Mental Health: Chapter 19: Addiction

Treats nutritional deficiencies:

- Folic acid (folate) - Teach the client about proper nutrition; the urine may be dark yellow. - Cyanocobalamin (vitamin B12) - Teach the client about proper nutrition.

A client is experiencing severe alcohol withdrawal. Which would the nurse most likely assess? Select all that apply.

- Marked diaphoresis! - Auditory hallucinations! - Gross uncontrollable tremors!

A client is brought to the emergency department after having overdosed on cocaine. When assessing the client, which would a nurse expect to find? Select all that apply.

- Seizures - Cardiac arrhythmias

In a person who abuses alcohol or is a chronic drinker, alcohol withdrawal syndrome usually begins within which time frame from abrupt discontinuation or an attempt to decrease consumption?

12 hours! - Page#359

Substance Intoxication:

A group of substance-induced disorders, and symptoms that people experience when they are "high" from drugs.

CNS Depressants Includes:

Alcohol, Inhalants, Sedatives, Hypnotics, Opioids.

Sedatives - CNS Depressants - Benzodiazepines:

Alprazolam (Xanax) Chlordiazepoxide (Librium) Diazepam (Valium) Clonazepam (Klonopin) Midazolam (Versed)

Which medication is used to prevent alcohol withdrawal symptoms?

Answer: Lorazepam (Ativan)! - Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms. Withdrawal can be accomplished by fixed-schedule dosing known as tapering or symptom-triggered dosing in which the presence and severity of withdrawal symptoms determine the amount of medication needed and the frequency of administration. - Page# 359

Alcohol Acute Withdrawal:

Appears within 4-12 hours of cessation or reduction in drinking Tongue, hands, eyelids coarse tremor Nausea or vomiting, malaise or weakness Elevated BP, tachycardia, diaphoresis Headache & SPIN Anxiety, depression or irritability, Seizures.

Chapter 19: Addiction - General Appearance and Motor Behavior:

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

A client is experiencing alcohol withdrawal symptoms. Which of the following would the nurse expect to be prescribed to assist with the withdrawal symptoms, acting as a substitute for the alcohol?

Benzodiazepines! Examples: - Lorazepam (Ativan) = Alcohol Withdraw Nursing Considerations: Monitor vital signs and global assessments for effectiveness; this may cause dizziness or drowsiness. - Chlordiazepoxide (Librium)= Alcohol Withdraw Nursing Considerations: Monitor vital signs and global assessments for effectiveness; this may cause dizziness or drowsiness. - Diazepam (Valium) = Alcohol Withdraw SideNotes: These medications can be administered on a fixed schedule around the clock during withdrawal. Giving these medications on an as-needed basis according to symptom parameters, however, is just as effective and results in a speedier withdrawal. Barbiturates can be used for benzodiazepine-resistant cases of alcohol withdrawal

While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?

CIWA-Ar!

A client admitted for acute alcohol intoxication begins to experience mild sweating, tachycardia, fever, and nausea and vomiting. Of the following, the drug treatment of choice would be what?

Chlordiazepoxide!

Chapter 19: Addiction - Judgment and Insight:

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

Chapter 19: Addiction - Sensorium and Intellectual Processes:

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

Chapter 19: Addiction - Self-Concept:

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

Chapter 19: Addiction - Roles and Relationships:

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

Ethyl alcohol - C2H5OH _________ ____ _________ B/C it is flavored has calories with no nutritional value

Considered a food!

A client with chronic alcoholism has been found to have Wernicke encephalopathy. This irreversible complication is characterized by what?

Thiamine, or vitamin B1, deficiency! is a neurological disease characterized by three main clinical symptoms: confusion, the inability to coordinate voluntary movement (ataxia) and eye (ocular) abnormalities. Symptoms includes: CNS symptoms, such as ataxia and peripheral neuropathy.

