Psychopharmacology

Anti Psychotic drugs, Antidepressant drugs, Mood stabilizing drugs, anxiolytic drugs, Anti Parkinsonism drugs, antabuse/anti craving medications

1. PSYCHOPHARMACOLOGY PREPARED BY Mrs. Divya Pancholi M.Sc. (Psychiatric Nursing) Assistant Professor SSRCN, Vapi

2. PSYCHOPHARMACOLOGY

3. Definition of psychopharmacology Psychopharmacology is the study of drugs used to treat psychiatric disorders. Medications that affect psychic function, behaviour or experience are called psychotropic medications.

4. terminology Efficacy: It refers to the maximal therapeutic effect that a drug can achieve. Potency: It describes the amount of the drug needed to achieve that maximum effect. Half-life: It is the time it takes for half of the drug to be moved from the bloodstream. Agonists: Drugs that activate receptors are termed as agonists. Antagonists: Drugs that block the receptors are termed as antagonists.

5. NEUROTRANSMISSION KEY Pre synaptic neuron Post synaptic neuron Mitochondria Synaptic vesicle Voltage gated ca ++ channel Synaptic cleft Neurotransmitter receptor Voltage gated ca ++ channel Neurotransmitter Neurotransmitter reuptake pump  

6. DRUGS AFFECT NEUROTRANSMISSION IN SEVERAL WAYS

7. SR NO AFFECTS DESCRIPTION 1. Release More neurotransmitters are released into the synapse from the storage vesicles in presynaptic cell. 2. Blockade The neurotransmitters are prevented from binding to the postsynaptic receptors. 3. Receptor sensitivity changes The receptor becomes more or less responsive to the neurotransmitter. 4. Blocked reuptake As the presynaptic cells does not reabsorb the neurotransmitter it is retained in the synapse & therefore enhance or prolongs the action. 5. Interference with storage vesicles Either released more or less. 6. Precursor chain interference The process that “makes” the neurotransmitter is either synthesized more or less. 7. Synaptic enzyme interference Less neurotransmitter is metabolised, so more remains available in the synapse.

8. Guidelines regarding drug administration in psychiatry The nurse should not administer any drug unless there is a written order. Do not hesitate to consult the doctor when in doubt about any medication. All medications given must be charted on the patient’s case record sheet. While giving medication. - Always address the patient by name and make certain of his identification. -Do not leave the patient until the drug is swallowed. -Do not permit the patient to go to the bathroom to take the medication. -Do not allow one patient to carry medicine to another.

9. Conti… If it is necessary to leave the patient to get water, do not leave the tray within the reach of the patient. Do not force oral medication because of the danger of aspiration. This is especially important in stupor us patients. Check drugs daily for any change in color, odor and number. Bottles should be tightly closed and labeled. Labels should be written legibly and in bold lettering. Poison dugs are to be legibly labeled and kept in separate cupboard Make sure that an adequate supply of drugs is on hand, but do not overstock. Drug cupboard should always be kept locked when not in use. Never allow a patient or worker to clean the drug cupboard. The drug cupboard keys should not be given o patients.  

10. Patient education related to psychopharmacology

11. Classification

12. 1. Antipsychotic drugs Used to treat psychotic symptoms

13. Antipsychotic drugs Also known as

14. INDICATIONS/ USE

15. CONTRAINDICATION 1) 3) 2)

16. 4) 6) RENAL DISEASES 5) 7)

17. 8) RESPIRATORY INSUFFICIENCY INTESTINAL OBSTRUCTION

18. Classification TYPICAL ANTIPSYCHOTICS Phenothiazines Chlorpromazine Thioxanthene Butyrophenones Haloperidol Trifluperidol Diphenylbutylpiperidines indolic derivatives Dibenzoxazepines ATYPICAL ANTIPSYCHOTICS Clozapine Risperidone Aripiprazol Olanzapine Quetiapine

19. PHARMACOKINETICS Absorption and distribution The oral liquid dose produces a peak level at 1.5 hours Intramuscular dose peaks at 30 minutes. Highly bound to plasma as well as protein (92-98%) Metabolized in liver, excreted through kidney. Elimination half-lives are 10-24 hrs. Most of this drug have therapeutic window. If blood level is below the window, the drug is ineffective, if the blood level is upper limit of the window, it results in to toxicity, the drug is again ineffective.

