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Alcohol & Substance Related Disorders :

Alcohol & Substance Related Disorders

Definitions and Overview:

Definitions and Overview The Complexity Of Alcohol And Substance-related Disorders Lies In Its Neurobiological And Behavioral Underpinnings

Disease Concept:

Disease Concept The Disease Concept of Addiction recognizes Substance Dependence as a complex biogenetic psychosocial disorder that is chronic, progressive and potentially fatal. Some object to the use of the term “disease” because using a substance the first time is typically a personal choice of the individual. We have yet to fully understand why most individuals stop at experimentation or occasional use, whereas others find it a first step to lengthy, if not lifelong struggle with addiction. Much remains to be discovered about the interplay of genetics, neurobiology, learning,motivation, environment and social factors. Knowledge of how these factors affect the onset, course, treatment and resolution of substance disorders will guide improved prevention and treatment.

Denial and Relapse:

Denial and Relapse Denial is an integral part of addiction and fuels the addictive behaviors. Patients minimize or disconnect from the negative impact of chemical use (alcohol or substance use). Working with a person in denial is often a source of frustration for the nurse especially when the patient fails to take advantage of treatment resources or returns again and again to substance use. Increasingly, substance dependence is being understood as a chronic, relapsing disorder with similarities to other long-term chronic illnesses e.g. diabetes, COPD. As in most other chronic diseases, relapses are part of the course of the illness. Treatment outcomes need to be viewed as effective on the basis of the decrease in substance use and the length of time that person has been drug or alcohol free.


Addiction Is a dependent pattern of behavior on alcohol or drugs in which the ability to moderate or stop use is repeatedly unsuccessful. There can be a sense of craving in the absence of the substance and an uncontrolled compulsion to use it again despite the knowledge of negative consequences. The loss of control over the frequency or amount is a key indicator of addiction.


Tolerance Is a pharmacologic property of some abused substances in which chronic use produces changes in the Central Nervous System so that more of the substance is needed to produce the desired effects. With cessation or reduction of use, depending on the pharmacologic properties of the substance, a withdrawal syndrome may occur.

DSM-IV-TR Substance Abuse :

DSM-IV-TR Substance Abuse A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, within a 12 month period . 1. Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home. 2. Recurrent substance use in situations in which it is physically hazardous. 3. Recurrent substance-related legal problems. 4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

DSM-IV-TR Substance Dependence:

DSM-IV-TR Substance Dependence See criteria A for Substance Abuse as manifested by three or (more) of the following occurring at the same time in the same 12 month period. 1 .Tolerance , as defined by either of the following: a. A need for markedly increased amounts of the substance to achieve intoxication or desired effect. b. Markedly diminished effect with continued use of the same amount of the substance. 2. Withdrawal, as manifested by either of the following: a.The characteristic withdrawal syndrome for the substance. b.The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.

Substance Dependence (cont):

Substance Dependence (cont) 3. The substance is often taken in larger amounts or over a longer period of time than was intended. 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 5. A great deal of time is spent in activities to obtain the substance, or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of the substance use. 7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely caused or exacerbated by the substance.

Substance Intoxication:

Substance Intoxication Features are characteristic to the specific substance and will eventually subside . Changes can be produced in alertness, coordination, attention, judgment and thinking as well as in pulse, respiration and blood pressure. Different substances can produce similar patterns of intoxification: cocaine and amphetamines as stimulants alcohol, benzodiazepines and opioids as (CNS) depressants All classes of substances (except caffeine &nicotine) may cause delirium and psychosis during intoxication as well as varying degrees of depression and anxiety with intoxication, or during/after withdrawal.

Substance Withdrawal:

Substance Withdrawal Typically, the symptoms of withdrawal are the opposite of the effects of the substance. Withdrawal syndromes are specific to the individual substance.


Detoxification Refers to the process of systematically and safely managing withdrawal from a substance. Going through “Detox” is often the first step of formal drug or alcohol treatment. The fear of discomfort of withdrawal can play a part in promoting continued compulsive use, particularly if dependence is on alcohol or opiates.


