MENTAL HEALTH: CHAPTER 19: ADDICTION:

Tolerance Break:

- After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol intoxicate the person.

Cannabis: Intoxication & Overdose:

- Cannabis begins to act less than 1 minute after inhalation. - Peak effects usually occur in 20 to 30 minutes and last at least 2 to 3 hours. - Users report a high feeling similar to that with alcohol, lowered inhibitions, relaxation, euphoria, and increased appetite. - Symptoms of intoxication include impaired motor coordination, inappropriate laughter, impaired judgment and short-term memory, and distortions of time and perception. - Anxiety, dysphoria, and social withdrawal may occur in some users. - Physiological effects, in addition to increased appetite, include conjunctival injection (bloodshot eyes), dry mouth, hypotension, and tachycardia. Excessive use of cannabis may produce delirium or rarely, cannabis-induced psychotic disorder, both of which are treated symptomatically. - Overdoses of cannabis do not occur.

Cultural Considerations: Ethnic Groups & Genetic Traits (Alcoholism):

- Certain ethnic groups have genetic traits that either predispose them to or protect them from developing alcoholism. - For instance, flushing, a reddening of the face and neck as a result of increased blood flow, has been linked to variants of genes for enzymes involved in alcohol metabolism. - Even small amounts of alcohol can produce flushing, which may be accompanied by headaches and nausea. - The flushing reaction is highest among people of Asian ancestry

Priorities:

- Educate to avoid any alcohol (food, vanilla extract, meds like cough syrup) - Read the labels b/c it could make them very sick - Or ask a pharmacist if it's ok to take with Antabuse

Other Symptoms:

- Headaches - Hypertension - Get full set of vitals (iing, pulse, hypertension): Analyze all data you get and go from 8-15, anything less than 8 is mild: no medication

Detoxification:

- Is the process of safely withdrawing from a substance.

Pharmacologic Treatment:

- Pharmacologic treatment in substance abuse has two main purposes: (1) to permit safe withdrawal from alcohol, sedative-hypnotics, and benzodiazepines and (2) to prevent relapse. - For clients whose primary substance is alcohol, vitamin B1 (thiamine) is often prescribed to prevent or to treat Wernicke-Korsakoff syndrome, which are neurologic conditions that can result from heavy alcohol use. - Cyanocobalamin (vitamin B12) and folic acid are often prescribed for clients with nutritional deficiencies. - Alcohol withdrawal is usually managed with a benzodiazepine anxiolytic agent, which is used to suppress the symptoms of abstinence. - The most commonly used benzodiazepines are lorazepam, chlordiazepoxide, and diazepam. - These medications can be administered on a fixed schedule around the clock during withdrawal. - Giving these medications on an as-needed basis according to symptom parameters, however, is just as effective and results in a speedier withdrawal. - Barbiturates can be used for benzodiazepine-resistant cases of alcohol withdrawal - Disulfiram (Antabuse) may be prescribed to help deter clients from drinking. - If a client taking disulfiram drinks alcohol, a severe adverse reaction occurs with flushing, a throbbing headache, sweating, nausea, and vomiting. - In severe cases, severe hypotension, confusion, coma, and even death may result - The client must also avoid a wide variety of products that contain alcohol, such as cough syrup, lotions, mouthwash, perfume, aftershave, vinegar, and vanilla and other extracts. - The client must read product labels carefully because any product containing alcohol can produce symptoms. - Ingestion of alcohol may cause unpleasant symptoms for 1 to 2 weeks after the last dose of disulfiram. - Acamprosate (Campral) may be prescribed for clients recovering from alcohol abuse or dependence to help reduce cravings for alcohol and decrease the physical and emotional discomfort that occurs especially in the first few months of recovery. - These include sweating, anxiety, and sleep disturbances. - The dosage is two tablets, 333 mg each, three times a day. - Individuals with renal impairment cannot take this drug. - Side effects are reported as mild and include diarrhea, nausea, flatulence, and pruritis. - Acamprosate is often thought to be more effective with "relief cravers," while naltrexone is more effective with "reward cravers" - Relief cravers seek mediation of negative effects of withdrawal, while reward cravers seek positive effects of drinking. - Methadone, a potent synthetic opiate, is used as a substitute for heroin in some maintenance programs. - The client takes 1 daily dose of methadone, which meets the physical need for opiates but does not produce cravings for more. - Methadone does not produce the high associated with heroin. - The client has essentially substituted his or her addiction to heroin for an addiction to methadone; however, methadone is safer because it is legal, controlled by a physician, and available in tablet form. - The client avoids the risks of IV drug use, the high cost of heroin (which often leads to criminal acts), and the questionable content of street drugs. - Levomethadyl is a narcotic analgesic with the only purpose of treating opiate dependence. It is used in the same manner as methadone. - Buprenorphine/naloxone (Suboxone) is a combination drug used for opiate maintenance and to decrease opiate cravings. - Buprenorphine is a semisynthetic opioid, and naloxone is an opioid inverse agonist. - The client takes 1 daily sublingual dose. Medication ingestion is supervised, at least initially, because Suboxone has the potential for abuse and diversion - Clients can be tapered from this medication after treatment and with adequate psychosocial support. - Some clients may remain on a maintenance dose for an extended time. Naltrexone (ReVia) is an opioid receptor antagonist often used to treat overdose. - It blocks the effects of any opioids that might be ingested, thereby negating the effects of using more opioids. - It has also been found to reduce the cravings for alcohol in abstinent clients. - Extended-release naltrexone has been effective in reduction of cravings during treatment and at 30- and 60-day intervals post-treatment - Naltrexone is also available as a once-monthly injectable marketed as Vivitrol. - There are four medications that are sometimes prescribed for the off-label use of decreasing craving for cocaine. - They are disulfiram (discussed earlier); modafinil (Provigil), an antinarcoleptics; propranolol (Inderal), a beta-blocker; and topiramate (Topamax), an anticonvulsant also used to stabilize moods and treat migraines. - Nalmefene is an opioid receptor antagonist marketed as Revex and is used in the United States to combat opioid overdose. - Clonidine (Catapres) is an alpha-2-adrenergic agonist used to treat hypertension. - It is given to clients with opiate dependence to suppress some effects of withdrawal or abstinence. - It is most effective against nausea, vomiting, and diarrhea, but produces modest relief from muscle aches, anxiety, and restlessness - Ondansetron (Zofran), a 5-HT3 antagonist that blocks the vagal stimulation effects of serotonin in the small intestine, is used as an antiemetic. - It has been used in young males at high risk for alcohol dependence or with early-onset alcohol dependence. - It is being studied for treatment of methamphetamine addiction. - It is important to remember that medications will help the client manage or tolerate symptoms, such as withdrawal or cravings, but pharmacology is not a specific treatment for substance abuse. - Participation in treatment and follow-up with community aftercare (such as AA meetings) are essential for long-term positive outcomes.

Poor Outcomes Associated With Early Onset:

- Poor outcomes have been associated with an earlier age at onset, longer periods of substance use, and the coexistence of a major psychiatric illness. - With extended use, the risk for mental and physical deterioration and infectious disease such as HIV and AIDS, hepatitis, and tuberculosis increases, especially for those with a history of intravenous (IV) drug use - . An increased number of alcohol-dependent people commit suicide.

