program rawatan,pemulihan dan penagihan alkohol dan nikotin

7/28/2019 Program Rawatan,Pemulihan Dan Penagihan Alkohol Dan Nikotin

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Oleh:Dr Izani Uzair bin ZubairKetua Penolong Pengarah(Perubatan)Jabatan Kesihatan Negeri Pulau Pinang


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Ethyl alcohol or ethanol

Fermentation process

Yeast organisms break down sugar

Distillation

Alcohol vapors are released from the mash at high

temperaturesProof

Measure of the percent alcohol

80 proof whiskey = 40% alcohol


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Wine and beer

Absorbed more slowly than distilled beverages

Carbonated alcoholic beverages (champagne and sparkling wines)

Absorbed more quickly than non-carbonated

Carbonated beverages (soda and seltzer) and drinks with mixers

Relax the pyloric valve and empty stomach contents intointestines

Increases rate of alcohol absorption

The more alcohol you consume, the longer absorption takes


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Alcohol and injuries

13% of ER visits by undergrads are for alcohol-

related injuries Patients with a BAC >0.08 are 3.2 times more likely

to have a violent injury than an unintentional injury

Most people admitted to ER are men 21 and over,most as a result of accidents or fights in which

alcohol was a factor


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Alcohol poisoning Consuming large amounts of alcohol in short period of time

can be lethal Alcohol alone or mixed with another drug responsible for more

deaths due to toxic overdose than any other substance Death caused by either central nervous system and respiratory

depression or by inhalation of vomit or fluid into the lungs Signs include inibility to be roused, weak and rapid pulse,

unusual breathing pattern, and cool, damp, pale or bluish skin

If wait to call for help until person is unconscious, risk of deathincreases tenfold


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Decision making skills impaired

Alcohol lowers inhibitions, impairing ability to makewise decisions regarding sexual activity

70% of college students admit to having engaged insexual activity primarily as a result of being under

influence of alcohol Less likely to use safer sex practices

Risk of contracting STI or unplanned pregnancyincreases among those who drink heavily


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Alcohol affects men and women differently

Women have less body fat

Women have half as much alcohol dehydrogenase enzyme that breaks down alcohol in the stomach

More vulnerable to impairment due to alcoholconsumption

Hormonal differences and use of oral contraceptiveslikely to contribute to longer periods of initoxication


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Immediate effects of alcohol

Reduces frequency of nerve transmissions

Dehydration

Water is lost from cerebrospinal fluid

Alcohol irritates the gastrointestinal system

Hangovers

Congeners forms of alcohol metabolized more slowly Be informed of drug and alcohol interactions

What are some symptoms experienced by someone with a hangover?


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Long-term effects of alcohol

Effects on the Nervous System

Cardiovascular Effects

Liver disease

Cirrhosis

Alcoholic hepatitis

Cancer

Chronic inflammation of pancreas

Impairs ability to recognize and fight bacteria and viruses


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Labs (BAL, CBC, Chem 22, Mg, TSH, RPR,lipase, UDS, UA, pregnancy test)

PPDCXREKGAcetaminophen and salicilate level as indicated


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Sites include stomach, small intestine, and colonDependent on gastric emptying time

Metabolized primarily in the liver by oxidationAlcohol dehydrogenase exhibits zero-order kinetics(15 mg/dl/hr)

Proportional to body weightMicrosomal ethanol oxidizing system (MEOS)Alcohol inhibits cytochrome P-450


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Alcohol ADH

Acetaldehyde ALDH

Acetic acid and water


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20-99mg% loss of muscular coordination, change in behavio100-199mg% ataxia, mental impairment200-299mg% obvious intoxication, nausea and vomiting300-399mg% severe dysarthria and amnesia


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400-600mg% coma occurs600-800mg% decreased respirations and blood pressure,

obtundation, often fatalImportant to remember the role of tolerance in all thesecategories


