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Substance related disorder
Substance related disorder
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Substance Use Disorder- ALCOHOLISM

  1. 1. Substance Use Disorders Mr. Visanth .V.S Asso.Professor IGSCON, Amethi
  2. 2.  Substance related disorders are composed of two groups: ◦ The substance use disorders (dependence and abuse) ◦ Substance induced disorders (intoxication, withdrawal, delirium, dementia, amnesia, psychosis, mood disorders, anxiety disorder, sexual dysfunction, and sleep disorders
  3. 3. Terminologies  Intoxication: The transient effects due to recent substance ingestion, which disappear when the substance is eliminated.  Addiction: compulsion to use a drug, usually for its psychic, rather than therapeutic, effects.  Tolerance: The state in which the same amount of a drug produces a decreased effect, so that increasingly larger doses must be administered to obtain the effects observed with the original use.  Physical Dependence: The development of withdrawal symptoms once a drug is stopped.
  4. 4. Contd…….  Withdrawal: A physiological state that follows cessation or reduction in the amount of a drug used.  Substance Dependence: is “a maladaptive pattern of substance use with adverse clinical consequences.”  Substance Abuse: A class of substance-related disorders that includes both substance abuse and substance dependence.  Toxicity: Poisonous nature; poisonous quality.
  5. 5. What is a drug?  A drug is a substance that has an action on biological tissues when administered  Some drugs influence mood cognition and behavior ◦ Psychoactive/Psychotropic drugs are like alcohol, cocaine, diazepam etc.
  6. 6. Psychoactive Drugs Substances active on CNS tissues when administered thereby causing changes in mood, cognition, behavior
  7. 7. Psychoactive Substance Psychoactive (psychotropic) substance is any substance which after absorption has influence on mental processes both cognitive and affective.
  8. 8. Drug Action on the Nervous System  Most drugs that are abused have a common effect on a particular NT pathway. The basic addiction pathway in the brain is a dopamine pathway followed by serotonin.  Activation of this pathway accounts for the positive reinforcement, feeling and makes us want to repeat the action that triggered the feeling.  Action on NT systems  Agonist  Antagonist
  9. 9. Drug Action on the Nervous System on Repeated Use  Tolerance ◦ Decreased response to repeated exposure  Dependence ◦ System adapts to presence of drug. Drug necessary for homeostasis  Withdrawal ◦ Response to drug leaving the system  Addiction ◦ Compulsive engagement in reinforcing behavior
  10. 10.  There are four important patterns of substance use disorders, which may overlap with each other.  Acute intoxication,  Withdrawal state,  Dependence syndrome  Harmful use.
  11. 11. Substance abuse Definition  A maladaptive pattern of substance leading to clinically significant impairment or distress as manifested by one or more of the following:  Failure to fulfill major role obligations at home, school, or work.  Recurrent substance use in situations in which it is physically hazardous.  Recurrent substance related legal problems.  Recurrent substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
  12. 12. ICD Classification  F10 Mental and behavioural disorders due to use of alcohol  F11 Mental and behavioural disorders due to use of opioids  F12Mental and behavioural disorders due to use of cannabinoids  F13 Mental and behavioural disorders due to use of sedatives or hypnotics  F14 Mental and behavioural disorders due to use of cocaine  F15 Mental and behavioural disorders due to use of other stimulants, including caffeine  F16 Mental and behavioural disorders due to use of hallucinogens  F17 Mental and behavioural disorders due to use of tobacco  F18 Mental and behavioural disorders due to use to volatile solvents  F19 Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances
  13. 13. COMMONLY USED PSYCHOACTIVE SUBSTANCES  CNS depressants ◦ Alcohol ◦ Sedatives, hypnotics or anxiolytics ◦ Inhalants (Volatile Solvents)  CNS stimulants ◦ Amphetamines ◦ Cocaine ◦ Caffeine ◦ Nicotine (tobacco)  Cannabis  Opioids  Hallucinogens  Phencyclidine  Others (e.g. anabolic Steroids, anticholinergic).
