NURSING/PHYSIOTHERAPY

SUBSTANCE MISUSE DISORDERS

DEFINITIONS
 Dependence The repeated use of a drug or

chemical substance, with or without physical dependence. Physical dependence indicates an altered physiologic state caused by repeated administration of a drug, the cessation of which results in a specific syndrome. Abuse Use of any drug, usually by selfadministration, in a manner that deviates from approved social or medical patterns.

DEFINITIONS
 Misuse Similar to abuse, but usually applies to drugs

prescribed by physicians that are not used properly.

 Addiction The repeated and increased use of a substance,

the deprivation of which gives rise to symptoms of distress and an irresistible urge to use the agent again and which leads also to physical and mental deterioration. The term is no longer included in the official nomenclature, having been replaced by the term dependence, but it is a useful term in common usage.
 Intoxication A reversible syndrome caused by a specific

substance (e.g., alcohol) that affects one or more of the following mental functions: memory, orientation, mood, judgment, and behavioral, social, or occupational functioning.

DEFINITIONS
 Withdrawal A substance-specific syndrome that

occurs after stopping or reducing the amount of the drug or substance that has been used regularly over a prolonged period of time.  The syndrome is characterized by physiologic signs and symptoms in addition to psychological changes, such as disturbances in thinking, feeling, and behavior. Also called abstinence syndrome or discontinuation syndrome.

DEFINITIONS
 Tolerance Phenomenon in which, after repeated

administration, a given dose of drug produces a decreased effect or increasingly larger doses must be administered to obtain the effect observed with the original dose. Cross-tolerance Refers to the ability of one drug to be substituted for another, each usually producing the same physiologic and psychological effect (e.g., diazepam and barbiturates). Also known as crossdependence.

Alcohol-Related Disorders
 Alcohol use disorders

Alcohol dependence Alcohol abuse

Alcohol-Related Disorders
 Alcohol-induced disorders

Alcohol intoxication Alcohol withdrawal Alcohol withdrawal delirium Alcohol-induced persisting amnestic disorder Alcohol-induced psychotic disorder Alcohol-induced mood disorder Alcohol-induced anxiety disorder

Substance/Alcohol Abuse


A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12month period: 1. recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 3. recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) 4. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) The symptoms have never met the criteria for Substance Dependence for this class of substance

Substance/Alcohol Dependence


A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

A. tolerance, as defined by either of the following: a need for markedly increased amounts of the substance to achieve intoxication or desired effect markedly diminished effect with continued use of the same amount of the substance B. withdrawal, as manifested by either of the following: the characteristic withdrawal syndrome for the substance the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms C. the substance is often taken in larger amounts or over a longer period than was intended D. there is a persistent desire or unsuccessful efforts to cut down or control substance use E. a great deal of time is spent in activities necessary to obtain the substance , use the substance , or recover from its effects

F. important social, occupational, or recreational activities are given up or reduced because of substance use G. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Alcohol Intoxication
 Recent ingestion of alcohol.  Clinically significant maladaptive behavioral or

psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that developed during, or shortly after, alcohol ingestion.  One (or more) of the following signs, developing during, or shortly after, alcohol use:
slurred speech in coordination unsteady gait nystagmus impairment in attention or memory stupor or coma

 The symptoms are not due to a general medical condition

and are not better accounted for by another mental disorder.

Alcohol Withdrawal
A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after Criterion A:
autonomic hyperactivity (e.g., sweating or pulse rate greater than 100) increased hand tremor (Classic sign after 6-8 hours) insomnia nausea or vomiting transient visual, tactile, or auditory hallucinations or illusions ( 8 to 12hours) psychomotor agitation anxiety grand mal seizures (12 to 24 hours)

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Drug Therapy for Alcohol Intoxication and Withdrawal

