Alcohol and Substance Abuse
Alcohol and Substance Abuse
Alcohol (ethanol) is a
CNS depressant. Large amounts consumed rapidly can cause respiratory
depression, coma, and death. Large amounts chronically consumed damage the
liver and many other organs. Alcohol withdrawal manifests as a continuum,
ranging from tremor to seizures, hallucinations, and life-threatening autonomic
instability in severe withdrawal (delirium tremens).
About 45 to 50% of adults globally are current
drinkers, 20% are former drinkers, and 30 to 35% are lifetime abstainers. For
most drinkers, the frequency and amount of alcohol consumption does not impair
physical or mental health or the ability to safely carry out daily activities.
However, acute alcohol intoxication is a significant factor in injuries,
particularly those due to interpersonal violence, suicide, and motor vehicle
crashes. Chronic abuse interferes with the ability to socialize and work. About
7 to 10% of adults meet criteria for an alcohol use disorder (abuse or
dependence) in any given year. Binge drinking, defined as consuming ≥ 5 drinks
per occasion for men and ≥ 4 drinks per occasion for women, is a particular
problem among younger people.
Alcohol and substance abuse have tremendous social and economic costs to
families and governments globally. In Zambia,
alcohol consumption and substance abuse are one of the most prevalent health
risk factors among adolescents and young adults. Where assessments have been
elsewhere, economic impacts are in the billions of
dollars, and include health care, treatment and lost productivity costs (Monge
et al., 1999). In order to gain an insight of the
personal and financial costs of alcohol and drug abuse, several nationwide
surveys have been examined. For instance, Poulin et al, (1999) examined the
economic costs of alcohol abuse in Canada for the year 1992 as around 7.52
billion dollars or 1.1% of the Gross Domestic Product. The biggest share of
costs through substance abuse remained tobacco use with an estimated 9.56
billion dollar economic costs. In the United States, the National Institute of
Health (1998) reported that the estimated economic cost of alcohol and drug
abuse was an estimated 246 billion dollars of which alcohol abuse and
alcoholism generated about 60% of these costs (148 billion dollars), while drug
abuse and dependence accounted for the remaining 98 billion dollars. No reliable
estimates have been available for the cost of drug-use in Germany, but Bergmann
and Horch (2000) report that the total costs caused by alcohol consumption in
Germany are about 40 billion marks per year. These are staggering numbers, but
pale still when we begin to examine the impact of chemicals on our children and
youth. Some statistics by the National Clearinghouse on Alcohol and Drug
Information one time claimed that 20% of 16–17 year olds used marijuana 1–7
days per week compared to 12% of 12–13 year olds.
Alcohol
is a central nervous system depressant. It plays a prominent role in the
development of at least depression and is often involved in other mental disorders. In addition, people who abuse alcohol are
at increased risk of mental
disorders related to nutritional deficiencies. A lack of thiamine, a B-vitamin,
can result in permanent brain damage in the form of severe dementia even at an
early age. People in withdrawal from alcohol are also at risk for delirium
tremens, a serious condition that can result in cardiovascular shock and death.
Two most notable problems linked with alcohol abuse are withdrawal and
dependency.
Withdrawal State
Chronic
effects: Tolerance to alcohol develops rapidly; similar amounts cause less
intoxication. Tolerance is caused by adaptational changes of CNS cells
(cellular, or pharmacodynamic, tolerance) and by induction of metabolic
enzymes. People who develop tolerance may reach incredibly high blood alcohol
content (BAC). However, ethanol tolerance is incomplete, and considerable
intoxication and impairment occur with a large enough amount. But even these
drinkers may die of respiratory depression secondary to alcohol overdose.
Alcohol-tolerant people are susceptible to alcoholic ketoacidosis, especially
during binge drinking. Alcohol-tolerant people are cross-tolerant of many other
CNS depressants (e.g., barbiturates, nonbarbiturate sedatives,
benzodiazepines).
Symptoms and
Signs of Alcohol Withdrawal
The physical dependence
accompanying tolerance is profound, and withdrawal has potentially fatal
adverse effects. A
mild withdrawal syndrome includes tremor, weakness, headache, sweating,
hyperreflexia, and GI symptoms. Symptoms usually begin within about 6 h of
cessation. Some patients have generalized tonic-clonic seizures (called
alcoholic epilepsy, or rum fits) but usually not > 2 in short succession.
