Substance abuse disorders Drug use when drugs are used to treat
an illness, prevent a disease and improve health condition, it is
termed drug use Drug abuse intake of drugs for reasons other than
medical in a manner that affect physical or mental functioning is
termed drug abuse. Tolerance it refers to a condition where the
user needs more and more of the drug to experience the same effect.
Smaller quantities, which were sufficient earlier, are no longer
effective and the user is forced to increase the amount of drug
intake 2
Slide 3
Intoxication - it is a condition that follows the
administration of a psychoactive substance and results in
disturbance in the level of consciousness, cognition, perception,
judgment, affect, or behavior, or other psych physiological
functions and responses. Dependence dependence syndrome is a
cluster of physiological, behavioral, and cognitive phenomena in
which the use of a substance or a class of substances taken on a
much higher priority for a given individual than other behaviors
that once had greater values 3
Slide 4
Psychological dependence psychological or psychic dependence
refers to the experience of impaired control over drinking or drug
use while physiological or physical dependence refers to tolerance
and withdrawal symptoms. Harmful use pattern of psychoactive
substance use that is causing damage to health. It may be physical
or mental 4
Slide 5
Abuse in DSM IV, psychoactive substance use is defined as a
maladaptive pattern of use indicated by continued use despite
knowledge of having a persistent or recurrent social, occupational,
psychological or physical problem that is caused or exacerbated by
the recurrent use in situations in which it is physically
hazardous. Withdrawal symptoms - when the drug intake is stopped,
withdrawal symptoms are experienced. Physical dependence gives rise
to withdrawals such as tremors and vomiting. Psychological
dependence causes withdrawal symptoms like restlessness or
depression. 5
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Definition DSM-IV, psychoactive substance abuse is defined as a
maladaptive pattern of use indicated by continued use despite
knowledge of having a persistent or recurrent social, occupational,
psychological or physical problem that is caused or exacerbated by
the recurrent use in situations in which it is physically
hazardous. 6
Slide 7
Epidemiology 14 million of U.S population reported current use
of illicit drugs Almost 6% of the population were heavy drinkers
WHO indicates 180 million people of the worlds population consumed
illicit substances The most commonly consumed substance was
cannabis, used by 144 million people of the worlds population
Annual prevalence of cannabis abuse among people aged 15-64 in
India is 3.2% 7
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Classification of addictive drugs 1. Narcotic Analgesics 2.
Stimulants 3. Depressants 4. Hallucinogens 5. Cannabis 6. Volatile
Solvents 7. Other drugs of abuse (muscle relaxants, painkillers,
anti histamines, anti emetics, antipsychotics ) 8
Slide 9
Commonly abused drugs in India Cannabis (bhang, ganja, charas)
Tranquilizers (hypnotics, sedatives) Barbiturates Amphetamines
Hallucinogens Narcotic drugs (opium, pethidine, morphine, morphine,
heroin, cocaine) Tobacco (cigar, cigarette, beedi, hukka ) Other
substances such as alcoho,inhalants, steroids 9
Slide 10
ICD 10 classification F10-F19 Mental and behavior disorders due
to psycho active substance use F10 Mental and behavioral disorders
due to use of alcohol F11 Mental and behavioral disorders due to
use of opioids F12 Mental and behavioral disorders due to use of
cannabinoids F13 Mental and behavioral disorders due to use of
sedatives or hypnotics F14 Mental and behavioral disorders due to
use of cocaine F16 Mental and behavioral disorders due to use of
hallucinogens 10
Slide 11
Causes of substance abuse Biological factors Genetic
vulnerability Co morbid psychiatric disorders Co morbid medical
disorders Reinforcing effects of drugs Withdrawal effects and
craving Biochemical factors 11
Slide 12
Psychological factors Curiosity Early initiation of alcohol and
tobacco Poor impulse control Sensation seeking Low self esteem
Concern regarding personal autonomy Poor stress management skills
Childhood trauma or loss Psychological distress Escapism 12
Slide 13
Social factors Peer pressure Modeling Easy availability
Interfamilial conflicts Religious reasons and cultural factors Poor
social and familial support Rapid urbanization Role of media
Popularity of drugs in various profession 13
Slide 14
Risk factors Chaotic home environment Ineffective parenting
Lack of nurturing and parental attachment Inappropriately
aggressive or shy behavior in classroom Poor social coping skills
Poor school performance Association with deviant peer group
Perception of approval of drug use behavior 14
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Stages of substance abuse 1. Stage 0 showing curiosity : it is
the first stage and it is the beginning of substance abuse 2. Stage
1- learning about the drug induced mood swings : the teen learns
more about use of drugs 3. Stage 2- seeking the drug induced mood
swings : learns to seek the heights of psychological effects 4.
