Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5536_Библиотеки_им_академика_М_И_Перельмана.pdf
Overview of Drugs
49
Injecting Drug Use Clinical Presentation
Obtain a complete history of the individual’s past alcohol and drug use, including
the following:
■ Age of onset for each drug used
■ Frequency of use
■ Quantities used
■ Progression of use with time
■ Medical and psychiatric symptoms associated with use
■ Routes of administration for each drug
■ Means of obtaining drugs or money for drugs
■ Longest periods of abstinence from drug use
■ History of prior chemical dependency treatments
Citation: http://www.gannett-cdn.com/-mm-/8c04b2c3842be1cdd4d2b9e0f1ca61c3e95
8ae36/c=0-222-3376-4719&r=537&c=0-0-534-712/local/-/media/Westchester/Westchest
er/2014/04/12//1397332049004-ts041214hepavaccine05.jpg
Ask those who report injecting drug use which injecting sites they use, whether
they use new or used needles, and whether they share other items used in the
preparation of drugs for injection (eg, cookers, cotton). Ask those who share needles
and syringes whether they attempt to clean the needles (eg, by using a bleach kit
distributed by outreach workers).
50
Citation: https://62e528761d0685343e1c-f3d1b99a743ffa4142d9d7f1978d9686.ssl.cf2.
rackcdn.com/files/115845/area14mp/image-20160321-30929-1rqpxhv.jpg
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Other risks associated with injecting drug use include contaminated drug solutions,
buying ready-filled syringes, and sharing rinse water. “Backloading” is a practice
in which a dealer transfers the drug solution from a larger syringe to a syringe
provided by the user. “Flashblood” is a practice initially reported among sex workers
in Dar es Salaam, in which an individual draws blood back into the syringe after
having injected heroin, and then passes the syringe to another individual to inject
the blood in the belief that this will prevent withdrawal symptoms.
Individuals may inject substances that are not supposed to be injected, such as
pulverized (and unsterile) pills mixed with liquid. The liquid used to prepare drugs
for injection is usually water, although use of lemonade and vinegar for this purpose
has also been reported.
Management of Low Level Problems
Low level drug and alcohol problems are much more common than dependence and
are major causes of morbidity and mortality. Individuals with low level problems
are better suited to brief and early interventions whereas individuals experiencing
more severe problems need more specialised treatment.
A ‘brief intervention’ is considered to be:
■ any intervention that involves a minimum of professional time in an attempt
to change drug use
■ Any intervention requiring a total of between five minutes and two hours
Overview of Drugs
Brief interventions are particularly suitable for primary care but can also be used
in emergency departments, hospital wards or outpatient clinics and a range of
non-medical settings.
They are recommended for individuals with:
■ hazardous/harmful alcohol use without dependence
■ a low to moderate dependence on alcohol
■ a dependence on nicotine
■ a low to moderate dependence on cannabis
There is compelling evidence for the effectiveness of brief interventions to reduce
hazardous and harmful alcohol consumption by 30–40%.
Brief interventions are not considered suitable for:
■ More complex patients with additional psychological/psychiatric issues
■ Patients with severe dependence
■ Patients with poor literacy skills
■ Patients with difficulties related to cognitive impairment
In these instances, more in-depth intervention is recommended.
51
Citation: http://netdoctor.cdnds.net/16/32/1600x800/landscape-1457361426-
pharmacy-597659879.jpg
Brief intervention can take a variety of forms but often includes:
■ brief assessment
■ self-help materials
■ information on safe levels of consumption
52
■ advice on reducing consumption
■ harm reduction
■ relapse prevention
■ assessment of readiness to change, including motivational interviewing
■ brief counselling, including problem solving and goal setting
■ follow-up
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Psychosocial Interventions
Psychological interventions are a key component of a comprehensive treatment
program and can involve group therapy or individual counselling. Counselling is a
joint approach between the counsellor and the client with treatment plans negotiated
and agreed upon by both parties. No single psychological approach is superior,
and the treatment program should be tailored to the individual patient/client, taking
into consideration such factors as culture, age, gender and presence of comorbidity.
