Substance Use and Addictive Disorders

Substance Use and Addictive Disorders

Overview

  • Presented by: Tony Dharmaraj RN, MSN

4 C’s of Addiction

  • Addiction is a chronic diagnosis categorized by:

    • Cravings: Strong desires or urges to use a substance.

    • Loss of Control: Inability to limit substance use despite the desire to do so.

    • Compulsion: Ongoing behavior of using a substance regardless of negative consequences.

    • Use Despite Consequences: Continued use despite understanding the harms or risks involved.

3 C’s for Dealing With a Loved One with Addictions

  • Important affirmations for support:

    • I did not cause it: Recognizes that the loved one’s addiction is not the fault of the family or friends.

    • I cannot cure it: Acknowledges the limits of an outsider’s ability to fix the addiction.

    • I cannot control it: Accepts that the individual with the addiction must be responsible for their own recovery.

Mechanism of Addiction

  • Dopamine's Role:

    • Ingesting a substance triggers the reward center in the brain, releasing dopamine, which makes a person feel pleasure.

    • With continued use, tolerance builds, requiring more of the substance to achieve the same dopamine release, leading to increased addiction.

Key Definitions

  • Intoxication or High: Excessive use of a substance.

  • Tolerance: A need for increased amounts of the same substance to achieve the same high.

  • Withdrawal Symptoms: Physiological signs that occur when a substance is discontinued.

  • Addiction: An inability to abstain from a substance or activity, connected to the 4 C’s.

  • Codependent: An excessive emotional and psychological reliance on a loved one, often requiring them to remember the 3 C's.

Process or Behavioral Addictions

  • Compulsive behaviors that activate the brain's reward system, leading to addiction:

    • Gambling

    • Internet gaming

    • Social media use

    • Shopping

    • Sexual activity

    • Consumption of processed food

Gambling Addiction

  • Characteristics:

    • Occurrences may be regular or episodic.

    • May involve illegal acts to fund gambling habits.

    • Preoccupation with gambling behavior; attempts to conceal addiction.

    • Dependency on others to pay off gambling debts.

    • Stress and depression can exacerbate gambling behaviors.

Gambling Treatment Options

  • Programs and Methods:

    • Gamblers Anonymous (GA): Peer support group.

    • Psychotherapy: Therapy tailored to gambling addiction.

    • Medications:

    • Antidepressant: Bupropion (Wellbutrin) - its mechanism of action? (MOA)

    • Opioid antagonist: Naltrexone (Vivitrol) used for severe symptoms.

Nursing Influence in Addiction Care

  • Key Figures: Marianne T. Marcus, Ed.D., R.N., F.A.A.N. - a leader in addiction nursing education.

  • Importance of empathy and compassionate care in nursing practice.

  • Focus on evidence-based skills and increasing interprofessional curricula related to substance use disorders.

    • Emphasizes prevention, screening, and treatment.

CNS Stimulants and Their Disorders

  • Common Stimulants:

    • Street Drugs: Meth, cocaine, MDMA (ecstasy).

    • Effects: Enhanced alertness, euphoria, increased energy, prolonged wakefulness.

    • Prescription Drugs: Methylphenidate (Ritalin, Concerta), Amphetamine-based drugs (Adderall).

Caffeine Usage

  • Source: Found in energy drinks, coffee, tea, cola.

  • Desired Effects: Increased alertness, decreased fatigue.

  • Intoxication Symptoms: Exceeding 250 mg can lead to:

    • Tachycardia

    • Arrhythmias

    • Muscle twitching

    • Diuresis

    • Gastrointestinal upset

    • Anxiety, insomnia.

  • Withdrawal Symptoms: Occur within 24 hours:

    • Headache

    • Nausea/vomiting

    • Muscle pain

    • Irritability

    • Difficulty concentrating.

Methamphetamine Intoxication and Consequences

  • Signs of Intoxication:

    • Euphoria, sociability, hypervigilance, anxiety, irritability.

  • Meth Psychosis:

    • Symptoms include compulsive behaviors such as pulling out hair and skin picking due to delusions.

  • Meth Mouth: Caused by dry mouth leading to poor oral hygiene practices.

Rhabdomyolysis and Ecstasy

  • Risk During Use: Ecstasy can cause overheating and lead to rhabdomyolysis:

    • Breakdown of muscle tissue during physical activity (e.g., prolonged dancing).

    • Can block gas exchange leading to organ failure in liver, kidneys, heart, lungs.

Stimulant Withdrawal Effects

  • Withdrawal Symptoms:

    • Most serious symptoms include depression, suicidal thoughts (“crashing”).

    • Other symptoms: tiredness, vivid nightmares, increased appetite, insomnia, agitation, impaired functioning.

Stimulant Withdrawal Therapy

  • Treatment Approaches:

    • Typically inpatient care.

    • Withdraw under either the same substance as taper or relevant antipsychotic or benzodiazepine for agitation.

    • Monitoring vital signs is essential: HR, BP, RR, O2 levels, EKG if needed.

  • Nursing Interventions:

    • 1:1 supervision may be required for patients with psychosis.

    • Assessment for suicides or self-harm for depressed patients.

