NURS132 Ch22 Substance-Related & Addictive Disorders

Tolerance

A phenomenon by which the body becomes increasingly resistant to a drug or other substance through continued exposure to the substance.

peripheral neuropathy

Chronic alcoholism leads to nutritional deficiencies, particularly thiamine, due to drinking rather than eating, leading to damage to the peripheral nervous system. "pins and needles" in the lower extremities numbness muscle weakness sensitivity to touch burning. Discontinuation of alcohol will prevent further deterioration

Environmental Factors

Chronic stressors often have roots in socioecononic factors Poverty raises risk unfavorable living situation, lack of parental supervision, poor educational resources, and impaired support systems. Disadvantages neighborhoods

T-ACE

Tolerance, Annoyance, Cutdown, Eye-opener

Acamprosate calcium (Campral)

Use: 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.

Disulfiram (Antabuse)

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

Clonidine (Catapres)

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

Lorazepam (Ativan), Chlordiazepoxide (Librium), Diazepam (Valium)

Uses: 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.

Anticonvulsants (Tegretol) Barbiturates (Phenobarbital)

Uses: 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.

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

Uses: 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.

Fetal Alcohol Syndrome

leading cause of intellectual disability in the US. Alcohol during pregnancy inhibits intrauterine growth and postnatal develop development resulting in microcephaly, craniofacial malformations, and limb and heart defects. As adults, affected individuals tend to have short stature. Women with alcohol-related disorders have a 35% risk of having a child with defects.

Detox

warranted when individual quits using a substance known to cause withdrawal or when the individudal is already in withdrawl. Medically managed inpatient program with 24-hour medical coverage while body clears itself of drugs. Process companies uncomfortable and even fatal side effects caused by withdrawal

Opioid Treatment

● General Treatment - Therapy (Individual, behavioral, CBT, family, and social skill training) - Support groups like Narcotics Anonymous (12 steps), best for highly motivated individuals - Methadone (Dolophine, Methadose) is a synthetic narcotic opioid used to decrease the painful symptoms of withdrawal and also blocks the euphoric effects of opiate drugs such as heroin, morphine, and codeine as well as semisynthetic opioids like oxycodone and hydrocodone. Methadone can only be dispensed thru opioid tx program certified by SAMHAS. Once a day dosing. Methadone eventually needs to be withdrawn due to dependence. In pregnant users, a low dose may be the safest course. Neonatal withdrawal is usually mild and can be managed with paregoric. (Paregoric is camphorated tincture of opium, a narcotic-containing drug that in large doses is poisonous; used in the symptomatic treatment of diarrhea) - Side effects of methadone - seek medical care if difficulty breathing or shallow breathing, feeling lightheaded for faint, or experience chest pain or a fast or pounding heartbeat. Hives, rash, swelling of face, lips, tongue or throat could also be serious. Hallucinations. - Buprenorphine: used to help people reduce of quit their use of heroin or other opiates such as pain relievers like morphine. It's a partial opioid agonist. Produces effects such as euphoria or respiratory depression, but effects are weaker than those of full drugs like heroin or methadone. FDA has approved the following schedule III buprenorphine products, some of which contain naloxone Subutex (buprenorphine) sublingual tablets Probuphine (buprenorphine) - supplied by 4 1 inch rods implanted under skin of upper arm for 6 months Bunavail (buprenorphine & naloxone) buccal film Suboxone (buprenorphine & naloxone)) sublingual tabs Zubsolv (buprenorphine & naloxone) sublingual tabs - Buprenorphine SE's: N/V, constipation, muscle aches and cramps, insomnia, irritability, and fever. Used only after abstaining from opioids for 12-24 hours and in early stages of opioid withdrawal. It can bring on acute withdrawal for patients not in early stages and have other opioids in their system. It's a long-acting drug so once stabilized can sometimes switch to every other day. - Naltrexone (Vivitrol) is an opioid antagonist indicated for the prevention of relapse to opioid dependence, followed by opioid detoxification. Long acting injectable version of drug, Revia, is given once a month. If a person relapses and uses the misused drug, Naltrexone blocks the euphoric and sedative effects. - SE's include: weakness, tiredness, insomnia, increased thirst, anxiety, nervousness, restlessness, irritability, light-headedness, fainting, muscle or joint aches, decreased sex drive, impotence, or difficulty having orgasm

How many American's reported using illicit substances in the month before the survey? Illicit substances include the nonmedical or nonprescribed use of the prescription drugs

for age 12-17, illicit drug use 9% for ages 18 to 25 - illicit drug use 25% Marijuana use on the rise Prescription pain reliever use on the rise - promoted greatest concern Nonmedical use of stimulants including amphetamine/dextroamphetamine (Adderall) &methylphenidate (Ritalin) has more than doubled the last few years Use of syntheitc drugs, e-cigarattes, and hookah are on the rise among young adults

Schedule II drugs

have a high potential for abuse, are considered dangerous, and are only available by prescription. Methadone meperidine (Demerol) methylphenidate (Ritalin)

