NUR401 - Psych Unit 2

stimulant: bath salts (MDPV)

*4x potency at Ritalin -once one formulation becomes illegal, they switch it up slightly and continue to sell it -can cause agitation, paranoia, hallucinations, chest pain, suicidality -A synthetic, stimulant powder product that contains amphetamine-like chemicals, including mephedrone, MDPV, and methylone; from the Khat plant -Ingredients are illegal to possess -Users snort it, shoot it, mix it with food and drink -"Blizzard, Blue Silk, Charge+, Ivory Snow, Ivory Wave, Ocean Burst, Pure Ivory, Purple Wave, Snow Leopard, Stardust, Vanilla Sky, White Dove, White Knight and White Lightning, Flakka" -Risk of stroke, heart attack and sudden death; high risk of OD -can have delirium; even death by suicide -Emotional and physical "crash-like" feelings of depression, anxiety and intense cravings for more of the drug; unknown if addictive -clinical presentation: agitation, psychosis, stimulatory effects

Scenario C: -Pt has gross nystagmus on lateral gaze. -Marked swaying and some difficulty with walking; speaks without slurring and appears drowsy. -Are you assessing for Intoxication; Sedative -hypnotic w/d or opioid withdrawal? -Is your patient in imminent danger of seizures? -Is medication indicated?

*alcohol intoxication* -nystagmus (2), marked swaying (2), difficulty walking (1), 0 for normal speech and 1 for drowsiness = 6 points -do not medicate - means pt is already feeling effects of intoxication and not in danger of seizures (but assess withdrawal symptoms regularly) -keep hydrated to prevent orthostatic hypotension, fall risk potential

manic depressive disorder = bipolar disorder

*bipolar and addiction are often closely linked

Wernicke's encephalopathy: etiology

*from a deficiency in Thiamine *can be caused from alcohol use disorder, gastritis, gastric carcinoma, etc. 1) Vitamin B1: *Thiamine deficiency that directly interferes with glucose production (the brain's main nutrient) •Chronic alcoholism can decrease intestinal absorption of thiamine by 70% •[Other possible causative factors related to thiamine deficiency: gastric carcinomas, starvation, chronic gastritis, hemodialysis in end stage renal disease patients.] -affects elderly, homeless, psychiatric populations most prevalently -alcoholic amnestic disorder resulting from heavy prolonged drinking is thought to be r/t poor nutrition

Scenario B: VS: T- 100.3; P-120; R- 24;BP 130/84 -Nurse observed that the patient had an episode of diarrhea; patient is yawning, has 'goosebumps' on arms and is requesting a blanket because he 'feels cold'; tremors of tongue and abdomen noted; pt is answering questions curtly and appears upset that he has to be examined (irritable); c/o feeling anxious and his eyes are tearing; slight achiness in joints. -Are you assessing for Intoxication; Sedative -hypnotic w/d or opioid withdrawal -How did your patient score? -Is medication indicated? -What nursing interventions are indicated?

*opioid w/d* -COWS score: 21 -medications indicated: 1) Per the opioid Withdrawal Protocol: Begin Clonidine taper with 0.2 mg four times daily on the first day; Check BP prior to each dose and withhold if BP < 90/60; Repeat BP one hour after each dose. 2) Tylenol (acetaminophen) 650 mg for body aches/ pains; 3) Kaopectate 30 ml p.o. (for diarrhea) 4) Vistaril (hydroxyzine) 50 mg p.o. (for anxiety) -interventions: comfort measures, encourage fluids, rest

medications

*some benzos, phenobarbitals, lots of variety -Librium (chlordiazepoxide) -Luminal (phenobarbital) -Valium (diazepam) -Ativan (lorazepam) -Catapres (clonidine ) -Klonopin -clonazepam) -Methadone -Dilantin (phenytoin) -Zofran (odansetron) -Phenergan (promethazine) -Atarax or Vistaril (hydroxyzine) -Desyrel / Trazorel (trazadone) -Vivitrol (naltrexone) -Suboxone (buprenorphine/naloxone combination) -Subutex (buprenorphine) -Thiamine (B1) -Campral (acamprosate) -Narcan (naloxone) -Antabuse (disulfirim) -Tylenol (acetaminophen) -Advil (ibuprofen) -Kaopectat -Lomotil (loperamide)

assessing for physiological signs of alcohol intoxication

-*Arousal*: awake - difficult to arouse -*Speech*: clear - pronounced slurring -*Gait*: ask patient to perform normal- tandem walk (toe to toe) observe for staggering/ inability to do -*Romberg*: tests proprioception (the ability to know one's body in space), sensation (the ability to feel touch, pressure, or vibration -- ex. to feel one's feet against the ground), and vision (which can be used to monitor changes in balance) *Romberg test*: the patient is asked to stand and close eyes. A loss of balance is interpreted as a positive Romberg sign -*Nystagmus*: move finger or pen in front of eyes left to right; positive sign if eyes 'vibrate' -Flushed face may also occur.

assessment pearls: opioid withdrawal

-*Dilated pupils* must be assessed in a room with good lighting. Dark rooms dilate the pupils unnaturally. Compare the patient's pupils with another person or in the mirror with yours. ( 3 = normal) -*Gooseflesh* is often a hallmark of severe withdrawal- to check, lightly run your fingers over inner aspect of forearm -*Muscle twitching*: observe hand movements; if in doubt look for twitching on patient's abdomen or in tongue movements -Patients may run in place or exercise to increase heart rate before withdrawal check. Place patient near observable area near nursing station for 5 minutes before assessing BP and Pulse. -Common 'fakes' are vomit made by patients of cereal and other food items; tell patient to save specimen to inspect it

long term medication management: alcohol: Antabuse (disulfiram)

