1. Complications of Substance Misuse
Substance misuse is a maladaptive pattern of substance use, resulting
in significant complications, using the Bio-Psycho-Social model:
Biological Complications:
 Acute Intoxication = Reversible abnormalities caused by the direct effects of the substance
 Chronic effects:
o Exacerbation of Pre-existing disorders e.g. Anabolic Steroids and Hypertension
o Cognitive Impairment Syndromes e.g. ↓Thiamine  Wernicke’s Encephalopathy
o Residual Disorders = Continuing symptoms, even when drug has been stopped
 E.g. LSD Flashbacks
 Withdrawal = Where there is Physical dependence on a drug, stopping it  Symptoms.
o Clinically significant withdrawal is seen in:
 Alcohol / Opiates / Nicotine / Benzodiazepines / Amphetamines and Cocaine.
Psychological Complications
 Dependence = ‘Addiction’:
o Physical adaptations e.g. ↑No of Nicotine receptors in Smoking, need more to get the
same effects.
o Behavioural adaptations e.g. won’t have fun / escape feelings without having the drug.
 Substance Induced Psychotic Disorder e.g. Cannabis  Relapsing Schizophrenia
Socially Complications
 Failure to fulfil usual obligations at Home / School / Work
o Home  Children taken into Social Services
o School  Expulsion, unable to complete education for
qualifications
o Work  Unemployment and subsequent reliance on Benefits
 Hazardous Behaviour = Dangerous driving / Criminal activity
 Legal Problems = Arrest for: Possession of drugs, Disorderly conduct or
loss of Children
 Interpersonal problems = Arguments and fights with Spouse
Alcohol
 Acute: ↓LOC↑Risk of accidents + Aspiration; Hypoglycaemia; Acute renal failure and Coma.
 Chronic:
o Hepatic  Fatty Liver / Alcoholic Hepatitis / Cirrhosis / Hepatocellular Cancer
o GI  Gastritis / Barrett’s / Mallory Weiss / Peptic Ulcers / Diarrohea / Pancreatitis
o CVS  HTN / Dilated Cardiomyopathy / AF / CVA
o Resp  TB / Klebsiella and Pneumococcal Pneumonia
 2° to: Poor nutrition and self-neglect
o Neuro  Peripheral Neuropathy / Cerebellar Degeneration / Optic
Atrophy
o GUM  Erectile Dysfunction and Hypogonadism (Men)
o Others  Fetal Alcohol Syndrome / Osteoporosis
 Withdrawal  Sweating; Nausea; Delirium Tremens and Seizures
 Psychiatric: Amnesia; Hallucinations; Delusions; Dementia; Pathological
jealousy and Wernicke’s leading to Korsakoff’s.
o Also exacerbates existing Anxiety and
Depression.

2. Drugs
Opiates:
 = Heroin / Dihydrocodeine / Methadone / Codeine / Buprenorphine / Pethidine
 Acute  Nausea; Vomiting; Constipation; Respiratory Depression and ↓LOC  Aspiration
 Injecting  Local Abscesses; Cellulitis; Osteomyelitis; Bacterial Endocarditis; Septicaemia
and the transmission of Blood Bourne Viruses (BBV’s)
 Withdrawal  Sweating / Dilated pupils / Tachycardia /
HTN / Piloerection / Watering Eyes and Nose / Yawning
/ Abdominal Cramping / Nausea, Vomiting and
Diarrohea / Tremor.
o NB: Opiate withdrawal is unpleasant, but
generally not medically dangerous
 Heroin is one of the most addictive drugs on the planet –
alongside smoking and alcohol
Depressants:
 = Benzodiazepines / Barbituates / GHB (Gamma-Hydroxybutyrate) / Rohypnol
 NB: Often used to counteract the unpleasant side effects of other drugs
of abuse
 Acute  Forgetfulness / Drowsiness/ ↓Consciousness and Co-ordination
o Rohypnol (Date Rape) can cause Anteroretrograde Amnesia
o Barbiturates can cause Respiratory Depression
 Injecting  Limb Ischemia and risks of Blood Bourne Viruses / Abscesses
 Withdrawal  Anxiety / Insomnia / Tremor / Agitation / Headache / Nausea /
Sweating / Depersonalisation / Seizures and Delirium
Stimulants:
 = Ecstasy / Amphetamines / Cocaine
 Acute  Arrythmias; Intense Anxiety; HTN ( CVA); Impulsivity and
Impaired judgement
o Ecstasy and Amphetamines  Hyperpyrexia and ↑Sweating
o Ecstasy in particular has been the cause of many
dehydration deaths.
