Alcohol and Substance Misuse

The use of alcohol and other recreational drugs use can lead to a variety of problems, ranging from short and long term side effects of use to syndromes of dependence and withdrawal. Drugs can also produce a variety of substance-induced disorders including amnesia, dementia, psychosis, anxiety, depression, mania, insomnia and sexual dysfunction. This entry looks at the mental health issues surrounding alcohol consumption and provides an overview of substance use problems.

Some Definitions

When talking about problems with alcohol and illicit substances, it is useful to use terms that have a specific meaning and criteria attached to them. Intoxication is used to describe the mental and physical state created by drug use, with the precise effects varying according to both the substance and the amount used. Withdrawal refers to the unpleasant state that follows discontinuation of drug use in those who have used it repeatedly, and also varies according to the substance. The word 'addiction' tends to be frowned upon by psychiatrists due to its catch-all nature and widespread use by lay persons; instead, the terms 'abuse' and 'dependence' are used. Substance abuse is used to describe a disruptive relationship with a drug that interferes with an individuals obligations, leads to dangerous behaviour and sparks continual arguments with others. Substance dependence refers to a collection of physical, mental and behavioural changes that indicate that an individual is dependent upon a drug. According to ICD-10¹, a diagnosis of dependence can be made with three or more of the following:

• A strong need to use the substance.
• Difficulty controlling the amount, timing and ending of use.
• Withdrawal symptoms when use is stopped or decreased, or continued use to avoid withdrawal.
• Use of increased amounts of the substance to produce the same effect (tolerance).
• Neglect of other activities in order to spend time obtaining, using or recovering from the substance.
• Persistence in taking substance despite obvious harmful physical or mental effects.

If an individual shows signs of tolerance or withdrawal, they are described as being physiologically dependent on the substance – this can have implications if the drug is suddenly stopped.

Dual Diagnosis

Some individuals, particularly those who are deprived or homeless, may have problems with substance abuse that co-exist with a mental illness. This may well take the form of self-medication in order to alleviate symptoms, and affects a wide range of individuals including those with few other risk factors for drug abuse. This can create a vicious cycle whereby the substance erodes the individual's lifestyle, make their mental illness harder to treat and may even worsen the illness itself, and the individual becomes increasingly reliant upon the substance to treat the symptoms of the illness. Mental illness may also cause downwards social mobility and leave the individual isolated, lacking a daytime activity and living in an area where drug abuse is common, all of which are risk factors for substance abuse.

Alcohol

Being widely and legally used around the world, alcohol features quite highly on the list of problem drugs. The h2g2 entry on The Ill Effects of Chronic Drinking deals with the long term physical consequences of alcohol consumption, and the entry on Alcohol Abuse takes a broad look at the effects of alcohol on individuals and society. This section will therefore deal with alcohol's effect on mental health and the treatment of individuals with alcohol dependence.

Alcohol dependence is a form of dependence as defined above, whereas alcohol abuse refers to the more widespread issue of harmful or 'problem' drinking. Alcohol dependence as a syndrome was first described in 1976 by Edwards and Gross, and includes the following features:

• Awareness of a strong need to drink.
• Development of a stereotyped pattern of drinking that is hard to alter.
• Withdrawal symptoms such as tremor, nausea, sweating, and agitation.
• A need to avoid withdrawal through drinking, often to the point of morning drinking.
• Tolerance of quantities of alcohol that would render normal individuals incapacitated.
• Maintenance of drinking habits at the expense of normal activities.
• Rapid redevelopment of dependence after long periods of abstinence.

Alcohol dependence is treated first by abstaining, thus triggering withdrawal (see below). Maintaining abstinence may be difficult and is helped by appropriate therapy and social support. Groups such as Alcoholics Anonymous may be useful for some, but it is important that the support offered is appropriate to the individual.

Alcohol-Induced Disorders

Alcohol intoxication hardly requires an introduction, but it is important to highlight the way in which symptoms vary depending upon the dose. A little alcohol in the bloodstream can create a sense of well-being, confidence and general control of the situation. This leads to disinhibited behaviour such as excessive talking and inappropriate flirting, but these aren't the sorts of symptoms that keep psychiatrists awake at night². Greater quantities of alcohol can precipitate violent or harassing behaviour in some and depression in others – in vulnerable individuals, a combination can lead to self-harm or suicidal behaviour. This is compounded by signs of cerebellar dysfunction – slurred speech, unsteadiness, nystagmus³ and amnesia are all indicative of excessive alcohol consumption. Beyond these symptoms lies a loss of consciousness, respiratory depression and a risk of coma and death.

