Miscellaneous

1. Miscellaneous • Drugs used in deaddiction

2. Objectives • To know about the organizational setup of the centre. • To know about the physical set up of the de-addiction centre. • To know about the background of the centre. • To know about various facilities provided by the De-addiction centre. • To know about records and reports maintained. • To gain knowledge regarding the treatment measures for patients with drug addiction

3. INTRODUCTION • Disorders due to psychoactive substance use refer to conditions arising from the abuse of alcohol, psychoactive drugs and other chemicals such as volatile agents • Substance abuse has also been referred to as any use of substances that poses significant hazards to health.

4. Definition • SUBSTANCE: The term substance is used in reference to any drug, medication or toxin that shares the potential for abuse. • ADDICTION: Addiction is a psychological and physiological dependence on alcohol or other drugs of abuse that effects the central nervous system in such a way that withdrawal symptoms are experienced when the substance is discontinued.

5. Classification F10-F19 Mental and behaviours disorders due to psychoactive substance use Mental behaviours disorders due to use of alcohol Mental and behavioural disorders due to use of opioids Mental and behavioural disorders due to use of cannabinoids Mental and behavioural disorders due to use of sedatives or hypnotics Mental and behavioural disorders due to use of cocaine Mental and behavioural disorders due to use of hallucinogen

6. Commonly used psychotropic substance • Alcohol • Opioids • Cannabis • Cocaine • Amphetamines and other sympathomimetics • Hallucinogens for example, phencyclidine • Sedatives and hypnotics, for example, barbiturates • Inhalants, for example, volatile solvents • Nicotine

7. Etiological factors in psychoactive substance use • 1. Biological factors: • • Genetic vulnerability • • Biochemical factors • • Neurobiological theories • • Withdrawal • • Comorbid medical disorder • 2. Behavioural theories • • Behavioural scientists view drug abuse as the result of conditioning, or cumulative reinforcement from drug abuse. • • Drug use causes euphoric experience perceived as rewarding, thereby motivating user to keep taking the drug (which then serves as a biological reward). • Stimuli and settings associated with drug use may themselves become reinforcing or may trigger drug carving that can lead to relapse (many recovering addicts change their environment cues that that could promote drug use).

8. Etiological factors in psychoactive substance use 3. Psychological factors: • General rebelliousness • Sense of inferiority • Poor impulse control all • Low self esteem • Inability to cope with the pressure of living and society (poor stress management skills) • Loneliness, unmet needs • Desire to escape from reality • Desire to experiment, a sense of adventure • Pleasure seeking

9. Etiological factors in psychoactive substance use 4. Social factors: • Religious reasons • Peer pressure • Urbanization • Extended periods of education • Unemployment • Overcrowding • Poor social support • Effects of television and other mass media • Occupation: Substance use is more common in chefs, barmen, executives, salesmen, actors, entertainers, army personnel, journalists, medical personnel etc.

10. Etiological factors in psychoactive substance use • 5. Easy availability of drugs • Taking drugs prescribed by doctors (for example, benzodiazepine dependence) • Taking drugs that can be bought legally without prescription (for example, nicotine, opioids) • Takingdrugsthatcanbeobtainedfromillicitsources (forexample,streetdrugs) • 6. Psychiatric disorders • Substance use disorders are more common in depression • Anxiety disorders (particularly social phobias) • Personality disorders (antisocial personality) • Occasionally in organic brain disease

11. Consequencesof substanceabuse • physical dependence, psychological dependence • Unhealthy lifestyles and behaviours such as poor diet • Impairs social and occupational functioning, creating personal, professional,financial,and legal problems

12. Consequencesof substanceabuse • In early adolescence may lead to emotional and • behavioural problems • In pregnant women, substance abuse jeopardizes foetal well-being • Psychoactive substances produce negative outcomes • including maladaptive behaviour, 'bad trips', and even long • term psychosis • Illicit street drugs pose added dangers; materials used to dilute them can cause toxic or allergic reactions

13. Dynamics of substance related disorders • Alcohol dependence syndrome: It refers to the use of alcoholic beverages to the point of causing damage to the individual, society or both. Signs and symptoms of alcohol dependence: • Minor complaints: Malaise, dyspepsia, mood swings or depression, increased incidence of infection. • Poor personal hygiene, untreated injuries (cigarette burns, fractures that cannot be explained)

14. Dynamics of substance related disorders • Unusually high tolerance for sedatives and opioids • Nutritional deficiency • Consumption of alcohol containing products (mouthwash, aftershave lotion, lighter fluid etc.) • Denial of problem • Tendency to blame others and rationalize problem

15. De-Addiction • Drug rehabilitation is a term for the processes of medical or psychotherapeutic treatment, for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cocaine. • The general intent is to enable the patient to cease substance abuse, in order to avoid the psychological, legal, financial, social, and physical consequences that can be caused, especially by extreme abuse.

