Psychiatric Nursing

INTRODUCTION

Amphetamine and amphetamine related substances are the second most widely misused drug in Asia and many other countries. Metamphetamine, a congener of amphetamine has become more popular in the recent years.

HISTORY

Amphetamine was first synthesized in 1887 and was introduced in to the clinical use in 1932 as an over the counter inhaler for the treatment of nasal congestion and asthma. 1n 1937 onwards it used for the treatment of narcolepsy, depression, post encephalitic Parkinsonism. The current FDA approved indications for amphetamine are for the treatment of attention deficit hyperactivity disorder and narcolepsy. In some countries it also uses for the treatment of obesity, depression, chronic fatigue syndrome, AIDS, and dementia.

PREPARATIONS

The major amphetamine preparations are

• Dextroamphetamine
• Metamphetamine (Desoxyn)
• A mixed detroamphetamine - amphetamine salt (Adderall)
• The amphetamine like compound methylphenidate (Ritalin)

These drugs go by such street names as ice, crystal, crystal meth and speed. Amphetamines are referred to as stimulants, sympathomimetics, analeptics and psycho stimulants. These are used to increase the performance and to improve the euphoric feeling. (Students studying for the exam, truck drivers, athletes for the competition,by soldiers during war time etc)

Other amphetamines like substances are ephedrine, psuedoepedrine, phenylepropanolamine (PPA). Amphetamine like dugs with abuse potential are also include phendimetrazine and diethylpropion, benzphetamine(Direx), and phentermine(ionamine).

EPIDEMIOLOGY

Amphetamine use occurs in all socioeconomic groups. According to DSM IV TR the life time prevalence of amphetamine dependence and abuse is 1.5% and the male to female ratio is 1.

ETIOLOGY

The familial, social, and psychological factors are relevant in the etiology of amphetamine misuse. Two-thirds to three-quarters of drug misusers have an underlying personality disorder, usually of the antisocial type,

CLINICAL FEATURES

• Amphetamine has a slower onset of action and a longer elimination half-life. Thus an amphetamine user may experience desired effects, unwanted mental effects, and withdrawal features over the course of a few days,
• A single 5mg dose increases the feeling of wellbeing and induces elation, euphoria and friendliness. Small doses usually improve performance and concentration. An associated decrease in fatigue, nightmares, fears, reduction of pain perception etc also seen.
• Mood is elevated, but these progresses to suspicion, in which true paranoid symptoms may be experienced and if use persists symptoms may become severe, or a more confused state develop.
• After stopping the drugs there are typically withdrawal effects of depressed mood, hyperphagia, and hypersomnia; such features are viewed as 'rebound' symptoms,
• It is commonly observed that amphetamine is non-addictive, or cause psychological but not physical dependence. It can be addictive' when individuals are injected amphetamine 10 or more times every day for many years,

Effects	Withdrawal effects
Increased energy Hyperactivity Euphoria Reduced appetite Insomnia Paranoid symptoms Confusion	Depression Irritability Agitation Craving Hyperactivity Hyperactivity Hypersomnia

NEUROPHARMACOLOGY

All the  amphetamines are rapidly absorbed orally(when compare to other stimulants like cocaine, its absorption rate is slow). And have rapid onset of action usually with in one hour when take orally. The classic amphetamines can take IV and the action will be very rapid in this route. Non described amphetamines and designer amphetamines can be inhaled (snorting). Tolerance develop with both classic and designer amphetamines. It is less addictive when compare with cocaine.

• The classic amphetamines produce primary effects by causing the release of catecholamines, particularly dopamine from the presynaptic terminals. It has effect on the dopaminergic neurons projecting from the ventral tegmental area to the cerebral cortex and limbic areas. This path way has been termed as reward circuit pathway and its activation is the major addictiong mechanism for the amphetamines.
• The designer amphetamines causes the release of the catecholamine's (dopamine and nor epinephrine) and of serotonin (the neurotransmitter implicated as the major neurochemical pathway of hallucinogens.). so the clinical effects of designer amphetamines are blend effect of classic amphetamines and those of hallucinogens.

DIAGNOSIS

DSM IV TR lists many amphetamine related disorders, but specific diagnostic criteria are available only for amphetamine intoxication, amphetamine withdrawal,  amphetamine related disorder not otherwise specified.

AMPHETAMINE (OR AMPHETAMINE-LIKE SUBSTANCE)-RELATED DISORDERS (DSM IV TR)

Amphetamine Use Disorders

304.40  Amphetamine Dependence a,b,c

305.70  Amphetamine Abuse

Amphetamine-Induced Disorders

292.89  Amphetamine Intoxication 

292.0  Amphetamine Withdrawal

292.81  Amphetamine Intoxication Delirium

292.xx  Amphetamine-Induced Psychotic Disorder

            .11 With Delusions

            .12 With Hallucinations

292.84  Amphetamine-Induced Mood Disorder,

292.89  Amphetamine-Induced Anxiety Disorder,  

292.89  Amphetamine-Induced Sexual Dysfunction,

292.85  Amphetamine-Induced Sleep Disorder     

292.9  Amphetamine-Related Disorder NOS

1.      Amphetamine dependence and amphetamine abuse

Amphetamine dependence dependence can result in a rapid downward spiral of a persons ability to cope with work, and family related obligations and stress. A person who abuse this drug requires high doses of amphetamine to to obtain the usual high and physical signs of amphetamine abuse(decreased weight and paranoid ideas) almost develop with the continuous use.

