Addiction Lesson 10 Notes

Alcohol Use Disorder: Overview

• National health problem.

• Prevalence in the United States:

  • 16.6 million adults (age ≥18 years).

  • 697,000 adolescents (age 12–17 years).

• Detrimental effects:

  • Third leading preventable cause of death in the United States.

  • Absenteeism at work.

  • Prenatal exposure.

  • Increased violence.

Opioid Crisis

• Cause of estimated 130 deaths daily in the United States (overdose).

• Crosses lines of gender, race, age.

• Department of Health and Human Services five-point program to improve (2019):

  • Access: Prevention, treatment, recovery services.

  • Data: Data on the epidemic.

  • Pain: Pain management.

  • Overdoses: Targeting of overdose-reversing drugs.

  • Research: Research on pain and addiction.

Categories of Drugs

• Alcohol.

• Sedatives, hypnotics, and anxiolytics.

• Stimulants.

• Cannabis.

• Opioids.

• Hallucinogens.

• Inhalants.

Substance Abuse Important Terms

• Intoxication: Maladaptive behavior due to substance use.

• Withdrawal syndrome: Negative psychological and physical reactions when substance use ceases or dramatically decreases.

• Detoxification: The process of safely withdrawing from a substance.

• Substance abuse: Using a drug in a way that is inconsistent with medical or social norms and despite negative consequences.

• Substance or chemical dependence: Problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance. Substance use/substance or dependence can be used interchangeably.

Onset and Clinical Course

• Average age for first episode of intoxication: adolescence.

• Episodes of “sipping” as early as 8 years old.

• Pattern of more severe difficulty in mid-20s to mid-30s:

  • Blackout .

  • Development of Tolerance.

  • Tolerance break.

• Functioning becoming affected.

  • Periods of abstinence/temporary controlled drinking.

• Lead to escalation of alcohol use- subsequent crisis.

• Cycle continues.

• For many, substance use is chronic illness:

  • Remissions and relapses.

  • Relapse rates from 60% to 90%.

• Highest rates for successful recovery—abstinence and high level of motivation.

• Spontaneous remission (natural recover).

• Poor outcomes associated with earlier age at onset.

Related Disorders

• Gambling disorder.

• Caffeine and tobacco addictions.

• Substances can induce symptoms similar to those other mental illness diagnoses.

Etiology

• Biologic factors:

  • Genetic vulnerability.

  • Neurochemical influences.

• Psychological factors:

  • Familial dynamics.

  • Coping mechanism.

• Social and environmental factors:

  • Culture, social attitudes, peer behaviors.

  • Laws, cost, availability.

Cultural Considerations

• Attitudes vary in different cultures.

  • Muslims do not drink alcohol.

  • Wine is an integral part of Jewish religious rites.

  • Some Native American tribes use peyote, a hallucinogen, in religious ceremonies.

• Certain ethnic groups have genetic traits that predispose them to or protect them against alcoholism.

• Variations in genes for enzymes involved in alcohol metabolism among various ethnic groups.

  • Flushing: a reddening of the face and neck as a result of increased blood flow.

• Alcohol abuse: plays a part in the five leading causes of death for Native Americans and Alaska Natives.

Alcohol

• Intoxication and overdose:

  • CNS depressant- relaxation/loss of inhibitions.

  • Intoxication:

    • Slurred speech, unsteady gait, lack of coordination, and impaired attention, memory, judgment.

    • Aggressive behavior or display of inappropriate sexual behavior; blackout.

  • Overdose:

    • Vomiting, unconsciousness, and respiratory depression.

  • Treatment: Gastric lavage or dialysis to remove the drug; support of respiratory and cardiovascular functioning in an intensive care unit.

• Withdrawal (see Box 19.2):

  • Begins 4 to 12 hours after cessation or marked reduction of alcohol intake. Usually peaks on the second day and complete in about 5 days.

  • Symptoms include: Coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting.

  • Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium—called delirium tremens (DTs).

  • Withdrawal can be life-threatening.

  • Benzodiazepines for safe withdrawal.