  14. 14. Etiology  Genetics  Genetic studies shows the vulnerability especially evident with alcoholism, and less so with other substances. Children of alcoholics are three times more likely than other children to become alcoholics.  Biochemical Factors  Neurotransmitters like dopamine and norepinephrine have a role in cocaine, ethanol and opioid dependence. Alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction.
  15. 15. Individual-related Risk Factors  Early age of onset  Presence of early childhood behavioral problems  Poor academic performance  Risk-taking behaviors  Favorable beliefs about substance use  Increased impulsivity  Self medication hypothesis: alcohol for anxiety
  16. 16. Family-related Risk Factors  Favorable beliefs about substance use in parents  Parental tolerance of substance use  Lack of closeness and attachment between adolescent and parent  Lack of discipline/supervision by parent  Parental substance use  Childhood physical or sexual abuse
  17. 17. Peer-related Risk Factors  Peer substance use  Favorable peer attitudes to use  Greater orientation of adolescents to peers as opposed to parents  Community-related Risk Factors ◦ Low Socio economic status ◦ High population density ◦ High crime rate ◦ Easy availability of drugs
  18. 18. Alcohol Use Disorders
  19. 19. Alcohol  Alcohol/ethanol/ ethyl alcohol is a chemical intoxicating ingredient found in beer, wine, and liquor.  Alcohol is produced by the fermentation of yeast, sugars, and starches.  It exerts a depressant effect on the CNS, resulting in behavioral & mood changes that are rapidly absorbed from the stomach and small intestine into the bloodstream.
  20. 20. Alcohol: Our Most Primitive Intoxicant Egypt ◦ Barley beer is probably the oldest drink in the world with its origin in Egypt prior to 4200 BC China ◦ 7000 BC - the production of a prehistoric mixed fermented beverage of rice, honey and fruit ◦ 2000 BC- unique cereal beverages (Shang and Western Zhou Dynasties)
  21. 21.  In India, an alcoholic beverage called sura, distilled from rice, was in use between 3000 and 2000 B.C.  The Babylonians worshiped a wine goddess as early as 2700 B.C.  Greek literature is full of warnings against excessive drinking.  Several Native Americans developed alcoholic beverages in pre-Columbian times.  A variety of fermented beverages were used in the Andes region of South America were created from corn, grapes or apples, called “chicha.”
  22. 22. Alcoholism -Definition  It is the use of alcoholic beverages to the point of causing damage to the individual, society or both.
  23. 23. Properties Of Alcohol  Alcohol is a clear liquid with a strong burning taste.  Rapid absorption is more into the blood stream.
  24. 24. Stages of Alcohol Use There are basically 3 stages in which all alcoholics may go through, they are;  Early Stage (Stage 1) ◦ To relax, relieve stress ◦ Begins to become intoxicated regularly. ◦ Makes excuses and tries to rationalize drinking behavior frequently.
  25. 25.  Middle Stage (Stage 2) ◦ Drinker denies or tries to hide problem. ◦ Gradually Body develops tolerance. ◦ Frequently absent from school or work. ◦ Drinking becomes is central event in a person’s life and drinks daily. ◦ Drinks lot when alone ◦ Drinks first thing in the morning
  26. 26.  Final Stage (Stage 3) ◦ Person becomes aggressive & isolated in this stage. ◦ Person become Malnourished because drinker consumes alcohol and does not worry about food. ◦ Body is addicted to alcohol. ◦ Try to quit leads to withdrawal ◦ Delirium Tremens: hot/cold flashes, tremors, nightmares, hallucinations, fear of people and animals
  27. 27. Blood Alcohol Concentration and Its Symptoms  25 -100 mg% excitement.  100 - 200 mg % leads to serious intoxication, slurred speech, in coordination, nystagmus  300-350 mg% - Hypothermia, dysarthria, cold sweats  350 -400 mg% - Coma, respiratory depression.  400 mg% - Death may occur.
  28. 28. Types of drinkers  Moderate drinkers  Problem drinkers ◦ The excessive consumption is starts with Experimental Recreational Relaxational compulsive
  29. 29. Epidemiology  Predominantly seen in males than in females and the rates for female users of alcohol are very low and less than 5% of all the female.  In India shows the use of alcohol in general population is 25.6 – 74.2% and in students it is 21.8 to 58.4% and among medical professionals it is 8.5 to 66.7%  The life time prevalence of alcohol disorders with schizophrenia and affective disorders is 33.7% and 21.8% respectively.
