Substance Abuse

• Continued use despite related problems• Recurrent use resulting in neglect of role

functions• Continued use despite recurrent social/legal

problems• Recurrent use in hazardous situations

Dependence Criteria At least 3 of the following

• Use of amounts greater than intended • Attempts to cut down or control • Excessive time spent in getting, using,

recovering • Use despite recurrent problems

Dependence (addiction) Criteria

• Presence of tolerance (more needed for effect)

• Presence of withdrawal symptoms • Substance often taken to relieve or avoid

withdrawal

Dual Diagnosis

• Pts with Schizophrenia more than 4 x likely to have substance use disorder

• Pts with Bipolar disorder more than 5 x likely

Alcoholism in the U.S.

• 14 Million cases & 200,000 deaths/yr • Accounts for:– 50% of auto fatalities– 33% of suicides– 67% of murders

• Life expectancy reduced 10-12 years• Economic cost $60 billion yearly

CAGE

• Cut down (have you tried to cut down)• Annoyed by criticism• Guilty (do you feel guilty for drinking too

much)• Eye-opener• (put star by this… good one to remember)• There are number of these to look at in the

book

Alcoholism

• Vivid memory of first drink• Self medication with alcohol• Controlled drinking• Social crutch• Frequent accidents

Alcoholism continued

• Personality change• Suicidal attempt• Elevated blood pressure• Alcohol myopathy (pain or edema in muscles)• Denial• Family enabling denial (family covers up for

person)

Predisposing Factors

• Biological, Genetic, Biochemical • Psychological links– depression, anxiety, antisocial & dependent

personality• Sociocultural Factors– nationality & ethnicity (native american’s, Irish)– religious beliefs– gender differences (

– Male sons of alcoholic fathers are 4X more likely

Medical Complications

• Hepatic- ascites, wt.loss, cirrhosis• Gastrointestinal-esophagitis; esophageal varices

(vessles in esophagus ruptures)• Cardiovascular-cardiomyopathy• Neurological-neuropathy• Nutritional-thiamine (decrease)• Infectious diseases• Obstetrical (fetal alcohol syndrome)• Myopathy: pain, edema in muscles, increased CPK, wasting & weakness. GI: esophagitis,

esophageal varices. Cardiovascular: cardiomyopathy. GI: esophagitis, esophageal varices. Cardiovascular: cardiomyopathy. Neurological: neuropathy. Nutritional: thiamine

Wernicke-Korsakoff Syndrome

• Wernicke encephalopathy (most serious form of Thiamine deficiency)– confusion– ataxia– abnormal eye movements

• may be treated with large doses of thiamin, but if it progresses to alcoholic amnestic syndrome (Korsakoff’s) the prognosis for reversal of memory loss is poor

Wernicke-Korsakoff syndrome

• Korsakoff’s Psychosis– Thiamin dementia

• alcohol reduces absorption

• Alcohol amnesiac disorder– recent memory impaired– appear apathetic

– (need to know what it is & that it is a terrible form of thiamine deficiency)

Alcohol Withdrawal Syndrome

• 6 hrs after fall in BAC; peaks 24-36 hrs subsides 48 hrs

• Tremulousness • Anorexia, N& V• Tachycardia, increased BP• Irritability, hyperreflexia, insomnia• Diaphoresis• Possible seizures (6-48 hours)

Alcoholic hallucinosis about 48 hours after last drink

• Hallucinations (auditory) • Delirium (visual)• Tactile (feel like things are crawling on them)

often they will deny these hallucinations… ask them about nightmares… may admit to the nightmares)

Acute Hallucinosis

• Don’t Leave Alone• Nonstimulating Environment• Sedate• Reassure• Restrain? (last resort, only to prevent harming

self… falling out of bed)• Prevent Injury

Delirium Tremens -DTs

• Medical emergency; 5% -10% fatal• 3-5 days after last drink• Exaggeration of earlier sx plus– Disorientation– Paranoia, delusions– Visual Hallucinations– Elevated VS, vomiting, diarrhea, diaphoresis

Intervention for Alcohol Withdrawal

• Benzodiazepines (Librium) Carbamezepine (Tegretol) Thiamine

• Seizure precautions• Safety and fall precautions• Maintain nutrition & hydration needs• Decrease environmental stimuli• Reorient when indicated

Abstinence

• Antabuse• Topamax (anticonvulsant)• Naltraxone• Revax• Campral

Alcoholics Anonymous; Women for Sobriety; Rational Recovery

• Education re: alcohol• Group support/forgiveness• Family involvement• Alleviation of loneliness• Confession/catharsis• Opportunity to help others• AA has religious component… • (smart, belonging is important)

Cocaine

• Status seekers-yuppies• Aging marijuana smokers• Medical misinformation (in past thought there

weren’t good side effects)• Celebrity endorsements (in movies) • Myths, denial, psychopharmacology• South American Indians stuff a wad of coca leaves in a cheek or brew them as tea. The

leaves are dissolved in hydrochloric acid to produce cocaine hydrochloride. Can be boiled in a solution of baking soda, smoked in a pipe like crack

