Substance Use and Addictive Disorders (Ch. 23)

Substance Use Disorder

a treatable mental disorder that affects a person's brain and behavior, leading to an inability to control their use of substances such as drugs, alcohol, or medications

SUD Spectrum of Severity

SUDS range from mild to severe

-addition = most severe form

-severity determined by number of diagnostic criteria met over a 12 month period

Unhealthy use

-harmful

-hazardous

-non-prescribed

AVOID: "misuse"

Binge

-heavy episode

-multiple days

Dependence

-physical

-addiction

Toxicology Screen

use terms "positive" or "negative"

AVOID: "clean, dirty"

Return to use

-recurrence

-remission

AVOID: "relapse"

Medication

agonist

AVOID: "substitution, assisted, replacement"

Neonatal Withdrawl

abstinence

AVOID: "addicted"

Motivational Interviewing (MI)

client-centered, directive method for enhancing motivation to change by exploring and resolving ambivalence

Motivational Interviewing Techniques

-open-ended questions

-reflective listening

-affirmations

-summarizing

Motivational Interviewing Goals

-enhance patient's motivation to change

-support commitment to positive changes

Harm Reduction

strategies to reduce negative consequences of drug use without the need for abstinence

Harm Reduction Techniques

-needle exchange programs

-supervised injection sites

-providing naloxone

-safe consumption education

Harm Reduction Goals

-improve overall health

-reduce harm

-engage patients in treatment

Relapse Prevention

techniques to help patients recognize and manage triggers, cravings, high-risk situations

Relapse Prevention Techniques

-trigger identification

-develop coping strategies

-prevention plan

-ongoing support

Relapse Prevention Goals

-maintain sobriety

-prevent remission

Psychoeducation

providing information about SUDs, treatment options, and coping strategies

Techniques of Psychoeducation

-educational session

-written materials

-group discussions

Goals of Psychoeducation

-increase knowledge

-reduce stigma

-empower patients and families to participate in recovery

Tolerance

1. need for markedly increased amounts of substance to achieve intoxication or desired effect

2. significantly diminished effect with continued use of the same amount of substance

Withdrawal

substance or closely related substance is taken to relieve or avoid symptoms of withdrawal

Genetics play ___-___% of a patient's vulnerability to SUDs

40-60%

Pleasurable effects from substance use act as a _________ __________ for continued use of that substance.

positive reinforcement

SUDS typically develop ______ over time.

gradually

Brain changes in SUD

SUDs typically develop gradually over time with repeated misuse, leading to changes in brain circuits governing:

1. reward

2. stress

3. executive functions

Substance Related Disorders (2)

1. substance-induced

-intoxications

-withdrawal symptoms

2. substance-use

-chronic, relapsing condition

-characterized by compulsive use despite harmful consequences

Substance-Induced Disorder

-intoxications

-withdrawal symptoms

Substance use disorder is characterized by...?

chronic relapsing condition that involves compulsive use despite harmful consequences

Intoxication

REVERSIBLE symptoms secondary to excessive use

Withdrawal (Discontinuation Syndrome)

involves physical and psychological symptoms

Substance Addiction

-use interferes with ability to fulfill role obligations

-FAILED attempts to cut down or control use

-INTENSE CRAVINGS cause excessive time spent procuring substance or recovering from effects

-difficulties in relationships, may lead to social isolation

-hazardous activities when impaired

-continued use despite awareness of issue or consequences

-tolerance, increased use, and withdrawal

Mild SUD

2-3 symptoms

Moderate SUD

4-5 symptoms

Severe SUD

6 or more symptoms

DSM-5 Criteria for SUDs

-substance is taken in larger amounts or over a longer period than originally intended

-persistent desire or unsuccessful efforts to cut down or control use

-significant time spent obtaining, using, recovering

-craving/strong desire to use

-recurrent use results in failure to fulfill obligations/roles

-continued use despite social/interpersonal issues

-important activities are given up or reduced

-recurrent use in dangerous situations

-continues use despite physical or psychological problems

-tolerance = need for inc. amounts or diminishing effects

-withdrawal symptoms or using to relieve withdrawal

Addiction

compulsive or chronic requirement

-NEED is strong

-craving creates distress in the person if unfulfilled

Alcohol Use Disorder (AUD) - Patterns of use/Phases

1. pre-alcoholic

2. early alcoholic

3. crucial phase

4. chronic phase

Pre-Alcoholic Phase (#1)

-drinking to relieve everyday stressors

-tolerance starts to develop when more and more is needed to achieve desired effect

*occasional drinking with few to no negative consequences; done to feel more relaxed

Early Alcoholic Phase (#2)

-begins with BLACKOUTS

-consumption is now required to get through days

*drinks to cope with stress and/or anxiety; may feel guilty and lie/hide drinking habits

Blackout

brief periods of amnesia that occur during or immediately following a period of drinking

Crucial Phase (#3)

-loss of control

-evident physiological dependence

-binge drinking = BAC's to 0.08 g/dL (women = 4 drinks and men = 5 drinks within 2 hours)

*interference of daily life and responsibilities with noticeable problems at work, school, or home; WD symptoms when they aren't drinking

Chronic Phase (#4)

-emotional and physical disintegration

-person is usually intoxicated rather than sober

-withdrawal can be fatal; drinking becomes necessary to function

-may experience serious health problems such as liver failure or cardiovascular symptoms

CAGE Screening

C: Have you ever felt you ought to CUT down on drinking?

