This document discusses substance abuse, focusing on alcohol overdose and cannabis intoxication. It defines substance abuse and lists the most common substances abused, including alcohol and cannabis. For alcohol overdose, it describes the lethal dose, signs and symptoms, diagnosis involving breathalyzer or blood tests, and emergency management following CAB principles. For cannabis intoxication, it discusses lethal doses, causes of dependency and overdose, signs of dependency and overdose, diagnosis using urine tests, and general emergency management involving supportive care.

1. Substance Abuse
PREPARED BY:
RN Arpana Bhusal
BNS

2. Content
 Substance Abuse
• Introduction
• Most common substance abuse
 Alcohol Overdose
• Introduction
• Lethal dose
• Cause
2

3. Contd..
• Sign and symptoms
• Diagnosis
• Emergency Management
 Cannabis Intoxication
• Introduction
• Lethal dose
• Cause
3

4. Contd..
• Sign and symptoms
• Diagnosis
• Emergency Management
 References
4

5. Introduction
● Substance abuse can be defined as using a drug in a way that is
inconsistent with medical or social norms and despite negative
consequences.
● Substance abuse denotes problem in social vocational, or legal
area of the person’s life
● Substance abuse refers to the harmful or hazardous use of
psychoactive substances , including alcohol and illicit drugs.
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6. Contd..
● Psychoactive substances use can lead to dependence syndrome– a
cluster of behavioral, cognitive and physiological phenomena that
develop after repeated substance use and that typically include a
strong desire to take the drug, difficulties in controlling its use,
persisting in its use despite harmful consequences, a higher priority
given to drug use than to other activities and obligations, increased
tolerance, and sometimes a physical with drawl state.
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7. Most common substance abuse are:
● Alcohol
● Cannabis
● Opioids
● Benzo-diazepam
● Hallucinogens
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8. Contd..
● Barbiturates
● Stimulants (cocaine, amphetamine)
● Tobaccos
● Inhalants and volatile solvents (Petrol, kerosene)
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10. Alcohol Overdose
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11. Introduction
● Alcohol poisoning can result from drinking any type of alcohol,
containing Ethanol (ethyl alcohol) or methanol (methyl alcohol)
including beer, wine or liquor. As the intake alcohol start to digest
in stomach and absorbs alcohol, the alcohol enters in the
bloodstream, and alcohol blood level begins to rise. The liver
breaks down alcohol. But when blood alcohol levels are high, the
overwhelmed liver can’t remove the toxins quickly enough.
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12. Contd..
● The extra alcohol in the bloodstream is a depressant.
That means it reduces normal function. In this case, it
affects the parts of the brain that control vital body
functions, such as breathing, heart rate, blood pressure
and temperature. As blood alcohol continues to rise, the
depressant effect is more substantial.
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13. Contd..
One drink refers to an alcoholic beverage that contains approximately
14 grams of pure alcohol. The following are examples of a standard
drink:
● Beer: 12 fluid ounces (one can of beer)
● Wine: Five fluid ounces (one glass of wine)
● Hard liquor: One and one-half fluid ounces (one shot of liquor)
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15. Lethal dose
● The lethal dose of alcohol is 5 to 8g/kg (3g/kg for
children) that is, for a 60kg person, 300g of alcohol can
kill, which is equal to 30 standard drinks (about 1 liter of
spirits or four bottles of wine)
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16. Cause
● Too much alcohol in the blood causes alcohol poisoning. The
condition is also called alcohol overdose. Determining how
much alcohol is in the blood is measured by blood-alcohol
content (BAC) as a percentage.
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17. Sign and Symptoms
• Mental confusion, stupor
• Difficulty remaining conscious, or inability to wake up
• Vomiting
• Seizures
• Slow breathing (fewer than 8 breaths per minute)
• Slow heart rate
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18. Contd..
• Clammy skin
• Dulled responses, such as no gag reflex
• Extremely low body temperature, bluish skin color, or
paleness
• Coma
• Death
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20. 20

