ALCOHOL RELATED DISORDER

AND ITS MANAGEMENT

 INTRODUCTION

Alcoholism refers to the use of alcoholics s, beverages to the point of causing damage to the
individual, society or both.

Alcohol is a clear colored liquid with a strong burning taste .the rate of absorption of alcohol into
the blood stream is more rapid than its elimination. Absorption of alcohol into the blood stream
is more rapid than its elimination. Absorption of alcohol into the blood stream is slower when
food is present in the stomach. A small amount is excreted through stool and urine small amount
is exhaled.

A concentration of 80-100 mg of alcohol per 100 ml of blood is considered intoxication. A

person with 200-250 mg will be toxic sleepy confused and his thought process will be alerted. If
blood level is 300mg/ 100ml of blood the person may lose consciousness concentration of
500mg/100ml is fatal. All the symptoms change according to tolerance.

Ethyl alcohol is the active ingredient of alcoholic drinks. The concentration of ethyl
alcohol(ethanol) varies across the preparations. The standard drink or a unit alcohol corresponds
to 10ml of absolute alcohol or 7.8gram of absolute alcohol.

EPIDEMIOLOGY

 The incidence of alcohol dependence is 2% in India.

 While 20- 40 % of subject aged about 15 are current users of alcohol , and nearly 10% of
them are regular or excessive users.
 Nearly , 15-30% of patients are developing alcohol related problems and seeking admission
in psychiatric hospitals.
AGE AND SEX
 The age group with the highest percentage of alcohol users, which is also the age group of

ICD 10 CLASSIFICATION

F10.-Mental and behavioral disorders due to use of alcohol.

ICD 10 CRITERIA FOR ALCOHOL DEPEDENCE

1) A strong desire or sense of compulsion to take substance.

2) Difficulty in controlling substance taking behavior in terms of it’s onset, termination or levels
of use.
3) A psychological withdrawal state when the substance use has ceased or reduced, as
evidenced by characteristic withdrawal syndrome for the substance; or use of the same with
the intention of relieving or avoiding withdrawal symptoms.
4) Evidence of tolerance such that increased dose of the psycho active substance are required in
order to achieve effects originally produced by lower doses.
5) Progressive neglect of alterative pleasure or interests because of psychoactive substance use,
increased amount of time necessary to obtain or take the substance or to recover from its
effects.
6) Persisting with substance use despite clear evidenceof overtly harmful consequences such as
harm to the liver through excessive drinking , depressive mood states consequent with
periods of cognitive functioning; efforts should be made to determine that the user was
actually or could be expected to be, aware of the nature ad extend of the harm.

The dependence syndrome can e further coded as :

1) Currently abstinent;
2) Currently abstinent but in a protected environment(e.g. in hospital , in a therapeutic
community, in prison, etc)
3) Currently on a clinically supervised maintenance or replacement regime(controlled
dependence , e.g. with methadone; nicotine gum or nicotine patch )
4) Currently abstinent but receiving treatment with aversive or blocking drugs( e.g.
naltrexone, or disulfiram)
5) Currently using substance
6) Continuous use
7) Episodic use

ALCOHOL USE DISORDERS

According to Jellynek there are five species of alcohol dependence (alcoholism) on the basis of
the patterns of use ( and not on the basis of severity).

1- Alpha
a) Excessive and inappropriate drinking to relieve physical or emotional pain.
b) No loss of control.
c) Ability to abstain present.
2- Beta
a) Excessive and inappropriate drinking.
b) Physical complications( cirrhosis, gastritis, and neuritis) due to cultural drinking
patterns and poor nutrition.
c) No dependence.
3- Gamma : also called as malignant alcoholism
 a) Progressive course
b) Physical dependence with tolerance and withdrawal symptoms.
c) Psychological dependence ,with inability to control drinking.
4- Delta
a) Inability to abstain.
b) Tolerance.
c) Withdrawal symptom.
d) The amount of alcohol consumed can be controlled.
e) Social disruption is minimal.
5- Epsilon
a) Dipsomania
b) Spree-drinking.

Factors Type 1 Type 3

Synonym Milieu limited Male limited
Gender Both sexes Mostly in males
Age of onset >25 years <25 years
Aetiological factors Genetic factors important; Heritable ; environmental
Strong environmental influences are limited
influences are contributory
Family history May be positive Parental alcoholism and
antisocial behavior usually
present
Loss of control present No loss of control
Other features Psychological dependence; Drinking followed by
and guilt present aggressive behavior;
spontaneous alcohol seeking
Pre morbid Harm avoidance Novelty seeking
Personality traits High reward dependence

ETIOLOGICAL FACTORS

1- Biological factors
a) Genetic vulnerability(family history of substance use disorder ; e.g.in type 2 alcoholism)
b) Co- morbid psychiatric disorder or personality disorder.
c) Co-morbid medical disorders
d) Reinforcing effects of drugs
e) Withdrawal effects and craving
f) Biochemical factors
2- Psychological factors
a) Curiosity; need for novelty seeking
b) General rebelliousness and social non conformity
 c) Early initiation of alcohol and tobacco
d) Poor impulse control
e) Sensation – seeking (high)
f) Low self esteem
g) Concerns regarding personal autonomy
h) Poor stress management skills
i) Childhood trauma or loss
j) Relief from fatigue
k) Escape from reality
l) Lack of interest in conventional goals
m) Psychological distress
3- Social factors
a) Peer pressure
b) Modeling
c) Ease of availability of alcohol
d) Strictness of drug law enforcement
e) Intra familial conflicts
f) Religious reasons
g) Poor social / family support
h) Perceived distance in the family
i) Rapid urbanization
j) Permissive social attitudes

SIGNS AND SYMPTOMS OF ALCOHOL DEPENDENCE

 Minor complaints: malaise, dyspepsia, moodswings, or depression, increased incidence

of infection.
 Poor personal hygiene, untreated injuries(cigarette burns,fractures, bruises, that can’t be
fully explained).
 Unusually high tolerance for sedatives and opioids.
 Nutritional deficiency (vitamins and minerals).
 Secretive behaviours (may attempts to hide disorder or alcohol supply).
 Consumption of alcohol containing products(mouth wash , after shave lotion, hair spray ,
lighter fluid)
 Denial of problem
 Tendency to blame others and rationalize problems(possibly displacing anger, guilt or
inadequacy on to others to avoid confronting illness)
7) Persisting with substance use despite clear evidence of harmful consequences.
Categories and definition for patterns of alcohol use

Category definition Organization

Moderate drinking Men, <2drinks/day NIAAA
Women , <1 drink/day
Person >65 years of age ,
<1drink/day
A risk drinking Men, >14 drinks / week or >4 NIAAA
drinks/ occation
Women ,>7 drinks/ week or
>3 drinks / occation
Hazardous drinking At risk for adverse WHO
consequences from alcohol
Harmful drinking Alcohol causing physical or WHO
psychological harm
Alcohol abuse </= 1 of the following events APA
in a year: recurrent use
resulting in failure to fulfill
major role obligations,
recurrent use in hazardous
situations, recurrent alcohol
related legal problems,
continued use despite social or
interpersonal problems caused
or exacerbated by alcohol
Alcohol dependence </= of the following events in
a year:tolerance; increased
amounts to achieve effect;
diminished effects from same
amount; withdrawal ; a great
deal of time spent obtaining
alcohol, using it , or
recovering from its
effect;important

