Chp 22 Substance use disorder

Substance use disorder

• Drugs all have the ability to impact the brain and functions of the central nervous system

• Natural or synthetic (designer drugs—created in illegal laboratories for profit)

• Abused drugs not always illegal (e.g., nicotine)

• Some drugs, like cocaine, used to be used therapeutically but are now illegal

• Newed definition: Self-administration of a drug in a manner that does not conform to the norms within one’s own culture and society

Addiction

• Overwhelming compulsion

• Repetitive drug-taking behavior despite serious health and social consequences

• Depends upon Interacting Variables

  • User-related factors:

    • Genetics, personality, prior experience, disorders

  • Environmental factors:

    • Societal and community norms, role models, peer influences, educational level

  • Agent or drug factors:

    • Cost, availability, dose, mode of administration, speed of onset/termination, length of drug use

Therapeutic use of scheduled drugs

• Addiction can begin with a legitimate need for pharmacotherapy

• Prescribed at lowest effective dose

• Prescribed for shortest time necessary

• Prescription drugs rarely cause addiction when used as prescribed

Dependence

• Overwhelming desire to take a drug

• Cannot stop taking drug

• Two categories:

  • psychologic & physical

• Examples of substances

  • Drugs for insomnia, Antianxiety drugs

Physical dependence

• Altered physical condition caused when nervous system adapts to repeated substance use

  • Uncomfortable symptoms result when the agent is discontinued—known as withdrawal

  • Examples of substances that may cause physical dependence

    • Opioids, Alcohol, Sedatives, Nicotine, CNS stimulants

Psychological dependence

• No obvious physical discomfort when substance discontinued

  • Overwhelming desire to continue substance use; may be associated with home or social environment

  • Craving continues for months or years

  • Craving responsible for relapse

Withdrawal syndrome

• Prescription drugs may be used to reduce severity

  • May be particularly severe for those who are dependent on alcohol or sedatives

  • Abusers often associate use of substance with their conditions and surroundings:

    • Counselors encourage distance from past social contacts

Tolerance

• Biologic condition; body adapts to repeated administration of a drug:

  • Requires higher doses of drug to produce initial effect

  • Common in substances that affect nervous system

  • Does not indicate addiction or substance abuse

  • Rates

    • some drugs develops quickly

    • some drugs develops slowly

    • some drugs never occurs

  • Cross-tolerance

    • May develop to closely related drugs

    • May require dosage adjustment to obtain therapeutic benefit

CNS depressants

• Cause patients to feel sedated or relaxed:

• i.e. Barbiturates, Nonbarbiturate sedative–hypnotics, Benzodiazepines, Alcohol, Opioids

• Actions, indications, safety profiles, and addictive potential are roughly equivalent

• Sedatives

  • Prescribed for sleep disorders and some forms of epilepsy

  • Physical dependence, psychological dependence, and tolerance to high doses over extended period of time

  • Many have long duration of action

  • Moderate-to-high psychological dependence

  • Moderate-to-extreme physical signs of withdrawal

  • Overdoses extremely dangerous

  • Commonly combined with other drugs of abuse, such as C N S stimulants or alcohol

  • Barbiturates and Similar Sedative–Hypnotics Withdrawal Symptoms

    • Insomnia, anxiety, weakness, and abdominal cramps

    • Tremor, anorexia, and seizures

    • Skin-hypersensitivity reactions

    • Hallucinations and delirium

  • Benzodiazepine Withdrawal Symptoms

    • Insomnia, restlessness, abdominal pain, and nausea

    • Sensitivity to light and sound

    • Headache, fatigue, and muscle twitches

CNS depressants- OPIOIDS

• AKA opioid narcotics

• Prescribed for severe pain

• Range of CNS effects

• Addiction can occur rapidly

• Intense withdrawal symptoms:

  • Not life-threatening, as with barbiturate withdrawal

• High psychological dependence

• Withdrawal Symptoms

  • Excessive sweating, restlessness, and pinpointed pupils

  • Agitation, goose bumps, tremor, and violent yawning

  • Increased heart rate, orthostatic hypotension

  • Nausea/vomiting and abdominal cramps and pain

  • Muscle spasms with kicking movements and weight loss

CNS depressants - ethyl alcohol

• drinking alcohol

  • One of most commonly abused

  • Legal for adults; readily available

  • Food in stomach slows onset of absorption

  • Effects of alcohol directly proportional to amount consumed

  • Liver detoxifies 1 drink/hour with or without food; slow, constant rate

  • Combination with other CNS depressants is cumulative; nurse must not assume alcohol is only drug in system