  30. 30. Etiology  Biological Factors  Genetic vulnerability- family history  Co-morbid psychiatric disorder or personality disorder  Co-morbid medical disorders  Withdrawal effects and craving (explains continuation of drug use)  Biochemical factors - role of dopamine and norepinephrine
  31. 31.  Psychological Factors  Curiosity  General rebelliousness  Early initiation of alcohol  Poor impulse control  Low self-esteem  Concerns regarding personal autonomy  Poor stress management skills  Childhood trauma or loss  Relief from fatigue and/or boredom  Escape from reality  Lack of interest in conventional goals  Psychological distress
  32. 32.  Social Factors  Peer pressure  Modeling (imitating behaviour of others)  Ease of availability of alcohol  Strictness of drug law enforcement  Intra-familial conflicts  Poor social/familial support  Rapid urbanization
  33. 33. EEFECTS OF ALCOHOL ON THE BODY  Short term effects ◦ Upset in stomach ◦ Headaches ◦ Breathing difficulties ◦ Distorted vision and hearing ◦ Impaired judgment ◦ Slurred speech ◦ Drowsiness ◦ Vomiting ◦ Diarrhoea ◦ Decreased perception and coordination ◦ Unconsciousness ◦ Anaemia Coma ◦ Blackouts (memory lapses, where the drinker cannot remember events that occurred while under the influence)
  34. 34. Long-term effects  Intentional injuries such as sexual assault, domestic violence.  Unintentional injuries such as car crash, falls, burns, drowning  Increased family problems, broken relationships  Alcohol poisoning  High blood pressure, stroke, and other heart-related diseases  Liver disease  Nerve damage  Sexual problems  Permanent damage to the brain  Vitamin B1 deficiency, which can lead to a disorder characterized by amnesia, apathy and disorientation (see next page for its treatment).  Gastritis and ulcers.  Malnutrition  Cancer of the mouth and throat
  35. 35. Psychiatric Disorders due to Alcohol Dependence  Acute Intoxication  Withdrawal Syndrome  Alcohol Induced Amnestic Disorders  Alcohol Induced Psychiatric Disorders
  36. 36. Acute Intoxication  Acute intoxication develops during or shortly after alcohol ingestion.  It is characterized by, Aggressive Behavior Inappropriate Sexual Behavior Mood Liability Poor Judgment Slurred Speech Unsteady Gait Nystagmus
  37. 37. Withdrawal Symptoms  In 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.  These are: 1. Simple withdrawal syndrome 2. Delirium tremens
  38. 38. 1.Simple withdrawal symptoms ◦ The most common withdrawal syndrome is a hangover on the next morning ◦ Mild Tremor ◦ Anxiety ◦ Increased heart rate and blood pressure ◦ Sweating ◦ Nausea, vomiting ◦ Insomnia ◦ Weakness ◦ Impaired attention ◦ Irritability
  39. 39. 2. Delirium Tremens  A sudden form of withdrawal that involves sudden and severe mental or neurological changes  Features ◦ Mental status changes/psychomotor agitation /restlessness/ excitement/decreased attention span/irritability/clouding of consciousness/altered sensorium ◦ Fluctuating consciousness ◦ Vivid hallucinations ◦ Agitation/shouting/fear ◦ Severe uncontrollable tremors/panic attack ◦ Mild hyperpyrexia/sweating/dilated pupils / tachycardia / convulsions ◦ Dehydration /leukocytosis/adrenergic storm ◦ Onset 48-72hours after the last drink (up to 7 days) ◦ Mortality: 10-15% (untreated)
  40. 40. Alcohol Induced Amnestic Disorder  WERNICKES ENCEPHALOPATHY ◦ This is an acute reaction which occurs due severe deficiency of thiamine, in chronic alcohol users, because alcohol reduces the absorption ability of thiamine in the stomach. ◦ The clinical signs are;  Ocular signs: Nystagmus, ophthalmoplegia with bilateral external rectus paralysis.  Higher mental function disturbance: Recent memory disturbances, Disorientation, confusion, poor attention span and distractibility.
