Substance related disorders


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Substance related disorders

  1. 1. MR. JAYESH
  2. 2. Introduction…• Psychoactive substances have been used by people inalmost all cultures since prehistoric times.• Psychoactive substances affect brain.• Substances-related disorders are composed of twogroups1. Substance – use disorders (dependence & abuse)2. Substance – induce disorders (intoxication, withdrawal,delirium, dementia, amnesia, psychosis, mooddisorder, anxiety disorder, sexual dysfunction & sleepdisorders)
  3. 3. Epidemiological Statistics…• A high prevalence of substance-relateddisorder occur between the ages of 18 & 24.• Substance-related disorder are diagnosedmore commonly in men than in women, butthe gender ratio vary with the class of
  4. 4. Defining the Terms…AbuseTo use wrongfully or in a harmful way. Impropertreatment or conduct that may result in injuryDependenceA compulsive or chronic requirement. The need isso strongly as to generate distress (eitherphysical or psychological) if left
  5. 5. Count…IntoxicationA physical & mental state of exhilaration &emotional frenzy or lethargy & stuporWithdrawalThe physiological & mental readjustment thataccompanies the discontinuation of anaddictive
  6. 6.
  7. 7. Substance AbuseDefinition:The DSM-IV-TR (APA, 2000) identifies substanceabuse as a maladaptive pattern of substance usemanifested by recurrent and significantadverse consequences related to repeated useof the substance. Substance abuse has alsobeen referred to as any use of substances thatposes significant hazards to
  8. 8. DSM-IV-TR Criteria for Substance Abuse• Recurrent substance use resulting in a failure tofulfill major role obligations at work, school, orhome (e.g., repeated absences or poor workperformance related to substance use; substance-related absences, suspensions, or expulsionsfrom school; neglect of children or household).• Recurrent substance use in situations in which itis physically hazardous (e.g., driving anautomobile or operating a machine whenimpaired by substance use)
  9. 9. Count…• Recurrent substance-related legal problems(e.g., arrests for substance-related disorderlyconduct).• Continued substance use despite havingpersistent or recurrent social or interpersonalproblems caused or exacerbated by the effectsof the substance (e.g., arguments with spouseabout consequences of intoxication, physicalfights)
  10. 10. Substance DependencePhysical Dependence:• Physical dependence on a substance is evidenced by acluster of cognitive, behavioral, and physiologicalsymptoms indicating that the individual continues use ofthe substance despite significant substance-relatedproblems (APA, 2000).• The development of physical dependence is promotedby the phenomenon of tolerance. Tolerance is defined asthe need for increasingly larger or more frequent dosesof a substance in order to obtain the desired effectsoriginally produced by a lower
  11. 11. Count…Psychological Dependence:• An individual is considered to be psychologicallydependent on a substance when there is anoverwhelming desire to repeat the use of aparticular drug to produce pleasure or avoiddiscomfort. It can be extremely powerful,producing intense craving for a substance aswell as its compulsive
  12. 12. DSM-IV-TR Criteria for Substance DependenceAt least three of the following characteristics mustbe present for a diagnosis of substancedependence:1. Evidence of tolerance, as defined by either of thefollowing:a. A need for markedly increased amounts of thesubstance to achieve intoxication or desiredeffects.b. Markedly diminished effect with continued useof the same amount of the
  13. 13. Count…2. Evidence of withdrawal symptoms, asmanifested by either of the following:a. The characteristic withdrawal syndrome for thesubstance.b. The same (or a closely related) substance istaken to relieve or avoid withdrawal symptoms.3. The substance is often taken in larger amountsor over a longer period than was intended.4. There is a persistent desire or unsuccessfulefforts to cut down or control substance
  14. 14. Count…5. A great deal of time is spent in activities necessary toobtain the substance (e.g., visiting multiple doctors ordriving long distances), use the substance (e.g., chainsmoking), or recover from its effects.6. Important social, occupation, or recreational activitiesare given up or reduced because of substance use.7. The substance use is continued despite knowledge ofhaving a persistent or recurrent physical or psychologicalproblem that is likely to have been caused orexacerbated by the substance (e.g., current cocaine usedespite recognition of cocaine-induced depression, orcontinued drinking despite recognition that an ulcer wasmade worse by alcohol consumption)
  15. 15.
