Substance Use Disorders
Mr. Visanth .V.S
Substance related disorders are
composed of two groups:
◦ The substance use disorders (dependence
◦ Substance induced disorders
(intoxication, withdrawal, delirium,
dementia, amnesia, psychosis, mood
disorders, anxiety disorder, sexual
dysfunction, and sleep disorders
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.
Withdrawal: A physiological state that follows
cessation or reduction in the amount of a drug
Substance Dependence: is “a maladaptive
pattern of substance use with adverse clinical
Substance Abuse: A class of substance-related
disorders that includes both substance abuse and
Toxicity: Poisonous nature; poisonous quality.
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
drugs are like alcohol,
cocaine, diazepam etc.
Substances active on
CNS tissues when
changes in mood,
Psychoactive (psychotropic) substance is any
substance which after absorption has
influence on mental processes both
cognitive and affective.
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
Action on NT systems
Drug Action on the Nervous System on
◦ Decreased response to repeated exposure
◦ System adapts to presence of drug. Drug necessary
◦ Response to drug leaving the system
◦ Compulsive engagement in reinforcing behavior
There are four important patterns of
substance use disorders, which may
overlap with each other.
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
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.
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
F14 Mental and behavioural disorders due to use of cocaine
F15 Mental and behavioural disorders due to use of other stimulants,
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
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.
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.
Individual-related Risk Factors
Early age of onset
Presence of early childhood behavioral
Poor academic performance
Favorable beliefs about substance use
Self medication hypothesis: alcohol for
Family-related Risk Factors
Favorable beliefs about substance use in
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
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
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.
Alcohol: Our Most Primitive Intoxicant
◦ Barley beer is probably the oldest drink in the
world with its origin in Egypt prior to 4200
◦ 7000 BC - the production of a prehistoric
mixed fermented beverage of rice, honey and
◦ 2000 BC- unique cereal beverages (Shang and
Western Zhou Dynasties)
In India, an alcoholic beverage called sura,
distilled from rice, was in use between 3000 and
The Babylonians worshiped a wine goddess as
early as 2700 B.C.
Greek literature is full of warnings against
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.”
It is the use of alcoholic beverages to the
point of causing damage to the
individual, society or both.
Properties Of Alcohol
Alcohol is a clear liquid with a strong
Rapid absorption is more into the
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.
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
Final Stage (Stage 3)
◦ Person becomes aggressive & isolated in this
◦ Person become Malnourished because drinker
consumes alcohol and does not worry about
◦ Body is addicted to alcohol.
◦ Try to quit leads to withdrawal
◦ Delirium Tremens: hot/cold flashes, tremors,
nightmares, hallucinations, fear of people and
Blood Alcohol Concentration and Its
25 -100 mg% excitement.
100 - 200 mg % leads to serious intoxication,
slurred speech, in coordination, nystagmus
300-350 mg% - Hypothermia, dysarthria, cold
350 -400 mg% - Coma, respiratory depression.
400 mg% - Death may occur.
Types of drinkers
◦ The excessive consumption is starts with
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.
Genetic vulnerability- family history
Co-morbid psychiatric disorder or personality
Co-morbid medical disorders
Withdrawal effects and craving (explains
continuation of drug use)
Biochemical factors - role of dopamine and
Early initiation of alcohol
Poor impulse control
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
Modeling (imitating behaviour of others)
Ease of availability of alcohol
Strictness of drug law enforcement
Poor social/familial support
EEFECTS OF ALCOHOL ON THE BODY
Short term effects
◦ Upset in stomach
◦ Breathing difficulties
◦ Distorted vision and
◦ Impaired judgment
◦ Slurred speech
◦ Decreased perception
◦ Anaemia Coma
◦ Blackouts (memory
lapses, where the
remember events that
occurred while under
Intentional injuries such as
sexual assault, domestic
Unintentional injuries such as
car crash, falls, burns,
Increased family problems,
High blood pressure, stroke,
and other heart-related
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.
Cancer of the mouth and throat
Acute intoxication develops during or shortly
after alcohol ingestion.