  41. 41. KORSAKOFF’S PSYCHOSIS  Most of the time it occurs followed by Wernicke’s encephalopathy.  Clinically it characterized by gross memory disturbance with confabulation. Insight is often impaired.
  42. 42. Alcoholic Seizures/Rum Fits Generalized tonic-clonic seizures occur in about 10% of alcohol dependence patients Develops usually after 12-48 hours of heavy bout of drinking.
  43. 43. Alcohol induced Psychiatric Disorders  Alcohol-induced dementia:  Alcoholic paranoid psychosis  Delusions- jealous, persecute  Alcohol-induced anxiety disorder  Alcohol induced mood disorders - Depression and Suicidality,  Alcoholic hallucinosis ◦ Auditory hallucinations without clouding of sensorium
  44. 44. Medical Complications  Gastro Intestinal Complications  Gastritis, peptic ulcer, reflux esophagitis, carcinoma of stomach and esophagus  Fatty liver, cirrhosis of liver, hepatitis, liver cell carcinoma  Acute and chronic pancreatitis  Malabsorption syndrome
  45. 45.  Cardiovascular system  Alcoholic cardiomyopathy  High risk for myocardial infarction  Central nervous system  Peripheral neuropathy  Epilepsy  Head injury  Cerebellar degeneration
  46. 46.  Miscellaneous  Protein malnutrition  Vitamin deficiency disorder  Peripheral muscle weakness  Acne  Sexual dysfunction in males, failure of ovulation in females  Social  Marital disharmony  Occupational problems  Financial problems  Criminality  Accidents
  47. 47. Fetal alcoholic syndrome  Fetal alcohol syndrome ◦ Facial abnormality ◦ Low birth weight ◦ Low intelligence  Increased stillbirths.  Alcohol dependence is responsible for 3percent of all cases of mental retardation
  48. 48. Alcohol intoxication Alcohol withdrawal syndrome It occurs as a result the amount of alcohol in blood stream increases. The higher the blood alcohol concentration is, the more impaired. Symptoms incude;  Inappropriate behavior,  unstable moods,  Impaired judgment,  Impaired attention.  Slurred speech,  Impaired attention or memory.  Poor coordination.  Aggression.  Lability of mood.  Unsteady gait.  Difficulty standing.  Nystagmus.  "Blackouts," where person don't remember any events during intoxicated period.  Decreased level of consciousness (e.g. stupor, coma).  Very high blood alcohol levels can lead to coma or even death.  Acute alcohol intoxication when severe may be accompanied by hypotension, hypothermia and Depression of the gag reflex. It can occur when alcohol use has been heavy and prolonged and is then stopped or greatly reduced. It can occur within several hours to four or five days later. Symptoms include;  Sweating, rapid heartbeat, hand tremors.  Problems sleeping (insomnia).  High blood pressure  Nausea and vomiting.  Hallucinations.  Restlessness and agitation.  Anxiety, and occasionally seizures.  Symptoms can be severe enough to impair ability to function at work or in social situations. (Above symptoms are more noticeable when person wake up with less alcohol in blood.)  The most severe type of withdrawal syndrome is known as delirium tremens (DT). Its signs and symptoms include: - Extreme confusion. - Extreme agitation. - High Fever. - Seizures (Grand mal convulsions) - Tactile hallucinations, such as having a sense of itching or burning that isn’t actually occurring. - Auditory hallucinations or hearing sounds that don’t exist. - Visual hallucinations, or seeing images that don’t exist
  49. 49. Diagnosis  Thorough history  MSE  Physical Examination  Blood examination  LFT  Nutritional test  Chest radiography etc
  50. 50. TREATMENT
  51. 51. ALCOHOL USE DISORDER (Alcohol Abuse And Dependence)  ALCOHOL DETERRENT THERAPY  Deterrent agents are those which are given to desensitize the individual to the effects of alcohol and maintain abstinence. The most commonly used drug is Disulfiram or Antabuse.  Antabuse (disulfiram) blocks an enzyme that is involved in metabolizing alcohol intake. Disulfiram produces very unpleasant side effects when combined with alcohol in the body.
