Substance-Related and Addictive Disorders Flashcards
Substance Addiction
- A chronic medical condition with roots in environment, neurotransmission, genetics and life experiences.
- A strong craving of substance
- Persistent desire to cut down without success.
- Impacts social, occupational, and recreational activities; unable to fulfill role obligations.
- May have an Increase in social isolation.
- Can result in hazardous activities.
- Continuation despite potential harmful consequences (physical and psychological)
- Excessive amount of time is spent trying to procure the substance or recover from its use.
- May result in tolerance or withdrawal
Specific Substance have their own disorder
- Alcohol Use Disorder
- Caffeine
- Cannabis
- Hallucinogens
- Inhalants
- Opioids
- Sedatives / Hypnotics
- Anxiolytics
- Stimulants
- Tobacco
Stigmatizing Language
- “Addict”
- “Alcoholic”
- “Drunk”
- “Substance or Drug Abuser”
- “Drug habit”
- “Dirty”
Countertransference
- unconscious feelings that the healthcare worker has toward the patient.
- It occurs when the nurse unconsciously displaces feelings related to significant figures in the nurse’s past onto the patient.
- often results in overinvolvement and impairs the therapeutic relationship.
- Nurses who care for persons with addictions must begin by examining their own attitudes about drinking and drug use, recognizing that their past experiences may impact their perceptions and influence how they provide care to persons with addictions
Risk Factors for Addiction
Biologic: Genetic predisposition
Neurobiological: neurotransmitters associated with substance use disorders.
Environmental influences: (e.g., chronic stressors, anxiety, exposure to physical, sexual, or emotional abuse or trauma, substance use or addiction in the family or among peers, access to an addictive substance; lack of or ineffective coping strategies)
Starting alcohol, nicotine or other drug use at an early age
Biological Aspects of Addiction
- Genetic predisposition
- Increased extracellular dopamine
- Immature brain development
- Function of acetate
- Having another mental health disorder:
- Depression, attention-deficit/hyperactivity disorder (ADHD) or post- traumatic stress disorder increase potential for self- medication with substances to relieve symptoms and mask feelings.
- Being male; however, progression of addictive disorders is faster in females
Biological: Dopamine and Drug Use
increased extracellular dopamine in the brain -> Excess of dopamine -> “feeling high.”
Cocaine –stops the molecules that usually mop up excess dopamine.
Amphetamines—push the dopamine out of the sacs where it is stored.
Heroin—makes the dopamine-containing neurons fire more.
Alcohol—helps release more dopamine.
Relapse is very common.
Dopamine
Feel good neurotransmitter
Immature Brain Development: Developing Brain
- Early experiences affect brain development
- Early stress and trauma change the brain’s responses
- The brain continues to develop until age 24 or later
- The adolescent brain matures from Back to Front
Back of Brain
areas of emotion, memory, impulse, psychomotor activity
Front Brain
areas of executive function, planning, problem-solving, judgment, impulse control, organization
Biological: Alcohol Craving and Acetate
- Alcohol breaks down into acetate
- Acetate triggers a craving for more acetate
- In a normal drinker, the acetate moves through the system quickly and exits.
- The liver and pancreas of the person addicted to alcohol process alcohol at 1/3 to 1/10th the rate of a normal pancreas and liver.
- In addiction the acetate of the first drink is barely processed out, so by staying in the body, it triggers a craving for more acetate.
- The person addicted to alcohol then has a second drink, now adding to most of the acetate of the first drink, and that makes them want a drink twice as much as the normal drinker. So, they have another.
- Control is lost. The craving cycle has begun.
- Acetate accumulates in their body with only ONE drink.
- And this NEVER CHANGES!
Reasons for Continued Use: The Addicted Brain
Repeated use leads to tolerance and withdrawal
* Via fundamental changes in the neurotransmitters
* Via decreased D2 receptors and decreased dopamine release.
Resulting in:
* compulsive behaviors
* decreased inhibitory control
* increased impulsivity
* impaired regulation of intentional action
Acetate metabolizes into
Alochol and Nicotine
Substance Intoxication
- Recent overuse/excessive use of a substance, such as an acute alcohol intoxication, that results in a reversible substance-specific syndrome.
- The symptoms are drug specific.
- Judgment is impaired; may lead to Inappropriate and maladaptive behaviors and Impaired social and occupational functioning.
- CNS changes occur; disruption in physiological and psychological functioning.
- Can happen with one time use of substance.
Alcohol intoxication can lead to
- physiological (slurring of speech, poor coordination, impaired memory, stupor, or coma).