20. Mechanism of action Blockade of D 2 receptors, Muscarianic cholinergic receptors (M 1 ), alpha adrenergic receptor (alpha 1 ), histamine receptors (H 1 )

21. Atypical antipsychotics Here total 9 receptors are affecting. 3 receptors (M 1, alpha 1, H 1 ) same as typical antipsychotics which causing EPS. Rest of 6 receptors affecting serotonin (5HT 2 , 5HT 3 , 5HT 2C )and dopamine (D 1 , D 2 , D 4 ) receptors And due to this SDA S ( serotonin-dopamine antagonists) there will be no side effect after using atypical antipsychotics.

22. Dopamine pathways

23. Mechanism of action

24. Adverse Effects of Antipsychotic Drugs EXTRA PYRAMIDAL SYMPTOMS (EPS ): (due to Antidopaminergic actions on basal ganglia) Neuroleptic-induced Parkinsonism Acute dystonia Akathisia Tardive dyskinesia Neuroleptic malignant syndrome SEIZURES SEDATION (due to Alpha-adrenergic blockade) AUTONOMIC SIDE-EFFECTS : Dry mouth, constipation, cyclopligia , mydriasis , urinary retention, orthostatic hypotension, impotence and impaired ejaculation. OTHER EFFECTS : Agranlocytosis (especially for clozapine) Sialorrhea or increased salivation (especially cially for clozapine) Weight gain Jaundice Dermatological effects (contact dermatitis, photosensitive reaction)

25. Extra pyramidal symptoms 1. PSEUDO PARKINSONISM Symptoms may appear 1 to 5 days following initiation of drug. It includes slow pill-rolling finger tremors, masklike facial expression, weakened voice absence of arm swing when walking, stiff stooped posture, and an impaired shuffling gait. Cogwheeling rigidity, assessed frequently in the arms, is a ratchet-like motion of the extremities during extension .

26. Conti… Mentally, the client can display bradyphrenia , or a slowed ability to think through familiar situations. One unique manifestation after prolonged use of the antipsychotic medication is the rabbit syndrome which is tremors of the lips and a constant chewing motion. The treatment of parkinsonism is anti cholinergic medication .

27. 2. AKATHISIA Agitation, restlessness, clients may demonstrate restlessness through actions such as pacing, marching, shuffling, foot-tapping, rocking motion, or shifting body weight from leg to leg. Restlessness can be throughout the entire body or confined to a section of the extremities. Muscle discomfort; Treatment:- change the antipsychotic drugs and anticholinergic drug.

28. 3. DYSTONIA Intense involuntary spasm of muscles of neck, tongue, face, jaw, eyes or trunk, affecting the tongue and throat muscles can affect the vocal cords, causing a hoarse voice, stiff or thick tongue Dysphagia, laryngeal or pharyngeal spasms, and potential obstruction, which becomes a medical emergency. Neck and trunk symptoms include torticollis,

29. Conti… Twisting of the cervical spine muscles, and opisthotonos , a severe form of back arching. In addition, clients may experience oculogyric crisis which is rolling of the eyes in a locked upward position. Treatment is decrease dose of antipsychotic, anticholinergic and antiparkinsonian agents are the first line of defence during acute dystonic reactions 

30. 4. TARDIVE DYSKINESIA The symptoms are Potentially irreversible. Rapid, repetitive, involuntary movements of the face, trunk, respiratory muscles, and extremities. Facial movements , which often occur in the oral area, can include a protruding or rolling tongue, lip smacking, grimacing, frowning, sucking or kissing motions, and facial distortions.

31. Conti… Stereotypic movements of the limbs can be irregular, rapid, purposeless motions or slow movements. A client’s trunk may rock, twist, jerk, or thrust forward. The drug should be withdrawn at the first sign. Treatment is benzodiazepines etc.

