Substance Abuse, Chapter 15

Pharmacologic treatment used to attain sobriety

*Disulfiram (Antabuse) - alcohol deterrent*, causes adverse affects when combined with alcohol, used to manage alcohol dependence in motivated pts, interferes with alcohol metabolism causing toxic levels of acetaldehyde which causes flushing, sweating, headache, chest pain, nausea, and vomiting *Naltrexone (ReVia) - opiate antagonist, decreases craving for alcohol and blocks effects of opioid medications*, doesn't cause severe reaction like disulfiram, effectiveness depends on medication adherence *Acamprosate (Campral) - assists alcohol dependent pts who are already abstinent maintain sobriety*, restores balance between neurotransmitters glutamate and gamma-aminobutyric acid (GABA) that was disrupted during chronic alcohol use *Methadone maintenance therapy* - used in daily doses, *long-standing treatment of opioid dependence* *Buprenorphine - opioid partial agonist, for withdrawal* or daily doses for maintenance therapy *Clonidine (Catapres)* - central alpha-adrenergic agonist hypotensive agent to treat *symptoms of alcohol, opiate, and nicotine withdrawal* *Naloxone injection (Narcan) - opioid antagonist, reverses or prevents effects of narcotic pain relievers, instantly reverses respiratory depression and hypotension* from overdoses *Bupropion (Zyban, Wellbutrin) - for smoking cessation*, increases dopamine and norepinephrine, doesn't cause weight gain, increases seizure risk *Varenicline (Chantix) - for smoking cessation*, decrease withdrawal symptoms, decreases pleasure associated with smoking *SSRI - can be used to decrease drinking or promote abstinence*

In what ways can the nurse be instrumental in motivating the client to accept treatment?

*Motivational interviewing* delivers interventions in a neutral and empathetic way, eliciting the client to identify pros and cons of sobriety. This is also known as *Motivational Enhancement Therapy*. It helps the patient to recognize and accept the need for change; less defensive, more proactive approach; alternative to confrontational style. There are 6 components and the mnemonic FRAMES is used: F= Feedback on personal impairment, R= Emphasis of personal responsibility, A= Clear advice to change, M= Menu of alternative options or choices, E= Empathy as a counseling style, S= Self-efficacy or removal of barriers to achieving goals. The strategies include open-ended questions, asking the client to present pros and cons of quitting, demonstrating listening by reflecting client's thoughts, summarizing client's thoughts, helping client identify and build on past attempts to quit, showing empathy, asking permission to provide information, asking client to identify strategies for quitting, and recognizing client's right to accept or reject change and offering to help when client is ready for change. With this technique, *clients set the agenda* and *therapists act as a partner rather than an authority*. Sometimes the client isn't ready for abstinence; work towards moderation.

Incidence and prevalence of substance-related disorders

-100 K people receive inpatient treatment due to alcohol and other substances a year -Persons between 18 and 24 use the greatest amount of all substances. -Average first marijuana use is 14, Alcohol is before 12 -Drugs depend on popularity and vailability, Marijuana and Cocaine are the most commonly used illicit drugs -Ecstasy and Methamphetamine are the common club and rave drugs -Oxycodone and Benzodiapzines are two prescription drugs are frequently abused -High doses of cough and cold preparations can cause a similar effect to PCP -Decongestants, pseudoephedrine, and ephedrine are used to make methamphetamine -Alcohol is associated with 100-200 K deaths a year

Describe the critical factors in the nurse-client relationship when treating the symptoms of intoxication and withdrawal.