Alcoholic hallucinosis (hallucinations
without other impairment of consciousness) follows abrupt cessation from
prolonged, excessive alcohol use; usually within 12 to 24 h. Hallucinations are
typically visual. Symptoms may also include auditory illusions and
hallucinations that frequently are accusatory and threatening; patients are
usually apprehensive and may be terrified by the hallucinations and by vivid,
frightening dreams. The syndrome may resemble schizophrenia, although thought
is usually not disordered and the history is not typical of schizophrenia.
Symptoms do not resemble the delirious state of an acute organic brain syndrome
as much as does delirium tremens or other pathologic reactions associated with
withdrawal. Consciousness remains clear, and the signs of autonomic lability
that occur in delirium tremens are usually absent. When hallucinosis occurs, it
usually precedes delirium tremens and is transient.
Delirium tremens usually begins 48 to
72 h after alcohol withdrawal; anxiety attacks, increasing confusion, poor
sleep (with frightening dreams or nocturnal illusions), profuse sweating, nausea, vomiting, weakness, irritability,
insomnia ,hypoglycaemia and severe depression also occur.
Fleeting hallucinations that arouse restlessness, fear, and even terror are
common. Typical of the initial delirious, confused, and disoriented state is a
return to a habitual activity; e.g., patients frequently imagine that they are
back at work and attempt to perform some related activity. Autonomic lability,
evidenced by diaphoresis and increased pulse rate and temperature, accompanies
the delirium and progresses with it. Mild delirium is usually accompanied by marked
diaphoresis, a pulse rate of 100 to 120 beats/min, and a temperature of 37.2 to
37.8° C. Marked delirium, with gross disorientation and cognitive disruption,
is accompanied by significant restlessness, a pulse of > 120 beats/min, and
a temperature of > 37.8° C; risk of death is high.
Symptoms progress proportionately
to the blood alcohol content (BAC). Actual levels required to produce given
symptoms vary with tolerance, but in typical users:
- 20
to 50 mg/dL: Tranquility, mild sedation, and some decrease in fine motor
coordination.
- 50
to 100 mg/dL: Impaired judgment and a further decrease in coordination
- 100
to 150 mg/dL: Unsteady gait, nystagmus, slurred speech, loss of
behavioural inhibitions, and memory impairment.
- 150
to 300 mg/dL: Delirium and lethargy (likely).
Emesis is common with
moderate to severe intoxication; because emesis usually occurs with
obtundation, aspiration is a significant risk. In addition due to prolonged use of alcohol, three of
the following disturbances may occur:
·
Delirium Tremens-occurs 2-4 days of complete
abstinence from heavy alcohol drinking and recovery is expected within seven
days. It is an acute brain syndrome characterised by clouding of consciousness
with disorientation in time and space. Poor
attention span and distractibility, visual (and also auditory) hallucinations
and illusions which are often vivid and frightening. Tactile hallucinations of
insects crawling over body may occur, marked autonomic disturbance i.e.
tachycardia, fever, sweating, hypotension and pupil dilatation, psychomotor
agitation and ataxia, insomnia with a reversal of sleep walk pattern,
dehydration with electrolyte imbalance.
·
Alcoholic seizures (rum fits)-these are generalised
tonic clonic seizures which occur in about 10% of alcohol dependant patients
usually 12-48 hours after a heavy bout of drinking. Status epilepticus may be
precipitated. Multiple seizures 2-6 at a time are more common than single
seizures.
·
Alcoholic Hallucinosis-this is characterised by the
presence of hallucinations (usually auditory in nature) during abstinence,
following regular alcohol intake. Classically, the hallucinations occur in
clear consciousness and recovery occurs within one month.
Alcohol Dependency Syndrome
Alcohol abuse remains a major public health issue and socioeconomic problem in today’s society, with a lifetime prevalence of
14% (McCrady and Langenbucher, 1996). Adverse effects of AWS on patient outcomes have been
well documented. In addition to causing discomfort, metabolic stress, and the potential
for serious outcomes including seizures, the syndrome also impairs effective health-care
delivery to the patient. Despite great
progress made in the field of psychiatry, the development of suitable
medications for the treatment of alcohol dependency remains a challenging goal
for alcohol research. The mechanism
between alcohol intoxication, tolerance, dependence and withdrawal is complex.
