Lifespan-5D: The Concept of Addiction

Collaboration for Substance Abuse

-Effective treatment of substance abuse, dependence results from efforts of interprofessional team specializing in treatment of psychiatric and substance abuse disorders Therapies may include •Detoxification •Aversion therapy •Group, individual, family counseling •Psychotropic medication •Cognitive-behavioral therapy •Self-help groups -Treatment in inpatient or outpatient setting -Substance overdose: life-threatening condition requiring emergency hospitalization *Manage overdose medically

Adolescents and Substance Abuse

-50% of high school seniors have taken an illegal drug, >20% have used a prescription drug for nonmedical reasons -Particularly vulnerable to substance abuse disorders because of developmental stage Factors influencing drug use -Availability -Peer use -Violence, physical or emotional abuse, mental illness, drug use in home -Possible genetic vulnerability -Personality traits -Mental health conditions -Drug use at early age: predictor of development of substance use disorder later

Psychiatric Problems Related to Trauma/Stress

-Adjustment disorder -Depression -Complicated grieving -Acute stress disorder -Post-traumatic stress disorder (PTSD) -Dissociative disorder

Hallucinogens

-Also called psychedelics -Bring on types of thoughts, perceptions, feelings -Schedule I PCP ("angel dust") -Developed as anesthetic -Discontinued for human use because of severe side effects Most common route of administration: smoking tobacco, marijuana or herbal cigarettes laced with PCP -PCP-intoxicated patients often violent, difficult to control -Haloperidol an effective medical intervention MDMA ("Ecstasy") "Club drug" available at parties -Can be used as date or rape drug -Use from 2004 to 2014 has been stable LSD -Affects serotonin receptors at multiple sites in brain, spinal cord -Usually taken orally but can be injected or smoked -Individual's response cannot be predicted -Psychologic effects and flashbacks common -Serotonin imbalance thought to affect impulse control -May be responsible for uninhibited sexual responses in women who are given LSD without their knowledge -Other hallucinogens similar to LSD have different potency, course of action -Physical dependence does not seem to occur -No withdrawal symptoms -Can be dosed in a tiny amount *PCP and LSD have flashback's

Pregnant Women and Substance Abuse

-An estimated 5.4% annual use illicit drugs Use of opiates during pregnancy can result in neonatal abstinence syndrome (NAS) -Occurring in epidemic numbers -Newborns with NAS more likely to have low birth weight, respiratory complications -Average of 16.9 days in hospital: compared to 2.1 days for other newborns To protect fetus -State court systems rely on criminal laws to attack prenatal substance abuse -In some states, prenatal drug exposure can provide grounds for terminating parental rights -Some states authorize forced admission to inpatient drug program for pregnant women who use drugs and alcohol -Some states require healthcare providers to report, test for prenatal drug exposure → evidence in child-welfare proceedings

Legal and Ethical Considerations

-Assisted suicide as topic of national legal, ethical debate (Oregon, the first state to adopt assisted suicide into law) -Nurse often cares for terminally or chronically ill people with poor quality of life. -Nurse's role to provide supportive care for patients, family as they work through decision-making process

Illegal drugs that may be abused to the point of addiction

-Cocaine (including crack) -Heroin -Hallucinogens -Inhalants -Marijuana/hashish use is illegal in many states

Concepts Related to Addiction

-Cognition -Family -Infection -Nutrition -Safety -Trauma

Pathophysiology for Substance Abuse

-Complex, multifactorial process combining biological, genetic, psychologic, sociocultural factors Craving may be heightened by kindling -Long-term changes in brain neurotransmission that occur after repeated detoxifications -Neuron sensitivity increases -Obsessive thoughts, cravings intensify -Brain responds spontaneously in dysfunctional way even when substance no longer being used -May explain why succeeding episodes of withdrawal get progressively worse

Rape and Sexual Assault

-Crime of violence, humiliation of victim expressed through sexual means Perpetration of act of sexual intercourse with female against her will and without consent -Whether will is overcome by force, fear of force, drugs, or intoxicants Also considered rape if woman incapable of exercising rational judgment because of mental deficiency or when younger than age of consent -Only slight penetration of vulva needed (full erection/ejaculation not necessary) -Strangers (approximately 26% of rapes), acquaintances, married people, people of same sex -Date rape (acquaintance rape) -Highly underreported crime -Most commonly occurring in woman's neighborhood, often inside or near home -Most rapes premeditated -Male rape significantly underreported -Alcohol frequently involved (34% of cases) Four categories of male rapists -Power assertive rapist (30%) -Power reassurance or opportunity rapist (30%) -Anger retaliation rapist (24%) -Anger excitement or sadistic rapist (16%) *Rape is about control and violence Feminist theory: women historically objects for aggression -Severe physical, psychological trauma-Medical problems Psychological problems -Fear, helplessness, shock, disbelief, guilt, humiliation, embarrassment -Avoidance of places or circumstances of rape; loss of previously pleasurable activities -Depression, anxiety, PTSD, sexual dysfunction, insomnia, impaired memory, suicidal thoughts Assessment -Physical examination; preservation of evidence (rape kit/rape protocol) -Description of what happened Treatment and intervention -Immediate support -Education -Prophylactic treatment of STIs, pregnancy -Therapy to restore victim's sense of control

