SUBSTANCE RELATED DISORDERS INTRODUCTION Substancerelated disorders are composed

SUBSTANCE RELATED DISORDERS

INTRODUCTION • Substance-related disorders are composed of two groups: 1. The substance-use disorders Abuse and dependence 2. The substance-induced disorders intoxication, withdrawal, delirium, dementia, amnesia, psychosis, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorders • Drugs are a pervasive part of our society. Certain mood-altering substances are quite socially acceptable and are used moderately by many

DEFINITIONS (SUD) Misuse implies overzealous or indiscreet administration of drugs by physicians. • To misuse a drug might be to take it for the wrong indication, in the wrong dosage, or for too long a period. Abuse implies any use of a drug for nonmedical purposes, almost always for altering consciousness. can be defined as using a drug • It can also be describe as using a drug in a way that is inconsistent with medical or social norms and despite negative consequences. • It denotes problems in social, vocational, or legal areas of the person’s life

DEFINITIONS (SUD) • Substance Dependence is a biologic phenomenon that includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance. • Physical Dependence is the presence of a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems • The withdrawal of the drug produces symptoms that are frequently the opposite of those sought by the user • The development of physical dependence is promoted by the phenomenon of tolerance

DEFINITIONS (SUD) 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 Psychological Dependence is manifested by compulsive drug-seeking behaviour in which the individual uses the drug repetitively for personal satisfaction i. e. to produce pleasure or avoid discomfort Addiction is usually taken to mean a state of physical and psychic dependence

DEFINITIONS (SID) • Intoxication – The development of a reversible substance-specific syndrome caused by the recent ingestion of (or exposure to) a substance. • These changes disappear when the substances is eliminated from the body. • Pathological Intoxication (Applies only to alcohol) Sudden onset of aggressive & often violent behaviour that is not typical of the individual when sober, very soon after drinking amount of alcohol that would not produce intoxication in most people

DEFINITIONS (SID) • Substance Withdrawal is the development of a substance specific maladaptive behavioral, physiological and cognitive change due to the cessation of, or reduction in, heavy and prolonged substance use • Withdrawal is usually, but not always, associated with substance dependence • Characteristics of the withdrawal syndrome vary with the substance used. • Frequently observed symptoms are • anxiety, restlessness, irritability, insomnia and impaired attention

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

EPIDEMIOLOGY • According to the Nigerian National Survey of Mental Health & Wellbeing (Gureje et al, 2007) the life time and past one year prevalence of the following substances are • Alcohol : 57. 6 % / 19. 9% • Tobacco: 16. 8% / 3. 4% • Sedatives: 13. 6% / 3. 4% • Cannabis: 2. 7% /0. 4%

AETIOLOGY • The exact causes of drug use, dependence, and addiction are not known, but various factors are thought to contribute to the development Biological Factors: • Children of alcoholic parents are at higher risk • Higher rate of concordance in twins studies • Ingestion stimulates dopamine pathways in the limbic system, which produces pleasant feelings or a “high” that is a reinforcing, or positive, experience. parents

AETIOLOGY (CONTD) Psychological Factors • Inconsistency in the parent’s behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse • Children who abhorred their family lives are likely to abuse substances as adults • Some people use alcohol as a coping mechanism • Personality: Antisocial personality and borderline personality disorder Social and environmental • Cultural factors, social attitudes, cost, peer pressure, availability of drugs, single parents and separation all influence initial and continued use of substances

Alcohol Abuse and Dependence • Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream. • Initially the effects are relaxation and loss of inhibitions. • With intoxication, there is slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration memory, and judgment. • Some people become aggressive or display inappropriate sexual behavior when intoxicated.

