Substance Abuse: Alcohol Abuse

Case Description

Name: Patient A, 65-year-old white woman. She taught elementary school for 28 years and has
not worked since retiring 15 years ago.

Lifestyle & Family History:

Patent A is married for 35 years to an accountant. They have 5 grown children and 12
grandchildren. Her mother suffered with hypertension and died of a cerebrovascular accident 10
years ago at age 81. Her father died after a heart attack more than 30 years ago at age 55. She has
2 younger sisters, aged 61 and 59 years old, who are basically in good health. She had an
appendectomy at age 28, and a cholecystectomy at age 55, 1 month after her mother died. She
sees her family doctor for control of asthma and high blood pressure. The same family doctor has
treated the patient for nearly 20 years.
The family doctor has been aware of the Patient A drinking problem. It apparently began
in the early 1970s after she was involved in a lawsuit initiated by a parent of one of her pupils.
Although the school backed her, and the case was eventually resolved in her favor, she
remembers the 2-year period as one of constant fear and uncertainty. She recalls subsequently
experiencing blackout spells. On 3 separate occasions, she was hospitalized for detoxification,
and brief periods of sobriety ensued. The doctor inquires regularly about her alcohol habit and
believes that the patient is mostly truthful about her bouts of drinking and times of abstinence.
One week ago, Patient A resumed daily drinking (about 1 pint of vodka) 3 months ago. At times,
she noticed that she slurred her words. Daughter has become fearful of leaving the grandchildren
with the patient. When they each spoke with her, she denied “heavy drinking” and thought they
made “more of the problem than there was.”
The doctor agreed to talk with his patient, telling her that her husband and daughter had spoken
with him, and she agreed to come in for an appointment. She pointed out, skillfully, that the
problem was not new, that it was having marital and family consequences for her, that she had
made several unsuccessful attempts to deal with it in the past, and that she felt it was time to take
a definitive step to resolve the problem. He was somewhat surprised when she agreed to accept a
referral to a psychiatrist for brief psychotherapy.
 Pathophysiology:

Non-Modifiable: Modifiable
 Health History :
- History of depression  Environment
History of anxiety  Lifestyle
 Alcohol Abuse

 Genetics
 Age
alcohol toxicity

(damage to the gastrointestinal

cardiovascular, immune, nervous, and other systems.)

Cellular toxicity initiated by the metabolism of ethanol

and subsequent accumulation of acetaldehyde,
a metabolite that can damage intracellular proteins

changes in the oxidation–reduction state of a cell

peripheral vasodilation and decreases contractility of the heart

, resulting in a mild decrease in blood pressure.

Release of opioids (endorphins)

Alcohol-dependent

Psychiatric Diagnosis:
There were no psychotic symptoms, no suicidal ideas, and no obsessions or
compulsions. She qualified was only diagnosed in alcohol intoxication.
Sign and symptoms:
 fear and uncertainty
 recalls subsequently experiencing blackout spells
 periods of sobriety
Medications:
 Antabuse (disulfiram)
 Case Analysis: Alcohol Abuse

Alcohol consumption cannot be only identify in younger adult and older adult but also in
adolescences even as young as school age individual has a bad habit and addiction in alcohol.
There are so many factors why people continuously consuming it. Like, broken family, stress and
the only thing to escape from stress is consuming alcohol.

According to lcohol is taken abundantly in a short period, and it results in a state that exceeds the
normal state of being drunk. As a result people may experience ataxia, disturbance of
consciousness, coma, respiratory depression, and hypotension may occur. In serious cases, it may
lead to death. Generally, treatment is necessary, including avoidance of dehydration, hypothermia,
hypotension, hypoglycemia, respiratory depression, metabolic acidosis, excitement, and anxiety.
Suicide related to alcohol consumption has also been reported occasionally; however, in-hospital
self-harm by hanging with restraint belts as a withdrawal from acute alcohol intoxication has not
been reported previously
The physical and mental responses typical of withdrawal syndrome are not usually seen with
alcohol intoxication; therefore, physicians who treat patients with acute alcohol intoxication must
pay enough attention to avoid unexpected adverse events. Usually, alcohol withdrawal syndrome
follows the withdrawal from chronic alcohol abuse, not acute alcohol intoxication, and the mental
response during recovery from acute alcohol intoxication is not fully understood. Goldberg
reported that medically complicated suicide attempters – male trauma patients with personality
disorders and elderly patients with delirium, patients in delirium tremens, and medical patients
with concurrent severe psychiatric disorders – require continuous observation. Substance abuse is
also included in these conditions. This case was not considered to be a medically complicated
suicide attempter, however, closer observation would be required to avoid self-harm event.
 Substance Abuse: Sedatives abuse
Case Description

Name: Patient B, a 50-year-old woman, widowed and a jobless woman.

Lifestyle & Family History:

Patient B has a long history of depression with periodic anxiety attacks. She has been
prescribed alprazolam (Xanax) for 5 years for anxiety and sleep problems. She describes episodes
of shaking and dyspnea with anxiety lasting for about an hour several times per day for which she
would take alprazolam 2-3 mg. For the past 3 months, she has had depressed mood with crying
spells, decreased appetite, and weight loss. She has gradually been increasing the amount of
alprazolam she takes, up to 7-10 mg per day. She admits to taking more alprazolam than
prescribed and denies buying any medications illegally without a prescription (“off the street”).
She wants to stop alprazolam because it has been causing memory problems (blackouts) and her
physicians have expressed concern about her overuse without much improvement in her
depression. However, she feels she needs it and wants something to help her anxiety symptoms
and her insomnia. She denies abusing illicit drugs or alcohol (she has one mixed drink per week)
and denies suicidal ideation. She is widowed and lives alone, and she has poor coping skills and
limited social support. She reports that her alprazolam vanished about a week ago; she was not
sure if it was stolen or if she had a blackout from taking it. At that time, she was started on
clonazepam (Klonopin), but she states she prefers alprazolam.

