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SUBSTANCE ABUSE DISORDERS

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Substance abuse disorders

Drug use – when drugs are used to treat an illness, prevent a disease and improve health condition, it is termed drug use

Drug abuse – intake of drugs for reasons other than medical in a manner that affect physical or mental functioning is termed drug abuse.

Tolerance – it refers to a condition where the user needs more and more of the drug to experience the same effect. Smaller quantities, which were sufficient earlier, are no longer effective and the user is forced to increase the amount of drug intake

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Intoxication - it is a condition that follows the administration of a psychoactive substance and results in disturbance in the level of consciousness, cognition, perception, judgment, affect, or behavior, or other psych physiological functions and responses.

Dependence – dependence syndrome is a cluster of physiological, behavioral, and cognitive phenomena in which the use of a substance or a class of substances taken on a much higher priority for a given individual than other behaviors that once had greater values

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Psychological dependence – psychological or psychic dependence refers to the experience of impaired control over drinking or drug use while physiological or physical dependence refers to tolerance and withdrawal symptoms.

Harmful use – pattern of psychoactive substance use that is causing damage to health. It may be physical or mental

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Abuse – in DSM IV, psychoactive substance use is defined as a maladaptive pattern of use indicated by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the recurrent use in situations in which it is physically hazardous.

Withdrawal symptoms - when the drug intake is stopped, withdrawal symptoms are experienced. Physical dependence gives rise to withdrawals such as tremors and vomiting. Psychological dependence causes withdrawal symptoms like restlessness or depression.

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Definition

DSM-IV, ‘psychoactive substance abuse’ is defined as a maladaptive pattern of use indicated by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the recurrent use in situations in which it is physically hazardous.

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Epidemiology

14 million of U.S population reported current use of illicit drugs

Almost 6% of the population were heavy drinkers

WHO indicates 180 million people of the world’s population consumed illicit substances

The most commonly consumed substance was cannabis, used by 144 million people of the world’s population

Annual prevalence of cannabis abuse among people aged 15-64 in India is 3.2%

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Classification of addictive drugs

1. Narcotic Analgesics2. Stimulants3. Depressants4. Hallucinogens5. Cannabis6. Volatile Solvents7. Other drugs of abuse (muscle relaxants,

painkillers, anti histamines, anti emetics, antipsychotics )

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Commonly abused drugs in India

Cannabis (bhang, ganja, charas)Tranquilizers (hypnotics, sedatives)Barbiturates Amphetamines Hallucinogens Narcotic drugs (opium, pethidine, morphine,

morphine, heroin, cocaine)Tobacco (cigar, cigarette, beedi, hukka )Other substances such as alcoho,inhalants,

steroids

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ICD 10 classification

F10-F19 Mental and behavior disorders due to psycho active substance use

F10 Mental and behavioral disorders due to use of alcoholF11 Mental and behavioral disorders due to use of opioidsF12 Mental and behavioral disorders due to use of

cannabinoidsF13 Mental and behavioral disorders due to use of

sedatives or hypnoticsF14 Mental and behavioral disorders due to use of cocaineF16 Mental and behavioral disorders due to use of

hallucinogens

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Causes of substance abuse

Biological factorsGenetic vulnerabilityCo morbid psychiatric disordersCo morbid medical disordersReinforcing effects of drugsWithdrawal effects and cravingBiochemical factors

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Psychological factorsCuriosityEarly initiation of alcohol and tobaccoPoor impulse controlSensation seekingLow self esteemConcern regarding personal autonomyPoor stress management skillsChildhood trauma or lossPsychological distressEscapism

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Social factorsPeer pressureModelingEasy availabilityInterfamilial conflictsReligious reasons and cultural factorsPoor social and familial supportRapid urbanizationRole of mediaPopularity of drugs in various profession

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Risk factors

Chaotic home environmentIneffective parentingLack of nurturing and parental attachmentInappropriately aggressive or shy behavior in

classroom Poor social coping skillsPoor school performanceAssociation with deviant peer groupPerception of approval of drug use behavior

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Stages of substance abuse

1. Stage 0 –showing curiosity : it is the first stage and it is the beginning of substance abuse

2. Stage 1- learning about the drug induced mood swings : the teen learns more about use of drugs

3. Stage 2- seeking the drug induced mood swings : learns to seek the heights of psychological effects

4. Stage3 – being preoccupied with the drug induced mood swings: behavior changes to stealing, truancy, lying, drug dealing etc

