SUBSTANCE SUBSTANCE USE/ABUSEUSE/ABUSE

PRESENTED BY PRESENTED BY

Jim Santana PA-CJim Santana PA-C

ALCOHOLALCOHOL ABUSE ABUSE►Classification:Classification:

Alcohol Abuse (DSM-IV)Alcohol Abuse (DSM-IV) Alcohol Dependence (alcoholism)Alcohol Dependence (alcoholism) Alcohol IntoxicationAlcohol Intoxication Alcohol WithdrawalAlcohol Withdrawal Alcohol Withdrawal DeliriumAlcohol Withdrawal Delirium Alcohol-Induced Psychotic D/O with Alcohol-Induced Psychotic D/O with

Halluc.Halluc. Alcohol-Induced Persisting Amnestic D/O Alcohol-Induced Persisting Amnestic D/O

(Korsakoff’s disease)(Korsakoff’s disease) Alcohol Induced Persisting DementiaAlcohol Induced Persisting Dementia

DEFINITIONSDEFINITIONS Alcohol Alcohol Abuse:Abuse: is diagnosed if there is is diagnosed if there is

clearly recurrent (but not continuous) clearly recurrent (but not continuous) impaired social & occupational functioning impaired social & occupational functioning due to alcohol use over a 1 year period.due to alcohol use over a 1 year period.

►Might be binges or mixedMight be binges or mixed►DEPRESSIONDEPRESSION►BlackoutsBlackouts

Alcohol Alcohol DependenceDependence: If the pt also has : If the pt also has TOLERANCETOLERANCE (increased amounts needed (increased amounts needed to achieve effect), to achieve effect), WITHDRAWAL, WITHDRAWAL, and/or and/or compulsive and continuous use.compulsive and continuous use.

NATURE AND/OR NURTURENATURE AND/OR NURTURE

►GENETICS:The eldest son of a male drinker 2 GENETICS:The eldest son of a male drinker 2 times more likely to become an alcoholictimes more likely to become an alcoholic

►Twin studiesTwin studies►Cultural/Ethnic differences in ability to Cultural/Ethnic differences in ability to

“handle” alcohol,Women vulnerable(smaller)“handle” alcohol,Women vulnerable(smaller)►NO stereotypical alcoholic “personality”NO stereotypical alcoholic “personality”

affects all genders, socioeconomic groups, ages.affects all genders, socioeconomic groups, ages.►Therefore remain EMPATHIC, non punitive, Therefore remain EMPATHIC, non punitive,

and nonjudgmental.and nonjudgmental.LISTENLISTEN/structure//structure/treattreat

RECOGNIZING THE RECOGNIZING THE ALCOHOLICALCOHOLIC

►Majority of alcoholics go unrecognizedMajority of alcoholics go unrecognized►Recognize the symptoms: Recognize the symptoms:

Anxiety/depression, Anxiety/depression, Insomnia,Insomnia, Headaches/blackoutsHeadaches/blackouts N &V/vague G.I. Problems(liver, PUD, or N &V/vague G.I. Problems(liver, PUD, or

pancreas)pancreas) PalpitationsPalpitations Frequent injuries/accidentsFrequent injuries/accidents

CAGE (ACRONYM)CAGE (ACRONYM)

►C: Have you ever felt you should C: Have you ever felt you should Cut Cut down on your drinking?down on your drinking?

►A: Have people A: Have people AnnoyedAnnoyed you by you by criticizing your drinking?criticizing your drinking?

►G: Have you ever felt bad or G: Have you ever felt bad or Guilty Guilty about about your drinking?your drinking?

►E: Have you ever had a drink first thing in E: Have you ever had a drink first thing in the morning to steady your nerves or get the morning to steady your nerves or get rid of a hangover (rid of a hangover (Eye-openerEye-opener)?)?