Schedule III drugs

have low to moderate potential for misuse and are available only by prescription. Testosterone acetaminophen/codeine buprenorphine (Suboxone)

Alcohol is a major contributing factor in

increased mortality and deaths morbidity and disease harm to others andinjury increased economic loss and disabilities

Esophagitis

inflammation of esophagus as direct result of toxic effects of alcohol on esophageal mucosa. Vomiting r/t to alcohol overuse is also contributory to these condition. Esophageal varices are distended veins within esophagus or upper part of stomach that result from heavy drinking. Veins are at risk for bursting.

alcoholic myopathy

is considered to be a toxic myopathy resulting from the body's response to long-term and/or heavy exposure to alcohol. It can either be acute, after the individual has binged on alcohol, or chronic, developing over time with regular, heavy alcohol consumption Characteristic symptom: significant reduction in muscle mass and resulting muscle weakness Recovery is possible if alcohol is avoided varying from rapid to months

Sociocultural factors

substance use can create a sense of community and belonging in otherwise isolated individuals; lifestyle can be alluraing and dramatic to vulnerable people Some countries prohibit alcohol use, and some it's part of everyday life

intoxication

1. The state of being poisoned by a drug or other toxic substance. 2. The state of being inebriated as a result of an excessive consumption of alcohol. 3. A state of mental or emotional hyperexcitability, usually euphoric.

Genetic vulnerability accounts for what percentage of an individuals risk for a substance use disorder

40-60% This is why prevention may be the best answer Pay attention to signs of trama

binge drinking is defined as... heavy drinking is defined as

5 drinks on one occasion in one day in the last month. About 60 million people (23%) admit to binge drinking 16 million (6%) report heavy drinking which is defined as 5 drinks on one occasion on at least five days in the last month

Alcohol Use Disorder

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. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: c. The characteristic withdrawal syndrome for alcohol. d. Alcohol (or a closely related substance such as a benzodiazepine) is taken to relieve or avoid withdrawal problems. Specify if: In early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4 may be met). In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4 may be met). Specify if: In a controlled environment: This additional specifier is used if the individual is in an environment where access to alcohol is restricted.

Prescription Stimulants

Amphetamine (Adderall, Benzedrine) - Sched II Acute Effects: increased alertness, increased blood pressure and heart rate, narrowed blood vessels, increased blood sugar Health Risks: Long-term high doses: heart problems, psychosis, anger Methylphenidate (Concerta, Ritalin) - Schedule II Same

Alcohol Acute Effects/Health Risks

Acute Effects: - 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, come death Health Risks: -Increased risk of injuries, violence, fetal damage, depression, neurologic deficits, hypertension, liver and heart disease, addiction & fatal overdose

Tobacco Acute Effects/Health Risks

Acute Effects: Increased BP and HR Health Risks: Chronic lung disease, CV disease, stroke, cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, bladder, and acute myeloid leukemia, adverse pregnancy outcomes, addiction

The DSM-5 provides diagnostic criteria for the following psychoactive substances

Alcohol Caffeine Cannabis Hallucinogen Inhalant Opioid Sedative, hypnotic, and anti-anxiety medication Stimulant Tobacco *Behaviors, too are gradually being recognized as addictive. Behavioral addictions are called process addictions.

AUDIT

Alcohol Use Disorders Identification Test Clinician can administer or pt can self report

Genetic Risk Factors

Alcohol use disorder runs in families and about 40-60% of the risk comes from inheritance. Up to a 4 fold increase in risk occurs in children of affected individuals, even when children are given up for adoption or raised in other homes - Some evidence that some genes may reduce the risk of alcohol consumption by impacting alcohol metabolism. For eg, certain alleles of the alcohol dehydrogenase and aldehyde dehydrogenase genes can cause a buildup of acetaldehyde that creates a classic flushing response Genetic underlying vulnerability to addiction that expresses itself in a variety of substances from hallucinogens to cocaine and opiates