5. Stage 4- burnout : at this stage they use drug just to feel normal, euphoric effects may be low.

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Opioid use disorders

The commonly abused opioids – heroin, brown sugar, smack

Synthetic preparation – pethidine, fortwin, buprenorphine

Acute IntoxicationApathyBradicardiaHypotensionRespiratory depression, subnormal temperaturePin point pupils, thready pulse, coma

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Watery eyesRunning noseYawningLoss of appetiteIrritabilityTremorsSweatingCrampsNausea

DiarrheaInsomniaRaised body

temperaturePiloerectionAnorexiaThe symptoms start with

in 12 hrs, lasts to 24-36 hrs and disappear in 5-6 days

Withdrawal syndromeWithdrawal syndrome

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Complications

ParkinsonismPeripheral neuropathyTransverse myelitisSkin infectionThrombophlebitisPulmonary embolismEndocarditisSepticemiaAIDS, viral hepatitisTetanus

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Treatment

Narcotic antagonists (naloxone, naltrexone)Detoxification (methadone, clonidine,

naltrexone, buprenorphine)Maintenance therapy (methadone

maintenance, opioid antagonists, individual therapy, group therapy, family therapy)

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Cannabis use disorder

The dried leaves and flowering tops are often referred to as Ganja or Marijuana

The resin of the plant is referred to as Hashish

Bhang is a drink made from cannabisCannabis is either smoked or taken in liquid

form

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Mild impairment of consciousness and orientation

TachycardiaSense of floating in the airEuphoria Dream like state ‘flashback’ phenomenaAlteration in psychomotor

activity

TremorsPhotophobiaLacrimationDry mouthIncreased appetitePerceptual

disturbances

Acute intoxication

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Withdrawal symptoms

Mostly found in 72-96 hoursIncreased salivationHyperthermiaInsomniaDecreased appetiteLoss of weightInsomnia

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Complications

Transient or short lasting psychiatric disorders

Acute anxietyParanoid psychosisHysterical fugueHypomaniaSchizophrenia like stateAmotivational syndromeMemory impairement

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Cocaine use disorder

Common street name is’crack’It is taken orally, intranasally or parenterallyAcute IntoxicationPupillary dilationTachycardiaHypertension Perspiration Nausea Hypomanic symptoms

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Withdrawal syndrome

AgitationDepressionAnorexiaFatigueSleepiness ComplicationsAcute anxiety reactionUncontrolled compulsive behaviorSeizures Respiratory depression, cardiac arrhythmias

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Treatment

Management of intoxication ( Amyl nitrate is antidote, diazepam or propranolol is used)

For withdrawal symptoms (antidepressants and psychotherapy)

Imipramine or amitriptiline

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Amphetamine use disorder

They are CNS stimulantsCommonly used amphetamines are pemoline and

methylphenidateAcute IntoxicationTachycardia pupillary dilationHypertension insomniaCardiac failure restlessnessSeizures irritabilityTremors paranoid hallucinatory

syndromehyperpyrexia

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Withdrawal syndrome

DepressionApathyFatigueHypersomniaInsomniaAgitationHyperphagia Complication Seizures, deliriumArrythmias, aggression, coma

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Barbiturate use disorder

Commonly abused barbiturates are secobarbital, pentobarbital and amobarbital

I n t o x i c a t i o n IrritabilityLability of moodDisinhibited behaviorSlurred speechIncoordinationAttention and memory impairment

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Complications Withdrawal syndrome

IV use lead to skin abscesses

CellulitisInfectionsEmbolismHypersensitivity

reactions

Severe restlessnessTremorsSeizuresDelirium tremens

like state

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Treatment

Induction of vomiting (in conscious patients)Use of activated charcoal (to reduce

absorption)Symptomatic treatment

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LSD use disorder (Lysergic acid diethylamide)

LSD is a hallucinogenFirst synthesized in 1938It acts on 5 HT levels of brain“trip” is the term used for the pattern of LSD

use (occasional use followed by long term abstinence)

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Intoxication

Perceptual changesDepersonalizationIllusionsSynesthesias (colours are heard, sounds are

felt)Autonomic hyperactivityAnxietyParanoid ideationImpaired judgement

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Withdrawal syndrome Complications

FlashbacksHallucinogenic

states

AnxietyDepressionPsychosisVisual hallucinations

Treatment is symptomatic, including, antianxiety, antidepressant and antipsychotic medications

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Inhalants or volatile solvent use disorders

Commonly used substances are petrol, aerosols, thinners, varnish remover and industrial solvents

IntoxicationEuphoriaExcitementBelligerence Slurred speechApathyImpaired judgment

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Withdrawal symptoms Complications

