NUR 3105-002: Substance-Related & Addictive Disorders

Substance Use Disorder

Exhibits at least two signs of:

- Tolerance and/or withdrawal

- Dependency (i.e loss of control over substance use)

- Adverse consequences due to substance use (Interference fullfilling social, work, school, or recreational activities)

Intoxication

Response of the body and mind to a substance

Reversible State

S/S depend on the substance

Intoxication Tolerance

More substance is needed to cause intoxication

Risk of Cross-Tolerance

Addiction

Dysfunction of the pleasure seeking / reward pathway (mesolimbic dopamine system) of the brain.

- Characterized by compulsiveness and cravings to use a substance, leading to chronic use

Addiction Adversities

- Not fulfilling the compulsion is psychologically or physically distressing

- The person struggles to cut down on the addiction (sign of dependency)

- Continued addiction activity further changes the reward pathway

Where are memories and habits created?

In the Midbrain (Mammal Brain)

- Habits controlled by the pleasure-seeking pathway

What part of the brain evaluates consequences?

Primate Brain (cortex)

- evaluates whether the consequences of the substance outweigh the euphoria

- Clients suffering from addiction are not thinking with the cortex of their brain.

Addiction Stage 1: Intoxication

Unnaturally large amount of dopamine and endorphines released in the mesolimbic dopamine system --> leads to euphoria

-- Memories are created (substance = pleasure)

-- Strong desire to make the feeling of euphoria happen again (cravings)

Second Stage of Addiction: Tolerance

The continued use of a substance resulting in an increased amount of the substances needed to achiever prior desired effects

Second Stage of Addiction: Withdrawal

Physiological, cognitive, and maladaptive behavioral responses that occur upon abrupt reduction or discontinuation of a substance that has been used over a prolonged period.

Third Stage of Addiction: Dependence

Inability to decrease use or stop using a substance, even when there is a persistent desire to stop

-- Each use of the substance reinforces the habit to use.

Dependence Resolution

You can replace the habit of wanting to use with new habits. However, the conditioned response will never completely resolve.

Alcohol Use Disorder: Stress Reliever

Alcohol seen as an acceptable method to relieve stress

- Person enjoys the feeling of intoxication

- Person starts having cravings to drink

Alcohol Use Disorder: Drinking recklessly

Person starts becoming preoccupied with drinking, regardless of consequences

- Increased amount of drinking occurs due to tolerance

- Person starts to experience signs of alcohol withdrawal if they stop drinking

Alcohol Use Disorder: Chronic Use

- Person drunk more of the day then not

- Person is dependent on alcohol and experiences extreme physical withdrawal if stops

Alcohol Intoxication: Alcohol MOA

Alcohol is a CNS depressant that results in mood and behavior changes.

- Side Effects on the CNS are proportional to blood alcohol concentration

Blood Alcohol Level: (0.01-0.05g/dl) Side Effects

Mild Euphoria

Decreased inhibitions

Diminished Attention and Judgement

Blood Alcohol Level: (0.05-0.10g/dl) Side Effects

Euphoria

Sedation

Impaired coordination

Decreased Sensory Response to stimuli

Decreased Judgement

Legal Alcohol Intoxication?

Blood alcohol level of 0.08g/dl

Blood Alcohol Level: (0.25-0.4g/dl) Side Effects

Sleep or Stupor

Marked muscular incoordination

Markedly decreased response to stimuli

Incontinence

Alcohol Poisoning: Blood Alcohol Concentration

(0.25-0.4g/dl)

250-400mg/dl

Blood Alcohol Level: (0.40-0.50g/dl) Side Effects

Coma

Hypothermia

Respiratory and Circulatory Failure

Possible Death

Screening for Problematic Drinking: CAGE

- Have you ever felt that you should CUT down on your drinking?

- Have you ever become ANNOYED by criticism of your drinking?

- Have you ever felt GUILTY about your drinking?

Have you ever had a morning EYE OPENER to get rid of a hangover?

CAGE: C stands for?

Concern:

Concern by the person is concerned that there is a problem

CAGE: A stands for?

