DRUG

ADDICTION &
TOLERANCE
Presented by:-
V.V.N.S. HARSHITHA
2 nd yr PG
Dept. of PUBLIC HEALTH DENTISTRY
CONTENTS
• Introduction • Diagnostic criteria
• Addiction • Prevention
• Drug Addiction • Treatment
• Definitions • Global & Indian scenario of Drug
• Types of Drugs Addiction
• Physiology of Neuro transmission • Rehabilitation
• Physiology of Drug Addiction • Dental considerations
• Mechanism of Action of Different • Conclusion
Drugs • References
• Factors influencing drug
addiction
• Symptoms of drug addiction
• Reasons for drug dependence
• Classification of substance
abused disorders
INTRODUCTION
• Drug addiction has become a worldwide problem and the leading cause of
death. The global problem of addiction and drug abuse is responsible for
millions of deaths and millions of new cases of HIV every year. In recent
years, India is seeing a rising trend in drug addiction. The most common
use of drug in India is alcohol, followed by cannabis and opiates.
• Addiction is more than a behavioral disorder. Features of addiction include
aspects of a person’s behaviors, cognitions, emotions, and interactions
with others, including a person’s ability to relate to members of their
family, to members of their community, to their own psychological state,
and to things that transcend their daily experience.
American Society of Addiction Medicine
• The abusive use of addictive drugs is a medical and societal problem
as old as recorded human history.
• Ancient references to drug abuse may be found in the oral and
written traditions of virtually all ethnic and cultural groups on the
planet.
• One of the most striking features of drug addiction is how few
chemicals are subject to abuse. If one takes all congeners of all
known chemicals, approximately 30,000,000 chemical substances
are known.
DEFINITION of ADDICTION:-

Addiction is a primary, chronic disease of brain reward,

motivation, memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological, social and
spiritual manifestations. This is reflected in an individual
pathologically pursuing reward and/or relief by substance use and
other behaviors.
-American Society of Addiction Medicine
CHARACTERSTICS OF ADDICTION:-

Addiction is characterized by:-

a. Inability to consistently Abstain

b. Impairment in Behavioural control

c. Craving; or increased “hunger” for drugs or rewarding experiences
d. Diminished recognition of significant problems with one’s behaviors
and
interpersonal relationships and
e. A dysfunctional Emotional response.

American Society of Addiction Medicine

 TYPES OF ADDICTION :
SUBSTANCE ADDICTION:-

• Different types of Drug Addiction

BEHAVIOURAL ADDICTION:-
 DEFINITIONS

• DRUG:- it is defined as any substance that, when taken into

living organism may modify one or more of it's functions.

-WHO

• DRUG ADDICTION:- it is defined as a state of periodic or

chronic intoxication detrimental to the individual and society
produced by repeated intake of habit forming drugs.
-National Institute on Drug Abuse, 2014

•
• DRUG ABUSE:- it is defined as self administration of drug for non
medical reasons in quantities and frequencies which may impair an
individual's ability to function effectively and which may result in
social, physical or emotional harm.

• DRUG DEPENDENCE:- it is described as a state, psychic and

sometimes also physical resulting from interaction between a living
organism and drug characterized by behavioural and other
responses that always include a compulsion to take drug on a
continuous or periodic basis in order to experience its psychic
effects and sometimes to avoid the discomfort of its absence
• TOLERANCE, as defined by either
of the following:
a. A need for markedly increased
amounts of the substance to
achieve intoxication or desired
effect.
b. A markedly diminished effect with
continued use of the same amount
of the substance.
• WITHDRAWAl, as manifested by
either of the following:
a. The characteristic withdrawal
syndrome for that substance (as
specified in the DSM-5 for each
substance).
b. The use of a substance (or a
closely related substance) to
relieve or avoid withdrawal
symptoms.
• The World Health Organization and the American Psychiatric
Association use the term “substance dependence” rather than
“drug addiction.”
• American Psychiatric Association has defined SUBSTANCE
DEPENDENCE as
Substance dependence is a cluster of cognitive, behavioral, and
physiological symptoms indicating that a person is continuing to use a
substance despite having clinically significant substance-related
problems. For substance dependence to be diagnosed, at least three
of the following must be present:
symptoms of tolerance;
symptoms of withdrawal;
the use of a substance in larger amounts or for longer periods than
intended
TYPES OF DRUGS
SEDATIVES- barbiturates, ethanol, opiates, and benzodiazepines

STIMULANTS- nicotine, cocaine, and the amphetamines

ANTI-NOCICEPTIVE - opiates and cannabinoids

PRO-NOCICEPTIVE

Adv Psychosom Med. 2011 ; 30: 22–60.