Cultural Considerations: Alcohol Abuse In Native Americans/Alaska Natives

- Statistics for individual tribes vary, but alcohol abuse overall plays a part in the five leading causes of death for Native Americans and Alaska Natives (motor vehicle crashes, alcoholism, cirrhosis, suicide, and homicide). - Among tribes with high rates of alcoholism, an estimated 75% of all accidents are alcohol related. - One-eighth of Native Americans are identified as needing treatment for alcohol or drugs—most commonly methamphetamine and marijuana. - Alaska Natives are seven times more likely than the general population to die of alcohol-related problems - In Japan, alcohol consumption has quadrupled since 1960.

Related Disorders: Substances Can Induce Symptoms Similar To Other Mental Health Illnesses:

- Substances can induce symptoms that are similar to other mental illness diagnoses, such as anxiety, psychosis, or mood disorders. - They are called substance-induced anxiety, substance-induced psychosis, and so forth. - The symptoms may subside once the substance is eliminated from the body, though this is not always the case. - For example, methamphetamine can cause substance-induced psychosis, but the psychotic symptoms may persist due to damage to the brain. - The nursing care for the client is the same as caring for any client with delusions and hallucinations, as discussed in other chapters. - A clinical care plan for a client receiving treatment for substance abuse is featured near the end of this chapter. - The effects on adults who grew up in a home with an alcoholic parent are discussed later, as are the special needs of clients with a dual diagnosis of substance use and a major psychiatric disorder.

Inhalants: Withdrawals & Detoxification:

- There are no withdrawal symptoms or detoxification procedures for inhalants as such, though frequent users report psychological cravings. - People who abuse inhalants may suffer from persistent dementia or inhalant-induced disorders, such as psychosis, anxiety, or mood disorders even if the inhalant abuse ceases. - These disorders are all treated symptomatically.

Blackout:

- Which is an episode during which the person continues to function but has no conscious awareness of his or her behavior at the time or any later memory of the behavior.

If Patient Gets Off Antabuse, How Long Should They Wait To Start Drinking?

1-2 weeks

What Is Alcohol?

CNS depressant

1. Which statement would indicate that teaching about naltrexone (ReVia) has been effective? a."I'll get sick if I use heroin while taking this medication." b."This medication will block the effects of any opioid substance I take." c."If I use opioids while taking naltrexone, I'll become extremely ill." d."Using naltrexone may make me dizzy."

b."This medication will block the effects of any opioid substance I take."

7. The client tells the nurse that she has a drink every morning to calm her nerves and stop her tremors. The nurse realizes the client is at risk for a.an anxiety disorder. b.a neurologic disorder. c.physical dependence. d.psychological addiction.

d.psychological addiction.

Substance Abuse: Mental Health Promotion:

- A person only has to watch televisioterm-81n or read a magazine to see many advertisements targeted at the promotion of responsible drinking or encouraging parents to be an "antidrug" influence for their children. - Increasing public awareness and educational advertising have not made any significant change in the rates of substance abuse in the United States. - Two populations currently identified for prevention programs are older adults and college-aged adults. - Late-onset alcoholism in older adults is usually milder and more amenable to treatment, yet health care professionals overlook it more frequently. - It has been suggested that use of a screening tool in all primary care settings would promote early identification of older adults with alcoholism. - Brief interventions have been effective in producing sustained abstinence or reduced levels of alcohol consumption, thereby decreasing hazardous and harmful drinking in this population.

Alcohol: Intoxication & Overdose:

- Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream. - Initially, the effects are relaxation and loss of inhibitions. - With intoxication, there is slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judgment. - Some people become aggressive or display inappropriate sexual behavior when intoxicated. - The person who is intoxicated may experience a blackout. - An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression. - This combination can cause aspiration pneumonia or pulmonary obstruction. - Alcohol-induced hypotension can lead to cardiovascular shock and death. - Treatment of an alcohol overdose is similar to that for any central nervous system depressant—gastric lavage or dialysis to remove the drug, and support of respiratory and cardiovascular functioning in an intensive care unit. - The administration of central nervous system stimulants is contraindicated

Substance Abuse: Interventions: Addressing Family Issues:

- Alcoholism (and other substance abuse) is often called a family illness. - All those who have a close relationship with a person who abuses substances suffer emotional, social, and sometimes physical anguish. - Codependence is a maladaptive coping pattern on the part of family members or others resulting from a prolonged relationship with the person who uses substances. - Characteristics of codependence are poor relationship skills, excessive anxiety and worry, compulsive behaviors, and resistance to change. - Family members learn these dysfunctional behavior patterns as they try to adjust to the behavior of the substance user. - One type of codependent behavior is called enabling, which is a behavior that seems helpful on the surface but actually perpetuates the substance use. - For example, a wife who continually calls in to her husband's job to report that he is sick when he is really drunk or hungover prevents the husband from having to face the true implications and repercussions of his behavior. - What appears to be a helpful action really just assists the husband in avoiding the consequences of his behavior and to continue abusing the substance. - Roles may shift dramatically, such as when a child actually looks out for or takes care of a parent. - Codependent behaviors have also been identified in health care professionals when they make excuses for a client's behavior or do things for clients that clients can do for themselves. - An adult child of an alcoholic is someone who was raised in a family in which one or both parents were addicted to alcohol and who has been subjected to the many dysfunctional aspects associated with parental alcoholism. - In addition to being at high risk for alcoholism and eating disorders, children of alcoholics often develop an inability to trust, an extreme need to control, an excessive sense of responsibility, and denial of feelings; these characteristics persist into adulthood. - Many people growing up in homes with parental alcoholism believe their problems will be solved when they are old enough to leave and escape the situation. - They may begin to have problems in relationships, have low self-esteem, and have excessive fears of abandonment or insecurity as adults. - Never having experienced normal family life, they may find that they do not know what "normal" is - Without support and help to understand and cope, many family members may develop substance abuse problems of their own, thus perpetuating the dysfunctional cycle. - Treatment and support groups are available to address the issues of family members. - Clients and families also need information about support groups, their purpose, and their locations in the community.

Cannabis:Withdrawal & Detoxification:

- Although some people have reported withdrawal symptoms of muscle aches, sweating, anxiety, and tremors, no clinically significant withdrawal syndrome is identified.

As nurse and have patient on the way home and they want to stop drinking alcohol and are serious and proactive about not wanting to drink anymore. What medication + education would they be given?

- Antabuse but only for patients who are seriously considering stopping drinking

Inhalants:

- Are a diverse group of drugs that include anesthetics, nitrates, and organic solvents that are inhaled for their effects. - The most common substances in this category are aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint. - Less frequently used halogenated hydrocarbons include cleaners, correction fluid, spray can propellants, and other compounds containing esters, ketones, and glycols. - Most of the vapors are inhaled from a rag soaked with the compound, from a paper or plastic bag, or directly from the container. Inhalants can cause significant brain damage, peripheral nervous system damage, and liver disease.

