Substance Related Disorders PPT for b.sc nursing students

the content includes all the substance related disorders in details. definition, classification, compositions, predisposing factors, clinical manifestations, diagnostic evaluation, treatment, nursing management,.

1. SUBSTANCE RELATED DISORDERS BY Shubhrima khan Assistant Professor

2. INTRODUCTION Substance related disorders are a significant health problem in today’s society problems. Substance related disorders are composed of two groups….. Substance-use disorders (Dependence and Abuse) Substance-induce disorders (Intoxication, Withdrawal, Delirium, Dementia, Amnesia, Psychosis, Mood disorder, Sleep disorder and Sexual dysfunction)

3. DEFINITION SUBSTANCE The term substance is used in reference to any drug, medication, or toxin that shares the potential for abuse. ABUSE It refers to the pathological use of drugs and alcohol with impairment in social and occupational functioning (failure to meet family obligations, criminal behavior, missing work or school) and a minimal duration of disturbance of at least one month. SUBSTANCE DEPENDENCE Substance dependence refers to certain physiological and psychological phenomena induced by the repeated taking of a substance.

4. INTOXICATION Intoxication refers to a reversible pattern of behavior or psychological changes produced by the substance’s action on Central Nervous System. TOLERANCE Tolerance is a state in which after repeated administration, a drug produce a decreased effect, or increasing doses are required to produce same effects. WITHDRAWAL A group of signs and symptoms recurring when a drug is reduced in amount or withdrawn, which last for a limited time.

5. CLASSIFICATION F10 – F19 – MENTAL AND BEHAVIOURAL DISORDERS DUE TO PSYCHOACTIVE SUBSTANCE USE F10 – Mental and behavioral disorders due to use of alcohol F11 - Mental and behavioral disorders due to use of opioid F12 - Mental and behavioral disorders due to use of cannabinoids F13 - Mental and behavioral disorders due to use of sedatives and hypnosis F14 - Mental and behavioral disorders due to use of cocaine F15 - Mental and behavioral disorders due to use of stimulants, including caffeine F16 - Mental and behavioral disorders due to use of hallucinogens F17 - Mental and behavioral disorders due to use of tobacco F18 - Mental and behavioral disorders due to use of volatile solvents. F19 - Mental and behavioral disorders due to use of multiple drug and other psychoactive substances.

6. COMMONLY USED PSYCHOACTIVE SUBSTANCE Alcohol Opioids Cannabis Cocaine Hallucinogens Tobacco Sedatives/ hypnotics Inhalants Caffeine

7. PREDISPOSING FACTORS OF SUBSTANCE RELATED DISORDERS

8. BIOLOGICAL FACTORS Genetics : Children of alcoholics are three times more likely than other children to become alcoholic. Monozygotic twins have a higher rate for concordance of alcoholism than dizygotic twins. Biological offspring of alcoholic parents have a significantly greater incidence of alcoholism than the adoptive parents.

9. BIOLOGICAL FACTORS Biochemical factors: Alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction. Role of dopamine and norepinephrine have been implicated in cocaine, ethanol and opioid dependence. Neurological theories: Drug addicts may have an inborn deficiency of endorphins. Others: Comorbid medical and psychological or personality disorders.

10. PSYCHOLOGICAL FACTORS Sense of inferiority Poor impulse control Low self esteem Poor stress management skills Loneliness, unmet needs Desire to escape from reality Pleasure seeking Sexual immaturity

11. SOCIAL FACTORS

12. EASY AVAILABILITY OF DRUGS Taking drug prescribed by doctors Taking drug or substances without prescription Taking drugs from illicit sources Depression Anxiety disorders Personality disorders Occasionally organic brain disease and schizophrenia PSYCHIATRIC DISORDERS