PHYSIOLOGY OF NEUROTRANSMISSION
PHYSIOLOGY OF DRUG ADDICTION
The brain’s reward circuitry was first discovered by Olds and Milner at
McGill University in the early 1950s.
REWARD:- It is an attractive and motivational property of a stimulus
that induces appetitive behavior also known as approach behavior.
• There are natural rewards as well as artificial rewards, such as drugs.
• Natural rewards such as food, water, sex, and nurturing allow the
organism to feel pleasure when eating, drinking, procreating, and
being nurtured.
• Such pleasurable feelings reinforce the behavior so that it will be
repeated.
• Each of these behaviors is required for the survival of the species.
MECHANISM OF ACTION OF DIFFERENT
DRUGS
1. OPIODS
• Opioids are a class of drugs naturally found in the opium poppy plant.
• Prescription opioids are used mostly to treat moderate to severe
pain, though some opioids can be used to treat coughing and
diarrhea
• highly addictive, and overdoses and death are common. Heroin is one
of the world’s most dangerous opioids, and is never used as a
medicine in the United States.
2. CANNABINOIDS:-
The use of marijuana or hashish produces feelings of relaxation and
well-being and impairs cognitive function and performance of
psychomotor tasks.
A high incidence of cannabis consumption has been reported among
patients with schizophrenia.
Symptoms of withdrawal — restlessness, irritability, and insomnia —
are subtle and appear in heavy consumers.
The cause of the marijuana amotivational syndrome — loss of energy
and drive to work — remains unclear
3. ALCOHOL:-
When ethanol is given at low doses or initially during acute ethanol
intoxication, it is perceived as a stimulant owing to the suppression of
central inhibitory systems, but as the plasma levels of ethanol
increase, sedation, motor incoordination, ataxia, and impaired
psychomotor performance appear. The withdrawal syndrome
(seizures and delirium tremens) may be severe and clinically
challenging.
4. COCAINE AND AMPHETAMINES:-
Cocaine is a potent blocker of the dopamine-, norepinephrine-, and
serotonin-uptake transporters. Amphetamines have a more complex
mechanism of action. Amphetamines cause neuronal storage vesicles
in the cytoplasm to release neurotransmitters to the synapse; inhibit
the uptake of dopamine, norepinephrine, and serotonin by membrane
transporters; and act as mild inhibitors of monoamine oxidase
FACTORS INFLUENCING DRUG ADDICTION
• AGENT FACTORS:-

Pharmacological & physicochemical properties of drugs:

• Liposolubility increases the passage of a drug through the blood–

brain barrier,

• Water solubility facilitates the injection of a drug,

• Volatility favors the inhalation of drugs in vapor form, and

• Heat resistance favors smoking of the drug.

Characteristics such as rapid onset and intensity of effect increase

the potential for abuse therefore, substances that rapidly reach high
levels in the brain are usually preferred
Personality and psychiatric disorders :-

• Risk-taking or novelty-seeking traits favor the use of addictive

drugs.

• Polydrug use is frequent among those with drug addiction, and

many fulfill the criteria for dependence on or abuse of (or both)
more than one substance.

• Psychiatric disorders, particularly schizophrenia, bipolar disorder,

depression, and attention-deficit–hyperactivity disorder, are
associated with an increased risk of abuse
Genetic factors:-
Genetic factors that influence the metabolism and
the effects of drugs contribute to the risk of
addiction.

