Group 5:

Substance-Related Disorders
Opioid-related disorders
Sedative-Hypnotic-, or Anxiolytic-related disorders
Anabolic-Androgenic Abuse
 Opioid-Related Disorders
OPIOIDS
● Opioids are used to relieve moderate to severe pain; used as analgesics
● prolonged use of opioids could increase risks of abuse and dependence. This can affect mood, behavior, and
cognition which could imitate other psychiatric disorders.
● opioid dependence is often a chronic, relapsing disorder and manifests as a cluster of physiological, behavioral,
and cognitive disturbances.
● opiate and opioid originated from the word opium which is the juice of the opium poppy

Epidemiology
● increasing of purity and decreasing of price results in an increase use of heroin among the vulnerable population
● estimated heroin users in the US in the year 2015: 600,000 to 800,000
● estimated number of people who used heroin at any time in their lives: approx. 3 million
● administration includes: injecting, smoking, and snorting
● male to female ratio of persons with heroin dependence is 3:1
● initial use occurs at teen age and early 20s.
● most people with opioid dependence are in their 30s-40s
● 40 years of age or the “maturing out” is the age at which dependence to remit usually begins.
● initial opioid induced experience usually occur in the early teens and could be as young as 10 years of age.
 Opioid-Related Disorders
Neuropharmacology

● the primary effects of the opioid drugs are mediated via the opioid receptors
● the µ-opioids receptors are involved in the regulation and mediation of analgesia, respiratory depression, constipation, and
drug dependence; k-opioids receptors with analgesia, diuresis, and sedation; δ-opioids receptors with analgesia
● 3 classes of endogenous opioids: endorphins, dynorphins, enkephalins
● endorphins are involved in neural transmission and pain suppression; released naturally when a person is hurt physically or
is stressed; they are also accounted to the absence of pain during acute injuries
● the endogenous opioids also interacts with other neuronal systems, such as the dopaminergic and noradrenergic
neurotransmitter systems
● addictive rewarding properties are mediated through activation of the ventral tegmental area dopaminergic neurons
● evidence also shows that endorphins are involved in other addictions
● naltrexone an opioid antagonist has shown value that it can mitigate alcohol addiction.

Tolerance and Dependence

● Tolerance to all actions of opioid drugs does not develop uniformly.
● The symptoms of opioid withdrawal do not appear unless a person has been using opioids for a long time or when cessation is
particularly abrupt, as occurs functionally when an opioid antagonist is given.
 Opioid-Related Disorders
Comorbidity
● 90% of people with opioid dependence have an additional psychiatric disorder; 15% attempt to commit suicide atleast once.
● Major depressive disorder, alcohol use disorders, antisocial personality disorder, and anxiety disorders - most
common comorbid psychiatric diagnoses.

Etiology (Psychosocial Factor)

● Social factors associated with urban poverty probably contribute to opioid dependence.
● Heroin behavior syndrome - consistent behavior patterns seem to be especially pronounced in adolescents with opioid
dependence.

Etiology (Biological and Genetic Factor)

● A person with an opioid-related disorder may have had genetically determined hypoactivity of the opiate system.
● A biological predisposition to an opioid-related disorder may also be associated with abnormal functioning in either the
dopaminergic or the noradrenergic neurotransmitter system.

Etiology (Psychodynamic Theory)

● The behavior of persons addicted to narcotics has been described in terms of libidinal fixation,with regression to pregenital,
oral, or even more archaic levels of psychosexual development.
● The relation of drug abuse, defense mechanisms, impulse control, affective disturbances, and adaptive mechanisms led to the
shift from psychosexual formulations to formulations emphasizing ego psychology.
 Opioid-Related Disorders
Diagnosis

Opioid Use Disorder

● Pattern of maladaptive use of an opioid drug
● Results in clinically significant impairment or distress
● Occurs within a 12-month period

Opioid Intoxication
● Maladaptive behavioral changes and specific physical symptoms of opioid use
● Altered mood, psychomotor retardation, drowsiness, slurred speech, and impaired memory and attention
in the presence of other indicators of recent opioid use = strongly suggest diagnosis of opioid intoxication

