Substance Abuse

Medical Consequences of barbiturates

Barbiturate use decreases REM sleep thus reduced dreaming Respiratory depression Hypotension Biphasic response to sexual functioning (first increased libido, then inability to maintain an erection)

Opioid Intoxication

Behavioral and physiological changes during or after use Euphoria followed by dysphoria Psychomotor agitation Impaired judgment Pupillary constriction Drowsiness Slurred speech Respiratory depression Coma and death can result from severe intoxication

Medical Intervention for Detoxification

CNS depressants- Benzodiazapines CNS stimulants:-Tranquilizers Narcotics- for overdose, a narcotic antagonist is used; for withdrawal, rest, nutrition, and methadone or buprenorphine is used. Hallucinogens- benzodiazapines can be used for anxiety or panic. Psychotic reactions can be treated with antipsychotics

Outcome Criteria

Decrease in pain score to below 5 on a 1 to 10 scale Identifies an AA/NA group to attend after discharge Vital signs remain stable during withdrawal phase Family communication patterns improve as seen in family meetings and visiting hours Expresses realistic appraisal of strengths and limitations Identifies relapse triggers and ways to avoid them Experiences decreased craving Sensorium remains clear throughout detoxification

Biological Factors

Genetics: Children of alcoholics are 3 times as likely to become alcoholics. This suggests a hereditary component. Other drugs do not show the same genetic effect. In 2013, one gene related to alcohol dependence was identified). Biochemical aspects: A morphine like substance produced in the brain by alcohol may cause the addictive response.

Role of the Nurse

On an inpatient unit, the nurse completes an initial assessment often getting a history of the drug use from family members. The nurse monitors vital signs, administers medications to manage withdrawal, institutes seizure precautions if warranted. In the acute stage in the hospital, the nurse's role includes facilitating support groups and therapy groups

Psychological Factors

There are personality traits which are associated with substance abuse. For example, people who want immediate gratification of needs, have low self esteem, and/or are depressed find substance use helps cope with these feelings. They do not have communication skills so when they are anxious, lonely, or in distress of any kind. rather than turning to others they withdraw through using drugs.

Delirium Tremens

Involves profound confusion and disorientation, hallucinations and seizures. Without medical treatment cardiovascular collapse can result in death.

The Chemically Impaired Nurse

It is estimated that 10-15% of nurses suffer from the disease (Thomas & Siela, 2011). There is often strong denial on the part of the impaired nurse and his/her colleagues. Clues for recognizing them: There may be high absenteeism if the source is outside of work or the individual rarely misses work if the substance is at work, There may be an increase in the wasting of drugs, higher incidence of incorrect narcotic counts, and a higher record of signing out drugs that from other nurses. Poor concentration, difficult meeting deadlines, inappropriate responses or poor memory, elaborate excuses for behavior and irritability.

Barbiturates Withdrawal

Length of time to symptoms depends on half life of drug. Lorazepam withdrawal may show signs in 6-8 hours of decreasing blood level. Diazepam withdrawal can take up to a week to show symptoms, with the peak of withdrawal in the second week. Autonomic hyperactivity- sweating Pulse > 100 Increased hand tremor Nausea and vomiting Insomnia Hallucinations Illusions Psychomotor agitation Anxiety Grand mal seizures

Opioid Withdrawal

Nausea and vomiting Muscle aches Lacrimation or rhinorrhea Pupillary dilation Sweating Abdominal cramping Yawning Insomnia Fever

Alcohol Withdrawal

Occurs within 4-12 hours of stopping or reducing alcohol use. Symptoms: include coarse tremor of hands, tongue, or eyelids, nausea or vomiting, malaise or weakness, tachycardia, sweating, elevated blood pressure, anxiety, depressed mood or irritability, transient hallucinations or illusions, headache, and insomnia. Withdrawal signs peak at about 4 days and subside gradually. It can take one to two more weeks before a person is symptom free. Medical emergencies can occur during this period if there are cardiovascular complications or renal disease. Benzodiazepines are the most commonly used group of drugs during withdrawal