Alcohol Assessment Tools CAGE -

Cut, Annoyed, Guilt, Eye Opener ‌ Have you ever felt you should "cut" down on your substance use? Have people "annoyed" you by criticizing your substance use? Have you felt bad or "guilty" about your substance use? Have you ever used a substance first thing in the morning to steady your nerves or start the day (an "eye" opener)?

Alcohol Assessment Tools CAGE-AID:

Cut, Annoyed, Guilty, Eye Opener - Adapted to include Drugs C: Have you ever felt that you ought to Cut down on your drinking or drug use? A: Have people Annoyed you by criticizing your drinking or drug use? G: Have you ever felt bad or Guilty about your drinking or drug use? E: Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

Alcohol intoxication Signs and Symptoms: (Ethyl alcohol - C2H5OH)

Disinhibition of sexual, aggressive impulse, labile behavior Impaired judgment, slurred speech, incoordination, unsteady gait, Nystagmus (eye movement) Flushed face. Impaired social occupational functioning BAL (Blood Alcohol Level) 100- 200mg/dl, BAL (Blood Alcohol Level) of 0.08 percent is illegal in most states Death reported at 400 to 700mg/dl.

The ingestion of mood-altering substances stimulates which neurotransmitter pathway in the limbic system to produce a "high" that is a pleasant experience?

Dopamine!

Chapter 19: Addiction - Thought Process and Content:

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

Binging:

Excessive intake

Hallucinogens Intoxication:

Generally has distorted perception of reality, altered sensory, perception & hallucinations (psychedelic properties) usually visual & depersonalization Bad Trips" as panic & fear of dying or going insane Flashbacks months after use Tolerance to recurrent use develops quickly Psychological addiction Produced from plants or synthetics Does not lead to physical addiction or withdrawal Sx

Clinical Institute Withdrawal Assessment Scale - Benzodiazepines

Guide to the Use of the Clinical Withdrawal Assessment Scale for Benzodiazepines Total Score Items 1 - 20 1-20 = mild withdrawal 41-60 = severe withdrawal 21-40 =moderate withdrawal 61-80 = very severe withdrawal.

Ecstasy is an example of which type of substance?

Hallucinogen!

Adaptation:

If a repetitive stimulus persists, the neurons will permanently restrict a sufficient number of their own receptors to permit functioning of the organism in the presence of the stimulus; this is called ___________________. In evolutionary terms, ___________________ began as a survival mechanism allowing the organism to establish a new equilibrium in the presence of an unceasing, long-term stimulus. Once adaptation to a repetitive stimulus occurs, the stimulus must be increased to overcome the adaptation for there to be perception of the same stimulus. A user of cocaine who has adapted to a particular dose, for example, will no longer perceive a high on the same dose; therefore the dose of cocaine must be increased to get high.

Stimulant Use Disorder- CNS Stimulants

Illegals: Club Drugs: GHB (Rohypnol) Date Rape drug, Ketamine, Ecstasy, MDMA/Molly, LSD Stimulant Effects/intoxication Signs and Symptoms Tremors, restlessness, anorexia, increased motor activity, SPIN, increase alertness Cardiovascular: tachy- bradycardia, cardiac arrhythmias, vasoconstriction can cause MI, Vfib, confusion, seizure, coma, sudden death GI Upset and difficult urination, Elevated Temp & Weight Loss Maladaptive behaviors and psychological changes, euphoria, blunt affect, hypervigilance, anxiety, tension, anger, impaired judgement Serious- psychosis, violence aggression, memory loss, pupil dilation, diaphoresis. Stimulant Withdrawal Signs and Symptoms Develops in a few hours after cessation or reduction "Crashing" syndrome: fatigue, cramps, depression, headaches, and nightmares Euphoria to Dysphoria - increases the risk of suicide Peak Withdrawal- is in 2-4 days of abstinence, Sx may begin wi 24 hrs with S&S of headache fatigue, drowsiness, dysphoric mood, irritability, difficulty concentration, flu-like symptoms, N/V, muscle pain & stiffness.