AnxietyDepression

Treatment includes reassurance and diazepam for intoxication

Irreversible damage to liver and kidneys

Peripheral neuropathy

Perceptual disturbances

Brain damage

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Treatment

CBTMultidimensional family therapyMotivational interviewingContingency management (motivational

incentives)Aversion therapyGroup therapyCounselling Residential treatment (therapeutic

community, 6-12 months, for drug free re socialization)

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Assessment Nursing diagnosis

BackgroundSubstance useMental health

problemsPsychological testsMental status

examination

AnxietyDisturbed sleep patternAltered nutrition less

than body requirementImpaired social

interactionsLow self esteemIneffective individual

copingRisk for violence

Nursing management

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Prevention of substance use disorders

Primary preventionEnhance government restrictionsStrengthen individuals coping skillsHealth education to college studentsIdentify and treat family member who may

contribute to drug abuse

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Secondary preventionEarly detection and counsellingMotivational interviewingComplete assessment to elicit the extend of

problemDetoxification with benzodiazepoxide

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Tertiary prevention Relapse prevention

Assertive trainingTeach coping skillsBehavior counselingPsychotherapySupportive

psychotherapyGuidance and

counseling

Motivation enhancementDealing with faulty

cognitionTime managementAnger controlFinancial managementStress managementRecreation and

spiritualityFamily counseling

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Goals Interventions

To enable the drug dependent to leave the drug

To establish new social contracts

To provide social support

To inculcate responsibility in protecting themselves

Participation in day care centers

Occupational and social rehabilitation

Teaching relaxation techniques

Religious therapyEnhance self esteemParticipation in self help

groups

Rehabilitation

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Follow up and home care

Nurses should be hopeful and appropriately supportive

Teach patient / family about the various complications of abuse

Explain to the family, that patient may use lies, denial or manipulation to continue drug

Teach them drug overdose may result in emergency/ death

Caution patient about transferring HIV or hepatitis B

Teach family to develop trust with patient and help in setting limits

Provide patient the full range of treatment and supportive measures

Teach them how to recognize psychological stressors and way to cope with that

Help to establish new life style.

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ALCOHOLISM

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INTRODUCTION

Alcoholism is the most common psychiatric disorder. Epidemiological studies carried out in India revealed that 20 to 40% of subjects aged above 15 are current users. Nearly 15 to 30% of patients seeking admission in psychiatric facilities are for alcohol related problems.

Alcoholism is classified under F10-F19, i.e. mental and behavior disorders due to psychoactive substance use in ICD 10 classification

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DEFINITION

1. Alcoholism refers to the use of alcoholic beverages to the point of causing damage to the individual and society or both.

2. Alcoholism is defined as a chronic disease manifested by repeated drinking that produces injury to the drinker’s health or to his society or economic functioning.

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PREVALANCE

In India the incidence of alcohol dependence is 2% and 20 to 40% of population aged above 15 are current users.

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WHAT IS ALCOHOL?

Alcohol includes liquors, beer and wine.

Chemical name: ethanol

Street names: booze, hooch, moonshine, sauce etc..

Mode of administration: oral

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HOW IT ACTS?

Acts on CNS in two ways

1. It potentiates GABA activity

2. It decreases glutamate activity In both cases the outcome is

depression.

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PROPERTIES OF ALCOHOL

Clear colored liquidStrong burning tasteRate of absorption into blood is more faster

than its elimination rate.Absorption is slower in the presence of foodA small amount is excreted through urine and

small amount is exhaled.

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Conti..

A conc. of 80-100mg per 100ml of blood is considered as intoxication

A person with 200-250mg per 100ml of blood will be toxic, sleepy, confused, and his thought process will be altered.

If the conc. is 300mg per 100ml of blood, the person may loose consciousness.

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Conti…

A conc. of 500mg per 100ml of blood is fatalAll the symptoms change according to the

tolerance of the person.

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ETIOLOGICAL FACTORS

1. Biological factors2. Psychological factors3. Social factors4. Availability5. Psychiatric disorders

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BIOLOGICAL FACTORS

Genetic vulnerability

Family history of substance abuse

Biochemical factors

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PSYCHOLOGICAL FACTORS

Sense of inferiority Poor impulse control Low self esteem Poor stress management skill Loneliness

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Conti…

Unmet needsDesire to escape from realityDesire to experimentA sense of adventurePleasure seekingSexual immaturity

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SOCIAL FACTORS

Peer pressure Urbanization Extended period of

education Unemployment Over crowding Social isolation

Poor social supportReligious reasons Effect of mass mediaOccupational factors

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AVAILABILTY

alcohol is easily available and drinking is accepted as a norm in functions and gatherings,

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PSYCHIATRIC DISORDERS

Depression Anxiety disorders Personality disorders Organic brain disorders schizophrenia

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STAGES IN ALCOHOLISM

1. EARLY STAGE (1st stage)

Increased tolerance Blackouts Pre-occupation Grossed drinking

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2 MIDDLE STAGE (2nd stage) Loss of control over amount, frequency Keeping away from alcohol for sometime,

but going back to obsessive drinking after each abstinent period.

