Subsatance abuse- Introduction. Alcohol abuse.pptx

Substance use disorders

1. WELCOME

2. NURSING MANAGEMENT OF PATIENT WITH SUBSTANCE USE DISORDERS

3. F 10-F 19  Mental and behavioral disorders due to psychoactive substance use Mental and behavioral disorders due to F 10 Alcohol F 11 Opoids F 12 Cannabinoids F 13 Sedatives/hypnotics F 14 Cocaine F1 5 Other stimulants including caffeine F 16 Hallucinogens F 17 Tobacco F 18 Volatile solvents F 19 Multiple drug use & use of other psychoactive substances ICD-10 CLASSIFICATION

4. F 1X. 0 Acute intoxication F 1X. 1 Harmful use F 1X. 2 Dependence syndrome F 1X. 3 Withdrawal state F 1X. 4 Withdrawal state with delirium F 1X. 5 Psychotic disorder F 1X. 6 Amnesic syndrome F 1X. 7 Residual and late onset psychotic disorder F 1X. 8 other mental and behavioral disorders F 1X. 9 unspecified mental and behavioral disorders

5. SUBSTANCE RELATED DISORDERS Substance use disorders Substance induced disorders Dependence Withdrawal Intoxication Abuse

6. Abuse: To use wrongfully or in a harmful way “ Maladaptive pattern of substance use manifested by recurrent & significant adverse consequences related to repeated use of the substance” [DSM-IV-TR] SUBSTANCE ABUSE

7. Manifested by one or more of the following occurring within a 12 month period Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home Recurrent substance use in situations in which it is physically hazardous Continued use of substance despite having persistent or recurrent social or interpersonal problems caused/exacerbated by the effects of the substance. SUBSTANCE ABUSE- DSM-IV-TR Diagnostic criteria

8. Dependence: A compulsive or chronic requirement. The need is so strong as to generate distress (either physically or psychologically) if left unfulfilled. Physical dependence Psychological dependence Tolerance SUBSTANCE DEPENDANCE

9. Three or more of the following have been present together at some time during the previous year A strong desire or sense of compulsion to take the substance Difficulties in controlling the substance taking behavior. A physiological withdrawal state when substance has ceased or been reduced Evidence of tolerance. CONTD……. SUBSTANCE DEPENDENCE- ICD-10 Diagnostic criteria

10. Progressive neglect of the alternate pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects. Persisting with substance use despite clear evidence of having overtly harmful consequences.

11. Intoxication: A physical or mental state of exhilaration and emotional frenzy or lethargy and stupor “ Development of a reversible substance specific syndrome caused by the recent ingestion of (or exposure to) a substance”. [APA, 2000] SUBSTANCE INTOXICATION

12. The development of a reversible substance specific syndrome caused by recent ingestion of a substance. Clinically significant maladaptive behavior or psychological changes that develop during or shortly after use of the substance. The symptoms are not due to a general medical condition and are not better accounted by another mental disorder. SUBSTANCE INTOXICATION- DSM-IV-TR Diagnostic criteria

13. Withdrawal: A physiological and mental readjustment that accompanies the discontinuation of an addictive substance. “ Development of a substance specific maladaptive behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use” SUBSTANCE WITHDRAWAL

14. The development of a substance specific syndrome caused by the cessation of (or reduction in) heavy and prolonged substance use. The substance specific syndrome causes clinically significant distress or impairment in social, occupational or other important areas of functioning. The symptoms are not caused by a general medical condition and are not better accounted by another mental disorder. SUBSTANCE WITHDRAWAL- DSM-IV-TR Diagnostic criteria

15. Exact etiology is unknown BIOLOGICAL FACTORS Genetics Children of alcoholics Monozygotic twins Adoption studies Biochemical Produces morphine like substances in the brain- responsible for addiction ( Eg :- amines+acetaldehyde = tetrahydropapaveroline ) ETIOLOGY

16. PSYCHOLOGICAL FACTORS Developmental influences Psychodynamic approach-punitive super ego and fixation at oral stage of psychosexual development Personality factors Low self esteem, frequent depression, passivity, inability to relax or defer gratification, inability to communicate effectively. Antisocial personality & depressive response styles

17. SOCIOCULTURAL FACTORS Social learning Modeling, imitation and identification Conditioning Pleasurable experience  Reinforces individual to seek out substance again and again Cultural and ethnic influence Cultural acceptance dependency (western) Genetic intolerance -Asians

18. Alcohol Amphetamines & related substances Caffeine Cannabis Cocaine Hallucinogens Inhalants contd …….. CLASSES OF PSYCHOACTIVE SUBSTANCES