Pathophysiology:
Non-Modifiable: Modifiable
 Health History :
- History of depression  Environment
History of anxiety  Lifestyle
 Alcohol Abuse

 Genetics
 Age
CNS depressants
(Benzodiazepines)

Most stimulate the activity of GABA,., enhance the effect of the neurotransmitter gamma-
aminobutyric acid (GABA)

abuse and serious toxic adverse effects.

It also appears to increase GABA B receptor activity and dopamine levels in the CNS.

Sedatives dependent

Sign and symptoms:

sleeping problems, Decreased appetite, weight loss.
periodic anxiety attacks, describes episodes of shaking
dyspnea with anxiety lasting for about an hour several times per day
 depressed mood with crying spells, memory problems (blackouts)

Psychiatric Diagnosis:
Patient B, diagnosed with depression with periodic anxiety.

Signs and symptoms:

 periodic anxiety attacks
 sleep problems
 describes episodes of shaking
 dyspnea with anxiety lasting for about an hour several times per day
 depressed mood with crying spells
 decreased appetite
 weight loss
 memory problems (blackouts)

Medication/s:
 clonazepam (Klonopin)
 alprazolam (Xanax) / 2

Case Analysis: Sedatives abuse

There are so many substances addiction can be use. Base on this case study, Patient B, was
diagnosed of depression due to family problem again, they are people who had a weak coping
mechanism and hard to adopt to the problem. They became more anxious and stress that lead him
to depression. The problem does not end with that. Patient became dependent to sedatives and use
it without a prescription of the physician. Factors why Patient B and other patient became
dependent to sedative is because lack of family support, patient may feel hopeless and helpless,
some feel they became a burden to their family.
There are many different types of sedatives, and they are widely prescribed for insomnia and
anxiety. Patients may misuse sedatives to self-medicate symptoms of underlying depression or
anxiety. To help prevent abuse and diversion of sedatives, prescribers should use appropriate
precautions, similar to those used when prescribing other controlled substances such as opioids.
Misuse or abuse of sedatives may lead to intoxication or a withdrawal syndrome, either of which
may be fatal. Like, what happen to Patient B. she created drug resistant and wish for more
sedatives and increase dosage of her medications. Sedative withdrawal syndrome can be avoided
by slowly tapering down the dose of the sedative over several weeks but Patient B, gradually
increasing the dose without consulting his physician and buy drugs over the counter. More serious
withdrawal is treated by substitution with a long-acting sedative and requires close medical
supervision in the outpatient or inpatient setting.
As a future nurse, it is our job to monitor the medications use by our patient and understand the
contraindications and adverse effect of medications. Nurse must patiently remind the client about
the scheduled of prescription and inform the client and the relatives about the medications.

Substance Abuse: Opioids abuse

Case Description
Name: Patient M, 30-year-old woman, housewife

Lifestyle & Family History

Patient M, a 30-year-old woman with a history of recent intravenous (IV) drug use is
admitted to the observation unit for IV antibiotics after the incision and drainage of an antecubital
abscess. She has a history of opioid and cocaine dependence. She receives IV morphine followed
by IV hydromorphone for acute pain, as she had a significant debridement performed. After the
procedure, she is demanding increasingly higher doses of IV opioids, and the observation unit
team is becoming uneasy regarding the dose and frequency of opioid medications that she is
receiving. The nursing staff raises concerns that she has tampered with her IV tubing and may be
using her IV to “inject something.”

Pathophysiology:

Modifiable Non-Modifiable:
 History of addiction —
 Environment mother side
 Lifestyle  Genetics
 Age

Repeated opioid use/ withdrawal

consolidates memory that opioids
alleviate stress and dysphoric states

Opioid Dependence

Abstinence life stress event

Withdrawal Symptoms

Drug Craving relapse

Initial opioid use is reinforced by euphoria and positive mood, promoting further drug use.
However, the motivation for opioid taking changes with repeated use, where positive reinforcing
effects of the drug wane in comparison to the drive to alleviate withdrawal effects (negative
reinforcement). With repeated drug use, opioid dependence develops and the learned association
with relief of the aversive withdrawal state is reinforced. Following abstinence, the risk of relapse
can be driven by three paths. The first is by direct negative reinforcement and relief of
withdrawal. The second path would be sensory or drug cues (e.g., drug paraphernalia, familiarity
of location to previous drug use, scent, etc.) and drug access (left side of figure), where incentive
salience drives craving and loss of inhibitory control drive relapse. The other (right side of figure)
is the trigger of life stress events that recall the memory of learned association between drug
taking and aversion relief. In individuals with pre-existing negative affective states, the prediction
is that the initial opioid use would immediately be associated with negative reinforcement in
alleviating dysphoric symptoms and a) memory consolidation would be established more rapidly
and b) the opioid would have increased salience during withdrawal for creating associative
memories due to exacerbated dysphoria.

