SUBSTANCE -RELATED AND ADDICTIVE DISORDERS

ALCOHOLISM & DRUG DEPENDENCE

Alcoholism is uncontrolled intake of alcoholic beverages that interferes with physical and mental
health, social and familiar relationships and occupational responsibilities.

Alcohol is a colorless volatile liquid obtained by fermentation of carbohydrates by yeast. It’s

used as an antiseptic and as a preservative for anatomical specimen.

Alcoholic – containing or pertaining to alcohol a person addicted to excessive consumption of

alcohol.

Drug- Any substance that is used as medicine

Drug Dependence- when the drug is used repeatedly by an individual to relieve some physical
or psychological discomfort.

Drinking Levels

1. Binge Drinking- it’s a pattern of drinking alcohol that brings blood alcohol concentration
(BAC) to 0.008% or 0.008 grams of alcohol per deciliter or higher.
For a typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or
more drinks (female), in about two hours.
2. Heavy alcohol use: its defined as use of more than 4 drinks on any day for men or more
than 3 drinks for women.

N/B Binge drinking and heavy alcohol use can increase an individual’s risk of alcohol use
disorder.

Avoid alcohol completely if;

1. Planning to drive or operate machinery or participate in activities that require skill,

coordination and alertness.
2. Take certain over-the- counter or prescription medications
3. Have certain medical conditions- heart failure, cardiomyopathy, diabetes, irregular heart
rhythm, a history of strokes and high triglycerides.
 4. Are recovering from alcohol use disorder or are unable to control the amount that they
drink
5. Are younger than age 21- Young people are at a greater risk of alcohol –related harm
than adults. As the brain keeps developing into your mid-twenties, drinking alcohol as a
teenager can greatly increase the risk of damage to the developing brain. It can also lead
to problems with alcohol later in life.
6. Are pregnant or trying to become pregnant. The baby may not grow properly especially
the brain. There is a risk that your baby may have a range of life –long problems, known
as fetal alcohol spectrum disorder (FASD) problems may be seen soon after birth.

Aetiology /causes /Predisposing factors

- Alcoholic is more common in men than women, probably 4 or 5 times

- Certain occupations predispose one to alcoholism and drug dependence e.g those who
work as brewers
- Biological/Family background whereby an offspring of one alcoholic parent is 7-8 times
more likely to become an alcoholic
- Psychological factors include the urge to drink alcohol to reduce anxiety or symptoms of
mental illness, the desire to avoid responsibility in familial, social and work relationships,
the need to bolster self- esteem
- Social cultural factors include the availability of alcoholic beverages, group or peer
pressure an excessively stressful life-style and social attitude that approve frequent
imbibing.
- Advertising supports society’s message that alcohol consumption is part of a healthy life-
style.
Effects of Alcoholism on an Individual

Physically- Loss of appetite has no time for his meals. Can spend all the money on drinks such
that he spares non for food both for himself and his family. The poor diet leads to many physical
changes. Alcohol esp. the spirits stimulates the secretion of hydrochloric acid which leads to
peptic ulceration.

Biliary liver Cirrhosis may occur which in turn may lead to esophageal varicose veins.
Hemorrhage from these thin walled vessels may occur.

Mentally – Alcohol has an inhibitory effects on the higher centre the brain so that

- Self criticism becomes reduced and the person the acts more freely and without
self –restraint.
- He may consider himself to be very efficient yet objectively he is less so. As more
and more alcohol is consumed the inhibitory effects spreads to the lower centres
of the brain.
- This impairs motor activity and if the individual tries to walk he staggers.
- Finally the vital centres becomes affected, consciousness is impaired and the
individual progresses from stupor to coma and even death

Socially- it disintegrates on individual who may have been successful into a shambled wreck
hated and despised by his family and members of the community.

The alcohol may instill in him some form of underlying guilt and become self centered, self
justifying and untruthful both at his place of work and at home.

Gradually the brain cells are damaged by the alcoholic’s inadequate diet, his memory starts to
fail, personal habits deteriorate and dementia (impairment of intellectual functioning without
impairment of consciousness) sets in.