Stimulants:

- Are drugs that stimulate or excite the central nervous system and have limited clinical use (with the exception of stimulants used to treat attention-deficit/hyperactivity disorder) and a high potential for abuse. - Amphetamines (uppers) were popular in the past; they were used by people who wanted to lose weight quickly or stay awake. - Cocaine, an illegal drug with virtually no clinical use in medicine, is highly addictive and a popular recreational drug because of the intense and immediate feeling of euphoria it produces. - Methamphetamine is particularly dangerous. - It is highly addictive and causes psychotic behavior. - Brain damage related to its use is frequent, primarily as a result of the substances used to make it—that is, liquid agricultural fertilizer. - The percentage of people admitted to inpatient settings for methamphetamine abuse had increased in 49 of the 50 states in the United States from 2000 to 2005. - Use of methamphetamine, however, seems to have peaked and actually declined in the past few years - It may well increase again in the future, reflecting the pattern of use of many substances.

Opioids:

- Are popular drugs of abuse because they desensitize the user to both physiological and psychological pain and induce a sense of euphoria and well-being. - Opioid compounds include both potent prescription analgesics such as morphine, meperidine (Demerol), codeine, hydromorphone, oxycodone, methadone, oxymorphone, hydrocodone, and propoxyphene as well as illegal substances such as heroin, illicitly produced fentanyl, and normethadone. - Fentanyl is a synthetic opioid used in clinical settings for anesthesia. It is 50 to 100 times more potent than morphine. - Illicitly produced fentanyl use has skyrocketed in the past decade and is thought to be responsible for the dramatic increase in deaths from opioid overdose. - People who abuse opioids spend a great deal of their time obtaining the drugs; they often engage in illegal activity to get money to purchase them. - Health care professionals who abuse opioids often write prescriptions for themselves or divert prescribed pain medication for clients to themselves.

Hallucinogens:

- Are substances that distort the user's perception of reality and produce symptoms similar to psychosis, including hallucinations (usually visual) and depersonalization. - Hallucinogens also cause increased pulse, blood pressure, and temperature; dilated pupils; and hyperreflexia. - Examples of hallucinogens are mescaline, psilocybin, lysergic acid diethylamide, and "designer drugs" such as ecstasy. - Phencyclidine (PCP), developed as an anesthetic, is included in this section because it acts similarly to hallucinogens.

How To Asses For Tremors:

- Arms straight out and fingers should be spread apart so you can see tremors - If you don't see it this way (if you don't visibly see tremors but they are tremoring): will be more towards 1-3 CIWA but you'll want to touch their hands and have them hold your hands: this works as a way to feel for sweaty palms to make sure they don't have sweaty/moist palms that aren't visible. (Squeeze my hand, might notice them shaking lightly when holding your hand)

Tolerance:

- As the person continues to drink, he or she often develops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect

Substance Abuse: Assessment: General Appearance & Motor Behavior:

- Assessment of general appearance and behavior usually reveals appearance and speech to be normal. - Clients may appear anxious, tired, and disheveled if they have just completed a difficult course of detoxification. - Depending on their overall health status and any health problems resulting from substance use, clients may appear physically ill. - Most clients are somewhat apprehensive about treatment, resent being in treatment, or feel pressured by others to be there. - This may be the first time in a long time that clients have had to deal with any difficulty without the help of a psychoactive substance.

Cultural Considerations:

- Attitudes toward substance use, patterns of use, and physiological differences to substances vary in different cultures. - Muslims do not drink alcohol, but wine is an integral part of Jewish religious rites. - Some Native American tribes use peyote, a hallucinogen, in religious ceremonies. - It is important to be aware of such beliefs when assessing for a substance abuse problem.

When Should It Peak?

- By 2nd day

Symptoms To Look Out For & Assessments Used:

- CIWA - Symptoms assessed during CIWA: tremors, temp, anxiety, alertness/orientation, hallucinations, nausea, vomiting

Related Disorders: Caffeine & Tobacco Addictions:

- Caffeine and tobacco or nicotine are substances that are addictive and are included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, but are not considered mental health problems per se. - There has also been discussion of possible addiction to the internet, noting that some people spend more than half of their waking hours on the computer and become upset and irritable if use is limited or curtailed. - Further study will determine whether or not this will be treated as a new type of addiction.

Cannabis:

- Cannabis sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and for oil from its seeds. - It has become widely known for its psychoactive resin. - This resin contains more than 60 substances, called cannabinoids, of which δ-9-tetrahydrocannabinol is thought to be responsible for most of the psychoactive effects. - Marijuana refers to the upper leaves, flowering tops, and stems of the plant; hashish is the dried resinous exudate from the leaves of the female plant -. Cannabis is often smoked in cigarettes (joints), and it can also be eaten. - The legal status of cannabis has changed in the United States. - While federal law still considers most cannabis use illegal, some individual states have changed their laws. - States may have legalized medical marijuana use, recreational use, both, or neither. - This will continue to change in future years but is a state-by-state approach at this point in time. - Research has shown that cannabis has short-term effects of lowering intraocular pressure, but it is not approved for the treatment of glaucoma. - It has also been studied for its effectiveness in relieving the nausea and vomiting associated with cancer chemotherapy and the anorexia and weight loss of AIDS. - Currently, two cannabinoids, dronabinol (Marinol) and nabilone (Cesamet), have been approved for treating nausea and vomiting from cancer chemotherapy. - Cannabis-related drugs have shown promise in the control of seizures in people who do not experience seizure control from other medications

Addiction: Etiology: Biological Factors:

- Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are children of nonalcoholic parents. - This increased risk is partly the result of environmental factors, but evidence points to the importance of genetic factors as well - Several studies of twins have shown a higher rate of concordance (when one twin has it, the other twin gets it) among identical than fraternal twins. - Adoption studies have shown higher rates of alcoholism in sons of biologic fathers with alcoholism than in those of nonalcoholic biologic fathers. - These studies led theorists to describe the genetic component of alcoholism as a genetic vulnerability that is then influenced by various social and environmental factors. - About 60% of the variation in causes of alcoholism was the result of genetics, with the remainder caused by environmental influences - Neurochemical influences on substance use patterns have been studied primarily in animal research. - The ingestion of mood-altering substances stimulates dopamine pathways in the limbic system, which produces pleasant feelings or a "high" that is a reinforcing, or positive, experience - Distribution of the substance throughout the brain alters the balance of neurotransmitters that modulate pleasure, pain, and reward responses. - Researchers have proposed that some people have an internal alarm that limits the amount of alcohol consumed to one or two drinks so that they feel a pleasant sensation but go no further. - People without this internal signaling mechanism experience the high initially but continue to drink until the central nervous system depression is marked and they are intoxicated.

Substance Abuse: Interventions: Providing Health Teaching For Client & Family:

- Clients and family members need facts about the substance, its effects, and recovery. T he nurse must dispel the following myths and misconceptions: •"It's a matter of willpower." •"I can't be an alcoholic if I only drink beer or if I only drink on weekends." •"I can learn to use drugs socially." •"I'm OK now; I could handle using once in a while." - Education about relapse is important. - Family members and friends should be aware that clients who begin to revert to old behaviors, return to substance-using acquaintances, or believe they can "handle myself now" are at high risk for relapse, and loved ones need to take action. - Whether a client plans to attend a self-help group or has other resources, a specific plan for continued support and involvement after treatment increases the client's chances for recovery.

Substance Abuse: Assessment: Judgement & Insight:

- Clients are likely to have exercised poor judgment, especially while under the influence of the substance. - Judgment may still be affected; clients may behave impulsively, such as leaving treatment to obtain the substance of choice. Insight is usually limited regarding substance use. - Clients may have difficulty acknowledging their behavior while using or may not see loss of jobs or relationships as connected to the substance use. - They may still believe they can control the substance use.

