Substance Use

Disorder

Candice Rachel U. Canlas, LPT-MD

School of Nursing
Emilio Aguinaldo College - Cavite
Terminology
Addiction – Psychologic or physical dependence on a drug or
psychoactive substance
Physical Dependence – A condition characterized by physiologic
reliance on a substance, usually indicated by tolerance to the
effects of the substance and development of withdrawal
symptoms when use of the substance is terminated
Psychologic Dependence – A condition characterized by strong
desires to obtain and use a substance
Withdrawal – A substance-specific mental disorder characterized
by physical symptoms, following the cessation or reduction in use
of a psychoactive substance that has been taken regularly to
induce a state of intoxication
Substance Use Spectrum
Example: Usage of Cannabis (Marijuana)
Opioids

➢ Synthetic versions of pain-relieving substances that were originally derived from opium
poppy
➢ Diacetylmorphine (Heroin) and opium are classified as Schedule I drugs = not available for
therapeutic use because of its high potential of abuse
➢ Heroin is the most abused opioid followed by codeine, hydrocodone, hydromorphone,
morphine, and oxycodone
➢ Heroin is often used in combination with stimulant drug cocaine
➢ Heroin is also recently laced with fentanyl and comes in pill form which has led to
overdoses and deaths
➢ Heroin is injected (mainlining or skin popping), sniffed (snorting), or smoked
➢ Binds to opioid receptors in the brain and causes intense euphoria (rush) followed by a
relaxed, contented state that persists for a couple of hours
➢ In large doses, can cause respiratory depression
Opioids

Mechanism of action:
➢ Bind to opioid pain receptors in the brain and cause analgesic response –
reduction of pain sensation
Drug effects:
➢ Drowsiness, euphoria, tranquility, and other alterations in mood
Indications:
➢ Relieve pain, reduce cough, relieve diarrhea, and induce anesthesia;
methadone – used for opioid dependence
Contraindications:
➢ Drug allergy, pregnancy, respiratory depression or severe asthma, paralytic
ileus (bowel paralysis)
Opioids

Adverse Effects: Management of Withdrawal, Toxicity, and

Overdose
• CNS – diuresis, miosis, convulsions, nausea,
vomiting, and respiratory depression • Detoxification Programs – while on withdrawal
symptoms
• NON-CNS – Secondary to release of
• Naloxone – opioid antagonist which can be used in
histamine → vasodilation, constipation, opioid overdose
flushing of skin, sweating, urticaria and • Naltrexone – for opioid abuse and dependence
pruritus and alcohol-dependent patients; eliminates
euphoria
• Buprenorphine
 Opioid
Withdrawal
Symptoms
Stimulants (Amphetamines,
Cocaine, etc.)
➢ Cause elevation of mood, reduction of fatigue,
a sense of alertness, and invigorating
aggressiveness
Amphetamine (3 Classes)
➢ Referred to designer drugs due psychoactive
properties along with stimulant properties
1. Salts of racemic amphetamine
2. Dextroamphetamine
3. Methamphetamine (example: Shabu)
 ➢ International: Crystal meth; Local:
Methamphetamine Shabu
➢ Chemical class of amphetamine,
but has much stronger effect on
the CNS than the other 2 classes
of amphetamine
➢ Pill form taken orally; Powder
form taken by snorting or
injecting
➢ Have risk of HIV and Hepatitis B
and C due to sharing of needles
➢ Usually taken with marijuana and
alcohol and leads to death
➢ OTC decongestant
pseudoephedrine is commonly
used to synthesize the drug in
illegal drug laboratories
Methylenedioxymethamphetamine
(MDMA, Ecstasy or E)

