Topic 10 - Substance-Related and Addictive Disorders Part 1

Self-help groups can complement and extend the effects of professional treatment. The most prominent self-help groups are those affiliated with Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model. Most drug addiction treatment programs encourage patients to participate in self-help group therapy during and after formal treatment. These groups can be particularly helpful during recovery, offering an added layer of community-level social support to help people achieve and maintain abstinence and other healthy lifestyle behaviors over the course of a lifetime.

12 step programs

Relapse prevention Begin taking on the fifth day of abstinence from alcohol. Tablets are taken three times a day. Side effects include diarrhea, gastrointestinal upset, appetite loss, dizziness, anxiety, and difficulty sleeping. Contraindicated in patients with renal impairment.

Acamprosate calcium (Campral)

Chronic medical condition with roots in the environment, neurotransmission, genetics, and life experiences.

Addiction

Swallowed Low doses: Euphoria, mild stimulation, relaxation, lowered inhibitions High doses: Drowsiness, slurred speech, nausea, emotional volatility, loss of coordination, visual distortions, impaired memory, loss of consciousness, respiratory arrest, seizures, coma, death Increased risk of injuries, violence, fetal damage, depression, neurological deficits, hypertension, liver and heart disease, addiction, fatal overdose

Alcohol

Alcohol use assessment is part of a comprehensive exam that includes the person as a whole. The general assessment has a section that can help identify those at risk for AUD and either generate a referral via the EHR , or prompt the nurse to do one. Family Assessment - Assessment of the family unit and identify any codependence behaviors that might be present Self-Assessment - Since the disorder is self-inflicted, important for the nurse to assess their own thoughts, opinions and feelings about alcohol use and abuse as a first step towards being able to be objective and form therapeutic and non-judgmental relationships with clients/patients.

Alcohol assessment

20 mg/dL (0.02 g/dL)—Two alcoholic drinks: Slower motor performance, decreased thinking ability, altered mood, and reduced ability to multitask. • 50 mg/dL (0.05 g/dL)—Three alcoholic drinks: Impaired judgment, exaggerated behavior, euphoria, and lower alertness. • 80 mg/dL (0.08 g/dL)—Four alcoholic drinks: Poor muscle coordination, altered speech and hearing, difficulty detecting danger, impaired judgment, poor self-control, and decreased reasoning. • 100 mg/dL (0.10 g/dL)—Five alcoholic drinks: Slurred speech, poor coordination, and slowed thinking. • 150 mg/dL (0.15 g/dL)—Six alcoholic drinks: Vomiting (unless high tolerance) and major loss of balance. • 200 mg/dL (0.20 g/dL)—Eight to 10 alcoholic drinks: Memory blackouts, nausea, and vomiting. • 300 mg/dL (0.30 g/dL)—More than 10 alcoholic drinks: Reduction of body temperature, blood pressure, respiratory rate, sleepiness, and amnesia. • 400 mg/dL (0.40 mg/dL)—Impaired vital signs and possible death.

Alcohol intoxication

most states require a blood alcohol level of 80 o1 100 mg per deciliter of blood (mg/dL) Signs and symptoms of specific BAL ranges are on pg. 419 (Halter, 2022) Based on several factors including how quickly drinks are ingested - which raises levels more rapidly - based on the standard drink size of 14 oz. of alcohol

Alcohol intoxication

uSedative with initial euphoria uSeverity based on number of DSM-V symptoms uMild: 2-3 symptoms uModerate: 4-5 symptoms uSevere: 5 or more symptoms uExtensive List in DSM-V box Decreased inhibitions. Cluster of both behavioral and physical symptoms - per the DSM-5

Alcohol use disorder

Epidemiology Alcohol use disorder is far too common. In 2018, 14.8 million (5.4%) people in the United States were estimated to have alcohol use disorder (SAMHSA, 2019). About 401,000 (1.6%) adolescents aged 12 to 17 had a past-year alcohol use disorder. Young adults are particularly affected by alcohol use. About 3.4 million (10.1%) young adults aged 18 to 25 are estimated to have had this disorder. About 11.0 million (5.1%) adults 26 and older had an alcohol use disorder in the preceding year. Rates of this disorder are higher, with almost twice the prevalence, among adult men versus adult women. In general, American Indians/Alaska Natives (12.1%) have the highest rates for alcohol use disorder and are disproportionately affected by alcohol problems (Vaeth, Wang-Schweig, & Caetano, 2017). Prevalence rates are higher in whites (8.9%), followed by Hispanics (7.5%), blacks (6.9%), and Asian Americans and Pacific Islanders (4.5%).

