SUBSTANCE RELATED DISORDERS & SLEEP AND WAKEFULNESS

Substance Abuse

using a drug in a way that is inconsistent with medical or social norm

Polysubstance abuse

using more than one substance in a way that is inconsistent with medical or social norms

Addiction

problems with tolerance, withdrawal, and unsuccessful attempts to stop using the substance

Intoxication

use of a substance that results in maladaptive behavior

Withdrawal syndrome

negative psychologic and physical reactions that occur when use of a substance ceases or dramatically decreases

Alcohol

• CNS depressant that is absorbed rapidly in the blood stream

• Develops TOLERANCE once drinking is continuous, due to and in which the effect is no longer the same, thus needing more

• Tolerance break: eventually, very small amounts will intoxicate the person

• Results to impaired functioning and may lead to abstinence by will or professional help

Tolerance break

eventually, very small amounts of alcohol intoxicate the person

Alcohol

• Intoxication results to slurred speech, unsteady gait, lack of coordination and impaired attention, concentration, memory, and judgment

• Overdose can result in vomiting, unconsciousness, and respiratory depression

60%-90%

Relapse rate of alcohol addiction

50%

Almost ? of alcohol relapse occur within the year after the treatment

spontaneous remission

Natural recovery without professional help

• CNS Depressants

• Intoxication is the same as Alcohol, with the addition of drowsiness and reduce anxiety.

• Lethargy and confusion may be present for benzodiazepine overdose.

• Barbiturates are lethal when in overdose

benzodiazepine

lethargy and confusion may be present for ? overdose

Stimulants

• CNS excitant

• Methamphetamines causes psychotic behavior and may result to brain damage

• Cocaine causes immediate feeling of Euphoria

• Intoxication develops rapidly, which includes Euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotype or repetitive behavior, anger, fighting, and impaired judgment.

Methamphetamines

Stimulant that causes psychotic behavior and may result to brain damage

Cocaine

Stimulant that causes immediate feeling of Euphoria

Cannabis

• Has a Psychoactive substance called Cannabinoids

• Activates rapidly (< 1 minute) after intoxication and peaks in 30 minutes, lasts for 3 hours. Feelings same as alcohol, with relaxation, euphoria, and increased appetite

• Intoxication include impaired motor coordination, inappropriate laughter, impaired judgment and short-term memory

• < 1 minute

• 30 minutes

• 3 hours

Cannabis activates rapidly (?) after intoxication and peaks in ?, lasts for ?.

Opioids

• Physical and Psychological Pain Reliever

• Both illegal compounds (such as Heroin), and legal compounds (such as Morphine) that can be potentially abused by healthcare professionals

• Intoxication includes Euphoric feeling, apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory.

Hallucinogens

• Distorts the user’s perception of reality such as hallucination and depersonalization

  • Mescaline

  • Psilocybin

  • Lysergic acid diethylamide

  • Designer Drugs

Ecstasy / MDMA

• Hallucinogen

• Contains:

  • Stimulant: Amphetamine

  • Hallucinogens

  • Unknown compounds: Random effect

Hallucinogens

• Intoxication involves to anxiety, depression, paranoid ideation, ideas of reference, fear of losing one’s mind, and potentially dangerous behaviors due to unrealistic thoughts

• Anesthetic Phencyclidine intoxication involves belligerence, aggression, impulsivity, and unpredictable behavior

Inhalants

• CNS effect and changes in the bahavior, caused by hydrocarbons

• Found in Anesthetics, nitrates and organic solvents

• Intoxication:

  • CNS effect involves dizziness, nystagmous, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision.

  • Behavior changes involves belligerence, aggression, apathy, impaired judgment, and inability to function.

60%

? of alcoholism is genetic

Dopamine

Inhalants stimulate ? pathways in the limbic system

Substance-induced symptoms

• Symptoms brought by substances, such as anxiety, psychosis, or mood disorder.

