SUBSTANCE ABUSE

11 Diagnostic Clases of
Substance Abuse
• Alcohol
• Amphetamines
• Caffeine
• Cannabis
• Cocaine
• Hallucinogens
• Inhalants
• Nicotine
• Opioids
• Phencyclidine (PCP)
• Sedatives, Hypnotics or anxiolytics
2 Groups of substance
related DO
• Abuse and Dependence
• Substance – induced
TERMS:
• Polysubstance abuse
– More than ONE
• Intoxication
– Is use of substance that results in maladaptive
behavior
• Withdrawal syndrome
– Refers to the negative psychological and
physical reactions that occur when use of a
substance ceases or dramatically decreases
• Detoxification
– The process of safely withdrawing the patient
from a substance
Substance abuse
• Using a drug in a way that is inconsistent
with medical or social norms and despite
negative consequences.
• Problems: SOCIAL, VOCATIONAL,
LEGAL areas of persons life
• 50% of people with substance abuse
disorder also have a mental health
diagnosis “DUAL DIAGNOSIS”
• DETOXIFICATION is the initial priority
ONSET and CLINICAL
COURSE
• 15 – 17 years of age
• Middle twenties to middle thirties
– Alcohol related breakup
– Arrest for public intoxication or
DRIVING WHILE INTOXICATED
– Health problems
• BLACKOUTS
– Person continues to function but has no
conscious awareness of his or her
behavior at the time or any later
memory of the behavior
CYCLE of ALCOHOL
• 15 – 17 years old
– AUDIT (Alcohol Use Disorders
Identification Test)
• Mid 20’s to 30’s
• Blackouts
• Tolerance
• Tolerance break
• Abstinence
• HEAVY DRINKING
• 60 – 70 % alcohol
• 2nd year RELAPSE
• Spontaneous remission or natural
recovery (20%)
• POOR PROGNOSIS:
– Early age of onset
– Longer period of substance use
– Coexistence of psychiatric illness / Medical
Illness
• 20% higher risk for SUICIDE
ETIOLOGY
• Biological
– Children of Alcoholic Parents
– Partly Genetics (eg Adoption)
• Psychological Factors
– Family dynamics
– Parents behavior
– Poor Modeling
– Stormy Relationship
– LACK OF ADAPTIVE COPING SKILLS
• Social and Environmental Factors
– CULTURE
• MUSLIMS – WINE but no ALCOHOL
• Native American – Peyote
– LOCATION
What Defense Mechanism?
DOWNER’s

–Barbiturates
• Morph
–Opiates • Code
–Narcotics • Hero
–Alcohol
UPPER’s

• Cocaine
• Hallucinogens
• Amphetamines
ALCOHOL
• Is a primary drug problem in the
North America
• Commonly abused substance
• Is a central nervous system
Depressant that is absorbed rapidly
into the blood stream.
• Ethanol
 ETIOLOGY
• Psychoanalytical
Theories
– Due to fixation in the oral
stage of development
• Learning theories
– Due to learned behaviors
• Biological theories
– Due to inherited traits
• Socio cultural Theories
– Effects of mass media
Physiologic effects

• Initially, RELAXATION and

DISINHIBITIONS
• Relief of anxiety
• As the CNS becomes more irritated the
normal drinkers feels sick and irritable
“HANGOVER” but lives through it,
perhaps vowing “never again”
• For the alcoholic/heavy drinker they have
to drink again to RESEDATE.
 INTOXICATION

• Slurred speech
• Unsteady gait
• Lack of coordination
• Impaired attention, concentration,
memory and judgment.
• Some becomes aggressive or display
inappropriate sexual behavior
• Intoxication can lead to BLACKOUT
 OVERDOSE OR
EXCESSIVE ALCOHOL

• People DIE of alcohol because it depresses the

CNS
• Vital centers becomes anesthesized
– Vomiting
– unconsciousness
– respiratory depression
– Respiratory depression + vomiting = aspiration
pneumonia
– Alcohol induced hypotension
– GI bleeding or hemorrhage
– Heat loss due to vasodilating effect
Treatment
• Gastric Lavage
• Dialysis
• Supportive care
– RESPI and CARDIO in the ICU
LONG TERM ALCOHOL USE

