Chpt 25-Addiction

Epidemiology

Alcohol most abused followed by weed 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. 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, and opportunistic infections (such as HIV) secondary to drug injection. Earlier studies have documented the connection between alcohol abuse and increased risk for diabetes mellitus (DM), gastrointestinal problems, hypertension, liver disease, and stroke

Disulfiram (Antabuse)

Antialcohol agent, enzyme inhibitor RECEPTOR AFFINITY: Inhibits the enzyme aldehyde dehydrogenase, blocking oxidation of alcohol and allowing acetaldehyde to accumulate to concentrations 5 to 10 times higher than normal in the blood during alcohol metabolism. Believed to inhibit norepinephrine synthesis. INDICATIONS: Management of selected patients with chronic alcohol use who want to remain in a state of enforced sobriety SELECTED SIDE EFFECTS: Drowsiness, fatigue, headache, metallic or garlic-like aftertaste. If taken with alcohol: flushing, throbbing in head and neck, throbbing headaches, respiratory difficulty, nausea, copious vomiting, sweating, thirst, chest pain, palpitations, dyspnea, hyperventilation, tachycardia, hypotension, syncope, weakness, vertigo, blurred vision, confusion; severe reactions may include arrhythmias, cardiovascular collapse, acute congestive heart failure, and unconsciousness. WARNINGS: Never administer to an intoxicated patient or without the patient's knowledge. Do not administer until patient has abstained from alcohol for at least 12 hours. Contraindicated in patients with severe myocardial disease, coronary occlusion, or psychoses and in patients receiving current or recent treatment with metronidazole, paraldehyde, alcohol, or alcohol-containing preparations. Use cautiously in patients with DM, hypothyroidism, epilepsy, cerebral damage, chronic and acute nephritis, cirrhosis or dysfunction. POSSIBLE DRUG INTERACTIONS: Concomitant administration of phenytoin, diazepam, or chlordiazepoxide may increase serum levels and risk for drug toxicity. Increased prothrombin time caused by disulfiram may lead to a need to adjust dosage of oral anticoagulants. SPECIFIC PATIENT AND FAMILY EDUCATION Take the drug daily; take it at bedtime if it makes you dizzy or tired. Crush or mix tablets with liquid if necessary. Do not take any form of alcohol (e.g., beer, wine, liquor, vinegar, cough mixtures, sauces containing alcohol, aftershave lotions, liniments, or cologne); doing so may cause a severely unpleasant reaction. Wear or carry medical identification with you at all times to alert any medical emergency personnel that you are taking this drug. Keep appointments for follow-up blood tests. Avoid driving or performing tasks that require alertness if drowsiness, fatigue, or blurred vision occur. Know that the metallic aftertaste is transient and will disappear after use of the drug is discontinued.

Biologic Response 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.

Detoxification opioid

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 of 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. 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 he or she is fully detoxified from opioids, withdrawal symptoms may appear 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. Buprenorphine and naloxone are combined into one formulation with a brand name of Bunavail, Suboxone, or Zubsolv, and is indicated for the maintenance treatment of opioid addiction. The medication is administered sublingually as a single dose. The purpose of adding the naloxone to the buprenorphine is to protect the patient from an overdose in case the patient has been misusing opiates. Otherwise, the naloxone has no beneficial purpose.

Effects long term abuse

People who use alcohol regularly usually develop alcohol tolerance, the ability to ingest an increasing amount of alcohol before they experience a "high" 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 Drinks 1-2 0.05 Impaired judgment, giddiness, mood changes 5-6 0.10 Difficulty driving and coordinating movements 10-12 0.20 Motor functions severely impaired, resulting in ataxia; emotional lability 15-20 0.30 Stupor, disorientation, and confusion 20-24 0.40 Coma 25 0.50 Respiratory failure, death

Methadone (Dolophine)

RUG CLASS: Narcotic agonist, analgesic RECEPTOR AFFINITY: 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, endorphins INDICATIONS: Detoxification and temporary maintenance treatment of narcotic addiction; relief of severe pain SELECTED SIDE EFFECTS: Lightheadedness, dizziness, sedation, nausea, vomiting, facial flushing, peripheral circulatory collapse, arrhythmia, palpitations, urethral spasm, urinary retention, respiratory depression, circulatory depression, respiratory arrest, shock, cardiac arrest 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 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. SPECIFIC PATIENT AND FAMILY EDUCATION Take drug exactly as prescribed. Avoid use of alcohol. 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.