• This can be resolved once the substance use is treated, but may be still present due to damage already in the brain caused by the substances

Dual-Diagnosis

• Substance abuse with another psychiatric illness which poses difficulty in treatment in substance abuse

  • Impaired abilities to process abstract concepts

  • May be contraindicated with psychoactive drugs

  • Limited recovery is not applicable in addiction

  • Life long abstinence maybe overwhelming

  • Use of alcohol and substance may not directly link to the symptoms presented

4-12

Alcohol withdrawal appears after ? to ? hours after cessation

2, 2

Alcohol withdrawal peaks at ? day, and may last for ? weeks

Alcohol Withdrawal

Withdrawal Symptoms:

• Hand tremors

• Sweating

• Elevated pulse and BP

• Insomnia

• Anxiety

• Nausea / Vomiting

• Benzodiazepine (Lorazepam / Chlordiazepoxide)

• Barbiturates

Meds for alcohol withdrawal

• Hallucinations

• Seizures

• Delirium

• Tremens

Severe Alcohol withdrawal symptoms

Sedatives, Hypnotics, and Anxiolytics Withdrawal

• Onset depends on the half-life of the drug

• Withdrawal Symptoms:

  • Increase PR, RR, BP

  • Hand Tremor

  • Insomnia

  • Anxiety

  • Nausea

  • Psychomotor Agitation

• seizures

• hallucination

Severe Sedatives, Hypnotics, and Anxiolytics withdrawal symptoms

Stimulants Withdrawal

• Occurs within few hours to several days after cessation

• Withdrawal Symptoms:

  • Dysphoria with

    • Fatigue

    • Vivid and unpleasant dreams

    • Insomnia or hypersomnia

    • Increased appetite

    • Psychomotor retardation or agitation

• Depressive episodes

• Suicidal Ideation

Crashing withdrawal symptoms for Stimulants

Cannabis

• No significant withdrawal symptoms

• Symptoms include:

  • Muscle aches

  • Sweating

  • Anxiety

  • Tremors

24 hrs, 7 days

Onset of Heroin is within ?, and lasts ?

Heroin Withdrawal

• Initial symptoms

  • Anxiety & Restlessness

  • Aching back and legs

  • More craving

• Progressive symptoms

  • Nausea / Vomiting / Diarrhea

  • Dysphoria

  • Lacrimation / Rhinorrhea / Sweating

  • Yawning

  • Fever & Insomnia

Methadone

• Given as Heroin substitute.

• No High and cravings produced

Hallucinogens Withdrawal

Withdrawal Symptoms:

• Marked by flashbacks of perceptual disturbances

• Can last to months up to 5 years

Inhalants Withdrawal

Withdrawal Symptoms:

• No significant withdrawals, only cravings

• May suffer Dementia, psychosis, anxiety and mood disorders

Detoxification

process of safe withdrawal of a person from substances

• gastric lavage

• dialysis

Treatment for Alcohol / Sedative, Hypnotics and Anxiolytics overdose

Chlorpromazine

Treatment for Stimulants overdose

• Naloxone

• Naltrexone

Treatment for Opioids overdose

Wernicke-Korsakoff Syndrome

• alcohol abuse

• Thiamine (Vit. B1 deficiency)

• Vitamin B1 (Thiamine)

• Vitamin B12 (Cyanocobalamin)

• Folic Acid

Treatment for Wernicke-Korsakoff Syndrome

• Disulfiram

• Acamprosate, Naltrexone

Treatment for Alcohol Relapse:

• ? for deterrence

• ? or ? for craving

• Buprenorphine / Naloxone

• Methadone, Levomethadyl

Treatment for Opioid Relapse:

• ? / ? combination for cravings

• ? (Synthetic Opiate) and ?(Narcotic) as Heroin substitute and reduce craving

Disulfiram

• Mode of Action

  • Aldehyde dehydrogenase inhibitor: prevents ethanol metabolism, which increases acetaldehyde in the blood stream (5-10 mins. onset)

• Adverse Reaction

  • Flushing, headache, sweating, dry mouth, N/V, dizziness and weakness for 30 mins to 2 hours

• intoxicated

• alcohol

• 1-2 weeks

Nursing Consideration for Disulfiram:

• Do not give while ?

• Avoid ? containing products

• May still cause alcohol reaction ? to ? after last dose

Acamprosate

• Indication

  • For sober patients that are “Relief Cravers”

  • Reduces the Physical and Emotional discomfort during sobriety

• Contraindication

  • Renal Impairment

Naltrexone

• Indication

  • For sober patients that are “Reward Cravers”

  • Reduces the cravings of the effects of drinking

Alcohol Anonymous

• Self-help group with a 12-step program for recovery

• Applied in different treatment settings and Programs

• Emphasizes on meeting for individual counseling and group sharing

Enabling

a type of codependence, which is a behavior that seems helpful on the surface but actually perpetuates the substance use

Inadequate Sleep Hygiene Insomnia

• Engaging in behaviors not conducive for sleep

• EX:

  • consuming caffeine / nicotine, excessive emotional or physical stimulation, daytime naps, wide variations of daily sleep-wake routines.