Stimulant Use Disorder

Amphetamine-type, cocaine, or other stimulant drugs are second only to cannabis as most widely used illicity substances in US. ● Typically produce euphoric feeling and high energy ● Long distance truckers, students, soldiers, athletes use these drugs ● increased use, craving, and tolerance accompanied by reduced ability to function in major roles ● disorder use pattern can occur in as little as one week ● Amphetamine use equal in M/F, cocaine use higher in males, intravenous stimulant higher in males ● Stimulant Intoxication: superhuman feeling, elation, euphoria, sociable. May also be hypervigilant, sensitive, anxious, tense and angry. Physical Sx may include two or more of the following: chest pain, cardiac arrhythmia, high or low BP, tachycardia or bradycardia, respiratory depression, dilated pupils, perspiration, chills, N/V, weight loss, psychomotor agitation or retardation, weakness, confusion, seizures or coma ● Stimulant Withdrawal: Withdrawal symptoms begin within a few hours to several days. Symptoms include tiredness, vivid nightmares, increased appetite, insomnia or hypersomnia, and psychomotor retardation or agitation. Functionality is impaired during this withdrawal process. Depression and suicidal thoughts are the most serious side effects of stimulant withdrawal. ● Stimulant Treatment: - For amphetamines, an inpatient setting is usually necessary. Individual, family, and group therapy are helpful. Depending upon the amphetamine used, specific drugs may be used short term. Antipsychotics may be prescribed for a few days. If there is no psychosis, diazepam (Valium) is useful in treating agitation and hyperactivity. Once the patient has been withdrawn from the amphetamine, depression can be treated with antidepressants such as bupropion (Wellbutrin). - The 1- to 2-week cocaine withdrawal period is distinct because there are no physiological disturbances that require inpatient care. Outpatient settings may be tried as a first approach. Some patients experience fatigue, mood changes, disturbed sleep, craving, and depression. There are no drugs that reliably reduce the intensity of these symptoms. The intense craving associated with cocaine withdrawal may require hospitalization to remove the affected individual from the usual social settings and drug sources. Unscheduled urine drug testing is usually warranted.

Classic Hallucinogens - Other Compounds

Anabolic steroids - Sched III Acute effects: No intoxication effects Health Risks: 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 Inhalants solvents, propellants, thinners, and fuels 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 Prescription Pain relievers (Codeine, Fentanyl, Oxycodone) - Schedule II, III, and V Drowsiness, lethargy, euphoria, slow breathing, death Prescription Sedatives (Benzodiazepines, barbituates, sleep aids) - Schedule II, III, IV Drowsiness, slurred speech, poor concentration, low blood pressure, decrease respiratory rate

Classic Hallucinogens

Ayahuasca: A brew that includes chacruna or chagropanga, dimethyltryptamine (DMT)-containing plants - listed in DEA's poisonous plant database Acute Effects: Strong hallucinations, altered vision and auditory perceptions, increased blood pressure, vomiting, diarrhea Dimethyltryptamine (DMT) Synthetic drug - sched I Acute Effects: 30-60 minutes of intense hallucinations, depersonalization, high blood pressure, rapid eye movements, agitation, seizures Lysergic acid diethylamide (LSD) - Sched I Acute Effects: 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 Health Risks: Flashbacks, hallucinogen persisting perception disorder Mescaline - Sched I Acute Effects: 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 Psilocybin - Sched I Acute Effects: Altered states of perception and feeling, hallucinations, nausea, nervousness, paranoia, panic

Excessive Drinking

Binge Drinking: drinking too much alcohol quickly For women, 4+ drinks within 2 hours. For men 5+ drinks within 2 hours. Heavy Drinking: characterized by drinking too much, too often. For women, 8+ or more drinks in a week constitutes heavy drinking, for men 14+ drinks in a week. Both

Sx of Opioid Intoxification

Bradycardia (slow pulse) Hypotension (low blood pressure) Hypothermia (low body temperature) Sedation Meiosis (pinpoint pupils) Hypokinesis (slowed movement) Slurred speech Head nodding Euphoria Analgesia (pain-killing effects) Calmness May also exhibit pupillary constriction, intense drowsiness can lead to coma

Stimulants

Cocaine (Cocaine hydrochloride) - Schedule II Amphetamine (Biphetamine, Dexedrine) - Schedule II Methamphetamine (Desoxyn) - Schedule II Acute Effects 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 Health Risks: Weight loss, insomnia, cardiac or cardiovascular complications, stroke, seizures, addiction Cocaine: Nasal damage from snorting Methamphetamine: Severe dental problems

Gambling Disorder

Compulsive activity that causes economic problems and significant disturbances in personal, social, or occupational functioning. Individuals are pre-occupied with this behavior, experience increasing desire to gamble, and lie to conceal the extend of the program. May try to control behavior. Otherwise honest people may commit illegal acts to finance their addiction. May rely on others to help pay off debts and gamble to recoup losses. ●. More common in males but progression is more rapid for females. Stress and depression may increase this behavior ● Treatment: legal problems, pressure form family, other psychiatric problems may bring the person who gambles excessively into treatment. - Gamblers Anonymous - involves public confession, peer pressure and peer counselors who are informed gamblers - Hospitalization may help by removal from enviro - Therapies (individual, group, and family) - Medications (SSRIs: buproprion) mood stabilizers (lithium) and anticonvulsants (topiramate) may be helpful. SGA's have also been used. Naltrexone (opioid antagonist) may be given to pt's with most severe symptoms