Alcohol withdrawal may be less familiar to some, as it only occurs in those who are physiologically dependant upon alcohol. As mentioned above, this dependence can come back quickly in those who have abstained from alcohol for some time, and so the best way to avoid withdrawal is not to drink too heavily in the first place. The withdrawal itself is unpleasantly like being drunk⁴. Sweating, nausea and vomiting, rapid heart rate and high blood pressure, tremors, anxiety, depression, trouble sleeping and a sensitivity to loud noises are just the beginning. Next come a raft of auditory and visual hallucinations that hardly bear a resemblance to cutesy pink elephants – human skulls and grotesque creatures are more likely. Seizures may also develop between seven hours and two days after withdrawal begins. Alcohol withdrawal in general is treated with a benzodiazepine such as chlordiazepoxide, along with thiamine to prevent Wernicke's encephalopathy⁵.

Delirium tremens may occur between a day and a week after withdrawal begins, and is most likely to occur on the third day. The individual suffers from a reduction in consciousness and has difficulty functioning. Heavy sweating, fever and severe tremor occur alongside vivid hallucinations and paranoid delusions. The increase in heart rate and blood pressure can cause the heart to fail, and the fever and sweating can lead to death through deranged body temperature control. Delirium tremens occurs more often in those drinkers with disease of the liver or pancreas. The condition is a medical emergency requiring hospitalisation, monitoring and management of any co-existing problems. Alcoholics who have managed to develop delirium tremens may well be malnourished, suffering from liver failure or infection, bleeding from varices⁶, or may have sustained a head injury from falling while intoxicated.

There are a number of other alcohol-induced disorders worth mentioning here. If left untreated, Wernicke's encephalopathy may progress to Korsakoff's syndrome, in which the individual loses the ability to make new memories, leading to amnesia and 'blackouts'. Alcohol can produce a fleeting psychotic state, in which the individual experiences hallucinations and delusions of persecution or grandiosity, and may trigger a depressive or anxious state in a significant number of drinkers. Alcohol may also interfere with sleep, leading to insomnia.

Illicit Drugs

Though illicit substance are illegal in the UK under the Misuse of Drugs Act (1971), the primary concern of the mental health team is to reduce the damage they cause to mental and physical health. It would be tedious to cover all the effects of the various illicit drugs here, and so this entry will look at just a few important drugs.

Opiates such as heroin produce a euphoric, drowsy state along with small pupils, nausea, constipation, itching and respiratory depression. Injecting can lead to infection with hepatitis B and C, HIV and infective endocarditis, and the cost of the drug produces a downward spiral in living conditions. Withdrawal is not life-threatening but can produce the distressing sensation of bugs crawling over the skin (formication). Withdrawal symptoms include dilated pupils, vomiting, diarrhoea, sweating, agitation and abdominal pain, and may be treated with lofexidine, an alpha-receptor agonist⁷. Severely dependent individuals may be transferred onto the oral opiate methadone, while those with only moderate dependence may be placed on buprenorphine, a partial opiate agonist which produces less of a high while blocking any other opiate use. Once an individual is clear of opiates, the opiate-blocking drug naltrexone may be used to prevent a relapse.

Stimulants such as cocaine and amphetamines produce a state of alertness, irritation, euphoria or general hyperactivity, while also producing matching symptoms of sweating, fever, tremor and rapid heart rate. The drugs may cause fitting and can induce a psychotic state, paranoid ideas and hallucinations. Fortunately, these drugs can be withdrawn quickly without a risk to the individual's health, although a depressive state does follow.

Benzodiazepines lead to a state of drowsiness, confusion and general lack of concentration and inhibition. They produce matching physical effects, such as low blood pressure, respiratory depression and problems with coordination. Withdrawal is dangerous and can produce fitting, hallucinations and a reduction in consciousness; a slow reduction in usage of the drug is required, and a successful withdrawal can take months.

Cannabis produces a euphoric, relaxed state along with an altered perception of time, but may also produce a drug-induced psychosis or trigger the relapse of a psychotic illness. Withdrawal leads to irritability, tremor, sweating and craving of the drug.

Hallucinogenic drugs such as LSD and psilocybin mushrooms produce hallucinations as would be expected. However, users suffer from chronic flashbacks, and using the drugs may produce a psychotic state, paranoid ideas or even suicidal or homicidal ideation. The hallucinogens are not thought to produce withdrawal symptoms.

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¹ International Classification of Diseases, 10th Revision.
² Unless, of course, they live above a nightclub.
³ Flicking of the eyes from side to side, giving the impression that the room is moving.
⁴ If you're not sure why this might be unpleasant, ask a glass of water.
⁵ A neurological condition caused by thiamine deficiency that is common in chronic alcoholics.
⁶ Swollen vessels in the gut wall which are prone to bleeding.
⁷ Alpha-receptor agonists stimulate receptors usually targeted by adrenaline and noradrenaline, and which control a variety of 'autonomic' responses such as pupil dilation/constriction, sweating, heart rate and blood pressure.