Nursing Care for Clients with a Substance Use Disorder

substance use disorder

substances produce such an intense activation of the reward system that normal activities may be neglected; pharmacological mechanisms by which each class of drugs reward are different, but the drugs typicaly activate the system and produce feelings of pleasure, often referred to as a “high”

substance use disorder symptoms

impaired control, social impairment, risk use, tolerance/withdrawal symptoms

substance use disorders

alcohol, opioid, stimulants

substance use disorder nursing assessment

reason for seeking tx, detailed hx of pt’s past substance use, previous detoxes, previous periods of sobriety, tox screen, symptoms of withdrawal, medical hx, psychosocial hx, safety, coping style

substance use disorder nursing interventions/tx

• SBIRT- screening, brief intervention, referral to treatment

• cognitive + CBT

• enhancing coping skills

• group intervention and early recovery

• individual therapies

• family therapy

• harm reduction strategies

• peer support self help groyp

• motivational interviewing

substance use

indigestion, smoking, sniffing, or injection of mild altering substance

substance abuse

use for purposes of intoxication or beyond intended use

physiological dependence

body has physical reaction to medication

psychological dependence

when you physically want the medication

withdrawal

symptoms occurring when blood o tissue concentrations of substance decline

detoxification

process of safe withhdrawal

psychotropic

a substance that affects your mental state and ability to cognitively function

psychoactive

substance that passess the BBB

neurotransmitters in the reward pathway of the brain

dopamine, glutamate, GABA, serotonin; connected to the areas of the brain that control behavior and memory

• makes connections between the activity and the pleasure, ensuring that we will repeat the behavior

key diagnostics for substance use disorders

• impaired glucose control

• social impairment

• risky use of substance and failure to abstain despite difficulty

• pharmacologic effects: tolerance/withdrawal syndrome

withdrawal syndrome

occurs when blood of tissue concentration of a substance declines

trends in substance use in the US

alc most common, marijuana follows

social risk factors for substance use

environmental factors, peer influences, dysfunctional family dynamics, deviance or social madalaptation, consequences of action

Psychological risk factors for substance use

depressed mood, low self esteem, self derogatory, excessive dependency, increased need for success or power, inability to cope with overwhelming feelings, personality disorder or hyperactivity

reasons pts don’t seek treatment

• thinking they can handle their own alc or drugs use on their own

• not being able to start treatment

• not being ready to stop or cut back on using alc or drugs

• being worried about what others will think or say

• expensive

• not enough time

• lack of knowledge on where or how to get treatment

• being worried information won’t be kept private

• thinking bad things will happen: losing job, home, or children

harm reduction examples

nicotine patch/gum, opioid substitution: methadone/buprenorphine, needle exchange programs for IV heroin users, narcan kits to first responders, decriminalization

Motivational interviewing

a guiding style of communication that sits between following (good listening) and directing (giving information and advice)

• Designed to empower people to change by drawing out their own meaning, importance and capacity for change

• based on a respectful and curious way of being with people that facilitates that natural process of change and honors client autonomy

alc effects

sedation, decreased inhibitions, relaxation, decreased coordination, slurred speech, nausea

alc overdose

resp depression, cardiac arrest

alc withdrawal

tremors; elevated temp, pulse, BP, diaphoresis; anxiety; delirium tremens (autonomic hyperarousal, disorientation, hallucinations); grand mal seizures, status epilepticus; DEATH

aka (acloholic ketoacidosis)

a life threatening metabolic disturbances caused by heavy alc use, starvation, and vomiting; leads to accumualtion of acidic ketones and metabolic acidosis

aka (alcoholic ketoacidosis) symptoms

abd pain, nausea, vomiting, confusion and rapid, labored breathing

alc prolonged use

affects all symptoms of the body

alcohol-induced amnestic disorders

• wernicke encephalopathy

• Korsakoff’s amnestic syndrome

Wernicke encephalopathy

degenerative brain disorder caused by thiamine deficiency characterized by vision impairment, ataxia, hypotension, confusion, and coma

Korsakoff amnestic syndrome (chronic)

problem acquiring new information and retrieving memories

Korsakoff amnestic syndrome (chronic) symptoms

amnesia, confabulation (e.g. telling a plausible but imagined scenario to compensate for memory loss), attention deficit, disorientation, vision impairment

