Ch.31: Addiction and Substance Use-Related Disorders

Definition of Addiction

A condition of continued use of substances (or reward-seeking behaviors) despite adverse consequences

Skills Training Group Topics

Interpersonal -Starting conversations -Giving and receiving compliments -Nonverbal communication -Receiving criticism -Receiving criticism about drinking -Drink and drug refusal skills -Refusing requests -Close and intimate relationships -Enhancing social support networks -Recognizing and Expressing Emotions Intrapersonal -Managing thoughts about alcohol -Problem solving -Increasing pleasant activities -Relaxation training -Awareness and management of anger -Awareness and management of negative thinking -Planning for emergencies -Coping with persistent problems

Effects of Abused Substances, Overdose, Withdrawal Syndromes, and Prolonged Use

Alcohol -E: Sedation, decreased inhibitions, relaxation, decreased coordination, slurred speech, nausea -O: Respiratory depression, cardiac arrest -W: Tremors; seizures, elevated temperature, pulse, and blood pressure; delirium tremens -P: Affects all systems of the body. Can lead to other dependencies, and malnutrition Stimulants (e.g., amphetamines, cocaine) -E: Euphoria, initial CNS stimulation and then depression, wakefulness, decreased appetite, insomnia, paranoia, aggressiveness, dilated pupils, tremors -O: Cardiac arrhythmias or arrest, increased or lowered blood pressure, respiratory depression, chest pain, vomiting, seizures, psychosis, confusion, seizures, dyskinesias, dystonias, coma -W: Depression: psychomotor retardation at first and then agitation; fatigue and then insomnia; severe dysphoria and anxiety; cravings, vivid, unpleasant dreams; increased appetite. Amphetamine withdrawal is not as pronounced as cocaine withdrawal -P: Often alternates with use of depressants. Weight loss and resulting malnutrition and increased susceptibility to infectious diseases. May produce schizophrenia-like syndrome with paranoid ideation, thought disturbance, hallucinations, and stereotyped movements. Deviated nasal septum, irreversible nasal damage Cannabis (marijuana, hashish, THC) -E: Euphoria or dysphoria, relaxation and drowsiness, heightened perception of color and sound, poor physical coordination, spatial perception and time distortion, unusual body sensations (e.g., weightlessness, tingling), dry mouth, dysarthria, and cravings for particular foods -O: Increased heart rate, reddened eyes, dysphoria, lability, disorientation -P: Can decrease motivation and cause cognitive deficits (e.g., inability to concentrate, impaired memory). Lung damage, may precipitate psychosis Hallucinogens (LSD, MDMA) -E: Euphoria or dysphoria, altered body image, distorted or sharpened visual and auditory perceptions, depersonalization, bizarre behavior, confusion, incoordination, impaired judgment and memory, signs of sympathetic and parasympathetic stimulation, palpitations (blurred vision, dilated pupils, sweating) -O: Paranoia, ideas of reference, fear of losing one's mind, depersonalization, derealization, illusions, hallucinations, synesthesia, self-destructive or aggressive behaviors, tremors -W: "Flashbacks" or Hallucinogenic Persisting perception disorder (HPPD) may occur after termination of use PCP -E: Feeling superhuman, decreased awareness of and detachment from the environment, stimulation of the respiratory and cardiovascular systems, ataxia, dysarthria, decreased pain perception -O: Hallucinations, paranoia, psychosis, aggression, adrenergic crisis (cardiac failure, cerebrovascular accident, malignant hyperthermia, status epilepticus, severe muscle contractions) -P: "Flashbacks," HPPD, organic brain syndromes with recurrent psychotic behavior, which can last up to 6 months after not using the drug, numerous psychiatric hospitalizations and police arrests Opioids (heroin, codeine) -E: Euphoria, sedation, reduced libido, memory and concentration difficulties, analgesia, constipation, constricted pupils -O: Respiratory depression, stupor, coma -W: Abdominal cramps, rhinorrhea, watery eyes, dilated pupils, yawning, "goose flesh," diaphoresis, nausea, diarrhea, anorexia, insomnia, fever -P: Can lead to criminal behavior to get money for drugs, risk for infection related to needle use (e.g., HIV, endocarditis, hepatitis, abscesses) Sedatives, hypnotics, anxiolytics) -E: Euphoria, sedation, reduced libido, emotional lability, impaired judgment -O: Respiratory depression, cardiac arrest -W: Anxiety rebound and agitation, hypertension, tachycardia, sweating, hyperpyrexia, sensory excitement, motor excitation, insomnia, possible tonic-clonic convulsions, nightmares, delirium, depersonalization, hallucinations -P: Often alternated with stimulants, use with alcohol enhances chance of overdose, risk for infection related to needle use Inhalants (e.g., glue, lighter fluid, gasoline, screen-cleaners, hair spray (other aerosol sprays) -E: Euphoria, giddiness, excitation -O: CNS depression: ataxia, nystagmus, dysarthria, coma, and convulsions -W: Similar to findings with alcohol but milder, with anxiety, tremors, hallucinations, and sleep disturbance as the primary symptoms -P: Long-term use can lead to hepatic and renal failure, blood dyscrasias, damage to the lungs; CNS damage (e.g., OBS, peripheral neuropathies, cerebral and optic atrophy, parkinsonism) Nicotine -E: Stimulation, enhanced performance and alertness, and appetite suppression -O: Anxiety -W: Mood changes (e.g., craving, anxiety) and physiologic changes (e.g., poor concentration, sleep disturbances, headaches, gastric distress, and increased appetite) -P: Increased chance for cardiac disease and lung disease (COPD, Cancer) Caffeine -E: Stimulation, increased mental acuity, inexhaustibility -O: Restlessness, nervousness, excitement, insomnia, flushing, diuresis, gastrointestinal distress, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, agitation -W: Headache, drowsiness, fatigue, craving, impaired psychomotor performance, difficulty concentrating, yawning, nausea -P: Physical consequences are under investigation, may have risks and benefits

Substance Abuse Assessment

Ask about -Alcohol -Stimulants -Opioids -Sedative-hypnotics and anxiolytic agents -Hallucinogens -Marijuana -Inhalants -Nicotine -Caffeine, other OTC's or herbal products Pattern of Use (amount, route, first use, frequency, and length of use) Abuse Indicators 1. Tolerance (increasing use of drug or alcohol with the same level of intoxication) 2. Withdrawal symptoms: a. Shakes? b. Tremors? c. Cramps, diarrhea, or rapid pulse? d. Feeling paranoid, fearful? e. Difficulty sleeping? 3. Consequences of use (e.g., presenting problems, persistent or recurrent emotional, social, legal, or other problems) 4. Loss of control of amount, frequency, or duration of use 5. Desire or efforts to decrease use or control use 6. Preoccupation (increasing focus or time spent on use and obtaining substances) 7. Social, vocational, recreational activities affected by use 8. Previous alcohol or drug abuse treatment

Medical Complications of Alcohol Abuse

Cardiovascular system: Cardiomyopathy, congestive heart failure, hypertension Respiratory system: Increased rate of pneumonia and other respiratory infections Hematologic system: Anemias, leukemia, hematomas Nervous system: Withdrawal symptoms, irritability, depression, anxiety disorders, sleep disorders, phobias, paranoid feelings, diminished brain size and functioning, organic brain disorders, blackouts, cerebellar degeneration, neuropathies, palsies, gait disturbances, visual problems Digestive system and nutritional deficiencies: Liver diseases (fatty liver, alcoholic hepatitis, cirrhosis), pancreatitis, ulcers, other inflammations of the GI tract, ulcers and GI bleeds, esophageal varices, cancers of the upper GI tract, pellagra, alcohol-amnestic disorder, dermatitis, stomatitis, cheilosis, scurvy Endocrine and metabolic systems: Increased incidence of diabetes mellitus, hyperlipidemia, hyperuricemia, and gout Immune system: Impaired immune functioning, higher incidence of infectious diseases, including tuberculosis and other bacterial infections Integumentary system: Skin lesions, increased incidence of infection, burns, and other traumatic injury Musculoskeletal system: Increased incidence of traumatic injury, myopathy Genitourinary system: Hypogonadism, increased secondary female sexual characteristics in men (hypoandrogenization and hyperestrogenization), erectile dysfunction in men, electrolyte imbalances due to excess urinary secretion of potassium and magnesium

Stimulants

Cocaine, Amphetamines, Methamphetamine, MDMA and other "Club Drugs", Nicotine, Caffeine

Drug Profile: Naltrexone (Relistor) Side Effects

Difficulty sleeping, anxiety, nervousness, headache, low energy, abdominal pain or cramps, nausea, vomiting, delayed ejaculations, decreased potency, rash, chills, increased thirst, joint and muscle pain

Brief Intervention and Harm Reduction

Discussing harm reduction strategies, especially those relating to the following: -Overdose -Violence -Driving under the influence -Safe practices (e.g., safe injecting, safe sex) -Offering and arranging a follow-up visit

FRAMES - Effective Elements of Brief Intervention

Feedback -Provide patients with personal feedback regarding their individual status, such as personal alcohol and other drug consumption relative to norms, information about elevated liver enzyme values, and other factors Responsibility -Emphasize the individual's freedom of choice and personal responsibility for change -General themes are as follows: 1. It's up to you; you're free to decide to change or not 2. No one else can decide for you or force you to change 3. You're the one who has to do it if it's going to happen Advice -Include a clear recommendation or advice on the need for change, typically in a supportive and concerned, rather than in a judgmental, manner Menu -Provide a menu of treatment options from which patients may pick those that seem more suitable or appealing Empathic Counseling -Show warmth, support, respect, and understanding in communication with patients Self-Efficacy -Reinforce self-efficacy or an optimistic feeling that they can change

Success of Brief Intervention

Is most successful when working with people who -Are experiencing few problems with their drug use -Have low levels of dependence -Have a short history of drug use -Have stable backgrounds -Are unsure or ambivalent about changing or ending their drug use

Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA)

Nausea and vomiting -Ask, "Do you feel sick to your stomach? Have you vomited?" Tactile disturbances -Ask, "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Tremor -Arms extended and fingers spread apart Auditory disturbances -Ask, "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Paroxysmal sweats Visual disturbances -Ask, "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Anxiety -Ask, "Do you feel nervous?" Headache, fullness in head -Ask, "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity Agitation Orientation and clouding of sensorium -Ask, "What day is this? Where are you? Who am I?" Maximum possible score of 67

Severity of Opioid Withdrawal Syndrome

Onset -8-12 h after last use of short-acting opioids -1-3 days after the last use for longer acting opioids, such as methadone Duration -Severe symptoms peak between 48 and 72 h -Symptoms abate in 7-10 days for short-acting opioids -Methadone withdrawal symptoms can last several weeks Mild -Physical: yawning, rhinorrhea, perspiration, restlessness, lacrimation, sleep disturbance -Emotional: increased craving, anxiety, dysphoria Moderate -Physical: dilated pupils, bone and muscle aches, sensation of "goose flesh," hot and cold flashes -Emotional: irritability, increased anxiety, and craving Severe -Nausea; vomiting; stomach cramps; diarrhea; weight loss; insomnia; twitching of muscles and kicking movements of legs; increased blood pressure, pulse, and respirations -Emotional: depression, increased anxiety, dysphoria, subjective sense of feeling "wretched"

Detoxification

Period of time where the patient is observed, usually in a hospital setting, and given medications to avoid withdrawal symptoms

