Substance-Related and Addiction Disorders

Learning Objectives for Substance-Related and Addiction Disorders

• Describe the impact that substance-related and addiction disorders have on a client’s overall health status.
• Explore the epidemiological and etiological risk factors that contribute to a client experiencing substance-related and addiction disorders.
• Differentiate between the various clinical presentations of clients experiencing substance-related and addiction disorders.
• Explore the professional role of the nurse when providing care for clients experiencing substance-related and addiction disorders.
• Apply the nursing process by utilizing clinical judgment functions while caring for clients experiencing substance-related and addiction disorders.
• Explore personal and nursing values specifically related to health care professionals who are chemically impaired.

Overview of Substance-Related and Addiction Disorders

• Core Concepts:     * Addiction involves both substances and specific behaviors.     * Overdose is a critical risk factor associated with substance use.     * Opioids represent a significant category within substance-related disorders.     * Mental health is deeply intertwined with addiction.     * Impact extends beyond the individual to the family unit.
• Manifestations: Addiction presents through cognitive, behavioral, and psychological manifestations.

Clinical Onset and Motivation for Use

• Lifespan Considerations: Substance use can occur throughout the entire lifespan.
• High-Risk Demographic: Adolescents represent the population at the highest risk for clinical onset.
• Reasons for Use:     * Self-medication: Individuals may use substances to treat manifestations of mental illness.     * Depression: Using substances to manage depressive symptoms.     * Anxiety: Using substances to mitigate anxious feelings.     * Pain management: Utilizing substances to control physical pain.     * Stress management: Using substances as a coping mechanism for stress.

Neural Reward Pathway and Biological Basis of Addiction

• Limbic System: This system is central to the reward pathway.
• Dopamine: Addiction is characterized by a "dopamine burst."
• Basal Ganglia:     * This area controls motivation.     * Excessive stimulation of the basal ganglia creates feelings of euphoria.
• Amygdala:     * Associated with feelings of anxiety and irritability.     * Responsible for illicit cravings.
• Prefrontal Cortex: This area is associated with the development of compulsive behaviors.

Etiology of Addiction: Risk and Protective Factors

• Risk Factors (Increase Vulnerability):     * Presence of mental illness.     * High levels of stress.     * Genetics.     * Peer pressure.     * History of abuse.
• Protective Factors (Decrease Vulnerability):     * Positive family support systems.     * Active caregiver involvement.     * Positive interpersonal relationships.     * Steady employment.     * Access to community resources.

Physiological Comorbidities

• Individuals with substance-related disorders often experience the following comorbidities:     * Heart disease.     * Stroke.     * Dental issues.     * Hepatitis.     * Cirrhosis.     * Mental illness.

Clinical Presentation: Alcohol Use and Withdrawal

• Symptoms of Use:     * Mood and behavior changes.     * Inability to coordinate movement.     * Slurring of words.
• Concerns When Under the Influence:     * Safety concerns.     * Being accident-prone.     * Increased risk for bleeding.     * Risk for a Driving Under the Influence (DUI) charge and/or accidents.
• Symptoms and Concerns of Withdrawal:     * Agitation and anxiety.     * Diaphoresis (sweating) and insomnia.     * Delirium.     * Tremors (ranging from mild to moderate to severe).     * Delirium Tremens (DTs): A severe and potentially fatal presentation of alcohol withdrawal.     * Vomiting and hallucinations.     * Confusion and syncope.     * Blood pressure fluctuations: hypotension or hypertension.     * Heart rate fluctuations: bradycardia or tachycardia.     * Seizures.

Clinical Presentation: Hallucinogens

• Symptoms of Use:     * Hallucinations, defined as false sensory experiences.
• Concerns When Under the Influence:     * General safety issues.     * Risk of sexual assault.     * Out-of-control behaviors.
• Symptoms and Concerns of Withdrawal:     * Headaches.     * Increased appetite.     * Sleepiness.     * Depression.

Clinical Presentation: Opioids

• Symptoms of Use:     * Relief of pain and induction of relaxation.     * Drowsiness and confusion.     * Nausea and constipation.     * Euphoria.     * Slowed breathing (respiratory depression).
• Dangerous Interactions: Using opioids in combination with alcohol can create a dangerous decrease in heart rate and breathing, potentially leading to coma or death.
• Symptoms and Concerns of Withdrawal:     * Restlessness.     * Muscle and bone pain.     * Insomnia.     * Diarrhea and vomiting.     * Cold flashes accompanied by goose bumps (referred to as "cold turkey").     * Involuntary leg movements.

