Chapter 14

1. Chapter 14 Substance-Related and Addictive Disorders

2. Substance use disorders • Substance abuse, substance dependence (addiction) • Substance induced disorders • Intoxication, withdrawal • Dementia, amnesia, psychosis, mood and anxiety disorders

3. Substance Use Disorder Substance dependence (Addiction) • Physical dependence • Need for increasing amounts to produce the desired effects (tolerance) • Syndrome of withdrawal upon cessation • Psychological dependence • Overwhelming desire to repeat the use of a particular drug to produce pleasure or avoid discomfort

4. Substance Use Disorder (cont’d) Substance Addiction (cont’d) • Use of the substance interferes with ability to fulfill role obligations • Attempts to cut down or control use fail • Intense craving for the substance • Excessive amount of time spent trying to obtain the substance or recover from its use

5. Substance Use Disorder (cont’d) • Substance Addiction (cont’d) • Use of the substance causes the person difficulty with interpersonal relationships or to become socially isolated • Engages in hazardous activities when impaired by the substance • Tolerance develops and the amount required to achieve the desired effect increases • Substance-specific symptoms occur upon discontinuation of use

6. Substance-Induced Disorders Substance Intoxication • Development of a reversible syndrome of symptoms following excessive use of a substance • Direct effect on the central nervous system • Disruption in physical and psychological functioning • Judgment is disturbed and social and occupational functioning is impaired

7. Substance-Induced Disorders (cont’d) Substance Withdrawal • Development of symptoms that occurs upon abrupt reduction or discontinuation of a substance that has been used regularly over a prolonged period of time • Symptoms are specific to the substance that has been used • Disruption in physical and psychological functioning, with disturbances in thinking, feeling, and behavior

8. Classes of Psychoactive Substances • Alcohol • Caffeine • Cannabis • Hallucinogens • Inhalants • Opioids • Sedatives/hypnotics • Stimulants • Tobacco

9. Predisposing Factors Biological factors • Genetics: apparent hereditary factor, particularly with alcoholism • Biochemical: alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction

10. Predisposing Factors (cont’d) Psychological factors • Developmental influences • Punitive superego • Fixation in the oral stage of psychosexual development S. Freud

11. Predisposing Factors (cont’d) Psychological factors (cont’d) • Personality factors:certain personality traits are thought to increase a tendency toward addictive behavior, including • Low self-esteem • Frequent depression • Passivity • Inability to relax or defer gratification • Inability to communicate effectively

12. Predisposing Factors (cont’d) Sociocultural factors • Social learning: children and adolescents more likely to use substances with parents who provide model for substance use • Use of substances may also be promoted within peer group

13. Predisposing Factors (cont’d) Sociocultural factors (cont’d) • Conditioning: pleasurable effects from substance use act as a positive reinforcement for continued use of substance • Cultural and ethnic influences: some cultures are more prone to substance abuse than others

14. Alcohol Use Disorder Patterns of use • Phase I. Prealcoholic phase: characterized by use of alcohol to relieve everyday stress and tensions of life. • Phase II. Early alcoholic phase:begins with blackouts—brief periods of amnesia that occur during or immediately following a period of drinking; alcohol is now required by the person. Feeling guilty but defensive about drinking

15. Alcohol use disorders Patterns of use (cont’d) • Phase III. The crucial phase:person has lost control; physiological dependence is clearly evident. S/S: binge drinking, anger, agression, loss of job, marriage or family • Phase IV. The chronic phase: characterized by emotional and physical disintegration. The person is usually intoxicated more often than sober. Severe withdrawal symptoms, depression, suicidal ideation

16. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body • Reversible depression of the CNS • At low doses, alcohol produces: • Relaxation • Lack of concentration • Drowsiness • Slurred speech • Sleep

17. Dynamics of Substance-Related Disorders (cont’d) • Alcohol intoxication: occurs at blood alcohol levels between 100 and 200 mg/dl • Alcohol withdrawal: occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use

18. Effects of alcohol on the body (chronic use or intoxication) • Peripheral neuropathy, characterized by • Peripheral nerve damage • Pain • Burning • Tingling • Prickly sensations of the extremities

19. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Alcoholic myopathy: thought to result from same B vitamin deficiency that contributes to peripheral neuropathy • Acute: sudden onset of muscle pain, swelling, and weakness; reddish tinge to the urine; rapid rise in muscle enzymes in the blood • Chronic: gradual wasting and weakness in skeletal muscles

20. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Wernicke’s encephalopathy: most serious form of thiamine deficiency in alcoholic patients • S/S: paralysis of ocular muscle, diplopia, ataxia, stupor • Korsakoff’s psychosis: syndrome of confusion, loss of recent memory, and confabulation in alcoholic patients

21. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Alcoholic cardiomyopathy: effect of alcohol on the heart is an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition • Arrhythmias, Congestive heart failure

22. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Esophagitis: inflammation and pain in the esophagus occurs because of the toxic effects of alcohol on the esophageal mucosa and also because of frequent vomiting associated with alcohol use

23. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Gastritis: effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention

24. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Pancreatitis • Acute: 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

25. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Pancreatitis (cont’d) • Chronic: leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus

26. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Alcoholic hepatitis • Caused by long-term heavy alcohol use • Symptoms: enlarged, tender liver; nausea and vomiting; lethargy; anorexia; elevated white cell count; fever; and jaundice. Also ascites and weight loss in severe cases.

27. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Cirrhosis of the liver • Cirrhosis is the end-stage of alcoholic liver disease and is believed to be caused by chronic heavy alcohol use. There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue.

28. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Cirrhosis of the liver (cont’d) • Portal hypertension: elevation of blood pressure through the portal circulation results from defective blood flow through cirrhotic liver

29. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Cirrhosis of the liver (cont’d) • Ascites: a condition in which an excessive amount of serous fluid accumulates in the abdominal cavity; occurs in response to portal hypertension

30. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Cirrhosis of the liver (cont’d) • Esophageal varices: veins in the esophagus become distended because of excessive pressure from defective blood flow through the cirrhotic liver

31. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Cirrhosis of the liver (cont’d) • Hepatic encephalopathy: occurs in response to the inability of the diseased liver to convert ammonia to urea for excretion. The continued rise in serum ammonia, if allowed to progress, leads to coma and eventual death.

32. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Leukopenia: impaired production, function, and movement of white blood cells • Thrombocytopenia: platelet production and survival are impaired as a result of the toxic effects of alcohol

33. Dynamics of Substance-Related Disorders (cont’d) Effects of alcohol on the body (cont’d) • Sexual dysfunction • In the short term, enhanced libido and failure of erection are common • Long-term effects include gynecomastia, sterility, impotence, and decreased libido

34. Dynamics of Substance-Related Disorders (cont’d) 2. A client is brought to the ED. The client is aggressive, has slurred speech, and impaired motor coordination. Blood alcohol level is 347 mg/dl. Among the physician’s orders is thiamine. Which is the rationale for this intervention? a) To prevent nutritional deficits b) To prevent pancreatitis c) To prevent alcoholic hepatitis d) To prevent Wernicke's encephalopathy

35. Dynamics of Substance-Related Disorders (cont’d) Correct answer: D Wernicke’s encephalopathy is the most serious form of thiamine deficiency in clients diagnosed with alcoholism. If thiamine replacement therapy is not undertaken quickly, death will ensue.

36. Dynamics of Substance-Related Disorders (cont’d) • Alcohol use during pregnancy can result in fetal alcohol spectrum disorders (FASDs) • Fetal alcohol syndrome (FAS): problems with learning, memory, attention span, communication, vision, and hearing • Alcohol-related neurodevelopmental disorder • Alcohol-related birth defects

37. Dynamics of Substance-Related Disorders (cont’d) • No amount of alcohol during pregnancy is considered safe • Alcohol can damage a fetus at any stage of pregnancy

38. Dynamics of Substance-Related Disorders (cont’d) Characteristics of FAS Learning difficulties Speech and language delays Intellectual disability Poor reasoning skills Sleep and sucking problems as a baby Vision or hearing problems Problems with the heart, kidneys, or bones • Abnormal facial features • Small head size • Shorter-than-average height • Low body weight • Poor coordination • Hyperactive behavior • Difficulty paying attention • Poor memory • Difficulty in school

39. Treatment Modalities for Substance-Related Disorders • Alcoholics Anonymous • A major self-help organization for the treatment of alcoholism • Based on the concept of • Peer support • Acceptance • Understanding from others who have experienced the same problem

40. Treatment Modalities for Substance-Related Disorders (cont’d) • Alcoholics Anonymous (cont’d) • The 12 steps that embody the philosophy of AA provide specific guidelines on how to attain and maintain sobriety. • Total abstinence is promoted as the only cure; the person can never safely return to social drinking.

41. Treatment Modalities for Substance-Related Disorders (cont’d) • Various support groups patterned after AA but for individuals with problems with other substances • Counseling • Group therapy

42. Treatment Modalities for Substance-Related Disorders (cont’d) • Pharmacotherapy for alcoholism • Disulfiram (Antabuse) • Other medications • Naltrexone (ReVia) • Nalmefene (Revex) • SSRIs • Acamprosate (Campral)

43. Treatment Modalities for Substance-Related Disorders (cont’d) • Psychopharmacology for substance intoxication and substance withdrawal • Alcohol • Benzodiazepines • Anticonvulsants • Multivitamin therapy • Thiamine

44. Dynamics of Substance-Related Disorders (cont’d) Sedative/Hypnotic Use Disorder • A profile of the substance • Barbiturates • Non-barbiturate hypnotics • Antianxiety agents (diazepam, alprazolam) • Club drugs

45. Sedative/Hypnotic Use Disorder Patterns of use • Effects on the body • Effects on sleep and dreaming • Respiratory depression • Cardiovascular effects (hypotension, decreased cardiac output) • Renal function

46. Sedative/Hypnotic Use Disorder(cont’d) • Effects on the body (cont’d) • Hepatic effects (jaundice, increase enzymes function) • Body temperature (hypothermia) • Sexual functioning

47. Sedative/Hypnotic-Induced Disorder • Intoxication • With these CNS depressants, effects can range from disinhibition and aggressiveness to coma and death • Impaired judgement, unsteady gait, slurred speech • Withdrawal • Onset of symptoms depends on the half-life of the drug from which the person is withdrawing. • Severe withdrawal from CNS depressants can be life threatening. • Sweating, tachycardia, insomnia, N/V, anxiety, seizures

48. Dynamics of Substance-Related Disorders Stimulant Use Disorder • A profile of the substance • Amphetamines • Synthetic stimulants • Non-amphetamine stimulants • Cocaine • Caffeine • Nicotine

49. Stimulant Use Disorder Patterns of use • Effects on the body • CNS effects • Cardiovascular effects • Pulmonary effects • Gastrointestinal and renal effects • Sexual functioning

50. Stimulant-Induced Disorders Intoxication • Amphetamine and cocaine intoxication produce euphoria, impaired judgment, confusion, changes in vital signs (even coma or death, depending on amount consumed). • Caffeine intoxication usually occurs following consumption in excess of 250 mg. Restlessness and insomnia are the most common symptoms.