SUBSTANCE ABUSE DISORDERS

1. SUBSTANCE ABUSE DISORDERS

2. Substance abuse disorders Drug use – when drugs are used to treat an illness, prevent a disease and improve health condition, it is termed drug use Drug abuse – intake of drugs for reasons other than medical in a manner that affect physical or mental functioning is termed drug abuse. Tolerance – it refers to a condition where the user needs more and more of the drug to experience the same effect. Smaller quantities, which were sufficient earlier, are no longer effective and the user is forced to increase the amount of drug intake

3. Intoxication - it is a condition that follows the administration of a psychoactive substance and results in disturbance in the level of consciousness, cognition, perception, judgment, affect, or behavior, or other psych physiological functions and responses. Dependence – dependence syndrome is a cluster of physiological, behavioral, and cognitive phenomena in which the use of a substance or a class of substances taken on a much higher priority for a given individual than other behaviors that once had greater values

4. Psychological dependence – psychological or psychic dependence refers to the experience of impaired control over drinking or drug use while physiological or physical dependence refers to tolerance and withdrawal symptoms. Harmful use – pattern of psychoactive substance use that is causing damage to health. It may be physical or mental

5. Abuse – in DSM IV, psychoactive substance use is defined as a maladaptive pattern of use indicated by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the recurrent use in situations in which it is physically hazardous. Withdrawal symptoms - when the drug intake is stopped, withdrawal symptoms are experienced. Physical dependence gives rise to withdrawals such as tremors and vomiting. Psychological dependence causes withdrawal symptoms like restlessness or depression.

6. Definition DSM-IV, ‘psychoactive substance abuse’ is defined as a maladaptive pattern of use indicated by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the recurrent use in situations in which it is physically hazardous.

7. Epidemiology 14 million of U.S population reported current use of illicit drugs Almost 6% of the population were heavy drinkers WHO indicates 180 million people of the world’s population consumed illicit substances The most commonly consumed substance was cannabis, used by 144 million people of the world’s population Annual prevalence of cannabis abuse among people aged 15-64 in India is 3.2%

8. Classification of addictive drugs Narcotic Analgesics Stimulants Depressants Hallucinogens Cannabis Volatile Solvents Other drugs of abuse (muscle relaxants, painkillers, anti histamines, anti emetics, antipsychotics )

9. Commonly abused drugs in India Cannabis (bhang, ganja, charas) Tranquilizers (hypnotics, sedatives) Barbiturates Amphetamines Hallucinogens Narcotic drugs (opium, pethidine, morphine, morphine, heroin, cocaine) Tobacco (cigar, cigarette, beedi, hukka ) Other substances such as alcoho,inhalants, steroids

10. ICD 10 classification F10-F19 Mental and behavior disorders due to psycho active substance use F10 Mental and behavioral disorders due to use of alcohol F11 Mental and behavioral disorders due to use of opioids F12 Mental and behavioral disorders due to use of cannabinoids F13 Mental and behavioral disorders due to use of sedatives or hypnotics F14 Mental and behavioral disorders due to use of cocaine F16 Mental and behavioral disorders due to use of hallucinogens

11. Causes of substance abuse Biological factors Genetic vulnerability Co morbid psychiatric disorders Co morbid medical disorders Reinforcing effects of drugs Withdrawal effects and craving Biochemical factors

12. Psychological factors Curiosity Early initiation of alcohol and tobacco Poor impulse control Sensation seeking Low self esteem Concern regarding personal autonomy Poor stress management skills Childhood trauma or loss Psychological distress Escapism

13. Social factors Peer pressure Modeling Easy availability Interfamilial conflicts Religious reasons and cultural factors Poor social and familial support Rapid urbanization Role of media Popularity of drugs in various profession

14. Risk factors Chaotic home environment Ineffective parenting Lack of nurturing and parental attachment Inappropriately aggressive or shy behavior in classroom Poor social coping skills Poor school performance Association with deviant peer group Perception of approval of drug use behavior

15. Stages of substance abuse Stage 0 –showing curiosity : it is the first stage and it is the beginning of substance abuse Stage 1- learning about the drug induced mood swings : the teen learns more about use of drugs Stage 2- seeking the drug induced mood swings : learns to seek the heights of psychological effects Stage3 – being preoccupied with the drug induced mood swings: behavior changes to stealing, truancy, lying, drug dealing etc Stage 4- burnout : at this stage they use drug just to feel normal, euphoric effects may be low.