Clinical Problem Tremulousness and mild to moderate agitation Hallucinosis Drug Route Chlordiazepoxide Oral Diazepam Lorazepam Oral Oral Dosage Comment 25-100 mg every Initial dose can 4-6 hr be repeated 5-20 mg every 4-6every 2 hr until patient is calm; hr subsequent 2-10 mg every 4doses must be 6 hr individualized and titrated 0.5 mg/kg at 12.5 mg/min 0.15 mg/kg at 2.5 mg/min 0.1 mg/kg at 2.0 mg/min Give until patient is calm; subsequent doses must be individualized and titrated

Extreme agitation Chlordiazepoxide Intravenous Withdrawal Diazepam seizures Delirium tremens Lorazepam Intravenous Intravenous

Substance/Alcohol intoxication delirium

 Disturbance of consciousness (i.e., reduced clarity of awareness of

the environment) with reduced ability to focus, sustain, or shift attention.

 A change in cognition (such as memory deficit, disorientation,

language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
 The disturbance develops over a short period of time (usually

hours to days) and tends to fluctuate during the course of the day.
 There is evidence from the history, physical examination, or

laboratory findings of either (1) or (2): 1. the symptoms in Criteria A and B developed during substance intoxication 2. medication use is etiologically related to the disturbance

Substance/Alcohol withdrawal delirium

 Disturbance of consciousness (i.e., reduced clarity of

awareness of the environment) with reduced ability to focus, sustain, or shift attention.  A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.  The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.  There is evidence from the history, physical examination, or laboratory findings that the symptoms in Criteria A and B developed during, or shortly after, a withdrawal syndrome.

Alcohol-Induced Persisting Amnestic Disorder

 Diagnosis and Clinical Features  The essential feature of alcohol-induced

persisting amnestic disorder is a disturbance in short-term memory caused by prolonged heavy use of alcohol. Because the disorder usually occurs in persons who have been drinking heavily for many years, the disorder is rare in persons younger than age 35.

Wernicke- Korsakoff's Syndrome

 Wernicke's encephalopathy (acute condition)  Korsakoff's syndrome (a chronic condition).  The pathophysiological connection between the

two syndromes is thiamine deficiency, caused either by poor nutritional habits or by malabsorption problems.

Wernicke's encephalopathy
 Wernicke's

    

encephalopathy, also called alcoholic encephalopathy, is an acute neurological disorder characterized by: Confusion Ataxia (affecting primarily the gait), Nystagmus Wernicke's encephalopathy is completely reversible with treatment Wernicke's encephalopathy may clear spontaneously in a few days or weeks or may progress into Korsakoff's syndrome.

Management
 Early stages, 100 to 300mg parenteral

thiamine, (effective in preventing the progression into Korsakoff's syndrome).  Followed by 100 to 300mg mg orally and is continued for 1 to 2 weeks.  In patients with alcohol-related disorders who are receiving IV administration of glucose solution, it is good practice to include 100 mg of thiamine in each litre of the glucose solution.

Korsakoff s Syndrome
 The cardinal features of Korsakoff's syndrome are

impaired recent memory and anterograde amnesia in an alert and responsive patient.  Confabulation.  Treatment: Thiamine 100 mg PO two to three times daily; the treatment regimen should continue for 3 to 12 months.  Only about 20 percent of patients with Korsakoff's syndrome recover.

Alcohol-Induced Psychotic Disorder

A. Prominent hallucinations or delusions. Note: Do not include hallucinations if the person has insight that they are substance induced. B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): 1. the symptoms in Criterion A developed during, or within a month of, substance intoxication or withdrawal 2. medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a psychotic disorder that is not substance induced. Evidence that the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non substance-induced psychotic disorder (e.g., a history of recurrent non substance-related episodes). D. The disturbance does not occur exclusively during the course of a delirium. Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.

Fetal Alcohol Syndrome

 Women who are pregnant or are breast-feeding

should not drink alcohol. When mothers drinking alcohol expose fetuses to alcohol in utero it inhibits intrauterine growth and postnatal development.  Fetal alcohol syndrome is the leading cause of mental retardation in the United States  Microcephaly, craniofacial malformations, and limb and heart defects are common in affected infants.  Women with alcohol-related disorders have a 35 percent risk of having a child with defects.