Substance Related and Addictive Disorders

What is Codependecy?

• Dysfunctional behaviours learned by people who were abused.

• The result; The victim acts as the “adult”.

• Codependcy can enable the victim’s maladaptive behaviour.

Fetal Alcohol Syndrome

• Brielfy explain what is the condition.

• Prenatal exposure of ETOH which affects the fetus. Often occurs during pregnancy.

• Women who are pregnant should avoid drinking at all times.

Fetal Alcohol Syndrome

• What are the characteristics that can be seen with fetal alcohol syndrome?

• What are some other problems that go along with FAS?

• A small head circumference, low nasal bridge with short nose, small eye openings, and a small midface, with thin upper lip.

• Lower IQ score, poor concentration, hyperactivity, learning disabilities, poore reasoning skills.

ETOH Blood Alcohol Levels/Drinks and S/S

• 0.05 or 1-2 drinks

• 0.10 or 2-3 drinks

• 0.15 or 3-4 drinks

• 0.20 or 4-5 drinks

• 0.30 or more than 6 drinks

• Relaxed, loss of inhibition, impaired judgement.

• Slurred speech, S/T memory loss, impaired motor skills.

• Mood swings, AMS, vomiting

• Loss of temperature, coma, unconscious

• Unresponsive, death.

ETOH Withdrawal Syndrome

• Stage 1 S/S (8 hours)

• Stage 2 S/S (1-3 days)

• Stage 3 S/S (1 weeks)

• Stage 1 is mild; anxiety, insomnia, nausea, abd pain.

• Stage 2 is moderate; HTN, increased body temp.

• Stage 3 is severe/DTS; Seizures, hallucinations, fever, agitation.

Difference between AUDIT and CIWA

• AUDIT is a screeening tool designed to assess if patient has EOTH dependency.

• CIWA is a screening tool often used during ETOH withdrawl and interventions are based on patients scores.

Sedative/Hypnotic/Anxiolytic Use Disorder

What are the clinical manifestations for intoxication?

• Memory disorientation, confusion, unsteady gait, impaired judgement, impaired attention, disinhibition of sexual or aggressive impulses.

Sedative/Hypnotic/Anxiolytic Use Disorder

• When does withdrawl symptoms begin?

• What are the clinical manifestations during withdrawl?

• Usually within 1 week of last use.

• Clinical manifestations include diaphoresis, tachycardia, nausea, vomiting, tremors, seizures, orthostatic HPTN, malaise.

Stimulant Intoxication

• What are the clinical manifestations for intoxication?

• Amphetamine and cocaine intoxication

• Physical symptoms such as tachycardia, pupil dialation, elevated blood pressure, sweating or chills, nausea, vomiting.

• Nonphysical symptoms such as fighting, grandiosity, hypervigilance, psychomotor agitation.

• Caffeine intoxication

• Restlessness, excitement, nervousness, GI disturbance, tachycardia, arrhythmias, psychomotor agitation may occur, rambling flow of thoughts.

• Usually occurs if greater than 250 mg of caffeine was consumed.

• Nicotine intoxication

• Nausea, vomiting, H/A, rapid heart rate, rapid respiratory rate, increased blood pressure, dizziness, and confusion.

Stimulant Withdrawal

• What are the clinical manifestations for withdrawal?

• When does withdrawal symptoms normally begin with stimulants?

• Caffeine withdrawal

• H/A

• Nicotine withdrawal

• Increased craving for the drug, anger, frustration, decreased heart rate, increased appetite, weight gain, H/A, restlessness.

• Withdrawal symptoms begin within 24 hours of last drug use and decrease in intensity throughout the days and weeks.

• Amphetamines & Cocaine withdrawal

• Depressed mood, suicidal ideation, insomnia or hypersomnia, psychomotor agitation, paranoia, anxiety.

• For amphetamines, usually withdrawal symptoms may begin 2-4 days but depression and irritability may persist for months.

• Large quantity of cocaine use can result in severe convulsion, arrythmias, and death.

Opioid-Use Disorder

What are the clinical manifestations for intoxication?

• Feeligns of euphoria, lethargic, drowsy, impaired judgement, slurred speech, decreased respiratory rate, decreased blood pressure, pupillary constriction.

Opioid-Use Disorder

When does withdrawal symptoms usually begin?

What are the clinical manifestations for withdrawal?

• Begins to appear within 6 to 8 hours after last dose, reaches a peak within 2-3 days, and will subside within 5 to 10 days.