PATTERNS OF USE

1) Phase -1 The pre alcoholic phase

 It is characterized by the use of alcohol to relieve the everyday stress and tensions of life
 The person may have observed parents or other adults drinking alcohol, and enjoying the
effect.
 The person learn that use of alcohol is a acceptable method of coping with stress.
 Tolerance develops, and the amount required to achieve the desired effect increases
steadly
 2) Phase 2 The early alcoholic phase
 It begins with blackouts- brief periods of amnesia that occur during or
immediately following a period of drinking
 Now the alcohol is no longer a source of pleasure or relief for the individual but
rather a drug that is required by the individual.
 Common behaviors include sneaking drinks or secret drinking , preoccupation
with drinking and maintaining the supply of alcohol, rapid gulping of drinks and
further blackouts.
 The individuals feels enormous guilt and becomes very defensive about his or her
drinking.
 Excessive use of denial and rationalization.
3) Phase- 3 The crucial phase
 Here the individual has lost control, and physiological addiction is clearly evident.
 This loss of control has been described as the inability to choose whether or not to drink.
 Binge drinking lasting from a few hours to several weeks, is common.
 These episodes are characterized by sickness, loss of consciousness, squalor, and
degradation.
 Here the individuals are extremely ill.
 Anger and aggression are common symptoms.
 Drinking is the total focus and he or she is willing to risk losing everything that was once
important in an effort to maintain the addiction.
 By this phase of the illness, it is common for the individual to have experienced the loss
of job, marriage, family friends and, most especially self respect.
4) Phase – 4 the chronic phase
 This phase characterized by emotional and physical disintegration.
 The individual is usually intoxicated more often than he or she is sober.
 Emotional disintegration is evidenced y profound helplessness and self pity.
 Impairment in the reality testing may result in psychosis.
 Life threatening manifestations may be evident in virtually every system of the body.
 Abstention from the alcohol results in a terrifying syndrome of symptoms that include
hallucinations, tremors, convulsions, severe agitation, and panic.
 Depression and ideas of suicide are common.
EFFECTS OF ALCOHOL ON BODY

ALCOHOLIC POLYNEUROPATHY

 It is a neurological disorderin which peripheral nerves throughout the body malfunction

simultaneously.
  It is defined by axonal degeneration in neurons of both the sensory andmotor systems and
initially occurs at the distal ends of the longest axons in the body.
 This nerve damage causes an individual to experience pain and motor weakness, first in
the feet and hands and then progressing centrally.
 Alcoholic polyneuropathy is caused primarily by chronic alcoholism; however, vitamin
deficiencies are also known to contribute to its development.
 This disease typically occurs in chronic alcoholics who have some sort of nutritional
deficiency.
 Treatment may involve nutritional supplementation, pain management, and abstaining from
alcohol.

ALCOHOLIC CARDIOMYOPATHY

 It is a disease in which the chronic long-term abuse ofalcohol (i.e., ethanol) leads to heart

failure.
  Alcoholic cardiomyopathy is a type of dilated cardiomyopathy.
 Due to the direct toxic effects of alcohol on heart muscle, the heart is unable to pump blood
efficiently, leading to heart failure. It can affect other parts of the body if the heart failure is
severe. It is most common in males between the ages of 35-50.

ALCOHOLIC MYOPATHY

 Alcohol can produce several myopathic disorders, including acute alcoholic myopathy with
or without myoglobinuria, hypokalemic myopathy, chronic atrophic myopathy, and
cardiomyopathy .

 Acute alcoholic myopathy (also termed alcoholic rhabdomyolysis and acute alcoholic
necrotizing myopathy) is an uncommon syndrome of abrupt muscle injury that typically
occurs in malnourished chronic alcoholics following a binge or in the first days of alcohol
withdrawal . 

 Severity ranges from asymptomatic transient elevation of creatine kinase to frank

rhabdomyolysis with myoglobinuria.

 Although in most instances full recovery occurs within days to weeks, death may occur in the
setting of acute renal failure and hyperkalemia.

 Chronic alcoholic myopathy is a gradually evolving syndrome of proximal weakness,

atrophy, and gait disturbance that frequently complicates years of alcohol abuse. 
WERNICKE–KORSAKOFF SYNDROME (WKS)
 It is the combined presence ofWernicke encephalopathy (WE) and alcoholic Korsakoff
syndrome.
 Due to the close relationship between these two disorders, people with either are usually
diagnosed with WKS, as a single syndrome.
 The cause of the disorder is thiamine (vitamin B1) deficiency, which can cause a range of
disorders including beriberi, Wernicke encephalopathy, and alcoholic Korsakoff syndrome.
 These disorders may manifest together or separately.
 WKS is usually secondary to alcohol abuse.
 It mainly causes vision changes, ataxia and impaired memory.
PANCREATITIS
 It may be categorized as acute or chronic.
 Acute pancreatitis usually occurs 1-2 days after a binge of excessive alcohol consumption.
 Symptoms include constant severe epigastric pain; nausea and vomiting; and abdominal
distension. The chronic condition leads to pancreatitic insufficiency resulting in steatorrhea,
malnutrition, weight loss, and diabetes mellitus.
ALCOHOLIC HEPATITIS
 It is hepatitis (inflammation of the liver) due to excessive intake of alcohol.
  It is usually found in association with fatty liver, an early stage of alcoholic liver disease,
and may contribute to the progression of fibrosis, leading to cirrhosis.
 Signs and symptoms of alcoholic hepatitis include jaundice, ascites (fluid accumulation in
theabdominal cavity), fatigue and hepatic encephalopathy (brain dysfunction due to liver
failure).
 Mild cases are self-limiting, but severe cases have a high risk of death.
 Severe cases may be treated with glucocorticoids.
ALCOHOLIC LIVER DISEASE
 It is a term that encompasses the livermanifestations of alcohol overconsumption,
including fatty liver, alcoholic hepatitis, and chronic hepatitis with liver fibrosis or cirrhosis.
 It is the major cause of liver disease in Western countries.
 Althoughsteatosis (fatty liver) will develop in any individual who consumes a large quantity
of alcoholic beverages over a long period of time, this process is transient and reversible. Of
 all chronic heavy drinkers, only 15–20% develops hepatitis or cirrhosis, which can occur
concomitantly or in succession.
 The mechanism behind this is not completely understood. 80% of alcohol passes through the
liver to be detoxified.
 Chronic consumption of alcohol results in the secretion of pro-
inflammatory cytokines (TNF-alpha,Interleukin 6 [IL6] and Interleukin 8 [IL8]), oxidative
stress, lipid peroxidation, and acetaldehyde toxicity.
 These factors causeinflammation, apoptosis and eventually fibrosis of liver cells. Why this
occurs in only a few individuals is still unclear.
 Additionally, the liver has tremendous capacity to regenerate and even when 75%
of hepatocytesare dead, it continues to function as normal.

