chapter 18 addictive disorders

date rape drugs

Flunitrazepam (Rohypnol or "roofies") Gamma hydroxybutyric acid (GHB) Rapidly produce Disinhibition Relaxation of voluntary muscles Anterograde amnesia The drugs most frequently used to facilitate a sexual assault (rape) are flunitrazepam (Rohypnol or "roofies," a fast-acting benzodiazepine) and γ-hydroxybutyric acid (GHB) and its congeners. They are odorless, tasteless, and colorless, mix easily with drinks, and can render a person unconscious in a matter of minutes. Perpetrators use these drugs because they rapidly produce disinhibition and relaxation of voluntary muscles; they also cause the victim to have lasting anterograde amnesia for events that occur. Alcohol potentiates their effects.

etiology

*Biological factors* Specific effects on neurotransmitter systems - it has recently been found that alcohol and drugs affect specific neurotransmitters and areas of the brain. The opioid, catecholamine, and GABA systems are the main systems affected. *The CNS depressants of which alcohol is one act on the GABA receptors and increase glutamate, norepinephrine and dopamine*. This shows the addictive and cross tolerance effects that happen when alcohol is taken in combination with barbiturates and benzodiazepines. *Cocaine and amphetamines increase norepinephrine, serotonin, and dopamine*. Research has shown that *dopamine is responsible for a phenomenon called incentive salience which is responsible for the craving of a substance many users have when not using the substance*. This generally what causes the person to relapse because they have the overwhelming urge to use the drug. *Psychological factors* Lack of tolerance for frustration and pain Lack of success in life Lack of affectionate and meaningful relationships Low self-esteem, lack of self-regard Risk-taking propensity Many people using numerous substances report having an unstable childhood and self-medicating then those that abuse only alcohol. *Individuals with personality disorders usually abuse substances*. Psychodynamic theorists claim that substance abuse is a defense for anxious impulses, a form of oral regression, or self-medicating for depression. The behaviorists focus on the positive reinforcing effects of drug-seeking behavior. *Sociocultural factors* Social and cultural norms Socioeconomic stress - The theorists try to explain the differences in the incidence of substance use in different groups. There are a *low percentage of those in the Asian culture that abuse alcohol*. One reasons for this is that about 50% of the Asian population has an aldehyde dehydrogenase deficiency which is the chemical that breaks down alcohol acetaldehyde. With the increased level of alcohol acetaldehyde in the blood, a severe flush and palpitations can occur and it actually keeps many people from drinking. It is also thought that the level of socioeconomic stress may correlate with substance abuse. Individuals in the drug culture that is the economically deprived and unstable environment have a sense of belonging and identity. Women are reported to have lower rates of use, but many times the statistics aren't realistic because many women hide their behaviors and this prevents them from receiving treatment and services.

Comorbidity

*Psychiatric comorbidity* - 6 out of 10 people affected by substance-abuse disorder also affected by mental health disorder Approximately 6 out of every 10 people affected by a substance-abuse disorder are also affected by a mental health disorder . Individuals who abuse alcohol are more likely to abuse other substances and vice versa. Alcohol dependence is associated with abuse of other substances, mood and anxiety disorders, and paranoid, histrionic, and antisocial personality disorders. Only 25% of people with alcohol dependence ever get treatment. Antisocial personality disorders are also associated with drug use. Drug dependence is significantly associated with generalized anxiety disorders and mood disorders. Treatment for drug-use disorders is not common. About 8% of drug abusers and 38% of drug-dependent people will seek help for their problems. Patients with comorbid mental illness and substance-abuse problems often experience more severe and chronic medical, social, and emotional problems. Because they have two or more disorders, they are vulnerable to both substance-abuse relapse and worsening of the psychiatric disorder. In addition, substance-abuse relapse often leads to psychiatric de-compensation, and worsening of psychiatric problems often leads to substance-abuse relapse. Compared with patients who have a single disorder, patients with co-occurring disorders often require longer treatment, experience more crises, and pro-gress more gradually in treatment. Common examples of co-occurring disorders include the combination of major depression with cocaine addiction, alcoholism with generalized anxiety disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. *Medical comorbidity* - alcohol-related medical problems are the comorbidities most commonly seen in medical settings Alcohol abuse is the most prevalent of the substance abuse disorders. Therefore, alcohol-related medical problems are the comorbidities most commonly seen in medical settings. Alcohol can affect all organ systems, in particular the CNS (resulting in disorders such as Wernicke's encephalopathy and Korsakoff's psychosis) and the gastrointestinal system (resulting in disorders such as esophagitis, gastritis, pancreatitis, alcoholic hepatitis, and cirrhosis of the liver). Also commonly associated with long-term alcohol use or abuse are tuberculosis, all types of accidents, suicide, and homicide. Alcohol use during pregnancy can have negative consequences for the fetus and result in fetal alcohol syndrome. The route of drug administration influences medical complications. Intravenous drug users have a higher incidence of infections and sclerosing of veins. Intranasal users may have sinusitis and a perforated nasal septum. Smoking a substance increases the likelihood of respiratory problems.

Withdrawal

*Psychological* changes occur when blood and tissue concentrations of drug decrease after heavy prolonged use of substance

Al-Anon

A support group for spouses and friends of alcoholics.

Advanced Practice Interventions and Evaluation

Advanced practice interventions psychotherapy Evaluation Increased time in abstinence Decreased denial Acceptable occupational functioning Improved family relationships Ability to relate comfortably to other individuals

implementation

Aim of treatment - self-responsibility Challenge - matching patients with types of treatment related to various needs Address physiological, psychological, and physiological, and sociocultural processes The aim of treatment is self-responsibility, not compliance. A major challenge is improving treatment effectiveness by matching subtypes of patients to specific types of treatment. Although addicts share some characteristics and dynamics, significant differences exist within the addict population with regard to physiological, psychological, and sociocultural processes. These differences influence the recovery process either positively or negatively. Often the choice of inpatient or outpatient care depends on cost and the availability of insurance coverage. Outpatient programs work best for people with substance abuse disorders who are employed and have an involved social support system. People who have no support and structure in their day may do better in inpatient programs when these programs are available. In addition, neuropsychological deficits have been associated with long-term alcohol abuse. Impairment has been found in abstract reasoning ability, ability to use feedback in learning new concepts, attention and concentration spans, cognitive flexibility, and subtle memory functions. These deficits undoubtedly have an impact on the process of alcoholism treatment. At all levels of practice, the nurse can play an important role in the intervention process by recognizing the signs of substance abuse in both the patient and the family and by being familiar with the resources available to help with the problem.

