Substance Use and Addictive Disorders Flashcards
what is the third leading cause of preventable death and disability in the US?
alcohol abuse and addiction
what is highest among young adults 18 to 25?
binge drinking and heavy alcohol
what is the most commonly used illicit drug in the US?
marijuana
what are the substances most commonly misused by college students?
alcohol
marijuana use
medically unsupervised amphetamines
medically unsupervised sedatives/tranquilizers
ectasy/3,4-methylenedioxymethamphetamine
prescription, opioid narcotics, cocaine, and hallucinogen
inhalants, gamma hydroxybutyrate, ketamine, and heroin
who has the highest usage of alcohol use?
Native Americans and Mexican-American adolescent males
what is the most widely used drug by African Americans?
alcohol
who reports the most frequent, heavy drinking and alcohol-related problems?
Mexican American men
which group has the lowest among Asian and Pacific Islanders and Cuban Americans?
substance abuse
which gender abuses chemicals ?
men
what is the definition of use?
when one drinks, swallows, smokes, sniffs, inhales, or injects a mind-altering substance
what is abuse?
use of alcohol or drugs for the purpose of intoxication, or, in the case of prescription drugs, for purposes beyond their intended use
what is addiciton?
an irresistible psychological and/or physiological need to continue the substance use or behavior despite the harm it causes; may or may not include physical dependence
what is physical dependence?
physiological requirement for the substance by the brain, as evidenced by development of tolerance and withdrawal when use decreases or stops
what is a craving?
an urgent desire for a substance or behavior to which one is addicted, often in response to triggers, that is very difficult to resist
what is tolerance?
physiological adaptation to a substance such that increasing amounts are needed to achieve the same affect
what is cross tolerance?
substances that are pharmacologically interchangeable in terms of how the body responds; e.g.g if one develops tolerance to alcohol, he also has tolerance for benzodiazepines and would require a higher dose of the benzodiazepines to achieve their usual effect. we take advantage of this property to treat dependence, e.g. we replace alcohol with benzodiazepines and gradually reduce their dosage during medically supervised detoxification
what is withdrawal?
state characterized by adverse physical and psychological symptoms occurring when on ceases using a substance to which the brain has acclimated
what is a trigger?
anything which cues or prompts a response, e.g. seeing a bar may trigger a craving for alcohol
what is detoxification?
safely withdrawing a person from an addictive substance, usually medical supervision, by providing a substance for which there is cross tolerance in gradually decreasing amounts
what is relapse?
the recurrence of alcohol- or drug-dependent behavior in an individual who has previously abstinence for a significant time beyond the period of detoxification
what are disorders wherein one has great difficulty refraining from using a substance or engaging in a behavior despite significant resulting harm?
substance-related and addictive disorders
what are type of substance-related and addictive disorders?
abuse of a substance
addiction and/or dependence on a substance
intoxication or withdrawal from a substance
behavioral addictions
what can happen with tox screens?
substances screened for in a standard tox screen can vary with the lab doing these, and screens do not test for all abusable substances
even when a screen tests for a substance some related substances may not show up
some common meds can causes false positives for other drugs
what is the chemical hook theory?
the nature of the substance itself reinforces its use- once the brain has been exposed, it “has to have it”
what is Alexander experiment?
addicted rats were divided into two groups, one placed in a “rat park” with toys and tunnels and food and company, while the other was in a traditional rat cage lacking amenities. this time, when offered the drugged water and plain water, the rats in the rat park chose the plain water, while the rats in the standard cage continued the abuse the drug; conclusion: if we have what we need we will not self medicated with drugs
what is impaired response inhibition and salience attribution (iRISA)?
with accumulating exposure to rewarding activites/substances, the brain narrows tis focus to just those behaviors/substances, resulting in an every-increasing focus on thoughts and actions that cue evokes; a common manifestation is the selective attention to cues related to that substance or behavior
at the same time the brain becomes less and less able to control one’s responses to those cues irrespective of resulting consequences
what is the etiology of substance abuse?
biological components
psychological components
social components
what are the biologic components?
genetic predisposition
neurotransmitter variations and effects
what are the psychological components?
temperament
feelings about self
environmental factors
what is the social components?
family and other relationships
peer pressure
what is alcohol?
