Chapter 19 Substance-Related and Addictive Disorders

Question 1

Compulsive behavior (finding and taking the substance)
Cravings
Chronic, relapsing brain disorder - more of a brain disorder than defect in personality
Cognitive impairment

Answer 1

The 4 C’s of addiction: The DSM-5 basis for a substance use disorder

Question 2

Variety defns
End stage disorder continuum
Addiction: loss of control with related pxs.
According to DSM 5: when drinking leads to interpersonal, psychological, occupational, or legal pxs. - concern is if causing probs in personal/work/school life
WART: With alcohol repeated trouble

Answer 2

An alcoholic is…

Question 3

Habitual use falls outside medical necessity - not using for medical reason
Use falls outside social acceptance
Use is for single purpose of altering mood, emotion, or consciousness

Answer 3

Substance abuse

Question 4

Chronic relapsing brain disease
Compulsive drug seeking motivated by cravings
Compulsion occurs despite harmful consequences
Results in long-lasting brain changes

Answer 4

Substance addiction

Question 5

High Incidence in Native Americans (3X’s the national average - higher percentage)
Low Incidence in Asians: tend to have a physical rx. (flushing, palpitations, h/a) Research indicates an isoenzyme quickly converts alcohol to acetaldehyde along with an absence of an isoenzyme to oxidize acetaldehyde. Result: rapid accumulation of acetaldehyde that produces sxs.
Fams drinking norm and expected - not mean alcoholics; consider these as doing assessments

Answer 5

Cultural considerations

Question 6

Personality traits: - probs with alcoholism/substance abuse issue

Answer 6

Common traits

Question 7

Dominant and critical personality
Personal insecurity and low self-esteem
Rebellious towards authority
Difficulty with intimate relationships
Utilization of denial, rationalization, projection - defense mechanism

Answer 7

Personality traits: - probs with alcoholism/substance abuse issue

Question 8

Dopamine (big neurotransmitter looking at) regulates pleasure and pain and plays a major role in all addictions - COCAINE - high and low quickly: cycle: unable to regenerate reward center to keep pleasure to keep high
Drugs of abuse affect the limbic (reward) system.
First-time use releases a large amount of dopamine - want get feeling of high release of dopamine
Intense pleasure results
Neurons are unable to regulate dopamine
Dopamine is unable to stimulate the reward center.
More of a drug is used to increase dopamine levels
Cycle of tolerance begins
Dependence and addiction occurs

Answer 8

The neurobiological process that occurs in the brain when a chemical substance of abuse enters the body - brain central

Question 9

Up - walking around
Not remember it
Functioning and doing things but not remember it

Answer 9

Blacking out

Question 10

Out and unconscious
Down on ground
On couch and everybody walking around you

Answer 10

Passing out

Question 11

biological need–if not supplied may see withdrawal
Not have it see some withdrawal; feel in body

Answer 11

Physical dependency

Question 12

Craving for the substance accompanied/increased by anxiety, perceived necessary to maintain optimal state of well being; function at best
Crave substance - have anxiety and feel like need it; much more social when have drinks; feel better if have it

Answer 12

Psychological dependency

Question 13

increased need for more drug to get same effect or more frequent use - keep dopamine level up
Need more drug of choice to get same effect

Answer 13

Tolerance: dependency

Question 14

See people with serious mental illness are dependent or addicted to illicit drug
Suicide risk 3-4 X’s higher; also see anxiety and depresision
Require longer tx., have more crisis and respond slowly to tx.
Alcohol
Nicotine:
Lot goes on that Impacts indiv and people around them

Answer 14

Dual dx: substance abuse and another psychiatric disorder

Question 15

Some difficulty
Increased tolerance - need more to have same effect
Occasional or partial memory lapses - black out - need some help and look at use
Drinking beyond one’s intentions
Sneaking drinks - hiding drinks
Preoccupation with alcohol - always thinking about it
Resentment when drinking discussed - defense mechanisms
Futile wagon attempts - fall off wagon
Rationalize loss of control
Other Indicators: Divorce, DWI, Financial pxs.

