1. Substance abuse

2. Definition
It’s a mental disorder that shows symptoms and maladaptive behavioral changes with the use of substances that affect the CNS.

3. Addiction: The habitual use of substances, such as alcohol, psychoactive drugs, and nicotine, and also compulsive behaviors, such as overeating, use of diet pills

4. Substance Use Terminology
Drinks alcohol, swallows, smokes, sniffs or injects
Drug misuse:
The occasionally inappropriate or unintentional use of a medication.
Abuse
Use for purposes of intoxication or for Rx beyond intended use
Dependence
Use despite adverse consequences

5. Substance Use Terminology
Two types of dependence:
Physical dependency:
Physiological changes that occur following prolonged substance use (the normal functioning of the person is not maintained until he takes a dose of the drug). Dependency is evidence of tolerance
Psychological dependence:
It’s craving for a substance that the person over use it over a prolonged period of time..

6. Substance Use Terminology
Tolerance
A need for increased dose of substance in order to achieve the same effect originally brought about by smaller doses of the same substance.
More substance is needed to achieve the same effect; or the same amount of the substance is not producing the same effectt
Cross tolerance
Tolerance to several drugs from the same classification (a person tolerant to heroin or alcohol will be tolerant to several other CNS depressant)

7. Substance Use Terminology
Substance Withdrawal
It is a maladaptive behavioral, cognitive, and physiological changes due to the reduction of heavy substance use ( symptoms are substance specific).
Detoxification
Process of safely and effectively withdrawing a person from an addictive substance
Relapse
Recurrence of alcohol- or drug-dependent behavior in person who had previously been abstinent.

8. Drug interaction
Addictive
Synergistic
Potentiating
Antagonistic

9. To make the effect of the drug more powerful and stronger
Drug interaction
Addiction (abuse)
Is the loss of control over substance intake to the extent that the person increases the dose to the point of dependency.
It’s loss of control of alcohol ingestion; drinking despite alcohol related problems, and a tendency to relapse.
Potentiating
To make the effect of the drug more powerful and stronger

10. Synergistic effects: Antagonistic effect: Drug interaction
Taking some drugs together that helps to intensify or prolong the effects of either or both drugs (combination of alcohol and barbiturate).
Antagonistic effect:
Is taking a combination of drugs to weaken or inhibit the effect of another drug (algat and barbiturate)

11. Substance Use Terminology
Co-dependence
Are constellation of maladaptive behaviors that are exhibited by the person who lives with a substance dependent person. These behaviors protect the dependent and enable him/her to continuo their dependency

12. Alcohol-Related Disorders
Alcohol Use Disorder
Alcohol Intoxication
Alcohol Withdrawal
Other Alcohol-induced Disorders
Unspecified Alcohol-Related Disorder

13. Alcohol Use Disorder - Diagnostic Criteria
A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

14. Alcohol Use Disorder - Diagnostic Criteria
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

15. Alcohol Use Disorder - Diagnostic Criteria
7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

16. Alcohol Use Disorder - Diagnostic Criteria
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.

17. Alcohol Use Disorder - Diagnostic Criteria
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal).
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

18. Alcohol Withdrawal Diagnostic Criteria
A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A:
1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
2. Increased hand tremor.

19. Alcohol Withdrawal Diagnostic Criteria
Criteria B continuo
3. Insomnia.
4. Nausea or vomiting.
5. Transient visual, tactile, or auditory hallucinations or illusions.
6. Psychomotor agitation.
7. Anxiety.
8. Generalized tonic-clonic seizures.

20. Alcohol Withdrawal Diagnostic Criteria
C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

21. Withdrawal Begin 8+ hours Peak at day 2 Diminish at day 5
Disappear months

22. Alcohol Intoxication - Diagnostic Criteria
A. Recent ingestion of alcohol.
B. Clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, alcohol ingestion.

