Week 4 Substance-Related and Addiction Disorders

Substance use

A pattern of use of any substance, legal or illegal, for mood- or behavior-altering purposes

Substance

A psychoactive drug/compound/substance that poses hazards to health and impacts all aspects of the client's life

Abuse

a state of both physical and psychological dependency which include cravings and uncontrollable urges to engage in compulsive behaviors even if there are harmful consequences

Addiction

A compulsion. If the need is unfulfilled or unmanaged, there will be physical or psychological distress

Withdrawal

The physiological and psychological symptoms experienced during the discontinuation of a substance on which a person is dependent

Tolerance

The need for larger amounts of more frequent doses of a substance

Diagnostic Criteria

Repeated use of substances, leading to clinically significant impairment during a 12-month period

The DSM-5 identifies 10 diagnostic categories of substances including

alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics, stimulants, tobacco, and others (reward seeking behaviors)

Substance use and addictive disorders are characterized by

loss of control due to the substance use or behavior, participation that continues despite continuing associated problems, and tendency to relapse back into the substance use or behavior

Population-Specific Considerations

-The rate of substance use is highest in clients who are 18-25 year of age.

-Cocaine use is decreased among adolescents. About half of adolescent population report access to marijuana.

-The younger the person is at the time of initial substance use, the higher the incidence of developing a substance use disorder.

-Substance use while pregnant creates risks for their infants, including an increased likelihood of prematurity, low birth weight, and neonatal abstinence syndrome.

-Health care providers are vulnerable to drug diversion.

-Older adults who use substances are especially prone to falls and other injuries, memory loss, somatic reports (headaches, pain), and changes in sleep patterns.

Risk Factors

-Genetics

-Chronic stress

-History of trauma: abuse, combat experience

-Lowered self-esteem

-Lowered tolerance for pain and frustration

-Risk taking tendencies

-Few meaningful relationships and life successes.

Protective Factors

-Positive family support, social relationships, and self-esteem

-Caregiver involvement in child and adolescent activities

-Availability of community resources and programs

-Employment

The Brain's Reward Pathway

The effects of excess dopamine can overwhelm the system

Basal ganglia

controls motivation and everyday activities such as eating, socializing, and sex

Amygdala (fear response center)

related anxiety, irritability, and uneasiness

Prefrontal cortex

-becomes imbalanced with substance use, creating a compulsive need for the client to acquire the substance

-Their impulse control, as well as their ability to plan, think, make decisions, and solve problems, are all affected by substance use

Alcohol (Ethanol) Route

oral

Alcohol (Ethanol) Intended effects

relaxation, decreased social anxiety, and stress reduction

Alcohol (Ethanol) Effects of intoxication

Slurred speech, nystagmus, memory impairment, AMS, decreased motor skills, decreased level of consciousness (stupor or coma), respiratory arrest, peripheral collapse, and death

Alcohol (Ethanol) Chronic use

cardiovascular damage, liver damage, erosive gastritis, GI bleeding, acute pancreatitis, and sexual dysfunction

Fetal alcohol syndrome symptoms include

microcephaly, craniofacial malformations, limb and heart defects, and development problems

Alcohol (Ethanol) Withdrawal Manifestations

-Abdominal cramping, vomiting

-Tremors, restlessness, and inability to sleep

-Tachycardia, hypertension, increased temperature, and increased respiratory rate.

-Tonic-clonic seizure

-Alcohol withdrawal syndrome (AWS)

Which scale do you use for alcohol withdrawal?

Clinical Institute Withdrawal Assessment Alcohol Scale Revised CIWA-AR

Alcohol (Ethanol) Blood alcohol concentration (BAC)

-0.08% (80mg/dL): legally intoxicated for operating automobiles in the US

-0.4% (400 mg/dL): considered acute toxicity, death could occur.

-BAC depends on body weight, gender, concentration of alcohol in drinks, number of drink, gastric absorption rate, and individual's tolerance.

-CIWA: Clinical Institute Withdrawal Assessment of Alcohol scale.

