Chapter 19 Substance-Related and Addictive Disorders Flashcards by Kelsey Klipfel

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

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

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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

An alcoholic is…

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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

Substance abuse

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

Substance addiction

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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

Cultural considerations

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Personality traits: - probs with alcoholism/substance abuse issue

Common traits

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

Personality traits: - probs with alcoholism/substance abuse issue

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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

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

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

Blacking out

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

Passing out

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

Physical dependency

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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

Psychological dependency

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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

Tolerance: dependency

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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

Dual dx: substance abuse and another psychiatric disorder

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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.

I would be headed towards alcoholism if…

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

Clin picture: alcohol

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

Intoxication: Only drug for which objective measures of intoxication exist

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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

Alcohol withdrawal

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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

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

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

Alcohol withdrawal/common symp

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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

Alcohol Withdrawal Delirium (DTs)

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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

Alcohol withdrawal

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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

Withdrawal delirium

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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

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

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

Effects on the body

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

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

inflammation and necrosis of the liver cells Common

Hepatitis:

liver cells destroyed and replaced with scar tissue

Cirrhosis:

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

Malnutrition

(result of deficiencies in B vitamins, especially thiamine)

Peripheral neuropathy

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

Wernickes’s—

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

Korsakoff’s Psychosis-

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

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.

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

I believe alcoholism is caused by…

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

Co-dependency

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

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

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

Assessment techniques - challenge

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

Pharmacologic interventions treatment of alcoholism

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

Naltrexone (ReVia, Vivitrol)

Helps patient abstain from alcohol. - used before antabused

Acamprosate (Campral)

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

Disulfiram (Antabuse)

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

Treatments

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

Antabuse: Must have consent of pt.

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

reduces craving

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

ALCOHOLIC ANNONYMOUS (AA)

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

Other drug use and abuse

10 X’s more potent today then 1970’s

Marijuana (Cannabis sativa)

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

Marijuana

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

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

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

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

Naloxone (Narcan) Methadone (Dolophine)

Pharmacologic therapy opioid addiction

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

Naloxone (Narcan)

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

Methadone (Dolophine)

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

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

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

Cocaine and crack

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

When smoked:

Anesthetic Stimulant

Have two main effects on the body.

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:

PCP - Flakka (sim effects of PCP)

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

TX:

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)

Hallucinogens

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

Depressants

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

Inhalants

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

Assessment strategies

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

Psychiatric history

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

Psychosocial issues

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

TX goals

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

Impaired professionals

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

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

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

Indicators of impairment

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

Profile of an addicted professional

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

Alternative-to-discipline (ATD) programs

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

Confrontations with abuser