➢ Usually prepared in illegal laboratories

➢ Tends to have more calming effects than other
amphetamine drugs
➢ Pill form but can be snorted or injected
➢ “Love Drug” - Users feel a strong sense of
social bonding with the acceptance of other
people
➢ Can be energizing which make it popular at
raves (all-night dance parties)
➢ “Molly” – pure crystalline powder of MDMA;
produces euphoric highs
Cocaine
➢ Highly addictive
➢ White powder derived from the leaves of the South
American coca plant
➢ Snorted or injected intravenously
➢ Tends to give a temporary illusion of limitless power and
energy but afterward leaves the user feeling depressed,
edgy, and craving for more
➢ Crack – smokable form of cocaine that has been chemically
altered
➢ Psychologic and physical dependence can erode physical
and mental health
 Mechanism of Action: Release biogenic amine, norepinephrine from its storage sites
in the nerve terminals
Drug Effects: Results in CNS stimulation, as well as cardiovascular stimulation, which
results in increased blood pressure and heart rate and possibly cardiac dysrhythmias;
Can treat enuresis (urinary incontinence) but results in painful and difficult micturition;
CNS – wakefulness, alertness, decreased sense of fatigue; elevation of mood with
increased initiative, self-confidence, and ability to concentrate; often elation and
euphoria; and increase in motor and speech activity
Indications: Treatment of attention deficit hyperactivity disorder; prevent narcolepsy
Pharmacokinetics Contraindications: Drug allergy, diabetes, cardiovascular disorders, states of agitation,
hypertension, known history of drug abuse, and Tourette’s syndrome
of Stimulants Adverse effects:
CNS: restlessness, syncope, dizziness, tremor, hyperactive reflexes, talkativeness,
tenseness, irritability, weakness, insomnia, fever, and sometimes euphoria: In mentally
ill patients – confusion, aggression, increased libido, anxiety, delirium, paranoid
hallucinations, panic states and suicidal or homicidal tendencies
CARDIOVASCULAR: headache, pallor or flushing, hypertension or hypotension, and
circulatory collapse
GI: dry mouth, anorexia, nausea, vomiting, diarrhea, and abdominal cramps
OTHERS: Fatal hyperthermia
Management of
Withdrawal, Toxicity, and
Overdose
Toxicity: Deaths are due to
poisoning or toxic levels as a result
of convulsions, coma or cerebral
hemorrhage during periods of
intoxication or withdrawal
Treatment: Supportive and
requires sedation of the patient
Depressants
➢ Relieve anxiety, irritability, and tension when used as intended
➢ Also used to treat seizure disorders and induce anesthesia
1. Benzodiazepines
✓ Relatively safe but are often intentionally or unintentionally misused
✓ Lethal when ingested with alcohol
❖Flunitrazepam (Rohypnol)/ “Roofies” – used to treat insomnia; creates a sleepy, relaxed,
drunken feeling that lasts 2-8 hours; used in combination with alcohol can cause
disinhibition and amnesia; Also called a “date-rape drug” – has no odor or taste so
victims don’t realize that it was slipped into their drinks
2. Barbiturates – Phenobarbital, Secobarbital etc.
3. Gamma-hydroxybutyric acid (GHB) – date rape drug; works by mimicking the natural inhibitory
brain neurotransmitter GABA; also known as liquid ecstasy; Used for their depressant and
hallucinogenic effects
Pharmacokinetics: Depressants
Mechanism of Action:
Benzodiazepines & Barbiturates – Increase the action of GABA (an amino acid in the brain that
inhibits nerve transmission in the CNS); Results in relief of anxiety, sedation, and muscle relaxation;
CNS effects: Cause amnesia and unconsciousness; also blood pressure decreases
Indications:
Benzodiazepines – relieve anxiety, induce sleep, produce sedation, and prevent seizures
Barbiturates – sedatives and anticonvulsants and to induce anesthesia