  52. 52.  Mechanism of action ◦ Disulfiram is an oral drug used for treating alcoholism. ◦ Alcohol is converted in the body into acetaldehyde by an enzyme called alcohol dehydrogenase. Another enzyme called acetaldehyde dehydrogenase then converts acetaldehyde into acetic acid. ◦ Disulfiram prevents acetaldehyde dehydrogenase from converting acetaldehyde into acetic acid, leading to a build up of acetaldehyde levels in the blood and in presence of alcohol it produces acetaldehyde-alcohol reaction in the body which is an unpleasant feeling to a person.
  53. 53. Ethanol AcetateAcetaldehyde •Flushing •Headache •Palpitations •Dizziness •Nausea ADH ALDH Disulfiram-Action
  54. 54. Disulfiram-Ethanol Reactions  Disulfiram-ethanol reactions often develop within 15 minutes after exposure to ethanol;  symptoms usually peak within 30 minutes to 1 hour, and then gradually subside over the next few hours.  Symptoms may be severe and life-threatening.  The disulfiram- alcohol reaction is characterised by: ◦ Intense vasodilation of the face and neck causing flushing, ◦ Increased body temperature, ◦ Sweating, nausea, vomiting. ◦ Pruritis, urticaria. ◦ Anxiety, dizziness, headache. ◦ Blurred vision. ◦ Dyspnoea, palpitations and hyperventilation. ◦ In severe cases tachycardia, hypotension, respiratory depression, chest pain, arrhythmias, coma and convulsions may occur. ◦ Rare complications include hypertension, bronchospasm and methaemoglobinaemia.
  55. 55.  Dosage: In the first phase of treatment, a maximum of 500 mg daily in the form of tablet is given in a single dose for one to two weeks.  Usually it is taken in the morning.  Maintenance Regimen The average maintenance dose is 250 mg daily (range, 125 to 500 mg), it should not exceed 500 mg daily.
  56. 56. Nurse responsibility in Disulfiram therapy  Educate the patient about Disulfiram and obtain informed consent.  Wait until the patient has abstained from alcohol at least 12 hours and/or breath or blood alcohol level is zero.  Advice patient to wear ID card which mentioning, about Disulfiram treatment, Doctors name & Contact number.  Advice him not to take alcohol.  Start Disulfiram after 12 hours of alcohol.  Advice him to avoid the substances contain alcohol.  Inform about DER.  Avoid CNS depressants.  Avoid driving.  Advice the patient not to use any alcohol content products like aftershave, spray. etc, while patient is in therapy.
  57. 57.  ACAMPROSATE (PREVENTING RELAPSE): It is used to prevent relapse in recovering alcohol-dependent patients. It is contraindicated in cases of renal insufficiency or severe hepatic failure.  NALTREXONE: Naltrexone tablet is indicated for use in alcohol dependence to reduce the risk of relapse, support abstinence and reduce alcohol craving. These drugs only deal with physical symptoms and do not treat the psychological causes of addiction.
  58. 58. Medication Target Year Approved Disulfiram Aldehyde Dehydrogenase 1949 Research from animal models over the past 25 years has provided promising targets for pharmacotherapy Naltrexone Mu Opioid Receptor 1994 Acamprosate Glutamate and GABA- Related 2004 Naltrexone Depot Mu Opioid Receptor 2006 FDA Approved Medications for Treating Alcohol Dependence
  59. 59. TREATMENT ALCOHOL INDUCED DISOREDR  Detoxification Therapy ◦ It’s the process by which an alcohol dependent person recovers from the intoxication and withdrawal effects in a supervised manner. ◦ Benzodiazepines- chlordizepoxide 80-200 mg/ day. ◦ Diazepam 40-80 mg/ day to control anxiety, agitation and tremors. ◦ Thiamine 100 mg intramuscular for 3-5 days followed by vitamin – B administration 100 mg OD for at least 6 months.
