Substance Abuse Midterm

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Addition is a Disease

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-->Strong genetic component-40-60% risk is in genetic vulnerabilities
-->polymorphisms =increased risk
-->Production of neuroactive substances in the brain

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major enzymes involved in breakdown of alcohol

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-Polymorphisms in aldehyde dehydrogenase
-->aldehyde dehydrogenase are
-->polymorphisms are variances of aldehyde dehydrogenase; influence metabolism of alcohol; associated w/ risk for developing alcohol dependence

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Production of neuroactive substances in the brain

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-Neuroactive substances in the brain of those w/ ddiction differ from those w/o addiction.
--> gaba's receptor genes & serotonin dysfunction are implicated in studies of vulnerabilities of addict

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Mu opioid receptors

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--> opioid receptor, primary site of the drug action.
-->polymorphisms of the mu receptor gene has been found that changes the receptors ability to bind w/ beta endorphins. It has been suggested that this polymorphisms may be implicated in the development or protection from opioid addiction.

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Addiction as a disease

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-disease is 100% FATAL if not treated
-Recovery is possible
-Untreated--->institutionalized, insanity, or death
-There is NO cure

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major areas of pleasure center in brain

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-Nucleus accumbens
-Ventral tegmental area
*Pathways are activated by dopamine
*Reward pathway circuit can be hijacked by psychoactive substances and certain behaviors

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opiates, gambling, sex addiction cause what re: the pleasure center of the brain?

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-cause Dopamine to be released 10X more

---->Reward pathway circuit can be hijacked by psychoactive substances and certain behaviors

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as a result of the increased dopamine

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As reward circuit adapts to ↑amounts of dopamine, it affects receptors which lead to cravings; in reacting to craving, brain resets pleasure center response; over time, tolerance is higher leading to drug tolerance

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HALLMARK for addiction

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Cravings

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Initial effects alcohol

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Stimulates the brain’s pleasure/reward system
• Relaxation
• Euphoria-alcohol buzz
• Sexual arousal-pleasurable or risk taking
• Gradual loosening of inhibitions

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Later effects

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-Loss of coordination
-Slowing of vital reflexes-impairs driving
-Mood changes-sad,low,hostile,angry,argumentative
-Lapses in judgment-do/say u ordinarily wouldn’t
-GI upset
-Loss of consciousness
-Resp. depression & potentially fatal: alcohol poisoning or aspiration of vomit while sleeping

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Alcohol depresses nerves that control involuntary actions:

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-Breathing, heart beat, gag reflex (prevents choking)
-Hypothermia
-↓blood sugars leading to seizures

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U.S. Standards: 0.6 oz of pure alcohol (4 g or 1.2 tbs) which is equivalent to:

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-Beer 12 oz
-Wine 5 oz
-Hard liquor 1.5 oz

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Binge Drinking-most common form of alcohol consumption (most are NOT alcoholics)

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-Women: 4 or more drinks on a single occasion
-Men: 5 or more

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Heaving Drinking

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-Women: more than 1 drink per day on average
-Men: 2 or more

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Assessment Screening Tool

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CAGE questioner

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-C
-A
-G
-E

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-Cut down-Have you ever felt you should cut down on your drinking?
-Annoyed-Have people annoyed you by counting your drinks?
-Guilty-Have you felt bad or guilty about your drinking?
-Eye-opener-Have you ever had a drink first thing in the AM to steady your nerve or get rid of a hangover?

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Results

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1 “yes” = needs closer assessment

2 “yes” = highly correlates w/ alcohol abuse

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Assessing for Alcohol Abuse

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-Frequency and amount: what the person drinks, how many, how often, time of last drink, and how many years they have been drinking

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Document your findings

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-Describe large quantities in terms of six-packs or cases, or size and number of bottles
-Indicate whether amounts are per day, per week, or per episode of heavy drinking
-Need to do best to estimate amount of intake and frequency

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Asking Sensitive Questions

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-Be matter-of-fact and nonjudgmental
-Ask the pt meds they are using. Start w/ least ex: caffeine; then nicotine; alcohol; recreational drug use (pain meds that are prescribed or "borrowed" from someone.

