Substance Use Disorders
Disease Entities And Substance Profiles
Note-Taking Outline
CNS DEPRESSANTS
ALCOHOL
Some Facts
 5-7% of Americans are Alcoholics
 Every alcoholic touches lives of 5 people
 A leading cause of death: from medical complications, accidents and suicides
 Fetal alcohol syndrome most common cause of mental retardation in children
 Potentiates other CNS depressants
 Alcoholism underreported in women and older adults
Alcohol: Intoxication
 Metabolism of alcohol is increased in heavy drinkers
 Women more easily intoxicated than men.
 Effects: CNS depression and Peripheral vasodilation
 Decreased muscle tension, lowered anxiety level, disinhibition, impaired judgment,
sedation
 Toxic effects: stupor, unconsciousness (including blackouts), coma, death
“Alcohol poisoning” s/t large amount consumed in short time period
Alcohol Withdrawal
 Usually develops 4-12 hours after cessation or reduction of alcohol use
 Rebound phenomenon (CNS irritability) as drug effects wear off:
 increased anxiety, tension, psychomotor activity
 sweats, tremors, tachycardia, increased temp. and BP
 nausea, vomiting, diarrhea
 Withdrawal seizures may occur 7-48 hours after cessation or reduction
 Alcohol 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
Alcohol: Interventions for Withdrawal
 Seizure precautions; anticonvulsants for DT’s
 Suicide assessment and precautions, if necessary
 Medications: 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
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CNS DEPRESSANTS: SEDATIVES, HYPNOTICS AND ANXIOLYTICS:
BARBITURATES AND BENZODIAZEPINES
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Commonly prescribed for sleep, anxiety, muscle spasms, etc.
Also used illicitly, including
• reducing effects of stimulant (esp amphetamine) abuse
• if other narcotics not available
• by sexual predators
Sedatives, Hypnotics, or Anxiolytics: Abuse and Dependence
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Potentiate each other and alcohol
Produce physiological dependence
Produce psychological dependence
Cross-tolerance and cross-dependence between CNS depressants
Withdrawal sx.: anxiety, insomnia, nausea, seizures
 Overdose and Fatal effects: respiratory depression, coma, death
Interventions for Sedative W/D
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Quiet, calm environment
Monitor vital signs
Taper dose gradually; may take weeks or months
Seizure precautions
CNS DEPRESSANTS: INHALANTS
 Inorganic and organic volatile substances-usually cheap and readily available
 Intoxication: CNS depression- elevated mood (silly and happy) and excitability,
possible sleepiness and confusion
Inhalents: Abuse and Dependence
 Dangerous due to inability to control amount inhaled
 Use is associated with
 CNS damage-memory, gait impairment
 Respiratory irritation, distress and depression
 GI distress
 Mouth ulcers
 Renal and hepatic damage
 Death from asphyxiation or suffocation
CNS DEPRESSANTS: OPIOIDS
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Opium and Heroin
Morphine
Codeine
SYNTHETIC MORPHINE DERIVATIVES, e.g:
 oxycodone (OxyContin)
 hydromorphone ((Dilaudid)
 hydrocodone (Vicodin)
 meperidine (Demerol)
Opioid Abuse and Dependence
 Activate endorphins, reduce pain and anxiety
 Many routes of use: po, subcut., IM, IV, inhaled
 IV use is associated with infection, including HIV and Hepatitis, bacterial endocarditis,
and abscesses
 May be prescribed or illicitly obtained
 Heroin--highest abuse and dependence potential
 CNS effects, including respiratory depression
 GI effects
Opioid Intoxication
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Initial euphoria
Followed by apathy, dysphoria, psychomotor agitation or retardation
Pupillary constriction
Drowsiness (“nodding”), slurred speech
Impaired judgment, memory and concentration
Opioid Overdose
 Pinpoint pupils
 Clammy skin
 Respiratory depression
 Coma (pupils will dilate secondary to anoxia)
 Death rapidly follows coma
Opioid Withdrawal: very uncomfortable but rarely dangerous
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Dysphoria, anxiety, cravings
Sweating and chills, piloerection
Lacrimation, rhinorrhea