Alcohol use disorder epidemiology

Alcohol withdrawal occurs after reducing or quitting alcohol after heavy and prolonged use. The classic sign of alcohol withdrawal is tremulousness, commonly called the shakes or the jitters, which begins 6 to 8 hours after alcohol cessation (Sadock et al., 2015). Mild to moderate alcohol withdrawal includes agitation, lack of appetite, nausea, vomiting, insomnia, impaired cognition, and mild perceptual changes. Both systolic and diastolic blood pressure increases, as does pulse and body temperature. Chlordiazepoxide (Librium) is useful for tremulousness and mild to moderate agitation. Psychotic and perceptual symptoms may begin in 8 to 10 hours. If your patient is undergoing withdrawal to the point of psychosis, it should be considered a medical emergency because of the risks of unconsciousness, seizures, and delirium. The benzodiazepines lorazepam (Ativan) or chlordiazepoxide (Librium) can be given either orally or intramuscularly and tapered over the following 5 to 7 days.

Alcohol withdrawal

Withdrawal seizures may occur within 12 to 24 hours after alcohol cessation. These seizures are generalized and tonic-clonic. Additional seizures may occur within hours of the first seizure. Diazepam (Valium) given intravenously is a common treatment for withdrawal seizures. Alcohol withdrawal delirium, also known as delirium tremens (DTs), is a medical emergency that can result in the death in 20% of untreated patients, usually as a result of medical problems such as pneumonia, renal disease, hepatic insufficiency, or heart failure (Sadock et al., 2015). Alcohol withdrawal delirium may happen anytime in the first 72 hours. Autonomic hyperactivity may result in tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension. Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium.

Alcohol withdrawal

occurs after reducing or quitting alcohol after heavy and/or prolonged use. Signs and symptoms usually occur 6 to 8 hours after stopping (Physical); psychotic and perceptual symptoms may start 8-10 hours after last drink. Presence of psychotic symptoms might signal a medical emergency. Benzodiazepines lorazepam (Ativan) or chlordiazepoxide (Librium) will be started and tapered over 5-7 days. Withdrawal seizures -can occur 12-24 hours after last drink -seizures are generalized and tonic-clonic in nature. May be more than one. Diazepam (Valium) IV is a common treatment.

Alcohol withdrawal

uEarly signs appear within a few hours of last drink uPeaks within 24 to 48 hours uRapidly and dramatically disappears (unless it progresses to delirium) uIrritability and "shaking inside" uGrand mal seizures possible 7 to 48 hours after last drink uIllusions

Alcohol withdrawal assessment

AA was founded in 1930 and is the oldest and best known of the 12-step programs. Anyone with the desire to quit drinking or using substances is welcome to attend meetings. Individuals learn how to be sober through the support of other members and the 12 steps. In most suburban and urban areas, meetings can be found every day and around the clock. Meetings are even available online and are structured for confidentiality and anonymity. Family members and other support are often welcome. The 12-step model has been adopted worldwide. An internet search should reveal a 12-step program for any substance use problem and even specific populations, such as women, men, and certain groups. The size of meetings ranges from small (around 15) to large (more than 50). There are also meetings to address the special needs of family and significant others, such as Al-Anon for friends and family members and Alateen for teenage relatives.

Alcoholics Anonymous

Tablet, chewable, liquid, swallowed, smoked, injected Increased alertness, increased blood pressure and heart rate, narrowed blood vessels, increased blood sugar Long-term high doses: heart problems, psychosis, anger

Amphetamine (Adderall, Benzedrine)

Injected, swallowed, applied to skin No intoxication effects Hypertension, blood clotting and cholesterol changes, liver cysts, hostility and aggression, acne; in adolescents premature stoppage of growth; in males, prostate cancer, reduced sperm production, shrunken testicles, breast enlargement; in females, menstrual irregularities, development of beard and other masculine characteristics

Anabolic steroids

Withdrawal Older treatments still used today. Other treatments have proven more effective and safer. Assess for seizures that could lead to delirium tremens if not treated, coma, and ultimately death.

