NSG 3320: Substance Use Disorders

Substance use disorder

Cluster of cognitive, behavioral, and physiological symptoms indicating significant substance-related problems, but the individual continues to use the substance

2-3

According to the DSM-5, ______ symptoms of substance use disorder indicates mild disorder

4-5

According to the DSM-5, ______ symptoms of substance use disorder indicates moderate disorder

6+

According to the DSM-5, ______ symptoms of substance use disorder indicates severe disorder

Larger amounts, longer periods

Can't cut down

Lots of time spent obtaining, using, recovering

Craving/strong desire to use

DSM diagnostic criteria for substance use disorder: IMPAIRED CONTROL symptoms

Failure in role obligations

Use despite social or interpersonal problems

Important activities given up

DSM diagnostic criteria for substance use disorder: SOCIAL IMPAIRMENT symptoms

Use when it is physically hazardous

Use despite knowledge of physical or psychological problem

DSM diagnostic criteria for substance use disorder: RISKY USE symptoms

Tolerance

Withdrawal

DSM diagnostic criteria for substance use disorder: PHARMACOLOGICAL symptoms

Tolerance

Need for markedly increased amounts of the substance to achieve intoxication or desired effect; markedly diminished effect with continued use of same amount off substance

Intoxication

Reversible physiological effects of the substance on the CNS and associated maladaptive behaviors; pleasure is high

Withdrawal

Physiological/psychological effects when someone stops using a substance after prolonged use; cravings, physical/psychological distress

Substance dependence

Physical or psychological dependence on or cravings for a substance characterized by symptoms of tolerance and withdrawal

GABA, glutamate, norepinephrine, domapine

Which receptors does alcohol act on?

Endorphin and secondary dopamine receptors

Which receptors do opioids act on?

Concurrent mental disorder

Mental illness plus substance use disorder

2x

People with a mental illness are ____ as likely to have a substance use problem

Transtheoretical Model of Change

Precontemplation, contemplation, preparation, action, maintenance, relapse

False

True or false? According to the Transtheoretical Model of Change, change is linear, not cyclical

Lapse

Singular or short-term return to previous substance use

Relapse

Longer term or several instances of substance use; risk developing a sense of failure and hopelessness; decreases sense of self-efficacy

False (other way around !)

True or false? When a patient lapses, their goals for change are abandoned, while a patient who relapses retains their goals for change

Dignity, regaining hope, connecting socially and in community, resiliency, meaning making, accepting vulnerabilities, overcoming stigma, regaining self-efficacy

What does recovery work include?

Decrease adverse health, social and economic consequences of drug use without requiring decrease in drug use

Goals of harm reduction

Alcohol

Most misused substance across all age groups in Canada; acute health effects dependent on dose, tolerance, and genetics

Alcohol intoxication

Depressed behavioral control, impaired motor/cognitive/speech function; blackouts, respiratory failure, coma, death

Deaths and cancer development

Alcohol is the leading global risk factor for ___________ ____ ___________________

Wernicke's encephalopathy

Alcohol-induced cognitive disorder caused by thiamine deficiency; acute, reversible; altered gait, confusion, oculomotor dysfunction, ataxia; treated with IV thiamine BID or TID 2-3 weeks

Korsakoff's syndrome

Alcohol-induced cognitive disorder caused by thiamine deficiency; chronic; amnesia w/ confabulations, increased severity of Wernicke's symptoms; treated with IV thiamine 3-12 months + nutritional support

2

How many drinks/week does the Canadian Centre on Substance Use and Addiction (CCSA) report remains a low health risk?

12 oz, 341 mL, 5% alcohol

Which beer/cider is considered a standard drink?

5 oz, 142 mL, 12% alcohol

Which wine is considered a standard drink?

1.5 oz, 43 mL, 40% alcohol

Which spirit is considered a standard drink?

5 for men, 4 for women

According to the CCSA, how many drinks constitute a binge-drinking episode?

