that genetic mechanisms might account for alcohol

consumption.
Biochemical factors: for example, role of dopamine
and norepinephrine have been implicated in cocaine,
ethanol and opioid dependence. Abnormalities in
alcohol dehydrogenase or in the neurotransmitter
mechanism are thought to play a role in alcohol
dependence.
Withdrawal and reinforcing effects of drugs (they
serve as maintaining factors). Co-morbid medical
disorder (e.g. to control chronic pain) .
Psychological Factors
General rebelliousness
Sense of inferiority Poor
impulse control Low self-
esteem
Inability to cope with the pressures of living and
society (poor stress management skills) Loneliness,
unmet needs Desire to escape from reality Desire to
experiment, a sense of adventure Pleasure-seeking
Machoism Sexual immaturity
Social Factors
Religious reasons
Peer pressure
Urbanization
Extended periods of education
Unemployment Overcrowding Poor
social support
Effects of television and other mass media
Occupation: substance use is more common in chefs,
barmen, executives, salesmen, actors, entertainers,
army personnel, journalists, medical personnel, etc
Easy Availability of Drugs
Taking drugs prescribed by doctors (e.g.
benzodiazepine dependence).
Taking drugs that can be hm^ without
prescription (e.g. nic:
Taking drugs that can be obtarre.: sources
(e.g. street drugs).
Psychiatric disorders Substance use are more
common in depress: t orders (particularly social
phot'::.- disorder (especially antisocial
occasionally in organic brain schizophrenia.
COHOL DEPENDENCE SYNDROUE
Alcoholism refers to the use of ale
to the point of causing damage to the
society or both.
Properties of Alcohol
Alcohol is a clear colored liquid witii
burning taste. The rate of absorpticr ;c
into the blood stream is more rar :
elimination. Absorption of alcohol ir.ro
stream is slower when food is pr
stomach. A small amount is excre:->_
urine and a small amount is exhaled
A concentration of 80 to 100 mg of
100 ml of blood is considered in: *
person with 200 mg to 250 mg will be t
confused and his thought process v. \ he
If blood level is 300 mg/100 ml of blooc
may lose consciousness. A concentra
mg /100 ml is fatal. All the symptoms
according to tolerance.
Epidemiology
The incidence of alcohol dependence
India 20 to 40% of subjects aged above !
are current users of alcohol, and near!v
them are regular or excessive users. Ne
3

30% of patients are developing alcoli
problems and seeking admission in ps\
hospitals.
'edical and Social Complications of -
cohol Dependence
Medical Z^trointestinal
system
Gastritis, peptic ulcer, reflux esophagitis, carcinoma
of stomach and esophagus
Fatty liver, cirrhosis of liver, hepatitis, liver cell
carcinoma
Acute and chronic pancreatitis
Malabsorption syndrome
Isrdiovascular system
Alcoholic cardiomyopathy
High risk for myocardial infarction
Central nervous system
Peripheral neuropathy
Epilepsy
Head injury
Cerebellar degeneration
Miscellaneous
Protein malnutrition
Vitamin deficiency disorder
Peripheral muscle weakness
Acne
Sexual dysfunction in males, failure of ovulation in
females
Damage to the fetus
reial alcohol syndrome (facial abnormality, low :
^hweight, low intelligence), increased scUbirths.
Alcohol dependence is responsible for
- r-ercent of all cases of mental retardation
B Social
Marital disharmony
Occupational problems
Financial problems
Criminality
Accidents
PSYCHIATRIC DISORDERS DUE TO
ALCOHOL DEPENDENCE
Acute intoxication
1 Withdrawal syndrome
Alcohol induced amnestic disorders 4 .Alcohol
induced psychiatric disorders
1. Acute intoxication: Acute intoxication develops during
or shortly after alcohol ingestion. It is characterized by
clinically significant maladaptive behavior or
psychological changes, e.g. inappropriate sexual or
aggressive behavior, mood lability, impaired judgment,
slurred speech, incoordination, unsteady gait,
nystagmus, impaired attention and memory finally
resulting in stupor or coma.
