Week 14: Substance Use Disorders and Withdrawal & Multimodal Interventions for Pain Management

Dependence

the state of relying on or being controlled by someone or something else

Tolerance

either of the following:

-a need for markedly increased amounts of alcohol to achieve intoxication or desired effect

-a markedly diminished effect with continued sue of the same amount of alcohol

Alcohol withdrawal syndrome

-begins within 6-24 hrs of the last drink or sudden reduction of chronic drinking

S/s of mild alcohol withdrawal

-anxiety

-agitation

-restlessness

-insomnia

-tremor

-diaphoresis

-palpitations

-headache

-loss of appetite

S/s of moderate/severe alcohol withdrawal:

-hallucinations

-seizures

-delirium

-tremens (seizures and delirium)

Withdrawal delirium

-rapid onset

-fluctuating disturbance of attention and cognition

Nursing considerations for alcohol withdrawal:

-assess risk

-establish severity

-decrease agitation and prevent withdrawal progression

-maintain electrolyte balance

-prevent complications

-initiate case management services

Opioid use disorder:

-an overpowering desire to use opioids

-increased opioid tolerance

-withdrawal syndrome when opioids are no longer in use

-range from dependence to addiction

S/s of opiate withdrawl:

-diaphoresis

-vomiting

-tachycardia

-abdominal pain/cramps

-muscle cramps

-diarrhea

What is important and most often prescribed in treatment of alcohol withdrawal and may help prevent Wernicke-Korsakoff syndrome?

Thiamine

You are teaching this person about Relapse. Which one of the following is most important to include in this teaching?

Relapse is a part of Recovery, and you can use it to learn and start again on abstinence

Common harm reduction interventions:

-designated driver campaigns to reduce morbidity

-condom use to prevent STI or pregnancy

-prescribing naloxone to prevent opioid overdose

-referral to syringe service programs to reduce infections associated w/unsafe injection

Nociceptive pain

somatic pain: burns, fractures, musculoskeletal pain, wounds, arthritis, gout

visceral pain: stomach, intestines, uterus, ureter, bladder pain, angina

How to treat somatic pain

NSAIDS and opioids

How to treat visceral pain

opioid analgesics

Neuropathic pain

pain caused by damage to peripheral nerves or structures in the central nervous system

-numb, shooting, stabbing, electrical shock-like

Nociplastic pain

pain without identifiable nerve or tissue damage

-thought to be caused by changes in how the nervous system processes pain signals

Multimodal pain management:

the combination of different pain management strategies that act by different mechanisms

-opioids to strong to stronger

MOA of Acetaminophen (Tylenol)

inhibit the synthesis of prostaglandins in the brain rather than the site of inflammation

-mild to moderate somatic pain control

Nursing considerations for Acetaminophen:

-monitor for nausea and vomiting

-monitor for hepatotoxicity

-monitor those w/alcohol use disorder or liver insufficiency

-reassess PO in 30 to 60 mins

Max dosing for Acetaminophen:

4,000 mg for normal person

3,000 for long-term use or drinkers/liver disease

Antidote for acute overdose of Acetaminophen:

-Activated charcoal (within 4 hrs of overdose)

-Acetylcysteine (Mucomyst)

MOA for NSAIDS:

prevent the production of prostaglandins by inhibiting the activity of COX enzymes

-decreases pain, inflammation, and fever

-increases risk for MI and stroke

Dosing for Ibuprofen:

-1,200 mg OTC

-3,200 mg w/prescription

Nursing considerations for ibuprofen:

-monitor for GI bleeding, HTN, and exacerbation of HTN

-long term use can affect the kidneys

-can prolong bleeding time (stop prior to procedure)

Why do we take off topical analgesics (lidocaine) q12 hours?

AVOID TOXICITY

Opioid Agonist

fully activate opioid receptors, especially mu receptors to produce typical opioid effects

-morphine, fentanyl, methadoone

Opioid Antagonist

block opioid receptors, preventing opioids from binding and activating them

-Naloxone and Naltrexone

Agonist Antagonist Opioids

act as an agonist at one receptor type and an antagonist at another

-Nalbuphine and Butorphanol

Nursing considerations for codeine:

there are patients that are immune to this med and others that are super metabolizers

-we don't use this one much anymore

Morphine Milligram Equivalents (MME):

-values that represent the potency of an opioid dose relative to morphine

-intended to help clinicians make safe, appropriate decisions concerning changes to opioid regimens

MME guidelines:

Low: 20 MME

Moderate: 20-50

High: greater than 90

What MME number is naloxone and overdose education provided?

50 AND ABOVE

-given naloxone and education

When would a nurse reassess an IV opioid pain medication?

15 to 30 minutes

-fentanyl is 5 minutes

Side effects of opioids:

-nausea/vomiting

-drowsiness

-constipation

-urinary retention

-confusion and hallucinations

-hypotension and bradycardia IN HIGH DOSES

Meds used in opioid-induced constipation:

-stool softener

-stool stimuland

-osmotic laxatives

-also increase fluids, fiber, and walking

Which medication to avoid for opioid-induced constipation:

BULK LAXATIVES such as Metamucil and citracel

Which patients have increase risk for opioid-induced respiratory depression?

-obstructive sleep apnea

-obesity

-advanced age

-COPD, HF, renal insufficiency

-high opioid tolerance

Pasero Opioid-induced sedation scale (POSS) score S:

S= sleep, easy to arouse

-acceptable, no action necessary

Pasero Opioid-induced sedation scale (POSS) score 1:

awake and alert

-acceptable, no action necessary

Pasero Opioid-induced sedation scale (POSS) score 2:

slightly drowsy; easily aroused

-acceptable, no action necessary

Pasero Opioid-induced sedation scale (POSS) score 3:

frequently drowsy; arousable; drifts off to sleep during conversation

-unacceptable; monitor respiratory status and sedation level

-decrease opioid dose

Pasero Opioid-induced sedation scale (POSS) score 4:

somnolent, minimal or no response to verbal and physical stimulation

-unacceptable; stop opioid, consider administering Naloxone

What is the opioid reversal agent?

NALOXONE (NARCAN)

-administer IV

-repeat q2-3 mins as needed

-administer slowly to decrease acute withdrawal

Which scheduling method is least effective (continuous or intermittent)?

Intermittent!!

-specifically nurse driven PRN

Types of sedation:

-minimal sedation

-moderate sedation (conscious sedation)

-deep sedation

-general anesthesia (need airway for both)

General Anesthesia

reversible state of unconsciousness with loss of sensation of entire body

Sedation Anesthesia

decreased LOC or relaxed state, but not fully conscious

Regional Anesthesia

blocks sensation in a large region or portion of the body

Local Anesthesia

blocks sensation in the specific area of the body

Nursing considerations for peripheral nerve block:

-perform a neurovascular assessment on the extremity DISTAL to the pump insertion

-monitor for Local Anesthetic Systemic Toxicity (LAST)

S/s of Local Anesthetic Systemic Toxicity (LAST)

-for continuous application of nerve block

-numbness of lips/mouth

-metallic taste

-tinnitus

-mental status changes

-bradycardia

-hypotension

-chest pain

Nursing considerations for spinal anesthesia:

-monitor for and report post-dural puncture headache (spinal headache)

-epidural blood patch will be placed

-monitor VS and CO2

-ensure safety for ambulation

Complications w/Epidural infusion

-urine retention

-decreased LOC and respiratory depression

-local anesthetic systemic toxicity (LAST)

-hematoma

-infections