Tolerance:

In turn, the brain neurochemically adapts to the increasing doses of cocaine in an addictive cycle known as __________________. - That is, habituation and adaptation cause tolerance.

Inhalants Intoxication and Overdose:

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

Opioids - Withdrawal and Detoxification

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

Stimulants Intoxication and Overdose:

Intoxication from stimulants develops rapidly; effects include the high or euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic or repetitive behavior, anger, fighting, and impaired judgment. Physiological effects include tachycardia, elevated blood pressure, dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmias. Overdoses of stimulants can result in seizures

Alcohol Delirium:

It appears 2-3 days after cessation or reduced heavy intake Difficult concentration, thinking (rambling, pressured, incoherent) Impaired reasoning and goal direction Disorientation, recent memory impairment Misperception of the environment Illusions and hallucinations SPIN Vivid dreams and nightmares Hypervigilance Restlessness, hyper, agitation, stupor/coma, or vegetative state. (When a person is awake but is showing no signs of awareness.)

An older adult client with liver disease is experiencing alcohol withdrawal. Based on the nurse's understanding of drug therapy, which of the following would the nurse expect to be prescribed?

Lorazepam!

Chapter 19: Addiction - Physiological Considerations:

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

Disulfiram (Antabuse): - Maintains abstinence from alcohol - "It can help to prevent you from drinking."

May be prescribed to help deter clients from drinking. If a client taking disulfiram drinks alcohol, a severe adverse reaction occurs with flushing, a throbbing headache, sweating, nausea, and vomiting. In severe cases, severe hypotension, confusion, coma, and even death may result (see Chapter 2). The client must also avoid a wide variety of products that contain alcohol, such as cough syrup, lotions, mouthwash, perfume, aftershave, vinegar, and vanilla, and other extracts. The client must read product labels carefully because any product containing alcohol can produce symptoms. Ingestion of alcohol may cause unpleasant symptoms for 1 to 2 weeks after the last dose of disulfiram. - Nursing Considerations: Teach the client to read labels to avoid products with alcohol. - Severe reaction if consuming alcohol products patient should be detoxed 1st Page#366

CNS Stimulants includes:

Methamphetamines Stimulants (amphetamine-type, cocaine, and other) Caffeine, Tobacco

12-step program:

Model for recovery (Box 19.3), which is based on the philosophy that total abstinence is essential and that alcoholics need the help and support of others to maintain sobriety. Key slogans reflect the ideas in the 12 steps, such as "one day at a time" (approach sobriety one day at a time), "easy does it" (don't get frenzied about daily life and problems), and "let go and let God" (turn your life over to a higher power). People who are early in recovery are encouraged to have a sponsor to help them progress through the 12 steps of AA. Once sober, a member can be a sponsor for another person.

A client is admitted to the detoxification unit on Sunday evening. The client discloses that the client's last alcoholic drink was just before the client was admitted to the unit. When can the nurse expect that the client's alcohol withdrawal symptoms will begin?

Monday morning! - Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. - Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however; and withdrawal may take 1 to 2 weeks.

Sedatives, Hypnotics, and Anxiolytics: - Intoxication and Overdose

This class of drugs includes all central nervous system depressants: barbiturates, nonbarbiturate hypnotics, and anxiolytics, particularly benzodiazepines. Benzodiazepines and barbiturates are the most frequently abused drugs in this category. The intensity of the effect depends on the particular drug. The effects of the drugs, symptoms of intoxication, and withdrawal symptoms are similar to those of alcohol. In the usual prescribed doses, these drugs cause drowsiness and reduce anxiety, which is the intended purpose. Intoxication symptoms include slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, and even stupor and coma.

Safety is the nursing priority for a client who is at risk for alcohol withdrawal. A care plan for the client who is in withdrawal must include which nursing interventions?

Observation for symptoms, vital signs, seizure and fall precautions, medications as ordered.

Substance Withdrawal

Occurs upon abrupt discontinuation of substance, which causes significant physical and psychological signs & symptoms are present.