- behavioral (inappropriate behavior)
BAC > 0.08% Typical Effects
- Muscle coordination becomes poor (e.g., balance, speech, vision, reaction time, and hearing)
- Harder to detect danger
- Judgment, self-control, reasoning, and memory are impaired
Predictable Effects on Driving
- Concentration
- Short-term memory loss
- Speed control
- Reduced information processing capability (e.g., signal detection, visual search)
- Impaired perception
Tolerance
- Occurs when a person no longer responds to the drug or substance in the way that the person initially responded.
- Using ‘increasing amounts’ of a substance over time to achieve the same level of response and a markedly diminished effect occurs with continued use.
- Some substances, such as cocaine, cause rapid physiological tolerance
- Other substances, such as prescription pain medications, may result in tolerance after weeks or months of use.
Blackouts
Blackouts- not the same as passing out; caused by excessive consumption of alcohol followed by episodes of amnesia. During these periods of time, a person actively engages in behaviors, can perform complicated tasks, and appears normal
Relapse
the recurrence of alcohol- or drug-dependent behavior in an individual who has previously achieved and maintained abstinence for a significant time beyond the period of detoxification
Dual Diagnosis
Co-occurring mental illness and substance use or addictive disorder
Substance Withdrawal
- A set of physiological symptoms that occur when a person stops using a substance
- Differ and are specific to each substance.
- Can be mild or life threatening
- The more intense symptoms a person has, the more likely the person is to start using the substance again to avoid the symptoms.
Estimated Timing of Symptom Appearance following Alcohol Intake
6-12 hours: Minor withdrawal symptoms: insomnia, tremulousness, mild anxiety, gastrointestinal upset, headache, diaphoresis, palpitations, anorexia.
12-24 hours: Alcoholic hallucinosis: visual, auditory, or tactile hallucinations
24-48 hours: Withdrawal seizures: generalized tonic-clonic seizures
48-72 hours: Alcohol withdrawal delirium (delirium tremens): hallucinations (predominately visual), disorientation, tachycardia, hypertension, low-grade fever, agitation, diaphoresis
Sedative Hypnotic/Alcohol Withdrawal: CIWA
- Nausea/ vomiting
- Tremors
- Anxiety
- Agitation
- Paroxysmal Sweats
- Orientation
- Headache
- Tactile Distrubance
- Auditory Disturbance
- Visual Disturbance
CIWA scores
0-9: minimal withdrawal
10-19: mild-moderate
>20: Severe
Goal for Alcohol Withdrawal
- Control agitation
- decrease the risk of seizures
- decrease morbidity and mortality
CIWA score of 8 to 10 or more:
- Chlordiazepoxide
- Diazepam
- Lorazepam
Essential Vitamin needed during alcohol withdrawal
Thiamine daily replacement is critical and should be given prior to IV dextrose support to prevent precipitation of Wernicke’s syndrome.
Delirium Tremens
* Most severe form of alcohol withdrawal
* A medical emergency that can result in the death that occurs anytime in the first 72 hours after cessation of heavy drinking.
* Serious physical illness such as hepatitis or pancreatitis may increase the likelihood of alcohol withdrawal delirium.
* It is rare to see this syndrome in individuals in good physical health.
Delirium Tremor Symptoms
- Agitation
- Increased anxiety
- Gross confusion and disorientation
- Coarse tremors
- Seizures
- Delusions
- Hallucinations (most commonly auditory and/or visual; also, tactile)
- Paranoia
- Autonomic hyperactivity (tachycardia, diaphoresis, fever, anxiety, insomnia and hypertension)
- Danger of misdiagnosis as psychiatric disorder
Best ways to treat Delirium Tremors
- PREVENT THEM!!
- Medicate and sedate adequately
- Monitor very closely
- Listen and respond to the patients report of symptoms
- Treat complications
- Give Thiamine and other nutrients
Delirium Tremor Treatments
- Prevention of alcohol withdrawal delirium or DTS is the goal.
- Life support/sustaining measures as indicated; can be life-threatening
- Labs: Electrolytes
- Hydrate
- Vital Signs
- Medications
- Treat seizures with anticonvulsants: phenytoin or phenobarbital
- Oral diazepam may be useful in the symptomatic relief of acute agitation, tremors, impending or acute DTS, and hallucinosis.
- However, once delirium appears, intravenous lorazepam is used to treat severe symptoms.
- Antipsychotics: haloperidol prn
- For Elevated BP: Clonidine
- Dehydration is often exacerbated by diaphoresis and fever but can be corrected with oral or intravenous fluids.
