Misuse of, and Dependence on Alcohol and.pptx

Misuse of, and Dependence on Alcohol

1. Misuse of, and Dependence on Alcohol and other Drugs Almost all countries in the world are dependant on drugs to facilitate social relations, mark festivals and enhance religious rituals. Drug use have consequences however and it is important to differentiate between pharmacology , the hazards inherent in route administration, dose, and frequency of use , health of the person in use. The setting in which drugs are consumed, surrounding, friends, attitudes and expectations. Drugs considered illegal in some countries are legal in others and even promoted.

2. Historical , cultural aspects of Alcohol consumption Ethyl alcohol is natural product of breakdown of carbohydrates in plants. Its euphoriant and intoxicating properties have been known from prehistoric times Early Egyptians and Greeks distinguished its benefits from problems of drunkenness before the 17 th century. 17 th century incentives were given however for production of cheap gin in Europe. The Temperance Movement however ensured change of this belief of incentives and by 1736 there was a ban of production in the UK when production had risen to 1 gallon a head per annum.

3. HX The temperance movement ensured constitutional change in the US in the 18 th century, restricting alcohol to medical use only. There was a gangsterism revolt to fight the ban in the US in the 18the century and so the law was repealed in 1933. There has been an increase in drinking ever since and control measures put in place but alcohol allowed to be consumed.

4. Prevention of use In the past primary prevention of alcohol and drug use was Controlling availability Ensuring resistance of individuals by way of education Persuasion Alternative provision- provision of bars/ number of hours etc.. Laws, 18years and above /21 years etc.

5. Prevention of use Secondary prevention These are already drinking and the aim is to prevent further damage such as disease or social function loss

6. Epidemiology The harm depends on Age Gender Setting Culture Genetic make up Pattern of consumption Amounts in units

7. EPI 1unit = 8g ethanol = half a pint of 3.5% alcohol volume bear. Or a glass of 125mls Tot of spirits Spain / Australia 1 drink contains 10g ethanol, USA 13g ethanol Unit alcohol= % alcohol x volume /1000 Mosi lager units of alcohol = 4%x 375mls/1000 = 1.5 units

8. Prediction to risk Men women 50 units per week 35 units 400g per week 280g/ week High risk 21 units per week 14 units/ week 168g/ week 112g/week Low risk (i.e. Mosi 2 bottles/ day) (1.3 bottles of M osi/day)

9. EPI Prevalence of alcohol related problems = alcohol consumption per person High consumption = high morbidity ( cirrhosis) Less sporadic drinking is less harmful than bout/ binge drinking patterns Drinking by women has gone up from the 20 th century. (reasons) Drinking is high in young age groups ( why) Ethnicity and religious minorities have different drinking patterns , Hindus / S ikhish /SDA/Baptists oppose /prohibit drinking In the US/UK heavy drinkers among the Indians, Pakistanis

10. EPI Occupations leads to heavy drinking Availability of alcohol at the work place Social expectations ( business meetings) Separation from normal, social and sexual relationships High income Doctors Lawyers Senior executives All among heavy consumers

11. EPI Other drug uses statistics and patterns difficult to elucidate because they are done in private Majority users of drugs are unknown

12. Dependency/ Addiction A cluster of physiological , behaviour and cognitive phenomena in which the use of a substance or class of substances takes on a higher priority for a given individual than other behaviour that once had great value.

13. ICD 10 dependency syndrome 3 of the following Strong sense of compulsion to take substance Difficulty in controlling sub taking behaviour in terms of onset, termination or level of use A physiological withdrawal state when sub has been ceased or reduced Evidence of tolerance Progressive neglect of alternatives pleasure or interests Persistent sub use despite clear overtly harmful consequences

14. Drug induced Psychiatry conditions These conditions ensure in vulnerable individuals but can reflect risk factor in mental health and substance use may be relief of symptoms

