Substance related disorders

MR. JAYESH PATIDAR
www.drjayeshpatidar.blogspot.com

Introduction…
• Psychoactive substances have been used by people in
almost all cultures since prehistoric times.
• Psychoactive substances affect brain.
• Substances-related disorders are composed of two
groups
1. Substance – use disorders (dependence & abuse)
2. Substance – induce disorders (intoxication, withdrawal,
delirium, dementia, amnesia, psychosis, mood
disorder, anxiety disorder, sexual dysfunction & sleep
disorders)

Epidemiological Statistics…
• A high prevalence of substance-related
disorder occur between the ages of 18 & 24.
• Substance-related disorder are diagnosed
more commonly in men than in women, but
the gender ratio vary with the class of the
substance.

Defining the Terms…
Abuse
To use wrongfully or in a harmful way. Improper
treatment or conduct that may result in injury
Dependence
A compulsive or chronic requirement. The need is
so strongly as to generate distress (either
physical or psychological) if left unfulfilled

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Intoxication
A physical & mental state of exhilaration &
emotional frenzy or lethargy & stupor
Withdrawal
The physiological & mental readjustment that
accompanies the discontinuation of an
addictive substance.

SUBSTANCE
USE
DISORDERS

Substance Abuse
Definition:
The DSM-IV-TR (APA, 2000) identifies substance
abuse as a maladaptive pattern of substance use
manifested by recurrent and significant
adverse consequences related to repeated use
of the substance. Substance abuse has also
been referred to as any use of substances that
poses significant hazards to health.

DSM-IV-TR Criteria for Substance Abuse
• Recurrent substance use resulting in a failure to
fulfill major role obligations at work, school, or
home (e.g., repeated absences or poor work
performance related to substance use; substance-
related absences, suspensions, or expulsions
from school; neglect of children or household).
• Recurrent substance use in situations in which it
is physically hazardous (e.g., driving an
automobile or operating a machine when
impaired by substance use).

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• Recurrent substance-related legal problems
(e.g., arrests for substance-related disorderly
conduct).
• Continued substance use despite having
persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects
of the substance (e.g., arguments with spouse
about consequences of intoxication, physical
fights).

Substance Dependence
Physical Dependence:
• Physical dependence on a substance is evidenced by a
cluster of cognitive, behavioral, and physiological
symptoms indicating that the individual continues use of
the substance despite significant substance-related
problems (APA, 2000).
• The development of physical dependence is promoted
by the phenomenon of tolerance. Tolerance is defined as
the need for increasingly larger or more frequent doses
of a substance in order to obtain the desired effects
originally produced by a lower dose.

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Psychological Dependence:
• An individual is considered to be psychologically
dependent on a substance when there is an
overwhelming desire to repeat the use of a
particular drug to produce pleasure or avoid
discomfort. It can be extremely powerful,
producing intense craving for a substance as
well as its compulsive use.

DSM-IV-TR Criteria for Substance Dependence
At least three of the following characteristics must
be present for a diagnosis of substance
dependence:
1. Evidence of tolerance, as defined by either of the
following:
a. A need for markedly increased amounts of the
substance to achieve intoxication or desired
effects.
b. Markedly diminished effect with continued use
of the same amount of the substance.

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2. Evidence of withdrawal symptoms, as
manifested by either of the following:
a. The characteristic withdrawal syndrome for the
substance.
b. The same (or a closely related) substance is
taken to relieve or avoid withdrawal symptoms.
3. The substance is often taken in larger amounts
or over a longer period than was intended.
4. There is a persistent desire or unsuccessful
efforts to cut down or control substance use.

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5. A great deal of time is spent in activities necessary to
obtain the substance (e.g., visiting multiple doctors or
driving long distances), use the substance (e.g., chain
smoking), or recover from its effects.
6. Important social, occupation, or recreational activities
are given up or reduced because of substance use.
7. The substance use is continued despite knowledge of
having a persistent or recurrent physical or psychological
problem that is likely to have been caused or
exacerbated by the substance (e.g., current cocaine use
despite recognition of cocaine-induced depression, or
continued drinking despite recognition that an ulcer was
made worse by alcohol consumption).