  16. 16. Definition:Substance intoxication is defined as thedevelopment of a reversible substance-specificsyndrome caused by the recent ingestion of (orexposure to) a substance (APA, 2000). Thebehavior changes can be attributed to thephysiological effects of the substance on the CNSand develop during or shortly after use of thesubstance. This category does not apply tonicotine.Substance
  17. 17. DSM-IV-TR Criteria for Substance Intoxication1.The development of a reversible substance-specificsyndrome caused by recent ingestion of (or exposure to)a substance.2. Clinically significant maladaptive behavior orpsychological changes that are due to the effect of thesubstance on the CNS (e.g., belligerence, mood liability,cognitive impairment, impaired judgment, impairedsocial or occupational functioning) and develop duringor shortly after use of the substance.3. The symptoms are not due to a general medicalcondition and are not better accounted for by anothermental
  18. 18. Definition:Substance withdrawal is the development of asubstance-specific maladaptive behavioralchange, with physiological and cognitiveconcomitants, that is due to the cessation of, orreduction in, heavy and prolonged substanceuse (APA, 2000). Withdrawal is usually, but notalways, associated with substance dependence.Substance
  19. 19. DSM-IV-TR Criteria for Substance Withdrawal1. The development of a substance-specificsyndrome caused by the cessation of (orreduction in) heavy and prolonged substance use.2. The substance-specific syndrome causes clinicallysignificant distress or impairment in social,occupational, or other important areas offunctioning.3. The symptoms are not caused by a generalmedical condition and are not better accountedfor by another mental
  20. 20. Predisposing Factors of Substance-related Disorders:-A number of factors have been implicated in thepredisposition to abuse of substances. At present,no single theory can adequately explain theetiology of this problem.• Biological factors• Psychological factors• Sociocultural
  21. 21. Biological FactorsGenetics:• Hereditary factor is involved in the development ofsubstance-use disorders.• This is especially evident with alcoholism, and less sowith other substances.• Children of alcoholics are three times more likely thanother children to become alcoholics• Monozygotic twins have a higher rate for concordance ofalcoholism than dizygotic twins• biological offspring of alcoholic parents have asignificantly greater incidence of alcoholism thanoffspring of nonalcoholic
  22. 22. Biochemical Factors:• Alcohol may produce morphine-like substancesin the brain that are responsible for alcoholaddiction.• Substances are formed by the reaction ofbiologically active amines (e.g., dopamine,serotonin) with products of alcohol metabolism,such as acetaldehyde• Examples of these morphinelike substancesinclude tetrahydropapaveroline and
  23. 23. Psychological FactorsDevelopmental Influences:• The psychodynamic approach - punitive superego andfixation at the oral stage of psychosexual development• Individuals with punitive superegos turn to alcohol todiminish unconscious anxiety.• Sadock and Sadock (2003) state, “Anxiety in peoplefixated at the oral stage may be reduced by takingsubstances, such as alcohol, by mouth.”• Alcohol may also serve to increase feelings of powerand self-worth in these
  24. 24. Count…Personality Factors:• Low self-esteem, frequent depression, passivity,the inability to relax or to defer gratification, andthe inability to communicate effectively arecommon in individuals who abuse substances.• Substance abuse has also been associated withantisocial personality and depressive
  25. 25. Sociocultural FactorsSocial Learning:• The effects of modeling, imitation, and identification onbehavior can be observed from early childhood onward.• Children and adolescents are more likely to usesubstances if they have parents who provide a model forsubstance use.• Peers often exert a great deal of influence in the life of thechild or adolescent who is being encouraged to usesubstances for the first time.• Plenty of leisure time with coworkers and where drinkingis valued and is used to express group
  26. 26. Count…Conditioning:• Important learning factor is the effect of the substanceitself.• Many substances create a pleasurable experience thatencourages the user to repeat it.• It is the intrinsically reinforcing properties of addictivedrugs that “condition” the individual to seek out theiruse again and again.• The environment in which the substance is taken alsocontributes to the reinforcement. If the environment ispleasurable, substance use is usually
  27. 27. Count…Cultural and Ethnic Influences:• Factors within an individual’s culture help to establishpatterns of substance use by molding attitudes,influencing patterns of consumption based on culturalacceptance, and determining the availability of thesubstance.• 45 percent of the Indian veterans were alcoholdependent, or twice the rate for non-Indian veterans. A• The incidence of alcohol dependence is higher amongnorthern Europeans than southern Europeans.• The incidence of alcohol dependence among Asians isrelatively
  28. 28. CLASSES OF PSYCHOACTIVESUBSTANCES1. Alcohol2. Amphetamines &related substances3. Caffeine4. Cannabis5. Cocaine6. Hallucinogens7. Inhalants8. Nicotine9. Opioids10.Phencyclidine (PCP) &related substances11.Sedative, hypnoties
  29. 29.
