substance use disorders

addiction

a condition of continued use of substances (or reward-seeking behaviors) despite adverse consequences

withdrawal

painful physical and or psychological symptoms that follow the discontinuance of the substance(s)

substance-induced disorder

occur when medications used for other medical/ mental health disorders cause intoxication or withdraw or other health problems

substance use disorder

occurs when substance use continues despite cognitive, behavioral and physiological symptoms.

addiction

•Behavior patterns with overwhelming compulsive involvement with securing and using a substance

•High tendency for relapse after discontinuation

•Disease of Perception

•Denial is a major component

•Refuse to admit powerlessness over the problems

•Continued use despite negative consequences

•Justification for behaviors and use with blame on external sources for addiction

key facts national survey on drug abuse

•2020 National Survey on Drug Use and Health (NSDUH), an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).

•Illicit drug use 2020, 21.4 % for persons age 12 and over

•Marijuana- 49.6 million persons used in US

•9.3 million misused prescription painkillers

•5.2 million used cocaine

•2020 National Survey on Drug Use and Health (NSDUH), an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).

•Illicit drug use 2020, 21.4 % for persons age 12 and over

•Marijuana- 49.6 million persons used in US

•9.3 million misused prescription painkillers

•5.2 million used cocaine

incidence and prevalence drinking

•Drinking more common in teens and young adults

•College students higher quantity, lower frequency than non-college students

•Men drink in more harmful ways than women

__ of people with a serious mental illness have a substance use disorder some time in their lives

50%

•Psychiatric disorders associated with substance abuse include:

•Acute and chronic cognitive impairment disorders

•Attention deficit disorder

•Borderline and antisocial personality disorders

•Anxiety disorders

•Depression and Higher risk for suicide

•Eating disorders

•Compulsive behavior

biological theory of addiction

•Specific effects on selected neurotransmitters, NIH- specific genes increase risk for addiction. Physiologic mechanisms for compulsion despite consequences- dopamine and pleasure 

Psychological- impulsive and risk taking behaviors theory of addiction

•Defense against anxious impulses

•Oral regression (dependency)

Self-medication for depression, hallucinations, thought disorders, PTSD, Stress Response, Coping Styles

behavioral theory of addiction

Positive reinforcement effects of drug-seeking behavior

sociocultural theory of addiction

•Social and cultural norms 

•Socioeconomic stress

Tolerance

The need for higher and higher doses to achieve the desired effect

withdrawal

•After a long period of continued use, stopping or reducing drug results in specific physical and psychological signs and symptoms

Healthy Liver can metabolize approximately ??? of alcohol per hour:

1 oz

the excess alcohol that the liver can not metabolize remains…

in the blood

Therefore that is BAC / BAL measured

0.05 BAL effect in non tolerant drinker

Change in mood, behavior, and   impaired judgment

0.20 BAL effect in non tolerant drinker

Staggering, ataxia, emotions are labile

0.40 BAL effect in non tolerant drinker

coma

0.50 BAL effect in non tolerant drinker

death from respiratory depression

BAL can be used to assess…

•level of intoxication and level of tolerance.

•As tolerance develops, a discrepancy is seen between BAL and expected behavior.

•Gastrointestinal system medical comorbidity alcohol

Esophagitis, Gastritis, Pancreatitis, Gastric Ulcers, related  issues of increased acid production and poor nutrition and absorption, impaired peristalsis

cardiovascular system medical comorbidity alcohol

HTN, Cardiomyopathy, Dysrhythmias, Malnutrition

liver damage medical comorbidity alcohol

Primary organ for metabolism, ETOH- heavy, chronic drinkers-Alcoholic Fatty Liver, hepatitis, cirrhosis

CLINICAL SIGNS- reddened palms, contractures and or clubbing of fingers and nails, white nails, nausea, vomiting, enlarged or inflamed liver elevated LFT’s

CNS medical comorbidity alcohol

Wernicke's Encephalopathy

Korsakoff's amnestic syndrome-

Wernicke's Encephalopathy-

Degenerative brain disorder caused by Thiamine deficiency. 

Leads to inability to learn new information, recall remote information, unsteady gait, myopathy (muscle weakness and wasting, as well as pain and tenderness).

Korsakoff's amnestic syndrome-

gait disturbance, confabulation, disorientation, memory impairment

both Wernicke's Encephalopathy- and Korsakoff's amnestic syndrome- are related to?

