Foundation of Addiction Medicine 2019

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Foundation of Addiction Management ECHO
2019

The materials are contributed by faculty and staffs of Centre for Addiction Medicine as well as NIMHANS Digital Academy.
Compiled by Ms Karishma and Mr Aurobind, NIMHANS Digital Academy

Please acknowledge Virtual Knowledge Network, Centre for Addiction Medicine NIMHANS
(web link) Feed back: [email protected]

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Table of Content

1. Addiction: an Overview
Prof. Pratima Murthy ……………………………………………………………………………………..……….. 06

2. Types of emerging addictive drugs/non-drug
Dr. Dipthadhi ………………………………………………………………………………………….….…..…….... 44

3. Assessments specific to Addiction Rating scales: AUDIT/ASSIST/ASRS
Dr Narasimha ……………………………………………………………………………………….….…...……….. 97

4. Understanding Addiction: Neurobiology
Prof. Vivek Benegal ………………………………………………………………………….….……..…….……..113

5. Is addiction heritable?
Dr. Bharath Holla ………………………………………………………………………….…….….….….…….…. 168

6. Urine Screening for clinical practice
Mrs. Shravanthi Daphinet …………………………………………………………….…….……..….………... 205

7. Vulnerability : Why some get addicted and majority NOT!
Dr Arun Kandasamy ……………………………………………………………………….……….….………….. 258

8. Role of Psychosocial factors in substance abuse
Ms Karishma Khan ……………………………………………………………………..………….…….………… 294

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Table of Content

9. Alcohol and its Physiological effects
Dr. Sumit Kumar Durugoji ……………………………………………………………………………………………. 325

10. Use -Abuse -Addiction Screening, Brief Intervention & Referral to Treatment (SBIRT)
Dr Prabhat ……………………………………………………………………………………………………….………… 352

11. Managing Alcohol Withdrawal: Simple
Dr Deepak G …………………………………………………………………………………………………..…………… 389

12. Managing Alcohol Withdrawal: Complicated
Dr Jaikrishnan ……………………………………………………………………………………………………………. 421

13. Alcohol Liver disease
Dr. Sagar ………………………………………………………………………………………………………..…………. 442

14. Prescribing Anticraving agents I (approved):Disulfiram, Acamprosate and Naltrexone
Dr Pawan ………………………………………………………………………………………………………………..… 473

15. Prescribing Anticraving agent II (off-label):
Baclofen, Topiramate, Gabapentin and Varenicline
Dr Shabina Sheth …………………………………………………………………………………………….……….… 517

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Table of Content

16. Psychosocial intervention in Alcohol use Disorder - Increasing Motivation 1
Ms Sandeepa ………………………………………………………………………………………………………….. 549

17. Psychosocial intervention in Alcohol use Disorder - Increasing Motivation II
Ms Shikha ………………………………………………………………………………………………………………. 573

18. Psychosocial intervention in Alcohol use Disorder - Relapse Prevention
Dr E. Sinu ……………………………………………………………………………………………………………….. 611

19. Psychosocial intervention in Alcohol use Disorder - Cognitive Behavior Therapy
Dr Seema …………………………………………………………………………………………………………….…. 640

20. Psychosocial intervention in Alcohol use Disorder - 12 step facilitation
Ms Karishma ……………………………………………………………………………………………….…….…… 666
.

21. Alternate and Complementary Therapy for Substance use disorders
(Evidence for Yoga and Mindfulness)
Dr Geetha L …………………………………………………………………………………………….………….…. 702

22. Effective Family therapy
Ms Shilpa ………………………………………………………………………………………………………….…… 735

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An introduction to addiction

Pratima Murthy
Professor of Psychiatry
Centre for Addiction Medicine
NIMHANS, Bangalore

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Tobacco, other drugs and
addictive behaviours

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What are ‘substances’?