Anticonvulsants (Tegretol) Barbiturates (phenobarbital)

Listed in the FDA's poisonous plant database Brewed as a tea Strong hallucinations, altered vision and auditory perceptions, increased blood pressure, vomiting, diarrhea

Ayahuasca, a brew that includes chacruna or chagropanga, dimethyltryptamine (DMT)-containing plants

Withdrawal Sedation, decreased anxiety, and blood pressure. Use CIWA-AR scale to assess dose according to agency policies. Assess for seizures that could lead to delirium tremens (DTs). If not treated, coma and ultimately death.

Benzodiazepines (lorazepam [Ativan], chlordiazepoxide [Librium], diazepam [Valium])

Genetic - Runs in families and about 40-60% is inherited (APA, 2013). Identical twins are more likely to share alcohol use problems than fraternal twins. Male identical twins have higher rates than females. Fourfold risk increase in children of affected family members, even if given up for adoption or raised in another setting. Neurobiological - Families with alcohol use disorders in them have alterations in their brains which can be found through Functional MRI studies

Biological risk factors for alcohol use disorder

0.05 % 1-2 drinks Changes in mood and behavior; impaired judgment 0.08 % 5-6 drinks Legal level of intoxication in most states. Clumsiness in voluntary motor activity 0.20 % 10-12 drinks Depressed function of entire motor area of the brain, causing staggering and ataxia; emotional lability 0.30 % 15-19 drinks Confusion, stupor 0.40 % 20-24 drinks Coma 0.50 % 25-30 drinks Death caused by respiratory depression

Blood alcohol level and effects in a non tolerant drinker

•C Have you ever felt you ought to Cut down on your drinking? •A Have people Annoyed you by criticizing your drinking? •G Have you ever felt bad or Guilty about your drinking? •E Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? Use this quick assessment to determine if someone has a problem with alcohol.

CAGE Screening Tool

Used to assess the need for alcohol detoxification. Treatment protocols are ordered with interventions guided by the client's scores in these areas: •Nausea/vomiting •Tremors •Anxiety •Agitation •Paroxysmal Sweats •Orientation •Tactile Disturbances •Auditory Disturbances •Visual Disturbances •Headaches What are we assessing for with alcohol withdrawal? Use an Internet search to retrieve and evaluate the CIWA-AR for Alcohol Withdrawal, which objectifies alcohol withdrawal symptoms to help to help guide therapy.

Clinical Institute Withdrawal Assessment (CIWA-AR)

Mild to moderate withdrawal Alpha-agonist antihypertensive agent. Give every 4-6 h as needed. Side effects dizziness, hypotension, fatigue, and headache.

Clonidine (Catapres)

Snorted, smoked, injected, snorted Increased heart rate, blood pressure, body temperature, metabolism, feelings of exhilaration, increased energy, mental alertness, tremors, reduced appetite, irritability, anxiety, panic, paranoia, violent behavior, psychosis Weight loss, insomnia, cardiac or cardiovascular complications, stroke, seizures, addiction Cocaine: Nasal damage from snorting Methamphetamine: Severe dental problems

Cocaine (Cocaine hydrochloride), Amphetamine (Biphetamine, Dexedrine), Methamphetamine (Desoxyn), and Methylenedioxy-methamphetamine (MDMA) Cocaine is NOT swallowed MDMA is NOT smoked

is a cluster of behaviors originally identified through research involving the families of alcoholic patients. People who are codependent often exhibit overly responsible behavior—doing for others what others could just as well do for themselves. People who are codependent often define their self-worth in terms of caring for others to the exclusion of their own needs.

Codependence

helps patients explore thinking patterns so that the core belief system and any irrational core beliefs can be identified. Positive and negative consequences of alcohol use are explored. Patients learn to self-monitor their cravings and challenge these cravings realistically.