19. Nicotine Opioids Phencyclidine (PCP) & related substances Sedatives, hypnotics or anxiolytics

20. ALCOHOL Natural substance formed by the reaction of fermenting sugar with yeast spores Ethyl alcohol (ETOH) C 2 H 5 OH- chemically Common names- booze, alcohol, liquor, drinks, cocktails etc Common preparations- beer, gin, rum, vodka, whiskey, wine, scotch, brandy, champagne ALCOHOL ABUSE AND DEPENDENCE

21. ABSORPTION: Rapidly absorbed directly from upper GI tract Carried to brain via blood stream Peak blood alcohol concentration (BAC) in 30-60 minutes after consuming on empty stomach Absorption influenced by – amount of food in stomach, sipped or gulped, type of liquor etc

22. METABOLISM Alcohol is eliminated from body at a rate of 7-10 gm (one standard drink) an hour Metabolized in liver by oxidation (2-4% through urine and lungs- breath analyzer) Alcohol-------> Acetaldehyde------------> Acetate Alcohol dehydrogenase Aldehyde dehydrogenase ---------> carbon dioxide & water

23. THERAPEUTIC USES: Antidote for methanol consumption Ingredient in many pharmacological concentrates

24. Jellineck (1952) Phase I : The Pre-alcoholic phase Phase II : The Early alcoholic phase Phase III: The Crucial phase Phase IV: The Chronic phase Phases of alcoholism

25. Phase I : The Pre-alcoholic phase Use of alcohol to relieve the everyday stress and tensions of life Use of alcohol by parents and other members of the society  Child observes  learns that it is an acceptable method of coping with stress Development of tolerance Phases of alcoholism

26. Phase II : The Early alcoholic phase Blackouts  Brief periods of amnesia during or immediately following a period of drinking Alcohol is no longer a pleasure or relief but rather a drug required Behaviors: sneaking drinking, secret drinks, preoccupation with drinking and maintaining supply, rapid gulps. Feels guilty and defensive. Excessive use of denial and rationalization. Phases of alcoholism

27. Phase III: The Crucial phase Loss of control, clearly evident physiological dependence. Binge drinking (few hours to several weeks)  sickness, loss of consciousness, squalor, degradation Extremely ill, anger, aggression Total focus on drinking, willing to risk losing everything to maintain addiction. Loss of job, marriage, family, friends and self-respect is common Phases of alcoholism

28. Phase IV: The Chronic phase Emotional and physical disintegration  profound helplessness and self-pity Intoxicated more than he or she is sober. Impairment in reality testing  psychosis Life threatening physical manifestation (multisystem) Abstention  terrifying syndrome  hallucination, tremors, convulsion, severe agitation, panic, depression, ideas of suicide. Phases of alcoholism

29. Induces general, nonselective, reversible depression of the CNS At low doses alcohol produces Relaxation Loss of inhibitions Lack of concentration Drowsiness Slurred speech Sleep EFFECTS OF ALCOHOL ON THE BODY

30. Reduces life expectancy by about 10-12 years Early starting  greater chance of developing serious illnesses Damages body tissues by direct irritation, changes during metabolism, interacts with other medicines, aggravates existing diseases. Risk of postoperative complications  Infection, bleeding, delayed wound healing

31. Chronic abuse causes multiple system physiological impairments Peripheral neuropathy Alcoholic myopathy- acute/ chronic Wernicke’s encephalopathy Korsakoff’s psychosis Alcoholic cardiomyopathy Eosophagitis Gastritis

32. Pancreatitis Alcoholic hepatitis Cirrhosis of liver Portal hypertension Ascites Esophageal varices Hepatic encephalopathy Leucopenia Thrombocytopenia Sexual dysfunction Use during pregnancy-Fetal alcohol syndrome

33. Peripheral nerve damage Pain, burning, tingling or prickly sensation of extremities Due to deficiency of vitamin B particularly thiamine May cause permanent muscle wasting and paralysis. Treatment: Abstinence, vitamin supplementation Peripheral neuropathy

34. Acute or chronic Acute  sudden onset of muscle pain, swelling and weakness, blood tinge in urine (breakdown of myoglobin), elevated muscle enzymes (CPK, LDH, AST). Chronic gradual wasting and weakness in skeletal muscles Treatment: Abstinence, nutritious diet, vitamin supplement Alcoholic myopathy

35. Serious form of thiamine deficiency Paralysis of ocular muscles, diplopia, ataxia, somnolence, stupor If thiamine is not supplemented immediately death will ensue Wernicke’s encephalopathy

36. Syndrome of confusion, loss of recent memory and confabulation in alcoholics Seen in clients recovering from Wernicke’s encephalopathy Treatment  parenteral and oral thiamine replacement Korsakoff’s psychosis

37. Accumulation of lipids in the myocardial cells, resulting in enlargement and weakened condition Symptoms similar to CHF and arrhythmia Tx  Total permanent abstinence Treatment of CHF Alcoholic cardiomyopathy

