1. Substance abuse Alcohol

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

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 Use – 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 4

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.. 5

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) 6

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. 7

8. 8 Drug interaction Addictive Synergistic Antagonistic Potentiating Poly drug use

9. 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 (benzodiazipines, such as xanax, valium, ativan etc. are all similar to alcohol. Mix them with alcohol, then the effect of the alcohol and pills potentiate each other making someone need much less of each to get drunk) – Although since they enhance each other, its easier to overdose on either one if used in excess or amounts that wouldn't be an overdose when taken individually 9

10. Poly Drug Interaction Synergistic effects: – Taking some drugs together that helps to 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) 10

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 11

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

13. Alcohol Use Disorder - Diagnostic Criteria A. 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. Begin 8+ hours Peak at day 2 Diminish at day 5 Disappear 3 - 6 months

22. Alcohol Withdrawal Early – Starts after 8 hours and more – anxiety, irritability, tremor, HA, insomnia, nausea, tachycardia, HTN, hyperthermia, hyperactive reflexes Seizures – generally seen 24-48 hours – most often Grand mal Withdrawal Delirium (DTs) – generally between 48-72 hours – altered mental status, hallucinations, marked autonomic instability – life-threatening

23. 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.

24. 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

25. Level of alcohol intoxication BAL (Blood Alcohol Level) Consequences 20-50 mg/dl blood (.02 -.05) No Legal intoxication, some uncoordination, potential changes in behavior. 80 – 100 mg/dl blood (.08 -.10) Legal intoxication, impaired ability to drive, slurred speech, staggered gait, impaired sensory function 100 – 150 mg/dl blood (.1 -.15) Markedly uncoordination, gross cognitive and judgment distortion Above 200 mg/dl blood ( >.20) Notable impaired sensory and motor function Above 300 mg/dl blood ( >.30) Potential for cardiovascular and respiratory collapse, coma, and death can occur,

26. 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.

27. Effects on the Body Alcoholic Myopathy – 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

28. Neurological Effects Blackouts – Occur most frequently with excessive use of alcohol – An early sign of alcoholism – Recollection of activities are lost from conscious recall but the individual remains conscious and appears to function normally to those in their environment

29. Neurological Effects Alcohol withdrawal delirium -- delirium tremens (DTs) – Most severe form of alcohol withdrawal – Occurs 24-72 hrs after the last drink – Occurs in heavy drinkers and is manifested by an acute psychotic state – Confusion and disorientation to time and place are common – Other signs include visual and auditory hallucinations that are accusatory and threatening to the patient – Illusions, severe agitation, profuse sweating, tachycardia, tachypnea, and possibly grand mal seizure activity can also occur

30. Neurological Effects Acute alcoholic hallucinosis – Occurs after a prolonged period of drinking – Characterized by threatening auditory hallucinations – Different from DTs in that the individual remains oriented to time and place

31. 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.

32. 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

33. 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.

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

35. 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.

36. 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

37. 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.

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

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

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

41. 41 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)?

42. Assessment Laboratory tests – A comprehensive urine drug screen – Other common laboratory tests useful in the diagnosis of alcohol abuse include: Blood alcohol level (BAL) GGT—rises in response to ETOH ingestion; 60-80% of individuals with chronic ETOH abuse will have an increased GGT MCV—elevated in 35% of individuals who are heavy drinkers

43. 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

44. Alcohol Withdrawal treatment Benzodiazepines – GABA agonist - cross-tolerant with alcohol – reduce risk of SZ; provide comfort/sedation Anticonvulsants – reduce risk of SZ and may reduce kindling – helpful for protracted withdrawal – Carbamazepine or Valproic acid Thiamine supplementation – Risk thiamine deficiency (Wernicke/Korsakoff)

45. Alcohol treatment Outpatient CD treatment: – support, education, skills training, psychiatric and psychological treatment, AA Medications: – Disulfiram – Naltrexone – Acamprosate

46. 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

47. 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 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

48. Nursing diagnosis Risk for infection – 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

49. Nursing diagnosis Risk for injury – 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

50. Nursing intervention Immediate: – Maintain patent airway and life threatening situation – Maintain safety of the client and others – Observe for additional S&S for overdose – Assess for psychological and physiological sing and symptoms for withdrawal and drug interaction – Initiate therapeutic intervention to treat withdrawal symptoms

51. Nursing intervention Recovery – Provide emotional support for client and family – Support nutrition and nutrients consumption – Provide carbohydrate intake, vitamin, minerals – Support client and family to acknowledge denial and deception – Teach family about substance use – Encourage client and family to engage in Alcohol Anonymous groups