Disulfiram (Antabuse)

Alcohol-disulfiram reaction causes unpleasant physical effects

LAAM (l-α-acetylmethadol)

An alternative to methadone is effective for up to 3 days (72 to 96 hours), so patients need to come to an outpatient facility for their medication only three times a week. *This regimen makes it easier for patients to keep jobs and gives them more freedom than is available with methadone maintenance*. is also an addictive narcotic: its therapeutic effects and side effects are the same as those of morphine. Its use has been found to be more *effective in retaining patients in treatment than methadone*

•Naltrexone (ReVia)

Antagonist that blocks euphoric effects of opioids is a relatively pure antagonist that blocks the euphoric effects of opioids. It has low toxicity and few side effects. A single dose provides an effective opiate blockade for up to 72 hours. Taking naltrexone three times a week is sufficient to maintain a fairly high level of opiate blockade. For many patients, long-term use results in gradual extinction of drug-seeking behaviors. *Naltrexone does not produce dependence*. As previously mentioned, it has also been approved for the treatment of alcoholism because it decreases the pleasant, reinforcing effects of alcohol.

•Buprenorphine (Subutex)

Blocks signs and symptoms of opioid withdrawal is a partial opioid agonist. At low doses (2 to 4 mg/day sublingually), the drug blocks signs and symptoms of opioid withdrawal. In experimental studies, buprenorphine has been shown to suppress heroin use in both inpatient and outpatient settings

club drugs

Common drugs Ecstasy - also called MDMA, Adam, yaba, XTC MDA - "love" MDE - "Eve" Produce subjective effects resembling stimulants and hallucinogens Ecstasy(3,4-methylenedioxy-methamphetamine), also called MDMA, Adam, yaba, and XTC, is a prototype of a class of substituted amphetamines that also includes MDA (methylenedioxyamphetamine, or "love") and MDE (3,4-methylenedioxy-ethylamphetamine, or "Eve"). These recreational drugs produce subjective effects resembling those of stimulants and hallucinogens. MDMA causes a *significant release of the neurochemicals serotonin, dopamine, and norepinephrine*. The brain's saturation of these neurotransmitters causes users to exhibit *major empathy towards others, reduced inhibitions, and an outpouring of good feelings about others and the world around them. It also causes introspection about oneself. The release of serotonin also causes all of a user's senses to be extremely sensitive*. Users will be hyperactive and have inexhaustible energy (dancing all night long), dilated pupils with impaired reaction to light, elevated temperature, elevated pulse, elevated blood pressure, diaphoresis, dystonia, bruxism (grinding of the teeth), and other symptoms of stimulant use, such as tachycardia, mydriasis, tremors, arrhythmias, parkinsonism, esophoria (eyes turn inward), central serotonin syndrome, and severe hyponatremia. Users must drink a large quantity of water during MDMA use to prevent dehydration and hyperthermia. After the effects of MDMA wear off, the user commonly goes through a *period of depression*. This depression is caused by a *depletion of serotonin, levels of which do not return to normal within the CNS for at least 3 to 4 days*. Many users describe the period after use with the term blue Tuesdays. Use of additional MDMA after serotonin stores have been depleted does not produce the same effects as the initial use, causing users to only experience the symptoms associated with the use of a stimulant amphetamine.

Psychological Changes

Denial Depression Anxiety Dependency Hopelessness Low self-esteem Various psychiatric disorders People who abuse substances are threatened on many levels in their interactions with nurses. First, they are concerned about being rejected because not all nurses are willing to care for people with addictions. In fact, many patients have experienced instances of rejection in past encounters with nursing personnel. Second, people who abuse substances may be anxious about giving up the substance they think they need to survive. Third, people addicted to substances often are concerned about failing at recovering. Addiction is a chronic, relapsing condition. In fact, relapse is one of the criteria for diagnosing addiction. Most addicts have tried recovery at least once before and have experienced relapse. As a result, many become discouraged about their chances of ever succeeding. Discouragement and a high level of hopelessness can act as barriers to recovery. These concerns can threaten the person's sense of security and sense of self, increasing anxiety levels. To protect against these feelings, the person with an addiction establishes a predictable defensive style. The elements of this style include various defense mechanisms (e.g., denial, projection, rationalization), as well as characteristic thought processes (e.g., all-or-none thinking, selective attention) and behaviors (e.g., conflict minimization and avoidance, passivity, and manipulation). The person is unable to give up these maladaptive coping styles until more positive and functional skills are learned.

Central Nervous System Stimulants (Common signs of stimulant abuse)

Dilation of the pupils Dryness of the oronasal cavity Excessive motor activity Cocaine, crack (short acting) tachycardia Dilated pupils Elevated blood pressure Nausea and vomiting Insomnia Psychological-perceptual: Assaultiveness Grandiosity Impaired judgment Impaired social and occupational functioning Euphoria Amphetamines (long-acting) Dextroamphetamine MethamphetamineIce (synthesized for street use) Increased energy Severe effects: State resembling paranoid schizophrenia Paranoia with delusions Psychosis Visual, auditory, and tactile hallucinations Severe to panic levels of anxiety Potential for violence Note: Paranoia and ideas of reference may persist for months afterward Cocaine is a naturally occurring stimulant extracted from the leaf of the coca bush, and crack is a cheap, widely available, alkalinized form of cocaine. When crack is smoked, it takes effect in 4 to 6 seconds, producing a fleeting high (5 to 7 minutes) followed by a period of deep depression that reinforces addictive behavior patterns and nearly guarantees continued use of the drug.

