Ch. 22 Substance-Related and Addictive Disorders💗

Objectives 

. Differentiate between various substance abuse disorders (e.g., alcohol, stimulants, sedatives, hallucinogens). Based on clinical manifestations, diagnostic criteria, and potential complications.

2. Develop individualized evidenced based nursing care plan for patients with substance-based use disorders incorporating physical, psychological, and social needs.

3. Implement therapeutic nursing interventions such as motivational interviewing, harm reduction strategies, and relapse prevention strategies for clients with substance use disorders.

4. Describe therapeutic interventions for patients with substance abuse disorders.

5. Describe appropriate pharmacologic treatments used in the management of substance use disorders, including medications for withdrawal, maintenance, maintenance, and relapse prevention (e.g., methadone, buprenorphine, naltrexone, disulfiram).

Substance Use Disorders

˜Pathological use of a substance that leads to a disorder of use.

Symptom fall into 4 major groups:

uImpaired control

uSocial impairment

uRisky use

uPhysical effects (i.e., intoxication, tolerance, and withdrawal)

˜need more and more bc of tolerance level

benzo- give narcan reversal

antebuse

if pt unstable- you have to act

if stable- assess

dont tell pt what to do

watch for headaches in them- bc higher risk for head bleeding. 

Substances That Lead to
Use Disorders

• ˜Alcohol

• ˜Caffeine

• ˜Cannabis

• ˜Hallucinogen

• ˜Inhalant- like spray can

• ˜Opioid- dilodid, morphine, tramidol

• ˜Sedative-hypnotic

• ˜Stimulant

• ˜Tobacco

Other:

In addition to substances behaviors can also be addictive. Process addictions—Gambling, shopping, sex, social media etc.

What are Concepts Central to Addictive Use Disorders

Addiction

uchronic medical condition

Intoxication

uin the process of using a substance to excess  

Tolerance

utakes a higher dose to achieve the initial level of response.

Withdrawal

usymptoms that occur when a person stops using a substance, can be mild or life threatening

How many people are addicted to substances

Alcohol

u15 million people addicted

Other substances

uAbout 8 million people addicted

uMarijuana: 4.5 million

Opioids: 2.0 million

Comorbidity

Psychiatric comorbidity

uAny combination of two or more substance use disorders and mental disorders

What are the risk factors

uGenetic factors- parents

uNeurobiological factors

Environmental factors- poor , bad neighborhoods, increased stress, anxiety-, depression.

What is caffeine use disorder 

Caffeine

• Most widely used psychoactive substance in the world. Its not an official use disorder. 

• Can result in intoxication, overdose, and withdrawal

• Excessive use is associated w bipolar, eating and sleep disorders. 

• Effects can happen 15 min after drinking and can last 6 hrs. 

What are the s/s of caffiene intoxication 

Intoxication- more than 250 mg. 

• S/S- restless, nervousness, excitement, agitation, rambling speech, inexhaustibility,

• Flushed face, diuresis ( increased urine), muscle twitching, tachycardia, cardiac arrhythmias.

What are the s/s of caffine overdose and how do we tx it 

Overdose and tx

• Fever, tachycardia or bradycardia, hypertension at first and then hypotension.

• Extremely high doses can cause seizures, respiratory failure, even death.

• Common- Mydriasis ( pupils dilate) , hyperreflexia, N/V.

• Disorganized thinking, agitation, delusions, hallucinations and seizures dt ischemia from vasoconstriction. 

• Tx- Hydration oral or IV, gastric lavage to remove excess caffeine or activated charcoal, Beta blockers for +HR, Vasopressors to maintain BP.

What are the s/s of caffiene withdraw

Withdraw

• Headache, drowsy, irritability, poor concentration, Flu like symptoms like N/V, muscle aches. Symptoms happen in 12-24 hrs after the last dose, peak in a day or two and resolve in a week 

What is cannibis disorder 

Cannibis (Marijuana)

• Third most commonly used psychoactive drug in the United States after alcohol, and illicit drugs. can have auditory, hallucinations, visual tactlie- thing something crawling on them. When stop- anxiety

• Hyperemsis canaboid disorder- N/V

What are the s/s of cannabis intoxication

• Heightens sensations, experience brighter colors, see new details in common stimuli, time goes more slowly, in higher doses can experience depersonalization and derealization. 