Alcohol Withdrawal Syndrome

Stage I: Mild -Heart rate elevated, temperature elevated, normal or slightly elevated systolic blood pressure -Slight diaphoresis -Oriented; no confusion; no hallucinations -Mild anxiety and restlessness -Restless sleep -Hand tremors; "shakes"; no convulsions -Impaired appetite, nausea Stage II: Moderate -Heart rate, 100-120 bpm; elevated systolic blood pressure and temperature -Usually obvious diaphoresis -Intermittent confusion; transient visual and auditory hallucinations and illusions (mostly at night) -Painful anxiety and motor restlessness -Insomnia and nightmares -Visible tremulousness, rare convulsions -Anorexia, nausea and vomiting Stage III: Severe -Heart rate, 120-140 bpm; elevated systolic and diastolic blood pressures; elevated temperature -Marked diaphoresis -Marked disorientation, confusion, disturbing visual and auditory hallucinations, misidentification of objects, delusions related to the hallucinations, delirium tremens, disturbances in consciousness -Agitation, extreme restlessness, and panic states -Unable to sleep -Gross uncontrollable tremors, convulsions common -Rejecting all fluid and food

Behaviors in Substance Use, Abuse, and Addiction

Substance Use -Does not have possible danger or potential legal problems -Engages in use to enhance social situations and interaction -Is not intended to result in intoxication -Has control of the amount and frequency of use -Exhibits socially acceptable behavior while using Prescription Medication Use -Use is for the dose, frequency, and indications prescribed -Use is for the particular episode of the condition for which it was prescribed -Use is coordinated among prescribing physicians Substance Abuse -Use for intoxication or feeling of being "high" -Use that interferes with normal life functions (e.g., producing sleep when inappropriate, excitability, or irritability interfering with social interaction) -Potential harm to self or others (e.g., driving while intoxicated, use of injection drug equipment) -Use that has legal consequences (e.g., all uses of illicit drugs) -Use resulting in socially unacceptable behavior (e.g., public drunkenness, verbal or physical abuse) -Use to alter normal feeling states such as sadness or anxiety Prescription Medication Abuse -Use is at a higher dose and greater frequency than prescribed -Use is for indications other than prescribed or for self-diagnosed condition -Use results in feeling tired, having a clouded mental state, or feeling "hyperactive" or nervous -Supplementing medication with alcohol or drugs -Soliciting more than one physician for the same medication -Inability to control the amount and frequency of use -Tolerance to larger amounts of the substance -Withdrawal symptoms when stopping use -Severe consequences from alcohol or drug use Substance Addiction -Drug craving -Compulsive use -Presence of aberrant drug-related behaviors -Repeated relapse into drug use after withdrawal

Drug Profile: Buprenorphine (Suboxone, Bunavail, Zubsolv)

-Partial opioid agonist/antagonist -Partial agonist at the μ-opioid receptor and an antagonist at the kappa receptor -Will displace morphine, methadone, and other opioid full agonists from the receptor -For pain management and during detoxification and opioid addiction, and long-term maintenance treatment of opioid addiction -May be initiated while the person is actively withdrawing from opioids -Pregnant women should receive the buprenorphine-only sublingual tablet (Subutex)

Acamprosate Calcium

-A delayed-release tablet that decreases alcohol intake and reduces the risk of returning to drink alcohol in the person who is alcohol-dependent -It is indicated for the maintenance of abstinence from alcohol in patients who are alcohol-dependent -Acamprosate is effective only if the individual is abstinent from alcohol prior to its initiation -The maintenance dose (333 to 666 mg orally) must be taken with meals three times daily, which can discourage compliance with treatment

Motivation

-A goal-oriented attitude that propels action for change and can help sustain the development of new activities and behaviors when additional support and treatment are available -Motivational approaches are priority interventions for patients with substance-related disorders -They help patients recognize a problem and begin to develop change strategies for continuing recovery and relapse prevention

Brief Intervention

-A growing body of evidence indicates that brief interventions are more effective than no treatment, and indications suggest that they are as effective as more intensive interventions -Screening, brief intervention, and referral to treatment (SBIRT) have been shown to be effective in helping individuals with high-risk alcohol use to seek help -Within the alcohol and other drugs field, brief intervention is a highly developed, researched, and widely accepted approach -Screening and brief intervention are two separate skills that can be used together to reduce risky substance use -Screening involves asking questions about alcohol or drug use -A brief intervention is a negotiated conversation between the professional and patient designed to reduce or eliminate alcohol and drug use -Not everyone who is screened will need a brief intervention, and not everyone who needs a brief intervention will require treatment -In fact, the goals of screening and brief intervention are to reduce risky substance use before people become dependent or addicted -Brief intervention is effective for several reasons -Research indicates that brief interventions are an appropriate response to patients presenting in a general health or community setting and who are unlikely to need, seek, or attend specialist treatment -Brief intervention—to be given clear concise information by a professional—may be all the patients may want -It is also an important part of the overall approach to harm reduction

Family Responses to Substance Use and Abuse

-Abuse of substances by one or more members has devastating effects on families, their functioning, and the community -Fetal alcohol syndrome (FAS) results from drinking alcohol during pregnancy and is one of the leading causes of irreversible mental retardation -Addictions lead to loss of jobs and family relationships due to behaviors such as lying, stealing, and putting the addiction before the well-being of one's self and family -Use of illegal substances can lead to arrest and prison and heated disputes over child custody -Many families try to help their family member learn to abstain or reduce the use of substances -Support groups provide education and help in understanding the addiction -Conversely, some persons who recover from substance abuse find that they must distance themselves from families that are actively using and abusing alcohol and drugs -Poor family relationships and dysfunction are important predictors of addictions to all psychoactive substances

Diversity and Disparity for Addiction

-Epidemiologic data show that in the United States, sex/race/ethnic groups differ in drug preferences, use, accessibility, and risk -Such identified differences should be used to direct the service needs for the population -For instance, youth identifying as sexual minorities were found to have higher substance use, experienced more violence victimization, and were at a higher risk for suicide than other teens -These teens need more access to crisis services, anti-bullying approaches, and more screening for suicide prevention -Furthermore, racial/ethnic minorities are disproportionately incarcerated for drug crimes and placed in facilities that have insufficient substance abuse treatment and follow-up -Identifying differences and disparities among the diverse US population is essential to the design of programs, services, and policies that can effectively address specific population needs

Addiction

-Alcohol, tobacco, marijuana, and illegal prescription drug use has reached epidemic proportions in the United States, with the incidence rising in younger age groups, particularly among adolescents and young adults -One of the goals of Healthy People 2020 is "to reduce substance abuse to protect the health, safety, and quality of life for all, especially children" -A major challenge facing our country is the opioid epidemic -The overriding concern about using mind-altering substances is that these substances compromise health, and the continued use will lead to addiction -Many mind-altering substances are physiologically addicting and easily can lead to severe health and legal problems -Use by ingestion, smoking, sniffing, or injection of some mind-altering substances such as alcohol, pain medication, tobacco, or caffeine is legal for adults -State laws on marijuana use are changing rapidly as more states legalize and decriminalize use for medicinal and/or recreational purposes -Other substances such as cocaine and heroin are illegal in the United States -Abuse occurs when a person uses alcohol or drugs for the purpose of intoxication or, in the case of prescription drugs, for purposes other than their intended use -Substance-related disorders involve substances that are commonly abused -Physiologic dependence can develop with many different types of medications such as beta-blockers, antidepressants, opioids, antianxiety agents, and others -As long as medications are used for their intended purposes and under the supervision of qualified health care providers, physiologic dependence is an expectation of treatment -That is, dependence can be a normal response to some medications

Peer Support Self-Help Group

-Alcoholics Anonymous (AA) was the first 12-step, self-help program -AA is a worldwide fellowship of people with alcoholism who provide support, individually and at meetings, to others who seek help -The program steps include spiritual, cognitive, and behavioral components -Many treatment programs discuss concepts from AA, hold meetings at the treatment facilities, and encourage patients to attend community meetings when appropriate -They also encourage continuing use of AA and other self-help groups as part of an ongoing plan for continued abstinence -Twelve-step programs do not solicit members; engage in political or religious activities; make medical or psychiatric diagnoses; engage in education about addiction to the general population; or provide mental health, vocational, or legal counseling -Using peer support and support groups is an accepted approach with many beneficial outcomes for participants, since nurses are often responsible for the selection and training of individuals who will serve as peer support specialists (PSS) -Much can be learned from studies that reveal member's ideas about what works best, and who they can best work with -Alternative peer support groups differ from these programs in their approach -Four such groups in the United States are Women for Sobriety, Moderation Management, Men for Sobriety, and Self-Management and Recovery Training (SMART) Recovery -These groups are based on harm reduction philosophies and missions

Alcohol Use Disorder

-All patients should be screened not only for alcohol use disorders but also for drinking patterns or behaviors that may place them at increased risk for experiencing adverse health effects or alcoholism -A frequently used screening tool is the CAGE Questionnaire -This tool consists of four self-report responses to questions about respondents' beliefs of cutting down on their drinking, their experience of others criticizing their drinking, the presence of guilt about drinking, and early morning drinking -People who abuse alcohol exhibit various patterns of use -Some engage in heavy drinking on a regular or daily basis, others may abstain from drinking during the week and engage in heavy drinking on the weekends, and still others experience longer periods of sobriety interspersed with bouts of binge drinking (several days of intoxication) -Another early detection screening tool commonly used is The Alcohol Use Disorders Identification Test (AUDIT), a 10-item tool developed by the World Health Organization, which has been validated for use across genders and racial groups and is approved for adolescents aged 14 to 18 -The level of CNS impairment while under the influence of alcohol depends on how much has been consumed in a given period of time and how rapidly the body metabolizes it -Intoxication is determined by the level of alcohol in the blood, called blood alcohol level (BAL) -The body can metabolize 1 oz of liquor, a 5-oz glass of wine, or a 12-oz can of beer per hour without intoxication

Cocaine

-Also known as coke, snow, nose candy, flake, blow, big c, lady, white, or snowbirds -Made from the leaves of the Erythroxylon coca plant, turned into a coca paste that is refined into cocaine hydrochloride, a crystalline form (thus the white powder appearance), which is commonly inhaled or "snorted" in the nose, injected intravenously (with water), or smoked -The smokable form of cocaine, often called free-base cocaine, can be made by mixing crystalline cocaine with ether or sodium hydroxide -Crack cocaine, often simply called "crack," is a form of free-base cocaine produced by mixing the crystal with water and baking soda or sodium bicarbonate and boiling it until a rock precipitant remains -The hardened crystal is then broken into pieces ("cracked") and smoked in cigarettes or water pipes -This extremely potent form produces a rapid high with intense euphoria and a dramatic crash -It is extremely addictive because of the intense and rapid onset of euphoric effects, which leave users craving for more -After cocaine is inhaled or injected, the user experiences a sudden burst of mental alertness and energy ("cocaine rush") and feelings of self-confidence, being in control, and sociability, which last 10 to 20 minutes -Enhanced sexual experiences and drive can get many started on regular use -This high is followed by an intense let-down effect ("cocaine crash"), in which the person feels irritable, depressed, tired, and craves more of the drug -Users experience a serious psychological addiction and pattern of abuse -Although cocaine users typically report that the drug enhances their feelings of well-being and reduces anxiety, cocaine is also known to bring on panic attacks in some individuals and may also contribute to sexual assault, as the user may not realize how rough they are being -This behavior can also contribute to sexually transmitted infections as condoms break, membranes tear, and blood or body fluids are exchanged -Long-term cocaine use leads to increased anxiety -Increased use of cocaine is associated with stress and drug craving, and toxic, potentially catastrophic cardiovascular problems, which may become chronic even in those whose exposure to cocaine is limited to occasional, recreational use

