REVISED SUD -ALCOHAL , CANNABIS, SEDATIVE, ETC DISORDERS

 Substance –related disorders are composed of two
groups: the substance-use disorders (abuse and
dependence) and the substance-induced
disorders(intoxication, withdrawal, delirium,
dementia, amnesia, psychosis, mood disorder, anxiety
disorder, sexual dysfunction and sleep disorder)
 Drugs are very pervasive part of our society.
 Man had used psychoactive drugs for a very long
period, not only to enhance pleasure, and relieve
discomfort but also to facilitate the achievement of
social, religious and ritualistic aims.

 In past use of psychoactive drugs by “elder person’s ’’in the
society.
 More by men than women.
 Certain proportion of those who took these drugs for
recreational purposes became dependent on them.
 Now it’s a social problem.
 Widely recognized that no-medical use of dependence-
producing drugs involves dynamic interactions among
three major factors:
- The properties of drug taken and the manner of use
- The characteristics of user
- The nature of the immediate, and larger socio-cultural
environment in which the drug use occurs.
• Drug addicts/junkies as they are called by peers, took drugs
for number of reasons: to relax, to forget problems, to be
sociable at parties, for fun, to relieve tension, for
experimental purposes.

Drug –drug is derived from a French word ‘drogue’. Any substance that
when taken into living organism, may modify one or more of its
function.(Acc. To WHO)
Psychoactive drug – Is one that is capable of altering the mental
functioning.
Abuse: to use wrongfully or in a harmful way. Improper treatment or
conduct that may result in injury/ consequences.
Substance Abuse: a maladaptive pattern of substance use manifested by
recurrent and significant adverse consequences related to repeated use of
substance.(Acc. To DSM –IV)
Dependence: a compulsive or chronic requirement. The need is so strong as
to generate distress i.e. physical or psychological if felt unfulfilled.
Acute Intoxication – A transient condition following the administration of
alcohol or other psychoactive substance, resulting in disturbance in level of
consciousness, cognition, perception, affect or behavior or other psycho
physiological functions and response.

Harmful use - A pattern of psychoactive substance use that is causing damage
to health. The damage may be physical (as in cases of hepatitis from the self-
administration of injected drugs) or mental (e.g. Episodes of depressive
disorder secondary to heavy consumption of alcohol).
Dependence syndrome - A cluster of physiological, behavioural, and
cognitive phenomena in which the use of a substance takes on a much higher
priority for a given individual.
Desire or sense of compulsion.
Difficulty in controlling substance taking behavior.
Withdrawal state.
Tolerance.
Progressive neglect of alternative pleasure.
Persisting use of substance despite clear evidence of harmful
consequence.
Withdrawal state – Symptoms occurring on absolute or relative withdrawal of
a substance after repeated, and usually prolonged use of that substance.
Convulsion.

Withdrawal state with delirium – Withdrawal state is complicated by
delirium.
Psychotic disorder - A cluster of psychotic phenomena that occur during or
immediately after psychoactive substance use.
Amnesic syndrome -A syndrome associated with impairment of recent
memory; remote memory is sometimes impaired, while immediate recall is
preserved.
Residual and late-onset psychotic disorder - A cluster of psychotic
phenomena that occur after 2 week of substance use.

Common psychoactive substance: –
•Alcohol-ethyl alcohol or ethonal (beer, whisky, brandy,
rum, vodka etc)
•Narcotics –opium, pethidine,
morphine, heroin, cocaine
•Hallucinogens & psychedelics : Cannabis- bhang, ganja,
charas, LSD, Psilocybin( psychotogenic mushrooms)
•Inhalants-Vicks, whitener, patrol, glues, spray paints,
thinners, varnish remover, industrial solvents.
•Sedatives/hypnotics-diazepam methaqualone,
benzodiazepines
•‘Barbiturates-Phenobarbital, secobarbital
•Stimulants: -Dextro-amphetamines
•Nicotine-Bidis, chewing tobacco, cigars, pipe tobacco,
snuff

Etiology/ Predisposing factors -
•Genetic factor- hereditary factor, children of alcoholic have 3
times more risk , monozygotic have higher rate.
• Biochemical: some hypothesis suggested that alcohol may
produce morphine like substances in the brain that are
responsible for alcohol addiction .These substances are formed
by reaction of dopamine or serotonin with products of alcohol
metabolism.
•Psychological factor:
-Punitive superego and fixation at the oral stage of psychosexual
development, broken families, unloving parents.
•Personality factor:
-Low self-esteem
-Frequent depression
-Passivity
-Inability to communicate effectively
-Anti social personality

• Socio –cultural factor: Modeling, Imitation, Identification on
behavior can be observed from early childhood onwards.
•Socioeconomic factor: Low socio-economic status, difficult life style-
poverty, hopelessness.
•Co-morbid psychiatric disorder.
•Cultural and ethnic factor:
•Youth culture: Adolescents try to follow the peer group.
•Pharmacological factors: (some substances or drugs like opium,
alcohol etc.)
•Curiosity.
•Poor impulse control.
•Poor stress management.
•Relief from boredom, fatigue.
•Peer pressure.
•Intrafamilial conflicts.
•Religious reasons.

