Ex 4 54/64 Substance Abuse

Thomas McLellan - University of Penn

"Addicts are by no means unique in their propensity to relapse. In a study comparing alcoholics & drug addicts to patients with diabetes, asthma & hypertension, McLellan found nearly identical rates of noncompliance and relapse; between 30 & 40 % of each group failed to follow even half their doctors' guidelines."

Heroin/Opioid Withdrawal

-4 hours: craving for drugs, anxiety -8 hours: yawning, perspiration, runny nose, tearing -12 hours: pupils dilated, goose bumps, tremors, hot and cold flashes, aching bones, joint pain, decreased appetite -18-24 hours: insomnia, elevated BP, elevated temp, increased pulse and respirations, restlessness, nausea -26-38 hours: curled-up position generally die to abdominal cramping, vomiting and diarrhea, weight loss, increased bowel sounds -Peak intensity of withdrawal is within 48 - 72 hours. -Withdrawal symptoms/discomfort may continue for months -Generally use Clonidine (catapres) in a tapering schedule. -Must monitor BP carefully.

Binge drinking

-5 or more drinks for men on the same occasion on at least 1 day in the 30 days prior to the survey. 4 or more drinks for women. -No major ethnic group is immune.

Impaired Professionals

-9% of Physicians use drugs and/or alcohol -10-20% of Nurses with substance abuse problems -OBN - lists of suspended licenses - see OBN web site listed on Harvey Oklahoma Peer Assistance Program - (OPAP) is a voluntary, confidential program, which assists licensed nurses whose competency may be impaired due to substance abuse and/or chemical dependency.

MDMA (Ecstasy)

-Adam, XTC, X, Clarity, Essence, Doves, Rave Energy, Cloud 9. -3,4-methyllenedioxy-methamphetamine -Effects levels of Serotonin and can lead to depression, learning deficits and memory loss -Causes involuntary jaw clenching

Neurotransmitters: dopamine

-All feelings of pleasure/enjoyable experiences result from dopamine. -Dopamine response with psychomotor stimulant drugs such as cocaine and amphetamine. Also shown to play a role in the reinforcement of opiates, nicotine, and alcohol.

Genetic predisposition

-Certain Populations? Which ones? -Different Pathway of Metabolizing Alcohol (next slide - THIQ-a morphine like substance) -There is an increased incidence of severe alcoholism in close family members. "The rate of problems with alcohol increases with the number of relatives with alcoholism, the severity of the disease, and the closeness of the genetic relationship to the person at risk." (old text)

Stimulants: Amphetamines, - Ritalin, Dexedrine

-Crank, Crystal Meth: Labs in cars, garages (sale of Pseudoephedrine law) -Legitimately used to treat narcolepsy, ADHD, obesity -Used by the military -Prior to steroids, given to increase athletic performance -Paranoid psychosis may be the result of sustained use (Amphetamine Psychosis) both during use and when in withdrawal -People become addicted to the high energy, alertness and sense of well being produced. -Meth - More than 12 million Americans have tried it and 1.5 million are regular users according to federal estimates. -Meth releases bursts of dopamine in the brain, producing a strong euphoric effect. -An "eight ball" of meth, one eighth of an ounce, is enough to get 15 people high.

OTC abuses

-Currently, 1 in 11 teens has abused an OTC medication such as cough medicine containing dextromethorphan (DMX). -Dextromethorphan is an attractive drug of abuse because it produces an intoxicating effect, is inexpensive and easy to purchase. The high is referred to as a plateau and there are different levels

Diagnostic Criteria

-DSM-V includes diagnoses related to substance use disorder, intoxication and/or withdrawal. See criteria box on page 379 in text -The diagnoses you will see both in the medical and the psychiatric environment most frequently will be alcohol use disorder, alcohol withdrawal and opiate use disorder and withdrawal. -DSM-V does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Rather, criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders, where relevant.

Model of Recovery - Donna Wing

-Denial -Dependence -Behavior Change -Life Planning

Behavioral theory of addiction

-Drinking is a learned behavior -Drinking can be unlearned -This is the support behind Aversion Therapy - Antabuse (Disulifram) -ReVia (Naltrexone) - Is used to block effects of alcohol and Narcotics, will diminish the "high" -Drug use develops and is reinforced through the positive physical and emotional effects of mood alterations that occur as a result of the drug use. It does stimulate the pleasure receptors in the brain.