Psychiatric Diagnosis:
She has been diagnosed substance abuse.
Sign and Symptoms:
 excessive opioid dose
 restlessness
 active arousal and wakefulness
 insomnia
 acute pain
Medication/s:
 IV morphine
 IV hydromorphone

Case Analysis: Opioid abuse

Consider the psychological adaptations revealing anxiety and negative affective states during
opioid abuse. There are instances were a patient abuse opioids like it was prescribed by a doctor
and the client became dependent on it due to negligence.
Opioids act by binding to opioid receptors on neurons distributed throughout the nervous system
and immune system. Understanding the role of endogenous peptides allows us to understand why
medications and drugs that bind to opioid receptors have such profound effects on so many organ
systems and bodily functions. Experiencing a persistent desire for the opioid or engaging in
unsuccessful efforts to cut down or control opioid use.
Spending a great deal of time in activities necessary to obtain, use, or recover from the effects of
the opioid. Continuing to use opioids despite knowledge of having persistent or recurrent
physical or psychological problems that are likely to have been caused or exacerbated by the
substance. Tolerance is the need for increasing doses of medication to achieve the initial effect of
the drug. Tolerance to the analgesic and euphoriant effects and unwanted adverse effects, such as
respiratory depression, sedation, and nausea, may develop. Opioids can make your brain and
body believe the drug is necessary for survival. As you learn to tolerate the dose you’ve been
prescribed, you may find that you need even more medication to relieve the pain or achieve well-
being,which can lead to dependency. Addiction takes hold of our brains in several ways — and is
far more complex and less forgiving than many people realize. f you or a loved one is considering
taking opioids to manage pain, it is vital to talk to a physician anesthesiologist or other pain
medicine specialist about using them safely and exploring alternative options if needed.

Substance Abuse: Stimulants

Case Description:

Name:. Patient Budang, a 29-year-old female, a sales lady

Lifestyle & Family History:

Budang and her friends continued using bath salts for the following two days. The friend called
911 when she found our patient curled up in a corner of the friend’s home. Paramedics found our
patient with a Glasgow Coma Score (GCS) of 11, on the floor. The patient was noted to have in
her possession two prescription bottles labeled trazodone and lithium, with three different types
of pills found in those two bottles. Her management in the emergency department began with
initial stabilization. She was given a 1-liter bolus of normal saline (NS) intravenously (IV). She
was administered 0.4 mg of Narcan IV, for which there was little response. At that point, poison
control was contacted. We later found out this patient had a history of bipolar disorder and
polysubstance abuse. She was currently prescribed lithium and trazodone. When patient became
more responsive, she admitted to a 2-day binge of drug use including snorting bath salts, followed
by the use of valium, lithium, and trazodone to help her sleep. This patient was discharged to
home with close psychiatry follow up. Her mother also has a bipolar disorder. His father died 3
years ago because addiction in marijuana.

Pathophysiology:
Non-Modifiable: Modifiable
 History of Bipolar—
mother side  Environment
 History of Marijuana  Lifestyle
addiction- father side
 Genetics
 Age Stress

Repeated stimulants use.

stimulants Dependence

Abstinence life stress event

Withdrawal Symptoms

Substance Craving relapse

Psychiatric Diagnosis:
Patient Budang has a history of bipolar disorder and polysubstance abuse.
Signs and symptoms:
 rapid heart rates
 palpitations and chest pain
 Headaches and seizures
 Hallucinations and Paranoia
 Insomnia and Agitation
 suicidal thoughts
Medication/s
 0.4 mg of Narcan IV
 Lithium
 trazodone

Case Analysis: “Bath Salts” Kind of Stimulants

Bath salts are becoming increasingly popular as a form of recreational drug use in our country.
These “bath salts” are being used as an alternative to street drugs such as cocaine. These bath
salts have no use for bathing, although sold under the name “bath salts,” a term usually meant to
describe a type of powdered soap to be added to bath water for cleaning. Some of the more
common street names for bath salts include red dove, vanilla sky, ivory wave, bliss, white
lightning, super coke, tranquility, zoom, and magic. This substance can be purchased over the
internet or locally in “head shops” or certain convenience stores. Many of these internet sites are
now international, and as such difficult to regulate. Bath salts work by stimulating release and
inhibiting the reuptake of norepinephrine, serotonin, and dopamine. Bath Salts cause symptoms
consistent with a sympathomimetic toxodrome. The most common symptoms include
hallucinations, paranoia, insomnia, agitation, and suicidal thoughts.
 Substance Abuse: Hallucinogens
Case Description:
Name:. Vice, female patient, now 33 years old and an architect by profession.
Lifestyle & Family History:
Patient Vice, came from broken family, they are 4 siblings in total. There was no mentioned
hereditary disorders both mother and father. During a 1-year stay in the USA at the age of 18 she
reported the recreational use of up to 30 doses of lysergic acid diethylamide (LSD; ‘tabs’). Each
single dose was probably limited to 100 µg and consumed in a peer group setting. She also used
marijuana for relaxation and occasionally experimented with ecstasy, psilocybin mushrooms and
ketamine.
The patient mentioned the occurrence of after images, the perception of motion in the periphery
of her visual fields, flickering when looking at patterned objects, halo effects, macro- and
micropsia, and in the patient’s own words, ‘a glow-worm effect’ meaning the perception of bright
little spots of light across the visual field. With her eyes shut, no such abnormalities were
perceived.
These symptoms persisted for the last 13 years, with little change in intensity and frequency. All
efforts at treatment, psychopharmacological as well as psychotherapeutic, failed to alleviate the
symptoms. Often the patient was unable to focus properly with her eyes and tired rapidly while
performing intense visual tasks – these deficiencies being detrimental to her studies and
professional work as an architect.
Earlier in 2011, the patient underwent an 8-week course of psychosomatic treatment for
depression as an outpatient at a university hospital clinic in southern Germany. Despite a
significant improvement in her mood, the remission was only partially leading to a low-level
continuous depression classified as dysthymia.