Tobacco Use Disorder

Craving, persistent and recurrent use, and tolerance are all symptoms of tobacco use disorder. Dependence happens quickly. Cigarettes are the most commonly used tobacco product. 12 month prevalence is about 13% in adults, slightly higher in males. Most people who use tobacco begin before age 18. Withdrawal: irritability, anxiety, depression, difficulty concentrating, restlessness, and insomnia. Within days after smoking cessation, HR decreases by 5 to 12 bpm. Within first year, people gain avg of 4-7 pounds. Withdrawal Treatment: - Behavioral therapy is useful to teach the patient to recognize cravings and respond to them appropriately. - Hypnosis has been used successfully - Nicotine replacement therapies (gum, lozenge, nasal spray, patches) - Non-nicotine therapy includes buproprion (Zyban) which reduced cravings for nicotine. clonidine (Catapres) decreased sympathetic activity and reduces withdrawal symptoms Varenicline (Chantix) provides some nicotine effects to ease withdrawal symptoms and block the effects of nicotine from cigarettes if smoking is resumed

Stimulant Withdrawal

Depression Hypersomnia (or insomnia) Fatigue Anxiety Irritability Poor concentration Psychomotor retardation Increased appetite Paranoia Drug craving

CAGE

Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? Score of 2 or more significant, score of 1 requires further assessment

Opioids

Heroin (Diacetylmorphine) - Schedule I Opium - Schedule II, III, V Acute Effects Euphoria, drowsiness, impaired coordination, dizziness, confusion, nausea, sedation, feeling of heaviness in the body, slowed or arrested breathing Health Risks: Constipation, endocarditis, hepatitis, HIV, addiction, fatal overdose

Dissociative Drugs

Ketamine (Ketalar) - schedule III Acute Effects: Feelings of being separate from one's body and environment, impaired motor function, analgesia, impaired memory, delirium, respiratory depression and arrest, death Health Risks: Anxiety, tremors, numbness, memory loss, nausea Phencyclidine (PCP) and analogs - Schedule I & II Acute Effects: Feelings of being separate from one's body and environment, impaired motor function, analgesia, psychosis, aggression, violence, slurred speech, loss of coordination, hallucinations Health Risks: Anxiety, tremors, numbness, memory loss, nausea Salvia divinorum Acute Effects: Feelings of being separate from one's body and environment, impaired motor function Health Risks: Anxiety, tremors, numbness, memory loss, nausea Dextromethorphan (DXM) - found in some cough syrups Acute Effects: Feelings of being separate from one's body and environment, impaired motor function, euphoria, slurred speech, confusion, dizziness, distorted visual perceptions Health Effects: Anxiety, tremors, numbness, memory loss, nausea

Family Assessment

Living with an individual who misuses alcohol or substances is a source of stress and requires family system adjustments Codependence: 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. They often define their self worth in terms of caring for others to the exclusion of their own needs

Cancer

Major risk factor for head and neck cancers, esp in oral cavity, pharynx, and larynx. Also associated iwth liver, breast, and colorectal cancers.

Cannabinoids

Marijuana & Hashish - schedule I??? Acute Effects: euphoria, relaxation, slowed reaction time, distorted sensory perception, impaired balance and coordination, increased HR and appetite, impaired learning, memory, anxiety, panic attacks psychosis/cough Health Risks: frequent respiratory infections, possible mental health decline, addiction

Club Drugs

Methylenedioxymethamphetamine (MDMA) - Sched I Acute Effects: Mild hallucinogenic effects, increased tactile sensitivity, empathic feelings, lowered inhibition, anxiety, chills, sweating, teeth clenching, muscle cramping Health Risks: Sleep disturbances, depression, impaired memory, hyperthermia, addiction Flunitrazepam (Rohypnol) Similar to benzodiazepine chemically - Sched IV Acute Effects: Sedation, muscle relaxation, confusion, memory loss, dizziness, impaired coordination Health Risks: Addiction Gamma-hydroxybutyrate (GHB) - Sched I Acute Effects: Drowsiness, nausea, headache, disorientation, loss of coordination, memory loss Health Risks: Unconsciousness, seizures, coma

NIDA

National Institute on Drug Abuse Mission: to advance science on the causes and consequences of drug use and abuse and to apply that knowledge to improve individual and public health

Pharmacological Interventions

Nurses must administer meds and provide ongoing assessment of their efficancy and SE's: - monitor vital signs freq: increase in BP, pulse, temp are clear signs of withdrawal. Goal is to stay ahead of withdrawal

Substance Use Disorder

Pathological use of a substance that leads to a disorder of use. Symptoms fall into 4 major groupings 1. Impaired control 2. Social impairment 3. Risky use 4. Physical effects (intoxication, tolerance, withdrawal) Substance use disorders encompass broad range of products that human beings take into their bodies through various means, ranging from fairly innocuous and innocent-seeming substances such as caffeine to absolutely illegal mind-altering drugs such as LSD.

pancreatitis

Prolonged and hazardous drinking resulting in pancreatic damage. Excessive drinking (5+ years usually) may result in acute attack. Continued misuse eventually results in chronic pancreatitis Sx: Abdominal pain, nausea, vomiting Withdrawal of alcohol in early stages will reverse this condition. Chronic condition results in malnutrition, weight loss, and DM