21. Diagnosis
● Breathalyzer: As someone drink, the alcohol goes through the
bloodstream to the lungs. There, it evaporates into the lungs, and
began to breathe it out. As you blow into the breathalyzer, it can
estimate your BAC by how much alcohol detects in your breath.
● Urine test: EtG (ethyl glucuronide) test can be done. Levels higher
than 1,000ng/mL of EtG in the urine is considered a “high” positive.
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22. Contd..
● Blood test: Analyzes for the blood alcohol concentration
(BAC). It is about 0.08 percent or higher. It i. The blood
test is most accurate within six to 12 hours after the last
drink you consume. Also analysis for blood glucose
level. Alcohol consumption causes an increase in insulin
secretion, which leads to low blood sugar.
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24. Emergency management
● C (Circulation)
● A (Airway)
● B (Breathing)
● Prevent from aspiration
● Administration of Intravenous fluid solution may be
required to hydrate the patient and reverse the electrolyte
imbalance and hypoglycemia.
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25. Contd..
● The Intravenous solution used contains dextrose, magnesium,
folate, thiamine and multivitamins (i.e a premixed intravenous
solution of 1 li of 5% dextrose and 0.45% sodium chloride, 2g of
magnesium sulfate, 1 mg of folate and 100 mg of thiamine.
● These patients often present with nausea and vomiting.
Therefore, antiemetic drugs should be used.
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26. Contd..
● Agitated and violent patients may require the use of sedative
drugs such as droperidol and haloperidol. Whenever sedative
drugs are used, the clinician must keep in mind the
possibility of interaction between the drug and the alcohol,
which can cause respiratory depression and hypotension.
● In some cases, mechanical ventilation and intensive care
must be provided.
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27. Contd..
● Fomepizole competitively inhibits ADH and is an
effective and safe antidote for both ethylene glycol and
methanol toxicity. In the presence of fomepizole, the
half-lives of ethylene glycol (in patients with normal
renal function) and methanol are 14.5 and 40 hours,
respectively.
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28. Contd..
● Loading dose of fomepizole is 15 mg/kg over 30 minutes
followed by a dose of 10 mg/kg every 12 hours, with the
frequency of dosing increased to every 4 hours during
hemodialysis. Fomepizole induces its own metabolism,
presumably through the cytochrome P-450 2E1 isoenzyme;
therefore, after 48 hours of drug administration, the fomepizole
dose should be increased to 15 mg/kg every 12 hours
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29. Contd..
● But according to the article published in Himalayan times
by Dr. Rakesh Ghimire on may 10, 2020 about
“Preventing methanol poisoning” the preferred antidote,
fomepizole, is not readily available in Nepal, and the
current price makes it unattainable for most victims in
high-risk countries where people are affected.
Fomepizole is registered in Nepal, but it is not available,
which could be due to the high cost.
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30. Contd..
● According to the research done by Reema Rajbhandari
on September 2018 about “Methanol poisoning our
experience with recent outbreak”. There was an outbreak
of methanol poisoning in Sindhupalchowk and Sindhuli
in Shrawan, 2065 BS treatment was done by:
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31. Contd..
● Treatment with high dose intravenous injection of
steroid i.e. Methylprednisolone 1gm was given for 3
days with other supportive treatment, Ethanol, Follinic
acid was used, Injection Sodium bicarbonate was given
and acidosis was corrected. And with additional
treatment with Hemodialysis twice.
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33. Cannabis
Intoxication
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34. Introduction
● The flowering tops of the female plant of cannabis sativa
(weeds) have a pleasant intoxication effects. It is widely
cultivated for its fiber, used to make rope and cloth and for its
seed, used to make oil.
● Research has shown that cannabis has short term effect of
lowering intracranial pressure, but it is not approved for the
treatment of glaucoma
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35. Contd..
● The primary psychoactive ingredient is believed to be
tetrahydrocannabinol (THC), which is also responsible
for most of the intoxicating effects experienced by users.
● It has been studies for its effectiveness of relieving
nausea and vomiting associated with cancer
chemotherapy and the anorexia and weight loss of AID.
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36. Contd..
● The amount absorbed by the body varies by the route of
administration and concentration of the source being used which
can vary widely. Cannabis is commonly smoked or vaporized due
to the rapid onset of symptoms, but cannabis can also be eaten,
(i.e., "grass" brownies), or drank, (i.e., marijuana tea or marijuana
tincture). Smoked cannabis has an increased potency, quoted as
high as 2.6 times by some sources.
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37. Intoxification and overdose
 Cannabis begains to act less than one mins.
 Peak effect usually occur in 20 to 30 mins and last at
least 2 to 3 hours.
 Symptoms to intoxification include impaired motor
coordination, inappropriate laughter, impaired judgments
and short term memory and disturbance in perception.
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38. Lethal Dose
● For obvious ethical reasons, there is no experimental evidence
to determine the lethal dose in humans; but the dose that kills
animals range from 40 mg/kg to 130 mg/kg intravenously.
● Extrapolation from the animal evidence suggests that the lethal
human dose of THC is at least as high as, and probably higher
than, that observed in the monkey. If this is so, then the toxic
dose of THC in a 65kg adult would be 8.45kg.
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39. Causes in term of Dependency
