DISEASE ENTITIES & SUBSTANCE PROFILES

1. RNSG 2213 SUBSTANCE-RELATED DISORDERS DISEASE ENTITIES & SUBSTANCE PROFILES

2. CNS DEPRESSANTS

3. ALCOHOL Some Facts • 5-7% of Americans are Alcoholics • Every alcoholic touches lives of 5 people • A leading cause of death: from medical complications, accidents and suicides • Fetal Alcohol Syndrome most common cause of mental retardation in children • Potentiates other CNS depressants • Alcoholism underreported in women and older adults

4. Alcohol: Intoxication • Metabolism of alcohol is increased in heavy drinkers • Women more easily intoxicated than men. • Effects: CNS depression and Peripheral vasodilation • Decreased muscle tension, lowered anxiety level, disinhibition, impaired judgment, sedation • Toxic effects: stupor, unconsciousness (including blackouts), coma, death • Alcohol poisoning s/t large amount consumed in short period of time

5. Alcohol Withdrawal • Usually develops 4-12 hours after cessation or reduction of alcohol use • Rebound phenomenon (CNS irritability) as drug effects wear off: • increased anxiety, tension, psychomotor activity • sweats, tremors, tachycardia, increased temp. and BP • nausea, vomiting, diarrhea

6. Alcohol Withdrawal, cont’d • Withdrawal seizures may occur 7-48 hours after cessation or reduction • Alcohol withdrawal delirium (also known as Delirium Tremens or DTs) may occur 48-72 hours following cessation or reduction- agitation, terror, hallucinations (A Belgian beer is named for this effect)

7. Alcohol Withdrawal • Use of validated withdrawal assessment rating scale assists in objective description of withdrawal severity

8. Validated withdrawal assessment scale: Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

9. Alcohol: Interventions for Withdrawal • Seizure precautions; anticonvulsants for DT’s • Suicide assessment and precautions, if necessary • Medications: for withdrawal • Benzodiazepines e.g. chlordiazepoxide (Librium), oxazepam (Serax), diazepam (Valium). Administration may depend on withdrawal rating parameters.

10. Alcohol: Interventions for Recovery • Medications to promote abstinence after detox. • disulfiram (Antabuse) = Aversive Therapy; produces unpleasant or even harmful effects when alcohol is consumed or absorbed in any form (in foods, fluids, cosmetics, medications, etc.). • naltrexone (ReVia) – opiate receptor antagonist-blocks the “high” • acamprosate (Campral) – reduces cravings

11. Complications of Alcohol Dependence: Physiologic • Esophagitis and gastritis (ulcers, hemorrhage) • Sexual dysfunction • Pancreatitis • Hepatitis • Leukopenia • Thrombocytopenia • Peripheral neuritis with LE numbness, pain

12. ALCOHOLISM: COMPLICATIONS • Cirrhosis-liver becomes fibrotic, fatty • complications include portal hypertension, ascites, esophageal varices and hepatic encephalopathy)

13. Complications of Alcoholism due to Thiamine (B1) Deficiency Wernicke’s Encephalopathy: ataxia, muscle weakness, nystagmus and confusion Korsakoff’s Syndrome: memory loss, amnesia, psychosis Often appear together = Wernicke-Korsakoff Syndrome

14. Alcoholic Cardiomyopathy Result of toxicity + nutritional deficiency

15. SEDATIVES, HYPNOTICS AND ANXIOLYTICS BARBITURATES, BENZODIAZEPINES • Commonly prescribed for sleep, anxiety, muscle spasms, etc. • Also used illicitly, including • reducing effects of stimulant (esp. amphetamine) abuse • if other narcotics not available • by sexual predators

16. Sedatives, Hypnotics, or Anxiolytics Abuse and Dependence Potentiate each other and alcohol Produce physiological dependence Produce psychological dependence Cross-tolerance and cross-dependence between CNS depressants

17. Sedatives, Hypnotics and Anxiolytics: Dependence • Withdrawal sx.: anxiety, insomnia, nausea, seizures  Overdose and Fatal effects: respiratory depression, coma, death

18. Interventions for Sedative W/D • Quiet, calm environment • Monitor vital signs • Taper dose gradually; may take weeks or months • Seizure precautions

19. Inhalents • Inorganic and organic volatile substances-usually cheap and readily available • Intoxication: CNS depression- elevated mood (silly and happy) and excitability, possible sleepiness and confusion

20. INHALANTS: Abuse and Dependence • Dangerous due to inability to control amount inhaled • Use is associated with • CNS damage • Respiratory irritation, distress and depression • GI distress • Mouth ulcers • Renal and hepatic damage  Death from asphyxiation or suffocation

22. OPIOIDS • OPIUM and HEROIN • MORPHINE • CODEINE • SYNTHETIC MORPHINE DERIVATIVES, e.g: • OXYCODONE (OxyContin) • HYDROMORPHONE ((Dilaudid) • HYDROCODONE (Vicodin) • MEPERIDINE (Demerol)

23. OPIOID Abuse and Dependence Activate endorphins, reduce pain and anxiety Many routes of use: po, subcut., IM, IV, inhaled IV use is associated with infection, including HIV and Hepatitis, bacterial endocarditis, and abscesses May be prescribed or illicitly obtained Heroin--highest abuse and dependence potential CNS effects, including respiratory depression GI effects

24. Opioid Intoxication Initial euphoria Followed by apathy, dysphoria, psychomotor agitation or retardation Pupillary constriction Drowsiness (“nodding”), slurred speech Impaired judgment, memory and concentration