SUBSTANCE
INDUSED
DISORDERS

Definition:
Substance intoxication is defined as the
development of a reversible substance-specific
syndrome caused by the recent ingestion of (or
exposure to) a substance (APA, 2000). The
behavior changes can be attributed to the
physiological effects of the substance on the CNS
and develop during or shortly after use of the
substance. This category does not apply to
nicotine.
Substance Intoxication

DSM-IV-TR Criteria for Substance Intoxication
1.The development of a reversible substance-specific
syndrome caused by recent ingestion of (or exposure to)
a substance.
2. Clinically significant maladaptive behavior or
psychological changes that are due to the effect of the
substance on the CNS (e.g., belligerence, mood liability,
cognitive impairment, impaired judgment, impaired
social or occupational functioning) and develop during
or shortly after use of the substance.
3. The symptoms are not due to a general medical
condition and are not better accounted for by another
mental disorder.

Definition:
Substance withdrawal is the development of a
substance-specific maladaptive behavioral
change, with physiological and cognitive
concomitants, that is due to the cessation of, or
reduction in, heavy and prolonged substance
use (APA, 2000). Withdrawal is usually, but not
always, associated with substance dependence.
Substance Withdrawal

DSM-IV-TR Criteria for Substance Withdrawal
1. The development of a substance-specific
syndrome caused by the cessation of (or
reduction in) heavy and prolonged substance use.
2. The substance-specific syndrome causes clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning.
3. The symptoms are not caused by a general
medical condition and are not better accounted
for by another mental disorder.

Predisposing Factors of Substance-
related Disorders:-
A number of factors have been implicated in the
predisposition to abuse of substances. At present,
no single theory can adequately explain the
etiology of this problem.
• Biological factors
• Psychological factors
• Sociocultural factors

Biological Factors
Genetics:
• Hereditary factor is involved in the development of
substance-use disorders.
• This is especially evident with alcoholism, and less so
with other substances.
• Children of alcoholics are three times more likely than
other children to become alcoholics
• Monozygotic twins have a higher rate for concordance of
alcoholism than dizygotic twins
• biological offspring of alcoholic parents have a
significantly greater incidence of alcoholism than
offspring of nonalcoholic parents.

Biochemical Factors:
• Alcohol may produce morphine-like substances
in the brain that are responsible for alcohol
addiction.
• Substances are formed by the reaction of
biologically active amines (e.g., dopamine,
serotonin) with products of alcohol metabolism,
such as acetaldehyde
• Examples of these morphinelike substances
include tetrahydropapaveroline and salsolinol.

Psychological Factors
Developmental Influences:
• The psychodynamic approach - punitive superego and
fixation at the oral stage of psychosexual development
• Individuals with punitive superegos turn to alcohol to
diminish unconscious anxiety.
• Sadock and Sadock (2003) state, “Anxiety in people
fixated at the oral stage may be reduced by taking
substances, such as alcohol, by mouth.”
• Alcohol may also serve to increase feelings of power
and self-worth in these individuals.

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Personality Factors:
• Low self-esteem, frequent depression, passivity,
the inability to relax or to defer gratification, and
the inability to communicate effectively are
common in individuals who abuse substances.
• Substance abuse has also been associated with
antisocial personality and depressive response
styles.

Sociocultural Factors
Social Learning:
• The effects of modeling, imitation, and identification on
behavior can be observed from early childhood onward.
• Children and adolescents are more likely to use
substances if they have parents who provide a model for
substance use.
• Peers often exert a great deal of influence in the life of the
child or adolescent who is being encouraged to use
substances for the first time.
• Plenty of leisure time with coworkers and where drinking
is valued and is used to express group cohesiveness.

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Conditioning:
• Important learning factor is the effect of the substance
itself.
• Many substances create a pleasurable experience that
encourages the user to repeat it.
• It is the intrinsically reinforcing properties of addictive
drugs that “condition” the individual to seek out their
use again and again.
• The environment in which the substance is taken also
contributes to the reinforcement. If the environment is
pleasurable, substance use is usually increased.