Nursing Assessment for Addiction

-Develop a trusting nurse-patient relationship -Understand ethical obligation to maintain confidentiality -Involve family members -Help patient understand importance of full disclosure of any addictions -To protect patient from treatment complications -Recognize clues of addiction SBIRT to identify patients with substance abuse issues -Screening -Brief intervention -Referral to treatment American Society of Addiction Medicine (ASAM) multidimensional assessment criteria -Acute intoxication or withdrawal potential -Biomedical conditions, complications -Emotional, behavioral, cognitive conditions, complications -Readiness to change -Relapse use, or continued problem potential -Recovery/living environment Hospitalization or other form of 24-hour medical care -For individuals in withdrawal -Safety and symptom-relief concerns -Concurrent mental health issues -Distressing physiologic symptoms -Nonmedical detoxification if in good health with no history of withdrawal reactions

Cultural Considerations with Abuse and Violence

-Domestic violence spanning families of all ages and from all ethnic, racial, religious, socioeconomic, sexual orientation backgrounds -Battered immigrant women at particular risk -Facing increased legal, social, economic, and language barriers

Mental Health Promotion

-Education to address stressors contributing to depressive illness -Efforts to improve primary care treatment of depression -Prevention and early detection, treatment for adolescents Screening for early detection of risk factors -Family strife -Parental alcoholism or mental illness -History of fighting -Access to weapons in the home

Physical Examination for Addiction

-Findings depend on nature of addiction, substance being used -Be alert for symptoms that are abnormal or not within expected boundaries -Assess patient's explanations for inconsistencies -May provide first indications of addiction *Any changes in pupils/Amphetamines-dilate, opioids-constrict *Sleep deprivation *Skin, hair, teeth, sores are affected by the amount they use

Impaired Nurses

-Healthcare providers are as susceptible as anyone else to substance abuse -Frequent contact with drugs presents high risk of substance abuse -10-20% of nurses may have current or prior substance abuse issues Two best predictors of recovery -Length of treatment -Nurse's willingness American Nurses Association Code of Ethics for Nurses provides framework -Do not ignore poor performance -Do not lighten or change nurse's patient assignments -Do not accept excuses -Do not allow self to be manipulated or fear confronting nurse if patient safety is in jeopardy -Most state nurses' associations offer peer assistance programs -#1 reason nurse's lose their license is using narcotics-easily accessible, stressful job

Cormorbidities of Addiction

-High rate of comorbidity with physical and mental illnesses Medical illnesses can be promoted or exacerbated by neglect of health often seen in substance abuse and addiction -Immunity often compromised by malnutrition, poor hygiene, risky behaviors -Central nervous system (CNS) manifestations of dependence, tolerance, craving, withdrawal Higher incidence of mental health disorders than general population -Depression associated with addiction different from diagnosable mental illness -Because substance abuse disorder often co-occurs with mental illness, patient presenting with one should be assessed for the other Social problems -The Substance Abuse and Mental Health Services Administration (SAMHSA) supports integrative care that includes addressing social needs

Self-Awareness Issues

-Importance of dealing with own feelings about suicide -Frustration possible when working with depressed or manic patients -Exhaustion possible when working with manic patients -Journaling to help deal with feelings; talking with colleagues often helpful

Central Nervous System Depressants

-Include barbiturates, benzodiazepines, paraldehyde, meprobamate, chloral hydrate -Cross-dependence exists among all central nervous system (CNS) depressants -Cross-tolerance can develop to alcohol, general anesthetics Chronic barbiturate users need progressively higher doses to achieve desired effects -Do not develop tolerance to respiratory depression caused by barbiturates -Risk of accidental overdose and death -Mild sedation → sleep → coma → death -Especially in combination with alcohol -Barbiturates still clinically useful in treating seizure disorders -Benzodiazepines alone are safer than barbiturates -Overdose of oral benzodiazepines seldom result in death

Opiates

-Include morphine, meperidine, codeine, hydrocodone, oxymorphone, oxycodone -Schedule II or III Common brand names: Vicodin, Percocet, OxyContin, Opana Narcotic analgesics: pain reliever derived from natural or synthetic opiates Estimated 2.1 million people in U.S. had substance abuse disorders related to prescription opiates in 2012 -Number of unintentional overdose deaths from prescription opiates has more than quadrupled since 1999 -Drug abuse-related emergency department (ED) visits involving narcotic analgesics increased 153% from 2004 to 2011 -Long-term use for pain management associated with significant rates of abuse, addiction Problematic physiologic effects -Hyperalgesia, hypogonadism, sexual dysfunction Heroin: a lot cheaper and easier to get -Usually administered intravenously -Immediate rush, followed by euphoria that lasts several hours -Tolerance develops to euphoria, respiratory depression, nausea but not to constipation, miosis -Physical dependence develops with long-term use Withdrawal First phase: usually lasts 10 days- Craving, lacrimation, rhinorrhea, yawning, diaphoresis Second phase: lasts months- Insomnia, irritability, fatigue, gastrointestinal (GI) hyperactivity, premature ejaculation Methadone -Synthetic opiate used to treat chronic pain and opiate addiction -Viable for support withdrawal

SUICIDE

-Intentional act of killing oneself -Men commit approximately 72% of suicides Suicidal ideation: thinking about killing oneself Warning signs: risk for suicide

Collaborative Therapies: Psychosocial Interventions

-Interpersonal or informational activities, techniques, or strategies targeting biological, behavioral, cognitive, emotional, interpersonal, social, or environmental factors Aim: improving health functioning and well-being -Well-documented efficacy, alone or with medication -Patients often prefer them to medications -Alternative for patients for whom medication is inadvisable Example: incorporation of trauma-informed care into treatment plan for patients with alcohol or substance abuse disorders and history of trauma