Psychosocial Interventions

Promoting safety and sleep are essential first-line interventions. Addressing nutritional status, hydration status Support self-care Develop therapeutic relationship to set stage for exploring harmful thoughts, anxiety, hopelessness, and spiritual distress. Assessment/Understanding of current coping skills Assistance in goal setting

Advanced practice interventions

Psychotherapy: - CBT: helps patients explore thinking patterns, identify maladaptive patterns and exploration of positive and negative consequences of alcohol use explored. Patients learn to self monitor and challenge cravings. - Motivational Interviewing: approach based on transtheoretical or stages of change theory. Gained popularity in use as a brief, long-term, and supplementary intervention. Person centered approach to strengthen motivation for change. Stage 1: Precontemplation - need assistance admitting there is a problem Stage 2: Contemplation: acknowledge the problem but not ready to commit to address it Goal of Tx is to assist in the development of awareness and a commitment Stage 3: Preparation - getting ready Stage 4: Action: changing take place Stage 5: Maintenance Stage 6: Relapse

Possible Nursing Diagnoses

Risk for suicide Risk for injury Disturbed sleep pattern Nutrition: less than body requirements Nutrition: more than body requirements Self neglect Ineffective Coping Ineffective denial Hopelessness Risk for impaired liver function Decreased cardiac output Dysfunctional family processes

CAGE-AID

Screen for all types of substance abuse Adjusted to Include drugs

Stimulant Intoxification

Short Term Increased energy Decreased appetite Mental alertness Increased heart rate/pressure Dilated pupils Long Term Irregular heartbeat Chest pains Increased risk of heart attack Panic attacks Depression Delusions/hallucinations "Cocaine bugs" (skin sensation)

Sx of Opioid Withdrawal

Tachycardia (fast pulse) Hypertension (high blood pressure) Hyperthermia (high body temperature) Insomnia Mydriasis (enlarged pupils) Hyperreflexia (abnormally heightened reflexes) Diaphoresis (sweating) Piloerection (gooseflesh) Increased respiratory rate Lacrimation (tearing), yawning Rhinorrhea (runny nose) Muscle spasms Abdominal cramps, nausea, vomiting, diarrhea Bone and muscle pain Anxiety Males may experience sweating and spontaneous ejaculations while awake

National Drug Take-Back Day Initiative

The DEA began hosting this as a response of drugs finding their way into the hands of people with use disorders. It provides a safe convenient reliable way of disposing of unneeded prescription drugs.

SAM-HSA

The Substance Abuse & Mental Health Administration Mission: serves a dual mission of reducing the impact of substance use and mental illness on communities in the US

Schedule I drugs

These drugs have NO accepted medical use in the united states. These drugs have the highest abuse potential Heroin Lysergic acid Diethylamide

Inhalant Use Disorder

Volatile hydrocarbons are toxic gases inhaled through the nose or mouth to enter the blood stream. ●. found in substances such as fuels, solvents, adhesives, aerosol propellants, and paint thinners ● Typically used for only short period of time. Characteristics of out of control use are using more freq craving, tolerance, failure in life roles and interpersonal problems ● "sudden sniffing death" from cardiac arrhythmias, particularly with butane and propane ● Inhalant intoxication: small doses results in disinhibition and euphoria, high doses causes fearlessness, illusions, auditory and visual hallucinations, and distorted body image. Apathy, diminished social and occupational functioning, impaired judgement, impulsive and aggressive behavior. Physical responses include nausea, anorexia, nystagmus, depressed reflexes, diplopia. high doses and long exposure can lead to stupor, unconsciousness, and amnesia. Delirium, dementia, and psychosis are serious possibilities. ● Treatment Inhalant intoxication usually does not require any treatment. Serious and potentially fatal responses such as coma, cardiac arrhythmias, or bronchospasm do happen. A psychotic response can be induced by inhalant intoxication. This self-limiting (a few hours to a few weeks) problem may require careful use of haloperidol (Haldol) to manage severe agitation.

Alcohol-Induced Persisting Amnestic Disorder

Wernicke-Korsakoff Syndrome: People with heavy use of alcohol over many years may suffer from shot-term memory disturbances. Pathophysiology between the two problems is a thiamine deficiency, which may be caused by poor nutrition associated with alcohol use or by malabsorption of nutrients Wernicke's (alcoholic) encephalopathy: acute and reversible condition. Characterized by altered gait, vestibular dysfunction, confusion, and severe ocular motility abnormalities (horizontal nystagmus, lateral orbital palsy, and gaze palsy). These eye-focused signs are bilateral but not necessarily symmetrical. Sluggish reaction to light and anisocoria (unequal pupil size are also symptoms). May clear up in a few weeks or progress into Korsakoff's. Tx: Wernicke's responds rapidly to large doses of IV thiamine 2-3x daily for 1-2 weeks. Korsakoff's Syndrome: chronic condition with recovery rate of only 20%. More severe. Tx: Thiamine for 3-12 months, most never fully recover although cognitive improvement may occur Blackouts - Caused by excessive consumption of alcohol followed by episodes of amnesia. During these periods of times, a person actively engages in behaviors, can perform complicated tasks, and appears normal. This phenomenon is due to alcohols ability to block the consolidation of new memories into ones through the hippocampus and related temporal lobe structures