Family Interventions

-Family therapy, a vital part of addiction treatment, can be used in several beneficial ways to initiate change and help the family when the substance-abusing person is unwilling to seek treatment -Behavioral couples therapy for people with alcoholism can improve family functioning, reduce stressors, smooth marital adjustment, and lessen domestic violence and verbal conflict -When the substance-abusing person seeks help, family therapy can help stabilize abstinence and relationships -Often, inpatient substance abuse treatment programs have family education and group therapy components that help meet these goals -Family therapy can also help to maintain long-term recovery and prevent relapse -Goals of family therapy should be realistic and obtainable -Action plans must be specific and organized into manageable increments -Target dates should be realistic, so pressure is minimal, yet there is motivation to act in a timely manner -Planning for the future is very difficult as long as alcohol or drug abuse continues

Alcohol-Induced Amnestic Disorders

-Although certain alcohol-related cognitive impairments are reversible with abstinence, long-term alcohol abuse can cause specific neurologic complications that lead to organic brain disorders, known as alcohol-induced amnestic disorders -Alcohol is directly toxic to the brain, causing atrophy of the frontal cortex and eventually chronic brain syndrome -Patients with alcohol-induced amnestic disorders usually have a history of many years of heavy alcohol use and are generally older than 40 years -Poor dietary intake leads to deficiencies or insufficiencies in folic acid and thiamine (and other B vitamins), which are particularly important to numerous aspects of brain functioning -Wernicke encephalopathy, a degenerative brain disorder caused by thiamine deficiency, is characterized by vision impairment, ataxia, hypotension, confusion, and coma -Korsakoff amnestic syndrome, associated with alcoholism, involves the heart and the vascular and nervous systems, but the primary problem is acquiring new information and retrieving memories -Symptoms include amnesia, confabulation (i.e., telling a plausible but imagined scenario to compensate for memory loss), attention deficit, disorientation, and vision impairment -Although Wernicke encephalopathy and Korsakoff amnestic syndrome can appear as two different disorders, they are generally considered to be different stages of the same disorder called Wernicke-Korsakoff syndrome, with Wernicke encephalopathy representing the acute phase and Korsakoff amnestic syndrome the chronic phase -Early symptoms can be reversed, but without long-term treatment, the prognosis is poor

Amphetamines

-Amphetamines, known on the street as speed, uppers, ups, black beauties, pep pills, or copilots, were first synthesized for medical use in the 1880s -Amphetamines (Biphetamine, Delcobese, dextroamphetamine) and other stimulants, such as phenmetrazine and methylphenidate (Ritalin, Focalin), act on the CNS and peripheral nervous system -They are used to treat ADHD (Attention Deficit Hyperactivity Disorder) in adults and children, narcolepsy, depression, and obesity (on a short-term basis) -Some people abuse these drugs to achieve the effects of alertness, increased concentration, a sense of increased energy, euphoria, and appetite suppression -Amphetamines are indirect catecholamine agonists and cause the release of newly synthesized norepinephrine -Similar to cocaine, they block the reuptake of norepinephrine and dopamine, but they do not affect the serotonergic system as strongly -They also affect the peripheral nervous system and are powerful sympathomimetics, stimulating both α- and β-receptors -This stimulation results in tachycardia, arrhythmias, increased systolic and diastolic blood pressures, and peripheral hyperthermia -The effects of amphetamine use, and the clinical course of an overdose, are similar to those of cocaine

Steroids

-Anabolic steroid is the name for synthetic substances related to the male sex hormones (androgens) -Developed in the late 1930s to treat hypogonadism, they are also used to treat delayed puberty, some types of impotence, and wasting of the body caused by HIV infection or other diseases -They promote growth of skeletal muscle and the development of male sexual characteristics -More than 100 different types exist; to be used legally, all require a prescription -Some dietary supplements, such as dehydroepiandrosterone (DHEA) and androstenedione (Andro), can be purchased in commercial health stores -They are often used in the belief that large doses can convert into testosterone or a similar compound in the body that promotes muscle growth -They can be taken orally or intramuscularly -Some are applied to the skin as a cream or gel -When abused, these preparations are taken at 10 to 100 times higher doses than are used for medical disorders -Although use among men is higher than among women, use among women is growing -Case reports and small studies indicate that in high doses, anabolic steroids increase irritability and aggression, "roid rage" -Some steroid users report that they have committed aggressive acts, such as physical fighting, armed robbery, using force to obtain something, committing property damage, domestic violence, stealing from stores, or breaking into a house or building -Users engage in these behaviors more often when they take steroids than when they are drug free -Other behavioral effects include euphoria, increased energy, sexual arousal, mood swings, distractibility, forgetfulness, and confusion -Anabolic steroids do not trigger a rapid increase in dopamine or cause the "high" associated with other drugs of abuse -However, long-term use can affect neurotransmitter pathways that regulate mood and behavior -With time, anabolic steroid use is associated with an increased risk for heart attacks and strokes, blood clotting, cholesterol changes, hypertension, depressed mood, fatigue, restlessness, loss of appetite, insomnia, reduced libido, muscle and joint pain, and severe liver problems (including hepatic cancer) -Males can have reduced sperm production, shrinking of the testes, and difficulty or pain in urinating -Other undesirable body changes include breast enlargement in men and masculinization of women's bodies -Both sexes may experience hair loss and acne -Intravenous or intramuscular use of the drug and needle sharing put users at risk for HIV, hepatitis B and C, and infective endocarditis, as well as bacterial infections at injection sites

Mental Health Nursing Assessment for Substance-Related Disorders

-Assessment is crucial to understanding level of use, abuse, or dependence and to determining the patient's denial or acceptance of treatment -Assessment is often detailed and may involve family members and other loved ones -Along with the psychiatric nursing interview, specific areas should be assessed -The nurse can use the Substance Abuse Assessment as a guide in eliciting a substance use history in the assessment process -Usually, nurses encounter individuals during crisis when they are seeking professional help -These situations offer an opportunity to explore the denial that keeps their addiction thriving -The nurse's approach should be caring, matter-of-fact, gentle, and direct -Approaches that are punitive or attempt to elicit feelings of guilt or shame are destructive to the therapeutic relationship

Maintenance Treatment (Buprenorphine)

-Buprenorphine is a long-acting partial agonist that acts on the same receptors as heroin and morphine, relieving drug cravings without producing the same intense "high" or dangerous side effects -At low doses, buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms -Buprenorphine carries a lower risk of abuse, addiction, and side effects, compared with full opioid agonists -Buprenorphine is highly bound to plasma proteins and metabolized by the liver -The half-life of buprenorphine is 24 to 60 hours -Buprenorphine has poor oral bioavailability and moderate sublingual bioavailability -Formulations for opioid addiction treatment are given as sublingual tablets, skin patches, or buccal films -Patients need careful instructions on handling and applying the films to achieve the correct dosage of medication -Buprenorphine and naloxone are combined into one formulation with a brand name of Bunavail, Suboxone, or Zubsolv, and are indicated for the maintenance treatment of opioid addiction -The medication is administered sublingually as a single dose, which may be repeated up to three times per day -The purpose of adding naloxone to buprenorphine is to protect the patient from an overdose in case the patient has been misusing opiates -Otherwise, naloxone has no beneficial purpose, due to the very low dose within this medication

Clinical Judgment

-For a hospitalized patient, the first priority is to determine whether the person will be withdrawing -After the person is no longer in danger of withdrawal symptoms, the nurse can discuss the use of substance and encourage the individual to seek help for the addiction -A patient's denial of a problem with substances is common and often a priority

Caffeine

-Caffeine is a stimulant found in many drinks (coffee, tea, cocoa, soft drinks), chocolate, and OTC medications, including analgesics, stimulants, appetite suppressants, and cold relief preparations -Metabolism of caffeine is very complicated, involving more than 25 metabolites, and varies among different populations -Recently, high-energy drinks, consisting of alcohol and caffeine, are being marketed to reduce the impairment caused by ingestion of alcohol -The reality is that these energy drinks give a false sense of physical and mental competence and decrease the awareness of impairment -Deaths have been associated with these drinks though causation is difficult to prove -Symptoms of caffeine intoxication can include the following: scattered thoughts, excessive talking, inability to focus on anything, irritability, elevated blood pressure, increased heart rate, nausea, anxiety, heart palpitations (arrhythmias), insomnia, sweating, dizziness, vomiting, cardiac arrest -These may also appear in persons with no tolerance or high caffeine sensitivity -Caffeine withdrawal syndrome involves headache, drowsiness, and fatigue, sometimes with impaired psychomotor performance; difficulty concentrating; craving; and psychophysiologic complaints, such as yawning or nausea -Patients with caffeine dependence can be supported in their efforts at withdrawal by learning about the caffeine content of beverages and medication, using decaffeinated beverages, and managing individual withdrawal symptoms

Long-Term Complications

-Chronic neurologic syndromes can result from long-term use, which is linked to widespread brain damage and cognitive abnormalities that can range from mild impairment to severe dementia -In recent studies, considerably more inhalant users than cocaine users had brain abnormalities, and their damage was more extensive -Inhalant users also performed significantly worse on tests of working memory with diminished ability to focus attention, plan, and solve problems -However, inhalants can change brain chemistry and may permanently damage the brain and CNS -Magnetic resonance imaging scans of users demonstrate severe changes in cerebral white matter

Biologic Responses to Cocaine

-Cocaine is absorbed rapidly through the blood-brain barrier and is also readily absorbed through skin and mucous membranes -Rapid intoxication occurs when cocaine is injected intravenously or inhaled -Cocaine increases dopaminergic and serotonergic activity by attaching to transport proteins and, in turn, by blocking neurotransmitter reuptake -Increased dopamine causes euphoria and psychotic symptoms -Cocaine increases norepinephrine levels in the blood, causing tachycardia, hypertension, dilated pupils, and rising body temperatures -Serotonin excess contributes to sleep disturbances and anorexia -With prolonged cocaine use, these neurotransmitters are eventually depleted

Cognitive and Cognitive Behavioral Interventions and Psychoeducation

-Cognitive approaches to addiction hypothesize that if a patient can change the way they think about a situation, both the emotional reaction to it and the behavioral response will change -Psychoeducational materials, groups, and one-on-one interactions with nurses also impart information to reduce knowledge deficits related to alcohol and drug dependence -CBT is a brief structured treatment that focuses on immediate problems -It enables patients to examine the thinking process that leads to decisions to use substances, analyze distortions in thinking, and develop rational responses to these distortions

Drug Profile: Naltrexone (Relistor) Warnings

-Contraindicated in pregnancy and patients allergic to narcotic antagonists -Use cautiously in narcotic addiction because the drug may produce withdrawal symptoms -Do not administer unless patient has been opioid free for 7-10 days; verify with a negative urine screen -Also, use cautiously in patients with acute hepatitis, liver failure, depression, or suicidal tendencies and in those who are breastfeeding -Must make certain patient is opioid free before administering naltrexone -Always give naloxone challenge test before using, except in patients showing clinical signs of opioid withdrawal