CNS depressant and euphoriant
what is legal intoxication?
is determined by the level of alcohol in the blood (blood alcohol level) but neurobehavioral manifestations vary with the degree of physiological tolernace
what can happen from excessive or long-term alcohol abuse?
it can harm any and all body systems
what can prenatal use of alcohol cause?
fetal alcohol syndrome
what is alcohol abuse?
one or more of the following in the year:
recurrent use in hazardous situations
recurrent alcohol-related legal problems
recurrent use and failure to meet role obligations
continued use despite social or interpersonal problems
what is alcohol dependence?
three or more of the following in a year:
tolerance
withdrawal
increase time spent in alcohol related activities
important activities given up or reduced
drinking more or longer than desired
persistent desire or unsuccessful efforts to cut down on alcohol us
continue use despite knowledge of self harm
what are the biologic responses to alcohol?
- increased GABA activity- causes relaxation, sedation
- acute- CNS depression and euphoria
- long-term-physiological tolerance and dependence
- Wernicke’s encephalopathy
- Korsakoff’s syndrome
- Wernicke and Korsakoffs often ooccur together as Wernicke-Korsakoff Syndrome
- liver damage and disease, esophageal varices
- pancreatitis
- increased risk of oropharyngeal, esophageal, and other cancers
- cardiovascular disease, coronary artery disease, and stroke
- depression and worsening of other psychiatric disorders
what is Wernicke’s encephalopathy?
alcohol causes gastric irritation, reduces absorption of B vitamins, interferes with conversion of thiamine into thiamine pyrophosophate
what is Wernicke’s encephalopathy characterized by?
acute onset; oculomotor dysfunction (bilateral abducens nerve palsy), ataxia, ptosis and confusion (may have any or all of these symptoms); requires emergency treatment to prevent permanent damage (IV thiamine)
what is Korsakoff’s syndrome?
gradual onset; retrograde and anterograde amnesia with sparing of intellectual function and some aspects of memory
what are the characteristic features of Korsakoff’s syndrome?
apathy or increased talkativeness; confabulation and cackling laugh
what can begin as soon as 2 hours after last drink (or dosage of last cross-tolerance medication)?
alcohol withdrawal
how can alcohol withdrawal be delayed?
it can be delayed when drugs that produce cross-tolerance are given
what are early symptoms of alcohol withdrawal?
tremors
diaphoresis
rapid pulse (>100)
elevated BP (>150/90)
headache
what is alcohol withdrawal syndrome?
hallucinations- primarily visual, patient usually recognizes as not real; usually starts 24+ hours after last drink
grand mal seizures- generally self-limiting, starts 24-48 hours after last drink
changes in cognition (memory, disorientation) at any point
what is severe alcohol withdrawal/delirium tremens?
is a medical emergency (>10% mortality rate even when treated)
ANS instability- tachycardia, HTN, pyrexia
mental status changes- disorientation, reduced awareness of environment, somnolence, delusions (paranoid), hallucinations (visual/tactile, patient believes are real), marked tremor, agitation, diaphoresis
what is the onset of the severe alcohol withdrawal?
3-5 days after last drink and other cross-tolerance medications (varies with liver function)
how long does severe alcohol withdrawal last?
2-3 days (usually; can last longer)
what are the treatments of alcohol withdrawal?
replace thiamine, niacin, folate, magnesium- all IV
replace electrolytes as needed- all IV
glycogen- D5W IV
benzodiazepines- usually diazepam or chlordiazepoxide, IV, replace alcohol, doses based on objective physiologic signs administered aggressively and in high doses as needed than gradually tapered off
high alcohol tolerance may require very high dosage
baclofen- GABA analog, muscle relaxant, rapid action; non-addictive; mechanisms unclear
antipsychotic for psychotic features- agitation, PRN
what is the treatment for lesser withdrawal states?
