Substance-related Disorders

1. Substance-related Disorders Chapter 16

2. Substance-Use Disorders Substance Abuse DSM-IV-TR Criteria • Recurrent substance-related legal problems • Continued substance use despite having persistent or recurrent social or interpersonal problems

3. Substance Dependence • Physical dependence Substance Dependence (cont.) • Psychological dependence Extremely powerful, producing intense craving for a substance as well as compulsive use of it Substance Dependence DSM-IV-TR Criteria • Evidence of tolerance • Evidence of withdrawal • Symptoms associated with the substance • Substance taken to relieve withdrawal symptoms

4. -Substance often taken in larger amounts or over a longer period • Persistent desire or unsuccessful efforts to cut down or control use • A great deal of time is spent • Obtaining the substance • Using the substance • Recovering from the effects • Social, occupational, recreational activities given up or decreased

5. Substance use continued despite knowledge of having a persistent or recurrent physical or psychological problem

6. Substance Intoxication DSM-IV-TR Criteria • Development of reversible substance syndrome caused by recurrent ingestion of substance • Clinically significant maladaptive behavior or psychological changes • Resulting from the effect of the substance on the CNS • Developed during or shortly after use of substance Symptoms not due to a general medical condition and not better accounted for by another mental disorder

7. Substance Withdrawal DSM-IV-TR Criteria • Development of a substance-specific syndrome caused by cessation of or reduction in heavy and prolonged substance use • Clinically significant distress or impairment in • Symptoms not due to a general medical condition and not better accounted for by another mental disorder.

8. Classes of Psychoactive Substances • Alcohol • Amphetamines and related substances • Caffeine • Cannabis • Cocaine • Hallucinogens • Inhalants • Nicotine • Opioids • Phencyclidine and related substances • Sedatives, hypnotics, or anxiolytics

9. Predisposing Factors Biological Factors • Genetics: apparent hereditary factor, particularly with alcoholism Biochemical: alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction Psychological Factors • Developmental influences: • Punitive superego • Fixation in the oral stage of psychosexual development • Personality factors:certain personality traits suggested to play a part in both development and maintenance of alcohol dependence, including • Low self-esteem • Frequent depression • Passivity • Inability to relax or defer gratification • Inability to communicate effectively

10. Sociocultural Factors • Social learning: children and adolescents more likely to use substances with parents who provide model for substance use • Use of substances may also be promoted within peer group • Conditioning: pleasurable effects from substance use act as a positive reinforcement for continued use of substance • Cultural and ethnic influences: some cultures are more prone to the abuse of substances than others

11. Alcohol: Patterns of Use or Abuse Alcohol Abuse and Dependence Patterns of Use or Abuse • Phase I: Prealcoholic phase: characterized by use of alcohol to relieve everyday stress and tensions of life • Phase II: Early alcoholic phase:begins with blackouts: brief periods of amnesia that occur during or immediately following a period of drinking; alcohol is now required by the person. • Phase III: The crucial phase:person has lost control; physiological dependence clearly evident • Phase IV: The chronic phase: characterized by emotional and physical disintegration; person is usually intoxicated more often than sober

12. Alcohol: Effects on the Body • Peripheral neuropathy characterized by: • Peripheral nerve damage • Alcohol myopathy • Acute: • Chronic: • Wernicke’s encephalopathy • Korsakoff’s psychosis • Alcoholic cardiomyopathy Effect of alcohol on the heart is in an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition.

13. Esophagitis • Gastritis • Pancreatitis • Acute: • Chronic:

14. Alcoholic hepatitis • Caused by long-term heavy alcohol use • Symptoms: • Cirrhosis of the liver • Portal hypertension: • Ascites: • Esophageal varices:. • Hepatic encephalopathy: • Leukopenia • Thrombocytopenia

15. Sexual dysfunction • Alcohol intoxication Occurs at blood alcohol levels between 100 and 200 mg/dL • Alcohol withdrawal Occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use.

16. Sedative, Hypnotic, or Anxiolytic Abuse and Dependence • A profile of the substance • Barbiturates • Nonbarbiturate hypnotics • Antianxiety agents • Pattern of use/abuse • Effects on the body • Intoxication • Withdrawal

17. CNS Stimulant Abuse and Dependence • A profile of the substance • Amphetamines • Nonamphetamine stimulants • Cocaine • Caffeine • Nicotine • Patterns of use and abuse • Effects on the body • CNS effects • Cardiovascular effects • Pulmonary effects • GI and renal effects • Sexual functioning

18. Intoxication • Amphetamine and cocaine intoxication produces euphoria or affective blunting, hypervigilance, anxiety, tension, anger, and impaired judgment. • Physical effects include tachycardia or bradycardia, pupillary dilation, elevated or lowered blood pressure, perspiration or chills, nausea or vomiting, weight loss, psychomotor agitation or retardation, muscular weakness, respiratorydepression, chest pain,confusion, seizures, coma. • Intoxication from caffeine usually occurs following consumption in excess of 250 mg • Symptoms include restlessness, nervousness, excitement, insomnia, flushed face, diuresis, GI disturbance, muscle twitching, rambling flow of thoughts and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, and psychomotor agitation.