-Motivation to achieve long-term treatment and sobriety that comes from establishing a relationship in a period of acute discomfort -Sensitivity to guilt, low self-esteem, and embarrassment; the client may be extra sensitive to rejection -Recognize the client's strengths and accomplishments -Validate the discomfort the client is experiencing -Give positive feedback when indicated -Create opportunities for the client to contribute to the unit or to assist other clients -ALWAYS show respect for the client as a person -The nurse must have self-awareness of personal prejudices regarding drug users and alcoholics -Watch WHAT you say and HOW you say it

Important teaching points for client and family to become familiar with that are related to Dual Diagnosis

-The neurobiology of the mental disorder and the addiction provides the foundation to help the client and family or significant other understand the relationship between two disorders. - The role of prescribed medication must be carefully explained, as well as the importance of not stopping the medication or changing the dosgae. Complinance indicates recovery and non-compliance is an indicator for relapse. - Inform the client of possible side effects of psychotropic medications and teach simple strategies to lessen discomfort. Clients have resorted to alcohol and drugs to attempt to relieve side effects. - Educate the client about the interaction between prescribed medications and possible substance abuse so that the client understands the increased risk of these substances present. Anticholinergic effects can be increased by marijuana use. neuroleptic effects are reduced if alcohol, sedatives, and nicotine are used. MAOIs may cause a hypertensive crisis if combined with alcohol or stimulants. - Families and clients need to be informed of the warning signs of relapse, and families need to recognize early signs of non-compliance with medication or substance use.

Etiology of substance abuse

-There is no one cause. -Combination of neurobiologic, genetic, social, and psychological factors. -Studies show a genetic predisposition with other variables that attribute to it. - More research required. - If parents have substance abuse disorders, the children are at an increased risk. -Depression, low self-esteem, loneliness, stress, pleasure seeking attitudes attribute. -Substance abuse is a very complex, multifactorial issue.

Issues of pregnancy and substance abuse and fetal alcohol syndrome.

-increased risk of complications such as miscarriage, preeclampsia, placental abruption, early labor -places fetus at higher risk for birth defects, low birth weight, stillbirth, prematurity, cardiac problems -babies withdrawing -FAS: severe end of FASD(fetal alcohol spectrum disorders) fetal death is most extreme outcome, but can cause abnormal facial features, growth problems and CNS problems(memory, communication, seeing, hearing, attention span, learning

What facts are important for the nurse to know when caring for a client undergoing detoxification?

1. *Alcohol and sedative-hypnotic medications may decrease efficacy of neuroleptic medications*, making them less effective in controlling the psychotic symptoms, depression, or seizures medication is useful for. 2. Using alcohol, sedatives, and cocaine while taking phenothiazine, neuroleptic, have increased risk for *respiratory depression*. 3. *Neuroleptic medication lowers the threshold for seizures* so patients taking them are *at risk for withdraw seizures* 4. *Lithium, used for bipolar disorder, is sensitive to changes in fluid and electrolyte balance*. Vomitting and diarrhea caused by withdrawal can result in *lithium toxicity*. Lithium levels should be evaluated during withdrawal as well as assessing for signs of Lithium toxicity. Signs include vomiting, diarrhea, slurred speech, drowsiness, muscle weakness or twitching, and decreased coordination

Two major assessment tools commonly used to assess substance abuse

1. Cage Test- 4 questions that were orginally for alcoholics. -Have u ever felt you ought to Cut down on your drinking or drug use? -Have people Annoyed you by criticizing your drinking or drug use? -Have you ever felt bad or Guilty about your drinking or drug use? -Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover? (have you ever had a drink or drugs as an Eye opener?) 2. Alcohol Use Disorder Identification Test (AUDIT) is useful in a variety of settnigs and with a range of target population. Includes 10 questions that client answers. -They start with How often. -Two or more positive answers is clinically significant, 1 means they need follow up -Remember they do not always report accurate amounts.

Korsakoff's syndrome

A cognitive disorder of anterograde amnesia (an inability to form new memories) and confabulation associated with a deficiency of thiamine, and usually found in chronic alcoholism. It follows the acute phase of Wernicke's encephalopathy.

Denial

A defense mechanism that prevents an individual from recognizing reality; commonly used by individuals who are unable to recognize the destructive effects of substance use.