32. 5. NEUROLEPTIC MALIGNANT SYNDROME Symptoms: Hyperthermia, muscle rigidity, autonomic instability Management: Discontinue antipsychotic

33. NURSING MANAGEMENT Assessment: History and Examination Implementation with Rationale The risk of extrapyramidal symptoms To prevent dry mouth –Sips of water & frequent mouthwashes, use of chewing gum Limit sun exposure, drink fluid or lozenges for dry mouth. Provide safety measures and seizure precautions High fiber diet to reduce constipation Provide thorough patient teaching, including drug Health education:

34. Conti… Patient receiving clozapine is at risk of developing Agranulocytosis. Monitor TC, DC in the 1 st weeks of treatment. Stop the drug if the WBC count drops to less than 3000/mm3 of blood. Teach the importance of drug compliance, side effects of drugs and reporting if too severe, regular follow ups. Give reassurance and reduce unfounded fears and anxieties.

35. 2. Anti-depressant drugs Uses to treat depressive illness.

36. Antidepressant drugs Also known as

37. Classification of antidepressants Tricyclic antidepressants (TCA) Selective serotonin reuptake inhibitor (SSRI ) Selective-norepinephrine reuptake inhibitors (SNRI) MAO inhibitors Atypical antidepressants Amitriptyline Imipramine clomipramine Desipramine Doxepine Trimipramine Sertraline Fluoxetine Paroxetine Citalopram Venlafexine Desvenlafaxin Duloxetine Phenelzine Isocarboxazid Bupropion Trazodone Mirtazepine

38. INDICATIONS/ USE DEPRESSION Depressive episode Dysthymia Reactive depression Secondary depression Abnormal grief reaction CHILDHOOD PSYCHIATRIC DISORDERS Enuresis Separation anxiety disorder School phobia Night terrors

39. Cont…. OTHER PSYCHIATRIC DISORDERS Panic attack Generalized anxiety disorder Agoraphobia, social phobia OCD with or without depression Eating disorder Borderline personality disorder MEDICAL DISORDER Chronic pain Migraine Peptic ulcer disease

40. contraindication Hypersensitivity Acute phase following MI Angle-closure glaucoma Elderly or debilitated Hepatic, renal or cardiac insufficiency BPH History of seizures

41. pharmacokinetics Highly lipophilic and protein-bound Half-life is long and usually more than 24 hours. Metabolized in liver.

42. Mechanism of action TCA S blocks the reuptake of serotonin and norepinephrine SSRI S specifically blocks the reuptake of serotonin MAOI S blocks the enzyme and stopping the breakdown of dopamine, norepinephrine, and serotonin.

43. Nursing management

44. CLIENT EDUCATION WHO RECEIVING ANTIDEPRESSANTS Continue to take the medication even though the symptoms have not subsided. The therapeutic effect may not be seen for as long as 4 weeks. If after this length of time no improvement is noted, the physician may prescribe a different medication. Not discontinue use of the drug abruptly. It might produce withdrawal symptoms, such as nausea, vertigo, insomnia, headache, malaise, nightmares, and return of symptoms for which the medication was prescribed. Use caution when driving or operating dangerous machinery . Drowsiness and dizziness can occur.

45. CONTI… Use sun block lotion and wear protective clothing when spending time outdoors. The skin may be sensitive to sunburn. Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure. Take frequent sips of water, chew sugarless gum, or suck on hard candy if dry mouth is a problem. Good oral care is very important. Avoid consuming the following tyramin containing foods or medications while taking MAOIs: aged cheese, wine, beer, chocolate, colas, coffee, tea, sour cream, smoked and processed meats, beef or chicken liver, canned figs, soy sauce, overripe and fermented foods, pickled herring, yogurt, yeast products, broad beans, cold remedies, diet pills. To do so could cause a life-threatening hypertensive crisis.