LEKOPENIA
 The productionfunction and movement of the white blood cells are impairedin chronic
alcoholics.
 This condition called leucopenia, places the individual atrisk for contracting infectious
diseases as well as for complicated recovery.
THROMBOCYTOPENIA
 Platelet production and survival are impaired because of the toxic effect of alcohol.
 This places alcoholics at risk for hemorrhage.
 Abstinence from alcohol rapidly reversesits deficiency.
SEXUAL DYSFUNCTION
 Alcohol interferes with the normal production and maintenance of male and female hormone.
 For women there will change in the menstrual cycle and a decreasedor loss of ability to
becomepregnant .
 For men decreased hormone levels results in a diminished libido, decreased sexual
performance, and the development of reactive or absolute impotence over time.
 PSYCHIATRIC DISORDERS DUE TO ALCOHOL DEPENDENCE

 Acute intoxication
 Withdrawal syndrome
 Alcohol induced amnestic disorders
 Alcohol induced psychiatric disorders

1) Acute intoxication:
 According to the ICD 10 acute intoxication is a transient condition following the
administration of alcohol or other psychoactive substances.
 acute intoxication develops during or shortly after alcohol ingestion.
 It is characterized y clinically significant maladaptive behavior or psychological
changes for example , inappropriate sexual or aggressive behavior, mood lability ,
impaired judgment , slurred speech, in coordination, unsteady gait, nystagmus,
impaired attention and memory finally resulting in coma or stupor.
 This is usually associated with high lood levels of the drug.
 However in certain cases, where the threshold is low (in chronic renal failure) or
idiosyncratic sensitivity is present, even a low dose may lead to intoxication.
 The intensity of intoxication lessens with time, ad effects eventually disappear in the
absence of the substance.
 The recovery is therefore complete, except where tissue damage or another
complication has arisen.
 The following codes may be used to indicate whether the acute intoxication was
associated with ay complications:

a) Uncomplicated (symptoms of varying severity, usually dose dependent,

particularly at high dose levels);
b) With trauma or other bodily injury;
c) With other medical complications(such as hematemesis, inhalation of vomitus);
d) With delirium;
e) With perceptual distortions;
f) With coma
g) With convulsions; and
h) Pathological intoxication
 Withdrawal syndrome:

 A withdrawal state characterized by a cluster of symptoms, often specific to the drug

used , which develop on total or partial withdrawal of a drug, usually after repeated ad or
high –dose use.
 In persons who have been drinking heavily over a prolonged period of time, any rapid
decrease in the amount of time, any rapid decrease in the amount of alcohol in the body is
likely to produce withdrawal symptoms these are ,
1- Simple withdrawal syndrome
2- Delirium tremens

ALCOHOL WITHDRAWAL SYNDROME 

 It is a set of symptoms that can occur following a reduction in alcohol use after a period of
excessive use.Symptoms typically include anxiety, shakiness, sweating, vomiting, fast heart
rate, and a mild fever. Symptoms typically begin around six hours following the last drink,
are worst at 24 to 72 hours, and improve by seven days.
 Alcohol withdrawal may occur in those who are alcohol dependent.This may occur following
a planned or unplanned decrease in alcohol intake.The underlying mechanism involves a
decreased responsiveness ofGABA receptors in the brain.[
 Signs and symptoms of alcohol withdrawal occur primarily in the central nervous system.
The severity of withdrawal can vary from mild symptoms such as sleep disturbances and
anxiety to severe and life-threatening symptoms such as delirium,hallucinations, and
autonomic instability.
 Withdrawal usually begins 6 to 24 hours after the last drink. It can last for up to one week.
To be classified as alcohol withdrawal syndrome, patients must exhibit at least two of the
following symptoms: increased hand tremor, insomnia, nausea or vomiting, transient
hallucinations (auditory, visual or tactile), psychomotor agitation, anxiety, tonic-clonic
seizures, andautonomic instability.

DELIRIUM TREMENS (DTS)

 It is a rapid onset of confusion usually caused bywithdrawal from alcohol.  When it occurs,

it is often three days into the withdrawal symptoms and lasts for two to three days. Physical
effects may include shaking, shivering, irregular heart rate, and sweating. People may
also see or hear things other people do not. Occasionally, a very high body
 temperature or seizures may result in death. Alcohol is one of the most dangerous drugs from
which to withdraw.
 Delirium tremens typically only occurs in people with a high intake of alcohol for more than
a month. A similar syndrome may occur withbenzodiazepine and barbiturate
withdrawal. Withdrawal from stimulants such as cocaine does not have major medical
complications. In a person with delirium tremens it is important to rule out other associated
problems such as electrolyte abnormalities, pancreatitis, and alcoholic hepatitis.
 Prevention is by treating withdrawal symptoms.If delirium tremens occurs, aggressive
treatment improves outcomes. Treatment in a quietintensive care unit with sufficient light is
often recommended.]Benzodiazepines are the medication of choice
with diazepam, lorazepam,chlordiazepoxide, and oxazepam all commonly used. They should
be given until a person is lightly sleeping. The antipsychotic haloperidolmay also be
used. The vitamin thiamine is recommended. Mortality without treatment is between 15%
and 40%. Currently death occurs in about 1% to 4% of cases.

ALCOHOL INDUCED AMNESTIC DISORDERS

a) Wernicker’s syndrome: this is characterized by prominent cerebellar ataxia , palsy of the
6th cranial nerve, peripheral neuropathy ad mental confusion.
b) Korsakoff’s syndrome: the prominent symptom is gross memory disturbance. Other
symptoms include;
 Disorientation
 Confusion
 Confabulation
 Poor attention spa and distractibility
 Impairment of insight
ALCOHOL INDUCED PSYCHIATRIC DISORDERS
a) Alcohol induced dementia
 Alcohol-related dementia is a broad term currently preferred among medical
professionals.
 Many experts use the terms alcohol (or alcoholic) dementia to describe a specific
form of ARD, characterized by impaired executive function (planning, thinking,
and judgment).
   Another form of ARD is known as wet brain (Wernicke-Korsakoff syndrome),
characterized by short term memory loss and thiamine (vitamin B1) deficiency.
 ARD patients often have symptoms of both forms, i.e. impaired ability to plan,
apathy, and memory loss.
 ARD may occur with other forms of dementia (mixed dementia).
 The diagnosis of ARD is widely recognized but rarely applied, due to a lack of
specific diagnostic criteria.

ALCOHOL INDUCED MOOD DISOSRDER

 High rates of major depressive disorder occur in heavy drinkers and those with alcoholism.
 Controversy has previously surrounded whether those who abused alcohol and developed
depression were self-medicating their pre-existing depression.
 But recent research has concluded that, while this may be true in some cases, alcohol misuse
directly causes the development of depression in a significant number of heavy drinkers.
Participants studied were also assessed during stressful events in their lives and measured on
a Feeling Bad Scale. Likewise, they were also assessed on their affiliation with deviantpeers,
unemployment, and their partner’s substance use and criminal offending.
 High rates of suicide also occur in those who have alcohol-related problems.
 It is usually possible to differentiate between alcohol-related depression and depression that
is not related to alcohol intake by taking a careful history of the patient.
  Depression and other mental health problems associated with alcohol misuse may be due to
distortion of brain chemistry, as they tend to improve on their own after a period of
abstinence.

SUICIDAL BEHAVIOR
 Suicidal rates are higher in alcoholics when compared to or alcoholics of the same
age.
 The risk factors for the suicidal behavior are continued drinking, co morbid major
depression, serious medical illness, and unemployment ad poor social support.

ALCOHOL INDUCED ANXIETY DISORDERS

Alcoholics reports panic attacks during acute withdrawal state, similarly during the
first 4 weeks to 6 weeks of abstinence

IMPAIRED PSYCHOSEXUAL FUCTION

Erectile dysfunction and delayed ejaculation are comma in chronic

 alcoholics

PATHOLOGICAL JEALOUSY

Excessive drinkers may develop am overvalued idea or delusion that the partner being unfaithful.

ALCOHOLIC SEIZURES ('rum fits')

Substance abuse Generalized alcohol withdrawal
related convulsions that present asstatus epilepticus, seen in chronic alcoholics 12to
48 hrs after a major decline in blood alcohol levelsClinical Hypocapnia and hypomagnesemia ha
ve a postulated but unproven role;1⁄3 of cases progressto delirium tremens. 