Codependence

A dynamic common among significant others of persons with substance dependence or abuse; characterized by behaviors that support or enable the substance use. Frequently family members and significant others may not have been aware of how their behaviors actually supported or enabled the drinking of drug use, creating a codependence. Suggest support groups for family members such as Al-Anon and Alateen

Tolerance

A person's need for increasing amounts of a substance to achieve the desired effects.

Wernicke's encephalopathy

A serious neurotoxic effect of alcohol abuse, related to thiamine deficiency; It is characterized by mental confusion, eye movement disturbances,and ataxia. It is the first stage of Wernicke-Korsakoff syndrome. (see Korsakoff syndrome)

Intoxication

A substance-specific syndrome that results from recent ingestion or exposure to a substance.

Motivational interviewing

A type of counseling in which interventions are delivered in a neutral and empathetic way, actively eliciting the client to identify the pros and cons of alternative problem solving approaches. It has been used effectively to change addictive behaviors that interfere with health.

All of the following substances are considered central nervous system stimulants, except A. cocaine B. caffeine C. methadone D. methamphetamine

All of the following substances are considered central nervous system stimulants, except C. methadone

Withdrawal delirium (book definition)

Also known as delirium tremens (DTs), a life-threatening complication of alcohol withdrawal characterized by agitation, disorientation, visual hallucinations, elevated temperature, and cardiac arrhythmias.

Important teaching points for client and family education about the nature of addictions

Be sure to check page 364 -Addiction is a chronic illnessand the causes are complex and not fully understood -Clients and families need to learn about the specific actions and effects of the substances involved. -The best success has been with a abstinence model. -Recovery often requires changes in the recovering persons lifestlye, including new friends and activites. -New coping skills can be taught such as social skills, assertive communication and relaxation techniques. -Clients need to learn to take care of themselves -Positive self esteem is crucial for staying sober. -Relationships may change when someone becomes sober. (think about co-dependence) -Family and significant others need education on how to assist the client.

Substance abuse

Brief or chronic episodes of substance use that result in failure to meet major role obligations, legal problems, or recurrent social or interpersonal problems. There is no evidence of physiologic or psychologic dependence.

CNS stimulants constrict the pupils. A. TRUE B. FALSE

CNS stimulants constrict the pupils. B. FALSE (Tiger walks into a room. Pupils dilate to take in more light and information, thus faster response.)

Problems surrounding the abuse of Cannabinoids, Phencyclidine and Inhalants

Cannabinoids (Marijuana and Hashish) -The drugs depress the higher organizational centers in the brain, resulting in the effect of euphoria and altered perceptions. -Intoxication is characterized by anxiety, suspiciousness, and impaired coordination and judgment, hallucinations, tachycardia, and red injected conjunctiva. Cannabinoids potentiate the effect of CNS depressants, including alcohol. -Withdrawal symptoms include restlessness, irritability, insomnia, sweating, nausea, vomiting, bad trips, delirium, or flashbacks. There is no treatment indicated for detoxification from cannabinoids. Phencyclidine (PCP and angel dust) -It produces peripheral sympathetic and anticholinergic effects, as well as central psychotomimetic, anticholinergic, and adrenergic effects. It is stored in the brain and adipose tissue resulting in serum half-life can be extended for up to 3 days. Based on the dose, PCP can act as an analgesic, depressant, or stimulant. -Intoxication is characterized by impairment, judgment, nystagmus, elevated heart rate and blood pressure, muscle rigidity, ataxia, seizures, delirium, paranoid, unpredictable and violent behavior. -Withdrawal symptoms include lethargy, depression, and drug craving. There is no detoxification is required. Inhalants (glue, paint, paint solvents, aerosol spray, cleaning fluids, gasoline, typewriter correction fluids, nitrous oxide, and amyl nitrate) -The drugs cause diffuse impairment of brain function. They produce euphoria, high, with altered perception. -Intoxication is characterized by slurred speech, ataxia, impaired judgment, dizziness, tremors, and sudden death due to acute arrhythmia, hypoxia or electrolyte abnormalities. -Withdrawal symptoms include irritability, dysphoria, sleep disturbance, headache, dry mouth, and lacrimation within 24 hours of abstinence and lasting for several days. Benzodiazepines might be a choice of treatment for inhalant withdrawal; however, there is no definite treatment is indicated.