-Antabuse is an alcohol antagonist and an aldehyde dehydrogenase inhibitor and works by disrupting alcohol to acetate metabolism. This leads to increased acetaldehyde accumulation. If alcohol is ingested, this increases acetaldehyde so much that it leads to the "disulfiram-ethanol reaction". Reaction is proportional to the disulfiram dose and amount of alcohol ingested. -s/s of disulfiram ethanol reaction: diaphoresis, flushing, nausea, vomiting, headache, tachycardia and hypotension -Probably excreted in breast milk. FDA has not approved for use in pregnancy -used for maintaining enforced sobriety in chronic alcohol dependence -Supplied as: 250 mg tablets Dosage: 125-250 milligrams/day -Begin treatment after BAC = 0 and 12 hours since last alcohol intake ***Disulfiram should never be administered until the patient has abstained from alcohol for at least 12 hours Initial Dosage Schedule: -A maximum of 500 mg daily in a single (usually AM) dose for one to two weeks. Maintenance Regimen -250 mg daily (range, 125 to 500 mg), it should not exceed 500 mg daily. -Patients must abstain from alcohol in any form; mouthwash, cold remedies etc. -even if ingested days after last disulfiram dose (can cause reaction)

long term med management: opioid = naltrexone (Vivitrol)

-Blocks the action of opioids by binding with opiate receptors but doesn't give the "high" -Approved for treating alcohol dependence too- prevents relapse -A person can take opioids while taking naltrexone but with little effect because the beta-endorphin highways are blocked = can't get that high -Unlike disulfiram, simultaneous alcohol consumption will not make the person sick, but makes the person less interested in the effects of alcohol -Potential SE: nausea, myalgia, headache and dizziness -Dosing is usually started at 25mg and increased over 2-3 days up to 50 mg - 100mg once daily. The extended release form is given IM 380mg once every four weeks. -Pregnancy Category C, Unknown if excreted in breast milk.

alcohol/S/H - withdrawal symptom assessment tool: CIWA-Ar

-Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-AR) -Can be used to assess patient status as often as q 30 minutes. Also -Refer to textbook (Mohr) -Chapter 30 -Pages: 640-641

opioid withdrawal symptom assessment tools

-Clinical Opioid Withdrawal Scale (COWS) [Note: Opiates are narcotic drugs that relieve pain. Cocaine is a stimulant, not an opiate.]

long term med management: opioids = methadone maintenance in pregnant opioid addicted women

-Decreases the variability of illicit drug use on the fetus -Newborns have more predictable outcome -Limits exposure to health risk for Mom and fetus from exposure to illicit drugs and unknown possibly toxic additives, dirty needles -Dosages may need to be adjusted upward as pregnancy progresses (so might look high dosage) -2x daily dosing INSTEAD of larger dose may also be an option -Dosage titrated dependent upon opioid withdrawal scoring -Action: a full agonist at opioid receptor sites to decrease craving and withdrawal; lower likelihood of respiratory depression; blocks the effects of other opioids -Methadone replaces 'street drugs' -Maintained til delivery, then withdrawn *Note: The fetus will still experiences symptoms of withdrawal, may be 2-3X as intense as the mother's symptoms. -Pregnancy category C

Substance Use Disorders, Withdrawal Education (w scenarios)

-Describe the physical and psychological impact of various drugs of abuse: opioids, alcohol / sedative-hypnotics, hallucinogenics, cocaine and stimulants. -ID s/s of opioid and alcohol/sedative-hypnotic withdrawal. -Determine the medication management for patients post abuse of opioids, stimulants and hallucinogenic drugs. -Use a standardized assessment protocol to determine medication management of opioid and alcohol/sedative-hypnotic withdrawal symptoms. -Assess intoxication or withdrawal symptoms in various case scenarios using evidence based instruments.

hallucinogenic: physiological effects

-Hallucinogenics (LSD, PCP, psilocybin mushroom) -Acute Effects: ↑HR, BP, + temp, body chills, impaired vision/ hearing, confusion, severe panic attacks, slurred/impaired speech -"bad trip" = make bad choices, can even kill themselves while on this -Long Term Effects: mental illness, hallucination, severe depression, flash backs, suicide

treatment d/t illicit drug intoxication- symptomatic and supportive care

-Hydration -Safety -Nutrition -Assess for infection -re-orientation -Therapeutic interaction

the opioid epidemic: overdose deaths

-In 2015, there were over 50,000 deaths by overdose nationally. Overdoses killed more people than car crashes or guns. -the powerful painkiller Fentanyl is linked to increase in deaths -Fayette Co. ranked in top 3 counties in KY for heroin and fentanyl-related deaths

stimulant: methylphenidate

-Increasing abuse - especially on college campuses -Tachycardia -HTN -very addictive -Dangerously high body temperatures ex. Ritalin *gives you "high," increases alertness and attention and energy (which raises BP, HR, RR) *weight loss effects *"help perform better in school"

DTs: treatment

-Life support/sustaining measures as indicated; can be life-threatening -Labs: electrolytes -Hydrate -VS -Treat seizures with anticonvulsants: phenytoin (Dilantin)or phenobarbital; or CNS depressants /benzodiazepines: diazepam (Valium) -Clonidine if elevated BP -Antipsychotics :haloperidol (Haldol) prn for hallucinations ___________ A hospital stay is required. The health care team will regularly check: Blood chemistry results, such as electrolyte levels Body fluid levels Vital signs (temperature, pulse, rate of breathing, blood pressure) Symptoms such as seizures and heart arrhythmias are treated with the following medications: Anticonvulsants such as phenytoin or phenobarbital Central nervous system depressants such as diazepam Clonidine to reduce cardiovascular symptoms and reduce anxiety Sedatives The patient may need to be put into a sedated state for a week or more until withdrawal is complete. Benzodiazepine medications such as diazepam or lorazepam are often used. These drugs also help treat seizures, anxiety, and tremors. Antipsychotic medications such as haloperidol may sometimes be necessary for persons with hallucinations. Long-term preventive treatment should begin after the patient recovers from acute symptoms. This may involve a "drying out" period, in which no alcohol is allowed. Total and lifelong abstinence is recommended for most people who go through withdrawal. The person should receive treatment for alcohol use or alcoholism, including: Counseling Support groups (such as Alcoholics Anonymous)

