PPN 302 Class 9: Partnering with persons who use Substances: Using a Harm Reduction Approach in assessment, treatment planning and intervention

Why We Need to Increase Substance Use Nursing Capacity

• Substance use disorders affect a wide range of persons encountered across all practice settings.

• Early assessment and management promotes substantially better outcomes.

• Stigma often promotes delayed care.

Stimulatnts “uppers”(Increase central nervous system activity )

• Effects: Wakefulness, euphoria, decreased appetite, aggression, rapid heart rate, elevated body temperature, agitation, paranoia, delusions, hallucinations

• Refer to medical care if client is very agitated (may need benzodiazepines), delusional (may need antipsychotics), or hyperventilating and experiencing severe sweating and convulsions (may indicate an overdose)

Stimulants “Uppers”

• Cocaine/crack

• Methamphetamine (crystal, crystal meth, meth, ice, crank, glass, chalk).

• Psychoactive bath salts

Individuals with a mental health disorder are…

2x more likely to develop a substance use disorder in their life

Individuals with a substance use disorder are….

4x more likely to develop a mental health disorder in their life

Concurrent disorders

• Mental health + Substance use problem

Examples of concurrent disorders

• Depression + Alcohol use

• Schizophrenia + Cannabis use 

The Foundations of Substance use nursing

• An appreciation that substance use disorders are a complex, interrelated condition that affects the whole person.

• Understands the bio-psycho-social aspects of substance use disorders.

• Is able to assess, manage, and provide care for persons in intoxication, withdrawal management, and throughout recovery.

• Understands treatment models and is knowledgeable about treatment options.

• Practices within a harm reduction framework

Harm Reduction

• defined as an approach, set of strategies, policy or program designed to reduce substance-related harm without requiring abstinence

Harm reduction at its core 

• is working together with people who use substances as partners to:

  • Reduce negative health, social, and economic consequences related to substance use

  • Promote public health, human rights, and social justice.

  • Promotes equity, inclusion, dignity, self-determination, and respect

Practical level (Harm reduction theory)

• pragmatic

• realistic

• low threshold

Goals of harm reduction (Harm reduction theory)

decreases adverse health, social, and economic consequences of drug use without requiring decrease in drug use

Conceptual (Harm reduction theory)

• Value-neutral view of drug use and user

• focuses on problems

• does not insist on abstinence

• active participation of user

Policy (Harm reduction theory)

• Middle range

• wild spectrum 

• embedded in existing policies 

Programs (Harm reduction theory)

• Needle exchange 

• Methadone maintenance 

• outreach 

• law-enforcement cooperation 

• illicit drug prescription

• tolerance zones

• Alcohol server intervention 

• Smoking control 

Alcohol (Harm Reduction Strategies) 

• Minimum, legal drinking age

• Impaired driving laws 

• Designated driver programs 

• Server intervention program - Smart serve program 

• low-risk drinking guidelines 

• LCBO/Hours 

• Taxation 

Opioids (Harm Reduction Strategies)

• Supervised injection services

• Naloxone kits 

• Opioid agonist maintenance treatment

• needle exchange

• decriminalisation 

• safer supply 

Tobacco (Harm Reduction Strategies)

• Limiting access and areas 

• Nicotine replacement 

• prescription medication (Zyban, Champix) 

Toronto Drug checking services

• Offers people who use drugs timely and detailed information on the contents of their drugs, helping them to make more informed decisions

• Accepted samples include drugs (10 mg of powder, crystals, rocks, or a crushed bit of a pill, a small piece of blotter, or a small amount of liquid) and drug equipment after it’s been used (a used cooker or filter, or leftover liquid from a syringe).

• Results are both qualitative and quantitative (i.e., which substances are found in each sample and varying degrees of
  information about how much of each substance is present) and are available within a business day or tw

Potential factors that increase risk of severity of use 

• Concurrent mental health concern

• self-medication

• emotional distress

• decreased coping

• childhood abuse

• personal or family history

Brain & Body (Potential factors that increase risk of severity of use) 

• Substances that tend to be more “addictive”:

  • Have a fast onset- Can be enhanced by injecting, smoking, crushing, snorting, etc.