Medical Consequences of Alcohol

Peripheral neuropathy- peripheral nerve damage causing pain, burning, tingling, prickly sensations of the extremities. Can result from deficiency of B vitamins. Alcoholic Myopathy is muscle pain, swelling, and weakness. This occurs in both acute and chronic states, but in the chronic state the muscles may show more of a gradual wasting without the pain. Wernicke's Encephalopathy result from Thiamine deficiency (B Vitamin). Symptoms include paralysis of ocular muscles, ataxia, and eventually stupor. Death occurs without replacement therapy. Korsakoff's Psychosis- confusion, recent memory loss, and confabulation. Also from thiamine deficiency. (together these two are known as Wernicke-Korsakof ). Alcoholic cardiomyopathy is an enlargement and weakened condition of the heart leading to CHF or arrhythmia. Esophagitis occurs due to toxic effects of alcohol directly on esophagus. Gastritis- inflammation of stomach lining from alcohol. Alcoholic hepatitis- Long term heavy use of alcohol can cause inflammation of the liver. Cirrhosis of the liver- end stage liver disease resulting from long term alcohol abuse. Fetal alcohol syndrome

Meperidine

Short acting opioid. Withdrawal symptoms can reach their peak in 8-12 hours.

Heroin

Short acting opioid. Causing withdrawal symptoms within 6-12 hours after the last dose. The symptoms peak within 1-3 days and gradually subside over 5-7 days.

Treating Codependency

Stage 1 The survival stage: Coda's must begin to let go of their denial that problems exist or that their personal capabilities are limited. Stage 2: The Reidentification stage: Codas are able to glimpse their true selves and break into a denial system. They accept the label of co-dependent and take responsibility for their won dysfunctional behavior. They are willing to accept their limitations and face their issues. Stage 3: Core Issues Stage: must face that relationships can not be managed by force of will. Each partner must be independent and autonomous. Stage 4 :The Reintegration Stage-Codas relinquish control over others that was not rightfully theirs and reclaim the personal power that they possess. Control is achieved through self-discipline and self confidence. Co-Dependents Anonymous (Coda)

Dual Diagnosis

Substance related disorder which co-occurs with another psychiatric disorder. The most common of the disorders are anxiety and depression. Schizophrenics have a high rate of substance abuse. Studies indicate that 70% of alcoholic patients meet criteria for another psychiatric diagnosis. Patient admitted to a psychiatric inpatient facility for substance related issues (e.g. overdose, withdrawal, rehab, hallucinations) needs to be assessed for such additional diagnoses and made part of the treatment plan. For example, it would be difficult to motivate someone to stop drinking if it's their method for grieing friend or family member who died. Focusing on healthy grieving such as talking about the loss, looking over old photos, crying, etc. in order to heal is a better coping strategy.

CNS stimulant withdrawal symptoms

The DSM-5 describes the symptoms of a crash as intense depression with possible paranoid or suicidal ideation Occur within hours to several days. Increase in appetite Extreme fatigue

Sedative-Hypnotics and Anxiolyics Dependency

The most frequently prescribed of all drugs by physicians. This category includes drugs which can induce CNS depression, from simple relief of anxiety to coma and death. They have an additive effect with each other and with the behavioral state of the user. They are capable of producing both physical and psychological dependency. Cross tolerance or cross-dependence can occur. Cross tolerance: means there is a reduced response to another drug in this category Cross dependence: means one drug can prevent withdrawal symptoms associated with physical dependence on a different drug. Included are barbiturate and non-barbiturate hypnotics and anti-anxiety agents

Hallucinogen Abuse

These "mind expanding" drugs cause visual hallucinations in typical street use and auditory hallucinations in schizophrenics. The experience is described by many as "spiritual" due to feeling out of body and watching whatever is happening. Bad trips are described as feeling as if you are going insane. Flashbacks can occur months after using the drug. There is no withdrawal syndrome, the experience can be extremely unpleasant and frightening for some people

