Chaptre 17 - Substance Abuse
Chaptre 17 - Substance Abuse
Chaptre 17 - Substance Abuse
Substance Abuse
Substance Abuse
• The actual prevalence of substance abuse is
difficult to determine
• Detrimental effects of substance abuse
include:
– Workplace injuries
– Motor vehicle accidents and fatalities
– Domestic abuse, homicide, and child
abuse and neglect
• 14% of adults have an alcohol-related
disorder
• 6.2% have a substance-related disorder
(excluding nicotine)
• Adolescent substance abuse is rising
• Increasing numbers of babies are being born
to substance-addicted mothers
• Half of all persons seeking alcohol-related
treatment have at least one alcoholic parent
Types of Substance Abuse
Classes of substances abused:
– Alcohol
– Amphetamines or similarly acting sympathomimetics
– Caffeine
– Cannabis
– Cocaine
– Hallucinogens
– Inhalants
– Nicotine
– Opioids
– Phencyclidine (PCP) or similarly acting drugs
– Sedatives, hypnotics, or anxiolytics
• Intoxication is use of a substance that results in
maladaptive behavior
• Withdrawal syndrome refers to the negative
psychological and physical reactions that occur when
use of a substance ceases or dramatically decreases
• Detoxification is the process of safely withdrawing
from a substance
• Substance abuse is using a drug in a way that is
inconsistent with medical or social norms and
despite negative consequences
• Substance dependence includes problems associated
with addiction such as tolerance, withdrawal, and
unsuccessful attempts to stop using the substance
Onset and Clinical Course
• Typically begins with the first episode of intoxication
between 15 and 17 years of age
• More severe difficulties begin in the mid-20s to
mid-30s
– Alcohol-related breakup of a significant
relationship
– An arrest for public intoxication or
driving while intoxicated
– Evidence of alcohol withdrawal
– Early alcohol-related health problems
– Significant interference with functioning at work
or school
• Blackout drinking in which the person continues to
function but has no conscious awareness of his or her
behavior at the time nor any later memory of the
behavior
• As the person continues to drink, he or she often
develops a tolerance for alcohol; that is, he or she needs
more alcohol to produce the same effect
• After continued heavy drinking, the person experiences a
tolerance break, which means that very small amounts of
alcohol will intoxicate the person
• The later course of alcoholism, when the person’s
functioning definitely is affected, is often characterized
by periods of abstinence or temporarily controlled
drinking
Etiology
• Biologic factors
– Genetic vulnerability
– Neurochemical influences
• Psychological factors
– Familial dynamics
– Coping styles
• Social and environmental factors
Cultural Considerations
• Muslims do not drink alcohol
• Wine is an integral part of Jewish religious rites
• Some Native American tribes use peyote, a hallucinogen, in
religious ceremonies
• The Japanese do not regard alcohol as a drug, and there are no
religious prohibitions against drinking
• Certain ethnic groups have genetic traits that either predispose
them to or protect them from developing alcoholism
• Variations have been found in enzymatic activities among
Asians, African Americans, and whites
• Alcohol abuse plays a part in the five leading causes of death
for Native Americans
• Drinking is a major health problem among some Aboriginal
people and in Russia
Alcohol
• Central nervous system depressant
• Overdose can result in vomiting,
unconsciousness, and respiratory depression
• Symptoms of withdrawal usually begin 4 to
12 hours after cessation or marked reduction
of alcohol intake
• Alcohol withdrawal usually peaks on the
second day and is over in about 5 days
• Withdrawal symptoms include:
– Coarse hand tremors, sweating, elevated pulse and
blood pressure, insomnia, anxiety, and nausea or
vomiting
– Severe or untreated withdrawal may progress to
transient hallucinations, seizures, or delirium—called
delirium tremens (DTs)
• Withdrawal symptoms are monitored using an
assessment tool such as the Clinical Institute Withdrawal
Assessment of Alcohol Scale, Revised (CIWA-AR)
• Benzodiazepines used for detoxification
– Lorazepam (Ativan), chlordiazepoxide (Librium), or
diazepam (Valium) suppress the withdrawal
symptoms
Sedatives, Hypnotics, and Anxiolytics
