Substance Use and Related Disorders MH unit7

Substance Use and Intoxication Terminology

• Intoxication: This is defined as maladaptive behavior resulting from substance use.
• Tolerance: A state where an individual has a higher threshold for a substance. This requires an increase in the amount used in order to obtain the same desired effect.
• Tolerance Break: A period of abstinence or reduced use that results in a lower threshold for the substance. Consequently, smaller amounts of the substance will cause a higher level of intoxication.     * Example: A person might take $10$ drinks and feel okay; however, after a tolerance break, having just $2$ drinks might lead to a feeling of "woah" or intense intoxication.
• Withdrawal: Negative physical and/or psychological reactions that occur after an individual stops using a substance.
• Detoxification: The process of safe withdrawal from a substance.
• Substance Abuse vs. Dependence:     * Abuse: Harmful use of a substance.     * Dependence: Characterized as addiction, involving tolerance, withdrawal symptoms, and failed attempts to quit the substance.

Non-Substance and Minor Addictive Disorders

• Gambling Disorder: Classified as a non-substance addiction involving betting of any kind. Behaviors include lying, borrowing money to fund the habit, and becoming irritable when attempts are made to force them to quit.
• Caffeine and Nicotine: These are recognized as addictions.     * Caffeine withdrawal is famously characterized by the onset of a headache when the substance is not consumed for a day.     * Note: While addictive, these are not currently classified as mental health disorders in the same way as other substance use disorders.
• Internet Addiction: Currently under study. This involves the excessive use of the internet. Individuals experience irritability when access is restricted.
• Substance-Induced Disorders: These occur when substance use triggers other mental health conditions, such as anxiety, psychosis, or mood disorders.     * Example: Methamphetamine-induced psychosis.

Etiology and Influences of Addiction

• Genetics: There is an increased risk for addiction if close relatives have an addiction disorder.
• Environmental Factors: These include culture and the use of substances among family or friends.     * The phrase "Birds of a feather flock together" is used to describe how social circles influence use.     * To stop an addiction, individuals often need to distance themselves from those environments and change their primary social circles.
• Coping Skills: Many individuals resort to alcohol or drugs because they lack healthy coping mechanisms. The goal of treatment is to teach patients healthy alternatives.
• Neurochemical Influences: Substances change brain chemistry by increasing specific neurotransmitters.     * Dopamine: Use of substances increases dopamine, which makes the user feel "happy" or "high." This positive reinforcement creates the desire to use the substance again.     * Stop Signals: Some individuals have a natural "stop signal" where they recognize they do not feel normal and can stop before a "point of no return." However, others lack this signal and will continue drinking or using until the brain slows down and they reach a dangerous state of intoxication.

Alcohol: Intoxication, Overdose, and Long-Term Effects

• Classification: Alcohol is a Central Nervous System (CNS) depressant.
• Intoxication Symptoms:     * Early effects: Relaxation and loss of inhibitions.     * Progressive effects: Slurred speech, unsteady gait (stumbling), impaired memory, and impaired judgment.     * Behavioral changes: Aggression and inappropriate sexual behavior.
• Blackout: A state where the individual continues to function without conscious awareness but has no memory of the events. This is described as a very scary feeling.
• Alcohol Overdose:     * Symptoms: Vomiting, unconsciousness, and respiratory depression.     * Risks: Aspiration pneumonia (due to vomiting while unconscious), cardiovascular shock, and death.     * Treatment: Gastric lavage (stomach pumping) or, in severe cases, dialysis. Patients are typically managed in the Intensive Care Unit (ICU).     * Contraindication: CNS stimulants should not be used to treat alcohol overdose.
• Chronic Effects of Alcohol Use:     * Liver damage: Cirrhosis, jaundice, and ascites.     * Organ systems: Seizures, pancreatitis, esophagitis, hepatitis, and all-organ failure.     * Hematologic effects: Leukopenia and thrombocytopenia.     * Wernicke-Korsakoff Syndrome:         * Wernicke Encephalopathy: Affects the brain, causing vision trouble and confusion. This stage is reversible.         * Korsakoff Psychosis: This stage is not reversible and is essentially alcohol-related dementia.     * Cardiac effects: Cardiac myopathy.