16. Prevention of substance use disorder • 1.Primary prevention: • • Reduction of over prescribing by doctors • • Identification and treatment of family members who may be contributing to the drug abuse. • • Introduction of social changes is likely to affect drinking patterns in the population as a whole. This is made possible by: • Putting up the price of alcohol and alcoholic beverages. • Controlling or abolishing the advertising of alcoholic drinks. • Controls on sales Sales • restricting availability • Control • • Strengthen the individual's personal and social skills to increase self-esteem and resistance to peer pressure. • • Health education to college students and the youth

17. Prevention of substance use disorder 3. Secondary prevention: • Early detection and counseling • Brief intervention in primary care • Motivational interviewing • A full assessment including an appraisal of current medical, psychological and social problems. • Detoxification with benzodiazepines (diazepam). 3. Tertiary prevention: • Alcohol deterrent therapy (Disulfiram) • Other therapies include assertiveness training, teaching copying skills, behaviour counseling, supportive psychotherapy • Agencies concerned with alcohol- related problems

18. Prevention of substance use disorder Some practical issues under relapse prevention include: • Motivation enhancement • Identifying high-risks situations and developing strategies to deal with them • Drink refusal skills (assertiveness training) • Dealing with faulty cognitions • Handling negative mood states • Time statement • Anger control' • Financial management • Developing the work habit • Stress management • Recreation and spirituality • Family counseling, to reduce interpersonal conflicts, which may otherwise trigger relapse.

19. TREATMENT • Treatment includes medication for depression or other disorders, counseling by experts and sharing of experience with other addicts. • Some rehab centres include meditation and spiritual wisdom in the treatment process. TYPES OF TREATMENT • Various types of programs offer help in drug rehabilitation • Some rehab centers offer age- and gender-specific programs. • The National Institute on Drug Abuse (NIDA) recommends detoxification followed by both medication and behavioural therapy, followed by relapse prevention.

20. Drugs used in CPR & emergency

21. Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped.

22. Cardio Pulmonary Resuscitation is a technique of basic life support for oxygenating the brain and heart until appropriate, definitive medicaltreatment can restore normal heart and ventilator action.

23. To maintain an open and clear airway (A). • To maintain breathing by external ventilation (B). • To maintain Blood circulation by external cardiac massages (C). • To save life of the Patient. • To provide basic life support till medical and advanced life support arrives.

24. CardiacArrest • Ventricularfibrillation(VF) • Ventriculartachycardia(VT) • Asystole • Pulselesselectricalactivity

25. RespiratoryArresst • Thismaybe resultoffollowing: • Drowning • Stroke • Foreignbodyinthroat • Smokeinhalation • Drugoverdose • Suffocation • Accident,injury • ·Coma • Epiglottisparalysis.

26. To restore effective circulation and ventilation. • To prevent irreversible cerebral damage due to anoxia. When the heart fails to maintain the cerebral circulation for approximately four minutes the brain may suffer irreversible damage.

27. CPRprocedure Sequences Of Procedures Performed To Restore The Circulation Of Oxygenated Blood After A Sudden Pulmonary And/or Cardiac Arrest Chest Compressions And Pulmonary Y Ventilation Performed By Anyone Ho Knows How To Do It, Anywhere, Immediately, Without Any Other Equipment

28. CHEST COMPRESSIONS • Place the heel of one hand in the centre of the chest • Place other hand on top • Interlock fingers • Compress the chest • Rate 100 min·1 • Depth 4-5 cm (1.5 to 2 inch) • Equal compression : relaxation • When possible change CPR operator every 2 min

29. Pinch the nose • Take a normal breath • Place lips over mouth • Blow until the chest rises • Take about 1second • Allow chest to fall • - Repeat

30. RECOMMENDATIONS: • Tidalvolume • 500 - 600 ml • Respiratory rate • give each breaths over about 1s w it Enough volume to make the victim's chest rise • Chest-compression-only • continuously at a rate of 100 min

31. Coronaryvesselinjury • Diaphragminjury • Hemopericardium • Hemothorax • Interferencewithventilation

32. Coronaryvesselinjury • Diaphragminjury • Hemopericardium • Hemothorax • Interferencewithventilation • Liverinjury • Myocardialinjury • Pneumothorax • Ribfractures • Spleeninjury • Sternalfracture

33. MEDICALMANAGEMENT • Adrenaline • Adrenaline (epinephrine) is the main drug used during resuscitation from cardiac arrest. • Atropine • Atropine as a single dose of 3mg is sufficient to block vagaltone completely and should be used once in cases of a systole. It is also indicated for symptomatic bradycardia in a dose of 0.5mg - 1mg. • Amiodarone • It is an antiarrhythmic drug.