Eventually the alcoholic lose his job due to deteriorated working relations. He forgets his
responsibilities towards his family and the members of his family suffer abuse, violence, poverty
and social stigmatization.
Effects of Drug Dependence on an Individual

- Powerful painkillers tend to induce a state of euphoria (an exaggerated feelings of well
being often not justified by circumstances) e.g pethidine, morphine. Pethidine causes
dependence more quickly than morphine
- Withdraw symptoms include feelings of anxiety, depression, restlessness, sleeplessness
and confusion with terrifying hallucinations.
- Psychological symptoms accompanied by some physical symptoms such as muscle
cramps, rise in temperature and blood pressure, nausea, tremors, vomiting, diarrhea and
running nose.
- Other drugs which create dependence include sedatives e.g. barbiturates (they depress
CNS activities due to physical and psychological dependence and have serious side
effects) and hallucinogen drugs (drug that produces hallucinations) e.g. cannabis,
Lysergic acid Diethylamide (LSD), mescaline.

Signs of alcohol and drug dependence

- Agitation
- Violence
- Anxiety
- Irritability
- Restlessness
- Tension
- Tremors
- Neglected hygiene
- Morbid suspicion
- Injection marks in case of drug abuse
- Hallucinations
- Illusions-false perception due to misinterpretation of stimuli arising from object
especially in depression
 - Malnutrition due to loss of appetite
- Signs of withdrawal e.g. muscle cramps

Features of alcohol and drug dependence

When a thorough social and medical history is taken then the following will be established

a. History of prolonged excessive alcohol consumption

b. History of regular taking of dependence or habit forming drugs
c. Loss of appetite
d. Lethargy- mental and physical sluggishness. A degree of inactivity and unresponsiveness
e. Delirium
f. Depression
g. Anxiety
h. Suspicion
i. Delusions
j. Illusions
k. Hallucinations
l. Hostility
m. Irritability
n. Many presents with signs of withdrawal e.g. sleeplessness, feelings of anxiety and
confusion.

Complications of alcohol use

Alcohol can damage body tissues by its direct irritating effects by charges that take place in the
body during its metabolism by aggravation (making worse) of existing disease, by accidents
occurring during intoxication and by interactions between the substance and drugs. Such tissue
damage can cause the following complications:-

 Cardiopulmonary complications- cardiac arhythmus, cardiomyopathy, chronic

obstructive pulmonary disease, essential hypertension, increased risk of TB, pneumonia.
 Hepatic complications- alcoholic hepatitis, cirrhosis, fatty liver
  Gastrointestinal complications- chronic diarrhea, esophageal cancer, esophageal varices,
esophagitis, gastric ulcers, gastritis, GI bleeding, malabsorption, pancreatitis.
 Neurologic complications-alcoholic dementia, alcoholic hallucinosis, alcoholic
withdrawal delirium, korsakoffs syndrome (impaired memory especially for recent events
disoriented to time and place), peripheral neuropathy, seizure disorders, subdural
hematoma, wernicked encephalopathy.
 Psychiatric complications- amotivational syndrome, depression, fetal alcohol syndrome,
impaired social and occupational functioning, multiple substance abuse, and suicide.
 Other complications- beriberi, hypoglycemia, leg and foot ulcers, prostatitis

Management of alcoholism

- Detoxification
- Admission to special units dealing with alcoholics and drug-dependents
- Nurse the patient in an alcohol free environment
- Give tranquilizers and sedating during the withdrawal of alcohol to promote relaxation
and sleep
- Asses and identify any underlying mental and physical ailments
- Drugs such as antabuse (disulfiram) are given to help the patient abstain from alcohol.
These drugs slow down the metabolism of alcohol and results in unpleasant reactions
such as pounding headaches and a sensation of choking. Disulfiram (antabuse 100-
200mg/day)
- It interferes with metabolism of alcohol by blocking one of the enzymes involved.
- As a result when alcohol is taken acetaldehyde accumulates, with consequents flushing,
headache, choking sensation, rapid pulse and anxiety.
- These unpleasant effects discourage the patient from drinking alcohol while taking the
drug.
- Should be started 12 hrs after the last ingestion of alcohol

