Substance abuse:-

2. SUBSTANCE ABUSE Disorders due to Psychoactive substance use refer to conditions arising from the abuse of Alcohol, Psychoactive drugs & Other Chemicals such as Volatile Solvents.

3. TERMINOLOGIES Substance refers to any Drugs, Medication, or Toxins that shares the potential of abuse. Addiction is a Physiological & Psychological dependence on Alcohol or other drugs of Abuse that affects the Central Nervous System in such a way that withdrawal symptoms are experienced when the substance is Discontinued.

4. Abuse refers to Maladaptive pattern of Substance use that impairs health in a board sense. Dependence refers to certain Physiological & Psychological phenomena induced by the repeated taking of a Substance. Tolerance is a state in which after repeated administration, a drug produced a decreased effect, or increasing doses are required to produce the same effect. Withdrawal State is a group of signs & symptoms recurring when a drug is reduced in amount or withdrawn, which last for a limited time.

5. ICD – 10 CLASSIFICATION F10 – F19 Mental & Behavior Disorders due to Psychoactive Substance Use. F10 – Mental & Behavior Disorders due to use of Alcohol. F11 – Mental & Behavior Disorders due to use of Opioids. F12 – Mental & Behavior Disorders due to use of Cannabinoids. F13 – Mental & Behavior Disorders due to use of Sedatives & Hypnotics. F14 – Mental & Behavior Disorders due to use of Cocaine. F16 – Mental & Behavior Disorders due to use of Hallucinogens.

6. COMMONLY USED PSYCHOTROPIC SUBSTANCE  Alcohol  Opioids  Cannabis  Cocaine  Amphetamines & other sympathomimetics  Sedatives & Hypnotics ( Eg : Barbiturates )  Inhalants ( Eg : Volatile Solvents )  Nicotine  Other Stimulants ( Eg : Caffeine )

7. ETIOLOGY BIOLOGICAL FACTORS
Genetic Vulnerability : Family History Of Substance use Disorders Biochemical Factors : Role of Dopamine & Nor-epinephrine have been implicated in Cocaine, Ethanol, & Opioid Dependence. Abnormalities in Alcohol dehydrogenase or in the Neurotransmitter mechanisms are thought to play a role in Alcohol Dependence.

8. Neurobiological theories :
Drug addict may have an inborn deficiency of Endomorphins. Enzymes produced by a given gene might influence hormones & Neurotransmitters, contributing to the development of a personality that is more sensitive to the peer pressure. Withdrawal & Reinforcing effects of drugs. Co-morbid medical Disorder (Eg: To Control Chronic Pain)

9. BEHAVIORAL THEORIES Drug abuse as the result of Conditioning / Cumulative reinforcement from drug use. Drug use causes euphoric experience perceived as rewarding, thereby motivating user to keep taking the drug. Stimuli & Setting associated with drug use may themselves become reinforcing or may trigger drug craving that can lead to relapse.

10. PSYCHOLOGICAL FACTORS  General Rebelliousness  Sense of Inferiority  Poor Impulse Control  Low Self-Esteem  Inability to cope up with the pressures of living & society (Poor Stress Management Skills)  Loneliness, Unmet needs  Desire to escape from reality  Desire to experiment, a sense of Adventure  Pleasure Seeking  Machoism  Sexual Immaturity

11. SOCIAL FACTORS  Religious Reasons, Peer Pressure  Urbanization, Extended Period of Education  Unemployment, Overcrowding  Poor Social Support  Effects of Television & Other Mass Media  Occupation: Substance use is more common in chefs, Barmen, Executives, Salesman, Actors, Entertainers, Army, Personnel, Journalists, Medical personnel, etc.,

12. EASY AVAILABILITY OF DRUGS Taking Drugs Prescribed by the Doctors (Eg: Benzodiazepine Dependence) Taking drugs that can be bought legally without Prescription (Eg: Nicotine, Opioids) Taking Drugs that can be Obtained from illicit Sources (Eg: Street Drugs)

13. PSYCHIATRIC DISORDERS Substance Use Disorders are more Common in Depression, Anxiety Disorders (Social Phobia), Personality Disorders (Especially Anti-Social Personality), & Occasionally in Organic Brain Disorders & Schizophrenia.

