Substance Abuse Disorders
NU124
Criteria: SUBSTANCE ABUSE
 Must have one or more in the past 12 months:
 Recurrent use in physically dangerous settings
 Recurrent drug-related legal problems
 Continued use despite recurring interpersonal
problems
Continued:
 Failure to fulfill role obligations at home, school, or
work
Criteria: SUBSTANCE DEPENDENCE
 Three more in the last 12 months:
 Drug intolerance
 Drug withdrawal
 Use is greater in amount and frequency of use than
intended (loss of control)
 Persistent desire and unsuccessful attempts to stop
or control
Continued:
 Increasing time and energy to obtain the drug
 Lifestyle changes (social, recreational or
occupational)
 Use continues despite problems
Intoxication
 Reversible substance-specific syndrome
 Clinically significant behavioral or psychological
changes
 Not due to another mental disorder
Withdrawal
 Substance-specific syndrome due to cessation
 Clinically significant distress
 Not due to another condition
Behaviors
 Manipulation
 Grandiosity
 Denial
 Isolation
 Decreased occupational functioning
 Impaired relationships
Assessment
 CAGE:
 Cut down?
 Annoyed?
 Guilty?
 Eye-opener?
ALCOHOL INTOXICATION
CNS Impairment – brain function to peripheral NS,
absorbed in stomach, all systems affected. See
Townsend, p. 416+
Acute, Metabolize – gone and symptoms go
Long tem effects with use =
Amounts
Quantities
****CNS depression****
Acute alcohol intoxication
Changes in mood
Poor psychomotor coordination
Impaired memory and judgment
Impaired social functioning
Behavior changes
BAL of 100-200 mg/ml
Remember “Tolerance”
Withdrawal
 What is the opposite of CNS depression?
 What have you studied in NU 110 that is similar to
this?
 ***Sympathetic NS Hyperactivity***
 Similar to physiological stress response
Symptoms
 Tremors
 Elevated VS
 Anxiety, irritability
 Insomnia
 Diaphoresis
 ***Onset: 4-12 hours after last drink
Withdrawal
 Peak is 2 – 3 days
 GREATEST RISK: Alcohol delirium, DT’s, Delirium
tremens
 *** A medical crisis
 Occurs on second to third day following last drink
 Prevent DT’s. Get pt. past this window.
Alcohol delirium
 Autonomic NS hyperactivity: cardiac, smooth




muscles, glands
Hallucinations, illusions, delusions
Fluctuating LOC
Seizures
N and V
Detoxification
 Priority #1: Physiological stability, safety
 Monitor: BP and P, R and T; q 4 hrs:
 Medicate: Use of cross dependent sedatives, titration
based on degree and number of symptoms. What
class of drugs have a sedative/CNS depressant
effect? Use
these_________________________
Continued:
 Fluids – replacement and enhance detoxification via
kidney and liver - if functioning normally
 Nutrition – alcohol decreases appetite;
Thiamine(Wernick’s encephalopathy), Folic acid and
MVI
Continued:
 Reduce risk of seizures: MgSo4, Anticipate
anticonvulsants
 Reduce risk of stroke: antihypertensives
Continued:
 Priority #2: Address the denial
 Around day 3
 Matter of fact, no judgment, tell the facts of patient
condition and directly link to alcohol use
 “As a result of your body’s dependency on alcohol, it
reacted with the symptoms
of__________________. This indicates damage
to …”
Continued:
 “Alcohol use is damaging your body. Examples of
this are____________.”
continued
 Priority #3: Plans for sobriety, learning to live
sober. Contingent upon belief that alcohol use has
created problems.
 “What would you like to have happen in your life
now?” “What do you wish for?”
 At discharge
 In-patient rehabilitation or, home and AA
Sobriety
 Medications – adjunct to learning to cope, re



