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\def\citeauthor{~Tejaswi~Gopisetty,
              ~Medhini~H~Gowda}
\def\citetitle{\textbf{Alcohol and Nicotine Use Disorder with Psychotic Features: A Case Study}}
\def\copyrightstmt{This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial- ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.}
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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\begin{document}


\def\RunningAuthor{Tejaswi Gopisetty and Medhini H Gowda}
\firstPage{173}
\articleType{Case Study}
\receivedDate{03 Dec 2021}
\acceptedDate{20 Dec 2021}
\revisedDate{18 Dec 2021}
\journalVolume{1}
\journalIssue{4}
\copyrightYear{2021}
\eISSN{2583-0953}
\journalDoi{10.26452/ijcpms.v1i4.266}
\def\authorCount{2}
\def\affCount{2}

\def\journalTitle{International Journal of Clinical Pharmacokinetics and Medical Sciences}

\title{\textbf{Alcohol and Nicotine Use Disorder with Psychotic Features: A Case Study}}
\author{Tejaswi~Gopisetty\textsuperscript{*}\textsuperscript{1}, 
            Medhini~H~Gowda\textsuperscript{2}~\\[5pt]{\textsuperscript{1}ASN Pharmacy College, Tenali, Andhra Pradesh, India}~\\{\textsuperscript{2}Sri Adichunchanagiri College of Pharmacy, B.G. Nagara-571448, Karnataka, India}}

\begin{abstract}
The purpose of this case is using an evidence-based medicine, approach to work through an unusual way of treating a common problem we looked at an example of an inpatient with severe anxiety disorder who had gone through the treatment of using anti-anxiety, anti-epileptics, mood stabilizers, sedatives, and hypnotics. Use of alcohol and nicotine substances is very common to observe psychotic features, especially anxiety disorders, to control these anxiety disorders are prescribed. The inpatient is under the observation of nursing staff because of his suicidal thoughts, to maintain his mental stability of the inpatient sedatives and hypnotics are suggested. We study the prevalence of alcohol and nicotine use among psychotic features of inpatient as well as comparing the demographic, diagnostic, and psychopathological profile of patient.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Nicotine,\newline Alcohol,\newline Psychotic Features,\newline Anxiety,\newline Schizophrenia
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright{\Large$^\ast$}Corresponding Author\par Name:\ Tejaswi~Gopisetty~\\ Phone:\ 7799326666~\\  Email:\ tejaswitejgopisetty1612@gmail.com
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        \makeatother
        
    
\section{Introduction}
Alcohol \& nicotine are most widely consumed components they share several common features. By consuming alcohol that leads to psychosis \& alcohol related psychosis is like schizophrenia. Consuming / smoking nicotine may improve cognitive and sensory deficits of schizophrenia, nicotine was associated with 127\% higher risk of schizophrenia \unskip~\cite{1323282:24131986}. Alcohol and tobacco use may lead to major health risks when used alone and together. In addition to contributing to traumatic death and injury (e.g., through car crashes), alcohol is associated with chronic liver disease, cancers, cardiovascular disease, acute alcohol poisoning (i.e., alcohol toxicity), and fetal alcohol syndrome \unskip~\cite{1323282:24131989}. Smoking is associated with lung disease, cancers, and cardiovascular disease. Additionally, a growing body of evidence suggests that these substances might be especially dangerous when they are used together; when combined, alcohol and tobacco dramatically increase the risk of certain cancers, tobacco and nicotine have very different effects and mechanisms of action, Funk and colleague speculate that they might act on common mechanisms in the brain, creating complex interactions \unskip~\cite{1323282:24131989}.

\textbf{Case Study }

A male patient aged 64 years admitted in the department of psychiatry with complaints of Hearing voices, Muttering of self, Seeing visual images of god, Abusing family members Irrelevant talk since 20 days, he also had palpitations, sweating, tremors and sleep disturbances. 

He was alcoholic for 40 years and from 3 years he used to have alcohol for 1 week when he consumed alcohol, he used to have sleep disturbances and abstinent for 3months, he had 4 years history of Diabetes Mellitus, Hypertension and Mental health disorders. 