•Clonidine (Catapres)

Effective somatic treatment when combined with naltrexone was initially marketed for high blood pressure, but it is also an effective somatic treatment for some chemically dependent individuals when combined with naltrexone. Clonidine is a nonopioid suppresser of opioid withdrawal symptoms. It is also nonaddicting

Blood Alcohol Level (BAL)

For the Blood Alcohol Level of 0.05% which occurs with 1 to 2 drinks causes the changes in mood and behavior and impaired judgment. For the Blood Alcohol Level of 0.10% which occurs with 5 to 6 drinks causes clumsiness in voluntary motor activity and is the legal level of intoxication in most states. For the Blood Alcohol Level of 0.20% which occurs with 10 to 12 drinks causes depressed function of the entire motor area of the brain, causing staggering and ataxia and emotional lability. For the Blood Alcohol Level of 0.30% which occurs with 15 to 18 drinks causes confusion and stupor. For the Blood Alcohol Level of 0.40% which occurs with 20 to 24 drinks causes the individual to go into a coma. For the Blood Alcohol Level of 0.50% which occurs with 25 to 30 drinks causes death due to respiratory depression

enabling

Helping a chemically dependent individual avoid experiencing the consequences of his or her drinking or drug use. It is one behavioral component of a codependency role

Acamprosate (Campral)

Helps client abstain from alcohol

counseling

Involves educating addicts on their disease Principles for counseling interventions Counseling involves working with dysfunctional anger, manipulation, impulsiveness, and grandiosity. A warm accepting relationship can assist the patient to feel safe enough to begin looking at problems with openness and honesty. Characteristics of a counselor that facilitate work with substance abusers include knowledge of addiction, ability to form caring relationships, capacity to tolerate anxiety and depression, persistence and patience, capacity to listen, and honesty. Principles for counseling interventions include the following: expect abstinence, individualized goals and interventions, set limits on behavior and on conditions under which treatment will continue, support and redirect defenses rather than attempt to remove them, recognize that recovery is carried out in stages, and look for therapeutic leverage.

alcohol poisoning

Large amounts of alcohol consumed quickly or over time can result when an individual has consumed large amounts of alcohol quickly or over time. can result in death from aspiration of emesis or a shutdown of body systems caused by severe CNS depression. *inability to arouse the individual, cool or clammy skin, respirations less than 10 per minute, cyanosis under the fingernails or gums, and emesis while semiconscious or unconscious*. Withdrawal reactions to alcohol and other CNS depressants are associated with severe morbidity and mortality, unlike withdrawal from other drugs. The syndrome for alcohol withdrawal is the same as that for the entire class of CNS depressant drugs; therefore, alcohol is used here as the prototype. The time intervals are delayed when other CNS depressants are the main drugs of choice or are used in combination with alcohol. In addition, as patients age, their symptoms of withdrawal continue for longer periods and are more severe than in younger patients. Multiple drug and alcohol dependencies can result in simultaneous withdrawal syndromes that present a bizarre clinical picture and may pose problems for safe withdrawal. Family and friends may help provide important information that can assist in care planning.

alcohol withdrawal delirium

Medical emergency Can result in death, even if treated *Autonomic hyperactivity Severe disturbances Fluctuating levels of consciousness Delusions, paranoia, agitated behavior, and ↑temp* is considered a medical emergency and can result in death even if treated. Death is usually due to *sepsis, myocardial infarction, fat embolism, peripheral vascular collapse, electrolyte imbalance, aspiration pneumonia, or suicide*. The state of delirium usually peaks 2 to 3 days (48 to 72 hours) after cessation or reduction of intake (although it can occur later) and lasts 2 to 3 days. In addition to anxiety, insomnia, anorexia, and delirium, features of alcohol withdrawal delirium include: • Autonomic hyperactivity (e.g., tachycardia, diaphoresis, elevated blood pressure) • Severe disturbance in sensorium (e.g., disorientation, clouding of consciousness) • Perceptual disturbances (e.g., visual or tactile hallucinations) • Fluctuating levels of consciousness (e.g., ranging from hyperexcitability to lethargy) • Delusions (paranoid), agitated behaviors, and fever (100 ° F to 103 ° F) Immediate medical attention is warranted. Alcohol is the only drug for which objective measures of intoxication exist. The relationship between BAL and behavior in a nontolerant individual is shown in. Knowledge of the BAL assists the nurse in determining the levels of intoxication and tolerance and in ascertaining whether the person accurately reported recent drinking during the nursing history. These factors are also assessed by means of behavioral cues. As tolerance develops, a discrepancy is seen between BAL and expected behavior. A person with tolerance to alcohol may have a high BAL but minimal signs of impairment

Tolerance

Person's *physiological* reaction to drug decreases with repeated administration of same dose

Health Teaching and Health Promotion

Primary prevention - health teaching FRAMES *F*eedback of personal risk *R*esponsibility of the patient *A*dvice to change *M*enu of ways to reduce substance use *E*mpathetic counseling *S*elf-efficacy or optimism of the patient *B*rief inteventions

Naltrexone (ReVia) Topiramate (Topamax)

Reduces or eliminates alcohol craving Works to decrease alcohol cravings

intervention strategies

Relapse prevention the basic goal of relapse prevention is to help the individual learn from relapse so that periods of sobriety can be lengthened over time and lapses and relapses are not viewed as total failure. The relapses are common during a patient's recovery. It can also result in a renewed and refined effort toward change. The general strategies for relapse prevention are cognitive and behavioral: recognizing and learning how to avoid or cope with threats to recovery, changing lifestyle, learning how to participate fully in society without drugs, and securing help from other people, or social support. Self-help groups for patient and family counseling and support should be encouraged for all families with an alcohol or drug-dependent member. Groups include Al-Anon, Alateen, Adult Children of Alcoholics, Cocaine Anonymous, Pills Anonymous, and Narcotics Anonymous. The self-help groups assist family members in dealing with many common issues. The work is based on a combination of educational and operational principles centered on acceptance of the disease model of addiction, including pragmatic methods for avoiding enabling behaviors 12-Step programs These programs have three fundamental concepts: 1. Individuals with addictive disorders are powerless over their addiction and their lives are unmanageable, 2. Although individuals with addictive disorders are not responsible for their disease, they are responsible for their recovery, and 3 individuals can no longer blame people, places, and things for their addiction - they must face their problems and their feelings, Alcoholics Anonymous (AA) is the prototype for other 12 Step programs such as Pills Anonymous, Narcotics Anonymous, and others. Each group offers the behavioral. Cognitive and dynamic structures necessary to help a people refrain from addictive behaviors and to change and grow. Self-help groups for family members that include Al-Anon, Nar-Anon and Alateen. These groups work with family issues and codependency issues. Residential programs - the residential programs are best suited for individuals who have a long history of antisocial behavior. The addict is expected to remain in the program at least 90 days and may stay a year or more in some residential communities. The goal of the program is to effect a lifestyle change, including abstinence from drugs, development of social skills, and elimination of antisocial behavior. Intensive outpatient programs - in the past patients who were hospitalized for treatment are now treated in the community, owing to cost-reduction necessities. The intensive outpatient programs are flexible, divers, cost-effective, and responsive to the specific needs of the individual. Outpatient drug-free programs and employee assistance programs the outpatient drug-free programs and employee assistance programs or EAPs are geared to the polydrug-abusing or alcoholic patient rather than the patient who is addicted to heroin. EAPs have been developed to provide delivery of mental health services in occupational settings. These are offered as an alternative to losing their jobs when the employees' work performance is negatively, affected by his or her impairment.