Answer 15

I would be headed towards alcoholism if…

Question 16

Intoxication: Only drug for which objective measures of intoxication exist
Alcohol Withdrawal
Alcohol Withdrawal Delirium (DTs)

Answer 16

Clin picture: alcohol

Question 17

Blood alcohol level (BAL): determines level of intoxication and tolerance; objective measure

Answer 17

Intoxication: Only drug for which objective measures of intoxication exist

Question 18

Normally a progression:
Sxs. first begin 4-12 hours after last drink or reduction of real heavy abuse: tremors, n&v, irritability - flu like symp
Need ask how much using so can recognize what dealing with
Sxs not relate what came in for recognize what going on
May progress to: - will die of withdrawal if not taken care of; take seriously

Answer 18

Alcohol withdrawal

Question 19

Delirium Tremons (DT’s)—result of CNS irritability; not recognize first critical areas and progresses to DTs
Will see DT’s approx. 48-72 hrs. after last drink
5% of people who have DT’s will die d/t cardiac or respiratory failure, dehydration, liver disease - withdrawal can die; imp recognize withdrawal because not want get to DT’s
Tx: antianxiety-often Librium - drinks a lot and often; now not drinking; used frequently as treatment; need on that because DTs not good - not enough to make them stop drinking

Answer 19

May progress to: - will die of withdrawal if not taken care of; take seriously

Question 20

Elevated vital signs
Tremors
Insomnia
N/V
Abdominal cramping
Seizures - if not caught
Hallucinations - if not caught
Antianxieties helpful when going through withdrawal

Answer 20

Alcohol withdrawal/common symp

Question 21

Medical emergency; potentially fatal
Peaks in 2 to 3 days after cessation
Psychotic symp: Hallucinations, delusions, agitation, fever, perceptual and autonomic disturbances; severe disturbance in sensorium; fluctuating levels of consciousness
Hope caught before go to DTs

Answer 21

Alcohol Withdrawal Delirium (DTs)

Question 22

Early signs within a few hours
Peaks within 24 to 48 hours
Rapidly and dramatically disappears unless it progresses to delirium
Irritability and “shaking inside”
Grand mal seizures possible in 7 to 48 hours after cessation
Illusion

Answer 22

Alcohol withdrawal

Question 23

Medical emergency
Possible death
Peaks 2 to 3 days after cessation and reduction greatly
Autonomic hyperactivity
Sensorial and perceptual disturbances
Fluctuating loss of consciousness (LOC)
Delusions (paranoid)
Agitated behaviors
Body temperature 100° F or higher - goes up sig

Answer 23

Withdrawal delirium

Question 24

C—Have you ever felt you ought to Cut down on your drinking (or drug use)?
A—Have people Annoyed you by criticizing your drinking (drug use)?
G—Have you ever felt bad or Guilty about your drinking (drug use)?
E—Have you ever had a drink (used drugs) first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
On assessments not tell truth; work up to harder questions
Ask how much drink - not tell truth; do more questioning
Quick and easy to use on all drugs and alcohol
Another Tool Sometimes Used: Short Michigan Alcoholism Screening Test (2 yes response indicate risk). Page 447 in Varcarolis - longer version

Answer 24

CAGE-AID screening tool (AID-adapted to includes all drugs)

Question 25

Alcohol: - not take lightly esp if used a lot; affects lot sys in body

Answer 25

Effects on the body

Question 26

CNS depressant—about 20% of single dose is absorbed directly into bloodstream thru abdomen-carried directly to brain. The other 80% only slightly more slowly thru intestinal tract, into bloodstream
Hepatitis:
Cirrhosis:
Malnutrition
Peripheral neuropathy
Wernickes’s—
Korsakoff’s Psychosis-
Usually see Wernicke-Korsakoff syndrome/disorder - decrease in thiamine
Tx.: parenteral or oral thiamine replacement: that is cause

Answer 26

Alcohol: - not take lightly esp if used a lot; affects lot sys in body

Question 27

inflammation and necrosis of the liver cells
Common

Answer 27

Hepatitis:

Question 28

liver cells destroyed and replaced with scar tissue

Answer 28

Cirrhosis:

Question 29

(folic acid thiamine decrease)
Imp - issue for sustained alcohol use for long-period time

Answer 29

Malnutrition

Question 30

(result of deficiencies in B vitamins, especially thiamine)

