Townsend Chap 23: Substance-Related and Addictive Disorders

gambling disorder: Tx modalities

1. Because most pathological gamblers deny that they have a problem, treatment is difficult. 2. Most gamblers only seek treatment due to legal difficulties, family pressures, or other psychiatric complaints. 3. Behavior therapy, cognitive-behavioral therapy, motivational interviewing, 12-step programs (Gamblers Anonymous) and self-help strategies such as bibliotherapy have all been used with pathological gambling with various degrees of success. 4. About one-third of individuals with gambling disorders recover naturally without need for treatment 5. Some medications have been used with effective results in the treatment of pathological gambling. i. SSRIs and clomipramine have been used to treat obsessive-compulsive disorders and may have benefits for those with gambling disorder who have comorbid obsessive-compulsive traits. ii. Lithium, carbamazepine, and naltrexone have also been shown effective. iii. Possibly the most effective treatment of pathological gambling is participation by the individual in Gamblers Anonymous (GA). This organization of inspirational group therapy is modeled after Alcoholics Anonymous.

codependency: Tx

1. Four stages in the recovery process for individuals with codependent personality: a. Stage I: The Survival Stage In this first stage, codependent persons must begin to let go of the denial that problems exist or that their personal capabilities are unlimited. b. Stage II: The Reidentification Stage Reidentification occurs when the individuals are able to glimpse their true selves through a break in the denial system. They accept the label of codependent and take responsibility for their own dysfunctional behavior. i. Codependents tend to enter reidentification only after being convinced that it is more painful not to do so. ii. They accept their limitations and are ready to face the issues of codependence. c. Stage III: The Core Issues Stage In this stage, the recovering codependent must face the fact that relationships cannot be managed by force of will. Each partner must be independent and autonomous. i. The goal of this stage is to detach from the struggles of life that exist because of prideful and willful efforts to control things that are beyond the individual's power to control. d. Stage IV: The Reintegration Stage This is a stage of self-acceptance and willingness to change when codependents relinquish the power over others that was not rightfully theirs but reclaim the personal power that they do possess. i. Self-help groups have been found helpful in the treatment of codependency. Groups developed for families of chemically addicted people, such as Al-Anon, may be of assistance. ii. Groups specific to codependency also exist. One of these groups, which bases its philosophy on the Twelve Steps of Alcoholics Anonymous (see the section that follows) is Co-Dependents Anonymous (CoDA)

gambling d/o: predisposing/risk factors

1. Genetic Familial and twin studies show an increased prevalence of pathological gambling in family members of individuals diagnosed with the disorder. 2. Physiological Studies of dopamine receptor systems have implicated this neurotransmitter in the development of addictive personality traits, including pathological gambling 3. Biochemical theories suggest that, ironically, both winning and losing (perhaps related to the excitement of taking a risk) may stimulate the reward and pleasure centers of the brain. This could contribute to persistent and repeated desire to gamble even when one is not winning. 4. Psychosocial Influences a. "loss of a parent by death b. separation c. divorce d. desertion before the child is 15 years of age e. inappropriate parental discipline (absence, inconsistency, or harshness) f. exposure to and availability of gambling activities for the adolescent g. a family emphasis on material and financial symbols and a lack of family emphasis on saving, planning, and budgeting

Group therapy

1. Group therapy has long been regarded as a powerful agent of change with those who abuse substances. i. In groups, individuals are able to share their experiences with others going through similar problems. They are able to "see themselves in others" and thus confront their defenses about giving up the substance. ii. They may recognize similar attitudes and defenses in others. iii. Groups also give individuals the capacity to communicate needs and feelings directly. iv. In task-oriented education groups, the leader is charged with presenting material associated with substance abuse and its effects on the person's life. v. Teaching groups differ from psychotherapy groups, whose focus is on helping individuals understand and manage difficult feelings and situations, particularly as they relate to substance use. vi. Therapy groups and self-help groups such as AA are complementary to each other. vii. Whereas the self-help group focus is on achieving and maintaining sobriety, in the therapy group the individual may learn more adaptive ways of coping, how to deal with problems that may have arisen from or were exacerbated by the former substance use, and ways to improve quality of life and function more effectively without substances.