Clinical Presentation: Alcohol Symptoms of Use

-mood and behavior changes

-unable to coordinate movement

-slurring words

Clinical Presentation: Alcohol Concerns When Under the Influence

-Safety

-Accident prone

-Risk for bleeding

-Risk for DUI charge and/or accident

Clinical Presentation: Alcohol Symptoms and Concerns of Withdrawal

-Agitation, anxiety, sweating, insomnia, delirium, mild, moderate, or severe tremor, DTs, vomiting, hallucinations, confusion, syncope, hypertension, tachycardia, seizures.

-Delirium tremens (DTs) is a severe and potentially fatal presentation of alcohol withdrawal.

Alcohol Withdrawal Timeline Stage 1

-4 to 8 hours after last alcoholic drink

-Manifestations during this phase can include anxiety, insomnia, nausea, abdominal discomfort, vomiting, loss of appetite, fatigue, tremors, headache, and increased heart rate and blood pressure.

Alcohol Withdrawal Timeline Stage 2

-Manifestations can become more critical

-This generally occurs within the first 3 days since last drink.

-Manifestations from the first phase may intensify and clients may experience irregular heart rate, confusion, sweating, increased irritability, mood disturbances, body temperature, and blood pressure increase.

Alcohol Withdrawal Timeline Stage 3

-The severity of manifestations may worsen, resulting in delirium tremens (DT)

-DT symptoms may include extreme confusion, extreme agitation, fever, seizures, hallucinations (tactile, auditory, visual).

Alcohol-Induced Amnestic Disorders

Organic brain disorders caused by long-term alcohol abuse result in frontal cortex atrophy, and dietary deficiencies (thiamine, folic acid, and other B vitamins).

Wernicke Encephalopathy

-caused by thiamine deficiency; characterized by ocular dysfunction, ataxia, hypotension, confusion, and coma

-Brain damage to the thalamus and hypothalamus, life threatening (acute phase)

Korsakoff amnestic syndrome

short term memory disturbance and confabulation, ocular dysfunction, inability to speak coherently, and ataxia

Confabulation

The client can make up stories when questioned about events or activities that they do not remember. This can seem like lying, but it is actually an unconscious attempt to save self-esteem and prevent admitting the inability to remember the occasion

Wernicke-Korsakoff Syndrome

two different stages of the same disorder, Wernicke being the acute phase and Korsakoff being the chronic phase

Opioids Route

Injected, smoked, inhaled, and oral

Opioids

-Heroin, morphine, and hydromorphone

-CNS depressants, Schedule II

Opioids Intended effects

rush of euphoria, relief from pain

Opioids Effects of Intoxication

slurred speech, impaired memory, pupillary changes, decreased respirations level of consciousness, maladaptive behavioral or psychological changes (judgment and social functioning).

Opioids Withdrawal Manifestations

-sweating, rhinorrhea progressing to piloerection, tremors, irritability, severe weakness, n/v/d, fever insomnia, pupil dilation, pain in muscles and bones, and muscle spasms (abstinence syndrome).

-Withdrawals are unpleasant but not life threatening, but can result in suicidal ideations.

Opioids Antidote

Naloxone; specific opioid antagonist. Available IM, SQ, IV, or via inhalation. Reversal agent.

Opioid screening tools

Clinical Opiate Withdrawal Scale (COWS)

Clinical Presentation: Opioids Symptoms of Use

-Can relieve pain and lead to relaxation.

-Drowsiness, confusion, nausea, constipation, euphoria, and slowed breathing.

Clinical Presentation: Opioids Concerns When Under the Influence

Using with alcohol can create a dangerous decrease of heart rate and breathing, coma, death.

Clinical Presentation: Opioids Symptoms and Concerns of Withdrawal

-Restlessness

-Muscle and bone Pain

-Insomnia

-Diarrhea

-Vomiting

-Cold flashes with goose bumps ("cold turkey")

-Leg movements

Sedative/Hypnotics/Anxiolytics Route

oral or injected

Sedative/Hypnotics/Anxiolytics

Benzodiazepines like diazepam, barbiturates like pentobarbital, or club drugs like flunitrazepam (date rape drug)

Sedative/Hypnotics/Anxiolytics Intended effects

sedations and decreased anxiety

Sedative/Hypnotics/Anxiolytics Effects of intoxication

-Increased drowsiness and sedation, agitation, slurred speech, uncoordinated motor activity, nystagmus, disorientation, nausea, vomiting