Cognitive behavioral therapy

Wernicke's Encephalopathy - is from long term heavy alcohol use may produce short-term memory loss which is an acute condition but reversible with treatment. Korsakoff syndrome is chronic with only a 20% recovery rate. Connection between the two is a thiamine deficiency from poor nutrition. Wernicke is helped by large doses of IV thiamine 2-3 time daily for 1-2 weeks. Treatment for Korsakoff is also thiamine for 3-12 months although most with that syndrome never fully recover. Blackouts are caused by excess intake of alcohol that his followed by short-term amnesia Fetal Alcohol Syndrome - Caused by alcohol used during pregnancy, it is a common cause of intellectual disability in the U.S. Inhibits intrauterine growth and postnatal development which can result in microcephaly, craniofacial malformations, and both limb and heart defects. Tend to be short statured as adults. Women who drink during pregnancy have a 35% risk of having a child born with FAS defects. Halter (2022), pp. 419-420

Cognitive disturbances of alcohol

Bipolar do, schizophrenia, and antisocial personality disorder associated with increased alcohol usage rates and major depressive disorders is both a risk factor for and as result of usage due to alcohol's depressant qualities. May also reduce immune response and leave individuals more open to infection.

Comorbidity

Bipolar disorders, schizophrenia, and antisocial personality disorder are associated with an increase in rates of alcohol use disorder. Major depressive disorder is a risk factor for and a result of alcohol use disorder due to alcohol's depressant qualities. Alcohol may also reduce the immune response and predispose users to infection.

Comorbidity of alcohol use disorder

uDetoxification uRehabilitation uHalfway Houses/Other Housing uPartial Hospitalization uIntensive Outpatient Program uOutpatient Treatment

Conventional treatments

A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either of the following: a

DSM-5 Criteria for Alcohol Use Disorder

•Disorientation to time, place, and person •Impaired attention •Agitation •Hallucinations (visual, tactile, and or auditory) •Potential seizures

Delirium tremens

Does not perceive danger of substance use or gambling, minimizes symptoms, refuses healthcare attention, unable to admit impact of disease on life pattern No denial: Accepts responsibility for behavior, maintains abstinence from substances

Denial

Swallowed Feelings of being separate from one's body and environment, impaired motor function, euphoria, slurred speech, confusion, dizziness, distorted visual perceptions Anxiety, tremors, numbness, memory loss, nausea

Dextromethorphan (DXM)

White or yellow powder, smoked, swallowed 30-60 min of intense hallucinations, depersonalization, high blood pressure, rapid eye movements, agitation, seizures

Dimethyltryptamine (DMT) synthetic drug

Maintenance, relapse prevention, aversion therapy Physical effects when alcohol is used: Intense nausea and vomiting, headache, diaphoresis (sweating), flushed skin, dyspnea (respiratory difficulties), and confusion. Avoid all alcohol and substances such as cough syrup and mouthwash containing alcohol.

Disulfiram (Antabuse)

Blaming, broken promises, lying, enabling, manipulation, rationalization, projection, deterioration of family relationships Improved family process: Identifies personal role in family dysfunction, honest communication, clear communication

Dysfunctional family process

Social - Adolescents strongly influenced by peers - sometimes called the 'social lubricant'. Using alcohol, tobacco and marijuana at an early age may be associated with lack of strong family supervision. Cultural - May create a sense of community in those otherwise isolated in some cultures where it's part of every day life. In others, to include some religious groups, alcohol is prohibited and considered sinful. Many Muslim cultures have prohibitions against alcohol and in the U.S. groups that are Pentecostal, Baptist and Mormon reject alcohol use.

Environmental risk factors of alcohol use disorder

SAMHSA's National Survey on Drugs (annual) primary source for drug use statistics 165 million (65%) used some type of substance within the last month. People with substance use disorder is estimated at about 20.3 million (which includes 15 million specifically with alcohol use disorder) More statistics about AUD are broken down and include the fact that twice as many adult males versus females are diagnosed. Ethnic/cultural groups: AI/AN 12.1% - the highest rates and disproportionate to the rest of the groups. This is followed by whites (8.9%), Hispanics (7.5%), African Americans (6.9%) and Asian Americans/Pacific Islanders (4.5%)

