DISEASE ENTITIES & SUBSTANCE PROFILES RNSG 2213 SUBSTANCE-RELATED DISORDERS

CNS DEPRESSANTS

ALCOHOL Some Facts 5-7% of Americans are Alcoholics 5-7% of Americans are Alcoholics Every alcoholic touches lives of 5 people Every alcoholic touches lives of 5 people A leading cause of death: from medical complications, accidents and suicides A leading cause of death: from medical complications, accidents and suicides Fetal Alcohol Syndrome most common cause of mental retardation in children Fetal Alcohol Syndrome most common cause of mental retardation in children Potentiates other CNS depressants Potentiates other CNS depressants Alcoholism underreported in women and older adults Alcoholism underreported in women and older adults

Alcohol: Intoxication Metabolism of alcohol is increased in heavy drinkers Women more easily intoxicated than men. Effects: CNS depression and Peripheral vasodilation Decreased muscle tension, lowered anxiety level, disinhibition, impaired judgment, sedation  Toxic effects: stupor, unconsciousness (including blackouts), coma, death  Alcohol poisoning s/t large amount consumed in short period of time

Alcohol Withdrawal Usually develops 4-12 hours after cessation or reduction of alcohol use Rebound phenomenon (CNS irritability) as drug effects wear off: increased anxiety, tension, psychomotor activity sweats, tremors, tachycardia, increased temp. and BP nausea, vomiting, diarrhea

Alcohol Withdrawal, cont’d Withdrawal seizures may occur 7-48 hours after cessation or reduction Alcohol withdrawal delirium (also known as Delirium Tremens or DTs) may occur hours following cessation or reduction- agitation, terror, hallucinations (A Belgian beer is named for this effect)

Alcohol Withdrawal Use of validated withdrawal assessment rating scale assists in objective description of withdrawal severity

Validated withdrawal assessment scale: Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

Alcohol: Interventions for Withdrawal Seizure precautions; anticonvulsants for DT’s Suicide assessment and precautions, if necessary Medications: for withdrawal Benzodiazepines e.g. chlordiazepoxide (Librium), oxazepam (Serax), diazepam (Valium). Administration may depend on withdrawal rating parameters.

Alcohol: Interventions for Recovery Medications to promote abstinence after detox. disulfiram (Antabuse) = Aversive Therapy ; produces unpleasant or even harmful effects when alcohol is consumed or absorbed in any form (in foods, fluids, cosmetics, medications, etc.). naltrexone (ReVia) – opiate receptor antagonist-blocks the “high” acamprosate (Campral) – reduces cravings

Complications of Alcohol Dependence: Physiologic Esophagitis and gastritis (ulcers, hemorrhage) Sexual dysfunction Pancreatitis Hepatitis Leukopenia Thrombocytopenia Peripheral neuritis with LE numbness, pain

ALCOHOLISM: COMPLICATIONS Cirrhosis-liver becomes fibrotic, fatty complications include portal hypertension, ascites, esophageal varices and hepatic encephalopathy)

Complications of Alcoholism due to Thiamine (B1) Deficiency Korsakoff’s Syndrome: memory loss, amnesia, psychosis Wernicke’s Encephalopathy: ataxia, muscle weakness, nystagmus and confusion Often appear together = Wernicke-Korsakoff Syndrome

Result of toxicity + nutritional deficiency Alcoholic Cardiomyopathy

SEDATIVES, HYPNOTICS AND ANXIOLYTICS BARBITURATES, BENZODIAZEPINES Commonly prescribed for sleep, anxiety, muscle spasms, etc. Also used illicitly, including reducing effects of stimulant (esp. amphetamine) abuse if other narcotics not available by sexual predators

Sedatives, Hypnotics, or Anxiolytics Abuse and Dependence Potentiate each other and alcohol Produce physiological dependence Produce psychological dependence Cross-tolerance and cross-dependence between CNS depressants

Sedatives, Hypnotics and Anxiolytics: Dependence Withdrawal sx.: anxiety, insomnia, nausea, seizures  Overdose and Fatal effects: respiratory depression, coma, death

Interventions for Sedative W/D Quiet, calm environment Monitor vital signs Taper dose gradually; may take weeks or months Seizure precautions

Inhalents Inorganic and organic volatile substances-usually cheap and readily available Intoxication: CNS depression- elevated mood (silly and happy) and excitability, possible sleepiness and confusion

INHALANTS: Abuse and Dependence Dangerous due to inability to control amount inhaled Use is associated with CNS damage Respiratory irritation, distress and depression GI distress Mouth ulcers Renal and hepatic damage  Death from asphyxiation or suffocation

OPIOIDS OPIUM and HEROIN MORPHINE CODEINE SYNTHETIC MORPHINE DERIVATIVES, e.g: OXYCODONE (OxyContin) HYDROMORPHONE ((Dilaudid) HYDROCODONE (Vicodin) MEPERIDINE (Demerol)

OPIOID Abuse and Dependence Activate endorphins, reduce pain and anxiety Many routes of use: po, subcut., IM, IV, inhaled IV use is associated with infection, including HIV and Hepatitis, bacterial endocarditis, and abscesses May be prescribed or illicitly obtained Heroin--highest abuse and dependence potential CNS effects, including respiratory depression GI effects