• LEGAL • ILLEGAL

– Tobacco – Cannabis (ganja, charas,
– Alcohol marijuana
– Prescription medicines
– Opioids (heroin or brown
• Sleeping tablets sugar, opium, synthetic
(benzodiazepines) opioids

• Cough syrup (containing – Stimulants (amphetamines,
codeine) cocaine)

• Prescription pain killers – Hallucinogens (LSD,
(containing opioids) Ecstacy)

• Antihistamines – Inhalants (whitener, petrol)
• Other psychotropic

medicines

1. They are used because of their mind altering properties 8
2. The patterns of use of many substances change over time
3. The majority of public health problems occur from legal

substances!!!

Substance Use Patterns

Patterns of Use Impact (on individual, family, work
and society)
• Experimental Use
• Recreational Use • Health
• Intoxication • Intoxication
• High risk or Hazardous • Crime
• Violence
use • Injury
• Harmful Use • Emotional problems to
• Addiction or
family members
Dependence • Problems at workplace

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Substance misuse as a growing
problem

• Alcohol and drug use contribute substantially
to the global burden of disease, not only
through substance use disorders but also from
other disease consequences resulting from
use.

Estimated cases Age-standardised prevalence/100000 (2016)

Alcohol 100·4 million 1320.8
dependence 289.7
353.0
Cannabis 22.1 million
dependence

Opioid dependence 26.8 million

Degenhardt et al 201810

World Drug Report 2018

• 275 million people worldwide, which is roughly 5.6 per
cent of the global population aged 15-64 years, used
drugs at least once during 2016.

• Some 31 million of people who use drugs suffer from
drug use disorders

• Roughly 450,000 people died as a result of drug use in
2015, according to WHO. Of those deaths, 167,750
were directly associated with drug use disorders
(mainly overdoses).

• The rest were indirectly attributable to drug use and
included deaths related to HIV and hepatitis C
acquired through unsafe injecting practices.

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Alcohol use prevalence in India

NHSDA 2004 12

Substance use disorder (NMHS 2015-16)

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Higher levels of use

• Poverty
• Illiteracy
• Certain employment sectors
• Unemployed Youth
• Vulnerable sections of society
• Cohort effect

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IDU estimates-NACO

• A mapping exercise carried out by NACO (2010) estimates
the total median number of IDUs at 177 000. Whereas
heroin injecting is prevalent in certain parts of the country
such as Manipur, pharmaceutical injecting is widespread
across the country.

• Pharmaceutical drugs are often used in combination by
IDUs and the popular ‘cocktails’ contain synthetic opioids
(e.g., buprenorphine injection), benzodiazepines (e.g.,
diazepam), and antihistamines such as promethazine or
pheniramine maleate.

• In the North-East, injecting of dextropropoxyphene (spasmo
proxyvon/proxyvon) is not uncommon.

• This has also spread to other parts of the country

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Growing population of women
affected by drugs

In India, while there were only case reports of women who injected drugs in the
1980’s, in the last two decades, rapid assessment and purposive surveys indicate a
growing population of women who use drugs, as well as inject drugs throughout the
country. Women partners of men who inject drugs receive inadequate attention.

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Emerging patterns among women
using drugs

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US – In 2010, 6.8% Germany : 15-25 per cent of the Russian Federation – 10 times
females and 11.2% males “hard-core” substance users women increase in addiction among women
reported current illicit EU- rates of pharmaceutical abuse Afghanistan – increasing use of
drug use higher among women opiates and pharmaceuticals among
Hardly any gender differences refugee women
between teenage girls and boys in Iran -6% of drug users are women
rates of cannabis use
UK-5.4% of women reported using China-increasing number of
drugs in 2009/10; 21% girls reported women using substances; report
ever using drugs in 2009 of sex for drugs among
women-opiates most common

Kenya- one heroin using Research reports indicate that women

women for every 20 are currently using drugs in Bangladesh,

males; many work in the China, India, Indonesia, Japan, Malaysia,

Brazil: a higher proportion of females sex industry Nepal, Pakistan, Philippines, Sri Lanka,
than males initiated cocaine use in a
study in Sao Paulo South Africa – growing Taiwan, Thailand and Vietnam, while
Chile- alcohol use increased among
adolescent females compared to males methamphetamine use there are likely many undocumented
Higher rates of cocaine dependence
reported among females than males among women, including cases in other Asian nations
(though lifetime use and recent use
more among males) pregnant women

Australia: 37.4 per cent of male and 37.9 per cent of
female 14-19 year olds report ever using an illicit
substance. Female rates of ever injecting a
substance in this group exceed those of males (1.7
per cent versus 1.0 per cent).