There is a significant information about the drug usage for diabetes mellitus (Glycomet SR 250mg). We didn't find any information about his hypertension medication, so, we recommended Ramipril 5mg 


\begin{table*}[!htbp]
\caption{\boldmath {Vitals at the time of Hospital Visit} }
\label{tw-f814da9d2e83}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.21339999999999996\linewidth-2\tabcolsep}p{\dimexpr.3569\linewidth-2\tabcolsep}p{\dimexpr.42970000000000006\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack S.No & \cAlignHack Vitals & \cAlignHack Values\\
\tblmidrule 
\cAlignHack 1. &
  \cAlignHack B.P &
  \cAlignHack 120/80mmHg\\
\cAlignHack 2. &
  \cAlignHack PR &
  \cAlignHack 90bpm\\
\cAlignHack 3. &
  \cAlignHack RR &
  \cAlignHack 22cpm\\
\cAlignHack 4. &
  \cAlignHack Temperature &
  \cAlignHack Afebrile\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
BID, and his allergic conditions are unknown. His younger brother is diagnosed by ``Psychosis''.

\textbf{Lab Investigations}

When he visited the hospital, patient is conscious and cohort, his vitals are completely normal were tabulated in Table~\ref{tw-f814da9d2e83}, S1 \& S2 sound are heard, no focal and neurological deficits are observed.

From Day 1 to Day 5 there are lot of ups and downs. In his vitals mainly Blood Pressure and Pulse rate, from Day 5 blood pressure is constant at 140/80mmhg, pulse rate is stable at 85bpm. B.P and PR chart tabulated in Table~\ref{tw-65c63717f893}.

By observing his vitals on Day 4 his vitals are completely high to control his blood pressure level we started Ramipril 5mg tablet after administration of the drug the vitals became stable \& controlled, the patient is very anxious he started quarrelling with their family members and he is out of control to maintain his mental stability and to relax the patient sedatives \& hypnotics are administered, psychotherapy sessions are started.


\begin{table*}[!htbp]
\caption{\boldmath {Vitals Observed from Day 1 to Day 9} }
\label{tw-65c63717f893}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{LLLLLLLLLL}
\tbltoprule \rowcolor{kwdboxcolor}Vitals & D1 & D2 & D3 & D4 & D5 & D6 & D7 & D8 & D9\\
\tblmidrule 
BP &
  130/70 mmhg &
  140/60 mmhg &
  140/90 mmhg &
  150/80 mmhg &
  140/80 mmhg &
  140/80 mmhg &
  140/80 mmhg &
  140/80 mmhg &
  140/80 mmhg\\
PR &
  92bpm &
  90bpm &
  76bpm &
  74bpm &
  85bpm &
  85bpm &
  85bpm &
  85bpm &
  85bpm\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Diagnostic Parameters} }
\label{tw-4f6f48ed6df7}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1596\linewidth-2\tabcolsep}p{\dimexpr.2649\linewidth-2\tabcolsep}p{\dimexpr.57550000000000004\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack S.No & \cAlignHack Lab tests & \cAlignHack Values\\
\tblmidrule 
\cAlignHack 1. &
  \cAlignHack Hb &
  \cAlignHack 11.5g/dl\\
\cAlignHack 2. &
  \cAlignHack WBC &
  \cAlignHack 4,800cells/mm\ensuremath{^{3}}\\
\cAlignHack 3. &
  \cAlignHack RBC &
  \cAlignHack 4.08 million cells/mm\ensuremath{^{3}}\\
\cAlignHack 4. &
  \cAlignHack Platelets &
  \cAlignHack 2.4 lakh cells/mm\ensuremath{^{3}}\\
\cAlignHack 5. &
  \cAlignHack PCV &
  \cAlignHack 34.8\%\\
\cAlignHack 6. &
  \cAlignHack MCV &
  \cAlignHack 85fl\\
\cAlignHack 7. &
  \cAlignHack MCHC &
  \cAlignHack 32.2g/dl\\
\cAlignHack 8. &
  \cAlignHack RDW &
  \cAlignHack 13.5\%\\
\cAlignHack 9. &
  \cAlignHack Sr. Urea &
  \cAlignHack 31mg/dl\\
\cAlignHack 10. &
  \cAlignHack Sr. Creatinine &
  \cAlignHack 0.9mg/dl\\
\cAlignHack 11. &
  \cAlignHack Sr. Sodium &
  \cAlignHack 139mmol/l\\
\cAlignHack 12. &
  \cAlignHack Sr. Potassium &
  \cAlignHack 3.8mmol/l\\
\cAlignHack 13. &
  \cAlignHack Sr. Protein &
  \cAlignHack 5.8g/dl\\
\cAlignHack 14. &
  \cAlignHack Sr. Globulin &
  \cAlignHack 2.5g/dl\\
\cAlignHack 15. &
  \cAlignHack SGOT &
  \cAlignHack 29U/L\\
\cAlignHack 16. &
  \cAlignHack SGPT &
  \cAlignHack 72U/L\\
\cAlignHack 17. &
  \cAlignHack HbA1C &
  \cAlignHack 9.1\%\\
\cAlignHack 18. &
  \cAlignHack FPG &
  \cAlignHack 191mg/dl\\
\cAlignHack 19. &
  \cAlignHack ECG &
  \cAlignHack Normal\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
By having awareness on the inpatient history and present illness we assessed that he is suffering from ``Alcoholic Nicotinic Use Disorder Along with Diabetes Mellitus''.