self assessment

Self-assessment •Although you may identify with (and have empathy for) patients addicted to caffeine or tobacco, your responses to patients who abuse other substances may not be so empathetic. A patient who has overdosed on heroin or cocaine or comes in with complications of ecstasy or other "techno drug" use may be met with disapproval, intolerance, and condemnation or may be considered morally weak. Also, the manipulative behaviors often seen in these patients may lead you to feel angry and exploited. You may want to help but perceive the patient who abuses drugs to be willful, uncooperative, and impossible to work with. •In some areas of the United States, the recreational use of cocaine, marijuana, and amphetamine is so common the nurse may not have much emotional reaction. Becoming inured, or hardened, is as detrimental as strong emotional disapproval, because you may underestimate the importance of supportive measures, patient education, and the need for follow-up psychotherapeutic intervention. •To come to a true personal understanding means that you must examine your own attitudes, feelings, and beliefs about addicts and addiction. It often means you must examine your own substance use and that of others you know, and this is not always pleasant work. A history of substance abuse in a nurse's own family can overshadow that nurse's interactions with addicts. The negative or positive experiences a nurse has had with addicted family members can influence interpersonal interactions with present or future patients. •Therefore, it is vitally important to attend to personal feelings that arise when working with addicts. All health care professionals require supervision if they are not experienced in this area. Those who do not attend to—and work through—expected negative feelings that arise during treatment have power struggles with patients, and the therapeutic process is generally ineffective. These issues can become evident when it is a fellow nurse who has a substance-abuse problem. Chemically impaired nurse Enabling • If the nurse doesn't get treatment, there is a definite potential to harm patients. *This nurse may work extra shifts. Their patients may complain of pain or not be able to sleep even after receiving pain meds or hypnotics. They may spend a great deal of time in the bathroom. There may be incorrect drug counts and multiple vial breakage. If this behavior is observed, it must be reported to the nurse manager*. *It is then the responsibility of the nurse manager to intervene*. *It is imperative that the behavior has been documented with detail about times, dates, events, and consequences of those events*. There are legal and ethical issues and responsibilities when addressing in-house reporting. When intervention occurs, harm to patients is prevented and possible damage to a colleague's career or even life is prevented. The reporting of an impaired colleague is not easy, but we have the responsibility to make sure no harm comes to our patients. If we don't report the impaired colleague's behavior, we are just *enabling, which is helping a chemically dependent individual avoid experiencing the consequences of his or her drinking or drug use*.

alcohol withdrawl

Signs develop within a few hours after cessation Peaks at 24 to 48 hours The early signs of __ develop within a few hours after cessation or reduction of alcohol (ethanol) intake. They peak after 24 to 48 hours and then rapidly and dramatically disappear unless the withdrawal progresses to alcohol withdrawal delirium. The person may appear *hyperalert, manifest jerky movements and irritability, startle easily, and experience subjective distress often described as "shaking inside*." Grand mal seizures may appear 7 to 48 hours after cessation of alcohol intake, particularly in people with a history of seizures. Careful assessment followed by appropriate medical and nursing interventions can prevent the more serious withdrawal reaction of delirium. A kind, warm, and supportive manner on the part of the nurse can allay anxiety and provide a sense of security. Consistent and frequent orientation to time and place may be necessary. Encouraging the family or close friends (one at a time) to stay with the patient in quiet surroundings can also help increase orientation and minimize confusion and anxiety.

Epidemiology

Statistics In U.S. ⅔ of adult population drink on a regular basis On higher education campuses About 50% of full time sutdents binge drink or use substances on a monthly basis. In the U.S. approximately ⅔ of the adult population drinks alcohol on a regular basis. About 18% of the population will abuse alcohol and 13% will become dependent. Alcohol abuse is more common in men young people, whites, and singles. Alcohol dependence is the greatest in men, young people, whites, Native Americans, low income groups, and singles. Addictive Disorders also has a cultural aspect to it. The increase in binge drinking is being blamed on the college and university culture. The college administrators are being criticized for not offering evidence-based interventions to reduce this activity. There are statistics about campus drinking which include: Approximately 50% of full time students binge drink or use substances on a monthly basis. About 25% of students abuse or are dependent upon alcohol, which is triple that of the general population. During the first 5 years of the 21st century, the number of alcohol related arrests increased by 21%, and More students drink to get drunk than they did a decade ago. The administration of colleges and universities don't think they should be policing the students in regards to drinking but there are those that think they should be doing something due to the increase in the number of students that are drinking and experiencing negative consequences as a result.

