SUBSTANCE USE DISORDER

- Mr. Manish BijalwanM.Sc Nursing 1st yr

SCON

TERMINOLOGY

Substance: Any physical matter Abuse: Wrong or harmful use Dependence: a compulsive or chronic

requirement Addiction: uncontrolled and

compulsive use Psychoactive substance: one that is

capable of altering the mental functions

DSM-V

Substance abuse or substance

dependence disorders are merged into substance use

disorder.

DEFINITIONS: SUBSTANCE ABUSE: Any use of substances that poses

significant hazards to health.

SUBSTANCE DEPENDENCE: A cluster of cognitive, behavioral

and physiological symptoms indicating that the individual continues use of the substance despite substance related problems (APA)

DEFINITIONS:

SUBSTANCE USE DISORDER:

A disorder in which the use of one or more substances leads to a clinically significant impairment or distress

PSYCHOACTIVE SUBSTANCES

1. Alcohol2. Opioids (opium,

heroin)3. Cannabinoids

(cannabis)4. Cocaine5. Amphetamines

and other sympathomimetics

6. Hallucinogens (LSD,

phencyclidine)7. Sedatives and

hypnotics (barbiturates)

8. Inhalants (volatile solvents)

9. Nicotine10.Other stimulants

(caffeine)

ETIOLOGY

1.BIOLOGICAL FACTORS: Family history Co morbid psychiatric disorders Co morbid medical disorders Reinforcing effects of drug use Withdrawal effects of drug use Biochemical factors

ETIOLOGY

2.PSYCHOLOGICAL FACTORS: Curiosity Early initiation

of alcohol or tobacco

Poor impulse control

Low self esteem Poor stress

management

skills Childhood

trauma or loss Relief from

boredom/ fatigue

Escape from reality

Psychological stress

Lack of goals

ETIOLOGY

3.SOCIAL FACTORS: Peer pressure Modeling Ease of

availability of alcohol or drugs

Intrafamilial conflicts

Religious

reasons Poor social/

familial support

Perceived distance within the family

Rapid urbanization

SUBSTANCE ABUSE

ADDICTIONDEPENDENC

Y

TOLERANCE

WITHDRAWAL

CLASSIFICATION:

1.ACUTE INTOXICATION2.WITHDRAWL STATE3.DEPENDENCY SYNDROME4.HARMFUL USE

CLASSIFICATION:

1.ACUTE INTOXICATION Administration of alcohol or other

psychoactive substances resulting in disturbances in the level of consciousness, cognition, perception, affect or behavior. high level in blood Low threshold (CRF) Idiosyncratic sensitivity

CLASSIFICATION:

1.ACUTE INTOXICATION Features

Trauma Delirium Coma Perceptual distortions Convulsions Alcohol intoxification (liver

cirrhosis)

CLASSIFICATION:

2.WITHDRAWL STATE Cluster of symptoms often

specific to drugs used, develop on total or partial withdrawal of drug

uncomplicated With convulsions With delirium

CLASSIFICATION:

3.DEPENDENCE SYNDROME Features:

Strong desire Sense of compulsion Difficulty in controlling Physiological withdrawal state Evidence of tolerance Neglect of alternative pleasures Persistant use of substance

CLASSIFICATION:

3.DEPENDENCE SYNDROME Types:

a) Physical dependenceb) Psychic dependencec) tolerance

S.NO

PSYCHOACTIVE SUBSTANCE

ROUTE PHYSICAL DEPENDEN

CE

PSYCHICDEPENDENC

E

TOLERANCE

1 Alcohol Oral moderate moderate mild

2 Opioids Oral, parentral, smoking

severe severe severe

3 Cannabis Oral, smoking

probable moderate Mild

4 Cocaine Oral, parentral, smoking,Inhalation

Little moderate nil

5 Amphetamines

Oral, parentral

moderate moderate severe

S.NO

PSYCHOACTIVE SUBSTANCE

ROUTE PHYSICAL DEPENDE

NCE

PSYCHICDEPENDEN

CE

TOLERANCE

6 Barbiturates Oral, parentral

moderate moderate Severe

7 Benzodiazepine

Oral, parentral

mild mild Mild

8 Volatile solvents

Inhalation

little moderate mild

9 caffeine Oral mild moderate mild

10 nicotine Oral, smoking

mild moderate mild

CLASSIFICATION:

4.HARMFUL USE continued drug use

despite the awareness of harmful medical or social effect of the drug

SIGN & SYMPTOMS

1.Behavioral changes2.Physical changes3.Social changes

SIGN & SYMPTOMS

1.Behavioral changes Drop in attendance and performance at

work or school Frequently getting into trouble (fights,

accidents, illegal activities) Using substances in physically hazardous

situations such as while driving or operating a machine

Engaging in secretive or suspicious behaviors

SIGN & SYMPTOMS

1.Behavioral changes Changes in appetite or sleep patterns Unexplained change in personality or

attitude Sudden mood swings, irritability, or

angry outbursts Periods of unusual hyperactivity,

agitation Lacking of motivation Appearing fearful, anxious, or paranoid,

with no reason

SIGN & SYMPTOMS

2.Physical changes Bloodshot eyes and abnormally

sized pupils Sudden weight loss or weight gain Deterioration of physical appearance Unusual smells on breath, body, or

clothing Tremors, slurred speech, or impaired

coordination

SIGN & SYMPTOMS

3.Social changes Sudden change in friends,

favorite hangouts, and hobbies Legal problems related to

substance use Unexplained need for money or

financial problems Using substances even though it

causes problems in relationships

DIFFERENT SUBSTANCE USE DISORDERS

ALCOHOL USE DISORDER

Previously known as alcoholism

Common in males Onset is late second or third decades

May be associated with other drug use

TYPES OF AUDS.NO

ALCOHOL USE

DISORDER

FEATURES

1 ALPHA •Excessive and inappropriate drinking•For physical or emotional relief•Control present•Able to abstain

2 BETA •Excessive and inappropriate drinking•Cultural drinking pattern or poor nutrition•Physical complications present•No dependence

3 GAMMA •Malignant disorder•Physical dependency with tolerance and withdrawal symptoms•Psychological dependency with lack of control

TYPES OF AUDS.NO ALCOHOL

USE DISORDE

R

FEATURES

4 DELTA •Inability to abstain•Tolerance•Withdrawal symptoms•Amount of consumption can be controlled•Minimal social disruption

5 EPSILON Compulsive drinking-dipsomaniaSpree drinking

MARKERS OF ALCOHOL DRUG DEPENDENCE

1.Gamma Glutyl transferase (GGT): 40 IU/L

2.Mean corpuscular volume (MCV): more than 92fl (n=80-90fl)

3.Blood alcohol concentration (BAC)- more than 25%

4.Breathe analyser

COMPLICATIONS

1. ACUTE INTOXICATION:

Alcohol consumption

25-100% BAC

CNS depression

Excitation period

Increased reaction time

Slowed thinking,Poor motor control

COMPLICATIONS

2.WITHDRAWAL SYNDROME Common symptoms: Hangover in the next morning,

Mild Tremors, Nausea, vomiting, Weakness, Irriatability

Three types1. Delirium tremens (2-4 days)2. Alcoholic seizures(12-8 hrs)3. Alcoholic hallucinosis

TREATMENT

1. Detoxification (benzodiazepines)2. Behavioral therapy 3. Psychotherapy4. Group therapy5. Deterrent agents (disulfiram,

nitrafezol)6. Anti craving drugs (naltrexone,

SSRIs)7. Psychosocial rehabilitation

OPIOIDS USE DISORDER

Dried exudate obtained from unripe seed capsules of papaver somniferum (morphine, codeine, papaverine, heroin, pethidine)

Heroin commonly called “smack” or “brown sugar”

OPIOIDS USE DISORDER

ACUTE INTOXICATION: Apathy, bradycardia,

hypotension, respiratory depression, delayed reflexes, thready pulse, coma

OPIOIDS USE DISORDER

WITHDRAWAL SYMPTOMS: Appear within 12-24 hrs Peak 24-72 hrs Subside after 7-10 days Pupillary dilation, sweating,

lacrimation, yawning, insomnia, generalised bodyache, severe anxiety

TREATMENT IN OPIOIDS USE DISORDER

Naloxone challenge test Treatment of overdose Detoxification (methadone) Maintenance therapy (20-

50 mg/day methadone, 100mg naltexone/ 3 day and 150 mg on 5th day)

TREATMENT IN OPIOIDS USE DISORDER

Behavioural therapy Self control strategies Family therapy Group therapy

Cannabis

Route : smoking, ingestion Common names : Ganja, charas, bhang,

hashish Intoxication : altered state of awareness,

relaxation, mild euphoria, reduced inhibition, red eyes, dry mouth, increase appetite, increase pulse, decrease reflexes, panic reaction.