Epidemiology statistics

Evaluation occurs on several levels: assessing the effectiveness of the treatment plan, using objective data to check whether nursing actions addressed the patient's symptoms, and measuring the changes in the patient's behaviors for progress toward meeting stated goals. Problematic behaviors, patterns of expression, or perceptions may improve or only undergo changes in small increments, requiring alterations in the action steps or even the goals of the treatment plan to meet the patient's needs. During the treatment experience, conduct ongoing evaluation of the process to ensure that any transference or countertransference is managed and that the goals and outcomes of treatment remain patient centered. Evaluation will also make it possible to ensure that the patient acquires the necessary skills and competencies for continued reflection and maintenance of the new lifestyle identification.

Evaluation of the nursing process for alcohol use disorder

Swallowed, snorted Sedation, muscle relaxation, confusion, memory loss, dizziness, impaired coordination Addiction

Flunitrazepam (Rohypnol), similar to benzodiazepine chemically

1.Impaired Control 2.Social impairment 3.Risky Use 4.Physical effects (intoxication, tolerance, and withdrawal)

Four major groups of substance abuse

Swallowed Drowsiness, nausea, headache, disorientation, loss of coordination, memory loss Unconsciousness, seizures, coma

Gamma-hydroxybutyrate (GHB)

Many therapeutic settings use group therapy to capitalize on the social reinforcement offered by peer discussion and to help promote drug-free lifestyles. Research has shown that when group therapy either is offered in conjunction with individualized drug counseling or is formatted to reflect the principles of cognitive-behavioral therapy or contingency management, positive outcomes are achieved. Currently, researchers are testing conditions in which group therapy can be standardized and made more community-friendly.

Group counseling

If genetic vulnerability accounts for 40% to 60% of an individual's risk, prevention may be the best answer to addressing alcohol misuse (NIDA, 2018). Health teaching is a part of the school curriculum, and schools may offer classes on understanding addiction as a brain disorder, its risk factors, and ways to prevent or limit exposure to psychoactive substances. Promoting classes for developing healthy coping and stress management skills and activities for increasing self-confidence and self-efficacy would also lower the risks for use of psychoactive substances. Social activities that increase supportive relationships reduce the impact of stressful life events and provide a venue for community activities that provide health education and promotion. Pay special attention to understanding the particular impact of trauma as a risk factor. Physical, sexual, or emotional abuse at any age; physical trauma from accidents; natural disasters; or acts of violence or war can all be predisposing factors for the use of psychoactive substances or processes.

Health teaching and health promotion for alcohol use disorder

Injected, smoked, snorted Euphoria, drowsiness, impaired coordination, dizziness, confusion, nausea, sedation, feeling of heaviness in the body, slowed or arrested breathing Constipation, endocarditis, hepatitis, HIV, addiction, fatal overdose

Heroin (Diacetylmorphine) and Opium (Opium is NOT snorted)

Substance use or gambling, lack of initiative, passivity, social isolation, reports no alternatives or personal control, anger, no meaning in life Expresses feelings of self-worth, verbalizes sense of personal identity, expresses meaning in life, sets goals, believes that actions impact outcomes

Hopelessness

Substance use or gambling, decreased use of social support, destructive behavior toward self and others, difficulty organizing information, inadequate problem-solving, poor concentration, reports inability to cope Effective coping: Modifies lifestyle as needed to maintain sobriety, maintains abstinence from substances, engages in satisfying relationships

Impaired coping

Reports not feeling well rested, decreased ability to function, reports awakening multiple times Improved sleep: Minimal awakening, feels restored after sleep, sleeps recommended hours based on age

Impaired sleep

uPromoting safety and sleep: first-line interventions uReintroduce good nutrition and hydration uSupport for self-care (hygiene) uExploring harmful thoughts and spiritual distress uHealth teaching and health promotion uPrevention against genetic vulnerability uPublic classes

Implementation of alcohol use disorder

Individualized drug counseling not only focuses on reducing or stopping illicit drug or alcohol use; it also addresses related areas of impaired functioning—such as employment status, illegal activity, and family/social relations—as well as the content and structure of the patient's recovery program. Through its emphasis on short-term behavioral goals, individualized counseling helps the patient develop coping strategies and tools to abstain from drug use and maintain abstinence. The addiction counselor encourages 12-step participation (at least one or two times per week) and makes referrals for needed supplemental medical, psychiatric, employment, and other services.