THYAMINE deficiencies, malnutrition.  They are both different stages of Wernicke- Korsakoff Syndrome

Alcoholic Dementia- may include permanent brain damage

Blackouts

Intoxication- fights, impaired judgments, interference with social and occupational functions

Alcohol Withdrawal Syndrome

•Early signs a few hours after decreasing alcohol

•Signs peak after 24 to 48 hours then rapidly disappear

Alcohol Withdrawal Syndrome S/S

•Increased heart rate

•Increased blood pressure

•Diaphoresis

•Mild anxiety and restlessness

•Hand tremors

Alcohol Withdrawal Syndrome common assessment tool

•CIWA- Clinical Institute Withdraw Assessment

Withdrawal Delirium Tremens (DT’s):

•A medical emergency that can result in death

Delirium peaks at 2 to 3 days after cessation of alcohol and lasts 2 to 3 days

Withdrawal Delirium Tremens (DT’s) S/S

•Autonomic hyperarousal

•Disorientation and clouding or changes in level of consciousness

•Visual or tactile hallucinations

•Hyper-excitability to lethargy

•Paranoid delusions, agitation

•Grand mal seizures- within first 48 hours if going to occur

Common signs of stimulant abuse:

•Dilation of the pupils, darting eye movements, avoidance or intense eye contact

•Dryness of the oronasal cavity, sniffling

•Excessive motor activity, hyperactivity, rapid speech and flight of ideas

•Defensiveness

Crack and cocaine

1.Extracted from leaf of coca bush

2.When smoked takes effect in 4 to 6 seconds; a
5- to 7-minute high follows, then a deep depression

Crack and cocaine two main effects on body:

1.Anesthetic

2.Stimulant

  Produces imbalance in neurotransmitters, severe cravings for the next ingestion

Crack and cocaine withdrawal symptoms include:

Severe anxiety, restlessness, agitation, depression, cravings

Marijuana (Cannabis sativa)

•Indian hemp plant

•Tetrahydrocannabinol (THC) is active ingredient in flowering tops and leaves

•Depressant and hallucinogenic properties

Usually smoked, can be orally ingested

Marijuana (Cannabis sativa) desired effects:

euphoria, detachment, relaxation

Marijuana (Cannabis sativa) other effects:

talkativeness, slowed perception of time, inappropriate hilarity, heightened sensitivity to external stimuli, anxiety, and paranoia

Marijuana (Cannabis sativa) long term effects:

lethargy, anhedonia(without pleasure), difficulty concentrating, loss of memory

Opioids

•Any substance that binds to an opioid receptor in the brain to produce an agonist action.

•Physical dependence can develop rapidly

•When the drug is discontinued, after a period of continuous use, a rebound hyper excitability withdraw syndrome usually occurs.

Two important effects produced by opioids are:

pleasure and pain relief

Heroin

is illegal highly addictive drug, rapid acting. It can be sniffed, snorted, smoked but most often injected, which leads to risks of sharing needles

Methadone maintenance

the treatment of people with opioid addiction with a daily stabilized dose of methadone

Naltrexone and Buprenorphine are frequently both used to treat…

treat opioid addiction. 

They were recently combined into one formulation with the brand name Suboxone.

Hallucinogens

•Lysergic acid diethylamide (LSD or acid)

•Mescaline (peyote)

•Psilocybin (magic mushroom)

•Phencyclidine piperidine (PCP, angel dust, horse tranquilizer, peace pill)

Inhalants: Volatile solvents

•Spray paint

•Glue

•Cigarette lighter fluid

•Propellant gases used in aerosols

•Computer cleaning solvents

•Bath Salts

•Synthetic Marijuana

Rave and Techno Drugs/Club Drugs

Ecstasy (3,4-methylenedioxymethamphetamine), also called

MDMA, Adam, yaba, XTC

MDA (methylenedioxyamphetamine) or "love"

MDE (3,4-methylenedioxyethylamphetamine) or "Eve"

Rave and Techno Drugs/Club Drugs side effects:

•Euphoria, increased energy

•Increased self-confidence

•Increased sociability

•Feeling of closeness to others

Rave and Techno Drugs/Club Drugs adverse effects

•Hyperthermia, heart failure, kidney failure, acute dehydration

Date Rape Drugs include:

•Flunitrazepam (Rohypnol or "roofies")

•γ-Hydroxybutyric acid (GHB)

date rape drugs rapidly produce:

•Disinhibition

•Relaxation of voluntary muscles

•Anterograde amnesia loss of ability to create new memories after event, inability to recall sudden trauma

Self-Assessment by the Nurse

•Examine your own attitudes, feelings, and beliefs about addicts and addiction. This may include examining your own use, use by your family members, or friends' use of addictive substances.

•Avoid disapproval, intolerance, condemnation, or lack of emotional reaction to client.

•Develop empathy and the ability to manage the manipulative behaviors and avoid power struggles with the clients

Chemically Impaired Nurse

•The wrong choice you can make; TO DO NOTHING!