ALCOHOLIC HALLUCINOSIS:

Characterized by presence of hallucination ( auditory) during abstinence, following regular

alcohol intake. Recovery occurs in one month

COMPLICATIONS

Cardio pulmonary

 Arrhythmias
 Cardiomyopathy
 Essential hypertention
 Chronic obstructive pulmonary disease
 Pneumonia
 Increased risk of tuberculosis

Gastro intestinal

 Chronic diarrhea
 Esophagitis
 Esophageal cancer
 Esophageal varices
 Gastric ulcers
 Gastritis
 GI bleeding
 Malabsorption
 pancreatitis

hepatic complication
 alcoholic hepatitis
 cirrhosis
 fatty liver

neurologic complication

 alcohol dementia
 alcoholic hallucination
 alcohol withdrawal delirium
 korsakoff’s syndrome
 peripheral neuropathy
 seizure disorder
 subdural hematoma
 wernicke’s encephalopathy

psychiatric complication

 amotivatioal syndrome
 depression
 impaired social andoccupationfunction
 multiple substanceabuse
 suicide

other complication

 beriberi
 fetal alcohol syndrome
 hypoglycemia
 leg and foot ulcers
 prostatitis
DIAGNOSIS
 bloodalcohol to indicate intoxication(200mg /dl)
 urine toxicology to reveal other substance use
 serum electrolyte analysis revealing electrolyte abnormalities associated with alcohol abuse
 liver function studies demonstrate the alcohol related liver damage
 Hematologic workup possibly revealing anemia thrombocytopenia
 ECG demonstrating cardiac problems
 based o ICD- 10 criteria
 TREATMENT

Alcohol intoxication :Acute alcohol poisoning is a medical emergency due to the risk of death
from respiratory depression or aspiration of vomit ifvomiting occurs while the person is
unresponsive. Emergency treatment strives to stabilize and maintain an open airway and
sufficient breathing, while waiting for the alcohol to metabolize. This can be done by removal of
any vomitus or, if the person is unconscious or has impaired gag reflex, intubation of the trachea.
[32]

Other measures may include

 Treat low blood sugar, with intravenous sugar solutions as ethanol induced low blood
sugar unresponsive to glucagon.
 Administer the vitamin thiamine to prevent Wernicke-Korsakoff syndrome, which can
cause a seizure (more usually a treatment for chronic alcoholism, but in the acute context
usually co-administered to ensure maximal benefit).
 Apply hemodialysis if the blood concentration is dangerously high (>400 mg/dL), and
especially if there is metabolic acidosis.
 Provide oxygen therapy as needed via nasal cannula or non-rebreather mask.
 While the medication metadoxine may speed the breakdown of alcohol, use in alcohol
intoxication Additional medication may be indicated for treatment of nausea, tremor,
and anxiety.
ALCOHOL DETTERRENT THERAPY

Disulfiram

 (sold under the trade names Antabuse and Antabuse) is a drug used to support the

treatment of chronic alcoholism by producing an acute sensitivity to ethanol (drinking
alcohol).
 Disulfiram works by inhibiting the enzyme acetaldehyde dehydrogenase, which means
that many of the effects of a "hangover" are felt immediately after alcohol is consumed.
 "Disulfiram plus alcohol, even small amounts, produce flushing, throbbing in head and
neck, throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating,
thirst, chest pain, palpitation, dyspnea, hyperventilation, tachycardia, hypotension,
syncope, marked uneasiness, weakness, vertigo, blurred vision, and confusion.
 In severe reactions there may be respiratory depression, cardiovascular collapse,
arrhythmias, myocardial infarction, acute congestive heart failure, unconsciousness,
convulsions, and death.
DOSAGE

Disulfiram should not be started unless a patient has stopped ingesting alcohol for at least 12
hours.

 The initial dose is 500 mg every day for 1 to 2 weeks.

 After two weeks a maintenance dose of 125 to 500 mg is given daily.
 The average maintenance dose is 250 mg daily.
 Treatment is continued until the patient develops self-control.
 Maintenance therapy may be required for months or even years.

Mechanism of action

In the body, alcohol is converted to acetaldehyde, which is then broken down by

acetaldehyde dehydrogenase. If the dehydrogenase enzyme is inhibited, acetaldehyde
builds up and causes unpleasant effects. Disulfiram should be used in conjunction with
counseling and support.

Indication
Disulfiram is has been studied as possible treatment for cancer and latent HIV infection.

Side effects
 The most common side effects in the absence of alcohol are headache, and a
metallic or garlic taste in the mouth, though more severe side effects may occur.
 Tryptophol, a chemical compound that induce sleep in humans, is formed in the
liver after disulfiram treatment.
  Less common side effects include decrease in libido, liver problems, skin rash,
and nerve inflammation.
  Liver toxicity is an uncommon, but potentially serious side effect, and risk
groups e.g. those with already impaired liver function should be monitored
closely.
INTERACTIONS
 Drug interactions may change how your medications work or increase your risk
for serious side effects. Keep a list of all the products you use (including
prescription/nonprescription drugs and herbal products) and share it with your
 doctor and pharmacist. Do not start, stop, or change the dosage of any medicines
without your doctor's approval.

 Some products that may interact with this drug are: alcohol-containing products
(e.g., cough and cold syrups, aftershave), amitriptyline, benznidazole, "blood
thinners" (e.g., warfarin), certain medications for seizures (e.g., hydantoins such
as phenytoin/fosphenytoin), isoniazid, metronidazole, theophylline, tinidazole.

 This medication can increase the side effects of caffeine. Avoid drinking large
amounts of beverages containing caffeine (coffee, tea, colas) or eating large
amounts of chocolate.

 This medication may interfere with certain laboratory tests (including urine
VMA/HVA tests), possibly causing false test results.

NURSES RESPONSIBILITIES

 Informed consent should be taken before starting treatment.

 A very serious allergic reaction to this drug is rare. However, seek immediate medical
attention if there notice any symptoms of a serious allergic reaction, including: rash,
itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble
breathing.

NURSING CONSIDERATIONS

Assessment

 History: Allergy to disulfiram or other thiuram derivatives; severe myocardial disease or

coronary occlusion; psychoses; current or recent treatment with metronidazole, paraldehyde,
alcohol, alcohol-containing preparations (eg, cough syrups, tonics); diabetes mellitus,
hypothyroidism, epilepsy, cerebral damage, chronic and acute nephritis, hepatic cirrhosis or
impairment; pregnancy
 Physical: Skin color, lesions; thyroid palpation; orientation, affect, reflexes; P, auscultation,
BP; R, adventitious sounds; liver evaluation; LFTs, renal function tests, CBC, SMA-12
Interventions

 Do not administer until patient has abstained from alcohol for at least 12 hr.
 Administer orally; tablets may be crushed and mixed with liquid beverages.
 Monitor liver function tests before, in 10–14 days, and every 6 mo during therapy to
evaluate for hepatic impairment.
 Monitor CBC, SMA-12 before and every 6 mo during therapy.
 Inform patient of the seriousness of disulfiram-alcohol reaction and the potential
consequences of alcohol use. Disulfiram should not be taken for at least 12 hr after alcohol
ingestion and a reaction may occur up to 2 week after disulfiram therapy is stopped; all
forms of alcohol must be avoided.
 Arrange for treatment with antihistamines if skin reaction occurs.
 WARNING: Institute supportive measures if disulfiram-alcohol reaction occurs; oxygen,
carbon dioxide combination, massive doses of vitamin C IV, ephedrine have been used.