Stimulant withdrawal

-Due to tolerance - withdrawal can happen while person still taking the drug -Physical signs of withdrawal are limited and may include nonspecific aches and pains; generally does not require hospitalization -Symptoms include - intense cravings, agitation, temporary intense depression, anorexia, fatigue, with insomnia, exhaustion -Generally occur within the first 9 hours and can last up to two weeks - followed by normalized sleep patterns, decrease in craving and more normal mood. -Withdrawal then progresses to a recurrence of fatigue, anhedonia and anxiety. Danger is of patient seeking other mood altering substances to fill the void experienced.

Additional interventions

-Education - patient & family -Relapse prevention plan -Discharge planning - community based support groups -Recognition and acceptance of alcoholism as an illness that affects the whole family system is essential. When the family member who abuses alcohol suddenly attains sobriety, the dynamics of the whole family change. -Teach patient and family about substance abuse, symptoms, management, treatment, and prevention -Support patient and family involvement in 12 step program and other support groups Specific to adolescents - the quality of their peer networks (fewer substance abusing friends) predicts a more positive outcome

Interventions

-Emergency situation -Provide safe environment -Treat symptoms - assess physiologic & psychologic symptoms of withdrawal and effects of prescribed medications during withdrawal -Initiate therapeutic interventions to treat symptoms - including anxiety and other complications -In an emergency situation - maintain airway, monitor VS, intervene if necessary...hemorrhage, seizure, cardiac arrest -Assist patient in meeting nutritional and metabolic needs -Initiate vitamin and mineral replacement -Intervene with secondary medical complications if needed -Establish trusting therapeutic relationship

Alcoholics Anonymous

-Founded in 1935 by two alcoholics -The Bill W. Story -12-step program, The Big Book -Sponsorship -Anonymity (AA On-Line) -Open to anyone who has a desire to stop drinking -A very effective treatment program The Twelve Steps of AA are listed on page 397 in the text. Al-Anon and Al-A-teen for family members. ACoA - Adult Children of Alcoholics Friends of Bill W. meetings on cruise ships and at resorts. -Narcotics Anonymous NA -Cocaine Anonymous CA -Overeaters Anonymous OA -All based upon the 12 Step Recovery Model Residential Treatment/Halfway Houses Intensive Day Treatment Programs (day and evening) 12 & 12, Inc. and Cushing Valley Hope are examples of longer term residential treatment programs in our area. Tulsa Women and Children's Treatment Center - accommodates women and their children - 52 beds - see article in file Narconon Arrowhead - some info in the local and national news over the years about the treatment approach and questionable ties to Scientology.

Revia

-Generally given as 50 mg daily or 100 mg every other day. -Approved for opioid and alcohol dependence. -Available in once per month injection (Vivitrol) for those who have a larger problem with compliance. -More than 75% of alcohol-dependent patients will relapse during the first year of treatment - this offers the advantage of not having to remember to take their medication daily.

Opiates: three signs of dependence

-Increased tolerance -Withdrawal symptoms: tearing, runny nose, diaphoresis, fever -Desire to take beyond need

Gambling Disorder 2

-Is often preoccupied with gambling (e.g. having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble). -Often gambles when feeling distressed (e.g. helpless, guilty, anxious, depressed). After losing money gambling, often returns another day to get even ("chasing one's losses"). -Lies to conceal the extent of involvement with gambling. -Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.

Dual Diagnosis

-Is the occurrence of both a substance abuse/dependence disorder and another major psychiatric disorder -"Studies have shown that individuals use different substances to regulate or affect their moods, depending on the psychiatric illnesses involved" (Daley, Moss, & Campbell, 1993) -It is important to address both issues. The mental health diagnosis can complicate the substance abuse recovery program and/or the concurrent substance abuse can slow down/complicate the mental health treatment (drug interactions, poor compliance, etc.)