• S/S required for a diagnosis-  Two or more symptoms- conjunctival infection- eyes red, increased appetitie, dry mouth, tachycardia. 

• Hallucinations w intact reality testing, auditory, visual, and tactile illusions in the absense of delirium 

What are the s/s of cannibis withdraw 

Withdraw

• happen within 1 wk of stopping. Irratable, anger, agression, anxiety, restless, depressed mood.

• Insomnia, distrubing dreams, decreased appetitie- can cause weight loss. 

• Physical symptoms include at least one of the following- abdominal pain, shakiness, sweating, fever, chills, or headache. 

What tx do we do for cannabis abuse

Tx- Abstinence and support. Therapy- either one. Antianxiety meds for short term relief, if they have underlying anxiety and depression - can do antidepressants. 

What are Hallucinogens

Hallucinogens

Cause a profound disturbance in reality,

They cause flashbacks, panic attacks, psychosis, delirum, mood and anxiety disorders 

Ex. Classic- LSD,   Dissociative drugs- Ketamine, Phencyclidine PCP

In a 12 month period they can have intense cravings, difficulty w role obligations, and impairment/ tolerance

What are the s/s of halluciongen intoxication

• Paranoia, impaired judgment, intensified perceptions, depersonalization, derealization.

• Illusions, hallucinations, synesthesia ( hearing colors or seeing sounds), 

• Dilation of pupils, tachycardia, sweating, palpitations, blurred vision, tremors, incoordination. 

What tx do we do for hallucinogen intoxication

Talk the pt down, reassure that symptoms are caused by the drug, and they will go away.

Physical restraints, 

Severe cases- haloperdiol- antipsychotic

benzodiazepine like diazepam in short term. 

What is Phencyclidine intoxication

• Medical emergency that can cause violent side effects. 

• They can be belligerent- hostile and aggressive, assultaive, impulsive and unpredictable.

S/S

• Nyastagmus ( eye movement), hypertension, tachycardia, diminished reponse to pain,

• ataxia ( loss of muscle control),

• dysarthria ( unclear speech),

• muscle rigidity, seizures, coma,

• hyperacusis ( sensitive to sound)

• Hyperthermia and seizure activity 

TX

• Cant be talked down- may require a restraint. 

• Calming med like benzodiazepine IM or IV

• Mechanical cooling for hyperthermia 

What are the s/s of hallucinogen withdraw

• red eyes, increase appetitie, dry mouth, hallucination, very irritable when wean them off

What is inhalant use disorder 

Inhalants

• Solvents for glues and adhesives

• Propellants

• Thinners

• Fuels

• paint sprays, gas, propane

• Toxic gases inhaled- Can cause death bc it goes into blood stream

What are the s/s of inhalant intoxication

• Small doses= Disinhibition and feel euphroria, auditory, impaired d

• High doses= fearfulness, illusions, aduitory and visual hallucinations, distorted body image. Apathy( loss of interest) , diminished social and occupational fx, impaired judgment, impulsive and agressive.

• Nystagmas, diplopia, nausea, anorexia, depressed reflexes,

• High doses-  stupor, unconscious, amnesia, delirium, psychosis, dementia

What is the tx for inhalant use

• Tx- end up in coma, arrhythmias, bronchospasm,

• WIll get haldol for agitation

What is opiod use disorder 

˜Heroin and prescription drugs

Opioid intoxication

uCravings result in larger amounts, longer periods of use, increasing tolerance to its effects

uResults in significant impairment in life roles, interpersonal conflict, and puts a person in physically hazardous situations

What are the s/s of opioid intoxication

• Psychomotor retardation- slowing down, drowsiness, slurred speech, altered mood ( withdrawn to elated), impaired memory and attention, 

• myosis- pinpoint pupils ( red flag), decrease bowel sounds. RR and BP low, HR low to normal

• track marks or fresh injection sites 

What are the s/s of opiod overdose

Opioid overdose

Death usually due to respiratory arrest

S/S

• unresposive, slow RR, coma, hypothermia, hypotension, bradycardia, 

• the big 3 symptoms tells you its an overdose- pinpoint pupils, coma, respiratory depression 

What is the tx for opiod overdose

Treatment:

1. promote breathing; aspirate secretions, insert airway, mechanical ventilation.