Answer 30

Peripheral neuropathy

Question 31

serious thiamine deficiency. Sxs: ataxia (unsteady gait), somnolence, stupor, abnormal eye movement (Eyes go back and forth really fast)
Long-term drinker - automatically put on thiamine

Answer 31

Wernickes’s—

Question 32

confusion, recent memory loss, confabulation (not lying just responding to question that they can remember; give answer - not correct but not lying when answering); memory and emotional
Psychotic type confusion

Answer 32

Korsakoff’s Psychosis-

Question 33

A client is brought to the ED. The client is aggressive, has slurred speech, and impaired motor coordination. Blood alcohol level is 347 mg/dl. Among the physician’s orders is thiamine. Which is the rationale for this intervention?
A. To prevent nutritional deficits
B. To prevent pancreatitis
C. To prevent alcoholic hepatitis
D. To prevent Wernicke’s encephalopathy

Answer 33

Correct answer: D
Wernicke’s encephalopathy is the most serious form of thiamine deficiency in clients diagnosed with alcoholism. If thiamine replacement therapy is not undertaken quickly, death will ensue.

Question 34

Biological: half children of alcoholics deal with abuse alcohol
Alcohol acts on GABA system; cocaine associated with deficiency in dopamine and norephinephrine
About 9 million children live with a parent who abuses drugs or alcohol
Psychological: A person uses substance to feel better and over time this habitual behavior develops into an addiction - leads to tolerance overtime

Answer 34

I believe alcoholism is caused by…

Question 35

Exaggerated dependent pattern of learned behavior, beliefs, feelings
Want fix/rescue people; cover up or excuses for people; do what can to help person; not helping them and making excuses for them
Dependence on people and things outside of self along with neglect of self to point of little self identify
Derived self-worth from others-feels responsible for happiness of others: can be stressful for person because what you do defines other person’s happiness
Al-Anon (support group for fam member’s that have substance abuse): 3 C’s: family member’s: I don’t CAUSE the disease; I can’t CONTROL it; I can’t CURE it

Answer 35

Co-dependency

Question 36

Excused or ignored peer/co-worker behaviors.
Never told a supervisor about behaviors that may indicate impairment
Accepted the responsibility for a colleague’s unfinished work
Believed that nurses do not use drugs or alcohol (impairment) - defense mechanisms
Liked to use drugs or alcohol myself and feel guilty for reporting
Exonerated peer’s irresponsible actions.
Defended a colleague
Make excuses for them; make everything right

Answer 36

Have I been co-dependent/enabled? - work environment

Question 37

Be nonjudgmental, matter-of-fact as doing assessment: self-awareness imp
Begin by asking about Prescribed legal drugs taking
O.T.C. and commonly used social drugs (alcohol, caffeine, tobacco)
A person with no px. answers specifically (a drink before dinner)
If further along the continuum may be evasive (I have no px. controlling my drinking)
If answer is “practically never” may respond “tell me about the times you do use” - drill down on that; more vague answers are those who have issues; keep asking; guide in responses; just keep asking questions

Answer 37

Assessment techniques - challenge

Question 38

Naltrexone (ReVia, Vivitrol)
Acamprosate (Campral)
Disulfiram (Antabuse)

Answer 38

Pharmacologic interventions treatment of alcoholism

Question 39

Reduces or eliminates alcohol craving. - used before antabused; reduce desire to use

Answer 39

Naltrexone (ReVia, Vivitrol)

Question 40

Helps patient abstain from alcohol. - used before antabused

Answer 40

Acamprosate (Campral)

Question 41

Alcohol-disulfiram reaction causes unpleasant physical effects
Not cure them; vomit if drink
Not given frequently
Behavioral mod technique - use alcohol get very ill
Give edu

Answer 41

Disulfiram (Antabuse)

Question 42

Antabuse: Must have consent of pt.
reduces craving
ALCOHOLIC ANNONYMOUS (AA)

Answer 42

Treatments

Question 43

Will cause vomiting and hypotension when taken with alcohol
Since get sick from using
Edu and other things with alcohol in them cause same result

Answer 43

Antabuse: Must have consent of pt.