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Cardiovascular and respiratory support to control bloodpressure and maintain airway

Intravenous fluids (Banana Bag-NS, thiamine, MVI,Folate, B-12)Assess for other drug use especiallybenzosor opioids as

antagonists can be usedClosely monitor until withdrawal begins and then starttreatment


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MSSA (Modified Selective SeverityAssessment)

CIWA-A (Clinical Institute WithdrawalAssessment for Alcohol)Advantage for personnel to monitor progressand treat accordinglyDisadvantage is cookbook approach


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Most people abstain or drink moderately placingthem at low risk for alcohol use disorders. In general,Moderate Drinking is up to 2 drinks/ day for men; up

to 1 drink/ day for women ONE DRINK-12 OUNCE CAN OR BOTTLE OFBEER OR WINE COOLER/ONE 5 OUNCE

GLASS OF WINE


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Nearly 3 in 10 U.S. adults engage in these high-risk drinking patterns 1

Men: more than 14 drinks in a typical week more than 4 drinks on any day

Women: more than 7 drinks in a typical week

more than 3 drinks on any day


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A binge is a pattern of dri nking alcohol that bri ngs blood

alcohol concentr ation (BAC) to 0.08 gm% or above. F or the typical adult, this pattern corresponds to consuming 5 or more drinks (male) or 4 or more drinks (female) in about 2 hours . Binge dri nking is clearl y dangerous for the dri nker and for society


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GENES : 60% addictive,both alcoholspecificand non specific

Enviroment : 40% both shared and nonshared


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Beer (4% ABV)1 pint 2 units

1 unit = 10ml of pure ethanol

Wine (12% ABV)

175ml glass 2 units 750ml bottle 9 units

Whiskey (40% ABV)

25ml measure 1 unit

Drinker typeUnits per week

Men Women

Moderate Less than 21 Less than 14

Hazardous 21 50 14 35

Harmful 50+ 35+


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Disorder Odds Anxiety Disorder 2.6x

Mood Disorders(especially Major Depression ) 4.1x Personality Disorders 4.0x Antisocial Personality Disorder 7.1x Drug Dependence 36.9x Nicotine Dependence 6.4x


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Alcohol use , abuse , and dependence arecomplex behavioral traits influenced by many

factors:genetic and biological responses

environmental influences

stages of development , from childhood to earlyadulthood


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Lots of alcoholism treatments use a combinationof psychological means (such as CBT) incombination with aversion therapy aided bydrugs.Most drugs used in treating alcoholism areaimed at creating adverse reaction to imbibingalcohol.Currently on the market, there are a limitednumber of drugs to treat alcoholism.


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Under normal conditions,alcohol is broken downby alcoholdehydrogenase into

acetaldehyde, which isfurther broken down intoacetic acid byacetaldehydedehydrogenase.

Antabuse works byblocking acetaldehydedehydrogenase, causingan excess build up of acetaldehyde.


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Due to the excess build up of acetaldehyde in thebloodstream, patients may feel nausea, vomit, haveheadaches, chest pain, and several other symptoms after only five to ten minutes after drinking.There appears to be no tolerance to Antabuse; extendeduse of the drug only adds to its effect as it is bothabsorbed and excreted slowly by the body.


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Due to its slow excretion from the body, Antabuse can be effective 5-7 days from the lastdose.

Therefore, patients using Antabuse to treatalcoholism must continually take the drug (thisdrug can be court mandated).

Antabuse also shows some effects as a

dopamine breakdown inhibitor, and therefore isalso being investigated as a treatment for cocaine addiction.


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Due to its interaction with the enzyme dopamine-beta-hydroxylase , which breaks down doapmine, Antabuseadverse affects when combined with drugs affecting therelease and re-uptake of dopamine (Such as Ritalin,

Adderall, and Cocaine).Metabolism of other drugs may be inhibited by Antabuse(such as Benzodiazepines, morphine, and barbituates).Extremely important to take under consideration whensomeone is undergoing other medical treatment alongwith the treatment for alcohol addiction.