2. nalaxone IN, IM,sub q, IV- increased rr and dilated pupils should happen quickly. Repeat if needed. Too much naloxone can cause withdraw symptoms

What are the s/s of opioid withdraw 

• Mood dysphoria ( persistent low mood), N/V, diarrhea, muscle aches, fever, insomnia,

• Lacrimation ( watery eyes)

• Rhinorrhea ( runny nose)

• pupils dilate, yawning 

• piloerection ( hairs stand up or goosebumps)

• Males- sweating and spontaneous ejaculations while awake. 

What are the meds given to tx opidod withdraw

Opioid withdrawal

methadone, clonidine, buprenorphine, lofexidine 

these meds help with pain but wont make you overdose. Wont put you in resp distress, or kill you.

Pts can wean off opiods witht these meds- will control the pain.

Opioid maintenance

uPharmacological

uPsychotherapies

always call poison control center

What are the s/s of methadone

• Methadone- used to decrease painful symptoms of opiod withdraw. It blocks the euphoric effects of drugs such as heroin, morphine, codeine, oxycodone, hydrocodone. if have these s/s need to seek medical care- difficulty breathing, light headed, fast herat beat, chest pain, anaphylaxis, hallucinations or confusion should re reported to provider.

What is clonidine

• clonidine- eases sweating, hot flashes, watery eyes, and restlessnes,, decreases anxiety,

What are the s/s of buprenorphine/naloxone

• buprenorphine/naloxone- used to help people reduce or quit opiates. Opioid partial agonist. Like opiods it produces euphoria or resp depression but these effects are weaker compared to heroin or methadone.

• S/S- N/V, constipation, muscle aches and cramps, insomnia, irratble, fever. used only after 12-24hrs after withdrawal.

• It can bring on acute withdraw for pts who arent in the early stages of withdrawl and who have other opioids in their system. Its a long acting drug, once pt is stablized they can switch to having it alternating oral tansmucosal instead of every day dosing.

What is Lofexidine

Lofexidine- can help people at home in a few days rather than a week.

What meds are given for opioid maintenance therapy 

• This is once sober we want to contiune abstinence. 

• Buprenorphine/ nalaxone and methadone reduce carvings. 

• Naltrexone- opioid antagonist that prevents intoxication. Blocks the activation of opiod receptors and the feeling of euphoria. 1x a day dosing. 

• Can also give injectable form naltrexone callled vivitrol- given 1 a month IM . good for pts struggle w nonadherance and problems w access to healthcare. 

• Naltrexone S/S- Gi distress, muscle cramps, dizzy, sedation, appetitie disturbances. Feel pain, sweeling brusing if injection site rx. Complications- cellulitis, induration- hardening or thickening of tissue, rarely- necrosis, abcesses.

What psycholigical tx do we do for opioid abuse

• All types of therapy- indvidual, behavioral, cognitive, family therapy,

• social skills training

• support groups like narcotics anonymous- 12 step program

• Residental tx and theraputic communities- more structure is provided. They work best w highly motivated individuals. Confronation in the group enviornment and isolation from the outside word are empahsized in these settings. 

What is Sedative, Hypnotic, and Antianxiety Medication Use Disorder

Problematic Substances

uBenzodiazepines- cant mix w alchohol

uBenzodiazepine-like drugs. Ex. zolpidem and zaleplon 

uCarbamates

uBarbiturates- Ex. Secobarbital

uBarbiturate-like hypnotics ex. mathaqualone 

This class includes all prescription medications and antianxiety meds. 