  60. 60. THERAPIES TO TREAT ALCOHOL DISORDER  Motivational Interviewing  Individual Psychotherapy  Group Therapy  Counselling  Aversive Conditioning  Behaviour Modification Techniques  Family Therapy  Self Help Groups
  61. 61. Self Help Groups  Alcoholic anonymous (AA) ◦ This is a self help organization founded in the USA by two alcoholic men, Dr Bob smith and Bill Wilson on 10th June 1935. ◦ AA considers alcoholism as a physical, mental and spiritual disease, a progressive one, which can be arrested but not cured. ◦ Members attend group meetings usually twice a week on a long term basis. ◦ Each member is assigned a support person. ◦ From whom he may seek help when the temptations to drink occur. ◦ In crisis he can obtain immediate help by telephone.
  62. 62.  AL-ANDN:- it is a group started by wife of Dr Bob ( Mrs. Anne), to support the spouses of alcoholics.  AL-ATEEN:- provides support to their teenage children.  HOSTELS:- these are for those rendered homeless due to alcohol- related problems. They provide rehabilitation and counselling.  ACOA (Adult Children of Alcoholics):- adult who grew up with an alcoholic in the home.  Children are people:- school age children with an alcoholic family members.  Women for sobriety:- meant for female alcoholics.
  63. 63. PREVENTION  Preventive programs: teach adolescents how to resist social pressure to use drugs.  Detoxification: substance specific  Drug rehabilitation: develop new coping skills  Self-help groups: alcoholics anonymous  Disulfiram  Naltrexone  methadone
  64. 64. Nursing Management  Assessment by CAGE questionnaire ◦ which consists of four questions:  Have you ever thought you should cut down on your drinking?  Have people annoyed you by criticising your drinking?  Have you ever felt guilty about your drinking?  Have you ever drunk an "eye-opener", which means: have you ever drunk alcohol first thing in the morning to get over a hangover and steady your nerves? ◦ If answer is "yes" to one or more of the questions above, it indicate that the person having problem with drinking. 
  65. 65. Nursing Care Plan Nursing care plan for Alcohol related disorder Nursing diagnosis: Risk for ineffective Breathing Pattern related to direct effect of alcohol toxicity on respiratory centre and sedative drugs given to decrease alcohol withdrawal symptoms Outcome Identification Nursing Intervention Client will be able to: - Maintain Effective Breathing Pattern With Respiratory Rate Within Normal Range,  Monitor respiratory rate/depth and pattern. Note for periods of apnea, Cheyne-Stokes respirations.  Auscultate for breath sounds. Note presence of adventitious sounds (e.g., rhonchi, wheezes).  Elevate head end of the bed.  Encourage deep-breathing coughing exercises.  Change positions frequently.  Keep suction equipment, airways ready.  Administer supplemental oxygen if needed.  Review serial chest x-rays, arterial blood gases (ABGs)/pulse oximetry as indicated.
  66. 66. Nursing diagnosis: Risk for Injury related to Cessation of alcohol and appearance of withdrawal symptoms, Involuntary clonic/tonic muscle activity (seizures), reduced muscle and hand/eye coordination. Outcome Identification Nursing Intervention Client will be able to: - Demonstrate absence of untoward effects of withdrawal. - Experience no physical injury.  Monitor for withdrawal symptoms.  Monitor/document seizure activity.  Maintain patent airway.  Provide safety to the patient (e.g., padded side rails, bed in low position).  Assess for gait.  Palpate upper arm to conform actual withdrawal versus medication-seeking behavior.  Assist patient in ambulation and self-care activities as needed.  Administer medications as indicated e.g.: Benzodiazepines (BZDs)
  67. 67. Nursing diagnosis: Anxiety or Fear related to physiologic withdrawal, Situational crisis (hospitalization) and perceived threat of death as evidenced by feelings of inadequacy, shame, increased helplessness/hopelessness and increased tension. Outcome Identification Nursing Intervention Client will be able to: - Verbalize reduction of fear and anxiety. - Demonstrate problem- solving skills and use resources effectively.  Identify cause of anxiety.  Explain that alcohol withdrawal usually increases anxiety and uneasiness.  Reassess level of anxiety on an ongoing basis.  Develop a trusting relationship with patient through frequent contact being honest and nonjudgmental.  Show an accepting attitude about alcoholism.  Reorient frequently.  Administer medications as indicated, e.g.:BDZs (e.g., chlordiazepoxide [Librium], diazepam [Valium]).  Referral patient for Detoxification and crisis centre.
  68. 68. Thank You

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