Treatment Setting & Programs:

- Clients being treated for intoxication and withdrawal or detoxification are encountered in a wide variety of medical settings from emergency departments to outpatient clinics. - Clients needing medically supervised detoxification are often treated on medical units in the hospital setting and then referred to an appropriate outpatient treatment setting when they are medically stable. - Health professionals provide extended or outpatient treatment in various settings, including clinics or centers offering day and evening programs, halfway houses, residential settings, or special chemical dependency units in hospitals. - Generally, the type of treatment setting selected is based on the client's needs as well as on his or her insurance coverage. - For example, for someone who has limited insurance coverage, is working, and has a supportive family, the outpatient setting may be chosen first because it is less expensive, the client can continue to work, and the family can provide support. - If the client cannot remain sober during outpatient treatment, then inpatient treatment may be required. - Clients with repeated treatment experiences may need the structure of a halfway house with a gradual transition into the community.

Substance Abuse: Assessment: Sensorium & Intellectual Processes:

- Clients generally are oriented and alert unless they are experiencing lingering effects of withdrawal. - Intellectual abilities are intact unless clients have experienced neurologic deficits from long-term alcohol use or inhalant use.

Substance Abuse: Assessment: Self-Concept:

- Clients generally have low self-esteem, which they may express directly or cover with grandiose behavior. - They do not feel adequate to cope with life and stress without the substance and are often uncomfortable around others when not using. - They often have difficulty identifying and expressing true feelings; in the past, they have preferred to escape feelings and avoid any personal pain or difficulty with the help of the substance.

Substance Abuse: Assessment: Roles & Relationships:

- Clients usually have experienced many difficulties with social, family, and occupational roles. - Absenteeism and poor work performance are common. - Often, family members have told these clients that the substance use was a concern, and it may have been the subject of family arguments. - Relationships in the family are often strained. - Clients may be angry with family members who were instrumental in bringing them to treatment or who threatened loss of a significant relationship.

Substance Abuse: Assessment: History:

- Clients with a parent or other family members with substance abuse problems may report a chaotic family life, though this is not always the case. - They generally describe some crisis that precipitated entry into treatment, such as physical problems or development of withdrawal symptoms while being treated for another condition. - Usually, other people such as an employer threatening loss of a job or a spouse or partner threatening loss of a relationship are involved in a client's decision to seek treatment. - It is less often that clients decide to seek treatment independently with no outside influence.

Addiction: Etiology: Social & Environmental Factors:

- Cultural factors, social attitudes, peer behaviors, laws, cost, and availability all influence initial and continued use of substances. - In general, younger experimenters use substances that carry less social disapproval such as alcohol and cannabis, while older people use drugs such as cocaine and opioids that are costlier and rate higher disapproval. - Alcohol consumption increases in areas where availability increases and decreases in areas where costs of alcohol are higher because of increased taxation. - Many people view the social use of cannabis, though still illegal in most states, as not harmful; many advocate legalizing the use of marijuana for social purposes. - Currently in the United States, there is a federal law that still classifies marijuana as a Schedule 1 drug, but some individual states have or are in the process of legalizing medical use or recreational use or both. - Urban areas where cocaine and opioids are readily available also have high crime rates, high unemployment, and substandard school systems that contribute to high rates of cocaine and opioid use, and low rates of recovery. - Thus, environment and social customs can influence a person's use of substances.

Alcohol Treatment: 12 Step Program:

- Current treatment modalities are based on the concept of alcoholism (and other addictions) as a medical illness that is progressive, chronic, and characterized by remissions and relapses. - Until the 1970s, organized treatment programs and clinics for substance abuse were scarce. - Before the illness of addiction was fully understood, most of society and even the medical community viewed chemical dependency as a personal problem; the user was advised to "pull yourself together" and "get control of your problem." - Founded in 1949, the Hazelden Clinic in Minnesota is the noted exception; because of its success, many programs are based on the Hazelden model of treatment. - Today, treatment for substance use is available in a variety of community settings, not all of which involve health professionals. - Alcoholics Anonymous (AA) was founded in the 1930s by alcoholics. - This self-help group developed the 12-step program model for recovery which is based on the philosophy that total abstinence is essential and that alcoholics need the help and support of others to maintain sobriety. - Key slogans reflect the ideas in the 12 steps, such as "one day at a time" (approach sobriety one day at a time), "easy does it" (don't get frenzied about daily life and problems), and "let go and let God" (turn your life over to a higher power). - People who are early in recovery are encouraged to have a sponsor to help them progress through the 12 steps of AA. - Once sober, a member can be a sponsor for another person. - Regular attendance at meetings is emphasized. - Meetings are available daily in large cities and at least weekly in smaller towns or rural areas. - AA meetings may be "closed" (only those who are pursuing recovery can attend) or "open" (anyone can attend). - Meetings may be educational with a featured speaker; other meetings focus on a reading, daily meditation, or a theme and then offer the opportunity for members to relate their battles with alcohol and to ask the others for help in staying sober. - Many treatment programs, regardless of setting, use the 12-step approach and emphasize participation in AA. - They also include individual counseling and a wide variety of groups. - Group experiences involve education about substances and their use, problem-solving techniques, and cognitive techniques to identify and modify faulty ways of thinking. - An overall theme is coping with life, stress, and other people without the use of substances. - Although traditional treatment programs and AA have been successful for many people, they are not effective for everyone. - Some object to the emphasis on God and spirituality; others do not respond well to the confrontational approach sometimes used in treatment or to identifying oneself as an alcoholic or an addict. - Women and minorities have reported feeling overlooked or ignored by an essentially "white, male, middle-class" organization. - Treatment programs have been developed to meet these needs, such as Women for Sobriety (exclusively for women) and Rainbow Recovery (for gay and lesbian individuals). - AA groups may also be designated for women or gay and lesbian people. - The 12-step concept of recovery has been used for other drugs as well. - Such groups include Narcotics Anonymous; Al-Anon, a support group for spouses, partners, and friends of alcoholics; and AlaTeen, a group for children of parents with substance problems. - This same model has been used in self-help groups for people with gambling problems and eating disorders.

Substance Use:

- Disorders and related disorders are a national health problem. - More than 16.6 million adult Americans and 697,000 adolescents aged 12 to 17 years have an alcohol use disorder. - Of adults (age 18 years or older), 14% report binge drinking in the past month. - Other statistics include the following: nearly 88,000 people die from alcohol-related causes each year; alcohol-related death is the third leading preventable cause of death in the United States; and 30% of driving fatalities are alcohol related (National Institute on Alcohol Abuse and Alcoholism - The actual precise prevalence of substance abuse is difficult to determine because many people who meet the criteria for diagnosis do not seek treatment, and surveys conducted to estimate prevalence are based on self-reported data that may be inaccurate. - Worldwide, 3 million deaths result from the harmful use of alcohol annually. - Alcohol is a causal factor in more than 200 disease and injury conditions. - Absenteeism at work is higher for employees who have alcohol-related problems, and they use more health benefits as well - The number of infants suffering the physiological and emotional consequences of prenatal exposure to alcohol or drugs (e.g., fetal alcohol syndrome, neonatal abstinence syndrome, "crack babies") is increasing at alarming rates. - Chemical abuse also results in increased violence, including domestic abuse, homicide, and child abuse and neglect. - These rising statistics regarding substance abuse do not bode well for future generations. - Approximately 8.7 million children aged 17 years or younger (one in eight) live with a parent who has a substance use disorder in any given year - Children of alcoholics are four times more likely than the general population to develop problems with alcohol. - Many adult people in treatment programs report having had their first drink of alcohol as a young child, when they were younger than 10 years of age. - This first drink was often a taste of the drink of a parent or family member. - With the increasing rates of use being reported among young people today, this problem could spiral out of control unless great strides can be made through programs for prevention, early detection, and effective treatment.