Leukopenia

When there is liver damage, alcoholism may cause low white blood cells due to vitamin deficiencies and low protein intake. This predisposes one to infection and disease. Sx:L. periodontitis, gingivitis, fatigue, weakness, fever, abdominal pain.

process addiction

a condition in which a person is dependent on (addicted to) some mood-altering behavior or process, such as gambling, internet gaming, social media, shopping and sexual activity

withdrawal

a set of physiological symptoms that occur when a person stops using a substance; it is specific to the substance being used and each substance will have its own characteristic syndrome - ranges from mild to life threatening - the same substance, or one with a similar action may be taken to avoid or relieve withdrawal symptoms - the more intense symptoms experienced, the more likely the person is to start using the substance to avoid them - behavioral addictions seldom have clearly identifiable intoxication or withdrawal symptoms

Cirrhosis of Liver

a slowly progressing disease in which healthy liver tissue is replaced with scar tissue, eventually liver can no longer funciton because dcar tissue blocks flow of blood through the liver slowing the processing of nutrients, hormones, drugs, and naturally produced toxins. 12th leading cause of death disease. Sx: easy bleeding, easy bruising, pruritis, jaundice, ascites, leg edema, weight loss, confusion, spider-like blood vessels on skin, tesicular atrophy. liver transplantation may be needed, low salt diets will reduce ascites

Hallucinogen USe Disorder

cognitive, biological, behavioral, and social problems associated with the use and abuse of hallucinogenic substances ● No medical use, by definition hallucinogens are intoxicants, cause profound disturbance in reality; both natural and synthetic substances ● associated with flashbacks, panic attacks, psychosis, delirium, and mood and anxiety disorders. ● two broad categories: classic hallucinogens and dissociative drugs. ● APA identified two use disorders r/t hallucinogens - PCP and other hallucinogens. both cause a clinically significant impairment or distress within 12 month period including craving, difficulty with role obligations, impairment and tolerance 1) Hallucinogen Intoxication: clinically significant psychological and behavioral changes. Paranoia, impaired judgment, intensification of perceptions, depersonalization, and derealization are commonly experienced while using hallucinogens. Illusions, hallucinations, and synesthesias (e.g., hearing colors or seeing sounds) are particularly prominent with this type of intoxication. Physical symptoms include pupillary dilation, tachycardia, sweating, palpitations, blurred vision, tremors, and incoordination. ● Treatment: includes talking the patient down. This refers to reassurance that the symptoms are caused by the drug and that the symptoms will subside. In severe cases , an antipsychotic such as haloperidol (Haldol) or a benzodiazepine such as diazepam (Valium) can be used in the short term. 2.) PCP intoxication is a medical emergency that can result in dangerous and violent side effects. People under the influence of this drug can be belligerent, assaultive, impulsive, and unpredictable. Significant physical manifestations of this drug include nystagmus (involuntary eye movements), hypertension, tachycardia, diminished response to pain, ataxia (loss of voluntary muscle control), dysarthria (unclear speech), muscle rigidity, seizures, coma, and hyperacusis (sensitivity to sound). Hyperthermia and seizure activity may also occur. Management of individuals intoxicated by PCP is primarily supportive. ● Treatment Patients who have ingested PCP cannot be talked down and may require restraint and a calming medication such as a benzodiazepine. Mechanical cooling may be necessary for severe hyperthermia. Hallucinogen withdrawal There is no official withdrawal diagnosis or pattern with prolonged hallucinogen use. However, hallucinogen persisting perception disorder may be experienced during periods of sobriety, particularly from LSD. The prevalence of this problem among hallucinogen users is about 4%. The hallmark of this problem is the reexperiencing of perceptual symptoms that were experienced while intoxicated. These symptoms are distressing and impair the individual from normal functioning for weeks, months, or even years.

Thrombocytopenia

complication of liver cirrhosis characterized by low platelet count. Caused by platelet pooling in enlarged spleen and decreased thromboprotein production in the liver. Sx include: excessive bruising (purpura), petechiae (esp on lower legs) prolonged bleeding from cuts. Platelet counts begin to rise 2-5 days after abstaining from alcohol

Screening, Brief Intervention, Referral to Treatment (SBIRT)

comprehensive, integrated public health approach to the delivery of early intervention and tx for services for persons with substance use disorders as well as those at risk for developing these disorders. Screening: Nurse or HCP assesses the severity of substance use and identifies appropriate level of Tx. Brief Intervention: focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change Referral to Treatment: provides those identified as needing more extensive treatment with access to specialty care

Alcoholic Hepatitis

condition resulting from prolonged use of alcohol, in which the liver is inflamed; can be fatal. Occurs in minority of heavy users. Genetic factors such as how the body processes alcohol, other ilver disorders, malnutrition, and being female increases risk. Sx: appetite changes, dry mouth, wieght loss, N/V, pain or swelling in abdomen, jaundice, fever, confusion, fatigue