heroin

-MAJOR MENTAL HEALTH ISSUE! HEROIN IS HIGHLY ADDICTIVE! -HUGE INCREASE IN OVERDOSES AND DEATH! -Inexpensive, easily accessible -Strength of product varies, increasing risk of overdose. -It is usually 'cut' to dilute it, with sugar, caffeine or even poisons like strychnine. -The additives do not fully dissolve, and when they are injected into the body, can clog the blood vessels that lead to the lungs, kidneys or brain. This itself can lead to infection or destruction of vital organs. -Is a fine white powder- but additives change the color to rose gray, brown or black -the user buying heroin on the street never knows the actual strength of the drug bc cut different ways, thus they're constantly as risk of an overdose -Heroin can be injected, smoked or sniffed. -Gives feeling of euphoria, "feeling high" the first time it's used; feel extroverted, able to communicate easily w others, may experience heightened sexual performance - but not for long -May impair the immune system -extremely addictive, withdrawal extremely painful Street names: -Big H -Brown Sugar -H -Hell dust -Horse -Junk -Nose Drops -Skag -Smack -Thunder

meth mouth

-Meth mouth is a dental condition characterized by severe decay and loss of teeth, as well as fracture, enamel erosion, and other oral problems symptomatic of extended use of the drug methamphetamine (meth) -The specific cause of the condition is unknown, although drug-induced xerostomia (dry mouth) and bruxism (grinding of the teeth) are thought to be involved -Other frequently cited factors are poor nutrition and lack of dental hygiene, common among long-term users of the drug -The legitimacy of meth mouth as a unique condition has been questioned because of the similar effects of some other drugs on teeth. Advocates of its status as a unique condition cite the pattern and scope of the decay as distinguishing factors.

CIWA-Ar assessment categories

-N/V -Tremor -Paroxysmal sweats (diaphoresis) -Anxiety -Tactile Disturbances -Auditory Disturbances -Visual Disturbances -HA, Fullness in head -Agitation -Orientation and clouding of sensorium *Note: VS aren't part of the tool, but orthostatic hypotension often occurs

drugs have long-term consequences

-PET scans reveal changes in the brain when you use drugs, decreased brain function = it screws up your brain!! *significant reduction in dopamine transporters -brain function improves after abstinence of drug *but brain will not be the same as when you started

medically assisted withdrawal (MAW) (detoxification)

-Safe removal of the chemical from the body -Provide for physical, emotional and psychological safety -Risk for injury related to substance withdrawal -Provide safe and supportive environment -Conduct withdrawal checks -Administer psychopharmacological substitution therapy

CIWA-Ar symptom scoring

-Scored on a scale of 0-7 -Not every number has a description -Score closest to assessment finding. Absent or minimal withdrawal: 0-9 Mild to moderate withdrawal: 10-19 More than 20: severe withdrawal

stimulant: cocaine

-Speeds up the body and brain -Acute Effects: ↑ RR, BP, + T; Increased alertness; chest pain, respiratory failure, nausea, abdominal pain, panic attacks, HA -Long term effects: lung damage, nasal ulcers, personality changes, violent/aggressive behavior, paranoia, hallucinations street names: aunt nora, bernice, binge, blow, C, charlie, coke, dust, flake, mojo, nose candy, paradise, sneeze, sniff, snow, toot, white *don't need to know any of the street names of these

stimulant: methamphetamine

-Speeds up the brain, nervous system and body -Acute Effects: ↑ RR, BP, + temp, more alert/ awake, restlessness, insomnia, decreased appetite -Long term effects: brain/heart damage, labile mood, violent/aggressive behavior, hallucinations, paranoia, weight loss -most meth is "homemade" and contains toxic and corrosive chemicals like ammonia, perchloric acid, red phosphorous, and battery acid - when smoked, these chemicals contact the teeth, eroding the enamel = GROSS teeth -bc of addiction, many neglect personal hygiene, esp. oral hygiene, becomes painful and teeth become soft, dry, and crumbly

assessment pearls with alcohol withdrawal

-Wetting of hands or splashing water on face may be done to simulate diaphoresis. Check the nape of the neck for diaphoresis. -To verify hallucinations, observe patient covertly for signs of eyes darting, picking at things, increased anxiety or fear or conversations with oneself. These are usually tactile 'bugs crawling on skin" but may be visual 'seeing bugs crawling on the wall'. -To verify true muscle twitching and tremors and you notice hands are tremulous, check for abdominal tremors or tremors of tongue.

key terms/concepts

-Withdrawal -Alcohol Intoxication -Delirium Tremens -Medically assisted withdrawal (detoxification) The following conditions will be covered in the Substance Use and Other Disorders In Class lecture: -Wernicke's Encephalopathy -Korsakoff Psychosis -Wernicke -Korsakoff Syndrome

can withdrawal symptoms emerge even in the absence of a measurable blood alcohol level?

-YES -a person who's a chronic alcohol abuser in large quantities may start with BAL of 400; this person could begin to experience withdrawal symptoms at a level of 100 -withdrawal symptoms may occur within 24-48 hours of the last drink, and may continue up to a week

psychological effects of stimulants - amphetamine

-abuse can cause psychotic symptoms

biological: genetic influence

-addiction has genetic contributions! -CYP2A6 (nicotine metabolism) tobacco dependence -FAAH (endogenous cannabinoid regulator) problem drug use -Mu-opioid receptor in heroin addiction *don't need to know genes

learning outcome: ID the s/s of alcohol/sedative-hypnotic withdrawal use a standardized assessment protocol to determine med management of withdrawal s/s: alcohol/sedative-hypnotic withdrawal

-alcohol -benzodiazepines -barbiturates

amygdala - watch a video of cocaine

-amydala will light up if you've done cocaine = will remember experience *won't light up if you see a nature documentary *if you do cocaine off a dollar bill, amydala lights up just seeing a dollar bill

treatment d/t illicit drug intoxication- hallucinogens/PCP

-benzodiazepines (ex valium, ativan) -antipsychotics

Score the scenario using either CIWA-Ar, COWS, s/s of intoxication -for exam, learn the s/s of each type of withdrawal and med management of each type of withdrawal, won't have to score on the test VS: T- 100.2F; P- 110; R-16; BP 180/90 Admission symptoms: -mild tremor in patient's hands; both palms moist and beads of sweat on forehead and continuously is wiping nose; severe headache and complaining of 'aching all over'; leg moves up and down while seated in the chair; face is flushed; cannot state correct date; pupils obviously dilated; asking for a basin in case he vomits. -Is your patient experiencing Intoxication; Sedative-hypnotic w/d or opioid withdrawal (w/d)? -How did your patient score? -Is medication indicated? -What nursing interventions would you initiate?

