Substance use and addiction disorders Flashcards
substance addiction
chronic medical condition rooted in environment, neuro, genetics, life exp
- strong sub craving
- desire to cut down w/o success
- can’t fulfill role obligations
- inc social iso sometimes
- hazardous activities
- continue despite potential harmful consequences
- excess time spent to get substances
- may cause tolerance or w/d
Biggest barrier to substance abuse
Stigma
- seen as moral weakness by many
Stigmatizing language
addict, alcoholic, drunk, sub/drug abuser, drug habit, drunk
countertransference
unconscious feel of HC worker to pt
- need to examine own perceptions toward addiction to dec bias and examine own attitudes
- often impairs the relx
Opioid epidemic
- 1st prescription opioids deaths (until 2010)
- then heroin OD (2013)
- synthetic opioid OD
Addiction rf
- genetic, males more but females faster
- NT w/ sub use dx—inc extracell Dp, immature brain dev
- enviro—stress, anx, sub use, use in fam/peers, lack coping
- starting alc, nic, drug use at an early age
- have other MH dx (self-medicate)
- higher among multiracial
Dopamine and addiction
- seek subs that release or inc release of DP in brain
- feel good NT
- inc extracellular Dp
Brain dev as rf for addiction
- early exp infl brain dev ( early trauma and stress chx)
- brain devs until 24 or later
- adol brain matures back to front
Decision making is more…
Frontal with adults and amygdala with teens
Alc cravings and acetate
- alc b/d to acetate (which triggers cravings for more)
- normal drinkers pass acetate thru quickly (panc and liver slower in addicts)
- in addicts, acetate does not process out so cont desire for more
- craving cycle
- acetate accum with 1 drink and does not change with ppl addicted
Neuro of tolerance
- from repeated use
- chx in NTs and dec D2r and dec dp release
- results in compulsive bx, dec inhib control, inc impulses, impair reg of intentional action
What other substance metabolizes into acetate
Nicotine - compounds effects
Substance intoxication
recent overuse of sub like acute alc intox casuing reversable substance-specific sx
- judgment impaired making maladaptive and inappropriate bx and impairing social and occupational functioning
- CNS chx
- alc: slur, poor coordination, stupor, dec memory
BAC legal intoxication
Over .08
Physical signs of alc intoxication
- muscle coord dec, hard to detect danger, judgment, memory impair
- driving - conc and memory dec, speed control, dec info process, impair perception
Tolerance
respond in diff way than initial drug response
- drink more for same response and diminished fxn with cont use
- rapid (coke) to w or m
Blackout
excess intake with amnesia
- may appear normal tho
relapse
drink after being abstinent for significant time beyond period of detox
Dual dx
AMI and sub/addictive use dx
substance w/d
- physio sx that occur when person stops using subs
- substance-specific
- more intense sx, more likely person is to start using subs again to avoid sx
Alcohol and BDZs timeline and w/d
- 6-12h mild insomnia, shaky, anx, GI, HA, diaphoretic, palpits, anorexia
- 12-24h halluc
- 24-48 w/d sz (t-c)
- 48-72h delirium tremens, halluc (mostly vis), tachy, low fever, agit, HTN, diaphoretic
- peak in 48h, over in 3-5d
How often to assess with CIWA
q4h
- assess n/v, tremor, anx, agit, paroxysmal sweats, orientation, HA, halluc/delusion
manage w/d of alc
- control agitate, dec sz, dec morb/mort
- may be fixed, schedules based on pt specific
- daily thiamine before IV dextrose to prevent Wernicke sx
- PRN for break thru
What meds are given for CIWA of 8-10+
chlordiazepoxide, diazepam, lorazepam
Delirium tremens
- severe w/d in 1st 72h post-drink
- panc and hepatitis inc risk
- rare in pt with good health
- agitate, conf, dis, tremor, sz, delus, halluc, paranoia, autonomic hyperactivity
- tachy, sweat, fever, anx, insomnia, HTN
***commonly mistaken as psych dx
Tx of delirium tremens
- goal is prevention
- sedate/medicate well
- listen to pt sx
- tx comps
- thiamine and other nuts
- labs–electros
- hydrate and meds
- VS
Meds for alc w/d
- tx sz with anticonvulsants—phenytoin or phenybarbitol
- oral diazepam for sx acute agitation, tremor, halluc, DTS
- IV lorazepam where severe sz appear
- haloperidol PRN
- clonidine for HR/BP
- dehydration bc sweat
opiate w/d sx
- COWS
resting pulse, sweat, restless, pupil size, bone/joint ache, runny nose/tear, GI upset, tremor in hand tongue, yawn, anx/irritate, gooseflesh
Nonpharm tx for opioid w/d
- nonpharm before PRN but give methadone on time!