46. Avoid smoking while receiving tricyclic therapy. Smoking increases the metabolism of tricyclics , requiring an adjustment in dosage to achieve the therapeutic effect. Avoid alcohol use while taking antidepressant therapy. These drugs potentiate the effects of each other. Avoid use of other medications (including over-the counter medications) without the physician’s approval while receiving antidepressant therapy. Many medications contain substances that, in combination with antidepressant medication, could precipitate a life-threatening hypertensive crisis. Avoid exposing application site to direct heat (e.g., heating pads, electric blankets, heat lamps, hot tub, or prolonged direct sunlight).

47. 3. Mood stabilizing drugs Uses to treat bipolar mood disorders.

48. COMMONLY USED MOOD STABILIZERS

49. LITHIUM Lithium is an element with atomic number 3 and atomic weight 7. Discovered in 1949 by FJ Cade for use in treatment of Mania, Equally effective in treating and preventing episodes of mania and depression in bipolar disorder

50. indications Treatment of acute mania Prophylaxis of bipolar disorder Schizoaffective disorder Cyclothymia Impulsivity and aggression OTHER: Premenstrual dysphoric disorders Bulimia nervosa Borderline personality disorder Episodes of binge eating Trichotilomania Cluster headaches

51. Pharmacokinetics Rapidly absorbed from GI tract Peak level within 30 mins to 3 hours Not protein bound Distribution in total body water Maximum levels in thyroid, saliva and CSF Steady state level in 5 to 7 days Excreted almost entirely by kidneys Reabsorbed in proximal tubules and is influenced by sodium balance. Depletion of sodium can precipitate lithium toxicity.

52. MECHANISM OF ACTION Accelerates presynaptic re-uptake and destruction of catecholamines , like norepinephrine Inhibits the release of catecholamines at the synapse Decreases postsynaptic serotonin receptor sensitivity

53. dosage LITHIUM CARBONATE: 300 mg tablets LITHIUM CITRATE: 300 mg/ 5 ml liquid

54. BLOOD LITHIUM LEVELS

55. Indications

56. CONTRA Indications

57. SIDE EFFECTS NEUROLOGICAL: TREMORS MOTOR HYPERACTIVITY MUSCULAR WEAKNESS COGWHEEL RIGIDITY SEIZURES NEUROTOXICITY RENAL: POLYDIPSIA POLYURIA TUBULAR ENLARGEMENT NEPHROTIC SYNDROME CARDIOVASCULAR: T-WAVE DEPRESSION

58. Conti … GASTROINTESTINAL: NAUSEA VOMMITIING DIARRHOEA ABDOMINAL PAIN AND METALIC TASTE ENDOCRINE ABNORMAL THYROID FUNCTION GOITER WEIGHT GAIN DERMATOLOGICAL: ACNEIFORM ERUPTIONS PAPULAR ERUPTIONS EXACERBATION OF PSORIASIS

59. Conti… SIDE-EFFECTS DURING PREGNANCY AND LACTATION: TERATOGENIC POSSIBILITY INCREASED INCIDENCE OF EBSTEIN’S ANOMALY (DISTORTION AND DOWNWARD DISOPLACEMENT OF TRICUSPID VALVE IN RIIGHT VENTRICLE) SECRETED IN MILK AND CAN CAUSE TOXICITY IN INFANT. LITHIUM TOXICITY:

60. Signs and symptoms of lithium toxicity Ataxia Coarse tremor Nausea and vomiting Impaired memory & concentration Nephrotoxicity Muscle weakness Convulsions Muscle twitching Dysarthria Coma nystagmus 3/19/2020 72

61. Management of lithium toxicity Discontinue Gastric lavage Adsorption with activated charcoal Ingest fluids Maintain fluid and electrolyte balance Serious manifestation of lithium toxicity, hemodialysis . 3/19/2020 73

62. Nurses responsibility for a patient receiving lithium

63. The pre-lithium work up: A complete physical history, ECG, blood studies (TC, DC, FBS, BUN, creatinine, electrolytes) urine examination (routine and microscopic) Assess renal function as renal side effects are common and the drug can be dangerous in an individual with compromised kidney function. Thyroid functions should also be assessed, as the drug is known to depress the thyroid gland.