  • Have a short half-life (T ½)-Leave body quickly—need to keep using

  • But: Medication treatments tend to have slow onset & long T ½

Addiction defined

“A treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviours that become compulsive and often continue despite harmful consequences.”

Intoxication (Physiological/psychological states)

• The direct and immediate physiological/psychological effects of taking substance(s)

• effects vary by type, quantity and route of substance use

Tolerance (Physiological/psychological states)

• A need for markedly increased amounts of substance to achieve intoxication or desired effect

• A markedly diminished effect with continued use of the same amount of a substance

• Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.

Withdrawal (Physiological/psychological states)

• Occurs when reducing or stopping substance. Withdrawal symptom parameters often are opposite to the induced effects of the substance

• The withdrawal parameters are specific and characteristic of the substance taken

Substance Use (ministry of health promotion, 2010; Rassool, 2010)

• The ingestion or administration of psychoactive substances that can be beneficial or harmful depending on the substance used and the quantity, frequency, method, and context of use

Substance Use disorder 

• DSM–5, identified as “a cluster of cognitive, behavioural, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems and harms”

• Patterns of behaviour include impaired control, social impairment, risky use, and pharmacological criteria

Non Substance related disorder (DSM-5 Substance us & SUD Categorisation)

• Gambling disorder

Substance use disorders (DSM-5 Substance us & SUD Categorisation)

• 10 Substances 

• Spectrum of severity:

  • Mild 

  • moderate 

  • severe

Substance Induced disorders (DSM-5 Substance us & SUD Categorisation)

• Intoxication

• Withdrawal

Substance use disorder DSM-5

• A problematic pattern of a substance use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  • Substance often taken in larger amounts or over a longer period than was intended.

  • Persistent desire or unsuccessful efforts to cut down or control use.

  • A great deal of time is spent in activities necessary to obtain, use, or recover from effects of substance.

  • Craving, or a strong desire or urge to use substance.

  • Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.

  • Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects .

  • Important social, occupational, or recreational activities are given up or reduced because of use.

  • Recurrent use in situations in which it is physically hazardous.

  • Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

  • Tolerance

  • Withdrawal

    
    

Spectrum of severity

• Mild

• Moderate

• Severe

Mild (spectrum of severity)

2-3 symptoms

Moderate (spectrum of severity)

4-5 symptoms

Severe (spectrum of severity)

6+ symptoms

Classes of psychoactive substance

• Depressants (i.e. alcohol, benzodiazepine, opioids)

• Stimulants (i.e. cocaine, crystal Methamphetamine)

• Hallucinogens (i.e. MDMA, Marijuana)

• Anabolic Steroids (i.e. Steroids)

Depressants

• Slows the central nervous system

• Slows mental processes

• Decreased alertness

• Slows heart rate while intoxicated

• Fast heart rate in withdrawal

Common depressants

• Alcohol

• Benzos

• Sedatives/Tranquiliizers 

Physiological (Indicators of Depressant use)

• Slowed heart rate 

• Slowed respiration

• Decreased body temp 

• Lowered blood pressure 

• incoordination  

• Unsteady gait 

Psychological/Cognitive

• Disorientation

• Confusion 

• Disinhibition 

• Irritability 

• Emotional lability 

• Impaired judgement

• Slurred speech

• Drowsiness

Alcohol usage range

• No risk

• Low risk

• Moderate risk

• Increasingly high risk

• Each standard risk: radially increases the risk of the alcohol-related consequences

No risk (alcohol usage)

• 0 drinks per week 

  • benefits: health, more sleep

Low risk (alcohol usage)

• 1 to 2 standard drinks per week

Moderate risk (alcohol usage)

3-6 standard drinks per week

• risk developing several different types of cancer; including breast, and colon cancer

Increasingly High risk (alcohol usage)