Independent Interventions for Addiction: Promote Participation in Treatment

-Keep promises, convey attitude of acceptance -Do not accept defense mechanisms such as rationalization or projection -Encourage patients to examine how unhealthy coping mechanisms, maladaptive behaviors affect them and the people they care about -Help patients learn more healthy ways of coping -Encourage participation in therapeutic group activities -Peer feedback often more acceptable than feedback from authority figures

Children and adolescents with Addiction

-Many adolescents start to drink at very young ages -By 12th grade, more than one third have tried smoking -Brain continues to develop well into the 20s Brain circuitry involving reward and memory, prefrontal cortex are still developing -May explain adolescent risk-taking behavior -Highly motivated to pursue pleasure but judgment impaired -Increased risk for substance abuse

Intimate Partner Violence

-Mistreatment or misuse of one person by another in context of emotionally intimate relationship Emotional or psychological: name-calling, belittling, screaming, yelling, destroying property, threatening, refusing to speak to or ignoring victim Physical: shoving, pushing, battering, choking Sexual: assaults during sexual relations, rape *Combination (common) Victims: primarily women (increased rates during pregnancy) -Prevalence in same-sex relationships as in heterosexual relationships; victims with fewer protections -Often perpetrated by husband against wife Clinical picture -Abuser's view of wife as belonging to him; strong feelings of inadequacy, low self-esteem; poor problem-solving and social skills -Increasing violence, abuse with any signs of independence -Victim commonly dependent; viewed as unable to function without husband Cycle of abuse and violence Violent episode → honeymoon phase → tension-building → violent episode *Abuse is to regain control *Usually takes multiple times before victim gets out *Typically leave after the violent episode -Identification important; victims commonly not seeking direct help for problems Screening/assessment: SAFE -Stress/safety -Afraid/abused -Friends/family -Emergency plan Treatment and interventions -Laws related to domestic violence; arrest -Restraining order/civil orders of protection -Shelters -Individual psychotherapy/counseling, group therapy, support and self-help groups -Treatment for anxiety/depression

Prescription medications that are dangerous when misused or abused

-Narcotics -Sedatives -Stimulants

Manifestations vary by substance

-Nicotine -Alcohol -Substance addiction Process addictions -Sex -Gambling -Shopping -Work Abuse for more than a few weeks → health and emotional problems -Increased risk for comorbid illness, family complications

Older Adults and Substance Abuse

-Number of adults ≥50 years with substance abuse disorder projected to double from 2.8 million in 2006 to 5.7 million in 2020 -Polypharmacy and cognitive decline may lead to improper use of medications -Older adults on fixed income may abuse another person's medication to save money -High rates of comorbid illnesses, age-related changes in drug metabolism, potential for drug interaction pose dangers Negative consequences of substance abuse more critical -Increased risk of falls -Substance abuse, dependence may be confused with common conditions of aging → treat symptoms rather than diagnose, treat substance abuse Potentially protective factors -Being married, never using alcohol or tobacco, regular attendance at religious services

Pharmacologic Therapy for Substance Use

-Opioid antagonists -Benzodiazepines -Abstinence medications -Anticonvulsants -Antidepressants -Vitamins

Characteristics of Stress/Trauma

-Poor coping -Difficulty managing stress -Emotional difficulties -Difficulty resuming activities of daily life Other symptoms -Anxiety -Insomnia -Grief

Suicide Assessment

-Previous suicide attempts (first 2 years after—highest risk period, especially first 3 months); relative who committed suicide -Warnings of suicidal intent, risky behavior -Lethality assessment -Data analysis/nursing diagnoses Outcome identification -Safety, free from self-harm Intervention -Authoritative role Safe environment: suicide precautions; no suicide/no self-harm contract -Support system list

The Nursing Process: Intervention

-Promoting patient's safety -Helping patient cope with stress, emotions using grounding techniques -Helping promote patient's self-esteem -Establishing social support

Addiction

-Psychologic or physical need for a substance or process to the extent that the individual will risk negative consequences in an attempt to meet the need -Wide sociocultural variations in acceptability of chemical use to modify mood, behavior

Risk Factors for Substance Abuse

-Risk factors are multifactorial, can affect individuals of any age, gender, or economic status Some factors affecting likelihood, speed of developing addiction -Family history of addiction -Presence of another mental disorder -Use of drugs as coping mechanism to manage anxiety, depression -Peer pressure -Lack of family involvement -Men are more likely to have drug problems, but progression of addiction is faster among women

Community Violence

-School violence (homicides, suicides, theft, violent crimes) -Bullying (correlated with an increase in suicides) -Hazing -Effects on children, young adults -Violence on larger scale (i.e., terrorism) -Early intervention, treatment for victims

Emergency Care for Overdose

-Serious medical emergency -Respiratory depression may require mechanical ventilation -Keep patient awake -Seizure is possible complication -Monitor for suicidal ideation -Signs of overdose and withdrawal vary with substances taken

Substance-induced disorder

-The actual process of becoming addicted to a substance Includes related conditions -Intoxication -Withdrawal -Substance/medication-related mental disorders •Psychosis •Bipolar and related disorders •Sleep disorders •Sexual dysfunction Multifaceted etiology -Childhood trauma, genetic variables, other factors thought to play role

Older Adults with Addiction

-Underestimated, under-identified, undertreated Providers often overlook substance abuse and misuse -Insufficient knowledge -Limited research data -Hurried office visits Diagnosis can be difficult -Symptoms mimic other medical, behavioral disorders •Diabetes •Dementia •Depression -Many older adults do not feel they need treatment, do not seek it