16. Opioid use disorders The commonly abused opioids – heroin, brown sugar, smack Synthetic preparation – pethidine, fortwin, buprenorphine Acute Intoxication Apathy Bradicardia Hypotension Respiratory depression, subnormal temperature Pin point pupils, thready pulse, coma

17. Withdrawal syndrome Withdrawal syndrome Watery eyes Running nose Yawning Loss of appetite Irritability Tremors Sweating Cramps Nausea Diarrhea Insomnia Raised body temperature Piloerection Anorexia The symptoms start with in 12 hrs, lasts to 24-36 hrs and disappear in 5-6 days

18. Complications Parkinsonism Peripheral neuropathy Transverse myelitis Skin infection Thrombophlebitis Pulmonary embolism Endocarditis Septicemia AIDS, viral hepatitis Tetanus

19. Treatment Narcotic antagonists (naloxone, naltrexone) Detoxification (methadone, clonidine, naltrexone, buprenorphine) Maintenance therapy (methadone maintenance, opioid antagonists, individual therapy, group therapy, family therapy)

20. Cannabis use disorder The dried leaves and flowering tops are often referred to as Ganja or Marijuana The resin of the plant is referred to as Hashish Bhang is a drink made from cannabis Cannabis is either smoked or taken in liquid form

21. Acute intoxication Tremors Photophobia Lacrimation Dry mouth Increased appetite Perceptual disturbances Mild impairment of consciousness and orientation Tachycardia Sense of floating in the air Euphoria Dream like state ‘flashback’ phenomena Alteration in psychomotor activity

22. Withdrawal symptoms Mostly found in 72-96 hours Increased salivation Hyperthermia Insomnia Decreased appetite Loss of weight Insomnia

23. Complications Transient or short lasting psychiatric disorders Acute anxiety Paranoid psychosis Hysterical fugue Hypomania Schizophrenia like state Amotivational syndrome Memory impairement

24. Cocaine use disorder Common street name is’crack’ It is taken orally, intranasally or parenterally Acute Intoxication Pupillary dilation Tachycardia Hypertension Perspiration Nausea Hypomanic symptoms

25. Withdrawal syndrome Agitation Depression Anorexia Fatigue Sleepiness Complications Acute anxiety reaction Uncontrolled compulsive behavior Seizures Respiratory depression, cardiac arrhythmias

26. Treatment Management of intoxication ( Amyl nitrate is antidote, diazepam or propranolol is used) For withdrawal symptoms (antidepressants and psychotherapy) Imipramine or amitriptiline

27. Amphetamine use disorder They are CNS stimulants Commonly used amphetamines are pemoline and methylphenidate Acute Intoxication Tachycardia pupillary dilation Hypertension insomnia Cardiac failure restlessness Seizures irritability Tremors paranoid hallucinatory syndrome hyperpyrexia

28. Withdrawal syndrome Depression Apathy Fatigue Hypersomnia Insomnia Agitation Hyperphagia Complication Seizures, delirium Arrythmias, aggression, coma

29. Barbiturate use disorder Commonly abused barbiturates are secobarbital, pentobarbital and amobarbital Intoxication Irritability Lability of mood Disinhibited behavior Slurred speech Incoordination Attention and memory impairment

30. Complications Withdrawal syndrome IV use lead to skin abscesses Cellulitis Infections Embolism Hypersensitivity reactions Severe restlessness Tremors Seizures Delirium tremens like state

31. Treatment Induction of vomiting (in conscious patients) Use of activated charcoal (to reduce absorption) Symptomatic treatment

32. LSD use disorder (Lysergic acid diethylamide) LSD is a hallucinogen First synthesized in 1938 It acts on 5 HT levels of brain “trip” is the term used for the pattern of LSD use (occasional use followed by long term abstinence)