Stage3 being preoccupied with the drug induced mood swings:
behavior changes to stealing, truancy, lying, drug dealing etc 5.
Stage 4- burnout : at this stage they use drug just to feel normal,
euphoric effects may be low. 15
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Opioid use disorders The commonly abused opioids heroin, brown
sugar, smack Synthetic preparation pethidine, fortwin,
buprenorphine Acute Intoxication Apathy Bradicardia Hypotension
Respiratory depression, subnormal temperature Pin point pupils,
thready pulse, coma 16
Slide 17
Watery eyes Running nose Yawning Loss of appetite Irritability
Tremors Sweating Cramps Nausea Diarrhea Insomnia Raised body
temperature Piloerection Anorexia The symptoms start with in 12
hrs, lasts to 24-36 hrs and disappear in 5-6 days 17 Withdrawal
syndrome
Cannabis use disorder The dried leaves and flowering tops are
often referred to as Ganja or Marijuana The resin of the plant is
referred to as Hashish Bhang is a drink made from cannabis Cannabis
is either smoked or taken in liquid form 20
Slide 21
Mild impairment of consciousness and orientation Tachycardia
Sense of floating in the air Euphoria Dream like state flashback
phenomena Alteration in psychomotor activity Tremors Photophobia
Lacrimation Dry mouth Increased appetite Perceptual disturbances 21
Acute intoxication
Slide 22
Withdrawal symptoms Mostly found in 72-96 hours Increased
salivation Hyperthermia Insomnia Decreased appetite Loss of weight
Insomnia 22
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Complications Transient or short lasting psychiatric disorders
Acute anxiety Paranoid psychosis Hysterical fugue Hypomania
Schizophrenia like state Amotivational syndrome Memory impairement
23
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Cocaine use disorder Common street name iscrack It is taken
orally, intranasally or parenterally Acute Intoxication Pupillary
dilation Tachycardia Hypertension Perspiration Nausea Hypomanic
symptoms 24
Treatment Management of intoxication ( Amyl nitrate is
antidote, diazepam or propranolol is used) For withdrawal symptoms
(antidepressants and psychotherapy) Imipramine or amitriptiline
26
Slide 27
Amphetamine use disorder They are CNS stimulants Commonly used
amphetamines are pemoline and methylphenidate Acute Intoxication
Tachycardia pupillary dilation Hypertension insomnia Cardiac
failure restlessness Seizures irritability Tremors paranoid
hallucinatory syndrome hyperpyrexia 27
Barbiturate use disorder Commonly abused barbiturates are
secobarbital, pentobarbital and amobarbital Intoxication
Irritability Lability of mood Disinhibited behavior Slurred speech
Incoordination Attention and memory impairment 29
Slide 30
Complications Withdrawal syndrome IV use lead to skin abscesses
Cellulitis Infections Embolism Hypersensitivity reactions Severe
restlessness Tremors Seizures Delirium tremens like state 30
Slide 31
Treatment 31 Induction of vomiting (in conscious patients) Use
of activated charcoal (to reduce absorption) Symptomatic
treatment
Slide 32
LSD use disorder (Lysergic acid diethylamide) 32 LSD is a
hallucinogen First synthesized in 1938 It acts on 5 HT levels of
brain trip is the term used for the pattern of LSD use (occasional
use followed by long term abstinence)
Slide 33
Intoxication 33 Perceptual changes Depersonalization Illusions
Synesthesias (colours are heard, sounds are felt) Autonomic
hyperactivity Anxiety Paranoid ideation Impaired judgement
Slide 34
Withdrawal syndrome Complications Flashbacks Hallucinogenic
states Anxiety Depression Psychosis Visual hallucinations Treatment
is symptomatic, including, antianxiety, antidepressant and
antipsychotic medications 34
Slide 35
Inhalants or volatile solvent use disorders 35 Commonly used
substances are petrol, aerosols, thinners, varnish remover and
industrial solvents Intoxication Euphoria Excitement Belligerence
Slurred speech Apathy Impaired judgment
Slide 36
Withdrawal symptoms Complications Anxiety Depression Treatment
includes reassurance and diazepam for intoxication Irreversible
