substance abuse disorders
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SUBSTANCE ABUSE DISORDERS. Substance abuse disorders. Drug use – when drugs are used to treat an illness, prevent a disease and improve health condition, it is termed drug use - PowerPoint PPT PresentationTRANSCRIPT
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SUBSTANCE ABUSE DISORDERS
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Substance abuse disorders
Drug use – when drugs are used to treat an illness, prevent a disease and improve health condition, it is termed drug use
Drug abuse – intake of drugs for reasons other than medical in a manner that affect physical or mental functioning is termed drug abuse.
Tolerance – it refers to a condition where the user needs more and more of the drug to experience the same effect. Smaller quantities, which were sufficient earlier, are no longer effective and the user is forced to increase the amount of drug intake
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Intoxication - it is a condition that follows the administration of a psychoactive substance and results in disturbance in the level of consciousness, cognition, perception, judgment, affect, or behavior, or other psych physiological functions and responses.
Dependence – dependence syndrome is a cluster of physiological, behavioral, and cognitive phenomena in which the use of a substance or a class of substances taken on a much higher priority for a given individual than other behaviors that once had greater values
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Psychological dependence – psychological or psychic dependence refers to the experience of impaired control over drinking or drug use while physiological or physical dependence refers to tolerance and withdrawal symptoms.
Harmful use – pattern of psychoactive substance use that is causing damage to health. It may be physical or mental
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Abuse – in DSM IV, psychoactive substance use is defined as a maladaptive pattern of use indicated by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the recurrent use in situations in which it is physically hazardous.
Withdrawal symptoms - when the drug intake is stopped, withdrawal symptoms are experienced. Physical dependence gives rise to withdrawals such as tremors and vomiting. Psychological dependence causes withdrawal symptoms like restlessness or depression.
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Definition
DSM-IV, ‘psychoactive substance abuse’ is defined as a maladaptive pattern of use indicated by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the recurrent use in situations in which it is physically hazardous.
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Epidemiology
14 million of U.S population reported current use of illicit drugs
Almost 6% of the population were heavy drinkers
WHO indicates 180 million people of the world’s population consumed illicit substances
The most commonly consumed substance was cannabis, used by 144 million people of the world’s population
Annual prevalence of cannabis abuse among people aged 15-64 in India is 3.2%
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Classification of addictive drugs
1. Narcotic Analgesics2. Stimulants3. Depressants4. Hallucinogens5. Cannabis6. Volatile Solvents7. Other drugs of abuse (muscle relaxants,
painkillers, anti histamines, anti emetics, antipsychotics )
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Commonly abused drugs in India
Cannabis (bhang, ganja, charas)Tranquilizers (hypnotics, sedatives)Barbiturates Amphetamines Hallucinogens Narcotic drugs (opium, pethidine, morphine,
morphine, heroin, cocaine)Tobacco (cigar, cigarette, beedi, hukka )Other substances such as alcoho,inhalants,
steroids
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ICD 10 classification
F10-F19 Mental and behavior disorders due to psycho active substance use
F10 Mental and behavioral disorders due to use of alcoholF11 Mental and behavioral disorders due to use of opioidsF12 Mental and behavioral disorders due to use of
cannabinoidsF13 Mental and behavioral disorders due to use of
sedatives or hypnoticsF14 Mental and behavioral disorders due to use of cocaineF16 Mental and behavioral disorders due to use of
hallucinogens
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Causes of substance abuse
Biological factorsGenetic vulnerabilityCo morbid psychiatric disordersCo morbid medical disordersReinforcing effects of drugsWithdrawal effects and cravingBiochemical factors
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Psychological factorsCuriosityEarly initiation of alcohol and tobaccoPoor impulse controlSensation seekingLow self esteemConcern regarding personal autonomyPoor stress management skillsChildhood trauma or lossPsychological distressEscapism
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Social factorsPeer pressureModelingEasy availabilityInterfamilial conflictsReligious reasons and cultural factorsPoor social and familial supportRapid urbanizationRole of mediaPopularity of drugs in various profession
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Risk factors
Chaotic home environmentIneffective parentingLack of nurturing and parental attachmentInappropriately aggressive or shy behavior in
classroom Poor social coping skillsPoor school performanceAssociation with deviant peer groupPerception of approval of drug use behavior
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Stages of substance abuse
1. Stage 0 –showing curiosity : it is the first stage and it is the beginning of substance abuse
2. Stage 1- learning about the drug induced mood swings : the teen learns more about use of drugs
3. Stage 2- seeking the drug induced mood swings : learns to seek the heights of psychological effects
4. Stage3 – being preoccupied with the drug induced mood swings: behavior changes to stealing, truancy, lying, drug dealing etc