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Cultural and Ethnic Influences:
• Factors within an individual’s culture help to establish
patterns of substance use by molding attitudes,
influencing patterns of consumption based on cultural
acceptance, and determining the availability of the
substance.
• 45 percent of the Indian veterans were alcohol
dependent, or twice the rate for non-Indian veterans. A
• The incidence of alcohol dependence is higher among
northern Europeans than southern Europeans.
• The incidence of alcohol dependence among Asians is
relatively low.

CLASSES OF PSYCHOACTIVE
SUBSTANCES
1. Alcohol
2. Amphetamines &
related substances
3. Caffeine
4. Cannabis
5. Cocaine
6. Hallucinogens
7. Inhalants
8. Nicotine
9. Opioids
10.Phencyclidine (PCP) &
related substances
11.Sedative, hypnoties or
anxiolytics

ALCOHOL

ALCOHOL ABUSE AND DEPENDENCE
A Profile of the Substance:
• Alcohol is a natural substance formed by the reaction of
fermenting sugar with yeast spores.
• The kind in alcoholic beverages is known scientifically as
ethyl 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 using
different sources of sugar for the fermentation process. For
example, beer is made from malted barley, wine from
grapes or berries, whiskey from malted grains, and rum
from molasses. www.drjayeshpatidar.blogspot.com

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• Distilled beverages (e.g., whiskey, scotch, gin, vodka, and
other “hard” liquors) derive their name from further
concentration of the alcohol through a process called
distillation.
• The alcohol content varies by type of beverage. For
example, most American beers contain 3 to 6 percent
alcohol, wines average 10 to 20 percent, and distilled
beverages range from 40 to 50 percent alcohol.
• Alcohol exerts a depressant effect on the CNS, resulting
in behavioral and mood changes. The effects of alcohol
on the CNS are proportional to the alcoholic
concentration in the blood.

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• Most states consider that an individual is legally
intoxicated with a blood alcohol level of 0.08 to 0.10
percent.
• The body burns alcohol at about 0.5 ounce per hour, so
behavioral changes would not be expected in an
individual who slowly consumes only one averaged-sized
drink per hour.
• Other factors do influence these effects, such as
individual size and whether or not the stomach contains
food at the time the alcohol is consumed. Alcohol is
thought to have a more profound effect when an
individual is emotionally stressed or fatigued [NIAAA],
2000).

Why do people drink?
• Drinking patterns in the United States show that
people use alcoholic beverages to enhance the
flavor of food with meals; at social gatherings to
encourage relaxation and conviviality among the
guests; and to promote a feeling of celebration
at special occasions such as weddings, birthdays,
and anniversaries.
• An alcoholic beverage (wine) is also used as part
of the sacred ritual in some religious
ceremonies.

Jellinek (1952) outlined four phases through which
the alcoholic’s pattern of drinking progresses.
(Psychopathology)
1. Phase I. The Pre alcoholic phase
2. Phase II. The early alcoholic phase
3. Phase III. The crucial phase
4. Phase IV. The chronic phase

Phase I. The Pre alcoholic phase
• This phase is characterized by the use of alcohol to
relieve the everyday stress and tensions of life.
• As a child, the individual may have observed
parents or other adults drinking alcohol and
enjoying the effects.
• The child learns that use of alcohol is an
acceptable method of coping with stress.
• Tolerance develops, and the amount required to
achieve the desired effect increases steadily.

Phase II. The Early Alcoholic Phase
• This phase begins with blackouts—brief periods of amnesia
that occur during or immediately following a period of
drinking.
• Now the alcohol is no longer a source of pleasure or relief
for the individual but rather a drug that is required by the
individual.
• Common behaviors include sneaking drinks or secret
drinking, preoccupation with drinking and maintaining the
supply of alcohol, rapid gulping of drinks, and further
blackouts.
• The individual feels enormous guilt and becomes very
defensive about his or her drinking. Excessive use of denial
and rationalization is evident.

Phase III. The Crucial Phase
• In this phase, the individual has lost control, and
physiological dependence is clearly evident.
• This loss of control has been described as the
inability to choose whether or not to drink.
• Binge drinking, lasting from a few hours to
several weeks, is common.
• These episodes are characterized by sickness,
loss of consciousness, squalor, and degradation.