  30. 30. ALCOHOL ABUSE AND DEPENDENCEA Profile of the Substance:• Alcohol is a natural substance formed by the reaction offermenting sugar with yeast spores.• The kind in alcoholic beverages is known scientifically asethyl alcohol & chemically as C2H5OH. Its abbreviation,ETOH.• Alcohol is classified as a food because it contains calories;however, it has no nutritional value.• Different alcoholic beverages are produced by usingdifferent sources of sugar for the fermentation process. Forexample, beer is made from malted barley, wine fromgrapes or berries, whiskey from malted grains, and rumfrom molasses.
  31. 31. Count…• Distilled beverages (e.g., whiskey, scotch, gin, vodka, andother “hard” liquors) derive their name from furtherconcentration of the alcohol through a process calleddistillation.• The alcohol content varies by type of beverage. Forexample, most American beers contain 3 to 6 percentalcohol, wines average 10 to 20 percent, and distilledbeverages range from 40 to 50 percent alcohol.• Alcohol exerts a depressant effect on the CNS, resultingin behavioral and mood changes. The effects of alcoholon the CNS are proportional to the alcoholicconcentration in the
  32. 32. Count…• Most states consider that an individual is legallyintoxicated with a blood alcohol level of 0.08 to 0.10percent.• The body burns alcohol at about 0.5 ounce per hour, sobehavioral changes would not be expected in anindividual who slowly consumes only one averaged-sizeddrink per hour.• Other factors do influence these effects, such asindividual size and whether or not the stomach containsfood at the time the alcohol is consumed. Alcohol isthought to have a more profound effect when anindividual is emotionally stressed or fatigued [NIAAA],2000)
  33. 33. Why do people drink?• Drinking patterns in the United States show thatpeople use alcoholic beverages to enhance theflavor of food with meals; at social gatherings toencourage relaxation and conviviality among theguests; and to promote a feeling of celebrationat special occasions such as weddings, birthdays,and anniversaries.• An alcoholic beverage (wine) is also used as partof the sacred ritual in some
  34. 34. Jellinek (1952) outlined four phases through whichthe alcoholic’s pattern of drinking progresses.(Psychopathology)1. Phase I. The Pre alcoholic phase2. Phase II. The early alcoholic phase3. Phase III. The crucial phase4. Phase IV. The chronic
  35. 35. Phase I. The Pre alcoholic phase• This phase is characterized by the use of alcohol torelieve the everyday stress and tensions of life.• As a child, the individual may have observedparents or other adults drinking alcohol andenjoying the effects.• The child learns that use of alcohol is anacceptable method of coping with stress.• Tolerance develops, and the amount required toachieve the desired effect increases
  36. 36. Phase II. The Early Alcoholic Phase• This phase begins with blackouts—brief periods of amnesiathat occur during or immediately following a period ofdrinking.• Now the alcohol is no longer a source of pleasure or relieffor the individual but rather a drug that is required by theindividual.• Common behaviors include sneaking drinks or secretdrinking, preoccupation with drinking and maintaining thesupply of alcohol, rapid gulping of drinks, and furtherblackouts.• The individual feels enormous guilt and becomes verydefensive about his or her drinking. Excessive use of denialand rationalization is
  37. 37. Phase III. The Crucial Phase• In this phase, the individual has lost control, andphysiological dependence is clearly evident.• This loss of control has been described as theinability to choose whether or not to drink.• Binge drinking, lasting from a few hours toseveral weeks, is common.• These episodes are characterized by sickness,loss of consciousness, squalor, and
  38. 38. Count…• In this phase, the individual is extremely ill.Anger and aggression are commonmanifestations.• Drinking is the total focus, and he or she is willingto risk losing everything that was onceimportant, in an effort to maintain the addiction.• By this phase of the illness, it is not uncommonfor the individual to have experienced the loss ofjob, marriage, family, friends, and mostespecially,
  39. 39. Phase IV. The Chronic Phase• This phase is characterized by emotional and physicaldisintegration.• The individual is usually intoxicated more than he or she issober. Emotional disintegration is evidenced by profoundhelplessness and self-pity.• Impairment in reality testing may result in psychosis. Lifethreatening physical manifestations may be evident invirtually every system of the body.• Abstention from alcohol results in a terrifying syndrome ofsymptoms that include hallucinations, tremors,convulsions, severe agitation, and panic. Depression andideas of suicide are not