Countertransference

-Countertransference is the total emotional reaction of the treatment provider to the patient -Patients with substance-related disorders can generate strong feelings and reactions in nurses and other health care providers -These feelings can be generated by overtly unpleasant behaviors of the substance-dependent persons, such as lying, deceit, manipulation, or hostility, or these feelings may be more subconscious and stem from past experiences with people with alcoholism or addicts or even from dealing with situations in the health care provider's own family -To be able to overcome countertransference feelings, nurses must recognize that the patient's behaviors are a part of the disease process involved in addiction -This also requires that nurse reflect on how their own behaviors toward patients with addictions can contribute or detract from the care they wish to provide

Denial of a Problem

-Denial can be expressed in diverse behaviors and attitudes and may not be expressed as an overt denial of the problem -For example, patients may admit to a problem and even thank the nurse for helping them to realize they have a problem but insist they can overcome the problem on their own and do not need outside help -This quandary about the nature of the problem has often been met with confrontation by nurses and other professionals in the past -But argumentation, presenting evidence of addiction, and lecturing often fail to elicit admission of a problem or induce behavior change

Opioid Intoxication or Overdose

-Emergency treatment of individuals with opioid intoxication is initiated with an assessment of CNS functioning, specifically arousal and respiratory functioning -Naloxone, an opioid antagonist, is given as a rescue drug when extreme drowsiness, slowed breathing, or loss of consciousness occurs -It reverses respiratory depression, sedation, and hypotension caused by the opioid agent -Administration of naloxone is life-saving -Naloxone is administered intravenously, intramuscularly, or intranasally -When administered intravenously, the pharmacologic effect is generally apparent within 2 minutes -When administered through other routes, the effect is more prolonged -Naloxone is active for 30 to 81 minutes -Depending upon the strength of the opiate, a second dose is often needed when reversing the overdose

Harm-Reduction Strategies

-Harm reduction, a community health intervention designed to reduce the harm of substance use to the individual, the family, and society, has replaced a moral or criminal approach to drug use and addiction -It recognizes that the ideal is abstinence but works with the individual regardless of their commitment to reduce use -The goal is to reduce the potential harm of the associated behavior -Harm reduction initiatives range from widely accepted designated driver campaigns to controversial initiatives, such as provision of condoms in schools, safe injection rooms, needle exchange programs, and heroin maintenance programs

Initial Opioid Detoxification

-Ideally, opioid detoxification is achieved by gradually reducing an opioid dose over several days or weeks -Many treatment programs include administering low doses of a substitute drug, such as buprenorphine, or methadone, which can help satisfy the drug craving without providing the same subjective high -If opioids are abruptly withdrawn ("cold turkey") from someone who is physically dependent on them, severe physical symptoms occur, including body aches, diarrhea, tachycardia, fever, runny nose, sneezing, sweating, yawning, nausea or vomiting, nervousness, restlessness or irritability, shivering or trembling, abdominal cramps, weakness, elevated blood pressure, and severe distress

Enhancing Coping Skills

-Improving coping skills is thought to be one component of preventing relapse into alcohol and drug use -Coping skills include the ability to use thought, emotion, and action effectively to solve interpersonal and intrapersonal problems and to achieve personal goals -Groups in addiction treatment programs that also have a relapse prevention component look at coping -Patients role-play new behaviors and learn from the feedback they receive from other group members -They also increase their sense of competency to use these skills in real-life situations

Age of Onset for Addiction

-In the United States, alcohol is the most abused substance, followed by marijuana -Alcohol use is at historically low levels for adolescents -Marijuana use reflects a change in attitude and perception that marijuana is a safe drug, especially in light of recent legalization of marijuana in some states -The nonmedical use of prescription and over-the-counter (OTC) medicines continues to represent a significant part of adolescent drug use, but prescription opioids have significantly decreased over the last 5 years -Fewer teens smoke cigarettes daily (1.8% of middle school students and 2.4% high school students) -Vaping, on the other hand, has increased, with 35.7% of middle schoolers and 30.95 of high schoolers reporting monthly use -Thousands of people with serious lung illness and dozens of deaths have been associated with vaping, and a thickening agent, vitamin E acetate, is a prime chemical of concern

Inhalant Intoxication

-Inhalants are easily absorbed through the lungs and are widely distributed in the body, reaching the highest concentrations in fat tissue and the nervous system, where the most profound effects are exhibited -Mild intoxication occurs within minutes and can last as long as 30 minutes -Often, the drugs are inhaled repeatedly to maintain an intoxicated state for hours -Initially, the person experiences a sense of euphoria, but as the dose increases, confusion, perceptual distortions, and severe CNS depression occur -Inhalant users are also at risk for sudden sniffing death, which can occur when the inhaled fumes replace oxygen in the lungs and CNS, causing the user to suffocate -Inhalants can also cause death by disrupting the normal heart rhythm, which can lead to cardiac arrest

Inhalants

-Inhalants are organic solvents, also known as volatile substances that are CNS depressants -When inhaled, they cause euphoria, sedation, emotional lability, and impaired judgment -Intoxication can result in respiratory depression, stupor, and coma -Inhalants are typically abused by young children, with adolescents using less than younger children -Different inhalants tend to be used by various age groups -New users (ages 12 to 15) are more likely to abuse glue, shoe polish, hair spray, spray paints, gasoline, and lighter fluids -The 16- to 17-year-olds most commonly abuse nitrous oxide or "whippets" and adults a class of nitrites such as amyl nitrites or "poppers" -Addiction is rare, but inhalants can be intermediate between legal and illegal drugs, and their use can be fatal -Most inhalants are common household or industrial products that give off mind-altering chemical fumes when sniffed -Most inhalants other than nitrites depress the CNS in a manner similar to alcohol (e.g., slurred speech, lack of coordination, euphoria, dizziness) -They may cause light-headedness, hallucinations, and delusions -The nitrites enhance sexual pleasure by dilating and relaxing blood vessels -They are thought to be antagonistic at the NMDA receptor and may cause neuronal damage in the mesolimbic system

Cocaine Intoxication

-Intoxication causes CNS stimulation, the length of which depends on the dosage and route of administration -With steadily increasing doses, restlessness proceeds to tremors and agitation followed by convulsions and CNS depression -In lethal overdose, death generally results from respiratory failure -Toxic psychosis is also possible; it may be accompanied by physical signs of CNS stimulation (e.g., tachycardia, hypertension, cardiac arrhythmias, sweating, hyperpyrexia, convulsions) -Cocaine and alcohol taken together could cause a potentially dangerous reaction -Taken in combination, the two drugs are converted by the body to cocaethylene, which has a longer duration of action in the brain and is more toxic than either drug individually -Notably, this mixture of cocaine and alcohol is a common two-drug combination that frequently results in drug-related death

Group Interventions and Early Recovery

-Isolation and alienation from friends and family are common themes in patients with substance-related disorders -In addition, thinking that has become distorted is left unchallenged without contact with others; thus, change is difficult -When a patient enters a group that is working with the goals of continuing recovery, numerous healing advantages can occur -Groups in treatment settings focus on immediate goals of maintaining sobriety and not on childhood issues -The emphasis is on using problem solving and other skills to deal with stressful events that threaten abstinence -This type of support group is also extremely effective in outpatient treatment settings -After a period of successful abstinence, group therapy can focus more on traditional psychotherapy work

Therapeutic Relationship

-It is critical that the nurse establish a therapeutic relationship with patients and families -Several general guidelines are available for establishing therapeutic interactions with patients in substance abuse treatment programs: 1. Encourage honest expression of feelings 2. Listen to what the individual is really saying 3. Express caring for the individual 4. Hold the individual responsible for their behavior 5. Provide fair and consistent consequences for negative behavior 6. Talk about specific objectionable actions 7. Do not compromise your own values or nursing practice 8. Communicate the treatment plan to the patient and to others on the treatment team 9. Monitor your own reactions to the patient -Confrontation, or pointing out the inconsistencies in thoughts, feelings, and actions, can promote the person's experience of the natural consequences of one's behavior -Learning from previous behavior and its consequences is how change occurs -Confrontation can be very threatening to patients and should only occur within the context of a trusting relationship

Comorbidity for Addiction

-Many people who abuse substances have other mental disorders -Some disorders are in part a byproduct of long-term substance use; others predispose the individual to alcohol or drug abuse -Whatever the reason, nurses should be aware that patients who abuse substances often have psychotic, anxiety, mood, or personality disorders -More than 67,300 Americans died from drug-involved overdose in 2018, including illicit drugs and prescription opioids -Individuals who abuse substances are at high risk for death from drug overdoses and are at increased risk for death from other causes, including homicide, suicide, accidents, and opportunistic infections (such as human immunodeficiency virus \[HIV\]) secondary to drug injection -Earlier studies have documented the connection between alcohol abuse and increased risk for diabetes mellitus (DM), gastrointestinal (GI) problems, hypertension, liver disease, and stroke

Cannabis

-Marijuana is the common name for the plant Cannabis sativa, also known as hemp and many other names -Two main cannabinoids from the marijuana plant are well known: cannabidiol (CBD) and D-9-tetrahydrocannabinol (THC) -Hashish, a resin found in flowers of the mature C. sativa plant, is its strongest form, containing 10% to 30% THC -Although there are other active ingredients in marijuana, THC gets the most attention because of its psychoactive properties -Marijuana is fat soluble and is absorbed rapidly after being smoked or taken orally -After ingestion, THC binds with an opioid receptor in the brain—the μ-receptor -This action engages endogenous brain opioid receptors, which are associated with enhanced dopamine activity because THC blocks dopamine reuptake -THC can be stored for weeks in fat tissue and in the brain and is released extremely slowly -Long-term use leads to the accumulation of cannabinoids in the body, primarily the frontal cortex, the limbic areas, and the brain's auditory and visual perception centers -In other areas of the brain, it exerts cardiovascular effects, results in ataxia, and causes increased psychotropic effects -Marijuana use impairs the ability to form memories, recall events, and shift attention from one thing to another -It disrupts coordination of movement, balance, and reaction time -Contrary to popular belief, marijuana is addictive, is an irritant to the lungs, and can produce the same respiratory problems experienced by tobacco users (i.e., daily cough, phlegm) -People who smoke marijuana miss work more often than those who do not smoke it, but it is not yet known whether marijuana smoke contributes to the risk of lung cancer -Marijuana is usually smoked and causes relaxation, euphoria, at times dyscoria (i.e., abnormal pupillary reaction or shape), spatial misperception, time distortion, and food cravings -It also causes relaxation and drowsiness, unlike other hallucinogens, and is often associated with decreased motivation after long-term use -Effects begin immediately after the drug enters the brain and last from 1 to 3 hours -The FDA has approved drugs containing marijuana, such as dronabinol (Marinol) and nabilone (Cesamet), which contain THC and are used to treat nausea caused by chemotherapy -The known safety issues related to marijuana include impairment of short-term memory, altered judgment and decision-making, anxiety, and paranoia or psychosis, especially in high doses -Marijuana is legal as a recreational drug in some states in the United States -"Spice" and "K2" are terms used for synthetic cannabinoid compounds found in various herbal mixtures that produce an experience similar to that of marijuana -Spice mixtures of this type are illegal to sell in the United States because of their addictive properties -The effects of synthetic cannabinoids can be unpredictable and severe or even life threatening -Some of these compounds bind more strongly to the same receptors as THC and could produce a more powerful and unpredictable effect -Spice products are popular among young people and are second only to marijuana among illegal drugs, used mostly by high school seniors -Emergency departments are seeing an alarming increase in adolescents being treated for severe adverse events related to synthetic cannabinoid use -Fatalities can occur, and there is no antidote available