  • Acute overdose—vomiting, severe hypotension, respiratory failure, coma, death

  • Psychological, physical dependence possible

  • Withdrawal can be severe to life-threatening

  • Benzodiazepines are preferred drug class for treatment of acute withdrawal

  • Withdrawal Symptoms

    • Tremors, fatigue, and anxiety

    • Delirium tremors (D T)

    • Abdominal cramping and hallucinations

    • Confusion, seizures, and delirium

  • AE of Chronic Alcohol Consumption

    • Large number of adverse health effects

    • Liver failure—cirrhosis

    • Delirium tremens (DT) may occur with very long-term consumption:

      • Hallucinations, confusion, disorientation

    • Withdrawal can be treated with antiseizure medications:

      • Disulfiram (Antabuse) can discourage relapses

Cannabinoids

• from hemp plant, Cannabis sativa

• Ingredient responsible for most of psychoactive properties is delta-9-tetrahydrocannabinol (THC)

• Marijuana and related substances

  • Most commonly used federally illicit drug

  • Slows motor activity, decreases coordination; causes disconnected thoughts, paranoia, euphoria

  • Causes thirst and craving for food, especially chocolate or other sweets

  • Causes red or bloodshot eyes

  • Produces little physical dependence or tolerance

  • Withdrawal Symptoms

    • Irritability and restlessness

    • Insomnia and tremors

    • Chills and weight loss

Hallucinogens

• C-I drugs

• No medical use

• Prototype substance for this class, sometimes called psychedelics, is LSD

• Withdrawal symptoms

  • Rarely observed

  • Depends upon specific drug

  • Flashbacks, tolerance, and moderate-to-high psychological dependence may occur but little or no physical dependence

• LSD:

  • Effects highly variable

  • Derived from a fungus that grows on rye and other grains

  • Nearly always taken orally

  • Distributed throughout the body immediately, lasts 6–12 hours

  • Flashbacks and tolerance possible

  • Little or no physical dependence

• Recreational & club drugs

  • Mescaline

  • MDMA (XTC, Ecstasy)

  • DOM (STP)

  • MDA (“love drug”)

  • Phencyclidine (PCP)

  • Ketamine (kitkat, special k)

CNS stimulants

• Increase blood pressure and respiratory rate

• Treatment of narcolepsy, obesity, ADHD

• Sense of exhilaration and reduced appetite

• Improved mental and physical performance

• Used for wakefulness, alertness, appetite reduction, and sense of “getting high”

• High psychological dependence; long-term use can result in restlessness, anxiety, fits of rage

• Overdoses can lead to seizures and cardiac arrest

CNS stimulant- Amphetamines and Methylphenidate

• Activate neurons in a part of the brain called the reticular formation

• Affect cardiovascular and respiratory activity

• No longer widely prescribed for medical use—very limited use now

• Dextroamphetamine (Dexedrine) may be prescribed for short-term weight loss

• Methamphetamine often used as a recreational drug

• Methylphenidate (Ritalin) widely prescribed for children with attention-deficit/ hyperactivity disorder

  • Calms children with ADHD; opposite effect on adults abusing it

  • C-II drug w/many of the same effects as cocaine & amphetamines

• Withdrawal symptoms

  • Mental depression and anxiety

  • Extreme fatigue and hunger

CNS stimulant- cocaine

• From leaves of coca plant; documented use for thousands of years

• C-II drug produces actions similar to those of the amphetamines

• Many routes of administration

• Overdose can cause dysrhythmias, convulsions, stroke, or death

• Withdrawal symptoms

  • Mental depression and anxiety

  • Extreme fatigue and hunger

CNS stimulant- caffeine

• Natural substance

• Sometimes added to OTC pain relievers

• Pronounced diuretic effect

• CNS stimulant—produces mental alertness, restlessness, nervousness, irritability, and insomnia

Nicotine

• Affects nervous, cardiovascular, and endocrine systems; stimulates the C N S directly

• Is highly carcinogenic; contains >1000 chemicals

• Feelings of alertness, relaxation, light-headedness; effects last 30 minutes to several hours

• Psychological and physical dependence occurs quickly

• Patients tend to continue drug use for many years

• Withdrawal symptoms: agitation, weight gain, anxiety, headache, extreme craving

• Bupropion (Zyban) and varenicline (Chantix) used to help patients quit

• Withdrawal Symptoms

  • Irritability, anxiety, and restlessness

  • Headache, increased appetite, and insomnia

  • Inability to concentrate

  • Increase in heart rate and blood pressure

Role of nurse in substance abuse

• With IV drug users, must consider

  • HIV infection

  • Hepatitis

  • Tuberculosis

• Prevention, diagnosis, treatment

• Thorough medical history must include substance abuse, if present

• Provide a list of social agencies dealing with dependency

• Involve family members when possible