  40. 40. EFFECTS OF ALCOHOL ON THE BODY• Alcohol can induce a general, nonselective,reversible depression of the CNS.• About 20 percent of a single dose of alcohol isabsorbed directly and immediately into thebloodstream through the stomach wall.• The blood carries it directly to the brain wherethe alcohol acts on the brain’s central controlareas, slowing down or depressing brain activity.•
  41. 41. Count…• The other 80 percent of the alcohol in one drink isprocessed only slightly slower through the upperintestinal tract and into the bloodstream.• Only moments after alcohol is consumed, it canbe found in all tissues, organs, and secretions ofthe body.• At low doses, alcohol produces relaxation, loss ofinhibitions, lack of concentration, drowsiness,slurred speech, and sleep. Chronic abuse resultsin multisystem physiological
  42. 42. Peripheral Neuropathy• It characterized by peripheral nerve damage,results in pain, burning, tingling, or pricklysensations of the extremities.• It is the direct result of deficiencies in the Bvitamins, particularly thiamine.• Nutritional deficiencies are common in chronicalcoholics because of insufficient intake ofnutrients as well as the toxic effect of alcohol thatresults in malabsorption of nutrients.• Permanent muscle wasting and paralysis can
  43. 43. Alcoholic Myopathy• Alcoholic myopathy may occur as an acute or chroniccondition.• In the acute condition, the individual experiences asudden onset of muscle pain, swelling, andweakness; a reddish tinge in the urine caused bymyoglobin, a breakdown product of muscle excreted inthe urine; and a rapid rise in muscle enzymes in theblood (Barclay, 2005).• Muscle symptoms are usually generalized, but pain andswelling may selectively involve the calves or othermuscle
  44. 44. Count…• Laboratory studies show elevations of the enzymes creatinephosphokinase (CPK), lactate dehydrogenase (LDH),aldolase, and aspartate aminotransferase (AST).• The symptoms of chronic alcoholic myopathy include agradual wasting and weakness in skeletal muscles.• Neither the pain and tenderness nor the elevated muscleenzymes seen in acute myopathy are evident in the chroniccondition.• Alcoholic myopathy is thought to be a result of the same Bvitamin deficiency that contributes to peripheralneuropathy.• Improvement is observed with abstinence from alcohol andthe return to a nutritious diet with vitamin
  45. 45. Wernicke’s Encephalopathy• Wernicke’s encephalopathy represents themost serious form of thiamine deficiency inalcoholics.• Symptoms include paralysis of the ocularmuscles, diplopia, ataxia, somnolence, andstupor.• If thiamine replacement therapy is notundertaken quickly, death will
  46. 46. Korsakoff ’s Psychosis• Korsakoff’s psychosis is identified by a syndromeof confusion, loss of recent memory, andconfabulation in alcoholics.• It is frequently encountered in clients recoveringfrom Wernicke’s encephalopathy.• In the United States, the two disorders are usuallyconsidered together and are called Wernicke-Korsakoff syndrome.• Treatment is with parenteral or oral
  47. 47. Alcoholic Cardiomyopathy• The effect of alcohol on the heart is an accumulation oflipids in the myocardial cells, resulting in enlargementand a weakened condition.• The clinical findings of it is generally relate to congestiveheart failure or arrhythmia.• Symptoms include decreased exercise tolerance,tachycardia, dyspnea, edema, palpitations, andnonproductive cough.• Laboratory studies may show elevation of the enzymesCPK, AST, alanine aminotransferase (ALT), and
  48. 48. Count…• Changes may be observed by electrocardiogram (ECG),and congestive heart failure may be evident on chest x-ray films• The treatment is total permanent abstinence fromalcohol.• Treatment of the congestive heart failure may includerest, oxygen, digitalization, sodium restriction, anddiuretics.• Prognosis is encouraging if treated in the early stages.The death rate is high for individuals with
  49. 49. Esophagitis• Esophagitis—inflammation and pain in theesophagus— occurs because of the toxiceffects of alcohol on the esophageal mucosa.• It also occurs because of frequent vomitingassociated with alcohol
  50. 50. Gastritis• The effects of alcohol on the stomach includeinflammation of the stomach liningcharacterized by epigastric distress, nausea,vomiting, and distention.• Alcohol breaks down the stomach’s protectivemucosal barrier, allowing hydrochloric acid toerode the stomach wall.• Damage to blood vessels may result