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**How we ask can make a huge difference in the accuracy of the information we get**

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“To give you the best and safest care, we need to know what your body is used to in the way of medications and substances”

say it matter-of-factly and nonjudgmental

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A maladaptive pattern of substance use leading to clinically significant impairment or distress must

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manifested by 2 (or more) of the 11 criteria, occurring w/ a 12 month period:

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1-5

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1.Failure to fulfill Roles
2.Use in Risky situations
3.Use despite persistent adverse effects on Relationships
4.Tolerance
5.Withdrawal

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tolerance

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(tolerance is not taken into consideration when there is a prescription for opioids and pt has built up a physical tolerance, unless the person has 2 or more of the other criteria)

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The characteristic withdrawal

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-Rule of thumb” generally the w/drawal of a substance is opposite of the effects of intoxication
-The same (or a closely related) substance is taken to relieve or avoid withdrawal

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6-9

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6.Use of higher doses or for a longer period than intended
7.Persistent desire or unsuccessful to cut down
8.A great deal of time is spent in activities to obtain the substance, use the substance, and recover from its effects-
9. Importance social, occupational or recreational activities are given up or reduced because of substance use-

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10 & 11

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10.The substance use is continued despite knowledge of having a related persistent or recurrent physical or psychological problem
11.Craving or a strong desire or urge to use a specific substance

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cravings

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- last a short period of time and use tools that rehabilitation teaches, they may get by the craving and learn how to cope adaptively

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Results: Moderate:
Severe:

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-2-3 criteria are positive
-4 or more criteria are positive

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Effects of Chronic Heavy Drinking on CNS

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-Neuropathy
-Cerebellar degeneration
-Dementia
-Wemick e-Korsakoff’s syndrome:


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Neuropathy

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-numbness/tingling in the hands & feet can be caused by alcohol dependence- peripheral pneumopathy
-if pt presents, get Hgb AIC to r/o DM and GTT & MCV liver enzymes as well to see if alcohol related

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-Cerebellar degeneration

-Dementia

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-gait disturbances

-cortico dementia occurs from long term effects on brain

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-Wemick e-Korsakoff’s syndrome:


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-thiamine deficiency that occurs b/c of malformation in the GI tract in those who use alcohol.
-leads to degeneration limbic system &other brain structures =confusion, nystagmus (involuntary eye movement), or paralysis of ocular muscles

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If Untreated:


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-severe short term memory loss with confabulation (makes up stories to cover for times that they don't remember but they do not realize)

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Intervention:

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Thiamine needed as soon as possible w/in first few hours over at least first few days; standard tx for those in detox; thiamine converts glucose into its metabolic active form & nerve cell function

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Effects of Chronic Heavy Drinking on Gastrointestinal

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-Alimentary/stomach
-Liver
-Pancreas
-Mallory Weiss Syndrome
-Varicosities
-GI cancers

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-Alimentary/stomach:

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Peptic ulcer disease & gastritis-caused by corrosive effects of alcohol

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Liver


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-Range from fatty liver (several hours after a few drinks) to alcoholic hepatitis (↑ALT & AST)
-Cirrhosis-inflammation causes hepatocyte damage leading to sclerosis/scarring causing liver to shrink; occurrence in 15% of alcoholics
-Hepatocellular cancer

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-Pancreas


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Pancreatitis & pancreatic cancer-alcohol affects insulin production and blood sugar regulation

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-Mallory Weiss Syndrome


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Tearing of gastroesophageal mucosa w/ severe upper GI bleeding
-Occurs from forceful vomiting
-MEDICAL & SURGICAL EMERGENCY!!!

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Varicosities


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Engorged vessels in the esophagus that have potential to tear and severely bleed

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GI cancers


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Nicotine has a synergistic effect on GI cancers

80% of alcoholics are smokers

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Effects of Chronic Heavy Drinking on Cardiovascular

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-Hypertension
-Cardiomyopathy-enlarge heart; alcohol is toxic to cardiac muscle
-Stroke

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Reproductive

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-Diminished hormone production
-Inadequate functioning of the testes and ovaries-testicular atrophy
-Sexual dysfunction and infertility: may want to ask about alcohol use w/ complaints of

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Effects of Chronic Heavy Drinking on Hematologic

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-Cause macrocytic anemia
-MCV

