Chemical Dependency, Abuse, and Neglect Lecture

Tolerance

A progressive decrease in a person's responsiveness to a drug.

H.I.T.S.

A tool has been developed that can be used for either sex, in a variety of situations, to screen for potential for Domestic Violence, using the H.I.T.S. (Hurt, Insulted, Threatened, Screamed) Screening How often does your partner physically hurt you? How often does your partner insult or talk down to you? How often does your partner threaten you with harm? How often does your partner scream or curse at you?

substance abuse

Any unnecessary or improper use of chemical substances for nonmedical purposes

Marijuana (THC)

Derived from hemp plant, the psychoactive ingredient is THC.

Opioid withdrawal symptoms

Dilated pupils and tearing Runny nose Piloerection Yawning Mild hypotension Tachycardia, some increased respirations Diarrhea Nausea/vomiting (Described as the worst flu ever!)

Emotional signs of Abuse in Children

Fear of caretakers, family members, or others Symptoms of depression or anxiety Sleep and eating disturbances Bedwetting problems Withdrawal from friends, family and activities (may include truancy in children, or running away in teens) Reduced ability to function at school or other activities Aggression, poor impulse control (sometimes cruelty toward animals) Self-harming behaviors Substance abuse Somatization (headaches, stomachaches)

Neglect

Intentionally or unintentionally not meeting the basic needs of dependent individual (child, significant other, elder)

Cocaine symptoms

Intoxication with cocaine produces: sweating, dilated pupils psychomotor agitation increased vital signs More severe symptoms include: fever, cardiac arrhythmias paranoia hallucinations (often tactile...feel bugs crawling on skin, sometimes called "cocaine bugs"_) intense craving for the drug post-use "crash" thought due to depletion of dopamine in the brain; also often treated for depression post-recovery

Heroin overdose antidote

Narcan

1. Which CNS depressant substances are known as "date rape" drugs?

Rohypnol and GHB

Inhalants

Substances whose fumes are sniffed or inhaled to give effect. Cause euphoria, dizziness, excitement. May lead to vfib, brain damage, and death. Ex: glue, fuels, paints, aerosols, air fresheners, propellants

Physical signs of Abuse in Elders

Weight loss Inadequately explained injuries, bruises, and/or fractures Lack of hygiene Skin breakdown Sexually transmitted diseases, genital pain or bleeding, UTIs

Fetal Alcohol Syndrome

physical and cognitive abnormalities in children caused by a pregnant woman's heavy drinking

Hallucinogens

psychedelic ("mind-manifesting") drugs that distort perceptions and evoke sensory images in the absence of sensory input. Ex: psilocybin, LSD, Ketamine, mescaline. Symptoms: hallucinations, synesthesias, intensified perceptions, panic reactions, flashbacks.

Alcohol Withdrawal Delirium Symptoms

-Elevated temperature -Severe diaphoresis -Tachycardia -Hypertension -Confusion -Disorientations -Agitation -Tremor -Hallucinations -Seizures

Communication Tips

1 Discuss patterns of drug and alcohol use in a nonjudgmental manner. 2 Be aware that individuals often minimize how much of a substance that they have used 3 Talk to patients in non-judgmental language; be aware of possible negative countertransference 4 If patient has had losses, the nurse should use firm, kind but direct confrontation to counteract the denial, such as, "I know that you have said you can quit drinking at any time, but it sounds like your drinking was a reason why your wife left you."

Nursing Assessment for Alcoholism

1. CAGE Assessment 2. Assess patient's lifestyle looking for problems like lack of a steady job, no income, obtaining money illegally by stealing, dealing or prostitution. 3. Obtain the patient's history, including kind, amount, route, and time of last drug use. 4. Consult the patient's family or significant others to obtain or validate the patient's information if necessary as the patient may report an inaccurate estimate of drug use. 5. Assess for commonly used defense mechanisms 6. Physical/medical status -nutritional, electrolyte, fluid status -evidence of IV injection of drugs -infectious diseases associated w/ drugs (HIV, Hep B, C, or D) -perforated nasal septum if drug is sniffed 7. Lab tests (urine/blood for any drugs, usually on admission)

Cognitive Interventions for Substance Abuse

1. Reorient the patient to person, time, place, and situation as needed. 2. Reassure the patient that the hallucinations (bugs, snakes, or auditory hallucinations). "I do not (see, hear...) that, but you seem very scared. You are safe here." 3. Assist the patient to see that addictive behaviors have led to the need for detoxification.