as for DT’s expect benzodiazepines, applicable other medications may be lower dosages (or not needed) and IM instead of IV
benzodiazepine dosages are usually somewhat lower than in DT’s but high dosage may still be needed d/t cross tolerance with alcohol
may feed pt instead of IV glucose
may feed patient instead of IV glucose
B-complex IM; multivitamins
what is the best treatment for alcohol withdrawal?
prevention
consistent and effective screening for risk
vigilance for early signs- tremor, tachycardia, HTN
risk can be delayed by cross tolerance medications, can increase as opioids or other cross-tolerant medications are decreased
must prevent with adequate amounts of benzodiapines (some undertreat)
what are the pharmacologic treatment of alcohol dependence?
disulfiram (antabuse)
naltrexone
acamprosate
citalopram
ondansetron
baclofen
gabapentin
what is disulfiram?
used adjunctively for aversion therapy, causes unpleasant response when alcohol is consumed: facial flushing, headache, nausea, vomiting, chest pain, weakness, blurred vision, mental confusion, sweating, choking, breathing difficulty, and anxiety
even small amounts of inadvertent alcohol produces adverse effects
infrequently used d/t often being discontinued by patient inadvertent alcohol exposure
what medications reduce craving and/or rewards from drinking?
naltrexone
acamprosate
citalopram
ondansetron
baclofen
what binds with opioid receptors to block euphoric effects of alcohol and reduce craving; available in LAI form?
naltrexone (revia)
what is an agonist activity at GABA recepotr, used after detox, neuronal excitation/inhibition imbalance?
acamprosate (campral)
what is an SSRI?
citalopram
what is a serotonin antagonist?
onadnsetron
what is a muscle relaxant, reduces craving, withdrawal?
baclofen
what is an anticonvulsant; reduces dysphoria, insomnia when stopping alcohol use, is an EBP for reducing relapse and amount of alcohol consumed?
gabapentin
what is a CNS stimulant produces a euphoric rush of mental alertness and energy, feelings of self-confidence, perception of being in control, and sociability; lasts 10-20 minutes; can produce paranoia and psychosis?
cocaine
what is the cocaine high followed by?
an intense let-down effect in which the person feels irritable, depressed, and tired, and craves more of the drug
what are the ways cocaine is consumed?
snort, snoke, inject (choice of route affects rapidity of absorption and duration of euphoria)
what are the biologic effects of cocaine?
increases the release of, and blocks the reuptake of norepinephrine, serotonin, and dopamine
increased dopamine- euphoria and potential for psychotic symptoms (paranoia and hallucinations)
increased norepinpeprhine- tachycardia and HTN (potentially fatal), dilated pupils and rising body temperature
increased serotonin- sleep disturbances (paranoia), anorexia (weight loss)
snorting coke can erode the nasal septum and destroy the mucus membranes
what happens when cocaine is utilized long-term?
depletion of dopamine= no longer able to experience pleasure
what happens during intoxication?
CNS stimulation followed by depression (crash)
increasing dose- restlessness leads to tremors and agitation leads to convulsion and then finally CNS depression
what happens during withdrawal?
norepinephrine depletion causes person to sleep 12-18 hours
then, sleep disturbances with rebound REM, lethargy, decreased libido, depression, suicdiality, poor concentraion, and cocaine craving
what happens during toxicity?
mydriasis, encephalopathy, seizures, decreased responsiveness, rapid and possibly irregular pulse, hyperpyrexia, coma, respiratory and cardiovascular failure
what are medications utilized for cocaine addiciton?
methylphenidate
gabapentin
vigabatrin
baclofen
n-acetylcysteine
topiramate
nocaine
what may aid self-control and reduce craving (but is abusable)?
methylphenidate (ritalin)
what may reduce tension, cravings?
gabapentin (neurontin)
what increases GABA and reduces craving?
vigabatrin (sabril)
what reduces craving?
baclofen
what seems to improve glutamate levels and reduce craving?
n-acetylcysteine
what decreases cocaine use?
