Substance use disorder.pptx
- 2. Emergencies related to substance use and its management
- 3. Objectives • To identify the patient of substance use • To manage/to help in managing the patient in ER
- 4. • Every 10 seconds a person dies from alcohol- related causes including cancer, heart disease, traffic accident and violence • Results in 3.3 million deaths/year • 275 million people used illicit drugs, (cannabis, amphetamines, opioids, and cocaine) • 31 million of people who use drugs suffer from drug use disorders
- 5. • Intoxication: • onset of specific syndromes related to the recent intake of (or exposure to) substances. • abnormal functioning of the CNS and of other systems. • T/t- stopping or reducing the acute effects of the substance.
- 6. • Symptoms of drug intoxication or withdrawal may present in atypical ways (modality of use, combination of drugs used, purity of the substance used, and characteristics of individual drugs). • Co-existing disease • Mental health disorders: mood disorders, anxiety disorders, personality disorders, and schizophrenia.
- 7. Guidelines for the treatment of SUD • Intense intoxication: • reducing exposure to external stimuli. • providing confidence, guidance, and reality testing in a safe and monitored environment. • Investigate: • which substances • routes of administration • doses • time since the last dose • whether the intoxication level is increasing or decreasing
- 8. Guidelines for the treatment of SUD • Removing the substance from the body • Reversing the effects of the substance with the administration of antagonists • Stabilizing the physical effects of the overdose
- 9. ABC
- 10. • Drug intoxication • Drug withdrawal
- 11. Benzodiazepines • Lorazepam, Alprazolam, Diazepam, Clonazepam, Temazepam,Fflurazepam. • Features: • drowsy • unsteady • confused • disoriented • less alert • Impaired judgment
- 12. Benzodiazepines • CNS depressors with acute intoxication effects (similar to alcohol). • Risk of respiratory depression. • Hypotension and bradycardia, (more pronounced when associated with other substances). • Excessive intake of benzodiazepines alone rarely induces deep coma and death. • long-acting compound (clonazepam), the clinical signs of intoxication can continue for 24 hours.
- 13. Benzodiazepines • Antidote: • Flumazenile- • Specific benzodiazepine antagonist (neurological or respiratory depression). • Contraindicated- TCA, aminophylline, and cocaine.
- 14. Benzodiazepines Withdrawal • Related to the sudden discontinuation in the use of these substances. • Risk factors: prolonged use of high doses. • Features: • anxiety, insomnia, headaches, anorexia, nausea, vomiting, tremor, orthostatic hypotension, and weakness may appear between 1 and 11 days after withdrawal.
- 15. Benzodiazepines Withdrawal • Discontinuation: • Short-acting- withdrawal symptoms within a few hours • Long-acting- delayed until the following day or even later
- 16. Benzodiazepines Withdrawal • Phenobarbital: 30mg equivalent to 10mg of diazepam, 30mg of chlordiazepoxide, 1mg of lorazepam, and 1mg of alprazolam. • After stabilization, progressive reduction is recommended in the daily rate of 10% of the initial dose.
- 17. Marijuana • Acute effect/High dose: • Psychotic symptoms and acute anxiety episodes resembling panic attacks (reasons to seek treatment) • T/t: primarily based on benzodiazepines (oral). • Intoxication: • aggressive behaviors, (due to the distorted perception of reality) • T/t: same as in cocaine users.
- 18. Marijuana Withdrawal • Symptoms: • irritability, appetite alterations, weight loss, and physical discomfort. • No specific pharmacological treatment.
- 19. Alcohol • Effects vary according to the level of consumption • Low dose: mild euphoria and uninhibited behavior • Substantial dose: may trigger irrational thinking, problematic behavior, psychomotor difficulties, and coma (rare cases).
- 20. Alcohol Blood alcohol level Clinical Features 20 - 40 mg% Impaired muscle coordination, mood and behavioral alterations, and increased motor activity 80 – 200 mg% Progressive neurological alterations, including ataxia and slurred speech. Impaired cognitive function. >300mg% Hypothermia and impaired level of consciousness 400 - 600mg% Coma 600-800mg% Usually fatal- (failure of respiratory, cardiovascular, and body temperature control)
- 21. Alcohol • Blood alcohol levels >150mg%: • Vitals monitoring in a quiet and safe environment, and the patient’s airways protected. • IVF (Normal Saline). • Hypertonic glucose (only in hypoglycaemia). • Thiamine- to avoid the risk of Wernicke’s encephalopathy
- 22. Alcohol • Alcohol: not absorbed by activated carbon and therefore its use is not indicated. • Elimination: 10-30mg% per hour. • Preserve the respiratory and cardiovascular functions until alcohol levels in the blood are within a safe range. • Monitoring of vital functions, preserving respiration and avoiding the aspiration of gastric contents, hypoglycemia, and thiamine deficiency.
- 23. Alcohol Agitation: • Better managed by using interpersonal and nursing approaches instead of additional medication (which may complicate and delay the elimination of alcohol).