Pathophysiology:
Patient Vice came from broken family. She started to use lysergic acid diethylamide.
Each single dose was probably limited to 100 µg and consumed in a peer group setting. She also
used marijuana for relaxation and occasionally experimented with ecstasy, psilocybin mushrooms
and ketamine. In the long run of consuming she manifested signs and symptoms of halo effects,
macro- and micropsia, and in the patient’s own words, ‘a glow-worm effect’ meaning the
perception of bright little spots of light across the visual field.
Psychiatric Diagnosis:
Patient Vice diagnose with hallucinogen-persisting perception disorder.
Signs and symptoms :
 depressed with latent suicidal impulses
 increasingly difficult to distinguish between ‘normal’ and ‘abnormal’ perceptions.
Medication/s:
 sertraline (200 mg/day) for 13 months
 italoprame (20–30 mg/day) for 6 months
 fluoxetine (20 mg/day) for 5 months
 Case Analysis: Hallucinogen-Persisting Perception Disorder.

This case shows a lot of learning on how hallucinogens dependent destroy our systems and life by
being dependent on it leading to disorder. For clinical practice it is important to remember that
first-generation ‘classical’ antipsychotics are not generally helpful in the treatment of persistent
hallucinogens. In fact, a worsening of symptoms has been frequently reported. Our own case
indicates that the antiepileptic and mood stabilizer lamotrigine may offer a novel treatment for
hallucinogen-persisting perception disorder. Obviously, treatment of hallucinogen-persisting
perception disorder. We should also involve abstinence from all substances of abuse, stress
reduction and treatment of comorbidities (depression, anxiety, and less often, psychosis). This
case study have also highlighted its addictive potentials and the chances of developing tolerance.
They have assimilated some of the interesting therapeutic uses of this drug, such as an
antianxiety agent, a creativity enhancer, a suggestibility enhancer, and a performance enhancer.
They have also described hallucinogen to be successfully used in drug and alcohol dependence,
and as a nursing student therapy in terminally ill patients. Hallucinogen-Persisting Perception
Disorder obviously affects the brains of those who use it, distorting and altering their perceptions
and sensations, but science really does not understand specifically all of the effects the drug has
on the human brain. These altered perceptions and sensations can cause panic in Hallucinogen-
Persisting Perception Disorder. Some experience terrifying thoughts, feelings of despair, fear of
losing control, fear of insanity and fear of death. These experiences are what is known as having a
"bad trip."
 Substance Abuse: Inhalants
Case Description:
Name:. Patient Z, 17 year old, male, grade 7 student.
Lifestyle & Family History:
Patient Z was brought by his mother with a history of frequent absenteeism from
school and remaining withdrawn for the last two months. The JCO was serving in field and the
family was staying in a rented accommodation close to the cantonment. The boy was studying in
Class XII in Kendriya Vidyalaya. Parents had noted gradual deterioration in his academic
performance over the last one year. He used to remain lost in his thoughts and was easily irritable.
He used to go out of house at odd hours and at times one had to search for him to get him back
home. There was no significant past or family history. The boy offered no complaints and denied
any addiction initially. But on probing gave the history that he used to smoke cigarettes with
friends occasionally. He came to know that some of his friends used to sniff a liquid in the class
room. Upon interacting with them he came to know that they were in the habit of inhaling
correction fluid (Eraz-ex of Kores) to which he was also introduced. He used to put the fluid onto
the handkerchief and keep smelling it during the class hours. He used to feel relaxed and happy
with the inhalation. Initially he used to buy a packet from the market with the money given by his
mother for purchase of groceries for the home. Gradually over the next few months he was
consuming about 4-5 bottles every day. To finance the habit, he started stealing money from home
and from the relatives. His concentration in studies became poor, he started missing classes and
was found to loiter around in the neighborhood. He used to feel restless when he could not get the
drug. Then he used to become irritable, lacked concentration and remained preoccupied with
thoughts of arranging money to procure the drug. Physical examination was normal. Mental
status examination showed an ill kempt young boy, cooperative with low tone coherent speech,
evasive of drug abuse, anxious affect, reduced psychomotor activity, no perceptual disturbance
and reduced biodrives. Investigations including hemogram, liver function tests, blood sugar and
blood urea were normal. He was counselled on harms of drug abuse and put on Tab Naltrexone
50 mg OD as an anticraving measure. Regular counselling sessions were given and family
members were involved in the therapy. He responded well, gradually got weaned off the drug and
in the follow up was found to be abstinent after three months. He changed the peer group and
showed improvement in academics.