• A Leu7Pro polymorphism of the neuropeptide Y gene  increased alcohol

consumption,
• Single-nucleotide polymorphisms of the gene encoding the µ opioid receptor 
heroin abuse
• A deficiency in the cytochrome P-450 2D6 gene blocks the enzymatic conversion
of codeine to morphine, thereby preventing codeine abuse.
• Defective cytochrome P-450 2A6 *2 and *4 alleles, which impair the metabolism
of nicotine, smoke fewer cigarettes and are less likely to be dependent than
subjects who are homozygous for these alleles.
• The minor (A1) allele of the TaqIA D2 dopamine receptor gene  severe
alcoholism
HOST FACTORS:-
• People who are unable to accept even minimum discomforts are
looking to drugs for solutions.
• The average age of drug users has decreased considerably in the
recent years.
• In late 1960s, drug use by teenagers has been increased in
developed countries.
ENVIRONMENTAL FACTORS:-
Rapid technological developments
Television
World travel, DRUG • ANTI-SOCIAL
• CRIMINAL
Affluence INTAKE SUBCULTURE
Freedom to speculate & experiment
Irrelevant perception of social values
• Taheri et al (2016) studied factors affecting the tendency for drug abuse in 32
patients presenting to an addiction treatment centre in Iran.
• Four main themes were extracted including
family factors (the presence of a drug user in the family, loneliness and
separation from the family, and family problems and disputes),
social factors (having a hard job, unemployment, the lack of access to
recreational facilities and the easy access to drugs);
environmental factors (friendly gatherings and socializing with drug users);
and
personal factors (wealth, illness, curiosity).
The findings of the study showed that environmental factors had the greatest
effect on the tendency for drug use (38%), followed by family factors (28.5%),
personal factors (22.2%) and social factors (11.1%).
J Addict Res Ther 7:270.
 RISK & PROTECTIVE FACTORS
Risk factors initiate &
RISK FACTORS PROTECTIVE FACTORS
continue Protective factors reduce the
Biologically basedthe drug use
susceptibility Family
risk supervision
of substance abuse &
Impulsiveness & Aggression promote
Having positivefriends
conventional development
Relatively young age at onset of drug use Placing an importance on high
achievement in school
Failure in school Cooperativeness
Negative peer influence Social competence
Perception of low risk of engaging in Neighborhood cohesiveness
problem behaviors
Chaotic home environments Lack of drug availability
Ineffective parenting
Lack of attachment to Parents
Poor social and coping skills
Poverty
SYMPTOMS OF DRUG ADDICTION
• Loss of interest in sports and daily routine
• Loss of appetite and body weight
• Unsteady gait, clumsy movements, tremors
• Reddening and puffiness of eyes, unclear vision
• Slurring of speech
• Fresh, numerous injection marks on body and blood stains on clothes
• Nausea, vomiting and body pain.
• Drowsiness or sleeplessness, lethargy and passivity
• Acute anxiety, depression , profuse sweating
• Changing mood, temper tantrums.
• Depersonalization and emotional detachment
• Impaired memory and concentration
• Presence of needles, syringes and strange packets at home.
REASONS FOR DRUG DEPENDENCE
• Curiosity
• Disturbed home environment
• An escape phenomenon
• Impact of disco, TV etc
• Ignorance regarding habit forming drugs.
CLASSIFICATION OF SUBSTANCE
DEPENDENCE DISORDERS
• ICD-10 classifies substance use disorders under “Mental and behavioural
disorders due to psychoactive substance use (F10–F19)” and describes four
pattern of substance use – acute intoxication, harmful use, dependence
syndrome, and withdrawal state.
• F10. – Mental and behavioural disorders due to use of alcohol
• F11. – Mental and behavioural disorders due to use of opioids
• F12. – Mental and behavioural disorders due to use of cannabinoids
• F13. – Mental and behavioural disorders due to use of sedative hypnotics
• F14. – Mental and behavioural disorders due to use of cocaine
• F15. – Mental and behavioural disorders due to use of other stimulants,
including caffeine
• F16. – Mental and behavioural disorders due to use of hallucinogens
• F17. – Mental and behavioural disorders due to use of tobacco
• F18. – Mental and behavioural disorders due to use of volatile solvents
• F19. – Mental and behavioural disorders due to multiple drug use and use of
other psychoactive substances
DIAGNOSTIC CRITERIA
• To determine the severity of the disorder, a criteria 1-11 has been
established