Maintenance Treatment (Methadone)

-Methadone maintenance is the treatment of people with opioid addiction with a daily stabilized dose of methadone -Methadone is used because of its long half-life of 15 to 30 hours -It is a potent opioid and is physiologically addicting, but it satisfies the opioid craving without producing the subjective high of heroin -Detoxification is accomplished by setting the beginning methadone dose and then slowly reducing it during the next 21 days -Treatment programs determine the dose of methadone that will block subjective feelings of craving and will not cause somnolence or intoxication in patients -The initial dose of methadone is determined by the severity of withdrawal symptoms and is usually 20 to 30 mg orally -If symptoms persist after 1 to 2 hours, the dosage can be raised -Dosage should then be re-evaluated daily during the first few days of treatment -Initial doses exceeding 40 mg can cause severe discomfort as the detoxification proceeds -Patients receive this dose daily in conjunction with regular drug abuse counseling focused on the elimination of illicit drug use; lifestyle changes, such as finding friends who do not use drugs or achieving stability in one's living situation; strengthening social supports; and structuring time into pursuits that do not involve drug use -After illicit drug use ceases for a period of time, major lifestyle changes have been made, and social supports are in place, patients may gradually detoxify from methadone with continuing support through community support groups, such as Narcotics Anonymous -The length of methadone treatment varies for each patient -The protocol for starting detoxification from methadone varies widely, depending on the patient's commitment to abstinence, lifestyle changes that have occurred, and strong peer group support, all of which are needed to sustain the patient during methadone detoxification when increased cravings often occur -Methadone treatment combined with behavioral therapy and counseling has been used effectively and safely to treat opioid addiction for more than 40 years -Combined with behavioral therapy and counseling, methadone enables patients to stop using heroin

Methamphetamine

-Methamphetamine, also known as meth, speed, ice, chalk, crank, fire, glass, and crystal, is an illegal potent CNS stimulant that releases excess dopamine responsible for the drug's toxic effects, including damage to nerve terminals -Highly addictive, it comes in many forms and can be smoked, snorted, orally ingested, or injected -A brief, intense sensation, or rush, is reported by those who smoke or inject methamphetamine -Oral ingestion or snorting produces a long-lasting high instead of a rush, which can continue for as long as half a day -This illegal substance is cheap, easy to make, and has devastating consequences -High doses can elevate body temperature and stimulate seizures -Methamphetamine has a longer duration of action than cocaine and leads to prolonged stimulant effects -Long-term effects include dependence and addiction psychosis (e.g., paranoia, hallucinations), mood disturbances, violent behavior, repetitive motor activity, stroke, contracting HIV and hepatitis, intense itching leading to skin sores from scratching, weight loss, and extensive tooth decay -Methamphetamine is often used in a "binge and crash" pattern -Tolerance occurs within minutes, and the pleasurable effect disappears even before the drug concentration in the blood falls significantly -After being assessed, referral of the patient to a drug treatment program is necessary -Long-term meth use can cause cardiac arrhythmias, similar to cocaine use -Babies born to meth-addicted mothers are highly irritable and frequently present with learning or other developmental delays -Parents addicted to methamphetamine often cannot meet parenting responsibilities even after abstaining -They often need continuing support to achieve the parenting role, including interdisciplinary support from child welfare and addiction treatment services

Motivation for Change

-Motivation is a key predictor of whether individuals will change their substance use behavior, but addiction is a chronic, relapsing biological condition -Motivation alone may be insufficient without additional support and treatment -People can only become addicted to substances that have receptors in the brain, which can be hi-jacked by the substance -This means that in the absence of the substance, the user does not experience pleasure and nothing besides the substance can take its place (not food, sex, or family) -Urges to use can be so powerful that they overcome the best of motivations, even the desire to regain custody of one's children or to avoid going to jail -Over time, addiction dominates every aspect of the individual's life -While nurses can capitalize on the individual's motivation to change, they can't really be helpful unless they understand that recovery is a life-long process, requiring dramatic changes at the individual and family level, which must indeed be dealt with, "one day at a time" -Motivational interviewing is a method of therapeutic intervention that seeks to elicit self-motivational statements from patients, which creates a disconnect between the patient's goals and their continued alcohol and substance use disorder -The acronym FRAMES (feedback, responsibility, advice, menu of strategies, empathy, and self-efficacy) summarizes elements of brief interventions with patients using motivational interviewing

Drug Profile: Buprenorphine (Suboxone, Bunavail, Zubsolv) Drug Interactions

-Multiple drug interactions including antianxiety, antidepressant or antipsychotic medications, and many others -Can also cause serious allergic reactions and life-threatening anaphylaxis requiring immediate attention

Promotion of Health: Adequate Nutrition and Supplemental Vitamins

-Multivitamins and adequate nutrition are essential for patients who are withdrawing from alcohol -Because malnutrition is common, other vitamin replacement may be necessary for certain individuals -Thiamine (vitamin B1) is initiated during detoxification, given to decrease ataxia and other symptoms of deficiency -It is usually given orally, 100 mg three to four times daily, but can be given intramuscularly or by intravenous infusion with glucose -Folic acid deficiency is corrected with administration of 1.0 mg orally four times daily -Magnesium deficiency is also found in those with long-term alcohol dependence -Magnesium sulfate, which enhances the body's response to thiamine and reduces seizures, is given prophylactically for patients with histories of withdrawal seizures -The usual dose is 1.0 g intramuscularly, four times daily for 2 days

Maintenance Treatment (Naltrexone)

-Naltrexone, similar to naloxone, has been used successfully to treat opioid addiction -It binds to opioid receptors in the CNS and competitively inhibits the action of opioid drugs, including those with mixed narcotic agonist-antagonist properties, thereby blocking the intoxicating effects -It differs from naloxone in that naltrexone is longer acting and is formulated as a 50 mg tablet given once daily -Naltrexone is not used as a rescue drug for respiratory depression associated with an opioid overdose -However, if an opioid-addicted individual takes naltrexone before they are fully detoxified from opioids, withdrawal symptoms may appear

Drug Profile: Methadone (Dolophine)

-Narcotic agonist, analgesic -Binds to opioid receptors in the CNS to produce analgesia, euphoria, sedation; the receptors mediating the effects of endogenous opioids, which are thought to be enkephalins or endorphins -Detoxification and temporary maintenance treatment of narcotic addiction; relief of severe pain

Drug Profile: Naltrexone (Relistor)

-Narcotic antagonist -Binds to opioid receptors in the CNS and competitively inhibits the action of opioid drugs, including those with mixed narcotic agonist-antagonist properties -Adjunctive treatment of alcohol or narcotic dependence as part of a comprehensive treatment program -Safety has not been established for use in children younger than 18 years

Drug Profile: Methadone (Dolophine) Warnings

-Never administer in the presence of hypersensitivity to narcotics, diarrhea caused by poisoning (before toxins are eliminated), bronchial asthma, or chronic obstructive pulmonary disease -Use caution in the presence of acute abdominal conditions and cardiovascular disease -Increased effect and toxicity of methadone are observed if taken concurrently with cimetidine and/or ranitidine -Methadone hydrochloride tablets are for PO administration only and must not be used for injection -It is recommended that methadone hydrochloride tablets, if dispensed, be packaged in child-resistant containers and kept out of the reach of children to prevent accidental injection

Emerging Drugs and Trends

-New drugs and drug-use trends rapidly enter our communities -The NIDA continuously reports on these drugs -Some of the newer drugs include synthetic cathinones (bath salts, Flakka), Krokodil (toxic homemade opioid), and synthetic hallucinogens (N-bomb) -Bath salts contain cathinone, an amphetamine like stimulant naturally found in the Khat plant (Catha edulis) -Severe intoxication and dangerous health effects are associated with these drugs -These drugs, which are chemically similar to methamphetamines and MDMA, produce euphoria, increased sociability, and increased sex drive, as well as paranoia, agitation, and hallucinatory delirium -Indication is that they are strongly linked to abuse -Synthetic hallucinogens (e.g., the N-bomb) are being sold as substitutes for LSD or mescaline -These chemicals, considered more powerful than LSD, act on serotonin receptors and can cause seizures, heart attack, or respiratory arrest and death

Biologic Response to Nicotine

-Nicotine stimulates the central, peripheral, and autonomic nervous systems, causing increased alertness, concentration, attention, and appetite suppression -Readily absorbed, it is carried in the bloodstream to the liver, where it is partially metabolized -It is also metabolized by the kidneys and excreted in urine -Nicotine acts as an agonist of the nicotinic cholinergic receptor sites and stimulates autonomic ganglia in both the parasympathetic and sympathetic nervous systems, resulting in increased release of norepinephrine or acetylcholine -The release of epinephrine by nicotine from the adrenal medulla increases fatty acids, glycerol, and lactate levels in the blood, thereby increasing the risk for atherosclerosis and cardiac muscle pathology -Other medical complications of nicotine use are numerous -Smoking cigarettes and cigars causes respiratory problems, lung cancer, emphysema, heart problems, and peripheral vascular disease -In fact, smoking is the largest preventable cause of premature death and disability -Cigarette smoking kills at least 480,000 people in the United States each year and makes countless others ill -The use of smokeless tobacco is also associated with serious health problems -Repeated use of nicotine produces both tolerance and addiction -Recent research has shown that nicotine addiction is extremely powerful and is at least as strong as addictions to other drugs; most of those who quit relapse within 1 year

Nicotine Withdrawal

-Nicotine withdrawal is marked by mood changes (e.g., craving, anxiety, irritability, depression) and physiologic changes (difficulty in concentrating, sleep disturbances, headaches, gastric distress, increased appetite) -Nicotine replacements, such as nicotine transdermal patches, nicotine gum, nasal spray, and inhalers, have been used successfully to assist in withdrawal by reducing the craving for tobacco -Patches are rotated on skin sites and help maintain a steady blood level of nicotine -They are used daily, with the decrease in strength of nicotine occurring during a period of 6 to 12 weeks

Nicotine

-Nicotine, the addictive chemical mainly responsible for the high prevalence of tobacco use, is the primary reason tobacco is named a public health menace -Smoking is more prevalent among people with alcoholism, polysubstance users, and persons with mental disorders than among the general population -Smoking is two to three times more prevalent in persons with mental illnesses than the general population and is two to six times higher among those with schizophrenia, bipolar disorder, post-traumatic stress disorder (PTSD), and alcohol/illicit drug use disorders

Individual Therapy

-Often, individual therapy is helpful, particularly in conjunction with group therapy or family therapy -In addiction treatment settings, counselors meet with individuals to maintain focus on the goals and objectives of their treatment, to review the fears and anxieties that often arise in early recovery, and to devise new and healthy responses and solutions to stressful and difficult situations -Therapy shouldn't be considered as one size fits all -For instance, anxiety disorders are common comorbidities in substance abuse, but individuals with social anxiety whose anxiety becomes alarmingly high when they are asked to speak in public shouldn't be expected to participate in groups -Forcing their group participation would be counterproductive not only to the individual but also for others in the group