Pathopysiology:
Non-Modifiable: Modifiable
 Age
 Environment
 Lifestyle
 Behavior
 Attitude

Harmful inhalants
(Eraz-ex of Kores).

stimulants Dependence

detoxification

Withdrawal Symptoms
 Substance Craving relapse

Inhalants are highly lipid soluble; they easily cross both alveolar membranes in the lungs and the
blood-brain barrier to reach high concentrations in the brain. Inhalation avoids first-pass hepatic
metabolism so the onset is fast. The inhaled concentration depends on the mode of administration.
Sniffing offers the lowest concentration, followed by huffing, and bagging offers the highest
concentration. With a few exceptions, elimination occurs primarily through the lungs, with many
inhaled compounds eliminated unchanged by exhalation. Some of the inhalants, including alkyl
nitrites, aromatics, and methylene chloride, undergo significant hepatic metabolism that can
produce damaging free nitrites and toxic carbon monoxide as byproducts. After that it our
nervous system will have a reaction causes hallucinations, release of hormones such as
endorphins causing the patient relax and happy when taking the inhalants,
Psychiatric diagnosis:
Ill kempt young boy, cooperative with low tone coherent speech, evasive of drug abuse,
anxious affect, reduced psychomotor activity, no perceptual disturbance and reduced biodrives.
Sign and symptoms:
 feel relaxed and happy
 restless
 irritable
 lacked concentration
 Anxious
 psychomotor activity
Medication/s:
 Naltrexone 50 mg OD
 Morphine Sulfate
 Case Analysis: Inhalants
It is evident that the client formed addiction to the substances called inhaling correction
fluid (Eraz-ex of Kores), Patient started to deteriorate the academic performances, became more
aggressive as the substances adverse effect. Behavior and attitude change a lot like craving.
Patient starts to find a way just to take the inhalants, no matter what form of action the patient
may do.
Abuse of organic volatile substances in children has become a social health problem that
has been increasing in the recent years. Management is generally supportive including health
education, family involvement and enhancing coping skills. Anticraving drugs may also be added
like in this case.
However the golden dictum of Addiction Psychiatry that “Prevention is better than cure” is
valid in case of inhalant abuse also. Inhalant or volatile substances are emerging as a major drug
of abuse in the preadolescent and adolescent age group in recent times. Among these substances,
toluene is highly preferred by abusers. The commonest source is typewriter erasing fluid and
thinner which contains toluene. It is a poorly recognized risk for both morbidity and mortality in
the young all over the world.
Inhalants are preferred by young due to its easy availability, cost effectiveness, convenient
packaging, lack of legal restrictions, instant high and acceptance by peers. We present a case
report of an adolescent who presented with toluene abuse and responded well to treatment.
In this case, Patient Z, learned to use inhalants because of his environment is school.
Peer groups highly contributed in this case. The patient shows weakness on determining which is
the right and wrong thing to do. Patient Z’s family became alert on what their son’s engaging and
tried so many procedures to help their son recover easily. They contributed a big role on patient
therapy by showing respect and support on his case. Nevertheless, we must be observant and sees
possible thing which can use to be inhalants like in the case of Patient Z, they use inhaling
correction fluid (Eraz-ex of Kores).
 Substance Abuse: Cannabis
Case Description:
Name:. Matthew is a 28 year-old male, grade 7 student.
Lifestyle & Family History:
Matthew is a 28 year-old male who lives in social housing in an inner-London borough, where he
grew up with his mother, father, fraternal twin and elder sibling until he was taken into care aged
twelve. Matthew recalls both parents smoking cigarettes; his mother was also alcohol dependent,
a reason to which he attributes statutory social service involvement from childhood. His fraternal
twin, with whom he was separated from aged twelve, smokes cigarettes and cannabis, and scores
high risk under the Alcohol Use Disorders Identification Test
Matthew was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) at aged eleven.
He recalls performing poorly at school, leaving at aged fifteen; his first arrest came shortly after,
and by his early twenties was registered as a Prolific and Priority Offender (PPO). He estimates
that he has spent well over half of his adult life in prison.
He started smoking cigarettes at twelve and cannabis from age fourteen, initially smoking Hash
before migrating to Skunk (a more potent strain of cannabis with much higher
tetrahydrocannabinol content) by aged sixteen. Matthew reported intermittent abstinence from
both cannabis and tobacco while in prison, ranging between three and eleven months. He was
offered nicotine replacement therapy each time he was incarcerated, and cited nicotine patches as
most effective in supporting tobacco abstinence. He estimated that he had made twelve previous
attempts at tobacco and cannabis cessation during his smoking career but had never succeeded in
the community. He cited previous attempts at stopping both simultaneously as ineffective, except
while in prison, which he felt “doesn’t count when you’re out in the real world.”
Pathophysiology:
Cannabis is considered the most abundant non-psychoactive cannabinoid in cannabis. It is the
constituent thought now to reduce many of the undesirable effects of THC; it significantly
reduces the anxiety and psychotic like symptoms that can be associated with THC. It is currently
under investigation for use as an anxiolytic and antipsychotic. Double-blinded tests on volunteers
have demonstrated its usefulness as an anxiolytic in anxiogenic test situations. Animal and human
studies also suggest that it has a pharmacologic profile similar to atypical antipsychotics; as such,
cannabis is being considered as an alternative effective treatment for schizophrenia. However,
THC has been more extensively studied; therefore, much of our understanding of the
physiological changes induced by marijuana is predicated on the binding and metabolism of
THC.
Smoking is the most common and efficient means of ingestion, with the dose being titrated by the
user through varying the depth and frequency of inhalation; thus, the delivery mechanism poses a
challenge for cannabis as a medication. THC can also be extracted by fat-containing foods or
dissolved in oil for pharmaceutical purposes.