Individualized drug counseling

Inhaled through nose or mouth Varies by chemical—stimulation, loss of inhibition, headache, nausea or vomiting, slurred speech, loss of motor coordination, wheezing Cramps, muscle weakness, depression, memory impairment, damage to cardiovascular and nervous systems, unconsciousness, sudden death

Inhalants Solvents, propellants, thinners, and fuels

When people are in the process of using a substance to excess, they are experiencing intoxication

Intoxication

Injected, snorted, smoked Feelings of being separate from one's body and environment, impaired motor function, analgesia, impaired memory, delirium, respiratory depression and arrest, death Anxiety, tremors, numbness, memory loss, nausea

Ketamine (Ketalar)

Long-term residential treatment provides care 24 hours a day, generally in non-hospital settings. The best-known residential treatment model is the therapeutic community (TC), with planned lengths of stay of between 6 and 12 months. TCs focus on the "re-socialization" of the individual and use the program's entire community—including other residents, staff, and the social context—as active components of treatment. Addiction is viewed in the context of an individual's social and psychological deficits, and treatment focuses on developing personal accountability and responsibility as well as socially productive lives. Treatment is highly structured and can be confrontational at times, with activities designed to help residents examine damaging beliefs, self-concepts, and destructive patterns of behavior and adopt new, more harmonious and constructive ways to interact with others. Many TCs offer comprehensive services, which can include employment training and other support services, onsite.

Long term residential treatment

Swallowed, absorbed through mouth tissues Altered states of perception and feeling, hallucinations, nausea, increased body temperature, heart rate, blood pressure, loss of appetite, sweating, sleeplessness, numbness, dizziness, weakness, tremors, impulsive behavior, rapid shifts in emotion Flashbacks, hallucinogen persisting perception disorder

Lysergic acid diethylamide (LSD)

Smoked, swallowed Euphoria, relaxation, slowed reaction time, distorted sensory perception, impaired balance and coordination, increased heart rate and appetite, impaired learning, memory, anxiety, panic attacks, psychosis/cough Frequent respiratory infections, possible mental health decline, addiction

Marijuana and Hashish

Swallowed, smoked Altered states of perception and feeling, hallucinations, nausea, increased body temperature, heart rate, blood pressure, loss of appetite, sweating, sleeplessness, numbness, dizziness, weakness, tremors, impulsive behavior, rapid shifts in emotion

Mescaline

Liquid, tablet, chewable tablet, capsule Swallowed, snorted, smoked, injected, chewed Increased alertness, increased blood pressure and heart rate, narrowed blood vessels, increased blood sugar Long-term high doses: heart problems, psychosis, anger

Methylphenidate (Concerta, Ritalin)

•Anxiety •Tremors (feeling 'shaky') •Insomnia •Headache •Palpitations •Gastrointestinal disturbances (cramping) •Orientation remains intact

Mild alcohol withdrawal

•Diaphoresis •Elevated systolic blood pressure •Tachypnea •Tachycardia •Confusion •Mild hyperthermia •Hallucinations (visual, tactile, and or auditory) •Orientation remains intact

Moderate -> severe alcohol withdrawal

is an approach based on the transtheoretical or stages of change theory. It has gained popularity in its use as a brief, long-term, and supplementary intervention, particularly in the treatment of substance use disorders. It uses a person-centered approach to strengthen motivation for change (Tan, Lee, Lim, Leong, & Lee, 2015). The advanced practice nurse and patient usually meet for an hour at a time.

Motivational interviewing

Withdrawal, relapse prevention, decreases pleasurable feelings and cravings Oral or long-acting (once a month) injectable form. Nausea usually goes away after first month; headache, sedation. Pain at injection site, patient needs to be opiate free 10 days before initiation of medication.