-both opioid and s/h alcohol w/d evident *opioid w/d assessment*: -COWS score: 21 *way we got this score on Canvas -meds indicated: 1) per the opioid withdrawal protocol, begin Clonidine taper w 0.2 mg 4x daily on the first day; check BP prior to each dose and withhold if BP <90/60; repeat BP one hour after each Clonidine dose 2) Tylenol (acetaminophen) 650 mg for body aches/pains nursing interventions: comfort measures for opioid w/d pain and nausea; warm/hot bath or compresses; tea, flat coke, crackers for nausea, reassess opioid withdrawal score w/ COWs q4 hours for 24 hours ___________ *alcohol/sedative hypnotic w/d assessment*: -CIWA-Ar score: 26 -meds indicated: 1) Valium (diazepam) 10 mg p.o. 3Xdaily; May gjve additional 10mg p.o. Valium if CIWA-Ar score remains above 15 at subsequent checks [Librium (chlordiazepoxide) 50 mg p.o OR OR Ativan (lorazepam) 2mg could also be used] 2) MVI daily (multivitamin) 3) Thiamine 100 mg p.o. daily 4) Folic acid 1 mg daily 5) Vistaril (hydroxyzine) 50 mg p.o. every 8 hours prn for anxiety interventions: -encourage fluids to prevent dehydration and orthostatic hypotension, repeat VS hourly for 8 hours, re-assess alcohol withdrawal score with CIWA-Ar hourly x 8 hours

sometimes you have to hit ROCK BOTTOM

-but sometimes the disease process keeps happening

stimulants

-cocaine -methamphetamine -ectacy -methylphenidate -bath salts

long term medication management: alcohol acamprosate (Campral)

-helps w cravings -Most effective is patient has abstained from use for awhile -Use after recent detoxification is not as successful -It is structurally similar to GABA, and may inhibit the glutamatergic system -Available in 333 mg tablets. Dosing: 666 mg daily. -SE: diarrhea and GI upset -Pregnancy Category C.

psychological effects of stimulants- LSD, a potent hallucinogen

-intense and vivid hallucinations -flashbacks

hallucinogenics

-lysergic acid (LSD) -phencyclidine (PCP) -psilocybin mushroom

alcohol: when do pts complete withdrawal

-most pts complete withdrawal within 3-5 days (w treatment) -peak untreated withdrawal occurs during the 2nd day (48 hours) after last drink *note: supplies of thiamine stored in the body are limited even in the absence of alcoholism. Therefore, thiamine should always be administered before giving an alcoholic patient glucose as an energy source to prevent precipitation of Wernicke syndrome by depletion of thiamine reserves.

treatment d/t illicit drug intoxication - stimulants

-no specific meds -under study: amantadine and modafinil

counter-transference

-nurses who care for persons with addictions must begin by examining their own attitudes about drinking and drug use, recognizing that past experiences may impact one's perceptions and influence how one provides care to persons with addictions -taking an experience you have in your past (ex friend with SUD) and projecting that feeling from that experience onto your patient = want to avoid that!!

how to opioids work?

-opioids attach to specific proteins called opioid receptors, found in the brain, spinal cord, and GI tract and block the transmission of pain -attaching to certain opioid receptors = block transmission of pain messages to the brain -can produce drowsiness, cause constipation, and depress respiration if too much taken -can also cause euphoria by affecting the brain regions that medicate what we perceive as pleasure

treatment d/t illicit drug intoxication- inhalants/solvents

-phenobarbital

hallucinogenic: LSD (lysergic acid)

-potent, mood-changing chemicals -From the ergot fungus that grows on rye and other grains -produced in crystal form -odorless, colorless, and has a slightly bitter taste. -Known as *"acid"* and by many other names -LSD is sold on the street in small tablets ("microdots"), capsules or gelatin squares ("window panes") -It is sometimes added to absorbent paper, with designs or cartoon characters ("loony toons") -Causes a serious disconnection from reality -LSD users call an LSD experience a "trip," typically lasting twelve hours; a "bad trip," is another name for a "living hell" (can't control if good or bad trip)

stigmatizing terminology: habit or drug habit

-this denies the medical nature of the condition and implies that resolution is simply a matter of will power instead... ex. Alcohol Use Disorder, Alcohol and drug disorder, alcohol and drug disease

stigmatizing terminology: abuser, alcoholic, addict

-this is demeaning, labels a person by their illness ex. person with alcohol/drug disease, person with substance use or addictive disorder SUAD, person experiencing an alcohol/drug problem, patient or client (if receiving services)

long term effects of drinking

-tingling, loss of sensation in hands and feet -hypertension -irregular pulse -enlarged heart - > chance of infections including TB -severe swelling and pian in liver -hepatitis -cirrhosis -liver cancer -impotence, shrinking of testicles, damaged/less sperm (men) -greater risk of gynacological problems, damage to fetus if pregnant (women) -chances in RBC -brain injury -loss of memory -confusion -hallucinations -inflamed stomach lining -bleeding, ulcers in stomach -inflammation of pancreas, causing pain -inflamed intestinal lining, ulcers -muscle weakness -loss of muscle tissue -flushing, sweating, bruising of skin -cirrhosis of liver

critical thinking: your pt has a long hx of abuse of alcohol and opioids, what would be the preferred management for their c/o severe HA and body aches r/t opioid withdrawal? pharmacological? alternative?