Substance Abuse: Assessment: Thought Process & Content:

- During assessment of thought process and content, clients are likely to minimize their substance use, blame others for their problems, and rationalize their behavior. - They may believe they cannot survive without the substance or may express no desire to do so. - They may focus their attention on finances, legal issues, or employment problems as the main source of difficulty rather than their substance use. - They may believe that they could quit "on their own" if they wanted to, and they continue to deny or minimize the extent of the problem.

Substance Abuse As Chronic Illness:

- For many people, substance use is a chronic illness characterized by remissions and relapses to former levels of use. - Relapse rates range from 60% to 90%, with nearly half of individuals relapsing in the year after treatment - A minority of people remain sober after the first treatment experience. - The highest rates for successful recovery are for people who abstain from substances, are highly motivated to have a substance-free lifestyle, and who actively work on relapse prevention.

Related Disorders: Gambling Disorder:

- Gambling disorder is a non-substance-related diagnosis. - It is characterized by problem gambling, spending money one cannot afford to lose, lying about gambling, getting money from others, and an inability to refrain from gambling for any specific time. - Attempts to quit or cut down result in restless, anxious, and irritable behavior.

Substance Abuse In Health Professions: General Warning Signs:

- General warning signs of abuse include poor work performance, frequent absenteeism, unusual behavior, slurred speech, and isolation from peers. More specific behaviors and signs that might indicate substance abuse include: •Incorrect drug counts •Excessive controlled substances listed as wasted or contaminated •Reports by clients of ineffective pain relief from medications, especially if relief had been adequate previously •Damaged or torn packaging on controlled substances •Increased reports of "pharmacy error" •Consistent offers to obtain controlled substances from pharmacy •Unexplained absences from the unit •Trips to the bathroom after contact with controlled substances •Consistent early arrivals at or late departures from work for no apparent reason - Nurses can become involved in substance abuse just as any other person might. - Nurses with abuse problems deserve the opportunity for treatment and recovery as well. - Reporting suspected substance abuse could be the crucial first step toward a nurse getting the help he or she needs.

Hallucinogens: Intoxication & Overdose:

- Hallucinogen intoxication is marked by several maladaptive behavioral or psychological changes: anxiety, depression, paranoid ideation, ideas of reference, fear of losing one's mind, and potentially dangerous behaviors such as jumping out a window in the belief that one can fly. - Physiological symptoms include sweating, tachycardia, palpitations, blurred vision, tremors, and lack of coordination. PCP intoxication often involves belligerence, aggression, impulsivity, and unpredictable behavior - Toxic reactions to hallucinogens (except PCP) are primarily psychological; overdoses as such do not occur. - These drugs are not a direct cause of death, though fatalities have occurred from related accidents, aggression, and suicide. - Treatment of toxic reactions is supportive. - Psychotic reactions are managed best by isolation from external stimuli; physical restraints may be necessary for the safety of the client and others. PCP toxicity can include seizures, hypertension, hyperthermia, and respiratory depression. - Medications are used to control seizures and blood pressure. - Cooling devices such as hyperthermia blankets are used, and mechanical ventilation is used to support respirations

Cultural Considerations: Russia:

- In Russia, high rates of alcohol abuse, suicide, cigarette smoking, accidents, violence, and cardiovascular disease are found in the male population. - Life expectancy for Russian males is 60.5 years, while it is 74 years for females. - This is a trend mirrored across the entire former Soviet Union

Addiction: Etiology: Psychological Factors:

- In addition to the genetic links to alcoholism, family dynamics are thought to play a part. - Children of alcoholics are four times as likely to develop alcoholism compared with the general population. - Some theorists believe that inconsistency in the parent's behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse. - Others hypothesize that even children who abhorred their family lives are likely to abuse substances as adults because they lack adaptive coping skills and cannot form successful relationships - Some people use alcohol as a coping mechanism or to relieve stress and tension, increase feelings of power, and decrease psychological pain. - High doses of alcohol, however, actually increase muscle tension and nervousness.

Inhalants: Intoxication & Overdose:

- Inhalant intoxication involves dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision. - Stupor and coma can occur. Significant behavioral symptoms are belligerence, aggression, apathy, impaired judgment, and inability to function. - Acute toxicity causes anoxia, respiratory depression, vagal stimulation, and dysrhythmias. - Death may occur from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomitus - Treatment consists of supporting respiratory and cardiac functioning until the substance is removed from the body. - There are no antidotes or specific medications to treat inhalant toxicity.

Stimulants: Intoxication & Overdose:

- Intoxication from stimulants develops rapidly; effects include the high or euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic or repetitive behavior, anger, fighting, and impaired judgment. - Physiological effects include tachycardia, elevated blood pressure, dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmias. - Overdoses of stimulants can result in seizures and coma; deaths are rare - Treatment with chlorpromazine (Thorazine), an antipsychotic, controls hallucinations, lowers blood pressure, and relieves nausea

Anything Above 8:

- Is treated with medication (benzo. specifically) : -lam, -pam - They are anxiolytics, CNS depressant - Symptoms: respiration depression and decreased heart rate, pulse, bp - Because given these medications, they are at increased risk for falls

Intoxication:

- Is use of a substance that results in maladaptive behavior.

If They're Confused In Any Situation:

- Make sure to stay with them or assign someone to stay with them bc/ if they're confused and disoriented then safety is an issue: so remain with patient or delegate to someone else for safety

Substance Abuse: Assessment: Physiological Considerations:

- Many clients have histories of poor nutrition (using rather than eating) and sleep disturbances that persist beyond detoxification. - They may have liver damage from drinking alcohol, hepatitis or HIV infection from IV drug use, or lung or neurologic damage from using inhalants.

Substance Abuse: Community Based Care:

- Many people receiving treatment for substance abuse do so in community-based settings, such as outpatient treatment, freestanding substance abuse treatment facilities, and recovery programs such as AA and Rational Recovery - Follow-up or aftercare for clients in the community is based on the client's preferences or the programs available. - Some clients remain active in self-help groups. - Others attend aftercare program sessions sponsored by the agency where they complete treatment. - Still others seek individual or family counseling. - In addition to formal aftercare, the nurse may also encounter recovering clients in clinics or physicians' offices.

