Post Drug Impairment Syndrome

 Clinical Manifestations:

Post- Drug Impairment Syndrome

Forest S. Tennant, Jr., M.D.

Post-drug Impairment Syndrome (PDIS) is a symptom complex frequently observed in people who are former abusers of drugs ad alcohol. It is now a common clinical problem, which can be chronic and possibly permanent, and it is likely caused by alterations in neurotransmitter metabolism and/or receptor sites. Among the most common symptoms of PDIS are low stress threshold, poor abstract reasoning, decreased attention span and instability of social functioning. The highest risk group appears to be adolescents who abuse multiple drugs and alcohol and then manifest the clinical syndrome when they become young adults.

Behavioral Objectives

After reading this continuing education article, the LP/VN should be able to:

      1.     Delineate the epidemiology of Post Drug Impairment Syndrome (PDIS)

      2.     Discuss the biochemical changes that may be found in the PDIS person

      3.     List the physical, emotional and psychological signs and symptoms of PDIS

      4.     Discuss why, at this time, there is no standard medication to treat PDIS

      5.     Name the benefits of family involvement in helping the PDIS person to function better

      6.     List some of the goals that are the most helpful in the management of PDIS patients

Forest S. Tennant, Jr., M.D., is an associate professor at the UCLA School of Public Health in Los Angeles. He is also the executive director of Community Health Projects, Inc., of West Covina, California.

This article reprinted with permission of Pharmacy Times.

 The Affected Population

PDIS occurs particularly in people who abused drugs and alcohol in their early teenage years, but it can happen to anyone exposed to certain drugs for a long enough time period.

Most people with PDIS who come to clinical attention are between the ages of 18 and 30 years. Characteristically, these people are unable to consistently hold a job, maintain personal relationships, achieve financial stability or endure much stress. They exhibit a bland personality, may be antisocial, demonstrate impaired abstract reasoning and have poor attention span.

The person who will most likely exhibit PDIS is someone who abuses drugs before the age of 15. Drug abuse usually involves marijuana plus at least one other substance such as alcohol, cocaine, phencyclidine (PCP), amphetamines, LSD, mushrooms or one of the so-called “designer drugs”, particularly methylenedioxy- amphetamine (MDMA or “Ecstasy”). (See table 1.) Phrases used to describe some of these individuals are “the chronic young adult psychiatric patient” and “the drug burnout.” The former description refers to young adults who are almost constantly under psychiatric care, and the latter is a term frequently used by “street users” to describe PDIS.

Based on clinical reports, some clinicians believe that PDIS is growing at an alarming rate. Various estimates suggest that the PDIS population is between three million and five million young people. Although the precise number is unknown, PDIS is clearly a major public health problem. Its growth appears to parallel the rise in drug abuse over the past decade and the increasing availability of more potent forms of Marijuana, PCP and cocaine. About five years ago, the potency of marijuana usually sold in the United States averaged only 1 percent to 2 percent tetrahydrocannabinol (THC) content. Today the potency is up to as high as 5 percent to 14 percent THC. Many people with PDIS may continue to abuse the same drugs that caused their impairment. While convincing most PDIS individuals to totally stop drug or alcohol abuse is extremely difficult, the major clinical problem id the underlying neurochemical impairment suffered by the impatient.

Table 1: Drugs associated with PDIS and some of the Neurotransmitters and receptors likely to be affected:

 Neurochemical Changes in PDIS

The best scientific evidence at this time indicates that drug abuse may damage specific receptor sites and/or neurotransmitter metabolism in the brain. Obviously, if a receptor site is damaged, neurotransmitters cannot appropriately perform their natural functions. When drug abuse alters the metabolism of a neurotransmitter, the brain may have too much or too little neurotransmitter. Thus, PDIS results basically from an imbalance of the chemical equilibrium of the brain. Some PDIS individuals have a pre-existing psychiatric disease prior to rug abuse, take excessive quantities of drugs, and then develop PDI, which is aggravated by the psychiatric illness. In some cases, it is clinically difficult to precisely determine if symptoms of PDIS are caused by drug abuse or by a pre-existing psychiatric problem. However, base on the observations of many clinicians, it appears that drug abuse per se commonly produces PDIS without apparent, pre-existing genetic or psychiatric illness.

Drug abuse may clearly alter nervous system neurotransmitters and receptor sites in such a manner that some of the neurochemical abnormalities can be detected by various biochemical assays. The term “brain damage” has frequently been used in medical practice to describe the individual who shows tissue damage as diagnosed by x-Ray, electroencephalogram (EEG), air encephalogram or computerized tomography (CT) scan. The type of biochemical changes found in PDIS do not show on these diagnostic studies because these tests are not sufficiently refined. At this time, clinical neurochemical testing is still in its infancy and is generally considered appropriate only for research.