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40. Causes in term of Overdose
• Polysubstance use or abuse is the most common risk factor that
increases the chance of overdosing; this involves taking
multiple drugs to attain a desired high.
• Certain drug combinations can be deadly, and the
consequences increase especially when marijuana is combined
with alcohol.
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42. Contd..
• Though the mechanisms aren’t entirely clear, beyond the
obvious risks introduced from combining two distinct
intoxicants, alcohol may increase the level of
marijuana’s primary psychoactive element, THC, in the
blood.
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43. Sign and symptoms in term of Dependency
1. Physical problems
2. Mental problems
3. Social problems
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44. 1. Physical problems
● Thin hair, red eye, dry mouth
● Sexual dysfunction
● Peptic ulcer
● Wasting of muscle
● Withdrawal symptoms include: stomach pain, bleeding,
vomiting, hallucination, restlessness, shaky and afraid
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45. 2. Psychiatric symptoms
● Personality and image change,
● Irritability , loss of concentration,
● Depression , loss of memory,
● Slurred speech
● Incoordination gait.
● Disturbance in perception
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46. 3. Social problems
● Fight, quarrel,
● Trouble with other,
● Loss of work
● Violent toward family
● Suicide
● Financial problems
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47. Sign and symptoms in term of Overdose
While rare, a marijuana overdose is still possible in some cases.
Some of these are could have an impact mentally, heart related
and lead to pale skin. Signs and symptoms of marijuana overdose
might include:
• Extreme anxiety or panic attacks.
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48. Contd..
• Psychotic reactions in which someone loses touch with
reality or becomes paranoid, sometimes in the form of
hallucinations, delusions, or a loss of personal identity.
• Decreased judgment, perception, and coordination that
can lead to injuries or even death.
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49. Contd..
• A fast heart rate, chest pain, or heart attack
• Uncontrollable shaking or seizures
• Pale skin color
• Unresponsiveness
• Sudden high blood pressure with headache
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50. Diagnosis
 Urine immunoassays are used to detect a conjugated delta-9-
tetrahydrocannanbinol (THC) metabolite, 11-nor-delta-9-THC
carboxylic acid. Features of the test results are as follows :
• After a single, acute use, THC is detectable in the urine for 7
days
• With chronic use, THC is detectable in the urine for 10-30
days
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51. Contd..
• Enzyme-multiplied immunoassay technique (EMIT) can
detect urine levels as low as 20-100 ng/mL.
• These screening tests correlate with prior exposure, not
with the amount used or degree of clinical effect.
 Blood tests can also be used to detect THC; however,
the levels correlate poorly with the clinical effects.
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52. Emergency Management in term of
overdose
● C (Circulation)
● A (Airway)
● B (Breathing)
● Prevent from aspiration
● Administration of Intravenous fluid solution may be required to
hydrate the patient and reverse the electrolyte imbalance and
hypoglycemia.
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53. Contd..
● Immediate management should be supportive, including
cardiovascular and neurological monitoring, and placement in
a quiet room.
● There is no specific antidote for cannabis toxicity. The opioid
receptor antagonist naloxone is often administered to patients
with suspected opioid overdose exhibiting hypoventilation,
somnolence, and bradycardia.
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54. General Management
● Rest in quiet.
● Antianxiety drugs to reduce agitation.
● Good nutrition.
● Anti-depressants or antipsychotic to treat any associated
psychiatric complications.
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55. Contd..
Treatment can be divided into two categories
 Physical method :-
Detoxification: It is the process by which an cannabis
dependent person recovers from the intoxication effects in a
supervised manner.
● Benzodiazepines : Chlordiazepoxide 80-200 mg/day.
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56. Contd..
● Diazepam 40-80 mg/day to control anxiety, insomnia,
agitation & tremors.
● Thiamine 100mg IM for 3-5 days followed by vitamin-B
administration 100mg OD for at least 6 months.
● If necessary use anti- convulsant, close observation for 5
days, maintenance of I/O chart.
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57. Contd..
● Strict monitoring of vital signs, observation of level of
consciousness & orientation , assess fluid and electrolyte
balance, if necessary administer I.V. fluids.
● High protein diet (if the liver is damaged).provision of
calm and safe environment
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58. Contd..
 Psychological methods :-
1. Behavioral Therapy (Disulfiram Therapy)
2. Supportive Psychotherapy :
3. Group Therapy :
4. Cognitive Behavioral Therapy (CBT) :
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59. References
● May 2021. “Understanding the Dangers of Alcohol
Overdose”. https://www.niaaa.nih.gov/
● June 22, 2021. Galbicsek. C. “What Is Alcohol
Poisoning?”. https://www.alcoholrehabguide.org/
● May 10,2020. Dr. Rakesh Ghimire. “Preventing
methanol poisoning” https://thehimalayantimes.com/
59

60. Contd..
● Sreevani. R. (2016). “A Guide to Mental Health &
Psychiatric Nursing”. 4th edition. Jaypee Brothers
Medical Publishers pvt. Ltd. India
● Sharma. C. (2016). “Essentials of Psychiatric and Mental
Health Nursing”. 2nd ed. Kathmandu, Nepal: Saurav
and Awish
60

61. Contd..
● September 2018. Reema Rajbhandari. “Methanol poisoning our
experience with recent outbreak”. https://www.researchgate.net/
● https://www.who.int/
● MAY 2015. “Psychiatric and Medical Management of
Marijuana Intoxication in the Emergency Department”.
https://westjem.com/
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