13. DYNAMICS OF SUBSTANCE RELATED DISORDER ALCOHOL USE DISORDER Concentration of alcohol: 80-100 mg/100ml of blood – Intoxication 200-250 mg/100ml of blood – Toxic, Sleepy, Confused and Altered thought process 300 mg/100ml of blood – Lose Consciousness 500 mg/100ml of blood – Fatal

14. TYPES OF DRINKING

15. PHASES OF ALCOHOLISM Phase I: The Prealcoholic Phase Phase II: The Early Alcoholic Phase Phase III: The Crucial Phase Phase IV: Chronic Phase

16. PHASES OF ALCOHOLISM Phase I: The Prealcoholic Phase: This phase is characterized by the use of alcohol to relieve the everyday stress and tensions of life. The individual learns that use of alcohol is an acceptable method of coping with stress. Tolerance develops, and the amount required to achieve the desired effect steadily increases. Phase II: The Early Alcoholic Phase: This phase begins with blackouts – brief periods of amnesia that occur during or immediately a period of drinking. Now the alcohol is no longer a source of pleasure or relief for the individual but rather a drug that is required by the individual

17. PHASES OF ALCOHOLISM Phase III: The Crucial Phase : In this phase, the individual has lost control of his or her use, and physiological addiction is clearly evident. Binge drinking, lasting from a few hours to several weeks, is common. In this phase, the individual is extremely ill. Anger and aggression are common manifestations. Drinking is the total focus. Phase IV: Chronic Phase: This phase is characterized by emotional and physical disintegration. The individual is usually intoxicated more often. Emotional disintegration is evidenced by profound helplessness. Life-threatening physical manifestations maybe evident in every system of the body.

18. Why do people drink too much? Peer pressure Easily available and quite cheap Feel stressed and can’t sleep Hard working and drink more Think that cope better with their problem

19. EFFECTS OF ALCOHOL ON THE BODY(GENERAL HEALTH PROBLEMS )

20. MENTAL HEALTH PROBLEMS Psychological dependency Experience of typical symptoms of common mental disorder Experience of hallucination Loss of memory and orientation Epileptic fits Increase risk of suicide

21. SOCIAL PROBLEMS Problems in the family: Arguments about spending too much money on alcohol Aggressive and violent behavior Hide bottle somewhere in the house Problems at work: Appearing drunken at work Problem with concentration Unreliable May loss job

22. COMPLICATION 1.Acute Intoxication Slurred Speech Incoordination Unsteady Gait Impaired judgment Impaired social functioning Occupational functioning Mood liability

23. COMPLICATION 2. Alcohol Withdrawal syndrome Simple withdrawal symptoms Delirium Tremens 3. Neuropsychiatric complication Wernicke's Encephalopathy Korsakoff’s psychosis 4. Others Alcoholic Dementia Alcoholic Anxiety disorders Suicidal behavior

24. DIAGNOSIS History taking MSE Physical Examination Neurological Examination CAGE Questionnaire MAST CIWA Scale Blood alcohol level Blood CDT test GGT Testosterone Serum electrolyte analysis Liver function test Blood MCV test Urine toxicology Eco cardiography and Electro cardiography Based on ICD 10 criteria

25. TREATMENT Acute Alcohol Intoxication: Respiratory support Fluid replacement IV glucose to prevent hypoglycemia Correction of hypothermia or acidosis Emergency measures for trauma Infection or GI bleeding

26. TREATMENT Detoxification (Treating alcohol withdrawal symptoms): Benzodiazepines Chlordiazepoxide 80-200 mg/day Diazepam 40-80 mg/day Treating Delirium tremens: IV administration of anti-anxiety medication IV Fluid Treating Seizure: Seizures are usually self-limited and treated with a Benzodiazepines IV Phenytoin along with Benzodiazepines (History of seizure)

27. TREATMENT Psychosis: Haloperidol (Hallucinations or extremely aggressive behavior) Injection Vitamin B1 ( korsakoff’s psychosis) Others: Vitamin B – 100mg of Thiamin parenterally BD for 3-5 days, followed by oral administration of Vitamin B for 6 months. Anticonvulsants Emergency measures for trauma, infection or GI bleeding Respiratory support Fluid replacement IV Glucose Correction of hypothermia