38. Inflammation and pain in the esophagus Due to toxic effects of alcohol, frequent vomiting Inflammation of stomach lining Epigastric distress, nausea, vomiting & distention Eosophagitis Gastritis

39. Acute: -1 or 2 days after a binge of excessive alcohol use -Constant severe epigastric pain, nausea, vomiting, abdominal distention Chronic : pancreatic insufficiency, steatorrhea, malnutrition, weight loss, DM Pancreatitis

40. Inflammation of liver Enlarged & tender liver, nausea, vomiting, lethargy, anorexia, elevated WBC count, fever, jaundice Ascites and weight loss in severe cases Tx  complete abstinence, proper nutrition, rest Alcoholic hepatitis

41. End stage alcoholic liver disease Destruction of liver cells  fibrous (scar) tissue Nausea, vomiting, anorexia, weight loss, abdominal pain, jaundice, edema, anemia, blood coagulation abnormalities Tx  abstinence, correction of malnutrition, supportive care to prevent complications contd …….. Cirrhosis of liver

42. Complications: portal hypertension, ascites, esophageal varices, hepatic encephalopathy Hepatic encephalopathy: -Liver unable to convert ammonia to urea for excretion -impaired mental functioning, apathy, euphoria or depression, sleep disturbance, confusion, coma and death - Tx abstinence , temporary elimination of protein from diet, reduction of intestinal ammonia using neomycin or lactulose

43. Production, function and movement of WBC are impaired High risk for infections Platelet production and survival are impaired Risk for hemorrhage Leucopenia Thrombocytopenia

44. Interferes with normal production and maintenance of male & female hormones Women  changes in menstrual cycle, decreased or loss ability to become pregnant Men decreased hormone levels results in diminished libido, decreased sexual performance, impaired fertility Sexual dysfunction

45. Use during pregnancy Causes disorders to fetus physical, mental, behavioral and learning disabilities Fetal alcohol syndrome

46. Symptoms  Disinhibition of sexual or aggressive impulses, mood lability, impaired judgment, impaired social & occupational functioning, slurred speech, in coordination, unsteady gait, nystagmus , flushed face. Intoxication at blood alcohol level 100-200 mg/dl Death may happen if 400-700 mg/dl Alcohol intoxication

47. Within 4-12 hours of cessation of or reduction in heavy and prolonged alcohol use  coarse tremor of hands, tongue or eyelids, nausea & vomiting, malaise or weakness, tachycardia, sweating, elevated BP, anxiety, depressed mood or irritability, transient hallucinations or illusions, headache and insomnia. Alcohol withdrawal

48. Otherwise known as delirium tremens Complicated withdrawal syndrome may progress Onset usually on second or third day after cessation of or reduction in prolonged, heavy alcohol use. Recovery usually within 3-7 days. Disturbances in cognition manifested by confusion, excitement, poor attention, disorientation, and a clouding of consciousness. Hallucinations (visual/ tactile) and illusions are common. Psychomotor agitation, tremulous hands picking up imaginary objects, truncal ataxia, autonomic disturbances, reversal of sleep-wake pattern/insomnia. Alcohol withdrawal delirium

49. Alcohol induced psychiatric disorders Alcohol-induced dementia Alcohol-induced mood disorder Suicidal behavior Alcohol-induced anxiety disorders Pathological jealousy Alcoholic seizures (rum fits): Generalized tonic clonic seizure – usually 12-48 hours after a heavy bout of drinking. Alcoholic hallucinosis other

50. Carbohydrate deficient transferrin (CDT): Marker of heavy drinking (FDA approved) Gamma- glutamyl transferase (GGT)- liver enzyme very sensitive to alcohol, elevated after moderate alcohol intake and chronic alcoholism. Testosterone  low levels in men with alcoholism Mean corpuscular volume (MCV)  size of RBC increased in alcoholics with vitamin deficiency Urine toxicology for other drugs S. electrolytes, LFT, Hematology ECG, ECHO ICD-10/ DSM criteria Diagnosis

51. Detoxification Adequate nutrition and rest Anticonvulsants Alcohol deterrent therapy: Aversion medications ( Disulfiram / Antabuse ) Other medications used - Naltrexone - Acamprosate Alcohol withdrawal-management

52. Detoxification: Tx of withdrawal symptoms. Benzodiazepines ( Chlordiazepoxide 80-200mg/day and diazepam 40-80 mg/day) Treating delirium tremens: Untreated delirium death rate  20% IV anti-anxiety medications and IV fluids Restraints if needed Anticonvulsants: Benzodiazepines/ phenytoin

53. Psychosis Tx with antipsychotics B1 (Thiamine) deficiency  IV replacement Vitamin replacement  Vit B parenteral for 3-5 days followed by oral for at least 6 months. Symptomatic treatment

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