Alcohol Withdrawal and Detoxification

• Timeline:     * Begins: $4$ to $12$ hours after the last drink.     * Peaks: Around day $2$.     * Duration: Typically lasts approximately $5$ days, but can extend up to $2$ weeks.
• Withdrawal Symptoms: Tremors, sweating, elevated heart rate, elevated blood pressure, insomnia, anxiety, nausea, and vomiting.
• Severe Withdrawal: Can lead to hallucinations, seizures, and Delirium Tremens (DTs), described as "withdrawal on steroids." This can result in death.
• Detoxification Management:     * Alcohol withdrawal is life-threatening and must be medically supervised.     * Nursing interventions: Monitor Level of Consciousness (LOC), track vital signs, and implement seizure precautions.     * Setting: Mild cases can be outpatient; severe cases must be inpatient (usually $3$ to $5$ days).
• Pharmacologic Treatment:     * Benzodiazepines: Commonly used (e.g., Librium), though they carry their own risk of addiction.     * Thiamine ($B_1$): Administered to prevent Wernicke-Korsakoff syndrome due to $B_1$ deficiency.
• Dosing Methods:     * Fixed schedule: The dose is gradually tapered over time.     * Symptom-triggered dosing: Medication is given based on the nurse's assessment of symptoms using the CIWA (Clinical Institute Withdrawal Assessment) protocol.
• CIWA Scoring:     * Low score: No medication needed.     * Score of $8$ to $15$: May require medication.     * Score greater than $15$: Definitely requires medication as the withdrawal is considered severe.

Sedatives, Hypnotics, and Anxiolytics

• Classification: These are CNS depressants.
• Types: Barbiturates, non-barbiturate hypnotics, and benzodiazepines.
• Intoxication Symptoms: Slurred speech, lack of coordination, unsteady gait, labile mood (rapidly changing), impaired attention, memory issues, stupor, or coma.
• Overdose:     * Benzodiazepines: Rarely fatal when taken alone. They cause lethargy and confusion. Treatment involves gastric lavage and activated charcoal.     * Barbiturates: These can be lethal. They cause coma, respiratory arrest, cardiac failure, and death. Treatment requires ICU care, gastric lavage, dialysis, and respiratory/cardiovascular support.
• Withdrawal:     * Onset depends on the drug's half-life (shorter half-life means sooner withdrawal).     * Symptoms: The opposite of the drug's effects. Includes increased heart rate, blood pressure, respiratory rate, and temperature. Also includes tremors, insomnia, anxiety, nausea, and psychomotor agitation.     * Severe cases: Seizures and hallucinations.
• Detoxification: These medications must not be stopped abruptly. They must be managed by gradually tapering the dose over days or weeks. This can involve decreasing the dosage amount or increasing the time between doses.

Stimulants

• Types: Amphetamines, cocaine, and methamphetamine.
• Action: They excite and stimulate the Central Nervous System. They carry a very high abuse potential.
• Intoxication: Onset is rapid.     * Symptoms: Euphoria, hyperactivity, fidgeting, hypervigilance, talkativeness, grandiosity, hallucinations, aggression, and impaired judgment.     * Physical signs: Elevated heart rate and blood pressure, dilated pupils, sweating, chills, nausea, chest pain, and cardiac arrhythmias.     * Overdose risk: Seizure, coma, and death.
• Withdrawal: Occurs within hours to days. It is typically not life-threatening but involves a "crash."     * Symptoms: Dysphoria, fatigue, vivid unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor agitation or retardation.     * Critical Risk: Severe depressive symptoms can lead to suicide.     * Treatment: There is no specific pharmacologic treatment for stimulant withdrawal.

Cannabis (Marijuana)

• Legal Status: Varies state by state; however, federal law still prohibits most use. In cases where they conflict, if a state allows it, federal charges are often dropped in favor of state law.
• Intoxication:     * Onset: Less than $1$ minute after inhalation.     * Peak: $20$ to $30$ minutes.     * Duration: $2$ to $3$ hours.     * Symptoms: Relaxation, lowered inhibitions, increased appetite, euphoria, and inappropriate laughter.     * Physical signs: Bloodshot eyes, dry mouth, lowered blood pressure, and tachycardia (increased heart rate).     * Cognitive signs: Impaired judgment, impaired memory, and time distortion.     * Chronic/Excessive use: Can lead to delirium or cannabis-induced psychosis, though this is rare.
• Overdose: Does not typically happen.
• Withdrawal: There is no clinically significant withdrawal syndrome, but users may experience muscle aches, sweating, anxiety, and tremors.

Questions & Discussion

• Question regarding medication withdrawal: Does withdrawal occur with medications like Ritalin?     * Response: Technically, an individual can withdraw from any medication if it is stopped, especially prescription drugs like blood pressure meds or stimulants like Ritalin. The severity varies. For Ritalin, which is a stimulant, a person may have been on it for $10$ years and should ideally be tapered off.
• Discussion on ADHD Medication Shortage: A student shared an anecdote about a child being unable to access medication due to a shortage.     * Response: Shortages are difficult because if there is no access to the medication, a doctor cannot provide a lower dose for tapering. While doctors might try to use extended-release versions or other alternatives, a true shortage means the medication is simply unavailable.
• Question on State vs. Federal Law: What happens if you get in trouble federally in a state where marijuana is legal?     * Response: Usually, if the state allows it, federal authorities may drop charges or defer to state law, though technically both laws could hold depending on the specific situation.