28. TREATMENT Anticraving Medications: Naltrexone ( ReVia , Vivitrol) Acamprosate ( Campral ) Disulfiram Topiramate (Topamax) Baclofen

29. DISULFIRAM Disulfiram is used to ensure abstinence in the treatment of alcohol dependence. Main effect is to produce a rapid and violently unpleasant reaction in a person who ingests even small amount of alcohol while taking Disulfiram. Dose: Initial dose – 500mg/day for first 2 weeks Maintenance dose- 250mg/day

30. Mechanism of action

31. Adverse Effects Flushing Throbbing headache Nausea and vomiting Respiratory difficulty Chest pain Thirst Sweating Hypotension Blurred vision Tachycardia Confusion

32. Nursing Responsibility Informed consent Ensure that at least 12 hours elapsed since the last ingestion of alcohol Patient should be warned against ingestion of any alcohol- containing preparation. Caution patient against taking CNS depression and OTC medication. Instruct the patient to avoid driving and other activities requiring alertness. Patient should be warned about disulfiram reaction. Patient should carry ID card describing disulfiram-alcohol reaction. Emphasize the importance of Follow-up visit.

33. PSYCHOLOGICAL THERAPY . Cognitive Behavioral Therapy Motivational Interviewing Group Therapy Aversion conditioning Relapse Prevention Technique Cue Exposure Technique Assertive Training Family Intervention Supportive & Individual Psychotherapy

34. AGENCIES CONCERNED WITH ALCOHOL-RELATED PROBLEMS Self-help organization founded by Dr. Bob Smith and Dr. Bill Wilson on 10 th June,1985 in USA. Based on concept of peer support, acceptance and understanding. The only requirement of membership is a desire on the part of alcoholic person to stop drinking. Group meeting twice a week. Help each other to achieve sobriety Alcohol Anonymous

35. Al-Anon Al-Anon is a group started by Mrs. Anne, wife of Dr. Bob to support the spouses of alcoholics. Al-Teen Provide support to their teenage children Hostels Intended mainly for those rendered homeless due to alcohol related problems. Provide rehabilitation and counselling . Abstinence is a condition of residence.

36. NURSING MANAGEMENT Nursing Assessment: History taking MSE Physical and Neurological examination Recognition of alcohol abuse by CAGE questionnaire Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener )?

37. NURSING DIAGNOSIS Risk for injury related to hallucinosis, acute intoxication as evidenced by confusion, disorientation, inability to identify potentially harmful situation. Ineffective denial related to weak, under developed ego as evidenced by lack of insight, blaming others, rationalization, failure to accept responsibility. Imbalance nutrition less than body requirement related to change in appetite as evidenced by pale, dry skin, under weight. Ineffective individual coping related to impairment of adoptive behavior and problem solving abilities as evidenced by use substance as coping mechanism.

38. OPIOID USE DISORDER The most important dependence producing derivatives are morphine and heroin. Opioids exert both a sedative and analgesic effect. Method of administration of opioid drugs include oral, snoring or smoking and by SC, IM and IV injection. Injecting drug users have become a high risk group for HIV infection

39. OPIOID INTOXICATION Apathy Dysphoria Psychomotor agitation or retardation Impairment in memory, concentration, judgment Bradycardia Hypotension Respiratory depression Pinpoint pupil In later stage – Delayed reflexes Thready pulse Coma

40. COMPLICATION Illicit drug use: Parkinsonism, Peripheral neuropathy, Transverse Myelitis IV Use : Skin infection, Thrombophlebitis, Pulmonary embolism, Endocarditis, Septicemia, AIDS, Viral Hepatitis, Tetanus Involvement in criminal activities.