Alcohol

-Or ethanol -Found in various proportions in liquor, wine, and beer relaxes inhibitions and heightens emotions -Mood swings can range from bouts of gaiety to angry outbursts, aggression, and assaultive behavior -Cognitive impairments can vary from reduced concentration or attention span to impaired judgment and memory -Alcohol ultimately produces a sedative effect by depressing the central nervous system (CNS) -Depending on the amount of alcohol ingested, the effects can range from feelings of mild sedation and relaxation to confusion and serious impairment of motor functions and speech to severe intoxication that can result in coma, respiratory failure, and death

Effects of Long-Term Use for Alcohol

-People who use alcohol regularly usually develop alcohol tolerance, the ability to ingest an increasing amount of alcohol before they experience a "high" or a "buzz" and show cognitive and motor effects -The locus coeruleus, which normally inhibits the action of ethanol, is believed to be instrumental in the development of alcohol tolerance -Even though these individuals do not appear intoxicated, their BALs reflect the increased amount of alcohol, which affects their bodies, as described in

Drug Profile: Buprenorphine (Suboxone, Bunavail, Zubsolv) Safe Handling

-Pill counts may be useful to encourage treatment adherence -Because the injectable is a narcotic, arrangements should be made to have the injection delivered by the pharmacy to the office where it will be administered -Prescribing qualifications are required -Keep out of the reach of children -Store in a closed container at room temperature, away from heat, moisture, and direct light; keep from freezing -Dispose medications in Drug Enforcement Administration (DEA) approved locations

Prevention of Relapse

-Relapse prevention is important in the recovery of people with substance-related disorders, and alcohol addiction is no exception -Psychosocial interventions such as self-help groups, psychoeducation, and cognitive behavioral therapy (CBT) are designed specifically for those with alcohol addictions -Other medications are used for those who are recovering -Disulfiram, Acamprosate calcium, Naltrexone

Mental Health Nursing Interventions

-Several treatment modalities are used in most addiction treatment, including 12-step program-focused, cognitive or psychoeducation, behavioral, group psychotherapy, and individual and family therapy -Discharge planning and relapse prevention are also essential components of successful treatment and so are incorporated into most programs -Because patients with substance-related disorders differ greatly, no single type of treatment program will work for every individual -Often, several approaches can work together, but others may be inappropriate -Treatment programs usually combine many different interventions to provide a comprehensive approach based on the individual's needs -Nursing interventions vary depending on the nature of the current problems and their severity -For a patient who is being detoxified, physical interventions (e.g., monitoring vital signs and neurologic functioning) are necessary -When the substance use disorder is secondary to other physical or psychiatric problems, education of patient and family may be a priority -Assessment and interventions should include culturally relevant data, such as unique physiologic responses to substances, behavioral responses to dependence, and social expectations and sanctions -Staff who are knowledgeable about cultural differences and issues are integral to successful treatment

Cocaine Withdrawal

-Severe anxiety, along with restlessness and agitation, is among the major symptoms of cocaine withdrawal -Users quickly seek more cocaine or other drugs, such as alcohol, marijuana, or sleeping pills, to rid themselves of the terrible effects of crashing -Withdrawal causes intense depression, craving (i.e., a strong desire to use cocaine despite negative consequences), and drug-seeking behavior that may last for weeks -Individuals who discontinue cocaine use often relapse -Long-term cocaine use depletes norepinephrine, resulting in a "crash" when use of the drug is discontinued that causes the user to sleep 12 to 18 hours -On awakening, withdrawal symptoms may occur, characterized by sleep disturbances with rebound rapid eye movement (REM) sleep, anergia (i.e., lack of energy), decreased libido, depression with possible suicidality, anhedonia, poor concentration, and cocaine craving -Treating individuals with cocaine addiction is complex because it involves assessing the psychobiologic, social, and pharmacologic aspects of abuse -In cocaine withdrawal, patients are excessively sleepy because of norepinephrine depletion -Recovery is difficult because of the intense cravings -Nursing interventions should focus on helping patients solve problems related to managing these cravings

Drug Profile: Buprenorphine (Suboxone, Bunavail, Zubsolv) Patient and Family Education

-Stopping this medication may cause withdrawal symptoms -Do not take other medications without first checking with your doctor -Tell your provider/dentist that you are using this medicine prior to any procedure -Notify your physician if you experience darkening or yellowing of the skin, diarrhea, tenderness in the upper stomach, pale stools, loss of appetite, nausea, or vomiting -Notify your physician should a rash, hives, hoarseness, trouble breathing or swallowing, swelling of hands, face, or mouth occur while you are using this medication

Drug Profile: Methadone (Dolophine) Safe Handling

-Store in a safe, locked place, use a calibrated measuring device, supervised compliance may continue for at least 6 months or longer -Dispense in a child-resistant container if home consumption is planned

Etiology of Addiction

-Substance abuse encompasses the body, the mind, and society's influences -Human and animal studies confirm a genetic predisposition for drinking and drug-abusing behaviors and self-administering mind-altering drugs -As yet, no precise genetic marker has been established, though clusters of genes are being identified that may play a role in addictions -Temperament, stress, self-concept, age, motivation for change, social consequences for problematic behaviors, parental and family relationships, and peer pressure all contribute to expression of substance abuse—a chronic and progressive disorder

Diagnostic Criteria for Addiction

-Substance-related disorders are categorized into two categories: substance use disorders and substance-induced disorders -Substance-induced disorders occur when medications used for other health problems or medical/mental health disorders cause intoxication, withdrawal, or other health-related problems -A substance use disorder occurs when an individual continues using substances despite cognitive, behavioral, and physiologic symptoms -The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) identifies 10 diagnostic categories of substances including alcohol, caffeine, cannabis (marijuana), hallucinogens, inhalants, opioids, sedative-hypnotics, stimulants, tobacco, and others -Gambling disorder is included within the substance use disorder category because gambling behaviors can activate the brain's reward system similar to the substance use disorders -A substance use disorder occurs when there is an underlying change in brain circuitry that may persist after detoxification, the process of safely and effectively withdrawing a person from an addictive substance, usually under medical supervision -These brain changes lead to pathologic behaviors that occur with repeated relapses and intense drug cravings when exposed to drug-related cues (e.g., a party, emotional experiences)

Maintenance Treatment (Subutex)

-Subutex, a buprenorphine-only preparation, is safe in pregnant women and provides consistent support -Fetal exposure to buprenorphine in utero is associated with significantly shorter hospitals stays, shorter length of neonatal abstinence syndrome (NAS), and decreased duration and frequency of pharmacotherapy for NAS -There is no need to decrease dosage as delivery nears because there is no evidence of buprenorphine having differential neurodevelopmental outcomes among infants with NAS

Smoking Cessation

-Successful smoking cessation usually requires more than one type of intervention, including social support and education -However, studies do show that even giving a brief instruction to patients about quitting smoking can be effective -Medications are often used as a smoking cessation strategy -The antidepressant bupropion is marketed as Zyban to help people quit smoking -Another medication, varenicline tartrate (Chantix), reduces the craving and rewarding effects of nicotine by preventing nicotine from accessing one of the acetylcholine receptor sites involved with nicotine dependence, but it can cause depression and related psychiatric symptoms in some people -This side effect may limit its usefulness for some people with psychiatric disorders -Auricular therapy, or ear acupressure, is being studied as a potential adjunctive treatment for nicotine addiction -Acupressure is based on the principles of an ancient Chinese system of medicine with a goal of returning the body to a harmonic balanced state -Through stimulating acupoints on the ear, endogenous endorphin levels and regulation of the sympathetic nervous system changes the taste for tobacco, suppressing nicotine addiction, decreasing nicotine withdrawal symptoms, reducing the desire to smoke, and promoting cessation for a short period of time -Emerging research into this therapy shows positive effects -Electronic cigarettes (e-cigarettes) were introduced as smoking cessation aids -They are smokeless, battery-operated devices designed to deliver nicotine with flavorings or other chemicals to the lungs without burning tobacco to do so -They resemble regular tobacco cigarettes, cigars, or pipes -More than 250 e-cigarette brands are on the market -E-cigarettes are designed to simulate the act of tobacco smoking without the toxic chemicals produced by burning tobacco leaves -Their safety and effectiveness in smoking cessation are being studied because e-cigarettes deliver highly addictive nicotine into the lungs, and the vapor of some of them contains known carcinogens and toxic chemicals -Additionally, adolescents are increasingly using e-cigarettes believing they are safe, but they may instead serve as a gateway to try other tobacco products -On May 5, 2016, the Food and Drug Administration (FDA) announced that nationwide tobacco regulations now extend to all tobacco products including e-cigarettes and their liquid solutions, cigars, hookah tobacco, and pipe tobacco

Drug Profile: Methadone (Dolophine) Patient and Family Education

-Take drug exactly as prescribed -Take the drug with food while lying quietly; this should minimize nausea -Eat small, frequent meals to treat nausea and loss of appetite -If experiencing dizziness and drowsiness, avoid driving a car or performing other tasks that require alertness -Administer mild laxative for constipation -Report severe nausea, vomiting, constipation, shortness of breath, or difficulty breathing -Methadone products, when used for treatment of narcotic addiction, shall be dispensed only by approved hospital and community pharmacies and maintenance programs approved by the FDA and designated state authority -CNS, central nervous system; COPD, chronic obstructive pulmonary disease; IM, intramuscular; PO, oral; SC, subcutaneous

Non-Substance-Related Addictive Disorders

-The DSM-5 reflects developing understandings that certain compulsive behaviors characterized by risky use, urges, cravings, and "highs" make them similar to substance intoxication and dependence -Behavioral addictions may have similar neurocircuitry involved in reward, motivation as substance use disorders -Gambling disorder was included in the DSM-5 and studies on other addictive behaviors (such as internet addiction, sex addiction, and food addiction) are accumulating -Gambling addiction is characterized by compulsive and problematic gambling behavior that leads to significant impairments in functioning or distress -Some evidence shows that changes in the serotonin system are associated with addiction behavior, similar to results reported for nicotine and alcohol dependence -Individuals with gambling problems are more likely to commit suicide than those who do not have a gambling problem and are less likely to seek mental health treatment -Compulsive gamblers feel omnipotent in their ability to win back what was lost -This omnipotence serves as self-deception that leads to denial -Care of these patients involves confronting such omnipotent beliefs -These individuals quickly irritate staff with their self-assurance and overbearing attitude -Staff education about the disorder is important -Family involvement is also crucial -Families often have been dealing with the patient in a dysfunctional manner -Relapse prevention involves learning about specific cues that trigger the gambling behavior

Evidence-Based Nursing Care for Persons with Substance-Related Disorders

-The assessment process is, in part, a treatment intervention -Patients are often in denial about the severity of the problem and about its emotional, social, legal, vocational, or other consequences

Codependence

-The concept of codependence emerged out of studies of women's relationships with husbands who abused alcohol -Today, the scope of codependency includes both men and women who grew up in any type of dysfunctional family system in which substance abuse may or may not have been a problem -Codependence has also been described as "enabling," in which an individual in a relationship with a person who abuses alcohol inadvertently reinforces the drinking behavior of the other person -The codependency label remains controversial and is viewed by some as an oversimplification of complex emotions and behaviors of family members -Mental health professionals should be careful not to use it as a catch-all diagnosis and to take special care to assess and plan interventions that address each person's particular situation, problems, and needs

MDMA and other "Club Drugs"