Intervention Strategies

Treatment of nicotine addiction Advanced practice interventions psychotherapy Treatment of nicotine addiction - this is a nicotine patch that provides transdermal doses of nicotine and has been shown to double long-term abstinence rates. Advanced practice intervention - psychotherapy - evidenced-based practice indicates that cognitive-behavioral therapy, psychodynamic and interpersonal therapies, group and family therapies, and participation in self-help groups are all effective treatment modalities. Critical issues that arise within the first six months of therapy include physical changes as the body adapts to functioning without the substance, needing to learn new responses to former cues to drink or use drugs, experiencing full-strength emotions instead of drug-mediated emotions, need to address family and co-worker responses to a patient's new behavior, and need to develop coping skills to prevent relapse and ensure prolonged sobriety. Treatment of nicotine addiction - this is a nicotine patch that provides transdermal doses of nicotine and has been shown to double long-term abstinence rates. Advanced practice intervention - psychotherapy - evidenced-based practice indicates that cognitive-behavioral therapy, psychodynamic and interpersonal therapies, group and family therapies, and participation in self-help groups are all effective treatment modalities. Critical issues that arise within the first six months of therapy include physical changes as the body adapts to functioning without the substance, needing to learn new responses to former cues to drink or use drugs, experiencing full-strength emotions instead of drug-mediated emotions, need to address family and co-worker responses to a patient's new behavior, and need to develop coping skills to prevent relapse and ensure prolonged sobriety.

assessments

Two questions of importance In the last year, have you ever drank or used drugs more than you meant to? Have you felt you wanted or needed to cut down on your drinking or drug use in the last year? Details include Drugs used Route Quantity Time of last use Usual pattern of use From that initial questioning, the nurse can then pinpoint specific drugs, depending on the particular clinical situation. The nurse should ask questions in a matter-of-fact, nonjudgmental fashion. Specific details include name(s) of drug(s) used, route, quantity, time of last use, and usual pattern of use. Responses that serve as red flags indicating the need for further assessment are rationalizations ("You'd smoke dope too if...."); automatic responses, as if the question were predicted ("I figured you'd ask me that."); and slow, prolonged responses (as if the person were being careful about what to say). If the person is not able to provide a drug history, the nurse should assess for indications of substance abuse, such as dilated or constricted pupils, abnormal vital signs, needle marks, tremors, and alcohol on the breath and obtain history information from family and friends. The clothing should be checked for drug paraphernalia, such as used syringes, crack vials, white powder, razor blades, bent spoons, and pipes. Intracranial hematomas, subdural hematomas, and other conditions can go unnoticed if symptoms of acute alcohol intoxication and withdrawal are not distinguished from the symptoms of a brain injury. Therefore, neurological signs (pupil size, equality, and reaction to light) should be assessed, especially in comatose patients suspected of having traumatic injuries. In addition, questions about alcohol abuse should be asked as part of the assessment of any trauma. A urine toxicology screen and blood alcohol level (BAL) can be useful for assessment purposes. Assessment strategies must include collection of data pertaining to both substance dependence and psychiatric impairment. Unexplained exacerbations of psychiatric disorders may be due to substance abuse or dependence. Substance abuse can go undetected in patients with depression, anxiety, or suicidal ideation unless a thorough history is taken. Similarly, the understanding and treatment of people with substance dependencies are enhanced by inquiries about symptoms of depression and anxiety. Once specific data are obtained, it is helpful to know if the person is abusing or is actively dependent on the substance.

Alateen

a nationwide network for children older than 10 years of age who have alcoholic parents

alcohol poisoning

caused by severe CNS depression, inability to arouse the individual, cool or clammy skin, respirations less than 10, cyanosis under fingernails and gums, vomiting awake or unconsious

opiates

constricted pupils, decreased respiration's drowsiness, decreased BP, slurred speech, psychomotor retardation treatment- Narcotic antagonist (Narcan)

co-occurring disorders

include the combination of major depression with cocaine addiction, alcoholism with generalized anxiety disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse

club drugs/date rape drugs

increases serotonin, so LOVE everything, hyperactive, in exhaustion, dilated pupils, bruxism (grind teeth), after wears off they go through depression for a couple days because of low serotonin called blue tuesdays Date rape drugs- Rohypnol (roofs), GHB renders a person unconscious in a matter of minutes, causes anterograde amnesia for events that occur

codependence

is a cluster of behaviors originally identified through research involving the families of alcoholic patients. Living with an individual who abuses alcohol or other substances is a source of stress and requires family system adjustments. People who are codependent often exhibit over-responsible behavior—doing for others what others could just as well do for themselves. They have a constellation of maladaptive thoughts, feelings, behaviors, and attitudes that effectively prevent them from living full and satisfying lives. Symptomatic of codependence is valuing oneself by what one does, what one looks like, and what one has, rather than by who one is

Codependence

is a term used to describe coping behaviors that *prevent individuals from taking care of their own needs and have as their core a preoccupation with the thoughts and feelings of another or others*. It usually refers to the dependence of one person on another person who is addicted in one form or another. These individuals have maladaptive thoughts, feelings, behaviors, and attitudes that prevent them from living full and satisfying lives. • Attempting to control someone else's drug use • Spending an inordinate amount of time thinking about the person with the addiction • Finding excuses for the person's substance abuse • Covering up the person's drinking/drug taking or lying • Feeling responsible for the person's drinking/drug use • Feeling guilty for the person's behavior • Avoiding family and social events because of concerns or shame about the behavior of the member with an addiction • Making threats regarding the consequences of the behavior of the person with the substance-abuse problem and failing to follow through • Eliciting promises for change • Feeling like they are "walking on eggshells" on a routine basis to avoid causing problems, especially in relation to alcohol or drug use • Allowing moods to be influenced by those of the person with the addiction • Searching for, hiding, and destroying the person's drug or alcohol supply • Assuming the duties and responsibilities of the person with the substance-abuse problem • Feeling forced to increase control over the family's finances • Often bailing the person with the addiction out of financial or legal problems

treatment for CNS depressants

keep awake induce vomiting give activated charcoal to aid absorption coma- airway, iv fluids, perform gastric lavage, with activated charcoal

substance abuse

maladaptive pattern of substance use leading to clinically significant impairment or distress, manifested by *one or more* of the following in a 12 month period inability to fulfill major role obligations at work, school and home. Doing physical hazards situations while impaired, recurrent legal or personal problems continued use despite recurrent social and interpersonal problems

substance dependence

maladaptive pattern of substance use leading to clinically significant impairment to distress, manifested by *3 or more* of the following in a 12 month period: presence of tolerance to the drug

hallucinogens

pupil dilation, tachycardia, diaphoresis, palpation, tremors, incoordination, elevated temperature, pulse, and respirations treatment- patient in low room with low stimuli, have a nurse stay with patient to "take them down" give diazepam, or chloral hydrate for anxiety

inhalants

signs of alcohol like effects: euphoria, impaired judgement, CNS depression more damage toxic to heart, liver, and kidneys, numbness, weakness

communication

strategies are developed in order to address behaviors that almost all individuals with substance abuse disorders have in common. A useful tool that is used help the resistant addict develop a willingness to engage in treatment is substance-abuse intervention. This concept is that addiction is a progressive disease and rarely goes into remission without outside help. Significant others meet with the addict to point out current problems and offer treatment alternatives.