23. Alcohol Intoxication - Diagnostic Criteria
C. One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use:
1. Slurred speech.
2. In-coordination.
3. Unsteady gait.
4. Nystagmus.
5. Impairment in attention or memory.
6. Stupor or coma.
Exclude physical disorders, psychiatric disorders. Or substance intoxication

24. Alcohol blood levels & behavior
0.05 – Changes in mood & normal behavior. Judgment and restraint are loose. Feel carefree
0.08— Voluntary motor action clumsy. illegal level
0.2— Staggering, Easily angered, shouting, weeping.
0.3 – Confusion, Stupor.
Coma.
Death.

25. Behavior Impairment BAC (% by vol.) 0.001–0.029
Average individual appears normal
Subtle effects that can be detected with special tests
0.030–0.059
Mild euphoria
Relaxation
Joyousness
Talkativeness
Decreased inhibition
Concentration
0.060–0.099
Blunted feelings
Euphoria
Disinhibition
Extroversion
Reasoning
Depth perception
Peripheral vision
Glare recovery
0.100–0.199
Over-expression
Boisterousness
Possibility of nausea and vomiting
Reflexes
Reaction time
Gross motor control
Staggering
Slurred speech
Temporary erectile dysfunction

26. Behavior Impairment BAC (% by vol.) .200–0.299 Nausea Vomiting
Emotional swings
Anger or sadness
Partial loss of understanding
Impaired sensations
Decreased libido
Possibility of stupor
Severe motor impairment
Loss of consciousness
Memory blackout
0.300–0.399
Stupor
Central nervous system depression
Loss of understanding
Lapses in and out of consciousness
Low possibility of death
Bladder function
Breathing
Dysequilibrium
Heart rate
0.400–0.500
Severe central nervous system depression
Coma
Possibility of death
Positional Alcohol Nystagmus
>0.50
High risk of poisoning
High possibility of death
Life

27. Effects on the Body Peripheral Neuropathy
Characterized by peripheral nerve damage, results in pain, burning, tingling sensations of the extremities.
It is the direct result of deficiencies in the B vitamins, particularly thiamine.
The process is reversible with abstinence from alcohol and restoration of nutritional deficiencies. Otherwise, permanent muscle wasting and paralysis can occur.

28. Alcoholic Myopathy Effects on the Body
May occur as an acute or chronic condition.
In the acute condition
Sudden onset of muscle pain,
swelling, and weakness;
reddish tinge in the urine caused by myoglobin, a breakdown product of muscle excreted in the urine; and a rapid rise in muscle enzymes in the blood
Alcoholic myopathy is thought to be a result of the same B vitamin deficiency that contributes to peripheral neuropathy.
Improvement is observed with abstinence from alcohol and the return to a nutritious diet with vitamin supplements

29. Wernicke’s encephalopathy
Effects on the Body
Wernicke’s encephalopathy
Represents the most serious form of thiamine deficiency in alcoholics.
Symptoms include
paralysis of the ocular muscles,
diplopia,
ataxia,
somnolence,
stupor.
If thiamine replacement therapy is not undertaken quickly, death will ensue.

30. Korsakoff’s psychosis Is identified by a syndrome of:
Effects on the Body
Korsakoff’s psychosis
Is identified by a syndrome of:
confusion,
loss of recent memory
Confabulation
It is frequently encountered in clients recovering from Wernicke’s encephalopathy.
Two disorders are usually considered together and are called Wernicke-Korsakoff syndrome.
Treatment is with parenteral or oral thiamine replacement

31. Alcoholic Cardiomyopathy
Effects on the Body
Alcoholic Cardiomyopathy
The effect of alcohol on the heart is an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition.
Alcoholic Hepatitis
Is inflammation of the liver caused by long-term heavy alcohol use.

32. Hepatic encephalopathy Leukopenia Thrombocytopenia Sexual Dysfunction
Effects on the Body
Esophagitis
Gastritis
Pancreatitis
Cirrhosis of the Liver
Portal hypertension
Ascites,
Esophageal varices
Hepatic encephalopathy
Leukopenia
Thrombocytopenia
Sexual Dysfunction

33. Predisposing Factors Biological Factors Genetics:
Children of alcoholics are four times more likely than other children to become alcoholic
Monozygotic twins have a higher rate for concordance of alcoholism than dizygotic
biological offspring of alcoholic parents have a significantly greater incidence of alcoholism than offspring of nonalcoholic parents.
Biochemical: the possibility that alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction.

