Disease EntitiesAnd Substance Profiles

Alcoholism: A Prototype Disease

Alcohol Dependence can be viewed as a prototype of chemical (substance) use and dependence.

E.M. Jellinek, pioneer of the disease model, identified phases of abuse-to-dependence

Jellinek’s Four PhasesThe individual with alcoholism progresses

through these phases.The characteristics of the phases can assist

clients, families and health care providers in understanding 1) the loss of control and 2) ethical deterioration characteristic of individuals with chronic chemical dependency (regardless of the chemical of choice).

View chart of these phases at: http://www.in.gov/judiciary/ijlap/docs/jellinek.pdf

Phase I: Pre-alcoholic Phase

Chemical used to relieve stressTolerance develops

Phase II: Early Alcoholic PhaseBegins with the first blackoutThe chemical is no longer associated with

pleasure or reliefThe individual requires the chemicalThe individual is increasingly secretive; becomes

preoccupied with chemical use and maintenance of supply

Individual is increasingly reliant upon the defense mechanisms of denial and rationalization

Use is associated with guilt and shame

Phase III: Middle or Crucial PhaseIndividual demonstrates signs and symptoms

of Physiological and Psychological dependence

Binge use often occursInteractions are characterized by anger and

aggressionFamily dysfunctionIndividual demonstrates impairment in social

and occupational functioning

Phase IV: Late or Chronic PhaseThe individual is almost always intoxicatedEthical deterioration is apparentImpaired reality testing, especially paranoia, is

evidentDepression with suicidal ideation is commonLife-threatening physical consequences are

evident:Peripheral neuritis with LE numbness, painAlcoholic myopathyWernicke-Korsakoff syndromeAlcoholic cardiomyopathy

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

Phase IV: Late or Chronic Phase, cont.HepatitisCirrhosis (complications include portal

hypertension, ascites, esophageal varices and hepatic encephalopathy)

Esophagitis and gastritis (ulcers, hemorrhage)

PancreatitisLeukopeniaThrombocytopeniaSexual dysfunction

Substance Profiles

ALCOHOL DEPENDENCE: Some Facts

5-7% of Americans are Alcoholics 5-7% of Americans are Alcoholics Every alcoholic touches lives of 5 Every alcoholic touches lives of 5

people people A leading cause of death: from medical A leading cause of death: from medical

complications, accidents and suicidescomplications, accidents and suicidesFetal alcohol syndrome most common Fetal alcohol syndrome most common

cause of mental retardation in children cause of mental retardation in children Potentiates other CNS depressantsPotentiates other CNS depressantsAlcoholism underreported in women Alcoholism underreported in women

and older adultsand older adults

Alcohol: IntoxicationMetabolism of alcohol is increased in heavy

drinkersWomen more easily intoxicated than men.Effects: CNS depression and Peripheral

vasodilationDecreased muscle tension, lowered anxiety

level, disinhibition, impaired judgment, sedation

Toxic effects: stupor, unconsciousness (including blackouts), coma, death

Alcohol WithdrawalUsually develops 4-12 hours after cessation

or reduction of alcohol useRebound phenomenon (CNS irritability) as

drug effects wear off: increased anxiety, tension, psychomotor

activitysweats, tremors, tachycardia, increased temp.

and BPnausea, vomiting, diarrhea

Alcohol Withdrawal, cont’dWithdrawal seizures may occur 7-48 hours

after cessation or reductionAlcohol withdrawal delirium (also known

as Delirium Tremens or DTs) may occur 48-72 hours following cessation or reduction- agitation, terror, hallucinations

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

(A Belgian beer is named for this effect)

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

Alcohol: InterventionsSeizure precautions; anticonvulsants for DT’sSuicide assessment and precautions, if necessaryMedications: for withdrawal

Benzodiazepines e.g. chlordiazepoxide (Librium), oxazepam (Serax), diazepam (Valium). Administration may depend on withdrawal rating parameters.