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• In this phase, the individual is extremely ill.
Anger and aggression are common
manifestations.
• Drinking is the total focus, and he or she is willing
to risk losing everything that was once
important, in an effort to maintain the addiction.
• By this phase of the illness, it is not uncommon
for the individual to have experienced the loss of
job, marriage, family, friends, and most
especially, self-respect.

Phase IV. The Chronic Phase
• This phase is characterized by emotional and physical
disintegration.
• The individual is usually intoxicated more than he or she is
sober. Emotional disintegration is evidenced by profound
helplessness and self-pity.
• Impairment in reality testing may result in psychosis. Life
threatening physical manifestations may be evident in
virtually every system of the body.
• Abstention from alcohol results in a terrifying syndrome of
symptoms that include hallucinations, tremors,
convulsions, severe agitation, and panic. Depression and
ideas of suicide are not uncommon.

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 is
absorbed directly and immediately into the
bloodstream through the stomach wall.
• The blood carries it directly to the brain where
the alcohol acts on the brain’s central control
areas, slowing down or depressing brain activity.
•

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• The other 80 percent of the alcohol in one drink is
processed only slightly slower through the upper
intestinal tract and into the bloodstream.
• Only moments after alcohol is consumed, it can
be found in all tissues, organs, and secretions of
the body.
• At low doses, alcohol produces relaxation, loss of
inhibitions, lack of concentration, drowsiness,
slurred speech, and sleep. Chronic abuse results
in multisystem physiological impairments.

Peripheral Neuropathy
• It characterized by peripheral nerve damage,
results in pain, burning, tingling, or prickly
sensations of the extremities.
• It is the direct result of deficiencies in the B
vitamins, particularly thiamine.
• Nutritional deficiencies are common in chronic
alcoholics because of insufficient intake of
nutrients as well as the toxic effect of alcohol that
results in malabsorption of nutrients.
• Permanent muscle wasting and paralysis can occur.

Alcoholic Myopathy
• Alcoholic myopathy may occur as an acute or chronic
condition.
• In the acute condition, the individual experiences a
sudden onset of muscle pain, swelling, and
weakness; a reddish tinge in the urine caused by
myoglobin, a breakdown product of muscle excreted in
the urine; and a rapid rise in muscle enzymes in the
blood (Barclay, 2005).
• Muscle symptoms are usually generalized, but pain and
swelling may selectively involve the calves or other
muscle groups.

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• Laboratory studies show elevations of the enzymes creatine
phosphokinase (CPK), lactate dehydrogenase (LDH),
aldolase, and aspartate aminotransferase (AST).
• The symptoms of chronic alcoholic myopathy include a
gradual wasting and weakness in skeletal muscles.
• Neither the pain and tenderness nor the elevated muscle
enzymes seen in acute myopathy are evident in the chronic
condition.
• Alcoholic myopathy is thought to be a result of the same B
vitamin deficiency that contributes to peripheral
neuropathy.
• Improvement is observed with abstinence from alcohol and
the return to a nutritious diet with vitamin supplements.www.drjayeshpatidar.blogspot.com

Wernicke’s Encephalopathy
• Wernicke’s encephalopathy represents the
most serious form of thiamine deficiency in
alcoholics.
• Symptoms include paralysis of the ocular
muscles, diplopia, ataxia, somnolence, and
stupor.
• If thiamine replacement therapy is not
undertaken quickly, death will ensue.

Korsakoff ’s Psychosis
• Korsakoff’s psychosis is identified by a syndrome
of confusion, loss of recent memory, and
confabulation in alcoholics.
• It is frequently encountered in clients recovering
from Wernicke’s encephalopathy.
• In the United States, the two disorders are usually
considered together and are called Wernicke-
Korsakoff syndrome.
• Treatment is with parenteral or oral thiamine
replacement.

Alcoholic Cardiomyopathy
• The effect of alcohol on the heart is an accumulation of
lipids in the myocardial cells, resulting in enlargement
and a weakened condition.
• The clinical findings of it is generally relate to congestive
heart failure or arrhythmia.
• Symptoms include decreased exercise tolerance,
tachycardia, dyspnea, edema, palpitations, and
nonproductive cough.
• Laboratory studies may show elevation of the enzymes
CPK, AST, alanine aminotransferase (ALT), and LDH.