ALWAYS DETERMINE THE ALWAYS DETERMINE THE PATIENTS RECENT DRINKING PATIENTS RECENT DRINKING

HISTORYHISTORY► Is the patient currently intoxicated?Is the patient currently intoxicated?►Time since last drink?Time since last drink?►Ask if pt smokes/uses caffeine/OTC meds/ Ask if pt smokes/uses caffeine/OTC meds/

Rx meds abuse/other substances of abuseRx meds abuse/other substances of abuse►Comorbidity?, Also ask: (“nerve medicine”)Comorbidity?, Also ask: (“nerve medicine”)►Been to rehabilitation for ETOH &/or Drugs?Been to rehabilitation for ETOH &/or Drugs?►Think about labs/correlate above with PEThink about labs/correlate above with PE

LAB TEST GIVE-AWAYSLAB TEST GIVE-AWAYS

►Chronic drinking frequently elevates Chronic drinking frequently elevates serum GGT and...MCV (most important of serum GGT and...MCV (most important of the RBC the RBC indices-)indices-)

►with/without B12 or Folate deficiencywith/without B12 or Folate deficiency►A characteristic anemia can existA characteristic anemia can exist►ThrombocytopeniaThrombocytopenia►Serum Protein changes, Triglycerides upSerum Protein changes, Triglycerides up►LFT’s elevated (dead give-away): Alk LFT’s elevated (dead give-away): Alk

Phos, LDH, Phos, LDH, SGOTSGOT(ALT), SGPT(AST)- occ (ALT), SGPT(AST)- occ bilirubinbilirubin

ALCOHOL ALCOHOL INTOXICATION(DSM-IV)INTOXICATION(DSM-IV)

►Early :Euphoria/disinhibition,alcohol breathEarly :Euphoria/disinhibition,alcohol breath Blood alcohol: (up to 100mg/ml)Blood alcohol: (up to 100mg/ml)

►Then CNS depressant becomes evident Then CNS depressant becomes evident grading into irritability, mood swings, and grading into irritability, mood swings, and incoordination(blood alcohol:100-150)incoordination(blood alcohol:100-150)

►Apathy, dysarthria, ataxia(150-250)Apathy, dysarthria, ataxia(150-250)►Alcoholic Coma: (250-400): An EMERGENCYAlcoholic Coma: (250-400): An EMERGENCY

check for other drugs, consider intensive care check for other drugs, consider intensive care unitunit

R/O differential diagnoses R/O differential diagnoses

WATCHWATCH ALCOHOL ALCOHOL WITHDRAWALWITHDRAWAL

(May need vital signs with Parameters)(May need vital signs with Parameters)

►Alcohol withdrawal- 1 dayAlcohol withdrawal- 1 day tremulous,tremulous,n&v,anxiety,tinnitus,blurred visionn&v,anxiety,tinnitus,blurred vision

►Alcohol convulsions- occurs 2 days laterAlcohol convulsions- occurs 2 days later►Alcohol withdrawal delirium(D.T.’s):2-8daysAlcohol withdrawal delirium(D.T.’s):2-8days

<5%,but <5%,but mortalitymortality is 10-15%, (disorientation) is 10-15%, (disorientation)

►Alcohol induced psychotic d/o with Alcohol induced psychotic d/o with hallucinations:3 days- voices,sounds,tremor hallucinations:3 days- voices,sounds,tremor but clear and orientedbut clear and oriented

Complications of Chronic Complications of Chronic AlcoholismAlcoholism

►PUD,pancreatitis,cirrhosis,hepatitis,varicesPUD,pancreatitis,cirrhosis,hepatitis,varices►neuropathy,cardiomyopathyneuropathy,cardiomyopathy►Wernicke’s encephalopathy- thiamin defWernicke’s encephalopathy- thiamin def►Korsakoff’s disease-thiamin def-can follow Korsakoff’s disease-thiamin def-can follow

Wernicke’s: Short term memory loss with Wernicke’s: Short term memory loss with confabulationconfabulation

►Other complications: Alcohol induced Other complications: Alcohol induced persisting dementia, SUICIDE, Drug abuse, persisting dementia, SUICIDE, Drug abuse, accidentsaccidents

