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Lecture 2 Subatance Abuse


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Published in: Health & Medicine

Lecture 2 Subatance Abuse

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