Treatment of Alcohol Withdrawal

1. Watch vital signs, they elevate as withdrawal symptoms worsen. 2. Monitor client's fluid status (often pts are dehydrated at first). If unable to take fluids PO, admin IV fluids. 3. Administer magnesium sulfate to decrease irritability and prevent seizures, which arise due to low magnesium levels. 4. Administer vitamins because pt may have vitamin deficiency. Especially thiamine (vitamin B1) because alcohol interferes with the absorption of B vitamins. 5. Prescribe benzodiazepines on a controlled taper (i.e. diazepam/Valium or chlordiazepoxide/Librium to prevent seizures and allow a controlled detox. 6. May be prescribed anti-seizure meds like Dilantin

When doing an admission assessment of a patient with a history of alcoholism, the most important factor to assess is: 1. the presence of track marks 2. when the patient last had a drink 3. previous coping skills 4. whether the patient has had previous treatment

2. when the patient last had a drink

withdrawal

A group of symptoms that occur when a dependent person stops taking a drug

Substance Abuse Disorder

According to DSM V: Maladaptive pattern of substance use defined by 2 or more of the following signs in 1 year: 1. Tolerance = Need more to achieve the same effect 2. Withdrawal = characteristic withdrawal syndrome for the substance, or taking the substance again to avoid symptoms 3. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home 4. Recurrent substance use in situations in which it is physically hazardous (e.g. driving a car) 5. Continued substance use despite having social problems because of it (e.g. arguments, fights) 6. Substance taking larger amounts or over longer period than was intended 7. Persistent desire or unsuccessful efforts to cut down 8. Great deal of teim spent in activities necessary to obtain, use, or recover from substance 9. Substance use continues despite knowledge of having a physical or psych problem which is caused or exacerbated by the substance 10. Craving/desire to use a specific substance Moderate: 2-3 criteria positive Severe: > or = to 4 criteria positive

Barbiturates, Sedatives/Hypnotics

Cause CNS depression, lethal when overdosing. Drugs ending in -barbital. Cause euphoric and relaxed feelings. First used to treat anxiety and insomnia.

Abuse

Causing physical or emotional harm to another individual

Emotional Signs of Abuse in the Elderly

Fear of caregivers, adult children or spouse Not allowing people in house if abuser is present Sleep and eating disturbances Withdrawal from activities and friends (doesn't go to church or senior center anymore) Withdrawn, secretive (particularly if abuser is a family member...embarassed and may have been threatened) Financial problems; unable to pay bills in spite of adequate income (family member may be taking money); sudden change in banking habits

2. Which CNS depressant is used by body builders?

GHB because it stimulates protein synthesis.

Physical signs of Abuse in Children

Inadequately explained injuries, bruises, and/or fractures Weight loss Lack of hygiene Enuresis (bedwetting) particularly in older children or teens Sexually transmitted diseases Repeated urinary tract infections Genital pain or bleeding

The patient with paranoid schizophrenia and cocaine abuse is at risk for: a. Decreased frequency and length of psychiatric hospitalizations. b. Increased psychiatric symptoms. c. Decreased tardive dyskinesia. d. Increased response to psychiatric medications.

Increased psychiatric symptoms. Rationales A. Decreased tardive dyskinesia. Tardive dyskinesia is an involuntary neurological movement syndrome caused by the long-term use of neuroleptic medications. The effects of cocaine abuse on the nervous system can exacerbate tardive dyskinesia. B. Increased psychiatric symptoms. The side effects of cocaine abuse increase the patient's psychiatric symptomatology. Patients may also be nonadherent with psychotropic medications during periods of cocaine abuse, thus increasing symptomatology. C. Increased response to psychiatric medications. Patients experience a decreased response to psychiatric medications when taken in conjunction with cocaine. The cocaine alters the patient's psychiatric and cardiac symptoms and may interfere with receptor sites for medication absorption. D. Decreased frequency and length of psychiatric hospitalizations. Patients with serious mental illness are at an increased risk for frequency and length of hospitalization when they abuse cocaine. Patients may self-medicate with cocaine and be nonadherent with prescribed medications, resulting in increased symptomatology. Length of stay in the hospital will increase as attempts are made to stabilize the patient's psychiatric symptoms and address the cocaine abuse.