Brief interventions

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 of harm reduction

Nurses

A nurse is just as susceptible to addiction as any other individual, but additional risk factors exist such as access and availability of drugs, training in the administration and injection of drugs, and a familiarity with and a frequency of administering drugs. Working conditions may be difficult and involve staffing shortages, acutely ill patients, inadequate patient to nurse ratios, shift rotation, shifts lasting longer than 8 hours, and increased overtime all add additional stress to the nurse which increases the risk of substance abuse. Because of the risk of losing a license to practice, nurses are very reluctant to seek help. To protect patients' safety and maintain the standards of the profession, many states have mandatory reporting laws. According to the nurse practice acts, any nurse who knows of any health care provider's incompetent, unethical, or illegal practice must report that information through proper channels. In 1982, the American Nurses Association House of Delegates adopted a national resolution to provide assistance to impaired nurses. The peer assistance programs strive to intervene early, reduce hazards to patients, and increase prospects for the nurse's recovery. The program offers consultation, referral, and monitoring for nurses whose practice is impaired, or potentially impaired, because of the use of illicit drugs or alcohol or a psychological or physiologic condition. A referral can be made confidentially by the employer, Employee Assistance Program, coworker, family member, friend, or the nurse herself or himself. If the nurse is willing to undergo a thorough evaluation to determine the extent of the problem and any treatment needed, all information is kept confidential from the Board of Nursing, so that the nurse does not face disciplinary action against his or her nursing license. Some signs of substance abuse in nurses include mood swings; inappropriate behavior at work; frequent days off for implausible reasons; noncompliance with acceptable policies and procedures; deteriorating appearance; deteriorating job performance; sloppy illegible charting; errors in charting; alcohol on the breath; forgetfulness; poor judgment and concentration; lying; and volunteering to act as the medications nurse. Other characteristics of nurses with substance abuse include high achievement, both as a student and a nurse; volunteering for overtime and extra duties; no drug use unless prescribed after surgery or for a chronic illness; and family history of alcoholism or addiction.

Effective treatment for addiction

Addiction is a complex but treatable disease that affects brain function and behavior. No single treatment is appropriate for everyone. Treatment needs to be readily available. Effective treatment attends to multiple needs of the individual, not just his or her drug use. Remaining in treatment for an adequate period of time is critical. Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. An individual's treatment and service plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. Many drug-addicted individuals also have concurrent mental disorders. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Treatment does not need to be voluntary to be effective. Drug use during treatment must be monitored continuously because lapses during treatment do occur. 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.

Alcohol

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. 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. 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). 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.

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. Wernicke encephalopathy, a degenerative brain disorder caused by thiamine deficiency, is characterized by vision impairment, ataxia, hypotension, confusion, and coma. Korsakoff's 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's 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's amnestic syndrome the chronic phase. Early symptoms can be reversed, but without long-term treatment, the prognosis is poor

Motivate for change

Ambivalence about substance use is normal and can be dealt with by working with the patients' own concerns about their use of alcohol and other drugs. Motivation is fluid and can be modified. Experiences such as increased distress levels, critical life events, a period of evaluation or appraisal of one's life, recognizing negative consequences of use, and positive and negative external incentives for change can all influence a patient's commitment to change. Techniques that enhance motivation are associated with increased success in treatment, higher rates of abstinence, and successful follow-up treatment. Motivational interviewing is a method of therapeutic intervention that seeks to elicit self-motivational statements from patients, supports behavioral change, and creates a disconnect between the patient's goals and their continued alcohol and other drug use. The acronym FRAMES (which is short form for feedback, responsibility, advice, menu of strategies, empathy, and self-efficacy) summarizes elements of brief interventions with patients using motivational interviewing

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 in 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 promote 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. Some steroid users report that they have committed aggressive acts, such as physical fighting, armed robbery, using force to obtain something, committing property damage, 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

Brief interventions

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 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 aboutThe consequences of a drug conviction in terms of international travel and employmentConsequences of further or heavier drug charges Discussing harm reduction strategies, especially those relating to: Overdose Violence Driving under the influence Safe practices (e.g., safe injecting, safe sex) Offering and arranging a follow-up visit