topiramate
what mimics effects of cocaine but at a weaker level while blocking the effects of cocaine itself; substitutes for cocaine while enabling users to gradually and safely decrease use?
nocaine
what are other example of stimulants?
amphetamines
methamphetamine (crystal meth)
MDMA (ecstasy)
nicotine
caffeine
what blocks reuptake of norepinehprine and dopamine, not as strong effect of serotonin as cocaine has and affect the peripheral nervous system?
amphetamines
what releases excess dopamine; highly addictive, relatively easy to make at home, even in car; chemical used are dangerous, potentially toxic, and longer duration “high”, used in a “binge and crash” pattern?
methamphetamine
what causes hallucinations, confusion, depression, sleep problems, drug craving, severe anxiety, and paranoia?
MDMA (ecstasy)
what stimulates the central, peripheral, and automatic nervous systems, causing increased alertness, concenctration, attention, and appetite suppression?
nicotine
what happens during nicotine withdrawal?
mood changes (anxiety, irritability, depression) and physiologic changes (craving, difficulty in concentrating, sleep disturbances, headaches, gastric distress, and increased appetite)
what is especially important in severe mental illness due to higher rates of smoking, greater inhalation?
treatment for tobacco addiction
what are the treatments for tobacco addiction?
nicotine replacement
nicotine replacement via electronic cigarettes
bupropion
varenicline
what reduces cravings and weight gain associated with smoking cessation?
bupropioin (wellbutrin)
what blocks nicotine receptors?
varenicline (chantix)
what stimulates cerebral cortex, increases mental acuity?
caffeine
what happens after 300 mg of caffeine?
can cause tremors, poor motor performance, and insomnia
what happens after above 500 mg of caffeine?
tachycardia, stimulate respiratory, vasomotor, and vagal centers and cardiac muscles; dilate pulmonary and coronary blood vessels; and constrict blood flow in the brain
what are used to lose weight, promote increased exercise tolerance?
concentrated powder of caffeine
what are the withdrawal symptoms of caffeine?
headache, drowsiness, and fatigue, sometimes with impaired psychomotor performance, difficulty concentrating, craving, and psychophysiologic complaints such as yawning or nausesa
what binds with an opioid receptor in the brain to block dopamine reuptake (may contribute to increased risk of psychosis in vulnerable persons)?
cannabis (marijuana)
what does marijuana produce?
it produces a euphoric sense of calm, increased social comfort
what impairs the ability to form memories, recall events, and shift attention from one thing to another?
marijuana
what does marijuana do?
blunts responsiveness to one’s environment, impairs judgment and responsiveness
what happens when a person utilizes marijuana long-term?
use produces amotivational syndrome, memory impairment
where can marijuana be stored in the body?
it can be stored for weeks in fat tissue and in the brain
what can contribute to respiratory disease?
marijuana
what is alleged to be cannibus analogues that mimic marijuana effects, but composition and effects vary?
synthetic marijuana
what are the side effects of synthetic marijuana?
HTN, agitation, nausea/vomiting, hallucinations, psychosis, seizures, and panic attacks blurred vision
what are examples of synthetics?
bath salts, plant food, purple wave
how are other synthetics labeled?
usually marked as “not for human consumption” to evade legal and other responsibility
what are the adverse effects of other synthetics?
HTN, tachycardia, various cardiac symptoms, headache, hyperthermia, diaphoresis, tremor, abnormal movement, seizures, mydriasis, paranoia, anxiety, panic, irritability, suicidaility, psychosis
what are examples of hallucinogens?
psilocybin (mushroom)
D-lysergic acid diethylamide (LSD)
mescaline
numerous amphetamine derivatives
what produce euphoria (or dysphoria), altered body image, distorted or sharpened visual and auditory perception, confusion, incoordination, perception of enhanced spirituality, dissociative effects in some cases, and impaired judgment and memory?
hallucinogens
what causes CNS depression and increase total sleep time but decrease the duration of REM sleep?
benzodiazepines
what may begin as long as 8 days after last taking it?
benzodiazepine withdrawal
what are the signs and symptoms of benzodiazepine withdrawal?
anxiety rebound
autonomic rebound
sensory excitement
motor excitation
cognitive excitation
what reduce signals to the conscious mind from other parts of the brain?
dissociative anesthetics
what are example of dissociative anesthetics?
ketamine
PCP (angel dust)
how long can the dissociative anesthetic intoxication last?