• 7 or more standard drinks per week 

  • your risk heart disease or stroke increases

Problematic drinking

• Number of drinks/week:

  • Male- More than 14

  • Female- More than 9

• Drinks moderately (fewer than 4/Day): Often

• Tolerance: Mld

• Withdrawal symptoms: No

• Neglect of major responsibilities: No

• Socially stable: Usually

Alcohol dependence

• Number of drinks/week:

  • More than 40-60 per week

• Drinks moderately (fewer than 4/Day): Rarely

• Tolerance: Marked

• Withdrawal symptoms: Often

• Neglect of major responsibilities: Yes

• Socially stable: Not Often

Biopsychosocial presentation of alcohol use

• Neurological

• Cardiovascular

• Gastrointestinal/Hepatic

• Reproductive

• Musculoskeletal

• psychological

• Behavioural

• Social

Neurologcial (Biopsychosocial presentation of alcohol use)

• Tremors

• ataxia- poor muscle control casusing clumsy movments

• Peripheral nephropathy

• seizures

• asterixis- Jrking of hands and feet whil trying yo ohol a hosition

• Stroke

• Wernicke-Korsakoff- “wet brain” causes confusion and sevre memory loss (permanent) treated wth thiamine

Cardiovascular (Biopsychosocial presentation of alcohol use)

• Hypertension

• Dysrhthymia  

• Cardomyopathy 

• CAD

Gastrointestinal/Hepatic (Biopsychosocial presentation of alcohol use)

• Gastritis 

• Dyspepsia 

• recurrent diarrhea 

• Pancreatitis 

• Fatty liver 

• Cirrhosis 

Reproductive (Biopsychosocial presentation of alcohol use)

• Impotence

• Menstrual irregularities

• Infertility 

Musculoskeletal (Biopsychosocial presentation of alcohol use)

• Trauma 

• myopathy 

• beer belly 

Psychological (Biopsychosocial presentation of alcohol use)

• Insomnia

• Fatigue

• depression

• anxiety 

• illicit/prescription drug use

Behavioural (Biopsychosocial presentation of alcohol use)

• Missed appointments

• Memory impairment 

Social (Biopsychosocial presentation of alcohol use)

• Marital discord

• Family violence

• Work/school absenteeism 

• poor performance

• impaired driving 

Alcohol: Health Impacts

• Liver impacts: cirrhosis

• Escalating tolerance & withdrawal

• Throat and stomach-related impacts: Esophageal varies, Reflux 

• Cardiac impacts 

• Cognitive impacts, Wernicke Korsakoffs

• Injuries MVA

• Concurrent anxiety, Depression

Screening for Alcohol Problems

• TAKE A COMPREHENSIVE PATIENT HISTORY

• Ask about alcohol use

• Ask about the number of drinks/week

• Explore the maximum amount consumed on any one day in the past three months

• Ask how many bottles & what size are consumed per week

• Ask about the previous week’s drinking pattern if the patient is vague

• Ask about other drug use, as it is not uncommon for heavy drinking and polysubstance use to co-exist.

• Ask if the patient has ever been hospitalized or required medication for alcohol withdrawal

Managing alcohol Intoxication/Overdose

• Medical management is mainly supportive

• Most important goals:

  • Prevent harm from respiratory depression

  • Protect airway against aspiration

  • Monitor for hypoglycemia

  • No known agent that is effective as an alcohol antagonist

Alcohol Withdrawal Symptoms

• Morning Relief

• Drinking 

• Tremor 

• Nausea or vomiting- depends on severity

• Headache 

• Auditory & visual disturbances

• Paroxysmal Sweating

• tactile disturbances- itching, pins and needles, burning or numbness 

• Anxiety

• Seizure (risk increases with previous history  of seizure 

• Delirium Tremens- a severe form of ethanol withdrawal 

  • orientation clouding/ clouding of sensorium

How many drinks triggers withdrawal

• withdrawal is common when consuming more than 40 drinks per week

Minor (the three stages of alcohol withdrawal)