2-3 symptoms MILD

4-5 symptoms MODERATE
6 or more SEVERE
 DIAGNOSTIC CRITERIA
1. The substance is often taken in larger amounts or over a longer period than
was intended.
2. There is a persistent desire or unsuccessful effort to cut down or control use
of the substance.
3. A great deal of time is spent in activities necessary to obtain the substance,
use the substance, or recover from its effects.
4. Craving, or a strong desire or urge to use the substance, occurs.
5. Recurrent use of the substance results in a failure to fulfill major role
obligations at work, school, or home.
6. Use of the substance continues despite having persistent or recurrent social
or interpersonal problems caused or exacerbated by the effects of its use.
7. Important social, occupational, or recreational activities are given up or
reduced because of use of the substance.
8. Use of the substance is recurrent in situations in which it is physically
9. hazardous.
Use of the substance is continued despite knowledge of having a persistent
or recurrent physical or psychological problem that is likely to have been
10. caused or exacerbated by the substance.
11. Tolerance
Withdrawal
CRITERIA TO CALL A PERSON DRUG ADDICT
• Psychological dependence:- compulsion to take drug by any means

• Physical dependence:- withdrawl symptoms are seen when the drug

is withdrawn.

• Development of Tolerance:- tendency to increase dose.

PREVENTION :-
Changes in attitudes and alteration in such aspects can be brought
slowly only.
1.LEGAL APPROACH:-
The legal control on the distribution of drugs applied effectively
remains an important approach in prevention of drug addiction.
Legislation restricting or prohibiting advertisements that directly or
indirectly promote the use of tobacco and alcohol has been increased
in recent years.
Anti smoking measures suggested are:-
Prohibit the tobacco sale to minors and advertising about them.
Restricted sale from automatic vending machines
Prohibition of smoking in school areas, public.
Establishment of mandatory public health education on smoking
consequences
Mandatory health warning on cigarette packets.
Mandatory jail sentences should
be made effective
EDUCATIONAL APPROACH:-
Educational programmes for school children and public information
campaigns on electronic media.
General principles of communication can be applied to increase the
effectiveness of educational approach.
COMMUNITY APPROACH:-

• There will be a strong emphasis on action at the community level to

prevent drug abuse

• Initiating preventive interventions in the community buildings

preventive action to the level of people's daily lives and actions

• Popular approach to the prevention of drug abuse is provision of

alternative activities which may help to prevent drug abuse.