Withdrawal from Barbiturates and Benzodiazepines

Increased vital signs Diaphoresis Anxiety, agitation, confusion, disorientation Insomnia Depression Tremors Hallucinations Seizures

Methadone (Dolophine)

Methadone blocks the craving for and the action of opiates. Abstinence maintenance med. Binds with opiate receptors in CNS to produce analgesic and euphoric effects. Prevents withdrawal symptoms in clients who were addicted to opiate drugs. Precautions/interactions: do not use in clients who have severe asthma, chronic respiratory disease, or history of head injury. Side/adverse effects: sedation, respiratory depression, paradoxical CNS excitation.

Minor Alcohol Withdrawal vs. Minor Alcohol Withdrawal

Minor withdrawal: occurs 6-12 hours after a drink and symptoms last 48-72 hours. Major withdrawal: when symptoms include hallucinations and seizures, usually developing 2-3 days after last drink.

Naltrexone

Naltrexone blocks the craving for alcohol and the pleasure derived from drinking

PCP

Originally used as an animal tranquilizer, PCP first appeared as a street drug in the 1960's. Use of PCP often causes violence, psychosis, and extreme agitation. Individuals are often very strong when intoxicated with PCP, and staff must use caution with suspected PCP users. PCP is also considered hallucinogenic.

Alcohol (ETOH)

Pg. 301 in text. Most widely abused. Metabolized in the liver by the enzyme alcohol dehydrogenase, which women, Asians, and Native Americans have less of. 6 shot glasses of liquor, 24oz bottle of table wine, and 6 beers are all the same amount. Complications of abuse include: -intoxication, overdose, poisioning, death -gastritis, esopogitis, eosphogeal varices -cirrhosis of liver -hypoglycemia -withdrawal and detox -Mg, B vitamins, Folate deficiencies

risk for injury interventions

Place the patient in a room near the nurses' station or where the staff can observe the patient closely. Monitor vital signs (elevated pulse, blood pressure may mean under medication for withdrawal while decreased pulse and blood pressure can mean over coverage for withdrawal) Monitor the patient's intake and output and any pertinent laboratory values, such as electrolytes. Intravenous therapy may be indicated for patients in severe withdrawal. Provide food or nourishing fluids as soon as the patient can tolerate eating; have something available at night. (Bland food usually is tolerated more easily at first.) Institute seizure precautions according to hospital policy (padded side rails up, airway at bedside, and so forth). Monitor the patient's sleep pattern; report difficulties with sleep to team psychiatrist. Use least restrictive measures to protect patient from harming self or others.

Commonly Used Defense Mechanisms

Rationalize: falsify an experience by giving a contrived socially acceptable and logical explanation to justify the behavior Projection: attributing an unconscious impulse, attitude or behavior to someone else. Denial: to escape unpleasant realities by ignoring their existence, which is a way of coping with a painful situation. By denying the person avoid responsibility. Blame: making excuses for the drinking by blaming the need to drink on work, home, family and relationship stressors. Regression: Returning to comfortable behavior that was used at an earlier point in one's life is regression.

Benzodiazepines/Anxiolytic Drugs

Reduce anxiety without excessive sedation and are addictive. Ex: diazepam/valium, lorazepam/ativan, alprazolam/xanax, tranzene, librium Affect norepinephrine and GABA neurotransmitters. Flumazil used for Benzo withdrawal.