Opioid Intoxication Delirium

● Most likely to happen when opioids are:
○ used in high doses
○ mixed with other psychoactive compounds
○ used by a person with preexisting brain damage or a central nervous system (CNS) disorder (e.g.,
epilepsy)
 Opioid-Related Disorders
Diagnosis

Opioid-Induced Psychotic Disorder

● Can begin during opioid intoxication
● Clinicians can specify whether hallucinations or delusions are the predominant symptoms

Opioid-Induced Mood Disorder

● Can begin during opioid intoxication
● Symptoms can be manic, depressive, or mixed nature
● A person coming to psychiatric attention with opioid-induced mood disorder → mixed symptoms,
combining irritability, expansiveness, and depression

Opioid-Induced Sleep Disorder and Opioid Induced Sexual Dysfunction

● Hypersomnia > Insomnia
● Impotence = most common
 Opioid-Related Disorders
Diagnosis
Opioid Withdrawal
● General rule (onset and duration of symptoms):
○ Substances with short durations of action = short, intense
○ Substances with long durations of action = prolonged, but mild
○ Exception = narcotic antagonist-precipitated withdrawal after long-acting opioid dependence → severe
● Abstinence syndrome → precipitated by administration of an opioid antagonist
○ Begins within seconds of such an IV injection
○ About 1 hour = peak
○ Opioid craving → rarely occurs if analgesic administration is for pain from physical disorders or surgery
○ Full withdrawal syndrome including intense craving for opioids → secondary to abrupt cessation of use in persons
with opioid dependence
● Morphine and Heroin
○ Begins 6 to 8 hours after last dose (After a 1 to 2 week period of continuous use or after the administration of a narcotic
antagonist)
○ 2nd or 3rd day = peak intensity
○ Next 7 to 10 days = subsides
■ Some symptoms may persists for 6 months or longer
● Meperidine
○ Begins quickly
○ 8 to 12 hours = peak
○ Ends in 4 to 5 days
 Opioid-Related Disorders
Diagnosis
● Methadone
○ Begins 1 to 3 days after the last dose
○ Ends in 10 to 14 days
● Symptoms
○ Consists of:
■ Severe muscle cramps and bone aches, profuse diarrhea, abdominal cramps,
rhinorrhea, lacrimation, piloerection or gooseflesh, yawning, fever, pupillary
dilation, hypertension, tachycardia, temperature dysregulation (hypothermia and
hyperthermia)
○ Persons with opioid dependence = seldom die from opioid withdrawal
○ Residual symptoms can persists for months after withdrawal
○ Restlessness, irritability, depression, tremor, weakness, nauseas, and vomiting =
associated features of opioid withdrawal
○ Single injection of morphine or heroin at any point throughout the abstinence phase
= eliminates all the symptoms
Unspecified Opioid-Related Disorder
● The DSM-5 includes diagnoses for other opioid-related disorders with symptoms of delirium, abnormal mood, psychosis,
abnormal sleep, and sexual dysfunction
● Clinical situations that do not fit into these categories exemplify appropriate cases for the use of the DSM-5 diagnosis of
unspecified opioid-related disorder
 Opioid-Related Disorders
Clinical Features

● Associated symptoms of opioid intake:

● Opioids can be taken:
- Feeling of warmth/being warm
- Orally - Extremities feel heavy
- Snorted intranasally - Dry mouth
- Injected intravenously (most addictive) - Itchiness on the face (particularly on the
- Injected subcutaneously nose)
- Flushed skin
● These drugs are subjectively addictive
due to euphoric “high” that users ● Opioid can induce:
experience. - Dysphoria
● After initial euphoria has been reached, - Nausea
there is a period of sedation or “nodding - Vomiting
off”.
 Opioid-Related Disorders
Clinical Features
● Physical effects of opioids:
- Respiratory depression
- Pupillary constriction
- Smooth muscle contraction
- Constipation
- Changes in one’s blood pressure, heart rate and body temp.