2. Withdrawal syndrome: In persons who have been
drinking heavily over a prolonged period of time, any
rapid decrease in the amount of alcohol in the body is
likely to produce withdrawal symptoms. These are:
Simple withdrawal syndrome
Delirium tremens
Simple withdrawal syndrome: It is characterized by mild
tremors, nausea, vomiting, weakness, irritability,
insomnia and anxiety.
Delirium tremens: It occurs usually within 2-4
days of complete or significant abstinence from heavy
alcohol drinking. The course is short, with recovery
occurring within 3-7 days.
It is characterized by:
A dramatic and rapidly changing picture of
disordered mental activity, with clouding of
consciousness and disorientation in time and place
Poor attention span
Vivid hallucinations which are usually visual; tactile
hallucinations can also occur
Severe psychomotor agitation, shouting and evident
fear
Grossly tremulous hands which sometimes pick up
imaginary objects; truncal ataxia
Autonomic disturbances such as sweating, fever,
tachycardia, raised blood pressure, pupillary
dilatation
Dehydration with electrolyte imbalances
Reversal of sleep-wake pattern or insomnia
Blood tests reveal leukocytosis and impaired liver
function
Death may occur due to cardiovascular collapse,
infection, hyperthermia or self- inflicted injury
3. Alcohol- induced amnestic disorders Chronic alcohol
abuse associated with thiamine (vitamin 'B') deficiency is
the most frequent cause of amnestic disorders. This
condition is divided into:
a) Wernicke's syndrome: This is characterized by
prominent cerebellar ataxia, palsy of the 6th cranial
nerve, peripheral neuropathy and mental confusion.
b) Korsakoff's syndrome: The prominent symptom in
Korsakoff's syndrome is gross memory disturbance.
Other symptoms include:
Disorientation
Confusion
Confabulation
Poor attention span and distractibility
Impairment of insight
4. Alcohol- induced psychiatric disorders
a) Alcohol-induced dementia: It is a long term
complication of alcohol abuse, characterized by
global decrease in cognitive functioning (decreased
intellectual functioning and memory). This disorder
tends to improve with abstinence, but most of the
patients may have permanent disabilities.
b) Alcohol-induced mood disorders: Excess drinking
may induce persistent depression or anxiety
c) Suicidal behavior: Suicidal rates are higher in
alcoholics when compared to non-alcoholics of the
same age. The risk factors for suicidal behavior are
continued drinking, co-morbid major depression,
serious medical illness, unempl oyment and poor
social support.
d) Alcohol-induced anxiety disorder: Alcohol persons
report panic attacks during acute withdrawal,
similarly during the first 4 to 6 weeks of abstinence.
e) Impaired psychosexual function: Erectile dysfunction
and delayed ejaculation are common in chronic
alcoholics
f) Pathological jealousy: Excessive drinkers may
develop an overvalued idea or delusion that the
partner is being unfaithful.
g) Alcoholic seizures (rum fits): Generalized tonic
clonic seizures occur usually within 12- 48 hours
after a heavy bout of drinking. Sometimes, status
epilepticus may be precipitated
h) . Alcoholic hallucinosis: This is characterized by
the presence of hallucinations (auditor} i during
abstinence, following regular alcohol intake.
Recovery occurs within one month.
Treatment
1. A full assessment, including an appraisal of current
medical, psychological and social problems.
2. Goal setting: Setting up of short-term goals that deal
with any accompanying problems in health,
marriage, job and social adjustments; long-term
goals can be set as treatment progresses, which are
concerned with trying to change factors that
precipitate or maintain excessive drinking, such as
tensions in the family.
3. Treatment of withdrawal from alcohol
a. Detoxification: Detoxification is the treatment for
alcohol withdrawal symptoms. The drugs of
choice are benzodiazepines. The most commonly
used drugs from this class are chlordiazepoxide
80-200 mg/ day and diazepam 40-80 mg/day, in
divided doses.
b. Others:
For vitamin B deficiency a preparation of
vitamin B containing 100 mg of thiamine
should be administered parenterally, twice
daily for 3 to 5 days. This should be followed
by oral administration of vitamin B for at
least 6 months.