• Central nervous system depressants
• Benzodiazepines alone, when taken orally
in overdose, are rarely fatal, but the person
will be lethargic and confused
• Barbiturates, in contrast, can be lethal
when taken in overdose. They can cause
coma, respiratory arrest, cardiac failure,
and death
• Withdrawal symptoms in 6 to 8 hours or up to 1
week
• Withdrawal syndrome is characterized by symptoms
opposite of the acute effects of the drug:
– Autonomic hyperactivity (increased pulse, blood
pressure, respirations, and temperature), hand
tremor, insomnia, anxiety, nausea, and
psychomotor agitation; seizures and
hallucinations occur rarely in severe
benzodiazepine withdrawal
• Detoxification from sedatives, hypnotics, and
anxiolytics is managed by tapering the amount of
the drug
Stimulants (Amphetamines, Cocaine, Others)
• Central nervous system stimulants
• Overdoses can result in seizures and coma
• Withdrawal occurs within hours to several days
• Withdrawal syndrome:
– Dysphoria accompanied by fatigue, vivid and
unpleasant dreams, insomnia or hypersomnia,
increased appetite, and psychomotor retardation or
agitation; withdrawal symptoms are referred to as
“crashing”--the person may experience depressive
symptoms, including suicidal ideation, for several
days
• Stimulant withdrawal is not treated pharmacologically
Cannabis (Marijuana)
• Used for its psychoactive effects
• Excessive use of cannabis may produce delirium
or cannabis-induced psychotic disorder;
overdoses of cannabis do not occur
• Withdrawal symptoms:
– Insomnia, muscle aches, sweating, anxiety,
and tremors
• Effects are treated symptomatically
Opioids
• Central nervous system depressants
• Overdose can lead to coma, respiratory depression,
pupillary constriction, unconsciousness, and death
• Withdrawal:
– Short-acting drugs: begins in 6 to 24 hours;
peaks in 2 to 3 days and gradually subside in 5
to 7 days
– Longer-acting drugs: begins in 2 to 4 days,
subsiding in 2 weeks
• Withdrawal symptoms:
– Anxiety, restlessness, aching back and legs,
cravings, nausea, vomiting, dysphoria,
lacrimation, rhinorrhea, sweating, diarrhea,
yawning, fever, and insomnia
• Withdrawal does not require pharmacologic
intervention
• Administration of naloxone (Narcan) is the
treatment of choice
• Methadone can be used as a replacement for heroin,
serving to reduce cravings
Hallucinogens
• Distort reality and produce symptoms similar to
psychosis, including hallucinations (usually visual) and
depersonalization
• Toxic reactions to hallucinogens (except PCP) are
primarily psychological; overdoses as such do not occur.
PCP toxicity can include seizures, hypertension,
hyperthermia, and respiratory depression
• Hallucinogens can produce flashbacks that may persist
for a few months up to 5 years
• Treatment is supportive:
– Isolation from external stimuli; physical restraints;
(for PCP) medications to control seizures and blood
pressure; cooling devices; mechanical ventilation
Inhalants
• Inhaled for their effects
• Overdose:
– Anoxia, respiratory depression, vagal stimulation, and
dysrhythmias
– Death may occur from bronchospasm, cardiac arrest,
suffocation, or aspiration of the compound or vomitus
– People who abuse inhalants may suffer from persistent
dementia or inhalant-induced disorders such as psychosis,
anxiety, or mood disorders even if the inhalant abuse
ceases
• Withdrawal symptoms: none
• Treatment:
– Supporting respiratory and cardiac functioning until the
substance is removed from the body
Substance Abuse Treatment
• Treatment is based on the concept that
alcoholism and drug addiction are medical
illnesses: chronic, progressive, characterized
by remissions and relapses
• Treatment models include:
– The Hazelden Clinic model
– 12-step program of Alcoholics Anonymous
(AA)
– Individual and group counseling
Treatment Settings and Programs
• Emergency departments
• Medical units
• Extended treatment
• Outpatient treatment
• Clinics offering day and evening programs
• Halfway houses
• Residential settings
• Chemical dependency units in hospitals
Pharmacologic Treatment
Two main purposes:
• To permit safe withdrawal from alcohol,
sedative-hypnotics, and
benzodiazepines
• To prevent relapse
Pharmacologic Treatment (cont’d)
Safe withdrawal from alcohol involves:
• Benzodiazepines to suppress withdrawal
symptoms
– Lorazepam, chlordiazepoxide, and diazepam