64. To achieve therapeutic effect and prevent lithium toxicity, the following precautions should be taken: • Lithium must be taken on a regular basis, preferably at the same time daily (for example, a client taking lithium on TID schedule, who forgets a dose should wait until the next scheduled time to take lithium and not take twice the amount at one time, because lithium toxicity can occur). When lithium therapy is initiated, mild side effects such as fine hand tremors, increased thirst and urination, nausea, anorexia etc may develop. Most of them are transient and do not represent lithium toxicity.

65. • Serious side-effects of lithium that necessitate its discontinuance include vomiting, extreme hand tremors, sedation, muscle weakness and vertigo. The psychiatrist should be notified immediately if any of these effects occur. • Since polyuria can lead to dehydration with the risk of lithium intoxication, patients should be advised to drink enough water to compensate for the fluid loss.

66. Various situations may require an adjustment in the amount of lithium administered to a client, such as the addition of a new medicine to the client's drug regimen, a new diet or an illness with fever or excessive sweating. In this connection, people involved in heavy outdoor labor are prone to excessive sodium loss through sweating . They must be advised to consume large quantities of water with salt, o prevent lithium toxicity due to decreased sodium levels. If severe vomiting or gastroenteritis develops , the patient should be told to report immediately to the doctor. These are the conditions that have a high potential for causing lithium toxicity by lowering serum sodium levels..

67. Frequent serum lithium level evaluation is important. Blood for determination of lithium levels should be drawn in the morning approximately 12-14hours after the last dose was taken. • The patient should be told about the importance of regular follow up. In every six months, blood sample should be taken for estimation of electrolytes, urea, creatinine, a full blood count, and thyroid function test.

68. carbamazepine It is available in the market under different trade names like Tegretol , Mazetol , Zeptol . And Zen retard.

69. DOSE The average daily dose is 600-1800 mg orally, in divided doses.

70. INDICATIONS Seizures-complex partial seizures, GTCs, seizures due to alcohol withdrawal. Psychiatric disorders- rapid cycling bipolar disorder, impulse control disorder, Aggression Psychosis with epilepsy Schizoaffective disorders Borderline personality disorders Cocaine withdrawal syndrome Paroxysmal pain syndromes-trigeminal neuralgia & phantom limb pain.

71. Mechanism of action Normally sodium moves into a neuronal cell by passing through a gated sodium channel in the cell membrane. Carbamazepine may prevent or halt seizures by closing or blocking Sodium channels, thus preventing sodium entering the cell. Keeping sodium out of the cell may slow nerve impulse transmission, thus slowing rate at which neurons fire.

72. SIDE EFFECTS Drowsiness Confusion Headache Hypertension Vomiting Diarrhea Abdominal pain Hepatitis Oliguria Thrombocytopenia Agranulocytosis Dry mouth

73. Nurse’s responsibilities

74. Role of the nurse Since the drug may cause dizziness and drowsiness advise him to avoid driving and other activities requiring alertness. • Advise patient not to consume alcohol when he is on the drug. • Emphasize the importance of regular follow up visits and periodic examination of blood count and monitoring of cardiac, renal, hepatic and bone marrow functions

75. Sodium valporate Also known as Encorate chrono valparin epilex epival

76. indications Acute mania, prophylactic treatment of bipolar I disorder, rapid cycling bipolar disorder Schizoaffective disorder Seizures Other disorders like bulimia nervosa, obsessive-compulsive disorder, agitation and PTSD

77. MECHANISM OF ACTION The drug acts on Gamma-aminobutyric acid (GABA) an inhibitory amino acid neurotransmitter. Anticonvulsant effect- blockade of voltage-gated sodium channels and increased GABA level. GABA receptor activation serves to reduce neuronal excitability.