Alcoholism • A very general term used to describe a state in which excessive indulgence in alcohol has become harmful to the individual’s physical or mental health, to his interpersonal relations, or to his social or economic functioning. • In contrast to the self-indulgent the heavy drinker who drinks because he likes it, the alcoholic is dependent on alcohol and drinks because he must • Alcoholism is not a uniform disorder, and a number of different types may be recognized. • Various methods of classification are known, but the following represent the main groups

Types of Alcoholism (a) Habitual Excessive Drinkers: • Drinking for pleasure or social reasons • They grow tolerance and no physical or mental complications • Outbursts of disturbed behaviour, loss of employment, financial difficulties and disruption of family relationship (b) Habitual Symptomatic Excessive Drinkers: • Psychological dependence on alcohol which is needed to relieve physical or emotional discomfort.

Types of Alcoholism (c) Periodic Excessive Drinkers: • Some alcoholics are subject to periodic bouts of heavy drinking (sometimes called “dipsomania”) but in the intervals can often abstain or drink only moderately. (d) Alcohol Addiction: • The body metabolism has become adapted to the presence of alcohol. • Physical dependency has developed and sudden interruption of alcohol consumption may lead to severe physical withdrawal symptoms.

Effects of Alcoholism Physical Psychological • ↓appetite with nausea and vomiting • Chronic gastritis • Cardiac myopathy • Pancreatitis • Esophagitis • Hepatitis • Cirrhosis • Leukopenia • Thrombocytopenia • Ascites • • • selfish, inconsiderate, Mood swing Delirium tremens Alcoholic hallucinosis Depression & suicidal behaviour Anxiety disorder Morbid jealousy Alcoholic dementia Sexual dysfunction

Effects of Alcoholism Social • Physical/sexual abuse of partner • Divorce • Child abuse • Later alcoholism in children • Family disharmony • Employment: Decrease productivity, increase accident at work -> eventual loss of job • Accidents – 80% fatal car accidents involve alcohol

Stages of Alcoholism Pre-alcoholic: It is characterized by a gradual change in socially motivated drinking to a means of relieving personal tension. Prodomal phase: Begins when the need for alcohol is no more social, rather it is psychological. Crucial Phase: There is loss of behavioural control, drinking become conspicuous and difficult to stop. He does not like correction and becomes aggressive. There is a decrease in sexual drive and malnutrition sets in.

Stages of Alcoholism • The Chronic Phase: There is marked ethical deterioration, impairment of thinking and can drink with anyone regardless of status. • He has lost complete control and he gets hopelessly and helplessly drunk. • He starts to loose tolerance for alcohol because of Liver damage. He now accepts defeat and is ready for treatment

Long Term Treatment (a) Apomorphine (b) Antabuse (Disulfiram) (c) Psychotherapy – Group therapy • Individual counseling (d) Alcoholics Anonymous (A. A. ) • Psychological care, • Physical care, • Diet • General observations • Rehabilitation of patient

Sedatives, Hypnotics, and Anxiolytics • This includes all CNS depressants: barbiturates, nonbarbiturate hypnotics, and anxiolytics particularly benzodiazepines. • Benzodiazepines and barbiturates are the most frequently abused drugs in this category • They cause drowsiness and reduce anxiety, which is their intended purpose • Intoxication symptoms include slurred speech, lack of coordination, unsteady gait

Sedatives, Hypnotics, and Anxiolytics • Benzodiazepines alone, when taken orally in overdose, are rarely fatal but the person will be lethargic and confused. • Treatment includes gastric lavage followed by ingestion of activated charcoal and a saline cathartic; dialysis can be used if symptoms are severe • Barbiturates overdose can cause coma, respiratory arrest, cardiac failure, and death. • Treatment in an intensive care unit is required using lavage or dialysis

Stimulants (Amphetamines, Cocaine, Caffeine, Nicotine, Others) • Drugs that stimulate or excite the CNS • The effects, intoxication, and withdrawal symptoms of these drugs are virtually identical • Stimulants have limited clinical use • The two most prevalent and widely used stimulants are caffeine and nicotine. • Caffeine a common ingredient in coffee, tea, colas, and chocolate. • Nicotine in tobacco products. • When used in moderation, these stimulants tend to relieve fatigue and increase alertness.