Naltrexone (Vivitrol—injectable, ReVia, Depade—oral)

Smoked, snorted, chewed Increased blood pressure and heart rate Chronic lung disease, cardiovascular disease, stroke, cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, bladder, and acute myeloid leukemia, adverse pregnancy outcomes, addiction

Nicotine

Basic nursing interventions are useful in providing a supportive environment for managing substance use disorders. Promoting safety and sleep are essential first-line interventions. Also, patients with alcohol use disorder may have severely compromised nutritional status due to choosing substance over sustenance. Gradually reintroducing healthy food and hydration helps support body systems and neurological functioning. Support and encouragement for self-care (hygiene) will help improve self-esteem in individuals who may have long neglected themselves. The development of a therapeutic relationship sets the stage for exploring harmful thoughts, anxiety, hopelessness, and spiritual distress. An understanding of current coping skills along with the identification of new skills provides tools to test in a safe setting. Assistance in goal setting helps a patient to see beyond the current situation and instills hope and direction. Nurses administer medications and provide ongoing assessment of their efficacy and side effects after administration. Nurses need to monitor vital signs frequently since an increase in pulse, blood pressure, and body temperatures are clear signs of withdrawal. The goa

Nursing interventions for alcohol use disorder

Outpatient treatment varies in the types and intensity of services offered. Such treatment costs less than residential or inpatient treatment and often is more suitable for people with jobs or extensive social supports. It should be noted, however, that low-intensity programs may offer little more than drug education. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient's characteristics and needs. In many outpatient programs, group counseling can be a major component. Some outpatient programs are also designed to treat patients with medical or other mental health problems in addition to their drug disorders.

Outpatient treatment programs

Depends on the overdosed substance (e.g., opiates—unresponsiveness, respiratory depression, pinpoint pupils, coma, hypothermia, hypotension, bradycardia) Overdose resolution: Returns to pre-overdose level of functioning, identifies mechanism of overdose

Overdose

Swallowed, smoked, injected Feelings of being separate from one's body and environment, impaired motor function, analgesia, psychosis, aggression, violence, slurred speech, loss of coordination, hallucinations Anxiety, tremors, numbness, memory loss, nausea

Phencyclidine (PCP) and analogs

Capsules, liquid, injected, swallowed, smoked, snorted Drowsiness, lethargy, euphoria, slow breathing, death

Prescription pain relievers

Pill, capsule, liquid, injected, swallowed Drowsiness, slurred speech, poor concentration, low blood pressure, decrease respiratory rate

Prescription sedatives

Swallowed Altered states of perception and feeling, hallucinations, nausea, nervousness, paranoia, panic

Psilocybin

uAny combination of two or more substance use disorders and mental disorders

Psychiatric comorbidity

uImportant aspect of recovery in Alcoholics Anonymous (AA) and other recovery modalities uSpirituality practices are related to improved outcomes. uHigher spiritual levels often correlate with: uSense of purpose uGratitude Forgiveness

Recovery and belief in higher power

12-Step Programs uAA, NA, Al-Anon, Ala-Teen SMART — self-management and recovery training

Recovery models

Intoxication: Impaired cognition/judgment, impaired physical coordination, psychomotor agitation or retardation Remains free from injury while intoxicated

Risk for injury

Impulsiveness, loss of relationships and occupation due to focus on substances or gambling, legal problems, social isolation Decreased suicide risk: Expresses feelings, verbalizes suicidal ideas, refrains from suicide attempts, plans for the future

Risk for suicide

Chewed, swallowed, smoked Feelings of being separate from one's body and environment, impaired motor function Anxiety, tremors, numbness, memory loss, nausea

Salvia divinorum

High potential for abuse; no acceptable medical use Ex: heroin and LSD

Schedule 1 (Five categories of drugs)

High potential for abuse, considered dangerous, prescription only Ex: methadone, meperidine (Demerol) and methylphenidate (Ritalin)

Schedule 2 (Five categories of drugs)

Low to moderate chance of abuse, prescription only Ex: testosterone, Tylenol with codeine, buprenorphine (Suboxone)

Schedule 3 (Five categories of drugs)

Low risk, prescription only Ex: alprazolam (Xanax), lorazepam (Ativan), and propoxyphene/acetaminophen (Darvocet)

Schedule 4 (Five categories of drugs)

Limited amounts of narcotic; OTC Ex: atropine/diphenoxylate (Lomotil), guaifenesin and codeine (Robitussin AC) and pregabalin (Lyrica)