Synthetic Opiates

-Maintenance or use for detox from heroin. Also legitimately used as a primary drug in chronic pain management. -Moral/ethical issues - Should needles be dispensed?

Cannabis or other Phencyclidine

-Marijuana and Hashish -Psychological dependence and tolerance develop over time -What about the medical use? Marinol -They may be called euphorics. -Cannabis is the world's most commonly used illicit drug. -Active ingredient is THC. -Marinol - is used to treat anorexia in AIDS patients, and N&V in chemo patients. Also said to reduce intraocular pressure associated with glaucoma.

NQF Best Practices

-National Quality Forum -7 evidence based treatment practices effective in treating substance use disorders (SUDs) -All patients should be screened for alcohol misuse in general and mental health care settings.

Time-Out Anthropological Theory

-Not a theory of addiction; it is a theory of drinking -In every society members have a reprieve from behaving in a socially responsible manner -During this "time-out" members are exempt from negative consequences of drinking

Topiramate - topamax

-Off label has shown usefulness in reducing cravings to etoh. Unclear but thought to work similar to campral. -Research trials initially started with volunteers who were drinking at the time of starting the medication. There is no delay necessary.

Gambling Disorder 1

-Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following criteria in a 12-month period: -Need to gamble with increasing amounts of money in order to achieve the desired excitement (i.e. tolerance). -Is restless or irritable when attempting to cut down or stop gambling. -Has made repeated unsuccessful efforts to control, cut back, or stop gambling.

Hallucinogens

-Peyote, Mushrooms, Mescaline, d-lysergic acid diethylamide(LSD, acid). -Phencyclidine (Angel Dust, PCP) - discovered when seeking a cure for schizophrenia (Sandoz Labs) -No physical dependence therefore no withdrawal -These alter perception, cognition and mood -May experience flashbacks

Opiates

-Physical and psychological dependence occurs -Heroin, Dilaudid, Morphine, Fentanyl, Codeine, Oxycontin, Meperidine, Vicodin, Methadone, and Darvon among others -Hydrocodone, the most abused prescription drug in this country. -Used for analgesia, cough suppressants, antidiarrheal agents & pain relievers Tolerance occurs, more is needed for same effect -Narcan (Naloxone) in case of an overdose; effective for 4-5 hours duration. The patient may need repeated dose.

Sedative, Hypnotic, or Anxiolytic

-Produce drowsy or calming effects by increasing GABA -Long term use develops tolerance -Used for anxiety, insomnia, anesthesia, and epilepsy -Cause physical and psychological dependence

Gambling Disorder 3

-Relies on others to provide money to relieve desperate financial situations caused by gambling. -The gambling behavior is not better explained by a manic episode. -Specify if episode or persistent -Specify severity -This is a new addition in DSM-V. It reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance abuse disorders to a certain extent.

Wernicke-Korsakoff

-Secondary to a thiamine deficiency in predisposed persons after many years of excessive alcohol consumption. -The Wernicke symptoms include inflammatory hemorrhagic degeneration of the brain. -The Korsakoff part is a form of amnesia greater than a general level of dementia and an inability to learn new skills.

Other - Bath Salts

-Stimulant containing powders for baths - nephedrone and methylenedioxypyrovalerone (MDPV) -As powerful as abusing methamphetamine or ecstasy. -09/07/11, The US Drug Enforcement Administration used its emergency scheduling authority to make these substances illegal for at least one year and it has continued to be extended. -Dopamine-norepinephrine reuptake inhibitor

Alcohol Withdrawal

-Symptoms - agitation, diaphoresis, DTs, major muscle spasms, N&V, hallucinations, depression, insomnia, elevated BP -Pulse differential from lying to standing positions or increased pulse -Use of Librium doses for withdrawal from Alcohol (regular and/or PRN doses) -Alcohol withdrawal generally begins 12 hours after last drink and peaks in 48 - 72 hours. Symptoms are less in 4 -5 days although some can last weeks to months. Insomnia often lasts for months.

All stimulant drugs pose a risk for both physical and psychological dependence.