CAGE- for alcohol withdrawal

cut, annoyed, guilty, eye

nursing assessments for alcohol withdrawal

CIWA-Ar; prevent and manage seizures is a priority

electrolyte abnormalities for alc withdrawal

hypomagnesemia, hypokalemia, hypophosphatemia, hyponatremia

CIWA screening

• Max score=67 

• Client receives medication based on score 

• Client scoring less than 10 generally do not require medication 

• Sections= nausea/vomiting, tremors, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, HA/fullness in head, orientation

CIWA <10 score

very mild withdrawal

CIWA 10-15 score

mild withdrawal

CIWA 16-20 score

moderate withdrawal

CIWA >20 score

severe withdrawal

medications for moderate and severe withdrawal

• Benzodiazepines

• Barbiturates

• Propofol

Benzodiazepines for withdrawal

diazepam (Valium), Lorazepam (Ativan), chlordiazepoxide (Librium)

Barbiturates

phenobarbital (Sezaby)

opioid effects

euphoria, sedation, reduced libido, memory and concentration difficulties, analgesia, constipation, constricted pupils

opioid overdose

resp depression, stupor, coma, DEATH

opioid withdrawal

GI upset, abd cramps, rhinorrhea, watery eyes, dilated pupils, yawning, “goose flesh”, diaphoresis, nausea, diarrhea, anorexia, insomnia, fever 

opioid prolonged use

can lead to criminal behavior to get money for drugs, risk for infection-related to needle use (e.g. HIV, endocarditis, hepatitis)

nursing assessment for opioid use

COWS

COWS- clinical opioid withdrawal scale

resting pulse rate, GI upset, sweating, tremor, restlessness, yawning, pupil size, anxiety/irritability, bone or joint aches, gooseflesh skin, runny nose or tearing

OUD meds

methadone, buprenorphine, naltrexone, naloxone

cannabis effects

euphoria or dysphoria, relaxation and drowsiness, heightened perception of color and sound, poor physical coordination, spatial perception and time distortion, unusual body sensations (e.g. weightlessness, tingling), dry mouth, dysarthria, and cravings for particular foods

cannabis overdose

increased HR, reddened eyes, dysphoria, lability, disorientation

cannabis prolonged use

can decrease motivation and cause cognitive deficits (e.g. inability to concentrate, impaired memory)

stimulant effects

euphoria, initial CNS, stimulation and then depression, wakefulness, decreased appetite, insomnia, paranoia, aggressiveness, dilated pupils, tremors

stimulants overdose

cardiac arrhythmias or arrest, increased or lowered BP, resp depression, chest pain, vomiting, seizures, psychosis, confusion, seizures, dyskinesias, dystonias, coma

stimulants withdrawal

depression; psychomotor retardation at first and then agitation; fatigue and then insomnia; severe dysphoria and anxiety; cravings, vivid, unpleasant dreams; increased appetite; amphetamine withdrawal is not as pronounced as cocaine withdrawal

stimulants prolonged use

weight loss resulting malnutrition and increased suspectibility to infectious diseases

schizophrenia like syndrome: paranoid ideation, thought disturbance, hallucinations, and stereotyped movements

hallucinogens effects

euphoria or dysphoria, altered body image, distorted or sharpened visual and auditory perceptions, depersonalization, bizzare behavior, confusion, incoordination, impaired judgement and memory, signs of sympathetic and parasympathetic stimulation, palpitations (blurred vision, dilated pupils, sweating)

hallucinognens overdose

paranoid, ideas of reference, fear of losing one’s mind, depersonalization, derealization, illusions, hallucinations, synesthesia, self destructive or aggressive behavior, tremors

hallucinogens withdrawal

flashbacks, mood symptoms

opioids commonly used

oxycodone, hydrocodone, morphine, fentanyl, codeine, barbituates (e.g. pentobarbital), and benzodiazepines

amphetamines commonly used

adderall, dexedrine, and methylphenidate (concerta, ritalin)

OTC drugs commonly used

cough medicine containing dextromethorphan (DXM)

physical intoxication of alc

slurred/incoherent speech, nausea/vomiting, drowsiness, dizziness, reduced alertness, loss of coordination, instability, flushed face, red/watery eyes, sweating

physical intoxication of opioids

altered mental status (confusion, delirium, or decreased awareness or responsiveness)

physical intoxication of stimulants

amphetamines (dilated pupils, twitching, HTN, tachycardia); Cocaine (dilated pupils, HTN, runny nose or nosebleeds, anorexia)