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Foetal Alcohol Syndrome

Raghavendra, Murthy et al

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Common factors associated with
adolescent drug use

Availability,
Accessibility,
acceptability of drug
use lack of
alternatives

Peer influence,
influence of

popular media,
poor life skills

Temperament
and coping, life

events

Family history
(genetic

vulnerability,
modelling)

Family support
(composition, drug

use, monitoring)

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Mental health morbidity and lifetime
substance use in prison

Badamath, Murthy et al 222010

Substance use in the Elderly a

growing problem 23

Consequences

Mortality Injuries

Total deaths attributable RTA- one in four
to alcohol unclear
Traumatic brain
10% of all deaths & 15 to injuries-one in three
20% of premature
mortality attributable to Emergency room- nearly 2
alcohol (Gururaj 2006) out of 3

(Gururaj et al 2004,
Benegal, Gururaj,
Murthy et al 2001)

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Consequences-studies from home and

farther afield

• Neuropsychiatric • Cancer
problems, particularly • Cirrhosis
seizures • Stroke
• Coronary artery disease
• Alcohol and high risk • Hypertension
behaviour • Dyslipidaemia
• Community related harm
• Suicide • Domestic violence
• Socio-economic costs
• Socio-economic losses

• Gender

• Foetal alcohol syndrome

• Psychiatric co-morbidity

Benegal et al 2001, 2004, Bonu et al 2004, Chandra et al 2003, Gururaj et al 2004, 2006,

Murthy et al 2008, 2010, Naik et al 2011, Nagaraja et al 2005, Narawane et al 1998,
Shanmugaiah et al 2001, Satyanarayana et al 2010, Vaswani et al 1997, Vohra et al 20032.5

Health

• All substances - Injuries, nutritional problems,
HIV and STI risk behaviours, CVD, cancers,
neuropsychiatric complications, liver disease,
mortality, suicides

• Alcohol – known to cause more than 60
disease conditions

• Tobacco – contains 4000 chemicals including
43 cancer causing chemicals

• Injecting drug use – infection, STIs, cardiac
complications

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Public health aspects

• Multiple public health problems
have a direct or indirect
association with alcohol and
other substances

• Health, economic and social
burden from the use of
substances

• Low rates of detection
• More than a 10 year delay in help

seeking for alcohol related
problems
• Policies and stigmatising
attitudes deter help-seeking
• Inadequate treatment services

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Addiction- a brain disease

Addiction is not simply a failure of will or
lack of strength of character, but occurs due
to changes in the brain
It is a chronic relapsing condition, similar to
hypertension and diabetes
Affected persons need to be educated,
supported, treated and followed-up

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Principles of prevention and
intervention

The ILO Traffic Light • Red zone (Addiction)
–intensive care and
support

• Amber zone- educate
and motivate and focus
on self-change

• Green zone-keep the
greens green. Healthy
lifestyles

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1. Principles of prevention

Enhance protective Should address all Messages should be
factors and reduce forms of drug abuse tailored to audience
characteristics (age,
risk factors (licit/illicit,
prescription drugs, background,
any substance with location)

abuse potential)

In order to be effective, preventive efforts should be long-term and
repeated (NIDA 2003)

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Addressing risks and protective factors

NIDA 2003 31

INTERRELATIONSHIP BETWEEN TOBACCO & OTHER RISK FACTORS and NCDs

DIABETES CANCER COMMON
MENTAL
HEALTH
DISORDER

CARDIOVASCULAR STROKE
DISEASES

TOBACCO

STRESS UNHEALTHY
ALCOHOL DIET

PHYSICAL 32
INACTIVITY

x

Pratima Murthy

Professor of Psychiatry

Centre for Addiction Medicine

NIMHANS

Bangalore 33

Slide courtesy: Dr Alok Sarin

“Caregivers express-we are losing our

love ones to Technology- “Need help”

• Kids 4-5 years handling mobile phones
• Kids facebooking by age 11
• One in twenty kids between 18-25 addicted to

social media
• 8% reported problematic internet use (Manoj

Kumar et al 2011, 2012).