Psychiatric Diagnosis:
Matthew was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)
Signs and symptoms:
 Self-focused behavior
 temper tantrums.
 Fidgetiness
 Lack of focus
 Daydreaming
Medication/s:
 amphetamine derivatives
 methylphenidate formulations
  atomoxetine - Capsules 18 mg OD

Case Analysis: Cannabis

For me it is important that the nurse must learn the proper care for the client. This case shows
how the client became more dependent to marijuana.
The nurse shall have an understanding of cannabis pharmacology and the research associated
with the medical use of cannabis. Cannabis (also called marijuana) is the most commonly used
illegal psychoactive substance worldwide. Its psychoactive properties are primarily due to one
cannabinoid: delta-9-tetrahydrocannabinol (THC); THC concentration is commonly used as a
measure of cannabis potency

The legal status of cannabis use, for medical as well as recreational purposes, varies
internationally as well as across the United States. The potency of cannabis has increased around
the world in recent decades, which may have contributed to increased rates of cannabis-related
adverse effects. Cannabis use disorder develops in approximately 10 percent of regular cannabis
users, and may be associated with cognitive impairment, poor school or work performance, and
psychiatric comorbidity such as mood disorders and psychosis.
 Substance Abuse: Opioid Intoxication
Case Description
Name:. Patient Betamax, 28-year-old man
Lifestyle & Family History:

A 28-year-old man was found unresponsive at home by a roommate. When emergency medical
services (EMS) arrived, he was found to have miosis and was cyanotic with respiratory
depression. He was unresponsive to intranasal naloxone (2 mg) that was administered via
mucosal atomizer twice. On admission to the emergency department, the patient had a systolic
blood pressure of 95 mmHg, a diastolic blood pressure of 70, oxygen saturation was 84% on
100% nonrebreather mask, and respiration rate was 10 breaths/min. Physical examination showed
pinpoint pupils. Per the roommate, this patient had been in a car accident a year prior and had
been prescribed hydrocodone. Because the patient's history and physical were consistent with an
opioid toxidrome, the clinician gave intravenous naloxone (0.4 mg) and the patient woke up.
He asked if there were any send-out tests that would detect new psychoactive substances that are
opioid in nature. After the intravenous naloxone, the patient was alert enough to answer questions
and confirmed the roommate's story about buying Norco on the street. He was discharged after
one day with no apparent sequelae. After being told about the toxicology results indicating he had
ingested U-47700, he was surprised that the street “Norco” was a counterfeit pill.

Pathophysiology:

Repeated opioid use/ withdrawal

consolidates memory that opioids
alleviate stress and dysphoric states

Opioid Dependence

Abstinence life stress event

Withdrawal Symptoms

Drug Craving relapse

Psychiatric Diagnosis:
Opioid Abuse and Addiction
Sign and symptoms:
 pinpoint pupils
 decrease oxygen saturation
Medication/s:
 intranasal naloxone -2 mg ; intravenous naloxone (0.4 mg)
 hydrocodone
 acetaminophen- <10 ug/mL
 Case Analysis: Opioid Intoxication
Opioid analgesic overdose is a preventable and potentially lethal condition that results from
prescribing practices, inadequate understanding on the patient's part of the risks of medication
misuse, errors in drug administration, and pharmaceutical abuse. However, the most easily
recognized abnormality in this cases of opioid overdose is a decline in respiratory rate
culminating in apnea. A respiratory rate of 12 breaths per minute or less in a patient who is not in
physiologic sleep strongly suggests acute opioid intoxication, particularly when accompanied by
miosis or stupor. Conversely, overdose from antipsychotic drugs, anticonvulsant agents, ethanol,
and other sedative hypnotic agents can cause miosis and coma, but the respiratory depression that
defines opioid toxicity is usually absent.
When patients present to the emergency department either unconscious or with altered mental
status, I observed that a urine toxicology screen is commonly ordered. In the case of the opiate
immunoassays, the majority are designed to detect morphine, but due to structural similarity,
codeine may also be detected. Opioid prescription drug abuse has increased over the past 10
years to epidemic proportions and has caused a public health emergency along with illicit opioid
use. The patients reported buying pills on the street that they believed contained
hydrocodone/acetaminophen.

They are substances manufactured to mimic commonly used recreational drugs such as
cannabinoids or stimulants and opioids, but they are often not scheduled. The misperception is
that because they are sold on the internet or in head shops that they are safe. However, they may
be as potent as the recreational drugs or more so. Further, due to high demand for recreational
opioids, drug dealers have been reported to sell drugs that mimic prescription drugs in appearance
but may be adulterated.
 Substance Abuse: Tobacco use Disorder
Case Description:
Name: Sam is a 43-year-old married man,
Lifestyle & Family History:
Sam who was referred to you by his employee assistance program for help with quitting smoking.
He reports to you that he has been trying to quit “cold turkey” without success and has noticed
that he has been smoking even more than his typical pack per day. Sam first started smoking
cigarettes when he was in college. At that time, he considered himself to be a “social smoker” –
smoking one or two times per week, when out with friends. He recalls a distinct shift in his
smoking habits when he transitioned to his first full-time job after college, noting that the
transition to “being a full-fledged adult” was difficult for him and he would pick up a cigarette at
the end of the work day as a reward or to relieve stress. Over time, his smoking increased to the
point where he felt like he needed to smoke throughout the day. He worried that if he didn’t have
the cigarette his body was expecting he might have symptoms of withdrawal or he might not be
able to manage his stress. He has always been aware of the potential negative health effects of
smoking but has told himself that if he quit smoking “soon” he would be okay. He also believes
that smoking has helped him to keep his weight in check – he struggled to maintain a healthy
weight as an adolescent and is convinced that he will “gain a ton of weight” if he quits smoking.
In recent years, as public establishments have become smoke-free, he has become self-conscious
about his smoking habit and actively works to hide it from others, particularly his 4-year-old
daughter. He is seeking help with smoking cessation now because it is negatively impacting his
marriage (his wife reminds him daily, “You promised me you would quit”) and he worries that he
won’t be able to keep his habit a secret from his daughter much longer.
Pathophysiology:
Chronic use of Cigarettes
(nicotine)

tobacco Dependence

Abstinence life stress event

(sometimes serves as relaxant)