14. CONSEQUENCES OF SUBSTANCE ABUSE This Commonly Leads to Physical Dependence, Psychological Dependence, Or Both. It may cause Unhealthy Lifestyles & Behaviors Such as poor diet. Chronic Substance abuse impairs Social & Occupational Functioning, Creating Personal, Professional, Financial, & Legal Problems (Drug Seeking is commonly associated with Illegal Activities, Such as Robbery or Assault).

15. Drug Use Beginning in early Adolescence may lead to emotional & behavioral Problems, Including Depression, Family Problems with Relations, problems with or Failure to Complete School, & Chronic Substance abuse Problems. In Pregnant women, substance Abuse Jeopardizes (Danger of Loss) fetal Well-being. Psychoactive substances Produce negative Outcomes In Many Patients, Including Maladaptive Behavior, “Bad Trips” – Drug Induced Psychosis, & even Long Term Psychosis.

16. • IV Drug Abuse May lead to Life Threatening Complications. • Illicit Street Drugs pose added Dangers; Materials used to dilute them can cause toxic Or allergic Reactions.

17. ALCOHOL DEPENDENCE SYNDROME Alcohol Means Essence, anciently it called as Magnus Hass which is derived from Arabic Word. Alcoholism refers to the uses of alcoholic Beverages to the Point of Causing Damage to the Individual, Society, Or Both. (Or) Chronic Dependence of Alcohol Characterized by Excessive & Compulsive Drinking that produce Disturbances in mental Or Cognitive level of functioning which interferes with social & Economic Levels.

18. PROPERTIES OF ALCOHOL Alcohol is a Clear Colored Liquid with a Strong Burning Taste. The Rate of Absorption of alcohol into the Blood stream is more Rapid than its Elimination. Absorption of Alcohol into the Bloodstream is Slower when food is Present in the Stomach. A Small amount is Excreted through Urine & a Small Amount is Exhaled.

19. CONCENTRATION OF ALCOHOL IN BLOOD

20. EPIDEMIOLOGY Incidence of Alcohol Dependence is 2% in India. 20 – 30 % of Subjects Aged Above 15years are Current Users Of Alcohol, & Nearly 10% of them are Regular Or Excessive Users. 15 – 30 % Of Patients are Developing Alcohol – Related Problems & Seeking admission in Psychiatric Hospitals.

21. TYPES OF DRINKERS MODERATE DRINKERS PROBLEM DRINKERS It does not Cause much problems physically & Mentally It Cause Impaired Health, Family & Society

22. CAUSES OF ALCOHOLISM Hard physical Labour, ( Occupations – Bar mates, Medical Professionals, Journalists & Actors). A Sudden loss of Properties or Closed ones. Ignorance Suddenly a person Become a Rich / Poor. Disorders Like Depression, Anxiety, Phobia, & Panic Disorders. Biochemical Factors (Alterations in Dopamine & Epinephrine) Psychological factors (Low self Esteem, Poor Impulse, Escape From reality, Pleasure Seeking). Sexual Immaturity Social Factors ( Over Crowding, Peer Pleasure, Urbanizations, Religious Reason, Unemployment, Poor Social Support, Isolation).

23. PROCESS OF ALCOHOLISM Experimental Stage Recreational Stage Relaxation Stage Compulsion Stage

24. STAGES OF ALCOHOLISM Progressive Phase Crucial Phase Chronic Phase Rehabilitative Phase Road For Recovery

25. CLINICAL FEATURES OF ALCOHOL DEPENDENCE Minor Complaints : (Malaise, Dyspepsia, Mood Swings Or Depression, Increased Incidence of Infection) Poor Personal Hygiene. Untreated Injuries (Cigarette Burns, Fractures, Bruises that cannot be fully Explained). Unusually High tolerance for Sedatives & Opioids. Nutritional Deficiency ( Vitamins & minerals).

26. Secretive Behavior (may Attempt to Hide disorder or Alcohol supply). Consumption Of Alcohol- Containing products (Mouthwash, After-Shave lotion, Hair Spray, Lighter Fluid, Body Spray, Shampoos). Denial of Problem. Tendency to Blame others & Rationalize Problems (Problems Displacing Anger, Guilt, Or Inadequacy Onto Others to Avoid Confronting Illness).