 Poor quality of child-parent relationship
 Family disruptions- divorce, acute or chronic stress
 Social isolation
 Abuse- sexual, physical, emotional
 Environmental factors: accessibility and availability of
a substance
 Social and legal policies- taxes, penalties (drinking and
driving)
 Media influence- such as promotion, use of substances
in movies etc.

Alcohol is a natural substance formed by the reaction
of fermenting sugar with yeast spores. Although
there are many alcohols, the kind in alcoholic
beverages is known scientifically as ethyl alcohol and
chemically as C2H5OH

• Beers 4-8%
• Wines 12%
• Whisky 40%
• Illicit 35-50%
Alcohol Concentration & Drinks

Alcohol use disorder/ dependence was previously called as alcoholism.
Alcohol use disorder is a pattern of alcohol use that involves problems in
controlling drinking, being preoccupied with alcohol, continuing to use alcohol
even when it causes problems, having to drink more to get the same effect, or
having withdrawal symptoms when rapidly decrease or stop drinking.
According to Jellinek, there are five ‘species’ of alcohol dependence
(alcoholism) on the basis of pattern of use (not on the basis of severity).
 Alpha :
 Excessive & inappropriate drinking to relieve physical/ emotional pain.
 No loss of control
 Ability to abstain present
 Beta:
 Excessive and inappropriate drinking
 Physical complications due to cultural drinking patterns and poor nutrition.
 No dependence

 Gamma : also called as malignant alcoholism
 Progressive course
 Physical dependence with tolerance & withdrawal symptoms
 Psychological dependence, with inability to control drinking
 Delta:
 Inability to abstain
 Tolerance
 Withdrawal symptoms
 The amount of alcohol consumed can be controlled
 Social disruption is minimal
 Epsilon :
 Dipsomania (compulsive drinking)
 Spree-drinking (chronic use of alcohol with compulsion to
heavy periodic drinking)

 Alcohol misuse includes “risky or
hazardous” and harmful drinking
that places a person at risk for
problems.
 Risky or hazardous drinking is
defined as more than seven drinks
per week or more than three drinks
per occasions for women and more
than 14 drinks per week or more
than 4 drinks per occasion for men.
 Harmful drinking include a person
who is experiencing physical, social
or psychological harm from alcohol
use .

 About half of Americans ages 12 years and older report
being current drinkers of alcohol.
 People use alcohol beverages to enhance the flavor of food
with meals, at social gatherings to encourage relaxation
and being friendly among the guests, to promote a feeling
of celebration at special occasions such as weddings,
birthday, and anniversaries.
 Also used as a part of the sacred ritual in some religious
ceremonies.
 Approximately 15% of the drinkers progress to alcoholism.

 Alcoholism is the third leading cause of
preventable death in US. Alcoholism
is the inability to control drinking due to
both a physical and emotional
dependence on alcohol.
 The person is able to drink more alcohol
than others before feeling of
intoxication.
 Person likes the feeling of intoxication
and continues to drink whenever
possible in large quantities.
 As this happen , drinking begins to
cause problems in person’s life, which
the person may explains away.
 The problems increases, the drinking
increases, physical and psychological
dependence develops.

Phase 1 : Pre-alcoholic phase
Phase 2: Early alcoholic phase
Phase 3: Crucial phase
Phase 4: Chronic phase

 PHASE-1: THE PRE-ALCOHOLIC PHASE:
this phase is characterized :
 As a child, the individual may have observed parents or
other adults drinking alcohol and enjoying the effects.
 by the use of alcohol to relieve the everyday stress and
tensions of life.
 The child learns that use of alcohol is an acceptable
method of coping with stress.

 The phase begins with:
 blackouts-brief period of
amnesia that occur during or
immediately following a
period of drinking.
 Common behavior includes
sneaking drinks, and
maintaining the supply of
alcohol, rapid gulping of
drinking.
 Excessive use of denial and
rationalization is evident.

 Individual has lost control
 Physiological dependence
 Binge drinking(lasting from
few hours to several wks)
 Episodes are characterized by
sickness, loss of
consciousness, degradation
 Individual is extremely ill
 Anger and aggression
 Drinking is total focus and
loosing everything (loss of
job, marriage, family, friends,
most especially self-respect)

 Emotional and physical
disintegration (profound
helplessness and self pity)
 Impairment in reality testing
may result in psychosis
 Life-threatening physical
manifestations
 Absenteeism from alcohol
may lead to terrifying
syndromes of symptoms like
hallucination, tremor,
convulsions, severe agitation
and panic.

Blood alcohol level Behaviors
.05-.15 g/dl Euphoria, labile mood, cognitive disturbances
.15-.25 g/dl Slurred speech, staggering gait, diplopia,
drowsiness, labile mood with outbursts.
.3 g/dl Stupor, aggressive behavior, incoherent speech,
labored breathing, vomiting
.4 g/dl coma
.5 g/dl Severe respiratory depression, death.