Cocaine • The most potent and highly addictive stimulant extracted from the leaves of the coca plant (erythroxylon coca) • Main route of intake is by inhalation – sniffing into the nostrils. It can also be injected • Amphetamines • Used for medical purposes through the 1960 s, but recognition of their abuse potential has sharply decreased clinical use (narcolepsy) • Because of their pleasurable effects, CNS stimulants have a high abuse potential.

Clinical effects • Excitements, increase energy, euphoria, dilated pupils, tachycardia, hypertension Adverse effects • Grandiose thinking, impaired judgement, sexual indiscretion • Higher dose -> visual and auditory hallucination • Paranoid ideation, violent behaviour • Formication (Cocaine bug) • Cardiac arrythmia, myocardial infarction, myocarditis, cardiomyopathy • Seizure, respiratory arrest • Perforation of the nasal septum (from sniffing)

Management • Acute intoxication – sedation with benzodiazepine and /or antipsychotics • Detoxification • Individual / group therapy • Harm reduction • Cognitive behavioural therapy (CBT)

Inhalant Abuse and Dependence • Inhalant disorders are induced by inhaling the aliphatic and aromatic hydrocarbons found in substances such as • fuels, solvents, adhesives, aerosol propellants, and paint thinners. • Specific examples of these substances include • gasoline, lighter fluid, glue, cleaning fluids, spray paint, and typewriter correction fluid. • Inhalant substances are readily available, legal, and inexpensive. • Hence, the drug of choice among the poor and among children and young adults.

Inhalant Abuse and Dependence Methods of use include • Huffing—a procedure in which a rag soaked with the substance is applied to the mouth and nose • Bagging—the substance is placed in a paper or plastic bag and inhaled from the bag by the user. • The substance may also be inhaled directly from the container, or sprayed in the mouth or nose. • Tolerance and withdrawal syndrome is possible with heavy use but not clinically significant • Intoxication: Dizziness Nystagmus, Incoordination, Slurred speech, Unsteady gait, Lethargy Depressed reflexes Psychomotor retardation

Opioid Abuse and Dependence • The term opioid refers to a group of compounds that includes opium, opium derivatives, and synthetic substitutes • They are popular drugs of abuse because they desensitize the user to both physiologic and psychological pain and induce a sense of euphoria and well being. • They have euphoriants and anxiolytic properties. • Drugs in this group include – Heroine, morphine, codeine and synthetic opiate-like drugs such as Meperidine, Methadone Propoxyphene, Pentazocine, Fentanyl , methadone, and dipipanone

Opioid Abuse and Dependence • Methods of administration of opioid drugs include oral, snorting, or smoking, and by subcutaneous, intramuscular, and intravenous injection. • Opioid intoxication develops soon after the initial euphoric feeling; symptoms include apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory. • Severe intoxication or opioid overdose can lead to coma, respiratory depression, pupillary constriction, unconsciousness, and death.

Management • Detoxification: - treat symptomatically • Loperamide or metochlorpramide – GIT symptoms • Analgesic - NSAIDs for pains • Methadone – used to replace heroine in patient dependent on heroine because it has a long half life (24 – 48 hrs) • Opioid Antagonist – Naltrexone, Naloxone • Rapid Opioid detoxification – Netrexone is given in conjunction with heavy sedation, sometimes general anaesthesia

Harm reduction • Methods of managing drug users in which it is accepted that steps can be taken to reduce the mortality and morbidity for the user without necessarily insisting on abstinence from drugs. Strategies include: Use of safer drugs or safer routes of administration Safer injecting practice Safe sex Prescription of maintenance opiates or benzodiazepines Assessment and treatment of co-morbid physical or mental illness • Engagement with other sources of help (social work, housing) • • •

Cannabis (Marijuana) Abuse and Dependence • It occurs naturally in the plant Cannabis sativa, which grows readily in warm climates. • It can be produced from the dried leaves, flowers, stems and seeds of the plant • It contains about 60 psychoactive cannabinoids, the most important of which is delta-9 tetrahydrocannabinol (THC). Methods • Smoked alone or with cigarette • Resin form may be eaten directly or • Incorporated into food stuffs

Cannabis (Marijuana) Abuse and Dependence • There has been some controversy in the past over their classification • At moderate dosages, they produce depressant effects but not classify as CNS depressants • Although they are legally classified as controlled substances, they are not narcotics, . • In very high dosages they can induce hallucinations, but are not hallucinogens. • They are not sedative-hypnotics, although they most closely resemble these substances.