Teaching points

 Take drug daily; if drug makes you dizzy or tired, take it at bedtime. Tablets may be
crushed and mixed with liquid.
 Abstain from forms of alcohol (beer, wine, liquor, vinegars, cough mixtures, sauces,
aftershave lotions, liniments, colognes, liquid medications). Using alcohol while taking this
drug can cause severe, unpleasant reactions—flushing, copious vomiting, throbbing
headache, difficulty breathing, even death.
 Wear or carry a medical ID while you are taking this drug to alert any medical emergency
personnel that you are taking it.
 Have periodic blood tests while taking drug to evaluate its effects on the liver.
 You may experience these side effects: Drowsiness, headache, fatigue, restlessness,
blurred vision (use caution driving or performing tasks that require alertness); metallic
aftertaste (transient).
 Report unusual bleeding or bruising, yellowing of skin or eyes, chest pain, difficulty
breathing, ingestion of any alcohol.

PSYCHOLOGICAL TREATMENT

Denial May be related to

 Personal vulnerability; difficulty handling new situations

  Previous ineffective/inadequate coping skills with substitution of drug(s)
 Learned response patterns; cultural factors, personal/family value systems

Possibly evidenced by

 Delay in seeking, or refusal of healthcare attention to the detriment of health/life

 Does not perceive personal relevance of symptoms or danger, or admit impact of
condition on life pattern; projection of blame/responsibility for problems
 Use of manipulation to avoid responsibility for self

Desired Outcomes

 Verbalize awareness of relationship of substance abuse to current situation.

 Engage in therapeutic program.
 Verbalize acceptance of responsibility for own behavior.

Nursing Interventions Rationale

Ascertain by what name patient would like to be Shows courtesy and respect, giving patient a sense
addressed. of orientation and control.

Convey attitude of acceptance, separating

Promotes feelings of dignity and self-worth.
individual from unacceptable behavior.

Provides insight into patient’s willingness to

commit to long-term behavioral change, and
Ascertain reason for beginning abstinence,
whether patient even believes that he or she can
involvement in therapy.
change. (Denial is one of the strongest and most
resistant symptoms ofsubstance abuse.)

Review definition of drug dependence and This information helps patient make decisions
categories of symptoms (patterns of use, regarding acceptance of problem and treatment
impairment caused by use, tolerance to substance). choices.

Answer questions honestly and provide factual

Creates trust, which is the basis of the therapeutic
information. Keep your word when agreements are
relationship.
made.
 Nursing Interventions Rationale

Progression of use continuum is from experimental

Provide information about addictive use versus or recreational to addictive use. Comprehending
experimental, occasional use; biochemical or this process is important in combating denial.
genetic disorder theory (genetic predisposition; use Education may relieve patient’s guilt and blame
activated by environment; compulsive desire.) and may help awareness of recurring addictive
characteristics.

First step in decreasing use of denial is for patient

Discuss current life situation and impact of
to see the relationship between substance use and
substance use.
personal problems.

Because denial is the major defense mechanism in

addictive disease, confrontation by peers can help
Confront and examine denial and rationalization in the patient accept the reality of adverse
peer group. Use confrontation with caring. consequences of behaviors and that drug use is a
major problem. Caring attitude preserves self-
concept and helps decrease defensive response.

Provide information regarding effects of addiction Individuals often mistake effects of addiction and
on mood and personality. use this to justify or excuse drug use.

Remain nonjudgmental. Be alert to changes in Confrontation can lead to increased agitation,

behavior, (restlessness, increased tension). which may compromise safety of patient and staff.

Provide positive feedback for expressing awareness Necessary to enhance self-esteem and to reinforce
of denial in self and others. insight into behavior.

Attendance is related to admitting need for help, to

Maintain firm expectation that patient attend
working with denial, and for maintenance of a
recovery support and therapy groups regularly.
long-term drug-free existence.

Encourage and support patient’s taking

responsibility for own recovery (development of Denial can be replaced with positive action when
alternative behaviors to drug urge and use). Assist patient accepts the reality of own responsibility.
patient to learn own responsibility for recovering.

Encourage family members to seek help whether or To assist the patient deal appropriately with the
not the abuser seeks it. situation.
 Anxiety& Fear:May be related to

 Cessation of alcohol intake/physiological withdrawal

 Situational crisis (hospitalization)
 Threat to self-concept, perceived threat of death

Possibly evidenced by

 Feelings of inadequacy, shame, self-disgust, and remorse

 Increased helplessness/hopelessness with loss of control of own life
 Increased tension, apprehension
 Fear of unspecified consequences; identifies object of fear

Desired Outcomes

 Verbalize reduction of fear and anxiety to an acceptable and manageable level.

 Express sense of regaining some control of situation/life.
 Demonstrate problem-solving skills and use resources effectively.

Nursing Interventions Rationale

Person in acute phase of withdrawal may

be unable to identify and accept what is
Determine cause of anxiety, involving patient in the
happening. Anxiety may be physiologically
process. Explain that alcohol withdrawal increases
or environmentally caused. Continued
anxiety and uneasiness. Reassess level of anxiety on an
alcohol toxicity will be manifested by
ongoing basis.
increased anxiety and agitation as effects of
medication wear off.

Provides patient with a sense of

Develop a trusting relationship through frequent contact humanness, helping to decrease paranoia
being honest and nonjudgmental. Project an accepting and distrust. Patient will be able to detect
attitude about alcoholism. biased or condescending attitude of
caregivers.

Maintain a calm environment, minimizing noise. Reduces stress.

 Nursing Interventions Rationale

Enhances sense of trust, and explanation

may increase cooperation and reduce
Inform patient about what you plan to do and why. anxiety. Provides sense of control over self
Include patient in planning process and provide choices in circumstance where loss of control is a
when possible. significant factor. Note: Feelings of self-
worth are intensified when one is treated as
a worthwhile person.

Patient may experience periods

Reorient frequently.
ofconfusion, resulting in increased anxiety.

He may also experience hallucinations and

Orient the patient to reality.
may try to harm himself and others.

Monitor patient for signs of depression. To prevent suicidal attempts.

Administer medications as indicated:

 Benzodiazepines: chlordiazepoxide Antianxiety agents are given during acute

(Librium), diazepam (Valium) withdrawal to help patient relax, be less
hyperactive, and feel more in control.

 Barbiturates: phenobarbital, or possibly These drugs suppress alcohol withdrawal

secobarbital (Seconal), pentobarbital but need to be used with caution because
they are respiratory depressants and REM
(Nembutal) sleep cycle inhibitors.

Process wherein SO and family members,

supported by staff, provide information
about how patient’s drinking and behavior
Arrange “Intervention” (confrontation) in controlled
have affected each one of them, helps
setting
patient acknowledge that drinking is a
problem and has resulted in current
situational crisis.
Provide consultation for referral to detoxification and Patient is more likely to contract for
crisis center for ongoing treatment program as soon as treatment while still hurting and
medically stable (oriented to reality). experiencing fear and anxiety from last
drinking episode. Motivation decreases as
 Nursing Interventions Rationale

well-being increases and person again feels

able to control the problem. Direct contact
with available treatment resources provides
realistic picture of help. Decreases time for
patient to “think about it,” change mind or
restructure and strengthen denial systems.