General counselling should include:
■ linking patients with the appropriate services while the patient is still engaged
■ anticipating and developing strategies with the patient to cope with
difficulties before they arise
■ specific evidence-based interventions where appropriate (e.g. goal setting,
cognitive behavioural therapy, motivational enhancement therapy, problem
solving)
■ focusing on positive internal and external resources and successes as well
as problems and disabilities
■ consideration of the wider picture and helping the patient on a practical
level (e.g. with food, finances, housing)
■ where appropriate, involving key supportive others to improve the possibility
of behavioural change outside the therapeutic environment
Mutual aid groups such as Alcoholics Anonymous, Narcotics Anonymous, Al-Anon
(for relatives of alcohol dependent individuals) and Alateen (for adolescent relatives)
are also available. Their approaches are based on the 12 Steps, a set of principles
that emphasise personal responsibility and honesty.
Overview of Drugs
Citation: https://www.nursingtimes.net/pictures/2000x2000fit/0/3/3/3003033_One-study-
found-support-groups-did-not-effectively-address-psychosocial-needs.jpg
53
Maintenance Pharmacotherapie
A number of effective therapeutic drugs are now available for the treatment of
dependence, primarily for alcohol, nicotine and opioid de pendence. It is likely
that the use of pharmacotherapies will increase in the future. Pharmacotherapies
should not be considered as stand alone treatments but should be used as part of a
comprehensive treatment program, including supportive counselling, other relevant
therapies and social support.
Pharmacotherapies for Alcohol Dependence
The pharmacotherapy for alcohol dependence was selected as an evidence report
topic by the Agency for Health Care Policy and Research (AHCPR) because of its
timeliness, the severity and impact of the disease, and the need for careful evaluation
of new therapeutic modalities for its treatment. Alcoholism is a prevalent disease
that will affect on the order of 10 percent of the adult population of the United
States. An estimated 100,000 Americans die each year from alcohol-related disease
or injury.
Alcohol dependence is a chronic disorder that results from a variety of genetic,
psychosocial, and environment factors. Over the last 20 years, there has been
considerable progress in efforts to reduce the enormous alcohol related costs to
society, such as traffic accidents in which the driver is intoxicated, and to set
boundaries for injudicious alcohol use in Korea. These socio-cultural changes have
probably been successful in lowering the prevalence of alcohol abuse but the
prevalence of alcohol dependence seems to have been less affected.
54
Treating alcohol dependence usually consists of two phases: detoxification and
rehabilitation. The initial detoxification stage deals with acute withdrawal symptoms.
The later rehabilitation stage attempts to prevent relapse and develops a lifestyle
compatible with long-term abstinence. Whereas detoxification is widely accepted as
a pharmacotherapeutic domain, rehabilitation, in clinical practice, has traditionally
involved psychosocial and psychotherapeutic interventions consisting of individual
and group psychotherapy, cognitive-behavioral treatments, and self-directed groups
such as Alcoholics Anonymous. Although psychosocial treatments have shown
effectiveness in reducing alcohol consumption and maintaining abstinence, 40
to 70% of patients still relapse to drinking within a year following treatment. As
a part of the efforts to improve the treatment outcomes for alcohol dependence,
pharmacotherapy is being investigated as another modality to enhance abstinence
and prevent relapse, complementing psychosocial interventions.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Citation: http://news.uic.edu/files/2015/04/DG15_04_10_011.jpg
The rationale of using pharmacotherapy for alcohol dependence is based on several
premises. First, advances in neurobiology have identified the neurobehavioral
effects of alcohol and their associated neurotransmitter systems which are related
to the development of dependence and, at the same time, are potential targets for
pharmacological approaches. Second, recent genetic studies have confirmed that
alcohol dependence is a heterogeneous condition. While some gene variations
predispose people to alcohol dependence, others confer protection. Third, animal
models of alcohol dependence relapse have demonstrated that pharmacologic
agents can reduce alcohol consumption and have proven to be fairly predictive
Overview of Drugs
of similar responses in human patients. Fourth, medications have improved the
treatment of other addictive disorders such as bupropion for nicotine dependence
and methadone for heroin dependence, encouraging pharmacotherapies for the
treatment of alcohol dependence.