DSM-5 criteria for substance abuse.

DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Criteria: -Substance abuse interferes with the person's major responsibilities at home, work, or school -Repeated use occurs in hazardous situations, such as driving while impaired -Person experiencing recurrent substance-related legal problems -Person has recurring social problems -Tolerance -Withdrawal - Greater use of substance than intended - Inability to stop use -Preoccupation with obtaining, using, or recovering from substance -Giving up important activities in order to use -Continues with substance even when risks are presented Severity of the DSM-5 substance use disorders is based on the number of criteria endorsed: 2-3 criteria = mild disorder 4-5 criteria =moderate disorder 6 or more = severe disorder. Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained remission is defined as at least 12 months without criteria (except craving).

Detoxification protocols have been developed and implemented for all of the following substances, except A. alcohol B. opioids C. cannabinoids D. nicotine

Detoxification protocols have been developed and implemented for all of the following substances, except C. cannabinoids

Issues surrounding CNS stimulants and abuse

Examples of CNS stimulants are caffeine, cocaine, amphetamines and methylphenidate (Ritalin). Crack is a form of cocaine, less expensive and readily available. It is highly addictive and is characterized by a quick high and sudden crash, accompanied by depression afterwards. Methamphetamines is also less expensive and produces a longer high like crack, resulting in an intense crash. Ecstasy known as MDMA, is a synthetic drug with amphetamine like effects. Methamphetamine and amphetamine can be consumed by smoking (ice, crystal meth), inhalation or injection. These drugs stimulate CNS by enhancing the actions of neurotransmitter dopamine and norepinephrine. Side effects: alertness, euphoria, decreased appetite, and an enhanced sexual response. Intoxication from CNS stimulants are characterized by anxiety, confusion, paranoia, irritability, grandiosity, rhinitis, insomnia, tactile hallucinations, increased or decreased heart rate, chest pain, cardiac arrhythmias, dilated pupils and respiratory distress. Seizures results from cocaine intoxication. Withdrawal symptoms: symptoms vary from person to person. Symptoms are: dysphoric mood, agitation, suicidal ideation, fatigue, insomnia, vivid dreams, extended sleep, hunger, and drug craving. Detoxification: stabilize the client's vital signs and manage behavior. Combination therapy and medication such as Librium and Haldol may be used, intravenous antihypertensive and diazepam may be used to control seizures. Clients who use heroine get into a program of detoxification using methadone (synthetic heroin). Side effects of methadone results in tooth decay, restlessness, weakness, joint pain, numbness etc.

What is the difference in substance abuse and substance dependence?

For abuse, the person is excessively using the substance without necessarily developing a tolerance or dependence, whereas with dependence the person has a strong physical NEED for the substance Substance abuse- maladaptive pattern of substance use manifested by *recurrent and significant adverse consequences* related to substance abuse Substance dependence- diagnosis is made on evidence of *tolerance, withdrawal, or a pattern of compulsive behavior* related to the substance

Fetal alcohol syndrome

Growth, physical, and mental problems that may result when a mother drinks alcohol during pregnancy. It is the severe end of the fetal alcohol spectrum disorders.

What are some guiding principles when considering pharmacologic treatment in the Dual Diagnosis patient?