Sensory/Perceptual Alterations:  May be related to

 Chemical alteration: Exogenous (e.g., alcohol consumption/sudden cessation) and

endogenous (e.g., electrolyte imbalance, elevated ammonia and BUN)
 Sleep deprivation
 Psychological stress (anxiety/fear)

Possibly evidenced by

 Disorientation to time, place, person, or situation

 Changes in usual response to stimuli; exaggerated emotional responses, change in
behavior
 Bizarre thinking
 Listlessness, irritability, apprehension, activity associated with visual/auditory
hallucinations
 Fear/anxiety

Desired Outcomes

 Regain/maintain usual level of consciousness.

 Report absence of/reduced hallucinations.
 Identify external factors that affect sensory-perceptual abilities.
 Nursing Interventions Rationale

Speech may be garbled, confused, or

slurred. Response to commands may
Assess level of consciousness; ability to speak, response to stimuli
reveal inability to concentrate, impaired
and commands.
judgment, or muscle coordination
deficits.

Hyperactivity related to CNS

disturbances may escalate rapidly.
Sleeplessness is common due to loss of
sedative effect gained from alcohol
Observe behavioral responses such as hyperactivity, usually consumed before bedtime. Sleep
disorientation, confusion, sleeplessness, irritability. deprivation may aggravate
disorientation and confusion.
Progression of symptoms may indicate
impending hallucinations (stage II) or
DTs (stage III).

To reduce the incidence of delusions

Provide calm environment, minimizing noise and shadows.
and hallucinations.

Avoid restraining the patient unless necessary. To protect patient and others.

Auditory hallucinations are reported to

be more frightening and threatening to
patient. Visual hallucinations occur
more at night and often include insects,
Note onset of hallucinations. Document as auditory, visual, and
animals, or faces of friends and enemies.
tactile.
Patients are frequently observed
“picking the air.” Yelling may occur if
patient is calling for help from perceived
threat (usually seen in stage III AWS).

Reduces external stimuli during

hyperactive stage. Patient may become
Provide quiet environment. Speak in calm, quiet voice. Regulate
more delirious when surroundings
lighting as indicated. Turn off radio and TV during sleep.
cannot be seen, but some respond better
to quiet, darkened room.
 Nursing Interventions Rationale

Promotes recognition of caregivers and

Provide care by same personnel whenever possible. a sense of consistency, which may
reduce fear.

To avoid harming himself and attempts

Monitor patient for signs of depression.
ofsuicide.

May have a calming effect, and may

Encourage SO to stay with patient whenever possible.
provide a reorienting influence.

Reorient frequently to person, place, time, and surrounding May reduce confusion, prevent and limit
environment as indicated. misinterpretation of external stimuli.

Patient may hear and misinterpret

Avoid bedside discussion about patient or topics unrelated to the
conversation, which can aggravate
patient that do not include the patient.
hallucinations.

Provide environmental safety (place bed in low position, leave

Patient may have distorted sense of
doors in full open or closed position, observe frequently, place
reality or be fearful or suicidal, requiring
call light or bell within reach, remove articles that can harm
protection from self.
patient).

Patients with excessive psychomotor

activity, severe hallucinations, violent
behavior, and suicidal gestures may
Provide seclusion, restraints as necessary. respond better to seclusion. Restraints
are usually ineffective and add to
patient’s agitation, but occasionally may
be required to prevent self-harm.

He may experience hallucinations and

Orient the patient to reality.
may try to harm himself and others.

Monitor laboratory Changes in organ function may

studies: electrolytes,magnesium levels, liver function studies, precipitate or potentiate sensory-
ammonia, BUN, glucose, ABGs. perceptual deficits. Electrolyte
imbalance is common. Liverfunction is
often impaired in the chronic alcoholic,
and ammonia intoxication can occur if
the liver is unable to convert ammonia
 Nursing Interventions Rationale

to urea. Ketoacidosis is sometimes

present without glycosuria;
however, hyperglycemia or hypoglycem
iamay occur, suggesting pancreatitis or
impaired gluconeogenesis in the liver.
Hypoxemia and hypercarbia are
common manifestations in chronic
alcoholics who are also heavy smokers.

Administer medications as Reduces hyperactivity, promoting relaxation and sleep. Drugs that have
indicated: Antianxiety agents as little effect on dreaming may be desired to allow dream recovery (REM
indicated rebound) to occur, which has previously been suppressed by alcohol use.

Vulnerable for injury

Risk factors may include

 Cessation of alcohol intake with varied autonomic nervous system responses to the

system’s suddenly altered state
 Involuntary clonic/tonic muscle activity (seizures)
 Equilibrium/balancing difficulties, reduced muscle and hand/eye coordination

Desired Outcomes

 Demonstrate absence of untoward effects of withdrawal.

 Experience no physical injury.

Nursing Interventions Rationale

Identify stage of AWS (alcohol withdrawal syndrome); i.e., Prompt recognition and intervention may
stage I is associated with signs and symptoms of hyperactivity halt progression of symptoms and
(tremors, sleeplessness, nausea and vomiting, diaphoresis, enhance recovery or improve prognosis.
 Nursing Interventions Rationale

tachycardia,hypertension). Stage II is manifested by increased In addition, recurrence or progression of

hyperactivity plus hallucinations and seizure activity. Stage III symptoms indicates need for changes in
symptoms include DTs and extreme autonomic hyperactivity drug therapy and more intense treatment
with profound confusion, anxiety, insomnia, fever. to prevent death.

Grand mal seizures are most common and

may be related to
decreased magnesiumlevels, hypoglycemi
a, elevated bloodalcohol, or history of
head trauma and
Monitor and document seizure activity. Maintain patent airway.
preexisting seizure disorder. Note: In
Provide environmental safety (padded side rails, bed in low
absence of history and other pathology
position).
causing seizures, they usually stop
spontaneously, requiring only
symptomatic treatment.
Note: Antiepileptic drugs are not
indicated for alcohol withdrawal seizures.

Reflexes may be depressed, absent, or

hyperactive. Peripheral neuropathies are
common, especially in malnourished
Check deep-tendon reflexes. Assess gait, if possible. patient. Ataxia (gait disturbance) is
associated with Wernicke’s syndrome
(thiamine deficiency) and cerebellar
degeneration.

Assist with ambulation and self-care activities as needed. Prevents falls with resultant injury.

Provide for environmental safety when indicated. May be required when equilibrium, hand
 Nursing Interventions Rationale

and eye coordination problems exist.

Administer medications as indicated:

BZDs are commonly used to control

neuronal hyperactivity because of
their minimal respiratory and cardiac
depression and anticonvulsant
properties. Studies have also shown
that these drugs can prevent
progression to more severe states of
withdrawal. IV and PO
administration is preferred route
because IM absorption is
 Benzodiazepines (BZDs):chlordiazepoxide unpredictable. Muscle-relaxant
(Librium), diazepam(Valium), clonazepam (Klonopin), qualities are particularly helpful to
oxazepam (Serax), clorazepate(Tranxene); patient in controlling “the shakes,”
trembling, and ataxic quality of
movements. Patient may initially
require large doses to achieve
desired effect, and then drugs may
be tapered and discontinued, usually
within 96 hr. Note: These agents are
used cautiously in patients with
known hepatic disease because they
are metabolized by the liver,
although Serax has a shorter half-
life.
 Haloperidol (Haldol) May be used in conjunction with
BZDs for patients experiencing
 Nursing Interventions Rationale

hallucinations.
Thiamine deficiency (common in
 Thiamine alcoholabuse) may lead to neuritis,
Wernecke’s syndrome, and
Korsakoff’s psychosis.
Reduces tremors and seizure activity
 Magnesium sulfate
by decreasing neuromuscular
excitability.