The Language of Addiction and Recovery

-Vocabulary used by professionals in all aspects of healthcare regardless of substance or process being abused Terms associated w/substance abuse -Abstinence -Codependence -Co-occurring disorders -Cross-tolerance -Delirium tremens (DTs) -Detoxification -Dual diagnosis -Korsakoff psychosis -Physical dependence -Polysubstance abuse -Psychologic dependence -Sobriety -Tolerance -Wernicke encephalopathy -Withdrawal syndrome

Collaborative Therapies: 5 A's

5 A's to help identify users and appropriate interventions 1. Ask: identify, document substance use status for each patient at each visit 2. Advise: urge every substance user to quit 3. Assess: is the user willing to make a quit attempt at this time? 4. Assist: counseling, pharmacology for user who is willing to make quit attempt 5. Arrange: schedule follow-up contact

Clinical Picture of Abuse and Violence

Abuse: wrongful use, maltreatment of another -Perpetrator typically someone the person knows Victims across lifespan: spouses, partners, children, elders -Evidence of physical injuries requiring medical attention -Psychological injuries with broad range of responses *Anytime they are withdrawn, injuries-could be abuse

Process Addiction

Addiction to certain behaviors -Activate biochemical reward system similar to those activated by drugs of abuse -Produce behavior symptoms comparable to those in substance abuse disorders -Addition not to a substance but to the behavior or the elicited feeling -Physical signs of drug addiction are absent Selected process addictions Gambling disorder: only one included in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) -Exercise addiction -Online shopping addiction -Internet gaming disorder -Sex addiction

The Nursing Process: Data Analysis

Common nursing diagnoses -Risk for self-mutilation -Ineffective coping -Posttrauma response -Chronic low self-esteem -Powerlessness

Complementary Health Approaches for Substance Abuse

Auricular acupuncture during opioid detoxification -May benefit patients dependent on heroin -Especially with mild habits -Acupuncture protocols in group settings used by many drug treatment programs, drug courts

Engel's biopsychosocial model

Biological factors: doesn't have to be drugs -Neurotransmitters -Reward circuit *Addiction can be anything that creates a reward (like how I feel when I get a Diet Dr. Pepper) Genetic factors -Account for 40-60% of a person's vulnerability to addiction Psychologic factors -Correlation between substance abuse, childhood and adolescent trauma -Link between substance abuse, psychiatric disorders Sociocultural factors -Family environment -Availability of drugs in community -Correlation between religion/spirituality and lower alcohol use -Correlation between gay culture/HIV status and substance abuse

Diagnostic Tests for Addiction

Based on type of addiction -Serum drug levels -Toxicology: the drug test to get into school/Urine test is based on what is being excreted at the time/depends on drugs half life -Chest x-ray for inhaled substances -Organ biopsies: for toxicity stuff -Urine, saliva, serum testing -Hair testing to determine substance use within a period of 90 days *Rules on drug testing: most of the time it is voluntary. Can't refuse a sobriety test/Breathalyzer when pulled over.

Behavior-Related Therapies for Addiction

Behavioral therapy -Patients learn techniques to modify or change addictive behaviors Behavioral modification therapy -Based on principle that behavior has specific consequences -Behavior can be changed by conditioning -Reinforcement: consequences that increase likelihood of a particular behavior -Positive reinforcement provides reward for the behavior -Negative reinforcement removes negative stimulus to increase behavior Punishment: negative consequences to decrease behavior Extinction: progressive weakening of a behavior through repeated non-reinforcement -Reinforcement more desirable than punishment

Diagnostic Tests for Substance Abuse

Body fluids -Blood, urine, saliva, perspiration, hair Urine drug screening: preferred method for detecting substances in body -Drugs can be found in blood urine for lengths varying from 24 hours to 30 days -Depending on dosage, metabolic properties of the drug -THC stored in fatty tissues, can be detected up to 6 weeks

Cannabis

Cannabis: source of marijuana Psychoactive component: delta-9-tetrahydrocannabinol (THC) -Activates specific cannabinoid receptors in brain Physiologic effects: dose-related Short term: Increase in heart rate, bronchodilation Chronic long-term use -Airway constriction, inflammation -Increased incidence of acute, chronic bronchitis -Decreased spermatogenesis, testosterone levels in men -Suppresses follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin in women, interfering with breastfeeding -Birth defects may be associated with cannabis use Pleasurable effects: euphoria and relaxation Other subjective effects: sedation, hallucinations Effects of increased use -Amotivational behaviors -Memory impairment Estimated 9% of users will become dependent -17% in those who start using it young -25-50% among daily users Mild withdrawal syndrome -Irritability, mood and sleep difficulties -Decreased appetite -Cravings -Restlessness, physical discomfort -Effects peak within first week after quitting -Last up to 2 weeks Potency has increased in past few decades -Average THC content in cannabis has more than doubled -New methods of smoking or eating deliver high levels of THC to user -Concerns that consequences could be worse among new users, young people -Marijuana continues to be most commonly used illicit drug Teenagers: (effects endocrine system), hinders growth, can make them impotent

Traumatic Events or Stressors Occur to Many People

Characteristics include the following -Experiences that are extraordinary in intensity or severity -These stressors are well beyond the stress of daily life.