41. OPIOID WITHDRAWAL Withdrawal symptoms begin within 12 hrs of last dose. Pick in 24 – 36 hrs Disappear in 5 – 6 days Watery eyes Running nose Yawing Loss of appetite Tremors Irritability Sweating Nausea Diarrhea Anorexia Insomnia Raised body temperature COMMON SYMTOMS:

42. TREATMENT Opioid Overdose: Narcotic antagonist (Naloxone, Naltrexone) Detoxification: Methadone, Clonidine, Naltrexone, Buprenorphine, etc. Maintenance therapy: After detoxification phase is over, the patient is maintained on one of the following regimen .. Methadone maintenance Opioid antagonist Psychological methods like individual psychotherapy, Behavioural therapy, Group and Family therapy.

43. CANNABIS USE DISORDER Cannabies derived from hemp plant, CANNABIES SATIVA. Dried leaves and flowering tops are often referred as GANJA or MARIJUANA . The resin of plant referred to HASHISH . BHANG is a drink made from cannabies .

44. ACUTE INTOXICATION Mild Intoxication: Mild impairment of consciousness and orientation Tachycardia Euphoria Dream like-state Alteration of psychomotor activity, Tremor Photophobia Lacrimation Dry mouth and Increase appetite Severe Intoxication: Depersolization and Derealization Hallucination

45. WITHDRAWAL SYMPTOMS Increased salivation Hyperthermia Insomnia Decreased appetite Loss of weight

46. COMPLICATION Short – lasting psychiatric disorders such as Acute anxiety, Paranoid psychosis, Hypomania, Hysterical fugue-like state, Schizophrenia-like state Memory impairment Supportive and symptomatic treatment TREATMENT

47. COCAINE USE DISORDER Cocaine is derived from the shrub “ Erythoxylon coca ” Common street name “ Crack ” It can be administered orally, intranasally by smoking, or parenterally

48. ACUTE INTOXICATION Pupillary dilatation Tachycardia, Hypertension Sweating Nausea Hypomanic picture Agitation Depression Anorexia Fatigue Sleepiness WITHDRAWAL SYNDROME

49. COMPLICATION Acute anxiety Uncontrolled compulsive behavior Seizure Respiratory depression Cardiac arrhythmias Management of intoxication: Amyl Nitrite is an antidote, Diazepam or Propranolol For withdrawal Symptoms: Antidepressants (Imipramine or Amitriptyline) Psychotherapy TREATMENT

50. NICOTINE USE DISORDER It is obtained from “ NICOTIANA TABACUM” Most highly addictive and heavily used drug.

51. TOBACCO PRODUCTS

52. CHEMICAL COMPONENTS IN CIGARETTE

53. ADVERSE EFFECTS OF NICOTINE Respiratory paralysis Salivation Pallor Weakness Abdominal pain Diarrhea Hypertension Tachycardia Tremor

54. .

55. SIGN AND SYMPTOMS OF TOBACCO WITHDRAWAL Urge to smoke Irritability Low mood Restlessness Insomnia Difficulty concentration Impatience Craving Decrease heart rate Impaired performance

56. AMPHETAMINE USE DISORDER Amphetamine are powerful CNS stimulants with peripheral sympathetic effects. Commonly used Amphetamine are Methylphenidate and Pemoline. One of the commonest pattern of use is seen amongst the students and sports-persons to overcome the need for sleep and fatigue

57. ROUTES Oral Nasal inhalation Oral Nasal inhalation Intravenous Insufflation Medical : Recreational :

58. ACUTE INTOXICATION WITHDRAWAL SYMPTOMS Tachycardia Hypertension Cardiac Failure Seizure Tremors Hyperpyrexia Pupillary Dilation Insomnia Restlessness Irritability Paranoid hallucinatory syndrome Amphetamine – induced psychosis Depression Apathy Fatigue Agitation Hyperphagia