-Respiratory depression and decreased level of consciousness, which can be fatal

Sedative/Hypnotics/Anxiolytics Withdrawal manifestations

Anxiety, insomnia, diaphoresis, hypertension, possible psychotic reactions, hand tremors, nausea, vomiting, hallucinations or illusions, psychomotor agitation, and possible seizure activity

Sedative/Hypnotics/Anxiolytics Antidote for benzodiazepines

Flumazenil; competitive receptor antagonist. Reverses sedative effects and toxicity. Available IV.

Sedative/Hypnotics/Anxiolytics Antidote for barbiturate

No antidote to reverse barbiturate toxicity

Sedative/Hypnotics/Anxiolytics Safety

high risk for injuries, and seizures for benzodiazepine withdrawals.

Clinical Presentation: Sedatives Symptoms of Use

-Decreased anxiety

-ability to sleep, drowsiness

-slurred speech

-poor concentration, confusion

-dizziness, problems with movement and memory

-lowered blood pressure

-slowed breathing

Clinical Presentation: Sedatives Concerns When Under the Influence

-Sedative intoxication resembles that of alcohol.

-Central nervous system depression and increased drowsiness make arousing of client difficult and mind-altering effects.

-A primary concern is the sedative effect on the client's airway which results in a significant risk for respiratory failure.

-These substances are used in sexual attacks commonly called date-rape drugs.

Clinical Presentation: Sedatives Symptoms of Withdrawal/Concerns During Withdrawal

-Must be discussed with a health care provider

-Withdrawal can cause a serious abstinence syndrome that may even include seizures.

Cannabis Route

smoke or orally ingested

Cannabis Intended effects

Euphoria, sedation, hallucinations, decrease of nausea and vomiting secondary to chemotherapy, management of chronic pain

Cannabis Effects of intoxication

paranoia, hallucinations, increased appetite, dry mouth, tachycardia, motor skills impairment 8-12 hours

Cannabis Chronic use

increased risk for lung cancer and other respiratory effects

Cannabis Withdrawal Manifestations

Irritability, aggression, anxiety, insomnia, lack of appetite, restlessness, depressed mood, abdominal pain, tremors, diaphoresis, fever, headache

Synthetic cannabinoids

K2 and spice, chemically close to marijuana but more portent. High risk for toxic doses

Stimulants

Cocaine and Amphetamines/Methamphetamines, Inhalants, Caffeine, Tobacco (Nicotine)

Cocaine route

injected, smoked, or inhaled (snorted

Cocaine Intended Effects

Rush of euphoria (extreme well-being) and pleasure, increased energy

Cocaine Effects of intoxication

-Mild toxicity: dizziness, irritability, tremor, blurred vision

-Severe effects: hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, possible cardiovascular collapse and death

Cocaine Withdrawal Manifestations

-Depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation

-Not life-threatening, but possible occurrence of suicidal ideation

Amphetamines/Methamphetamines Routes

Can be taken orally, injected intravenously, snorted, or smoked

Amphetamines/Methamphetamines Intended effects

Increased energy, euphoria similar to cocaine

Amphetamines/Methamphetamines Effects of Intoxication

impaired judgement psychomotor agitation, hypervigilance, extreme irritability, acute cardiovascular effects (increased heart rate and bp).

Amphetamines/Methamphetamines Withdrawal manifestations

-Craving, depression, fatigue, sleeping

-Not life-threatening

Clinical Presentation: Stimulants Symptoms of Use

-Euphoria, "a rush," increased alertness, attention, energy

-increased blood pressure and heart rate

-narrowed blood vessels

-increased blood sugar

-opened-up breathing passages.

Clinical Presentation: Stimulants Concerns When Under the Influence

Used in combination with alcohol, there is a greater risk of cardiac toxicity than from either drug alone.

Clinical Presentation: Stimulants Symptoms of Withdrawal/Concerns During Withdrawal

-Depression

-tiredness

-increased appetite

-insomnia

-vivid unpleasant dreams

-slowed thinking and movement

-restlessness

Inhalants

Amyl nitrate, nitrous oxide, and solvents are sniffed, huffed, or bagged, often by children or adolescents.