-The drug 3,4-methylenedioxymethamphetamine (MDMA), also known as Ecstasy or Molly, is known as a "club drug" because it is used by teens and young adults as part of the nightclub, bar, and rave scenes -MDMA, chemically similar to both stimulants and hallucinogens, causes activity of dopamine, norepinephrine, and serotonin to increase -It produces feelings of increased energy, pleasure, emotional warmth, and distorted sensory and time perception -MDMA can cause hallucinations, confusion, depression, paranoia, sleep problems, drug craving, severe anxiety, nausea, muscle cramping, involuntary teeth clenching, blurred vision, chills, and sweating -In higher doses, MDMA can sharply increase body temperature (i.e., malignant hyperthermia), leading to muscle breakdown, kidney and cardiovascular failure, and death -MDMA effects last about 3 to 6 hours -Other drugs abused, such as Rohypnol gamma-hydroxybutyrate (GHB) and ketamine, which are predominantly CNS depressants, are also considered to be "club drugs" -Often colorless, tasteless, and odorless, the drugs can be ingested unknowingly -Known also as "date rape" drugs when mixed with alcohol, they can be incapacitating, causing a euphoric, sedative like effect and producing an "anterograde amnesia," which means that individuals may not remember events they experience while under the influence of these drugs -Ketamine is associated with an increased heart rate and blood pressure, impaired motor function, memory loss, numbness, and vomiting -At high doses, delirium, depression, respiratory depression, and cardiac arrest can occur -Ketamine is used as an anesthetic in veterinary practice and is now an accepted treatment for depression related to chronic pain

Treatment and Recovery for Addiction

-The goal for persons abusing substances is to recover from the abuse -Recovery involves a partnership between health care providers and the individual and family -For many individuals, a period of intense treatment is necessary to safely manage the physical and psychological withdrawal symptoms that occur when a substance is no longer used -Specific withdrawal symptoms depend on the addictive substance and are explained in the following sections as the substances are discussed -The withdrawal process usually involves detoxification -After a person has safely withdrawn from the substance of abuse, the real work toward recovery can begin -A primary concern is relapse, the recurrence of alcohol- or drug-dependent behavior in an individual who has previously achieved and maintained abstinence for a significant time beyond the period of detoxification -Relapse is an expected part of the chronic disease of addiction, and the cycle of use-detoxication-sobriety and relapse will likely continue for years

Gambling Disorder Characteristics and Criteria

-The individual with problematic and compulsive gambling leading to significant impairment in functioning or distress exhibits four (4) or more of the following over a 12-month course -Need to use increasing amounts of money in order to achieve desired level of excitement -Is restless or excessively irritable when attempting to control or abstain from gambling -Repeated unsuccessful attempts made to control, reduce, or abstain from gambling -Regularly preoccupied with gambling -Seeks out gambling in order to cope with feelings of distress -Regularly attempts to 'get even' by returning to gamble after losing large quantities of money -Exhibits erratic behavior, such as lying in order to minimize or conceal gambling involvement -Impairments noted in terms of interpersonal relationships, functioning at work, or performance in school -Is reliant on others financially as the result of gambling

Prescription and Over-the-Counter Drugs

-The overall opioid prescribing rate in the United States has been declining since 2012, after peaking and leveling off in 2010-2012, but the amount of opioids prescribed per person is still around three times higher than it was in 1999 -The United States is still in the midst of an epidemic of prescription opioid overdose deaths -In 2017, an average of 41 persons died each day from an overdose -Abuse of prescription and OTC drugs occurs when one of the following criteria is met: 1. Taking a medication that has been prescribed for someone else 2. Taking a drug in higher quantity or in another manner than prescribed 3. Taking a drug for another purpose than prescribed -The opioids (e.g., oxycodone, hydrocodone, morphine, fentanyl, codeine) prescribed for pain are some of the more commonly abused prescription medications -The most commonly abused CNS depressants are the benzodiazepines \[diazepam, alprazolam, clonazepam, lorazepam\]), which are prescribed for anxiety and sleep -The DSM-5 diagnosis Sedative, hypnotic, or anxiolytic use disorder would be given when these drugs are abused -Amphetamines (Adderall, Dexedrine) and methylphenidate (Concerta, Ritalin) are stimulants prescribed for ADHD that are also frequently abused or diverted for illicit purposes -Nurses are well positioned to address the significant public health problem of opioid (and other drug) diversion, through patient education and medication monitoring -Often, patients combine these drugs with alcohol, which is extremely dangerous and can put patients at risk for overdose, causing coma or death -OTC cough medicine containing DXM can produce the same effects as those of ketamine or PCP, such as impaired motor function, numbness, nausea or vomiting, and increased heart rate and blood pressure -In some cases, severe respiratory depression and hypoxia have occurred

Denial

-The patient's inability to accept their loss of control over substance use or the severity of the consequences associated with the substance abuse or addiction -Remember that denial may appear as confusion, distorted comparisons with other's drinking, difficulty reconciling past positive alcohol experiences with current problems, misunderstanding about the diagnosis of substance use, misguided beliefs that one can overcome an addiction by sheer will power, and refusal to believe that alcohol has had an effect on one's thoughts, feeling, behaviors, or relationships with others

Hallucinogens and Dissociative Drugs

-The term hallucinogen refers to drugs that produce euphoria or dysphoria, altered body image, distorted or sharpened visual and auditory perception, confusion, lack of coordination, and impaired judgment and memory -Hallucinogens cause hallucinations and profound distortions in a person's perceptions of reality -These drugs can be made from plant sources and mushrooms or are man made -They are categorized as hallucinogens and dissociative drugs -When under the influence of either type of drug, people report rapid, intense emotional swings and seeing images, hearing sounds, and feeling sensations that seem real but are not -Severe reactions may cause paranoia, fear of losing one's mind, depersonalization, illusions, delusions, and hallucinations -Hallucinogens typically affect the autonomic and regulatory nervous systems first, increasing heart rate and body temperature, and slightly elevating blood pressure -The individual may experience a dry mouth, dizziness, and subjective feelings of being hot or cold -Gradually, these physiologic changes fade, but then perceptual distortions and hallucinations may become prominent -Intense mood and sexual behavior changes may occur; the user may feel unusually close to others or distant and isolated -Classic hallucinogens include LSD (d-lysergic acid diethylamide), psilocybin (4-phosphoryloxy-N, N-dimethyltryptamine), Peyote (Mescaline), DMT (dimethyltryptamine), and Ayahuasca (an ethnogenic brew, often used for spiritual ceremonies) -Dissociative drugs include PCP (phencyclidine), DXM (dextromethorphan), Salvia divinorum, and ketamine -DXM is a cough suppressant and expectorant ingredient in some OTC cold and cough medicines and is commonly abused by adolescents and young adults -The true content of hallucinogenic drugs purchased on the street is always in doubt; they are often misidentified or adulterated with other drugs -There are more than 100 different hallucinogens with substantially different molecular structures -Patients in acute states of intoxication or in dissociated states may become combative -During the acute state, the primary intervention goals are to reduce stimuli, maintain a safe environment for the patient and others, manage behavior, and observe the patient carefully for medical and psychiatric complications -Instructions to the patient should be clear, short, and simple, and delivered in a firm but nonthreatening tone

Opioids and Morphine Derivatives

-The term opioid refers to any substance that binds to an opioid receptor in the brain to produce an agonist action -Derived from poppies, opioids are powerful drugs that have been used for centuries to relieve pain -They include opium, heroin, fentanyl, morphine, and codeine -Even centuries after their discovery, opioids are still the most effective pain relievers -They also cause CNS depression, sleep, or stupor -Although heroin has no medicinal use, other opioids, such as morphine and codeine, are used to treat pain related to illnesses (e.g., cancer) and during medical and dental procedures -When used as directed by a clinician, opioids are safe and generally do not produce addiction -However, opioids also possess very strong reinforcing properties and can quickly trigger addiction when used improperly -Two important effects produced by opioids are pleasure (or reward) and pain relief -The brain itself also produces substances known as endorphins that activate the opioid receptors -Opioids cause tolerance and physical dependence that appear to be specific for each receptor subtype -Tolerance develops, particularly to the analgesic, respiratory depression, and sedative actions of opioids -Often, a 100% increase in dose is used to achieve the same physical effects when tolerance exists -Physical dependence can develop rapidly -When the use of the drug is discontinued, after a period of continuous use, a rebound hyperexcitability withdrawal syndrome usually occurs -Heroin is an illegal, highly addictive drug that is mostly abused and the most rapidly acting of the opioids -Typically sold as a white or brownish powder or as the black sticky substance known as "black tar heroin" on the streets, it is frequently "cut" with other substances, such as sugar, starch, powdered milk, quinine, and strychnine, or other poisons -It can be sniffed, snorted, and smoked but is most frequently injected, which poses risks for transmission of HIV devices and other diseases resulting from the sharing of needles or other injection equipment -Naturally occurring neurotransmitters normally bind to the µ-opioid receptors, which are involved in pain, hormonal release, and feelings of well-being -When heroin enters the brain, it is converted to morphine and immediately binds to the µ-opioid receptors, stimulating the release of dopamine, which causes an intense pleasurable rush -Usually, the individual also experiences a warm flushing of the skin, dry mouth, and a heavy feeling in the limbs -Side effects include nausea, vomiting, and severe itching -Following these initial side effects, drowsiness, clouded mental function, slowing of the heart rate, and extreme slowing of breathing can occur -One of the most detrimental long-term side effects of heroin is addiction itself, which causes neurochemical and molecular changes and profoundly alters brain structure and composition -Enlarged ventricular spaces and loss of frontal volume are reported -Heroin also produces profound degrees of tolerance and physical dependence, which are powerful motivating factors for compulsive use and abuse -After becoming addicted, heroin users gradually spend more and more time and energy obtaining and using the drug until these activities become their primary purpose in life -Recently, there has been a sharp increase in opioid deaths, attributed to illegally produced fentanyl -While the prescription rates have remained relatively stable, there have been unprecedented increases in the global supply, processing, and distribution of fentanyl by criminal elements beginning in 2013 -An urgent, collaborative public health and law enforcement response is recommended by the Centers for Disease Control and Prevention

Drug Profile: Naltrexone (Relistor) Patient and Family Education

-Understand that this drug will help facilitate abstinence from alcohol and block the effects of narcotics -Wear a medical identification tag to alert emergency personnel that you are taking this drug -Avoid use of heroin or other opioid drugs; small doses may have no effect, but large doses can cause death, serious injury, or coma -Report any signs and symptoms of adverse effects -Notify other health care providers that you are taking this drug -Keep appointments for follow-up blood tests and treatment program -CNS, central nervous system; PO, oral

Naltrexone

-Was originally used as a treatment for heroin abuse, but it is now approved for the treatment of alcohol dependence -Naltrexone is formulated in a once-daily pill and a monthly injection (Vivitrol) -Naltrexone does not treat withdrawal symptoms; its effects are due to blocking the mu receptors (opioid) in the brain -It has no abuse protentional and does not result in the development of physical dependence -Reports from successfully treated patients suggest three kinds of effects: (1) it can reduce craving (the urge or desire to drink or use drugs despite negative consequences), (2) it can help maintain abstinence, and (3) it can interfere with the tendency to want to drink more if a recovering patient slips and has a drink -Naltrexone may be particularly useful in patients who continue to drink heavily -Some controversy still remains about the effectiveness of these harm-reduction medications in promoting abstinence or reducing alcohol consumption -Patients have been known to stop using naltrexone if they plan to drink alcohol and restart it later, leaving them open to relapsing -More research considering other harm-reduction outcomes (reduced mortality, reduced incidence of adverse events) and studies that are better controlled to avoid attrition and selection bias are needed -Naltrexone can also be administered via an intramuscular injection (Vivitrol), which must be given after opioid detoxification and may cause injection site reactions, including intense hip pain, induration, swelling, bruising, and severe reactions such as open wounds or sterile abscesses -Patients must have adequate gluteal muscle mass to support 4cc injection, and nurses must carefully monitor and rotate injection sites -Adverse reactions and pain at the injection site can contribute to nonadherence with therapy