59. COMPLICATIONS Seizure Delirium Arrhythmias Aggressive Behavior Coma

60. TREATMENT Absorption of drug can be reduced by administering activated charcoal. Hyperpyrexia: Parenteral Antipyretics Hypertension: Antihypertensive Seizure: Parenteral Diazepam Psychotic symptoms: Antipsychotic Antidepressants Supportive psychotherapy

61. LSD USE DISORDER LSD (Lysergic acid diethylamide) is a powerful hallucinogenic substance derived from the ergot fungus . Water soluble, tasteless, colorless and odorless drug

62. FORMS OF LSD Powder Capsule Tablet Gel tabs Liquid Blotter

63. PHYSICAL EFFECTS OF LSD

64. INTOXICATION WITHDRAWAL SYMPTOMS Depersonalization Derealization Illusions Synesthias Hyperactivity Anxiety Paranoid ideation Impairment of judgment Flashback ( Brief experiences of the hallucinogenic state)

65. COMPLICATION Anxiety Depression Psychosis or visual hallucination Antianxiety Antidepressant Antipsychotic TREATMENT

66. BARBITURATE USE DISORDER The Commonly abused Barbiturates are secobarbital, pentobarbital, amobarbital Lability of mood Disinhibited behavior Slurring of speech Incoordination Attention and memory impairment INTOXICATION

67. COMPLICATIONS Intravenous use can lead to skin abscess Cellulitis Infection Embolism Hypersensitivity reaction

68. WITHDRAWAL SYMPTOMS Restless Tremors Seizure Induction of vomiting and activated charcoal can reduce the absorption Symptomatic treatment TREATMENT

69. INHALANT USE DISORDER Volatile solvents: Petrol Aerosols Thinners Varnish Remover Industrial Solvent Dendrite

70. INTOXICATION WITHDRAWAL SYMPTOMS Euphoria Excitement Slurring of speech Apathy Neurological sign Impaired judgment Anxiety Depression

71. HARMFUL EFFECTS OF INHALANTS Permanent brain damage, Memory loss Slurred speech Suffocation and Sudden Death Irregular heart beat, Heart attack and Death Liver damage, Kidney damage Abdominal pain Nausea, Vomiting Muscle weakness and cramping Involuntary passing of urine & feces Bone Marrow Depression Hearing loss Nose bleed & loss of smell

72. COMPLICATION Irreversible damage of liver and kidneys Peripheral neuropathy Perceptual disturbance Brain damage Reassurance and Diazepam for intoxication TREATMENT

73. PREVENTION OF SUBSTANCE USE DISORDER Reduction of over prescribing drug Identification and treatment of family member who may be contributing to drug abuse. Strengthen individual’s personal and social skills. Heath education to college students and youth. Improvement of socio-economic condition. Primary prevention

74. Secondary Prevention Early detection and counselling Motivational interviewing Full assessment of medical, psychological and social problems. Detoxification with Benzodiazepines

75. Tertiary Prevention Alcohol deterrent therapy and other therapy. Agencies: AA, Al-anon Relapse prevention Motivation enhancement Identifying high-risk situation Drink refusal skills Stress management Sleep hygiene Recreation and spirituality Family counselling

76. Bibliography:   R Sreevani : A GUIDE TO MENTAL HEALTH & PSYCHIATRIC NURSING; 4 th Edition, 2016; The Health Sciences Publisher; Page No. 240-258   Prof.( Dr. ) BIMLA KAPOOR: A Textbook of PSYCHIATRIC NURSING; 3 rd Edition, 2019; KUMAR PUBLISHING HOUSE; Page No.222-233   Mary C. Towndend:Psychiatric Mental Health Nursing: Concept of care in Evidence-Based Practice; Eighth Edition,2015; F.A.Davis Company; Page No. 365-413   D.Elakkuvana Bhaskara Raj: DERB’S MENTAL HEALTH(PSYCHIATRIC) NURSING; 1 st Edition,2014; EMMESS Medical Publishers; Page No. 381-406