Ch. 31 Addiction and Substance Related Disorders Flashcards
CAGE Questionnaire
Have you ever felt you should Cut down your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning (an “Eye-opener”) to steady your nerves or to get rid of a hangover?
Scoring: Two “yes” answers indicate probably alcohol abuse and warrant further assessment
Risky Substance Use Limits
For men up to age 65: more than 4 drinks/day and/or more than 14 drinks/week
For women and men who are over 65: more than 3 drinks in one day and/or more than 7 drinks/week
Prescription misuse and illicit drugs: Any Rx misuse or illicit drugs use at any age by men or women
Any tobacco use
Diagnostic Criteria
Substance-related disorders are disorders related to taking a drug of abuse, including alcohol, stimulants, cannabis (marijuana), hallucinogens, inhalants, tobacco, opioids, sedatives-hypnotics and anxiolytics, caffeine, other unknown substances
These disorders are further categorized as:
- Substance Use Disorder
- Substance Induced Disorder
There are 10 classes of drugs that are abused
All of the drugs of abuse cause direct activation of the reward centers of the brain
Gambling does also, so it was included in the DSM 5.
Substance Use Disorder has how many criteria? How many categories?
11 criteria grouped into 4 categories
Substance Use Disorder: A. Impaired Control
- Taking in larger amounts than intended.
- Unsuccessful attempts to cut down.
- Excessive time spent obtaining, using, and recovering the substance.
- Craving
Substance Use Disorder: B. Social Impairment
- Not meeting work, home, or school obligations
- Continued use despite persistent problems
- Withdrawing from important family, social, occupation, recreational activities to use
Substance Use Disorder: C. Risky Use
- Recurrent use in physically hazardous situations
9. Continued use despite recurrent physical or psychological problems
Substance Use Disorder: D. Pharmacological
- Tolerance - needing increasing amounts of a substance to produce desired effect
- Withdrawal - the adverse physical and psychological symptoms that occur when a person ceases using a substance
How many categories of Substance-Induced Disorders are there?
3
Substance-Induced Disorders: A. Substance Intoxication
behavioral/psychological changes due to recent ingestion of the substance
Substance-Induced Disorders: B. Substance Withdrawal
behavioral/cognitive/psychological changes due to cessation or reduction in use after heavy prolonged use
Substance-Induced Disorders: C. Substance Induced Mental Disorder
- Temporary examples - Methamphetamine induced psychotic disorder and Cocaine withdrawal induced depression
- Potentially permanent neurocognitive changes from alcohol, inhalants, and sedative-hypnotic anxiolytic drugs
Epidemiology
Over 50% of Americans over 12 years old drink alcohol
15 million are dependent on alcohol
16% of the population has alcoholism, 80% or more of the alcohol consumed in the United States is consumed by people w/ alcoholism
Rates of binge drinking and heavy alcohol use are highest among young adults ages 18 to 25 years
14 million Americans (6.3% of the population 12 years and older) are current illicit drug users
Marijuana is the most commonly used illicit drug (used by 76.4%)
New epidemic of heroin abuse (locally as well)
Nonmedical use of oxycodone
Cultural Issues
Alcohol is the drug most widely used by African American youth
African American youth use both licit and illicit substances at lower rates than do Caucasians, but experience more associated health and legal problems
Drug use is high among Mexican American and Puerto Rican adolescent boys
Mexican American men and Native Americans report the most frequent, heavy drinking and alcohol-related problems
Cuban Americans report the lowest percentage of problems
Use is lowest among Asian and Pacific Islanders
Men more than women
Etiology: Biologic Components
Genetic predisposition
Children of alcoholics (COA) are 3-4 times more likely to have alcohol/drug problems
Etiology: Psychological Components
Temperament (impulsivity)
Feelings about self
Mood
Inability to cope w/ feelings
Etiology: Social Components
Parental and family relationships
Family history can cause less sensitivity to effects of alcohol (high tolerance)