• Cardiac Myopathy • Cirrhosis –

• Wernicke’s obstructed BF
Encepalopathy – Portal HPN
• Korsakoff’s – Ascites
Psychosis – Esophageal
• Pancreatitis varices
• Esophagitis • Peripheral
• Hepatitis neuritis
• Leukopenia
• Thrombocytopenia
• WERNICKE’S Encephalopathy
• Confusion/delirium
• Opthalmoplegia/palsy of 6th cranial
nerve
• Ataxia
• Thiamine deficiency
• Wernicke-KORSAKOFF Syndrome
– Memory Disturbance – essential
feature
– Retrograde amnesia
– Anterograde amnesia
– Confabulation
– Korsakoff’s Psychosis
 WITHDRAWAL AND
DETOXIFICATION
• Symptoms usually begins 4 – 12 hours
• Peaks on second day and is over by day 5 (1 – 2
weeks)
• Withdrawal is life threatening, detoxification needs to
be accomplished under medical supervision.
– Coarse hand tremors - HALLMARK
– Sweating
– Elevated pulse and BP
– Insomnia
– Anxiety
– Nausea and vomiting
• SEVERE/UNTREATED
– Delirium Tremens
• HALLUCINATIONS, SEIZURES or DELIRIUM
• Vitamin B1 (thiamine) 100 mg
– To prevent or to treat Wernicke’s
Encephalopathy and Wernicke-
Korsakoff syndrome ; neurologic
conditions that can result from heavy
alcohol use.
• Vitamin B12 (cyanocobalamin) and
Folic acid
– For nutritional deficiencies
Disulfiram (ANTABUSE)
• To help deter clients from drinking
• Inhibits breakdown of acetaldehyde
by the enzyme aldehyde
dehydrogenase
If taken with alcohol a
severe adverse reaction
occurs:
• Flushing
• A throbbing headache
• Sweating
• Nausea and vomiting
• Severe hypotension
• Confusion
• Coma
• Death
 AVOID! Products that
contain alcohol

• Cough syrup
• Lotions
• Aftershaves
• Mouthwash
• Perfume
• Vinegar
Odansetron (ZOFRAN)
• Antiemetics
• Used in young males at high risk for
alcohol dependence or early onset
alcohol dependence
• Treatment for methampetamine
Acamprosate (CAMPRAL)
• Modulates transmission of GABA
• Decreases alcohol cravings and to
maintain abstinence (UK)
ALCOHOL ANONYMOUS
• Founded 1930’s
• 12 step program model for recovery
• PHILOSOPHY:
– “abstinence is essential and that
alcoholics need the help and support of
others to maintain sobriety”
SLOGANS
• “one day at a time”
• “easy does it”
• “let go and let GOD”
• NARCOTICS anonymous
• Al – Anon
• Ala teen
• Gambling problems and eating
problems
SEDATIVES, HYPNOTICS,
AND ANXIOLYTICS

• Barbiturates
– Relieve anxiety or to produce sleep
– Thiopental (anesthesia)
– Phenobarbital (epilepsy)
• Non barbiturates
• Anxiolytics (benzodiazepines)
INTOXICATION
• Slurred speech
• Lack of coordination
• Unsteady gait
• Labile mood
• Impaired attention
• Stupor or coma
OVERDOSE
• Benzodiazepines (Rarely fatal)
– Lethargy and confusion
• Management
– Gastric lavage followed by ingestion of activated
CHARCOAL and SALINE cathartic
– Dialysis if severe
• BARBITURATES
– Lethal
– Coma, respiratory arrest, cardiac failure
and death
– Same with Alcohol
WITHDRAWAL AND
DETOXIFICATION
• Depends on the half life of the drug
• Like lorazepam, actions typically last
after 10 hrs. produces withdrawal
symptoms in 6 to 8 hours.
• Longer medications such as
diazepam may not produce
withdrawal symptoms for 1 week.
WITHDRAWAL
SYNDROME
• Autonomic hyperactivity
– Increased PR, BP, RR and TEMP
• Hand tremors
• Insomnia
• Anxiety
• Nausea
• Psychomotor agitation
• Seizures and hallucination (severe
withdrawal of benzodiazepine)
DETOXIFICATION
• Tapering the amount of the drug.
– 10% each day
– E.g. Valium 10 mg 4 times a day
– Decreased every 3 days
– 3 times a day
 OPIOIDS

