NURS 451 Substance Related & Addictive Disorders

dual diagnosis for substance abuse disorder

-poor tx adherence

-exacerbation of sx

-increased risk of homelessness, suicide, and violence

what is substance abuse disorder?

a pathological use of a

substance that leads to a disorder of use,

intoxication, and often, withdrawal if the substance is taking away. the symptoms fall into 4 groups

what are the 4 groupings of substance abuse disorder?

1. impaired control

2. social impairment

3. risky use

4. physical effect

what groups of sx are there for substance abuse disorder sx?

Cognitive, behavioral and physiologic symptoms

pts with SUD have a desire to reduce the use, but

diffuclty doing so

eventually, pts with SUD will need greater

amounts of the substance to achieve the same effect

SUD pts neglect

normal activities due to focus on obtaining or using more of the substance

SUD pts have a persistent

desire or craving

types of substances that are abused often

-Alcohol

-Caffeine

-Cannabis

-Hallucinogens

-Inhalants

-Opioids

-Sedatives, Hypnotics and

Anxiolytics

-Stimulants

-Tobacco

-Other (or unknown) substances

-Nonsubstance-(Process) Gambling, Internet

Gaming, Social Media, Shopping, Sexual Activity

what are the top 3 drugs with the highest % of misuse?

1. marijuana

2. pain relievers

3. cocaine

the younger the age of misuse, the greater

the likelihood of misuse in adulthood

who has the highest rate of substance abuse?

adults in their 20s

who is more likely to use: males or females?

males twice as likely

people that use have a high prevalence of

psychiatric comorbidities. -Dual Diagnosis

what ethnic groups have the highest chance of use?

alaska natives and american indians

Excessive ETOH factor in ____% of all deaths from acute traumatic injuries

50%

Approximately _______% of all hospital admissions can be tied either directly or indirect to ETOH use/abuse

40

Hospitalized person with an SUD are more likely to require re-hospitalization within

30 days of d/c than

non users

Approximately _______% of pts seen by the primary care physician have an SUD

25

most important reward pathway and its function

mesolimbic dopamine system - responsible for survival

through a reward of pleasure and memory coupled with motivational reinforcement or salience.

primary areas of the mesolimbic dopamine system

ventral tegmental area (VTA) and nucleus accumbens

VTA is the site of

dopaminergic neurons, which tell the person

whether an environmental stimulus (natural reward, drug

of abuse, stress) is rewarding or aversive.

what is the nucleus accumbens, and what is its function?

is a principle target of VTA dopamine neurons. This region mediates the rewarding effects of natural rewards and drugs of abuse.

what is dopamine?

the neurotransmitter that activate the neural pathways between these two areas.

Pleasurable activities cue the ____________ and _______________ for memories of the experience; the frontal cortex is

stimulated, releasing glutamate and closing the circuit.

amygdala; hippocampus

Prolonged and repeated release of excessive amounts of dopamine in the brain causes ___________changes

and increased tolerance to levels of dopamine. This creates increasing need for higher levels of dopamine to have the same pleasurable.

synaptic

tolerance

to the analgesic properties of the drug no longer respond to the drug in the initial way. tolderance occurs in the pain passage pathway that includes the thalamus and spinal cord.

addiction develops when

the neurons adapt to exposure of the drug and only function normally in the presence of the drug

what can cause SUD

-Chronic Stress

-Trauma

-Abuse/Neglect

-Poverty

-Unhealthy Relationships

-Domestic Violence

-Combat Experience

personality traits of SUD

-Dominant and Critical Behavior w/ underlying self-doubts and passivity

-Overt extraversion

-Personal insecurity

-Problems w/ sexual identification

-Rebellious toward authority

-Escapist or sensation seeking defense mechanisms

-Difficulty with intimacy

-Absence of a strong and

efficient superego

-Narcissistic trends

-Difficulty w/ impulse control and feelings

sociocultural and economic causes of SUD

-Poverty

-Lack of Parental Supervision

-Describes parents as self-reliant/efficient but not emotionally warm

-Poor Educational Resources

-Impaired Support Systems

addiction may come from which dysfunctional family role

hero or matyr (oldest, caretaker)

codependent family role

mascot (baby of the family; anxious and underachieving)

physical sx to watch for that may indicate SUD

Weight loss, skin infections or rashes, respiratory symptoms, coughing, shortness of breath, cardiac symptoms,

chest pain, gastrointestinal symptoms, nausea, vomiting, abdominal pain, ulcers

psychological/behavioral sx to watch for that may indicate SUD

agitation, anxiety, sleep problems, difficulty concentrating, low energy, depression, feeling of helplessness or hopelessness

social sx to watch for that may indicate SUD

Relationship difficulties, problems at work, financial

problems, problems at school

do patients often answer honestly about doing drugs?

yes, Most patients understand that disclosing this information in a primary care setting does not lead to legal implications.

what may be used during a patient's initial assessment to gather information on the extent of their substance abuse?

a questionnare

CAGE screening tool

cut down, annoyed, guilty, eye opener

what is the frames model used for, and what does it stand for?

This model is used as a brief intervention in a primary care setting.

