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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 FactorsGeneral 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^ withoutprescription (e.g. nic:

Taking drugs that can be obtarre.: sources(e.g. street drugs).

Psychiatric disordersSubstance 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. Ne3

30% of patients are developing alcoli

problems and seeking admission in ps\

hospitals.

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'edical and Social Complications of - cohol Dependence

Medical Z^trointestinal

system

Gastritis, peptic ulcer, reflux esophagitis, carcinomaof stomach and esophagus

Fatty liver, cirrhosis of liver, hepatitis, liver cellcarcinoma

Acute and chronic pancreatitis Malabsorption syndromeIsrdiovascular system

Alcoholic cardiomyopathy High risk for myocardial infarctionCentral 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 retardationB Social

Marital disharmony Occupational problems Financial problems Criminality AccidentsPSYCHIATRIC DISORDERS DUE TO

ALCOHOL DEPENDENCE

Acute intoxication1 Withdrawal syndromeAlcohol induced amnestic disorders 4 .Alcohol

induced psychiatric disorders

1. Acute intoxication:Acute intoxication develops duringor 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 beendrinking 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 tremensSimple 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 ofdisordered 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 evidentfear

Grossly tremulous hands which sometimes pick upimaginary 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

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Death may occur due to cardiovascular collapse,infection, hyperthermia or self- inflicted injury

3. Alcohol- induced amnestic disorders Chronic alcoholabuse 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 byprominent cerebellar ataxia, palsy of the 6th cranial

nerve, peripheral neuropathy and mental confusion.

b) Korsakoff's syndrome: The prominent symptom inKorsakoff's syndrome is gross memory disturbance.

Other symptoms include:

Disorientation Confusion Confabulation

Poor attention span and distractibility Impairment of insight

4. Alcohol- induced psychiatric disordersa) 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 drinkingmay induce persistent depression or anxiety

c) Suicidal behavior: Suicidal rates are higher inalcoholics 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, unemployment and poor

social support.

d) Alcohol-induced anxiety disorder: Alcohol personsreport panic attacks during acute withdrawal,

similarly during the first 4 to 6 weeks of abstinence.

e) Impaired psychosexual function: Erectile dysfunctionand delayed ejaculation are common in chronic

alcoholics

f) Pathological jealousy: Excessive drinkers maydevelop an overvalued idea or delusion that the

partner is being unfaithful.

g) Alcoholic seizures (rum fits): Generalized tonicclonic 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 bythe 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 currentmedical, psychological and social problems.

2. Goal setting:Setting up of short-term goals that dealwith 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 alcohola. 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, individed 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 asnecessary, maintaining fluid and electrolyte

balance, strict monitoring of vitals, level of

consciousness and orientation. Close

observation is essential, especially duringthe first five days.

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4. Alcohol deterrent therapy: Deterrent agents are thosewhich 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 beforestarting treatment.

Ensure that at least 12 hours have elapsed sincethe last ingestion of alcohol before administering

the drug.

Patient must be instructed that ingestion of eventhe 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 againstingestion 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 depressantsor any OTC (over-the-counter) medications

during disulfiram therapy.

Instruct patient to avoid driving or otheractivities requiring alertness until response to

drug is known.

Patients should be warned that the disulfiram-alcohol reaction may continue for as long as 1 to2 weeks after the last dose of disulfiram.

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Patients should carry identification cardsdescribing disulfiram-alcohol reaction and listing

the name and telephone number of the physician

to be called.

Emphasize the importance of follow-up visits tothe physician to monitor progress in long-term

therapy.

5. Psychological treatmentMotivational 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 cognitivedistortions. 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 bytwo 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 primarypurpose 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-thatour lives had become unmanageable.

2. Came to believe that a Power greater thanourselves could restore us to sanity.

3. Made a decision to turn our will and our livesover to the care of God as we understood Him.

4. Made a searching and fearless moral inventory ofourselves.

5. Admitted to God, to ourselves and to anotherhuman being the exact nature of our wrongs.

6. Were entirely ready to have God remove all thesedefects of character.

7. Humbly asked Him to remove our shortcomings.

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8. Made a list of all persons we had harmed, andbecame willing to make amends to them all.

9. Made direct amends to such people whereverpossible, except when to do so would injure them

or others.

10. Continued to take personal inventory and whenwe were wrong promptly admitted it.

11. Sought through prayer and meditation to improveour 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 ofthese 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; personalrecovery depends upon A.A. unity.

2. For our group purpose there is but one ultimateauthority - 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 adesire to stop drinking.

4. Each group should be autonomous except inmatters affecting other groups or A.A. as a whole.

5. Each group has but one primary purpose to carryits message to the alcoholic who still suffers.

6. An A.A. group ought never endorse, finance, or lendthe 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 maycreate service boards or committees directly

responsible to those they serve.

10. Alcoholics Anonymous has no opinion on outsideissues; 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 ourtraditions, 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 DrugAddiction in India: UN Report (The IndianExpress Feb.1999)

Of the 4 million registered drug addicts in South Asia,

1.25 lakh are in India.

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Distribution:

Alcohol: 42% (including social drinkers) Opium: 20% Heroin: 13% Cannabis: 6.2% Others: 1.8%

Heroin abusers are now estimated to be around40,000.

The majority of drug addicts are aged between 16and 30 years.

These drug abusers are mostly unmarried, and fromthe 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 psychotherapy, 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

ganjaor marijuana.The resin the plant is referred to as

hashish. Bhangis 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