Risk for Decreased Cardiac Output: .

Risk factors may include

 Direct effect of alcohol on the heart muscle

 Altered systemic vascular resistance
 Electrical alterations in rate, rhythm, conduction

Desired Outcomes

 Display vital signs within patient’s normal range; absence of/reduced frequency of
dysrhythmias.
 Demonstrate an increase in activity tolerance.

Nursing Interventions Rationale

Monitor vital signs frequently during acute Hypertension frequently occurs in acute withdrawal
withdrawal. phase. Extreme hyperexcitability, accompanied by
catecholamine release and increased peripheral
vascular resistance, raises BP and heart rate;
however, BP may become labile and progress
to hypotension. Note:Patient may have underlying
cardiovascular disease, which is compounded by
 Nursing Interventions Rationale

alcohol withdrawal.

Long-term alcohol abuse may result in

cardiomyopathy or HF. Tachycardia is common
because of sympathetic response to increased
Monitor cardiac rate and rhythm. Document
circulating catecholamines. Irregularities and
irregularities and dysrhythmias.
dysrhythmias may develop with electrolyte shifts
and imbalance. All of these may have an adverse
effect on cardiac function and output.

Elevation may occur because of sympathetic

stimulation, dehydration, and infections, causing
Monitor body temperature.
vasodilation and compromising venous return and
cardiac output.

Preexisting dehydration, vomiting, fever, and

diaphoresis may result in decreased circulating
volume that can compromise cardiovascular
Monitor I&O. Note 24-hr fluid balance. function. Note: Hydration is difficult to assess in
the alcoholic patient because the usual indicators
are not reliable, and overhydration is a risk in the
presence of compromised cardiac function.

Causes of death during acute withdrawal stages

include cardiac dysrhythmias, respiratory
depression and arrest, oversedation, excessive
Be prepared and assist in cardiopulmonary
psychomotor activity, severe dehydration or
resuscitation.
overhydration, and massive infections. Mortality
for unrecognized and untreated delirium tremens
(DTs) may be as high as 25%.

Electrolyte imbalance: potassium,magnesium,
Monitor laboratory studies: serum electrolyte
potentiate risk of cardiac dysrhythmias and CNS
levels.
excitability.

Administer fluids and electrolytes, as indicated Severe alcohol withdrawal causes the patient to be
susceptible to fluid losses (associated with fever,
diaphoresis, and vomiting) and electrolyte
imbalances, especially potassium, magnesium,
 Nursing Interventions Rationale

andglucose.

Although the use of benzodiazepines is often

sufficient to control hypertension during initial
withdrawal from alcohol, some patients may
require more specific therapy. Note: Atenolol and
Administer medications as
other b-adrenergic blockers may speed up the
indicated:Clonidine (Catapres), atenolol
withdrawal process and eliminate tremors, as well
(Tenormin);Potassium.
as lower the heart rate, blood pressure, and body
temperature.
Corrects deficits that can result in life-threatening
dysrhythmias.

Risk for Ineffective Breathing Pattern:  Risk factors may include

 Direct effect of alcohol toxicity on respiratory center and/or sedative drugs given to
decrease alcohol withdrawal symptoms
 Tracheobronchial obstruction
 Presence of chronic respiratory problems, inflammatory process
 Decreased energy/fatigue

Desired Outcomes

 Maintain effective breathing pattern with respiratory rate within normal

range, lungs clear; be free of cyanosis and other signs/symptoms of hypoxia.

Nursing Interventions Rationale

Monitor respiratory rate and depth and pattern as Frequent assessment is important because toxicity
indicated. Note periods of apnea, Cheyne-Stokes levels may change rapidly. Hyperventilation is
respirations. common during acute withdrawal phase.
Kussmaul’s respirations are sometimes present
because of acidotic state associated with vomiting
and malnutrition. However, marked respiratory
depression can occur because of CNS depressant
 Nursing Interventions Rationale

effects of alcohol if acute intoxication is present.

This may be compounded by drugs used to control
alcohol withdrawal symptoms (AWS).

Patient is at risk for atelectasis related to

hypoventilation and pneumonia. Right lower
Auscultate breath sounds. Note presence of lobe pneumonia is common in alcohol-debilitated
adventitious sounds: rhonchi, wheezes. patients and is often due to chronic aspiration.
Chronic lung diseases are also
common: emphysema, bronchitis.

Decreases potential for aspiration;

Elevate head of bed.
lowersdiaphragm, enhancing lung inflation.

Facilitates lung expansion and mobilization of

Encourage cough and deep-breathing exercises and
secretions to reduce risk of atelectasis
frequent position changes.
and pneumonia.

Sedative effects of alcohol and drugs potentiates

risk of aspiration, relaxation of oropharyngeal
Have suction equipment, airway adjuncts available.
muscles, and respiratory depression, requiring
intervention to prevent respiratory arrest.

Hypoxia may occur with CNS and respiratory

Administer supplemental oxygen if necessary.
depression.

Monitors presence of secondary complications such

Review serial chest x-rays, ABGs and pulse as atelectasis andpneumonia; evaluates
oximetry as available and indicated effectiveness of respiratory effort, identifies
therapy needs.

Imbalanced Nutrition: Less Than Body Requirements:  May be related to

 Insufficient dietary intake to meet metabolic needs for psychological, physiological,

or economic reasons

Possibly evidenced by
  Weight loss; weight below norm for height/body build; decreased subcutaneous
fat/muscle mass
 Reported altered taste sensation; lack of interest in food
 Poor muscle tone
 Sore, inflamed buccal cavity
 Laboratory evidence of protein/vitamin deficiencies

Desired Outcomes

 Demonstrate progressive weight gain toward goal with normalization of laboratory

values and absence of signs of malnutrition.
 Verbalize understanding of effects of substance abuse, reduced dietary intake on
nutritional status.
 Demonstrate behaviors, lifestyle changes to regain and maintain appropriate weight.

Nursing Interventions Rationale

Monitor the patient’s nutritional intake. To promote adequate nutrition

Provides information about individual on which to

Assess height and weight, age, body build,
base caloric needs and dietary plan. Type of diet or
strength, activity and rest level. Note condition of
foods may be affected by condition of mucous
oral cavity.
membranes and teeth.

Take anthropometric Calculates subcutaneous fat and muscle mass to aid

measurements (triceps skinfold, when available). in determining dietary needs.

Note total daily calorie intake; maintain a diary of Information will help identify nutritional needs and
intake, as well as times and patterns of eating. deficiencies.

Evaluate energy expenditure (pacing or sedentary), Activity level affects nutritional needs. Exercise
and establish an individualized exercise program. enhances muscle tone, may stimulate appetite.

Provide opportunity to choose foods and snacks to Enhances participation or sense of control, may
meet dietary plan. promote resolution of nutritional deficiencies, and
helps evaluate patient’s understanding of dietary
 Nursing Interventions Rationale

teaching.

Provides information regarding effectiveness of

Recommend monitoring weight weekly.
dietary plan.

Useful in establishing individual dietary needs and

Consult with dietitian.
plan and provides additional resource for learning.

Identifies anemias, electrolyte imbalances, and

Review laboratory studies as indicated, (glucose,
other abnormalities that may be present, requiring
serum albumin and prealbumin,electrolytes).
specific therapy.

Teeth are essential to good nutritional intake and

Refer for dental consultation as necessary. dental hygiene and care is often a neglected area in
this population.