• Autonomic Hyperactivity:

  • Nausea/Vomiting

  • Coarse Tremor

  • Sweating

  • Tachycardia

  • Hypertension

Minor - symptoms (the three stages of alcohol withdrawal)

• tend to appear within 6-12 hours of last drink

• usually resolve within 48-72 hours

Intermediate (the three stages of alcohol withdrawal)

• Autonomic Hyperactivity:

  • Seizures

  • Dysrhythmias (Atrial Fibrillation, Supraventricular, Ventricular Tachycardia)

  • Hallucinations (Auditory/Visual)

Intermediate- symptoms (the three stages of alcohol withdrawal) 

• withdrawal seizures usually occur between 12-72 hours after drinking has stopped 

• Seizure protocol: 20mg Valiium q1hr x 3 doses min 

Major (the three stages of alcohol withdrawal)

• Delirium Tremens:

  • Severe agitation

  • gross tremulousness

  • global confusion

  • disorientation

  • auditory

  • tactile

  • visual hallucinations

  • psychomotor & autonomic

  • hyperactivity (hypertension, fever...etc.) 

Major- symptoms (the three stages of alcohol withdrawal)

• typically occur 5-6 days after severe, untreated withdrawal

• sudden death can occur

Pharmacological Management of alcohol withdrawal

• Primary goal = prevention of seizures 

• assessment utilising CIWA informs decisions to provide pharmacotherapy 

  • Score > 10- Give benzodiazepine 

  • Score </= 10- Mild withdrawal; no benzodiazepine given 

  • 3 negative scores (</=10)- discontinue CIWA

Diazepam

long acting medication - half life approx 100 hours

• Preferred medication unless relative contradictions 

Lorazepam

Intermediate acting medication - half life approx 10-20 hours 

• Alternative medication if any of the following present:

  • frail elderly 

  • history of poorly controlled respiratory disease (asthma, COPD)

  • current use of opioids

  • cirrhosis

When to send to ER (Alcohol Withdrawal)

• Escalating symptoms of tremor/shakiness, disorientation, sweating, hallucinations 

• symptoms are not getting better 

Medications to help with cravings/relapse

• Acamprosate

• Naltrexone

• Disulfiram 

Medications to help with cravings/relapse (effects)

• reduce heavy drinking

• help prevent relapse to alcohol

• reduce cravings for alcohol

• Individual’s goals 

Acamprosate

• Works to restore/balance excitatory neurons that become dysregulated in alcohol withdrawal and early abstinence

• medication is available as a capsule and is taken three three times daily by mouth 

Acamprosate (side effects, interactions, cautions)

• Can cause: Nausea, Diarrhea

• No significant interactions

• contraiindicatons for use- renal dysfunction contraindications

Naltrexone

• an opioid receptor antagonist that reduces the rewarding effects of alcohol 

• this medication is available as a tablet and is taken once daily by mouth

Naltrexone (side effects, interactions, cautions)

• Can cause: Nausea, Headache 

• contraindicated with current opioid use

• Contraindications for use- acute hepatitis, liver failure

Disulfiram

• Acetaldehyde dehydrogenase inhibitor: leads to the accumulation of acetaldehyde if a person consumes alcohol

• considered an aversive therapy rather than a medication to help with cravings

• people stop drinking due to fear of an unpleasant physical reaction that occurs when alcohol is combined with med

• Desired reaction: Nausea, Vomiting, Flushing, Tachycardia, Hypotension 

• This medication is taken only as a compounded capsule that is not commercially available, once daily by mouth 

Disulfiram (side effects, interactions, cautions)

• Can cause: metallic taste, dermatitis

• Interacts with alcohol containing products- mouthwashes, cold medicines, topical products etc)

• Psychosis, severe cardiovascular disease

Benzodiazepines

• Lorazepam (Ativan)

• Diazepam (Valium)

• Temazepam

• Alprazolam (Xanax)