codependency

1. Includes all individuals from families that harbor secrets of physical or emotional abuse or pathological conditions. 2. Living under these conditions results in unmet needs for autonomy and self-esteem and a profound sense of powerlessness. 3. The codependent person is able to achieve a sense of control only through fulfilling the needs of others. 4. Personal identity is relinquished and boundaries with the other person become blurred. 5. The codependent person disowns his or her own needs and wants in order to respond to external demands and the demands of others. 6. Codependence has been called "a dysfunctional relationship with oneself." 7. The traits associated with a codependent personality are varied. In a relationship, the codependent person derives self-worth from that of the partner, whose feelings and behaviors determine how the codependent should feel and behave. 8. In order for the codependent to feel good, his or her partner must be happy and behave in appropriate ways. If the partner is not happy, the codependent feels responsible for making him or her happy. 9. The codependent's home life is fraught with stress. 10. Ego boundaries are weak and behaviors are often enmeshed with those of the pathological partner. 11. Denial that problems exist is common. 12. Feelings are kept in control, and anxiety may be released in the form of stress-related illnesses or compulsive behaviors such as eating, spending, working, or use of substances.

Nursing Process: substance abuse d/o: Pt/family education

1. Nature of the Illness a. Effects of (substance) on the body Alcohol b. Other CNS depressants c. CNS stimulants d. Hallucinogens e. Inhalants f. Opioids g. Cannabinols h. Ways in which use of (substance) affects life. 2. Management of the illness a. Activities to substitute for (substance) in times of stress b. Relaxation techniques c. Progressive relaxation d. Tense and relax e. Deep breathing f. Autogenics g. Problem-solving skills h. The essentials of good nutrition 3. support services a.Financial assistance b. Legal assistance c. Alcoholics Anonymous (or other support group specific to another substance) d. One-to-one support person

Nursing Process: substance abuse d/o: Dx

1. Nursing Dx a. Denial b. Ineffective coping c. Imbalanced nutrition: Less than body requirements/Deficient fluid volume d. Risk for infection e. Chronic low self-esteem f. Deficient knowledge FOR THE CLIENT WITHDRAWING FROM CNS DEPRESSANTS: g. Risk for injury FOR THE CLIENT WITHDRAWING FROM CNS STIMULANTS: h. Risk for suicide

substance abuse d/o: Tx modalities

1. Self help groups eg Alcoholics Anonymous 2. Counseling therapy 3. Group therapy 4. Substitution therapy c. Depressants i. Substitution therapy for CNS depressant withdrawal (particularly barbiturates) is most commonly combined with the long-acting barbiturate phenobarbital (Luminal). ii. Long acting benzodiazepines are commonly used for substitution therapy when the abused substance is a nonbarbiturate CNS depressant. d. Stimulants i. Treatment of stimulant intoxication usually begins with minor tranquilizers such as chlordiazepoxide and progresses to major tranquilizers such as haloperidol (Haldol). ii. Antipsychotics should be administered with caution because of their propensity to lower seizure threshold. iii. Repeated seizures are treated with intravenous diazepam. iv. Withdrawal from CNS stimulants is not the medical emergency observed with CNS depressants. v. Treatment is usually aimed at reducing drug craving and managing severe depression. vi. The client is placed in a quiet atmosphere and allowed to sleep and eat as much as needed or desired. vii. Suicide precautions may need to be instituted. viii. Antidepressant therapy may be helpful in treating symptoms of depression. e. Hallucinogens and Cannabinols i. Substitution therapy is not required with these drugs. ii. When adverse reactions such as anxiety or panic occur, benzodiazepines (e.g., diazepam or chlordiazepoxide) may be prescribed to prevent harm to the client or others. iii. Psychotic reactions may be treated with antipsychotic medications.