Clinical Manifestations of Substance Abuse

Clinical manifestations and their severity depends on -Amount, frequency, specific combinations of substances used -Linked to specific substance being used

Behavior-Related Therapies-Addiction: Contingency Contracts

Contingency contracts -Patient rewarded contingent on meeting desired outcomes -Effective incentives: vouchers, cash equivalents, prize-based approaches Token economies: formalized programs of contingency contracts -Patients can accumulate token rewards to exchange for privileges or actions Cognitive-behavioral therapy -Combines behavioral techniques with cognitive psychology Cognitive psychology: scientific study of mental processes such as perception, memory, reasoning, decision making, problem solving Goal: to replace maladaptive behavior and faulty cognitions with thoughts, self-statements that promote adaptive behaviors Variants -Rational-emotive behavior therapy -Dialectical behavior therapy

Addiction differentiated from dependence

Dependence: physiologic need for a substance that the patient cannot control and results in withdrawal symptoms if stopped or withheld Tolerance: requiring greater quantities of substance to achieve desired effects *Way around it, is taking little vacations from it Addiction: physiologic process of dependence + psychologic need to seek substance *Marijuana is a dependence *Alcohol is an addiction

Elder Considerations with Suicide

Depression common among the elderly; marked increase when elders are medically ill -Psychotic features common -Increased intolerance to medications -ECT more commonly used for treatment; more rapid response -Suicide increased among elderly

Prevalence of Addiction

Estimated numbers of users -27 million Americans reported use of illicit drugs or misuse of prescription drugs in 2015 -66 million Americans reported binge drinking in past month in 2015 -Almost one fourth of adolescent & adult population -22.2 million Americans age 12 or older were current users of marijuana in 2014 -435,000 Americans age 12 or older were current users of heroin in 2014 Costs related to crime, lost work productivity, healthcare: -Alcohol misuse: $249 billion/year -Illicit drug use: $193 billion/year

Etiology and Epidemiology of Substance Abuse

Etiology of substance use: multifactorial -Humans seek pleasure, avoid stress, pain -In 2015, >27 million Americans reported current use of illicit drugs of misuse or prescription drugs Marijuana: most commonly used illicit drug/ symptom manager-won't cure Non-medical use of psychotherapeutic drugs: second most common > 50% of first-time users were < age 18 when they first used >50% of new users were female Substance use disorders in United States cost > $700 billion/year -Includes cost of treatment, related health problems, absenteeism, lost productivity, drug-related crime and incarceration, education and prevention -Relapse rates for drug addiction: 40-60% Prescription opioid use -In 2012, estimated 2.1 million people in United States experienced SUD related to prescription opioid pain relievers -Compared to estimated 467,000 addicted to heroin -Individuals with chronic pain being referred more often to pain specialists who may use non-opioid analgesics Heroin use -Dangerous because of addictiveness, high risk for overdosing -Lack of control over purity of drug, possible contamination with other drugs -Heroin use has increased in United States among men and women, most age groups, all income levels -Heroin-related overdose deaths nearly quadrupled between 2002 and 2013 -Drug cultures can differ according to the substance, geographic area, other social factors

Evaluation for Substance Abuse

Expected outcomes may include that the patient -Experiences no complications from withdrawal -Admits problem with substance abuse and seeks help -Enters substance abuse program -Can describe choices that contributed to substance abuse -Attends daily support group meetings -Remains substance free for appropriate period of time Relapse rate for substance abuse: 40-60% Substance addiction should be treated like any other chronic illness -Relapse serves as trigger for renewed intervention

Family Therapy for Addiction

Family behavior therapy -Positive results in adults, adolescents -Addresses co-occurring problems as well as substance use problems -Patient and at least one significant other apply strategies taught in sessions -Family involvement particularly important in treatment of adolescents Brief Strategic Family Therapy -Family systems view -Engage family in treatment process, enhance motivation for change -Modify family behavior using CM techniques, communication, problem solving, behavior contracts Multidimensional Family Therapy -Effective even with more severe substance abuse disorders Multisystemic Therapy -Effective with severe substance abuse, delinquent and/or violent behavior

Suicide-Family and Nurse's Response

Family response -Suicide as ultimate rejection of family, friends -Families react with guilt, shame, anger Nurse's response -Need for unconditional positive regard for person -Avoidance of patient blame -Nonjudgmental approach, tone -Belief that one person can make a difference in another's life -Possible devastation of staff if patient commits suicide

Characteristics of Violent Families

Family violence: spouse battering; neglect, and physical, emotional, or sexual abuse of children; elder abuse; marital rape Common characteristics regardless of type of abuse -Social isolation -Abuse of power, control -Alcohol, other drug abuse -Intergenerational transmission process

Independent Interventions for Addiction

Goal of all interventions: move patient toward treatment, recovery Recovery: a state of voluntary sobriety in which person maintains health and functions normally in society without use of addictive substance or behavior -No single intervention sufficient to ensure recovery -Requires substantial work on part of the individual -Sobriety: Persons choice unless mandated/can't force Focus of nursing interventions -Care for specific presenting symptoms -Developing, maintaining therapeutic nurse-patient relationship -Promoting healthy patient communication, coping skills

Collaborative Therapies: Intervention

Goals -To prevent addict from denying problem -To force addict to face negative aspects of behavior -To get addict to enroll in treatment Family intervention -Professional clinician conducts intervention -Family members state how the person's addiction affects family Not recommended that clinician use direct confrontation solely to force treatment -Treatment programs that rely on confrontational clinician techniques yield poor outcomes

Group Therapy for Addiction

Group deals with psychologic, cognitive, behavioral spiritual dysfunctions -Facilitated by professional group therapist Characteristics of successful groups -Goal setting -Group size -Duration of therapy -Leader, member characteristics -Functional groups generate heightened emotional reflection, create atmosphere of group trust, support → valuable self-reflection -Held in variety of settings -Nurses can function as group therapists or share leadership with a co-therapist -Adolescents can participate in group therapy, other peer support programs