27. ICD-10 CRITERIA FOR ALCOHOL DEPENDENCE A Strong Desire to take the Substance Difficulty in Controlling Substance Taking Behavior A Physiological Withdrawal State. Progressive neglect of Alternative pleasures or Interests. Persisting with Substance Use Despite Clear Evidence of Harmful Consequences

28. PSYCHIATRIC DISORDERS DUE TO ALCOHOL DEPENDENCE Acute Intoxication Withdrawal Syndrome Alcohol-Induced Amnestic Disorders Alcohol-Induced psychiatric Disorders

29. ACUTE INTOXICATION It Develops During Or Shortly After Alcohol Ingestion. It is Characterized by,  Clinically Significant Maladaptive Behavior or Psychological Changes (Eg’s: Inappropriate Sexual or Aggressive Behavior).  Mood Lability  Impaired Judgment  Slurred Speech  Inco-ordination  Unsteady gait  Nystagmus  Impaired Attention & Memory  Finally Resulting in Stupor or Coma.

30. WITHDRAWAL SYNDROME Person Who Have been Drinking Heavily Over a Prolonged period of time, Any Rapid Decrease in the amount of Alcohol in the Body is likely to Produce Withdrawal Symptoms. These are: Simple Withdrawal Symptoms Delirium Tremens

31. SIMPLE WITHDRAWAL SYNDROME: It is Characterized by, Mild tremors Nausea Vomiting Weakness Irritability Insomnia Anxiety

32. DELIRIUM TREMENS It Occurs Usually within 2- 4days of Complete or Significant Abstinence From Heavy drinking. The course is Very Short, with Recovery Occurring within 3-7days.

33. It is Characterized by,  A Dramatic & Rapidly Changing Picture of Disordered Mental Activity, with Clouding Of Consciousness & Disorientation in Time & Place.  Poor Attention Span.  Vivid Hallucinations which are Usually Visual, Tactile Hallucinations Can also Occur.  Severe Psychomotor Agitation  Shouting & Evident Fear  Grossly Tremulous Hands which Sometimes Pick-Up Imaginary Objects; Truncal ataxia.  Autonomic Disturbances Such as Sweating, Fever, Tachycardia, Raised Blood pressure, Pupillary dilation.  Dehydration with Electrolyte Imbalances.  Reversal of Sleep-Wake Pattern or Insomnia  Blood tests to Reveal Leucocytosis & LFT  Death may Occur due to Cardiovascular Collapse, Infection, Hyperthermia, Or self Inflicted Injury.

34. ALCOHOL-INDUCED AMNESTIC DISORDERS Chronic Alcohol Abuse associated with Thiamine Deficiency (Vitamin B) is the most frequent Cause of Amnestic Disorders. This Condition is Divided into : Wernicke’s Syndrome Korsakoff’s Syndrome

35. WERNICKE’S SYNDROME is Characterized by, Prominent Cerebellar Ataxia Palsy of the 6th Cranial Nerve Peripheral Neuropathy Mental Confusion KORSAKOFF’S SYNDROME The Prominent Symptoms in this Syndrome is Gross Memory disturbance. Other Symptoms Include: Disorientation Confusion Confabulation Poor Attention Span & Distractibility Impairment of Insight

36. ALCOHOL-INDUCED PSYCHIATRIC DISORDERS Alcohol Induced Dementia: It is a long term Complication of Alcohol Abuse, Characterized by Global decrease in cognitive Functioning (Decreased Intellectual Functioning & Memory). This Disorder tends to Improve With Abstinence, But Most of The Patients may have Permanent disabilities.

37. Alcohol-Induced Mood Disorders: Persistent Depression & Anxiety Suicidal Behavior Alcohol-Induced Anxiety Disorders: Panic Attacks Impaired Psychosexual Dysfunction: Erectile Dysfunction & Delayed Ejaculation Pathological Jealousy: Delusion of Infidelity Alcoholic Seizures:  Generalized Tonic – Clonic Seizures Occur Within 12-48 Hours After a Heavy Bout of Drinking.  Status Epilepticus Alcoholic Hallucinosis:  Presence of Auditory Hallucination during Abstinence  Regular Alcohol Intake

38. RELAPSE Relapse refers to the process of returning to the use of alcohol or drugs after a period of Abstinence. Relapse Dangers: The presence of drugs or Alcohol, Drug users, Places where you used Drugs. Negative Feelings, Anger, Sadness, Loneliness, Guilt, Fear, & Anxiety. Positive Feelings which make you celebrate. Boredom – A State of Feeling Bored. Increase the Intake of drug. Physical pain Lot of Cash