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) – opioid receptor antagonist-blocks the “high”

acamprosate (Campral) – reduces cravings

SEDATIVES, HYPNOTICS AND ANXIOLYTICSBARBITURATES &BENZODIAZEPINES• Are CNS depressants• Commonly prescribed for sleep, anxiety,

muscle spasms, etc.• Also used illicitly, including

• reducing effects of amphetamine abuse• if other narcotics not available• by sexual predators

Sedative, Hypnotic, or Anxiolytic Abuse and DependencePotentiate each other and alcoholProduce physiological dependenceProduce psychological dependenceCross-tolerance and cross-dependence

between CNS depressantsWithdrawal sx.: anxiety, insomnia, nausea,

seizures Overdose and Fatal effects: respiratory

depression, coma, death

Interventions for Sedative W/DQuiet, calm environmentMonitor vital signsTaper dose gradually; may take weeks or

monthsSeizure precautions

INHALANTS: Abuse and DependenceGenerally act as CNS depressantsDangerous due to inability to control amount

inhaledUse is associated with

CNS damageRespiratory irritation, distress and depressionGI distressMouth ulcersRenal and hepatic damage Death from asphyxiation or suffocation

OPIOIDSOPIUM and HEROINMORPHINECODEINESYNTHETIC MORPHINE

DERIVATIVES, e.g:OXYCODONE (OxyContin)HYDROMORPHONE

((Dilaudid)HYDROCODONE (Vicodin)MEPERIDINE (Demerol)

OPIOID Abuse and DependenceActivate endorphins, reduce pain and anxietyMany routes of use: po, subcut., IM, IV, inhaledIV use is associated with infection, including

HIV and Hepatitis, bacterial endocarditis, and abscesses

May be prescribed or illicitly obtainedHeroin--highest abuse and dependence

potentialCNS effects, including respiratory depressionGI effects

Opioid IntoxicationInitial euphoria Followed by apathy, dysphoria, psychomotor

agitation or retardation, impaired judgmentPupillary constrictionDrowsiness (“nodding”), slurred speechImpaired memory and concentration

Opioid Overdose Pinpoint pupils Clammy skin Respiratory depression Coma (pupils will dilate secondary to anoxia) Death rapidly follows coma

Narcotic antagonist used to reverse overdose: naloxone (Narcan)

Opioid WithdrawalSymptoms 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• Yawning

Going “cold turkey”means withdrawal without clinical supervision

(begins 6-14 hrs after last dose)

Treatment for Opioid WithdrawalPrimarily supportive careTreat symptomaticallySpecific pharmacotherapy:

clonidine-for n/v/diarrheabuprenorphine (Buprenex) –reduces pain

and discomfort

Example of clinical assessment tool for opiate withdrawal (COWS)

Opioid Dependence: Interventions

Promoting AbstinenceMaintenance Pharmacotherapy to reduce

cravings and block the “high” :naltrexone (Trexan, ReVia) methadone –requires enrollment in

maintenance program (federally controlled supervision)

CNS STIMULANTS

Cocaine and crackAmphetamines: prescribed or illicit Non-amphetamine stimulants

CaffeineNicotineHerbal

CNS Stimulants: IntoxicationVarious Effects:

increased alertness, arousal and enduranceDecreased need for food and sleepHR and BP

Neurobiological (different for different drugs):facilitate norepinephrine, dopamine activitynicotinic receptor agonists adenosine receptor antagonists

STIMULANTS: Cocaine Intoxication and DependenceCocaine –Blocks dopamine reuptake esp. in

nucleus accumbens (“pleasure center”)IV or intranasal route; Crack (dilute) form is

smokedRapid effects and rapidly metabolized:

Intense euphoriaIncreased mental alertnessIncreased motor and cardiac activityIncreased muscle strength

Psychological dependence is even more severe than physical dependence; cravings are intense

Nucleus accumbens

STIMULANTS: Amphetamines: Intoxication and DependenceOften are prescribed, widely abusedAmphetamine: Inhibits reuptake of dopamine and

norepi.Methamphetamine: Slower metabolic effects,

often mixed with cocaine (cheaper)Routes: IV, intranasal, po, smokedImmediate intense pleasure, lasting high“Crash” occurs as drug effects wear offIntense cravings promote frequent, repetitive use Neglect of nutrition; damage to teeth, gums“meth mouth”

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

Treatment of Overdose:Induce vomiting, diuretics, administer IM antipsychotic

for drug-induced psychosis/agitation(There are no medications that can treat stimulant

dependence)

Comparison Chart