Inhalants Intended Effects

euphoria

Inhalants Effects of Intoxication

behavioral or psychological changes, dizziness, nystagmus, uncoordinated movements or gait, slurred speech, drowsiness, hyporeflexia, muscle weakness, diplopia, stupor or coma, respiratory depression, and possible death

Inhalants Withdrawal manifestations

none, but can cause permanent brain damage

Hallucinogens

Lysergic acid diethylamide (LSD), mescaline (peyote), and phencyclidine piperidine (PCP) are usually ingested orally but can be injected or smoked.

Hallucinogens Intended Effects

Heightened sense of self and altered perceptions (colors being more vivid while under the influence)

Hallucinogens Effects of Intoxication

Anxiety, depression, paranoia, impaired judgment, impaired social functioning, pupil dilation, tachycardia, diaphoresis, palpitations, blurred vision, tremors, incoordination, and panic attacks

Hallucinogens Withdrawal Manifestations

Hallucinogen persisting perception disorder: visual disturbances or flashback hallucinations can occur intermittently for years

Clinical Presentation: Hallucinogens Symptoms of Use

-Hallucination: Visions that seem real but are imaginary.

-Dissociative drugs such as PCP cause people to feel out of control or disconnected from their body and environment.

Clinical Presentation: Hallucinogens Concerns When Under the Influence

-Safety

-sexual assault

-out-of-control behaviors

Clinical Presentation: Hallucinogens Symptoms of Withdrawal/Concerns During Withdrawal

-Headaches

-increased appetite

-sleepiness

-depression

Caffeine Route

Oral

Caffeine

cola drinks, coffee, tea, chocolate, energy drinks

Caffeine Intended Effects

Increased level of alertness and decreased fatigue

Caffeine Effects of Intoxication

-Intoxication commonly occurs with ingestion of greater than 250 mg. (One 2 oz high-energy drink can contain 215 to 240 mg caffeine.)

-Tachycardia and arrhythmias, flushed face, muscle twitching, restlessness, diuresis, GI disturbances, anxiety, insomnia.

Caffeine Withdrawal Manifestations

-Can occur within 24 hr of last consumption

-Headache, nausea, vomiting, muscle pain, irritability, inability to focus, drowsiness

Tobacco (Nicotine) Route

inhaled, chewed, or snuffed. Cigarettes, cigars, and smokeless Tobacco.

Tobacco (Nicotine) Intended effects

Relaxation, decreased anxiety

Tobacco (Nicotine) Effects of intoxication

-Long-term effects

-Cardiovascular disease (hypertension, stroke), respiratory disease (emphysema, lung cancer)

-With smokeless tobacco, there can be irritation to oral mucous membranes and oral cancers

Tobacco (Nicotine) Withdrawal Manifestations

irritability, craving, nervousness, restlessness, anxiety, insomnia, increased appetite, difficulty concentrating, anger, and depressed mood.

Non-Substance-Related Addictive Disorders

-Gambling disorder, sex activity, shopping, social media, and internet gaming.

-Compulsive behaviors characterized by risky use, urges, cravings, and "high" .

-Changes in serotonin system are observed with addiction behavior (similar to nicotine and alcohol)

Alcohol Withdrawal Medications

-Chlordiazepoxide/Librium

-Diazepam/Valium

-Lorazepam/Ativan

-Oxazepam

Alcohol Withdrawal Medications Intended Effects

-Maintenance of vital signs within expected reference ranges

-Decrease in the risk of seizures

-Decrease in the intensity of withdrawal manifestations

-Substitution therapy during alcohol withdrawal

Alcohol Withdrawal Medications Nursing Actions

-Administer around-the-clock or PRN as prescribed.

-Obtain baseline vital signs.

-Monitor vital signs and neurologic status on an ongoing basis.

-Initiate seizure precautions.

Alcohol Withdrawal Adjunct Medications

-Carbamazepine

-Clonidine

-Propranolol

-Atenolol

Carbamazepine intended effects

Reduction of manifestations of withdrawal and decrease in seizures