Denial Feeling of guilt and shame Chronic hangover Projection

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3 CHRONIC STAGE Getting drunk even on small amount of alcohol intake Willing to lie, beg, borrow, steal to maintain supply of

alcohol Living to drink Avoiding family and friends Loss of interest Problem with low Moral deterioration Impaired thinking Loss of tolerance to alcohol

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Signs and symptoms of ADS

Malaise, dyspepsia, mood swings,Poor personal hygiene, untreated injuries (cigarette

burns, bruises)Unusually high tolerance for sedatives and opioids Nutritional deficienciesSecretive behaviorConsumption of alcohol containing productsDenial of problemTendency to blame others and rationalize problems Impaired controlWithdrawal symptomsNeglect of other activitiesPersistent use

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Psychiatric disorders due to alcohol dependence

1. Acute intoxication 2. Withdrawal syndrome3. Alcohol induced amnestic disorders4. Alcohol induced psychiatric disorders

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Acute intoxication

Develops during or shortly after alcohol ingestion.

Inappropriate sexual or aggressive behaviorMood labilityImpaired judgmentSlurred speechUnsteady gaitImpaired attention

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Withdrawal symptoms

Persons who have been drinking heavily over a prolonged period of time, any rapid decrease in the amount of alcohol in the body is likely to produce withdrawal symptoms

a) Mild withdrawal symptomsb) Delirium tremons

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Mild withdrawal symptoms

Mild tremorsNauseaVomitingWeaknessIrritabilityInsomniaAnxietyDepression Fatigue Night tremors

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Delirium tremens

Occurs within 2-4 days of complete abstinent from heavy drinking

Recovery occurs within 3-7 days• Clouding of consciousness• Disorientation• Poor attention span• Hallucinations• Grossly tremors of hands• Sweating, fever, tachycardia, increased BP

(autonomic disturbances)

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Cont…

• Visual and tactile hallucination• Truncle ataxia (Impairment of the ability to

perform smoothly coordinated voluntary movements. This condition may affect the limbs, trunk, eyes, pharynx, larynx, and other structures )

• Dehydration, electrolyte imbalances• Insomnia• Infection, self inflicted injury• Cardiovascular collapse• Death

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Cont….

. SweatingFeverTachycardiaRaised BPDehydrationDeath may occur due to cardiovascular

collapse, infection, self inflicted injuries

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Alcohol induced amnestic disorders

Chronic alcohol abuse associated with thiamine (vita B) deficiency is the most frequent cause of AD

1. Wernicke’s syndrome Cerebellar ataxia Palsy of 6th cranial nerve peripheral neuropathy Mental confusion

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Korsakoff’s syndrome

DisorientationConfusionConfabulationPoor attention span

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alcohol induced psychiatric disorders

DementiaMood disordersSuicidal behaviorAnxiety disorderImpaired psychosexual functionPathological jealousyAlcoholic seizuresAlcoholic hallucinosis

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COMPLICATIONS

1. Medical complications

2. Social complications

3. Psychiatric complications

CirrhosisPancreatitisPolyneuropathyRisk for cancerViolenceRapesViolating lowAnxietyConfusionOrganic brain

syndrome

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A Medical complications

1 GI SYSTEM Gastritis Peptic ulcer Vomiting Carcinoma Malabsorption syndrome Fatty liver

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Conti..