-tylenol (if no liver involvement) -hot showers, warm compresses

tolerance

-using 'increasing amounts' of a substance over time to achieve the same effect and a markedly diminished effect occurs with continued use

acute and long term physiological effects of alcohol

1) Acute Effects -CNS depressant— produces mild to extreme sedation -Confusion, impaired motor function and/or speech -Potentially may lead to coma, respiratory failure, and even death 2) Long-term effects -cerebellar degeneration (lose braincells), impaired coordination, broad-based unsteady gait, and fine tremors -Serious health complications—alcohol dependence, cirrhosis of the liver, and alcohol-induced amnestic disorders

long term med managment for opioids

1) Buprenorphine/Naloxone Combination = *Suboxone*, a sublingual tablet -comes in two dosage forms: 2 mg buprenorphine/0.5 mg naloxone and 8 mg buprenorphine/2 mg naloxone -Buprenorphine *Subutex*, also a sublingual tablet -is available in 2 mg and 8 mg strengths. -Reduce drug cravings without producing the same drug 'high' or dangerous side effects; blocks effects of other opioids; milder withdrawal; lower abuse potential -Both are in Pregnancy Category C.

Wernicke's encephalopathy: treatment

1) Condition is reversible with thiamine replacement (give them thiamine!) 2) Improve nutritional status Outcome: 1.Symptom improvement 2.w/o treatment, 80-90% may advance to Korsakoff psychosis

other drugs of abuse

1) Depressant -GHB (Gamma hydroxybutyrate) (Xyrem) -ROHYPNOL -Barbiturates *"date rape" drugs 2) Dissociative agents -KETAMINE -Kratom 3) Many Rx meds -Dextromethorphan 4) Inhalants -Solvents, paint thinners, butane, propane, aerosol propellants, paint, markers, glue 5) Cannabinoids -MJ (marijuana) /THC -K2/Spice 6) Anabolic steroids

some basic interventions

1) Holistic Care -Assessment and reassessment as needed (reassess if you see increased s/s) -Healthy diet -Fluid management-correct electrolyte imbalances, re-hydrate -Non-pharmacologic interventions (so they can do these at home) -Medical care -Empathy -Health teaching/Empowerment 2) CONSISTENT, CARING, FAIR, KIND, NURSING CARE WITH APPROPRIATELY FIRM LIMIT SETTING THAT MEETS THE PATIENT'S PSYCHOLOGICAL AND PHYSICAL NEEDS. 3) Referrals to Programs ex. Step Works Addiction Program in Elizabethtown, KY Dr. Ingram at http://www.stepworks.com/general_info.php nAA finder: http://www.aa.org/lang/en/meeting_finder.cfm?origpage=29 nNA finder: http://portaltools.na.org/portaltools/MeetingLoc/ *note: drug dependent persons will neglect their health, including vitamin supplements

medication management: stimulants

1) Stimulants: give them... -Minor tranquilizers (benzos?) -Major tranquilizers (antipsychotics) -Anticonvulsants -Antidepressants 2) Hallucinogens and Cannabinols -Benzodiazepines -Antipsychotics 3) Depressants -Phenobarbital (Luminal) -Long-acting benzodiazepines

estimated timing of symptom appearance s/p alcohol intake

1) minor withdrawal s/s: *6-12 hours* after cessation of alcohol use -insomnia -tremulouness -mild anxiety -GI upset -HA -diaphoresis -palpitations -anorexia 2) alcoholic hallucinosis: *12-24 hours* *s/s usually resolve within 48 hours -visual, auditory, or tactile hallucinations 3) withdrawal seizures: *24-48 hours* *s/s reported as early as 2 hours after cessation -generalized tonic-clonic seizures 4) alcohol withdrawal delirium (delirium tremens): *48-72 hours* *symptoms peak at 5 days -hallucinaitons (mostly visual) -tachycardia -HTN -low grade fever -agitation -diaphoresis

Wernicke's encephalopathy: classic symptoms

1)Mental Confusion: *mild to severe decrease in mental functioning 2)Ataxia: *unsteady gait /myopathy 3.Mental status changes: *Decreased recall of remote information (long-term memory) *Damage to the hippocampus-person cannot form new memories despite intact intelligence (short term memory) 4) Opthalmoplegia: *paralysis or weakness of one or more of the muscles that control eye movement AEB nystagmus (eyes shift rapidly) *approximately 80-90% of people w Wenicke's encephalopathy also develop Korsakoff's psychosis

prn meds (if non-pharmacologic measures are ineffective)

1)Nausea and vomiting: -Zofran (odansetron) -Phenergan (promethazine) PO or rectal suppository *Avoid giving phenergan as IM if requested by patient r/t 'rush' effect. 2) Anxiety, Lacrimation, Rhinorrhea (runny nose) -Atarax or Vistaril (hydroxyzine) -Avoid benzodiazepines (addicting class of med) 3)Insomnia -Desyrel / Trazorel (trazadone) 4) Myalgias -Tylenol (acetaminophen) *NOTE: if long term alcohol use, the patient may have esophageal varices or gastric ulcers (so use tylenol instead of asprin) -NSAIDS ex. Advil (ibuprofen) 5) Diarrhea -Kaopectate preferred choice -Avoid Lomotil (loperamide) because of sedation effect sought by patient *note: avoid benzos, if person has opioid addiction, it's likely they could develop benzo addiction; pts usually have comorbid addictions w opioids (alcohol or BZD) - don't want to reinforce dependence on drugs or contribute to continuation of pt's "high" as they try and detox

the best ways to treat DTs

1.PREVENT THEM!!!!! 2.PREVENT THEM!!!!! 3.MEDICATE / SEDATE ADEQUATELY!!!!! 4.MONITOR VERY CLOSELY!!!!! 5.LISTEN AND RESPOND TO THE PATIENT'S REPORT OF SYMPTOMS!!!!! 6.TREAT COMPLICATIONS!!!!! 7.GIVE FLUIDS AND THIAMINE AND OTHER NUTRIENTS!!!!!