15. Schizophrenia Often considered as co morbid disorders Complications to drug use arise in form of violence, suicide, Non compliance to R x Earlier psychiatry breakdown Exacerbation of psychotic symptoms Increased hospitalization/ relapse Tardive dyskinesia Delirium tremens Homelessness Poor prognosis NB sub misuse most prevent with schz ( symptoms show before schz)

16. Other conditions OCD increase with alcohol PTSD Eating disorders

17. Psychiatry complications of alcohol use Withdrawal states F10 Delirium tremens Presents in 5% Tremors in the limbs Body and tongue Restlessness Loss of contact with reality Clouding consciousness Disorientation Illusions Progressive hallucinations – visual Tactile or auditory Paranoid delusions Sweating Tachycardia

18. DT Onset 1-14 days 10% mortality Fever Dehydration Shock Wernicke's encephalopathy Metabolic disturbance hypoglycaemia

19. DT Seizure When they set in , its serious Management Use benzodiazepines- clordiazepoxide100mg -150/day-DZ 50-100mg /day Oral Admission Safety of the room Dimly lit and well spread lighting Parenteral vitamins - vitamin B complex Haloperidol 10mg /day Balance electrolytes and monitor sugar Titrate benzodiazepines to not more that 14days On recovery consider counselling/relative / family etc.. Long term management

20. Alcoholic Hallucinosis Hallucinations occur in clear consciousness Auditory- unpleasant remarks, commands , persecutory Mgt Assessment Admit/ or not Withdraw alcohol Antipsychotics Other considerations

21. Pathological Jealous – Othello's syndrome F10.5 Firm delusions of infidelity Comes from alcohol stemmed impotence Spouse growing indifference from drunken partner Repeated accusations Aggressive demands of prof sexual contact with others Violence Tragedy- murder Alcohol is not the only cause of PJ Mgt Counselling to establish depth and possible treatment Complete couple separation permanently

22. Depression and Anxiety Alcohol releases inhibitions making it easier to express sadness or self destruction impulse The problems that were overcome/ overshadowed during drinking suddenly come back especially during hangover Depression due to alcohol more common in females It is important not to make diagnosis of Anxiety in an alcoholic consuming person until at least 3 weeks of abstinence since alcohol withdrawal can mimic anxiety. Manage the anxiety or depression and alcohol use.

23. Cognitive impairment and Brain Damage Memory ↓ Rigidity of thought New learning↓ Factors for the above reasons may be Thiamine deficiency ( Wernicke's) Head injury Alcohol withdrawal fits Dementia Cerebellar degeneration, cerebellar pontine degeneration. Marchiafava Bignami syndrome- progressive neurological disease of alcoholism- corpus callosum demyelination and necrosis and subsequent atrophy. Management Hx. Ex Lab Imaging – MRI/ CT white matter= cortical atrophy- ventricular enlargement. Appropriate alcohol/ co morbid management

24. Medical complications Peripheral neuropathy Often with absence of ankle reflexes Assess and manage accordingly Alcoholic myopathy Metabolic complications Hypo G Alcoholic stupor Acute renal failure NB screen for RFT/ DM Give dex intravenously Consider diuresis if completely deranged RFT with loss of consciousness.

25. MC Wernicke's encephalopathy Triad Confusion Ataxia Ocular palsy= ophthalmoplegia and nystagmus Patients dying show haemorrhages in brain stem and thalamus There are associated changes in the – peri -aquiductal and ventricular areas Mgt Admit Withdraw alcohol Parenteral thiamine urgent- Pabrinex 2 – 4 ampoules TDS for 3 days then daily for 3 days Dilute each ampoule in 50 – 100mls of NS or DNS of 5 % dext and given in 3o minutes Watch for complications – anaphylactic shock- DT NB . It is important to give Pabrinex parenterally to malnourished alcoholics for 3 days once or twice even to those that have vomiting and diarrhoea or intercurrent illness or those with peripheral neuropathy or those undergoing detoxification Disturbance of consciousness in alcohol DD traumatic subdural haematoma ,hypo G, hepatic encephalopathy and dementia. They will have initial incontinence, generalised weakness, slurred speech, ataxia, cerebellar degeneration ( gait and stance ataxia)