Schedule V drugs

contain limited quantities of certain narcotics for the treatment of diarrhea, coughing, and pain atropine/dyphenoxylate (Lomotil) guaifenesin and codieine (Robitussin AC) pregabalin (Lyrica)

Alcoholic cardiomyopathy

direct toxic effects of alcohol can weaken and thin muscles of the heart leading to enlargement and eventual heart failure. Sx: fatigue, SOB, edema of legs and feet

Alcohol Intoxification

legal definition in most states requires a blood concentration of 80 to 100 mg ethanol per deciliter of blood mg/dL or 0.08 to 0.10 g/dL. S/Sx: • 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. Intoxication is based on a number of factors including how quickly the alcohol is consumed. Quicker ingestion results in higher levels of blood alcohol. In the United States, a standard drink is one that contains about 14 grams of pure alcohol This amount is found in 12 ounces of beer with 5% alcohol content, 5 ounces of wine with 12% alcohol content, and 1.5 ounces of distilled spirits with 40% alcohol content.

Schedule IV drugs

low risk drugs and available by prescription alprazolam (Xanax) lorazepam (Ativan) propoxyphene/acetaminophen (Darvocet)

Co-occuring disorders

may include any combination of two or more substance use disorders and mental disorders identified in DSM-5 MDD, bipolar disorder, and anxiety disorders are 2x more likely as unaffected individuals to have a substance use disorder. Antisocial personality disorder and conduct disorder commonly associated with substance abuse

How many individuals over the age of 12 are estimated to have a substance use disorder?

more than 21 million or 9% of the population

The major NT's involved in developing substance use disorders are

opioid, catecholamine (especially dopamine) and gamma-aminobutyric acid (GABA) systems. The dopaminergic neurons in the ventral tegmental area (VTA) are especially impt in the sensation of reward

Systemic Effects Include the Followin

peripheral neuropathy Alcoholic myopathy Alcoholic cardiomyopathy Esophagitis Gastritis Pancreatitis Alcoholic Hepatitis Cirrhosis of the Liver Leukopenia Thrombocytopenia Cancer

Addiction

primary, chronic disease of brain reward, motivation, memory and related circuitry. ● Disease of dysregulation in the hedonic (pleasure seeking) or reward pathway in the brain. ● Addicted individuals are unable to consistently abstain from the substance or activity; are unable to recognize the extent to which the addictions are creating serious problems in functioning, interpersonal relationships, and emotional responses. ● Cycles of relapse and remission. ● Addiction without treatment is progressive and often results in disability or premature death

Caffeine

● Most widely used psychoactive substance in world; not an official disorder but it CAN result in intoxication and withdrawal. ● Half life 3-10 hours, peak concentration for most is 40-60 minutes ●. Caffeine Intoxication: characterized by behavioral symptoms such as restlessness, nervousness, excitement, agitation, rambling speech, and inexhaustibility. Physical symptoms are flushed face, diuresis, GI disturbance, muscle twitching, tachycardia, or cardiac arrhythmia. Can result in impairment to normal areas of functioning. Some have high tolerances and may not have symptoms. Extremely high doses may result in grand mal seizures and respiratory failure may cause death. Excessive use associated with many psychiatric disorders including bipolar, eating, and sleep disorders ● Caffeine withdrawal is not associated with med problems for the need for intervention. Headache, drowsiness, irritability, poor concentration. Some ppl experience flu-like symptoms such as N/V, muscle aches. Symptoms occur within 12-24 hrs after last dose, peak in 24-48 hours, and resolve within 1 week

Alcohol Withdrawl

● Occurs after reducing or quitting alcohol after heavy and prolonged use. ● Classic sign of withdrawal is tremulousness aka "shakes" or "jitters" ● Mild to moderate withdrawal includes agitation, lack of appetite, N/V, insomnia, impaired cognition, and mild perceptual changes. Both systolic and diastolic BP increases, Pulse and Temp increase ----Chlordiazepoxide (Librium) is useful for tremulousness and mild to moderate agitation ● Psychotic and perceptual symptoms may begin in 8-10 hrs. if pt experiences psychosis, considered a medical emergency b/c of the risks of unconsciousness, seizures, and delirium. -- Benzodiazepines: lorazepam (ativan) or Chlordiazepoxide (Librium) may be given orally or IM and tapered over following 5-7 days ● Withdrawal Seizures: May occur within 12-24 hrs after alcohol cessation. These are generalized and tonic-clonic. Additional seizures may occur within hrs after first --Diazepam (Valium) given IV is common Tx ● Alcohol Withdrawal Delirium (delirium tremens DTs) is med emergency that can result in death of 20% of untreated patients, usually as result of medical problems such as pneumonia, renal disease, hepatic insufficiency, or HF. May happen any time in first 72 hours. Autonomic hyperactivity may result in tachycardia, diaphoresis, fever, anxiety, insomnia, and htn. Delusions, visual and tactile hallucinations are common. Prevention of this syndrome is the goal --Oral diazepam (Ativan) is used to treat these severe symptoms. Seclusion may be needed. Dehydration can be corrected with oral or IV fluids.