• Popular drug abuse because they

desensitize the user to both physiologic
and psychological pain and induce a
sense of euphoria and well being.
• Primarily used for Analgesia
• Morphine • hydromorphone
• hydrocodone
• Meperedine • oxycodone
(Demerol) • oxymorphone
• Codeine • hydrocodone
• HEROIN • propoxyphene
• NORMETHADONE
• methadone • Cocaine + heroin =
speed balling
INTOXICATION

• EUPHORIA
• Apathy
• Lethargy
• Impaired judgment
• Psychomotor agitation or retardation
• Constricted pupils
• Drowsiness
• Slurred speech
• Impaired attention and memory
OVERDOSE
• Coma
• Respiratory depression – primary
effect
• Pupillary constriction
• Unconsciousness
• Death
MANAGEMENT
• Naloxone (NARCAN)
– Given every few hours until the level drops to non
toxic; may take for days
• Nalorphine (nalline)
• Naltrexone (REVIA)
– For overdose and dependence
– Reduce cravings for alcohol
• Clonidine (CATAPRES)
– Is an alpha 2 adrenergic agonist used to treat
HYPERTENSION
– For opiate dependence to suppress some effects of
withdrawal or abstinence.
WITHDRAWAL AND
INTOXICATION “painful”
• Early
– Yawning • Late
– Tearing – Muscle spasm
– Rhinorrhea
– Sweating – Fever
– Gooseflesh – Nausea and
• Intermediate vomiting
– Flushing
– Piloerection
– Repetetive
– Tachycardia sneezing
– Tremor – Abdominal cramps
– Restlessness
– irritability – backache
• METHADONE (Dolophine)
– A potent synthetic opiate
– To prevent withdrawal symptoms esp
HEROIN
– Which meets the physical needs for opiates
but does not produce cravings for more.
– DECREASED every 2 weeks
• LEVOMETHADYL
– Treatment of opiate dependence
INHALANTS
• CNS depressants
• Most common substances in this category
are ALIPATHIC and AROMATIC
hydrocarbons
3 Basic forms of
Inhalants
• Solvents (gasoline, glues)
• Aerosol propellants (spray cans)
• Anesthetic (chloroform, nitrous
oxide)
 INTOXICATION
• Dizziness • Aggression
• Nystagmus • Apathy
• • Impaired judgment
Lack of coordination
• Inability to function
• Slurred speech
• Acute toxicity: anoxia,
• Unsteady gait respiratory
• Tremor depression, vagal
• Muscle weakness stimulation,
• Blurred vision dysrhythmia, death from
brochospasm, cardiac
• Stupor and coma arrest, suffocation,
• Belligerence aspiration of the
compound or vomitus.
MANAGEMENT
• Supportive
• No specific treatment for
INHALANTS
WITHDRAWAL AND
DETOX
• none
STIMULANTS (Amphetamines,
Cocaine, Others)
• Amphetamines
– “uppers” “speed” or “Crank”
– for losing weight and staying awake,
– ADHD
• Cocaine
– illegal drug, no clinical use in medicine,
highly addictive and popular
recreational drug because of intense
and immediate feeling of EUPHORIA it
produce.
• Methamphetamines (SHABU)
– dangerous, highly addictive and causes
psychotic behavior. Brain damage.
INTOXICATION (develops
rapidly)
• High or euphoric • Anger
feeling • Fighting
• Hyperactivity • Impaired judgment
• Hypervigilance • Physiologic effects
• Talkativeness
• Anxiety
• Grandiosity
• Hallucinations
• Stereotypic or
repetitive behavior
OVERDOSE
• Arrhythmia and Respiratory
Collapse
• Seizures
• Coma
• Death (rare)
MANAGEMENT
• Induction of vomiting
• Forced diuresis
• Chlorpromazine
• Odansetron (ZOFRAN)
– A 5HT3 antagonist that blocks the vagal
stimulation effects of serotonin in the
small intestine is used as an antiemetic.
WITHDRAWAL
DETOXIFICATION
• Withdrawal occurs after few hours or
several days
– DYSPHORIA ,.
– Suicide ideation, Depression =
CRASHING
• DETOX
– NO treatment
HALLUCINOGENS
“psychosis like reaction”