Shaken Baby Syndrome

SBS is caused by vigorously shaking an infant by the shoulders, arms, or legs. Shaking often occurs in response to a baby crying or having a toilet-training accident. The abuser is usually male, and either the biological father, or the mother's boyfriend. The "whiplash" effect can cause intracranial or intraocular bleeding. Often there is no obvious external head trauma. Children with SBS may display some outward signs, such as: difficulty awakening, seizures, slurred speech, uncontrollable crying, and/or inability to nurse or eat. SBS can result in death, mental retardation, developmental delays, paralysis, severe motor dysfunction, spasticity, blindness, and seizures. (Interestingly, SBS is the diagnosis that is now given to football players who continually suffer from head injury and concussions from frequent impact during activity)

Question: Treatment interventions to assist the patient with a current history of drug and alcohol abuse and prevent relapse include: (Select all that apply.) a. Lifestyle changes. b. Twelve-step program. c. Support from established friendships. d. Self-help groups. e. Individual therapy.

Twelve-step program.Lifestyle changes.Self-help group.Individual therapy. Rationale 1. Individual therapy. Individual therapy provides the patient with the opportunity to work with a health care provider to address psychological issues. This is especially important for the patient who is trying to maintain sobriety and prevent relapse. Through treatment the patient will learn effective coping skills, identify triggers to relapse and treatment prevention. 2. Self-help groups. Participants in self-help groups have similar problems and help one another by sharing their individual experiences and treatment strategies, and by educating one another. This is a very effective aspect of relapse prevention. 3. Twelve-step program. The twelve-step programs are typically spiritual programs based on fellowship among members. Groups meet daily or more often. Participants acknowledge they are powerless over chemicals and live ''one day at a time.' '4. Lifestyle changes. Patients learn to identify different coping strategies and discover new interests and capabilities within themselves. Patients learn that hanging out with previous friends who continue to abuse drugs or alcohol places them at greater risk of relapse. 5. Support from established friendships. Encouraging associations with friends who may very well be users themselves would not be helpful in preventing relapse.

Complications of chronic heroin use

Use of contaminated needles and increased risk for HIV and Hepatitis C Abcesses formed at the sites of injection, often difficult to treat. Veins, from frequent access, are often damaged and difficult to use for IV solutions. Rapid development of addiction and tolerance. Need to use increasingly larger doses which can become very expensive Many heroin abusers turn to dealing drugs and/or prostitution in order to financially support the heroin addiction Weight loss, lethargy, chronic constipation Pinpoint pupils, drowsy ("nodding off"), slurred speech

CAGE Assessment

Used to assess symptoms of alcohol abuse, but similar questions are used for substance abuse generally. C: cut down (ever felt a need to cut down your drinking?) A: annoyed (ever felt annoyed by criticism about your drinking?) G: guilty (ever felt guilty about your drinking?) E: eyes (ever need a drink in the morning to rid a hangover and open your eyes?) Two "yes" responses indicate an alcohol problem and require further assessment.

General Rule For Withdrawal Symptoms

When a patient is going through withdrawal of an illicit substance they will experience the opposite of the effects induced by the drug they abuse. This is because their body experiences the sudden absence of the drug. i.e. Withdrawal from Depressants causes symptoms of Stimulants, Withdrawal from Stimulants causes symptoms of Depressants.

Alcohol withdrawal (AKA Alcohol withdrawal syndrome)

Withdrawal begins 4-12 hours or 6-8 hours after the last drink, and is called a "hangover" when its mild. Symptoms peak 24-32 hours or 1-2 days after the last drink. Mortality rate for alcohol withdrawal is 10% for otherwise healthy people. Symptoms Include: -nausea/vomiting and diarrhea -anxiety/agitation/irritability -tachycardia -tremor -hypertension -diaphoresis

physical dependence

a biological need that occurs when the body becomes used to having the substance in the system

substance dependence

a pattern of compulsive drug taking that results in tolerance, withdrawal symptoms, or other specific symptoms for at least a year

Cocaine

a powerful and addictive stimulant, derived from the coca plant, producing temporarily increased alertness and euphoria. Smoked, snorted, heated, or injected. It is not physically addicting, but is psychologically addicting.

Nicotine

a stimulating and highly addictive psychoactive drug in tobacco. Smoked, chewed, or sniffed. Very commonly used by individuals who suffer from mental disorders including Schizophrenia and PTSD.