Contra indicated in

 Patient who have had recent heart disease

  Significant suicidal ideation
 Severe liver disease.
- In very severe cases the individual can collapse. To counteract these symptoms an IV
injection of ascorbic acid 1gm is given
- The administration of antabuse should be combined with psychotherapy (for patient to
gain insight into problems that make him drink)
- Before antabuse administration a test is carried out to ascertain the dose suitable for
individual patient
- Deconditioning/aversion therapy. The aim is to try to produce in the alcoholic a distaste
for alcohol. The patient is given his favorite alcohol beverage together with an injection
of emetin or apomorphine which then produces vomiting
When this is repeated on several occasions it establishes a reflex reaction and the patient
becomes nauseated even by the smell of alcohol, let alone the taste. After this is repeated
several times the reaction is reinforced and the patient stops drinking altogether.
- Alcoholic anonymous (AA). Alcoholics subject themselves to self- criticism, admit their
failures and try to atone their past misdeeds. The nurse can introduce the patient to this
organization.
- Give your patient a balanced diet with lots of vitamins
- Encourage the patient to participate in therapeutic group activities as his condition
improves. This helps the patient to gain insight into his own alcohol problem.
- Encourage the family members to be involved in the patients care and not to neglect him.
- Let the patient attend recreational and occupational therapy
- Encourage the patient to actively participate in personal hygiene
- Provide health education to the patient and members of the family. Educate them about
the etiology and features of alcohol and drug dependence.

Management of drug dependence

- Nurse the patient in an environment free from dependence drug

- Once the patient has withdrawn from the drug, psychotherapy on individual and group
basis is instituted.
 - Give the patient a balanced diet with lots of vitamins.
- Encourage the patient to participate actively in group therapeutic activities to gain more
insight into his own problems.
- Encourage the family members to get involved in the patients care so that the patient may
develop a sense of belonging and thus see the need for becoming responsible
- Encourage the patient to participate actively in recreational and occupational therapy
since this will introduce reality to the patient and help him to deal with his frustrations.
- Provide health education for the patient and his family members. Educate them about the
aetiology, signs and symptoms of drug dependence

Disulfiram (antabuse)
- It induces unpleasantly
- It inhibit the enzyme aldehyde dehydrogenase so that acetaldehyde (toxic metabolic of
alcohol) accumulates
- This is so unpleasant that the patient do not want to experience it again
- Disulfiram reinforces the will power
- Given after the 5th day so that patients can be taught what to expect and also to induce an
aversion (distaste of alcohol) from alcohol
- A ‘test drink’ should not be given since it can lead to death
- A typical reactions of medium severity comes on about 5 min after taking alcohol and
consist of generalized vasodilation and fall in blood pressure, sweating, dyspnoea,
headache, chest pain, nausea and vomiting. Severe reactions include convulsions and
circulating collapse. They may last several hours
- Disulfiram has the same reaction with paraldehyde and inhibits metabolism of warfarin
phenytoin and diazepam. The effect persists for days after cessation of use.

Administration by mouth

- Alcohol should not be consumed for at least 24hrs before initiating treatment and avoid
alcohol for 1 wk
 - Side effects- drowsiness and fatigue, nausea, vomiting, halitosis, educed libido,
depression, mania etc
- Dose- 800mg as a single dose on first day, reducing over 5 days to 100-200mg daily;
should not be continued for longer than 6 months without review.

Drug and Alcohol Detox

Detox from drugs and alcohol can be dangerous. A medically assisted detox can reduce
withdrawal symptoms and ensure safety.

What Is Detoxification?

Detoxification, or detox, is the process of letting the body remove the drugs in it. The purpose of
detox is to safely manage withdrawal symptoms when someone stops taking drugs or alcohol.

Everyone has a different experience with detox. The type of drug and how long it was used affect
what detox will be like.

Medications used in detox help keep former users comfortable while the drugs leave their body.

It can take days or months to get through withdrawal symptoms for most drugs. The length of
withdrawal depends on a number of factors, including:

 Type of substance the user is addicted to

 Duration an addiction has lasted
 The severity of the addiction
 Method of abuse (snorting, smoking, injecting, or swallowing)
 The amount of a substance the user takes at one time
 Family history
 Genetic makeup
 Medical condition
  Underlying mental health conditions

Speak with someone who can help you find a medically assisted detox.

Can I Detox at Home?

Choosing to detox at home can be deadly. Quitting “cold turkey” or without medical supervision
can lead to serious issues such as seizures and severe dehydration.

There are inpatient and outpatient detox programs that help prevent dangerous complications.
People with severe addictions should seek inpatient detox because withdrawal can be fatal.
Inpatient detox includes 24-hour support and monitoring.