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• 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 from
alcohol.
• Treatment of the congestive heart failure may include
rest, oxygen, digitalization, sodium restriction, and
diuretics.
• Prognosis is encouraging if treated in the early stages.
The death rate is high for individuals with advanced
symptomatology.

Esophagitis
• Esophagitis—inflammation and pain in the
esophagus— occurs because of the toxic
effects of alcohol on the esophageal mucosa.
• It also occurs because of frequent vomiting
associated with alcohol abuse.

Gastritis
• The effects of alcohol on the stomach include
inflammation of the stomach lining
characterized by epigastric distress, nausea,
vomiting, and distention.
• Alcohol breaks down the stomach’s protective
mucosal barrier, allowing hydrochloric acid to
erode the stomach wall.
• Damage to blood vessels may result in
hemorrhage.

Pancreatitis
• This condition may be categorized as acute or
chronic.
• Acute pancreatitis usually occurs 1 or 2 days after
a binge of excessive alcohol consumption.
• Symptoms include constant, severe epigastric
pain; nausea and vomiting; and abdominal
distention.
• The chronic condition leads to pancreatic
insufficiency resulting in steatorrhea,
malnutrition, weight loss, and diabetes mellitus.

Alcoholic Hepatitis
• Alcoholic hepatitis is inflammation of the liver caused by
long-term heavy alcohol use.
• Clinical manifestations include an enlarged and tender
liver, nausea and vomiting, lethargy, anorexia, elevated
white blood cell count, fever, and jaundice.
• Ascites and weight loss may be evident in more severe
cases. With treatment— which includes strict abstinence
from alcohol, proper nutrition, and rest—the individual
can experience complete recovery.
• Severe cases can lead to cirrhosis or hepatic
encephalopathy.

Cirrhosis of the Liver
• Cirrhosis is the end stage of alcoholic liver disease and
results 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, correction
of malnutrition, and supportive care to prevent
complications of the disease. Complications of cirrhosis
include:
1. Portal Hypertension 2. Ascites
3. Esophageal Varies 4. Hepatic encephalopathy

Leukopenia
• The production, function, and movement of
the white blood cells are impaired in chronic
alcoholics.
• This condition, called leukopenia, places the
individual at high risk for contracting
infectious diseases as well as for complicated
recovery.

Thrombocytopenia
• Platelet production and survival are impaired
as a result of the toxic effects of alcohol.
• This places the alcoholic at risk for
hemorrhage.
• Abstinence from alcohol rapidly reverses this
deficiency.

Sexual Dysfunction
• Alcohol interferes with the normal production
and maintenance of female and male hormones
(National
• For women, this can mean changes in the
menstrual cycles and a decreased or loss of
ability to become pregnant.
• For men, the decreased hormone levels result in
a diminished libido, decreased sexual
performance, and impaired fertility

Alcohol Dependence:
• Many alcoholics hide or deny their addiction &
temporarily manage to maintain a functional life which
can make assessment a challenge. Nonetheless, certain
physical & psychological symptoms suggest alcoholism.
• For example, the patient may have minor complaints
that are alcohol related- malaise, dyspepsia, mood swing
or depression & an increased incidence of infection.
• Also check for poor personal hygiene & untreated
injuries, such as cigarette burns, fractures & bruises, that
he can’t fully explained.
SIGNS AND SYMPTOMS

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• Assess for signs of nutritional deficiency, including
vitamin & mineral deficiency. Watch for secretive
behavior which may be an attempt to hide the disorder
or the alcohol supply.
• When deprived of his usual supply of alcohol, an
alcoholic may consume it in any form he can find-
mouthwash, aftershave lotion, hair spray & even lighter
fluid.
• Characteristically, the alcoholic denies he has a problem
or rationalizes the problem. He also tends to blame
others & to rationalize problem areas in his life. he may
project his anger or feelings of guilt or inadequacy onto
others to avoid confronting his illness.

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Overt signs & symptoms:
• Overt indications of excessive alcohol use
include:
- Episodes of anesthesia or amnesia during
intoxication (Blackouts).
- Violent behavior when intoxicated.
- The need for daily or episodic alcohol use to
function adequately.
- Inability to stop or reduce intake.