39. RELAPSING

40. Warning Signs Of Relapse:  Stopping medications on one’s own or against the advise of medical professionals.  Hanging around old drinking haunts & drug using Friends.  Isolating themselves.  Keeping Alcohol, drugs around the houses for some reason.  Obsessive thinking about using drugs / Drinking.  Fail to follow their treatment plan, Quitting therapies, Skipping doctor’s appointments.  Feeling Over – Confident  Difficulties in Maintaining Relationships.  Setting Unrealistic Goals.  Changes in Diet, Sleep, Energy levels, & Personal Hygiene.  Feeling Overwhelmed.  Constant Boredom.  Sudden Changes in Psychiatric Symptoms.  Unresolved Conflicts.  Avoidance.  Major life Changes – loss, Grief, Trauma, Painful Emotions, Winning the Lotteries.  Ignoring Relapse warning Signs & Symptoms

41. Signs & Symptoms of Relapse: Experiencing Post acute Withdrawal Return to denial Avoidance & defensive Behavior Starting to Build Crisis Feeling Immobilized (Stuck) Become depressed Loss of control Urges & Cravings Chemical Loss of Control

42. COMPLICATIONS OF ALCOHOL ABUSE Alcohol Damages body Tissues by Irritating them Directly Changes that Occur During Alcohol Metabolism by Interacting With other drugs Aggravating Existing disease / Accidents brought on by Intoxcification Tissue Damage can Lead to a Host of Complications

43. Gastro Intestinal Complications Neurologic Complications Chronic Diarrhea Esophagitis Esophageal Cancer Esophageal Varices Gastric Ulcers Gastritis Gastro Intestinal Bleeding Malabsorption Pancreatitis Alcohol Dementia Alcoholic hallucinosis Alcohol Withdrawal Delirium Korsakoff’s Syndrome Peripheral Neuropathy Seizure Disorders Subdural Hematoma Wernicke’s Encephalopathy Cardiopulmonary Complications Psychiatric Complications Arrhythmias Cardiomyopathy Essential Hypertension Chronic Obstructive Pulmonary Disease Pneumonia Increased Risk of Tuberculosis Amotivational Syndrome Depression Impaired Social & Occupational Functioning Multiple Substance Abuse Suicide

44. Hepatic Complications Other Complications Alcoholic Hepatitis Cirrhosis Fatty Liver Beri Beri Fetal Alcohol Syndrome Hypoglycemia Leg & Foot Ulcers Prosatitis

45. DIAGNOSTIC EVALUATION  History collection.  Mental Status Examination.  Physical Examination.  Neurologic Examination.  CAGE Questionnaires.  Michigan Alcohol Screening Tests (MAST).  Alcohol Use Disorders Identification Tests (AUDIT).  Paddington Alcohol Test (PAT).  Blood Alcohol Level to indicate Intoxication (200mg/dl).  Urine Toxicology to reveal use of Other Drugs.  Serum Electrolytes Analysis Revealing Electrolyte Abnormalities associated with Alcohol Use.  Liver function Studies demonstrating alcohol related Liver Damage.  Hematologic Workup Possibly revealing Anemia, Thrombocytopenia.  Echocardiography & Electrocardiography demonstrating Cardiac Problems.  Based on ICD10 Criteria.

46. TREATMENT MODALITIES Symptomatic Treatment. Fluid Replacement Therapy. IV Glucose to Prevent Hypoglycemia. Correction of Hypothermia / Acidosis. Emergency Measures for Trauma, Infection or GI Bleeding.

47. TREATMENT FOR WITHDRAWAL SYMPTOMS DETOXIFICATION: The Drugs of Choice are Benzodiazepines. Egs: Chlordiazepoxide 80-200 mg/day Diazepam 40-80 mg/day, in divided doses. OTHERS:  Vitamin B – 100mg of Thiamine Parenterally, Bd 3 to 5 days, Followed by Oral Administration for Atleast 6 months.  Anticonvulsants  Maintaining Fluid & electrolyte Balance  Strict Monitoring of Vitals, Level of Consciousness & Orientation.  Close Observation is Essential

48. ALCOHOL DETERRENT THERAPY Deterrent agents are given to desensitize the individual to the effects of alcohol & Abstinence. The Most commonly Used Drug is Disulfiram or Tetraethyl thiuram disulfide or Antabuse.

