Substance Abuse

SUBSTANCE ABUSE DEFINITION OF TERMS: • Use – when a person drinks alcohol or swallows, smokes, sniffs, or injects a mind-altering substance •

Abuse – when a person is using alcohol or drugs for the purpose of intoxication or, in the case of prescription drugs, for the purpose beyond their intended use

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Dependence – the continuing use of alcohol or drugs despite adverse consequences to one’s physical, social and psychological well-being

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Addiction – describes that state when the person experiences severe psychological and behavioral dependence on drugs or alcohol

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Intoxication – use of substance that results in maladaptive behavior

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Withdrawal – is the adverse physical and psychological symptoms that occur when the person ceases using a substance

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Tolerance – the need for greatly increased amounts of substance to obtain desired effect

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Detoxification – the process of safely and effectively withdrawing a person from an addictive substance, usually under medical supervision

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Spontaneous Remission – natural recovery Relapse – the recurrence of alcohol – or drug-dependent behavior in an individual who has previously achieved and maintained abstinence for a significant time beyond the period of detoxification

TYPES OF SUBSTANCE ABUSE: • • • • • • • •

Alcohol Amphetamine Cannabis Hallucinogen Inhalant Opioid Phencyclidine (PCP) Sedatives, hypnotics, anxiolytics

DIAGNOSTIC CRITERIA: • Maladaptive pattern of substance use leading to clinically significant impairment or distress

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• Impairment manifested by three or more of the following occurring within a 12 month-period A. Failure to fulfill major role obligations at work, school, or home B. Recurrent substance use in hazardous situations C. Recurrent substance-related legal problems D. Continued substance use despite problems • Symptoms never met criteria for substance dependence

ETIOLOGY: A. Biological theory Genetic factors: incidence of alcohol abuse in the children of alcoholics is four times greater than in the general population • Biochemical factors: •

B. Psychological Theory Family dynamics: children of alcoholics are four times as likely to develop alcoholism • Inconsistent parental behavior, poor role modeling, and lack of nurturing • Maladaptation in early stage of development leads to oral fixation in dependent personality – relief from guilt and shame is sought by taking substance •

C. Sociocultural theory • Hopelessness and defeat of living conditions (poverty and related problems) leading to the use of substances for relief • Peer pressure, especially during adolescence when individual is most vulnerable to pressure from peer group • Easy availability of substances combined with attitude that substance use is viable method of stress relief • Societal ambivalence about use of substances, partially validating message that medicine solves problems

D. Behavioral Theory •

Substance use is a response to stressful stimuli; use is reinforced because substances effectively provide temporary relief of anxiety

Common Personality Traits are Associated with Substance Abusers: a. Dominant and critical behavior toward others (masks self-doubt and passivity) b. Personal insecurity, decreased self-esteem c. Rebellious attitude towards authority d. Difficulty with intimate relationships, tendency toward narcissism e. Use of defense mechanisms including denial, rationalization, and projection Commonly Abused Substances and Effects: 2

A. Alcohol 1. Central Nervous System (CNS) Depressant a. Immediate Effects due to action on brain (acute intoxication) – causes slurred speech, incoordination, unsteady gait, impaired attention and memory. High doses may cause stupor and coma b. Overdose: respiratory depression and cardiac arrest c. Chronic use causes multisystem dysfunction • Intoxication: blood alcohol level 0.15 (150 mg alcohol/100cc blood) • Legal level: 0.08 – 0.10 2. Withdrawal symptoms related to CNS excitation a. Early phase (6-12 hours after last drink): anxiety and agitation,

tremors, tachycardia, and hypertension, diaphoresis, nausea and vomiting b. Delirium Tremens: increased temperature , profuse diaphoresis, hypertension and tachycardia, seizures, perceptual disturbances such as illusions and hallucinations  Most serious form of alcohol withdrawal  Drug of choice: benzodiazepine 3. Fetal Alcohol Syndrome a. Can occur in infants born to alcoholic mothers b. Causes intellectual deficits, physical abnormalities c. Requires infant withdrawal from alcohol 4. Alcohol-induced Amnestic Disorders a. Wernicke’s syndrome: caused by thiamine deficiency (Vit. B1); wernicke’s encephalopathy presents with oculomotor dysfunctions (involuntary rapid eye movements), ataxia, confusion, palsy of the 6th cranial nerve leading to nystagmus b. Korsakoff’s psychosis: characterized by both retrograde and

anterograde amnesia with sparing of intellectual function; confabulation, chronic irreservible disorder following wernicke’s encephalopathy 5. Alcohol-deterrent therapy with disulfiram (Antabuse)

a. Inhibits breakdown of alcohol in the body b. Produces hypersensitivity reaction following alcohol ingestion c. Inhibits hepatic enzymes from normal metabolic breakdown of alcohol resulting in high levels of acetaldehyde, leading to disulfiram alcohol reactions (flushing, throbbing headache, copious vomiting, tachycardia, hypotension, blurred vision to death) d. Client should abstain from alcohol at least 12 hours before initial dose. e. Purpose: to discourage individual from taking alcohol 3

f. Avoid

alcohol, including ingestion of elixirs (drug preparation that use alcohol), topical application (mouthwash, lotions, liniment, shaving cream) and inhalation (paints and varnishes)