• Treatment:

  • Sleep hygiene measures, Cognitive-behavioral techniques, Medication.

Psychophysiological Insomnia

• Conditioned arousal associated with the thought of sleep

• EX:

  • whenever a person sees the bed/bedroom, there is excessive worry about sleeping, such as trying too hard to sleep, rumination, increased muscle tension, and other anxiety symptoms

• Treatment:

  • Sleep hygiene measures, Relaxation therapy

Paradoxical Insomnia

• When rumination continues into sleep, the person believes s/he is awake, but the brainwave is consistent with normal sleep.

• Treatment:

  • Address rumination and worry about not sleeping.

Behavioral insomnia of childhood

• When a child must have specific stimulation, objects, or a setting for falling asleep, or returning to sleep.

• Treatment:

  • Parent / Caregiver education for limit setting

Idiopathic Insomnia

• Lifelong. Considered a neurologic deficit.

• Treatment:

  • Sleep Hygiene measures, relaxation therapy, medication

Insomnia due to mental disorder, medical condition, or drug/substance use

• Treatment:

  • Treat the underlying cause (may not eliminate insomnia)

  • Sleep medication

  • Sleep hygiene measures

  • Avoidance of stimulants (eg. caffeine/nicotine)

HYPERSOMNOLENCE DISORDER

For at least 1 month...

• Prolonged sleep episodes (8-12 hours) or daily daytime sleeping; or

• Prolonged daily daytime sleeping that leaves the person uunrefreshed upon awakening.

• Both can cause significant distress or impairment in functioning.

NARCOLEPSY

• Chronic excessive sleepiness... repeated, irresistable sleep attacks.

• Sleep attacks can occur at inopportune times (eg. important work, driving a car)

• Cataplexy

• Recurrent intrusions of REM sleep, manifested by paralysis of voluntary muscles or dream-like hallucinations

Cataplexy

sudden episodes of bilateral, reversible loss of muscle tone that last for seconds to minutes

10-20 mins

A normal person naps for ? to ?, then wakes feeling refreshed.

Obstructive Sleep Apnea

• sleep-related breathing disorder

• repeated episodes of upper airway obstruction

• risk factor: obesity

Central Sleep Apnea

• sleep-related breathing disorder

• episodic cessation of ventilation without airway obstruction

• risk factor: older adults

Central Alveolar Hypoventilation

• sleep-related breathing disorder

• hypoventilation resulting in low arterial oxygen levels

• risk factor: obesity

• CPAP

• hypoglossal nerve stimulating implant / tracheotomy

Treatment for sleep-related breathing disorder:

• ?; or

• Surgery:

CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS

Persistent or recurring sleep disruption, resulting from altered functioning of circadian rhythm or a mismatch between the circadian rhythm and external demands.

Delayed sleep phase

• circadian rhythm sleep-wake disorder

• unable to sleep or remain awake during socially acceptable hours as a result of a work schedule

Jet lag

• circadian rhythm sleep-wake disorder

• conflict of sleep-wake schedule and a new time zone

Shift work

• circadian rhythm sleep-wake disorder

• conflict between circadian rhythm and demands of wakefulness for shift work

Unspecified

• circadian rhythm sleep-wake disorder

• circadian rhythm pattern is longer than 24 hours

• Sleep hygiene measures

• Melatonin

• Bright light therapy

Treatment for circadian rhythm sleep-wake disorders

PARASOMNIAS

• abnormal behaviors or psychological events associated with sleep, which involves activation of physiologic systems:

  • autonomic nervous system

  • motor system

  • cognitive processes

NIGHTMARE DISORDER

• Parasomnia

• Lengthy and elaborate nightmares.

SLEEP TERROR DISORDER

• Parasomnia

• Among children, abrupt awakenings with a panicky scream or cry.

• No memory of the dream

SLEEPWALKING DISORDER

• Parasomnia

• Children 4to 8 y/o, getting out of bed and walking around.

• Disoriented, confused or violent