Opioid Intoxication Initial euphoria Followed by apathy, dysphoria, psychomotor agitation or retardation Pupillary constriction Drowsiness (“nodding”), slurred speech Impaired judgment, memory and concentration

Opioid Overdose  Pinpoint pupils  Clammy skin  Respiratory depression  Coma (pupils will dilate secondary to anoxia)  Death rapidly follows coma TX of Overdose: Narcotic antagonist: naloxone (Narcan)

Opioid Withdrawal Very uncomfortable but rarely dangerous: Dysphoria, anxiety, cravings Sweating and chills, piloerection Lacrimation, rhinorrhea GI distress (anorexia, n/v, cramping, diarrhea) Muscle aches, bone pain Restlessness Tremors Sleep disturbances

Interventions for Opioid Withdrawal Primarily supportive care Treat symptomatically Specific pharmacotherapy: clonidine-for n/v/diarrhea buprenorphine (Buprenex) –reduces pain and discomfort

Example of clinical assessment tool for opiate withdrawal (COWS)

Interventions for Opioid Dependence Medications which Promote Abstinence: Maintenance Pharmacotherapy to reduce cravings and block the “high” : naltrexone (Trexan, ReVia) methadone –requires enrollment in maintenance program (federally controlled supervision)

CNS STIMULANTS

Cocaine Amphetamines: prescribed or illicit Non-amphetamine stimulants Caffeine Nicotine

STIMULANTS: Intoxication Various Effects: Increased alertness, arousal and endurance Decreased need for food and sleep  HR and BP

Stimulants: Neurobiology Different for different drugs: facilitate norepinephrine, dopamine activity nicotinic receptor agonists adenosine receptor antagonists

STIMULANTS: COCAINE Intoxication Blocks dopamine reuptake esp. in nucleus accumbens (“pleasure center”) IV or intranasal route; Crack (dilute) form is smoked Rapid Effects and Rapidly metabolized: Intense euphoria Increased mental alertness Increased motor and cardiac activity Increased muscle strength

Stimulants: Cocaine Dependence Psychological dependence is even more severe than physical dependence; cravings are intense

Stimulants: AMPHETAMINES Intoxication and Dependence Often are prescribed, widely abused Methamphetamine: Slower metabolic effects, often mixed with cocaine (cheaper) Routes: IV, intranasal, po, smoked Immediate intense pleasure, lasting high “Crash” occurs as drug effects wear off Intense cravings promote frequent, repetitive use Damage to teeth, gums

STIMULANTS: WITHDRAWAL AND COMPLICATIONS Toxic effects: Hallucinations and paranoid delusions Severe hypertension, cardiac ischemia Withdrawal: severe agitation, anxiety, depression  Death from cardiac arrhythmias, seizures, suicide, respiratory collapse, stroke

STIMULANTS: Treatment of Overdose Induce vomiting, diuretics Administer IM antipsychotic for drug-induced psychosis/agitation

HALLUCINOGENS

HALLUCINOGENS Natural or synthetic substances Effects vary from enhancement of sensory stimuli to loss of reality and hallucinations (Psychotic symptoms) Effects highly unpredictable

HALLUCINOGENS: CANNABINOLS (MARIJUANA and Related) Not strictly a hallucinogen Most widely used illegal drug in US Active Ingredient: THC (delta-9-tetrahydrocannbinol Detectable in blood and urine for up to 4 weeks Smoked or ingested Hashish-resinous form “Medical marijuana” antiemetic and for chronic pain Legal RX: drobinol (Marinol) Plant form legal in some states

CANNABIS: INTOXICATION Euphoria, relaxation, disinhibition Alteration in sensory and time perception Increased appetite Anxiety Tachycardia and Hypotension

CANNABIS: DEPENDENCE ?Physical? Psychological- tolerance

CANNABIS: COMPLICATIONS AND ADVERSE EFFECTS Impaired memory, concentration Apathy and loss of motivation (heavy users) Pulmonary compromise ?Reduced female, male hormones and sperm count? Paranoia and panic Flashbacks

HALLUCINOGENS: LYSERGIC ACID DIETHYLAMIDE (LSD) Semisynthetic-binds to serotonin receptors LSD Intoxication: Episodic and binge use common Effects last up to 12 hours Synesthesia experiences-blending of sensory perceptions

LSD: ADVERSE EFFECTS Hypertension and tachycardia Acute psychosis: delusions, paranoia Flashbacks Panic

HALLUCINOGENS: PHENCYCLIDINE (PCP) Synthetic anesthetic PCP Intoxication: Euphoria and relaxation PCP Adverse Effects: Ataxia, vomiting Agitation, violent outbursts, catatonia Severe elevations in HR and BP

HALLUCINOGENS: LSD and PCP  Overdose and Fatal effects; Complications Psychotic break (persisting psychosis) Perceptual distortions cause client to harm self/suicide or others Cardiac arrest PCP-seizures

HALLUCINOGENS: LSD and PCP Psychological tolerance Frequent users-cravings No physiologic dependence

LSD and PCP Treatment of Acute Intoxication or Overdose Diazepam (Valium) for seizures [PCP], paranoia and panic IM haloperidol (Haldol) for agitation and aggression

Comparison Chart