34. Predisposing Factors Psychological Factors Developmental Influences
Sadock and Sadock (2007) state, “As a form of self-medication, alcohol may be used to control panic, opioids to diminish anger, and amphetamines to alleviate depression” (p. 386).
Certain personality traits are thought to increase a tendency toward addictive behavior
low self-esteem,
frequent depression,
passivity,
the inability to relax
the inability to communicate effectively
depressive responsive style
antisocial personality disorder

35. Sociocultural Factors Social Learning
Predisposing Factors
Sociocultural Factors
Social Learning
The effects of parents and peers on modeling, imitation, and identification of substance abuse behavior
Conditioning
Many substances create a pleasurable experience that encourages the user to repeat it.
it is the intrinsically reinforcing properties of addictive drugs that “condition” the individual to seek out their use again and again.
The environment in which the substance is taken also contributes to the reinforcement. If the environment is pleasurable, substance use is usually increased.

36. Cultural and Ethnic Influences Cultural acceptance
Predisposing Factors
Cultural and Ethnic Influences
Cultural acceptance
Availability of the substance
Money

37. Alcohol and other drugs are associated with Up to 50% 20 - 35%
Spousal abuse %
Suicides
50%
Traffic fatalities
62%
Assaults
Alcohol and
other drugs are
associated
with
52%
Rapes
49%
Murder
38%
Child abuse
68%
Manslaughter
charges
69%
Drownning

38. Assessment (Pointers to ask questions)
Ask All Patients About Problems In:
Relationships
School or job
Accidents
Arrests
Health
THEN tie in substances

39. A = Annoyed by family to stop substance intake. G = Feeling of guilt.
Assessment Alcohol
C = cutting down trials
A = Annoyed by family to stop substance intake.
G = Feeling of guilt.
E = Need for eye opener in the morning.
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking ?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of hang over ( Eye opener)?

40. Stages of Treatment Identification Detoxification
Physical exam and history
Vitamins (multi vitamins and thimine)
Reassurance
+ Benzodiazepines (CNS depressant)
Disulfiram (antabuse) –alcohol-
Naltrexone for the treatment of heroin
SSRIs -alcohol-
Tegratol
Rehabilitation
Aftercare
Counseling & group therapy AA

41. Nursing diagnosis Ineffective denial
Makes statements such as, “I don’t have a problem with (substance).
I can quit any time I want to.” Delays seeking assistance; does not perceive problems related to use of substances; minimizes use of substances; unable to admit impact of disease on life pattern

42. Nursing diagnosis Ineffective coping
Abuse of chemical agents; destructive behavior toward others and self; inability to meet basic needs; inability to meet role expectations; risk taking

43. Nursing Diagnosis
Imbalanced nutrition: Less than body requirements/Deficient fl uid volume
Loss of weight, pale conjunctiva and mucous membranes, decreased skin turgor, electrolyte imbalance, anemia, drinks alcohol instead of eating

44. Nursing diagnosis Risk for infection Chronic low self-esteem
Risk factors: Malnutrition, altered immune condition, failing to avoid exposure to pathogens
Chronic low self-esteem
Criticizes self and others, self-destructive behavior (abuse of substances as a coping mechanism), dysfunctional family background
Deficient knowledge
Denies that substance is harmful; continues to use substance in light of obvious consequences

45. Nursing diagnosis Risk for injury Risk for suicide
For the client withdrawing from central nervous system (CNS) depressants:
Risk factors: CNS agitation (tremors, elevated blood pressure, nausea and vomiting, hallucinations, illusions, tachycardia, anxiety, seizures)
Risk for suicide
Risk factors: Intense feelings of lassitude and depression; “crashing,” suicidal ideation