Altered Family Processes/Role Performance:  May be related to

 Abuse of substance(s); resistance to treatment

 Family history of substance abuse
 Addictive personality
 Inadequate coping skills, lack of problem-solving skills

Possibly evidenced by

 Anxiety; anger/suppressed rage; shame and embarrassment

 Emotional isolation/loneliness; vulnerability; repressed emotions
 Disturbed family dynamics; closed communication systems, ineffective spousal
communication and marital problems
 Altered role function/disruption of family roles
 Manipulation; dependency; criticizing; rationalization/denial of problems
  Enabling to maintain drinking (substance abuse); refusal to get help/inability to accept
and receive help appropriately

Desired Outcomes

 Verbalize understanding of dynamics of enabling behaviors.

 Participate in individual family programs.
 Identify ineffective coping behaviors and consequences.
 Initiate and plan for necessary lifestyle changes.
 Take action to change self-destructive behaviors/alter behaviors that contribute to
partner’s/SO’s addiction.

Nursing Interventions Rationale

Review family history; explore roles of family

members, circumstances involving drug use, Determines areas for focus, potential for change.
strengths, areas for growth.

The person who enables also suffers from the same

Explore how the SO has coped with the patient’s
feelings as the patient and uses ineffective methods
habit, (denial, repression, rationalization, hurt,
for dealing with the situation, necessitating help in
loneliness, projection).
learning new and effective coping skills.

Determine understanding of current situation and Provides information on which to base present plan
previous methods of coping with life’s problems. of care.

Assess current level of functioning of family

Affects individual’s ability to cope with situation.
members.

Enabling is doing for the patient what he or she

needs to do for self (rescuing). People want to be
Determine extent of enabling behaviors being helpful and do not want to feel powerless to help
evidenced by family members; explore with each their loved one stop substance use and change the
individual and patient. behavior that is so destructive. However, the
substance abuser often relies on others to cover up
own inability to cope with daily responsibilities.

Provide information about enabling behavior, Awareness and knowledge of behaviors (avoiding
addictive disease characteristics for both user and and shielding, taking over responsibilities,
 Nursing Interventions Rationale

rationalizing, and subserving) provide opportunity

nonuser.
for individuals to begin the process of change.

Even though family member(s) may verbalize a

desire for the individual to become substance-free,
the reality of interactive dynamics is that they may
Identify and discuss sabotage behaviors of family unconsciously not want the individual to recover
members. because this would affect the family member(s)’
own role in the relationship. Additionally, they may
receive sympathy and attention from others
(secondary gain).

Serves as a release for feelings (anger, grief,

Encourage participation in therapeutic writing such
stress); helps move individuals forward in
as journaling (narrative), guided or focused.
treatment process.

Many patients and SOs are not aware of the nature

Provide factual information to patient and family
of addiction. If patient is using legally obtained
about the effects of addictive behaviors on the
drugs, he or she may believe this does not
family and what to expect after discharge.
constitute abuse.

When the enabling family members become aware

Encourage family members to be aware of their
of their own actions that perpetuate the addict’s
own feelings, look at the situation with perspective
problems, they need to decide to change
and objectivity. They can ask themselves: “Am I
themselves. If they change, the patient can then
being conned? Am I acting out of fear, shame,
face the consequences of his or her own actions and
guilt, or anger? Do I have a need to control?”
may choose to get well.

Provide support for enabling partner(s). Encourage Families and SOs need support to produce change
group work. as much as the person who is addicted.

Assist the patient’s partner to become aware that Partners need to learn that user’s habit may or may
patient’s abstinence and drug use are not the not change despite partner’s involvement in
partner’s responsibility. treatment.

Help the recovering (former user) partner who is

Enabling behavior can be partner’s attempts at
enabling to distinguish between destructive aspects
personal survival.
of behavior and genuine motivation to aid the user.

Note how partner relates to the treatment team and Determines enabling style. A parallel exists
 Nursing Interventions Rationale

between how partner relates to user and to staff,

staff.
based on partner’s feelings about self and situation.

Explore conflicting feelings the enabling partner Useful in establishing the need for therapy for the
may have about treatment including the feelings partner. This individual’s own identity may have
similar to those of abuser (blend of anger, guilt, been lost, she or he may fear self-disclosure to
fear, exhaustion, embarrassment, loneliness, staff, and may have difficulty giving up the
distrust, grief, and possibly relief). dependent relationship.

Drug abuse is a family illness. Because the family

has been so involved in dealing with the substance
abuse behavior, family members need help
Involve family in discharge referral plans. adjusting to the new behavior of sobriety
and abstinence. Incidence of recovery is almost
doubled when the family is treated along with the
patient.

Lack of understanding of enabling can result in

Be aware of staff’s enabling behaviors and feelings
non-therapeutic approaches to patients and their
about patient and enabling partners.
families.

Encourage involvement with self-help associations, Puts patient and family in direct contact with
Alcoholics and NarcoticsAnonymous, Al-Anon, support systems necessary for continued sobriety
Alateen, and professional family therapy. and to assist with problem resolution.

Sexual Dysfunction:  May be related to

 Altered body function: Neurological damage and debilitating effects of drug use
(particularly alcohol and opiates)

Possibly evidenced by

 Progressive interference with sexual functioning

 In men: a significant degree of testicular atrophy is noted (testes are smaller and softer
than normal); gynecomastia (breast enlargement); impotence/decreased sperm counts
  In women: loss of body hair, thin soft skin, and spider angioma (elevated estrogen);
amenorrhea/increase in miscarriages

Desired Outcomes

 Verbally acknowledge effects of drug use on sexual functioning/reproduction.

 Identify interventions to correct/overcome individual situation.

Nursing Interventions Rationale

Ascertain patient’s beliefs and expectations. Have Determines level of knowledge, identifies
patient describe problem in own words. misperceptions and specific learning needs.

Most people find it difficult to talk about this

Encourage and accept individual expressions of
sensitive subject and may not ask directly for
concern.
information.

Provide education opportunity (pamphlets, Much of denial and hesitancy to seek treatment
consultation with appropriate persons) for patient may be reduced as a result of sufficient and
to learn effects of drug on sexual functioning. appropriate information.

Sexual functioning may have been affected by drug

(alcohol) itself or psychological factors (such as
Provide information about individual’s condition. stress or depression). Information can assist patient
to understand own situation and identify actions to
be taken.

Assess drinking and drug history of pregnant Awareness of the negative effects of alcohol and
patient. Provide information about effects of other drugs on reproduction may motivate patient
substance abuse on the reproductive system and to stop using drug(s). When patient is pregnant,
fetus ( increased risk of premature identification of potential problems aids in
birth, brain damage, and fetal malformation). planning for future fetal needs and concerns.

In about 50% of cases, impotence is reversed

Discuss prognosis for sexual with abstinence from drug(s); in 25% the return to
dysfunction (impotence, low sexual desire). normal functioning is delayed; and approximately
25% remain impotent.

Refer for sexual counseling, if indicated. Couple may need additional assistance to resolve
more severe problems and situations. Patient may
 Nursing Interventions Rationale

have difficulty adjusting if drug has improved

sexual experience (heroin decreases dyspareunia in
women, premature ejaculation in men).
Furthermore, the patient may have engaged
enjoyably in bizarre, erotic sexual behavior under
influence of the stimulant drug; patient may have
found no substitute for the drug, may have driven a
partner away, and may have no motivation to adjust
to sexual experience without drugs.

Assesses fetal growth and development to identify

Review results of sonogram if pregnant. possibility of fetal alcohol syndrome and future
needs.