It is characterized by,
Inappropriate Sexual Behavior
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.
1. Simple withdrawal syndrome
2. Delirium tremens
1.Simple withdrawal symptoms
◦ The most common withdrawal syndrome is a
hangover on the next morning
◦ Mild Tremor
◦ Increased heart rate and blood pressure
◦ Nausea, vomiting
◦ Impaired attention
2. Delirium Tremens
A sudden form of withdrawal that involves sudden and
severe mental or neurological changes
◦ Mental status changes/psychomotor agitation /restlessness/
excitement/decreased attention span/irritability/clouding of
◦ Fluctuating consciousness
◦ Vivid hallucinations
◦ Severe uncontrollable tremors/panic attack
◦ Mild hyperpyrexia/sweating/dilated pupils / tachycardia /
◦ Dehydration /leukocytosis/adrenergic storm
◦ Onset 48-72hours after the last drink (up to 7 days)
◦ Mortality: 10-15% (untreated)
Alcohol Induced Amnestic Disorder
◦ 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.
Most of the time it occurs followed by
Clinically it characterized by gross
memory disturbance with confabulation.
Insight is often impaired.
Alcoholic Seizures/Rum Fits
Generalized tonic-clonic seizures
occur in about 10% of alcohol
Develops usually after 12-48 hours
of heavy bout of drinking.
Gastro Intestinal Complications
Gastritis, peptic ulcer, reflux
esophagitis, carcinoma of stomach and
Fatty liver, cirrhosis of liver, hepatitis,
liver cell carcinoma
Acute and chronic pancreatitis
High risk for myocardial infarction
Central nervous system
Vitamin deficiency disorder
Peripheral muscle weakness
Sexual dysfunction in males, failure of ovulation in
Fetal alcoholic syndrome
Fetal alcohol syndrome
◦ Facial abnormality
◦ Low birth weight
◦ Low intelligence
Alcohol dependence is responsible for
3percent of all cases of mental
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 attention or memory.
Lability of mood.
"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
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.
Sweating, rapid heartbeat, hand tremors.
Problems sleeping (insomnia).
High blood pressure
Nausea and vomiting.
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
- Visual hallucinations, or seeing images that don’t
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.
Mechanism of action
◦ Disulfiram is an oral drug used for treating
◦ Alcohol is converted in the body into acetaldehyde
by an enzyme called alcohol dehydrogenase.
Another enzyme called acetaldehyde
dehydrogenase then converts acetaldehyde into
◦ 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.
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.
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
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
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.
Advice the patient not to use any alcohol content products like
aftershave, spray. etc, while patient is in therapy.
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.
Medication Target Year Approved
Research from animal models over the past 25 years has
provided promising targets for pharmacotherapy
Naltrexone Mu Opioid Receptor 1994
Acamprosate Glutamate and GABA-
Naltrexone Depot Mu Opioid Receptor 2006
FDA Approved Medications for Treating
TREATMENT ALCOHOL INDUCED DISOREDR
◦ 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.
THERAPIES TO TREAT ALCOHOL DISORDER
Behaviour Modification Techniques
Self Help Groups
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
◦ AA considers alcoholism as a physical, mental and spiritual
disease, a progressive one, which can be arrested but not
◦ 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
◦ In crisis he can obtain immediate help by telephone.
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
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.
Preventive programs: teach adolescents how
to resist social pressure to use drugs.
Detoxification: substance specific
Drug rehabilitation: develop new coping
Self-help groups: alcoholics anonymous
Assessment by CAGE questionnaire
◦ which consists of four questions:
Have you ever thought you should cut down on your
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.
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:
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.
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:
- Experience no
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
Assist patient in ambulation and self-care
activities as needed.
Administer medications as indicated e.g.:
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
Outcome Identification Nursing Intervention
Client will be able to:
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.
Administer medications as indicated, e.g.:BDZs (e.g.,
chlordiazepoxide [Librium], diazepam [Valium]).
Referral patient for Detoxification and crisis centre.
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