Opioid Withdrawal: COWS
- Resting pulse rate
- Sweating
- Restlessness
- Pupil size
- Bone or Joint aches
- Runny nose or tearing
- GI upset
- Tremor
- Yawning
- Anxiety or irritability
- Gooseflesh skin
Non-pharmacologic interventions before PRN medications when treating Opioid Withdrawal
- Schdedule methadone on time!!
- Nausea: crackers, ginger ale, tea, flat warm coca-cola
- Muscle aches: hot showers, warm compresses
- Anxiety reduction: distraction, relaxation therapy, talk therapy
Pharmacologic Interventions Opioid Withdrawal: Nausea and Vomiting
- **must see emesis prior to giving for vomiting **
- ondansetron
- promethazine orally or rectal suppository (Avoid giving as IM if requested by patient r/t ‘rush’ effect)
Pharmacologic Interventions Opioid Withdrawal: Anxiety, Lacrimation, Rhinorrhea
- hydroxyzine
- Avoid benzodiazepines
Pharmacologic Interventions Opioid Withdrawal: Insomnia
Trazadone
Pharmacologic Interventions Opioid Withdrawal: Aches and Pain
- acetaminophen –NOTE: if long term alcohol use the patient may have esophageal varices or gastric ulcers
- NSAIDS e.g. ibuprofen
Pharmacologic Interventions Opioid Withdrawal: Diarrhea
- Kaopectate preferred choice
- Avoid loperamide because of sedation effect sought by patient
Medication-Assisted Treatment
A combination of medication, counseling and behavioral therapies are effective in the treatment of substance use disorders and can help some people to sustain recovery.
Pharmacotherapy
Naltrexone
Disulfiram
Clonidine
Acamprosate
Reduce cravings and controls withdrawal symptoms for OA
- Methadone- No ceiling effect; monitor closely
- Buprenorphine & Naloxone
- Buprenorphine- ceiling effect; limits overdose potential
Long-Term Medication Management: Methadone Maintenance for Pregnant Women
- Decreases the variability of illicit drug use on the fetus and Newborns have more predictable outcome
- Limits exposure to health risk for Mom and fetus from exposure to illicit drugs and unknown possibly toxic additives, dirty needles.
- Dosages:
- may need to be adjusted upward as pregancy progresses.
- Twice daily dosing INSTEAD of larger dose may also be an option.
- Dosage titrated dependent upon opioid withdrawal scoring
- Maintained til delivery, then withdrawn
- The fetus experiences symptoms of withdrawal that may be 2-3X as intense as the mother’s symptoms.
Emergency Treatment: Naloxone Kits
- Naloxone kits can be sent home with patients at risk for overdose.
- Naloxone is a drug available as an injection (EVZIO) or nasal mist (Naloxone nasal spray) that can quickly reverse the effects of a heroin overdose.
- Paramedics carry naloxone and administer it when they find an overdose victim.
Psychological Treatment for Opioid Use Disorder
- Individual therapy
- Behavioral therapy
- CBT
- Family therapy
- Social skills training
- Support groups (e.g., Narcotics Anonymous)
Wernicke-Korsakoff Syndrome
- Neurological disorder caused by lack of thiamine (vitamin B1), requiring immediate treatment.
- Consists of 2 stages:
- Wernicke Encephalopathy
- Korsakoff Syndrome
- Develops most often in people with alcohol use disorder and malnutrition
- Chronic alcoholism can decrease intestinal absorption of thiamine by 70%
- Rule out other causes for thiamine deficiency (e.g. poor nutrition, eating disorders, chronic infections, surgery, including bariatric)
- About 50% of those who develop Wernicke encephalopathy eventually develop Korsakoff syndrome
Wernicke’s Encephalopathy:Classic Symptoms
- Confusion
- Loss of muscle coordination (Ataxia)—affecting posture and balance that can lead to tremors
- Vision changes–abnormal eye movements (Nystagmus), double vision and eyelid drooping
Acute and reversible condition
Wernicke’s Encephalopathy
may clear up within a few weeks or may progress into Korsakoff’s syndrome, the more severe and chronic version of this problem.
Treatment Wernicke’s Encephalopathy
- thiamine replacement
- Improve nutritional status
Outcomes Wernicke’s Encephalopathy
- Symptom improvement
- Without treatment 80-90% may advance to Korsakoff Syndrome
Korsakoff Syndrome
Chronic and debilitating syndrome
** is NOT Completely reversible**
Symptoms Include those seen in Wernicke’s encephalopathy as well as:
- Severe, irreversible, persistent memory impairments including problems forming and recalling memories
- Confabulation
- Hallucinations
- Repetitious speech and actions
- Problems with decision-making
CAGE
Felt you should CUT down
ANNOYED you with criticism.
Felt GUILTY
Had EYE-OPENER drink