Tx of Alcohol WithdrawalTx of Alcohol Withdrawal►VS with Parameters(observe for VS with Parameters(observe for

withdrawal)withdrawal) consider Librium taper consider Librium taper

initially(benzodiazepine)initially(benzodiazepine)►Exclude subdural hematoma/injuryExclude subdural hematoma/injury►Do/monitor labs etcDo/monitor labs etc►Tx rest/nutritionTx rest/nutrition►Thiamin/folate given routinelyThiamin/folate given routinely►watch for withdrawal seizure and consider watch for withdrawal seizure and consider

valium 10mg valium 10mg slowly slowly I.V. if in status I.V. if in status epilepticusepilepticus

►Do urine screen for drug abuse-(check to Do urine screen for drug abuse-(check to see what other meds he/she might be on)see what other meds he/she might be on)

TREATMENT OF ALCOHOLISMTREATMENT OF ALCOHOLISM►Continue tx of medical/nutritional needsContinue tx of medical/nutritional needs►Get him/her to consider rehab/AA ASAPGet him/her to consider rehab/AA ASAP►Cont. to address psychosocial/family needsCont. to address psychosocial/family needs►Spirit./peer counselor of pts choice if wants Spirit./peer counselor of pts choice if wants ►Cont to encourage abstinence with Cont to encourage abstinence with

empathyempathy►Wean off drug crutches ASAP- try ReViaWean off drug crutches ASAP- try ReVia►Social work/occupational/education helpSocial work/occupational/education help►Antabuse being used less often(caution)Antabuse being used less often(caution)►KEEP TRYINGKEEP TRYING

DRUG ABUSEDRUG ABUSE►Abuse: Marked social/occupational Abuse: Marked social/occupational

impairment and compulsive excessive impairment and compulsive excessive drug use over a period of a yeardrug use over a period of a year

►Dependence: All of the above with the Dependence: All of the above with the addition of the development of addition of the development of tolerance and withdrawaltolerance and withdrawal

Dangers of IV Drug UseDangers of IV Drug Use

►HIV/STD’sHIV/STD’s►HepatitisHepatitis►SBESBE►TetanusTetanus►Pneumonia or TBPneumonia or TB►Cellulitis, ThrombophlebitisCellulitis, Thrombophlebitis

OPIOIDSOPIOIDS

►OpiumOpium►Morphine/HeroineMorphine/Heroine►MethadoneMethadone►CodeineCodeine►PercodanPercodan►DilaudidDilaudid►TalwinTalwin►DemerolDemerol►DarvonDarvon

Opioid IntoxicationOpioid Intoxication

►Rush or Dysphoria followed by Rush or Dysphoria followed by drowsinessdrowsiness physical signs: miosis, slurred speech, physical signs: miosis, slurred speech,

CNS & resp dep, n&vCNS & resp dep, n&v O.D. - Respiratory depression - tx with O.D. - Respiratory depression - tx with

Narcan-,if needs >4doses, consider Narcan-,if needs >4doses, consider another etiology-always consider multiple another etiology-always consider multiple drug/ETOH use. Narcan might trigger drug/ETOH use. Narcan might trigger withdrawalwithdrawal

OPIOID WITHDRAWALOPIOID WITHDRAWAL

► Intense craving, decreased appetite, Intense craving, decreased appetite, yawning, sweating, pupil dilatation, yawning, sweating, pupil dilatation, nausea & vomiting and occassional nausea & vomiting and occassional feverfever

►Treatment:Treatment: similar to alcohol, but consider similar to alcohol, but consider

methadone tapermethadone taper

SEDATIVES-HYPNOTICSSEDATIVES-HYPNOTICS

►QuaaludeQuaalude

►BarbituratesBarbiturates phenobarb, secobarb, etcphenobarb, secobarb, etc

►BenzodiazepinesBenzodiazepines valiumvalium LibriumLibrium AtivanAtivan HalcionHalcion