sedative, hypnotic or anxiolytic: withdrawal

1. Sx develop after a marked decrease in or cessation of heavy or prolonged intake. 2. Onset of symptoms depends on the drug from which the individual is withdrawing. 3. With short-acting sedative-hypnotics (e.g., alprazolam, lorazepam), symptoms may begin between 12 and 24 hours after the last dose, reach peak intensity between 24 and 72 hours, and subside in 5 to 10 days.

substance-related disorders: predisposing factors

1. biological factors: genetics, biochemistry 2. psychological factors: developmental influences, personality factors (low self-esteem, frequent depression), cognitive factors 3. sociocultural factors: social learning, conditioning, cultural and ethnic influences

Disulfiram (Antabuse)

1. can be administered as a deterrent to drinking to individuals who abuse alcohol. 2. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that produce substantial discomfort for the individual and even result in death if the blood alcohol level is high.

sedative, hypnotic or anxiolytic: intoxication

1. inappropriate sexual or aggressive behavior 2. mood lability 3. impaired judgment 4. impaired social or occupational functioning. 5. slurred speech 6. incoordination 7. unsteady gait 8. nystagmus 9. impairment in attention or memory 10. stupor or coma.

sedatives, hypnotics or anxiolytics

1. induce varying degrees of CNS depression; effects depend on size of dose and potency 2. categories: barbiturates, non-barbiturate hypnotics and antianxiety agents 3. effects of CNS depressants are additive with one another and with the behavioral state of the user 4. CNS depressants are capable of producing physiological addiction 5. cross-tolerance and cross-dependence may exist between various CNS depressants 6. two patterns of addiction: a) individual is prescribed substance for anxiety or insomnia and independently increases dose and b) people in their teens and early 20s using the substance illegally with their peers to experience euphoria

non-substance abuse d/o: gambling disorder

1. persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress 2. The preoccupation with and impulse to gamble often intensifies when the individual is under stress. 3. Many impulsive gamblers describe a physical sensation of restlessness and anticipation that can be relieved only by placing a bet. 4. In some cases the initial change in gambling behavior leading to pathological gambling begins with a "big win," bringing a rapid development of preoccupation, tolerance, and loss of control. 5. Winning brings feelings of special status, power, and omnipotence. 6. The gambler increasingly depends on this activity to cope with disappointments, problems, and negative emotional states, pulling away from emotional attachment to family and friends. 7. As the need to gamble increases, the individual is forced to obtain money by any means available. 8. This may include borrowing money from illegal sources or pawning personal items (or items that belong to others). 9. As gambling debts accrue, or out of a need to continue gambling, the individual may desperately resort to forgery, theft, or even embezzlement. 10. Family relationships are disrupted, and impairment in occupational functioning may occur because of absences from work in order to gamble. 11. Gambling behavior usually begins in adolescence; however, compulsive behaviors rarely occur before young adulthood. 12. The disorder generally runs a chronic course, with periods of waxing and waning that are largely dependent on psychosocial stress. 13. This condition is more common among men than women. 14. Various personality disorder traits have been associated with pathological gambling. 15. The most prevalent included narcissistic, antisocial, avoidant, obsessive-compulsive, and borderline traits. 16. The researchers conclude that in any treatment setting for gambling disorders, screening and treatment for these common comorbid conditions must be addressed. 17. Gambling problems may be episodic and increase during periods of stress or depression, or the behavior may be persistent.