• Pupil dialation, yawning, rrhinorrhea, lacrimination (flow of tears), craving of the drug, nausea, vomiting, sweating, diarrhea, muscle aches.

Cannabis Use Disorder

• What are the clinical manifestations for intoxication?

• When does intoxication occur and how long does it last?

• Sense of slowed time, pink eyes, increased appetite, impaired judgement, euphoria, anxiety, dry mouth, tachycardia, social withdrawal.

• Intoxication will occur usually immediately and lasts for 3 hours.

Cannabis Use Disorder

• What are the clinical manifestations for withdrawal symptoms?

• Stomach pains, fever, chills, H/A, depressed mood, loss of appetite, irritability, tremors.

Opioid Overdose S/S

• Respiratory - Shallow breathing, respiratory arrest

• Cardiovascular - Slowed pulse

• Skin - clammy skin

• Neuro - convulsion, coma.

Amphetamine Overdose S/S

• Cardiovascular - Rapid pulse, HTN, cardiac arrythmias

• Neuro - Coma, convulsions

Cocaine Overdose S/S

• Cardiovascular - Cardiac arrest

• Respiratory - Respiratory failure

• Neuro - Convulsion, coma, hallucinations

ETOH Overdose S/S

• GI - N/V

• Respiratory - Shallow breaths

• Cardiac - Weak pulse

• Skin - Cool, clammy skin

• Neuro - Coma

Cannabis Overdose S/S

• Hallucinations

• Delusions

• Paranoia

• Psychosis

Sedative/Hypnotics/Anxiolytics Overdose S/S

• Tremors

• Delirium

• Convulsions

• Disorientation

• Hallucinations

Nursing Diagnosis For Substance Use Disorders

• Denial

• Inneffective Coping

• Imbalance Nutrition; Less than body requirements

• Risk for infection

• Chronic low self-esteem

• Deficient knowledge

• Risk for injury (mostly seen with CNS depressant withdrawal)

• Risk for suicide (mostly seen with CNS stimulant withdrawal)

• Will make statements that deny having an addiction problem, with either refuse to seek help or delay seeking assistance, will often say they can quit anytime they want.

• Abuse of chemical agents, risk taking, destructive behaviors toward others.

• Weight loss, anemic, drinking ETOH rather than eating, poor skin turgor, pale.

• Malnutrition, altered immune condition, failing to avoid exposure to pathogens.

• Critizes self and others, self-destructive behaviour, dysfunctional family background.

• Denies substance is harmful, continues to use it despite being aware of its consequences.

• CNS agitation (tremors, elevated blood pressure, tachycardia, nausea and vomiting, hallucinations, seizures).

• Intense feelings of depression and lassitude (feeling weak), suicidal ideation, “crashing” experience.

Nursing Actions for Risk of Injury

• Explain outcomes and nursing interventions to meet these outcomes (both short-term and long-term goals).

• Short term goal is the patient’s condition will stabilize within 72 hours.

• Long term goal is the patient won’t experience physical injury.

• Nursing interventions

• Assess patient’s level of disorientation, obtain their drug hx, and get a urine sample.

• Minimize external stimuli by transfering them to a quiter environment.

• Observe patient frequently throughout their admission.

• Frequent orientation and VS taken q15min.

• Suicide precautions should be taken if patient is withdrawling for CNS stimulants.

• Pad the SR and headboard in case of seizures since it may occur for CNS depressants.

Nursing Actions for Denial

• Explain outcomes and nursing interventions to meet these outcomes (both short-term and long-term goals).

• Short-term goal is the patient will focus on behavioral outcomes associated with substance use.

• Long-term goal is the patient will acknowledge their problem and vocalize acceptance and responsibility for their behavior.

• Nursing interventions

• Establish a rapport

• Use of acceptance to the patient (best example is to accept the patient but not accept their behavior)

• Re-educate the patient about common misconceptions and to not accept irrational thinking patterns such as rationalization or projection.

• Encourage participation in group activities

• Offer positive recognition when patient is making progress.

• Confront the patient whenever they are fantazing about their lifestyle to deny their denial but do so with a caring attitude.

• Speak objectively and w/o judgement.

Nursing Actions for Inneffective Coping

• Explain outcomes and nursing interventions to meet these outcomes (both short-term and long-term goals).

• Short-term goal is that the patient begins to express their true feelings about using substance to cope with their stressors.

• Long-term goal is the patient verbalizing use of adaptive coping mechanisms rather than substance use when responding to stress.

• Nursing interventions

• Establsh a rapport

• Encourage patient to verbalize their feelings of fear and anxiety.