Adverse Effects
● Transmission of hepatitis and HIV through contaminated needles is the most common and serious effect with this
disorder. Anaphylactic shock, pulmonary edema and or death may occur towards those who experience an allergic
reaction to the use of opioids.
● An interaction between meperidine and monoamine oxidase inhibitors is also an adverse effect - which may result in
gross autonomic instability, behavioral agitation, a coma, seizure and death. These two drugs are not given together.

Opioid Overdose
- Death due to respiratory arrest (by apnea/respiratory dysfunction)
- Symptoms of an overdose: (1) unresponsiveness, (2) coma, (3) slow respiration/breathing, (4) hypothermia, (5)
hypotension and (6) bradycardia
 Opioid-Related Disorders
Treatment and Rehabilitation
● Overdose Treatment
- The first task in overdose treatment: ensure an adequate airway!
- The pt. Should be mechanically ventilated until naloxone is given. Naloxone is administered intravenously at a slow rate (0.8mg per
70kg of BW).
- Signs of improvement are: increased respir and dilation of the pupils | Note: a large amount of naloxone towards opioid dependent
pts. may produce withdrawal signs and also reversal of overdosage
- If no response to the first initial dosage of naloxone, administration can be repeated after a few minutes.

● Medically Supervised Withdrawal and Detoxification

Opioid Agents for Treating Opioid Withdrawal
- Methadone - a synthetic narcotic (also an opioid) that substitutes for heroin and can also be taken orally.
- Addicts would replace their usual substance of abuse, and use methadone instead – in order to suppress withdrawal symptoms.
- A daily dose of 20-80 mg is enough to stabilize the patient (do note that 120mg has also been used)
- Once-daily dosing is adequate, since the duration of action for Methadone is over 24 hours.
- Methadone maintenance/use is continued until the patient can withdraw from methadone - which can cause dependence.
- Lastly, Clonidine (0.1-0.3mg/3 to four times a day) is given during the detoxification period.

Other Opioid Substitutes

- Levomethadyl (LAAM) is an opioid agonist used to suppress opioid withdrawal – although it is no longer used.
- Buprenorphine, also an opioid agonist – used to reduce heroin use.
 Opioid-Related Disorders
Treatment and Rehabilitation
Opioid Antagonists
- Opioid Antagonists are used to block the effects of opioids.
- The theory for antagonist use for disorders related to opioids is to block the effect of euphoria, which would discourage the user in
using the drug - and to decondition the behavior of drug use.

Pregnant Women with Opioid Dependence

- Neonatal addiction is a prominent, significant problem - 3/4ths of infants are born to addicted mothers with withdrawal syndrome.

Neonatal Withdrawal
- Opioid withdrawal is rarely fatal to adults, but it is fatal to the fetus (leading to death or miscarriage)
- A low dose of methadone (10-40mg daily) must be maintained to the pregnant woman with opioid dependence – and is the least
hazardous course to follow.
- If withdrawal is necessary or desired by the woman, the least hazardous time to do this is during the second trimester.

