Transcript Substance abuse sept 25

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
3 of the following
At least
• 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
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Vivid memory of first drink
Self medication with alcohol
Controlled drinking
Social crutch
Frequent accidents
Alcoholism continued
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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)
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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
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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
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alcohol reduces absorption
• Alcohol amnesiac disorder
– recent memory impaired
– appear apathetic
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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
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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
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Antabuse
Topamax (anticonvulsant)
Naltraxone
Revax
Campral
Alcoholics Anonymous; Women for
Sobriety; Rational Recovery
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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
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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
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Euphoria
Mental stimulation
Sexual stimulation
Energy
Sociability
Crash
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Rebound dysphoric reaction
Restlessness & irritability
Craving
Depression
Sexual disinterest, impotence
Fatigue, memory & concentration problems
Toxic consequences of Cocaine
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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
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Amotivational syndrome
Toxic psychosis
Gynecomastia
(second only to alcohol as most widely abused
drug in the US)
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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
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Opium, heroin
Meperidine, morphine
Codeine, methadone
Oxycontin, lortab, vicoden,
(oxycodone in percodan,
Hydrocodone: hycodon, vicodin, lortab)
Opiate Withdrawal
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Anorexia
Stomach cramps and diarrhea
Lacrimation, rhinorrhea
Muscle aches
Mild elevation in V.S
Profuse sweating
Insomnia, agitation, depression, anxiety
Irritability & restlessness
Physical Symptoms
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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
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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
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LSD; PCP; Inhalants (flashback w/ LSD)
Reassurance
“Talk down”
Safe environment, minimal stimulation
Do not touch
Behaviors of Abuse & Dependence
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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
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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
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Methylenedioxymethamphetamine (MDMA)
Affects serotonin
Euephoria, increased energy & sexual arousal
Suppresses need to eat, drink or sleep
Fever, muscle breakdown, kidney & heart
failure, death
Ecstacy
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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
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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
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W/drawl seizures can occur a week or more after cessation of use
AKA date rape drug
GHB
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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