PDIS patients have demonstrated some neurotransmitter abnormalities; however, no predictable or consistent pattern has been identified. Because laboratory tests have the potential of determining the precise chemical defects I PDIS, it is hoped that when these tests are perfected, individuals with PDIS can be better treated.

Clinical Characteristics

The clinical signs and symptoms of PDIS are relatively easy to recognize. Today, many parents, relatives, friends and employers realize that there may be something wrong with an individual who has previously used drugs, but they do not quite know how to characterize it or understand what has happened. A review of Table 2 will help determine if a given individual has PDIS. If a person who ha previously abused drugs demonstrates at least half of the signs and symptoms listed in Table 2, the presence of PDIS is relatively certain. 

A primary symptom of PDIS is the inability of the individual to endure life’s everyday stresses and maintain patterns of social consistency, e.e, holding a job, sustaining a marriage, saving money, completing school or taking care of such personal belongings as a car and clothes. The low stress threshold is often manifested in sudden outbursts of temper, depression or bizarre behavior that may include delusions. Further, the social instability is sometimes manifested by these individuals moving from house to house or town to town, never living in one place very long. Often, they will stay with their parents for a few weeks, suddenly disappear for days, and then re-appear completely oblivious to the fact that they left without warning; nor can they understand their parents’ concern. These individuals frequently join communes, residential groups or religious cults because there they experience less stress and responsibility.

Another typical symptom is the inability to concentrate properly or maintain an adequate attention span. This results in the PDIS person constantly changing his mind and not being able to complete tasks. Sometimes, the first symptom is the inability to do abstract thinking. Impaired abstract reasoning shows itself by the individual not being able to reason properly when presented with more than two or three facts. This manifests itself by the individual making poor judgments and decisions. Additionally, this impairment prohibits the patient from maintaining sophisticated employment or being a strong competitor.

Although PDIS individuals state that they have “lots of friends,” close observation usually reveals the contrary; they have only one or two people of either sex that they stay in close contact with for very long. In other words, they are “loners”, but they do not see themselves as such. In general, PDIS individuals do not perceive the world as most normal people do. They commonly believe they are fine and functioning well despite ample evidence to the contrary. 

Table 2: Common Signs and Symptoms in PDIS Patients

Poor abstract reasoning. Makes poor judgments when faced with several facts

Can’t hold a job or remain in school very long

Doesn’t maintain interpersonal relationships with friends or spouse

Can’t endure much stress, including everyday social stresses

Can’t maintain personal belongings, including clothes and car

Exhibits poor hygiene and dress

Poor attention span and ability to concentrate

Doesn’t finish many tasks

Can’t save or handle money; spends money on foolish, frivolous or impractical items

Poor memory; loses belongings

Has bland or dull personality

Lacks a proper sense of humor

Frequent temper tantrums

Moves frequently from one living quarters to another- often without notice

Feels alienated from society; blames others for problems

Doesn’t respond appropriately to instructions or advice

Feels alienated from society; blames others for problems

Doesn’t respond appropriately to instructions or advice

Feels “nothing is wrong”, even when facts are obviously to the contrary

Changes mood constantly

Poor conversationalist

Poor sense or time, misses appointments, and is repeatedly tardy

Entertains self for hours by constant television watching or aimless wandering

Seldom reads a newspaper, magazine or book

Seizure disorder (epilepsy)

Unusual headaches or pains, tremor, neuropathies (tingling sensations in arms, legs or face).

Abuses alcohol and possibly continues some drug abuse.

Treatment Modalities

Currently, there is no predictable, effective treatment for PDIS. Unfortunately, before this condition is accurately diagnosed, these individuals and their families may spend great amounts of time and money in psychiatric facilities or in various drug abuse treatment programs. In some severe cases, the PDIS patient may never clinically improve, even with treatment. Other people appear to almost recover or greatly improve if they abstain from drugs of abuse for an extended period of time. In many cases, medication will have some beneficial effect, but there is no standard medication for these people at this time. Table 3 shows some medications that have been found to be clinically helpful in some PDIS cases. In addition, amino acids (tyrosine and tryptophan) and multivitamin supplements may be used.

Most PDIS patients are forced into treatment by their parents or other family members who may later be disappointed with the results. What happens is that after treatment, the PDIS individual may begin behaving almost normally and may even start being socially productive, but this may only last for a few days or weeks. It is at this point that the PDIS person begins to exhibit the common signs and symptoms of PDIS mentioned in Table 2.