2. Amphetamine intoxications.

The symptoms of intoxication are mostly resolved after 24 hours and are generally completely resolved after 48 hours.

3.      Amphetamine withdrawal

After amphetamine intoxication, a crash occurs with symptoms of anxiety, dysphoric mood, lethargy, fatigue, night mares, head ache, profuse sweating, muscle cramps, stomach cramps etc. it will be peak in 2-4 days and are resolved with in one week. The most serious withdrawal symptom is depression which can be severe after the continuous use of the drug and also associated with suicidal ideations

4.      Amphetamine intoxication delirium

Delirium associated with amphetamine use generally result of high doses or of sustained use of the drug. The combination of amphetamine with other drugs and the use of amphetamine by the persons with pre existing brain damage also will lead to the development of delirium.

5.      Amphetamine induced psychotic disorder

Amphetamine induced psychotic disorder are similar to the clinical presentation of paranoid schizophrenia. The hall mark of amphetamine induced psychosis is paranoia. The amphetamine induced psychosis can be distinguished from paranoid schizophrenia by the clinical features such as visual hallucinations, ambivalence, association disturbances which are evident schizophrenia. The treatment of choice for this condition is the use of antipsychotics such as haloperidol.

6.      Amphetamine induced mood disorder

According to DSM IV TR the mood disorders associated eith amphetamine are during the intoxication and withdrawal states. Intoxication is associated with manic or mixed mood states where as withdrawal is associated with depressive symptoms

7.      Amphetamine induced anxiety disorders

Amphetamine induced anxiety disorders can also during intoxication and withdrawal periods. Amphetamines can induce symptoms which are similar to OCD, panic disorders, and phobia

8.      Amphetamine induced sexual dysfunction

Amphetamines can be use as an antidote to the sexual side effects of serotonergic agents such as fluoxetine, but they often misuse to enhance sexual experience. High doses and long term use are associated with erectile problems and other sexual problems. It is more evident in the intoxication states also.

9.      Amphetamine induced sleep disorder

Sleep disorders are present in intoxication as well as withdrawal states. Intoxication can cause insomnia and sleep deprivation and withdrawal can cause hyper somnolence and nightmares.

ADEVERSE EFFECTS

PHYSICAL

• Can produce most serous adverse effects which include cerebrovascular, cardiac and gastro intestinal effects. The life threatening conditions like MI, severe hypertension, CVA, and ischemic colitis are more common among abusers
• A continuum of neurological symptoms like twitching, tetany, seizures , coma, death etc can develop.
• IV use of the drug can cause the transmission of infectious diseases like AIDS and hepatitis.
• The non threatening adverse effects are flushing, fatigue, pallor, cyanosis, fever, bradycardia, palpitations, nausea, vomiting, bruxism, shortness of breath, tremor and ataxia.
• Pregnant women who use this drug often have babies of low birth weight, small head circumference, early gestational age and growth retardation

PSYCHOLOGICAL

• The adverse psycho logical effects include restlessness, dysphoria, irritability, hostility, confusion
• Amphetamine use can also lead to disorders like anxiety disorders, panic disorders, ideas of reference, paranoid delusions, and hallucinations
• Acute intoxication may present as a paranoid hallucinatory syndrome which closely mimic paranoid schizophrenia. The distinguish features of this are prominence of visual hallucinations, absence of thought abnormalities, presence of confusion.
• Tactile hallucinations in clear consciousness may occur in chronic amphetamine intoxication

TREATMENT

Treatment of intoxication

• Acute intoxication is treated by symptomatic management.(eg: hypepyrexia- cold sponging, seizures-diazepam, psychotic symptoms- haloperidol and hypertension-antihypertensives).
• Acidification of urine with oral NH4CL 500mg every 4 hours facilitates the elimination of amphetamines

Treatment of withdrawal symptoms

• The presence of suicidal depression requires hospitalization
• The treatment includes symptomatic management, use of antidepressants and supportive psychotherapy. The management of withdrawal syndrome is the first step of treatment of amphetamine dependence.
• Physicians should establish therapeutic alliance with the clients to treat the underlying depression and personality problems
• Bupropion can be use once the patient recover from the withdrawal symptom to enhance the feeling of well being.

REFERENCES

• Kaplan HI, Sadok BJ. Synopsis of psychiatry-behavioural science or clinical psychiatry.9^th edn. Hong Kong.William and Wilkinsons publications. 1998.
• GelderM,Gath D,Mayou R,Cowen P. New oxford text book of psychiatry. 4^th edn.Oxford. Oxford university press.2004
• Ahuja N.A short text book of psychiatry. 5^th edn. New Delhi. Jaypee brothers medical publishers.2004.
• Townsend MC. Psychiatric mental health nursing. 3^rd edn. Philadelphia. FH Davis publishers.