Minor alcohol withdrawal

Can develop within a few hours of last intake and resolves in 48-72 hours; may include anxiety, N/V, coarse tremor, sweating, tachycardia, and HTN

Major alcohol withdrawal delirium (aka delirium tremens)

Onset 48hrs-days following cessation of heavy alcohol use; can result in death of 20% of untreated patients; autonomic hyperactivity, severe disturbance in cognition, visual or tactile hallucinations, delusions, fever, insomnia, anorexia

True

True or false? Major alcohol withdrawal delirium is a medical emergency

Monitor fluids/electrolytes, IV therapy as indicated, monitor VS, respiratory depression, frequently reorient, reduce environmental stimuli, continuous presence of support person

Nursing interventions for alcohol withdrawal treatment

Benzodiazepines, barbiturates, thiamine, folic acid

Medications to administer during withdrawal

Acamprosate

Reduces alcohol cravings and urges; does not curb withdrawal symptoms; taken TID (adherence to frequency may be a a challenge)

Naltrexone

Reduces craving and reduced pleasure effects if alcohol is consumed (drug blocks sopamine stimulation)

Disulfiram

Causes escalating unpleasant symptoms when alcohol is consumed; only for persons with goal of abstinence bc heavy alcohol use increases risk for hypotension, SOB, tachycardia, MI

Morphine, heroin, meperidine, codeine, hydromorphone, OxyContin, fentanyl

Examples of opioids

Action of opioids

CNS depressant; sleep or stupor, respiratory depression; exogenous analgesics bind to receptor for endogenous produced analgesics; alleviate pain and provide calming or euphoric sensations

Opioid intoxication

Apathy, lethargy, impaired judgement, agitation, constricted pupils, drowsiness, slurred speech

Opiate OD

Saturation of analgesic Mu, kappa, and delta receptors (endorphin receptors); excessive overstimulation of Mu receptors in medulla causes respiratory depression, hypoxia, and death by respiratory arrest within 3-5 min

No tolerance, return to use after cessation, other medical problems, previous OD, using alone

Patient risk factors for opioid OD

Potency, contaminants, routes of administration, polysubstance use

Drug risk factors for opioid OD

Signs of opioids OD

↓ LOC, pinpoint pupils, choking/snorting/gurgling sounds, blue lips/fingernails, cold and clammy skin, limp body or rigid muscles, vomiting/foaming

↓ RR, HR, BP, O2 sat

Arms, between shoulder and wrist

What is the safest place to inject drugs?

Neck, face, wrist, groin, genitals

What are the most dangerous spots to inject drugs?

Naloxone

Nasal spray or IM injection opiate antagonist (knock opioids off Mu receptors and binds to it, reversing respiratory depression; takes 2-3 min to work and lasts 20-90 min (depends on dose of opioid taken, body weight, etc)

Effects of naloxone

Agitation, anxiety, muscle aches, pain, sweating, nausea, vomiting

Early symptoms of opioid withdrawal

Begin in first 24 hrs after person stops using drug; drug craving, muscle aches, restlessness/anxiety, lacrimation, runny nose, excessive sweating, insomnia, yawning often

Later symptoms of opioid withdrawal

Begin in 1st day or so; diarrhea, N/V, abdominal cramping, bone pain, goose bumps, dilated pupils, blurry vision, tachycardia, HTN

Methadone, buprenorphine (suboxone), heroin

Medications for opioid maintenance treatment

Cognitive behavioral therapy

Cognitive approaches to addiction has the individual change the way they think about a situation and their emotional reaction to it; will result in behavioral response to change

12 step facilitation

Set of semi-structured therapies designed to help people abstain from alcohol and other drugs by systematically linking them to and encouraging their active participation in community based 12 step mutual help organizations

Have you ever...

1. Felt the need to cut down on drinking?

2. Become annoyed by criticisms of your drinking?

3. Felt guilty about your drinking?

4. Needed a drink in the morning to steady your nerves or get rid of a hangover (eye-opener)?

CAGE questionnaire

False ("yes" to 2 questions is enough to indicate a possible problem)

True or false? If a patient answers "yes" to 3 or more of the questions in the CAGE screening tool, there is a possible problem

Gambling disorder

Repeated, problem gambling behavior which leads to problems for the individual, families, and society; individuals continue even when it causes significant problems

Drug diversion

Theft of pharmaceuticals by those who have access due to their position for personal use (addiction or trafficking)

Report to management and document

Nursing interventions when suspecting drug diversion

CNS symptoms reflecting Wernicke-Korsakoff syndrome

A client has a chronic alcohol use disorder. Which of the following problems are related to thiamin deficiency?

Delirium tremens

A client with alcoholism is in the process of detoxification. The client begins to have a seizure and experience hallucinations. These severe symptoms of withdrawal are referred to as:

An example of controlled drinking is eating before consuming alcohol

Which of the following statements are true about Canada's low risk drinking guidelines?

Report your suspicions to the nurse manager

You observe a co-worker acting erratically. The clients assigned to this co-worker don't seem to get relief when pain medications are administered. Which action should you take?