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Naltrexone ismetabolized in the liver into a variety of metabolites, with the 6- -

naltrexol being themetabolite useful intreating alcoholism.The mechanism of actionis not quite fullyunderstood.

Approved for use in thetreatment of alcoholismin April of 2006.


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After metabolizing into the 6- -naltrexol, the metabolite isbelieved to act as a competetive antagonist at opiodreceptors.It is because of this reaction that Naltrexone is believed tointeract with the dopaminergic mesolimbic pathway, whichalcohol activates, therby causing pleasurable feelings.


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Naltrexone is aimed at reducing thepsychological need or craving for alcohol.

Naltrexone can be administered in a 50mgtablet with some nauseating side effects. A Naltrexone shot, administerd intr-muscularly, is also available.Naltrexone has been shown to beeffective for up to 30 days.


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Naltrexone is considered a relatively safe drugfor the treatment of Alcoholism.Little drug-drug interactions have been shownand do not seem significant, except for Naltrexones interaction with opiod analgetics.Some patients, while on Naltrexone have beenshown to turn away from alcohol only to pick upanother drug.

After treatment with naltrexone, opiod receptorsare very sensitive and can lead patients tooverdose on some other drug.


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First approved by theFDA in 2004,although it has been

approved in Europesince 1989Part of the reason for the delay of approval

in the US was due tothe action of Acamprosate notbeing fullyunderstood


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Alcohol inhibits the activity of receptors known as N-Methy-D-aspartate receptors (or NMDARs), causingthe brain to create more NMDARs

Absence of alcohol, or no inhibition of the receptor,causes these receptors to be overly active andcause symptoms such as delirium tremens (DT).

Acamprosate is thought to reduce glutamate surgesthat excite NMDARs. This property makes

Acamprosate useful in treating the withdrawalsymptoms in alcoholics.

Acamprosate has also been shown in some studiesto act as a neuro-protectant and protect neuronsfrom damage caused by alcohol withdrawal


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Benzodiazepines have also been used totreat alcohol withdrawal due to their

interaction with the GABA receptor.Emetine can be used in combination withother drugs (creating a literal drugcocktail) and be used in aversion therapyas the cocktail will induce nausea andvomiting.


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Because of the complexity of alcoholism, drugsalone are not effective in curing alcoholism.Cases must also be treated on a case by casebasis, there is no set proven effective methodfor everyone.Psychological measures (CBT) in combinationwith drugs are usually employed, althoughsometimes addictions are treated without druguse.


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Cognitive behavioral therapy tries tounderstand how an individual's learninghas occurred.

A therapist using CBT will, firstly,attempt to help you understand thereasons for your 'bad' behavior andwhy you developed such a negativeresponse to certain 'triggers'.more important goal of CBT, is to

identify and learn better responses, orcoping strategies, for the triggers.


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You, for example, may suffer from stress.In order to unwind after a bad day youhave a drink which relaxes you. You learnthat alcohol relieves stress. Over time youbecome dependent on this drink to relax,before long you are having two, three, abottle. Your wife complains you are drinkingtoo much, the relationship suffers.

Hangovers become common and you getinto trouble at work ultimately being maderedundant. This causes more friction withyour wife and so on.


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A therapist , using your testimony,will help you identify the reasons foryour drinking; you learned that alcohol

relieved stress, and every time youdrank to ease the stress, the idea thatdrink relieved stress was reinforced.However, over time drink no longerfulfilled this function, in fact it createdmore stress. Despite this you continuedwith the behavior becuase of the 'maladaptive learning process' .


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Having identified the reason for thebehavior you and the therapist

would then identify coping skills thatcould be utilized to deal with stressin the future. Skills that didn'tinvolve drinking.

program rawatan,pemulihan dan penagihan alkohol dan nikotin

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