Effects of Addiction on Families

Increased risk for social isolation of family members -Decreased access to social supports -Defensive coping mechanisms -Interference with normal daily activities -Secrecy and shame common -Family may engage in enabling behavior -Poor communication within and outside family system Addiction should be viewed and treated as a family disease -Denial, enabling -Codependence -Children especially at risk for physical and mental problems, parental abuse and neglect

Examples of Trauma or Stress

Individual trauma/stressors -Abuse -Illness -Victim of crime (robbery, etc.) Group trauma/stress -War/terrorist attack -Natural disaster -Community loss (death of prominent citizen)

Child Abuse

Intentional injury of a child -Physical abuse or injuries -Neglect or failure to prevent harm -Failure to provide adequate physical or emotional care or supervision -Abandonment -Sexual assault or intrusion -Overt torture or maiming Clinical picture of parents -Minimal parenting knowledge, skills -Emotionally immature, needy, incapable of meeting own needs -View children as property -Cycle of family violence: adults raising children in same way they were raised (adults as victims of abuse frequently abuse their own children) -Identification important -Report suspected child abuse Treatment and intervention -Child safety, well-being a priority -Psychiatric evaluation/possible long-term therapy/play therapy (for very young child) -Family therapy if reuniting feasible -Psychiatric or substance abuse for parents -Foster care (short or long term)

Independent Interventions for Addiction: Limit Setting and Boundary Violations

Limit setting: establishing parameters of desirable and acceptable behavior -Helps patients feel safe -Advances therapeutic goals by eliminating nonproductive behaviors -Promotes positive behavior change -Protects significant others and children from user's unacceptable behaviors -Teaches the person that there are choices, with consequences -Can be challenging for clinicians, family members Substance abusers may frequently cross boundaries -Encourage family to set, enforce clear personal boundaries with defined consequences -Clinicians need to maintain professional boundaries, guard against ambiguous relationships where multiple roles exist -If patient is also student, friend, family member, employee, and so on

Pharmacologic Therapies for Addiction

Medications -Treat, prevent symptoms of withdrawal -Reducing psychologic cravings -Reducing anxiety that may be stimulus for using substance -Preventing dangerous withdrawal symptoms -Treat overdose Many have multiple drug interactions, should be used with caution Example: disulfiram -Should never be used during pregnancy -Should be used in caution in patients taking phenytoin Classifications -Opioid antagonists -Benzodiazepines -Abstinence medications -Antiseizure drugs -Nicotine replacement therapy -Antidepressants -Nicotine acetylcholine receptor agonists -Vitamins: Vitamin B1 use with alcoholics

Psychostimulants

Main subjective effect: euphoria Cocaine: can be used in a lot of different ways/Schedule II/do prescribe Routes of administration: Powdered: inhaled Freebase: smoked Pure cocaine hydrochloride: inhaled or injected intravenously -Skin popping (subcutaneous injection) may lead to abscesses under skin -Duration of euphoria depends on route of administration -Pleasurable effects do not last long -Highly addictive properties can lead to overdose -Long-term use can cause atrophy of nasal mucosa, necrosis and perforation of nasal septum, lung damage -Crack cocaine injection associated with increased rates of high-risk behaviors Amphetamine Methamphetamine -Highly addictive form of amphetamine -Widely used because of its ease of manufacture -Often taken in combination with other drugs -Smoking or injection provide greatest euphoria -Can also be inhaled, ingested -Chronic use or abuse → paranoia, hallucinations, compulsions *Narcolepsy, has a paradoxical effect on kids, weight loss drug Effects of amphetamines -Arousal & elevation of mood -Sense of increased strength, mental capacity, self-confidence -Reduced need for food & sleep -Dependence more psychologic than physical -Withdrawal → dysphoria, craving, fatigue, excessive eating, depression *Tweeker

Elder Abuse

Maltreatment of older adults -Physical, sexual, psychological abuse, or neglect -Self-neglect -Financial exploitation -Denial of adequate medical treatment -60-65% are women, 10% of population over age 65 -People who abuse elders almost always in caretaker role or elders depend on them in some way -Elders often reluctant to report abuse due to fear of alternative (nursing home) Clinical picture: variable depending on type of abuse Treatment and intervention -Caregiver stress relief -Additional resources -Possible removal of elder or caregiver *Can be well intended, like caregiver fatigue *Elder abuse is a felony

Nursing Process with Substance Abuse

Nurses may interact with patients experiencing substance abuse, dependence in variety of settings Most common: alcohol/drug abuse treatment program -Emergency departments and medical-surgical units after falls, accidents -Occupational, community treatment settings -Urgent care centers, pain clinics, ambulatory care centers -Nursing care of patient with substance abuse or dependence: challenging, requiring nonjudgmental atmosphere promoting trust, respect Goals of health promotion efforts -Preventing drug use among children, adolescents -Reducing risks among adults

Nursing Diagnosis for Substance Abuse

Nursing diagnoses may include •Injury, Risk for •Other-Directed Violence, Risk for •Self-Directed Violence, Risk for •Denial, Ineffective •Coping, Ineffective •Imbalanced Nutrition: Less Than Body Requirements •Chronic or Situational Low Self-Esteem •Deficient Knowledge •Processes •Acute or Chronic Confusion (NANDA-I © 2014, 2015-2017)