-Symptoms from cocaine/crack use - dilated pupils, nose bleeds, nasal congestion, sniffling, tachycardia, impaired movement, elevated BP, insomnia, anorexia, possibility of seizures. -It decreases the reuptake of dopamine and norepinephrine -Crack cocaine is smoked - very addictive

Epidemiology of dependence

-The National Survey on Drug Use and Health (NSDUH) obtains information on nine categories of illicit drug use: use of marijuana, cocaine, heroin, hallucinogens, and inhalants, as well as the nonmedical use of prescription-type pain relievers, tranquilizers, stimulants, and sedatives. -Alcohol use/ abuse is investigated separately.

Co-dependency

-The unconscious compulsion to rescue and control others by "fixing" their problems. -Examples: 1. Lack of objectivity, a warped sense of responsibility to enable, rescue or fix others 2. Easily controlled (desperate need to please others) -Loneliness -ARE NURSES CO-DEPENDENT BY NATURE? -Enabling -Roles of family members -Al-Anon as a resource - Al-a-Teen

Epidemiology alcohol

-There were 138.3 million past month alcohol drinkers aged 12 or older in 2014, including 66 million who were binge alcohol users and 17.3 million who were heavy alcohol users. -In 201, 22.8 percent of underage people were current alcohol users, 13.4 percent were binge alcohol users, and 3.3 percent were heavy alcohol users.

Inhalants: Solvents, Gases, Nitrites

-They cross the blood brain barrier quickly. -They cause effects similar to anesthesia and slow the body functions. -Tolerance and physical dependence may occur -Model airplane glue, gasoline and paint thinner Rubber cement & cleaning fluids-Tetra Hydro-carbonate (Carbon Tetrachloride) -Inhalants cause 37% of all acute fatalities -Butane- can be fatal (Aluminum phosphide) -Aerosols, whippets, nitrous oxide (poppers) -Spray Paint and aromatic hydrocarbons -Amyl and Butyl Nitrites associated with Kaposi's sarcoma -Additional symptoms of inhalant abuse in students: general apathy, paint or stains on body or clothing, chemical soaked rags, bags, or socks, spots or sores around mouth, red or runny eyes or nose, chemical breath odor. -Long term effects can include short term memory loss, hearing loss, limp spasms, permanent brain damage, bone marrow damage, liver & kidney damage and death.

Alcohol Detoxification

-Thiamine- Vitamin B1 (Thiamine) for Prevention of -Wernicke-Korsakoff Syndrome & Folic Acid (Folate) -Treatment - Prevent injury, maintain comfort, alleviate fear, maintain Fluids & Electrolytes and nutritional status, provide medication to counteract symptoms -Untreated Delirium Tremens (DT's) can be fatal Tegretol and Clonidine (Catapres) along with withdrawal Meds.

Dual-Diagnosis

-Which treatment comes first, mental illness or substance use? -It's controversial -Inpatient - treat addiction first as drugs exacerbate mental disorders -Outpatient, treat both immediately -Alcohol aggravates mental health symptoms vs. perception of self-medication -This is controversial. If you treat the mental health issue, some of the stressors may decrease and the substance abuse may be eliminated. But, in practice, the substance use/abuse/dependence will complicate any mental health treatment and so needs to be one of the first things addressed.

NDX

-Withdrawal - states related to stimulants, depressants, and opioids are the most likely to lead to medical emergencies -Priority diagnosis would relate to safe, physical withdrawal

Sedative-, hypnotic-, anxiolytic withdrawl

-Withdrawal symptoms are the opposite of the drug effects -Length of acute withdrawal r/t the half-life of the drug -Withdrawal symptoms include insomnia, increased anxiety, increased body temp, pulse, & respirations, GI upset, muscle aches, diaphoresis, strong craving. -May also see cognitive changes -Generally lasts 3 - 7 days for short acting medications and 3 - 6 months for long acting ones. -Will generally try to taper the medication down over a LONG period of time (weeks) to avoid withdrawal symptoms.

Other information/sites

-http://ncadi.samhsa.gov - US dept of Health & Human Services & SAMHSA national clearinghouse for drug and alcohol information -http://www.ok.gov/nursing/peer.html

Risk for relapse

-relapse for alcohol dependence is very high in the first 6 - 12 months after stopping drinking. It gradually diminishes over several years. A minimum initial period of 3 months of pharmacotherapy is recommended. It is reasonable to continue treatment for a year. -The medications are not prone to abuse so they do not pose a conflict with other support strategies that emphasize abstinence.