The Process of Detoxification

Everyone’s detox needs are different. The drug detox process helps addicted people get
personalized treatment. In most cases, the process involves three steps:

Evaluation

The medical team screens incoming patients for physical and mental health issues.
Doctors use blood tests to measure the amount of drugs in the patient’s system. This
helps determine the level of medications needed.

There is also a comprehensive review of drug, medical and psychiatric histories. This
information sets up the basis for the patient’s long-term treatment plan.

Stabilization

The next step is to stabilize the patient with medical and psychological therapy. The goal
of stabilization is to prevent any form of harm to the patient. Doctors can prescribe
addiction treatment medications to prevent complications and reduce withdrawal
symptoms.

Preparing Entry into Treatment

 The final step of detox is preparation for a treatment program. Doctors familiarize their
patients with the treatment process and what to expect. Inpatient rehab offers the best
chances of success after detox.

Side Effects of Detox

The process of drug detox can be painful and dangerous. This is why medical detox is so
important. Detox with medical supervision allows patients to detox in a safe and comfortable
environment. The extent of supervision is different in inpatient and outpatient rehab.

A medically supervised detox prevents dangerous complications of drug and alcohol withdrawal.

Although medical detox limits the symptoms of withdrawal, some are unavoidable. Some of the
most common side effects may include:

 Nervousness or anxiety
 Insomnia
 Nausea
 Body discomfort
 Mood swings
 Poor sleep
 Difficulty concentrating

Drug Detox During Pregnancy

A pregnant woman has a strong motive to quit drugs for her baby’s sake. Drinking alcohol or
using drugs while pregnant can harm not only the mother, but also the unborn child as these
substances cross the placenta to the baby. Detox, especially if done cold turkey, can cause stress
on the unborn child such as preterm labor or severe fetal distress.

Detox with medical supervision is an absolute must for pregnant women, as withdrawal
symptoms may be especially harmful to the fetus. The goal of detox for pregnant women is to
prevent relapse and manage pain.

Detox specialists can keep babies safe and healthy by treating pregnant women in detox.

Doctors often prescribe medications to stabilize pregnant women in detox. Alcohol and opiate
detox usually pose the most risks to unborn children.

Detox by Drug Type

Detox is more difficult for some people depending on the drugs they used. Depending on the
drug, withdrawal symptoms may be more physical or more mental.

Cocaine withdrawal, for instance, is psychological. Detox involves managing initial cravings and
anxiety. But alcohol withdrawal includes physical symptoms that can cause seizures or death in
some cases.

Detox often includes medications that mimic the effects of drugs to reduce withdrawal
symptoms. Medications may also target co-occurring disorders or general discomfort.

Drugs that are most dangerous to detox from, and often require medication, include alcohol and
benzodiazepines. The drugs that are considered the most uncomfortable to detox from are
opioids, especially heroin.

Rapid and Ultra-rapid Detox and Risks

Rapid detox is a method of removing substances from a user’s system faster than regular detox.
Advocates of rapid detox say it’s a faster way to get the drugs out of the body while avoiding
painful withdrawal symptoms.

Rapid detox can be dangerous as well as expensive.

In rapid detox, the addicted person is sedated with anesthesia and given medications that replace
the drugs in the body. This method was originally developed for people addicted to opiate drugs
like heroin and painkillers. The risks of rapid detox often outweigh the benefits.

Rapid detox can cause

 Heart attack
 Paranoia
 High body temperature
 Infection
 Nausea
 Vomiting
 Aspiration
 Choking
 Death

“Ultra-rapid detox” programs can take as little as a few hours. Approximately 1 in 500 people
die from ultra rapid detox, according to the Coleman Institute.

Traditional rapid detox programs take about two to three days to complete and carry less danger,
but are still more expensive than a typical detox. It can cost up to $10,000 and isn’t generally
covered by insurance.

Most people who complete rapid or ultra-rapid detox report continuation of withdrawal
symptoms, albeit at a lower severity. Patients who choose rapid or ultra-rapid detox are much
less likely to continue on in treatment, such as attending inpatient or outpatient rehab. Because of
this, they are less likely to work on relapse prevention, possible co-occurring mental health
conditions, and life planning and therefore more likely to experience relapse. Life After Detox

Detox is just the first part of addiction treatment. Detox on its own is usually insufficient for a
successful recovery. Addicted people need to treat the psychological part of their addiction. They
can accomplish this with counseling, support groups or an inpatient rehab program. An addiction
specialist will help you transition into your new treatment plan.