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Lecture 2 Subatance Abuse

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  • 1. SUBSTANCE USE/ABUSE PRESENTED BY Jim Santana PA-C
  • 2. ALCOHOL ABUSE
    • Classification:
      • Alcohol Abuse (DSM-IV)
      • Alcohol Dependence (alcoholism)
      • Alcohol Intoxication
      • Alcohol Withdrawal
      • Alcohol Withdrawal Delirium
      • Alcohol-Induced Psychotic D/O with Halluc.
      • Alcohol-Induced Persisting Amnestic D/O (Korsakoff’s disease)
      • Alcohol Induced Persisting Dementia
  • 3. DEFINITIONS
      • Alcohol Abuse: is diagnosed if there is clearly recurrent (but not continuous) impaired social & occupational functioning due to alcohol use over a 1 year period.
        • Might be binges or mixed
        • DEPRESSION
        • Blackouts
      • Alcohol Dependence : If the pt also has TOLERANCE (increased amounts needed to achieve effect), WITHDRAWAL, and/or compulsive and continuous use.
  • 4. NATURE AND/OR NURTURE
    • GENETICS:The eldest son of a male drinker 2 times more likely to become an alcoholic
    • Twin studies
    • Cultural/Ethnic differences in ability to “handle” alcohol,Women vulnerable(smaller)
    • NO stereotypical alcoholic “personality”
      • affects all genders, socioeconomic groups, ages.
    • Therefore remain EMPATHIC, non punitive, and nonjudgmental. LISTEN /structure/ treat
  • 5. RECOGNIZING THE ALCOHOLIC
    • Majority of alcoholics go unrecognized
    • Recognize the symptoms:
      • Anxiety/depression,
      • Insomnia,
      • Headaches/blackouts
      • N &V/vague G.I. Problems(liver, PUD, or pancreas)
      • Palpitations
      • Frequent injuries/accidents
  • 6. CAGE (ACRONYM)
    • C: Have you ever felt you should Cut down on your drinking?
    • A: Have people Annoyed you by criticizing your drinking?
    • G: Have you ever felt bad or Guilty about your drinking?
    • E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover ( Eye-opener )?
  • 7. ALWAYS DETERMINE THE PATIENTS RECENT DRINKING HISTORY
    • Is the patient currently intoxicated?
    • Time since last drink?
    • Ask if pt smokes/uses caffeine/OTC meds/ Rx meds abuse/other substances of abuse
    • Comorbidity?, Also ask: (“nerve medicine”)
    • Been to rehabilitation for ETOH &/or Drugs?
    • Think about labs/correlate above with PE
  • 8. LAB TEST GIVE-AWAYS
    • Chronic drinking frequently elevates serum GGT and...MCV (most important of the RBC indices-)
    • with/without B12 or Folate deficiency
    • A characteristic anemia can exist
    • Thrombocytopenia
    • Serum Protein changes, Triglycerides up
    • LFT’s elevated (dead give-away): Alk Phos, LDH, SGOT (ALT), SGPT(AST)- occ bilirubin
  • 9. ALCOHOL INTOXICATION(DSM-IV)
    • Early :Euphoria/disinhibition,alcohol breath
      • Blood alcohol: (up to 100mg/ml)
    • Then CNS depressant becomes evident grading into irritability, mood swings, and incoordination(blood alcohol:100-150)
    • Apathy, dysarthria, ataxia(150-250)
    • Alcoholic Coma: (250-400): An EMERGENCY
      • check for other drugs, consider intensive care unit
      • R/O differential diagnoses
  • 10. WATCH ALCOHOL WITHDRAWAL
      • (May need vital signs with Parameters)
    • Alcohol withdrawal- 1 day
      • tremulous, n&v,anxiety,tinnitus,blurred vision
    • Alcohol convulsions- occurs 2 days later
    • Alcohol withdrawal delirium(D.T.’s):2-8days
      • <5%,but mortality is 10-15%, (disorientation)
    • Alcohol induced psychotic d/o with hallucinations:3 days- voices,sounds,tremor but clear and oriented
  • 11. Complications of Chronic Alcoholism
    • PUD,pancreatitis,cirrhosis,hepatitis,varices
    • neuropathy,cardiomyopathy
    • Wernicke’s encephalopathy- thiamin def
    • Korsakoff’s disease-thiamin def-can follow Wernicke’s: Short term memory loss with confabulation
    • Other complications: Alcohol induced persisting dementia, SUICIDE, Drug abuse, accidents
  • 12. Tx of Alcohol Withdrawal
    • VS with Parameters(observe for withdrawal)
      • consider Librium taper initially(benzodiazepine)
    • Exclude subdural hematoma/injury
    • Do/monitor labs etc
    • Tx rest/nutrition
    • Thiamin/folate given routinely