Fetal AIDS Transmission

- Acquired immune deficiency syndrome or AIDS, is a major risk factor towards the fetus with opioid dependence.
- Pregnant women can pass HIV, to the fetus through the placental circulation – an HIV infected woman can also pass HIV via
breastfeeding.
- Using zidovudine or Retrovir, or in combination with another anti-HIV medication can decrease the incidence of HIV towards
newborns.
 Sedative-Hypnotic-, or Anxiolytic-Related Disorders
BENZODIAZEPINES
● Used primarily as anxiolytics, hypnotic,
antiepileptics, and anesthetics, as well
as for alcohol withdrawal.
● Approximately 15% of all persons in
the United States are prescribed
medicines.
○ Increase awareness of being
risk for independence on
benzodiazepines
○ Increase regulatory
requirements, however have
decreased the number of
benzodiazepine prescriptions.
● Classifies as Schedule IV controlled
substances.
● Flunitrazepam (Rohypnol) used in
Mexico, South America and Europe
● Non - benzodiazepine sedative such
as: Zolpidem (Ambien), Zaleplon
(Sonata) and Eszopiclone (Lunesta) –
“Z Drug”
BARBITURATE
● Useful and effective sedatives but they
are highly lethal with only ten times the
normal dose producing coma and death.
The drugs are under the same federal
legal controls as morphine in the United
States, meaning they are no longer
classed as narcotics.
● Secobarbital, Pentobarbital and
Secobarbital-amobarbital
combination
● Easily available on the street from drug
dealers.
● First Barbiturate, Barbital (Veronal)
● Barbital and phenobarbital (Solfoton,
Luminal) - long-acting drugs with
half-lives of 12 to 24 hours.
● Amobarbital - intermediate-acting
with a half-life of 6 to 12 hours.
● Pentobarbital and secobarbital -
short-acting barbiturates w/ half-lives
of 3 to 6 hours.
○ BARBITURATE-LIKE SUBSTANCES
● Methaqualone (st. name “Mandrakes”)
○ M/c abused barbiturate-like
substance
○ Often used by young people
who believe that the substance
heightens the pleasure of sexual
activity,
○ Take one or two standard tablets
○ 300mg per tablet
● Meprobamate (Equanil),
○ A carbamate derivative that has
weak efficacy as an antianxiety
agent
○ Has muscle relaxant effect
● Chloral hydrate
○ A hypnotic highly toxic to the
(GI) system and, when
combined w/ alcohol, is known
as a "mickey finn"
● Ethchlorvynol
○ Rapidly acting sedative agent
with anticonvulsant and
muscle-relaxant properties.
 Sedative-Hypnotic-, or Anxiolytic-Related Disorders
Epidemiology

● 6% - illicit use of sedatives / tranquilizers

● Age: 26-34 y/o (18-25 y/o prior yr)
● Benzodiazepine: F>M 3:1
● Barbiturate: M>F
● Alone / With Cocaine / With Opioids / With PCP

Neuropharmacology

● Primary effects on GABAA receptor complex

○ Binding site for benzodiazepines: Chloride ion channel
● Effect after binding:
○ Increased affinity for GABA
○ increased flow of chloride ions through the channel into the neuron
■ Causing inhibition and hyperpolarization of neuron
 Sedative-Hypnotic-, or Anxiolytic-Related Disorders
Clinical Features
Patterns of Abuse
Oral ● Effect (if regular): Constant, usually mild,
Use intoxication state
○ MC with middle-aged, middle-class
persons with prescriptions for insomnia
or anxiety
● Effect (if occasional): Relaxation for an
evening, intensification of sexual activities,
short-lived period of mild euphoria
○ MC with young persons
IV ● Involved in severe form of abuse
Use ● Associated with a pleasant, warm, drowsy
feeling
○ Rapid and profound tolerance and
dependence with severe withdrawal
symptoms
● Barbiturates > Opioids
● Increased risks for transmission of HIV,
cellulitis, vascular complications, infections,
allergic reactions
Overdose
Benzodiaze ● Lethal to effective dose: 200:1 or
pines higher
● Drowsiness, lethargy, ataxia,
confusion, mild depression of VS,
death (only with alcohol)
● Flumazenil - reverse effects
Barbiturate ● Lethal to effective dose: b/n 3:1 and
30:1
● Respiratory depression/arrest,
coma, CV failure, death
● Average of dependent users: 1.5 g
of short-acting barbiturate
Barbiturate ● Overdose of Methaqualone =
-like Restlessness, delirium, hypertonia,
Substance mm spasm, convulsions, death
● Most fatalities result from
methaqualone + alcohol
 Sedative-Hypnotic-, or Anxiolytic-Related Disorders
Diagnosis