  51. 51. Pancreatitis• This condition may be categorized as acute orchronic.• Acute pancreatitis usually occurs 1 or 2 days aftera binge of excessive alcohol consumption.• Symptoms include constant, severe epigastricpain; nausea and vomiting; and abdominaldistention.• The chronic condition leads to pancreaticinsufficiency resulting in steatorrhea,malnutrition, weight loss, and diabetes
  52. 52. Alcoholic Hepatitis• Alcoholic hepatitis is inflammation of the liver caused bylong-term heavy alcohol use.• Clinical manifestations include an enlarged and tenderliver, nausea and vomiting, lethargy, anorexia, elevatedwhite blood cell count, fever, and jaundice.• Ascites and weight loss may be evident in more severecases. With treatment— which includes strict abstinencefrom alcohol, proper nutrition, and rest—the individualcan experience complete recovery.• Severe cases can lead to cirrhosis or
  53. 53. Cirrhosis of the Liver• Cirrhosis is the end stage of alcoholic liver disease andresults from long-term chronic alcohol abuse.• Clinical manifestations include nausea and vomiting,anorexia, weight loss, abdominal pain, jaundice, edema,anemia, and blood coagulation abnormalities.• Treatment includes abstention from alcohol, correctionof malnutrition, and supportive care to preventcomplications of the disease. Complications of cirrhosisinclude:1. Portal Hypertension 2. Ascites3. Esophageal Varies 4. Hepatic
  54. 54. Leukopenia• The production, function, and movement ofthe white blood cells are impaired in chronicalcoholics.• This condition, called leukopenia, places theindividual at high risk for contractinginfectious diseases as well as for
  55. 55. Thrombocytopenia• Platelet production and survival are impairedas a result of the toxic effects of alcohol.• This places the alcoholic at risk forhemorrhage.• Abstinence from alcohol rapidly reverses
  56. 56. Sexual Dysfunction• Alcohol interferes with the normal productionand maintenance of female and male hormones(National• For women, this can mean changes in themenstrual cycles and a decreased or loss ofability to become pregnant.• For men, the decreased hormone levels result ina diminished libido, decreased sexualperformance, and impaired
  57. 57. Alcohol Dependence:• Many alcoholics hide or deny their addiction &temporarily manage to maintain a functional life whichcan make assessment a challenge. Nonetheless, certainphysical & psychological symptoms suggest alcoholism.• For example, the patient may have minor complaintsthat are alcohol related- malaise, dyspepsia, mood swingor depression & an increased incidence of infection.• Also check for poor personal hygiene & untreatedinjuries, such as cigarette burns, fractures & bruises, thathe can’t fully explained.www.drjayeshpatidar.blogspot.comSIGNS AND SYMPTOMS
  58. 58. Count…• Assess for signs of nutritional deficiency, includingvitamin & mineral deficiency. Watch for secretivebehavior which may be an attempt to hide the disorderor the alcohol supply.• When deprived of his usual supply of alcohol, analcoholic may consume it in any form he can find-mouthwash, aftershave lotion, hair spray & even lighterfluid.• Characteristically, the alcoholic denies he has a problemor rationalizes the problem. He also tends to blameothers & to rationalize problem areas in his life. he mayproject his anger or feelings of guilt or inadequacy ontoothers to avoid confronting his
  59. 59. Count…Overt signs & symptoms:• Overt indications of excessive alcohol useinclude:- Episodes of anesthesia or amnesia duringintoxication (Blackouts).- Violent behavior when intoxicated.- The need for daily or episodic alcohol use tofunction adequately.- Inability to stop or reduce
  60. 60. Alcohol Intoxication:Intoxication usually occurs at blood alcohollevels between 100 & 200 mg/dl. Death hasbeen reported at levels ranging from 400 to 700mg/dl. Symptoms include:• Disinhibition of sexual oraggressive impulses.• Mood lability• Impaired judgment• Impaired social oroccupational functioning.• Slurred speech• incoordination• Unsteady gait• Nystagmus• Flushed
  61. 61. Alcohol Withdrawal:A heavy drinker who stops drinking or abruptlyreduces his alcohol intake is likely to go throughwithdrawal. Within 4 to 12 hours of cessation of orreduction in heavy & prolonged (several days orlonger) alcohol use. Symptoms include:• Coarse tremor of hands,tongue or eyelids• Nausea or vomiting• Malaise or weakness• Tachycardia• Sweating• Elevated BP• Anxiety• Depressed mood or irritability• Transient hallucinations orillusions• Headache &
  62. 62. Count…• Alcohol withdrawal delirium – onset ofdelirium is usually on the second or third dayfollowing cessation of or reduction inprolonged, heavy alcohol use. It manifest asdelirium accompanied by tremor, severeagitation & autonomic overactivity – dramaticincreases pulse, respiration &