Methadone (Dolophine)

synthetic opiate blocks craving for and effects of heroin is a synthetic opiate that blocks the craving for and effects of heroin. It has to be taken every day, is highly addicting, and when stopped produces withdrawal. For methadone to be effective, the patient must take a dose that will prevent withdrawal symptoms, block drug craving, and block any effects of illicit use of short-acting narcotics. *__ is the only medication currently approved for the treatment of the pregnant opioid addict*. The clinical studies available demonstrate that methadone maintenance at the appropriate dosage, when combined with prenatal care and a comprehensive program of support, can significantly improve fetal and neonatal outcome.

CNS stimulants

tachycardia, dilated pupils, elevated BP, nausea, vomiting, insomnia treatment- antipsychotics, medical and nursing management, hyperpyrexia (cooling) Convulsions (Diazepam), respiratory distress, cardiovascular shock, acidification or urine.

Synergistic effect

when drugs are taken together, effect of either or both is *intensified or prolonged* is the intensification or prolongation of the effects of drugs taken together. For example if alcohol is combined with benzodiazepines, opiates, or barbiturates there is a much greater central nervous system depressant effect. There have been individuals that have taken a combination that created a synergistic effect that resulted in death

Antagonistic effects

when drugs are taken together, effect of one is *inhibited or weakened* is the inhibition of the effects of one drug when taken with another drug. For example if an individual has overdosed on heroin which is a CNS depressant, Naloxone or Narcan is given which is an opiate antagonist that will reverse respiratory and CSN depression. When this is done, the patient needs to be constantly monitored as it may become necessary to administer more Narcan.

inhalants

•Volatile solvents •Spray paint •Glue •Cigarette lighter fluid •Propellant gases used in aerosols Organic solvents (gases or liquids that vaporize at room temperature): Toluene Gasoline Lighter fluid Paint thinner Nail-polish remover Benzene Acetone Chloroform Model-airplane glue •Alcohol-like effects: euphoria, impaired judgment, slurred speech, flushing, CNS depression •Visual hallucinations and disorientation •Chronic use is toxic to heart, liver, and kidneys. •Toxicity may result in sudden death from anoxia, vagal stimulation, respiratory depression, and dysrhythmias. Volatile nitrites: Room deodorizers Products sold for recreational use •Enhancement of sexual pleasure •Venodilation causes profound systolic blood pressure drop (dizziness, lightheadedness, palpitations, pulsate headache). Toxic dose may result in methemoglobinemia. Anesthetics: Gas—especially nitrous oxide (used in dental procedures and as a propellent for whipped cream) Liquid Local •Giggling, laughter Euphoria •Numbness, weakness, sensory loss, loss of balance. May cause physical dependence. Possible polyneuropathy and myelopathy occurring in chronic users.

cocaine and crack (CNS stimulants)

• Extracted from leaf of coca bush • When smoked, takes effect in 4 to 6 seconds; a 5- to 7-minute high follows, then a deep depression Two main effects on body • Anesthetic • Stimulant • Produces imbalance in neurotransmitters • Withdrawal symptoms include - Depression, paranoia, lethargy, anxiety, insomnia, nausea, vomiting, sweating, chills is classified as a schedule II substance with high abuse potential; it has some recognized medical uses. Cocaine exerts two main effects on the body: *anesthetic and stimulant*. As an anesthetic, it blocks the conduction of electrical impulses within the nerve cells involved in sensory transmission, primarily pain transmission. It also acts as a stimulant for both sexual arousal and violent behavior. blocks the reuptake of norepinephrine, dopamine, and serotonin, and this imbalance of neurotransmitters (dopamine and norepinephrine) may be responsible for many of the physical withdrawal symptoms reported by heavy, chronic cocaine users: *depression, paranoia, lethargy, anxiety, insomnia, nausea and vomiting, sweating and chills, and an intense craving for the drug*. These are all signs of the body's struggle to regain its normal chemical balance. Withdrawal has been classified as having three distinct phases. Phase one, the crash phase, can last up to 4 days. Users report depression, anergia, and an acute onset of agitated depression. Craving for the drug peaks during this phase, along with anxiety and paranoia. Inpatient care to prevent access to further doses of the drug is helpful during the first and second phase of withdrawal. The second phase is described as a prolonged sense of dysphoria, anhedonia, and a lack of motivation, along with intense cravings that can last up to 10 weeks. Relapse is most likely during the second phase of withdrawal. The third phase is characterized by intermittent craving and can last indefinitely • Phase 1 - is called the crash phase that lasts up to 4 days. There is a complaint of depression, anergia which is a lack of energy or passivity, and an acute onset of agitated depression. There is a craving to use along with anxiety and paranoia. • Phase 2 - has a prolonged sense of dysphoria which is an emotional state marked by anxiety, depression, and restlessness, anhedonia which is an absence of pleasure from the performance of acts that would normally be pleasurable, and a lack of motivation along with intense craving lasting up to 10 weeks. Relapse frequently occurs during this phase. • Phase 3 - has an intermittent craving that can last indefinitely.