• Withdrawal symptoms are monitored using an assessment tool such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar).

• Benzodiazepines used for detoxification:

  • Lorazepam (Ativan), chlordiazepoxide (Librium), and diazepam (Valium) suppress the withdrawal symptoms.

• Safe withdrawal from alcohol involves:

  • Benzodiazepines to suppress withdrawal symptoms: Lorazepam, chlordiazepoxide, and diazepam.

  • Vitamin B1 (thiamine) to prevent or to treat Wernicke’s syndrome - Korsakoff’s syndrome.

  • Cyanocobalamin (vitamin B12) and folic acid for nutritional deficiencies.

Sedatives, Hypnotics, and Anxiolytics

• Intoxication and overdose:

  • CNS depressants.

  • Intensity depends on drug.

  • Intoxication symptoms: slurred speech, lack of coordination, unsteady gait, labile mood, stupor.

  • Barbiturates, in contrast, can be lethal when taken in overdose; they can cause coma, respiratory arrest, cardiac failure, and death.

• Onset of withdrawal symptoms occur in 6 to 8 hours or up to 1 week, Onset depends on the half-life of the drug.

• Withdrawal syndrome is characterized by symptoms opposite of the acute effects of the drug:

  • Autonomic hyperactivity (increased pulse, blood pressure, respirations, and temperature).

  • Hand tremor, insomnia, anxiety, nausea, and psychomotor agitation.

  • Seizures and hallucinations occur rarely in severe benzodiazepine withdrawal.

  • Detoxification via drug tapering.

Stimulants (Amphetamines, Cocaine)

• CNS Stimulant.

• Intoxication and overdose:

  • High or euphoric feeling, hyperactivity, hypervigilance; anger, elevated BP, chest pain, confusion.

  • Seizures and coma with overdose.

• Withdrawal:

  • Within hours to several days.

  • Primary symptom is marked dysphoria.

  • Also, fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increase appetite, psychomotor retardation or agitation, depressive symptoms including suicidal ideation for several days.

  • “Crashing”.

  • Not treating pharmacologically.

Cannabis (Marijuana)

• Used for its psychoactive effects; Medical applications.

• Intoxication:

  • Lowered inhibitions, relaxation, euphoria, increased appetite.

  • Symptoms of intoxication include impaired motor control, impaired judgment.

  • Delirium, cannabis-induced psychotic disorder.

• No overdose.

• No clinically significant withdrawal syndrome:

  • Possible symptoms of muscle aches, sweating, anxiety, tremors.

Opioids

• CNS depressants-desensitization to pain, euphoria, well-being.

• Intoxication: apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory.

• Overdose- coma, respiratory depression, pupillary constriction, unconsciousness, and death.

  • Treatment: Naloxone (Narcan).

• Withdrawal:

  • Nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia.

  • Symptoms cause significant distress, but do not require pharmacologic intervention to support life or bodily functions.

  • Short-acting drugs (e.g., heroin): onset in 6 to 24 hours; peaking in 2 to 3 days and gradually subsiding in 5 to 7 days.

  • Longer-acting drugs (e.g., methadone): onset in 2 to 4 days, subsiding in 2 weeks.

Hallucinogens

• Distort reality and produce symptoms similar to psychosis including hallucinations (usually visual) and depersonalization.

  • Cause increased pulse, blood pressure, and temperature; dilated pupils; and hyperreflexia.

• Intoxication: maladaptive behavioral/psychological changes, anxiety, depression, paranoid ideation.

• No overdose; toxic reactions to hallucinogens (except PCP) are primarily psychological.

• Phencyclidine (PCP) toxicity can include seizures, hypertension, hyperthermia, and respiratory depression.

  • Medication to control seizures and blood pressure.

  • Cooling devices.

  • Mechanic ventilation.

• No withdrawal syndrome:

  • Some report a craving for the drug

• Flashbacks which may persist from a few months to 5 years.

Inhalants

• Inhaled for their effects: neurological, behavioral symptoms.

• Acute toxicity:

  • Anoxia, respiratory depression, vagal stimulation, and dysrhythmias.