Epidemiology Alcohol remains the most used and abused substance in all age groups. Binge drinking (5 or more drinks on the same occasion in the past month). Heavy Drinking ( 5 or more drinks on the same occasion on each of 5 days on the same month). Adults who first used substances before age 18 are more likely to be dependent than those adults who initiated use at a later age. Substance use among males is about 2 times greater than females. Female use is often woven within the context of intimate relationships. Physiologically, women are more susceptible to the effects of ETOH because they absorb more ETOH through the GI tract than men. Men have a greater amount of ETOH dehydrogenase which is an enzyme that metabolizes ETOH and lowers blood ETOH. Men often find their way to treatment due to legal problems. Women often seek treatment in response to health concerns.

CNS Depressants Alcohol:

CNS Depressants Alcohol Alcohol is absorbed quickly from the stomach and small intestine. It is metabolized by the liver at a fixed rate about one drink (1 oz) an hour. Alcohol stimulates the release of the body’s own opioids and endorphins which turn on the the central dopamine reward system.


ALCOHOL Abuse and Dependence are underdiagnosed and undertreated in the primary care setting. Psychosocial consequences related to legal, occupational and interpersonal relationship difficulties are frequently part of a person’s history. A history of vehicle crashes, falls or other traumas should trigger further assessment of alcohol use. Chronic alcohol use affects all body systems and predisposes a person to a variety of health problems.


ALCOHOL WITHDRAWAL Withdrawal is associated with neuronal excitation in the face of abrupt cessation of the depressant action of alcohol. It is dose dependent in that heavier drinkers are more likely to develop withdrawal. The brain adapts to regular doses and can’t function sufficiently without the presence of alcohol. The last time and the amount of alcohol consumed is an important assessment question.

ETOH WITHDRAWAL Signs & Symptoms:

ETOH WITHDRAWAL Signs & Symptoms Tremor: “The Shakes” Hyperarousal: easily startled, anxious, or irritable. Insomnia, loss of appetite, tachycardia, elevated B/P, N,V,D, flushing or diaphoresis can occur. Hallucinations: misinterpreting noises as voices, spots on the wall as bugs, or shadows as people not there. Symptoms peak at about 4 days after the last drink and gradually subside over a period of days. Symptoms can persist for 1-2 weeks. Withdrawal can become a medical emergency especially in the presence of medical comorbidity such as cardiovascular or renal disease.

ALCOHOL WITHDRAWAL Delirium Tremens or DTs:

ALCOHOL WITHDRAWAL Delirium Tremens or DTs Seizures Profound confusion and disorientation Hallucinations Autonomic Nervous System Arousal: Hyperprexia, Hypertension, Tachycardia, Course Tremor and Agitation **Without medical intervention Hyperthermia and/or Cardiovascular Collapse can occur

Pharmacotherapy for Alcohol Withdrawal :

Pharmacotherapy for Alcohol Withdrawal Benzodiazepines: GABA produces inhibitory effects in the CNS Promote rest and are anxiolytic Librium or Ativan given in progressively decreasing doses over the course of days to facilitate safe withdrawal Selection of medication and dosing guided by Pt.’s liver function Antipsychotics are use for hallucinations, delusions and severe agitation

Vitamin Therapy:

Vitamin Therapy IV Thiamine 100mg should be given as soon as possible, followed by daily doses of 50-100mg. Risk for Thiamine deficiency due to inadequate nutritional intake or poor GI absorption. Thiamine is administered to prevent Wernicke’s Encephalopathy.

Wernicke’s Encephalopathy Wernicke-Korsakoff Syndrome:

Wernicke’s Encephalopathy Wernicke-Korsakoff Syndrome Wernicke’s Encephalopathy : a reversible condition associated with thiamine deficiency . Symptoms include ataxia, delirium and palsy of the 6th cranial nerve (abducens muscle of the eye). Wernicke-Korsakoff Syndrome: Thiamine Deficiency characterized by profound memory impairment and an inability to learn new material: 50% of cases have permanent impairment.