programming responses
Antabuse – negative reinforcement
Naltrexone – decrease cravings
Campral – decrease distress, improve mood,
contraindicated in liver inpairment
MEMORIZE THESE
Continued:
 Continue to address denial and powerlessness over
alcohol – AA
 Practice new ways to cope
 Counseling on coping and repairing relationships
 New relationships, lifestyle changes
Family
 Don’t feel
 Don’t trust
 Don’t expect
Continued:
 Deny the problem
 Use a substance
 Develop a symptom
 Kick the user out
 Co-dependence (part of denial) – the need to be
needed
 Learn to cope with substances
Family treatment
 Family therapy to repair relationships, family
structures, re-set family roles
 Alanon – adult – learn to give up responsibility for
the user and his/her substance use
 Alteen – Adolescents: Leaning to cope, not overfunction, have sx., or use substances
Part II - Other drugs
 Why does the brain prefer opium to broccoli?
 A shortcut to the brain’s reward system
 Floods the nucleus accumbens with dopamine
 Hippocampus lays down memories of rapid
satisfaction – Feels GREAT
Continued:
 Amygdala creates a condition response to certain
stimuli
 Stressors or something associated with substance
use, trips the mental machinery of relapse* Conditioned
response
 Very neuophysiologic

*Harvard Mental Health Newsletter, Volume 21, No. 1, 2004, p.1.
OTHER DRUGS
 CNS DEPRESSANTS: Opiods
 Effects: Suppress sympathetic NS. Load endorphin
receptor sites = euphoria and analgesia
 Depletes serotonin which regulates pain perception
and anxiety
 Heroin
 Name other similar CNS depressants _____
Continued:
 Withdrawal: 6 – 8 hrs = nervous and edgy
 Runny nose, tearing, pilorection
 Muscle, joints and bones ache
 N and V, diarrhea
 Lasts 4 – 8 days
 Not lethal
Continued:
 Treatment: No CNS drugs;will cause cross addiction
 Systems support - e.g., diarrhea
 Fluids and nutrition as tolerated
 Emotion support
 Replacement therapy/ methadone clinics
 Lifestyle change and coping
 STIMULANTS: Cocaine/crack
 Effects: Stimulates CNS = well-being, energy and
euphoria
 Blocks reuptake of norepinephrine, dopamine and
serotonin
 Tachycardia, HTN, increased resp. and metabolic
rate
 Name other stimulants: ____________
Continued:
 Anorexia but craves high-sugar, restlessness
 Massive systematic vasoconstriction = MI, CVA,
spontaneous abortion

Who will be at risk? Aged, pregnant f females
Continued:
 Withdrawal: Overwhelming fatigue
 Dysphoria and anhedonia
 Even after drug has been detoxed, neurotransmitter
levels are so unbalanced = clinical depression
 Suicide precautions
STIMULANT: Methamphetamine
 Coming soon to your neighborhood
 Releases high levels of dopamine
 Enhances mood
 Intense rush or “flash”. Very different from cocaine
 MA high lasts 8 – 24 hrs; cocaine lasts 20 - 30
minutes
Continued:
 MA effects
 Euphoria, increased attention and libido
 Increased activity with decreased fatigue and
appetite
 Toxicity from binging – visual hallucinations,
violence, elevated BP, R, and Temp.
 Tolerance
Continued:
 Treatment for toxicity (Intoxication)
 Acute ER: IV Haldol for agitation, IV medications for
controlling BP and preventing seizures
 Cardiac monitoring, IV hydration
 Reducing hyperthermia if present
Continued:
 Chronic use at lower dosages:
No physical manifestations of withdrawal
 BUT: Depression, anxiety, fatigue, paranoia,
aggression and an intense craving for the drug

HALLUCINOGENS
 Mind Altering: PCP, LSD
 Low doses – euphoria
 Higher - hallucinations, delusions, peripheral
anesthesia, agitation
 Risk for trauma due to altered state
 Long term: sympathomimetic signs
Continued:
 Treatment:
 No Withdrawal syndrome but:
 When insufficiently metabolized, stored in fat.
Metabolize fat tissue = released into circulation
producing hallucinations later = flashbacks OR brain
damage due to use.
 Acute sx. in ER – agitation, ensure pt. safety
Inhalants
 Benzene, nitrates: paint, glue, lighter fluid
 Very addicting
 Affects Cardiac and CNS
 Intoxication: euphoria, giddiness, drowsiness
 Chronic: Dysrythmias, renal and liver, organic
mental changes
 Teens – buy in drugstore or hardware store