New drugs

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

Nursing interventions

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

behaviors of countertransference

Behaves as a victim Feels a sense of helplessness, increased need to give advice and "fix" the situation and the patient; shows anger toward the patient for not being able to take care of the situation him- or herself Is intrusive, hostile, belittling Can be frightened, withdraw from patient, express anger overtly, or be passive-aggressive (i.e., suggesting discharge to the team or ignoring legitimate requests from patient) Does everything right, is insightful, pleasant, and so forth Congratulates self on therapeutic interventions; can become bored or complacent Relapses into drug or alcohol use Feels angry, personally betrayed; withdraws from other patients; doubts own abilities Asks personal questions about staff qualifications or prior drug or alcohol abuse Reveals personal information, resents the intrusion, and may regret divulging information Is silent or divulges minimal information Tries harder, doubts own therapeutic ability, is angered by patient's resistance Tries to "bend" or ignore rules of milieu and group rules May permit program rule infractions; may feel pressured, angry, or passive-aggressive Insists that no one can help him or her Feels pressure to be the one who can help; may feel angry and inept or helpless

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. Symptoms of caffeine intoxication can include five or more of the following: restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, and psychomotor agitation 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.

Complications for withdrawal

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 gastrointestinal (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

Stimulant

Cocaine (also known as coke, snow, nose candy, flake, blow, big c, lady, white, or snowbirds) is made from the leaves of the Erythroxylum coca plant 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 smokeable form of cocaine, often called free-base cocaine, can be made by mixing the 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 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. 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 also is known to bring on panic attacks in some individuals. Long-term cocaine use leads to increased anxiety. Increased use of cocaine is associated with stress and drug craving

Countertransference Codependence

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. 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

Naltrexone (Relistor)

DRUG CLASS: Narcotic antagonist RECEPTOR AFFINITY: Binds to opioid receptors in the CNS and competitively inhibits the action of opioid drugs, including those with mixed narcotic agonist-antagonist properties INDICATIONS: Adjunctive treatment of alcohol or narcotic dependence as part of a comprehensive treatment program SELECTED 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 WARNINGS: Contraindicated in pregnancy and patients allergic to narcotic antagonists. Use cautiously in narcotic addiction because may produce withdrawal symptoms. Do not administer unless patient has been opioid free for 7 to 10 days. Also, use cautiously in patients with acute hepatitis, liver failure, depression, or suicidal tendencies and in those who are breast-feeding. 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. SPECIFIC 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.

Assessment

Denial 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 you 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 Confusion about severity of drinking history: "I went out drinking with friends last week and didn't have any problems; I don't get drunk all the time." Difficulty reconciling early positive experiences of alcohol use with current problems: "I used to drink with my buddies after work to unwind. We had a great time. Those were some good times. ..." Confusion regarding the definition of alcoholic: "Well, I don't have withdrawal symptoms, so I can't be an alcoholic." Relief when they compare themselves with others and find the others in worse condition: "They are the alcoholics, not me!" A delusion that drinking can be self-controlled: "If I search hard enough or long enough, I will find a way to control and enjoy drinking." Confusion or trouble accepting that behavior is different when intoxicated: "I couldn't have done that; that's just not like me." 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.

Hallucinogens

Dextromethorphan 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.

Smoke 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 questioned 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 instead, they may instead serve as a gateway to try other tobacco products. On May 5, 2016, the 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

Overdose Detoxification

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. 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 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, and elevated blood pressure.

Therapeutic relationship

Encourage honest expression of feelings. Listen to what the individual is really saying. Express caring for the individual. Hold the individual responsible for his or her behavior. Provide fair and consistent consequences for negative behavior. Talk about specific objectionable actions. Do not compromise your own values or nursing practice. Communicate the treatment plan to the patient and to others on the treatment team. 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

Frames

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: It's up to you; you're free to decide to change or not. No one else can decide for you or force you to change. 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 he or she can change.

Harm Reduction Peer support

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 his or her 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. 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 12 step program

Skills training

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 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

Coping mechanisms Group intervention

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. The skills listed in Box 25.13 are often taught as coping strategies for dealing with alcohol and drug cravings. 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. 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.