26. MC Gastro intestinal complications Korsakoff syndrome- amnesia, confabulation, no response to thiamine, may have confusion. Liver disease-obesity, fatty liver and cirrhosis CVS disease Sexual impairment ↑ arousal Impaired erectile function pharmacologically Anxiety after impairment ensures ↓erection Direct toxicity on leydig cells of testis, ↓ testosterone ,↓ spermatogenesis, infertility, testicular atrophy,

27. MC Foetal alcohol syndrome Heavy drinkers have spontaneous abortion IUGR Foetal alcohol syndrome Developmental and growth restrictions / retardation Facial and neurological abnormalities Brain development impairment Behavioural difficulties NB – antenatal should screen for alcohol us i.e. use of 1-2 drinks per week.

28. Alcohol related social harm Family relationships Economic factors Employment problems Crime Drunkenness offences

29. Recognition and clinical management of alcohol related problems There are many diagnoses when alcohol is not recognized as the cause- stress, anxiety, depression, injuries, gastritis, gases, debility and so on. Always remember to take a good hx- quantities, problems associated, dependence, withdrawal, harm, social hx , personal hx and other drug use Examination- cutaneous and superficial signs Spider naevi, talengiectasia,facial mooning, parotid enlargement, palmer erythema, dupytrens contracture, gynaecomastia etc. Labs – blood test ( MCV ↑), U &Es, albumin, LFT - triglycerides, clotting time ( cirrhosis)

30. Recognition and clinical management of alcohol related problems Alcohol related physical harm Acute and chronic superficial signs- effects of high risk drinking head to toe Aggression, irrational arguments, violence, nervousness, alc dependence, memory loss, premature aging, drinkers nose Cancer of throat Frequent colds, reduced tolerance to infections, pneumonia Weakness of heart muscle/ heart failure, anaemia, impaired clotting time, breast ca, liver disease Vit deficiency Bleeding, inflammation of stomach, vomiting , diarrhoea, malnutrition, Trembling hands, tingling fingers, numbness, painful nerves. Ulcers Pancreatitis Impaired sensation leading to falls Impaired sexual performance, birth deformities, retarded babies, LBW Toes- numbness, tingling, painful nerves

31. Recognition and clinical management of alcohol related problems Early interventions - screening tools are used- AUDIT/FAST/CAGE or SIPS are used – English Screening and Intervention Program for sensible screening . Motivation interventions- allow patient own concern and chat them up from there to encourage them. Other strategies Set goals Involve family Enhance self esteem Review impediments Identify associated conditions Consider other agencies Follow ups Faith hope and empathy NB identify negative influences and deal with them-stress, dependence, illness, influence, stereotypes expectations

32. Pharmacotherapy and alcohol dependence This is medication to minimise withdrawal symptoms Admit after assessment , seizures, delirium etc. Detoxification Benzodiazepines –chlordiazepoxide 80- 100 mg /day divided doses DZ Chlormethiazole effectively controls withdraw symptoms , however not safe for out patient. Alcohol and chlormethiazole interaction causes death – respiratory depression. When do we allow home- when fits have gone, feeds well, confusion is gone Vit supplementation can go on for several months

33. Pharmacotherapy and alcohol dependence Deterrent medication Disulfiram- antabuse Ethanol ↓ ↓alcohol dehydrogenase ↓ Acetaldehyde ↓ ↓aldehyde dehydrogenase + Disulfiram ←←↖↓XXXXX ↓ Acetic acid→ H2O + CO2

34. Pharmacotherapy and alcohol dependence Disulfiram is given in a dose of 200mg – 800mg per day. Acetaldehyde accumulates in blood and causes discomfort. flushing Headache Nausea Hypotension Laboured breathing It should be given when alcohol breath test is ZERO and can not be given to persons with Heart disease Suicidal tendencies Hypotension treatment Active liver disease