damage to liver and kidneys Peripheral neuropathy Perceptual
disturbances Brain damage 36
Slide 37
Treatment 37 CBT Multidimensional family therapy Motivational
interviewing Contingency management (motivational incentives)
Aversion therapy Group therapy Counselling Residential treatment
(therapeutic community, 6-12 months, for drug free re
socialization)
Slide 38
Assessment Nursing diagnosis Background Substance use Mental
health problems Psychological tests Mental status examination
Anxiety Disturbed sleep pattern Altered nutrition less than body
requirement Impaired social interactions Low self esteem
Ineffective individual coping Risk for violence 38 Nursing
management
Slide 39
Prevention of substance use disorders 39 Primary prevention
Enhance government restrictions Strengthen individuals coping
skills Health education to college students Identify and treat
family member who may contribute to drug abuse
Slide 40
40 Secondary prevention Early detection and counselling
Motivational interviewing Complete assessment to elicit the extend
of problem Detoxification with benzodiazepoxide
Slide 41
Tertiary prevention Relapse prevention Assertive training Teach
coping skills Behavior counseling Psychotherapy Supportive
psychotherapy Guidance and counseling Motivation enhancement
Dealing with faulty cognition Time management Anger control
Financial management Stress management Recreation and spirituality
Family counseling 41
Slide 42
Goals Interventions To enable the drug dependent to leave the
drug To establish new social contracts To provide social support To
inculcate responsibility in protecting themselves Participation in
day care centers Occupational and social rehabilitation Teaching
relaxation techniques Religious therapy Enhance self esteem
Participation in self help groups 42 Rehabilitation
Slide 43
Follow up and home care 43 Nurses should be hopeful and
appropriately supportive Teach patient / family about the various
complications of abuse Explain to the family, that patient may use
lies, denial or manipulation to continue drug Teach them drug
overdose may result in emergency/ death Caution patient about
transferring HIV or hepatitis B Teach family to develop trust with
patient and help in setting limits Provide patient the full range
of treatment and supportive measures Teach them how to recognize
psychological stressors and way to cope with that Help to establish
new life style.
Slide 44
ALCOHOLISM 44
Slide 45
INTRODUCTION Alcoholism is the most common psychiatric
disorder. Epidemiological studies carried out in India revealed
that 20 to 40% of subjects aged above 15 are current users. Nearly
15 to 30% of patients seeking admission in psychiatric facilities
are for alcohol related problems. Alcoholism is classified under
F10-F19, i.e. mental and behavior disorders due to psychoactive
substance use in ICD 10 classification 45
Slide 46
DEFINITION 1. Alcoholism refers to the use of alcoholic
beverages to the point of causing damage to the individual and
society or both. 2. Alcoholism is defined as a chronic disease
manifested by repeated drinking that produces injury to the
drinkers health or to his society or economic functioning. 46
Slide 47
PREVALANCE In India the incidence of alcohol dependence is 2%
and 20 to 40% of population aged above 15 are current users.
47
Slide 48
WHAT IS ALCOHOL? Alcohol includes liquors, beer and wine.
Chemical name: ethanol Street names: booze, hooch, moonshine, sauce
etc.. Mode of administration: oral 48
Slide 49
HOW IT ACTS? t Acts on CNS in two ways 1. It potentiates GABA
activity 2. It decreases glutamate activity In both cases the
outcome is depression. 49
Slide 50
PROPERTIES OF ALCOHOL Clear colored liquid Strong burning taste
Rate of absorption into blood is more faster than its elimination
rate. Absorption is slower in the presence of food A small amount
is excreted through urine and small amount is exhaled. 50
Slide 51
Conti.. A conc. of 80-100mg per 100ml of blood is considered as
intoxication A person with 200-250mg per 100ml of blood will be
toxic, sleepy, confused, and his thought process will be altered.