 Chronic:
o Ecstasy  Neurotoxicity; Hepatotoxicity and Cognitive impairment
o Amphetamines  Anxiety and depressive symptoms
o Cocaine  Nasal Septum necrosis; fetal damage; panic and
anxiety disorders; persecutory delusions and Psychosis.
 Dependency:
o ↓ Dependency for Ecstasy or Amphetamines – other than
psychological addiction e.g. Will have more fun at the party tonight if I take it.
o Cocaine is associated with Classical dependence – with a compulsive pattern
Hallucinogens:
 = LSD / Magic Mushrooms / Ketamine
 Acute  Behavioural Toxicity (“I can fly”) and Bad Trips 
Dissociation, fear, incipient madness and frightening perceptions.
o Mushrooms can also  GI Symptoms + Risk of consuming
toxic fungi!
o Ketamine can also  Nausea/ Ataxia and Slurred Speech
 Chronic  Flashbacks; Persistent Psychosis; Persistent Anxiety /
Depressive symptoms
 NB: There is no risk of overdose, physiological dependence or withdrawal

3. Cannabis:
 Acute  Mild Paranoia / Panic attacks / Accidents and ↓Reaction times
 Chronic  Dysthymia / Anxiety and Depression / ‘Amotivational syndrome’
and it can precipitate or cause a relapse of Schizophrenia.
 Withdrawal  May occur in a heavy user, symptoms: Insomnia, anxiety
and irritability
 NB: There are no reports of fatal overdose and there is little physical
dependency.
Anabolic Steroids
 = Nandrolone and Stanozolol
o Prescription medication – legitimately used to Rx: Aplastic
Anaemia and Osteoporosis, but abused by Body Builders
and Athletes  Enhance performance
 Medically  Hypertension; Hypogonadism; Gynaecomastia;
Amenorrhoea; Liver Damage; Impotence and Male pattern
baldness
 Psychiatric  Acute emotional instability (‘Roid Rage’);
↑Aggressiveness; Persecutory/ Grandiose delusions; Depression and Chronic Fatigue.
 NB: There is no withdrawal syndrome, but injecting Steroids can lead to infections.
 Other drugs misused by Athletes = Thyroxine / GH / Diuretics / Epo / Amphetamines
Volatile Substances
 = Glue / Solvents / Lighter fuel / Paint Stripper / Fire Extinguishers / Aerosols / Paints/
Petrol / Correction fluid and Nail Varnish Remover
 All contain simple hydrocarbons:
 Acetone, Toluene, Xylene and Butane
 Acute  Local irritation; Headache; Cardiac Arrhythmias;
Suffocation (Bag or Laryngeal Oedema); LOC; Aspiration
and Sudden Death.
 Chronic  Liver and Kidney damage and Cognitive
impairment
 Withdrawal  Similar to Alcohol e.g. Sweating / Nausea /
Tremors
 Patients can become psychologically dependent upon it.
Key Points:
1. Use of any drugs can have Biological, Psychological and Social Complications
2. The most common drugs of abuse include:
o Alcohol / Opiates / Depressants / Stimulants / Hallucinogens / Cannabis and Volatile
Substances
3. Clinically Significant withdrawal is only seen in:
o Alcohol / Opiates / Nicotine / Benzodiazepines / Amphetamines and Cocaine.
o This is what makes these the most addictive drugs.
4. Other drugs can also become addictive because of their ability to:
a. Create associations with: Friends and Pleasurable experiences
b. Allow a degree of Escapism from reality
c. Allow the user to achieve a previously unreachable goal e.g. Anabolic Steroids
5. Always ask if a drug is being injected – because this creates an additional risk of Blood
Bourne Viruses, Infections e.g. Abscesses and Endocarditis and Blood clots.
References:
 Semple, D. Oxford Handbook of Psychiatry: 2nd
Edition. Oxford University Press; 2009
 Bourke, Castle and Cameron. Crash Course Psychiatry. 3rd
Edition. Mosby Elsevier; 2008