4 to 6 hours
what are the symptoms of taking dissociative anesthetics?
horizontal and vertical nystagmus, increased muscular rigidity, dissociation (blank stare), slow/disorganized speech, increased pain threshold, agitation, combativeness, hallucinations, elevated vital signs, and delirium
what are interventions for those taking dissociative anesthetics?
reduce stimuli, maintain a safe environment for the patient and others, manage behavioral manifestations, and observe for medical and psychiatric complications
what is an example of a “club drug”?
“Molly”
MDMA
GHB (Xyrem)
what is “Molly”?
crystalline form of MDMA but often cut with other drugs; e.g. methamphetamine; confusion, anxiety, depression, paranoia, sleep problems, muscle tension and cramps, tremors, involuntary teeth clenching, nausea, faintness, chills, sweating, and blurred vision
what happens when taking larger doses of “Molly”?
interfere with temperature regulation leading to acute hyperthermia that can lead to liver, kidney, and cardiovascular faiulre
what can cause severe dehydration and hyperthermia?
“Molly”
what do user report when using MDMA?
they report euprhoria, sense of emotional oneness with others, emotional openness, increased empathy or sympathy with others, increased energy, heightened sexual arousal and pleasure, increased sensory sensitivity; can cause potentially fatal hypnoatremia and hyperpyrexia
what is a CNS depressant, treatment for narcolepsy, metabolite of GABA; “date rape drug”; coma and seizures can occur; can result in nausea and breathing difficulties when combined with alcohol?
GHB
what are often taken at parties or raves, they are marketed under the names such as Nexus, Erox, Perfromax, Toonies, Bromo, Spectrum, and Venus?
designer MDMA
when do designer MDMA reach maximum effect?
in 15-30 minutes
when does designer MDMA plateau?
2-7 hours
what are opioid medication?
codeine, fentanyl, heroin, morphine, oxycodone, and hydrocodone
what is an increasing concern opioid medications?
heroin is replacing more expensive pharmaceuticals, cause high risk of unintentional OD because heroin can be cut with more potent drugs, or addicts who’ve been detoxed resume previous levels of use without first re-building tolerance
what are opiate withdrawal symptom?
rebound hyperexcitability
autonomic symptoms- diarrhea, rhinorrhea, diaphoresis, lacrimation, shivering, nausea, vomiting, fever, HTN, hypotension, bradycardia or tachycardia, piloerection
central nervous system- sleeplessness, restlessness, agitation, fasciculations and tremor, yawning, impaired concetration, dysphoria, irritability
pain- abdominal cramping, bone pain, backache, and diffuse muscle aching
what medications are used for opiate addiction?
LAAM- every other day
methadone taken daily
what are the actions of the medications used for opiate addiction?
both replace opiates and although addicting, they do not significantly impair functioning or produce significant euphoria
what is a narcotic antagonist, used in emergency treatment of opiate intoxication or overdose to reverse the effects of narcotic; causes immediate withdrawal by displacing opiates from receptors?
naloxone
what is taken every 3 days; mimics effects of narcotics in some ways but not others?
buprenorphine
what is the ceiling action of buprenorphine?
blocks further effects of opioids when present in higher amounts
what is used for detox in pregnancy?
buprenorphine
what are related opioid antagonists that reduce opioid receptor response to abused opioids, essentially blocking the effects of opioids; they reduce craving and relapse and treat opioid OD?
nalmfene
what are the side effects of nalmefene?
nausea and in high dosages can cause hepatocellular injury
what is a dsyfunctional coping pattern resulting from living in a committed relationship with a person with an alcohol, substance, or behavioral addiciton and sacrificing self for the relationships?
codependency
what are the signs of codependency?