Sedative, Hypnotic, or Anxiolytic Use Disorder

7. there is a persistent desire or unsuccessful efforts to cut
General criteria in the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) for down or control substance use
substance use disorder: 8. a great deal of time is spent in activities necessary to
obtain the substance, use the substance, or recover from its
1. recurrent substance use resulting in a failure to fulfill major
effects
role obligations at work, school, or home (e.g., repeated
absences or poor work performance related to substance use; 9. important social, occupational, or recreational activities
substance-related absences, suspensions, or expulsions from are given up or reduced because of substance use
school; neglect of children or household) 10. the substance use is continued despite knowledge of
2. recurrent substance use in situations in which it is physically
having a persistent or recurrent physical or psychological
hazardous (e.g., driving an automobile or operating a machine
when impaired by substance use) problem that is likely to have been caused or exacerbated
3. continued substance use despite having persistent or by the substance
recurrent social or interpersonal problems caused or 11. craving or a strong desire or urge to use a specific
exacerbated by the effects of the substance (e.g., arguments substance.
with spouse about consequences of intoxication, physical fights)
4. tolerance, as defined by either of the following: a. a need for
markedly increased amounts of the substance to achieve Sedative, Hypnotic, or Anxiolytic Intoxication
intoxication or desired effect b. markedly diminished effect with
continued use of the same amount of the substance ● Blood sample would best confirm the diagnosis for
5. withdrawal, as manifested by either of the following: a. the
characteristic withdrawal syndrome for the substance b. the intoxication by one of this class of substances.
same (or a closely related) substance is taken to relieve or avoid
withdrawal symptoms
6. the substance is often taken in larger amounts or over a
longer period than was intended
 Sedative-Hypnotic-, or Anxiolytic-Related Disorders
Diagnosis
Benzodiazepines
● May be associated with behavioral disinhibition -> hostile/aggressive
behavior commonly seen when substance is taken in combination
with alcohol.
● Associated with less euphoria compared to other drugs in this class.
Barbiturates and Barbiturate-like Substances
● When taken in low doses, clinical syndrome of intoxication is
indistinguishable from that associated with alcohol intoxication.
● Symptoms include: sluggishness, incoordination, difficulty thinking,
poor memory, slow speech & comprehension, faulty judgement,
disinhibited sexual aggressive impulses, narrowed range of attention,
emotional lability, and exaggerated basic personality traits.
● Impaired motor skills may remain for 12-24 hours
● Other potential symptoms: hostility, argumentativeness, moroseness,
paranoid & suicidal ideation.
● Neurological effects include: nystagmus, diplopia, strabismus, ataxit
gait (+) romberg’s sign, hypotonia, and ↓ superficial reflexes.
Barbiturates and Barbiturate-like Substances
● Mild symptoms: anxiety, weakness, sweating, insomnia
Sedative, Hypnotic, or Anxiolytic Withdrawal ● Severe symptoms: seizures, delirium, cardiovascular collapse, death
● Abusing phenobarbital in the range of 400 mg/day -> mild withdrawal
Benzodiazepines sx.
● Severity of withdrawal syndrome varies significantly depending on ● Abusing phenobarbital in the range of 800 mg/day -> orthostatic
average dose and duration of use. hypotension, weakness, tremor, severe anxiety.
● Likely to occur at cessation of dosages - 40 mg/day ● Dosages higher than 800 mg/day -> anorexia, delirium, hallucinations,
● Onset of withdrawal symptoms usually occurs 2-3 days repeated seizures.
● For long-acting drugs, it may take 5-6 days ● Most symptoms occur in the first 3 days of abstinence
● Symptoms: anxiety, dysphoria, intolerance for bright lights & loud noises, ● If seizures occur, it usually precedes Delirium
nausea, sweating, muscle twitching, seizures. ● Psychotic disorder may develop
● Various associated symptoms may last as long as 2 weeks
● First episode of the syndrome usually occurs after 5 to 15 years of
heavy substance use.
 Sedative-Hypnotic-, or Anxiolytic-Related Disorders
Diagnosis