Question 44

A narcotic antagonist that blocks euphoric effects
used after w/d and abstinence
SSRI’s: mixed results to decrease craving in moderate drinkers

Answer 44

reduces craving

Question 45

12 steps: Fundamental concept: powerless over addiction—found telling their story helpful—Individual not responsible for disease, responsible for recovery—No longer to blame other people, places, things for addiction; changing thinking and people around - avoid triggers
Great treatment

Answer 45

ALCOHOLIC ANNONYMOUS (AA)

Question 46

Cannabis (Marijuana)
Hallucinogens (LSD, PCP)
Depressants (Barbiturates, Alcohol)
CNS Stimulants (Cocaine, Crack, Amphetamines, Caffeine)
Narcotics (Opiates, Morphine, Heroin)

Answer 46

Other drug use and abuse

Question 47

10 X’s more potent today then 1970’s

Answer 47

Marijuana (Cannabis sativa)

Question 48

Is from the Indian hemp plant
Is usually smoked
Tetrahydrocannabinol (THC) is the active ingredient.
Has depressant and hallucinogenic properties
Desired effects include euphoria, detachment, and relaxation
Long-term effects are lethargy, anhedonia, difficulty concentrating, and loss of memory - amotivational syndrome - gets into trouble; not matter what do; this when gets into trouble
Not phys addiction

Answer 48

Marijuana

Question 49

Constricted pupils
Decreased respiration
Decreased blood pressure
Slurred speech
Drowsiness
Psychomotor retardation
Initial: euphoria
Later: dysphoria
Impaired:
Concentration
Judgment
Memory
Almost as if drunk

Answer 49

Intoxication Effects: Opiates: Morphine, Heroin, Codiene, Fentanyl, Methodone: crisis of OD

Question 50

Yawning
Insomnia
Irritability
Rhinorrhea
Panic
Diaphoresis
Cramps
Nausea and vomiting
Muscle aches
Chills and fever
Lacrimation
Diarrhea

Answer 50

Withdrawal Effects: Opiates: Morphine, Heroin, Codiene, Fentanyl, Methodone: crisis of OD

Question 51

Naloxone (Narcan)
Methadone (Dolophine)

Answer 51

Pharmacologic therapy opioid addiction

Question 52

First choice to treat opioid toxicity
Very effective to treat OD
Disadvantage: short-acting

Answer 52

Naloxone (Narcan)

Question 53

Detox tool; synthetic opiate that blocks the craving for and effects of heroin
Sometimes think getting addicted to this
Effective - saves lives and gets off other drugs but one addiction for another

Answer 53

Methadone (Dolophine)

Question 54

Dilation of the pupils
Dryness of the nasal cavity
Excessive motor activity
Cocaine and crack
Methamphetamine
Caffeine and nicotine

Answer 54

Common signs of CNS stimulant abuse - let them teach you: CNS stimulants

Question 55

Are extracted from the leaf of the coca bush.
Addiction is quickly; such rush and high so want cont cycle
When smoked:
Have two main effects on the body.
Produce an imbalance in the neurotransmitters
Withdrawal symptoms include: depression, paranoia, lethargy, anxiety, insomnia, nausea, vomiting, sweating, and chills

Answer 55

Cocaine and crack

Question 56

It takes effect in 4 to 6 seconds.
After 5 to 7 minutes, a “high” follows

Answer 56

When smoked:

Question 57

Anesthetic
Stimulant

Answer 57

Have two main effects on the body.

Question 58

From China
Aka Angel Dust (PCP)
Present as if superhuman; like body blows up
Behaviors: very agitated, very violent, delusional, decreased pain response; concerned about safety and those around them
Become animal like - look like animal - so strong
TX:

Answer 58

PCP - Flakka (sim effects of PCP)

Question 59

Low stimulus
Safe place
Long time to get to under control so safe situation
LSD: May talk down - not violent - hallucinogen; PCP: Safety—Not bother talked down; trying contain them and keep them down and keep others safe

Answer 59

TX:

Question 60

Alters mood, perceptions, sensations
LSD is odorless, tasteless, colorless - easily given to someone and not know ingesting them
Can be swallowed, injected, absorbed on paper (stamps, stickers) - get effects of drugs without knowing
Injected into bloodstream (mainlining)
Injected into muscle or skin (skin popping)