6. Treatment of withdrawal a. Anxiolytics such as chlordiazepoxide (Librium) and oxazepam (Serax) administered over 5 to 7 days in gradually decreasing doses b. Anticonvulsant such as phenytoin (Dilantin) or carbamezapine (Tegretol) for seizure prevention. Magnesium sulfate can also be used for seizure prevention caused by magnesium deficiency c. Use of measures to promote adequate nutrition and fluid and electrolyte balance • Vitamin supplementation including multivitamin preparation , vitamin B1 (Thiamin) and folic acid • Balanced diet with supplements as necessary • Symptomatic treatment of nausea and vomiting • Increased fluid intake B. Amphetamines – crank or speed

1. CNS Stimulant a. Immediate effects due to action on the CNS: causes increased energy and euphoria; extreme vigilance, hostility and impaired judgment; elevated blood pressure, tachycardia, dilated pupils, nausea and vomiting b. Chronic use can lead to psychosis with paranoid ideation 2. Commonly abused drugs: dextroamphetamine (Dexedrine), metamphetamine 3. Withdrawal is characterized by severe depression, vivid dreams, insomnia or hypersomnia, and psychomotor agitation 4. Treatment of withdrawal is symptomatic a. Antidepressants to counteract severe depression b. Neuroleptics to treat any paranoia or psychosis c. Anxiolytics to treat psychomotor agitation C. Cocaine 1. CNS Stimulant and dopamine depletion a. Immediate Effects due to action on CNS causes euphoria, anxiety, anger; impaired judgment and paranoid thinking, tachycardia, dilated pupils; elevated blood pressure; insomnia b. Chronic use can lead to tolerance with need for increased amount of drug c. Can also cause chronic fatigue, irritability, anxiety, mental confusion, paranoia, suicidal depression, infectious disease related to intravenous use d. Can cause symptoms of runny nose or damaged mucous membranes from chronic snorting cocaine 4

2. Commonly abused drug forms include: cocaine powder (snorted or 3.

4.

5. D. 1.

2. 3. 4.

injected), and crack crystal a cocaine derivative (smoked) Withdrawal is characterized by: severe depression, fatigue, vivid dreams and hypersomnia or insomnia, psychomotor agitation Treatment of Withdrawal a. Anxiolytics to treat psychomotor agitation b. Antidepressants to counteract depression c. Beta-adrenergic blockers to treat hypertension and tachycardia d. Dopamine receptor agonist such as bromocryptine (Parlodel) to decrease cocaine craving from dopamine depletion Crosses placental barrier causing fetal addiction possibly brain damage, and seizure disorders in infants Cannabis – pot or hashish Alters sensory perception due to active ingredient, tetrahydrocannibol (THC), which is a psychoactive substance a. Immediate effects: euphoria, sensation of slowed time, impaired motor coordination, social withdrawal, conjunctival irritation(red eyes), increased appetite, dry mouth, tachycardia b. Chronic can cause decreased testosterone levels in males; may also cause a chronic lung disease (emphysema and lung cancer) Commonly abused drug forms include marijuana and hashis Possible symptoms of withdrawal: irritability and anxious mood accompanied by physiologic changes such as tremor, perspiration, nausea, and sleep disturbance Crosses placental barrier – increases risk of low birth weight and smaller head circumference in infant