I) The clinical should *avoid prescribing medications with a high potential for abuse* (e.g. benzodiazepines, barbiturates) II) The potential for overdose with prescribed medication, either alone or in combination with substances of abuse, must be considered. III) The clinician should consider the interactions that may occur between the prescribed medication and the substance of abuse to minimize the chance of relapse. IV) To adhere to the prescribed dose, the side effects must be tolerable; the client should not need to use alcohol or other drugs to counter unpleasant side effects. V) The benzodiazepines such as lorazepam (Ativan), alprazolam (Xanax), and diazepam are highly addictive, mood-altering drugs that are contraindicated for the dual-diagnosed client after the completion of detoxification. Propranolol (Inderal), and Buspirone (BuSpar) selectively diminish multiple symptoms of generalized and performance anxiety without the acute mood alteration, sedation, and addictive potential of the benzodiazepines.

Inhalant use can result in sudden death due to acute arrhythmia. A. TRUE B. FALSE

Inhalant use can result in sudden death due to acute arrhythmia. A. TRUE

Substance-induced disorders

Intoxication and withdrawal as well as other disorders induced by substances, including delirium, dementia, amnesia, paranoia, depression, anxiety, sexual dysfunction, and sleep disorders.

Issues of abuse with opiates and hallucinogens

Opiates- Effects of opiates include analgesia and decreased gastrointestinal motility. Intoxication from opiates is characterized by respiratory depression, slurred speech, constricted pupils, impaired judgement and functioning, nausea, and vomitting. If person overdoses on opiates is indicated b severe respiratory depression, pinpoint, pupils, and can lead to coma. Narcan is the most used drug to reverse opiod induced respiratory depression. Withdrawal- symptoms of opiate withdrawal are chills, sweating, increase pulse and bloo pressure, muscle aches, abdominal crampls, drug craving, rhinorrhea, yawning, drowsiness, and coma. They begin within hours or days after use. Lasts about a week to two weeks. Detoxification- Methadone is given in decreasing doses to detoxify patients. Pregnant women are maintained on methadone until after delivery.Clonidine is an alternative drug that manages the symptoms of opiates however bp has to be managed since the side effects are sedation and hypotension with Clonidine. Hallucinogens- They alter the client's sensory perception; taste, smell, and touch are highly intensified; the sense of time and space is distorted, and the client experiences visual illusions and emotional lability. Intoxication is characterized by tachycardia, hypertension, and dilated pupils. Withdrawal- Since there is no physical dependence on hallucinogens there is no withdrawal symptoms. However, there are adverse reactions such as panic response or bad trip, delrium, manifested by hallucinations, paranoia, and agitation. These symptoms end in 24 hours. Detoxification- There is no detoxification since the effects subside within 24 hours

Blackouts

Periods of amnesia during which a person appears to function normally but later does not recall the events that transpired.

Persons who use hallucinogens can experience flashbacks for months after the last drug use. A. TRUE B. FALSE

Persons who use hallucinogens can experience flashbacks for months after the last drug use. A. TRUE

Describe the major categories of nursing assessment and substance-related disorders.

Physical assessment: -Vital Signs, neuro checks, lab values Acute medical conditions , e.g. - Hypoglycemia - Subdural hematoma - Pancreatitis - Esophageal varices - Dementia - Hepatitis, cirrhosis Psychiatric assessment - Hx of psychiatric symptoms, treatment, hospitalizations - Be aware of possibility of dual diagnoses Alcohol and drug history - Type and amount of substances used - Method of use - Frequency of use and time last used to anticipate withdrawal onset - History of detoxification, withdrawal, treatment Assess for denial- client minimizes amount of substance use and consequences - Two drinks a day could be two 8-ounce drinks Assess for loss of control - Failed efforts to stop or reduce use - Use more than planned for longer time History of sobriety - How it was achieved - Motivation - Quality of life at time sober - Situation or events surrounding relapse (if applicable)

Explain the difference in substance-induced disorders and substance-use disorders.