5. Stage 4- burnout : at this stage they use drug just to feel normal, euphoric effects may be low.
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Opioid use disorders
The commonly abused opioids – heroin, brown sugar, smack
Synthetic preparation – pethidine, fortwin, buprenorphine
Acute IntoxicationApathyBradicardiaHypotensionRespiratory depression, subnormal temperaturePin point pupils, thready pulse, coma
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Watery eyesRunning noseYawningLoss of appetiteIrritabilityTremorsSweatingCrampsNausea
DiarrheaInsomniaRaised body
temperaturePiloerectionAnorexiaThe symptoms start with
in 12 hrs, lasts to 24-36 hrs and disappear in 5-6 days
Withdrawal syndromeWithdrawal syndrome
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Complications
ParkinsonismPeripheral neuropathyTransverse myelitisSkin infectionThrombophlebitisPulmonary embolismEndocarditisSepticemiaAIDS, viral hepatitisTetanus
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Treatment
Narcotic antagonists (naloxone, naltrexone)Detoxification (methadone, clonidine,
naltrexone, buprenorphine)Maintenance therapy (methadone
maintenance, opioid antagonists, individual therapy, group therapy, family therapy)
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Cannabis use disorder
The dried leaves and flowering tops are often referred to as Ganja or Marijuana
The resin of the plant is referred to as Hashish
Bhang is a drink made from cannabisCannabis is either smoked or taken in liquid
form
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Mild impairment of consciousness and orientation
TachycardiaSense of floating in the airEuphoria Dream like state ‘flashback’ phenomenaAlteration in psychomotor
activity
TremorsPhotophobiaLacrimationDry mouthIncreased appetitePerceptual
disturbances
Acute intoxication
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Withdrawal symptoms
Mostly found in 72-96 hoursIncreased salivationHyperthermiaInsomniaDecreased appetiteLoss of weightInsomnia
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Complications
Transient or short lasting psychiatric disorders
Acute anxietyParanoid psychosisHysterical fugueHypomaniaSchizophrenia like stateAmotivational syndromeMemory impairement
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Cocaine use disorder
Common street name is’crack’It is taken orally, intranasally or parenterallyAcute IntoxicationPupillary dilationTachycardiaHypertension Perspiration Nausea Hypomanic symptoms
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Withdrawal syndrome
AgitationDepressionAnorexiaFatigueSleepiness ComplicationsAcute anxiety reactionUncontrolled compulsive behaviorSeizures Respiratory depression, cardiac arrhythmias
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Treatment
Management of intoxication ( Amyl nitrate is antidote, diazepam or propranolol is used)
For withdrawal symptoms (antidepressants and psychotherapy)
Imipramine or amitriptiline
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Amphetamine use disorder
They are CNS stimulantsCommonly used amphetamines are pemoline and
methylphenidateAcute IntoxicationTachycardia pupillary dilationHypertension insomniaCardiac failure restlessnessSeizures irritabilityTremors paranoid hallucinatory
syndromehyperpyrexia
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Withdrawal syndrome
DepressionApathyFatigueHypersomniaInsomniaAgitationHyperphagia Complication Seizures, deliriumArrythmias, aggression, coma
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Barbiturate use disorder
Commonly abused barbiturates are secobarbital, pentobarbital and amobarbital
I n t o x i c a t i o n IrritabilityLability of moodDisinhibited behaviorSlurred speechIncoordinationAttention and memory impairment
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Complications Withdrawal syndrome
IV use lead to skin abscesses
CellulitisInfectionsEmbolismHypersensitivity
reactions
Severe restlessnessTremorsSeizuresDelirium tremens
like state
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Treatment
Induction of vomiting (in conscious patients)Use of activated charcoal (to reduce
absorption)Symptomatic treatment
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LSD use disorder (Lysergic acid diethylamide)
LSD is a hallucinogenFirst synthesized in 1938It acts on 5 HT levels of brain“trip” is the term used for the pattern of LSD
use (occasional use followed by long term abstinence)
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Intoxication
Perceptual changesDepersonalizationIllusionsSynesthesias (colours are heard, sounds are
felt)Autonomic hyperactivityAnxietyParanoid ideationImpaired judgement
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Withdrawal syndrome Complications
FlashbacksHallucinogenic
states
AnxietyDepressionPsychosisVisual hallucinations
Treatment is symptomatic, including, antianxiety, antidepressant and antipsychotic medications
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Inhalants or volatile solvent use disorders
Commonly used substances are petrol, aerosols, thinners, varnish remover and industrial solvents