Schedule 5 (Five categories of drugs)

A variety of other screening tools are available to assist healthcare practitioners in gaining important information on which to base plans of care. Additional screening tools are: • AUDIT (The Alcohol Use Disorders Identification Test) • CAGE (Questions: Have you felt you needed to cut down on your drinking? Are people annoyed by your drinking? Have you felt guilty about your drinking? Have you ever had a drink in the morning (eye-opener)? A score of 2 or more is significant, although a score of 1 requires further assessment. • CAGE-AID (Questions are the same as CAGE but refers to Adapted to Include Drugs.) • T-ACE (Tolerance, Annoyance, Cut down, Eye-opener)

Screening tools

Short-term residential programs provide intensive but relatively brief treatment based on a modified 12-step approach. These programs were originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980s, many began to treat other types of substance use disorders. The original residential treatment model consisted of a 3- to 6-week hospital-based inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as AA. Following stays in residential treatment programs, it is important for individuals to remain engaged in outpatient treatment programs and/or aftercare programs. These programs help to reduce the risk of relapse once a patient leaves the residential setting.

Short term residential treatment

Individuals may be at stage one, precontemplation, and need assistance in admitting there is a problem. If they have acknowledged the problem, contemplation, they may still not be ready to commit to addressing it. The goal of treatment is to assist in the development of awareness and a commitment. Preparation, or getting ready, and action, or changing, take place in early treatment phases. The maintenance stage is the ongoing commitment to a recovery program. Without continuing action, the individual will likely return to previous behavior, relapse.

Stages of substance use disorder

"Pathological use of a substance that leads to a disorder of use"

Substance abuse

uPeripheral neuropathy uAlcoholic myopathy and cardiomyopathy uEsophagitis, gastritis, and pancreatitis uAlcoholic hepatitis uCirrhosis of the liver uLeukopenia uThrombocytopenia Cancer (especially head and neck)

Systemic effects of alcohol use disorder

Screening: A nurse or other healthcare professional in any healthcare setting assesses the severity of substance use and identifies the appropriate level of treatment. • Brief Intervention: A nurse or other healthcare professional focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. • Referral to Treatment: A nurse or other healthcare professional provides those identified as needing more extensive treatment with access to specialty care.

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) program

occurs when a person doesn't respond to the substance the way they initially did and needs a higher dosage to achieve the initial response. Cocaine for example causes a rapid physical tolerance, others make take weeks.

Tolerance

uInpatient uPartial Hospitalization uResidential Treatment uOutpatient uSelf-Help uSupport Groups 12 Step Programs (self-help groups

Treatment options

•Cognitive Behavioral Therapy: Seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs. •Motivational Incentives: Uses positive reinforcement such as providing rewards or privileges for remaining drug free, for attending and participating in counseling sessions, or for taking treatment medications as prescribed. •Motivational Interviewing: Employs strategies to evoke rapid and internally motivated behavior change to stop drug use and facilitate treatment entry. •Group Therapy: Helps patients face their drug abuse realistically, come to terms with its harmful consequences, and boost their motivation to stay drug free. Patients learn effective ways to solve their emotional and interpersonal problems without resorting to drugs.

Types of therapy

Depends on the substance of withdrawal (e.g., opiates—mood dysphoria, nausea, muscle aches, fever, insomnia, lacrimation, rhinorrhea, pupillary dilation, yawning, gooseflesh) Withdrawal cessation: Symptoms are controlled, returns to pre-withdrawal functioning

Withdrawal

set of physiological symptoms that occur when the person stops using the substance - can range from mild to life-threatening. Relapse can be common during this time to avoid withdrawal symptoms. Behavioral addictions such as gambling can cause psychological symptoms such as craving, sleep problems, anxiety and depression.

Withdrawal

uMedical emergency uPossibility of death uPeaks 2 to 3 days after cessation or reduction of alcohol intake uAutonomic hyperactivity uSensorial and perceptual disturbances uFluctuating level of consciousness (LOC) uDelusions (paranoid) uAgitated behaviors uBody temperature 100° F or higher

Withdrawal delirium assessment