Other Sedative-, Hypnotic-, or Anxiolytic-lnduced Disorder

Delirium
● Delirium that is indistinguishable from delirium associated with alcohol
withdrawal is commonly seen with barbiturate withdrawal.
● Delirium associated with intoxication can be seen in both barbiturates or
benzodiazepines if dosages are high. Other Disorders
● mood disorders, anxiety disorders, sleep disorders, and sexual
Persisting Dementia dysfunctions
● The existence of dementia brought by sedative/hypnotic substances is
controversial because of uncertainty whether it is caused by the Unspecified Sedative-, Hypnotic-, or Anxiolytic Related
substance itself or by associated features of the substance use.
Disorder
● When none of the previously discussed diagnostic categories is
Persisting Amnestic Disorder
appropriate for a person with sedative-, hypnotic-, or anxiolytic-related
● May be underdiagnosed
disorder, and he or she does not meet the diagnostic criteria for any
● One exception -> increased number of reports of amnestic episode
general substance-related disorder -> unspecified sedative-,
associated with short-term use of benzodiazepines with short half-lives.
hypnotic-, or anxiolytic-related disorder
Psychotic Disorders
● Psychotic symptoms of barbiturate withdrawal can be indistinguishable
from those of alcohol-associated delirium tremens.
● Agitation, delusions, hallucinations develop after about 1 week of
abstinence
● Psychotic symptoms associated with intoxication or withdrawal are more
common with barbiturates
● Reality testing is intact -> diagnosed in DSM-5 as sedative, hypnotic,
or anxiolytic withdrawal with perceptual disturbances
● Reality testing is NOT intact -> diagnosis of substance/
medication-induced psychotic disorder
 Sedative-Hypnotic-, or Anxiolytic-Related Disorders
Treatment and Rehabilitation

● Withdrawal
○ Benzodiazepines are slow to be eliminated by the body, withdrawal symptoms can develop for
several weeks.
○ Gradual reduction of dosage is done in order to prevent this.
○ Evaluation, obtaining drug hx, urine, and blood samples for assay, determining proper dosage,
detoxification of supratherapeutic and therapeutic dosages, and psychological interventions
are part of the guidelines for treatment of benzodiazepine withdrawal.
○ Barbiturate withdrawal may cause sudden death during the process. In order to prevent this
clinicians must follow a conservative guideline.
○ Clinicians must determine the usual dosage of the pt. and verify it clinically. From there, the dosage
can be reduced by 10%, long acting barbiturates may then be used during the detoxification phase,
where withdrawal symptoms may start to appear.
○ After the completion of the withdrawal, the pt. must then control the desire to take the substance
again.
○ If a user finally becomes substance free, follow up treatments must be done in order for the pt. to
not relapse.
 Sedative-Hypnotic-, or Anxiolytic-Related Disorders
Treatment and Rehabilitation

Overdose treatments

● Gastric lavage
● Activated charcoal
● Monitoring of vital signs and CNS activity

● Patients undergoing overdose must be kept awake and avoid letting the patient become unconscious.
● When conscious, vomiting should be induced and activated charcoal is then administered to delay
gastric absorption.
● When unconscious, IV fluid line must be started and a endotracheal tube should be inserted to
maintain proper airway along with mechanical ventilation, if necessary. ICU is recommended during
the early stages of overdose for recovery.
 Anabolic-Androgenic Abuse
ANABOLIC-ANDROGENIC STEROIDS (AAS) - are testosterone-like hormonal drugs
which are widely used illegally , specifically by boys and young men to enhance muscle
mass & strength usually for athletic objectives or merely to improve their appearance.

● Each year, an estimated 286,000 men and 26,000 women in the United States use
steroids. Nearly 1/3 of the people, or 98,000, were between the ages of 12 and 17.