\begin{table*}[!htbp]
\caption{\boldmath {Treatment Chart} }
\label{tw-6eadc49f5028}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.2628\linewidth-2\tabcolsep}p{\dimexpr.2807\linewidth-2\tabcolsep}p{\dimexpr.2306\linewidth-2\tabcolsep}p{\dimexpr.12459999999999999\linewidth-2\tabcolsep}p{\dimexpr.1013\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Brand Name & \cAlignHack Generic Name & \cAlignHack Dosage regimen & \cAlignHack Start & \cAlignHack Stop\\
\tblmidrule 
Inj. Thiacors &
  \cAlignHack Mirtazapine &
  \cAlignHack 100ml IV TID &
  \cAlignHack D0 &
  \cAlignHack \\
T. Ativan &
  \cAlignHack Lorazepam &
  \cAlignHack 2mg PO TID &
  \cAlignHack D0 &
  \cAlignHack \\
T. Tormap &
  \cAlignHack Ferrous furate folic acid &
  \cAlignHack 50mg PO BD &
  \cAlignHack D1 &
  \cAlignHack D2\\
T. Risperdal &
  \cAlignHack Sertaline &
  \cAlignHack 25mg PO OD &
  \cAlignHack D1 &
  \cAlignHack \\
T.Microliv Forte &
  \cAlignHack Ferrous sulphate &
  \cAlignHack 100mg in 100ml &
  \cAlignHack D1 &
  \cAlignHack \\
T. Rabilove &
  \cAlignHack Rabeprazole &
  \cAlignHack 20mg PO OD &
  \cAlignHack D2 &
  \cAlignHack \\
T. Librium &
  \cAlignHack chlordiazepoxide &
  \cAlignHack 25mg TID &
  \cAlignHack D1 &
  \cAlignHack \\
Inj. Lora+ Inj. Serence &
  \cAlignHack Lorazepam + haloperidol &
  \cAlignHack 1amp IM SOS &
  \cAlignHack D2 &
  \cAlignHack \\
T. Glycomet {\textendash} SR &
  \cAlignHack metformin &
  \cAlignHack 250mg PO BD &
  \cAlignHack D4 &
  \cAlignHack \\
T. Pacitane &
  \cAlignHack Trihexphenidyl &
  \cAlignHack 2mg PO BD &
  \cAlignHack D4 &
  \cAlignHack \\
Syp. Cremaffin &
  \cAlignHack Sodium picosulphate + liquid paraffin &
  \cAlignHack 15ml PO BD &
  \cAlignHack D7 &
  \cAlignHack \\
Protein Powder &
  \cAlignHack Essential amino acids &
  \cAlignHack 2tsp PO TID &
  \cAlignHack D7 &
  \cAlignHack \\
T. Quitiapine &
  \cAlignHack Quitiapine &
  \cAlignHack 500mg OD &
  \cAlignHack D2 &
  \cAlignHack \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
The goal of treatment for this patient is to decrease hallucinations, maintaining the patient stable in alcohol abstinent condition. The increased risk of the disease affected in this patient is due high amount alcohol intake The drug therapies which are used for the treatment are Antipsychotics, Antidepressants, Antianxiety, Mood Stabilizers. Schizophrenia is treated by using these drugs T.Ativan 2mg (lorazepam), Inj. Lora + Serence 1amp (Lorazepam + Haloperidol), T. Quetapine 500mg (quetiapine), Risperdal 25mg (sertraline)- it is an Atypical antipsychotic drug, also act as Mood stabilizer, it is a 2\ensuremath{^{nd}} generation anti psychotic, also used to treat Schizophrenia. The main psychotic feature of the inpatient is anxiety to treat that Librium 25mg (Chlordiazepoxide) is used, it is a sedative-hypnotic Benzodiazepine, By using different class of drugs and dosage forms it leads to GIT disorders, heart burns, etc., and to clear the acidity, indigestion, and constipation problems these drugs are used T.Rabilove 20mg \{rabeprazole\} {\textendash} GIT disorders, Syp. Cremaffin{\textendash}2tps (Sodium picosulphate+ liquid paraffin) for acidity, indigestion, constipation problems, T. Glycomet SR 250 mg (metformin){\textendash} used to treat Diabetes Mellitus. The patient is having vitamin B1 deficiency to treat that they administered Thiacros an 100ml IV injection. Due to the composition of Lorazepam + Sertraline, it leads to impairement of motor disorders. Pacitane 2mg used to treat the motor disorders. Non drug therapy {\textendash} avoiding alcohol intake and other addictive drugs will be helpful [Table~\ref{tw-4f6f48ed6df7}, Table~\ref{tw-6eadc49f5028}].