49. DISULFIRAM Disulfiram is used to ensure Abstinence in the Treatment of Alcohol Dependence. Its Main effect is to Produce a rapid & Violently Unpleasant Reaction in a Person who ingests even a Small amount of alcohol While Taking Disulfiram.

50. DOSAGE: Initial Dose is 500mg/day orally for the 1st 2weeks, followed by a maintenance dosage of 250mg/day. The Dosage should not exceed 500mg/day. INDICATIONS: Disulfiram use is as an Aversive Conditioning Treatment for Alcohol Dependence. CONTRAINDICATIONS: Pulmonary & Cardiovascular Disease Disulfiram Should be used with caution in patients with Nephritis, Brain Damage, Hypothyroidism, Diabetes, Hepatic Disease, Seizures, Poly-drug Dependence or an Abnormal EEG. High Risk for Alcohol Ingestion.

51. ACTION: It is an Aldehyde Dehydrogenase inhibitor that interferes with the metabolism of alcohol & Produces a marked increase in blood acetaldehyde levels. Accumulation of acetaldehyde( more than 10 times which occurs in the normal metabolism of alcohol) produces a wide array of Unpleasant reactions Called DISULFIRAM-ETHANOL REACTION (DER). Characterized by Nausea, Throbbing headache, Hypotension, Sweating, thirst, Chest Pain, tachycardia, Vertigo, blurred Vision associated with Severe Anxiety.

52. ADVERSE EFFECTS: Fatigue, Dermatitis, Impotence, Optic Neuritis, Mental Changes, Acute Polyneuropathy, Hepatic Damage, Convulsions, Respiratory Depression, cardiovascular Collapse, Myocardial Infarction, Death.

53. NURSING RESPONSIBILITY:  An informed Consent should be taken before Starting treatment.  Ensure that at least 12hours have elapsed since the last ingestion of Alcohol before Administering the Drug.  Patient should be warned against Ingestion of any alcohol- containing preparations such as Cough Syrups, Sauces, Aftershave Lotions, Etc.,  Caution patient against taking CNS Depressants & Over-the- Counter(OTC) Medications during disulfiram therapy.  Instruct The Patient to avoid driving or other activities requiring alertness.  Patients should be warned that the Disulfiram-alcohol Reaction may continue for as long as 1or 2 weeks after the last dose of disulfiram.  Patients should carry identification cards describing Disulfiram- alcohol reaction & listing the name & phone number of the physician to be called.  Emphasize the Importance of Follow-Up visits to the physician to monitor progress in long-term therapy.

54. PSYCOLOGICAL THERAPIES

55. PSYCHOLOGICAL THERAPY:  Motivational Interviewing  Group Therapy  Aversive Conditioning / Therapy  Cognitive Therapy  Relapse Prevention Technique: This technique helps the patient to identify high-risk relapse factors & develop strategies to deal with them.  Cue Exposure Technique: The technique aims through repeated exposure to desensitize drug abusers to drug effects, & thus improve their ability to Remain Abstinent.  Assertive Training  Behavior Counseling  Supportive Psychotherapy  Individual Psychotherapy

56. AGENCIES CONCERNED WITH ALCOHOL-RELATED PROBLEMS This is a self Help organization founded in the USA by 2 Alcoholic men Dr. Bob Smith & Dr. Bill Wilson On 10th june,1985. Alcoholic Anonymous considers Alcoholism as a Physical, Mental, Spiritual disease, a Progressive one, which can be Arrested but not Cured. Members attend Group meetings usually twice a week on a long – term basis. Each member is assigned a support person from whom he may seek help when the temptation to drink occurs.

57. In Crisis he can obtain immediate help by telephone. Once Sobriety is achieved he is Expected to help others. The Organization works on the firm belief that Abstinence must be Complete. The only Requirement for membership is a Desire to stop drinking. There is no authority, but only a fellowship of imperfect alcoholics whose strength is formed out of weakness. Their primary purpose is to help each other stay sober and help each other alcoholics to achieve sobriety.

58. Al-Anon This is a Group Started by Mrs. Annie, Wife of Dr. Bob to support the Spouses of Alcoholics. Al-Teen Provides Support to their Teenage Children. Hostels These are intended mainly for those rendered homeless due to alcohol-relate

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