 General, non-selective, reversible depression of the CNS.
 At low doses, produces relaxation, lack of concentration, drowsiness,
slurred speech, and sleep.
 Chronic abuse results in multisystem physiological impairments.
Physiological complications includes:
 Alcoholic myopathy
 Peripheral neuropathy
 wernicke’s encephalopathy
 Korsakoffs psychosis
 Alcoholic cardiomyopathy
 Esophagitis
 Gastritis

 Pancreatitis
 Alcoholic hepatitis
 Cirrhosis of liver
 Leucopenia
 Thrombocytopenia
 Sexual dysfunction

 Acute Intoxication –
 Excitement.
 CNS depression – Increased RT, Slowed thinking, Poor motor control,
dysarthria, ataxia and in coordination, disinhibition.
 Drowsiness, coma, respiratory depression, Death.
 Withdrawal Syndrome – hangover on next morning.
1.General symptoms:
 Tremor.
 Nausea, vomiting.
 Weakness.
 Irritability.
 Insomnia.

2. Specific symptoms :
 Delirium tremens – (within 2-4 days of complete of significant
abstinence from alcohol drinking)
• Clouding of consciousness with disorientation.
• Poor attention span and distractibility
• Hallucination, illusions(visual, auditory, tactile)
• Autonomic disturbance with tachycardia, fever., sweating, hypertension.
• Insomnia
• Dehydration with electrolyte imbalance
• Death, if occurs, is often due to: cardiovascular collapse, infection,
hyperthermia or self-inflicted injury.

 Alcoholic seizure (‘rum fits’).
 Generalized tonic- clonic seizures-12-48 hrs of heavy drinking
 Multiple seizures (2-6 at one time)
 Alcoholic hallucinations:-usually auditory during partial or
complete abstinence
 visual

 Pink Elephants" is a common way to refer to alcohol-
related hallucinations. The term was originally coined
by Jack London — himself a famous drinker — in his
autobiographical novel John Barleycorn. It is now
widely used to refer to any sort of alcohol-related
hallucinations — even those that don't involve
elephants of any color.
 Seeing pink elephants" is a euphemism for
drunken hallucination caused by alcoholic
hallucinosis or delirium tremens. The term dates back
to at least the early 20th century, emerging from earlier
idioms about snakes and other creatures. An alcoholic
character in Jack London's 1913 novel John
Barleycorn is said to hallucinate "blue mice and pink
elephants".

History of the euphemism
 For many decades before "pink elephant" became the standard
drunken hallucination, people were known to "see snakes" or "see
snakes in their boots.“

 Beginning in about 1889, and throughout the 1890s, writers made
increasingly elaborate modifications to the standard "snakes" idiom.
They changed the animal to rats, monkeys, giraffes,
hippopotamuses or elephants – or combinations there of; and
added color – blue, red, green, pink – and many combinations thereof.
 In 1896, for example, in what may be the earliest recorded example of a
(partially) pink elephant, one of Henry Wallace Phillips' "Fables of our
Times" referred to a drunken man seeing a "pink and green elephant
and the feathered hippopotamus.“
 In 1897, a humorous notice about a play entitled "The Blue Monkey,"
noted that, "We have seen it. Also the pink elephant with the orange
trunk and the yellow giraffe with green trimmings. Also other things.“
 An early literary use of the term is by Jack London in 1913, who
describes one kind of alcoholic, in the autobiographical John
Barleycorn.

Neuropsychiatric Complications –
•Wernicke’s encephalopathy-severe deficiency of thiamine. Onset occurs
after a period of persistent vomiting
•Signs: ocular signs-nystagmus, opthalmoplegia,
pupillary irregularities, retinal hemorrhage,papeledema.
•Higher mental function disturbance: earlier sign apathy, ataxia
•Korsakoff’s psychosis: organic amnestic syndrome(gross memory
disturbance with confabulation) insight is often impaired.

 Other complications:
o Alcoholic dementia
o Cerebellar degeneration
o Peripheral neuropathy

ASSESSMENT:
 In pre-introductory phase of relationship development, the nurse must
examine feelings about working with a client who abuses substances.
 Whether alone or in a group, the nurse may gain a greater
understanding about attitudes and feelings related to substance abuse.
 Assessment Tools:
 Nursing history-drug history
 CIWA-Ar( clinical institute withdrawal assessment for alcohol scale,
Revised)
 It is an excellent tool, used by many hospitals to assess risk and severity
of withdrawal from alcohol.
 Initial assessment as well as ongoing monitoring of alcohol withdrawal
symptoms.

 MAST-Michigan Alcoholism Screening Test
 The CAGE questionnaires:
 How you ever felt you should cut down on your drinking?
 Have people annoyed you by criticizing your drinking?
 Have you ever felt bad or guilty about your drinking?
 Have you ever had a drink first thing in the morning to
steady your nerves or get rid of a hangover (Eye-opener)
 TACE questionnaires
 T: How many drinks does it take to get you high.
 A- Annoyed
 C- CUTDOWN
 E-Eye opener

 Before starting any treatment, it is important to follow these
steps:
 Diagnosing any physical disorder
 Diagnosing any psychiatric disorder
 Assessment of motivation for treatment
 Assessment of social support system
 Assessment of personality characteristics of the patient
 Assessment of current & past social, interpersonal, and
occupational functioning

1. Detoxification – (symptomatic management)+alcohal
withdrawal)
 Chlordiazepoxide, Lorazepam, Diazepam.
 Vitamins especially thiamine.
 Hospitalization
2. Treatment of alcohol dependence –
 Psychotherapy – behavior therapy(aversion therapy-electric
shock,emetic-apomorphine), AT, Self control skills,possitive
reinforcements.
 Group therapy – Group meeting, Group therapy, AA.
 Counseling-anticipatory guidance through ROLE PLAY.

