Specific Substance Related Disorders

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I. Alcohol, Sedatives, Hypnotics, and Anxiolytics

A. Diagnostic Criteria for Intoxication

1. Behavioral and psychological changes are present.

2. One or more of the following: slurred speech, incoordination, unsteady gait, nystagmus, impaired attention or memory, stupor or coma.

B. Clinical Features of Intoxication

1. Amnesia is often present.

2. Behavioral disinhibition (the behavioral expression of aggressive or sexual impulses) is a common finding.

C. Addiction

1. Tolerance develops to sedative effects.

2. Tolerance to brainstem depressant effects develops more slowly. As users require higher doses to achieve a "high," the risk for respiratory depression is increased.

D. Withdrawal from Alcohol and other Sedatives

1. Detoxification may be necessary after prolonged use of central nervous system depressants, or when there are signs of abuse or addiction.

2. Sedatives associated with withdrawal syndromes include alcohol, benzodiazepines, barbiturates, and chloral hydrate.

E. Detoxification of Patients Dependent on Alcohol, Sedatives or

Hypnotics

1. Provide a supervised stepwise dose reduction of the drug or substitute a cross-tolerant, longer-acting substance (diazepam) which has less risk of severe withdrawal symptoms.

2. The cross-tolerated drug is given in gradually tapering doses. To prevent withdrawal symptoms, the dose of medication should be reduced gradually over 1 to 2 weeks.

II. Cocaine

A. Diagnostic Criteria for Intoxication

1. Psychological or behavioral changes, such as euphoria, hyperactivity, hypersexuality, grandiosity, anxiety, or impaired judgement, are present.

2. Two or more of the following: tachycardia or bradycardia, mydriasis (dilated pupils), high or low blood pressure, chills or perspiration, nausea or vomiting, weight loss, agitation or retardation, weakness, arrhythmias, confusion, seizures, coma, respiratory depression, dyskinesias, or dystonia.

B. Clinical Features of Cocaine Abuse

1. Irritability, poor concentration, insomnia, and personality change are common.

2. Intoxication can result in euphoria, impulsive behavior, poor judgement, and perceptual disturbances.

3. Physical sequelae include seizures, nasal congestion and bleeding, cerebral infarcts, and arrhythmias.

4. Chronic use is associated with paranoid ideation, aggressive behavior, depression, and weight loss.

C. Addiction. Psychological dependence is frequent. Tolerance develops with repeated use.

D. Withdrawal is characterized by depression, hypersomnia, anhedonia, anxiety, fatigue, and an intense craving for the drug; withdrawal generally remits in 2-5 days except for craving which is often long-standing.

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