NU124

Substance Abuse Disorders

Criteria: SUBSTANCE ABUSE

Must have one or more in the past 12 months:

Recurrent use in physically dangerous settings

Recurrent drug-related legal problemsContinued use despite recurring

interpersonal problems

Continued:

Failure to fulfill role obligations at home, school, or work

Criteria: SUBSTANCE DEPENDENCE

Three more in the last 12 months: Drug intoleranceDrug withdrawal

Use is greater in amount and frequency of use than intended (loss of control)

Persistent desire and unsuccessful attempts to stop or control

Continued:

Increasing time and energy to obtain the drug

Lifestyle changes (social, recreational or occupational)

Use continues despite problems

Intoxication

Reversible substance-specific syndromeClinically significant behavioral or

psychological changesNot due to another mental disorder

Withdrawal

Substance-specific syndrome due to cessationClinically significant distressNot due to another condition

Behaviors

ManipulationGrandiosityDenialIsolationDecreased occupational functioningImpaired relationships

Assessment

CAGE: Cut down? Annoyed? Guilty? Eye-opener?

ALCOHOL INTOXICATION

CNS Impairment – brain function to peripheral NS, absorbed in stomach, all systems affected. See Townsend, p. 416+

Acute, Metabolize – gone and symptoms goLong tem effects with use = Amounts Quantities****CNS depression****

Acute alcohol intoxication

Changes in moodPoor psychomotor coordinationImpaired memory and judgmentImpaired social functioningBehavior changesBAL of 100-200 mg/mlRemember “Tolerance”

Withdrawal

What is the opposite of CNS depression?What have you studied in NU 110 that is

similar to this?***Sympathetic NS Hyperactivity***Similar to physiological stress response

Symptoms

TremorsElevated VSAnxiety, irritabilityInsomniaDiaphoresis***Onset: 4-12 hours after last drink

Withdrawal

Peak is 2 – 3 daysGREATEST RISK: Alcohol delirium, DT’s,

Delirium tremens*** A medical crisisOccurs on second to third day following last

drinkPrevent DT’s. Get pt. past this window.

Alcohol delirium

Autonomic NS hyperactivity: cardiac, smooth muscles, glands

Hallucinations, illusions, delusionsFluctuating LOCSeizuresN and V

Detoxification

Priority #1: Physiological stability, safetyMonitor: BP and P, R and T; q 4 hrs:Medicate: Use of cross dependent sedatives,

titration based on degree and number of symptoms. What class of drugs have a sedative/CNS depressant effect? Use these_________________________

Continued:

Fluids – replacement and enhance detoxification via kidney and liver - if functioning normally

Nutrition – alcohol decreases appetite; Thiamine(Wernick’s encephalopathy), Folic acid and MVI

Continued:

Reduce risk of seizures: MgSo4, Anticipate anticonvulsants

Reduce risk of stroke: antihypertensives

Continued:

Priority #2: Address the denialAround day 3Matter of fact, no judgment, tell the facts of

patient condition and directly link to alcohol use

“As a result of your body’s dependency on alcohol, it reacted with the symptoms of__________________. This indicates damage to …”

Continued:

“Alcohol use is damaging your body. Examples of this are____________.”

continued

Priority #3: Plans for sobriety, learning to live sober. Contingent upon belief that alcohol use has created problems.

“What would you like to have happen in your life now?” “What do you wish for?”

At dischargeIn-patient rehabilitation or, home and AA

Sobriety

Medications – adjunct to learning to cope, re-programming responses

Antabuse – negative reinforcementNaltrexone – decrease cravingsCampral – decrease distress, improve mood,

contraindicated in liver inpairmentMEMORIZE THESE

Continued:

Continue to address denial and powerlessness over alcohol – AA

Practice new ways to cope Counseling on coping and repairing

relationshipsNew relationships, lifestyle changes

Family

Don’t feelDon’t trustDon’t expect

Continued:

Deny the problemUse a substanceDevelop a symptomKick the user outCo-dependence (part of denial) – the need to

be neededLearn to cope with substances

Family treatment

Family therapy to repair relationships, family structures, re-set family roles

Alanon – adult – learn to give up responsibility for the user and his/her substance use

Alteen – Adolescents: Leaning to cope, not over-function, have sx., or use substances

Part II - Other drugs

Why does the brain prefer opium to broccoli?A shortcut to the brain’s reward systemFloods the nucleus accumbens with dopamineHippocampus lays down memories of rapid

satisfaction – Feels GREAT

Continued:

Amygdala creates a condition response to certain stimuli

Stressors or something associated with substance use, trips the mental machinery of relapse* Conditioned response

Very neuophysiologic

*Harvard Mental Health Newsletter, Volume 21, No. 1, 2004, p.1.

OTHER DRUGS

CNS DEPRESSANTS: OpiodsEffects: Suppress sympathetic NS. Load

endorphin receptor sites = euphoria and analgesia

Depletes serotonin which regulates pain perception and anxiety

HeroinName other similar CNS depressants _____

Continued:

Withdrawal: 6 – 8 hrs = nervous and edgyRunny nose, tearing, pilorectionMuscle, joints and bones ache N and V, diarrheaLasts 4 – 8 daysNot lethal

Continued:

Treatment: No CNS drugs;will cause cross addiction

Systems support - e.g., diarrheaFluids and nutrition as toleratedEmotion supportReplacement therapy/ methadone clinicsLifestyle change and coping

STIMULANTS: Cocaine/crackEffects: Stimulates CNS = well-being, energy

and euphoriaBlocks reuptake of norepinephrine, dopamine

and serotoninTachycardia, HTN, increased resp. and

metabolic rateName other stimulants: ____________

Continued:

Anorexia but craves high-sugar, restlessnessMassive systematic vasoconstriction = MI,

CVA, spontaneous abortion Who will be at risk? Aged, pregnant f

females

Continued:

Withdrawal: Overwhelming fatigueDysphoria and anhedoniaEven after drug has been detoxed,

neurotransmitter levels are so unbalanced = clinical depression

Suicide precautions

STIMULANT: Methamphetamine

Coming soon to your neighborhoodReleases high levels of dopamineEnhances moodIntense rush or “flash”. Very different from

cocaineMA high lasts 8 – 24 hrs; cocaine lasts 20 - 30

minutes

Continued:

MA effects Euphoria, increased attention and libido Increased activity with decreased fatigue

and appetite Toxicity from binging – visual hallucinations,

violence, elevated BP, R, and Temp. Tolerance

Continued:

Treatment for toxicity (Intoxication)Acute ER: IV Haldol for agitation, IV

medications for controlling BP and preventing seizures

Cardiac monitoring, IV hydrationReducing hyperthermia if present

Continued:

Chronic use at lower dosages: No physical manifestations of withdrawalBUT: Depression, anxiety, fatigue, paranoia,

aggression and an intense craving for the drug

HALLUCINOGENS

Mind Altering: PCP, LSDLow doses – euphoriaHigher - hallucinations, delusions, peripheral

anesthesia, agitationRisk for trauma due to altered stateLong term: sympathomimetic signs

Continued:

Treatment: No Withdrawal syndrome but: When insufficiently metabolized, stored in

fat. Metabolize fat tissue = released into circulation producing hallucinations later = flashbacks OR brain damage due to use.

Acute sx. in ER – agitation, ensure pt. safety

Inhalants

Benzene, nitrates: paint, glue, lighter fluidVery addictingAffects Cardiac and CNSIntoxication: euphoria, giddiness, drowsinessChronic: Dysrythmias, renal and liver,

organic mental changesTeens – buy in drugstore or hardware store