Opioid Use Disorder

● Ratio of Males/Females is 1.5 to 5 ● Most begin in late teens or early 20's, late age associated with fewer affected individuals likely r/t early mortality and cessation after age 40. ● Opioid Intoxication: psychomotor retardation, drowsiness, slurred speech, altered mood, impaired memory and attention. May also exhibit pupillary constriction, intense drowsiness can lead to coma ● Opioid Withdrawal: withdrawal occurs after cessation or heavy reduction in opioid use, or after an opioid antagonist has been administered. - Morphine, heroin, and methadone withdrawal syndrome begins 6-8 hours after last dose following a period of at least a week of use. It reaches intensity during the 2nd or 34d day and then subsides during the next week. - Meperidine (Demerol) withdrawal begins within 8 to 12 hours from abstinence and lasts about 5 days. ● Opioid Overdose: usually stems from respiratory arrest due to the respiratory depressant effect of drug. 3 symptoms: coma, pinpoint pupils and respiratory depression are strongly suggestive of overdose. Other Sx of overdose include unresponsiveness, slow respiration, coma, hypothermia, hypotension, and bradycardia.

Cannabis Use Disorder

● defined by the DSM-5 as cannabis use meeting the criteria for a substance use disorder ●.4th most commonly used psychoactive drug in the US. ● Comes from the dried leaves, flowers, stems, and seeds from the hemp plant Cannabis sativa. A chemical, delta-9-tetrahydrocannabinol (THC) is responsible for the mind-altering effects ● Males more likely to have this disorder ● Sx: using larger amts over longer period of time, craving, tolerance, and withdrawal. May try to quit, cut down, or control use. Too much time spent obtaining it, using it, and recovering from it. May result in problems at work, home, education, social, and physical well being ● Cannabis intoxication: heightened sensations, bright colors, see new details in common stimuli, and time goes more slowly. In higher doses, experience depersonalization and derealization. motor skills impacted for 8 to 12 hours, driving/machinery may be hazardous. Delirium results in marketed impairment of cognition and and performance. Physical Sx include conjunctival infection (red eyes from vessel dilation), increased appetite, dry mouth, tachycardia ● Cannabis withdrawal - within 1 week after cessation. Sx include irritability, anger, aggression, anxiety, restlessness, and depressed mood. B/c it's often used as a sleep aid, insomnia and disturbing dreams may ensue. Decreased appetite may lead to weight loss. Physical Sx include at least one of the following: abdominal pain, shakiness, sweating, fever, chills or headache ● Treatment: Drug screens can detect cannabis for up to 4 weeks after use. Abstinence and support are main principles for support. Hospitalization or outpatient care may be required. Individual, family, and group therapies may be useful. Anti-anxiety meds may be used for short-term relief. Treat underling anxiety/depression with antidepressants if applicable

Sedative, Hypnotic, And Anti-Anxiety Medication Use Disorder

●. Benzodiazepines, Benzodiazepine-like drugs (zolpidem, zaleplon), carbamates, barbiturates (secobarbital) and barbiturate like hypnotics (methaqualone). Includes all sleeping meds and almost all prescription anti-anxiety drugs ● Craving is a typical feature. Use of these brain depressants negatively affects role performance and relationships. Significant tolerance and withdrawal can develop, even if using for intended purpose ● Occurs slightly more often in females. Sedative, hypnotic, and anti-anxiety meds are highest among 18-29 year olds and lowest among adults 65+ ● Intoxication: criteria for intoxication make sense: slurred speech, incoordination, unsteady gait, nystagmus, and impaired thinking. Coma is a dangerous possibility with this class of drugs. Inappropriate aggression and sexual behavior, mood fluctuation, and impaired judgment may also be side effects ● Overdose treatment: includes gastric lavage, activated charcoal, and careful vital sign monitoring. Patients who are awake after overdosing should be kept awake to prevent a loss of consciousness. If unconscious, an intravenous fluid line should be established. An endotracheal tube may be required to provide a patent airway, and mechanical ventilation can be used if necessary. ● Withdrawal: Repeated depressing of the central nervous system, along with the body's daily attempt to return to homeostasis, results in rebound hyperactivity with the removal of the substance. Hence, we may see symptoms such as autonomic hyperactivity, tremor, insomnia, psychomotor agitation, anxiety, and grand mal seizures. The degree and timing of the withdrawal syndrome depends on the specific substance. Half-life is an important predictor of time. ● Withdrawal treatment Gradual reduction of benzodiazepines will prevent seizures and other withdrawal symptoms. Barbiturate withdrawal can be aided by using a long-acting barbiturate such as phenobarbital.