Substance use & opiates - mental health

Opiates include

• Morphine, meperidine, codeine, hydrocodone, oxymorphone, oxycodone

• Common brand names: Vicodin, Percocet, OxyContin, Opana

Opiates - narcotic analgesics

• prescribed pain reliever derived from natural or synthetic opiates

Long-term use for pain management associated with significant rates of abuse, addiction!!

Opiates - heroin

• Usually administered intravenously

• Immediate rush, followed by euphoria that lasts several hours

• Tolerance develops to euphoria, respiratory depression, nausea but not to constipation, miosis (excessive constriction of the pupil)

• Physical dependence develops with long-term use

Opiate overdose:

• pupils constricted due to anoxia (complete lack of oxygen supply to body tissues or organs), respiratory depression, coma, shock, convulsions, death.

• Emergency treatment of opioid intoxication or overdose

  • naloxone (Narcan) to reverse CNS depressant effects!!!

Opiate overdose - emergency care

• Serious medical emergency

• Respiratory depression may require mechanical ventilation

• Keep patient awake - may be hard with respiratory depression

• Seizure is possible complication

• Monitor for Suicidal ideation

S&S of opiate withdrawal:

• Assess resting pulse (tachycardia)

• Diaphoresis

• Restlessness

• Dilated pupils

• Muscle, bone or joint aches

• Runny nose or tearing  (rhinorrhea and lacrimation)

• GI upset (nausea and vomiting)

• Tremor

• Yawning; insomnia

• Anxiety or irritability 

• Gooseflesh skin

Pharm therapy - withdrawal syndrome

• Use clinical opiate withdrawal scale (COWS)

Pharm therapy - initial detoxification:

• gradual reduction in opioid dose and frequency over 5 days - gradually taper the dosage over time - gradually withdrawing amount

• tramadol (ultram)

• buprenorphine (buprenex)

• buprenorphine and naloxone (Suboxone)

• Dolophine (methadone)

Pharm therapy - initial detoxification: buprenorphine

• (buprenex) - synthetic opiate - prescribed as a substitute to help safely withdrawal pt from opiate

• Acts on same receptors as heroin and morphine

• Relieves cravings without producing the same intense “high” or dangerous side effects

Pharm therapy - initial detoxification: buprenorphine and naloxone

• (Suboxone)

• naloxone (narcan) reverses CNS depression

(if the pt misuses/abuse the buprenorphine, the naloxone will reverse the CNS depressant effects - so if they try to misuse, they won’t die from the overdose/misuse)

Pharm therapy - initial detoxification: dolophine

• (Methadone)

• Synthetic opiate blocks craving for and effects of heroin

• Only medication currently approved to treat pregnant opioid addict

Health promotion

Prevention efforts revolve around education.

• Substance Abuse and Mental Health Service Administration

  • samhsas.gov

• Community and local initiatives

• Nurses assess patients' risk for substance abuse and provide education related to prevention

• Health promotion activities particularly important for patients in recovery from addiction

  • Reviewing with patient the situations or feelings that triggered past use

  • Helping patient recall, maintain healthy, successful coping strategies

  • Provide additional resources for patients during challenging times

Diagnostic tests - body fluids:

• Blood, urine, saliva, perspiration, hair

• Urine drug screening: preferred method for detecting substances in body

• Drugs can be found in blood urine for lengths varying from 24 hours to 30 days

  • Depending on dosage, metabolic properties of the drug

• THC stored in fatty tissues, can be detected up to 6 weeks

Nursing Process

• Nurses may interact with patients experiencing substance abuse, dependence in variety of settings

  • Most common: alcohol/drug abuse treatment program

  • Emergency departments and medical–surgical units after falls, accidents

  • Occupational, community treatment settings

  • Urgent care centers, pain clinics, ambulatory care centers

• Nursing care of patient with substance abuse or dependence: challenging, requiring nonjudgmental atmosphere promoting trust, respect

  • Use open-ended questions

  • Self-awareness – nurse’s attitudes, feelings and beliefs about addiction

Assessment

Observation and patient interview

• High-functioning substance abusers do not fit stereotypes

  • Often function in many responsible roles

  • May not use substance every day

  • May avoid serious consequences of substance use

  • Can spend years or decades in denial

  • Family, friends might not recognize the problem

• Comprehensive approach to assessment of all patients for possible substance use

  • History of past substance use, medical and psychiatric history

  • Psychosocial issues  - codependency, motivation to change, defense mechanisms

Diagnosis

• Injury, Risk for

• Other-Directed Violence, Risk for

• Self-Directed Violence, Risk for

• Denial, Ineffective

• Coping, Ineffective

• Imbalanced Nutrition: Less Than Body Requirements

• Chronic or Situational Low Self-Esteem

• Deficient Knowledge

• Processes

• Acute or Chronic Confusion

   (NANDA-I © 2014, 2015–2017)

Planning care - client will

• admit having a substance use problem and having lost control

• seek help to stop using the substance

• experience no complications as a result of drug withdrawal symptoms

• enter a drug rehabilitation program to change behavior

• explore the impact of addiction on family, job, and friends

• describe and recognize denial in avoiding problems

• regularly attend a support group

• remain free of substance and maintain sobriety

Implementation - promote safety

• Consider higher level of care if patient cannot withdraw safely in home or community setting

• Obtain drug history and urine, blood samples

• Place patient in quiet, private room

• Frequently orient patient to reality, environment

• Ensure that patient has no access to potentially harmful objects

Promote patient safety during withdrawal

• Observe for withdrawal symptoms, monitor vital signs

• Assess LOC frequently – orient, reassure patient

• Explain all interventions before approaching patient

• Use simple step by step instructions, face-to-face interaction

• Administer medications per schedule

Implementation - provide pt education

• Assess level of knowledge, readiness to learn

• Develop teaching plan with measurable objectives, including short-term goals

• Begin with simple concepts, progress to more complex issues

• Use interactive teaching strategies, written materials appropriate for patient

• Include information on physiologic effects of substances, dependence, risks to fetus if patient is pregnant

• Teach expected therapeutic effects of medications prescribed post-withdrawal and caution about potential risks

  • buprenorphine and naloxone (indefinitely) - very formal program

  • naltrexone (Vivitrol) - long acting injectable - need to wait 7-14 days to give

• Encourage participation in 12-step program

  • NA – Narcotics Anonymous

Evaluation

Expected outcomes may include that the patient

• Experiences no complications from withdrawal

• Admits problem with substance abuse and seeks help

• Enters substance abuse program

• Can describe choices that contributed to substance abuse

• Attends daily support groups and 12- step programs

• Remains substance free

Relapse rate for substance abuse: 40–60%

Substance addiction should be treated like any other chronic illness

• Relapse serves as trigger for renewed intervention