Counseling therapy

3. Counseling on a one-to-one basis is often used to help the client who abuses substances. a. The relationship is goal directed, and the length of the counseling may vary from weeks to years. b. The focus is on current reality, development of a working treatment relationship, and strengthening ego assets. c. The counselor must be warm, kind, and nonjudgmental yet able to set limits firmly. d. Research consistently demonstrates that personal characteristics of counselors are highly predictive of client outcome. e. In addition to technical counseling skills, many important therapeutic qualities affect the outcome of counseling, including insight, respect, genuineness, concreteness, and empathy f. Counseling of the client who abuses substances passes through various phases, each of which is of indeterminate length. i. In the first phase, an assessment is conducted. Factual data are collected to determine whether the client does indeed have a problem with substances ii. Following the assessment, in the working phase of the relationship, the counselor assists the individual to accept that the use of substances causes problems in significant life areas and that he or she is not able to prevent this from occurring. The client states a desire to make changes. iii. The strength of the denial system is determined by the duration and extent of substance-related adverse effects in the person's life. iv. Thus, those individuals with rather minor substance-related problems of recent origin have less difficulty with this stage than those with long-term extensive impairment. v. The individual also works to gain self-control and abstain from substances. vi. Once the problem has been identified and sobriety achieved, the client must have a concrete and workable plan for getting through the early weeks of abstinence. vii. Counseling often includes the family or specific family members. In family counseling, the therapist tries to help each member see how he or she has affected, and been affected by, the substance abuse behavior. Family strengths are mobilized, and family members are encouraged to move in a positive direction. viii. Referrals are often made to self-help groups such as Al-Anon, Nar-Anon, Alateen, Families Anonymous, and Adult Children of Alcoholics.

Sedative, hypnotic and anxiolytics: withdrawal Sx

4. Withdrawal symptoms from substances with longer half-lives (e.g., diazepam, phenobarbital, chlordiazepoxide) may begin within 2 to 7 days, peak on the fifth to eighth day, and subside in 10 to 16 days. 5. Withdrawal symptoms include: a. autonomic hyperactivity (e.g., sweating or pulse rate greater than 100) b. increased hand tremor c. insomnia d. nausea e. vomiting f. hallucinations g. illusions h. psychomotor agitation, anxiety, or grand mal seizures.

sedative, hypnotic or anxiolytic use disorder: effects on the body

A) depress activity of the brain , nerves, muscles and heart tissue; primary action is on nervous tissue b) reduce rate of metabolism in a variety of tissues and depress any system that uses energy c) more selective in their action at lower doses 2. effects on sleep and dreaming: decreases the amount of sleep time spent dreaming, rebound insomnia & increased dreaming with abrupt withdrawal 3. respiratory depression: barbiturates are incapable of inhibiting the reticular activating system, resulting in respiratory depression 4. CV effects: hypotension, decreased cardiac output, decreased cerebral blood flow & direct impairment of myocardial contractility with large doses 5. renal function; barbiturates suppress urine function in doses high enough to produce anesthesia 6. hepatic effects: jaundice with doses large enough to produce acute intoxication and in ppl with existing liver disease by stimulating liver enzyme production; in ppl with existing liver dz, these enzymes are already elevated. 7. body temp: barbiturates in high doses can decrease body temp 8 sexual function: initial increase in libido followed by impaired sexual pleasure; in men a decreased ability to maintain an erection

Alcoholics Anonymous (AA)

Alcoholics Anonymous (AA) is a major self-help organization for the treatment of alcoholism. The self-help groups are based on the concept of peer support—acceptance and understanding from others who have experienced the same problems. The only requirement for membership is a desire on the part of the alcoholic person to stop drinking. a. Each new member is assigned a support person from whom he or she may seek assistance when the temptation to drink occurs. b. The sole purpose of AA is to help members stay sober. When sobriety has been achieved, they in turn are expected to help other alcoholic persons. The Twelve Steps that embody the philosophy of AA provide specific guidelines on how to attain and maintain sobriety c. AA accepts alcoholism as an illness and promotes total abstinence as the only cure, emphasizing that the alcoholic person can never safely return to social drinking. d. They encourage the members to seek sobriety, taking one day at a time.