Methadone maintenance

a treatment program for heroin abusers in which heroin is replaced by the long-term intake of methadone

Wernicke Syndrome

acute confused state with ataxia, confusion, delirium and peripheral neuropathy. It can clear spontaneously in a few days or weeks and responds to thiamine (Vitamin B1) in large doses. A type of encephalopathy.

A graduate nurse is assigned to work on a unit with mentally ill chemically abusing patients. Which of the following statements by the nurse is reason for concern? a. "I never really understood what the patients were going through until I attended a counseling group session." b. "These patients have more excuses for their problems than anyone I know." c. "It must be very frightening for the patient who experiences hallucinations while withdrawing from using alcohol." d. "The patient should be complimented for maintaining 1 week of sobriety."

b. "These patients have more excuses for their problems than anyone I know." Rationales 1. ''These patients have more excuses for their problems than anyone I know.'' MICA patients are at risk for frequent relapses and setbacks. Chronic mental illness often impairs their judgment and insight, limiting their ability to acknowledge their problems or solve them. The nurse's response reflects her lack of understanding of the complexity of mental illnesses and substance use. 2. ''I never really understood what the patients were going through until I attended a counseling group session.'' This statement reflects the nurse's insight into understanding the complexity of the disorders. 3. ''The patient should be commended for maintaining 1 week of sobriety.'' MICA patients experience frequent setbacks and relapses. Progress is slow, and each positive step toward reduction of harm and abstinence should be acknowledged and promoted. 4. ''It must be very frightening for the patient who experiences hallucinations while withdrawing from using alcohol.'' The nurse's comments reflect understanding and insight regarding the symptomatology associated with chronic mental illness and substance abuse. The nurse's response also reflects empathy.

Which of the following statements by the patient participating in group therapy for meperidine (Demerol) abuse indicates that the patient is making progress in treatment? a. "I would not have to use as much Demerol if my nerves were not shot." b. "I cannot get addicted to Demerol. You have to take twice as much Demerol as I do to get addicted." c. "I have not used Demerol in 2 days since I started using relaxation exercises." d. "I cannot get addicted to Demerol. You have to take twice as much Demerol as I do to get addicted."

c. ''I have not used Demerol in 2 days since I started using relaxation exercises.'' Rationale a. ''I would not have to use as much Demerol if my nerves were not shot.'' The patient is rationalizing (excusing) using Demerol and blaming it on shot nerves. This type of response indicates the patient has not accepted responsibility for personal actions. b. ''I cannot get addicted to Demerol. You have to take twice as much Demerol as I do to get addicted.'' The patient's statement reflects the patient's denial of drug use. This statement indicates the patient has not acknowledged having a substance abuse problem. c. ''I have not used Demerol in 2 days since I started using relaxation exercises.'' This response reflects the patient's adaptation of coping mechanisms that are effective. Not using for 2 days is a measurable outcome. d. ''I'm trying to work a full day but the boss keeps sending me home.'' The patient chooses to blame another person (the boss) for not being able to work a full day. The patient is not effectively dealing with the substance abuse issue.

A priority nursing diagnosis for the patient experiencing alcohol withdrawal delirium is: a. Fluid Volume Excess.b. Altered Nutrition, Less than Body Requirements. c. Risk for Injury. d. Ineffective Coping related to alcohol abuse.

c. Risk for Injury. Patient needs to be protected from injury r/t seizures or delirium/confusion.

The nurse is assessing a patient who has a current history of alcohol dependence for signs of major withdrawal. What findings would the nurse expect to find? a. Hypotension, bradycardia b. Anxiety and increased appetite c. Tachycardia, severe diaphoresis d. Cold, clammy skin, decreased body temperature

c. Tachycardia, severe diaphoresis Rationale 1. Hypotension, bradycardia. Symptoms associated with major withdrawal, also known as delirium tremens (DTs), are not low blood pressure and a slow heartbeat, but hypertension and tachycardia. 2. Cold, clammy skin, decreased body temperature. Severe diaphoresis and elevated body temperature are physical symptoms of impending DTs (delirium tremens). 3. Tachycardia, severe diaphoresis. Tachycardia and severe diaphoresis are associated with major withdrawal from alcohol. 4. Anxiety and increased appetite. Patients experiencing a minor withdrawal from alcohol may experience anxiety and gastrointestinal-related symptoms such as nausea, vomiting, and anorexia.