Alcohol Intoxication:
Intoxication usually occurs at blood alcohol
levels between 100 & 200 mg/dl. Death has
been reported at levels ranging from 400 to 700
mg/dl. Symptoms include:
• Disinhibition of sexual or
aggressive impulses.
• Mood lability
• Impaired judgment
• Impaired social or
occupational functioning.
• Slurred speech
• incoordination
• Unsteady gait
• Nystagmus
• Flushed face

Alcohol Withdrawal:
A heavy drinker who stops drinking or abruptly
reduces his alcohol intake is likely to go through
withdrawal. Within 4 to 12 hours of cessation of or
reduction in heavy & prolonged (several days or
longer) 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 or
illusions
• Headache & insomnia

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• Alcohol withdrawal delirium – onset of
delirium is usually on the second or third day
following cessation of or reduction in
prolonged, heavy alcohol use. It manifest as
delirium accompanied by tremor, severe
agitation & autonomic overactivity – dramatic
increases pulse, respiration & BP

Various laboratory tests may suggest alcoholism &
help evaluate for complication for such as
cirrhosis of liver.
• A blood alcohol level of 0.10% wt/volume (200
mg/dl) indicate alcohol intoxication. Although this
test can’t confirm alcoholism, it can reveal how
recently the patient has been drinking & thus
when to expect withdrawal symptoms is he’s a
heavy drinker.
• Urine toxicology may uncover the use of other
drugs www.drjayeshpatidar.blogspot.com
DIAGNOSIS FOR ALCOHOLISM

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• Serum electrolyte analysis may identify electrolyte
abnormalities associated with alcohol use.
• Blood urea nitrogen level rises & serum glucose level drops
in a patient with severe liver disease.
• Increased plasma ammonia level indicates severe liver
disease, as in cirrhosis.
• Liver function studies may point to alcohol-related liver
damage
• Hematologic workup identify anemia, thrombocytopenia &
increased prothromin & partial thromboplastin times.
• Echocardiography & ECG may reveal cardiac problems
related to alcoholism such as enlarged heart (cardiomegaly)

• Acute alcohol intoxication calls for
symptomatic treatment, which may
involve respiratory support, fluid
replacement, IV glucose to prevent
hypoglycemia, correction of
hypothermia or acidosis, &
emergency measures for trauma,
infection or GI bleeding as needed.
TREATMENT MODALITIES

Alcohol Anonymous
• Alcoholics Anonymous (AA) is a major self-help
organization for the treatment of alcoholism.
• It was founded in 1935 by two alcoholics—a stockbroker,
Bill Wilson, and a physician, Dr. Bob Smith—who
discovered that they could remain sober through mutual
support.
• They accomplished this not as professionals, but as peers
who were able to share their common experiences.
• The self-help groups are based on the concept of peer
support—acceptance and understanding from others
who have experienced the same problems in their lives.

Alcohol Anonymous
• The only requirement for membership is a desire on the
part of the alcoholic person to stop drinking.
• Each new member is assigned a support person from
whom he or she may seek assistance when the
temptation to drink occurs.
• The sole purpose of AA is to help members stay sober.
When sobriety has been achieved, they in turn are
expected to help other alcoholic persons. The Twelve
Steps that embody the philosophy of AA provide
specific guidelines on how to attain and maintain
sobriety

The Twelve Steps of Alcoholics:-
1. We admitted we were powerless over alcohol—that our
lives have become unmanageable.
2. Came to believe that a Power greater than ourselves could
restore us to sanity.
3. Made a decision to turn our will and our lives over to the
care of God as we understood Him.
4. Made a searching and fearless moral inventory of
ourselves.
5. Admitted to God, to ourselves, and to another human
being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects
of character.
7. Humbly asked Him to remove our shortcomings.

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8. Made a list of all persons we had harmed and became
willing to make amends to them all.
9. Made direct amends to such people whenever possible
except when to do so would injure them or others.
10. Continued to take personal inventory and when we were
wrong promptly admitted it.
11. Sought through prayer and meditation to improve our
conscious contact with God as we understood Him, praying
only for knowledge of His will for us and the power to carry
that out.
12. Having a spiritual awakening as the result of these steps,
we tried to carry this message to alcoholics and to practice
these principles in all our affairs.