Craving is a typical feature

What are the s/s of Sedative, Hypnotic, and Antianxiety Medication Use Disorder

• This is a group of depressants- think calms you down

• Slurred speech, incordination, unsteady gait, nystagmus, impaired thinking. Coma

• Inappropriate agression and sexual behavior, mood flucation, imapired judgment

What tx do you do for overdose of Sedative, Hypnotic, and Antianxiety Medication Use Disorder

sent to ICU with withdraw and overdose symptoms. Have to be intubated bc have respiratory depression

Overdose: gastric lavage, activated charcoal, VS, if they’re awake after overdosing then they should be kept awake to prevent loss of consciousness. if uncosious- Iv fluid line, ETT for airway, mechanical ventilation. 

What are the s/s of Sedative, Hypnotic, and Antianxiety Medication Use withdraw

Withdrawal:

• We can have rebound hyperactivity where body has depressed CNS and then it tried to return to homeostasis.

S/S

• Autonomic hyperactivity, tremors, insomnia, psychomotor agitation, anxiety, grand mal seizures

Tx

• gradual reduction of benzodiazepines to prevent seizures and other symptoms. Barbituate withdraw can be aided by using long acting barbituate like phenobabital. 

What is Stimulant Use Disorder 

Clinical Picture

uAmphetamine-type, cocaine, or other stimulant drugs.

uSecond only to cannabis as the most widely used illicit substances in the United States

• Truckers, athletes, studying exams

• disordered pattern can occur in as little as 1 wk
  Euphoria, high energy

what are the s/s of stimulant intoxication 

• feel superhuman

• euphoric, socialable, elated, hypervigilant, sensitive, anxious, angry, tense agitated

• 2 or more of the following- , chest pain, arrythmias.  high or low bp and hr, resp depression, dilated pupils,  diaphoretic- perspiration,chills, N/V, weight loss, psychomotor agitation or retardation, weakness, confusions, seizures, coma 

What are the s/s of stimulant withdraw 

• can happen within few hrs or several days. Tired, vivid nightmares, increased apeitite, insomnia or hypersomnia, psychomotor agitation or retardation. Function is impaired

• depression and suicidal thoughts

What withdraw do we do for stimulate use disorder 

Withdrawal treatment

Amphetamines- inpatient setting is necessary. 

• Group/ family and individual therapy

• Antipyschotics for a few days

• If there is no pyschosis- Possible diazepam for agitation

• 1 to 2 weeks’ cocaine withdrawal requires no inpatient care; no drugs reduce symptoms such as fatigue, mood changes, disturbed sleep. 

• Depression treatment once withdrawal is complete (e.g., bupropion)

• Intense cravings for cocaine- might hospitalized. 

• unscheduled urine drug tests 

What are other disorders 

Tobacco

˜Withdrawal is distressing- have these patterns around cigarette and its so addicting.

Withdraw s/s- irritability, anxiety, depression, difficulty concentrating, restlessness, insomnia. Within days of them quiting smoking their HR decrease by 5-12 beats/ min. Within a year they increase their weight by 4-7 lbs.

˜Withdrawal treatment: behavioral therapy- to teach them how to recognize their cravings. hypnosis, nicotine replacement therapies- ex. gum, patches. ; antidepressant- bupropion or varenicline- mimics the effects of nicotine- nicotine receptor antagonist - partially blocks the receptor and blunts the effect of nicotine if they resume smoking.

Gambling disorder

Lie to conceal gambling, it can be regular or episodic. Heavy gambling may be interspersed with abstinence. Stress and depression increase this behavior.

Tx-

˜Gamblers Anonymous (GA)- 12 step program kind of like AA- publicly confess, peer pressure, peer counselors who used to gamble and are now reformed.

Hospitalization can remove them from a gambling environment. Individual, group and family therapy.

˜Possible treatment with SSRIs, bupropion- antidepressant (Wellbutrin), mood stabilizers- lithium , and anticonvulsants like topiramate.

what is Alcohol Use Disorder

uSedative with initial euphoria

Severity based on number of DSM-V symptoms

uMild: 2–3 symptoms

uModerate: 4–5 symptoms

uSevere: 5 or more symptoms

uExtensive List in DSM-V box

What other disorders do people with Alcohol Use Disorder have

Epidemiology

uAlmost twice the prevalence among adult men than adult women- runs in family

uAmerican Indians/Alaska Natives (12.1%) have the highest rates; disproportionately affected by alcohol problems.