Some PDIS persons will relate to a counselor, minister, teacher, social worker, psychologist, nurse or physician. Counseling is best focused toward having the PDIS person be a productive citizen who is not engaging in antisocial, illegal or violent activities. Generally, the PDIA patient will function best in a low-stress, but highly-structured and disciplined, environment. This is most often achieved if counseling is done at frequent and regular intervals. Some PDIS will attend support group therapy sessions, particularly when these groups are lead by a knowledgeable professional. Unfortunately, few PDIS patients will stay with any type of group or individual treatment for very long due to their inability to maintain any long-term relationship.

Table 3: Therapeutic Agents for PDIS*

 Name of Drug                                                   Recommended Dosage

Amantadine (Symmertel)                                 100 mg to 300 mg/day

Carbamazpine (Tegretol)                                 400 mg to 800 mg/day

Lithium                                                                60 mg to 900 mg/day

Naltrexone (Trexon)                                          25 mg to 50 mg/day

 *These agents have appeared to be clinically helpful to the author in individual cases of PDIS, but there have not been controlled studies.

Short-term Hospitalization

Short-term hospitalization can be effective in many cases. This period may allow for diagnostic testing, stabilization, the starting of medication and development of an outpatient care plan. Unfortunately, since few psychiatrists. Pharmacists, psychologists, physicians and hospitals are yet familiar with PDIS; they will try to treat the PDIS patient like a traditional psychiatric patient, which is usually not helpful. When a family is searching for an appropriate physician or hospital, in-depth professional expertise in drug abuse and PDIS should be ascertained. The best hope for the future PDIS treatment lies in research. With better identification of the precise nuerochemical defects in PDIS, it may be possible to select medication that it will be specific for the individual.

Guidelines and Goals for PDIS

The most important thing a parent or family member can do for someone who has PDIS is to recognize the fact that this syndrome is real, likely to be chronic or permanent, and that there is no reliable treatment. The family must emotionally accept the fact that the patient as impaired his neurochemical system. Once this is accepted, the family can then develop realistic plans to help take care of the individual over a period of many years. This situation has great commonality with families who have a member who is mentally retarded, schizophrenic or senile.

As a reasonable goal of case management, it is recommended that the PDIS patient be guided toward: (1) having a productive, structured and highly- supervised job that has little stress; (2) developing behavior that does not include further drug abuse or illegal actions; (3) acquiring the necessary skills for hygiene and nutritional needs; and (4) managing money well enough to be reasonably independent (Table 4). It is also generally recommended that the individual not have children because he will seldom be capable of raising them appropriately.

Table 4: Goals and Guidelines for Management of PDIS Patient

Obtain low stress, productive employment

Isolate intermittently from other family members

Teach responsible financial management

Attempt to structure time for regular diet, hygiene, exercise and sleep

Discourage driving of motor vehicles

Assess financial risk if patient is allowed to drive

Find a physician who will try various medications to control symptoms

Find a knowledgeable counselor who will help structure behavior

Ensure that medical and counseling appointments are kept and prescribed medication taken

Try to eliminate further alcohol or drug abuse

Caution against having children

If the family determines that the PDIS individual needs to stay home, he should be given a separate room or portion of the house to minimize interference with the lives of other family members. The PDIS person will almost always have numerous objectionable habits and behaviors that will disrupt and antagonize other family members. Such people usually need to e isolated for the mental health of other family members.

Since PDIS persons may not handle money well, they should never be given very much with which to manage their personal affairs unless they can demonstrate financial responsibility, nor should they be allowed to drive cars because they have frequent auto accidents.

Families should be prepared for the PDIS person to leave home and job without warning- then to suddenly return after a few days, weeks or months and expect to be treated as before. If there are attempts at hospital or medical treatment, no beneficial, long-term effects should be counted on; thus, the family may wish to avoid these costs, which can be exorbitant in futile attempts at treatment.

Any progress that the family makes in getting the PDIS individual to take multiple vitamins, eat a balanced diet, maintain a regular sleep pattern and do physical exercise will probably be rewarded with a healthier patient who may function better. Anecdotal evidence that someone who has “drug burnout” may sometimes benefit from high doses of multiple vitamins and amino acids. Although scientific evidence for this approach is scant, this therapy is inexpensive and may help individuals who have PDIS. Exercise is known to stimulate neurotransmitters in the brain, so this may be particularly beneficial; on the other hand, exercise might stimulate the “wrong” neurotransmitters and make the patient worse.