staying in an abusive/unrewarding relationship; focusing on changing the other person while neglecting oneself; chronic pain, hurt, and strife
what is part of the assessment related to addiction?
reflect to increase own self awareness re: attitudes toward substance abuse
physical and mental status exams, laboratory test including tox screen
thorough, nonjudmental substance use history and related risk factors
motivation
codependency and enabling in family
corrobrate with family and/or friends
observe for denial, projection, rationalization
screening and rating questionnaires and scales
what are some nursing interventions and treatment modalities for substance abuse?
assure self awareness and continually monitor self for countertransference- assure objectivity (though do not need to compromise your own values)
administer prescribed medications and monitor response
address cognitive deficit- cognition (especially memory judgment) can be impaired for up to 2 months- repetition of teaching, visual cues and reminders, handouts, etc.
observe for and respond to risk of withdrawal and signs of withdrawal
assure adequate nutrition and rest
communicate the treatment plan to the patient and to others on teh treatment team
encourage recongition and honest expression of feelings
listen to what the individual is really saying
express caring for the individual
promote hopefulness, relapse happens, is normal never give up
hold the individual responsible for behavior
Talk about how specific actions contribute to negative responses in others, the costs of substance use vs the benefits
Guide pt to discover, use more adaptive ways of meeting needs, replacing what pt sees as benefits of using
Monitor for inappropriate behavior, e.g. encouraging substance use by others, bringing contraband into treatment setting, boundary violations, testing or violating limits
Cognitive and cognitive behavioral interventions to alter irrational/automatic thinking
Psychoeducation re: Harm-reduction strategies, relapse prevention; expect & plan for impaired memory
Group therapy = primary modality, EBP
12-step programs: AA, NA, AlAnon
For opiate addiction: Medication Assisted Treatment (MAT): supervised meds to replace opiates or to dull their effects, plus counseling and other services
Treat for related issues, e.g. loss, depression
Family therapy to increase understanding, counter co- dependence and enabling, reduce unhelpful responses’Brief Intervention Therapy (e.g. during ER visits)
*Teach re: how to reduce drug use (e.g. avoid all peers who use), cope with craving
*Provide harm reduction info and/or self-help manuals
*Giving info about the consequences of a drug conviction on travel, housing and employment;
*Provide info on and discuss harm reduction strategies, e.g. Overdose (e.g. use with peers, naloxone)
Violence reduction (victim and perpetrator)
Don’t drive under the influence
Safe practices (e.g. safe injecting, safe sex) *Offering and arranging a follow-up visit
what is the treatment for the person with a dual diagnosis?
first came the sequential treatment model (treat primary disorder first, then secondary disorder)
then came the parallel treatment model (treat both at once but in different settings)
what are the five principles to motivate change?
express empathy
develop discrepancy- help patient see contradictions in behavior, how actions interfere with goals
avoid arguments- be neutral, matter-of-fact
“roll” with resistance
support self-efficacy
what is professional treatment?
led by specially trained personnel, usually licensed; some are in recovery themselves
follow varying treatment models
may or may not include detox, pharmacological treatment
what are support groups/lay treatment?
Led by volunteers, may or may not have training
*Most are 12-step programs or incorporate their principles *Do not include detox, pharmacological treatments
*Group based—usually are open groups, open ended (no start or stop dates, addicts who want services now can drop in any time, in any meeting location
*Free—subsist on donated space & funds
*Access varies with the size of community; populous areas
have more #’ of groups, types of groups, and mtg times *Acceptance, peer support, informal education are stressed
*Usually tolerant of ambivalent members who vary in their commitment and degree of sobriety; most accept court- ordered members
what are the signs and symptoms of chemical dependency in nurses?
poor judgment and concentration
lying
volunteering to be the med nurse
high achievement, both as a student and a nurse
volunteering for overtime, extra duties
alcohol on breath
increased time in bathroom
forgetfulness
mood swings
inappropriate behavior
frequent days off
noncompliance with policies and procedures
deteriorating appearance
deteriorating job performance, increased errors
sloppy, poor quality charting