If the conc. is 300mg per 100ml of blood, the person may loose
consciousness. 51
Slide 52
Conti A conc. of 500mg per 100ml of blood is fatal All the
symptoms change according to the tolerance of the person. 52
BIOLOGICAL FACTORS Genetic vulnerability Family history of
substance abuse Biochemical factors 54
Slide 55
PSYCHOLOGICAL FACTORS Sense of inferiority Poor impulse control
Low self esteem Poor stress management skill Loneliness 55
Slide 56
Conti Unmet needs Desire to escape from reality Desire to
experiment A sense of adventure Pleasure seeking Sexual immaturity
56
Slide 57
SOCIAL FACTORS 57 Peer pressure Urbanization Extended period of
education Unemployment Over crowding Social isolation Poor social
support Religious reasons Effect of mass media Occupational
factors
Slide 58
AVAILABILTY alcohol is easily available and drinking is
accepted as a norm in functions and gatherings, 58
STAGES IN ALCOHOLISM 1. EARLY STAGE (1 st stage) Increased
tolerance Blackouts Pre-occupation Grossed drinking 60
Slide 61
2 MIDDLE STAGE (2 nd stage) Loss of control over amount,
frequency Keeping away from alcohol for sometime, but going back to
obsessive drinking after each abstinent period. Denial Feeling of
guilt and shame Chronic hangover Projection 61
Slide 62
3 CHRONIC STAGE Getting drunk even on small amount of alcohol
intake Willing to lie, beg, borrow, steal to maintain supply of
alcohol Living to drink Avoiding family and friends Loss of
interest Problem with low Moral deterioration Impaired thinking
Loss of tolerance to alcohol 62
Slide 63
Signs and symptoms of ADS Malaise, dyspepsia, mood swings, Poor
personal hygiene, untreated injuries (cigarette burns, bruises)
Unusually high tolerance for sedatives and opioids Nutritional
deficiencies Secretive behavior Consumption of alcohol containing
products Denial of problem Tendency to blame others and rationalize
problems Impaired control Withdrawal symptoms Neglect of other
activities Persistent use 63
Acute intoxication Develops during or shortly after alcohol
ingestion. Inappropriate sexual or aggressive behavior Mood
lability Impaired judgment Slurred speech Unsteady gait Impaired
attention 65
Slide 66
Withdrawal symptoms Persons 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 a)
Mild withdrawal symptoms b) Delirium tremons 66
Delirium tremens Occurs within 2-4 days of complete abstinent
from heavy drinking Recovery occurs within 3-7 days Clouding of
consciousness Disorientation Poor attention span Hallucinations
Grossly tremors of hands Sweating, fever, tachycardia, increased BP
(autonomic disturbances) 68
Slide 69
Cont Visual and tactile hallucination Truncle ataxia
(Impairment of the ability to perform smoothly coordinated
voluntary movements. This condition may affect the limbs, trunk,
eyes, pharynx, larynx, and other structures ) Dehydration,
electrolyte imbalances Insomnia Infection, self inflicted injury
Cardiovascular collapse Death 69
Slide 70
Cont.. Sweating Fever Tachycardia Raised BP Dehydration Death
may occur due to cardiovascular collapse, infection, self inflicted
injuries 70
Slide 71
Alcohol induced amnestic disorders Chronic alcohol abuse
associated with thiamine (vita B) deficiency is the most frequent
cause of AD 1. Wernickes syndrome Cerebellar ataxia Palsy of 6 th
cranial nerve peripheral neuropathy Mental confusion 71
8 Reproductive system Sexual dysfunction in males Failure of
ovulation in females 80
Slide 81
81
Slide 82
B Social complications Marital disharmony Occupational problems
Financial problems Criminality accidents 82
Slide 83
C psychiatric complications t Acute intoxication 1. Maladaptive
behavior 2. Psychological changes t Withdrawal syndrome 1. Simple
withdrawal syndrome 2. Delirium tremens 3. Alcoholic seizures 4.