- 24. Alcohol Withdrawal • Symptoms- • Generally begin within 4-12 hours after use cessation or reduction. • Intensity reaches its peak on the 2nd day and ends in 4 – 5 days. • Tremors, GI discomfort, anxiety, irritability, elevated BP, tachycardia, and overactivity of the autonomic system, seizures, hallucinations, and delirium.
- 25. Alcohol Withdrawal • Treatment: • Thiamine (50mg diluted in 100ml of NS and infused for 30 minutes, three times a day, for 2 -3 days.) • Maintenance of the water balance • Benzodiazepines (chlordiazepoxide, diazepam and lorazepam) • Anticonvulsants • Clonidine • Antipsychotics
- 26. Alcohol Withdrawal • Wernicke’s encephalopathy: • Clinically diagnosed and its existence should be considered in cases of nutritional deficiency, nystagmus, ataxia, and mental state alterations. • Acute thiamine deficiency • Small fraction of cases (around 15%) are identified before death • Thiamine should be administered prior to or during the administration of glucose.
- 27. Alcohol Withdrawal • Delirium Tremens: • Up to 72 hours after of the last dose • May last from 2 - 10 days • Alterations in the level of consciousness, depersonalization, and dysphoric mood, oscillating between apathy and intense agitation and even aggressiveness. • Tonic-clonic seizures
- 28. Cocaine and Amphetamines • Intoxication: • Restlessness, anxiety, hyperactivity, euphoria, dysphoria, increased BP, HR and RR. • Hallucinations and paranoid delusions. • Can be potentiated by alcohol • Cardiac arrhythmias and extremely elevated BP (may be life-threatening). • Hyperthermia, brain hemorrhage, seizures, respiratory insufficiency, and cardiac insufficiency. • Intoxication is usually self-limited and requires only monitoring and support interventions.
- 29. Cocaine • Extremely intense psychomotor agitation, hyperthermia, aggressiveness, and hostility have been reported “excited delirium”. • Risk of death • Must receive intensive care. • T/t: benzodiazepines / neuroleptics • IM/IV- intense psychomotor agitation and aggressiveness.
- 30. Cocaine • Precordial pain may be associated with acute myocardial infarction (AMI) • ECG, CBC, LFT, RFT, electrolytes, and creatine phosphokinase-MB. • Treated as regular cases of ACUTE CORONARY SYNDROME.
- 31. Amphetamines Intoxication: • decreased appetite, increased stamina and physical energy, irritability, aggressiveness, psychotic features, increased sexual drive, involuntary bodily movements, increased perspiration, hyperactivity, jitteriness, nausea, increased and irregular heart rate, and rarely, seizure.
- 32. Amphetamines • Intake of high doses of amphetamines may require gastric lavage and activated carbon (around 30 minutes). • Presence of hypertension, seizures, and persecutory delusions in some patients who use stimulants may require specific treatment.
- 33. Cocaine and Amphetamine Withdrawal • 3 phases: • 1st phase: few hours up to five days. Intense craving in the beginning, irritability, and agitation, evolving with hypersomnolence, depression, anhedonia, and exhaustion, followed by a reduction in craving. • 2nd phase: relapse of craving and with depression and anxiety symptoms, lasting up to 10 weeks. • 3rd phase: gradual reduction in craving and the tendency to normalize mood, sleep, and anxiety. • Pharmacological treatments are rarely beneficial in the management of cocaine withdrawal symptoms.
- 34. Opioids • Euphoric effects of opioids contribute to their widespread abuse. (Heroin, morphine, codeine, oxycodone, and fentanyl) • Signs of intoxication: • Sedation, psychomotor difficulties, confusion, pinpoint pupils and, in more extreme cases, respiratory depression.
- 35. Opioids • Intoxication: • mild to moderate cases- specific treatment is usually not necessary. • Overdose: • myosis and bradycardia, respiratory depression, stupor, or coma. • Hospitalization and support ventilation
- 36. Opioids • Long half-life opioids (methadone) require greater attention. • Observe for 24 - 48 hours (respiratory depression- can be fatal) • Naloxone: • 0.05-0.4 mg IV • Lower doses are used in patients addicted to opioids (risk of severe withdrawal syndrome)
- 37. Opioids Withdrawal • On discontinuation, the withdrawal usually appears within a few hours for most of the drugs in this class and may last up to 1 week. • Signs and symptoms (most common) • diarrhea, abdominal cramping, generalized pain, piloerection, and rhinorrhea. • Withdrawal- usually very uncomfortable, it is not life-threatening
- 39. Opioids Withdrawal • Mydriasis, increased SBP, increased PR, sweating, chills, yawning, pain throughout the body, diarrhea, rhinorrhea, and tears. • Methadone- • maintenance of methadone replacement is not recommended outside of the hospital environment.
- 40. Opioids Withdrawal Clonidine: • 2nd line indication • 0.1-0.3mg divided in three doses • Contraindicated: recent history of CVA or heart disease
- 41. Summary • Maintain the Airway, Breathing and Circulation. • Control the symptoms of drug overdose or withdrawal
- 42. THANK YOU