Withdrawal Symptoms

Drug Craving relapse

Nicotine exerts its neurophysiologic action principally through the brain’s reward center. This
neuroanatomic complex, otherwise known as the mesolimbic dopamine system, stretches from
the ventral tegmental area to the basal forebrain. The nucleus accumbens, a dopamine-rich area, is
an intersection where all addictive behaviors meet. The release of dopamine at this site promotes
pleasure and reinforces the associated behaviors, such as the use of alcohol and drugs, to replicate
the positive experience.

Other factors may also promote nicotine dependence, such as nicotine’s reduction in the
monoamine oxidase inhibitor enzyme. This enzyme is involved in the metabolism of
catecholamines, including dopamine. The net effect would be a lingering presence of the
stimulating dopamine at the nucleus accumbens.
Psychiatric Diagnosis:
Tobacco abuse and addiction
Sign and Symptoms:
 Emotion Dysregulation
 Substance Abuse
 anxiety, frustration
 irritability, depression
 difficulty concentrating
 increased appetite, and weight gain.
Medication/s:
 Varenicline- 1 mg PO twice daily
 Case Analysis: Tobacco use Disorder

The use of tobacco, nicotine is one of the most heavily used addictive substances and the leading
preventable cause of disease and disability. When a person is addicted to a substance, they have a
compulsive urge to seek out and use the substance, even when they understand the harmful
effects it can have. Tobacco products are addictive. With each inhalation of a cigarette the smoker
pulls nicotine and other harmful substances into the lungs, where it is absorbed into the blood
stream. Theses brain cells or neurons have specialized proteins called receptors, into which
specific neurotransmitters fit. This effect wears off quickly, causing the smoker to get the urge to
light up another cigarette for another dose of the drug. Nicotine is the primary addictive
component in tobacco according to Brunton, Chabner, & Knollman, 2011.
Long-term use of nicotine products leads to addiction. The way nicotine is absorbed and
metabolized by the body enhances its addictive potential. Inhalation brings rapid distribution of
nicotine to the brain, but it quickly disappears along with the pleasurable feelings. This triggers
the smoker to seek that same pleasurable sensation throughout the day. Over the course of the day
tolerance develops, requiring more frequent doses or higher doses to get the same effect.
Nicotine, heroin, and cocaine have similar effects on the brain. Many people who have a nicotine
addiction are in denial. They may be social smokers, meaning they only smoke when out with
friends, or they believe they can stop when they are ready. Recognizing the signs of addiction is
important for the getting over the addiction. Common signs of addiction include requiring
increased use of tobacco to get the same satisfaction, experiencing withdrawal when nicotine
levels are low, having the desire to quit but not being able to, experiencing cravings and urges to
smoke, and continuing to smoke despite being aware of the health risks (Center for Disease
Control and Prevention, 2008).
The physical symptoms of nicotine addiction are caused by withdrawal. Withdrawal occurs
because the brain can no longer naturally produce adequate levels of dopamine. Nicotine
withdrawal symptoms include anxiety, frustration, irritability, depression, difficulty concentrating,
increased appetite, and weight gain.
If the smoker is thinking about quitting, or has made the decision to quit, there are several
products to help in the process of quitting and prevent many of the withdrawal symptoms.
Nicotine replacement is an alternative to stopping cold. Many people find it easier to use a
replacement therapy such as the nicotine patch, inhaler, or nicotine gum. This may make the
transition easier and more comfortable for the person trying to quit (Center for Disease Control
and Prevention, 2008).
Clients should be counselled about the nature of addiction. Addiction is a chronic, relapsing
condition, and single episodes of treatment rarely lead to permanent remission. Exploring with
clients the factors leading to substance use is more effective than lecturing them.
Encourage smoke-free homes, which includes helping clients to develop the skills they need to
modify their habits and minimize, avoid or counter tobacco-use triggers.
 Substance Abuse: Caffeine Intoxication
Case Description:
Name:. Patient Bb, a 32-year-old woman
Lifestyle & Family:
Patient Bb has no significant medical and family history presented to the local emergency
department (ED) referring malaise, anxiety, dizziness and nausea. Symptoms like chest pain,
syncope, palpitations or fever were denied.
The initial physical examination at triage revealed a Glasgow Coma Scale (GCS) of 15, a
respiratory rate of 19 breaths/min, 100% oxygen saturation on room air, blood pressure of 112/70 
mm Hg, pulse of 80 beats/min and had a normal tympanic temperature. Also, the blood sugar was
147 mg/dL.

After observation, the patient had an episode of presyncope followed by agitation and vomiting.
At this point, the patient was pale and sweaty with a GCS of 11 (eye opening: 4; verbal response:
2; motor response: 5), blood pressure of 115/75 mm Hg, tachycardia (160 beats/min) and 99%
oxygen saturation on room air. Her pupils were equally round and reactive to light, and no muscle
weakness or sensory deficits were found.

The ECG showed a polymorphic broad QRS tachycardia and the arterial blood gas revealed
metabolic acidaemia with severe hypokalemia. The dysrhythmia was successfully treated with 5 
mg of propranolol intravenous in total. Acid–base and hydroelectrolytic disorders were also
corrected.