Opioids - Intoxication and Overdose:

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

Dynamics of Substance- Effects of alcohol on the body: Slide 10 The nurse is performing a history and physical examination on a client with chronic alcoholism. The client has a history of gastritis, esophagitis, elevated liver enzymes, cardiomyopathy, and pancreatitis. Which of these conditions are attributable to the client's history of alcohol abuse?

Peripheral Neuropathy Myopathy Cardiomyopathy ltis - pancreatitis, - esophagitis, - gastritis Answer: All the conditions are attributable to alcohol abuse! SideNote: - "Any type of serious liver disease can cause esophageal varices. - Cirrhosis is the most common type of liver disease. - More than 90% of these patients will develop esophageal varices sometimes in their lifetime, and about 30% will bleed" Cleveland Clinic.

Non-Substance Addictions Gambling Disorder:

Persistent and recurrent problematic gambling Behavior that intensifies when the individual is under stress. As the need to gamble increases, the individual may use any means required to obtain money to continue the addiction. Medications for Gambling Disorder SSRIs, TCA, Lithium Carbonate, Clomipramine (Anafranil) Anticonvulsants, i.e. Tegretol, Carbatrol, Equetro Narcotic Antagonist Naltrexone (Revia, Vivitrol) Addictive personality Rx

Dynamics of Substance- Effects of alcohol on the body Wernicke-Korsakoff syndrome:

Portal Hypertension Varices Sexual Dysfunction

Which term is used to describe the amount of the drug needed to achieve the maximum effect?

Potency!

Thiamine (vitamin B1):

Prevents or treats Wernicke-Korsakoff syndrome in alcoholism. - Teach the client about proper nutrition. - Page#366

Opioids Effects/intoxication Signs and Symptoms: - Severe Intoxication

Pupillary constriction (Dilation dt anoxia in overdose) Respiratory depression, coma, and death

ASSESSMENT CONSISTS OF THREE MAJOR COMPONENTS:

Screening — a healthcare professional assesses a patient for risky substance use behaviors using standardized screening tools. Screening can occur in any healthcare setting Brief Intervention — a healthcare professional engages a patient showing risky substance use behaviors in a short conversation, providing feedback and advice Referral to Treatment — a healthcare professional provides a referral to brief therapy or additional treatment to patients who screen in need of additional services

Sedatives - CNS Depressants - Barbiturates

Secobarbital (Seconal) Nembutal Sodium (Pentobarbital or Luminol)

CNS Depressants: Sedative, Hypnotics, Anxiolytics: Benzos, Inhalants:

Signs and Symptoms Intoxication - Respiratory depression, cardiac, renal, and hepatic effects Slurred speech, SPIN, Body temperature deregulation (TDR) incoordination- unsteady gait, nystagmus, poor attention or memory changes, stupor or coma Maladaptive Behavior with psychological changes: inappropriate/dysfunctional sexual or aggressive behavior, lability, impaired judgement or social occupational functioning impaired. Withdrawal after reduction or cessation Onset depends on the drugs being used May begin wi 12 to 24 hours & Peaks at 24 to 72 hours Severe Symptoms (after high dosage/use): Autonomic hyperactivity (diaphoresis, Tachycardia) Hand tremors, SPIN, N&V, hallucinations, illusions Psychomotor agitation, anxiety, and grand mal seizures

Opioids Effects/intoxication Signs and Symptoms - Withdrawal:

Starts within 24 hrs and peaks in 2-4 days of abstinence (may vary) S&S: headache, fatigue, drowsiness, dysphoric mood, irritable, difficult concentration, flu like symptoms, N/V, diarrhea muscle pain & stiffness lacrimation or rhinorrhea, pupillary dilation, yawning, SPIN

Acamprosate (Campral):

Suppress alcohol cravings! maybe prescribed for clients recovering from alcohol abuse or dependence to help reduce cravings for alcohol and decrease the physical and emotional discomfort that occurs especially in the first few months of recovery. These include sweating, anxiety, and sleep disturbances. The dosage is two tablets, 333 mg each, three times a day. Individuals with renal impairment cannot take this drug. Side effects are reported as mild and include diarrhea, nausea, flatulence, and pruritis. Acamprosate is often thought to be more effective with "relief cravers," while naltrexone Nursing Considerations: Monitor for diarrhea, vomiting, flatulence, and pruritis

Alcohol Withdrawal and Detoxification: A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, the pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions are occurring?

Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse, and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called DELIRIUM TREMENS. Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however; and withdrawal may take 1 to 2 weeks. ANSWER: Delirium tremens! - Page#359

Cannabis Use Disorder:

THC Cannabis Sativa -Psychoactive substance Marijuana, Hash/Hashish, K2 Spice Classification- controlled substance not narcotic, not hallucinogen (but causes hallucinations) Not hypnotic or Sedative but act alike. Creates psychological addiction, tolerance Intoxication Cardiovascular- Tachycardia & orthostatic hypotension Respiratory- More tar than Tobacco when smoked will deteriorate the lungs. Initially, bronchodilatation then turns into COPD Laryngitis, bronchitis, cough hoarseness. Contains More carcinogen than tobacco- the risk of cancer Reproductive- Lowers sperm count & suppresses ovulation, disrupts menstruation and hormones CNS- feelings of being "HI or Drunk" Euphoria, disorientation, depersonalization and relaxation, altered sensory perception. Toxic- Panic attacks Long-term- a motivational SX Withdrawal Irritability, anger and aggression, Nervousness, SPIN, Decreased appetite weight loss Depressed mood, Physical- abdominal pain, tremors, fever, chills, or headache.

CLINICAL INSTITUTE NARCOTIC ASSESSMENT (CINA) SCALE FOR WITHDRAWAL SYMPTOMS

The Clinical Institute Narcotic Assessment (CINA) Scale measures 11 signs and symptoms commonly seen in patients during narcotic withdrawal. This can help to gauge the severity of the symptoms and to monitor changes in the clinical status over time.

Clinical Opiate Withdrawal Scale (COWS)

The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale designed to be administered by a clinician. This tool can be used in inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. The summed score for the full scale can be used to help clinicians determine the stage or severity of opiate withdrawal and assess the level of physical dependence on opioids. Practitioners sometimes express concern about the objectivity of the items in the COWS; however, the symptoms of opioid withdrawal have been likened to severe influenza infection (e.g., nausea, vomiting, sweating, joint aches, agitation, tremor). Patients should not exceed the lowest score in most categories without exhibiting some observable sign or symptom of withdrawal. Score: 5-1 2 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal

Alcohol Assessment Tools MAST- Michigan Alcoholism Screening Test

The MAST screening tool is a 25-question test that is used to help identify an alcohol dependency. MAST stands for The Michigan Alcohol Screening Test. There are also shortened, and modified versions published over time including the Brief MAST, SMAST, and Mm-MAST.

Dual Diagnosis:

The client with both substance abuse and another psychiatric illness. Page#368

Sedatives, Hypnotics, and Anxiolytics: - Withdrawal and Detoxification

The onset of withdrawal symptoms depends on the half-life of the drug (see Chapter 2). Medications such as lorazepam, with actions that typically last about 10 hours, produce withdrawal symptoms in 6 to 8 hours; longer acting medications, such as diazepam, may not produce withdrawal symptoms for 1 week. The withdrawal syndrome is characterized by symptoms that are the opposite of the acute effects of the drug—autonomic hyperactivity (increased pulse, blood pressure, respirations, and temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitation. Seizures and hallucinations occur only rarely in severe benzodiazepine withdrawal. Detoxification from sedatives, hypnotics, and anxiolytics is often medically managed by tapering the amount of the drug the client receives over a period of days or weeks, depending on the drug and the amount the client had been using.

Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-AR):

The protocol used is based on an assessment tool such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, shown in Box 19.2. Total scores less than 8 indicate mild withdrawal. Scores from 8 to 15 indicate moderate withdrawal (marked arousal). Scores greater than 15 indicate severe withdrawal. Clients on symptom-triggered dosing receive medication based on scores of this scale alone, while clients on fixed-dose tapers can also receive additional doses depending on the level of scores from this scale. Both methods of medicating clients are safe and effective.

When a person can ingest an increasing amount of alcohol before he or she experiences a "high" and begins to show effects on cognitive and motor skills, it is termed which of the following?

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

Craving:

Unable to abstain

Methadone: (Dolophine) - a potent synthetic opiate (opioid analgesics) Agonist

Used as a substitute for heroin in some maintenance programs. The client takes 1 daily dose of methadone which meets the physical need for opiates but does not produce cravings for more. - It does not produce the high associated with heroin. - Maintains abstinence from heroin. - May cause Nausea and Vomiting. - It is a legal medication. - It is controlled by a health care provider. - It is available in tablet form.

Sedatives, Hypnotics, and Anxiolytics: - Benzodiazepines:

When taken orally in overdose, are rarely fatal, but the person is lethargic and confused. Treatment includes gastric lavage followed by ingestion of activated charcoal and a saline cathartic; dialysis can be used if symptoms are severe. The client's confusion and lethargy improve as the drug is excreted.

Tolerance Break:

Which means that very small amounts of alcohol intoxicate the person.

Chapter 19: Addiction - Mood and Affect:

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

Stimulants Withdrawal and Detoxification

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

Sedatives - CNS Depressants - Hypnotics- non Benzo

Zaleplon (Sonata) Zolpidem (Ambien) (Eszopiclone) Lunesta Choral hydrate "knockout drops" or "Mickey Finn

Habituation:

_________________ begins when neurons that receive a repetitive stimulus chemically inhibit their own receptors to restrict the stimulus. __________________ permits the organism to tolerate primal suffering such as hunger pain during a famine, but habituation also facilitates higher order functioning. For example, as a result of habituation, city dwellers are able to sleep in the presence of city sounds such as traffic noise or sirens.

Ondansetron (Zofran):

a 5-HT3 antagonist that blocks the vagal stimulation effects of serotonin in the small intestine, is used as an antiemetic. It has been used in young males at high risk for alcohol dependence or with early-onset alcohol dependence. It is being studied for the treatment of methamphetamine addiction.

Alcohol Intoxication:

a central nervous system depressant that is absorbed rapidly into the bloodstream. Initially, the effects are relaxation and loss of inhibitions. With intoxication, there is slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judgment. Some people become aggressive or display inappropriate sexual behavior when intoxicated. The person who is intoxicated may experience a blackout.

Inhalants:

are a diverse group of drugs that include anesthetics, nitrates, and organic solvents that are inhaled for their effects. The most common substances in this category are aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint.

Stimulants:

are drugs that stimulate or excite the central nervous system and have limited clinical use (with the exception of stimulates used to treat attention-deficit/hyperactivity disorder) and a high potential for abuse. - Amphetamines( (upper): were used by people who wanted to lose weight. - Cocaine: an illegal drug with virtually no clinical use in medicine, is a highly addictive and popular recreational drug because of the intense and immediate feeling of euphoria. - Methamphetamine is particularly dangerous. It is highly addictive and causes psychotic behavior. Brain damage related to its use is frequent, primarily as a result of the substances used to make it—that is, liquid agricultural fertilizer.

Opioids:

are popular drugs of abuse because they desensitize the user to both physiological and psychological pain and induce a sense of euphoria and well-being. Opioid compounds include both potent prescription analgesics such as morphine, meperidine (Demerol), codeine, hydromorphone, oxycodone, methadone, oxymorphone, hydrocodone, and propoxyphene as well as illegal substances such as heroin, illicitly produced fentanyl, and normethadone.