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Effects of Chronic Heavy Drinking on Musculoskeletal

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-Cause osteoporosis
-Myopathies where muscles are tender to touch
--->Muscle weakness
---> May see wide stance gait which is a combination of musculoskeletal and cerebellum damage

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Effects of Chronic Heavy Drinking on Endocrine

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-Hyperuricemia-underlying cause of gout
-Hyperlipidemia
-hyperglycemia

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-Dermatologic

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-Cheilosis-fissuring or scaling of lips and end corners of mouth
-TX: reduce or eliminate alcohol; nutritious high protein diet & thiamine replacement

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These blood tests are good markers for heavy drinking

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• GGT ( > 30)
• AST/ALT
• MCV ( > 90)

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-GGT ( > 30)

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-Gamma glutamyl transaminase
-Good sensitivity and specificity
-70-80% sensitive and specific and generally is the 1st of the liver enzymes to elevate
-Ex: 6-12 drinks a day for several weeks = elevation of GGT

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-AST/ALT

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-Aspartate aminotransferase/alanine aminotransferase
-Not as helpful since only elevate when hepatocytes are damage which is usually elevated at chronic stages

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-MCV ( > 90)

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-Mean Corpuscular Volume
-Measure of how large the RBCs are, ↑w/ heavy drinking and poor nutrition-Vit B12 & Folic acid

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-Urine Toxicology Screen

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-Useful in detecting acute intoxication w/ alcohol and drugs
-w/ alcohol, only useful w/in 6-8 h of ingestion

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When taking a history, ask about

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life problems, family, marital, job problems, accidents, legal like OUIs and then transition into nonthreatening, nonjudgmental about alcohol, drug, and nicotine use

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Acute Withdrawal Syndrome

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-Acute physiological rebound when deprived of high levels of a substance that it has been exposed to for a significant period of time (substance becomes part of the body’s chemistry). causes changes to neural pathways and availability of neural transmitters so when physiological rebound occurs, person is ill. **Withdrawal effects are opposite of intoxication**

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S/S of withdrawal

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-may emerge a few hours after last drink (4-8 h)
-Occurs w/ heavy drinkers
-Often seen in ER, may still be intoxicated, but have some trauma that need care
-They peak after 24-48 hours
-Symptoms subside by day 5 for most people
-For severe withdrawal 2 or more weeks
-Some pts are sedated and stay in ICU during w/drawal for their physical & psychological safety

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Withdrawal seizures

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-Withdrawal seizures can occur at any time, regardless of severit-up to 72 hours, high risk for seizures-important to tx withdrawal symptoms effectively

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Withdrawal Effects Cardiovascular

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-Hypertension--->cerebral event
-Tachycardia

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Withdrawal Effects Neurological

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-Headache
-Tremors--->1st neurological sign
-Seizures

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Withdrawal Effects Mental Status

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-Labile mood
-Irritability
-Transient confusion or hallucinations

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Withdrawal Effects GI

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-Nausea
-Vomiting

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Withdrawal Effects Autonomic

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-Fever --->fluid loss--->dehydration
-Diaphoresis--->dehydration--->↑fever
-Insomnia
-Anxiety

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Tremors

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--->1st neurological sign
-Tremors occur upon awakening after a night of drinking (may deal w/ this by drinking a little bit more or to stave off w/d)

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delirium tremans.

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And this occurs in less than 5% cases of withdrawal. It is particularly severe. It is more likely to occur in someone who is already ill and has multiple medical conditions. altered mental status + shakes

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Life span shortened

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up to 15 yrs w/ heavy drinking hx and few periods of abstinence

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Severe AWS
(Alcohol Withdrawal Delirium)

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-Formerly known as delirium tremens (DTs)
-Potentially life-threatening-occurs < 5%; prevent by early intervention
-Delirium may appear suddenly & be accompanied by seizures

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Symptoms
Severe AWS
(Alcohol Withdrawal Delirium)

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-Uncontrollable shaking-can’t hold onto anything, getting out of bed is unsafe
-Profuse diaphoresis
-HTN, tachycardia, & tachypnea worsen
-Possible hyperthermia
-Extreme agitation, fluctuating disorientation, confusion, and hallucinations