 Anticraving drugs – Acamprosate, naltrexone,
topiramate,fluoxetine.
 Antabuse drugs – Disulfiram,(tetraethylthiuram
disulfiram)(interfere with alcohal metabolism) calcium
carbamide(Temposil)-it produces lesser hypotension and ECG
changes.
 Disulphiram action: one of the oldest and most commonly
used medication.
 Aldehyde dehydrogenase inhibitor interferes with the
metabolism of alcohol and produce a marked increase in blood
acetaldehyde levels.
 This leads to accumulation of acetaldehyde (ten times greater
than normal amount) produces a wide array of unpleasant
reaction called Disulfiram ethanol reaction (DER)
 It may further cause nausea, throbbing headache,
hypotension, sweating, thirst, chest pain, tachycardia, vertigo,
blurred vision associated with severe anxiety.

 Short-term and long-term residential programs aim to
build a recovery support system and to work on ways to
keep them from drinking again (relapsing).
 Short-term program: last less than four weeks. These
are structured programs that provide therapy,
education, skill training and help to develop a long-
term plan to prevent relapsing.
Psychosocial rehabilitation

 Outpatient counselling: It can provide education on
alcoholism and recovery, can help the person learn
skills not to drink and spot early signs of potential
relapse.
 Self- help programs: A well-known self-help program
is alcoholics anonymous (AA).
 Other self help programs (women for sobriety,
rational recovery, and SMART recovery) allow
alcoholics to stop drinking and remain sober on their
own.

 It is a counselling approach that helps the individuals
to resolve their ambivalence about engaging in
treatment and stopping their drug use.
 This therapy consists of an initial assessment battery
session, followed by 2-4 individual treatment sessions
with a therapist.
 In the first treatment session, the therapist provides
feedback to the initial assessment , stimulating
discussion about personal substance use and eliciting
self motivational statements.

 Developing and expressing sympathy
 Acknowledging the disparity between thoughts and
reality
 Avoiding arguments
 Accepting resistance as a part of the process
 Supporting a recovering addict’s self efficacy.

 Don’t hesitate and say in firm and clear voice- no thanks, I
don’t want to or No thanks.
 Give a reason, fact or excuse. E.g: I forgot that I have an
appointment with dentist or my mom just call me. Sorry I
have to go.
 Walk away. Just leave the situations
 Change the subject by offering alternative activity
 Use humor. E.g- no thanks. This stuff stunts my growth. I
want to be tall to play ball.
 Repeated refusal. Don’t feel guilty in it, feel good or proud
yourself.
 Ignore or avoid the risky situation.

 Confrontation of denial – major obstacles to therapeutic
success are the patient’s denial of the severity of the
problem and his or her wish to continue drinking.
Repeated statements that the patient is not in control of
the drinking and repeated confrontation with the
complications of the alcoholism may be necessary before
the patient agrees to treatment.
 Insistence on abstinence: since it is not possible to
identify in advance the very few patients who may be able
to succeed with controlled drinking, total abstinence is the
only realistic goal.

 Assessment of motivation: The patient who is willing to
consider abstaining completely for at least one month is
usually sufficiently motivated to give up alcohol
completely.
 Involvement of family: the patient’s family can be an
important source of support. Occasionally a statement by a
spouse that he or she will not remain with the patient
unless the patient stops drinking is the only force strong
enough to convince the patient to agree to a trial of
abstinence. Such threats should be mobilized only rarely
and only when they are a true expression of the involved
individual’s feelings. Employers and other important
individuals in the patients life should also be involved in
treatment whenever possible.

 Referral to specialized services: Alcohol
Anonymous , other counselling programs also provides
peer support and encouragement for the patient to
stop drinking. Behaviour therapy which consists
primarily of punishing drinking and rewarding
sobriety, is useful for patients who consider their
drinking a bad habit. Psychotherapy is appropriate for
patients who feel that their drinking is motivated by
unresolved emotional conflicts.
 Ongoing emotional support by primary
physician- helping the patient to confront the
problem and to maintain sobriety.

NARCOTICS –OPIUM, PETHIDINE,
MORPHINE, HEROIN, COCAINE
 Narcotics are referred to as ‘hard stuff’ by drug
abusers. Narcotic analgesics are drugs that are
highly addictives. These drugs alleviates physical
pain, anxiety and tension, induce relaxation,
produce euphoria and a sense of well being. These
drugs can be classified as:
Opioid derivatives like:
 Natural alkaloids of opium: Morphine, codeine
(brown sugar, smack etc)
 Synthetic compounds: heroin, nalorphrine,
pethidine (smoking)

 Injection form: a sense of pleasure, gratification towards
hunger, pain, restlessness, nausea, vomiting.
 Oral form: physical effects- nausea, vomiting, insensitivity
to pain, contractions of pupils, increased urination,
constipation, sweating, itchy skin and slowed breathing.
 In large dose: pupil contract to pinpoint, skin become cold,
moist, bluish, breathing completely stops, resulting in
death.
 Heroin +alcohol= death
 Chronic users: lung problems
 Injection abscesses due to use of unsterilized needles-
tetanus, brain damage, infective endocarditis, osteomylitis.