After stabilisation, the patient informed the ED’s physician that when she was preparing the pre-
workout supplement, used the same dosage of the proteic supplement for anhydrous caffeine,
instead of 1 dose of 300 mg (6 mg/kg) of anhydrous caffeine, the patient consumed a total of
5000 mg (89 mg/kg), 30 min before going to the ED.

Pathophysiology:
Chronic use of Cigarettes
(nicotine)

tobacco Dependence

Abstinence life stress event

(sometimes serves as relaxant)

Withdrawal Symptoms

Drug Craving relapse

Psychiatric Diagnosis: Caffeine Intoxication

Caffeine abuse and addiction
Signs and symptoms:
 headache, fever
 nausea, vomiting
 tachycardia, dizziness
 Tinnitus
 anxiety
 Irritability
 insomnia and seizures
Medication/s:
 lorazepam- 2-3 mg PO q8-12hr PRN

Case Analysis: Caffeine Intoxication

Treatment of caffeine toxicity can vary on case-to-case basis. However, it should
begin with careful and immediate assessment of the patient’s airway, breathing and circulation.
Not only should non-invasive monitoring, like continuous cardiac monitoring, and fingerstick
glucose level be rapidly obtained, but also intravenous access must be established. Symptoms of
caffeine intoxication may include headache, fever, nausea, vomiting, tachycardia, dizziness,
tinnitus, anxiety, irritability, insomnia and seizures.
The determination of blood caffeine concentration might be useful in confirming
the diagnosis. Nevertheless, it is not easily measured the statistics result of how many individual
abuse caffeine. To prevent systemic effects of the caffeine metabolism, activated charcoal and
intravenous lipid emulsion can be useful interventions. To address hypotension, intravenous fluid
therapy with isotonic fluid should be initiated.12
In conclusion, we describe a case of severe caffeine intoxication due to an
accidental high dosage of this component as pre workout dietary supplement. Too much tobacco
use can cause cardiac arrhythmias which can lead to death by caffeine overdose, sports
practitioners should be informed on the potential health hazards related to excessive caffeine
intake, as well as, dietary supplements should be better regulated and reported on food labels.
In the future, I hope people may realize that tobacco use is not healthy to our
body as it causes risk for all systemic disorder even cancer. Caffeine overdose can be fatal.
Cardiac arrhythmia is a frequent consequence that needs immediate management. Clinical
awareness of caffeine toxicity should be increased.
 Substance Abuse: Phencyclidine Intoxication
Case Description
Name:. Jay, a 20-year-old man
Lifestyle & Family:
Jay brought to the emergency department of an inner-city general hospital by the police after he is
taken into custody for fighting and then resisting arrest. The patient is extraordinarily agitated and
has to be placed in leather restraints immediately upon being brought to the ED. He does not
complain of pain and seems to deny having any when asked. With considerable difficulty, the
triage nurse is able to take some of his vital signs. His pulse is elevated at 128 beats per minute,
and his blood pressure is also high at 150/98.
Because of the agitation and screaming, the psychiatric resident on call is asked to see the patient
as quickly as possible. She arrives in the ED some 20 minutes later. At that point, the patient is
sobbing uncontrollably and babbling about of his fear of suicide. Trying without success to
perform at least a partial cognitive examination, the resident asks her faculty attending to come to
the ED to see Jay. By the time the attending arrives, the patient is talking calmly and, when asked
about drug use, admits to smoking some “really great pot” earlier that day.
When a urine drug screen is finally obtained on the inpatient unit in a moment of relative calm,
cannabis is present, but so is Phencyclidine. Later that evening, radiography also confirms a right
wrist fracture about which the patient has yet to complain. Unbeknownst to Jay, his marijuana had
been laced with Phencyclidine by his drug dealer to "give it a bigger kick."

Pathophysiology:
Non-Modifiable Modifiable
- Genetic - Lacking of sense of purpose
- Variations in - Stress
neurotransmitter - diagnosed schizophrenia,
systems cycling bipolar disorder

Chronic use of Phencyclidine

Phencyclidine Dependence

Abstinence life stress event

(sometimes serves as relaxant)

Withdrawal Symptoms

Drug Craving relapse

Signs and Symptoms:

Agigated
Aggressive
 Delusions
Dilated pupils

Psychiatric Diagnosis:
Jay was diagnosed schizophrenia, cycling bipolar disorder
Sign and symtomps:
 agitated
 sobbing uncontrollably
 restlessness
Medication/s:
 Phenobarbital

Case Analysis: Phencyclidine Intoxication

According to my research Phencyclidine has gone by many street names, including angel dust,
crystal, hog, embalming fluid, ozone, and rocket fuel. In combination with marijuana, street
names such as krystal joint (KJ), mintweed, supergrass, and killer weed have been used. When
PCP is combined with cocaine, the resultant concoction is sometimes called space base or tragic
magic. PCP can be smoked, ingested orally, snorted intranasally, or injected intravenously.
The management of PCP intoxication begins just as any other intoxication would. First, the
patient’s airway, breathing, circulation, thermoregulation, and neurologic status must be
stabilized. The patient should then be restrained and sedated if necessary to prevent self-inflicted
injury, which is the most common cause of morbidity and mortality in these patient.
In this case study, the Patient shows extreme effect of this substance, vital signs were not stable,
He manifested signs of being psychotic like extreme shouting, agitated.
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