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Substance Abuse
• Continued use despite related problems• Recurrent use resulting in neglect of role
functions• Continued use despite recurrent social/legal
problems• Recurrent use in hazardous situations
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Dependence Criteria At least 3 of the following
• Use of amounts greater than intended • Attempts to cut down or control • Excessive time spent in getting, using,
recovering • Use despite recurrent problems
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Dependence (addiction) Criteria
• Presence of tolerance (more needed for effect)
• Presence of withdrawal symptoms • Substance often taken to relieve or avoid
withdrawal
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Dual Diagnosis
• Pts with Schizophrenia more than 4 x likely to have substance use disorder
• Pts with Bipolar disorder more than 5 x likely
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Alcoholism in the U.S.
• 14 Million cases & 200,000 deaths/yr • Accounts for:– 50% of auto fatalities– 33% of suicides– 67% of murders
• Life expectancy reduced 10-12 years• Economic cost $60 billion yearly
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CAGE
• Cut down (have you tried to cut down)• Annoyed by criticism• Guilty (do you feel guilty for drinking too
much)• Eye-opener• (put star by this… good one to remember)• There are number of these to look at in the
book
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Alcoholism
• Vivid memory of first drink• Self medication with alcohol• Controlled drinking• Social crutch• Frequent accidents
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Alcoholism continued
• Personality change• Suicidal attempt• Elevated blood pressure• Alcohol myopathy (pain or edema in muscles)• Denial• Family enabling denial (family covers up for
person)
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Predisposing Factors
• Biological, Genetic, Biochemical • Psychological links– depression, anxiety, antisocial & dependent
personality• Sociocultural Factors– nationality & ethnicity (native american’s, Irish)– religious beliefs– gender differences (
– Male sons of alcoholic fathers are 4X more likely
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Medical Complications
• Hepatic- ascites, wt.loss, cirrhosis• Gastrointestinal-esophagitis; esophageal varices
(vessles in esophagus ruptures)• Cardiovascular-cardiomyopathy• Neurological-neuropathy• Nutritional-thiamine (decrease)• Infectious diseases• Obstetrical (fetal alcohol syndrome)• Myopathy: pain, edema in muscles, increased CPK, wasting & weakness. GI: esophagitis,
esophageal varices. Cardiovascular: cardiomyopathy. GI: esophagitis, esophageal varices. Cardiovascular: cardiomyopathy. Neurological: neuropathy. Nutritional: thiamine
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Wernicke-Korsakoff Syndrome
• Wernicke encephalopathy (most serious form of Thiamine deficiency)– confusion– ataxia– abnormal eye movements
• may be treated with large doses of thiamin, but if it progresses to alcoholic amnestic syndrome (Korsakoff’s) the prognosis for reversal of memory loss is poor
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Wernicke-Korsakoff syndrome
• Korsakoff’s Psychosis– Thiamin dementia
• alcohol reduces absorption
• Alcohol amnesiac disorder– recent memory impaired– appear apathetic
– (need to know what it is & that it is a terrible form of thiamine deficiency)
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Alcohol Withdrawal Syndrome
• 6 hrs after fall in BAC; peaks 24-36 hrs subsides 48 hrs
• Tremulousness • Anorexia, N& V• Tachycardia, increased BP• Irritability, hyperreflexia, insomnia• Diaphoresis• Possible seizures (6-48 hours)
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Alcoholic hallucinosis about 48 hours after last drink
• Hallucinations (auditory) • Delirium (visual)• Tactile (feel like things are crawling on them)
often they will deny these hallucinations… ask them about nightmares… may admit to the nightmares)
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Acute Hallucinosis
• Don’t Leave Alone• Nonstimulating Environment• Sedate• Reassure• Restrain? (last resort, only to prevent harming
self… falling out of bed)• Prevent Injury
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Delirium Tremens -DTs
• Medical emergency; 5% -10% fatal• 3-5 days after last drink• Exaggeration of earlier sx plus– Disorientation– Paranoia, delusions– Visual Hallucinations– Elevated VS, vomiting, diarrhea, diaphoresis
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Intervention for Alcohol Withdrawal
• Benzodiazepines (Librium) Carbamezepine (Tegretol) Thiamine
• Seizure precautions• Safety and fall precautions• Maintain nutrition & hydration needs• Decrease environmental stimuli• Reorient when indicated
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Abstinence
• Antabuse• Topamax (anticonvulsant)• Naltraxone• Revax• Campral
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Alcoholics Anonymous; Women for Sobriety; Rational Recovery
• Education re: alcohol• Group support/forgiveness• Family involvement• Alleviation of loneliness• Confession/catharsis• Opportunity to help others• AA has religious component… • (smart, belonging is important)
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Cocaine
• Status seekers-yuppies• Aging marijuana smokers• Medical misinformation (in past thought there
weren’t good side effects)• Celebrity endorsements (in movies) • Myths, denial, psychopharmacology• South American Indians stuff a wad of coca leaves in a cheek or brew them as tea. The