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Buzzfield.com 35

Five ‘schools’ of thought

1) Addictive disorder
2) Impulsive - Compulsive spectrum disorder
3) Reshaping of “established” psychiatric disorders and

phenomena (anxiety, depression, OCD, ADHD, ASPD)
4) Combination of all above (continuum vs categorical)
5) It is not a ‘disorder’ at all but rather a sociocultural

phenomenon that should not be ‘medicalised’ at all

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Broad approaches

• Overdose/Intoxication/Excessive use
• Withdrawal
• Relapse Prevention
• Harm minimization
• Approach as a chronic relapsing disorder
• Pharmacotherapeutic approaches
• Psychosocial approaches

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Interventions to address the huge
treatment gap

• Brief interventions
• Outpatient and inpatient treatment
• Emergency room management
• Integrated medical and psycho-social

management
• Follow-up and aftercare
• Mobilising community support
• Community resource networking (health, welfare,

education, labour, voluntary sector…)
• Preventive policies and comprehensive programs

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All values indicate %

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Need for a shift to public health- led
policy

• Availability
• Politics
• Consumption
• Consequences
• Responses
• Need for a coherent

policy

NIMHANS- Epidemiology and 41
Centre for Addiction Medicine

Policies, laws and regulations

• Address issues of supply and demand
• Be responsive to ground realities

Regular monitoring of on the ground situation
(prevalence of the problem, target groups affected,
causes, consequences, responses, response gap analysis)
• Deterrence of supply violations, restrict use, provide

treatment, respect human rights of users
• Involve other stakeholders – media, local leaders,

religious leaders, key opinion makers,
parliamentarians

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Conclusion

• Substance use a growing global and national
concern

• Divisions between different drugs is artificial and
many use licit and illicit drugs both of which
produce serious problems for individuals, families
and the community

• Programs must take into concern holistically
addressing antecedent factors and consequences of
substance misuse and addiction

• Resources and strategies for both prevention and
intervention, as well as monitoring must be
generated

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Types of emerging
Addictive

drugs/non-drug

Dr Diptadhi Mukherjee
DM Addiction Psychiatry Senior resident

CAM, NIMHANS

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Types of Drugs

Legal provision Mechanism of action

• Licit
✓ Alcohol
✓ Tobacco
• Illicit

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Yet another classification….

• “Classic”/ “Traditional” • Newer psychoactive
drugs substances (NPS)/
“Designer” drugs/
• Like heroin, cocaine, Emerging Drugs
alcohol

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• What do we mean by emerging addictive drugs?

➢ Drugs (with little or no history of medical) discovered to
be used recently with addictive potential used for
recreational purpose

➢ Drugs used for medical purposes for many years back,
but being used for recreational purposes in recent time

➢ Drugs used in specific region of world as traditional use
but has been found to be used by many other parts of
the world

➢ Drugs of addictive potential yet to be included in the
under international control (or included very recently)

• Most of the definitions include epidemiological
characteristics.

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NPS

• Concept of Newer Psychoactive Substances (NPS)
• UNODC started global monitoring of NPS in 2009
• The substances reported by the largest number of
countries and territories include ketamine, khat,
JWH-018, methylone, 4-methylmethcathinone,
25I-NBOMe, 5F-APINACA which were each
reported by at least 47 countries.
• With exception of ketamine and khat, all of those
substances were placed under international control
between 2015 and 2017.

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Cannabis
(Bhang, Charas, Ganja,

Hashish)

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Cannabis products

• Bhang (leaves) Oral
Smoked
• Ganja (dried
flowering stem of the Smoked
plant)
Smoked
• Charas / Hashish
(extracted from the
resin covering the
plant)

• Hashish Oil
(extracting THC using
chemical methods)

-50-