E. Barbiturates,

Other sedatives

and hypnotics and

anxiolytics 1. CNS depressants a. Immediate effects due to action on CNS. Causes drowsiness, slurred speech, motor incoordination, mood lability, talkativeness, postural hypotension b. At high doses: respiratory depression, coma, death c. Chronic use: depression and paranoia 2. Commonly abused types a. Barbiturates: secobarbital (Seconal), pentobarbital (Nembutal) b. Sedative/hypnotics: methaqualone (Quaalude), chloralhydrate (Noctec) c. Anxiolytics: lorazepam (Ativan), alprazalone (Xanax), diazepam (Valium), chlordiazepoxide (Librium) 3. Withdrawal a. Occurs within 24 hours to 72 hours after last dose b. Characterized by: nausea, vomiting, hypertension, tachycardia, anxiety, depression, irritability, seizures (which may occur after 2 weeks of withdrawal), possibly respiratory failure 4. Treatment of Withdrawal a. Anxiolytics b. Neuroleptics for psychotic-like symptoms 5

c. Anticonvulsants to prevent and/or treat seizures F. Opioids 1. CNS depressants a. Immediate effects due to action on brain: causes euphoria, impaired attention and memory, apparent sedation, psychomotor retardation, increased sensitivity to pain, apathy, pinpoint constricted pupils, slurred speech, hypothermia, b. At high doses: respiratory depression c. Chronic use: multiple infectious disease related to intravenous drug use 2. Commonly abused types: heroin(most addictive), morphine(major

pain killer), hydromorphone, codeine (found in cough syrups), methadone, opium 3. Withdrawal a. occurs within a few hours after last dose of short-acting opioids; begins 2-3 days after last dose of longer-acting opioids b. characterized by: dilated pupils, tearing, runny nose, sweating, diarrhea, fever, insomnia, tachycardia, mild hypotension, restlessness, piloerection, yawning 4. Treatment of Withdrawal a. methadone for first 3-5 days b. clonidine hydrochloride (Catapres) to block withdrawal symptoms, may be given for 14 days G. Hallucinogens 1. Mind-altering drugs affecting sensory perceptions a. Immediate effects: intensified perception; depersonalization, heightened response to color, textures, sounds; illusions and hallucinations; anxiety and depression; dilated pupils, tachycardia, and sweating b. Chronic use: paranoia. “Bad trips” may occur which can cause panic attacks. Flashbacks can occur at unpredictable times c. Phencyclidine (PCP) dependence may be marked by extreme violent behavior followed by unresponsiveness 2. Commonly abused drug types: PCP, lysergic acid (LSD), mescaline, peyote 3. No withdrawal symptoms described

MANAGEMENT: f.r.a.m.e.s – Effective Elements of Brief Intervention FEEDBACK – about patient’s individual status (personal alcohol and other drug consumption relative to norms, information about elevated liver enzyme values) RESPONSIBILITY 6

Emphasize the individual’s freedom of choice and personal responsibility for change. General themes are as follows: a. It’s up to you; you’re free to decide to change or not b. No one else can decide for you or force you to change c. You’re the one who has to do it if it’s going to happen

ADVICE Include clear recommendation on the need for change, in a supportive and concerned rather than in a judgmental manner. MENU Provide a menu of treatment options, from which patients may pick those that seem more suitable or appealing EMPATHETIC COUNSELING Show warmth, support, respect and understanding in communication with patients. SELF-EFFICACY Reinforce self-efficacy, or an optimistic feeling that he or she can change. • Detoxification followed by residential or outpatient rehabilitation programs. • Self-help 12-step programs designed to help members achieve and achieve sobriety one day at a time.

The Twelve Steps 1. We admitted we were powerless, that our lives had become unmanageable. 2. We came to believe that a Power greater than ourselves could restore us to sanity. 3. We made a decision to turn our will and our lives over to the care of God as we understood Him. 4. We made a searching and fearless moral inventory of ourselves. 5. We admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. We are entirely ready to have God remove all these defects of character. 7. We humbly ask Him to remove our shortcomings. 8. We made a list of all persons we had harmed, and became willing to make amends to them all. 9. We made direct amends to such people whenever possible, except when to do so would injure them or others. 7

10. We continued to make personal inventory, and when we are wrong, promptly admitted them. 11. We sought trough prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will and the power to carry that out. 12. Having had the spiritual awakening as a result of these steps, we tried to carry this message and to practice these principles in all our affairs.

Principles of Addiction Treatment 1. NO single treatment s appropriate for all individuals. 2. Treatment needs to be readily available. 3. Effective treatment attends to multiple needs of the individual, not just his or her drug use. 4. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person’s changing needs. 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. 6. Counseling and other behavioral therapies are critical components of effective treatment for addiction. 7. Medications are an important treatment for many patients, especially when combined with counseling and other behavioral therapies. 8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated ways. 9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. 10. Treatment does not need to be voluntary to be effective. 11. Possible drug use during treatment must be monitored continuously. 12. Treatment programs should provide assessment for HIV/AIDS, Hepatitis b and c , tuberculosis and other infectious diseases and counseling to help patients modify or change behaviors that place themselves and others at risk for infection. 13. Recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment. • Psychotherapy • Family therapy • Family support groups (Al-Anon, Alateen)

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