In simple terms, alcohol has a depressive effect on the central nervous system
(CNS). The brain adapts to this depressant effect if large amounts of alcohol
are consumed over time, thus instigating a level of tolerance. Abrupt cessation
of alcohol consumption causes rebound excitation of the central nervous system
and consequent autonomic hyperactivity (Smith-Alnimer and Watford, 2004).
It must be stated that alcohol dependency is cluster of physiological, behavioural and cognitive
phenomena in which the use of alcohol or a class of substances (drugs) takes on
a much higher priority for a given individual than other behaviours that had
greater value. The central descriptive characteristic of alcohol dependence
syndrome is the desire (often strong, sometimes over powering) to take alcohol.
The notable signs and symptoms of the disorder include:
·
Strong desire or sense of compulsion to
take alcohol
·
Difficulties in controlling amounts
taken and timing
·
Presence of withdrawal signs and
symptoms when alcohol is not taken e.g. tremors and sweating
·
Evidence of tolerance (large amounts of
alcohol are required to achieve desired effects)
·
Progressive neglect of alternative
pleasures or interest because of alcohol use
·
Persisting with substance use despite
evidence of overtly harmful consequences (medical, mental or psychosocial
problems)
·
Narrowing of personal drinking
repertoire (predictable and repetitive patterns of drinking on weekends and
workdays regardless of social constraints)
Essentials of Diagnosis for Alcohol Withdrawal
A.
Cessation of
(or reduction in) alcohol use that has been heavy and prolonged.
B.
Two (or
more) of the following, developing within several hours to a few days after
criterion A:
1.
Autonomic
hyperactivity (eg, sweating or pulse rate greater than 100 beats per minute)
2.
Increased
hand tremor
3.
Insomnia
4.
Nausea or
vomiting
5.
Transient
visual, tactile, or auditory hallucinations or illusions
6.
Psychomotor
agitation
7.
Anxiety
8.
Grand mal
seizures
C.
The symptoms
in criterion B cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D.
The symptoms
are not due to a general medical condition and are not better accounted for by
another mental disorder.
Street drugs
are well known for their effects on young people's mood and behaviour.
Permanent brain damage may result from the use of some "designer"
drugs. One example is "Ecstasy," which can cause permanent memory
loss and severe depression that responds only slowly to treatment. Street drugs
must always be considered as a possible factor in the sudden onset of a mental disorder in a young person. Moreover, drugs may precipitate a
first psychotic episode in a person with a genetic predisposition to
schizophrenia. In this case, the drug is the stressor that reveals the person's
dormant susceptibility to the disorder.
General Signs/Characteristics
A.
Definitions regarding
psychoactive substances (i.e. substances that activate the brain and cause
effects on thoughts, emotions, and behaviours).
1.
Intoxication –
maladaptive behaviour associated with recent drug ingestion.
2.
Withdrawal – adverse
physical and psychological symptoms that occur following cessation of the drug.
3.
Tolerance – the need
for more substance to attain the same level of effect.
4.
Abuse
or Misuse – a maladaptive pattern of use leading to repetitive problems and
negative consequences (i.e. use in dangerous situations such as driving; use
leading to legal, social and occupational problems).
5.
Dependence
(addiction) — continued desire for and use of a psychoactive substance to
satisfy pleasurable urges and/or to alleviate the effects of withdrawal.
Dependence may be psychological or physical in nature.
Psychological dependence: Persistent
substance use, despite evidence of its harmful consequences.
Difficulties in controlling the use of the
substance.
Neglect of interests and an increased
amount of time taken to obtain the substance or recover from its effects.
Evidence of tolerance such that higher
doses are required to achieve the same effect.
Compulsion or craving: a strong desire to
take the substance.
Anxiety or mood disturbance occurs if drug
is not taken.
6.
Physical dependence:
Physical symptoms occur if drug is not taken (e.g. headache;
gastrointestinal distress; changes in blood pressure, heart rate; sweating;
tremors; muscular pain).
B.
Effects of
psychoactive substances
Intoxication and withdrawal are physical and psychological
effects that may occur with psychoactive substance dependence or abuse.