35. Pharmacotherapy and alcohol dependence Acamprosate More tolerable GABA agonist Glutamate antagonist Given 666mg TDS 6/12 or 2g daily divided doses Causes Diarrhoea Irregular heart beat Headache >65 years its not indicated

36. Pharmacotherapy and alcohol dependence Naltrexone GABA agonist Glutamate antagonist Opiate antagonist Blocks euphoric effects It is not dose dependant This drug limits the amounts one can drink Then it gives Nausea, Dizziness, headache, insomnia

37. Pharmacotherapy and alcohol dependence Nelmefene/ nelmetrene/silincro Similar in effect to naltrexone

38. Pharmacotherapy and alcohol dependence Antidepressants Fluoxetine Fluvoxamine After detox insomnia is experienced - relapse give trazedone a GABA agonist/ muscle relaxant

39. Psychological Management Social skills training CBT Group therapy Co joint & family therapy Community and reinforcement approach social network behavioural therapy Alcohol advice centre Employment policies Alcoholics anonymous Specialized centres

40. Question List signs and symptoms of alcohol withdrawal and alcohol intoxication.

41. Aetiology of alcohol dependence and misuse Availability Culture and tradition Environment Genetics- heavy drinking runs in families .

42. Drug misuse and dependence drug Act 1971 UK Class A Class B Class C Cocaine oral preps benzodiazepines Heroine amphetamines steroids Methadone Barbiturates cannabis Injectable others methamphetamine ecstasy

43. OPIATES They act on opioid receptors in the brain Heroin- diacetylmorphine- diamorphone The receptors are responsible for Analgesia Euphoria Depression Positive reinforcement Respiratory depression Dysphoria Depersonalization addiction

44. OPIATES Intoxication withdrawal Bradycardia tachycardia Hypotension hypertension Sedation hyperthermia Meiosis mydriasis Slurred speech hyperflexia Head nodding pilo erection Symptoms tachypnoe Euphoria lacrimation Analgesia rhinorrhoea Calmness abd cramps, N V D, bone &muscle pain, anxiety

45. Management Opiate dependence Assessment Comprehensive history investigations Risk factors FBC Drug use and impact LFT Degree of motivation infection Hep B, C, HIV Degree of dependence opioid in urine Examination Vital evidence Needle tracks Withdrawal Mental health Poor nutrition Anaemia TB Depression Delusions Self harm hallucination

46. Management Opiate dependence Substitution prescription Reduce opioid use Can not withdrawal drug Withdrawal has serious consequences that can not be treated under normal practice Patient made to take a non progressive quantity of addiction No relapsing is seen Agents Agonists- methadone, morphine, dehydrocodiene, diamorphine Partial agonists-buprenorphine Antagonists- naltrexone, naloxone Alpha adrenergic antagonist- lofexidine, clonidine

47. Management Opiate dependence Watch for cardiac patients and methadone induction 20mg ↑weekly 5-10mg Prolongation of QT intervals Hypernatremia Drug interactions with benzodiazepines High risk of misuse Withdrawal Congenital abnormalities Admit neonatal unit LBW Do not detoxify in first trimester Neonatal abstinence syndrome- can use short acting opiates- heroin –up to 72 hrs. and methadone 1-2 weeks

48. Management Opiate dependence Child would have methadone CNS Irritability Tremors Hypertonia Excessive crying Seizures GI Poor sucking Swallowing Risk for aspiration Diarrhoea Suboptimal wt.