55
The Neurobiology of Alcohol Dependence
For many years, it has been suggested that alcohol exerts its neurobiological
effects mainly by increasing membrane fluidity, altering the function of macromolecules in the cell membrane. New evidence, however, indicates that alcohol
binds to hydrophobic pockets of proteins, modulating their function by changing
their 3-dimensional structure. Proteins that are particularly sensitive to this effect
include ion-channels, neurotransmitter receptors, and enzymes involved in signal
transduction. Neurotransmitters with notable sensitivity to this effect include dopamine,
serotonin, gamma-aminobutyric-acid (GABA), glutamic acid, adenosine, neuropeptide
Y, norepinephrine, cannabinoid receptors, and opioid peptides. These neurotransmitter
systems are involved in the different components of alcohol dependence and are
therefore targets for pharmacotherapeutic interventions.
Citation: https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/dopaminetransporters.gif
The brain reward system: dopamine and endogenous opioid
Considerable evidence has emerged suggesting that the dopamine system plays a
central role in the biology of alcoholism. Mesolimbic dopamine A10 neurons are
activated by alcohol, resulting in a release of the neurotransmitter in the nucleus
accumbens and mediating positive reinforcement and reward. It is postulated that
repeated alcohol use sensitizes the system, so that behavioral stimuli associated
with alcohol also cause the release of dopamine and facilitate additional alcohol
use. This sensitization may account for the craving and preoccupation with alcohol
that are the hallmarks of alcohol dependence.
56
The endogenous opioid system seems to play a modulatory role on the dopaminergic
system, whereby activation of opiate receptors stimulates the release of dopamine
in the brain. Alcohol consumption increases the release of endorphins in the brain,
thus indirectly activating the dopaminergic reinforcement/reward system. It has
been postulated that individual differences in the sensitivity of endogenous opioid
systems may underlie individual differences in the intensity of alcohol craving and
the risk of becoming alcohol dependent.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Subclinical withdrawal symptoms: glutamate and GABA
The facilitation of inhibitory GABAergic and the inhibition of excitatory glutamatergic
neurotransmission are important targets for the acute effects of alcohol. Potentiation
of GABAergic inhibition is widely accepted as the underlying cause of the acute
sedative effects of alcohol. Long-term adaptive changes to the sedative effects of
alcohol in these two neurotransmitter systems are thought to underlie the development
of alcohol dependence. After chronic exposure to alcohol, there is a compensatory
up-regulation of the glutamatergic system (and down-regulation of the GABA system)
in an attempt to balance alcohol’s inhibitory action. The result is an increased
tolerance for alcohol. When alcohol is abruptly withdrawn, however, a state of
hyper-excitability emerges. This is perceived by the patient as a disagreeable state
of arousal, anxiety and sleeplessness and is the core of the negative affective state
which the alcoholic patient will drink to relieve. These plastic changes in the brain,
brought about by change in protein synthesis, are only slowly reversible. This may
explain the persistence of negative craving during alcohol withdrawal and why stable
abstinence after acute detoxification is so difficult to achieve. Antiglutamamatergic
agents, such as NMDA antagonists and anticonvulsant agents, have been proposed to
reduce the motivation for drinking by suppressing symptoms of alcohol withdrawal.
Recent data suggest that NMDA antagonists may have other beneficial effects in
alcohol dependent patients, such as substituting for deficits in negative feedback
signals or reducing the development of tolerance/sensitization to alcohol.
Currently Approved Agents for Alcohol Dependence
The first agent to be approved for treatment of alcohol dependence was disulfiram.