CNS Depressants Overview

  • Common Forms: sedatives, tranquilizers, hypnotics.

  • Effects: Slow brain activity; useful for treating anxiety, panic attacks, sleep disorders.

  • Street Names: Bars, blues, zanies, lean.

  • Prescription Medications: Benzodiazepines, Ambien, Lunesta, Oxycodone, Morphine.

Alcohol Use Disorder Criteria (DSM-5)

  1. Alcohol taken in larger amounts or over longer periods than intended.

  2. Persistent desire to cut down or control alcohol use.

  3. Significant time spent in activities surrounding obtaining, using, or recovering from alcohol.

  4. Craving for alcohol or a strong desire to use.

  5. Recurrent alcohol use leading to failure in fulfilling social, occupational, or recreational obligations.

  6. Continued use despite social issues exacerbated by alcohol.

  7. Important activities reduced or given up due to alcohol use.

  8. Using alcohol in physically hazardous situations.

  9. Continued use despite negative physical/psychological problems associated with alcohol.

  10. Tolerance:

    • Need for increased amounts to achieve effect or diminished effect with continued use.

  11. Withdrawal: Taking alcohol to relieve withdrawal symptoms.

  • Severity Classification:

    • Mild: 2-3 symptoms

    • Moderate: 4-5 symptoms

    • Severe: 6 or more symptoms.

The Reality of Alcoholism

  • Functioning alcoholics tend to be in denial and rationalize their actions.

  • CAGE Questionnaire for identifying addiction behaviors.

  • Concept of tolerance plays a significant role in addiction.

Screening for Substance Use Disorders

  • SBIRT: Brief Intervention Model.

  • Standard Drink Sizes:

    • 12 fl. oz. of beer (5% alcohol)

    • 8-9 fl. oz. of malt liquor (7% alcohol)

    • 5 fl. oz. of wine (12% alcohol)

    • 1.5 fl. oz. of distilled spirits (40% alcohol).

  • Substance Use Risk Zones:

    • Lower Risk: Non-users or within recommended limits.

    • Risky: Exceeds limits leading to potential problems.

    • Harmful: Experiences negative health effects or social consequences.

    • High Risk: Requires further assessment.

Inpatient Treatment for Alcohol Withdrawal

  • Essential to know the last drink time.

  • Withdrawal symptoms start 48-72 hours after last use.

  • Assessment Tool: CIWA-Ar used for severity grading (0-67 point scale).

  • Score over 10 indicates need for medication-assisted treatment.

Alcohol Withdrawal Monitoring

  • Symptoms of Withdrawal:

    • Stage 1 (8 hours): Shakiness, vomiting, nausea, loss of appetite, fatigue.

    • Stage 2 (12-48 hours): Elevated blood pressure, anxiety, mood swings.

    • Stage 3 (48-72 hours): Hallucinations, delirium tremens, seizures.

Delirium Tremens (DT)

  • Rapid onset of confusion, typically occurring 48 hours into withdrawal.

  • Symptoms include shaking, irregular heart rate, sweating.

Wernicke-Korsakoff Syndrome (WKS)

  • Cause: Thiamine deficiency due to excessive alcohol consumption.

  • Consequences: Impaired glucose metabolism and neurotoxicity from alcohol.

  • Key Presentation: Confabulation and memory impairment.

Medications for Alcohol Withdrawal

  • Benzodiazepines: Ativan, Librium, Valium - targets GABA receptors to prevent seizures and delirium tremens.

Medications for Alcohol Use Disorder Relapse Prevention

  • Antabuse: Creates adverse effects when alcohol is consumed (e.g., vomiting), requires a contract for abstinence.

  • Naltrexone: Opioid antagonist that reduces pleasurable feelings associated with alcohol consumption (e.g., monthly injection of Vivitrol).

Vivitrol Overview

  • Mechanism of Action: Blocks the release of dopamine, preventing pleasure from substance use.

  • Side Effects: Can lead to depression or mood swings.

Nursing Interventions for Alcohol Withdrawal

  • Recognize signs and symptoms of withdrawal.

  • Importance of documentation for monitoring patient status.

  • Close monitoring for delusions or hallucinations may require 1:1 supervision.

Therapy Treatment Approaches

  • Motivational Interviewing: Connects current behaviors with future goals.

  • AA (Alcoholics Anonymous): Peer support structure based on the 12-step model.

  • Intensive Outpatient Therapy: Often mandated by court for compliance.

  • Outpatient Programs: Combining individual and group therapy, including online resources.

  • Rehab and Halfway Houses: Residential treatment focused on detox and relapse prevention.

Benzodiazepine Use and Addiction

  • Sources: Anti-anxiety medications such as Lorazepam, Diazepam, Alprazolam.

  • Abuse Issues: Highly addictive, enhancing GABA which results in euphoria.

  • Intoxication Symptoms: CNS depression leading to impaired balance and severe drowsiness.

  • Withdrawal Symptoms: Anxiety, panic, irritability, insomnia, and serious outcomes like delirium or seizures.

Benzodiazepine Addiction Treatment

  • Tapering: Gradual reduction of dosage.