49. Management Opiate dependence Respiratory methadone Tachypnoe Respiratory alkalosis Apnoea Cyanotic spells Excessive sneezing Yawning Tearing sweating

50. Management Opiate dependence Buprenorphine Induction 4mg increased daily D1, D1+D2 etc. until desire is achieved Superior to Methadone craving↓ withdrawal↓ completion↑ Follow-up can be done in 16 weeks Water soluble easy to inject However death when mixed with benzos No evidence in pregnancy

51. Management Opiate dependence Saboxone Buprenorphine + naloxone 4:1 Useful combination in detoxification

52. Management Opiate dependence Maintenance Rx Psychosocial counselling Risk assessment Motivation Use of substances Abuse House needs Physical needs Family planning Safe injection practices Child care linkages

53. Management Opiate dependence Detoxification Lofexidine Methadone Buprenorphine Naltrexone Then methadone maintenance and continue counselling

54. Stimulants Recreational use Cocaine Methamphetamine Block uptake of dopamine nucleus accumbens euphoria

55. Stimulants Short term effects Energy up Appetite up Mental alertness up Heart rate up BP up Long term effects Dependence Mood disturbance Anxiety Irritability Restlessness aggression psychosis

56. Stimulants complications CVS Arrhythmias Myocardial infarction Respiratory Chest pain

57. Stimulants complications Neurological CVA Headache Epileptic seizures Maternal use Decreased wt. Head circumference Prem Crack babies Exposure to HIV, STDS, Hep due to IV use

58. Stimulants complications Amphetamines cause Violence Anxiety Confusion Sleep disorders Tactile hallucinations Psychosis Aggression Suicide Homicide

59. Clinical signs amphetamine BP up RR up Sweating Dehydration Dilated pupils Euphoria Anxiety Irritability aggression Perceptual disturbance Talkativeness restlessness NB- physiological, psychological, behavioural signs

60. Clinical signs amphetamine Withdrawal Fatigue Mental depression Appetite down Anxiety Agitation Excessive sleep Suicidal ideation Vivid dreams

61. management Depends on phase Substitution Dexamphetamine 60mg / day Greater retention in treatment Mainly symptomatic- anti psychotics , antidepressants Reducing usage Detox abstinence

62. amphetamines 3,4 methylenedioxymethamphatamine MDMA Ecstasy young adults 15- 34 years Acts on 5HT systems Blocks reuptake hallucinogenic neurotoxic

63. amphetamines 3,4 methylenedioxymethamphatamine MDMA Ecstasy Enhanced mood Perceptual disturbance Disinhibition Openness Enhanced closeness Sociability Increased energy

64. amphetamines 3,4 methylenedioxymethamphatamine MDMA Ecstasy Undesired effects Hyperthermia Renal and hepatic failure DIC Convulsions Flashbacks neurotoxic

65. Khat Green leafed shrub Chewed for centuries / east Africa Similar to amphetamine Contains cathinone and cathine Legal in UK Long term effects psychotic features.

66. Psychoactive Drugs Synthetic drugs piperizine derivatives Mephendrone and cathinone derivatives Naphyrone These give intense stimuli compared with cocaine and amphetamines Alertness Euphoria Empathy Closeness Moderate sexual arousal Perceptual distortions Sociability Long term effects unknown

67. Other drugs Benzodiazepines Hypnotics Anxiolytics Sedatives Anticonvulsants Muscle relaxants

68. benzodiazepines Intoxication Sedation/ drowsiness Ataxia Lethargy Slurred speech Amnesia Impaired motor function Impaired judgement altered sleep pattern

69. benzodiazepine Withdrawal Night mares Anxiety Tremors profuse sweating Muscle cramps Abd cramps Nausea Vomiting Visual/ auditory hallucinations Hyperflexia Confusion seizures death

70. Hallucinogens LSD Solvents Magic mushroom Ketamine PCP Cyclidine Cannabis

71. Hallucinogens Alteration of consciousness Perception Euphoria Feeling of well being Stress reduction Distortion of perception of time and space Altered body image Auditory/ visual hallucinations Dissociation HR, dry mouth, reddening eyes, sensations of cold feet and hands

72. Hallucinogens Long term effects Schiz Depression Cancers head and neck Infertility Solvents Glue Gasoline Girasols Rubber

73. question Briefly explain the mechanism of action involved in the use of Benzodiazepine, hallucinogens, solvents, nicotine and ketamine. Highlight briefly on each items intoxication and withdrawal findings End