Onset & Clinical Course Of Addiction:

- Much research on substance use has focused on alcohol because it is legal and more widely used; thus, more is known about alcohol's effects. - The prognosis for alcohol use in general is unclear because only people seeking treatment for problems with alcohol are usually studied. - In the United States, the average age for an initial alcohol intoxication episode is during adolescent years - However, the early course of alcoholism typically begins much earlier, with the first episode of intoxication between the ages of 12 and 14 years; the first evidence of minor alcohol-related problems is seen in the late teens. - Episodes of "sipping" alcohol may occur as early as 8 years - A pattern of more severe difficulties for people with alcoholism begins to emerge in the mid-20s to the mid-30s; these difficulties can be the alcohol-related breakup of a significant relationship, an arrest for public intoxication or driving while intoxicated, evidence of alcohol withdrawal, early alcohol-related health problems, or significant interference with functioning at work or school. - During this time, the person experiences his or her first blackout

Hallucinogens: Withdrawal & Detoxification:

- No withdrawal syndrome has been identified for hallucinogens, though some people have reported a craving for the drug. - Hallucinogens can produce flashbacks, which are transient recurrences of perceptual disturbances like those experienced with hallucinogen use. - These episodes occur even after all traces of the hallucinogen are gone and may persist for a few months up to 5 years.

Substance Abuse: Intervention: Promoting Coping Skills:

- Nurses can encourage clients to identify problem areas in their lives and to explore the ways that substance use may have intensified those problems. - Clients should not believe that all life's problems will disappear with sobriety; rather, sobriety will assist them in thinking about the problems clearly. - The nurse may need to redirect a client's attention to his or her behavior and how it influenced his or her problems. - The nurse should not allow clients to focus on external events or other people without discussing their role in the problem. Nurse: "Can you describe some problems you've been having?" Client: "My wife is always nagging; nothing is ever good enough. So we don't get along very well." Nurse: "How do you communicate with your wife?" Client: "I can't talk to her about anything; she won't listen." Nurse: "Are you saying that you don't talk to her much?" - It may be helpful to role-play situations that clients have found difficult. - This is also an opportunity to help clients learn to solve problems or to discuss situations with others calmly and more effectively. - In the group setting in treatment, it is helpful to encourage clients to give and to receive feedback about how others perceive their interaction or ability to listen. - The nurse can also help clients find ways to relieve stress or anxiety that do not involve substance use. - Relaxing, exercising, listening to music, or engaging in activities may be effective. - Clients may also need to develop new social activities or leisure pursuits if most of their friends or habits of socializing involved the use of substances. - The nurse can help clients focus on the present, not the past. - It is not helpful for clients to dwell on past problems and regrets. - Rather, they must focus on what they can do now regarding their behavior or relationships. - Clients may need support from the nurse to view life and sobriety in feasible terms—taking it one day at a time. - The nurse can encourage clients to set attainable goals such as, "What can I do today to stay sober?" instead of feeling overwhelmed by thinking "How can I avoid substances for the rest of my life?" - Clients need to believe that they can succeed.

Substance Abuse: Elderly Considerations:

- Onset of initial drinking problems after the age of 50 years is not uncommon. - Some older adults with alcohol use problems are those who had a drinking problem early in life, had a significant period of abstinence, and then resumed drinking again in later life. - Others may have been heavy or reactive consumers of alcohol early in life. - However, estimates are that 30% to 60% of elders in treatment programs began drinking abusively after age 60. - Risk factors for late-onset substance abuse in older adults include chronic illness that causes pain, long-term use of prescription medication (sedative-hypnotics, anxiolytics), life stress, loss, social isolation, grief, depression, and an abundance of discretionary time and money. - Elders may experience physical problems associated with substance abuse rather quickly, especially if their overall medical health is compromised by other illnesses

Opioids: Intoxication & Overdose:

- Opioid intoxication develops soon after the initial euphoric feeling; symptoms include apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory. - Severe intoxication or opioid overdose can lead to coma, respiratory depression, pupillary constriction, unconsciousness, and death. - Administration of naloxone (Narcan), an opioid antagonist, is the treatment of choice because it reverses all signs of opioid toxicity. - Naloxone is given every few hours until the opioid level drops to nontoxic; this process may take days - Opioid overdoses have increased dramatically in the United States; many first responders now carry naloxone in autoinjector form

Opioids: Withdrawal & Detoxification:

- Opioid withdrawal develops when drug intake ceases or decreases markedly, or it can be precipitated by the administration of an opioid antagonist. - Initial symptoms are anxiety, restlessness, aching back and legs, and cravings for more opioids. - Symptoms that develop as withdrawal progresses include nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia. - Symptoms of opioid withdrawal cause significant distress, but do not require pharmacologic intervention to support life or bodily functions. - Short-acting drugs such as heroin produce withdrawal symptoms in 6 to 24 hours; the symptoms peak in 2 to 3 days and gradually subside in 5 to 7 days. - Longer acting substances such as methadone may not produce significant withdrawal symptoms for 2 to 4 days, and the symptoms may take 2 weeks to subside. - Methadone can be used as a replacement for opioids, and the dosage is then decreased over 2 weeks. - Substitution of methadone during detoxification reduces symptoms to no worse than a mild case of flu - Withdrawal symptoms such as anxiety, insomnia, dysphoria, anhedonia, and drug craving may persist for weeks or months.

Substance Abuse In Health Professions:

- Physicians, dentists, and nurses have far higher rates of dependence on controlled substances, such as opioids, stimulants, and sedatives, than other professionals of comparable educational achievement, such as lawyers. - One reason is thought to be the ease of obtaining controlled substances. - Health care professionals also have higher rates of alcoholism than the general population. - The issue of reporting colleagues with suspected substance abuse is an important and extremely sensitive one. - It is difficult for colleagues and supervisors to report their peers for suspected abuse. - Nurses may hesitate to report suspected behaviors for several reasons: they have difficulty believing that a trained health care professional would engage in abuse; they may feel guilty or fear falsely accusing someone; or they may simply want to avoid conflict. - Substance abuse by health professionals is serious, however, because it can endanger clients. - Nurses have an ethical responsibility to report suspicious behavior to a supervisor and, in some states, a legal obligation as defined in the state's nurse practice act. - Nurses should not try to handle such situations alone by warning the coworker; this often just allows the coworker to continue to abuse the substance without suffering any repercussions.

Withdrawal Syndrome:

- Refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases.

Spontaneous Remission:

- Reports exist that some people with alcohol-related problems can modify or quit drinking on their own without a treatment program; this is called spontaneous remission or natural recovery. - Although there is a dearth of recent scientific literature, anecdotal reports state that the abstinence was often in response to a crisis or a promise to a loved one and was accomplished by engaging in alternative activities, relying on relationships with family and friends, and avoiding alcohol, alcohol users, and social cues associated with drinking.

Substance Abuse & Substance Dependence:

- Substance abuse can be defined as using a drug in a way that is inconsistent with medical or social norms and despite negative consequences. - Substance abuse denotes problems in social, vocational, or legal areas of the person's life, while substance dependence also includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance. - This distinction between abuse and dependence is frequently viewed as unclear and unnecessary because the distinction does not affect clinical decisions once withdrawal or detoxification has been completed. - Hence, the terms substance abuse and substance dependence or chemical dependence can be used interchangeably. - In this chapter, the term substance use is used to include both abuse and dependence; it is not meant to refer to occasional or one-time use.