OTHER CNS DEPRESSANTS Sedatives-Hypnotics and Anxiolytics: Abuse and Dependence usually consists of obtaining Rxs from multiple physicians. Alprazolam (Xanax) associated with immediate and severe withdrawal due to the substances short half-life .


CNS DEPRESANTS (CONT) Opioids : Morphine & Codeine tolerance, dependence & withdrawal Heroin : can be used IV or Nasally Stimulation of Opioid receptors not only produces analgesia but also effects respiratory depression, pupillary constriction, decreased GI motility & euphoria Narcan competes for receptor binding sites and reverses the depressant effects

Opioid Withdrawal Signs and Symptoms:

Opioid Withdrawal Signs and Symptoms Restlessness, Anxiety, Insomnia, Craving, N/V, Rhinorrhea, Inceased Lacrimation, Diaphoresis & Dialated Pupils. Chills and piloerection “gooseflesh” are the basis for the term “cold turkey” as a reference to withdrawing suddenly. More serious sxs: fever, elevated b/p and pulse, tremors, agitation and muscle spasms.

Opioid Withdrawal:

Opioid Withdrawal For Rx Opioid Dependence, a gradual decrease in dose over time can provide an effective and safe withdrawal. Opioid (Heroin) withdrawal management: Methadone, Clonidine, Muscle Relaxants, Anxiolytics and Antiemetics Methadone Maintenance

CNS Stimulants:

CNS Stimulants Caffeine Nicotine Amphetamines & Cocaine Hallucinogens Cannabis Inhalants Club Drugs PCP

Miscellaneous Definitions Substance-Related Disorders:

Miscellaneous Definitions Substance-Related Disorders Dual Diagnosis is the term used to describe the presence of substance-related disorders and psychiatric disorders occurring at the same time. Codependency/Enabling: The spouse or significant other of the individual with a substance-related disorder may devote inordinate amounts of time and energy to control the addicted person’s behavior and forestall or soften a variety of impending disruptions or crises.

Types of Treatment:

Types of Treatment Inpatient Detox Inpatient Rehab Outpatient Rehab Individual Therapy Group Therapy Self Help Support Groups For Patients & Family Members

Pharmacologic Therapies:

Pharmacologic Therapies Disulfiram (Antabuse) Naltrexone (ReVia) Acamprosate (Campral) Methadone LAAM (long-acting methadone)

Goals of Recovery The Process of Change:

Goals of Recovery The Process of Change Learning to live without chemicals and coping with the realities of everyday life. This begins, but doesn’t end, with abstinence. Although chemical use may stop, behavioral problems such as poor frustration tolerance, a lack of regard for others, lying, an impaired ability to delay gratification and an excessive desire to control can continue. The process of developing emotional maturity is impeded when chemicals take the primary focus in life. A person needs to learn to cope with the emotional waves of living every day life without the use of chemicals to blunt, obliterate, or to control is crucial.

Important Nursing Considerations:

Important Nursing Considerations It is imperative for nurses to be aware of their attitudes toward those who have substance-related disorders and to accept them as people in need of help managing a serious health problem. A nurse may be reminded of unresolved anger and pain associated with a relative or friend with a substance-related disorder. How well informed the nurse is about addiction science and “their own” attitudes can influence the quality of the nurse’s contribution to the assessment and treatment process.

CAGE Questionaire:

CAGE Questionaire Four Short Questions that can be asked using Formal or Informal Language. It is particularly suited to use as part of a general health history: The individual is asked whether or not they have ever: Felt the need to: C ut down on drinking? Felt : A nnoyed by criticism or complaining by others about their alcohol use? Felt : G uilty about drinking? Or if an: E ye opener in the morning was ever needed to calm nerves or to treat a hangover? Two or more affirmative answers indicates a clinically significant alcohol use disorder