Specific symptoms of intoxication and withdrawal for varied substances (that
have been studied in western societies) are outlined below in the table.
Medication treatments and counselling interventions are also included in the
following sections.
Substance abuse and
dependence not only have psychological and physical effects, but also social
effects. Deteriorating job/educational performance, family conflict, and legal
difficulties are social problems that have been associated with substance
addiction.
Symptoms and Medication Treatment for Intoxication and
Withdrawal Associated with Psychoactive Substances
Counselling Interventions for Substance Use Disorders
1.
Anxiety and depression
may underlie substance abuse. Also, some individuals with bipolar disorder or a
psychotic disorder may use alcohol or drugs to self-medicate or deal with
symptoms. It is therefore important to evaluate for these psychiatric
conditions and pro-vide the appropriate treatments. For some patients, drug and
alcohol use is decreased if underlying anxiety, mood disturbance, or other
distress is relieved.
2.
Teach breathing and
relaxation techniques as a means for controlling anxiety (see chapter on
―Anxiety Disorders for technique instructions).
3.
Encourage individuals
to identify people who can be contacted for support when cravings or distress
occurs. Another who is also recovering from addiction and is sober can be a
good ally.
Encourage the patient to make a list of and use ―Constructive
Responses to Cravings and Distress (see example below). The point is to
interrupt the craving or distress with a constructive, health promoting response:
Then,
with the patient, on a regular basis:
a) Discuss
the emotions;
b) Review,
reiterate, and add more responses (as indicated) to the ―Constructive Responses
list;
c) Give
praise and encouragement for following through with the constructive responses.
1. Use
problem-solving approaches to address practical is-sues and difficulties
arising from substance abuse (e.g. financial problems, job loss, marital
difficulties).
2. Self-help
groups – use the principles of the self-help group to help individuals with the
common problem of sub-stance abuse gain knowledge and support.
Medication Therapy
· If there are any concomitant medical conditions, treat them.
· Attempt detoxification by withdrawing the drug of abuse and
treating the side-effects.
· Attend to nutritional and electrolyte/hydration imbalances.
· If service is available psychosocial counseling and support
should be commence once the patient’s mental state is stable.
· Apart from alcohol, clients presenting with complications
from other psychoactive substances of abuse may be referred for specialist
treatment.
·
Alcohol
Withdrawal: Patients with severe withdrawal or Delirium Tremens should be managed
in an ICU until these symptoms improve. Treatment may include the following to
prevent Wernicke-Korsakoff syndrome and other complications: IV thiamin and Benzodiazepines.
Thiamin 100 mg IV is given to prevent
Wernicke-Korsakoff syndrome. Alcohol-tolerant
people are cross-tolerant of some drugs commonly used to treat withdrawal (eg,
benzodiazepines).
·
Alcohol
Dependency: refers to frequent consumption of large amounts of alcohol with ≥ 3 of
the following:
§ Tolerance
§ Withdrawal
symptoms
§ Drinking
larger amounts than intended
§ Persistent
desire to reduce use without success
§ Substantial
time spent obtaining, drinking, or recovering from alcohol
§ Sacrifice
of other life events for drinking
§ Continued
use despite physical or psychologic problems
Alcoholism is
often used as an equivalent term for alcohol dependence, especially when
drinking results in significant toxicity and tissue damage.
Aetiology
The maladaptive pattern of drinking
that constitutes alcohol abuse may begin with a desire to reach a state of
feeling high. Some drinkers who find the feeling rewarding then focus on
repeatedly reaching that state. Many who abuse alcohol chronically have certain
personality traits: feelings of isolation, loneliness, shyness, depression,
dependency, hostile and self-destructive impulsivity, and sexual immaturity.
Alcoholics may come from a broken home and have a disturbed relationship with
their family. Societal factors—attitudes transmitted through the culture or
child rearing—affect patterns of drinking and consequent behaviour. However,
such generalizations should not obscure the fact that alcohol use disorders can
occur in anyone, regardless of their age, sex, background, ethnicity, or social
situation. Thus, health workers should screen for alcohol problems in all
patients.
The incidence of alcohol abuse and
dependence is higher in biologic children of people with alcohol problems than
in adoptive children, and the percentage of biologic children of alcoholics who
are problem drinkers is greater than that of the general population. There is
evidence of genetic or biochemical predisposition, including data that suggest
some people who become alcoholics are less easily intoxicated; i.e., they have
a higher threshold for CNS effects.