Alcohol: Withdrawal & Detoxification:

- Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. - Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. - Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremens. - Alcohol withdrawal usually peaks on the second day and is over in about 5 days. - This can vary, however; and withdrawal may take 1 to 2 weeks. - Because alcohol withdrawal can be life-threatening, detoxification needs to be accomplished under medical supervision. - If the client's withdrawal symptoms are mild and he or she can abstain from alcohol, he or she can be treated safely at home. For more severe withdrawal or for clients who cannot abstain during detoxification, a short admission of 3 to 5 days is the most common setting. - Some psychiatric units also admit clients for detoxification, but this is less common. - Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms. - Withdrawal can be accomplished by fixed-schedule dosing known as tapering, or symptom-triggered dosing in which the presence and severity of withdrawal symptoms determine the amount of medication needed and the frequency of administration. - Often, the protocol used is based on an assessment tool such as the Clinical Institute Withdrawal - Clients on symptom-triggered dosing receive medication based on scores of this scale alone, while clients on fixed-dose tapers can also receive additional doses depending on the level of scores from this scale. Both methods of medicating clients are safe and effective.

If Patient Starts Drinking On Antabuse:

- Symptoms: Sweating, vomiting, tachycardia, flushing, HA, sweating, hypotensive, confusion = adverse effects - Could possibly lead to death but they are taught that if they drink they will experience these symptoms - Has defer adverse effects to deter them from drinking

Cultural Considerations: Japan:

- The Japanese do not regard alcohol as a drug, and there are no religious prohibitions against drinking. - Excessive alcohol consumption is widely condoned at parties, business functions, and at home, and few - Japanese people go for alcohol treatment

Dual Diagnosis:

- The client with both substance abuse and another psychiatric illness is said to have a dual diagnosis. - Dual diagnosis clients who have schizophrenia, schizoaffective disorder, or bipolar disorder present the greatest challenge to health care professionals. - It is estimated that 50% of people with a substance abuse disorder also have mental health diagnoses. Traditional methods for treatment of major psychiatric illness or primary substance abuse often have limited success in these clients for the following reasons: •Clients with a major psychiatric illness may have impaired abilities to process abstract concepts; this is a major barrier in substance abuse programs. •Substance use treatment emphasizes avoidance of all psychoactive drugs. This may not be possible for the client who needs psychotropic drugs to treat his or her mental illness. •The concept of "limited recovery" is more acceptable in the treatment of psychiatric illnesses, but substance abuse has no limited recovery concept. •The notion of lifelong abstinence, which is central to substance use treatment, may seem overwhelming and impossible to the client who lives "day to day" with a chronic mental illness. •The use of alcohol and other drugs can precipitate psychotic behavior; this makes it difficult for professionals to identify whether symptoms are the result of active mental illness or substance abuse. - Clients with a dual diagnosis (substance use and mental illness) present challenges that traditional settings cannot meet. - Studies of successful treatment and relapse prevention strategies for this population found that integrated treatment programs that address many unmet needs are more likely to succeed - Several key elements that need to be addressed include healthy, nurturing, supportive living environments; assistance with fundamental life changes, such as finding a job and abstinent friends; connections with other recovering people; and treatment of comorbid conditions. - Clients identified the need for stable housing, positive social support, using prayer or relying on a higher power, participation in meaningful activity, eating regularly, getting sufficient sleep, and looking presentable as important components of relapse prevention.

Substance Abuse Evaluation:

- The effectiveness of substance abuse treatment is based heavily on the client's abstinence from substances. - In addition, successful treatment should result in more stable role performance, improved interpersonal relationships, and increased satisfaction with quality of life.

Periods Of Abstinence Or Temporarily Controlled Drinking:

- The later course of alcoholism, when the person's functioning is definitely affected, is often characterized by periods of abstinence or temporarily controlled drinking. - Abstinence may occur after some legal, social, or interpersonal crisis, and the person may then set up rules about drinking, such as drinking only at certain times or drinking only beer. - This period of temporarily controlled drinking soon leads to an escalation of alcohol intake, more problems, and a subsequent crisis. - The cycle repeats continuously.

Substance Abuse: Self-Awareness Issues:

- The nurse must examine his or her beliefs and attitudes about substance abuse. - A history of substance use in the nurse's family can influence strongly his or her interaction with clients. - The nurse may be overly harsh and critical, telling the client he or she should "realize how you're hurting your family." - Conversely, the nurse may unknowingly act out old family roles and engage in enabling behavior such as sympathizing with the client's reasons for using substances. - Examining one's own substance use or the use by close friends and family may be difficult and unpleasant, but it is necessary if the nurse is to have therapeutic relationships with clients. - The nurse might also have different attitudes about various substances of abuse. - For example, a nurse may have empathy for clients who are addicted to prescription medication but is disgusted by clients who use heroin or other illegal substances. - It is important to remember that the treatment process and underlying issues of substance abuse, remission, and relapse are quite similar regardless of the substance. - Many clients experience periodic relapses. For some, being sober is a lifelong struggle. - The nurse may become cynical or pessimistic when clients return for multiple attempts at substance use treatment. - Such thoughts as "he deserves health problems if he keeps drinking" or "she should expect to get hepatitis or HIV infection if she keeps doing IV drugs" are signs that the nurse has some self-awareness problems that prevent him or her from working effectively with clients and their families.

Sedatives, Hypnotics, and Anxiolytics: Withdrawal & Detoxification:

- The onset of withdrawal symptoms depends on the half-life of the drug - Medications such as lorazepam, with actions that typically last about 10 hours, produce withdrawal symptoms in 6 to 8 hours; longer acting medications, such as diazepam, may not produce withdrawal symptoms for 1 week. - The withdrawal syndrome is characterized by symptoms that are the opposite of the acute effects of the drug—autonomic hyperactivity (increased pulse, blood pressure, respirations, and temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitation. - Seizures and hallucinations occur only rarely in severe benzodiazepine withdrawal - Detoxification from sedatives, hypnotics, and anxiolytics is often medically managed by tapering the amount of the drug the client receives over a period of days or weeks, depending on the drug and the amount the client had been using. - Tapering, or administering decreasing doses of a medication, is essential with barbiturates to prevent coma and death that occur if the drug is stopped abruptly. - For example, when tapering the dosage of a benzodiazepine, the client may be given Valium, 10 mg four times a day; the dose is decreased every 3 days, and the number of times a day the dose is given is also decreased until the client safely withdraws from the drug.

Sedatives, Hypnotics, and Anxiolytics: Intoxication & Overdose:

- This class of drugs includes all central nervous system depressants: barbiturates, nonbarbiturate hypnotics, and anxiolytics, particularly benzodiazepines. - Benzodiazepines and barbiturates are the most frequently abused drugs in this category. - The intensity of the effect depends on the particular drug. - The effects of the drugs, symptoms of intoxication, and withdrawal symptoms are similar to those of alcohol. - In the usual prescribed doses, these drugs cause drowsiness and reduce anxiety, which is the intended purpose. - Intoxication symptoms include slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, and even stupor and coma. - Benzodiazepines alone, when taken orally in overdose, are rarely fatal, but the person is lethargic and confused. - Treatment includes gastric lavage followed by ingestion of activated charcoal and a saline cathartic; dialysis can be used if symptoms are severe - The client's confusion and lethargy improve as the drug is excreted. - Barbiturates, in contrast, can be lethal when taken in overdose. - They can cause coma, respiratory arrest, cardiac failure, and death. - Treatment in an intensive care unit is required using lavage or dialysis to remove the drug from the system and to support respiratory and cardiovascular function.