Administration of anticonvulsants as
necessary, maintaining fluid and electrolyte
balance, strict monitoring of vitals, level of
consciousness and orientation. Close
observation is essential, especially during
the first five days.
4. Alcohol deterrent therapy: Deterrent agents are those
which are given to desensitize the individual to the
effects of alcohol and maintain abstinence. The most
commonly used drug is disulfiram (tetraethyl
thiuram disulfide) or antabuse.
Disulfiram: Disulfiram is used to ensure abstinence in
the treatment of alcohol dependence. Its main effect
is to produce a rapid and violently unpleasant
reaction in a person who ingests even a small amount
of alcohol while taking disulfiram.
Mechanism of action Disulfiram is an aldehyde
dehydrogenase inhibitor that interferes with the
metabolism of alcohol and produces a marked
increase in blood acetal- dehyde levels. The
accumulation of acetal- dehyde (to a level of 10 times
more than that which occurs in the normal
metabolism of alcohol) produces a wide array of
unpleasant reactions called the disulfiram-ethanol
reaction (DER), characterized by nausea, throbbing
headache, vomiting, hypotension, flushing, sweating,
thirst, dyspnea, tachycardia, chest pain, vertigo,
blurred vision and a sense of impending doom
associated with severe anxiety. The reaction occurs
almost immediately after the ingestion of even one
alcoholic drink and may last up to 30 minutes.
Therapeutic indications The primary indication for
disulfiram use is as an aversive conditioning
treatment for alcohol dependence.
Side-effects The adverse effects of disulfiram in the
absence of alcohol consumption include fatigue,
dermatitis, impotence, optic neuritis, mental changes,
acute polyneuropathy and hepatic damage.
With alcohol consumption the intensity of the
disulfiram-alcohol reactions varies with each patient.
In extreme cases it is marked by convulsions,
respiratory depression, cardiovascular collapse,
myocardial infarction and death.
Contraindications
Pulmonary and cardiovascular disease.
Disulfiram should be used with caution in
patients with nephritis, brain damage,
hypothyroidism, diabetes, hepatic disease,
seizures, poly-drug dependence or an abnormal
electroencephalogram.
Patients at high risk of alcohol ingestion.
Dosage Disulfiram is supplied in tablets of 250 and
500 mg. The usual initial dose is 500 mg/day orally
for the first 2 weeks, followed by a maintenance
dosage of 250 mg/day. The dosage should not
exceed 500 mg/day.
Nurse's responsibility
An informed consent should be taken before
starting treatment.
Ensure that at least 12 hours have elapsed since
the last ingestion of alcohol before administering
the drug.
Patient must be instructed that ingestion of even
the smallest amount of alcohol brings on a
disulfiram-ethanol reaction with all its
unpleasant effects ; he should therefore be
strictly warned not to take any alcohol whatever.
The patient should also be warned against
ingestion of any alcohol-containing preparations
such as cough syrups, drops of any kind, and
alcohol-containing foods and sauces. Advise not
to use alcohol based aftershave lotions and
advise against inhalation of paints, warnishes,
etc., containing alcohol. Any topical applications
containing alcohol should also be avoided.
Caution patient against taking CNS depressants
or any OTC (over-the-counter) medications
during disulfiram therapy.
Instruct patient to avoid driving or other
activities requiring alertness until response to
drug is known.
Patients should be warned that the disulfiram-
alcohol reaction may continue for as long as 1 to
2 weeks after the last dose of disulfiram.
Patients should carry identification cards
describing disulfiram-alcohol reaction and listing
the name and telephone number of the physician
to be called.
Emphasize the importance of follow-up visits to
the physician to monitor progress in long-term
therapy.
5. Psychological treatment
Motivational interviewing: This involves providing
feedback to the patient on the personal risks that
alcohol poses, together with a number of options for
change.