  63. 63. Various laboratory tests may suggest alcoholism &help evaluate for complication for such ascirrhosis of liver.• A blood alcohol level of 0.10% wt/volume (200mg/dl) indicate alcohol intoxication. Although thistest can’t confirm alcoholism, it can reveal howrecently the patient has been drinking & thuswhen to expect withdrawal symptoms is he’s aheavy drinker.• Urine toxicology may uncover the use of otherdrugs www.drjayeshpatidar.blogspot.comDIAGNOSIS FOR ALCOHOLISM
  64. 64. Count…• Serum electrolyte analysis may identify electrolyteabnormalities associated with alcohol use.• Blood urea nitrogen level rises & serum glucose level dropsin a patient with severe liver disease.• Increased plasma ammonia level indicates severe liverdisease, as in cirrhosis.• Liver function studies may point to alcohol-related liverdamage• Hematologic workup identify anemia, thrombocytopenia &increased prothromin & partial thromboplastin times.• Echocardiography & ECG may reveal cardiac problemsrelated to alcoholism such as enlarged heart (cardiomegaly)
  65. 65. • Acute alcohol intoxication calls forsymptomatic treatment, which mayinvolve respiratory support, fluidreplacement, IV glucose to preventhypoglycemia, correction ofhypothermia or acidosis, &emergency measures for trauma,infection or GI bleeding as needed.www.drjayeshpatidar.blogspot.comTREATMENT MODALITIES
  66. 66. Alcohol Anonymous• Alcoholics Anonymous (AA) is a major self-helporganization for the treatment of alcoholism.• It was founded in 1935 by two alcoholics—a stockbroker,Bill Wilson, and a physician, Dr. Bob Smith—whodiscovered that they could remain sober through mutualsupport.• They accomplished this not as professionals, but as peerswho were able to share their common experiences.• The self-help groups are based on the concept of peersupport—acceptance and understanding from otherswho have experienced the same problems in their
  67. 67. Alcohol Anonymous• The only requirement for membership is a desire on thepart of the alcoholic person to stop drinking.• Each new member is assigned a support person fromwhom he or she may seek assistance when thetemptation to drink occurs.• The sole purpose of AA is to help members stay sober.When sobriety has been achieved, they in turn areexpected to help other alcoholic persons. The TwelveSteps that embody the philosophy of AA providespecific guidelines on how to attain and
  68. 68. The Twelve Steps of Alcoholics:-1. We admitted we were powerless over alcohol—that ourlives have become unmanageable.2. Came to believe that a Power greater than ourselves couldrestore us to sanity.3. Made a decision to turn our will and our lives over to thecare of God as we understood Him.4. Made a searching and fearless moral inventory ofourselves.5. Admitted to God, to ourselves, and to another humanbeing the exact nature of our wrongs.6. Were entirely ready to have God remove all these defectsof character.7. Humbly asked Him to remove our
  69. 69. Count…8. Made a list of all persons we had harmed and becamewilling to make amends to them all.9. Made direct amends to such people whenever possibleexcept when to do so would injure them or others.10. Continued to take personal inventory and when we werewrong promptly admitted it.11. Sought through prayer and meditation to improve ourconscious contact with God as we understood Him, prayingonly for knowledge of His will for us and the power to carrythat out.12. Having a spiritual awakening as the result of these steps,we tried to carry this message to alcoholics and to practicethese principles in all our
  70. 70. PharmacotherapyDisulfiram (Antabuse):• Disulfiram is a drug that can be administered toindividuals who abuse alcohol as a deterrent todrinking.• Ingestion of alcohol while Disulfiram is in the bodyresults in a syndrome of symptoms that canproduce a good deal of discomfort for theindividual. It can even result in death if the bloodalcohol level is
  71. 71. Count…• Disulfiram works by inhibiting the enzymealdehyde dehydrogenase, thereby blocking theoxidation of alcohol at the stage whenacetaldehyde is converted to acetate.• This results in an accumulation of acetaldehyde inthe blood, which is thought to produce thesymptoms associated with the disulfiram-alcoholreaction.• Symptoms of disulfiram-alcohol reaction canoccur within 5 to 10 minutes of ingestion
  72. 72. Count…• Mild reactions can occur at blood alcohol levels as low as5 to 10 mg/dl.• Symptoms are fully developed at approximately 50 mg/dland may include flushed skin, throbbing in the head andneck, respiratory difficulty, dizziness, nausea andvomiting, sweating, hyperventilation, tachycardia,hypotension, weakness, blurred vision, and confusion.• With a blood alcohol level of approximately 125 to 150mg/dl, severe reactions can occur, including respiratorydepression, cardiovascular collapse, arrhythmias,myocardial infarction, acute congestive heart failure,unconsciousness, convulsions, and