Stages of Recovery - behavior change

1. Build on personal strengths 2. Daily affirmations 3. Test new behavior 4. Role models The clients goals are healthy, growth goals such as becoming responsible or developing a positive self-image.

Stages of Recovery - denial

1. Different forms of denial 2. Transcending denial 3. At risk for relapse 4. Manipulation - don't buy into stories 5. Place responsibility on patient 6. Confrontation Vs. Enabling Usually the person is coerced into treatment. Their goal is usually to complete treatment so that no punitive consequence is received.

Stages of Recovery - dependence

1. Grieving process 2. Setting boundaries 3. Detachment 4. Build on strengths 5. Daily affirmations -The alcoholic wishes to become sober to acquire or maintain a specific goal such as preserving a marriage or keeping a job. -The risk of relapse is high during this stage.

Stages of Recovery - Life Planning

1. Types of life planning goals 2. Referrals Characterized by emotional maturity and long-term goal setting. Specific goals relate to family, career, education, and finance.

TU Specific CORE Survey Results

60% consumed alcohol in the past year 46 % consumed alcohol in the past 30 days 24 % reported binge drinking in the prior 2 weeks 20% reported marijuana use in the past year

Nalmefene (Revex)

A newer opioid antagonist lacking abuse potential. IV or IM. No dose dependent liver toxicity side effect.

Signs of adult substance abuse

Absenteeism, especially after days off Frequent accidents or injuries Drowsiness Slurred speech Inattention to appearance Increased isolation Frequent secretive disappearances Tremors Odors of alcohol

Fatty liver

Accumulation of fats and proteins in the liver cells producing swelling.

ACoA

Adult Children of Alcoholics

Alcohol > Acetaldehyde (toxic) > THIQ (Tetrahydroisoquinalene)

Alcohol > Acetaldehyde (toxic) > Acetic Acid > Excreted

Designer Drugs

Analogues of currently controlled drugs, molecular structure is changed by underground chemists

Performance Enhancing Drugs

Androstenedione Creatine Anabolic steroids Stimulants

Vivitrol (naltrexone for extended-release injectable suspension)

Approved for outpatient treatment. Administered as a once-monthly. **Patients should carry documentation to alert medical personnel to the fact that they are taking vivitrol.

Assessment

Assess your own thoughts & beliefs Assess the immediate need - Safety, ? Withdrawal symptoms Assess history - substance use, physical, family, social Physical examination - rule out complications - confirm physical problems r/t the substance abuse Need to approach this assessment in a nonjudgmental manner.

Disulfiram (antabuse)

Aversive conditioning; blocks the normal breakdown of etoh - if alcohol is consumed; flushing, hypotension, nausea, dizziness, blurred vision, palpitations, occur.

Physical signs

Bloodshot, red eyes; droopy eyelids Wearing sunglasses at inappropriate times Changes in sleep patterns (napping, insomnia)

Enmeshed

Blurred boundaries within the family. Many secrets and/or myths used as survival measure. They cut off communication with those outside the family system. Many authors and researchers describe the offspring of alcoholic parents as an at risk population. They tend to trust others to support them less due to parental messages that taught mistrust.

C.A.G.E. Evaluation for Alcoholism (Disease Model and Behavioral Assessment)

C- cutting down A- annoyance G- guilt E- eye opener

Acamprosate (Campral)

Calms the withdrawal effects of alcohol by restoring the balance to CNS glutamate (excitatory decreases) and GABA (inhibitory increases) neurotransmitters

MTPT

China white, analogue of Demerol, can cause rigidity of Parkinson's

Ascites

Fluid accumulation in the abdomen

Campral

Generally given as two 333 mg tablets tid

Ketamine

Highly available (animal tranquilizer), anesthetic

Epidemiology elicit drugs

In 2015, 20.8 million people aged 12 or older used an illicit drug in the past year

Other Health Risk Factors

In addition to the specific physiological responses to drugs of abuse, there exists the risk of HIV/AIDS transmission with those drugs utilized by needle and poor decision making related to sexual behaviors or safety (driving) when high.