GI distress (anorexia, n/v, cramping, diarrhea)
Muscle aches, bone pain
Restlessness
Tremors
Sleep disturbances
Interventions for Opioid Withdrawal
 Primarily supportive care
 Treat symptomatically
 Specific pharmacotherapy:
 clonidine-for n/v/diarrhea
 buprenorphine (Buprenex) –reduces pain and discomfort
Interventions for Opioid Dependence
 Promoting Abstinence:
 Maintenance Pharmacotherapy to reduce cravings and block the “high” :
 naltrexone (Trexan, ReVia)
 methadone –requires enrollment in maintenance program (federally controlled
supervision)
CNS STIMULANTS
CNS Stimulants: Intoxication
 Various Effects:
 increased alertness, arousal and endurance
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Decreased need for food and sleep
HR and BP
 Neurobiology (different for different drugs):
 facilitate norepinephrine, dopamine activity
 nicotinic receptor agonists
 adenosine receptor antagonists
STIMULANTS: COCAINE
Cocaine Intoxication and Dependence
 Blocks dopamine reuptake esp. in nucleus accumbens (“pleasure center”)
 IV or intranasal route; Crack (dilute) form is smoked
 Rapid effects and rapidly metabolized:
 Intense euphoria
 Increased mental alertness
 Increased motor and cardiac activity
 Increased muscle strength
 Psychological dependence is even more severe than physical dependence; cravings
are intense
STIMULANTS: AMPHETAMINES
Amphetamine Intoxication and Dependence
 Often are prescribed, widely abused
 Amphetamine: Inhibits reuptake of dopamine and norepi.
 Methamphetamine: Slower metabolic effects, often mixed with cocaine (cheaper)
 Routes: IV, intranasal, po, smoked
 Immediate intense pleasure, lasting high
 “Crash” occurs as drug effects wear off
 Intense cravings promote frequent, repetitive use
 Damage to teeth, gums
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 Stimulant Overdose:
 Induce vomiting, diuretics, administer IM antipsychotic if drug-induced
psychosis/agitation
HALLUCINOGENS
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Natural or synthetic substances
Effects vary from enhancement of sensory stimuli to loss of reality and hallucinations
(Psychotic symptoms)
Effects highly unpredictable
HALLUCINOGENS: CANNABINOLS (MARIJUANA and Related)
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Not strictly a hallucinogen
Most widely used illegal drug in US
Active Ingredient: THC (delta-9-tetrahydrocannbinol
o Detectable in blood and urine for up to 4 weeks
Smoked or ingested
Hashish-resinous form
“Medical marijuana” antiemetic and for chronic pain
o Legal RX: drobinol (Marinol)
o Plant form legal in some states
Cannabis: Intoxication
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Euphoria, relaxation, disinhibition
Alteration in sensory and time perception
Increased appetite
Anxiety
Tachycardia and Hypotension
Cannabis Dependence
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?Physical?
Psychological- tolerance
Cannabis: Complications and Adverse Effects
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Impaired memory, concentration
Apathy and loss of motivation (heavy users)
Pulmonary compromise
?Reduced female, male hormones and sperm count?
Paranoia and panic
Flashbacks
HALLUCINOGENS: LYSERGIC ACID DIETHYLAMIDE (LSD)
PHENCYCLIDINE (PCP)
LSD- Semisynthetic-binds to serotonin receptors
LSD Intoxication:
 Episodic and binge use common
 Effects last up to 12 hours
 Synesthesia experiences-blending of sensory perceptions
LSD Adverse Effects:
 Hypertension and tachycardia
 Acute psychosis: delusions, paranoia
 Flashbacks
 Panic
PCP-Synthetic anesthetic
PCP Intoxication:
 Euphoria and relaxation
PCP Adverse Effects:
 Ataxia, vomiting
 Agitation, violent outbursts, catatonia
 Severe elevations in HR and BP
LSD and PCP: Overdose and Fatal effects; Complications
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Psychotic break (persisting psychosis)
Perceptual distortions cause client to harm self/suicide or others
Cardiac arrest
PCP-seizures
Dependence: Psychological tolerance
Frequent users-cravings
No physiologic dependence
Treatment of Acute Intoxication or Overdose
Diazepam (Valium) for seizures [PCP], paranoia and panic
IM haloperidol (Haldol) for agitation and aggression