biological aspects of addiction

Biological Components: •Genetic predisposition •Increased extracellular dopamine *dopamine is the extracellular NT associated with addiction *increased dopamine = feel euphoric -if you have a mental health disorder, often your dopamine is low = addiction to feel more dopamine -"I feel doped up" •Immature brain development •Function of acetate •Having another mental health disorder (depression, attention-deficit/hyperactivity disorder (ADHD) or post- traumatic stress disorder increase potential for self- medication with substances to relieve symptoms, mask feelings) •Being male *(However, progression of addictive disorders is faster in females.)

stigmatizing terminology: craving

Craving = intense need (we often use it in life as a want, but it's a NEED, you'll do anything to get it) •As "wanting" the drug increases... "liking" the drug decreases (bc you'll do whatever to get it) •Acetate accumulation increases craving NOTE: •Nicotine use and alcohol use both metabolize into acetaldehyde (which then breaks down into acetate) which is thought to increase tolerance and dependence = additive effect *why a lot of people smoke and drink at same time

medication management for opioids- emergency management for resp depression, for withdrawal symptoms

Emergency Management for presence of respiratory depression: -Naloxone (Narcan) narcotic antagonist: 0.4mg to 2mg IV; May Repeat in 2-3 minute intervals up to 10mg *note: if no response after 10 mg of Narcan, diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned *IM or SQ admin may be necessary if the IV route isn't available *she said she'd like us to know these dosages -For Post-Op Recovery: Narcan: 0.1-0.2mg IV at 2-3 minute intervals until desired result (titrate based on pt's response) For Withdrawal Symptoms: -Methadone- LIP must have special licensure to prescribe -Clonidine- Total daily dosage range between 0.5 and 1.5 mg for elevated BP: doesn't help with muscle cramps, insomnia or drug craving

med management for alcohol withdrawal

For a CIWA-Ar score of 8 to 10 or more: -Chlordiazepoxide (Librium) 50-100 mg -Diazepam (Valium), 10-20 mg -Lorazepam (Ativan), 2-4mg *will choose one of these For a fixed, scheduled regimen, one of the following medications may be given: -Chlordiazepoxide 50mg q 6 hours for 4 doses; then 25mg q 6 hours for 8 doses n -Diazepam, 10mg q 6 hours for four doses, then 5mg q 6 hours for 8 doses -Lorazepam 2mg q 6 hours for 4 doses then 1mg q 6 hours for 8 doses -Thiamine 100mg daily replacement is critical and should be given prior to IV dextrose support to prevent precipitation of Wernicke's syndrome Other: Phenobarbital, Inderal, Clonidine, Magnesium sulfate, MVI, antipsychotics -PRN dosing for breakthrough scoring of autonomic symptoms is usually included in the protocol *note= BZD are the 1st line agent for treatment; long acting (Valium) are more effective in preventing seizures

key concept: addiction

IMPORTANT SLIDE •A *pattern* of problematic alcohol use that causes distress and significant impairment •There is a strong craving for drug (will do anything to get it, all I think about, a need, often people start to isolate from people who can't help them get their need) •Persistent desire to cut down without success •Impacts social, occupational, and recreational activities; unable to fulfill role obligations *ex stop showing up at work, stop showing up at home and parenting •Increase in social isolation •Can result in hazardous activities ex. prostitution, bank robbery to get the money for substance •Continuation in spite of consequences (physical and psychological) •Excessive amount of time is spent trying to procure the substance or recover from its use •May result in tolerance or withdrawal *note: specific substances have their own disorder -Alcohol Use Disorder -Cannabis -Hallucinogens -Inhalants -Opioids -Sedatives / Hypnotic use disorder -Anxiolytics -Stimulants -Tobacco

severe alcohol withdrawal: delirium tremens (DTs) s/s

If alcohol withdrawal is not treated, Delirium Tremens may result, AEB: -Increased anxiety -Delusions -Coarse tremors (pretty much precursor to seizure) -Seizures -Hallucinations (most commonly auditory and/or visual; also tactile) -Gross confusion and disorientation -Autonomic hyperactivity (tachycardia, fever, diaphoresis, hypertension, precordial pain). -Agitation -Paranoia. -Danger of misdiagnosis as psychiatric disorder •Withdrawal symptoms can emerge, particularly in the absence of a measurable blood alcohol level •Florid delirium tremens (DT) is the most serious and potentially fatal alcohol withdrawal syndrome. •These patients are often agitated and paranoid and may not readily allow physical examination. •The temptation to view an agitated, paranoid, overtly hallucinating patient as in need of nothing further than admission to a psychiatric unit may be a grave mistake because untreated DT is potentially fatal.

opioids (not on exam)

Opioids can be divided into 3 classes: 1) Naturally occurring opioids -The classic natural opioids are opium and morphine. -Opium is extracted from the plant Papaver somniferum (the opium poppy), and morphine is the primary active component of opium. 2) Semi-synthetic opioids -include heroin, oxycodone, oxymorphone, and hydrocodone. -Semisynthesis is a type of chemical synthesis that uses compounds isolated from natural sources (e.g., plants) as starting materials. 3) Synthetic opioids -include buprenorphine, methadone, fentanyl, alfentanil, levorphanol, meperidine, codeine, and propoxyphene. -Synthetic opioids are made using total synthesis, in which large molecules are synthesized from a stepwise combination of small and cheap (petrochemical) building blocks. -Endogenous opioid peptides, produced naturally in the body, such as endorphins, enkephalins, dynorphins, and endomorphins