Group therapy: Group therapy enables the patients to
observe their own problems mirrored in others and
to work out better ways of coping with them.
Aversive conditioning: This therapy is based on classical
conditioning. In alcoholism the behavior patterns are
self-reinforcing and pleasurable, but are maladaptive
for reasons outside the control of the client. In this
technique the client is exposed to chemically-
induced vomiting or shock when he takes alcohol.
Cognitive therapy: This involves reduction in alcohol
intake by identifying and modifying maladaptive
thinking patterns.
Relapse prevention technique: This technique helps the
patient to identify high-risk relapse factors and
develop strategies to deal with them. It also enables
the patient to learn methods to cope with cognitive
distortions. Cue exposure technique: This technique
aims through repeated exposure to desensitize drug
abusers to drug effects, and thus improve their ability
to remain abstinent.
Other therapies include assertiveness training, behavior
counseling, supportive psychotherapy and individual
psychotherapy.
Agencies Concerned with Alcohol-
related Problems
Alcoholics Anonymous (AA)
This is a self-help organization founded in the USA by
two alcoholic men, Dr. Bob Smith
and Bill Wilson, a stockbroker on the 10th or June,1935. It
has since then spread to mar;- countries in the world. AA
considers alcoholisrr. as a physical, mental and spiritual
disease, a progressive one, which can be arrested but not
cured. Members attend group meetings usuallv twice a
week on a long-term basis. Each member is assigned a
support person from whom he may seek help when the
temptation to drink occurs. In crisis he can obtain
immediate help by telephone. Once sobriety is achieved
he is expected to help others.
The organization works on the firm belief that
abstinence must be complete. The only requirement for
membership is a desire to stop drinking There is no
authority, but only a fellowship of imperfect alcoholics
whose strength is formed out of weakness. Their primary
purpose is to help each other stay sober and help other
alcoholics to achieve sobriety.
"Twelve Steps" of A. A.
The "Twleve Steps" are the core of the A.A. program of
personal recovery from alcoholism They are not abstract
theories; but are based or the trial-and-error experience
of early members of A. A. They describe the attitudes
and activities that these early members believe were
important ir helping them to achieve sobriety.
Acceptance of the "Twelve Steps" is not mandatory in
any sense
1. We admitted we were powerless over alcohol-that
our lives had become unmanageable.
2. Came to believe that a Power greater than
ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives
over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of
ourselves.
5. Admitted to God, to ourselves and to another
human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these
defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and
became willing to make amends to them all.
9. Made direct amends to such people wherever
possible, except when to do so would injure them
or others.
10. Continued to take personal inventory and when
we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve
our conscious contact with God, as we understood
Him, praying only for knowledge of His will for us
and the power to carry that out.
12. Having had a spiritual awakening as the result of
these steps, we tried to carry this message to
alcoholics, and to practice these principles in all
our affairs.
"Twelve Traditions" of A. A.
The "Twelve Traditions" of A.A. are suggested principles
to ensure the survival and growth of the thousands of
groups that make up the Fellowship. They are based on
the experience of groups themselves during the critical
early years of the movement.
The Traditions are important to both oldtimers and
newcomers as reminders of the true foundations of A.A.
as a society of men and women whose primary concern is
to maintain their own sobriety and help others to achieve
sobriety:
1. Our common welfare should come first; personal
recovery depends upon A.A. unity.
2. For our group purpose there is but one ultimate
authority - a loving God as He may express
Himself in our group conscience. Our leaders are
but trusted servants; they do not govern.
3. The only requirement for A.A. membership is a
desire to stop drinking.
4. Each group should be autonomous except in
matters affecting other groups or A.A. as a whole.
5. Each group has but one primary purpose to carry
its message to the alcoholic who still suffers.
6. An A.A. group ought never endorse, finance, or lend
the A.A. name to any related facility or outside
enterprize, lest problems of money, property, and
prestige divert us from our primary purpose.
7. Every A.A. group ought to be fully self-supporting,
declining outside contributions.
8. Alcoholics Anonymous should remain forever non-
professional, but our service centers may employ
special workers.