• Such activities include

Establishing group of organizations interested in athletics, sports,

music, public policy, religion, artistic activities etc.
TREATMENT
Effective treatment typically incorporates many components —
pharmacotherapy, behavioural therapy and social support — each
directed towards a particular aspect of the disorder and matching an
individual’s particular problems and needs.
1. Pharmacotherapy :-
• Methadone, buprenorphine, and naltrexone, are available for
individuals addicted to opioids,
• Nicotine preparations (patches, gum, lozenges, and nasal spray) and
the medications varenicline and bupropion are available for
treatment of tobacco addiction.
• Alcohol dependence can be treated using medications such as
disulfiram, acamprosate, and naltrexone.
• Buprenorphine, used to treat heroin addiction, can also be used to
treat addiction to opioid pain medications.
2. PSYCHOLOGICAL TREATMENT
a) Motivational enhancement therapy:-
Motivational Enhancement Therapy (MET) is based on the trans-
theoretical model of behaviour change (Prochaska & Diclemente 1982,
1984, 1986, 1992) which postulates that change in behaviour takes
place in different stages.
The key elements of MET which are believed to be active ingredient of
the intervention are summarized by the acronym FRAMES (Miller &
Sanchez 1994, Miller 1995);
i. FEEDBACK of personal risk or impairment
ii. Emphasis on personal RESPONSIBILITY for change
iii. Clear ADVICE to change
iv. A MENU of alternative change options
v. Therapist EMPATHY
vi. Facilitation of client SELF-EFFICACY or optimism
B) Behavioual therapies
Based on the principles of learning, the target behavior of habitual
excessive substance use is altered through systematic environmental
manipulations that vary widely depending on the specific substance
use behavior.
• Contingency contracting
• Cue exposure
• Aversion therapy
• Cognitive behavioral therapies.
GLOBAL SCENARIO
• According to the World Drug Report of the United Nations Office
on Drugs and Crime (UNODC), (2016)
• The figure stands at 29 million people as compared to the earlier
figure of 27 million.
• Approximately 27 million people are problem drug users, almost
half of whom are people who inject drugs (PWID). About 1.65
million of people who inject drugs were living with HIV in 2013. In
2014, 207,000 drug related deaths were reported; an unacceptably
high number of deaths which are preventable if adequate
interventions are in place.
• By analyzing trends over several years, the report shows that with
changing social norms towards cannabis, its use has climbed in
parallel with higher acceptability towards the drug.
• The global problem of addiction and drug abuse is responsible for 5
million deaths and about 42 million new cases of HIV every year
INDIAN SCENARIO
• One of the first studies on drug use in India was the National Survey
on Extent, Pattern and Trends of Drug Abuse in India (2000) with a
sample size of 40,697 males (12-60 yrs).
• The most used substance was alcohol (21%), followed by cannabis
(3%) and opiates (0.7%). The percentage of poly-drug users was
22.3%.
• Tobacco use prevalence was high at 55.8% among males, with
maximum use in the age group 41-50 years.
• Prevalence of drug abuse among males in the general population is
significant.
• Drug abuse among women exists. Hazards and burden on women
due to drug abuse is significant.
• Number of dependent users ‘not in treatment’ is significant.
REHABILITATION
• Нere are many rehabilitation programs for drug and alcohol
addiction.
• These programs include:
• Assessment of drug users which entails brief history of the
substance in use, any past treatment and mental status
examination. This should be done before any treatment program is
drawn for the client (drug addict),
• Self-management programs and
• Self-directed behavior which includes teaching the rehabilitees how
to live a self-directed life and not to be dependents,
• Counseling which will help people identify their problems and how
to cope with them, individualized treatment plan, pharmacotherapy
and medical care which deals with physiological effects of drugs
which need medication such as detoxification, and relapse
prevention techniques is to help the rehabilitees remain sober after
being discharged from the rehabilitation centers
DENTAL CONSIDERATIONS
• Dentists should be aware of these factors in order to manage drug
addict patients sensitively and effectively.
• Important management issues include medical problems
associated with drug abuse, dental problems and how drug abuse
and its subsequent treatment affect the dentition, behavioural
disorders, pain management, and control of cross-infection.
• N Z Dent J. 1999 Jun;95(420):58-61.
• Health care systems worldwide deliver services for addicts, but
most lack oral health care programs. Barriers against oral health
promotion among addicts include difficulty in accessing addicts as a
target population, lack of appropriate settings and of valid
assessment protocols for conducting oral health studies, and poor
collaboration between dental and general health care sectors
serving addicts.
• Oral health problems associated with opiates-tooth loss, decay on
smooth and cervical regions, salivary hypofunction, periodontitis.
• Oral health problems associated with cannabis- increased risk of
oral cancer, dry mouth, periodontitis.
• Oral health problems associated with stimulants-
i. Cocaine- bruxism,dental erosion
ii. Amphetamine- tooth wear, xerostomia rampant caries
• Oral health problems associated with hallucinogens-
i. Dry mouth, malnutrition, TMJ tenderness, oral tissue necrosis.
-Iranian J Publ Health, Vol. 42, No. 9, Sep 2013
CONCLUSION
• The current studies on prevalence of substance use throughout the
world show a vast majority of people suffering from drug use
disorders. Drug related death is a major concern. One of
the first studies on drug use in India was the National Survey on
Extent, Pattern and Trends of Drug Abuse in India (2000) which
highlighted the need for intervention.
• Present studies points to the high prevalence of drug use in India,
with increasing rates of cannabis abuse, abuse of prescription
medications and poly substance abuse.
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