Acute Intoxication –
Apathy.
Bradycardia.
Hypotension.
Respiratory depression.
Subnormal core body temperature.
Pin-point pupils.
Withdrawal Syndrome –( with in 12-24 hrs)
Lacrimation.
Rhinorrhea.
Pupillary dilation.
Sweating.
Diarrhea.
Yawning.
Tachycardia.
Muscle cramps and body ache.

 Withdrawal symptoms after 36 hrs:
- Uncontrolled twitching of muscles, cramps in legs,
abdomen and back, restlessness, unable to sleep,
increase in pulse, and BP, vomiting, diarrhea.
• 48 hrs from the last dose: symptoms becomes more
intense.

Complications –
Due to Contaminants: parkinsonism,
peripheral neuropathy
Due to IV use: AIDS, Skin infections ,
septicemia, viral hepatitis
Criminal activities, drug paddling

 Before treatment, a correct diagnosis must be made
on the basis of history, examination( pin point pupils
during intoxication or withdrawal symptoms) and
laboratory tests. These test are:
 Naloxone challenge test: (to precipitate the
withdrawal symptoms + to determine the person’s
current level of physical dependence on opioids).

 The treatment can be divided in to three main types:
- Treatment of overdose
- Detoxification
- Maintenance therapy
1. Treatment of opioids overdose:
Narcotic antagonists
E.g. naloxone,naltrexone.
2. Detoxification –
 Methadone.
 Clonidine.
 Buprinorphine.

3. Maintenance therapy –
 Methadone maintenance
 Naltrexone.
 Nalaxone.
 Other methods –
- Individual psychotherapy
- Behavior therapy
- Interpersonal therapy
- CBT
- Motivational enhancement therapy(MET)
- Psychotropic drugs for associated psychopathology
- Family therapy
- Group therapy
- NA
• Psychosocial rehabilitation:

 Hallucinogens are drugs which dramatically affect
perceptions, emotions, and mental processes.
They destroy senses and can cause Hallucinations.
Sensory images are similar to nightmares. They can
commonly described as “mind expansion” drugs. The
hallucinogens & psychedelics drugs are:
Hallucinogens & psychedelics : Cannabis- bhang, ganja, charas, LSD,
Psilocybin( psychotogenic mushrooms)

 PSILOCYBIN
( PSYCHOTOGENIC
MUSHROOMS)

 Physiological effects: nausea & vomiting
Chills, pupil dilation, increased vital signs, anorexia,
insomnia, sweating, slow respiration.
 Psychological effects:
 Heightened response to color, texture, & sounds
 Heightened body awareness
 Distortion of vision
 All feelings magnified- for love, hate, joy, anger, pain, etc.
 Euphoria
 Depersonalization
 derealization

Cannabis Use Disorder
Cannabis- bhang, ganja, charas (DSM-5)
 Cannabis is one of the most
widely used drugs in the world
after alcohol.
 In the united states, 49% of
people have used cannabis.
 An estimated 9% of those who
use cannabis continuously
develop dependence.
 Cannabis is derived from the
Hemp plant, cannabis sativa,
which has several varieties( e.g.
sativa indica in India & Pakistan,
& Americana in America)

 Cannabis (street names: Marijuana- grass, joint, weed,
Mary Jane, hay ) Hashish- chars, hash, bhang, ganja)
produces more than 400 identifiable chemicals of
which about 50 are cannabinoids.
 CBD & THC

 This includes cannabidiol (CBD) and
tetrahydrocannabinol (THC), two natural compounds
found in plants of the Cannabis genus.
 CBD can be extracted from hemp or cannabis.
 Legal hemp must contain 0.3 percent THC or less. CBD is
sold in the form of gels, gummies, oils, supplements,
extracts, and more.
 THC is the main psychoactive compound in cannabis that
produces the high sensation. It can be consumed by
smoking cannabis. It’s also available in oils, edibles,
tinctures, capsules, and more.

 Both CBD and THC have the exact same molecular structure: 21 carbon
atoms, 30 hydrogen atoms, and 2 oxygen atoms. A slight difference in
how the atoms are arranged accounts for the differing effects on your
body.
 Both CBD and THC are chemically similar to your body’s
endocannabinoids. This allows them to interact with cannabinoid
receptors.
 The interaction affects the release of neurotransmitters in your brain.
Neurotransmitters are chemicals responsible for relaying messages
between cells and have roles in pain, immune function, stress, and
sleep etc.
Medical uses
 THC is an active ingredient in Nabiximols, a specific extract
of Cannabis that was approved as a botanical drug in the United
Kingdom in 2010 as a mouth spray for people with multiple sclerosis to
alleviate neuropathic pain, spasticity, overactive bladder, and other
symptoms. Nabiximols (as Sativex) is available as a prescription drug in
Canada. In 2021, Nabiximols was approved for medical use in Ukraine.

Cannabis Use Disorder –
Acute Intoxication –
 mild impairment of consciousness
,orientation
Tachycardia.
Sense of floating in the air.
Alternation in psychomotor
Activities & tremor
Euphoric dream-like state.
Reddening of conjunctiva.
Dry mouth.
Increased appetite.
Perceptual disturbance- depersonalization,
Derealization, hallucinations( visual, ranging
from elementary flashes of lights &
geometrical figures to complex human faces
& pictures)

 Cannabis withdrawal – (few hrs of stoppage – 4-5
days)
 Irritability
 Tremors
 Restlessness.
 Nervousness.
 Insomnia.
 Decreased appetite.
 Craving
CAUSES:
 Cannabis dependency is often due to prolonged and
increasing use of the drug.
 Increasing the strength of cannabis taken & an
increasing use of more effective method of delivery –
increase the progression of cannabis dependency.