Gambling

Individuals with this disorder are preoccupied with gambling and experience an aroused, euphoric state during the actual betting. The action of seeking an aroused state is often more important to the pathologic gambler than the desire for money itself. They are drawn to the games and begin making bigger and bigger bets. Characteristically, they relentlessly chase their losses in an attempt to win them back. They are unable to control their gaming and may lie to family, friends, and employers to hide their gambling habit. They have an intense need to gamble and often turn to gambling when feeling distressed. These individuals are highly competitive, energetic, restless, and easily bored. Some evidence shows that changes in the serotonin system are associated with addiction behavior, similar to results reported for nicotine and alcohol dependence Commit suicide This disorder is conceptualized as similar to alcohol and other substances of dependence. When substances are used in conjunction with gambling, they cause a deterioration in play and accelerate the progression of the gambling disorder. Other comorbid disorders include depression, ADHD, Tourette syndrome, and personality disorders (Karlsson & Håkansson, 2018). The disorder has four phases: winning, losing, desperation, and hopelessness. Pathologic gambling can be treated by psychotherapists experienced in this disorder; for many of these addicts, Gamblers Anonymous is sufficient to curb the disorder. 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.

Inhalant intoxication Long term complications

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 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

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, 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 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; 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" 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 lightheadedness, 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

Substance abuse

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. 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 β-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 a part of treatment. That is, dependence can be a normal response to some medications

Weed

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 and treatment

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

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.

Promotion of health

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 also is 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.

Opioid

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

Biologic response to smoke

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

Withdrawal and smoke cessation

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. 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

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 five times higher among those with schizophrenia, bipolar disorder, posttraumatic stress disorder (PTSD), and alcohol/illicit drug use disorders

Individual therapy Family interventions

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. 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.

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. These interventions are discussed later in this chapter. Other medications are used for those who are recovering. Disulfiram (Antabuse) is neither a treatment nor a cure for alcoholism, but it can be used as adjunct therapy 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 side effects. Severe reactions may include respiratory depression, cardiovascular collapse, arrhythmias, myocardial infarction, acute congestive heart failure, unconsciousness, convulsions, and death. Acamprosate calcium is 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 if the individual is abstinent from alcohol prior to its initiation 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). The precise mechanism of action for naltrexone's effect is unknown; however, reports from successfully treated patients suggest three kinds of effects: (1) it can reduce craving (the urge or desire to drink 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

Behaviors in abuse

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

Withdrawal

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 the 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. 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.

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), and 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

Etiology and response

Substance abuse encompasses the body, the mind, and society's influences. Human and animal studies confirm a genetic predisposition for drinking behaviors and self-administering mind-altering drugs, but as yet no precise genetic marker has been established. Temperament, 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. 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. Addictions lead to loss of jobs and family relationships. Use of illegal substances can lead to arrest and prison. 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

Diagnostic criteria

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 causes 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 DSM-National 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 the drug-related cues (e.g., a party, emotional experiences)

OTC

Taking a medication that has been prescribed for someone else Taking a drug in higher quantity or in another manner than prescribed Taking a drug for another purpose than prescribed (NIDA, 2018i) 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 barbiturates (e.g., pentobarbital and 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. 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

MDMA

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 Rohypnol gamma-hydroxybutyrate (GHB) and ketamine are predominantly CNS depressants but are also considered "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

Treatment and recovery

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 of the 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 below 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.

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 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. Dissociative drugs include PCP (phencyclidine), DXM (dextromethorphan), Salvia divinorum, and ketamine

Opioid and Morphine

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, 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 human immunodeficiency (HIV) devices and other diseases resulting from the sharing of needles or other injection equipment.

Weed

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

AA

We admitted we were powerless over alcohol—that our lives had become unmanageable. Came to believe that a Power greater than ourselves could restore us to sanity. Made a decision to turn our will and our lives over to the care of God as we understood Him. Made a searching and fearless moral inventory of ourselves. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. Were entirely ready to have God remove all these defects of character. Humbly asked Him to remove our shortcomings. Made a list of all persons we had harmed, and became willing to make amends to them all. Made direct amends to such people wherever possible, except when to do so would injure them or others. Continued to take personal inventory and, when we were wrong, promptly admitted it. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs

Alcohol withdrawal and detox

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) and grand mal (tonic-clonic) seizures. 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. Detoxification is period of time where the patient is observed, usually in a hospital setting and given medication to avoid withdrawal symptoms. 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