Apparent:

Apparent to others that there is a problem

CAGE: G stands for?

Grave:

Grave Consequences

CAGE: E stands for?

Evidence:

Evidence of dependence or tolerance

Concerns for Extreme Daily Alcohol Usage

Poor Nutrition + decreased ability to absorb vitamins --> Thiamine Deficiency

What is prescribed when alcohol abuse is suspected?

Thiamine

( take a multivitamin, folate, and thiamine tablet once a day for a year)

Alcohol-induced thiamine (vitamin B1) deficiency complications

Wernicke-Korsakoff syndrome

Symptoms of Wernicke-Korsakoff syndrome

Peripheral Neuropathy

Wernicke's encephalopathy

Korsakoff psychosis

Wernicke-Korsakoff Syndrome: Peripheral Neuropathy

May be reversible or permanent

Numbness

Tingling

Burning pain in the hands and feet.

Wernicke-Korsakoff syndrome: Wernicke's encephalopathy

- Reversible if treated

- Ataxia (wobbling gait)

- Decreased attention

- Confusion / disorientation

- Can progress to Korsakoff psychosis

Wernicke-Korsakoff Syndrome: Korsakoff psychosis

- Impaired short- & long-term memory

- Confabulation

- Often a permanent condition

Risks of Alcohol Withdrawal

Alcohol withdrawal can be fatal and should be managed in a hospital

What happens when alcohol withdrawal is not well managed?

- Seizures can occur between 6 and 48 hours

- Hallucinations can occur between 12 to 48 hours

- Delirium tremens usually occurs after 48 hours

- Most symptoms resolve by 72 hours

Delirium Tremens (alcohol withdrawal delirium)

Acute delirium

Medical emergency: associated with withdrawal from alcohol after prolonged heavy consumption

Delirium Tremens S/S

- Nausea / vomiting

- Drenching sweats

- Severe tremor

- Anxious / agitated

- Vivid hallucinations

- Severe headache

- Disorientation / inattentive

- Hypertension/ tachycardia

Delirium Tremens Treatment

IV Benzodiazepines (reverse withdrawal)

Fluid / Electrolyte Replacement

Delirium Tremens: Nursing Interventions

Client at risk of injury from falls, seizures, harm to self/others:

- Fall precautions (low bed/side rails)

- 1:1 to help orient client

- PRN antipsychotic if prominent psychotic symptoms

- Low stimuli environment

- Physical restraints if needed

Alcohol Withdrawal Treatment

Intermediate- to long-acting benzodiazepine tapered down over around 5 to 7 days

- Ativan (Lorazepam)

- Librium (chlordiazepoxide

- Valium (diazepam)

Alcohol Withdrawal Treatment: CIWA-Ar Scale

Monitor symptoms q4H

- After rating each symptom, the total score dictates treatment for breakthrough withdrawal symptoms

Alcohol Addiction Treatment After Detox: Family Therapy

Family therapy is highly recommended for the treatment of alcohol use disorder

Alcohol Addiction: Family Therapy Disadvantages

Blurred Boundaries: Family members tend to be codependent and enmeshed

- Family may enable the client's addictive behavior

- Family focuses on the client to avoid their individual issues

Alcohol Addiction Treatment After Detox: Medication and Recovery

Most effective

- Rehabilitation Service

- Sober Living Housing

- Outpatient Counseling

- 12-step peer support group (AA, NA)

Alcohol Addiction Treatment After Detox: Naltrexone

Opioid Antagonist

- Decrease drinking by reducing the rewarding influence of alcohol on the pleasure-seeking reward pathway of the brain (reduces cravings)

Naltrexone Dose

- Monthly injection (Vivitrol) is more effective than the daily pill (ReVia)

-- Both are safe and well tolerated

Alcohol Addiction Treatment After Detox: Acamprosate (Campral)

- Unknown mechanism of action but helps reduce cravings to drink

- Overall safe and well tolerated except in people with kidney disease

- Slightly more effective compared to naltrexone

Nonadherence to Acamprosate (Campral):