The family of a PDIS patient should attempt to find a knowledgeable physician they can confide in, as well as one who is willing to try a variety of different medications over a period of time (Table 3), in an attempt to improve the patient’s behavior and control his symptoms. A family physician or psychiatrist may have to try different medicines before finding one that will be effective enough to help the PDIS individual become productive in society.

In addition, a counselor or therapist who will work to achieve the case management goals noted in Table 4 can be helpful. Unfortunately, PDIS individuals usually do not perceive themselves as having a problem. Consequently, they seldom keep regular medical or counseling appointments or take medication as prescribed. All persons involved with a PDIS patient can help if they insist that medical appointments be kept and prescribed medication taken.

Examination on

Post-Drug Impairment Syndrome

(Choose one most correct answer)

1.     Which of these is the drug of choice for treating PDIS?

         a.      Haloperidol

         b.     Amitriptyline

         c.     Phenobarbital

         d.     There is no predictable effective treatment

2.     What type of environment is best for the PDIS patient?

         a.      Highly structured

         b.     Low stress

         c.     Highly disciplined

         d.     All of the above

3.     Which of the following drugs is commonly associated with PDIS

         a.      Cocaine

         b.     Diazepam

         c.     Phenobarbital

         d.     All of the above

4.     Which of these neurotransmitters/ receptors is/are likely affected by alcohol in PDIS patients?

         a.      Norepinephrine

         b.     Endorphin

         c.     Dopamine

         d.     All of the above

5.     Which of the following is not a common sign of PDIS?

         a.      Poor memory

         b.     Good conversationalist

         c.     Poor sense of time

         d.     All of the above

6.     Which of the following is an extremely- useful diagnostic test for PDIS?

         a.      Electroencephalogram

         b.     Computerized tomography scan

         c.     X-ray

         d.     None of the above

7.     Inability to do abstract thinking is:

         a.      Rarely observed in PDIS patients

         b.     Frequently a late sign of PDIS

         c.     Sometimes an early sign of PDIS

         d.     None of the above

8.     The person who will most likely exhibit PDIS is someone who abuses drugs before the age of :

         a.      10

         b.     15

         c.     18

         d.     21

9.     Low stress threshold, secondary to PDIS, is often manifested in;

         a.      Sudden outbursts of temper

         b.     Depression

         c.     Bizarre behavior

         d.     All of the above

10.    In some severe cases, the PDIS patient may:

         a.     Never clinically improve

         b.     Never pose a major public health problem

         c.     Obtain high-stress, productive employment

         d.     None of the above

11.    Short-term hospitalization for patients with PDIS may be affective for:

         a.     Diagnostic testing

         b.     Beginning drug therapy

         c.     Developing an outpatient care plan

         d.     All of the above

12.    Which of the following Drugs associated with PDIS most likely affects the norepinephrine neurotransmitter/receptor?

         a.      Phencyclidine

         b.     Cocaine/amphetamine

         c.     MDMA

         d.     All of the above

13.     Patients with PDIS frequently:

         a.      Have no problem maintaining a responsible position

         b.     Join communes, residential groups or cults

         c.     Have many friends for a long period of time

         d.     None of the above

14.     Most PDIS patients are forced to begin treatment by their:

         a.      Parents

         b.     Family physician

         c.     Pharmacist

         d.     Local law enforcement agency.

15.     Which of these is/are a common sign(s) of a PDIS patient?

         a.      Does not finish many tasks

         b.     Frequently reads the newspaper excessively

         c.     Will never watch television

         d.     All of the above

16.    Which of the following have been clinically helpful in some PDIS cases?

         a.      Lithium

         b.     Potassium supplement

         c.     Sodium supplement

         d.     Calcium supplement

17.    It has been estimated that the PDIS population is between/about:

         a.      10,000 to 15,000 young people

         b.     15,000 to 25,000 young people

         c.     One million young people

         d.     Three million to five million young people

18.    Patients with PDIS usually:

         a.      Make excellent parents

         b.     Believe that nothing is wrong with them

         c.     Cause no problems when living with family members

         d.     All of the above

19.    Which of the following may help the PDIS patient to function better?

         a.      A balanced diet

         b.     Multiple vitamins

         c.     Proper physical exercise

         d.     All of the above

20.    Which of these neurotransmitters/ receptors is/are likely affected by LSD in PDIS patients?

         a.      Serotonin

         b.     Gamma Amino Butyric acid

         c.     Endorphin

         d.     All of the above

(JPN’s C.E. program is presented in cooperation wih the Arnold and Marie Schwartz College of Pharmacy & Health Sciences; St. John’s University College of Pharmacy & Allied Health Professional; and Pharmacy Times.)