IntoxicationEuphoriaExcitementBelligerence Slurred speechApathyImpaired judgment
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Withdrawal symptoms Complications
AnxietyDepression
Treatment includes reassurance and diazepam for intoxication
Irreversible damage to liver and kidneys
Peripheral neuropathy
Perceptual disturbances
Brain damage
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Treatment
CBTMultidimensional family therapyMotivational interviewingContingency management (motivational
incentives)Aversion therapyGroup therapyCounselling Residential treatment (therapeutic
community, 6-12 months, for drug free re socialization)
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Assessment Nursing diagnosis
BackgroundSubstance useMental health
problemsPsychological testsMental status
examination
AnxietyDisturbed sleep patternAltered nutrition less
than body requirementImpaired social
interactionsLow self esteemIneffective individual
copingRisk for violence
Nursing management
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Prevention of substance use disorders
Primary preventionEnhance government restrictionsStrengthen individuals coping skillsHealth education to college studentsIdentify and treat family member who may
contribute to drug abuse
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Secondary preventionEarly detection and counsellingMotivational interviewingComplete assessment to elicit the extend of
problemDetoxification with benzodiazepoxide
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Tertiary prevention Relapse prevention
Assertive trainingTeach coping skillsBehavior counselingPsychotherapySupportive
psychotherapyGuidance and
counseling
Motivation enhancementDealing with faulty
cognitionTime managementAnger controlFinancial managementStress managementRecreation and
spiritualityFamily counseling
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Goals Interventions
To enable the drug dependent to leave the drug
To establish new social contracts
To provide social support
To inculcate responsibility in protecting themselves
Participation in day care centers
Occupational and social rehabilitation
Teaching relaxation techniques
Religious therapyEnhance self esteemParticipation in self help
groups
Rehabilitation
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Follow up and home care
Nurses should be hopeful and appropriately supportive
Teach patient / family about the various complications of abuse
Explain to the family, that patient may use lies, denial or manipulation to continue drug
Teach them drug overdose may result in emergency/ death
Caution patient about transferring HIV or hepatitis B
Teach family to develop trust with patient and help in setting limits
Provide patient the full range of treatment and supportive measures
Teach them how to recognize psychological stressors and way to cope with that
Help to establish new life style.
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ALCOHOLISM
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INTRODUCTION
Alcoholism is the most common psychiatric disorder. Epidemiological studies carried out in India revealed that 20 to 40% of subjects aged above 15 are current users. Nearly 15 to 30% of patients seeking admission in psychiatric facilities are for alcohol related problems.
Alcoholism is classified under F10-F19, i.e. mental and behavior disorders due to psychoactive substance use in ICD 10 classification
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DEFINITION
1. Alcoholism refers to the use of alcoholic beverages to the point of causing damage to the individual and society or both.
2. Alcoholism is defined as a chronic disease manifested by repeated drinking that produces injury to the drinker’s health or to his society or economic functioning.
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PREVALANCE
In India the incidence of alcohol dependence is 2% and 20 to 40% of population aged above 15 are current users.
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WHAT IS ALCOHOL?
Alcohol includes liquors, beer and wine.
Chemical name: ethanol
Street names: booze, hooch, moonshine, sauce etc..
Mode of administration: oral
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HOW IT ACTS?
Acts on CNS in two ways
1. It potentiates GABA activity
2. It decreases glutamate activity In both cases the outcome is
depression.
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PROPERTIES OF ALCOHOL
Clear colored liquidStrong burning tasteRate of absorption into blood is more faster
than its elimination rate.Absorption is slower in the presence of foodA small amount is excreted through urine and
small amount is exhaled.
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Conti..
A conc. of 80-100mg per 100ml of blood is considered as intoxication
A person with 200-250mg per 100ml of blood will be toxic, sleepy, confused, and his thought process will be altered.
If the conc. is 300mg per 100ml of blood, the person may loose consciousness.
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Conti…
A conc. of 500mg per 100ml of blood is fatalAll the symptoms change according to the
tolerance of the person.