Environmental factors
Peer pressure
Alcohol
Intoxication is determined by blood alcohol level (0.08% in MO)
People who abuse alcohol can exhibit various patterns of use
Medical Complications of Alcohol Dependence: Cardiovascular System
Congestive heart failure, cardiomyopathy, and high BP
Medical Complications of Alcohol Dependence: Respiratory System
pneumonia and other infections
Medical Complications of Alcohol Dependence: Hematologic System
anemia, leukemia, hematoma
Medical Complications of Alcohol Dependence: Nervous System
paranoia, anxiety, depression, irritability, dementia, gait disturbances, sleep, and vision problems
Medical Complications of Alcohol Dependence: Nutritional Deficiencies
scurvy (vitamin C), Pellagra (vitamin B3, niacin), Cheilosis (B vitamins)
Medical Complications of Alcohol Dependence: Digestive
GI bleeding, esophageal varices and pancreatitis
jaundice, ascites, spider angioma, and liver cirrhosis
Medical Complications of Alcohol Dependence: Endocrine and Metabolic
gout, diabetes, neuropathies, hyperlipidemia
Medical Complications of Alcohol Dependence: Immune System
TB, STIs
Medical Complications of Alcohol Dependence: Integumentary System
abscesses
Medical Complications of Alcohol Dependence: Musculoskeletal
osteoporosis, myopathy (disease of muscle tissue)
Medical Complications of Alcohol Dependence: Genitourinary
incontinence, hypogonads, Hypokalemia (low K+), men and women develop secondary sex characteristics of the opposite sex
Medical Complications of Alcohol Dependence: Reproductive System
Fetal Alcohol Syndrome (FAS)
Wernicke’s Syndrome
Thiamine deficiency (B1):
- -Oculomotor dysfunctions (eyes), ataxia (unsteady gait), and confusion
- -Treat w/ Thiamine
Associated w/ chronic alcohol use/abuse
Korsakoff’s Syndrome
If Wernicke’s is not treated then Korsakoff’s psychosis occurs (alcohol amnestic disorder).
Symptoms are retrograde and anterograde amnesia, lack of insight, paucity of speech (won’t say much), confabulation (makes up answers), apathy (lack of interest in much anything).
Treat w/ Thiamine
Associated w/ chronic alcohol use/abuse
Biologic Responses to Alcohol
Tolerance (initial rapid metabolism increases)
Alcohol intoxication
Alcohol withdrawal syndrome
changes in vital signs, diaphoresis, and GI and CNS adverse effects
Delirium tremens - short term mental status changes - life threatening
Principles of Alcohol Detoxification (detox)
The long-acting benzodiazepines are the drugs of choice because they effectively reduce signs and symptoms of withdrawal, prevent seizures, and have a better margin of safety than other drugs
A symptom-triggering closed regimen is preferred over fixed-schedule closing because it is effective, requires less medication, and appears to prevent seizures as well as fixed schemes
The use of a withdrawal assessment tool is recommended for medication determinations b/c it reduces overmedication caused by patient over-reporting of symptoms or fixed regimes, and under-medication resulting from staff reluctance to treat
Pharmacologic Treatment of Alcohol Withdrawal
Benzodiazepines - Diazepam (Valium), Chlordiazepoxide (Librium)
- -Given for elevations in HR, BP, and temperature, and in the presence of tremors
- -When given early in withdrawal and in sufficient dosages, can prevent delirium tremens
Long-acting CNS depressants
–Produce sedation and reduce anxiety symptoms
Antipsychotic medications
Also give vitamins and folic acid (folate) for vitamin deficiencies, thiamine (vitamin B1), and magnesium sulfate to reduce seizures
Alcohol Withdrawal
Early Signs:
1-2 hours following cessation of the drug, peak after 24-48 hours, and then rapidly disappear unless the withdrawal progresses to delirium tremens (DT)
Delirium Tremens:
A medical emergency that usually occurs 2 to 5 days following alcohol withdrawal and persists 2 to 3 days
Alcohol Withdrawal Symptoms
- Tremor - mild to severe
- Tachycardia (fast HR)
- Hypertension (HTN)
- Sweating - mild to soaking the bed
- Nausea, vomiting
- Fever
- Agitation
- Confusion, out of contact w/ reality
- Sleeplessness
- Hallucinations (small animals and bugs on bed common)
- Convulsions (emergency situation)
Pharmacologic Treatment of Alcohol Use Disorder
Disulfiram (Antabuse)
- Use adjunctively for aversion therapy
