Disease Entities
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 Phases
 The 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 stress
 Tolerance develops
Phase II: Early Alcoholic Phase
 Begins with the first blackout
 The chemical is no longer associated with pleasure or relief
 The individual requires the chemical
 The 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 Phase
 Individual demonstrates signs and symptoms of
Physiological and Psychological dependence
 Binge use often occurs
 Interactions are characterized by anger and aggression
 Family dysfunction
 Individual demonstrates impairment in social and
occupational functioning
Phase IV: Late or Chronic Phase
 The individual is almost always intoxicated
 Ethical deterioration is apparent
 Impaired reality testing, especially paranoia, is evident
 Depression with suicidal ideation is common
 Life-threatening physical consequences are evident:
 Peripheral neuritis with LE numbness, pain
 Alcoholic myopathy
 Wernicke-Korsakoff syndrome
 Alcoholic cardiopathy
Phase IV: Late or Chronic Phase, cont.
 Hepatitis
 Cirrhosis (complications include portal hypertension,
ascites, esophageal varices and hepatic
encephalopathy)
 Esophagitis and gastritis (ulcers, hemorrhage)
 Pancreatitis
 Leukopenia
 Thrombocytopenia
 Sexual dysfunction
Substance Profiles
ALCOHOL DEPENDENCE:
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 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
Alcohol Withdrawal, cont’d
 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
(A Belgian beer is named for this effect)
 Use of validated withdrawal assessment rating scale
assists in objective description of withdrawal severity
Validated withdrawal
assessment scale:
Clinical Institute
Withdrawal Assessment
for Alcohol (CIWA-Ar)
Alcohol: Interventions
 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) – opiate receptor antagonist-blocks the “high”
 acamprosate (Campral) – reduces cravings
SEDATIVES, HYPNOTICS AND
ANXIOLYTICS
BARBITURATES
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 Dependence
 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
 Quiet, calm environment
 Monitor vital signs
 Taper dose gradually; may take weeks or months
 Seizure precautions
INHALANTS:
Abuse and Dependence
 Generally act as CNS depressants
 Dangerous due to inability to control amount inhaled
 Use is associated with
 CNS damage
 Respiratory irritation, distress and depression
 GI distress
 Mouth ulcers
 Renal and hepatic damage
 Death from asphyxiation or suffocation
OPIOIDS
 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
 Initial euphoria
 Followed by apathy, dysphoria, psychomotor agitation
or retardation, impaired judgment
 Pupillary constriction
 Drowsiness (“nodding”), slurred speech
 Impaired 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 Withdrawal
Symptoms very uncomfortable but rarely dangerous:
• Dysphoria, anxiety, cravings
• Sweating and chills
• Lacrimation, rhinorrhea
• GI distress (anorexia, n/v, cramping, diarrhea)
• Muscle aches, bone pain
• Restlessness
• Tremors
• Sleep disturbances
• Yawning
Treatment for Opioid Withdrawal
 Primarily supportive care
 Treat symptomatically
 Specific pharmacotherapy:
 clonidine-for n/v/diarrhea
 buprenorphine (Buprenex) –reduces pain and
discomfort
Example of clinical
assessment tool for
opiate withdrawal
(COWS)
Opioid Dependence:
Interventions
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: Abuse and
Dependence
 Cocaine
 Amphetamines: prescribed or illicit
 Non-amphetamine stimulants
 Caffeine
 Nicotine
STIMULANTS: Cocaine
Intoxication and Dependence
 Cocaine –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
Amphetamines: Intoxication and
Dependence
 Often are prescribed, widely abused
 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
 Neglect of nutrition and dental care
STIMULANTS: 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 druginduced psychosis/agitation
(There are no medications that can treat stimulant dependence)
Comparison Chart