25. Opioid Overdose  Pinpoint pupils  Clammy skin  Respiratory depression  Coma (pupils will dilate secondary to anoxia) • Death rapidly follows coma TX of Overdose: Narcotic antagonist: naloxone (Narcan)

26. Opioid Withdrawal Very uncomfortable but rarely dangerous: • Dysphoria, anxiety, cravings • Sweating and chills, piloerection • Lacrimation, rhinorrhea • GI distress (anorexia, n/v, cramping, diarrhea) • Muscle aches, bone pain • Restlessness • Tremors • Sleep disturbances

27. Interventionsfor Opioid Withdrawal • Primarily supportive care • Treat symptomatically • Specific pharmacotherapy: • clonidine-for n/v/diarrhea • buprenorphine (Buprenex) –reduces pain and discomfort

28. Example of clinical assessment tool for opiate withdrawal (COWS)

29. Interventions for Opioid Dependence Medications which Promote Abstinence: • Maintenance Pharmacotherapy to reduce cravings and block the “high” : • naltrexone (Trexan, ReVia) • methadone –requires enrollment in maintenance program (federally controlled supervision)

30. CNS STIMULANTS

31. CNS STIMULANTS Cocaine Amphetamines: prescribed or illicit Non-amphetamine stimulants Caffeine Nicotine

32. STIMULANTS: Intoxication • Various Effects: • Increased alertness, arousal and endurance • Decreased need for food and sleep • HR and BP

33. Stimulants: Neurobiology Different for different drugs: • facilitate norepinephrine, dopamine activity • nicotinic receptor agonists • adenosine receptor antagonists

34. STIMULANTS: COCAINEIntoxication • Blocks dopamine reuptake esp. in nucleus accumbens (“pleasure center”) • IV or intranasal route; Crack (dilute) form is smoked • Rapid Effects and Rapidly metabolized: • Intense euphoria • Increased mental alertness • Increased motor and cardiac activity • Increased muscle strength

35. Stimulants: Cocaine Dependence • Psychological dependence is even more severe than physical dependence; cravings are intense

36. Stimulants: AMPHETAMINESIntoxication and Dependence • Often are prescribed, widely abused • Methamphetamine: Slower metabolic effects, often mixed with cocaine (cheaper) • Routes: IV, intranasal, po, smoked • Immediate intense pleasure, lasting high • “Crash” occurs as drug effects wear off • Intense cravings promote frequent, repetitive use • Damage to teeth, gums

37. STIMULANTS: WITHDRAWAL AND COMPLICATIONS • Toxic effects: Hallucinations and paranoid delusions • Severe hypertension, cardiac ischemia • Withdrawal: severe agitation, anxiety, depression  Death from cardiac arrhythmias, seizures, suicide, respiratory collapse, stroke

38. STIMULANTS: Treatment of Overdose • Induce vomiting, diuretics • Administer IM antipsychotic for drug-induced psychosis/agitation

39. HALLUCINOGENS

40. HALLUCINOGENS • Natural or synthetic substances • Effects vary from enhancement of sensory stimuli to loss of reality and hallucinations (Psychotic symptoms) • Effects highly unpredictable

41. HALLUCINOGENS: CANNABINOLS (MARIJUANA and Related) • Not strictly a hallucinogen • Most widely used illegal drug in US • Active Ingredient: THC (delta-9-tetrahydrocannbinol • Detectable in blood and urine for up to 4 weeks • Smoked or ingested • Hashish-resinous form • “Medical marijuana” antiemetic and for chronic pain • Legal RX: drobinol (Marinol) • Plant form legal in some states

42. CANNABIS: INTOXICATION • Euphoria, relaxation, disinhibition • Alteration in sensory and time perception • Increased appetite • Anxiety • Tachycardia and Hypotension

43. CANNABIS: DEPENDENCE • ?Physical? • Psychological- tolerance

44. CANNABIS: COMPLICATIONS AND ADVERSE EFFECTS • Impaired memory, concentration • Apathy and loss of motivation (heavy users) • Pulmonary compromise • ?Reduced female, male hormones and sperm count? • Paranoia and panic • Flashbacks

45. HALLUCINOGENS: LYSERGIC ACID DIETHYLAMIDE (LSD) • Semisynthetic-binds to serotonin receptors • LSD Intoxication: • Episodic and binge use common • Effects last up to 12 hours • Synesthesia experiences-blending of sensory perceptions

46. LSD: ADVERSE EFFECTS • Hypertension and tachycardia • Acute psychosis: delusions, paranoia • Flashbacks • Panic

47. HALLUCINOGENS:PHENCYCLIDINE (PCP) • Synthetic anesthetic • PCP Intoxication: • Euphoria and relaxation • PCP Adverse Effects: • Ataxia, vomiting • Agitation, violent outbursts, catatonia • Severe elevations in HR and BP

48. HALLUCINOGENS: LSD and PCP Overdose and Fatal effects; Complications • Psychotic break (persisting psychosis) • Perceptual distortions cause client to harm self/suicide or others • Cardiac arrest • PCP-seizures

49. HALLUCINOGENS: LSD and PCP • Psychological tolerance • Frequent users-cravings • No physiologic dependence

50. LSD and PCP • Treatment of Acute Intoxication or Overdose • Diazepam (Valium) for seizures [PCP], paranoia and panic • IM haloperidol (Haldol) for agitation and aggression