Over dose : toxic psychosis Withdrawal symptoms : irritability, difficulty

sleeping

Sedatives & Hypnotics

Barbiturates & benzodiazepines Depressant drug Route : Ingestion or injection Other names : Barbs, beans, downers,

candy, yellow jackets, yellows. Effects : depression of mood, cognition,

attention, concentration, insight, judgment, memory, affect; psychomotor impairment, increased reaction time, lack of hand to mouth coordination, motor ataxia, unconsciousness , coma , respiratory depression , death.

Withdrawal syndrome

Potential for Seizures, delirium and cardiovascular collapse

Insomnia, anxiety, profuse sweating, weakness

Must Be W/d Gradually

Stimulants

Amphetamines Route :-Ingestion

Common names:-AMT, bam, bennies, crystal, diet pills, dolls, eye openers, lid openers, Purple hearts, wake ups

Effects :-Euphoria, abrupt awakening, increased energy, talkativeness, elation, agitation, hyperactivity, irritability, grandiosity, pressured speech.

Cocaine Route :-Inhalation, Smoking, injection, Topical

Common names:-Bernice, big C, blow C, coke, dust, girl, sugar, white lady, crack.

Effects :-Increase temperature, blood pressure & pulse,

Tachycardia, ectopic heartbeats, chest pain, urinary retention, constipation, dry mouth

Stimulants

Over dose : seizure, cardiac arrhythmias coronary artery spasm, myocardial infarction, marked increase in B.P.& temperature that may lead to cardiovascular shock, convulsions, cardiac arrest & death.

Withdrawal Symptoms : intense & pleasant feelings of depression & fatigue & sometimes suicidal ideationAnxiety, anhedonia, sleep disturbance, increase appetite,

Cocaine abuse

It is a potent form of cocaine hydrochloride mixed with baking soda and water, heated (cooked), allowed to harden and then is broken or “cracked”into little pieces and smoked in cigarettes or glass water pipes.

Cardiac dysrhythmias, respiratory paralysis and seizures are some of the dangers associated with crack abuse

Cocaine abuse

INTOXICATION Increased Pulse And B.P. Euphoria and a Sense of Well Being Dilated Pupils Insomnia AnorexiaOVERDOSE Seizures Cardiac Arrest Convulsions & Death

Hallucinogens

LSD, Mescaline, peyote,psilocybin Route : ingestion, smoking

Intoxication : distorted perceptions, hallucinations (in presence of a clear sensorium) ; distortion of time space, illusions, depersonalizations, mystical experiences, heightened sense of awareness; extreme mood liability, tremor, dizziness, nausea & vomiting; increase temperature, pulse, B.P. & salivation ; panic reaction

Inhalants

Gasoline, glue, aerosol sprays, paint thinner

Route : Inhalation Intoxication : assaultive, apathy,

impaired judgment ; dizziness, nystagmus, incoordination, slurred speech, unsteady gait, depressed reflex, tremor, blurred vision, euphoria, anorexia.

Overdose : lethargy, stupor/coma, respiratory arrest, cardiac arrhythmia

Nicotine

Route : smoking, chewing, buccalCommon names : cigarettes, cigars, bidis, kreteks, pipe tobacco, snuff, chewing tobaccoIntoxication : feeling of pleasure, increased alertness, enhanced mental performance, increased heart rate & B.P. Withdrawal : anger, anxiety, depressed mood, difficulty in concentration, increased appetite & craving for nicotine.

Treatment goals

Abstinence Harm minimization Improvement of health, social &

occupational functions Improvement of quality of life.

Role of Nurse

Monitor vital sign, observe the patient care fully Decrease stimulation , provide care Evaluate the patient hydration and serum electrolytes Maintain intake output chart Care fully evaluate the patient – medcal/

surgical problem- head trauma,GI bleeding , hepatic disease, withdrawal from other drug.

Institute high calorie and high carbohydrate diet Add vit.thiamine 100 mg im than oral Folic 1 mg

PO daily for 7- 10 day Initiate pharmacotherapy