Alcoholic hallucinosis 83
Slide 84
Diagnosis 84 Blood alcohol level 200mg/dl Urine toxicology to
reveal use of other drugs Serum electrolyte analysis LFT
Hematologic studies ECG, echo cardiogram Blood glucose level
Elevated ALT and AST
Treatment for withdrawal symptoms 1. Detoxification
*benzodiazepines (chlordiazepoxide 80- 200mg/day) * diazepam 40-80
mg/day * 100mg of thiamine twice daily fro 3-5 days, then oral
administration for 6 months *anticonvulsants if necessary *
maintain electrolyte balance 86
Slide 87
Cont Alcohol deterrent therapy 2. Alcohol deterrent therapy
Deterrent agents are those which are given to desensitize the
individual to the effects of alcohol and maintain abstinence. The
most commonly used drug is disulphiram(tetraethyl thiuram
disulfide) or antabuse 87
Disulfiram 89 It is used to ensure abstinence in the treatment
of alcohol dependence. Its main effect is to produce a rapid and
violently unpleasant reaction in a person who ingests even a small
amount of alcohol while taking disufiram
Slide 90
Dosage 90 Tablets 200-500 mg Initial dose 500 mg/ day orally
for initial 2 weeks Maintenance dose later, of 250mg/day Dose
should not exceed 500mg/day
Slide 91
Mechanism of action 91 When alcohol is consumed, it is
metabolized by the body into acetaldehyde, a very toxic substance,
that causes many hang over symptoms. Disulfiram interferes with the
metabolism of alcohol that increases the acetaldehyde level (10
times > in normal alcoholics) and it produces a wide variety of
unpleasant reactions called Disulfiram Ethanol Reaction (DER)
Side effects Contraindications Fatigue Dermatitis Impotence
Optic neuritis Mental changes Acute polyneuropathy Hepatic damage
Pulmonary and cardiovascular disease Use with caution in patients
with nephritis, brain damage, hypothyroidism, diabetes, hepatic
disease, seizures and poly drug dependence 93
Slide 94
Nurses responsibility in Deterrent therapy 94 Get informed
consent before therapy starts Administer the medicine after 12
hours of the last ingestion of alcohol Strictly inform the patient
not to take even a small amount of alcohol after therapy starts
Instruct him about reaction. Avoid any topical application, and
food stuffs, medicines containing alcohol Patient should not take
any CNS depressants or OTC medicines Avoid driving and activities
require alertness Instruct them DER will last for 1-2 weeks after
the last dose Importance of follow up
Slide 95
Alcoholics anonymous (AA) 95 Found in USA on 10 th June 1935 by
two alcoholic men, Dr. Bob Smith and Bill Wilson. AA considers
alcoholism as a physical, mental and spiritual disease, a
progressive disease which can be arrested but not cured Members
attend group meetings usually twice a week on long term basis Each
member is assigned a support person, from whom he may seek help
when the temptation to drink occurs
Slide 96
96 Once sobriety is achieved, he is expected to help others The
only requirement for membership is the desire to stop drinking
Their primary purpose is to help each other stay sober and help
other alcoholics to achieve sobriety. Al-Anon Support group for
wives of alcoholics, started by Mrs. Anne, wife of Dr. Bob Al-Ateen
Provides support to teen children of alcoholics
Slide 97
Nursing management 97 Assessment through CAGE questionnaire C-
Have you ever felt you ought to CUT DOWN on your drinking? A- Have
people ANNOYED you by criticizing your drinking? G- Have you ever
felt GUILTY about your drinking? E Have you ever had a drink first
thing in the morning as an EYE OPENER to steady your nerves or get
rid of a hangover?
Slide 98
Nursing diagnosis 98 Risk for injury related to hallucinosis,
acute intoxication evidenced by confusion, disorientation,
inability to identify potentially harmful situations Altered health
maintenance related to inability to identify, manage or seek out
help to maintain health, evidenced by various physical symptoms,
exhaustion, sleep disturbance etc. Ineffective denial related to
weak, underdeveloped ego, evidenced by lack of insight,
rationalization of problems, blaming others, failure to accept
responsibility of his behavior