  • Medications for Withdrawal: Gabapentin or Propranolol for symptoms.

  • Therapy Support: Narcotics Anonymous for relapse prevention.

Opioid Basics and Crisis Overview

  • Prescription Opioids: Commonly prescribed opioids include Oxycodone, Hydrocodone, Fentanyl, and Methadone.

  • Opioid Use Disorder: Originates from prescription pain medications, leading to severe cravings, tolerance, and impaired daily functioning.

Opioid Intoxication and Effects

  • Signs: Psychomotor retardation, pupil constriction, slurred speech, drowsiness, and potential coma due to CNS depression.

Understanding the Opioid Epidemic

  • Fentanyl's Dangerous Role: Fentanyl is often mixed with other drugs to increase potency and addiction potential.

  • Risks: Overdose can occur from unawareness of drug composition, emphasizing the need for fentanyl testing.

Regional Fentanyl Overdose Statistics

  • In San Bernardino County:

    • 2018: 30 deaths

    • 2019: 74 deaths

    • 2020: 227 deaths

    • 2021: 354 deaths.

Fentanyl Abuse Dangers

  • Potency: Fentanyl is 50 times stronger than heroin and 100 times stronger than morphine, leading to lethal overdoses even in small quantities.

Opioid Withdrawal Symptoms

  • Symptoms commence 6-8 hours post last use:

    • Nausea/vomiting/diarrhea

    • Muscle aches, fever, insomnia

    • Symptoms include lacrimation (watery eyes), piloerection (goosebumps), yawning, rhinorrhea (runny nose), hallucinations, dilated pupils.

Treatment for Opioid Overdose

  • Key Symptoms: Coma, pinpoint pupils, respiratory depression, could lead to death.

  • Immediate Actions: Aspirate secretions, provide mechanical ventilation, and use naloxone (Narcan) IM, SubQ, or IV.

Narcan Usage

  • Application: Naloxone is an opioid antagonist that can rapidly reverse opioid overdoses by binding to opioid receptors.

  • Important Considerations: A second dose may be necessary; must monitor for 2 hours after treatment and seek emergency care promptly.

Opioid Abuse Treatment Methods

  • Withdrawal Treatment: Opioid and partial agonists to ease transitions during withdrawal.

  • Clinics: Provide Methadone tapering and opioid agonist treatments like Buprenorphine (Subutex) and Naltrexone (Vivitrol).

Tobacco Use Disorder Overview

  • Tobacco can act as both a stimulant and a depressant with rapid dependence formation.

  • Withdrawal Symptoms: Include irritability, anxiety, depression, difficulty concentrating, and insomnia.

Tobacco Use Treatment Options

  • Medications:

    • Nicotine Replacement Therapy: gum, lozenges, patches.

    • Bupropion: Reduces cravings and should be started 2 weeks before quit date.

    • Clonidine: Reduces sympathetic responses, easing withdrawal symptoms.

    • Varenicline (Chantix): Provides mild nicotine effects and blocks nicotine's impact.

Hallucinogen Disorder

  • Common Hallucinogens: PCP, LSD, ketamine.

  • Effects: Alters reality perception, leading to auditory/visual hallucinations, panic, psychosis, delirium, and mood disorders.

  • Intoxication Symptoms: Paranoia, intense perceptions, impaired judgment, depersonalization.

  • Withdrawal Symptoms: Headaches, cravings, sweating.

Synesthesia

  • A phenomenon associated with hallucinogen use where senses overlap (e.g., "I can taste red").

Cannabis Use Disorder

  • Most Commonly Used Drug: Following caffeine, alcohol, and nicotine, often referred to as a psychoactive substance.

  • THC Effects: Alters perception, leading to intensified experiences ("cross fading" when combined with alcohol).

  • Higher Doses Symptoms: Reduced motor skills, red eyes, appetite stimulation, cognitive impairment.

  • Withdrawal Symptoms: Generally consist of anxiety, insomnia, and restlessness lasting up to a week.

Benefits of THC

  • Potential benefits for cancer patients (e.g., increased appetite, reduced nausea from chemotherapy).

  • Some cultures use cannabis for religious purposes, complicating the negative educational aspect on its side effects.

Combating Stigma in Nursing

  • The stigma surrounding mental health can influence nurse attitudes and prevent seeking care for oneself.

12 Step Support Groups

  • Various support groups include Alcoholics Anonymous, Narcotics Anonymous, Gambling Anonymous, and Codependents Anonymous, promoting recovery through shared experiences.

The Twelve Steps of Recovery

  1. Admission of powerlessness over the substance and unmanageable life.

  2. Belief in a higher power for restoration.

  3. Decision to turn over will and life to a higher power.

  4. Taking a moral inventory of self.

  5. Admission of wrongdoings to God, oneself, and another person.

  6. Readiness to have shortcomings removed.

  7. Asking for help to remove shortcomings.

  8. Listing all people harmed and willingness to amend.

  9. Making direct amends except where it would hurt them or others.

  10. Continuing personal inventory and admitting wrongs promptly.

  11. Seeking conscious contact through prayer and meditation.

  12. Sharing the message of recovery with others and practicing these principles in all affairs.