Codependents

Have a long history of focusing thoughts and behavior on other people. b. Are "people pleasers" and will do almost anything to get the approval of others. c. Outwardly appear very competent, but actually feel quite needy, helpless, or perhaps nothing at all. d. Have experienced abuse or emotional neglect as a child. e. Are outwardly focused toward others and know very little about how to direct their own lives from their own sense of self.

alcohol use d/o: Pharmacotherapy

a. Disulfiram b. naltrexone (ReVia) c. acamprosate

Substance abuse: dual Dx

a. If the client is diagnosed with both mental illness and a coexisting substance disorder, he or she may be assigned to a special program that targets both problems. b. Traditional counseling approaches use more confrontation than is considered appropriate for clients with dual diagnoses. c. Most dual diagnosis programs take a supportive, less confrontational approach. d. Peer support groups are an important part of the treatment program. e. Group members offer encouragement and practical advice to each other. f. Cognitive and behavioral therapies are helpful in training clients to monitor moods and thought patterns that lead to substance abuse. g. Teaching clients about coping skills and stress management also promotes skills in maintaining abstinence and dealing with substance cravings. g. Dx is reached via the various assessment tools, including interviewing, CIWA, MAST and the CAGE questionnaire. h. Individuals with dual diagnoses should be educated about 12-step recovery programs (e.g., Alcoholics Anonymous or Narcotics Anonymous). i. Dual diagnosis clients are sometimes resistant to attending 12-step programs, and they often do better in substance abuse support groups specifically designed for people with psychiatric disorders. j. Substance-abuse groups are usually integrated into regular programming for the psychiatric client with a dual diagnosis. k. An individual in a psychiatric facility or day treatment program will attend a substance abuse group periodically in lieu of another scheduled activity therapy. l. Topics are directed toward areas that are unique to clients with mental illness, such as mixing medications with other substances, as well as topics that are common to primary substance abusers. Individuals are encouraged to discuss their personal problems. m. Continued attendance at 12-step group meetings is encouraged upon discharge from treatment. n. Family involvement is enlisted, and preventive strategies are outlined. o. Individual case management is common, and success is often promoted by this close supervision.

substance intoxication

development of a reversible syndrome of symptoms following excessive use of a substance; Sx are drug-specific and occur during or shortly after ingestion of the substance

Acamprosate: MOA

hypothesized to restore the normal balance between neuronal excitation and inhibition by interacting with glutamate and gamma-aminobutyric acid (GABA) neurotransmitter systems.

Substitution therapy

may be required to reduce the life-threatening effects of intoxication or withdrawal from some substances. a. Alcohol i. Benzodiazepines are the most widely used group of drugs for substitution therapy in alcohol withdrawal. a) Chlordiazepoxide (Librium) b) oxazepam (Serax) c) lorazepam (Ativan) d) diazepam (Valium) are the most common agents. ii. The approach to treatment with benzodiazepines for alcohol withdrawal is to start with relatively high doses and reduce the dosage by 20 to 25 percent each day until withdrawal is complete. iii. Additional doses may be given for breakthrough signs or symptoms iv. In clients with liver disease, accumulation of longer-acting agents (chlordiazepoxide and diazepam) may be problematic, and use of shorter-acting benzodiazepines (lorazepam or oxazepam) is more appropriate. v. Some physicians may order anticonvulsant medication for management of withdrawal seizures: a) carbamazepine b) valproic acid c) gabapentin. vi. These drugs are particularly useful in individuals who undergo repeated episodes of alcohol withdrawal, which appear to "kindle" even more serious withdrawal episodes, including the production of withdrawal seizures that can result in brain damage. vii. Anticonvulsants have been used successfully in both acute withdrawal and longer-term craving situations. vii. Multivitamin replacement therapy, in combination with daily injections or oral administration of thiamine (B1) is common protocol. Thiamine is commonly deficient in chronic alcoholics. viii. Replacement therapy is required to prevent neuropathy, confusion, and encephalopathy.

Substance Withdrawal

occurs upon abrupt reduction or discontinuation of a substance that has been used regularly over a prolonged period of time

intoxication

physical and mental state of exhilaration and emotional frenzy or lethargy and stupor

withdrawal

physiological and mental readjustment that accompanies discontinuation of an addictive substance.

addiction

primary chronic disease of brain reward, motivation, memory, and related circuitry where a dysfunction in these circuits is connected to an individual pathologically pursuing reward and/or relief by substance use and other behaviors