Observation and Patient Interview for Addiction

Observable manifestations of addiction issues -Unsteady gait and poor balance, lack of coordination -Slurred speech -Tremors -Unusual smells on breath, body, or clothes -Loss of interest in personal hygiene -Watering or bloodshot eyes, large or small pupils -Rhinorrhea -Obvious weight gain or loss -Inability to concentrate, hyperactivity, agitation, or giddiness -Anger, frustration, or mood swings -Appearing fearful, anxious, or paranoid with no reason -Appearing lethargic or "spaced out" *Self care usually takes a back seat Nursing history -Patient may be reluctant to share information -Shame, contempt, embarrassment -Fear of legal reprisal Assess extent of crisis patient faces in life -Stress -Employment -Self-harm potential -Family roles -Lifestyle changes -Possible resources -Community assessment

Assessment for Substance Abuse

Observation and patient interview -High-functioning substance abusers do not fit stereotypes -Often function in many responsible roles -May not use substance every day -May avoid serious consequences of substance use -Can spend years or decades in denial -Family, friends might not recognize the problem -Comprehensive approach to assessment of all patients for possible substance use Many patients struggle with communication, trust Essential: therapeutic communication techniques, open-ended questions -History of past substance use -Medical and psychiatric history -Psychosocial issues Screening tools -Brief Drug Abuse Screening Test (B-DAST) -Objective Opiate Withdrawal Scale (OOWS) -Subjective Opiate Withdrawal Scale (SOWS

The Nursing Process: Evaluation

Outcomes possibly taking years to achieve -Protection of self -Ability to manage stress, emotions -Ability to function in daily life

Independent Interventions for Addiction: Promote Communication

Patient at center of all communication -Many patients with addictions have poor communication skills -Patients may hide addictions, avoid discussion of addiction Communication must be simple, direct, and powerful -Do not use euphemisms or subtlety, do not talk too much -Express concerns, pass on information without judgment -Use "I" statements to describe concerns -Remain calm -Listen for contingency words signaling that the person will not follow through -Hold patient accountable for what was agreed to -Practice active listening skills, noticing patients' defense mechanisms -Notice body language

Independent Interventions for Addiction: Promote adequate Nutrition

Patients who engage in substance abuse at risk for nutritional deficiencies -Alcoholism → thiamine deficiency Nursing interventions -Administer vitamins, dietary substances as ordered -Monitor lab work, report significant changes to provider -Collaborate with dietitians to determine necessary caloric intake -Teach patients about adequate nutrition, physical effects of substance abuse on body

Collaborative Therapies: Crisis

Person enters treatment because inability to manage life skills, events results in crisis -Legal issues -Job loss -Financial difficulties -Relationship problems -Medical problems Most common motivation for entering treatment -Inability to maintain emotional equilibrium important but short-lived High level of anxiety may have 3 outcomes 1. Return to previous level of addiction 2. Develop more constructive coping skills, seek help 3. Decompensated to lower level of functioning

Pregnant Women with Addiction

Pregnant women -Illicit drug use lowest in third trimester -Those who engaged in binge drinking reported higher frequency of binging, more alcohol consumed compared to nonpregnant women -Alcohol, nicotine, some prescription drugs are teratogens -Alcohol use in pregnancy can led to fetal alcohol spectrum disorders, other adverse birth outcomes Substance use disorder (SUD) can cause neonates to experience -Substance dependence -Withdrawal symptoms -Low birth weight -Neurologic issues -Developmental delays -Health promotion related to substance use important before pregnancy *Effect of Nicotine on fetus: decreased blood flow through placenta-low birth weight, premature delivery, withdrawals

Health Promotion for Addiction

Prevention efforts revolve around education -SAMHSA -Community and local initiatives -Nurses assess patients' risk for substance abuse and provide education related to prevention Health promotion activities particularly important for patients in recovery from addiction -Reviewing with patient the situations or feelings that triggered past use -Helping patient recall, maintain healthy, successful coping strategies -Additional resources for sober patients during challenging times Example: mother with history of substance abuse who has given birth to a premature infant

Implementation for Substance Abuse

Promote safety -Assess level of disorientation -Consider higher level of care if patient cannot withdraw safely in home or community setting -Obtain drug history and urine, blood samples -Place patient in quiet, private room -Frequently orient patient to reality, environment -Ensure that patient has no access to potentially harmful objects -Monitor vital signs every 15 minutes until stable Promote patient safety during withdrawal -Observe for withdrawal symptoms, monitor vital signs -Provide adequate nutrition, hydration -Assess level of consciousness (LOC) frequently -Orient, reassure patient safety in presence of hallucinations -Explain all interventions before approaching patient -Administer medications per schedule -Provide positive reinforcement of appropriate thinking, behavior or recognition that delusions are not based in reality -Use simple step-by-step instructions, face-to-face interaction -Express reasonable doubt if patient relays suspicious or paranoid beliefs -Do not argue with patient experiencing hallucinations, delusions -Talk to patient about real events, real people -Respond to patient's feelings, reassure patient about safety from harm Provide patient education -Assess level of knowledge, readiness to learn -Develop teaching plan with measurable objectives, including short-term goals -Begin with simple concepts, progress to more complex issues -Use interactive teaching strategies, written materials appropriate for patient -Include information on physiologic effects of substances, dependence, risks to fetus if patient is pregnant