CORTICOSTEROIDS AAS

Muscle-building ✔ ⛌
properties

Treatment Inflammatory conditions (e.g.: Hypogonadism, wasting syndrome (HIV),

prescription for poison ivy & asthma) hereditary angioedema, fanconi’s anemia

Abuse potential Little - none high

PHARMACOLOGY

● 300 - 1000 ng/dL - range for normal men testosterone plasma concentration
● Eugonadal Male - no net rise in testosterone levels
● Hypogonadal Male - 200mg of testosterone cypionate taken every 2 weeks
○ Illicit users consume higher dosage of AAS (10-100 times) than prescribed
ones to achieve supraphysiological effect.
 Anabolic-Androgenic Abuse
Therapeutic Indication
● Testosterone deficiency (male hypogonadism), hereditary angioedema (a congenital skin disorder), and some
uncommon forms of anemia caused by bone marrow or renal failure.
● Men: male contraceptive and for treating major depressive disorder and sexual disorders in eugonadal men
● Women: metastatic breast cancer, osteoporosis, endometriosis, and adjunctive treatment of menopausal symptoms
● AIDS

Adverse Reaction
● MC side effects of AAS: cardiovascular, hepatic, reproductive, and dermatological systems
● Cholesterol: Increases levels of low-density lipoprotein & decreases levels of high-density lipoprotein cholesterol
● Men: testicular atrophy, sterility, & gynecomastia
● Women: shrinking of breast tissue, irregular menstruation, and masculinization.
● Children: shortened stature

Etiology
● AAS can improve athletic performance & physical appearance
 Anabolic-Androgenic Abuse
Diagnosis and Clinical Features Treatment
● Steroids may induce ● Abstinence
○ Euphoria and Hyperactivity ○ Treatment goal of choice
○ Increased anger, arousal, irritability, hostility, ● Delayed gratification
anxiety, somatization, depression ● Culturally endorsed values of physical
● Anabolic steroid abusers (2 to 15%) fitness, success, victory, and goal
○ Hypomanic or manic episodes directedness
○ Psychotic symptoms ● Therapeutic alliance based on
(smaller percentage) ○ Thorough and nonjudgmental
● “Roid Rage” understanding of patient’s values and
○ A correlation between steroid abuse and motivations for using AAS
violence
● Murders and other violent crimes
○ Steroid abusers with no records of antisocial
behavior and violence
● Iatrogenic addiction
 Anabolic-Androgenic Abuse
AAS withdrawal
Antidepressant agents
● are best reserved for patients whose depressive
symptomatology persists for several weeks after AAS
discontinuation.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
● useful to treat musculoskeletal pain and headaches.
Physical withdrawal symptoms
● are not life-threatening and do not ordinarily require
pharmacotherapy
Selective serotonin reuptake inhibitors (SSRis)
● It has low risk of side effects and efficacy in the sole case
series of treated AAS users with severe depressive
disorder
Anabolic steroid-induced MOOD disorder
● Irritability, aggression, hypomania, and frankt
mania are all symptoms of anabolic steroid usage,
and they are undoubtedly one of the most serious
public health concerns.
Depressive Syndrome
● most likely as a result of the hypothalamus
pituitary-gonadal axis depression caused by
exogenous AAS treatment.
● It can occured a higher risk of suicide.
Anabolic steroid-induced PSYCHOTIC Disorder
Psychotic symptoms
● uncommon in people who take anabolic steroids
● have been grandiose or paranoid delusions, which
have occurred most frequently in the setting of a
manic episode
● decreased quickly (within a few weeks) if the
offending substance was stopped
● antipsychotic medications were occasionally
needed to manage the symptoms temporarily.
 Anabolic-Androgenic Abuse
Other Anabolic Steroid-Related Disorders that can
occur during AAS use:
1. Anxiety Disorders/Symptoms
a. Panic Disorder: An intense anxiety attack
occurring together with feelings of
impending doom.
b. Social Phobia/Agoraphobia: Fear/Anxiety
of areas where you may feel is difficult to
escape. (usually a complication of panic
disorder)
● A study of men admitted for substance dependence
treatment in Massachusetts produced similar
findings.
Dehydroepiandrosterone and Androstenedione Use:
- An OTC precursor hormone for both Estrogens and
Androgens
● Recent studies show interests in improvements of
cognition, depression, sexual drive, and wellbeing in
elderly.
● Dosages ranging from 50 to 100 mg daily show
improvements in health and well-being of women aged
40-70.
● androgenic effects includes: such as irreversible
hirsutism and voice deepening
● In theory has potential to enhance tumor growth for latent,
hormone sensitive malignancy.