•Without intervention or treatment the potential for client harm increases.

•6-8% of practicing nurses are chemically dependent.

•Co-worker's responsibilities:

•Clear documentation (dates, times, events, consequences)

•Report facts to nurse manager

•Nurse manager then takes facts to nursing administration

•If no action is taken by nurse manager and co-worker's behavior continues, take facts to the next level in the chain of command.

Behaviors seen with the impaired nurse

•Increased patient complaints of ineffective pain management for assigned patients

•Frequency volunteers for alternative shifts

•Absenteeism

•Offers to medicate other patients than assigned

•Diversions of medications

•Frequent requests for medication wasting

•Mood swings

•Agitation, Defensiveness and poor concentration

•Work and personal appearance deterioration

Ana’s guidelines

•Nursing’s ethical responsibility is the foundation for ANA’s strong support for “alternative to discipline” or “peer assistance” programs offered by most – but not all – of the state boards of nursing. These programs offer comprehensive monitoring and support services to reasonably assure the safe rehabilitation and return of the nurse to her or his professional community. Generally organized by state regulatory boards, in collaboration with nursing organizations or schools of nursing, these programs offer a non-punitive approach in which an impaired nurse typically signs an agreement to be monitored for several years while completing a treatment and rehabilitation plan.

Assessment of Chemically Impaired Clients

•Suicidal or homicidal thoughts or plans

•Overdose needing immediate medical attention

•Withdrawal symptoms

•Physical complications

•Client's interest in treating addiction

•Client's and family's knowledge of community resources

Relevant Nursing Diagnoses

•Risk for suicide 

•Risk for self-directed or other-directed violence

•Ineffective airway clearance

•Ineffective breathing pattern

•Decreased cardiac output

•Deficient fluid volume

•Disturbed thought processes

•Risk for infection

•Imbalanced nutrition: less than body requirements

interventions

Aim of treatment: self-responsibility

Challenges: matching clients with types of treatment considering various needs

•Type of addiction

•Age

•Physical health

•Neuropsychological health; readiness for recovery

•Financial situation

•Location of program

•Length of time of program

•Family needs

•Behaviors to be addressed:

•Dysfunctional anger

•Manipulation

•Impulsiveness

•Grandiosity

communication guidelines:

•Make abstinence and sobriety worthwhile for client. Must find benefits in recovery

•Communicate in culturally appropriate ways

Intervention Strategies: primary intervention

•HEALTH TEACHING

•Promote Healthy Activities- that facilitate healing, exercise, hobbies, awareness of boredom, emotions, loneliness, past habits that can be triggers for relapse

•Nurse must evaluate effectiveness of treatment;

•Safety of client through the withdrawal process

•Refrained from use

•Acknowledges addiction

•Developing healthy stress management

•Identified alternative activities

•Active participation in treatment plan

interventions

•Dual-diagnosis principles Treat concurrently

•Psychotherapy

•Relapse prevention

•Self-help groups for client and family

•12-Step programs- Alcoholics Anonymous (AA)

•Residential programs

•Intensive outpatient programs

•Outpatient drug-free programs

•Employee assistance programs

Psychopharmacology ALCOHOL:

1. Trexan, Revia (naltrexone)

2. Campral (acamprosate)

3. Antabuse (disulfiram)

•Trexan, Revia (naltrexone)

•Blocks opiate receptors

•Interferes with mechanism of reinforcement

•Reduces or eliminates alcohol craving

•Campral (acamprosate)

•Helps client abstain from alcohol

•Mechanism not well understood

•Antabuse (disulfiram)

•Works on classical conditioning principle

•Alcohol-disulfiram reaction causes unpleasant physical effects

Psychopharmacology Opiates

1. Dolophine (methadone)

2. Naltrexone

3. buprenorphine

•Dolophine (methadone)

•Synthetic opiate blocks craving for and effects of heroin

•Naltrexone

•Antagonist that blocks euphoric effects of opioids

•Buprenorphine

•Long acting partial agonist that acts on the same receptors as heroin and morphine, which relieves cravings.  Buprenorphine and Naltrexone have been combined which is administered sublingually-  Suboxone

Outcomes

•Client's blood pressure will not be compromised.

•Client will have no seizure activity.

•Client will consistently demonstrate a commitment to alcohol use control strategies.

•Client will consistently demonstrate acknowledgement of personal consequences associated with drug misuse.

•Client will describe actions to prevent and manage relapses in substance use.

Evaluation

• Increased time in abstinence

• Decreased denial

• Acceptable occupational functioning

• Improved family relationships

• Ability to relate comfortably to other individuals