• “Psychotomimetics” or
“psychedelics”
2 basic groups
• Natural
– Mescaline (peyote) from cactus
– Psilocybin from mushrooms
– Marijuana
• Synthetic
– Lysergic acid diethylamide (LSD)
– “Designer drugs”
• ecstasy
– phencyclidine (PCP), anesthetic
• Increased PR, BP and TEMP,
Dilated pupils, Hyperreflexia
 INTOXICATION

• Anxiety
• Depression
• Paranoid ideation
• Ideas of reference
• Fear of losing one’s mind
• Jumping out of the window
• PCP: belligerence, aggression, impulsivity
and unpredictable behavior.
• Toxic reactions to hallucinogens = primarily
psychological Except PCP
PCP TOXICITY
• Seizures
• hypertension
• hyperthermia
• Respiratory depression

• TREATMENT
– Supportive
OVERDOSE
• None
MANAGEMENT
• Valium
• Psychotic reactions – isolation from
external stimuli
• Restraints
WITHDRAWAL AND
DETOXIFICATION
• None
• Cravings
• Flashbacks “NIGHTMARES”
– Months to years
CANNABIS SATIVA

• Is an Indian hemp plant similar to ABACA

• Widely known for its psychoactive resin
• RESINS contains 60 cannabinoids
– Delta 9 - tetrahydrocannabinol
• Refers to the upper leaves, flowering tops, stems of
the plant
• Hashish – is the dried resinous exudate from leaves
of female plant.
• Most often smoked in cigarettes “joints”
• Known to decrease the IOP
• Relieving nausea & vomiting associated with cancer
chemotherapy and the anorexia of weight loss of
AIDS.
• Tetrahydrocannabinol
– Changed into metabolites and stored in
fatty tissues
– Remains in the body up to 6 weeks
• Acts less than 1 minute after
inhalation
• PEAK is 20 – 30 minutes and last at
least 2 – 3 hours.
• Ingested – 12 hours
• Effects similar to your alcohol, lowered
inhibition, relaxation, euphoria,
increased appetite “munchies”,
conjunctival injection (bloodshot eyes),
dry mouth, hypotension and
tachycardia.
• 2 cannabinoids
– Dronabinol (marinol)
– Nabilone (Cesamet)
• For nausea and vomiting from cancer
chemotherapy
INTOXICATION
• Impaired motor coordination
• Inappropriate laughter
• Impaired judgment
• Short term memory
OVERDOSES
• Do not occur
WITHDRAWAL
• No clinically withdrawal syndrome
– Muscle aches
– Sweating
– Anxiety
– Tremors
PSYCHOTHERAPEUTIC
MANAGEMENT
PRIORITY

• Detoxification
 TNPR
• Education
– The nurse must dispel the following myths
and misconception
• “it’s a matter of will power”
• I can’t be an Alcoholic if I only drink beer on
weekends
• I can learn to use drugs socially
• I’m okay now; I could handle using once in a
while.
• Addressing family issues
– Alcoholism and other substance often is
called a FAMILY ILLNESS
– CODEPENDENCE is a maladaptive
coping pattern on the part of the family
members or others
• Promoting coping skills
• Focus on here and now with clients
– Set realistic goals such as staying
sober today.
PHARMACOLOGIC
TREATMENT
• TWO main Purposes
– To permit safe withdrawal from alcohol,
sedatives/hypnotics, benzodiazepines
– To prevent relapse
• ALOCOHOL
– W: Benzodiazepines
– R: Disulfiram
• Heroin
– W: Methadone
– R: levomethadyl
– O: Naltrexone (Revia)
• Blocks the effects of OPIODS
• Alcohol cravings
MILIEU
• Safety
– Drug free environment
• Structure
– Active meaningful schedule provide for less downtime
• Norms
– Non violent behavior
– Openness
– feedback
• Limit setting
• Balance and Environmental Modification
CBQ
• Short term Goal for Alcoholism
– Cut off denial
• Long term
– Abstinence
• Heroine
– CAT’S eye phenomenon
 OVERDOSE
• DOWNERS
– Brady
• UPPERS – Moist mouth
– Tachypnea/cardia
– Constriction of
– Dry mouth pupil
– Dilated pupils – Urinary retention
– Hypertension – Hypotension
– Euphoria – Sleep
– Seizure – Coma
– Weight loss – Hungry – eats –
weight gain