Pharmacological Interventions Treatment of Alcoholism

•*Naltrexone (ReVia)* Reduces or eliminates alcohol craving •*Acamprosate (Campral)* Helps client abstain from alcohol •*Topiramate (Topamax)* Works to decrease alcohol cravings •*Disulfiram (Antabuse)* Alcohol-disulfiram reaction causes unpleasant physical effects is used with motivated patients who have shown the ability to stay sober. Disulfiram works on the *classical conditioning* principle of inhibiting impulsive drinking because the patient tries to avoid the unpleasant physical effects caused by the alcohol-disulfiram reaction. These effects consist of *facial flushing, sweating, throbbing headache, neck pain, tachycardia, respiratory distress, a potentially serious decrease in blood pressure, and nausea and vomiting*. The adverse reaction usually begins within minutes to a half hour after drinking and may last 30 to 120 minutes. These symptoms are usually followed by drowsiness and are gone after the person naps must be taken *daily*. The action of the drug can last from 5 days to 2 weeks after the last dose. It is most effectively used early in the recovery process while the individual is making the major life changes associated with long-term recovery from alcoholism. should always be prescribed with the full knowledge and consent of the patient. *The patient needs to be told about the side effects and must be well aware that any substances that contain alcohol can trigger an adverse reaction*. Three primary sources of hidden alcohol exist—*food, medicines, and preparations that are applied to the skin*. *People also need to be careful to avoid inhaling fumes from substances that might contain alcohol, such as paints, wood stains, and stripping compounds*. Voluntary compliance with the disulfiram regimen is often poor, but it may work best as a "psychological threat" and an adjunct to other pharmacological treatments

outcomes identification

•*Withdrawal* Fluid balance-Patient's blood pressure will not be compromised. Neurological status: consciousnes-Patient will have no seizure activity. Distorted thought self-control-Patient will consistently describe content of hallucinations. •*Initial and active drug treatment* Risk control - alcohol use -Patient will consistently demonstrate a commitment to alcohol use control strategies. Risk control - drug use- Patient will consistently demonstrate acknowledgment of personal consequences associated with drug misuse. substance Addiction Consequences: Patient will demonstrate no difficulty supporting self financially. •*Substance addiction consequences* Health maintenance-Patient will describe actions to prevent and manage relapses in substance use. Knowledge: substance abuse control- Patient will describe actions to prevent and manage relapses in substance use. Family coping-Family will consistently demonstrate care for needs of all family members.

Assessment Guidelinesfor the Chemically Impaired

•Assess for withdrawal syndrome •Assess for overdose that warrants medical attention •Assess for suicidal thoughts or other self-destructive behaviors •Evaluate for physical complications related to drug abuse •Explore interests in doing something about drug or alcohol problem •Assess patient and family for knowledge of community resources

Caffeine and Nicotine

•Caffeine -Coffee, tea, soft drinks •Nicotine -1 in 4 Americans smoke -Up to 20% are nicotine dependent -Successful treatments •Wellbutrin (Zyban •Nicotine-replacement therapy Most people consume caffeine by way of coffee, tea, or soft drinks. People ingest coffee as a drug ("I've got to have two cups in the morning to function."), for social reasons ("Let's get together for coffee."), or as a reward ("After I finish this job, I'm going to take a coffee break."). About one out of four Americans is an active smoker, with 20% of the population meeting the criteria for nicotine dependence. A high proportion of psychiatric outpatients are nicotine dependent: up to 90% of patients with schizophrenia and about 70% of patients with bipolar I disorder or another substance-abuse disorder. Wellbutrin (Zyban) and nicotine-replacement therapy are successful treatments for many individuals during smoking cessation.

Marijuana (Cannabis sativa)

•Indian hemp plant •Tetrahydrocannabinol (THC) is active ingredient •Depressant and hallucinogenic properties •Usually smoked •Desired effects - euphoria, detachment, relaxation •Long-term effects - lethargy, anhedonia, difficulty concentrating, loss of memory Marijuana or cannabis sativa is an Indian hemp plant. The active ingredient is Tetrahydrocannabinol or THC and is found in the resin secreted from the flowering tops and leaves of the cannabis plant. It has both depressant and hallucinogenic properties. Most often it is smoked, but it can be ingested. It is widely used in America and is considered an illicit drug. The anticipated effects are *euphoria, detachment, and relaxation*. Other effects that can occur are *talkativeness, slowed perception of time, inappropriate hilarity, heightened sensitivity to external stimuli, anxiety or paranoia, dry mouth, fast pulse, increased appetite or known as the "munchies", and reddened eyes*. With long term use, individuals can experience *lethargy, anhedonia, difficulty concentrating, and loss of memory*. The overdose and withdrawal symptoms such as hallucinations and anxiety are rare. *The most common symptom is craving*. The medical community has discovered medical uses for TCH. These would be the control of chemotherapy-induced nausea, reduction of intraocular pressure in glaucoma, and appetite stimulation in AIDS wasting syndrome.

hallucinogens

•Lysergic acid diethylamide (LSD or acid) Mescaline (peyote) Psilocybin (magic mushroom) Phencyclidine piperidine (PCP, angel dust, horse tranquilizer, peace pill) •Hallucinogens produce abnormal mental phenomena in the cognitive and perceptual spheres for example distortion in space and time, hallucinations, delusions either paranoid or grandiose and synesthesia can occur. *Synesthesia is a condition in which one sense is simultaneously perceived as if by one or more additional senses*. For example if a person has this condition the person hears violins playing also feels a tickling sensation on the back of the neck. •Lysergic acid diethylamide also known as LSD or acid, Mescaline or peyote, and psilocybin Mexicana or Magic mushrooms - These are hallucinogens. Mescaline and Psilocybin Mexicana have been used in religious rites by Native Americans in Southwestern U.S. and northern Mexico for centuries. The hallucinogenic experience that is produced by LSD is called "a trip". •Phencyclidine peperidine - It is also known as PCP, angel dust, horse tranquilizer, or peace ill. The onset of symptoms can occur about 1 hour after oral ingestion but when taken intravenously, intranasally, or smoked occur within 5 minutes. *PCP intoxication demonstrates signs and symptoms that range from acute anxiety to acute psychosis. It produces a generalized anesthesia that diminishes the sensations of touch and pain*. These individuals that are chronic users have long-term effects that include *dulled thinking, lethargy, loss of impulse control, poor memory, and depression*. *These clients need to be assessed for suicidal risk especially in cases of toxicity or coma. Once patient wakes up, it is imperative to find to find out if the patient is suicidal and treated*. The nurse needs to determine whether the patient has had a previous suicide attempt or if the patient has a family history of suicide. •*LSD* Pupil dilation Tachycardia Diaphoresis Palpitations Tremors Incoordination Elevated temperature, pulse, respiration Fear of going crazy Paranoid ideas Marked anxiety, depression Synesthesia (e.g., colors are heard; sounds are seen) Depersonalization Hallucinations, although sensorium is clear Grandiosity (e.g., thinking one can fly) •*PCP* Vertical or horizontal nystagmus Increased blood pressure, pulse, and temperature Ataxia Muscle rigidity Seizures Blank stare Chronic jerking Agitated, repetitive movements Hallucinations, paranoia Bizarre behavior (e.g., barking like a dog, grimacing, repetitive chanting speech) Regressive behavior Violent bizarre behaviors Very labile behaviors