Indications for Benzodiazepines

• commonly prescribed drugs

• controversy around thee most appropriate use and effectiveness of benzodiazepines

• Most commonly prescribed for: 

  • Anxiety disorders (panic disorder, Generalized anxiety disorder_ 

  • Mood disorder (depression) 

  • Sleep disorders (Insomnia) 

  • Alcohol withdrawal & Seizure disorder 

Benzodiazepines intoxication and overdose

• Rarely lead to death when taken by themselves

• Most important to monitor the airway and ensure adequate respirations

Benzodiazepine receptor antagonist

• Flumazenil

Mild/moderate effects (Benzodiazepines intoxication and overdose) 

• Ataxia- Poor muscle control that causes clumsy movements

• Dysarthria- weak muscles cause difficulty speaking

• Muscle weakness

• Nystagmus-rapid uncontrolled movements

• Fatigue

• Drowsiness 

Severe effects (Benzodiazepines intoxication and overdose)

• Hypotension 

• Respiratory depression

• Stupor

• Coma

Monitoring the discontinuation of benzodiazepines

1. Do not abruptly stop taking if you have been taking for several months/years unless there is a medically sound reason, such as serious complications that warrant immediate discontinuation

   1. Due to the increased risk of seizure

2. Withdrawal regimens for tapering off benzodiazepines should be
   slow and gradual with the support of the primary physician/NP

   
   

Benzodiazepine Withdrawal Considerations

• Often Benzos found in fentanyl 

• Xanax is fast acting more potent benzo that has higher likelihood of severe withdrawal  

• Slow Taper Preferred

• might happen silently if the primary substance concern is not benzo

  • ie came in for help for X but forgot to mention they usually regularly take benzos or did not their fentanyl or other substance had benzo- they didn’t know how much it affected them

Short -acting (Benzo Withdrawal symptoms drug type onset)

• Onset of withdrawal: Within 24 hours of cessation 

• Peak severity of withdrawal: 1-5 days after cessation 

• Duration of Acute withdrawal: 7-21 days 

Long acting (Benzo Withdrawal symptoms drug type onset)

• Onset of withdrawal: Within 5 days of cessation 

• Peak severity of withdrawal: 1-9 days 

• Duration of Acute withdrawal: 10-28 days 

Vital signs (Benzodiazepine withdrawal symptoms) 

• Tachycardia 

• Hypertension 

• Fever 

CNS (Benzodiazepine withdrawal symptoms) 

• Agitation 

• Restlessness

• Anxiety 

• Insomnia 

• Irritability 

• Muscle tension 

• Sensory disturbances 

• Tremor 

• Nightmares 

• Hallucinations 

Ears (Benzodiazepine withdrawal symptoms) 

• Tinnitus

GI (Benzodiazepine withdrawal symptoms) 

• Anorexia

• Nausea 

• Diarrhea 

Severe withdrawal (Benzodiazepine withdrawal symptoms) 

• Seizures 

• Delirium 

• Death 

Opioids defined

• Substances that engage opioid receptors (“pain killers- such as narcotic pain meds or heroin) 

Opium, Heroin

• non-synthetic, smoked, injection, snorted

Prescription Narcotic pain Medications

• Morphine, Percocet, oxycontin, Dilaudid, Codeine

• Swallow pills, crush, inject, snorted

Fentanyl,Car-fentanyl

• Much more potent, longer duration of action

  • Fentanyl 80-100 times than morphine

  • Carfentanil 10 000 times more than morphine

• Highly contaminated street supply

• Intravenous, oral tablets, snort, smoked

Kratom

• has properties of both opiates and stimulants: Lower doses cause stimulant effects, and higher doses cause opiate effects.

Opioid effects (intoxication)

• Sedation, drowsiness

• Slowed breathing

• Decreased level of consciousness

• Feelings of calmness/pleasure

• Slurred/slowed speech

• Sensation of heavy limbs, pinpoint pupils

  • if not rousable, trouble breathing, blue lips/fingernails, call 911 and administer naloxone