- governmental agencies or the private sector. Professor Muhammad Saeed 61  Heroin is often blamed for many of society's ills, however, many addicts prefer to rely on highly addictive mind-bending legal drugs instead. A recent report from local agency found the deadly drugs including Xanax and Tramadol are on sale at seemingly reputable pharmacies in Cairo for the small sum of 8 LE, as written on the box and without a prescription. Youth and teenagers, starting from as young as twelve, are the age group most affected by addiction in Egypt. Professor Muhammad Saeed 62  The results are clear; Egypt has a drug problem and experts believe that the problem is now out of control. Professor Muhammad Saeed 63  Alcohol ,Marijuana ,PCP, LSD and other hallucinogens. Inhalants such as, paint thinners and glue. Opioid pain killers, such as codeine and oxycodone. Heroin. Sedatives, hypnotics and Anxiolytics. Cocaine. Methamphetamine and other stimulants. Tobacco. New addicting medications: Xanax, Tramadol. Professor Muhammad Saeed 64  Definitions Professor Muhammad Saeed 65  The term Substance Use Disorder has replaced substance abuse and dependence. A substance use disorder is a clinical syndrome characterized by the following statement from the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: “The essential feature of a substance use disorder is a Cluster Of Cognitive, Behavioral, And Physiological Symptoms Indicating That The Individual Continues Using The Substance Despite Significant Substance-related Problems. Professor Muhammad Saeed 66  The syndrome is a series of 11 symptoms, of which the individual needs to meet two or more in the same 12-month period to warrant a diagnosis of a substance use disorder: Professor Muhammad Saeed 67  CRITERIA FOR SUBSTANCE USE DISORDERS IMPAIRED CONTROL 1. Took larger amounts/for longer period of time than intended. 2. Persistent desire or unsuccessful attempts to stop or reduce use. 3. Much time spent using a substance or recovering from its effects. 4. Craving. SOCIAL IMPAIRMENT 5. Failure to fulfill home, work, or school obligations because of repeated substance use. 6. Continued use despite experiencing interpersonal problems. 7. Reducing/giving up important social, recreational, or occupational activities. RISKY USE 8. Recurrent use in hazardous situations. 9. Physical/psychological problems related to use. PHARMACOLOGICAL CRITERIA 10. Tolerance, when relevant* 11. Physical dependence, when relevant* Professor Muhammad Saeed 68 Major Drugs Of Abuse Professor Muhammad Saeed 69  Opioids can be divided into four categories: 1) Natural Opium Alkaloids, including opium, morphine, and codeine; 2) Semisynthetic Derivatives Of Morphine, including heroin and oxycodone; 3) Synthetic Opioids that are not derived from morphine, including methadone and meperidine; and 4) opioid containing preparations, such as elixir of terpin hydrate. Professor Muhammad Saeed 70 Professor Muhammad Saeed 71  Opioids work by binding to specific opioid receptors and then exerting their activity. Most of the commonly abused opioids bind as agonists to the μ-receptor and typically produce the effects most commonly associated with opioids: Miosis, Respiratory Depression, Analgesia, Euphoria, And Drowsiness. Opioids that bind to the κ-receptor, unlike μ-receptor agonists, often produce Dysphoria Rather Than Euphoria. Professor Muhammad Saeed 72  Physical dependence on opioids leads to a characteristic withdrawal syndrome, the key signs of which include elevated heart rate and blood pressure, mydriasis, abdominal cramps, sweating, rhinorrhea, lacrimation, and gastrointestinal distress, particularly diarrhea, nausea, and vomiting. Professor Muhammad Saeed 73  Common medical problems among heroin users include Hepatitis B, Hepatitis C, Infective Endocarditis, Talc Granulomatosis, HIV Infection, Cellulitis, And Abscesses, all typically related to needle use. An important noninfectious complication that has been reported with opioid use disorders is alteration of the cardiac conduction system, with a Prolongation Of The QT Interval; this can lead to potentially serious arrhythmias, including torsades de pointes. Professor Muhammad Saeed 74 Central Nervous System Stimulants: Cocaine And Amphetamines Professor Muhammad Saeed 75  The two most important central nervous system stimulants, Cocaine And Amphetamine (including methamphetamine5), are