Substance Use Disorders

what is substance abuse

• habitual use

• falls outside of medical necessity and/or social acceptance

• used to alter mood, emotion, and consciousness

What is a substance use disorder (SUD)

• maladaptive pattern of use

• clinically significant impairment or distress

• categorized as mild, moderate, and severe

key features of substance use disorder

• role failure

• use in hazardous situations

• legal problems

• continued use despite social and/or interpersonal problems

• issues w tolerance and w/drawal

• symptoms not associated with other mental health disorders

Classes of drugs in SUD

• alcohol

• caffeine

• cannabis

• hallucinogens

• inhalants

• opioids

• sedatives

• hypnotics

• anxiolytics

• anxiolytics

• stimulants

• tobacco

what is intoxication

• disturbances of LOC, cognition, perception, affect or behavior

• under effects of drug

what is dual diagnosis/co-ocurring disease

• substance use and other mental health disorder

what is tolerance

• increased amnt of drug to get the same effect

what is w/drawal

• when a substance is stopped or reduced, physical and psychological symptoms occur

what are flashbacks

• occur while in drug free state

• visual distortions, time expansion , loss of ego boundaries, and intense emotions

• bad trip

• from earlier hallucinogenic drug use

what is codependence

• overresponsibility for someone elses substance use

• feeling guilty, lying and covering up for them, etc

what is synergistic effect

• enhance the effectiveness of each other

• can be positive or negative

what is antagonistic effect

• working aginst each other

• ex. narcan

cross tolerance

ex.) tolerance to alcohol may need to higher dose of benzos

what is cross dependence

• dependent on one substance and transferring dependence to a healthier drug

• ex. heroine use to methadone

define addiction

• behavior motivated by emotions ranging along lines of craving to compulsive spectrum

• continued use to desire adverse consequences to mental health, mental status, relationships, occupation, and finances

• loss of control from a chronic relapsing brain disorder

• cognitive impairment

what is medical comorbidity

alcohol related medical problems are often seen in medical settings

body systems affected w alcohol

• nervous system

• GI system

• CV

body systems affected w stimulants

• CV

• anxiety

• malnutrition (cocaine)

ody systems affected w nicotine

• resp

• CV

• immunity

• GI (cancer in mouth and throat)

body systems affected w IV drug use

• skin

• HIV, hep bd and c

what can happen w intranasal drug use

perforated septum

what is affected w marijuana use

• lungs

• increased infection

• decreased motivation

what is affected w caffeine use

• GI distress (GI ulcers)

• CV (tachy & HTN)

• increased blood sugar

biological factors etiology

• brainstem

• limbic system

  • positive feelings for alcohol and drug use

• Cerebral cortex

  • frontal cortex allows us to think, plan, solve problems, and make decisions

psychological factors etiology

• lack of tolerance for frustration and pain

• lack of success in life

• lack of affectionate and meaningful relationships

• low self esteem and lack of self regard

• risk taking proprensity

sociocultural etiology

• social and cultural norms

• socioeconomic stress

• adverse childhood events

pregnant women & alcohol use

• can be neurotoxic for baby

• fetal alcohol syndrom and spectrum disorder

  • malformation in face, cranium, learning disabilities, ADHD, autism

pregnant women and nicotine use

• low birth weight

• vasoconstriction and decreased blood flow to placenta

• cleft lip & palate

• increased risk for asthma

• neonatal abstinence syndrome (w/drawal in babies: hard to feed, shaking)

key features of chemically impaired nurses

• important to report abusing nurses to nurse manager for appropriate intervention and referral to tx

• alternative to discipline program:

  • KARE, ATD program (ongoing program of care, regular drug screening, dont lose license)

clues to help detect impaired nurse

• missing work, particularly after days off

• working all the time

• sloppy charting

• frequent trips to the bathroom

• pt complaints of no pain relief

• tremors

• behavioral and mood changes

• runny nose, watery eyes

• frequent use of mouthwash

• alcohol on breath

• wanting to give all the meds to everyones pt’s

what to ask substance abuse

• what are you using

• how often

• how much

• last use

• need these questions for every substance

initial screening questions

• in the past yr, have you ever drank or used more drugs than you meant to

• have you felt you wanted to cut down on drinking or drug use in the past year

screening tools

• AUDIT- adults, alcohol

• B-DAST- drugs, adults

• CRAFFT- adolescents, alcohol & drugs, using r/t care

• CaGE-AID- adapted to include drugs

what does CAAGE involve

• cut down

• others annoyed

• guilty

• eye opener

wernickes

• acute/subcut

• confused

• ataxia (unsteady gait)

• nystagmus

• vitamin B def from malnutrition (B1, thymine)

• can resolve w/out vitamin replacement

korsakoffs

• chronic

• difficulty learning new info and w memory (confabulation)

• ataxia is worse

• disoriented

• vitamin B def from malnutrition (b1, thymine)