  73. 73. Count…• Disulfiram should not be administered until it has beenascertained that the client has abstained from alcohol forat least 12 hours.• If disulfiram is discontinued, it is important for the clientto understand that the sensitivity to alcohol may last foras long as 2 weeks.• Consuming alcohol or alcohol-containing substancesduring this 2-week period could result in the disulfiram-alcohol reaction.• The client receiving disulfiram therapy should be awareof the great number of alcohol-containing
  74. 74. Count…• These products (e.g., liquid cough and cold preparations,vanilla extract, aftershave lotions, colognes, mouthwash,nail polish removers, and isopropyl alcohol), if ingestedor even rubbed on the skin, are capable of producing thesymptoms described. The• Disulfiram therapy is not a cure for alcoholism. Itprovides a measure of control for the individual whodesires to avoid impulse drinking. Clients receivingdisulfiram therapy are encouraged to seek otherassistance with their problem, such as AA or othersupport group, to aid in the recovery
  75. 75. Other Medications for Treatment ofAlcoholism• The narcotic antagonist naltrexone (ReVia) wasapproved by the Food and Drug Administration(FDA) in 1994 for the treatment of alcoholdependence.• Naltrexone – a narcotic antagonist, may reducealcohol craving & help prevent an alcoholic fromrelapsing to heavy drinking, when its combinedwith counseling Naltrexone blocks the brains so –called pleasure centers, reducing the urge to drink.Usually naltrexone therapy lasts at least 12
  76. 76. Count…• SSRIs in the decrease of alcohol craving amongalcohol dependent individuals has yieldedmixed results• Acamprosate (Campral), which is indicated forthe maintenance of abstinence from alcohol inpatients with alcohol dependence who areabstinent at treatment
  77. 77. Managing Acute Withdrawal• The patient may require IV glucose administration &administration of fluids containing thiamin & other B-complex vits to correct nutritional deficiencies & aidglucose metabolism.Other treatment measures may include:• Furosemide, to ease over hydration• Magnesium sulfate, to reduce CNS irritability.• Chlordiazepoxide, diazepam, anticonvulsants, antiemeticor antidiarrheals as needed to ease withdrawal symptoms• Antipsychotics, to control hyperactivity & psychosis.• Phenobarbital, for
  78. 78. Treatment of Chronic Alcoholism• Alcohol dependence has no known cure & totalabstinence is the only effective treatment.Management commonly involves:• Medications that deter alcohol use (as in aversion,emetic or antagonist therapy) & treat withdrawalsymptoms.• Measures to relieve associated physical problems.• Psychotherapy, usually involving behavior modification,group therapy & family therapy.• Counseling & ongoing support groups to help thepatient overcome alcohol
  79. 79. Aversion Therapy• In aversion therapy, the patient receives a dailyoral dose of disulfiram (antabuse) to preventcompulsive drinking. Disulfiram impedes alcoholmetabolism & increased blood acetaldehydelevels. Consuming alcohol within 2 weeks ofdisulfiram uses causes an immediate unpleasantreaction that resembles a bad hangover.• Another form of aversion therapy attempts toinduce aversion by administering alcohol alongwith an emetic
  80. 80. Counseling and Psychotherapy• For long term abstinence, supportive programsthat offer detoxification, rehabilitation &aftercare – including continued involvement inAlcoholics Anonymous (AA) – provide the bestresults. Along with individual, group, or familypsychotherapy, theses programs improve thepatient’s ability to cope with stress, anxiety &frustration & help him gain insight into theproblems that may have led him to
  81. 81. Count…• For alcoholics who have lost contact withfamily & friends & have a long history ofunemployment, trouble with the law or otherproblems related to alcohol abuse,rehabilitation may involve job trainingsheltered workshops, halfway houses or othersupervised
  82. 82. NURSING MANAGEMENT• In the preintroductory phase of relationshipdevelopment, the nurse must examine his or her feelingsabout working with a client who abuses substances.• Whether alone or in a group, the nurse may gain agreater understanding about attitudes and feelingsrelated to substance abuse by responding to thefollowing types of questions. What are my drinking patterns? If I drink, why do I drink? When, where, and how much? If I don’t drink, why do I abstain?