Comorbidity

uBipolar disorders, schizophrenia, antisocial personality disorder, major depressive disorder

What are the risk factors of alcohol use disorder 

Risk Factors

uGenetics

uNeurobiological

uSocial

uCultural

Types of Problematic Drinking

uBinge Drinking

uHeavy Drinking

What is alcohol withdraw s/s

Alcohol intoxication

uLegal definition of intoxication in most states: blood concentration of 80 or 100 mg ethanol per deciliter of blood (mg/dL).

uOften expressed as 0.08 to 0.10 g/dL.

uAlcohol withdrawal

s/s

• Tremulosness aka shakes or jitters- classic sign happens 6-8 hr after withdrawl.

• Agitation, lack of appetitie, N/V, insomnia, impaired cognition, mild perceptual changes- they can have delusions and hallucinations if they have delirium.

• BP, HR, temp increase

• Chlodiazepoxide can be used for tremulousness and mild to moderate agitation.

• if psychotic and perceptual symptoms- medical emergency bc of risk of unconscious, seizures, delirium. Give lorazepam and Chlodiazepoxide PO or IM

• Withdraw seizures- generalized tonic clonic - Diazepam IV

• Alchohol withdraw delirium- aka delireum tremens - medical emergency that can result in death. can happen anytime within the first 72 hrs. Autonomic hyperacitvity- + HR, diaphoresis, fever, anxiety, insomnia, hypertension, delusions and visual and tactile hallucinations are common. -Give oral diazepam for acute symptoms, Chlodiazepoxide to keep them out of danger, once delirium disappears lorazepam IV for severe symptoms. Seclusion, correct dehydration dt sweating or fever w oral or iv fluids. 

What is Wernicke-Korsakoff syndrome

Cognitive disturbances people w heavy alcohol use may suffer from short term memory disturbances.

encephalopathy, dont absorb nutrients, become malnourished rather drink than eat. Can get cognitively impaired, confusion,- decrease in thiamine

eye. abnormalities. tremors

Wernicke-Korsakoff syndrome-

Wernickle enecepalopthay- acute and reversable.

• S/S- Altered gait, vestibular dysfunction, confused, eye problems ex. horizontal nystagmus, lateral orbital palsy, gaze palsy. Eyes not symetrical. sluggish rx to light, anasocria- uneven pupil size

Korsakoff- chronic condition that can kill you.

• medical emergency. mimick stroke symptoms. Have to get IV vitamins ( banana bag) and nutritional support 

• both are tx w thiamine

Fetal alcohol syndrome- teach them to not drink alchohol at all 

What are the effects of Alcohol Use Disorder 

Systemic effects

uPeripheral neuropathy- nerve damage - presethesia like numbness, pain, muscle weakness, sensitvity to touch, burning.  gait issues, thymine/ folic acid replacement. discontinuing alchohol will prevent further deteroriation. 

uAlcoholic myopathy- muscle weakness and myonecrosis- muscle damage. signifant reduction in muscle mass 

Alchoholic  cardiomyopathy- weakens and thins the muscle of heart. Leads to enlargment and HF. fatigue, sob, edmea 

uEsophagitis, gastritis, and pancreatitis-

gastritis- alchohol irriate lining of stomach and can cause ulcers. also have n/v, loss apetite, belching, and bloating. 

if pancrease dies- get diabetes, vomit, nausea,  have bad abdominal pain, increase amylase, lipase, gonna be IV fluids, NPO, monitor shock. Chronic pancreatitis- malnutriton, weight loss, diabetes mellitus. 

 vommiting and damage to esophagus- burns tissue and can get worn down. this can cause esophageal varacies

uAlcoholic hepatitis- diseased and inflamed liver. appetite changes, dry mouth, weight loss, N/V, pain, swelling in abdomen, jaundice, fever, confusion, fatigue.

uCirrhosis of the liver- makes clotting factors. AST. ALT, increase PT and INR, blood thin not clotting. Need vit K but they’re not absorbing that. S/S- bleeding and bruising, pruritus, jaundice, ascites, leg edema, weight loss, confusion, spider like vessels, petechiae, Tx- transplant , low Na diet

uLeukopenia- bone marrow not working, doesnt make WBC so risk infection. Low WBC dt vitamin deficiencies and low protein.

uThrombocytopenia- Low plts- bleeding.