• neuropathy in hands and feet

• not reversible w vitamins

when should you do urine toxicology screen or blood alcohol test

ASAP

psychological changes SUD

• use of defense mechanisms

• characteristic thought processes

  • all or nothing thinking

  • selective attention

• common avoidance and manipulation

complications of intoxication w CNS depressants

• ex. alcohol, benzos, barbituates

• slurred speech

• incoordination

• unsteady gait

• drowsiness

• decreased BP

• impaired judgement

• sexual disinhibition

• impaired memory

• irritability

tx of CNS depressant OD

• protect airway and circulation

• benso: flumazenil

what can happen w OD in CNS depressants

• CV/resp collapse

• coma

• shock

• death

what is alcohol poisoning

• from large amnt in a short time

• kidneys and liver cant filter fast enough

• vomiting and aspiration

• unconscious, cool and clammy skin, rr <10

alcohol w/drawal

• peaks 24-48 hrs and resolves rapidly in most cases

s/s alcohol w/drawal

• shaky

• over alert

• irritable

• can progress to alcohol w/drawal delirium

what is alcohol w/ drawal delirium

• peaks 48-72 hrs and lasts 2-5 days

• medical emergency

• seizures

• hallucination

• increase BP, RR, temp

drug for alcohol w/drawal

• small dose of benzos and decrease dose over several days

• anticonvulsants daily

• b vitamins

• beta blockers (propanolol)

intoxication of cocaine and amphetamines

• increased vs

• n/v

• insomnia

• assaultive behavior

• euphoria

• increased energy

• paranoia

• at risk for seizures

• cocaine: intense high then sink into deep depression, suicide risk

s/s OD cocaine and amphetamines

• MI

• stroke

• coma

• death

tx of cocaine and amphetamines OD

• maintain ABC

• IV hydration

• cooling if fever

• anticonvulsants

• benzos?

ex of opioids

• oxycodone

• demerol

• morphine

• codeine

• fentanyl

• heroin

s/s intoxication opioids

• pinpoint pupils

• bradypnea

• drowsiness

• low bp

• slurred speech

• slowed movements

• feeling euphoric or dysphoric

• impaired judgement, attention, and memory

triad for od in opioids

• coma

• resp depression

• pinpoint pupils

tx for od of opioids

• narcan

• methadone

• suboxone

• clonidine (for GI)

• buprenorphine

toxic effects of club drugs

• huge rush of serotonin but gets depleted quickly

• hyperthermia leading to organ failure

• hyponatremia

• dehydration

• euphoric or dysphoric

• impaired judgement, attn, and memory

tx for club drugs

• no antidote

• tx symptoms and maintain cv/resp

• activated charcoal to prevent further absorption

• keep cool

• may need sedation

• maintain hydration

intoxication w hallucinogens

• dilated pupils

• tachycardia

• diaphoresis

• tremors

• lack of coordination

• may feel paranoid, anxious, depressed

• synesthesia

• depersonalization or hallucinogens

ex of hallucinogens

• LSD

• mescaline

OD of hallucinogens can cause

• psychosis

• brain damage

• death

tx of hallucinogens OD

• lower stimulation

• keep pt safe

• benzos for anxiety

intoxication w inhalants

s/s similar to alcohol

ex of inhalants

• paint thinners

• glue

• gas

• aerosols

OD of inhalants can cause

• severe liver and brain damage

• HF

• resp arrest

• can have permanent neuro damage from destruction of myelin sheath

tx for inhalant OD

• supportive

• vitamine b12 and folate

dissociative drug ex

• PCP

• ketamine

intoxication of dissociative drug

• out of body feelings

• hallucinations

• elevated VS

OD od dissociative drugs can cause

• HTN crisis

• resp arrest

• hyperthermia

tx for OD dissociative drugs

• monitor vitals

• calm environemnt

• antipsychotics (haloperidol) or benzos to tx hallucinations or behavior issues

marijuana category

• mixed depressant and hallucinogenic

intoxication weed short term

• euphoria

• detachment

• relaxation

• increased appetite

• change in perception

intoxication weed long-term

• mental health probs

• amotivational syndrome

• resp problems

• potential for cannaboid hyperemesis syndrome (hot showers help)

common date rape drugs

• flunitrazepam (rohypnol)

• GHB

s/s intoxication of date rape drugs

• similar effects of benzos

• amnesia

best outcome time for tx of SUD

• 90-180 days

key concepts relapse prevention

• relapse is not failure

• person needs to be aware of cues that may indicate relapse may occur

• identifying and planning management of triggers

• develop strategies to manage cravings

• working toward healthy coping mechanisms

strategies for relapse prevention

• keep program simple

• encourage use of notebook and journaling

• use cognitive behavioral principles to increase coping

• encourage pt to join relapse prevention group

• encourage pt to enhance personal insight through therapy

alcohol detox

• 3-5 days, worst s/s on 2nd day

• CIWA-AR: subjective and objective data, prn dosese based on scores

short term tx alcohol detox

• benzos are drug og choice

• doses vary on assessment findings

long term tx for alcohol detox

• disulfiram: no alcohol in any form (hand sanitizer, mouthwash), causes ha, nv, sweaty, feel like gonna dies

• acamprosate: reduces unpleasant s/s like anxiety and dysphoria

• naltrexone: helps w cravings, blocks pleasure, can be used for opioids

tx of opioid addiction

• methadone: very strict prescribing and UDS

• buprenorphine: partial opioid agonist, still an opioid but less likely to OD, very strict prescribing and uds

• naltrexone: euphoria, may help w cravings

• clonidine: alpha blockers, useful in acute wdrawal to manage symptoms

other modalities for SUD

• psychotherapy (CBT, DBT)

  • assists in identifying and using alternative coping mechanisms instead of reliance on substances

  • self help help groups for pt and family

  • 12 step programs very effective (aa, al-anon and alateen for family members)

tx outcomes for SUD

• increases length of time in abstinence

• decreased denial

• acceptable occupational and social function

• ability to use coping strategies

• attendance at 12 step support program