Substance Use and Eating Disorders MH unit7/2

Opioid Substances: Classification and Intoxication

• Substance Categories:     * Prescription Analgesics: Includes morphine, codeine, oxycodone, methadone, and hydrocodone.     * Illegal Substances: Includes heroin and illicit fentanyl. While fentanyl has legitimate medical uses, it is also distributed illegally.
• Clinical Features of Intoxication:     * Psychological/Behavioral Symptoms: Apathy, lethargy, impaired judgment, and psychomotor changes.     * Physical Signs: Constricted (miotic) pupils, drowsiness, slurred speech, and impaired attention or memory.
• Overdose and Severe Toxicity:     * Can result in coma, respiratory depression, unconsciousness, and death.
• Acute Treatment:     * Naloxone (NARCAN): An opioid antagonist used to reverse opioid toxicity.     * Dosage Frequency: A single dose may not be sufficient; repeated doses are often necessary, particularly in cases involving synthetic opioids (e.g., fentanyl).

Opioid Withdrawal and Long-Term Management

• Triggers: Withdrawal is initiated by the cessation of the drug or the administration of an opioid antagonist.
• Early Withdrawal Symptoms: Anxiety, restlessness, cravings, and physical pain in the back and legs.
• Progressive Symptoms:     * Nausea, vomiting, and dysphoria.     * Excessive Secretions: Lacrimation (runny eyes), rhinorrhea (runny nose), sweating, and diarrhea.     * Other Physiological Responses: Yawning, fever, and insomnia.
• Treatment of Withdrawal:     * Methadone Taper: Typically tapered over a duration of $2$ weeks to minimize symptom severity.     * Prognosis: While symptoms cause extreme distress, they are generally not life-threatening.     * Persistent Symptoms: Anxiety, insomnia, and cravings may persist for several weeks or months.

Hallucinogens: LSD, Ecstasy, and PCP

• Common Substances: LSD, ecstasy (MDMA), PCP (Phencyclidine), and mescaline.
• Mechanism of Action: These substances distort the user's perception of reality, often mimicking symptoms of psychosis.
• Symptoms of Intoxication:     * Perceptual: Hallucinations and depersonalization.     * Physiological: Increased pulse (tachycardia), elevated blood pressure (hypertension), and increased temperature (hyperthermia).     * Pupillary Response: Pupils are typically dilated (mydriasis).     * Neurological: Hyperreflexia (overactive reflexes).
• Psychological and Behavioral Risks:     * Anxiety, depression, and paranoia.     * Fear of losing control, which paradoxically leads to dangerous behaviors (e.g., jumping out of windows).     * Physical symptoms include sweating, palpitations, blurred vision, tremors, and poor coordination.
• PCP-Specific Behavior: Characterized by high levels of aggression, belligerence, impulsivity, and unpredictable behavior.
• Toxicity and Fatalities:     * True physiological overdose is rare except with PCP.     * Most fatalities are associated with behavior-related accidents (e.g., suicide or accidental falls).
• Treatment Protocols:     * Supportive care: Isolated environment with minimal stimuli.     * PCP Toxicity Concerns: Risks include seizures, hypertension, hyperthermia, and respiratory depression.     * Medical Interventions: Medication to counter symptoms, cooling devices for hyperthermia, and mechanical ventilation for respiratory depression.     * Preferred Management Strategy: "Talking down" the patient with reassurance. Benzodiazepines or paliperidol may be administered if needed.
• Flashbacks: Hallucinogen-induced flashbacks can occur months to $5$ years after the last consumption.

Inhalants and Volatile Substances

• Common Inhalants:     * Whipped cream canisters (referred to as "whippets").     * Computer dusters and aerosol sprays.     * Anesthetics, nitrates, and organic solvents (e.g., gasoline, glue, paint thinner, diesel, spray paint).
• Physiological and Long-Term Risks:     * Chronic use can lead to brain damage and peripheral neuropathy.     * Severe risks include liver disease.
• Intoxication Symptoms: Dizziness, slurred speech, unsteady gait, tremors, muscle weakness, blurred vision, and belligerence/aggression. It can progress to stupor or coma.
• Acute Toxicity:     * Can lead to respiratory depression, vagal stimulation, and cardiac dysrhythmias.     * Causes of Death: Suffocation, aspiration, bronchospasm, or sudden cardiac arrest.
• Treatment and Management:     * Antidotes: There is no specific antidote or medication to reverse inhalant toxicity.     * Supportive Care: Supporting respiratory and cardiac function until the substance is cleared.     * Withdrawal/Detox: No identified withdrawal syndrome or formal detox protocol exists, though users report cravings.     * Psychiatric Complications: May induce persistent dementia, psychosis, anxiety, or mood disorders.

Community Support and the Twelve-Step Model

• Alcoholics Anonymous (AA):     * Founded in the $1930\text{s}$.     * Utilizes a $12$-step program emphasizing total abstinence and peer support.     * Conceptualization of Relapse: Even when sober, individuals remain at risk for relapse; recovery is a lifelong process.     * Slogans: "One day at a time," "Easy does it," "Let go and let God."     * Structure: Meetings can be open or closed and include sharing sessions/education. Sponsors guide newcomers through recovery.
• Other Related Groups:     * Narcotics Anonymous (NA): For drug dependency.     * Al-Anon: Support for family and friends of individuals with addictions.     * Alateen: Specifically for children of individuals with addictions.
• Extended Model: The $12$-step model is also applied to gambling and eating disorders.
• Focus of Treatment: Developing healthy coping strategies for life’s challenges, as substances are maladaptive coping mechanisms.