Cirrhosis of liverHepatitis

2 Cardio vascular system Alcoholic cardiomyopathy High risk for MI

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3 CNS Peripheral neuropathy Epilepsy Head injury Cerebellar degeneration

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4 Blood Anemia Decreased WBC production Protein malnutrition5 Skin Spider angiomas acne

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6 Joints Gout7 Pregnancy Fetal alcohol syndrome Fetal abnormalities Mental retardation Growth deficiency

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8 Reproductive system Sexual dysfunction in males Failure of ovulation in females

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B Social complications

Marital disharmonyOccupational problemsFinancial problemsCriminalityaccidents

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C psychiatric complications

Acute intoxication1. Maladaptive behavior2. Psychological changesWithdrawal syndrome1. Simple withdrawal syndrome2. Delirium tremens3. Alcoholic seizures4. Alcoholic hallucinosis

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Diagnosis

Blood alcohol level 200mg/dlUrine toxicology to reveal use of other drugsSerum electrolyte analysisLFTHematologic studiesECG, echo cardiogramBlood glucose levelElevated ALT and AST

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Treatment

Symptomatic Rx involve respiratory support, fluid replacement, emergency measures for trauma etc

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Treatment for withdrawal symptoms

1. Detoxification *benzodiazepines (chlordiazepoxide 80-

200mg/day) * diazepam 40-80 mg/day * 100mg of thiamine twice daily fro 3-5

days, then oral administration for 6 months *anticonvulsants if necessary * maintain electrolyte balance

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Cont…

2. Alcohol deterrent therapyDeterrent agents are those which are given to

desensitize the individual to the effects of alcohol and maintain abstinence. The most commonly used drug is disulphiram(tetraethyl thiuram disulfide) or antabuse

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Psychological Rx

Motivational interviewingGroup therapyAversive conditioningCognitive therapyRelapse prevention techniquesCue exposure technique

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Disulfiram

It is used to ensure abstinence in the treatment of alcohol dependence. Its main effect is to produce a rapid and violently unpleasant reaction in a person who ingests even a small amount of alcohol while taking disufiram

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Dosage

Tablets 200-500 mgInitial dose – 500 mg/ day orally for initial 2

weeksMaintenance dose later, of 250mg/dayDose should not exceed 500mg/day

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Mechanism of action

When alcohol is consumed, it is metabolized by the body into acetaldehyde, a very toxic substance , that causes many ‘hang over’ symptoms. Disulfiram interferes with the metabolism of alcohol that increases the acetaldehyde level (10 times > in normal alcoholics) and it produces a wide variety of unpleasant reactions called Disulfiram Ethanol Reaction (DER)

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DER symptoms

FlushingNauseaVomitingSweatingThirstThrobbing headacheRespiratory difficultyChest painPalpitationsDyspnea

HyperventilationTachycardiaHypotensionSyncopeSevere uneasinessWeaknessVertigoBlurred visionconfusion

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Side effects Contraindications

FatigueDermatitisImpotenceOptic neuritisMental changesAcute

polyneuropathyHepatic damage

Pulmonary and cardiovascular disease

Use with caution in patients with nephritis, brain damage, hypothyroidism, diabetes, hepatic disease, seizures and poly drug dependence

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Nurses responsibility in Deterrent therapy

Get informed consent before therapy starts

Administer the medicine after 12 hours of the last ingestion of alcohol

Strictly inform the patient not to take even a small amount of alcohol after therapy starts

Instruct him about reaction.

Avoid any topical application, and food stuffs , medicines containing alcohol

Patient should not take any CNS depressants or OTC medicines

Avoid driving and activities require alertness

Instruct them DER will last for 1-2 weeks after the last dose

Importance of follow up

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Alcoholics anonymous (AA)

Found in USA on 10th June 1935 by two alcoholic men, Dr. Bob Smith and Bill Wilson.

AA considers alcoholism as a physical, mental and spiritual disease, a progressive disease which can be arrested but not cured

Members attend group meetings usually twice a week on long term basis

Each member is assigned a support person, from whom he may seek help when the temptation to drink occurs

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Once sobriety is achieved, he is expected to help others

The only requirement for membership is the desire to stop drinking

Their primary purpose is to help each other stay sober and help other alcoholics to achieve sobriety.

A l - A n o nSupport group for wives of alcoholics, started by

Mrs. Anne, wife of Dr. BobA l - A t e e nProvides support to teen children of alcoholics

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Nursing management

Assessment through CAGE questionnaireC- Have you ever felt you ought to CUT

DOWN on your drinking?A- Have people ANNOYED you by criticizing

your drinking?G- Have you ever felt GUILTY about your

drinking?E – Have you ever had a drink first thing in

the morning as an EYE OPENER to steady your nerves or get rid of a hangover?

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Nursing diagnosis

Risk for injury related to hallucinosis, acute intoxication evidenced by confusion, disorientation, inability to identify potentially harmful situations

Altered health maintenance related to inability to identify, manage or seek out help to maintain health, evidenced by various physical symptoms, exhaustion, sleep disturbance etc.

Ineffective denial related to weak, underdeveloped ego, evidenced by lack of insight, rationalization of problems, blaming others, failure to accept responsibility of his behavior

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