Stimulants: . Cocaine

Increased motor activity with low doses Convulsions with high doses With very high doses, respiratory centers are affected - tachypnea Cardiac problem

Neurotransmitters - serotonin

Increased serotonin at 5-HT synapses results in decreased alcohol consumption, and some synapses may be involved in cocaine positive reinforcement.

Neurotransmitters - opioids

Involved in the reinforcement of opiates, alcohol and nicotine

Neurotransmitters - GABA

Major inhibitory neurotransmitter mediates the effects of sedative-hypnotic drugs such as alcohol and benzodiazepines.

Family Theory

Multigenerational transmission process - follow the incidence of the disease in the family Bowen, 1978 - children from these families become enmeshed in the family system. Partly learned; partly genetic vulnerability

Over the Lifespan

Neonatal & perinatal issues Fetal Alcohol Syndrome Children and adolescents Adults Senior Population

Substances of Abuse

Nicotine Caffeine Alcohol Cannabis- marijuana, hash, THC Stimulants Depressants Opioids Inhalants Hallucinogens Steroids Prescription Drugs Over the counter medications-antihistamines, cough syrups, sleeping pills Designer drugs

Peripheral neuropathy

Numbness in hands & feet, tingling

Naltrexone (Revia, Vivitrol)

Opioid antagonist - blocks the mu opiate receptor sites eliminating the drug or alcohol euphoria - reduces cravings

Physiologic Effects - Alcohol

Peripheral neuropathy Fatty liver Ascites Esophageal varices Pancreatitis Increased BP Other - sleep disturbance, nutritional problems

Signs of Adolescent Substance Abuse

Psychosocial Unexplained periods of moodiness, depression, anxiety, or irritability Decreased interaction and communication with family Change in friends, won't introduce new friends Decline in academic performance Loss of motivation and interest in school activities, previous hobbies, sports Disappearance of money or items of value

Psychological contributors to addiction

Regression Dependent personality Low self-esteem Lack of success Lack of meaningful relationships Depression Difficulty with intimacy An understanding of these can help with approach to therapy.

Senior Population - 4 factors that promote abuse issues

Retirement- boredom, role status changes Deaths- among relatives and friends Poor health- discomfort issues Loneliness- esp. among elderly women

Diagnostic Categories

Sedative-,Hypnotic-or Anxiolytic: Stimulant, Cannabis, Opiates, Hallucinogen, Inhalant

Fentanyl citrate

Sublimyl:100 times as potent as morphine and 20 to 40Xs heroin

Buprenorphine HCl/naloxone HCL

Suboxone - for outpatient opioid withdrawal - prescriber needs to be specially certified. It is also used in pain management.

T-A-C-E questions:

T - "How many drinks does it take to make you feel high?" - TWO or more = positive A - "Do you feel ANNOYED when someone criticizes your drinking?" C - "Do you wish to CUT down on your drinking?" E - "Do you ever take a morning drink (EYE opener) to feel better?"

Dependence

Term used for Addiction

Theories - cigarettes and alcohol use

There is no single explanation of substance abuse. Theories include genetic, behavioral, psychoanalytic, time-out anthropological, family & peers and transition from gateway drugs

Physiological dependence

Tolerance, withdrawal symptoms

Benzodiazepines (BZDs) - do not cause much CNS depression but are HIGHLY ADDICTIVE

Valium- Diazepam Ativan-(Lorazepam) Xanax-(Alprazolam)-especially addictive * Halcion and other sleep medications Rohypnol- GHB (Date rape drug) *Shorter acting/rapid onset more likely to be abused

Treatment Plan for Alcoholic

Withdrawal and Safety Issues Detox and Treatment 12 Step Program, Sponsor and Support Group Relapse Prevention Plan Individual, Group and Family Sessions Nutrition Social and Recreational Plan Address Work and Living Environment Treatment of Underlying or Co-morbid diagnoses Codependency Issues Medication Management Medical Problem Consultation e.g. Liver Pathology, Ulcers or Pancreatitis Online AA Recovery Resources

Psychological dependence

patterned need