- Disulfiram plus even small amounts of alcohol produces adverse effects
Naltrexone (Trexan)
-Can reduce cravings, can help maintain abstinence, and can interfere w/ wanting to drink more if a recovering patient relapses
Multivitamin, thiamine, folic acid (folate)
Cocaine
CNS stimulant
Produces a sudden burst of mental alertness and energy and feelings of self-confidence, being in control, and sociability
“Cocaine rush” lasts 10-20 minutes
High is followed by an intense let-down effect in which the person feels irritable, depressed, and tired, and craves more of the drug
Biologic Responses to Cocaine
Increase the release and blockage of the reuptake of neurotransmitter
Increases dopamine: euphoria and psychotic symptoms
Increase norepinephrine: tachycardia, HTN, dilated pupils, and rising body temperature
Increase serotonin: sleep disturbances, anorexia
Long-term use: depletion of dopamine
Cocaine Intoxication
CNS stimulation followed by depression
Increasing doses: restlessness —> tremors and agitation —> convulsions —> CNS depression
Death: respiratory failure
Cocaine Withdrawal
Norepinephrine depletion causes person to sleep 12-18 hours
Then, sleep disturbances w/ rebound REM, anergia (lack of physical activity/energy), decreased libido (sex drive), depression, suicidality, anhedonia (lack of enjoyment), poor concentration and cocaine craving may last for weeks
Respiratory depression can cause unconsciousness and intubation so a machine is breathing for the patient
Other Stimulants: Amphetamines
Block reuptake of norepinephrine and dopamine, not as strong effect on serotonin (as cocaine does)
Effects on PNS
Other Stimulants: Methamphetamine
Releases excess dopamine, the “rush” damages nerve terminals
Highly addictive - used in a “binge and crash” pattern
MO meth capital of the world - a woman lives an average of 10 years after addiction
5.2% of the population has tried meth
Other Stimulants: MDMA (Ecstasy)
Causes hallucinations, confusion, depression, sleep problems, drug cravings, severe anxiety, and paranoia
Other Stimulants: Nicotine
Addiction at least as strong as heroin or cocaine, 70% relapse w/in a year
Stimulates the CNS, PNS, and autonomic nervous systems, causing increased alertness, concentration, attention, and appetite suppression
Nicotine Withdrawal
Nicotine withdrawal is marked by mood changes (craving, anxiety, irritability, depression) and physiologic changes (difficulty in concentrating, sleep disturbances, headaches, gastric distress, and increased appetite)
Nicotine Treatment
Treated w/ replacements such as transdermal patches, nicotine gum, nasal spray, and inhalers, Varenicline (Chantix) is medication to help stop but does increase suicidal thoughts
Other Stimulants: Caffeine
Stimulates cerebral cortex and increase mental acuity
At a dose of 300 mg (a little over 3 cups) caffeine can cause tremors, poor motor performance, and insomnia
Doses exceeding 500 mg increase HR; stimulate respiratory, vasomotor, and vagal centers and cardiac muscles; dilate pulmonary and coronary blood vessels; and constrict blood flow to the cerebral vascular system
Caffeine Withdrawal
Withdrawal syndrome includes headache, drowsiness, and fatigue, sometimes w/ impaired psychomotor performance, difficulty concentrating, craving, and yawning or nausea
Cannabis (Marijuana)
Binds w/ an opioid receptor in the brain to block dopamine reuptake
Can be stored for weeks in fat tissue in the brain
Impairs the ability to form memories, recall events, and shift attention from one thing to another
Long-term marijuana use produces anti-motivational syndrome
Hallucinogens
More than 100 different hallucinogens:
- Psilocybin (mushroom)
- D-lysergic acid diethylamide (LSD)
- Mescaline
- Numerous amphetamine derivatives
Produce euphoria or dysphoria, altered body image, distorted or sharpened visual auditory perception, confusion, incoordination, and impaired judgement and memory
Benzodiazepines (substance abuse)
Cause CNS depression
Although benzodiazepines increase total sleep time, they decrease duration of REM sleep
Withdrawal symptoms may begin as long as 8 days after cessation depending on half-life
Benzodiazepines (substance abuse): Withdrawal Symptoms
Anxiety rebound
Autonomic rebound
Sensory excitement
Motor excitation