Substance-induced means you are experiencing different disorders as a RESULT of taking a substance. Fall into two major categories Some of those include delirium, dementia, amnesia, paranoia, depression, anxiety, sexual dysfunction, and sleep disorders. "Substance induced disorders refer to 2 main categories; intoxication and withdrawal." Substance-use disorders refer to a dependence or abuse of a substance. Not really talking about what the substance does to the person, more of how the person needs or uses it. "Substance use disorders- 2 categories- Can occur as a chronic problem or can be excessive use of a substance over a brief period of time." *Two major substance-use disorders include substance dependence and substance abuse*

Problems surrounding CNS depressants and abuse

The effects of CNS depressants include the relaxation of muscles, sedation, and decreased anxiety. Intoxication from CNS depressants is characterized by slurred speech, ataxia, impaired judgement, agitation, and depression. Severe intoxication can result in paranoia, seizures, stupor, coma, apnea, and even death. Alcohol abuse has also been associated with blackouts or periods of amnesia during which the person appears to function normally but later does not recall the events that transpired. Combining these drugs with alcohol potentiates the effects of intoxication, particularly respiratory depression.

Substance dependence

The excessive and continued use of a substance despite significant impairment to at least one aspect of life: physiologic, psychologic, behavioral, or social. Dependence includes additional symptoms that may include tolerance, withdrawal, preoccupation with the substance, compulsive behavior, or inability to stop or reduce the use of the substance.

Cross-tolerance

The increased tolerance that develops for drugs in the same category.

Detoxification

The process of gradual withdrawal from a substance on which the person is physiologically dependent. This process usually involves the administration of decreasing doses of a substitute medication.

Withdrawal

The process that occurs when a person who is physically addicted to a substance stops using or reduces the intake of that substance after heavy, prolonged consumption. The symptoms of withdrawal vary across substances. (see withdrawal delirium, aka delirium tremens)

Dual diagnosis

The simultaneous existence of one or more substance use disorders and at least one other primary mental disorder. -This is either alcohol, sedatives, amphetamines, cocaine, heroin, marijuana or phenocyclidine. MIXED WITH -either mood disorders such as depression or bipolar, schizophrenia, anxiety disorders including panic attacks, phobias, PTSD, eating disorders, conduct disorder, ADD, personality disorder- most common of these personality disorders are antisocial or borderline personality disorder. MICA- mentally ill chemical abuse Mental illness usually preceeds substance abuse for a while. This is hard to diagnose because you may not know what their symptoms are caused by and the substances can worsen their illness.

Which of the following complications of substance abuse is considered life threatening? A. Drug craving B. Hallucinogen flashbacks C. Delirium tremens D. Opioid withdrawal

Which of the following complications of substance abuse is considered life threatening? C. Delirium tremens Side note: Delirium tremens can occur when you stop drinking alcohol after a period of heavy drinking, especially if you do not eat enough food. Symptoms include: *Seizures* (may occur without other symptoms of DTs; Most common in first 12 - 48 hours after last drink) Body tremors Changes in mental function Agitation, irritability Confusion, disorientation Hallucinations Symptoms of alcohol withdrawal

Which of the following medications is frequently used to detoxify a client in alcohol withdrawal? A. Diazepam (Valium) B. Haloperidol (Haldol) C. Clonidine (Capapres) D. Sertaline (Zoloft)

Which of the following medications is frequently used to detoxify a client in alcohol withdrawal? A. Diazepam (Valium) Side note: Haldol (haloperidol) is indicated for use in the treatment of schizophrenia. Clonidine hydrochloride is indicated for the treatment of HTN as well as ADHD as monotherapy and as adjunctive therapy to stimulant medications. Zoloft (sertraline hydrochloride) is indicated for the treatment of Major Depressive Disorder, OCD, Panic Disorder, PTSD, and Social Anxiety Disorder

Which of the following statements most accurately describes the concept of tolerance? A. A person needs increasing amounts of a substance to achieve a desired effect. B. A person develops over time a psychological dependence on a substance. C. A person uses greater amounts of a substance for longer periods than he/she intended. D. A person has frequent periods of unsuccessfully trying to stop using the substance.

Which of the following statements most accurately describes the concept of tolerance? A. A person needs increasing amounts of a substance to achieve a desired effect.