9. A. A., as such ought never be organized; but we may
create service boards or committees directly
responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside
issues; hence the A.A. name ought never be drawn
into public controversy.
11. Our public relations policy is based on attraction
rather than promotion; we need always maintain
personal anonymity at the level of press, radio, and
films.
12. Anonymity is the spiritual foundation of all our
traditions, ever reminding us to place principles
before personalities.
Al-Anon
Al-Anon is a group started by Mrs.Anne, wife of Dr.Bob
to support the spouses of alcoholics.
Al-Ateen
Provides support to their teenage children. Hostels
These are intended mainly for those rendered homeless
due to alcohol-related problems. They provide
rehabilitation and counseling. Usually abstinence is a
condition of residence.
[Refer p. 139 and 140 for rehabilitation and nursing
management]
OTHER SUBSTANCE USE DISORDERS Drug
Addiction in India: UN Report (The Indian
Express Feb.1999)
Of the 4 million registered drug addicts in South Asia,
1.25 lakh are in India.
Distribution:
Alcohol: 42% (including social drinkers)
Opium: 20%
Heroin: 13%
Cannabis: 6.2%
Others: 1.8%
Heroin abusers are now estimated to be around
40,000.
The majority of drug addicts are aged between 16
and 30 years.
These drug abusers are mostly unmarried, and from
the lower socio-economic strata; 33 percent of them
are engaged in antisocial activities.
Opioid Use Disorders
In the last few decades, the use of opioids has increased
markedly world over. India, surrounded on both sides by
routes of illicit transport, namely Golden Triangle
(Burma, Thailand, Laos) and Golden Crescent (Iran,
Afghanistan, Pakistan), is particularly affected. The most
important dependence producing derivatives are
morphine and heroin.
The commonly abused opioids (narcotics) in our
country are heroin (brown sugar, smack) and synthetic
preparations like pethidine, fortwin (pentazocine) and
tidigesic (buprenorphine).The drugs that are injected
through needle are heroin, buprenorphine and
pentazocine. Though most opiate users had begun
chasing (inhaling the smoke or chasing the dragon) heroin
they gradually shifted to needle use. These injecting drug
users have become a high risk group for HIV infection.
Acute Intoxication
It is characterized by apathy, bradycardia, hypotension,
respiratory depression, subnormal temperature and
pinpoint pupils. Later delayed reflexes, thready pulse
and coma can occur.
Withdrawal Syndrome
Narcotic withdrawal rarely produces a life-threa- tening
situation. Common symptoms include watery eyes,
running nose, yawning, loss of
appetite, irritability, tremors, sweating, cramps nausea,
diarrhea, insomnia, raised body tempts rature,
piloerection and anorexia.
Withdrawal symptoms begin within 12 hour? of the
last dose, peak in 24 to 36 hours anc disappear in 5 to 6
days.
Complications
Complications due to illicit drug use Parkinsonism,
peripheral neuropathy transverse myelitis.
Complications due to intravenous use: S' infection,
thrombophlebitis, pulmonary embo- lism,
endocarditis, septicemia, AIDS, vir hepatitis and
tetanus.
Involvement in criminal activities.
Treatment
Treatment of opioid overdose: Opioid overdose car be
treated with narcotic antagonists, e.g.naloxone
naltrexone
Detoxification: Withdrawal symptoms can managed by
methadone, clonidine, naltrexon buprenorphine, etc.
Maintenance therapy: After the detoxification phas is
over, the patient is maintained on one of following
regimens:
Methadone maintenance
Opioid antagonists
Psychological methods like individual psy
chotherapy, behavior therapy, group therap and
family therapy
Cannabis Use Disorder
Cannabis is derived from hemp plant, CanruiJ sativa.
The dried leaves and flowering tops often referred to as
ganja or marijuana. The resin the plant is referred to as
hashish. Bhang is a d made from cannabis.
Cannabis is either smoked or taken in liq form.
Acute Intoxication
Mild intoxication is characterized by mild impair ment
of consciousness and orientation, tach