Medical and Pharmacologic Interventions

• Detoxification Settings:     * Initial care typically occurs in hospitals, Emergency Departments (EDs), or ICUs.     * Mild cases may be managed as outpatients, but all detox must be medically supervised.
• Alcohol Recovery Medications:     * Benzodiazepines: Used for safe withdrawal, such as Librium.     * CIWA Protocol: The standardized assessment tool used to determine the need for withdrawal medication.     * Nutritional Support: Essential to prevent Wernicke-Korsakoff syndrome (which is irreversible). Primary treatment is Vitamin $B_1$ (thiamine), plus $B_{12}$ and folic acid.     * Relapse Prevention:         * Disulfiram (Antabuse): Causes a severe Disulfiram Reaction if alcohol is consumed (flushing, headache, sweating, nausea, vomiting, hypotension, confusion, coma, or death). Patients must avoid all alcohol-containing products, including mouthwash, vanilla extract, cough syrup, wine in cooking, perfumes, and aftershaves.         * Acamprosate (Campral): Reduces cravings and discomfort; contraindicated in patients with renal impairment.         * Naltrexone (Vivitrol, Revia): Blocks opioid effects and reduces alcohol cravings; available in a monthly injectable form.
• Opioid Recovery Medications:     * Methadone: Daily maintenance dose; considered safer than heroin despite its own addictive potential.     * Levomethadyl: Similar to methadone.     * Suboxone (Buprenorphine/Naloxone): Highly regulated; requires special provider training. Patients typically receive a month supply or less, must undergo monthly drug testing, and are monitored via the CSMD (Controlled Substance Monitoring Database).     * Naltrexone: Reduces cravings by blocking opioid effects.

Professional Responsibilities and Warning Signs in Healthcare

• Substance Use in Health Professionals:     * Higher risk among physicians, dentists, and nurses due to easy access and high-stress environments.     * Reporting Requirements: Nurses are duty-bound to report suspicious behavior in colleagues. Do not confront the individual alone; notify a supervisor.
• Warning Signs of Diversion/Abuse:     * Discrepancies in drug counts.     * Excessive "wasting" of medications.     * Slurred speech or inappropriate behavior.     * Attendance issues: Early arrival, late departure, or frequent unexplained absences.     * Damaged medication packaging (e.g., tiny punctures in vials from safety needles).
• Self-Awareness: Nurses must examine their own biases regarding addiction to ensure they do not withhold necessary pain medication or treat relapsed patients with cynicism.

Eating Disorders: Anorexia and Bulimia

• Continuum of Behaviors: Includes Anorexia Nervosa, Bulimia Nervosa, and Obesity.     * $30$ to $35\%$ of individuals with bulimia have a history of anorexia.     * $50\%$ of individuals with anorexia exhibit bulimic behaviors (binging/purging).
• Demographics: $90\%$ of cases occur in females, though male athletes are also affected but less likely to seek help.
• Triggers: Often begins with dieting as a way to exert control over one’s life, often in overprotective or enmeshed families.
• Anorexia Nervosa:     * Life-threatening; characterized by self-starvation and a body weight below the minimum expected level.     * Ritualistic Behaviors: Preoccupation with food, calorie counting, cutting food into tiny pieces, and excessive exercise (typically exceeding $1.5$ to $2$ hours daily).     * Physical Findings: Lanugo (fine body hair), amenorrhea (absence of menstrual cycle), fatigue, bradycardia, hypothermia, muscle atrophy, and dental caries.     * Treatment: Inpatient care for electrolyte stabilization. Medications include Amitriptyline (for weight gain) and Olanzapine (for body image distortion).
• Bulimia Nervosa:     * Weight is typically near normal, making it harder to detect.     * Episodes are triggered by strong emotions/anxiety, followed by guilt and purging.     * Detection: Often first identified by dentists due to tooth enamel erosion from stomach acid.     * Treatment: DBT (Dialectical Behavior Therapy) is the most effective therapy for breaking the cycle.

Additional Disorders and Interventions

• Related Disorders:     * Binge Eating Disorder: Binging without purging; individuals are typically overweight.     * Night Eating Syndrome: Characterized by hyperphasia in the evening, with over $50\%$ of calories consumed after dinner.     * Pica: Consuming non-food substances.     * Rumination: Regurgitating and rechewing food.     * Orthorexia Nervosa: An obsession with "healthy" eating, involving excessive ingredient checking and food group elimination.
• Nursing Interventions:     * Alexithymia: Address the difficulty patients have in identifying feelings by encouraging emotional description.     * Communication: Teach effective communication to prevent the need for food-based control.     * Nutrition: Provide education on basic nutritional needs and the harmful effects of purging and restrictive dieting without forcing the client to eat, which requires professional treatment.