Needs to be taken TID, could influence adherence issues

Alcohol Addiction Treatment After Detox: Disulfiram (Antabuse)

- Used to be the only medication option for prevention of alcohol use

- No longer first line treatment due to it being a deterrent to drink vs. treating cravings

- Inhibits the breakdown of alcohol

Disulfiram (Antabuse) Side Effects

Flushing, dizzy, nausea, headache

Uncomfortable but not dangerous

Overall safe medication

Disulfiram (Antabuse) Contraindications

Client cannot come in contact with alcohol products

- Ex: Mouthwash, antiperspirant, paint thinner

- Educate the Client that a reaction will occur

Opioid Use Disorders

Opioids are used for pain relief, relief of cough, and treatment of diarrhea

-- ○pioids also desensitize the person to physiological pain and can induce a feeling of euphoria, leading to cravings to use more

Opioid Tolerance

Tolerance quickly develops and the opioid is less effective

- More opioid or a stronger opioid is needed

- Risk of death from respiratory failure

Opioid Intoxication: Respiratory Depression (S/S)

(MUST HELP)

Mental Confusion

Unresponsive

Snoring/Gasping for Air

Throwing Up

Hypothermia

Erratic Breathing

Loss of Consciousness

Paleness/Blueness of Skin

Naloxone: Reversing an Overdose

Nalaxone has a stronger affinity to the opioid receptors than opioids.

-- Knock the opioids off the receptors for a short time (30-90 minutes)

-- Allows person to breathe and reverse OD

Opioid Intoxication vs Withdrawal: Intoxication

Increased Parasympathetic Nervous System:

"Rest and Digest"

Sedation

Relaxed Muscle Tone

Pinpoint Pupils

Bradycardia

Respiratory Depression

Opioid Intoxication "Advantages"

Diarrhea Treatment

Pain Relief

Cough Relief

Opioid Intoxication vs Withdrawal: Withdrawal

Sympathetic Overdrive:

Fight of Flight

Restless

Anxious

Irritable

Tremor

Dilated Pupils

Opioid Intoxication Withdrawal: Adverse Effects

Diarrhea and Vomiting

Muscle Aches and joint pain

Tearing

Runny Nose

Yawning

Opioid withdrawal

- Short-acting opioids: generate w/d symptoms within 12 hours

- Long-acting opioids may emerge in 72 hours

- The worst of withdrawal resolves in 5 days

How are withdrawal symptoms monitored?

Clinical Opiate Withdrawal Scale (COWS)

Treatment during Opioid Detox

- Supportive PRN medication based on COWS

(Fluid/electrolyte replacement if vomiting)

Opioid Withdrawal in Pregnancy?

- Associated with miscarriage and premature delivery

-Need to start on an opioid agonist to mitigate withdrawal by activating opioid receptors

- Goal of treatment during pregnancy: No to mild withdrawal

Ex: Keep COWS 10 points or lower

Opioid Treatment: Methadone and Buprenorphine

Agonist

Activate opioid receptors

Maintain Physical dependence on opioids

Opioid Treatment: Naltrexone

Agonist

Competitive antagonist at the opiate receptor;

- At high opiate concentrations, an opiate can displace naltrexone

Motivational Interviewing

A brief intervention to help clients find the inner-motivation to change a behavior

MI Process: Step 1

Engage the client to discover life goals

- Build trust by using the nursing skills below

MI Process: Step 2

Focus the client on a behavior that may be preventing goal attainment

- Nonjudgmentally point out discrepancies between the client's goals and their current behaviors

MI Process: Step 3

Evoke change talk to assess the client's motivation to change

MI Process: Step 4

Plan next steps

Spirit of MI

Empathy

Warmth

Compassion

Nursing Process: Resistance

○Resistance is an expected part of behavioral change

○Do not argue with the client or act judgemental

Nursing Process: Relapse

Relapse is a part of recovery

- The goal is to learn for relapse and get back on track as soon as possible

Nursing Process: Planning Next Steps

Help the client set a SMART goal (i.e., a learning objective that can be evaluated)

- S - Specific, M - Measurable, A - Attainable, R - Realistic, T - Timely