Cognitive excitation
Dissociative Anesthetics
Reduce (or block) signals to the conscious mind from other parts of the brain
Ketamine, PCP (angel dust)
Intoxication can last 4-6 hours
Interventions to reduce stimuli, maintain a safe environment for the patient and others, manage behavior, and observe for medical and psychiatric complications
Opiates and Morphine Derivatives
Codeine, fentanyl, heroin, morphine, oxycodone, and hydrocodone
Effects are pleasure (or reward) and pain relief
Physical dependence can develop rapidly
Withdrawal syndrome includes rebound hyper-excitability
Pharmacologic Treatment of Opiate Use Disorder: Suboxone
combination of Buprenorphrine and Naloxone - used for easier, safer opiate withdrawal and long term replacement therapy
Pharmacologic Treatment of Opiate Use Disorder: Suboxone: Buprenorphrine
semi-synthetic opioid - used to treat opioid addiction. It is a long term replacement therapy w/o so many side-effects
Pharmacologic Treatment of Opiate Use Disorder: Suboxone: Naloxone (Narcan)
given in emergency treatment of opiate intoxication - IV in 2 minutes reverses respiratory depression, sedation, and HTN
Pharmacologic Treatment of Opiate Use Disorder: Methadone
daily use, a substitute w/ less side effects
Pharmacologic Treatment of Opiate Use Disorder: Naltrexone (Revia-daily, Vivitrol-monthly injection)
blocks the euphoric effects of opioids, has little effect on opioid cravings (unlike alcohol)
Inhalants
CNS depression
Common household products - glue, aerosols, paint, dust-off
Cause euphoria, sedation, emotional lability, and impaired judgement
Intoxication can result in respiratory depression, stupor, and coma
Risk for sudden sniffing death
Chronic neurologic syndromes can result from long-term use
Steroids
Increase irritability and aggression
Behavioral effects include euphoria, increased energy, sexual arousal, mood swings, distractibility, forgetfulness, and confusion
Increased risk for heart attacks and strokes, blood clotting, cholesterol changes, HTN, depressed mood, fatigue, restlessness, loss of appetite, insomnia, reduced libido, muscle and joint pain, and severe liver problems
Reduced sperm production, shrinking of testes, and difficulty or pain in urinating
Breast enlargement in men and masculinization in women
Nursing Assessment
Denial of a problem
Motivation for change
Countertransference
Codependence
Nursing Diagnosis
Ineffective denial
Others based on type of substance
Goal Setting: Long Term goals
Total abstinence/reduced relapse, improved functioning
Goal Setting: Short Term goals
Attend AA 90 meetings in 90 days
Talk w/ sponsor daily
Written contract - patient to sign
ODAAT - one day at a time, stay away from substances
Nursing Interventions and Treatment Modalities
Pharmacologic modalities
12-step-program-focused groups
Cognitive or psycho-educational groups
Behavioral therapy
Group psychotherapy
Individual and family therapy
Discharge planning
Relapse therapy
12 Step Self Help Groups
AA (alcoholics anonymous)
–Dr. Bob Smith and Bill Wilson are AA founders
NA (narcotics anonymous)
Al-Anon/Ala-Teen- groups for families who have an addicted member
Overeaters anonymous
Gamblers anonymous
Therapeutic Interactions
- Encourage honest expression of feelings
- Listen to what the individual is really saying
- Express caring for the individual
- Hold the individual responsible for behavior
- Provide consequences for negative behavior that are fair and consistent
- Talk about specific actions that are objectionable
- 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
Nursing Interventions and Treatment Modalities: Brief Interventions
Advising how to reduce client’s drug use
Providing self-help manuals that are relevant to the client
Giving the client information about:
- The consequences of drug conviction on travel and employment
- The consequences of further or heavier drug charges
Offering and arranging a follow-up visit
Nursing Interventions and Treatment Modalities: Brief Interventions - Discussing harm reduction strategies, especially those relating to:
Overdose
Violence
Driving under the influence
Safe practices (e.g. safe injecting, safe sex)
Nursing Interventions and Treatment Modalities: Brief Interventions - Relapse Prevention could mean things like?