Contraindications: Drug allergy, dyspnea or airway obstruction, narrow-angle glaucoma, and
porphyria
Adverse effects: Drowsiness, sedation, loss of coordination, dizziness, blurred vision, headaches,
and paradoxical reactions (insomnia, increased excitability, hallucinations)
Depressants: Management of Withdrawal,
Toxicity, and Overdose
Benzodiazepines
✓ Fatal poisoning is unusual
✓ With alcohol or barbiturates, the combination can be
lethal
✓ Death is typically due to respiratory arrest
✓ Abrupt withdrawal: autonomic withdrawal symptoms,
seizures, delirium, rebound anxiety, myoclonus
(involuntary muscle contractions), myalgia, and sleep
disturbances
✓ Implicated in suicides
Treatment:
Flumazenil – benzodiazepine reversal agent; antagonizes the
action of benzodiazepines on the CNS by competing at the
benzodiazepine receptor and reversing sedation
Depressant: Marijuana
✓ Derived from cannabis plant
✓ Most commonly abused drug worldwide
✓ Smoked as a cigarette (joint) or in a pipe (bong)
✓ Can be mixed in food or tea
✓ Active ingredient: cannabinoids; most active is tetrahydrocannabinol (THC)
✓ Mechanism of action: Bind and stimulate 2 cannabinoid receptors in the CNS; THC stimulates sympathetic receptors and
inhibits parasympathetic receptors in the cardiac tissue which leads to tachycardia
✓ Drug effects: Smoking – acute sensorial changes within 3 mins, peak in 20-30 mins, lasts for 2-3 hours; Oral route – longer
effects
✓ Specific effects: mild euphoria, memory lapses, dry mouth, enhanced appetite, motor awkwardness, and distorted sense
of time and space
✓ Other effects: hallucinations, anxiety, paranoia, and unsteady gait
✓ Indications: Treatment of chronic pain, reduction of nausea and vomiting associated with cancer treatment, appetite
stimulation with wasting syndromes (i.e. patients with AIDS)
✓ Adverse Effects: Chronic respiratory symptoms and memory and attention deficit problems
✓ Treatment: Effects are self-limiting and usually resolve within few hours
Other
Abused Legal
Substances
Alcohol
➢ Ethanol (ETOH) is a CNS depressant
➢ CNS Depression is caused by 1) Lipid membranes get dissolved in the
CNS 2) Augmentation of GABA-mediated synaptic inhibition and fluxes of
chloride
➢ Moderate amounts of alcohol stimulate or depress respirations; cause
vasodilation; feeling of warmth because it enhances cutaneous and
gastric blood flow; cause increased sweating thus heat is lost more
rapidly and the internal body temperature falls
➢ Long term ingestion of alcohol is one of the primary causes of liver failure
➢ Ethanol exerts a diuretic effect by inhibiting antidiuretic hormone
secretion
 Alcohol
INDICATIONS:
Solvent - vehicle for medicinal mixtures; Acts as a coolant when
applied to the skin; Used topically it can be a skin disinfectant;
Systemic uses are limited to treatment of methyl alcohol and ethylene
glycol intoxication (antifreeze solution); Small amounts can have
cardiovascular benefits
ADVERSE EFFECTS:
✓ Neurologic and mental disorders
✓ Nutritional and vitamin deficiencies – vitamin B deficiencies which
can lead to Wernicke’s encephalopathy, Korsakoff’s psychosis,
polyneuritis, and nicotinic acid deficiency encephalopathy
✓ Cardio-respiratory depression
✓ Alcoholic hepatitis or cirrhosis
✓ Teratogenic effects: Inhibits embryonic cellular proliferation early in
gestation; Fetal Alcohol Syndrome - craniofacial abnormalities,
CNS dysfunction, and both prenatal and postnatal growth
retardation of the infant
 Alcohol
INTERACTIONS: Intensify sedative effects that work in the CNS
(benzodiazepines, antidepressants, antipsychotics etc.); Interact
with metronidazole causing disulfiram reaction; Hepatotoxicity
when taken with paracetamol; Increases bioavailability of blood
thinner, Warfarin, which increases chances of bleeding
MANAGEMENT OF WITHDRAWAL, TOXICITY AND OVERDOSE