A: Have people ANNOYED you by criticizing your drinking?

G: Have you ever felt bad or GUILTY about your drinking?

E: Have you ever had a drink first thing in the morning as an EYE OPENER?

Cage Screening Score

the higher the score the greater the indication of alcohol problems; total score of 2 or greater = clinically significant

BAC = 0.08-0.10%

considered legal intoxication

-impaired driving ability and balance

-euphoria

-fatigue

-impaired speech, reaction time, hearing, vision

BAC = 0.25-0.39

very severe impairment of mental, physical, and sensory functions; increased risk of asphyxiation from choking and injuries from falls

BAC over 0.40

-can be potentially fatal

-risk of coma and death due to respiratory arrest

AUD & Peripheral Neuropathy

-direct damage to peripheral nerves RT chronic alcohol use

-nutritional/vitamin deficiencies; especially thiamine (B1)

Symptoms of Peripheral Neuropathy (AUD)

-numbness or tingling in hands and feet

-sharp, burning pain

-sensitivity to touch

-muscle weakness

-difficulty with coordination and balance

-muscle cramping or spasms

Wenicke-Korsakoff Syndrome

severe neurological condition due to thiamine (B1) deficiency

Treatment of peripheral neuropathy caused by AUD

-detoxification

-ongoing support

-vitamin supplementation, especially thiamine

Acute Alcoholic Myopathy

severe muscle pain and weakness, particularly in the arms and legs that can lead to kidney failure

Chronic Alcoholic Myopathy

characterized by muscle weakness and wasting, particularly in the legs

Symptoms of Alcoholic Myopathy

-muscle pain and weakness

-difficulty walking, climbing stairs, or getting up

-swollen legs

-dark urine

Megaloblastic Anemia

anemia characterized by presence of abnormally large and immature red blood cells (megaloblasts) in the bone marrow and blood

Cause of Megaloblastic Anemia

deficient folate or VitB12, which disrupts DNA synthesis in bone marrow

Symptoms of Megaloblastic Anemia

-weakness, fatigue, pallor, SOB

-glossitis (tongue inflammation)

-neurological symptoms: numbness, tingling, and cognitive disturbances (due to b12 def.)

Treatment of Megaloblastic Anemia

-oral or injectable folate

-b12 supplements

-dietary changes

Hepatic Encephalopathy

occurs when the liver is unable to adequately remove toxins from the blood, leading to the accumulation of these substances in the brain, particularly ammonia

Symptoms of Hepatic Encephalopathy

-cognitive impairment

-asterixis (flapping hand tremor)

-behavioral changes

-motor symptoms

-sleep disturbances (reversed sleep-wake cycles)

-stupor and coma

Treatment of Hepatic Encephalopathy

1. lactulose

2. surgery

3. antibiotics that reduce ammonia producing bacteria

Esophageal Varices

small veins that are not designed to handle high pressure become enlarged and twisted, forming varices; THIS IS IMPORTANT BECAUSE THEY CAN BURST, CAUSING A MASSIVE HEMORRHAGE!

-develops in individuals with chronic liver disease, particularly cirrhosis, which is commonly caused by long-term excessive alcohol consumption

-2/2 portal hypertension and collateral circulation

Wernicke's Encephalopathy

a group of conditions that cause brain dysfunction

-appears as confusion, memory loss, personality changes, or coma in the most severe form

-nystagmus and ophthalmoplegia is seen

-ataxia

Diagnosis of Wernicke's Encephalopathy

-blood testing to CHECK THIAMINE LEVELS!

-MRI or CT

Treatment of Wernicke's Encephalopathy

immediate thiamine replacement, usually through IV

What can Wernicke's encephalopathy progress to?

korsakoff syndrome

Korsakoff Syndrome

chronic and debilitating condition involving severe memory problems

Korsakoff's Psychosis - Etiology

primarily DT lack of thiamine

-untreated wernicke's encephalopathy can lead to this

Korsakoff's Psychosis - Signs/Symptoms

-severe memory loss, pts have trouble forming memories

-confabulation, "gap filling"

-lack of insight; unaware of memory issues

-difficulty with complex thinking and solving problems

Thiamine (B1) Deficiency

can lead to wernicke-korsakoff syndrome, neuropathy, confusion, and visual changes

Folate (B9) Deficiency

symptoms include fatigue, depression, confusion, and memory loss

Life-threatening complications of chronic alcohol abuse

-severe alcohol withdrawal

-hepatic encephalopathy

-ruptured esophageal varices

Symptoms of Alcohol Withdrawal

THINK INCREASED CNS

-headache

-tremors

-diaphoresis

-anxiety, agitation

-nausea/vomiting

-confusion and disorientation

-elevated BP, tachycardia, tachypnea

-seizures

Early signs of alcohol withdrawal

6-12 hours from last drink

-anxiety and irritability

-tremors

-insomnia

-sweating

-nausea/vomiting

-headache

-tachycardia

Middle signs of alcohol withdrawal

12-48 hours from last drink

-increased agitation, tremors

-disorientation

-tactile (bugs on skin) and auditory hallucinations

-seizures

-moderate confusion

-increased BP and HR

Late signs of alcohol withdrawal

48-96 hours from last drink

-DELIRIUM & severe confusion

-uncontrollable shaking (tremors)