Answer 60

Hallucinogens

Question 61

High degree of physical and psychological dependency - alcohol: CNS depressant
Combo with alcohol enhances effects (synergistic: combine two CNS depressant enhanced effect) and may lead to OD and major probs

Answer 61

Depressants

Question 62

17% of US teens have tried to get high by sniffing (aerosol deod., gasoline, glue, asthma inhalers)
Inhale anything that is accessible - sig prob and deadly

Answer 62

Inhalants

Question 63

Same questions of anyone else and good phys
History of substance use - biggest challenge is getting honest answers
Medical history
Psychiatric history
Psychosocial issues

Answer 63

Assessment strategies

Question 64

Depression? Personality or conduct disorder? Schizophrenia?
Medications on? Outcomes?
Abuse? Family violence? Suicidal or homicidal ideation?
Trauma in life

Answer 64

Psychiatric history

Question 65

Poor work record?
Has substance use affected relationships? Family? Friends? Professional peers?
Support systems? Coping styles - how to cope?
Self-medicate
Police or criminal record? Legal problems?
Able func in life - affected life

Answer 65

Psychosocial issues

Question 66

Verbalize addictive process
ID support systems/people
Find substitute behaviors
Assertiveness training
Avoid triggers - identify triggers: when and why use
Self responsibility - breakdown defenses
AA
Cognitive therapy - turning stinking thinking around; not easy avoid triggers so need support sys
Will have setback

Answer 66

TX goals

Question 67

High stressed area/environment; easy access to pain med; get addicted to pain med
Chemical dependency among nurses - impaired nurses high reality; suscept impaired: suspicious; leave or try to hide it; need address it and help them
estimated 30-50% times greater than among the general population

Answer 67

Impaired professionals

Question 68

IF YOU SUSPECT A CO-WORKER
Not go to them: defense mechanisms; quit and leave
Clear and accurate documentation - take to manager; concern and here is reason why
Inform nurse manager!
Peer Assistance program: developed by ANA in 1982 to: assist impaired nurse in obtaining tx., to regain accountability, Contract to detail guidelines for tx. usually 2 years; not lose nursing license - not around narcotics; help nurses so not lose license
Suspicion go to manager and address with indiv

Answer 68

estimated 30-50% times greater than among the general population

Question 69

Isolation/withdrawal
Mood swings
Complaints from patients or co-workers about deteriorating work
Absences with unusual explanations/volunteer work extra shifts if getting drugs from work
Frequent illnesses
Poor documentation
Missing drugs/patients not responding to medications as expected - no relief from pain
Frequent bathroom breaks or unexplained absences while at work - disappear while at work
Not show up to work; volunteer work more shifts
Pats complaining getting pain meds but not relief

Answer 69

Indicators of impairment

Question 70

VERY High functioning, Perfectionist - bright; expect lot self
Intolerance to others standards that are perceived as less than their own - standards high and expect others be like that
Does not take care of their own emotional, physical, spiritual health (Co-dependent type personalities)
Suppress feelings d/t need to appear competent
Low tolerance to accept criticism about professional abilities - pride self on being good nurse

Answer 70

Profile of an addicted professional

Question 71

Up to 20% of practicing nurses are addicted to substances
No relief from pain med - first indicator something up so pay attention
Nursing students are vulnerable
Reporting an impaired colleague is a peer responsibility.
Clear documentation by co-workers is crucial
Intervention is the responsibility of the nurse manager and administrators
If an impaired nurse remains in the situation and no action is taken by the nurse manager, then information must be taken to the next level in the chain of command
Provide alternative-to-discipline (ATD) programs

Answer 71

Alternative-to-discipline (ATD) programs

Question 72

Don’t confront when person is using - have obj person to lead it
Often deal with indivs abusing and want approprach them
It should take place after a crisis - not when during use
3-6 people—hold in private-Obj. Facilitator; if doing intervention; do someone obj
Confront with facts and feelings-be specific what see and concerned
Be nonjudgmental-firm, concerned
Towards end of the confrontation, lay all the cards on the table-What are you going to do if person does not seek tx - may sound harsh but gets attention to get help; describe what do if not seek treatment

Answer 72

Confrontations with abuser