  83. 83. Count…Am I comfortable with my drinking patterns?If I decided not to drink any more, would that bea problem for me?What did I learn from my parents aboutdrinking?Have my attitudes changed as an adult?What are my feelings about people who becomeintoxicated?Does it seem more acceptable for someindividuals than for others?
  84. 84. Count…Do I ever use terms like “sot,” “drunk,” or“boozer” to describe some individuals whooverindulge, yet overlook it in others?Do I ever overindulge myself?Has the use of alcohol (by myself or others)affected my life in any way?Do I see alcohol/drug abuse as a sign ofweakness? A moral problem? An illness?
  85. 85. Nursing Diagnosis• Ineffective denial related to weak, underdeveloped egoevidenced by “I don’t have a problem with (substance). Ican quit any time I want to.”• Ineffective coping related to inadequate coping skills andweak ego evidenced by use of substances as a copingmechanism.• Imbalanced nutrition: Less than body requirements/deficient fluid volume related to drinking or taking drugsinstead of eating, evidenced by loss of weight, paleconjunctiva and mucous membranes, poor skin turgor,electrolyte imbalance, anemias, and other signs andsymptoms of malnutrition/
  86. 86. Count…• Risk for infection related to malnutrition andaltered immune condition.• Low self-esteem related to weak ego, lack ofpositive feedback evidenced by criticism of selfand others and use of substances as a copingmechanism (self-destructive behavior).• Deficient knowledge (effects of substance abuseon the body) related to denial of problems withsubstances evidenced by abuse of
  87. 87. Count…For the client in substance withdrawal,possible nursing diagnoses include:• Risk for injury related to CNS agitation(withdrawal from CNS depressants).• Risk for suicide related to depressed mood(withdrawal from CNS stimulants)
  88. 88. Nursing Intervention• If the patient is taking disulfiram, warn him thateven a small amount of alcohol (such as the amountin cough medicines, mouthwashes & liquidvitamins) will induce an adverse reaction. Tell himthat the longer he takes the drug, the greater hisalcohol sensitivity will be. Also inform him thatparaldehyde, a sedative, is chemically similar toalcohol & may provoke a disulfiram reaction.• As appropriate, offer to arrange a visit from aconcerned religious advisor who can help providethe motivation for a commitment to
  89. 89. Count…• Tell the patient about AA, a self-help group withmore than a million members worldwide thatoffers emotional support from others with similarproblems. Stress how this organization canprovide the support he’ll need to abstain fromalcohol offer to arrange a visit from an AAmember.• Inform a female patient that she may prefer awomen’s AA group rather than a mixed groupwhere she might hesitate to explore her
  90. 90. Count…• Teach the patient’s family about Al-Anon &Alateen, two other self-help groups. By joiningthese groups, family members learn to relinquishresponsibility for the alcoholic’s drinking so thatthey can live meaningful & productive lives. Pointout that family involvement in rehabilitation alsoreduces family tensions.• Refer adult children of alcoholics to the NationalAssociation for children of Alcoholic. Theseorganization may provide support inunderstanding & coping with the
  91. 91.