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ETIOLOGICAL FACTORS
1. Biological factors2. Psychological factors3. Social factors4. Availability5. Psychiatric disorders
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BIOLOGICAL FACTORS
Genetic vulnerability
Family history of substance abuse
Biochemical factors
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PSYCHOLOGICAL FACTORS
Sense of inferiority Poor impulse control Low self esteem Poor stress management skill Loneliness
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Conti…
Unmet needsDesire to escape from realityDesire to experimentA sense of adventurePleasure seekingSexual immaturity
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SOCIAL FACTORS
Peer pressure Urbanization Extended period of
education Unemployment Over crowding Social isolation
Poor social supportReligious reasons Effect of mass mediaOccupational factors
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AVAILABILTY
alcohol is easily available and drinking is accepted as a norm in functions and gatherings,
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PSYCHIATRIC DISORDERS
Depression Anxiety disorders Personality disorders Organic brain disorders schizophrenia
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STAGES IN ALCOHOLISM
1. EARLY STAGE (1st stage)
Increased tolerance Blackouts Pre-occupation Grossed drinking
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2 MIDDLE STAGE (2nd stage) Loss of control over amount, frequency Keeping away from alcohol for sometime,
but going back to obsessive drinking after each abstinent period.
Denial Feeling of guilt and shame Chronic hangover Projection
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3 CHRONIC STAGE Getting drunk even on small amount of alcohol intake Willing to lie, beg, borrow, steal to maintain supply of
alcohol Living to drink Avoiding family and friends Loss of interest Problem with low Moral deterioration Impaired thinking Loss of tolerance to alcohol
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Signs and symptoms of ADS
Malaise, dyspepsia, mood swings,Poor personal hygiene, untreated injuries (cigarette
burns, bruises)Unusually high tolerance for sedatives and opioids Nutritional deficienciesSecretive behaviorConsumption of alcohol containing productsDenial of problemTendency to blame others and rationalize problems Impaired controlWithdrawal symptomsNeglect of other activitiesPersistent use
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Psychiatric disorders due to alcohol dependence
1. Acute intoxication 2. Withdrawal syndrome3. Alcohol induced amnestic disorders4. Alcohol induced psychiatric disorders
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Acute intoxication
Develops during or shortly after alcohol ingestion.
Inappropriate sexual or aggressive behaviorMood labilityImpaired judgmentSlurred speechUnsteady gaitImpaired attention
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Withdrawal symptoms
Persons who have been drinking heavily over a prolonged period of time, any rapid decrease in the amount of alcohol in the body is likely to produce withdrawal symptoms
a) Mild withdrawal symptomsb) Delirium tremons
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Mild withdrawal symptoms
Mild tremorsNauseaVomitingWeaknessIrritabilityInsomniaAnxietyDepression Fatigue Night tremors
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Delirium tremens
Occurs within 2-4 days of complete abstinent from heavy drinking
Recovery occurs within 3-7 days• Clouding of consciousness• Disorientation• Poor attention span• Hallucinations• Grossly tremors of hands• Sweating, fever, tachycardia, increased BP
(autonomic disturbances)
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Cont…
• Visual and tactile hallucination• Truncle ataxia (Impairment of the ability to
perform smoothly coordinated voluntary movements. This condition may affect the limbs, trunk, eyes, pharynx, larynx, and other structures )
• Dehydration, electrolyte imbalances• Insomnia• Infection, self inflicted injury• Cardiovascular collapse• Death
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Cont….
. SweatingFeverTachycardiaRaised BPDehydrationDeath may occur due to cardiovascular
collapse, infection, self inflicted injuries
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Alcohol induced amnestic disorders
Chronic alcohol abuse associated with thiamine (vita B) deficiency is the most frequent cause of AD
1. Wernicke’s syndrome Cerebellar ataxia Palsy of 6th cranial nerve peripheral neuropathy Mental confusion
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Korsakoff’s syndrome
DisorientationConfusionConfabulationPoor attention span
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alcohol induced psychiatric disorders
DementiaMood disordersSuicidal behaviorAnxiety disorderImpaired psychosexual functionPathological jealousyAlcoholic seizuresAlcoholic hallucinosis
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COMPLICATIONS
1. Medical complications
2. Social complications
3. Psychiatric complications
CirrhosisPancreatitisPolyneuropathyRisk for cancerViolenceRapesViolating lowAnxietyConfusionOrganic brain
syndrome
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A Medical complications
1 GI SYSTEM Gastritis Peptic ulcer Vomiting Carcinoma Malabsorption syndrome Fatty liver
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Conti..