  • Death possible from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomitus.

• No withdrawal or detoxification frequent users report cravings supportive treatment-respiratory and cardiac functioning until the substance is removed from the body.

• People who abuse inhalants may suffer from persistent dementia or inhalant-induced disorders such as psychosis, anxiety, or mood disorders even if the inhalant abuse ceases.

Substance Abuse Treatment

• Concept: medical illnesses, chronic, progressive, characterized by remissions and relapses.

• Treatment models include:

  • The Hazelden Clinic model.

  • 12-step program of Alcoholics Anonymous (AA; see Box 19.3)).

• Individual and group counseling.

• Treatment settings.

• Pharmacological treatment: safe withdrawal; prevent relapse (see Table 19.1):

  • Medications help manage withdrawal or cravings but are not a specific treatment for substance abuse.

• Relapse prevention involves:

  • Disulfiram (Antabuse).

  • Acamprosate (Campral).

  • Methadone.

  • Buprenorphine and Naloxone (Suboxone).

  • Naltrexone (ReVia).

  • Clonidine (Catapres).

  • Ondansetron (Zofran).

• Off-label uses:

  • Disulfiram (Antabuse).

  • Modafinil (Provigil).

  • Propanolol (Inderal).

  • Topiramate (Topamax).

Dual Diagnosis

• Substance abuse + another psychiatric illness.

• An estimated 75% of people with severe mental illness also have a substance use disorder.

• Successful treatment and relapse prevention strategies (see Plan of Care for a Client with Dual Diagnosis):

  • Healthy, nurturing, supportive living environments.

  • Assisting with fundamental life changes, such as finding a job and abstinent friends.

  • Connections with other recovering people.

  • Treatment of co-morbid conditions.

Substance Use Disorders

• The nurse may encounter clients with substance problems in various settings unrelated to mental health:

  • Seeking treatment of medical problems related to alcohol use.

  • Withdrawal symptoms may develop while in the hospital for surgery or an unrelated condition.

• Be alert to the possibility of substance use in these situations and be prepared to make appropriate referrals.

Substance Use Disorders and Nursing Process Application

• Assessment:

  • History: chaotic family life.

  • General appearance.

  • Mood, affect.

  • Thought process, content.

  • Sensorium.

  • Judgment, insight.

  • Self-concept.

  • Roles, relationships.

  • Physiologic considerations.

• Data analysis/nursing diagnoses:

  • Related to physical health status.

  • Related to substance use.

• Outcome identification:

  • Abstain from alcohol and drug use.

  • Express feelings openly and directly.

  • Accept responsibility for own behavior.

  • Practice non–chemical-coping alternatives.

  • Establish an effective after-care plan.

• Actions:

  • Health teaching for patient, family (see Client Family Education box).

  • Addressing family issues (codependence, enabling, shifting roles).

  • Promoting coping skills.

• Evaluation.

Age-Related Considerations

• Children and adolescents:

  • 10% of alcohol consumed in the United States is by 12-to 20- year-olds.

  • College student drinking is a major problem.

• Older Adults:

  • Approximately 30% to 60% of elders in treatment began drinking abusively after age 60.

  • Physical problems associated with substance abuse more quickly.

Community-Based Care

• Outpatient treatment.

• Freestanding substance abuse treatment facilities.

• Self-help programs such as AA and Rational Recovery.

• Agency-sponsored aftercare program.

• Individual or family counseling.

• Clinic or physician’s office.

Mental Health Promotion

• Public awareness and educational advertising.

• Early identification of older adults with alcoholism.

• The College Drinking Prevention Program.

Substance Use Disorder in Health Professionals

• Ethical and legal responsibility to report suspicious behavior to a supervisor.

• Specific behaviors.

• General warning signs:

  • Poor work performance/frequent absenteeism.

  • Unusual behavior/slurred speech.

  • Isolation from peers.

Self-Awareness Issues

• Examine own beliefs about alcohol and drugs.

• History of substance use.

• Recognize that substance abuse is a chronic illness with relapses and remissions.

• Remain open and objective.