Feedback

Responsibility

Advice

Menu

Empathy

Self-efficacy

feedback

Give feedback on the risks and negative consequences of substance use. Seek the client's reaction and listen carefully to their response

responsibility

Emphasize that the individual is capable of making their own decisions about their drug use.

advice

Give straightforward advice on modifying drug use (educational advice)

menu of options

give menus of options to choose from, fostering the client's involvement in the decision making process.

empathy

Be empathetic, respectful, and non-judgmental.

self-efficacy

express optimism that the individual can modify his or her substance use if they choose.

short-term biological testing for substances

48-72 hours

-Urine testing: alcohol, amphetamines, benzodiazepines, marijuana, cocaine, and opioids

-Blood testing, sweat testing, and

saliva testing

long-term biological testing for substances

Hair testing: often used in pre- employment screenings. Provides information over a

long period of time, normally a 3 cm sample of hair can provide a history of drug use for the past 90 days

alcohol effect on brain

Sedative and CNS depressant

BAC for intoxication

Blood Alcohol Levels (BAL) is 80 to 100

mg ethanol per deciliter of blood (mg/dl) also expressed 0.08-0.10%

binge drinking classification for men and women

women - 4+ drinks in 2 hours

men - 5+ drinks in 2 hours

6-8 hours after last drink may cause these alcohol withdrawal sx:

tremulousness, agitation, lack of appetite, N&V, insomnia, impaired cognition and mild perceptual changes. BP/Pulse/Temp increases

8-10 hours after last drink may cause these alcohol withdrawal sx:

psychotic and perceptual

symptoms (considered for higher risk symptoms)

12-24 hours after last drink may cause these alcohol withdrawal sx:

Generalized, tonic clonic sezures

emergency: autonomic hyperactivity- tachy, diaphoresis, fever, anxiety, insomnia and hypertension

tx of withdrawal

1. monitor fluid status - if unable to take PO, IVF

2. Magnesium sulfate (if pt having seizures, IV dazepam and client may be placed on Phenytoin (dilantin))

3. Vitamins (Thiamine, B1)

4. Benzo's (Diazepam (valium) or Chlordiazepoxide

(librium) to help prevent DTs

Once DTs appear, IV Lorazepam (Ativan) for severe symptoms

gabapentin order for alcohol withdrawal stabilization

Gapapentin (Neurontin) 300 mg oral TID, (if pt takes Neurontin at home and dosage is higher continue home dosage)

methocarbamol order for alcohol withdrawal stabilization

Methocarbamol (Robaxin) 750 mg oral q 6 hours prn muscle spasms

dicyclomine order for alcohol withdrawal stabilization

Dicyclomine (Bentyl) 20 mg oral q 6 hours prn stomach cramps

hydroxyzine order for alcohol withdrawal stabilization

Hydroxyzine (Vistaril) 50 mg oral prn anxiety

odansetron order for alcohol withdrawal stabilization

Ondansetron (Zofran) 4mg sublingual q 6 hours prn N/V

multivitamin order for alcohol withdrawal stabilization

Multivitamin 1 tab oral daily

thiamine order for alcohol withdrawal stabilization

Thiamine (Thiamine) 100 mg IM on arrival, then 100 mg oral daily

oxazepam order for alcohol withdrawal stabilization

Then Oxazepam (Serax) or Lorazepam (Ativan) taper

meds for AWS based on

CIWA score

negative effects of alcohol

-Wernicke-Korsakoff Syndrome

-Blackouts

-Fetal Alcohol Syndrome

-Peripheral Neuropathy

-Alcoholic Myopathy

-Alcoholic Cardiomyopathy

-Esophagitis

-Gastritis

-Pancreatitis

-Alcoholic Hepatitis

-Cirrhosis of the Liver

-Leukopenia

-Thrombocytopenia

-Cancer

warning signs of addicted healthcare workers

-Frequent absenteeism

-Irritable

-Abrupt mood changes

-Sloppy charting/poor client care

-Problems with record keeping of drugs

-Frequent errors

-Alcohol on breath

-Frequently missing

-Offering to give meds to clients who do not need it

-Frequent night shift

-Patients who continue to complain of pain after health care provider has administered meds

motivational interviewing use

to motivate the client to change, address feelings about change, and emphasize client responsibility and ability to make choices.

motivational interviewing incorporates the following principles:

-Empathy

-Reflective listening

-Positive focus

-Support

-Helping the client to recognize the discrepancies between their goals and behavior

5 parts to motivational interviewing

1. Open-ended questions- elicit a breadth of information from the client

2. Reflective listening- mirrors what the client says without adding further meaning

3. Affirmations- convey respect and understanding while encouraging more progress

4. Summarizing- reflecting back to the client the essence of what the health care provider has heard over the course of the conversation

5. Eliciting self-motivational statements- this assesses the client's problem recognition, concerns, intent to change, and optimism.

nonpharmacological tx for SUD

-Detox

-Rehabilitation

-Halfway House

-Other Housing

-Partial Hospitalization Programs

-Intensive Outpatient Programs

-Outpatient Treatment

-AA

-Relapse Prevention

other behavioral disorders

-Gambling

-Binge eating

-Internet use

-Tanning

-Exercise

-Shopping

-Sex