physiological effects of opioids

Opioids provide: -Enhancement of the feeling of emotional well-being -Feelings of euphoria -Help with emotional numbing post trauma. -Relief of underlying psychological conditions Opioids result in: -Addiction -Memory deficits -Hallucinations -Delusions -Paranoia -Worsening of mental health -Increase in symptoms of mental illnesses. -Drowsiness, sedation, depressed respiration, constipation

psychological aspects of addiction

Psychological Components: •to deal with ... STRESS •Depression •Low self-esteem •Increased need for success/power •Inability to cope •Anxiety •Loneliness *Using drugs can become a way of coping with these painful psychological feelings and can worsen these problems

reasons for continued use: the addicted brain

Repeated use leads to tolerance and withdrawal: •via fundamental changes in the neurotransmitters •via decreased D2 receptors and decreased dopamine release This results in: •compulsive behaviors •decreased inhibitory control •increased impulsivity •impaired regulation of intentional acts

symptoms of opioid withdrawal: objective (scoring, physiological symptoms)

Scoring (COW): -Based on a score of 0-5 or 0-4 for each parameter -Not all numbers have an assessment parameter -Mild: *5-12* -Moderate: *13-24* -Moderately severe: *25-36* -More than 36: *severe withdrawal* Physiological Symptoms -Tachycardia -Sweating -Restlessness -Dilated pupils -Bone or joint aches -Runny nose or tearing -GI upset: cramps, nausea, loose stool or diarrhea -Tremor: slight, gross or muscle twitching -Yawning -Gooseflesh skin / pilorection

social aspects of addiction

Social Components: •Social stigma/controversy •Environmental factors ex. tailgating is popular, getting a drink after work is normal •Peer influence *there's a triad between trauma/abuse, substance use, and mental health dx -use substances to cope with trauma and or mental health disorder* •Dysfunctional family dynamics •Abusive history •Social maladaptation •Family history of addiction •Peer pressure, particularly for young people •Lack of family involvement. •Difficult family situations; lack of a bond with parents or siblings; lack of parental supervision.

symptoms of opiate withdrawal: subjective

Subjective Symptoms: -nausea -muscle aches -increased anxiety Symptom relief: -Encourage non-medical interventions before PRN medications; but give scheduled methadone on time! -Nausea: crackers, ginger ale, tea, flat warm coca-cola -Muscle aches: hot showers, warm compresses, tylenol -Anxiety reduction: distraction, relaxation therapy, talk therapy.

withdrawal pt education handout (mainly to prevent falls d/t orthostatic hypotension)

To Prevent Orthostatic Hypotension: -Get up slowly from a sitting or lying position. -If you are lying down, sit on the edge of the bed for a full minute before standing. -Drink at least 8-10 glasses of water each day. -Report ANY dizziness to your nurse. Other: -If you vomit or have diarrhea, DO NOT FLUSH! This is an important symptom for your nurse to document accurately so you can receive the correct medication dose. -MEDICATION CANNOT BE GIVEN FOR UNOBSERVED VOMITING OR DIARRHEA!

stigmas of addiction

Who says there is stigma toward addiction? -91% of primary care physicians -89% of people in recovery from addiction -80% of the general public Who says there are barriers to treatment? -66% of public believe social embarrassment and fear of discrimination are barriers Who says alcoholism is a moral weakness? -66% of the general public *note: addiction affects everyone/doesn't discriminate/no set socioeconomic status or gender or race, even those we think "have it made" = celebrities

addiction, like cardiovascular disease, has environmental contributions: environmental influences on addiction

drug abuse: -early physical or sexual abuse -witnessing violence -stress -peers who use drugs -drug availability

key concept: behavioral addiction

ex. gambling -addiction, good or bad, is still an addiction *internet, sexual addiction not in the DSM V but are likely diagnoses

PET scan can be used to look at your brain on drugs

ex. minute by minute = lights up, hits peak, then over in like 20 minutes w cocaine = need to "use again"

substance intoxication

intoxication = when you have the peak amount of that substance in your system; impaired judgement, euphoric *sometimes intoxication can happen with first use •The symptoms are drug specific •Recent overuse/excessive use of a substance, such as an acute alcohol intoxication, that results in a reversible substance-specific syndrome •Judgment is impaired •Inappropriate and maladaptive behavior •Impaired social and occupational functioning •CNS changes occur; disruption in physiological and psychological functioning •ex. alcohol: •physiological (slurring of speech, poor coordination, impaired memory, stupor, or coma) •behavioral (inappropriate behavior) •Can happen with one time use of substance *heroin = different dosages/cut different each time = can take the same dose as yesterday and die (often cut with fentanyl)

stimulant: amphetamine - Ecstacy

street names: -ecstacy, MDMA, Adam, Cardillac, Beans, California, Sunrise, Clarity, E, Essence, Elephants, Eve, Hug, Hug drug, love drug, love pill, lover's speed, roll, scooby snacks, snowball, X, XE, XTC

hospital stays involving MSUD

•25% (10 million stays) with principal or secondary MSUD Dx •15% have an active SUD •25% of patients admitted to critical care units will have alcohol-related issues (ex. cirrhosis, esophageal varicies, MVA r/t alcohol) •Delirium, pneumonia, acute respiratory distress syndrome (ARDS), sepsis, GI hemorrhage, trauma and burn injuries •Costs were higher and hospital stays longer with a MSUD DX •MSUD Dx more likely to be admitted thru ED •Principal MSUD Dx less likely to result in death •Age range mostly 18-64 years •60% billed to public payers; 10% no pay or self-pay •Rural and urban equal with principal MSUD; more in rural for secondary Dx of MSUD •Alcohol and Opioid most common substances •Depressive D/O and Schizophrenia most common mental D/O