Sedative-Hypnotic-Sedative-Hypnotic-Anxiolytics Withdrawal Anxiolytics Withdrawal

and Treatmentand Treatment►The most dangerous of the withdrawal The most dangerous of the withdrawal

syndromessyndromes tremulous, N & V,diaphoresis,hypotension, tremulous, N & V,diaphoresis,hypotension,

tachycardia-tachycardia- SEIZURES SEIZURES may occur may occur Sedative-Hypnotic-Anxiolytic induced Sedative-Hypnotic-Anxiolytic induced

persistent amnestic disorder: A profound persistent amnestic disorder: A profound short term memory loss that is usually short term memory loss that is usually reversible off of the offending drugreversible off of the offending drug

Treat withdrawal vigorously and carefully Treat withdrawal vigorously and carefully with tapering with same/similar drug slowlywith tapering with same/similar drug slowly

LSD AND MESCALINE LSD AND MESCALINE (HALLUCINOGENS)(HALLUCINOGENS)

►Hallucinations and delusionsHallucinations and delusions Can talk patient down in a couple of hoursCan talk patient down in a couple of hours Treatment: Benzodiazepines/HaldolTreatment: Benzodiazepines/Haldol Can have “Flashbacks”Can have “Flashbacks” Can abstain- and then still have psychotic Can abstain- and then still have psychotic

symptoms that mimic a major psychotic symptoms that mimic a major psychotic disorder, indistinguishable from the real disorder, indistinguishable from the real thing, especially if they mixed their thing, especially if they mixed their substances.substances.

Marijuana(cannabis sativa)Marijuana(cannabis sativa) Euphoria, then people develop apathy and Euphoria, then people develop apathy and

motivational behavior. Distortion of speed motivational behavior. Distortion of speed not uncommon. Poor Judgement often not uncommon. Poor Judgement often accompanies intoxication. Short term accompanies intoxication. Short term memory loss very common.memory loss very common.

tachycardia, conjunctival injection, dry tachycardia, conjunctival injection, dry mouth, increased appetite can occurmouth, increased appetite can occur

Toxic psychosis has been reported with Toxic psychosis has been reported with high dose use.- dependence apparently high dose use.- dependence apparently rare rare

urine test - can be positive a month after urine test - can be positive a month after heavy use.heavy use.

Treatment: Supportive/abstinence the goalTreatment: Supportive/abstinence the goal

Inhalants and Anabolic Inhalants and Anabolic SteroidsSteroids

► Inhalants: Dependence apparently Inhalants: Dependence apparently develops, and at least anecdotal develops, and at least anecdotal information indicates that prolonged information indicates that prolonged inhaling, of especially spray can paint, inhaling, of especially spray can paint, seems to deteriorate global cognitive seems to deteriorate global cognitive functioning to a lasting (apparently functioning to a lasting (apparently irreversible) degreeirreversible) degree

►Anabolic Steroids: Can produce euphoria, Anabolic Steroids: Can produce euphoria, irritability, and aggressiveness on use, and irritability, and aggressiveness on use, and depression on withdrawaldepression on withdrawal

STIMULANTSSTIMULANTS

►Amphetamines(speed, ecstasy, for Amphetamines(speed, ecstasy, for example) example)

►Phen-phen, - Diet Pills, and OTC diet Phen-phen, - Diet Pills, and OTC diet pillspills

►Caffeine Caffeine ►Ephedrine-like OTC “cold” pillsEphedrine-like OTC “cold” pills►COCAINECOCAINE

COCAINECOCAINE► Can produce serious med complications, Can produce serious med complications,

especially with crack(alkaloid free base especially with crack(alkaloid free base form, widely available, inexpensive, and form, widely available, inexpensive, and extremely addicting.)extremely addicting.)

► For example, MI, as in the case of Len Bias, For example, MI, as in the case of Len Bias, perhaps, or anoxia secondary to seizures perhaps, or anoxia secondary to seizures can be fatal. can be fatal.

► Mixing with heroin and O.D.ing is not Mixing with heroin and O.D.ing is not uncommon, and very dangerous. uncommon, and very dangerous.

► Crack when smoked, produces a high within Crack when smoked, produces a high within seconds,followed in minutes by a depressive seconds,followed in minutes by a depressive crash- leading to a craving for the euphoria crash- leading to a craving for the euphoria and a desire to rid the depression-VERY and a desire to rid the depression-VERY ADDICTINGADDICTING