leaves are dissolved in hydrochloric acid to produce cocaine hydrochloride. Can be boiled in a solution of baking soda, smoked in a pipe like crack
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Cocaine
• Interacts with dopamine • Animals choice over drug or food• Sexually deprived monkey (in laboratory) – will choose cocaine over a monkey in heat
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Effects of cocaine
• Euphoria• Mental stimulation• Sexual stimulation• Energy• Sociability
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Crash
• Rebound dysphoric reaction• Restlessness & irritability• Craving• Depression• Sexual disinterest, impotence• Fatigue, memory & concentration problems
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Toxic consequences of Cocaine
• Panic anxiety reaction• Agitation & confusion• Increased pulse rate • Increased pupil size• Seizures
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Toxicity continued
• Cardiac Arrest• Violent or suicidal behavior• Paranoid Psychosis– no Haldol or Mellaril when in toxic state
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Marijuana
• Amotivational syndrome• Toxic psychosis• Gynecomastia• (second only to alcohol as most widely abused
drug in the US)• All kinds of side effects (listed in book… read chapter in text) • Greater amts of tar than tobacco… abnormal sperm count, CNS on high, tremors, impairment
of judgment, cannabis toxication, impaired motor coordination
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Opiates
• Opium, heroin• Meperidine, morphine• Codeine, methadone• Oxycontin, lortab, vicoden,• (oxycodone in percodan, • Hydrocodone: hycodon, vicodin, lortab)
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Opiate Withdrawal
• Anorexia• Stomach cramps and diarrhea• Lacrimation, rhinorrhea• Muscle aches• Mild elevation in V.S• Profuse sweating• Insomnia, agitation, depression, anxiety• Irritability & restlessness
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Physical Symptoms
• Dilated pupils• Diarrhea• Rhinorrhea• Piloerection (raised hair on arm)• Tremors
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Intervention for narcotic withdrawal
• Clonidine (Catapres)• Cyclobenzaprine (Flexeril): muscle relaxant• Suboxone –Sublingual preparation– Part Opiate– Part Anti-Opiate
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Suboxone
• 4 parts Buprenorphine 1 part Narcan• Buprenorphine (a partial agonist)– Gives pt. enough opiate to alleviate sx of
withdrawal
• Naloxone (Narcan) An antagonist• Prevents abuse from injection
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Nicotine Dependence
• Most damaging drug to society !!!• Classified by FDA as an addictive drug• Causes impotence!• Pts require larger doses of SSRIs• Zyban may decrease craving
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Agents to Maintain Abstinence
• Alcohol– Naltrexone, Disulfiram (Antabuse) topamax is an
anticonvulsant…• Cocaine – Bromocriptine (Parlodel), Carbamazepine
• Opiates – Methadone, Naltrexone
• Nicotine – Zyban (Wellbutrin sr)
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Hallucinogens
• LSD; PCP; Inhalants (flashback w/ LSD)• Reassurance• “Talk down”• Safe environment, minimal stimulation• Do not touch
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Behaviors of Abuse & Dependence
• IV Drug use• Accidents, violence, self neglect• Skin Abscesses, Cellulitis• Hepatitis B (HBV)• Bacterial Endocarditis• HIV (AIDS)
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Codependent Behaviors
• Fulfills Others Needs (ACOA ??) child ends up taking care of the parents
• Anxiety Around Intimacy• Boundary Distortions• Enmeshment• Denial• Depression, Anxiety, Addictions• Stress-Related Medical Illness
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CNS Depressants
• Barbiturates– Seconal, nembutal, amytal, phenobarbital– drowsiness, tolerance– popular street drugs– physical and psychological dependence
• Benzodiazepines (1960s) – Valium, Xanax, Librium, Dalmane
• Withdrawal from CNS Depressants most dangerous
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Ecstasy
• Methylenedioxymethamphetamine (MDMA)• Affects serotonin• Euephoria, increased energy & sexual arousal• Suppresses need to eat, drink or sleep• Fever, muscle breakdown, kidney & heart
failure, death
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Ecstacy
• Brain damage worse for women• Persistent memory problems• Problems with verbal reasoning & attention• Amphetamines are cleared more quickly in
the presence of testosterone
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Flunitrazepam Rohypnol “roofies” forget pill
• Physiological effects similar to diazepam (Valium) but 10 times more potent!
• Adverse: decreased blood pressure, memory impairment, drowsiness, visual disturbances, dizziness, confusion, gastrointestinal and urinary retention
• Ingested orally, frequently in conjunction w/ alcohol or other drugs. Effects begin w/in 30 min., peak w/in 2 hours & may persist for up to 8 hours.
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Rohypnol
• Classified as a depressant (benzodiazepine) but can induce excitability or aggressive behavior
• Withdrawal: headache, muscle pain, numbness, anxiety, tension, confusion,
• Hallucinations, delirium, convulsions, shock and cardiovascular collapse
• W/drawl seizures can occur a week or more after cessation of use• AKA date rape drug
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GHB
• Gamma Hydroxy Butyrate “G”• Used by ecstasy users to prolong high• Odorless, tasteless and colorless• Clear liquid (visine bottle)• Causes muscle weakness & amnesia!– Allergic reactions: seizures, coma, death
• Detection through urine testing