Pharmacological Interventions Treatment of Opioid Addiction

•Methadone (Dolophine) Synthetic opiate blocks craving for and effects of heroin is a synthetic opiate that blocks the craving for and effects of heroin. It has to be taken every day, is highly addicting, and when stopped produces withdrawal. For methadone to be effective, the patient must take a dose that will prevent withdrawal symptoms, block drug craving, and block any effects of illicit use of short-acting narcotics. *Methadone is the only medication currently approved for the treatment of the pregnant opioid addict*. The clinical studies available demonstrate that methadone maintenance at the appropriate dosage, when combined with prenatal care and a comprehensive program of support, can significantly improve fetal and neonatal outcome. •LAAM (l-α-acetylmethadol) An alternative to methadone is effective for up to 3 days (72 to 96 hours), so patients need to come to an outpatient facility for their medication only three times a week. *This regimen makes it easier for patients to keep jobs and gives them more freedom than is available with methadone maintenance*. LAAM is also an addictive narcotic: its therapeutic effects and side effects are the same as those of morphine. Its use has been found to be more *effective in retaining patients in treatment than methadone* •Naltrexone (ReVia) Antagonist that blocks euphoric effects of opioids is a relatively pure antagonist that blocks the euphoric effects of opioids. It has low toxicity and few side effects. A single dose provides an effective opiate blockade for up to 72 hours. Taking naltrexone three times a week is sufficient to maintain a fairly high level of opiate blockade. For many patients, long-term use results in gradual extinction of drug-seeking behaviors. *Naltrexone does not produce dependence*. As previously mentioned, it has also been approved for the treatment of alcoholism because it decreases the pleasant, reinforcing effects of alcohol. •Clonidine (Catapres) Effective somatic treatment when combined with naltrexone was initially marketed for high blood pressure, but it is also an effective somatic treatment for some chemically dependent individuals when combined with naltrexone. Clonidine is a nonopioid suppresser of opioid withdrawal symptoms. It is also nonaddicting •Buprenorphine (Subutex) Blocks signs and symptoms of opioid withdrawal is a partial opioid agonist. At low doses (2 to 4 mg/day sublingually), the drug blocks signs and symptoms of opioid withdrawal. In experimental studies, buprenorphine has been shown to suppress heroin use in both inpatient and outpatient settings

opiates

•Morphine •Heroin •Codeine •Fentanyl •Methadone •Meperidine Heroin is one of the most widely abused opiates. Heroin intoxication can be classified into four distinct phases. The first phase is a euphoria or rush that occurs almost immediately after injection of the drug. Users frequently characterize this euphoria in sexual terms. The euphoric phase is characterized physiologically by facial flushing and a deepening of the voice. The second phase is classified as "the high" and has been described as a sense of well being. This phase can extend for several hours. The third phase, which is often termed the nod, is an escape from reality that can range from lethargy to virtual unconsciousness. The fourth phase is the period before withdrawal occurs. During the fourth phase, users often seek more of the drug in order to avoid withdrawal. Heroin intoxication has four stages or phases. • Phase 1 - is a euphoria or a rush that occurs immediately after the intravenous injection of the drug. Many times the individuals describe their euphoria in sexual terms. This euphoric phase demonstrates physiologically by facial flushing and deepening of the voice. • Phase 2 - is "the high" and the individual has a sense of well-being. This phase can last several hours. • Phase 3 - is also called "the nod". It is an escape from reality that ranges from lethargy to unconsciousness. • Phase 4 - this is the period before withdrawal occurs and when individuals will seek to use in order to avoid withdrawal symptoms. A common complaint of *withdrawal symptoms is that they are flu-like*. These symptoms are *headache, fatigue, runny or stuffy nose, generalized muscle aches and cramping also described as "bone pain", chills and diaphoresis or sweats, loss of appetite, vomiting and diarrhea, along with yawning, insomnia, irritability, panic, fear, and lacrimation or tearing*. Physical: Constricted pupils Decreased respiration Drowsiness Decreased blood pressure Slurred speech Psychomotor retardation Psychological-perceptual: Initial euphoria followed by dysphoria and impairment of attention, judgment, and memory

planning

•Treatment goal of all addicts is abstinence •Must address major physiological, psychological, and sociocultural problems Attention to the patient's social status, income, ethnic background, gender, age, substance use history, and current condition is required for planning the patient's care. The treatment goal of all addicts is abstinence. It is related to good work adjustment, positive health status, comfortable interpersonal relationships, and general social stability. Major physiological, psychological, sociocultural problems, and substance using behaviors must be addressed. The involvement of family members is essential. Many instances with the patient's continued substance use, there is a deterioration of work, home, health, interpersonal relationships, and general social stability. This can be a complicating factor in treatment planning, but other options are available such as housing, support groups, and if need hospitalization. Planning care requires attention to the patient's social status, income, ethnic background, gender, age, substance use history, and current condition. It is safest to propose abstinence as a treatment goal for all addicts. Abstinence is strongly related to good work adjustment, positive health status, comfortable interpersonal relationships, and general social stability. Planning must also address the patient's major psychological, social, and medical problems, as well as the substance-using behavior. Involvement of appropriate family members is essential. Unfortunately a person's social status and social relations often deteriorate as a result of addiction. Job demotion or loss of job, with resultant reduced or nonexistent income, may occur. Meeting basic needs for food, shelter, and clothing is thereby hampered. Marriage and other close relationships often deteriorate and fail, and the person is often left alone and isolated