Hallucinogens -

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

Opioids Effects/intoxication Signs and Symptoms: - GI/GU

diminished peristalsis leads to constipation Cardiovascular- Used to Tx MI pain & relieve pulmonary edema. Hypotension, Sexual dysfunction

Opioids Effects/intoxication Signs and Symptoms: - CNS

euphoria to dysphoria (apathy) mood changes mental clouding drowsiness & pain reduction, antitussive effect, N/V Psychomotor retardation, Impaired judgment.

Sedatives, Hypnotics, and Anxiolytics: Barbiturates:

in contrast, can be lethal when taken in overdose. They can cause coma, respiratory arrest, cardiac failure, and death. Treatment in an intensive care unit is required using lavage or dialysis to remove the drug from the system and to support respiratory and cardiovascular function.

Buprenorphine/naloxone (Suboxone)

is a combination drug used for opiate maintenance and to decrease opiate cravings. Buprenorphine is a semisynthetic opioid, and naloxone is an opioid inverse agonist. The client takes 1 daily sublingual dose. Medication ingestion is supervised, at least initially, because Suboxone has the potential for abuse and diversion. Clients can be tapered from this medication after treatment and with adequate psychosocial support. Some clients may remain on a maintenance dose for an extended time. Maintains abstinence from opiates and decreases opiate cravings. - Nursing Considerations: May cause orthostatic hypotension, and sedation; avoid CNS depressants

Levomethadyl (Orlaam):

is a narcotic analgesic with the only purpose of treating opiate dependence. It is used in the same manner as methadone. - Maintains abstinence from opiates - Nursing Considerations: Do not take drugs on consecutive days; take-home doses are not permitted

Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD)

is a useful screening device to detect hazardous drinking patterns as well as full-blown substance use disorders. This tool (Box 19.4) promotes recognition of problem drinking or drug use. Early detection and treatment are associated with more positive outcomes, so increased use of this or a similar screening device is encouraged.

Clonidine (Catapres):

is an alpha-2-adrenergic agonist used to treat hypertension. It is given to clients with opiate dependence to suppress some effects of withdrawal or abstinence. It is most effective against nausea, vomiting, and DIARRHEA, but produces modest relief from muscle aches, anxiety, and restlessness Suppresses opiate withdrawal symptoms - Nursing Considerations: Take blood pressure before each dose; withhold if the client is hypotensive.

Nalmefene:

is an opioid receptor antagonist marketed as Revex and is used in the United States to combat opioid overdose. In Europe, it has been approved in oral tablet form to diminish alcohol and opioid cravings. It has not been approved for this use by the FDA.

Naltrexone (ReVia, Trexan): Narcotic antagonist- naltrexone (Revia or Vivitrol ) blocks effects of opiates and decreases cravings neurotransmitter effect - regulates dopamine

is an opioid receptor antagonist often used to treat overdose. It blocks the effects of any opioids that might be ingested, thereby negating the effects of using, more opioids. It has also been found to reduce the cravings for alcohol in abstinent clients. Extended-release naltrexone has been effective in the reduction of cravings during treatment and at 30- and 60-day intervals post-treatment Blocks the effects of opiates; reduces alcohol cravings. - Nursing Considerations: The client may not respond to narcotics used to treat cough, diarrhea, or pain; take with food or milk; may cause headache, restlessness, or irritability.

Tapering:

or administering decreasing doses of a medication, is essential with barbiturates to prevent coma and death that occur if the drug is stopped abruptly. For example, when tapering the dosage of a benzodiazepine, the client may be given Valium, 10 mg four times a day; the dose is decreased every 3 days, and the number of times a day the dose is given is also decreased until the client safely withdraws from the drug.

An overdose, or excessive alcohol intake in a short period, can result in

vomiting, unconsciousness, and respiratory depression. - This combination can cause aspiration pneumonia or pulmonary obstruction. - Alcohol-induced hypotension can lead to cardiovascular shock and death. Treatment of an alcohol overdose is similar to that for any central nervous system depressant—gastric lavage or dialysis to remove the drug, and support respiratory and cardiovascular functioning in an intensive care unit. Page#359