ADDICTION

SUBSTANCE ABUSE

The Nursing Process: Assessment

Sensorium, intellectual processes -Disorientation (during flashbacks), memory gaps Judgment, insight -Impaired decision-making, problem-solving abilities Self-concept -Low self-esteem Roles, relationships -Problems with relationships, work, authority figures Physiologic considerations -Difficulty sleeping, under- or overeating, use of alcohol or drugs for self-medication -History of trauma or abuse General appearance, motor behavior -Hyperalertness, anxiety, agitation Mood, affect -Wide-ranging emotions from passivity to anger Thought processes, content -Nightmare, flashbacks, destructive thoughts, or impulses

Planning for substance Abuse

Short-term goals may include that patient will -Admit having substance abuse problem and having lost control of life as a result -Seek help to stop using substance -Experience no complications of drug withdrawal -Enter a drug rehabilitation program to change behavior Long-term goals may include that patient will -Explore impact of addiction on family, job, friends -Describe, recognize use of denial -Change thinking, behavior -Regularly attend support group -Remain free of substance and maintain sobriety

Caffeine

Stimulant -Increases heart rate -Acts as diuretic Commonly consumed daily -Coffee, tea, soft drinks, chocolate, some pain relievers Dosage -300 mg/day safe for most healthy adults -600 mg considered excessive -Individuals with history of cardiac disease should reduce or eliminate intake Withdrawal symptoms -Headaches, irritability Increasing number of adolescents developing symptoms of caffeine dependence -Caffeinated energy drinks contain much more caffeine than cola -Young people who ingest energy drinks more likely to participate in unhealthy behaviors People who consume alcoholic beverages mixed with energy drinks -3 times more likely to binge drink -2 times more likely to report being taken advantage of sexually, to take advantage of someone else sexually -2 times more likely to report riding with driver under the influence of alcohol

Substance Abuse

Substance abuse: the use of any chemical in a manner inconsistent with medical or culturally defined social norms Substance abuse disorder (SUD): cluster of cognitive, behavioral, physiologic symptoms that indicate continued use of a substance despite significant negative consequences -May involve permanent brain changes -Diagnosis involves problematic pattern of substance use, pathologic pattern of behaviors related to substance abuse Symptoms of impaired control -Taking substance in larger amounts over longer time -Wanting to reduce use but multiple unsuccessful attempts to cut down or quit -Spending much time obtaining, using, or recovering from effects of substance -Having daily activities that revolve around the substance Withdrawal -Occurs when a person reduces or stops drug that has been used heavily over a long period of time -Cluster of substance-specific behavioral symptoms -Causes clinically significant distress or impairment in social, occupational, other important areas of function -Uncomfortable, distressing, or even dangerous symptoms occur within hours -May put patient in medical danger -May last up to several days -Substance use disorders range from mild to severe -Substance use can induce disorders such as psychosis -Substance use/abuse can co-occur with other mental health disorders -Substance use disorders second only to mood disorders as risk factor for suicide

Group Therapy for Addiction: Support Groups

Support groups -Peers share thoughts, feelings and help one another examine issues -May or may not be assisted by mental health professional •SMART Recovery (Self-Management And Recovery Training) -Scientific use of psychologic treatments and legally prescribed psychiatric and addiction medication -Substance abuse, addiction considered to be complex maladaptive behaviors with possible physiologic factors -Emphasizes increasing self-reliance rather than powerlessness Focuses -Building, maintaining motivation -Coping with urges -Managing thoughts, feelings, behaviors -Living a balanced life

Milieu Therapy for Addiction

Supportive recovery environment -Safety and structure -Consistent routine -Clear communication Benefits of structure -Helps patients contain negative behavior -Provides opportunities to learn how to respond to challenging situations -Staff and peer feedback -Modeling constructive behavior Goal: to support constructive, permanent behavioral change by -Treating patients as responsible individuals -Encouraging group, social interaction -Emphasizing patients' rights to choose, participate in variety of treatments -Accentuating informal relationships with healthcare professionals

The Nursing Process: Outcome Identification

The patient will -Be physically safe -Distinguish between self-harm ideas and taking action on those ideas -Learn healthy ways to deal with stress -Express emotions nondestructively -Establish social support network in community

Collaborative Therapies: Treatments

Treatment depends on level of severity and how the person came to seek treatment -Adjudicated to treatment by judicial system -Involuntary admission -Admission for medical care associated with injury

Group Therapy for Addiction: 12 Step Programs

Twelve-step programs -Support groups with spiritual plan for recovery Examples: Alcoholics Anonymous, Al-Anon, Narcotics Anonymous, Adult Children of Alcoholics, Gamblers Anonymous, Overeaters Anonymous -Program consists of prescribed beliefs, values, behaviors Sequential plan for recovery stated in 12 steps -Begins with admitting powerlessness over the substance -Continues through steps to take responsibility for behaviors Only requirement: sincere desire to change Some research has found modest outcomes -Reduced relapse rates, increased treatment retention, improved relationship with treatment providers, increase participant satisfaction -Benefits may be indistinguishable from those of concurrent recovery activities

Inhalants

Types of inhalants Anesthetics -Most abused anesthetics: nitrous oxide, ether Volatile nitrates -Amyl nitrate, butyl nitrate, isobutyl nitrate → venodilation, anal sphincter relaxation Organic solvents -Widely available to children -Ingested by bagging, huffing, or sniffing -Effects similar to those of alcohol -Prolonged use can lead to multiple toxicities -Makes you hypoxic -Brain damage can occur on 1st, 10th, or 100th inhalant use → "sudden sniffing death" -Mild withdrawal syndrome can occur with long-term use

Substance abuse disorder

Use of one or more substances to the extent of becoming addicted, unable to stop, despite negative consequences