 Recognized in DSM-5
 By assessment
 The average adult who seeks treatment has consumed
cannabis for over 10 years almost daily and has actively
attempted to six or more times.

 Short lasting psychiatric disorder
 Amotivational syndrome : chronic cannabis use may
cause lethargy, apathy, anergia, reduced drive, lack of
ambition.
 ‘Hemp insanity’ or cannabis psychosis: acute
schizophreniform disorder with disorientation &
confusion.
 Other complications: memory impairment,
worsening or relapse in schizophrenia or mood
disorder, COPD, pulmonary malignancies etc.

 As the withdrawal symptoms are usually very mild, the
management consist of supportive & symptomatic
treatment.
 For psychiatric symptoms- appropriate psychotropic drugs
& sometimes hospitalization.
 Psychotherapy & psycho education
 Rehabilitation
 CBT
 MET
 Marijuana Anonymous-a group for people with common
desire to maintain abstinence from marijuana.

PHARMACOLOGICAL:
 Treatment modalities –agonist substitution,
modulation of other neurotransmitter system
 Agonist substitution: Dronabinol,
 Entacapon- decreased cannabis craving
 Acetylcysteine – decreased cannabis use
 Buspirone – treatment for dependence

 It is the most potent hallucinogen leading to
addiction.
 1st synthesized by Albert Hoffman in 1938 and
popularly known as ‘acid’.
 It is found in ‘Morning glory seeds’.

 As little as 100 micro gm
is sufficient to produce
behavioral effects in
man.
 Tolerance
 Psychological
dependence

 Perceptual changes occurs in a clear consciousness
These includes: depersonalization, derealization, illusion
& hallucinations.
 Autonomic hyperactivity: Pupillary dilation, tachycardia,
sweating, tremors, in coordination, palpitations, raised
temperature, giddiness.
 Marked anxiety and depression, euphoria, acute panic
reaction.
 Suicidal acts
 Its use is a ‘trip’(occasional use)
 Person undergo ‘bad trips’ –the user may jump from high
places, set themselves to fire, & die.

 No specific
 Sometimes there is spontaneous recurrence of the LSD
use.
 Flashback- weeks to months after the last experience.
 COMPLICATIONS:
 Psychiatric symptoms: anxiety, depression, psychosis,
visual hallucinations.
 Fetal abnormalities

 Hospitalization-antipsychotic treatment
 ‘Bad trips’ flashbacks & psychological dependence-
psychotherapy is needed. symptomatic management-
anti anxiety, antidepressants, antipsychotics.
 Supportive psychotherapy.

 The commonly used volatile solvents includes
gasoline( petrol), glues, aerosol(spray paints),
thinners, industrial solvents.
 Its misuse is very common in early adolescence as a
group activity, particularly in low socio-economical
groups.

Inhalants Use Disorder –
Intoxication –
Euphoria.
Excitement.
Dizziness.
Slurring of speech.
Apathy.
Impaired judgment.
Ataxia.
Nystagmus
Neurological signs- decreased reflexes,
ataxia, in coordination & coma
Death may occur due to respiratory
depression, asphyxia etc.

 Irreversible damage to liver & kidney
 Peripheral neuropathy
 Perceptual disturbances
 Brain damage

 No specific treatment
 Often an associated psychiatric disorder (usually
schizophrenia, or personality disorder, particularly in
solitary sniffers)
 Hospitalization
 Symptomatic management

These are the drugs that slows down or depress the functions
of the CNS. They reduce tension, induce relaxation & sleep.
The individual may also experience the feelings of
euphoria.
 These drugs are also known as ‘Red devil’.
 Benzodiazepines produce their effects by acting on the
benzodiazepines receptors ( GABA- benzodiazepines
receptors COMPLEX),there by indirectly increasing the
action of GABA.

Sedative-Hypnotic Use Disorder –
Intoxication -
Resemble alcohol intoxication.
In large doses causes respiratory depression, coma and death.
Withdrawal Syndrome –( after prolonged use-> 4-6 wks)
Dose- >60-80mg/day.
Anxiety.
Irritability.
Tremors.
Insomnia.
Weakness.
Autonomic hyperactivity.
Seizures, depression, psychotic episodes
suicidal ideation, perceptual disturbances
Rarely delirium.

 Benzodiazepine intoxication- symptomatic mxmt.
 In case of coma due to overdose- flumazenil( .3-1.0
m,IV)
 For Low dose diazepam dependence(app. 15
mg/day) – withdrawal symptomatic management.
 For mod. to high dose dependence – best managed
by gradual withdrawal in a step wise manner (
reduction in apprx- 10 mg every day)
 Follow up & supportive treatment.

 Now subsumed under
sedative, hypnotic and
anxiolytic disorders
 Described separately as it
has some distinctive
features.
 Described in 1903
 Commonly abused
barbiturates are
secobarbital, pentobarbital
& amobarbital.
 Produce marked physical
and psychological
dependence.