Pharmacotherapy
Disulfiram (Antabuse):
• Disulfiram is a drug that can be administered to
individuals who abuse alcohol as a deterrent to
drinking.
• Ingestion of alcohol while Disulfiram is in the body
results in a syndrome of symptoms that can
produce a good deal of discomfort for the
individual. It can even result in death if the blood
alcohol level is high

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• Disulfiram works by inhibiting the enzyme
aldehyde dehydrogenase, thereby blocking the
oxidation of alcohol at the stage when
acetaldehyde is converted to acetate.
• This results in an accumulation of acetaldehyde in
the blood, which is thought to produce the
symptoms associated with the disulfiram-alcohol
reaction.
• Symptoms of disulfiram-alcohol reaction can
occur within 5 to 10 minutes of ingestion of
alcohol.

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• Mild reactions can occur at blood alcohol levels as low as
5 to 10 mg/dl.
• Symptoms are fully developed at approximately 50 mg/dl
and may include flushed skin, throbbing in the head and
neck, respiratory difficulty, dizziness, nausea and
vomiting, sweating, hyperventilation, tachycardia,
hypotension, weakness, blurred vision, and confusion.
• With a blood alcohol level of approximately 125 to 150
mg/dl, severe reactions can occur, including respiratory
depression, cardiovascular collapse, arrhythmias,
myocardial infarction, acute congestive heart failure,
unconsciousness, convulsions, and death.

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• Disulfiram should not be administered until it has been
ascertained that the client has abstained from alcohol for
at least 12 hours.
• If disulfiram is discontinued, it is important for the client
to understand that the sensitivity to alcohol may last for
as long as 2 weeks.
• Consuming alcohol or alcohol-containing substances
during this 2-week period could result in the disulfiram-
alcohol reaction.
• The client receiving disulfiram therapy should be aware
of the great number of alcohol-containing substances.

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• These products (e.g., liquid cough and cold preparations,
vanilla extract, aftershave lotions, colognes, mouthwash,
nail polish removers, and isopropyl alcohol), if ingested
or even rubbed on the skin, are capable of producing the
symptoms described. The
• Disulfiram therapy is not a cure for alcoholism. It
provides a measure of control for the individual who
desires to avoid impulse drinking. Clients receiving
disulfiram therapy are encouraged to seek other
assistance with their problem, such as AA or other
support group, to aid in the recovery process.

Other Medications for Treatment of
Alcoholism
• The narcotic antagonist naltrexone (ReVia) was
approved by the Food and Drug Administration
(FDA) in 1994 for the treatment of alcohol
dependence.
• Naltrexone – a narcotic antagonist, may reduce
alcohol craving & help prevent an alcoholic from
relapsing to heavy drinking, when its combined
with counseling Naltrexone blocks the brains so –
called pleasure centers, reducing the urge to drink.
Usually naltrexone therapy lasts at least 12 weeks.

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• SSRIs in the decrease of alcohol craving among
alcohol dependent individuals has yielded
mixed results
• Acamprosate (Campral), which is indicated for
the maintenance of abstinence from alcohol in
patients with alcohol dependence who are
abstinent at treatment initiation.

Managing Acute Withdrawal
• The patient may require IV glucose administration &
administration of fluids containing thiamin & other B-
complex vits to correct nutritional deficiencies & aid
glucose metabolism.
Other treatment measures may include:
• Furosemide, to ease over hydration
• Magnesium sulfate, to reduce CNS irritability.
• Chlordiazepoxide, diazepam, anticonvulsants, antiemetic
or antidiarrheals as needed to ease withdrawal symptoms
• Antipsychotics, to control hyperactivity & psychosis.
• Phenobarbital, for sedation.

Treatment of Chronic Alcoholism
• Alcohol dependence has no known cure & total
abstinence is the only effective treatment.
Management commonly involves:
• Medications that deter alcohol use (as in aversion,
emetic or antagonist therapy) & treat withdrawal
symptoms.
• Measures to relieve associated physical problems.
• Psychotherapy, usually involving behavior modification,
group therapy & family therapy.
• Counseling & ongoing support groups to help the
patient overcome alcohol dependence.