\textbf{Interactions }

Here we observed the duplication of drug they are 

\textbf{Ativan + Lora + Haloperidol}

Ativan and lora both are having the same composition their main is Lorazepam and when it is administered along with the Haloperidol that leads to increased side effects, by using this combination, we used to have drowsiness generally, but by having them with Haloperidol that increases side effects.

\textbf{Lorazepam + Sertaline Sertalin}

Increases the side effects of Lorazepam a prone to dizziness, drowsiness, confusion, and difficulty in concentrating.

\textbf{Note}

In this In-patient, we observed impairment in thinking, impairment in judgement and impairment of motor coordinators due to these drug interactions.

\textbf{Quetiapine + Metformin }

Quetiapine may interfere with blood glucose control and reduce the effectiveness of metformin. We must monitor the patient blood sugar levels closely. If needed a dosage adjustment of diabetic medications during and after treatment with quetiapine.
    
\section{DISCUSSION}
About disease: alcoholic use disorder is a condition in which the patient experience symptoms like tremors, seizure, hallucinations because of abnormality in neurotransmitters. Hypertension: this is a condition in which patient is having increased blood pressure i.e, systolic pressure greater than 140mmHg and diastolic pressure greater than 90mmHg. The main issues observed in the patient are Diabetes Mellitus and Psychotic features in the inpatient. The drug related problems are untreated conditions we can control them by using medication, we must start the counselling sessions based on the patient condition and his symptoms by having counselling sessions, recovery of the patient condition will gradually improve. Sessions are typically conducted three or more times a week. Supportive therapy uses guidance and encouragement, it helps to build self-esteem, reduce anxiety, strengthen coping mechanisms, and improve social and community functioning. Avoiding alcohol is the best thing, Restrict salt intake (\textless\ 1.5mg/day) it will help to control the hypertension conditions.

\textbf{Abbreviations}

BP: blood pressure; PR: pulse rate; RR: respiration rate; Hb: hemoglobin; WBC: white blood cells; RBC: red blood cells; PCV: packed cell volume; MCV: mean corpuscular volume; MCHC: mean corpuscular volume concentration; RDW: red cell distribution width; MPV: mean platelet volume; SGOT: serum glutamic oxaloacetic transaminase; SGPT: serum glutamic pyruvic transaminase; ECG: electrocardiography; SYP: syrup; INJ: injection; CVS: central nervous system; IV: intravenous.
    
\section{CONCLUSION }
In this case, we have observed the duplication of drugs, \& drug-drug interactions in the patient. Alcohol, nicotine{\textendash}related psychosis disorder is a secondary psychosis in this state we can observe so many conditions, like we observed in this patient (hallucinations, seizures, mood fluctuations, schizophrenia, anxiety disorders) the treatment is given to reduce these conditions and psychotherapy sessions are taken 2 {\textendash} 3 times in a week, and these sessions will be continued until the patient comes to normal condition, at the time of discharge his vitals are stable (BP - 140/80 mmHg, PR- 85bpm, Temperature{\textendash} normal, CVS {\textendash} S1, S2) and the patient is alert and oriented. By avoiding the alcohol, nicotine, and other drug addictions we can easily improve the patient mental health condition.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest}

The authors declare that there is no conflict of interest.
    
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