-fever

-profuse sweating

-severe agitation

***potential for delirium tremens

Protracted Withdrawal

beyond 96 hours

-persistent anxiety

-insomnia

-dysphoria

-fatigue

Delirium Tremens

a dangerous set of symptoms DT CNS hyperactivity

1. delirium

-profound confusion, disorientation, altered mental status

2. hallucinations: visual, auditory, tactile

3. autonomic hyperactivity

-tachycardia, hypertension, diaphoresis, and fever

4. agitation and anxiety

5. seizures

Pharmacological Management of Alcohol Withdrawal

1. benzodiazepines

-quickly relaxes CNS and relieves s/sx of WD

-diazepam, lorazepam, chlordiazepoxide

2. thiamine (vitamin B1)

3. antipsychotics

-haloperidol for severe agitation/hallucinations

Alcohol Withdrawal - Nursing Interventions

1. CIWA-Ar assessment

2. vitals & cardiac monitoring (dysrhythmias)

3. fall risk, seizure, and aspiration precautions****

4. meds based on CIWA or as ordered

5. HOURLY rounding

6. hydration (fluid at each assessment & water at bedside)

7. I & O

8. encourage meals and snacks

9. observe for signs of over sedation or respiratory depression

10. provide quiet, supportive, comforting environment

11. manage N/V

Disulfiram

deters drinking by causing unpleasant reactions (nausea, headache, flushing, vomiting) upon contact with alcohol

-requires patient motivation and compliance

Naltrexone

reduces drinking and increases abstinence by blocking opioid receptors, reducing the rewarding effect of both substances

-indicated for OUD and AUD

-slower onset, much longer duration

-used for maintenance treatment of addiction

Acamprosate

reduces cravings and withdrawal symptoms by restoration of neurotransmitter balance

Benzodiazepines

helps manage acute alcohol withdrawal symptoms and prevents seizures during detoxification by enhancing GABA

-SHORT-TERM USE

B Vitamin Therapy

corrects the deficiencies in alcohol use disorder, preventing complications such as neuropathy & megaloblastic anemia

Symptoms of Opioid Use Disorder

THINK CNS IS DECREASED!

-miosis (pinpoint pupils)

-slow or fast HR

-bradypnea

-hypotension

-hypothermia

-slurred speech

-euphoria

-severe intoxication -> respiratory depression

Symptoms of Opioid Withdrawal

THINK CNS IS INCREASED!

-hypertension, tachycardia, tachypnea, hyperthermia

-dysphoria, anxiety, yawning, insomnia

-muscle aching, hyperreflexia, spasms

-nausea/vomiting/diarrhea; abdominal cramping

-lacrimation

-rhinorrhea

-mydriasis

-piloerection (goosebumps)

-diaphoresis

Peak Symptoms of Opioid Withdrawal

occur 72 hours post last dose

1. CNS wakes up

-tachycardia, diaphoresis, tremor, restlessness, mydriasis

2. GI wakes up

-abdominal cramping and NVD

3. flulike symptoms

-joint pain

-rhinorrhea

-yawning

Naloxone

fast-acting, short-duration, emergency overdose reversal

Methadone

used for detoxification and maintenance treatment of OUD

-long-acting opioid that reduces cravings and WD symptoms without causing the same high

Buprenorphine

produces some opioid effects (reducing WD and cravings) but has "ceiling effect", meaning effects level at high doses; lowers risk of respiratory depression compared to full agonists

Buprenorphine-Naloxone

primarily used for maintenance treatment of OUD

-naloxone added to deter misuse by injection

Inhalant Use Disorder

after an initial feeling of excitement or "rush", primary effect is CNS depression

Inhalant Use Intoxication

-euphoria

-dizziness

-disorientation and incoordination

-headache

Inhalent Use Withdrawal

24-48 HOURS AFTER LAST USE OR REDUCTION IN USE

-irritability

-anxiety

-depression

-headaches

-cravings

-possibility of seizures

Sedative Use Disorder

-CNS depressant

-reduces excitement without inducing sleep or affecting the motor functions

-anxiolytics when used in therapeutic doses

Hypnotic Use Disorder

-CNS depressant

-used for initiating sleep

-higher doses produce general anesthesia

Sedative/Hypnotic Intoxication

1. might seem overly happy or carefree at first

-euphoria = intense high before dangerous effects

-this can quickly turn in to severe overdose symptoms

2. appears unbelievably tired or "out of it"

-drowsiness, lethargy, sedation

-slumped posture, struggling to open eyes, nodding off

3. confusion and clumsiness

4. emergency = SLOW & SHALLOW RESPIRATIONS