- nausea - crackers, ginger ale, tea, flat warm coke
- muscle aches - hot shower, warm compress
- anx dec distraction, relax, talk therapy
Opioid w/d meds for n/v
ondansetron or oral/rectal supps
- promethazine (avoid IM bc of rush feeling)
- need to see vom before giving to assess
opioid w/d pharm for anx, lacrimation and rhinorrhea
hydroxyzine and no BDZs
opioid w/d insomnia meds
trazadone
opioid w/d aches and pains med
acetaminophen
- NOT for long term alc use
- NSAIDs like ibu
opioid w/d meds for diarrhea
kaopectate (bismuth)
- avoid loperamide bc sedative fx sought by pt
medically assisted tx
- combo meds
- counseling
- bx
naltrexone
- block opioid fx and alc
- dec craving and relapse
- does not tx w/d sx
- can’t use opioids 10-14d before start bc can make sick (knocks opioid off rec—quick w/d)
disulfiram (Antabuse)
- prevent b/d of acetaldehyde
- does not dec cravings
- will make pt sick if wear anything with alc like perfume, hand sani, pain thinner, mouthwash, nyquil
clonidine
dec BP and HR
acamprosate
dec alc craving in pt
methadone
- no ceiling effect
- watch closely - works slowly (is opiate)
- slow taper off
buprenorphine-naloxone
- OUD
- dec cravings and w/d sx
- dec risk of OD
Buprenorphine
- OUD
- no euphoric or dangerous fx
- sub for drug in body
- dec bad SE
- ceiling fx (dec OD potential)
Psych tx for opioid use dx
- ind, bx CBT, fam, social
- support groups
Methadone for preg women
- dec variability of illicit drug use on fetus
- more predictable outcomes
- dose may need to adjusted thru preg
- maintain til delivery then taper off
Wernicke-Korsakoff syndrome
Immediate dx from lack B12 (thiamine)
- from AUD and malnutrition
- chronic alc dec intestinal abs of thiamine
How is Korsakoff diagnosed
R/o other causes
Wernicke’s encephalopathy symptoms
- confusion
- lose motor coordination (ataxia)
- nystagmus
- tremor
- double vision, eye droop
What can Wernicke’s turn into
Korsakoff’s
Wernicke’s tx
- acute and reversible (can clear w/i weeks)
- tx with IV thiamine and improved nutrition (2-3x/d for 1-2w)
Korsakoff’s symptoms
- severe, irritating, persistent memory impairment and probs forming and recalling new memories
- confabulation, hallucinations, repetitious speech, prob decision making
Korsakoff’s tx
- Thiamine for 3-12M
- pt specific
- memory rehab tx
Is Korsakoff’s reversible?
NO
- chronic and debilitating
Patient recovery plan elements
- life goals
- hope
- therapy
- harm reduction
- family involvement
- relaxation techniques
- relapse prevention plans
SBIRT
- Screen severity of sub use and ID tx
- Brief Intervention - nurse or HCP inc insight and awareness about sub use and motivation to change
- Referral to Tx prn
Steps of Brief Negotiated Interview
- Rapport
- Pro/con of behavior discussed and summarize
- give info and get feedback
- Discuss screening tools
- determine motivation to change
- negotiate action plan
Technique used for giving info and getting feedback
Elicit, provide, elicit
- assess knowledge and info like presence of drinking bx (including risky) and see if pt learned info
Elements of motivation to change
Importance, confidence, readiness
OARS
Technique for motivational interviewing
Open-minded, affirmative, reflective listening, summarizing
Steps of motivational interviewing
Empathy
Develop discrepancies
Avoid arguments
Roll with resistance
Support self-efficacy
AUDIT
gives risk categories and screen for unhealthy alc use
- framework to Dec consumption
CRAFFT
Tool for assessing adolescent drinking
CAGE
Tool for assessing need to cut down on drinking and if there is a problem
Risky drinking
- any use of alc while preg
- driving, taking some meds
- having severe conditions
- in recovery or if can’t control drinking
Hazardous drinking
Inc risk for adverse consequences
Harmful drinking
Neg consequences already occurred from drinking
What amount of alcohol is high risk? M and F
M >4/d or >14/w
F >3/d or >7/w
Effects of alc on body
- dep, anx, aggression
- throat and mouth cancer
- liver
- premature aging
- pancreatic inflam
- painful nerves
Social services for AUD
- outpt counsel weekly
- acute tx (medical detox)—4-7d w/ transition to oupt
- clinical stabilization service—full med detox with 7-10d residential
- peer support
Nursing Considerations for AUD
- monitor rxns
- express Ind caring
- help dev a realistic plan
- hold Ind responsible for bx
- prioritize care needs—coping
- encourage honest expression