Co-occuring disorders (COD)

coexistence of substance abuse and psychiatric disorder.

Korsakoff's syndrome

cognitive disturbance (dementia) of short term memory in users that have been drinking heavily for many years and have a long-term thiamine deficiency. If treated early with thiamine it is reversible, but if untreated it is irreversible and impairment can be severe and permanent. Memory: KorsakOFF - his memory is OFF

Addiction

compulsive drug craving and use, despite adverse consequences

The patient presents in the emergency room with constricted pupils, slurred speech, drowsiness, and respirations of 8/min. The person who accompanied the patient to the emergency room reports the patient had taken an unknown quantity of meperidine (Demerol) tablets 30 minutes earlier. Which medication should the nurse anticipate giving the patient? a. Methadone b. Diazepam (Valium) c. Phenytoin (Dilantin) d. Naloxone (Narcan)

d. Naloxone (Narcan) Rationale 1. Diazepam (Valium). Diazepam (Valium) is a centrally acting benzodiazepine used to treat seizures, anxiety, and skeletal muscle spasms. The drug depresses the central nervous system, which is responsible for maintaining vital signs. Giving diazepam to the patient will further depress the respiratory center of the brain. 2. Phenytoin (Dilantin). Phenytoin (Dilantin) is an anticonvulsant and antiarrhythmic used to treat seizures. The nurse would not expect to administer this medication unless the patient experiences seizures. 3. Naloxone (Narcan) Naloxone (Narcan) is a narcotic antagonist that reverses the central nervous system depression and respiratory depression associated with opioid overdoses. The patient ingested an unknown amount of a narcotic. 4. Methadone. Methadone suppresses withdrawal symptoms in opioid detoxification. It alleviates the patient's craving for the narcotic. Methadone depresses respirations and therefore would exacerbate the problem.

Amphetamines

drugs that stimulate neural activity, causing speeded-up body functions and associated energy and mood changes. Referred to as "speed". Ex: methamphetamines, dexedrine, benzedrine, ritalin PET scan is used to show brain activity in meth patients.

Opioids

heroin, morphine, and synthetic drugs such as oxycontin, demerol, codeine, methadone.

CNS Depressants

increase GABA levels, cause a sensation of relaxation and well-being. Includes: alcohol, opioids, and other pain medications

Stimulants

increase dopamine and cause hyperstimulation in brain and body. Causes raised vital signs cans cardiovascular stress. Withdrawal can mimic an MI. Includes: cocaine, meth, crack, speed

Abuser

individual who abuses others or is at risk for becoming abusive toward others

Victim

individual who has been abused or believes they have been abused

Bully

individual who intimidates, threatens, or mistreats someone who is weaker or more vulnerable (this may occur at any age, at school, work or other social situations)

Highest Risk Group for Substance Abuse

male, unemployed or medical profession, 18-25 years old risk takers, rebels, low self-esteem, lack of affection/relationships, lack of life success, low pain tolerance, narcissistic behaviors, impulsive

Rum Fits/Generalized Seizures

seizures which can occur 2-3 days after stopping drinking.

12 Step Programs

self help support groups where there are no professionals are involved. These groups meet daily, weekly, or monthly in neighborhood churches, hospitals, community centers or other public buildings. There are patient programs such as Alcohol Anonymous (AA) or Narcotic Anonymous (NA). There are family or significant others programs such as Adult Children of Alcoholics(ACoA), Al-Anon and Alateen.

Blood Alcohol Level (BAL)

the amount of alcohol in the blood, measured in grams per 100 milliliters 0.05-0.15 g/dL: euphoria, mood lability, cognitive disturbances (lack of concentration, impaired judgement, sexual disinhibition) 0.15-0.25 g/dL: Mood lability with outburts, slurred speech, staggered gait & ataxia, diplopia, drowsiness 0.3 g/dL: agressive behavior, incoherent speech, labored breathing, vomiting, stupor 0.4 g/dL: coma 0.5 g/dL: severe respiratory depression, death