78. DOSE The usual dose is 15mg/kg/day with a maximum of 60mg/kg/day orally.

79. Side effects Nausea Vomiting Diarhhoea Sedation Ataxia Dysarthria Tremor Weight gain Loss of hair Thrombocytopenia Platelet dysfunction

80. Nurse’s responsibilities

81. Explain to the patient to take the drug immediately after food to reduce GI irritation. • Advise to come for regular follow-up and periodic examination of blood count, hepatic function and thyroid function . Therapeutic serum level of valproic acid is 50-100 micrograms/ml .

82. 4. anxiolytics Used to treat anxiety.

83. Anxiolytics drugs Also known as

84. BARBITURATES NONBARBITURATE NONBENZODIZEPINE BENZODIAZEPINE CLASSIFICATION

85. BARBITURATES PHENOBARBITAL ( LUMINAL ) (30-200 MG) PENTOBARBITAL (NEBUTAL) (150-200 MG) SECOBARBITAL ( SECONA ) (100MG AS HYPNOTICS) ( 200-300 PRE OP SEDATIVE )

86. NON BARBITURATE / NON BENZODIAZEPINE ETHANOL DIPHENHYDRAMINE METHAQUALON

87. BENZODIAZEPINE LONG ACTING (EFFECTIVE HALF LIFE MORE THAN 24 HOURS ) DIAZEPAM ( VALIUM,CAMPOSE ) (10-30 MG) FLURAZEPAM (DALMONE ) (15-30 MG) SHORT ACTING ( HALF LIFE 5-24 HRS) LORAZEPAM (LARPOSE) (1-4 MG) OXAZEPAM ( SERAPAX) (45-60 MG) VERY SHORT ACTING ( LESS THAN 5 HRS) ALPRAZOLAM ( ALPRAX) ( 0.75 – 1.50 MG) TRIAZOLAM ( HALCION ) ( 0.25 MG)

88. INDICATION TREAT ANXIETY DISORDER

89. INSOMNIA

90. PHOBIC ANXIETY OR PANIC DISORDERS

91. DEPRESSION

92. POST TRAUMATIC STRESS DISORDER

93. OBSESSIVE-COMPULSIVE DISORDER

94. CONTRAINDICATION RENAL IMPAIREMENT LIVER IMPAIREMENT

95. Mechanism of action Benzodiazepines bind to specific sites on the GABA receptors and increase GABA level. Since GABA is an inhibitory neurotransmitter, it has calming effect on the central nervous system, thus reducing anxiety.

96. Side effects Nausea Vomiting Weakness Vertigo Blurring of vision Body aches Epigastric pain Diarrhoea Impotence Sedation Increased reaction time Ataxia Dry mouth Retrograde amnesia Impairment of driving skills Dependence Withdrawal symptoms

97. Nurse’s responsibilities

98. Administer with food to minimize gastric irritation. • Advise the patient to take medication exactly as directed . Abrupt withdrawal may cause insomnia, irritability and sometimes even seizures. • Explain about adverse effects and advise him to avoid activities that require alertness. • Caution the patient to avoid alcohol or any other CNS depressants along with benzodiazepines ; also instruct him not to take any over-the-counter (OTC)medications. • If IM administration is preferred give deep IM . • For IV administration do not mix with any other drug. Give slow IV as respiratory or cardiac arrest can occur; monitor vital signs during IV administration. Prevent extravasations since it can cause phlebitis and venous thrombosis.

99. 5. ANTIPARKINSONIAN AGENTS Used to treat Parkinson disease

100. classification 1.Anticholinergics - Trihexyphenidyl - Benztropine - Biperiden 2.Dopaminergic Agents - Bromocriptine - Carbidopa/Levodopa 3.Monamine Oxidase Type B Inhibitors: - Selegiline 4.Trihexyphenidyl: - Artane - Trihexane - Trihexy - Pacitane

101. indication Drug induced parkinsonism Adjunct in the management of parkinsonism

102. Mechanism of action It crosses into the brain through the "blood- brain barrier." Once it crosses, it is converted to dopamine. The resulting increase in brain dopamine concentrations is believed to improve nerve conduction and assist the movement disorders in Parkinson disease

103. DOSE 1-2 mg per day initially, maximum dose up to 15 mg/day in divided dose.

104. Side effects Dizziness Nervousness Drowsiness Weakness Headache Confusion Blurred vision Mydriasis Tachycardia Orthostatic hypotension Dry mouth Nausea Constipation Vomiting Urinary retention Decreased sweating

105. Nursing Responsibility Assess parkinsonian and extrapyramidal symptoms. Medication should be tapered gradually . Caution patient to make position changes slowly to minimize orthostatic hypotension . Instruct the patient about frequent rinsing of mouth and good oral hygiene. Caution patient that his medication decrease perspiration and over-heating may occur during hot weather.