19. Withdrawal • From amphetamines and cocaine may include dysphoria, fatigue, sleep disturbances, increased appetite, and psychomotor retardation or agitation. • From caffeine may include headache, fatigue, anxiety, irritability, depression, impaired psychomotor performance, nausea, vomiting, craving for caffeine, and muscle pain and stiffness • From nicotine may include dysphoria, anxiety, difficulty concentrating, restlessness, insomnia, irritability, frustration, decreased heart rate, and increased appetite

20. Inhalant Abuse and Dependence • A profile of the substance • Aliphatic and aromatic hydrocarbons found in substances such as fuels, solvents, adhesives, aerosol propellants, and paint thinners • A profile of the substance • Aliphatic and aromatic hydrocarbons found in substances such as fuels, solvents, adhesives, aerosol propellants, and paint thinners • Patterns of use/abuse • Effects on the body • CNS effects • Respiratory effects • GI effects • Renal system effects

21. Inhalant Intoxication • Develops during or shortly after use of or exposure to volatile inhalants • Symptoms include • Dizziness, incoordination, unsteady gait • Nystagmus, slurred speech, tremor • Lethargy, psychomotor retardation • Blurred vision, euphoria • Stupor or coma

22. Opioid Abuse and Dependence • A profile of the substance • Opioids of natural origin • Opioid derivatives • Synthetic opiate-like drugs • Patterns of use or abuse • Effects on the body • CNS • Gastrointestinal effects • Cardiovascular effects • Sexual functioning • Intoxication • Symptoms are consistent with the half-life of most opioid drugs and usually last for several hours. • Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment. • Severe opioid intoxication can lead to respiratory depression, coma, and death.

23. Withdrawal • From short-acting drugs (e.g., heroin): • Symptoms occur within 6–12 hr and subside in 5–7 days • From long-acting drugs (e.g., methadone): • Symptoms occur within 1–3 days and subside in 10–14 days • From ultra-short-acting meperidine: • Symptoms begin quickly, peak in 8–12 hr, and subside in 4–5 days • Symptoms of Opioid Withdrawal

24. Hallucinogen Abuse and Dependence • A profile of the substance • Naturally occurring hallucinogens • Synthetic compounds • Patterns of use/abuse • Use is usually episodic • Hallucinogen intoxication • Occurs within minutes to a few hours after using drug • Symptoms include perceptual alteration, depersonalization, derealization, tachycardia, palpitations

25. Effects on the Body • Physiological • Nausea/vomiting • Chills • Pupil dilation • Increased BP, pulse • Loss of appetite • Insomnia • Elevated blood sugar • Decreased respirations • Psychological • Heightened response to color, sounds • Distorted vision • Sense of slowed time • Magnified feelings • Paranoia, panic • Euphoria, peace • Depersonalization • Derealization • Increased libido

26. Hallucinogen intoxication • Symptoms of PCP intoxication include belligerence and assaultiveness and may proceed to seizures or coma Cannabis Abuse and Dependence • A profile of the substance • Marijuana • Hashish • Patterns of use or abuse • Effects on the body • Cardiovascular effects • Respiratory effects • Reproductive effects • CNS effects • Sexual functioning • Intoxication • Symptoms include impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment. • Physical symptoms include conjunctival injection, increased appetite, dry mouth, and tachycardia. • Impairment of motor skills lasts for 8 to 12 hours.

27. Assessment • Various assessment tools are available for determining the extent of the problem a client has with substances • Michigan Alcoholism Screening Test (MAST) • CAGE Questionnaire • CAGE Questionnaire • Have you ever felt you should Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt bad or Guilty about your drinking? • Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)

28. Nursing Diagnosis Dual Diagnosis

29. Detoxification • Provide safe and supportive environment • Administer substitution therapy • Intermediate Care • Provide explanations of physical symptoms. • Promote understanding and identify causes of substance dependency. • Provide education and assistance to client and family. • Rehabilitation • Nature of the illness • Management of the illness

30. Treatment Modalities for Substance-Related Disorders • Alcoholics Anonymous • Disulfiram (Antabuse) • Other medications for treatment of alcoholism • Counseling • Group therapy • Alcohol • Benzodiazepines • Anticonvulsants • Multivitamin therapy • Thiamine • Opioids • Narcotic antagonists • Naloxone (Narcan) • Naltrexone (ReVia) • Nalmefene (Revex) • Methadone • Buprenorphine • Clonidine • Stimulants • Minor tranquilizers • Major tranquilizers • Anticonvulsants • Antidepressants • Hallucinogens and Cannabinols • Benzodiazepines • Antipsychotics