Ethanol toxicity – supportive treatment and stabilizing the patient
and maintain airway
Disulfiram (Antabuse) – alters metabolism of alcohol; not a cure but
helps patients to stop drinking; may cause acetaldehyde syndrome
Naltrexone – less noxious therapy option
Acamprosate
• GABA agonist/glutamate antagonist
• Used to maintain abstinence from alcohol
Alcohol Withdrawal and Treatment
Signs and Symptoms of Alcohol Withdrawal
1. Mild – BP > than 150/90, PR > 110, temp > 37.7 deg C, tremors, insomnia,
agitation
2. Moderate – BP 150-200/90-140, PR 110- 140, temp 37.7-38.3 deg C, tremors,
insomnia, agitation
3. Severe (Delirium Tremens) – BP > 200/140, PR> 140, temp > 38.3 deg C,
tremors, insomnia, agitation
Treatment
Benzodiazepines
✓Treatment of choice for ethanol withdrawal
✓Oral route is preferred; IV is used for severe withdrawal
✓Other therapies: Thiamine administration, hydration, magnesium replacement
Nicotine
➢Isolated from leaves in tobacco
➢Medical Significance: Presence in tobacco causes toxicity, and propensity for eliciting
dependence in its users
➢Users believe that cigarettes calm their nerves, when actually the calming effect is
associated with deep breathing not smoking
➢Smoking releases epinephrine, a hormone that creates physiologic stress
➢Addictive and most users develop a tolerance for nicotine and need high amounts to
produce desired effects
➢Smokers can become physically and psychologically dependent and will suffer withdrawal
symptoms in its absence
➢Smoking is particularly dangerous in adolescents because their bodies is still developing
and changing
➢Chemicals in cigarettes, which include 200 known poisons, can adversely affect the
maturation of cells
Nicotine
Mechanism of Action:
Directly stimulates the autonomic ganglia of nicotinic
receptors which is present in several body systems (adrenal
glands, skeletal muscles and CNS)
Starts with transient stimulation followed by more
persistent depression of all autonomic ganglia
Drug Effects:
CNS – stimulates CNS (including respiratory stimulation)
followed by depression
Cardiovascular System: Increases heart rate and blood
pressure
GI system: Increased tone and activity of the bowel which
leads to nausea and vomiting and occasional diarrhea
Nicotine
Indications: No known therapeutic use / The only other use of nicotine products is to reduce cravings and
promote smoking cessation (available in chewing gum, transdermal patches, vaporizer, and nasal spray)
Adverse effects:
CNS: Large dose – tremors and convulsions; Death is due to central paralysis and peripheral blockade of
respiratory muscles
Management of Withdrawal, Toxicity, and Overdose
Acute Toxicity
✓ Occurs in children who accidentally ingested cigarettes
✓ Treatment: Supportive and may include activated charcoal
Smoking Cessation
✓ Primary cause of withdrawal; manifests as cigarette craving, irritability, restlessness, and a decrease in heart
rate and blood pressure
✓ Managed by behavior therapy and medications
Common Methods Used for Nicotine
Withdrawal
1. Nicotine Transdermal System (Patch)
✓ Uses a stepwise reduction in subcutaneous delivery to gradually decrease the nicotine dose
✓ Better compliance than gums
2. Nicotine Polacrilex (Gum)
✓ Used for acute relief from withdrawal symptoms because rapid chewing releases an immediate
dose of nicotine
3. Bupropion
✓ Antidepressant
✓ Approved first-line therapy to aid in smoking cessation treatment
4. Varenicline (Chantix)
✓ Newest drug indicated for smoking cessation
✓ Activates and antagonizes the alpha-4-beta—2 nicotinic receptors in the brain;
Stimulates nicotine receptors while reducing pleasurable effects of nicotine from
smoking
✓ Greater efficacy than bupropion
✓ Adverse effects: nausea, vomiting, headache, flatulence, insomnia, and taste
disturbances; drowsiness has also been reported
E-Cigarettes