106. 6. ANTABUSE drugs

107. disulfiram Disulfiram is used to ensure abstinenece 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 disulfiram.

108. METABOLISM OF ALCOHOL Alcohol dehydrogenase Acetaldehyde dehydrogenase Under normal  metabolism , alcohol is broken down in the  liver  by the  enzyme   alcohol dehydrogenase  to  acetaldehyde , which is then converted by the enzyme  acetaldehyde dehydrogenase  to the harmless  acetic acid .

109. Mechanism of action Alcohol dehydrogenase Acetaldehyde dehydrogenase Disulfiram blocks this reaction at the intermediate stage by blocking acetaldehyde dehydrogenase. After alcohol intake under the influence of disulfiram, the concentration of acetaldehyde in the blood may be 5 to 10 times higher than that found during metabolism of the same amount of alcohol alone.

110. Produces a wide array of unpleasant reactions called the DISULFIRAMETHANOL REACTION (DER) Symptoms include   flushing  of the skin accelerated heart rate shortness of breath Nausea   vomiting , throbbing headache visual disturbance mental confusion postural syncope , and   circulatory collapse .

111. Dosage and administration 500 mg every day (single dose) initially for 1 to 2 wk. Maintainance dose is 125 to 500 mg every day (max, 500 mg/day). Disulfiram should never be administered until the patient has abstained from alcohol for at least 12 hours.

112. Duration of therapy The daily, uninterrupted administration of disulfiram must be continued until the patient is fully recovered socially and a basis for permanent self-control is established. Depending on the individual patient,  maintenance therapy may be required for months or even years.

113. Indication chronic alcoholism cocaine  dependence

114. Contraindication Patients who are receiving or have recently received metronidazole, paraldehyde, alcohol, or alcohol-containing preparations, e.g.,  cough  syrups, tonics etc. Disulfiram is contraindicated in the presence of severe myocardial disease, psychosis, and hypersensitivity to disulfiram. Children Pregnant women

115. Things to be avoided during disulfiram Cough syrups Vitamin tonics Ayurvedic tonics After shave lotion Perfumes Sprits Food containing alcohol content

116. Side effects An allergic reaction (swelling of your lips, tongue, or face; shortness of breath; closing of your throat; or hives) Fatigue Dermatitis Impotence Optic neuritis Acute polyneuropathy Hepatic damage Seizures. Respiratory depression cardiovascular collapse Myocardial infarction death

117. Nurses role Obtain informed consent for disulfiram therapy. Explain the ingestion of even small quantities of alcohol may produce DER reaction Warn against consuming alcohol preparation like cough syrups, tonics, and ayurvedic medicines. Collect the base line values of hemoglobin and liver function test.

118. Cont … Warn patient that DER may occur even one to two weeks after the last dose of disulfiram. Monitor haemogram and liver function test every 3 months. Look for signs of peripheral neuropathy .

119. 7. ANTi -craving drugs Used to help prevent relapse both during the detox phase and in early recovery phase. Medications used: Naltrexone Naloxene Subutex Topiramate Baclofen Acamprosate Methadone Neurontin

120. Mechanism of action Through detoxification process the withdrawal symptoms of a particular type of drug or chemical are managed as the toxins from the drug are removed from the body. The removal of drug from the body is accompanied by physical, psychological and emotional cravings. A number of stimuli can put off a craving response within the brain. Anti-craving drugs seem to work by blocking the receptors associated with cues that set off relapse.

121. Thank You