Alcohol Withdrawal and Detoxification

-Withdrawal from alcohol presents many physiologic and psychological challenges -Because of physiologic addiction, abrupt cessation of alcohol ingestion can cause mild-to-severe physical withdrawal symptoms, depending on the length and amount of alcohol use -Alcohol withdrawal syndrome is characterized by an increased heart rate and blood pressure, diaphoresis, mild anxiety, restlessness, and hand tremors -The most severe symptoms are delirium tremens (autonomic hyperarousal, disorientation, hallucinations), grand mal (tonic-clonic) seizures, and even status epilepticus (continuous seizures, lasting more than 30 minutes) -These symptoms can be life threatening -In patients with alcoholism and in chronic drinkers, the alcohol withdrawal syndrome usually begins within 12 hours after abrupt discontinuation or attempt to decrease consumption -If seizures occur, they usually do so within the first 48 hours of withdrawal -Alcohol withdrawal can be accomplished safely without a person experiencing serious physical consequences -Uncomplicated alcohol withdrawal is usually completed within 48 to 96 hours -Assessing for vital sign changes, nausea, vomiting, tremors, perspiration, agitation, headache, and change in mental status are important nursing interventions -The Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) is frequently used for assessment -Close monitoring continues until there is no indication of withdrawal symptoms -Several medications are used to prevent physiologic complications and provide a gradual withdrawal from alcohol -Antianxiety and sedating drugs, such as benzodiazepines, are titrated downwardly over several days as a substitution for alcohol -Chlordiazepoxide (Librium) and diazepam have longer half-lives and smoother tapers -Lorazepam (Ativan) is better for older adults and people with liver impairment -Antidepressants are usually initiated to treat mood states, and sleep medication is used to promote a regular sleep pattern -Anticonvulsive and antipsychotic medications are also used if needed -Alcohol withdrawal symptoms can occur in any patient who abuses alcohol and is forced to stop drinking because of an admission to a hospital or any alcohol-free environment -Patients who abuse alcohol for long periods of time are at high risk for alcohol withdrawal syndrome -Observing for signs of seizure activity is a priority nursing intervention

Disulfiram (Antabuse)

-neither a treatment nor a cure for alcoholism, but it can be used to help deter some individuals from drinking while using other treatment modalities to teach new coping skills to alter abuse behaviors -Disulfiram plus even small amounts of alcohol produces episodes of severe nausea and vomiting -These unpleasant reactions are expected to deter drinking -Severe reactions may also occur, and these include respiratory depression, cardiovascular collapse, arrhythmias, myocardial infarction, acute congestive heart failure, unconsciousness, convulsions, and death -Those taking this drug must be informed about consuming unexpected sources of alcohol (wine and malt vinegar, baked goods, nonalcoholic beer, and others) and that alcohol can be absorbed transdermally through the use of aftershaves, or lotions that contain alcohol -Informed consent is required to initiate disulfiram therapy, and there is some conjecture that disulfiram's effectiveness for alcohol aversion is attributable to the patient's awareness of having consumed it

Blood Alcohol Levels (BAL) and Behavior

1-2 number of drinks -0.05 BAL -Impaired judgment, giddiness, mood changes 5-6 number of drinks -0.10 BAL -Difficulty driving and coordinating movements 10-12 number of drinks -0.20 BAL -Motor functions severely impaired, resulting in ataxia; emotional lability 15-20 number of drinks -0.30 BAL -Stupor, disorientation, and confusion 20-24 number of drinks -0.40 BAL -Coma 25 number of drinks -0.50 BAL -Respiratory failure, death

Principles of Effective Treatment for Addiction

1. Addiction is a complex but treatable disease that affects brain function and behavior 2. No single treatment is appropriate for everyone 3. Treatment needs to be readily available 4. Effective treatment attends to multiple needs of the individual, not just their drug use 5. Remaining in treatment for an adequate period of time is critical 6. Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies 8. An individual's treatment and service plan must be assessed continually and modified as necessary to ensure that it meets their changing needs 9. Many drug-addicted individuals also have concurrent mental disorders 10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse 11. Treatment does not need to be voluntary to be effective 12. Drug use during treatment must be monitored continuously because lapses during treatment do occur 13. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, as well as provide targeted risk-reduction counseling, linking patients to treatment as necessary

Recommendations for Brief Intervention

It is recommended that brief intervention at a minimum include -Advising how to reduce patient's drug use -Providing harm reduction information or self-help manuals relevant to the patient -Giving the patient relevant information about the following: 1. The consequences of a drug conviction in terms of international travel and employment 2. Consequences of further or heavier drug charges

Drug Profile: Methadone (Dolophine) Side Effects

Light-headedness, dizziness, sedation, nausea, vomiting, facial flushing, peripheral circulatory collapse, arrhythmia, palpitations, urethral spasm, urinary retention, respiratory depression, circulatory depression, respiratory arrest, shock, cardiac arrest

Drug Profile: Buprenorphine (Suboxone, Bunavail, Zubsolv) Side Effects

Lightheadedness, dizziness or fainting with position changes, cough, feeling of warmth or heat, flushing, headache, painful or difficult urination, slower back or side pain

Chemical Dependence Treatment Approaches: Past and Present

Psychiatric -Conception of etiology: Symptom of underlying emotional problem -Conception of patient: Emotionally disturbed -Conception of treatment outcome: Emotional conflicts are resolved; emotional health improves -Conception of treatment process: Psychotherapy, medication to treat cause of substance abuse -Advantages of approach: Not punitive, treats comorbidity -Disadvantages of approach: Focus is only on treatment of mental disorder Social -Conception of etiology: Society and environment cause dependence -Conception of patient: Victim of circumstance -Conception of treatment outcome: Improved social functioning or improved environment -Conception of treatment process: Removal of environmental influences and increasing coping responses to it -Advantages of approach: Stresses social supports and coping skills -Disadvantages of approach: Blames "ills of society"—the person is not responsible for having an addiction Moral -Conception of etiology: Person is morally weak—can't say "no" -Conception of patient: "Hustler," morally deficient Addict -Conception of treatment outcome: Moral recovery, increased willpower, self-control, and responsible behavior -Conception of treatment process: "Street addict" behavior and manipulation confronted -Advantages of approach: Holds person responsible for actions and making amends -Disadvantages of approach: Punitive, increases low self-esteem and sense of failure. No longer an accepted medical approach Learning -Conception of etiology: Abuse is a learned, reinforced behavior -Conception of patient: Has distorted thinking, poor coping skills -Conception of treatment outcome: Patient learns new ways of thinking and new coping skills -Conception of treatment process: Cognitive therapy techniques and coping skills taught -Advantages of approach: Not punitive; teaches new coping skills -Disadvantages of approach: Places emphasis on control of use Disease -Conception of etiology: Probably caused by genetic or biologic factors -Conception of patient: Has a chronically progressive disease -Conception of treatment outcome: Abstinence, arresting disease progression, and beginning of recovery process -Conception of treatment process: Is treated as a primary disease, reinforces patient is an addict and is sick -Advantages of approach: Not punitive, stresses support and education -Disadvantages of approach: Minimizes mental health disorders; discounts return to social use 12-Step -Conception of etiology: Combination of disease concept and "spiritual bankruptcy" -Conception of patient: Has an addiction and is powerless over substances -Conception of treatment outcome: Abstinence, ongoing spiritual recovery -Conception of treatment process: Use 12 steps, seeking spiritual support, making amends, serving others in need -Advantages of approach: Widespread success, emphasis is on quality of life and spiritual growth -Disadvantages of approach: Self-help group, not a treatment program Dual diagnosis -Conception of etiology: Both a primary substance dependency and a mental health disorder -Conception of patient: Has both mental and substance abuse disorder -Conception of treatment outcome: Improvement in both mental health and substance abuse disorders -Conception of treatment process: Concurrent treatment of both disorders -Advantages of approach: Treats both mental health disorder and dependency, minimizing relapse potential -Disadvantages of approach: Not inclusive enough; does not include social or other issues Biopsychosocial -Conception of etiology: Biologic basis, with social and psychological influences -Conception of patient: Has deficiencies in all three interacting areas -Conception of treatment outcome: Improvement in mental and physical health, utilization of social supports -Conception of treatment process: Concurrent treatment of all issues -Advantages of approach: Uses different modalities; is more inclusive -Disadvantages of approach: Does not match patient and specific interventions Multivariant -Conception of etiology: Many different causes; may be different for each individual -Conception of patient: Has multiple issues to be assessed and addressed -Conception of treatment outcome: Particular issues for individual addressed, so improvement occurs -Conception of treatment process: Treatment strategies are matched with individual patient needs -Advantages of approach: Treatment matched to individual's needs -Disadvantages of approach: Logistical problems can occur during its implementation Neurobiological Medication-Assisted Treatment (MAT) -Conception of etiology: Primarily addiction is a brain-based disorder, involving the neurocircuitry in the brain associated with memory, reward and motivation and hi-jacking of mu receptors in the brain -Conception of patient: Modification of behaviors related to alcohol or substance use and addictive behaviors -Conception of treatment outcome: Use of medications to re-establish brain functions and support person through detoxification and recovery to prevent relapse to using -Conception of treatment process: Medication-assisted treatment improves quality of life, allows person to resume functioning and goal-oriented behavior unrelated to drug-seeking -Disadvantages of approach: Controversial Access issues for many; Cost

Examples of Inhalants

Volatile Solvents -Liquids that vaporize at room temperature, such as paint thinners or removers, degreasers, dry-cleaning fluids, gasoline, and lighter fluid -Office supply solvents include correction fluids, felt-tip marker fluid, electronic contact cleaners, and glue Aerosols -Sprays that contain propellant and solvents, such as spray paint, hair spray, fabric protector spray, aerosol computer cleaning products, vegetable oil spray, analgesics, asthma sprays, deodorants, and air fresheners Gases -Household or commercial products, such as butane lighters and propane tanks, whipped cream aerosols or dispensers, and refrigerant gases, and medical anesthetics such as ether, chloroform, halothane, and nitrous oxide ("laughing gas") Nitrites -Organic nitrites include cyclohexyl, butyl, and amyl nitrites -When marketed for illicit uses, organic nitrates are sold in small brown bottles labeled "video head cleaner," "room odorizer," "leather cleaner," or "room deodorizer"

Substance Abuse Teaching Plan

When caring for the patient and family with substance abuse, be sure to include the following topic areas in the family's teaching plan: -Psychopharmacologic agents, if used, including drug action, dosage, frequency, and possible side effects -Manifestations of intoxication, overdose, and withdrawal -Emergency medical system activation -Nutrition -Coping strategies -Structured planning -Safety measures -Available treatment programs -Family therapy referral -Self-help groups and other community resources -Follow-up laboratory testing, if indicated