33. Intoxication Perceptual changes Depersonalization Illusions Synesthesias (colours are heard, sounds are felt) Autonomic hyperactivity Anxiety Paranoid ideation Impaired judgement

34. Withdrawal syndrome Complications Flashbacks Hallucinogenic states Anxiety Depression Psychosis Visual hallucinations Treatment is symptomatic, including, antianxiety, antidepressant and antipsychotic medications

35. Inhalants or volatile solvent use disorders Commonly used substances are petrol, aerosols, thinners, varnish remover and industrial solvents Intoxication Euphoria Excitement Belligerence Slurred speech Apathy Impaired judgment

36. Withdrawal symptoms Complications Anxiety Depression Treatment includes reassurance and diazepam for intoxication Irreversible damage to liver and kidneys Peripheral neuropathy Perceptual disturbances Brain damage

37. Treatment CBT Multidimensional family therapy Motivational interviewing Contingency management (motivational incentives) Aversion therapy Group therapy Counselling Residential treatment (therapeutic community, 6-12 months, for drug free re socialization)

38. Nursing management Assessment Nursing diagnosis Background Substance use Mental health problems Psychological tests Mental status examination Anxiety Disturbed sleep pattern Altered nutrition less than body requirement Impaired social interactions Low self esteem Ineffective individual coping Risk for violence

39. Prevention of substance use disorders Primary prevention Enhance government restrictions Strengthen individuals coping skills Health education to college students Identify and treat family member who may contribute to drug abuse

40. Secondary prevention Early detection and counselling Motivational interviewing Complete assessment to elicit the extend of problem Detoxification with benzodiazepoxide

41. Tertiary prevention Relapse prevention Assertive training Teach coping skills Behavior counseling Psychotherapy Supportive psychotherapy Guidance and counseling Motivation enhancement Dealing with faulty cognition Time management Anger control Financial management Stress management Recreation and spirituality Family counseling

42. Rehabilitation Goals Interventions To enable the drug dependent to leave the drug To establish new social contracts To provide social support To inculcate responsibility in protecting themselves Participation in day care centers Occupational and social rehabilitation Teaching relaxation techniques Religious therapy Enhance self esteem Participation in self help groups

43. Follow up and home care Nurses should be hopeful and appropriately supportive Teach patient / family about the various complications of abuse Explain to the family, that patient may use lies, denial or manipulation to continue drug Teach them drug overdose may result in emergency/ death Caution patient about transferring HIV or hepatitis B Teach family to develop trust with patient and help in setting limits Provide patient the full range of treatment and supportive measures Teach them how to recognize psychological stressors and way to cope with that Help to establish new life style.

44. ALCOHOLISM

45. INTRODUCTION Alcoholism is the most common psychiatric disorder. Epidemiological studies carried out in India revealed that 20 to 40% of subjects aged above 15 are current users. Nearly 15 to 30% of patients seeking admission in psychiatric facilities are for alcohol related problems. Alcoholism is classified under F10-F19, i.e. mental and behavior disorders due to psychoactive substance use in ICD 10 classification

46. DEFINITION Alcoholism refers to the use of alcoholic beverages to the point of causing damage to the individual and society or both. Alcoholism is defined as a chronic disease manifested by repeated drinking that produces injury to the drinker’s health or to his society or economic functioning.

47. PREVALANCE In India the incidence of alcohol dependence is 2% and 20 to 40% of population aged above 15 are current users.

48. WHAT IS ALCOHOL? Alcohol includes liquors, beer and wine. Chemical name: ethanol Street names: booze, hooch, moonshine, sauce etc.. Mode of administration: oral

49. HOW IT ACTS? • Acts on CNS in two ways • It potentiates GABA activity • It decreases glutamate activity In both cases the outcome is depression.

50. PROPERTIES OF ALCOHOL Clear colored liquid Strong burning taste Rate of absorption into blood is more faster than its elimination rate. Absorption is slower in the presence of food A small amount is excreted through urine and small amount is exhaled.