34. NURSINGMANAGEMENT • Maintains airway patency with use of airway adjuncts as required (suction, high f low oxygen with 02 or bag valve mask • ventilation). • Assist with intubation and securing of ETT • Inserts gastric tube and/or facilitates gastric decompression post intubation as required. • Assists with ongoing management of airway patency and adequate ventilation

35. Supports less experienced staff by coaching/guidance e.g. drug preparation • If a shock able rhythm is present (VF/VT) ensure manual defibrillator pads are applied and connected. • If CPR is in progress, prepare and • independently double check and label 3 doses of adrenaline • Prepare and administer IV fluids • Document medications administered (including time)

36. IMMUNOSUPPRESSANTS lmmunosuppression Immunosuppressantinvolves an act that reduces the activation or efficacy of the immune system. Some port ions of the immune system itself have immune-suppressive effects on other parts of the immune system , and immunosuppressant may occur as an adverse reaction to treatment of other conditions.

37. lmmunosuppressant An immunosuppressant is any agent that causes immunosuppressant, including immunosuppressive drugs and some environmental toxins. One of the primary uses of immunosuppressant drugs is to lower the body's ability to reject a transplanted organ, such as a liver, heart or kidney.

38. Classification Thesedrugs can be classified into 4 categories. Selective inhibitors of cytokine production and function Immunosuppressive antimetabolites Antibodies Adrenocorticois

39. Selective inhibitor of cytokine productionandfunction • Cyclosporine • Everolimus • Sirolimus • •Tacrolimus

40. Cytokines are soluble, Antigen Non specific, signaling proteins that bind to cell surface receptors on a variety of cells. The term cytokines includes the molecules known as interleukins (ILs), interferons (IFNs), tumor necrosis factors (TNFs), transforming growth factors and colony stimulating factors.

41. Cyclosporine Mechanism of action: Cyclosporine preferentially suppresses cell mediated immune reactions, whereas Hum oralimmunity is affected to a far lesser extent. Cyclosporine blocks the transcription of cytokine genes in activated T cells. After diffusing into the T cells, cyclosporine binds to a cyclophilin to form a complex that binds to calcineurin. The latter is responsible for dephosphorylatin NFATc. Because the cyclosporine-ca lcineurin complex can t perform this reacbon, NFATc can't enter the nucleus to promote the reactions that are required for the synthesis of a number of cytokines, including I L2. The end result is a decrease in I L-2, which is the primary chemical stimulus for increasing the no. of T- lymphocytes.

42. Tacrolimus Mechanism of action It exerts its immunosuppressive effects in the same manner as cyclosporine, except that it binds to a d ifferentimmunophilin, FI<-binding protein-12

43. Sirolimus It binds to same cytoplasm FK-BP as Tacrolimus, but instead of forming a complex with calcineu rin,Sirolimus binds to mTOR.

44. Immunosuppressive antimetabolites • Azathioprine • Mycophenolatemofetil • Mycophenolatesodium • These agents are generally used in combination with corticosteroids and calcineurin inhibitors, cyclosporine and Tacrolimus.

45. Azathioprine • An immunosuppressive antimetabolite pro-drug. • It inter feres with the purine synthesis and is cytotoxic. • This drug is converted into 6-merca ptopurine and • then to the corresponding nucleotide, thioinosinic acid that inhibit DNA synthesis.

46. Mycophenolatemofetil Mechanism of action It is converted into mycophenolic acid, which retains proliferation of both Tand B lymphocytes and reduce the product ion of cytotoxic T cells by inhibiting inosine monophosphate dehydrogenase, an enzyme crucial for de novo purine biosynthesis in both T and B cells, so the drug has fairly selective action.

47. Antibodies • Alemtuzumab • Antithymocyteglobulins • Basiliximab • Daclizumab • Muromonab-CD3

48. Alemtuzumab • It exerts its effects by causing profound depletion of T cells from the peripheral circulation. • Antithymocyte globulins • Thymocytesare developed in thymus and serve as precursors. • The antibodies bind tp the surface of circulating T lymphocytes, which then undergoes complement mediated destruction, Ab. Depending cytotoxicity, apoptosis and opsonization. The Ab. Bound cells are phagocytosed in the liver and spleen, resulting in Iymphopenia and impaired T­ cell responses.

49. IL-2receptorantagonist • Basiliximab • Daclizumab • Mechanism of action • Both compounds are anti-CD-2 antibodies and bind to the ex chain of the IL-2 receptor on activa ted T-cells.They thus • interfere with the proliferation of these cells. Basiliximabis • iofold more potent than Daclizumab as a blocker of IL-2 stimulated T-cell replica tion. Blockade of this receptor foils the ability of any antigenic stimulus to activate the T-cell response system.

50. Muromonab-CD3 • Mechanism of action • Binding to CD3 protein results in a disrupt ion of T­ lymphocyte function, because access of antigen to the recognition site is blocked . Circulating T-cells are • depleted, thereby decreasing their participat ion in the immune response. Because muromonab recognizes only one antigenic site, the immunosuppression is less • broad than that seen with the polyclonal antibodies. T cells usually return to normal within 48 hours of • discontinuat ion of therapy.