This substance was serendipitously discovered to be an agent causing alcohol
aversion in Ohio rubber workers in 1939. The major metabolic pathway for alcohol
metabolism is a two-step enzymatic process (ethanol → acetaldehyde → acetic acid).
Disulfiram is an irreversible inhibitor that blocks the second stage of alcohol
metabolism, causing an accumulation of toxic intermediate acetaldehyde, which
results in hypotension, flushing, nausea, and vomiting. The objective of disulfiram
treatment is thus to create an aversion to alcohol, rather than to modulate its
neurochemical effects. Although many studies have been performed with disufiram,
controlled clinical trials demonstrated inconsistent findings for alcohol drinking
outcomes between disulfiram and placebo, and have failed to clearly establish the
therapeutic benefit of this treatment in enhancing abstinence. However, it is difficult
to conclude the efficacy of the treatment through classical double-blind, placebo-
Overview of Drugs
controlled trials, since it is the psychological deterrent effect of the drug rather than
its biological effect that is useful. Fuller et al observed no significant differences
in abstinence rates or in the time to first relapse among groups taking placebo, 1
mg/day disulfiram (an inactive dose) or 250 mg/day disulfiram (the standard dose).
The patients receiving 250 mg disulfiram, however, had fewer drinking days once
they relapsed than did the other two groups.
57
Citation: http://www.sedonaintensive.com/wp-content/uploads/2015/01/bigstock-Silhouette-
Of-Alcoholic-Drunk-68357878.jpg
The disulfiram dosage is usually 250 mg per day with a maximum of 500 mg
per day. While normal results of alcohol consumption after taking disulfiram are
palpitations, flushing, nausea, vomiting and headaches, more severe reactions could
include myocardial infarction, congestive heart failure, respiratory depression, and
death. The use of disulfiram appears to be most useful in adherent patients, in
special high-risk patients, and when administration is supervised.
Acamprosate
Acamprosate is a medication available for the treatment of alcohol addiction in
patients who have stopped drinking and are in therapy to address addictive behaviors.
This medication works by altering brain chemistry to address the changes in the brain
associated with alcoholism. It is taken several times a day on a regular schedule to
maintain steady levels of the drug in the body, and is most effective when it is part
of combination therapy with other treatment methods. Acamprosate alone will not
cure alcoholism, and it is not effective in patients who are still actively drinking.
This is an anticraving agent which acts as a GABA-receptor agonist. Randomised
controlled trials have shown:
■ Trials of acamprosate in alcohol dependence are large but limited to
European populations.
58
■ There is good evidence that acamprosate enhances abstinence and reduces
drinking days in alcohol-dependent subjects.
■ There is minimal evidence on the effects of acamprosate on craving or
rates of severe relapse in alcohol-dependent subjects.
■ There is good evidence that acamprosate is reasonably well tolerated and
without serious harms.
■ reduced quantity and frequency of drinking in patients who do not achieve
complete abstinence
■ reduced rates of relapse (where relapse is defined as consumption of any
alcohol)
■ increased percentages of abstinent days during treatment
■ increased rates of abstinence
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Citation: http://www.alcoholrehabguide.org/app/uploads/2017/02/bigstock-healthy-lifestyle-
medicine-n-108073487.jpg
This drug interacts with neurotransmitters released during alcohol withdrawal and
over the long term as people with a history of alcoholism recover. It appears to
blunt some effects of withdrawal, and can also protect neurons from damage
associated with drinking or withdrawal. The medication is taken in the long term
to help patients abstain from alcohol, and the dosage may need adjustment under
medical supervision if the drug is not working properly.
While taking acamprosate, patients also need to be in therapy for alcoholism. This
can take a number of different forms, and people may need to try several options
to find one that suits their needs. Patients who are not in therapy are more likely
to relapse, as they lack the social and medical support to stay away from alcohol.
It is also important to continue abstaining while on acamprosate, as the drug does
not work as well in people who have been drinking.