derived from different sources; cocaine is extracted from coca leaves, whereas amphetamine is a synthetic compound. However, both induce similar psychoactive activity when they are taken illicitly and can produce similar adverse consequences. Professor Muhammad Saeed 76  Cocaine can be used Intranasally, By Intravenous Injection, Or By Smoking. Adding an alkaline compound such as baking soda to an aqueous solution of cocaine hydrochloride produces a rocklike compound known as crack, which can be smoked. Smoking cocaine produces the most rapid onset of intoxication (6 to 10 seconds) and the shortest period of drug effect (10 to 15 minutes). Professor Muhammad Saeed 77  Both cocaine and amphetamines reliably produce euphoria, wakefulness, a sense of initiative, increased self-confidence (sometimes to the point of grandiosity), and, in some instances, sexual stimulation. With higher doses, users may feel “wired,” a syndrome characterized by anxiety, irritability, and perhaps paranoia. Withdrawal from either of these agents leads to opposite effects from those of intoxication: increased appetite, hypersomnia, and depression, which can occasionally be serious. Professor Muhammad Saeed 78 Professor Muhammad Saeed 79  Medical complications related to cocaine use are related to a combination of cocaine’s stimulant activity (increased heart rate and blood pressure) and its vasoconstrictor properties. Local complications that result from the drug’s vasoconstrictor activity include ulcerations of the nasal mucosa, perforation of the nasal septum, and decreased pulmonary diffusion capacity. Systemic complications include myocardial infarction, intracranial hemorrhage, grand mal seizures (as a result of intoxication, not withdrawal), and ventricular tachyarrhythmias, which may be responsible for sudden death. Professor Muhammad Saeed 80 Sedative-hypnotic And Anxiolytic Drugs Professor Muhammad Saeed 81  Benzodiazepines and other sedative-hypnotic and anxiolytic medications such as barbiturates and zolpidem are frequently prescribed for the treatment of anxiety and sleep difficulties. Although different classifications of these drugs have very different chemical structures, they are grouped together according to their therapeutic applications. Most of these drugs act at the γ-aminobutyric acid type A receptor and can cause physical dependence. Professor Muhammad Saeed 82  Because the benzodiazepines are far and away the most commonly prescribed sedative-hypnotics, they are also the most widely abused. There are two major patterns of benzodiazepine abuse. Many people who ultimately abuse these medications have initially received a legitimate benzodiazepine prescription for the treatment of anxiety or insomnia. However, a combination of tolerance and decreased effectiveness of the agent over time may lead some people to increase the dose on their own. In such circumstances, attempts by the physician to taper the person off of the medication can be very difficult. Professor Muhammad Saeed 83  Marijuana Professor Muhammad Saeed 84  Marijuana, which refers to the dried leaves and flowers of the plant Cannabis sativa, has been used for its psychoactive and medicinal properties for centuries. The major psychoactive substance in marijuana is Δ9-tetrahydrocannabinol (THC). Professor Muhammad Saeed 85 Professor Muhammad Saeed 86  Marijuana and other cannabinoids such as hashish (dried cannabis resin) exert their effects by binding to the cannabinoid receptors, of which two are currently known. Binding to the CB1 receptor, which is located primarily in the brain, appears to be responsible for the psychoactive effects of THC, whereas the CB2 receptor may be associated with immune system responses. Professor Muhammad Saeed 87 Professor Muhammad Saeed 88  When marijuana is smoked, its psychoactive effects occur almost immediately, with peak intensity approximately 30 minutes later; effects tend to disappear within 3 hours. Oral administration of marijuana leads to a delayed onset of action, but the effects of the drug persist for a longer time. Physiologic effects of marijuana intoxication include increased heart rate and conjunctival injection. Psychological effects include a sense of euphoria and well- being, friendliness, increased appetite, a distorted sense of time. Professor Muhammad Saeed 89 Professor Muhammad Saeed 90 Best Wishes Professor Muhammad Saeed 91