Clinical Presentation: Stimulants

• Symptoms of Use:     * Euphoria and a sensation of "a rush."     * Increased alertness, attention, and energy.     * Increased blood pressure and heart rate.     * Vasoconstriction (narrowed blood vessels).     * Increased blood sugar levels.     * Bronchodilation (opened-up breathing passages).
• Dangerous Interactions: Used in combination with alcohol, there is a greater risk of cardiac toxicity than from either drug alone.
• Symptoms and Concerns of Withdrawal:     * Depression.     * Tiredness.     * Increased appetite.     * Insomnia.     * Vivid, unpleasant dreams.     * Slowed thinking and movement.     * Restlessness.

Clinical Presentation: Sedatives

• Symptoms of Use:     * Decreased anxiety.     * Ability to sleep and drowsiness.     * Slurred speech.     * Poor concentration and confusion.     * Dizziness.     * Problems with movement and memory.     * Lowered blood pressure.     * Slowed breathing.
• Specific Substances used as "Date Rape Drugs":     * Flunitrazepam.     * Gamma-hydroxybutyric acid (GHB).     * Gamma-butyrolactone (GBL).     * Ketamine.
• Symptoms and Concerns of Withdrawal:     * Withdrawal must be discussed with and monitored by a health care provider.     * Withdrawal can cause a serious abstinence syndrome, which may include seizures.

Warning Signs and Indicators of Substance Use

• Noticeable changes in mood.
• Changes in peer groups or social circles.
• Changes in weight or sleeping habits.
• Loss of interest in overall personal health.
• Decline in performance at school or work.
• Financial issues: loss of money, missing valuables, or frequent borrowing.

Detailed Manifestations of Alcohol Withdrawal

• Timeline: Manifestations typically develop within $4$ to $6\,hours$ since the last drink.
• Physical Symptoms:     * Tremors.     * Diaphoresis (excessive sweating).     * Increased heart rate (tachycardia).     * Increased blood pressure (hypertension).     * Nausea and vomiting.     * Seizures.
• Psychological Symptoms:     * Anxiety.     * Irritability.

Role of the Nurse: Prevention and Treatment Strategies

• Prevention:     * Address individual risk factors.     * Promote protective factors.     * Provide comprehensive substance use education.     * Promote early treatment.
• Manifestation Management during Treatment:     * Alcohol Withdrawal Medications:         * Benzodiazepines.         * Barbiturates.         * Antiepileptics.         * Thiamine.     * Alcohol Abstinence Medications:         * Naltrexone.         * Acamprosate.         * Disulfiram.
• Community-Based Treatment:     * $12$-step programs.     * Motivational enhancement therapy.     * Peer support groups.

Client and Family Education and Support

• Evaluation of treatment beliefs.
• Reinforcement of healthy coping skills.
• Education regarding the disease of addiction.
• Education on risk factors.
• Understanding the difference between withdrawal versus intoxication.
• Milieu management.
• Maintenance of safety.

Substance Use Treatment Settings

• Outpatient Treatment:     * Standard outpatient care.     * Intensive outpatient programs.     * Partial hospitalization.
• Inpatient Treatment:     * Standard inpatient care.     * Residential treatment centers.

Chemically Impaired Health Care Professionals and Disciplinary Processes

• Factors Contributing to Professional Impairment:     * Drug diversion (unauthorized redirection of medication from a client to the professional).     * Stress and job burnout.     * Staffing shortages.     * Working excessive overtime.     * Inadequate nurse-client ratios.     * Physical pain related to occupational duties.
• Disciplinary Procedures:     * Complaint: A complaint is received by the state board of nursing.     * Self-Report: The professional may self-report their impairment.     * Response: The professional must respond to the board in writing.     * Investigation: Evidence is investigated.     * Hearing: A hearing is held regarding the nursing practice violation.     * Intervention: Referral to a nurse assistance program.     * Consequences: The professional risks losing or suspending their nursing license.