Clinical Effects of Cannabis • Exaggeration of the preexisting mood • Increased enjoyment of aesthetic experiences • Distortion of the perception of time and space • Reddening of the eyes, increase appetite • Dry mouth • Irritation the respiratory tract Adverse effect include: • Anxiety , mild paranoid ideation, toxic confusional state and psychosis • Amotivational syndrome

Management • Detoxification • If psychotic – Antipsychotic drug • Group/individual psychotherapy , Cognitive Behavioral Therapy • Abstinence is the goal of therapy

Hallucinogen Abuse and Dependence • Substances capable of distorting an individual’s perception of reality and induce hallucinations • They are sometimes referred to as “mind expanding. ” • Examples are mescaline, psilocybin, lysergic acid diethylamide (LSD), and Phencyclidine (PCP) • Recurrent use can produce tolerance, encouraging users to resort to higher and higher dosages • No evidence of physical dependence when the drug is withdrawn; however, recurrent use appears to induce a psychological dependence which varies according to the drug, the dose, and the individual user

Hallucinogen Abuse and Dependence • Intoxication is marked by several maladaptive behavioral or psychological changes such as: • anxiety, depression, paranoid ideation, ideas of reference, fear of losing one’s mind and jumping out a window in the belief that one can fly • Physiologic symptoms include • sweating, tachycardia, palpitations, blurred vision, tremors, and lack of coordination • Benzodiazepines may be prescribed to prevent harm to the client or others • Group therapy • Counseling

Assessment of Patients • Biodata – name, age, address etc • Reason for consultation: pressure from family, pending conviction, increase difficulty injecting • Current drug use – ask about each drug taken over the previous 4 weeks, frequency of use and no of times taken each day. Amount taken and route. Episodes of withdrawal and about tolerance • IV user – find out about needle or other equipment sharing • Lifetime drug use: Age of first use of drug, changing pattern of drug use, period of abstinence or stability reason for this (Prison, relationship, treatment programme)

Assessment of Patient • Complication – overdose (deliberate or accidental), cellulitis abscesses, phlebitis, hepatitis B & C and HIV status if known • Previous treatments and psychiatric history • Family history – drug use especially alcohol • Social history – accommodation, sexual orientation and no of partners • Forensic history – previous or pending conviction, imprisonment • Patient’s aims in seeking treatment: what is the patients attitude to drug use. What treatment option he/she favours

Assessment of Patients • MSE- look for objective signs of depressed mood, suicidal thought or plan, anxiety and panic attack. Paranoid ideas and hallucinatory experience and relationship with drug. • Physical exam: sign of IV use (Needle tracks, phlebitis, abscess, old scarring) liver – enlarged? Signs of drug withdrawal • Investigation – depends on history and examination • Urine screening

Nursing Diagnoses • Ineffective Denial – related to weak, underdeveloped ego evidenced by statements indicating no problem with substance use • Ineffective Role Performance • Imbalanced nutrition ↓ than body requirements – related to use of substances instead of eating evidenced by weight loss, pale conjunctiva and mucous membranes • Risk for injury – related to tremors, elevated blood pressure, hallucinations, illusions, tachycardia • Risk for suicide – related to intense feelings of lassitude and depression

Nursing Diagnoses • Dysfunctional Family Processes: Alcoholism • Ineffective Coping – related to Inadequate coping skills and weak ego evidenced by use of substances as a coping mechanism; manipulative behavior • Chronic low self-esteem • Deficient knowledge – related to SU evidenced by continues to use substance in light of obvious consequences

Nursing Interventions for SUD • Health teaching for the client and family • Dispel myths surrounding substance abuse • Decrease codependent behaviors among family members • Make appropriate referrals for family members • Promote coping skills • Role-play potentially difficult situations • Focus on the here-and-now with clients • Set realistic goals such as staying sober today