Cancer (especially head and neck)- 

cant fx until get drink- have tolerance as well. 

rapid hr, sweating, delusion, hallucinations- psychosis delirium. cant miss a pt whos an alcoholic

screen everyone

What are screening tools 

˜SBIRT: Screening, brief intervention, and referral to treatment

˜AUDIT: Alcohol use disorders identification test

˜CAGE: 4 questions to identify alcohol abuse- have you felt the need to cut down on your drinking. Are you annoyed by your drinking. Have you felt guilty about your drinking. Have you ever had a drink in the morning ( eye opener) . Score of 2 or more is signifcant.

˜CAGE-AID: Same questions as CAGE but adds drug use to alcohol. Adapted to Include Drugs

˜T-ACE: Tolerance, Annoyance, Cut down, Eye-opener

good response- your answers help us figure out how to tx you. What concerns you.

What drugs do we give

Pharmacotherapy

uDisulfiram- antebuse, tachycradia, sweating, blurry vision, resp distress, teach not to drink alchohol, contraindicated in pregnancy. Inform the patient that ingesting alcohol while taking this medication produces a toxic reaction that causes intense nausea and vomiting, headache, sweating, flushed skin, respiratory difficulties, and confusion. Avoid all alcohol and substances like cough syrup and mouthwash that contain alcohol.

Disulfiram must be taken consistently to maintain the aversion to alcohol.

uNaltrexone- used for withdraw and relapse prevention

uBenzodiazepines- LAM/PAMS

WHat do we assess, and plan

Assessment

uFamily assessment (codependence)- doing things for others when they are capable of doing it themselves. Their self worth is dependent on caring for others at the expense of their own needs. Enabling- calls in for spouse, covering for them, bail out of jail.

Planning

uIdentifying problem

uSetting a goal

uDetermining the interventions that will accomplish the goal

Care Continuum for Substance Use Disorders

uDetoxification (detox)- 24 hr medical coverage while they detox.

uRehabilitation- short term rehab offers rehabilitation ( learning a lost skill) long term rehab offers habilitation ( learning a new skill).

uHalfway houses- focus on extending the period of sobriety. Get case management involved in addressing educational, economic, and social needs.

uOther housing- not part of treatment. Ex. therapeutic communities, housing programs that offer a drug free environment and classes to remediate the skills needed for daily living. They attend outpatient substance use treatment.

uPartial hospitalization program- Ex. 5 days a wk for 6 hrs a day. Can live in supportive housing or an independent home. Dont need 24hr residential tx.

uIntensive outpatient programs- 3 days a wk for 3 hrs a day. Not a residential program. Highly structured w scheduled tx groups and at least 1 individual session.

uOutpatient treatment- Mix of individual and psychotherapy groups. Structured, drug free, non residential. No more than 5 contact hrs a week, web- where its is self paced and anonymous.

uAlcoholics Anonymous (AA)- can also include friends and family

Relapse prevention- pts learning health coping skills, stress management. learning skills to continue not drinking if relapse occurs.

Psychotherapy

Motivational interviewing- strengthens motivation for change. Ex.

WHat implementation do we do

Implementation

uPromoting safety and sleep: first-line interventions

uReintroduce good nutrition and hydration

uSupport for self-care (hygiene)

uExploring harmful thoughts and spiritual distress

Health teaching and health promotion

uPrevention against genetic vulnerability

uPublic classes

Give thymine before glucose

benzoz and alchohol withdraw can kill

complications. MI, stroke, hyperthermia

DKA- IV insulin.

Know how to give thymine.