• Explore with the patient available options to help them cope rather than continuing on using substances.

• Educate patient about the harmful effects substances have on the body

• Do not encourage manipulative behavior

• Use of positive reinforcement

Nursing actions for Imbalanced Nutrition; Less than Body Requirements

• What are the short-term and long-term outcomes along with nursing interventions?

• Short term goal is that VS, BP, and lab values are WNL.

• Long term goal is that the patient will verbalize importance of adequate nutrition.

• Nursing Interventions

• Monitor I/O and daily weights

• Restrict sodium to minimize fluid retention

• Monitor protein intake for a patient with impaired liver function

• Provide small, frequent feedings.

• Consult with dietitian.

Nursing actions for Deficient Knowledge

• What are the short term and long term outcomes along with the nursing interventions?

• Short-term outcome is that patient will verbalize negative effects substance has on their body.

• Long-term outcome is the patient will verbalize knowledge about medication to take while abstaining from substance-use (mostly seen with ETOH and opiods).

• Nursing interventions

• Assess patient’s level of knowledge and readiness to learn.

• Provide information about the negative effects a substance has on the persons body.

• Include others in teaching if possible (such as significant other or family)

• Educate patient about medication that need to be taken to help treat their substance use.

Treatment Modalities for Substance-Use Disorder

• Explain all forms of treatment to assist a patient who has substance-use disorder.

• Encourage use of AA or NA for patients who suffer from alcohol or opioid use.

• Encourage counseling and group therapy

• Medication-assisted treatment is heavily used as well with managing withdrawal symptoms or intoxication or even overdose.

Medication-Assisted Treatment - Psychpharmacology

• What medications are used for ETOH withdrawal?

• What medications are used for ETOH abstinence?

• What other treatment is used for ETOH?

• Benzodiazepines (lorazepam, diazepam) are commonly used. Dose is initially high and is reduced to 20% until withdrawal is complete.

• Anticonvulsants (carbamazepine, gabapentin, valproic acid) are also used to help with withdrawal, specifially used to prevent withdrawal seizures.

• A narcotic antagonist (naltrexone) is used for treating ETOH addiction.

• Disulfiram is a common drug given for ETOH abstinence. However, there are a few things to know about this drug.

• Any time a patient consumes ETOH, a mild reaction occurs within 5 to 10 minutes, giving of discomforting symptoms.

• Disulfiram can only be given if patient has abstained from ETOH for at least 12 hours.

• Under this therapy, patient should avoid ETOH substances such as vanilla extract, OTC medications (cold medications), mouthwash, cologne, aftershave, nailpolish.

• Consuming ETOH along with disulfiram can result in a reaction which can lead to death if too much ETOH was consumed.

• Multivitamin replacement therapy along with thiamine is used for ETOH.

Disulfiram-Alcohol Reaction Signs and Symptoms

• Blood Alcohol Level of 5-10 mg/dL

• Blood Alcohol Level of 50 mg/dL

• Blood Alcohol Level of 125 to 150 mg/dL

• Mild reactions occurs.

• Flushed skin, throbbing sensation at the head and neck, respiratory difficulty, nausea, vomiting, tachycardia, sweating, HPTN.

• Respiratory depression, cardiovascular collapse, arrhythmias, myocardial infarction, convulsions, death.

Medication-Assisted Treatment - Psychpharmacology

• What medication are used for opiate intoxication?

• What medication are used for opiate withdrawal?

• Naloxone can be given. Also naltrexone can help however a patient must not have taken any opiods for at least 1 to 2 weeks prior to starting therapy.

• Methadone is the drug of choice. The dose is slowly tapered over a specific time.

• Buprenorphine is a safer choice and works best for mild to moderate addiction of opiods.

• Clonidine may also be used. Not as effective as methadone though.

Medication-Assisted Treatment - Psychpharmacology

• What medications are used to treating barbiturate withdrawal symptoms?

• Phenobarbital is often used. Once patient is stabilized, the dose is gradually decreased by 30 mg/dL until withdrawal is complete.

Medication-Assisted Treatment - Psychpharmacology

• What medications are used to treat stimulant intoxication?

• What medications are used to treat stimulant withdrawal?

• Mild to major tranquilizers are used. Chlordiazepoxide as a minor tranquilizer is used. If a mjaor tranquilizer is needed, than haloperidol is used.

• Antipsychotic medications may be useful since they lower the risk for seizures.

• IV diazepam can be used for repeated seizures.

• With withdrawal symptoms, potentially anti-depressants can be used if depression symptoms appear.