Symptoms
of AWS
Clinical symptoms of AWS manifest with variable intensity in proportion to the amount of alcohol consumed
and the duration of a recent drinking habit (Bayard et al., 2004). Compton
Diagnosis of AWS
Some alcohol-related problems are
diagnosed when people seek medical treatment for their drinking or for obvious
alcohol-related illness (eg, delirium tremens, cirrhosis). However, many of
these people remain unrecognized for a long time. Female alcoholics are, in
general, more likely to drink alone and are less likely to manifest some of the
social signs. Therefore, many governmental and professional organizations
recommend alcohol screening during routine health care visits.
Treatment of AWS
All patients should be counseled to decrease their alcohol use to below
at-risk levels. For patients identified as
at-risk drinkers, treatment may begin with a brief discussion of the medical
and social consequences and a recommendation to reduce or cease drinking, with
follow-up regarding compliance.
For patients with more serious problems,
particularly after less intensive measures have been unsuccessful, a
rehabilitation program is often the best approach. Rehabilitation programs
combine psychotherapy, including one-on-one and group therapy, with medical
supervision. For most patients, outpatient rehabilitation is sufficient; how
long patients remain enrolled in programs varies, typically weeks to months,
but longer if needed. Inpatient rehabilitation programs are reserved for
patients with more severe alcohol dependence and those with significant and
comorbid medical, psychoactive, and substance abuse problems. Treatment
duration is usually briefer (typically days to weeks) than that of outpatient
programs.
Psychotherapy involves techniques that enhance
motivation and teach patients to avoid circumstances that precipitate drinking.
Social support of abstinence, including the support of family and friends, is
important.
Maintenance: Maintaining sobriety is difficult. Patients should
be warned that after a few weeks, when they have recovered from their last
bout, they are likely to find an excuse to drink. They should also be told
that, although they may be able to practice controlled drinking for a few days
or, rarely, a few weeks, they will most likely lose control eventually.
In addition to the counseling provided in
outpatient and inpatient alcohol treatment programs, self-help groups and
certain drugs may help prevent relapse in some patients. Alcoholics Anonymous (AA) is the most common
self-help group. Patients must find an AA group they feel comfortable in. AA
provides patients with nondrinking friends who are always available and a
nondrinking environment in which to socialize. Patients also hear others
discuss every rationalization they have ever used for their own drinking. The
help they give other alcoholics may give them the self-regard and confidence
formerly found only in alcohol. Many alcoholics are reluctant to go to AA and
find individual counseling or group or family treatment more acceptable.
Alternative organizations, such as Life Ring Recovery (Secular Organizations
for Sobriety), exist for patients seeking another approach.
Drug therapy should be used with counseling rather than as sole treatment. Disulfiram, the first drug available to prevent relapse in alcohol dependence, interferes with the metabolism of acetaldehyde (an intermediary product in the oxidation of alcohol) so that acetaldehyde accumulates. Drinking alcohol within 12 h of taking disulfiram causes facial flushing in 5 to 15 min, then intense vasodilation of the face and neck with suffusion of the conjunctivae, throbbing headache, tachycardia, hyperpnea, and sweating. With high doses of alcohol, nausea and vomiting may follow in 30 to 60 min and may lead to hypotension, dizziness, and sometimes fainting and collapse. The reaction can last up to 3 h. Few patients risk drinking alcohol while taking disulfiram because of the intense discomfort. Drugs that contain alcohol (eg, tinctures; elixirs; some OTC liquid cough and cold preparations, which contain as much as 40% alcohol) must also be avoided. Disulfiram is contraindicated during pregnancy and in patients with cardiac decompensation. It may be given on an outpatient basis after 4 or 5 days of abstinence. The initial dosage is 0.5 g po once/day for 1 to 3 wk, followed by a maintenance dosage of 0.25 g once/day. Effects may persist for 3 to 7 days after the last dose. Periodic physician visits are needed to encourage continuation of disulfiram as part of an abstinence program. 's general usefulness has not been established, and many patients are noncompliant. Compliance usually requires adequate social support, such as observation of drinking. For these reasons, use of disulfiram is most effective when given under close supervision to highly motivated patients.
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