    • watch for withdrawal seizure and consider valium 10mg slowly I.V. if in status epilepticus
    • Do urine screen for drug abuse-(check to see what other meds he/she might be on)
  • 13. TREATMENT OF ALCOHOLISM
    • Continue tx of medical/nutritional needs
    • Get him/her to consider rehab/AA ASAP
    • Cont. to address psychosocial/family needs
    • Spirit./peer counselor of pts choice if wants
    • Cont to encourage abstinence with empathy
    • Wean off drug crutches ASAP- try ReVia
    • Social work/occupational/education help
    • Antabuse being used less often(caution)
    • KEEP TRYING
  • 14. DRUG ABUSE
    • Abuse: Marked social/occupational impairment and compulsive excessive drug use over a period of a year
    • Dependence: All of the above with the addition of the development of tolerance and withdrawal
  • 15. Dangers of IV Drug Use
    • HIV/STD’s
    • Hepatitis
    • SBE
    • Tetanus
    • Pneumonia or TB
    • Cellulitis, Thrombophlebitis
  • 16. OPIOIDS
    • Opium
    • Morphine/Heroine
    • Methadone
    • Codeine
    • Percodan
    • Dilaudid
    • Talwin
    • Demerol
    • Darvon
  • 17. Opioid Intoxication
    • Rush or Dysphoria followed by drowsiness
      • physical signs: miosis, slurred speech, CNS & resp dep, n&v
      • O.D. - Respiratory depression - tx with Narcan-,if needs >4doses, consider another etiology-always consider multiple drug/ETOH use. Narcan might trigger withdrawal
  • 18. OPIOID WITHDRAWAL
    • Intense craving, decreased appetite, yawning, sweating, pupil dilatation, nausea & vomiting and occassional fever
    • Treatment:
      • similar to alcohol, but consider methadone taper
  • 19. SEDATIVES-HYPNOTICS
    • Quaalude
    • Barbiturates
      • phenobarb, secobarb, etc
    • Benzodiazepines
      • valium
      • Librium
      • Ativan
      • Halcion
  • 20. Sedative-Hypnotic-Anxiolytics Withdrawal and Treatment
    • The most dangerous of the withdrawal syndromes
      • tremulous, N & V,diaphoresis,hypotension, tachycardia- SEIZURES may occur
      • Sedative-Hypnotic-Anxiolytic induced persistent amnestic disorder: A profound short term memory loss that is usually reversible off of the offending drug
      • Treat withdrawal vigorously and carefully with tapering with same/similar drug slowly
  • 21. LSD AND MESCALINE (HALLUCINOGENS)
    • Hallucinations and delusions
      • Can talk patient down in a couple of hours
      • Treatment: Benzodiazepines/Haldol
      • Can have “Flashbacks”
      • Can abstain- and then still have psychotic symptoms that mimic a major psychotic disorder, indistinguishable from the real thing, especially if they mixed their substances.
  • 22. Marijuana(cannabis sativa)
      • Euphoria, then people develop apathy and motivational behavior. Distortion of speed not uncommon. Poor Judgement often accompanies intoxication. Short term memory loss very common.
      • tachycardia, conjunctival injection, dry mouth, increased appetite can occur
      • Toxic psychosis has been reported with high dose use.- dependence apparently rare
      • urine test - can be positive a month after heavy use.
      • Treatment: Supportive/abstinence the goal
  • 23. Inhalants and Anabolic Steroids
    • Inhalants: Dependence apparently develops, and at least anecdotal information indicates that prolonged inhaling, of especially spray can paint, seems to deteriorate global cognitive functioning to a lasting (apparently irreversible) degree
    • Anabolic Steroids: Can produce euphoria, irritability, and aggressiveness on use, and depression on withdrawal
  • 24. STIMULANTS
    • Amphetamines(speed, ecstasy, for example)
    • Phen-phen, - Diet Pills, and OTC diet pills
    • Caffeine
    • Ephedrine-like OTC “cold” pills
    • COCAINE
  • 25. COCAINE
    • Can produce serious med complications, especially with crack(alkaloid free base form, widely available, inexpensive, and extremely addicting.)
    • For example, MI, as in the case of Len Bias, perhaps, or anoxia secondary to seizures can be fatal.
    • Mixing with heroin and O.D.ing is not uncommon, and very dangerous.
    • Crack when smoked, produces a high within seconds,followed in minutes by a depressive crash- leading to a craving for the euphoria and a desire to rid the depression-VERY ADDICTING