- Avoiding people who encourage use of substances
- Avoiding bars or substance abuse hangouts
- ->Driving a different way home if needed
- Finding recreation that they enjoy
- Joining groups that do not use
- Making new friends
- Repairing relationships
- New employment, job training
- Moving out the apartment shared w/ other addicts
Nursing Interventions and Treatment Modalities: Brief Interventions - Therapies
Cognitive and cognitive behavioral interventions and psycho-education
Enhancing coping therapies
Group therapy
Individual therapy
Family therapy
12-step programs
Multifamily groups
Decisional Balance Worksheet: Old Behavior
Pros/Benefits:
- Like taste of alcohol
- Helps me to relax
Cons/Costs:
- Costs a lot of money
- Led to DWI - costly, embarrassing, and inconvenient
Decisional Balance Worksheet: New Behavior
Pros/Benefits:
- Better relationship w/ spouse
- No more DWIs
Cons/Costs:
- Will miss my drinking friends
- Don’t know how to have fun w/o it
Substance Use Disorder and Professional Nurses
Estimated prevalence of chemical dependency for nursing professionals of approximately 10-15%
Nursing licenses can be suspended as a result of addictions
Some states have mandatory reporting laws
Any nurse who knows of any health care provider’s incompetent, unethical, or illegal practice must report that information through proper channels
Peer assistance programs
Impaired nurses may wear long sleeves to hide tracks (from drug use)
Signs of Substance Use Disorder in Nurses (Be able to know some of them, this is a long list)
- Mood swings
- Inappropriate behavior at work
- Frequent days off
- Noncompliance w/ acceptable policies and procedures
- Deteriorating appearance
- Deteriorating job performance
- Sloppy, illegible charting
- Errors in charting
- Alcohol on breath
- Forgetfulness
- Poor judgment and concentration
- Lying
- Volunteering to be the med nurse
- High achievement, both as a student and a nurse
- Volunteering for overtime and extra duties
- No drug use until prescribed following surgery or a chronic illness
- Family history of alcoholism or addiction
Cocaine affects what 2 organs?
Brain
Heart
What is Eosinophilia?
Increased WBCs
Indicates possible infection or inflammation
Occurs w/ chronic cocaine use
List some long term effects of Cannabis.
- several types of cancer
- birth defects if used during pregnancy
- circulatory system problems
- lack of motivation
- short term memory loss
- panic attacks
- exacerbations of schizophrenia and psychosis
List side effects of Oxycodone.
CNS:
- hallucination
- fainting
- dizziness
- confusion
Skin:
- hives
- rash
Respiratory:
- difficulty breathing
- slowed breathing
Face/Eyes:
-swelling
Throat:
- hoarseness
- swelling
- difficulty swallowing
Heart:
-fast/slow heartbeat
Muscular:
-seizures
What are the long term effects of heroin?
- neurochemical/molecular changes in the brain
- profound degrees of tolerance/physical dependence –> abuse
What are the side effects of codeine?
Very constipating - given for pain relief after surgery frequently. Constipation can be very painful for patient if that happens, and it’s preventable.