biological: alcohol craving and acetate

•Alcohol breaks down into acetate *w substance use disorder, acetate hangs around longer in your body •Acetate triggers a craving for more acetate •The liver and pancreas of the person addicted to alcohol process alcohol at 1/3 to 1/10th the rate of a normal pancreas and liver = acetate builds up more = when it builds up you want more acetate = another drink •In a normal drinker, the acetate moves through the system quickly and exits •In addiction, the acetate of the first drink is barely processed out, so by staying in the body, it triggers a craving for more acetate •The person addicted to alcohol then has a second drink, now adding to most of the acetate of the first drink, and that makes them want a drink twice as much as the normal drinker. So they have another •Control is lost. The craving cycle has begun •Acetate accumulates in their body with only ONE drink •And this NEVER CHANGES! =acetate starts building up with just one drink with a substance use disorder -no SUD? = you filter out acetate, doesn't build up as dramatically

addictive disease: a child's problem

•Based on data from the combined 2009 to 2014 National Surveys on Drug Use and Health •1 in 8 children (8.7 million) aged 17 or younger lived in households with at least one parent who had a past year substance use disorder (SUD) •About 1 in 10 children (7.5 million) lived in households with at least one parent who had a past year alcohol use disorder. •About 1 in 35 children (2.1 million) lived in households with at least one parent who had a past year illicit drug use disorder.

key terms/concepts

•Blood alcohol level •Dual diagnosis •Substance Addiction •*Substance Intoxication •*Substance Withdrawal *These topics covered under Voiceover: "Withdrawal Education with Scenarios" Or SBIRT voiceover •Non-substance addiction: gambling, internet, sexual •Wernicke's Encephalopathy •Korsakoff Psychosis •Tolerance •Blackouts •Relapse •Rehabilitation •Recovery •Drugs of Abuse Screen Screening Instruments: •CAGE-Aid •*CRAFFT •*AUDIT

biological: dopamine and drug use

•Cocaine: *stops the molecules that usually mop up excess dopamine. •Amphetamines: *push the dopamine out of the sacs where it is stored •Heroin: *makes the dopamine-containing neurons fire more •Alcohol: *helps release more dopamine •Excess of dopamine ---> "feeling high." •Relapse is very common.

Substance-Use and Addictive Disorders (SUAD)

•Discuss the current incidence, trends and epidemiology of Addictive Disease.- not exam material. *need to know the s/s of addiction from the pwpt on addiction education, will NOT be giving a numeric score to a symptom, need to know how to differentiate the s/s of the 2 types of withdrawal •Describe the social, psychological and biological processes of *SUAD •Understand the role of dopamine in addiction and the role of acetate in the physiological process of craving. •Explain the concepts of addiction, intoxication, withdrawal and tolerance. •Understand the symptoms and management of Wernicke's Encephalopathy and Korsakoff Psychosis.. •Use non-stigmatizing language when referring to the care of persons with SUAD. •Apply the nursing process to care of the client with an SUAD. •Understand the interdisciplinary focus of care for persons with an SUAD.

immature brain development: developing brain

•Early experiences affect brain development -if you start to use when you're younger = predisposition *easier to become addicted when younger bc worse judgement/brain not developed yet •Early stress and trauma change the brain's responses •The brain continues to develop until age 24 or later •The adolescent brain matures from Back to Front •Back: *areas of emotion, memory, impulse, psychomotor activity (amygdala) •Front: *areas of executive function, planning, problem-solving, judgment, impulse control, organization •Pathways and patterns are established *when making a decision, adults rely more on the frontal cortex, while teens rely more on the amygdala *brain doesn't finish developing until a person is 25-28 years old; there's a reason insurance companies won't let you rent a car until you're 25 = impulsivity is strong and decision making isn't fully developed

predisposing factors for child addiction

•Genetic predisposition •Certain brain chemistry (reaction: euphoric or ill) •Psychological factors (e.g., stress, personality traits like high impulsivity or sensation seeking, depression, anxiety, eating disorders, personality and other psychiatric disorders) •Environmental influences (e.g., exposure to physical, sexual, or emotional abuse or trauma, substance use or addiction in the family or among peers, access to an addictive substance; exposure to popular culture references that encourage substance use) -having access (ex parent's alcohol in the fridge = readily available) -if mom and dad have alcohol or drug use problem= it's in the home •Starting alcohol, nicotine or other drug use at an early age!

MSUD (mental and substance use disorders) prevalence

•In 2016, 55 MILLION people age 18 and older •45 mental disorder alone •11 million SUD alone •8 million MSUD (mental AND SUD = dual diagnosis) •Estimated cost of treating MSUD including lost work and productivity = $402 BILLION •MSUD linked to many physical conditions such as diabetes, heart disease an asthma

psychological effects of stimulants- ecstasy (derived from amphetamine)

•Initially, it causes mild euphoria, increased energy, and increased libido •Depression, anxiety, and psychosis have also been described with regular use

Korsakoff psychosis

•It is *NOT reversible* (thiamine won't fix) -have psychosis (delirious, hallucinations) •*Persistent learning and memory problems* •Chronic and debilitating syndrome •Ataxia •Disorientation •*Delirium/psychosis* •*Confabulation*- filling in memory gaps with fabricated or imagined data -a case of anterograde amnesia; clients have no awareness of their memory defect, nor do they care •Neuropathy *typically happens over decades of use, but not always

alcohol and drug abuse - what's the problem

•Nearly ½ of injuries brought into the ER are EtOH-related ex. MVA, cirrhosis •"Problem drinkers" high risk for recurrent injury if EtOH problem remains untreated •Trauma pts highly likely to be "hazardous or harmful" drinkers

psychological effects of stimulants - cocaine

•euphoria /increased alertness and energy similar to mania •After use, > anxiety and depression, often with drug craving •w/ continued regular use, symptoms of psychosis (ex. hallucinations and paranoid delusions)

psychological effects of stimulants- phenycylidine (PCP) intoxication

•may present with psychosis and with particularly agitated and violent behavior

substance withdrawal

•s/s develop when a substance is discontinued abruptly after frequent, heavy, and prolonged substance use •s/s (anxiety, irritability, restlessness, insomnia, fatigue) differ and are specific to each substance (cocaine, alcohol) *alcohol and benzo withdrawal is scarier