 Occurs in an episodic phenomenon same as alcohol
intoxication
 Irritability, increased productivity of speech
 Slurring of speech
 In coordination
 Inattention & memory impairment
 Ataxia
 Severe symptoms occurs – diplopia, nystagmus,
hypotonic.
 +ve romberg’s sign,
 Suicidal ideation

 Worst about 72 hrs after the last dose
 Occurs when taking 600-800 mg/day for more than
one month
 Marked restlessness
 Tremor, hypertension
 Seizures,
 in severe cases- psychosis
 coma, death

 Intravenous use- skin abscesses,
 Cellulitis
 Infections
 Embolism
 Hypersensensitivity reactions.
TREATMENT:
 Symptomatic treatment
 If patient is conscious- induction of vomiting, use of
activated charcoal can reduce the absorption of drug
 Coma- intensive care measures
 Withdrawal symptoms- pentobarbital substitution therapy

 Powerful CNS stimulant
 Synthesized by Edleano in 1887
 Introduced in medicine in 1932 as Benzedrine inhaler,
for coryza, rhinitis & asthma.
 Later recommended for others- narcolepsy, post-
encephalitis, obesity, parkinsonism, depression,
ADHD etc.

 Tachycardia, hypertension, hemorrhage, cardiac failure,
cardiovascular shock.
 Seizures, hyperpyrexia, tremor, ataxia, euphoria, tetany &
coma.
 Neuropsychiatric manifestations- anxiety, panic, insomnia,
restlessness, irritability, hostility, bruxism.
 Paranoid hallucinatory syndrome- closely mimics paranoid
schizophrenia
 Visual hallucinations
 Fearful emotional reactions, presence of confusion
 Severe intoxication- compulsive craving for the drug, tactile
hallucinations

 Abrupt discontinuation of amphetamines after a period of
chronic use.
 Depression( with suicidal ideations)
 Apathy
 Fatigue
 Hypersomnia/ insomnia
 Agitation
 Hyperphagia.
 Diagnosis: estimation of the recent urinary amphetamines
levels.
 Amp. Psychosis usually resolved with in seven days of
urinary clearance of amphetamines.

 Treatment of intoxication- symptomatic measures
 E.g.- hyperpyrexia- cold sponging, parenteral antipyretics.
 Seizures- parenteral diazepam
 Psychotic symptoms- antipsychotics
 Hypertension- antihypertensive
 Acidification of urine indicates the elimination of
amphetamines.
 Treatment of withdrawal symptoms- hospitalization
 Symptomatic management- use of antidepressants,
supportive psychotherapy.

 Cocaine is an alkaloid derived
from the coca bush,
erythroxylum coca, found in
bolivia & peru.
 Used by karl koller (a friend of
Freud) in 1884 as the 1st effective
local anesthetic agent.
 Other names to describe
different forms of cocaine
include "crack," "coke," "snow,"
and "speedball."
 Cocaine is sometimes used in
combination with opiates like
heroin or amphetamines.

 Cocaine may be taken in different ways:
 Snorting: Inhaling it through the nose
 Shooting up: Dissolving it in water and injected it
into a vein
 Speedball: Mixed with heroin and shot into a vein
 Smoked: Cocaine may be changed into a smokeable
form known as freebase or crack

 Pupillary dilatation
 Tachycardia
 Hypertension
 Sweating
 Nausea or vomiting
 Hypomania- Decreased psychomotor activity,
grandiosity, hyper vigilance, increased speech output
 later judgment is impaired, social or occupational
functioning impaired.

 Very mild physical, but strong psychological
dependence.
 Triphasic withdrawal syndrome-
1. Crash phase- 4-9 days after discontinuation
 Agitation, depression, anorexia, craving, fatigue,
depression, sleepiness, exhaustion, hyperphagia
2. Phase – 4-7 days after discontinuation
 Normal sleep, improved mood, craving, anxiety,
anergia, anhedonia
3. Extinction phase- after 7-10 days of discontinuation
 No withdrawal symptoms
 Increased vulnerability to relapse.

 Assess physical and psychiatric disorder
( particularly mood disorder, major depression,
cyclothymia
 Assess motivation for treatment
 Treatment of cocaine overdose:
 Oxygenation, muscle relaxants, IV theopentone, IV diazepam, ( for seizures &
severe anxiety).
 Antagonist of cocaine induced symp. Effects: IV propranolol
 Psychosis- haloperidol
 Treatment of chronic cocaine use:
 Bromocriptine & amantadine – reducing cocaine craving
 Desipramine& trazodone – reducing craving, for antidepressant effect
 Psychosocial management tech.- supportive psychotherapy, behavior therapy.

 Bidis, chewing tobacco, cigars, pipe tobacco, snuff
 Most widely used substances
 Both legally available
 Can cause intoxication, dependence, tolerance, & withdrawal syndrome.
 Nicotine use is more common in schizophrenia, depression( in the form
of smoking)
 Smoking often predisposes - cardiovascular disease, respiratory disease,
cancer.
 Similarly caffeine is widely used in the normal population as well as in
the patients with psychiatric disorders
 DSM-IV defines caffeinism ( caffeine intoxication)- consumption usually
250 mg/day
 Symptoms-restlessness, nervousness, excitement, insomnia, flushed
face, diuresis, GI disturbance, muscle twitching, tachycardia or cardiac
arrhythmia etc.