Cirrhosis of liverHepatitis
2 Cardio vascular system Alcoholic cardiomyopathy High risk for MI
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3 CNS Peripheral neuropathy Epilepsy Head injury Cerebellar degeneration
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4 Blood Anemia Decreased WBC production Protein malnutrition5 Skin Spider angiomas acne
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6 Joints Gout7 Pregnancy Fetal alcohol syndrome Fetal abnormalities Mental retardation Growth deficiency
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8 Reproductive system Sexual dysfunction in males Failure of ovulation in females
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B Social complications
Marital disharmonyOccupational problemsFinancial problemsCriminalityaccidents
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C psychiatric complications
Acute intoxication1. Maladaptive behavior2. Psychological changesWithdrawal syndrome1. Simple withdrawal syndrome2. Delirium tremens3. Alcoholic seizures4. Alcoholic hallucinosis
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Diagnosis
Blood alcohol level 200mg/dlUrine toxicology to reveal use of other drugsSerum electrolyte analysisLFTHematologic studiesECG, echo cardiogramBlood glucose levelElevated ALT and AST
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Treatment
Symptomatic Rx involve respiratory support, fluid replacement, emergency measures for trauma etc
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Treatment for withdrawal symptoms
1. Detoxification *benzodiazepines (chlordiazepoxide 80-
200mg/day) * diazepam 40-80 mg/day * 100mg of thiamine twice daily fro 3-5
days, then oral administration for 6 months *anticonvulsants if necessary * maintain electrolyte balance
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Cont…
2. Alcohol deterrent therapyDeterrent agents are those which are given to
desensitize the individual to the effects of alcohol and maintain abstinence. The most commonly used drug is disulphiram(tetraethyl thiuram disulfide) or antabuse
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Psychological Rx
Motivational interviewingGroup therapyAversive conditioningCognitive therapyRelapse prevention techniquesCue exposure technique
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Disulfiram
It is used to ensure abstinence in the treatment of alcohol dependence. Its main effect is to produce a rapid and violently unpleasant reaction in a person who ingests even a small amount of alcohol while taking disufiram
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Dosage
Tablets 200-500 mgInitial dose – 500 mg/ day orally for initial 2
weeksMaintenance dose later, of 250mg/dayDose should not exceed 500mg/day
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Mechanism of action
When alcohol is consumed, it is metabolized by the body into acetaldehyde, a very toxic substance , that causes many ‘hang over’ symptoms. Disulfiram interferes with the metabolism of alcohol that increases the acetaldehyde level (10 times > in normal alcoholics) and it produces a wide variety of unpleasant reactions called Disulfiram Ethanol Reaction (DER)
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DER symptoms
FlushingNauseaVomitingSweatingThirstThrobbing headacheRespiratory difficultyChest painPalpitationsDyspnea
HyperventilationTachycardiaHypotensionSyncopeSevere uneasinessWeaknessVertigoBlurred visionconfusion
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Side effects Contraindications
FatigueDermatitisImpotenceOptic neuritisMental changesAcute
polyneuropathyHepatic damage
Pulmonary and cardiovascular disease
Use with caution in patients with nephritis, brain damage, hypothyroidism, diabetes, hepatic disease, seizures and poly drug dependence
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Nurses responsibility in Deterrent therapy
Get informed consent before therapy starts
Administer the medicine after 12 hours of the last ingestion of alcohol
Strictly inform the patient not to take even a small amount of alcohol after therapy starts
Instruct him about reaction.
Avoid any topical application, and food stuffs , medicines containing alcohol
Patient should not take any CNS depressants or OTC medicines
Avoid driving and activities require alertness
Instruct them DER will last for 1-2 weeks after the last dose
Importance of follow up
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Alcoholics anonymous (AA)
Found in USA on 10th June 1935 by two alcoholic men, Dr. Bob Smith and Bill Wilson.
AA considers alcoholism as a physical, mental and spiritual disease, a progressive disease which can be arrested but not cured
Members attend group meetings usually twice a week on long term basis
Each member is assigned a support person, from whom he may seek help when the temptation to drink occurs
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Once sobriety is achieved, he is expected to help others
The only requirement for membership is the desire to stop drinking
Their primary purpose is to help each other stay sober and help other alcoholics to achieve sobriety.
A l - A n o nSupport group for wives of alcoholics, started by
Mrs. Anne, wife of Dr. BobA l - A t e e nProvides support to teen children of alcoholics
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Nursing management
Assessment through CAGE questionnaireC- Have you ever felt you ought to CUT
DOWN on your drinking?A- Have people ANNOYED you by criticizing
your drinking?G- Have you ever felt GUILTY about your
drinking?E – Have you ever had a drink first thing in
the morning as an EYE OPENER to steady your nerves or get rid of a hangover?
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Nursing diagnosis
Risk for injury related to hallucinosis, acute intoxication evidenced by confusion, disorientation, inability to identify potentially harmful situations
Altered health maintenance related to inability to identify, manage or seek out help to maintain health, evidenced by various physical symptoms, exhaustion, sleep disturbance etc.
Ineffective denial related to weak, underdeveloped ego, evidenced by lack of insight, rationalization of problems, blaming others, failure to accept responsibility of his behavior
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