Cocaine

• Interacts with dopamine • Animals choice over drug or food• Sexually deprived monkey (in laboratory) – will choose cocaine over a monkey in heat

Effects of cocaine

• Euphoria• Mental stimulation• Sexual stimulation• Energy• Sociability

Crash

• Rebound dysphoric reaction• Restlessness & irritability• Craving• Depression• Sexual disinterest, impotence• Fatigue, memory & concentration problems

Toxic consequences of Cocaine

• Panic anxiety reaction• Agitation & confusion• Increased pulse rate • Increased pupil size• Seizures

Toxicity continued

• Cardiac Arrest• Violent or suicidal behavior• Paranoid Psychosis– no Haldol or Mellaril when in toxic state

Marijuana

• Amotivational syndrome• Toxic psychosis• Gynecomastia• (second only to alcohol as most widely abused

drug in the US)• All kinds of side effects (listed in book… read chapter in text) • Greater amts of tar than tobacco… abnormal sperm count, CNS on high, tremors, impairment

of judgment, cannabis toxication, impaired motor coordination

Opiates

• Opium, heroin• Meperidine, morphine• Codeine, methadone• Oxycontin, lortab, vicoden,• (oxycodone in percodan, • Hydrocodone: hycodon, vicodin, lortab)

Opiate Withdrawal

• Anorexia• Stomach cramps and diarrhea• Lacrimation, rhinorrhea• Muscle aches• Mild elevation in V.S• Profuse sweating• Insomnia, agitation, depression, anxiety• Irritability & restlessness

Physical Symptoms

• Dilated pupils• Diarrhea• Rhinorrhea• Piloerection (raised hair on arm)• Tremors

Intervention for narcotic withdrawal

• Clonidine (Catapres)• Cyclobenzaprine (Flexeril): muscle relaxant• Suboxone –Sublingual preparation– Part Opiate– Part Anti-Opiate

Suboxone

• 4 parts Buprenorphine 1 part Narcan• Buprenorphine (a partial agonist)– Gives pt. enough opiate to alleviate sx of

withdrawal

• Naloxone (Narcan) An antagonist• Prevents abuse from injection

Nicotine Dependence

• Most damaging drug to society !!!• Classified by FDA as an addictive drug• Causes impotence!• Pts require larger doses of SSRIs• Zyban may decrease craving

Agents to Maintain Abstinence

• Alcohol– Naltrexone, Disulfiram (Antabuse) topamax is an

anticonvulsant…• Cocaine – Bromocriptine (Parlodel), Carbamazepine

• Opiates – Methadone, Naltrexone

• Nicotine – Zyban (Wellbutrin sr)

Hallucinogens

• LSD; PCP; Inhalants (flashback w/ LSD)• Reassurance• “Talk down”• Safe environment, minimal stimulation• Do not touch

Behaviors of Abuse & Dependence

• IV Drug use• Accidents, violence, self neglect• Skin Abscesses, Cellulitis• Hepatitis B (HBV)• Bacterial Endocarditis• HIV (AIDS)

Codependent Behaviors

• Fulfills Others Needs (ACOA ??) child ends up taking care of the parents

• Anxiety Around Intimacy• Boundary Distortions• Enmeshment• Denial• Depression, Anxiety, Addictions• Stress-Related Medical Illness

CNS Depressants

• Barbiturates– Seconal, nembutal, amytal, phenobarbital– drowsiness, tolerance– popular street drugs– physical and psychological dependence

• Benzodiazepines (1960s) – Valium, Xanax, Librium, Dalmane

• Withdrawal from CNS Depressants most dangerous

Ecstasy

• Methylenedioxymethamphetamine (MDMA)• Affects serotonin• Euephoria, increased energy & sexual arousal• Suppresses need to eat, drink or sleep• Fever, muscle breakdown, kidney & heart

failure, death

Ecstacy

• Brain damage worse for women• Persistent memory problems• Problems with verbal reasoning & attention• Amphetamines are cleared more quickly in

the presence of testosterone

Flunitrazepam Rohypnol “roofies” forget pill

• Physiological effects similar to diazepam (Valium) but 10 times more potent!

• Adverse: decreased blood pressure, memory impairment, drowsiness, visual disturbances, dizziness, confusion, gastrointestinal and urinary retention

• Ingested orally, frequently in conjunction w/ alcohol or other drugs. Effects begin w/in 30 min., peak w/in 2 hours & may persist for up to 8 hours.

Rohypnol

• Classified as a depressant (benzodiazepine) but can induce excitability or aggressive behavior

• Withdrawal: headache, muscle pain, numbness, anxiety, tension, confusion,

• Hallucinations, delirium, convulsions, shock and cardiovascular collapse

• W/drawl seizures can occur a week or more after cessation of use• AKA date rape drug

GHB

• Gamma Hydroxy Butyrate “G”• Used by ecstasy users to prolong high• Odorless, tasteless and colorless• Clear liquid (visine bottle)• Causes muscle weakness & amnesia!– Allergic reactions: seizures, coma, death

• Detection through urine testing