Phencyclidine use disorder
Angel dust( hallucinogen drug phencyclidine hydrochloride)
PCP is an illegal drug that comes as a white powder, which can be
dissolved in alcohol or water.
PCP may be smoked, shot into a vein, or taken by mouth.
How quickly it affects you depends on how you take it.
Shooting up: If given through a vein, PCP's effects start within 2-5 minutes.
Smoked: The effects begin within 2 - 5 minutes, peaking at 15 - 30 minutes.
Taken by mouth: In pill form, or mixed with food or drinks, PCP's effects
usually start within 30 minutes. The effects tend to peak in about 2 - 5 hours.
Intoxication-
Impulsiveness.
Agitation.
Impaired social judgment.
Feeling of numbness and inability to move.
Delirium, Psychosis, Paranoid hallucination.
Ataxia and seizure.

 Withdrawal syndrome-
 No clear cut syndrome.
 Craving.
 Social withdrawal.
 Anxiety.
 Depression.
 Impaired cognitive function.
 Treatment- Gastric lavage, Antipsychotics,
Anticonvulsant.

 It is estimated that early onset (before the age of 65)
substance abusers make up two-thirds of the geriatric
alcoholic population.
 Alcohol and tobacco use is quite prevalent among
older adults.
 Older adults take more prescribed and over-the
counter medications than younger adults, this
increases the risk for harmful drug interactions,
misuse, and abuse. Substance use behaviors develop
among elderly population for the number of stressful
life situations.

 Substances may greatly impair cognition among older
adults than younger adults.
 Consequences from substance use can occur from
using relatively small amounts.
 Elderly may not recognize cravings in the same way as
the general adult population.
 Role obligations may not exist for older adults in the
same way as for younger adults because of life stage
transitions , such as retirement.
 Older patients may not realize the problems they
experience from substance use.

 Older adults may engage in fewer activities regardless
of substance use, making it difficult to detect.
 Older patients may not identify or understand that
their use is hazardous, especially when using
substances in smaller amounts.
 Because of the increased sensitivity to substances at
this age, older adults will seem to have lower tolerance
to substance.

• A session with your doctor
• Medication
• Individual or group therapy
• A detox program
• Support groups
• Many behavioral therapies and medications have been
successful in treating substance use disorders
• CBT
• Counselling and community based rehabilitation

 Club drugs, also called rave drugs or party drugs,
are a loosely defined category of recreational
drugs which are associated with discothèques in the
1970s and nightclubs, dance clubs, electronic dance
music (EDM) parties, and raves in the 1980s to
today.[1][2][3] This group of drugs is also called "designer
drugs“.

Club drug users take the drugs because the substances'
effects enhance the experience of rave and electronic
dance music clubs' pulsating lights, brightly colored
projected images and massive sound systems with
heavy basslines.
What is a party drug?
When you are at a party, festival or concert, you might be offered drugs
with the promise of having an even better time. Although taking party or
recreational drugs might seem fun, there are lots of risks and downsides to
taking them. And they are usually illegal.

 Party drugs can be either stimulants or depressants. They get
their name because young people view these drugs to enhance
their enjoyment at parties. Unfortunately, party drugs can and
are often abused.
 They have no odor and no color, which means they can be
secretly added to someone’s drink without their knowledge.
 That’s the main reason why party drugs are also known as “date
rape” drugs.
 The substances can render someone helpless to another’s
advances. Some of the physical impairments possible with
party/club drugs include:
 Loss of memory
 Cognitive difficulties
 Extreme sleepiness
 Disorientation
 Lack of muscle control
 Depressed breathing

 Depressants(CNS Depressants), including GHB(Gamma-
hydroxybutyric acid ) Rohypnol, and marijuana (cannabis)
 Stimulants , including cocaine (coke,
charlie), amphetamines(speed) and methamphetamines
(ice, crystal meth), mephedrone (‘meow meow’),
benzylpiperazine (BZP), N-ethylpentylone / eutylone (bath
salts)
 Hallucinogens , including LSD
(acid), MDMA (methylenedioxymethamphetamine) street name
of “Molly, (ecstasy), ketamine also known as “special K” or “kit
kat,”, magic mushrooms and DMT.
 Inhalants, including amyl nitrate (‘poppers”) and nitrous oxide.
 Benzodiazepines may be used to ‘come down’ from stimulant
use.

A selection of MDMA pills, which are often
nicknamed "Ecstasy"

 Risk for injury related to hyperactivity/ increased
psychomotor activities
 Ineffective denial related to weak, underdeveloped ego as
evidenced by statements indicating no problem with
substance use, I will leave , if I want to, or refusing to take
any substance.
 Ineffective coping related to abuse of substance or any
psychological factor as evidenced by use of alcohol as a
coping/ defense mechanism
 Imbalanced nutritional status less than body requirement
related to abuse of substance as evidenced by weight loss
 Deficient knowledge related to occurrence disease
conditions as evidenced by unable to verbalize
physiological effects of alcohol abuse.

REVISED SUD -ALCOHAL , CANNABIS, SEDATIVE, ETC DISORDERS

REVISED SUD -ALCOHAL , CANNABIS, SEDATIVE, ETC DISORDERS

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