Codependent person

This individual is able to achieve a sense of control only through fulfilling the needs of others. Personal identity is relinquished and boundaries with the other person becomes blurred. The codependent person disowns his or her own need s and wants to respond to external demands and the demands of others. Codependence has been called a "dysfunctional relationship with oneself." "People-pleasers "and will do anything to get the approval of others. Outwardly they appear very competent, but actually feel quite needy, helpless or nothing at all. Have experienced abuse or emotional neglect as a child. Are outwardly focused towards others . They know very little how to direct their own lives from their own sense of self

Sociocultural Factors

When alcohol or other substances are used freely in the home, social learning occurs. the person begins to have a pleasurable experience, conditioning occurs and the behavior is repeated.

Substance Dependence Criteria

1. Tolerance, is defined by either of the following: (a) A need for markedly increased amounts of the substance to achieve intoxication or the desired effect or (b) Markedly diminished effect with continued use of the same amount of the substance. 2. Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for the substance or (b) The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms. 3. Substance is taken in larger amounts or over a longer period than intended. 4. Persistent desire or unsuccessful efforts to cut down or control substance use. 5. Great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of substance use. 7. Substance use is continued despite knowledge of persistent physical or psychological problem likely caused or exacerbated by the substance (for example, current cocaine use despite recognition of cocaine-induced depression or continued.

Codependency and Nursing

Certain characteristics of Codependence has been associated with nursing. Such as large ratio of pts with small amount of nurses. Expect that they should take care of everyone. Especially those who have been reared in homes with chemically dependent people may have unresolved "fixer" roles. They are attracted to a profession that they are needed but feel resentment for receiving so little in return. They may work excessively, food or spending addictions. They also may strive to be super moms. High risk of physical and emotional burnout Codependent nurses have a need to be in control, strive for unrealistic levels of achieving. Their self-worth comes from the feeling of being needed by others and maintaining control over their environment. They nurture the dependence of others and accept responsibility for the happiness of others. They rarely express their true feelings and do whatever necessary to preserve harmony and maintain control. They are high risk for physical and emotional burnout.

Cultural Factors

Culture can influence alcohol consumption. In some European countries drinking is common. Italy has no minimum drinking age, children have wine with meals. In Native American culture there is a high degree of alcohol dependency (more than 7 times the national average).

Codependency

Describe the protective, caretaking role of a family member in keeping the drug use a secret, making excuses for the person's use, and generally taking care of any problems that arise in the context of the abuse. Allows the drug user to continue, while also allowing the codependent person to continue to be needed. The concept of codependency came from defining dysfunctional behaviors that are evident among members of the family of a chemically addicted person. It has now been expanded to include all individuals from families that have secrets of physical or emotional abuse, other cruelties, or pathological conditions. A codependent is confused about his/her own identity. In a relationship, the codependent derives self-worth from that partner, whose feelings and behaviors determine how the codependent should feel and behave. She/he only feels good when his/her partner is happy and behaves in appropriate ways. If the partner is not happy, the codependent feels responsible for making him happy. Hence, stressful home lives, ego boundaries weak and behaviors are enmeshed. Feelings are kept under control, and anxiety is released ion the form of stress-related illness or compulsive behaviors such as eating, spending, working or use of substances.

CNS Stimulant Abuse and Dependence

Include psychomotor stimulants which work through stimulation of neurotransmitters (norepinephrine, epinephrine,or dopamine) General cellular stimulants which act directly on cellular activity. The former type includes cocaine and amphetamines. The latter type includes caffeine and nicotine. Effects: Tremor, restlessness, anorexia, insomnia, agitation, increase in alertness, decrease in fatigue Stimulant Intoxication: euphoria, hypervigilance, anxiety, tension or anger, impaired judgment