Purpose Of CIWA:

- To detect withdrawal early - As withdrawal progresses & you don't address, what happens besides death?: Seizures, delirium tremors (assessing for delirium tremors b/c we don't want this to happen) - Point of CIWA is so delirium tremors is not an issue with patient (hallucinations that are tactile: feel things crawling, visual, auditory: visual & tactile are more common) - Really agitated and increased anxiety and could go into a seizure then coma then possible death

Touching Patients:

- Touch patient b/c you want to make sure what you're seeing is real - If you see visible sweat on their forehead, rub your finger on their forehead and palms to check sweating

Main Things Is Preventing Withdrawal:

- Try to do assessment frequently - When they come in q2, q4, q8, q-shift - About 5 days for withdrawal: do wake patients for assessments. - While assessing them, if they start to get confused or hallucinate, then they are about to be in DT and you want to give them prescribed meds. (benzo usually) and watch for respiration depression b/c they are CNS depressants and when they go home educate them and make sure they have support - If they do go home with Antabuse, educate them properly - They may have a support group like AA, 12-step program: it is a support group open or closed and ran by a peer and it's to help them support them through sobriety

Catching Withdrawals:

- Want to catch withdrawal symptoms fast before they progress

Substance Abuse: Assessment: Mood & Affect:

- Wide ranges of mood and affect are possible. - Some clients are sad and tearful, expressing guilt and remorse for their behavior and circumstances. - Others may be angry and sarcastic or quiet and sullen, unwilling to talk to the nurse. - Irritability is common because clients are newly free of substances. - Clients may be pleasant and seemingly happy, appearing unaffected by the situation, especially if they are still in denial about the substance use.

Stimulants: Withdrawal & Detoxification:

- Withdrawal from stimulants occurs within a few hours to several days after cessation of the drug and is not life-threatening. - Marked dysphoria is the primary symptom and is accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation. - Marked withdrawal symptoms are referred to as "crashing"; the person may experience depressive symptoms, including suicidal ideation, for several days. - Stimulant withdrawal is not treated pharmacologically.

Categories Of Drugs:

1. Alcohol 2. Sedatives, hypnotics, and anxiolytics 3. Stimulants 4 .Cannabis 5. Opioids 6. Hallucinogens 7. Inhalants

When Could You Start Seeing Withdrawal Symptoms?

4-12 hours, it depends on how heavily they drink. - Super heavy drinker and drinkers who drink all day non-stop will see withdrawal symptoms in 4-5 hours. - People who drink in the evening and drink a lot daily might see more the next day - Time period depends on how long and how heavy of a drinker they are and how long they've gone without it - Once the body has a certain amount of alcohol left in there the body is dependent on the drug, once the drug starts to decrease, that's when symptoms start.

Substance Abuse: Data Analysis:

Each client has nursing diagnoses specific to his or her physical health status. These may include: •Imbalanced nutrition: Less than body requirements •Risk for infection •Risk for injury •Diarrhea •Excess fluid volume •Activity intolerance •Self-care deficits Nursing diagnoses commonly used when working with clients with substance use include: •Ineffective denial •Ineffective role performance •Dysfunctional family processes: Alcoholism •Ineffective coping

Is the following statement true or false? Alcohol is a central nervous system stimulant.

False - Rationale: Alcohol is classified as a central nervous system depressant.

Is the following statement true or false? A person who abuses hallucinogens will experience withdrawal syndrome on cessation of use.

False - Rationale: There is no withdrawal syndrome associated with hallucinogen use.

Substance Abuse: Mental Health Promotion: The College Drinking Prevention Program:

The College Drinking Prevention Program, which is government sponsoterm-65red, is a response to some of the following statistics about college students between the ages of 18 and 24 (NIAAA, 2015): •1825 students die annually from alcohol-related unintentional injuries. •599,000 students are unintentionally injured while under the influence of alcohol. •696,000 students are assaulted by another student under the influence of alcohol. •97,000 students are victims of alcohol-related assault or date rape. •400,000 students reported having unsafe sex; 100,000 students reported being too drunk to know if they consented to sexual activity. •150,000 students develop an alcohol-related health problem; 1.2% to 1.5% of these students report attempting suicide in the past year because of drinking or drug use. •3.6 million students reported driving under the influence of alcohol. •About 25% of students report academic consequences of drinking, such as missing class, falling behind, doing poorly in exams or papers, and receiving lower grades overall. - This prevention program was designed to help college students avoid the "predictable" or expected binge drinking common in U.S. colleges and universities. - Some campuses offer alcohol- and drug-free dormitories for students, and some college-wide activities no longer allow alcohol to be served. - Educational programs (about the previous statistics) are designed to raise student awareness about excessive drinking - Students who wish to abstain from alcohol are encouraged to socialize together and provide support to one another for this lifestyle choice.

Substance Abuse: Outcome Identification:

Treatment outcomes for clients with substance use may include: •The client will abstain from alcohol and drug use. •The client will express feelings openly and directly. •The client will verbalize acceptance of responsibility for his or her own behavior. •The client will practice nonchemical alternatives to deal with stress or difficult situations. •The client will establish an effective aftercare plan.

Is the following statement true or false? A client who abuses substances will commonly state that he or she can control his or her use of the substance

True - Rationale: Typically, the client is in denial and commonly states that he or she can stop using the drug anytime.

2. Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which nursing assessment is essential before giving a dose of this medication? a.Assessing the client's blood pressure b.Determining when the client last used an opiate c.Monitoring the client for tremors d.Completing a thorough physical assessment

a.Assessing the client's blood pressure

6. A client comes to day treatment intoxicated but says he is not. The nurse identifies that the client is exhibiting symptoms of a.denial. b.reaction formation. c.projection. d.transference.

a.denial.

3. Which behaviors would indicate stimulant intoxication? a.Slurred speech, unsteady gait, impaired concentration b.Hyperactivity, talkativeness, euphoria c.Relaxed inhibitions, increased appetite, distorted perceptions d.Depersonalization, dilated pupils, visual hallucinations

b.Hyperactivity, talkativeness, euphoria

5. The nurse has provided an in-service program on impaired professionals. She knows that teaching has been effective when staff identify which as the highest risk for substance abuse among professionals? a.Most nurses are codependent in their personal and professional relationships. b.Most nurses come from dysfunctional families and are at risk for developing addiction. c.Most nurses are exposed to various substances and believe they are not at risk of developing the disease. d.Most nurses have preconceived ideas about what kind of people become addicted.

c.Most nurses are exposed to various substances and believe they are not at risk of developing the disease.

4. The 12 steps of AA teach that a.acceptance of being an alcoholic will prevent urges to drink. b.a higher power will protect individuals if they feel like drinking. c.once a person has learned to be sober, he or she can graduate and leave AA. d.once a person is sober, he or she remains at risk for drinking.

d.once a person is sober, he or she remains at risk for drinking.

Points To Consider When Working With Client & Families With Substance Abuse Problems:

•Remember that substance abuse is a chronic, recurring disease for many people, just like diabetes or heart disease. Even though clients look like they should be able to control their substance abuse easily, they cannot without assistance and understanding. •Examine substance abuse problems in your own family and friends, even though it may be painful. Recognizing your own background, beliefs, and attitudes is the first step toward managing those feelings effectively so that they do not interfere with the care of clients and families. •Approach each treatment experience with an open and objective attitude. The client may be successful in maintaining abstinence after his or her second or third (or more) treatment experience.