Aversion Therapy
• In aversion therapy, the patient receives a daily
oral dose of disulfiram (antabuse) to prevent
compulsive drinking. Disulfiram impedes alcohol
metabolism & increased blood acetaldehyde
levels. Consuming alcohol within 2 weeks of
disulfiram uses causes an immediate unpleasant
reaction that resembles a bad hangover.
• Another form of aversion therapy attempts to
induce aversion by administering alcohol along
with an emetic agent.

Counseling and Psychotherapy
• For long term abstinence, supportive programs
that offer detoxification, rehabilitation &
aftercare – including continued involvement in
Alcoholics Anonymous (AA) – provide the best
results. Along with individual, group, or family
psychotherapy, theses programs improve the
patient’s ability to cope with stress, anxiety &
frustration & help him gain insight into the
problems that may have led him to abuse
alcohol.

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• For alcoholics who have lost contact with
family & friends & have a long history of
unemployment, trouble with the law or other
problems related to alcohol abuse,
rehabilitation may involve job training
sheltered workshops, halfway houses or other
supervised facilities.

NURSING MANAGEMENT
• In the preintroductory phase of relationship
development, the nurse must examine his or her feelings
about working with a client who abuses substances.
• Whether alone or in a group, the nurse may gain a
greater understanding about attitudes and feelings
related to substance abuse by responding to the
following 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?

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Am I comfortable with my drinking patterns?
If I decided not to drink any more, would that be
a problem for me?
What did I learn from my parents about
drinking?
Have my attitudes changed as an adult?
What are my feelings about people who become
intoxicated?
Does it seem more acceptable for some
individuals than for others?

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Do I ever use terms like “sot,” “drunk,” or
“boozer” to describe some individuals who
overindulge, 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 of
weakness? A moral problem? An illness?

Nursing Diagnosis
• Ineffective denial related to weak, underdeveloped ego
evidenced by “I don’t have a problem with (substance). I
can quit any time I want to.”
• Ineffective coping related to inadequate coping skills and
weak ego evidenced by use of substances as a coping
mechanism.
• Imbalanced nutrition: Less than body requirements/
deficient fluid volume related to drinking or taking drugs
instead of eating, evidenced by loss of weight, pale
conjunctiva and mucous membranes, poor skin turgor,
electrolyte imbalance, anemias, and other signs and
symptoms of malnutrition/dehydration.

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• Risk for infection related to malnutrition and
altered immune condition.
• Low self-esteem related to weak ego, lack of
positive feedback evidenced by criticism of self
and others and use of substances as a coping
mechanism (self-destructive behavior).
• Deficient knowledge (effects of substance abuse
on the body) related to denial of problems with
substances evidenced by abuse of substances.

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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).

Nursing Intervention
• If the patient is taking disulfiram, warn him that
even a small amount of alcohol (such as the amount
in cough medicines, mouthwashes & liquid
vitamins) will induce an adverse reaction. Tell him
that the longer he takes the drug, the greater his
alcohol sensitivity will be. Also inform him that
paraldehyde, a sedative, is chemically similar to
alcohol & may provoke a disulfiram reaction.
• As appropriate, offer to arrange a visit from a
concerned religious advisor who can help provide
the motivation for a commitment to sobriety.www.drjayeshpatidar.blogspot.com

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• Tell the patient about AA, a self-help group with
more than a million members worldwide that
offers emotional support from others with similar
problems. Stress how this organization can
provide the support he’ll need to abstain from
alcohol offer to arrange a visit from an AA
member.
• Inform a female patient that she may prefer a
women’s AA group rather than a mixed group
where she might hesitate to explore her feelings
fully.

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• Teach the patient’s family about Al-Anon &
Alateen, two other self-help groups. By joining
these groups, family members learn to relinquish
responsibility for the alcoholic’s drinking so that
they can live meaningful & productive lives. Point
out that family involvement in rehabilitation also
reduces family tensions.
• Refer adult children of alcoholics to the National
Association for children of Alcoholic. These
organization may provide support in
understanding & coping with the past.

Thank
You

Substance related disorders

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