Week 11: Substance abuse Flashcards
What topics did the clinician raise during the
“Provide feedback” part of the interview
Outlined the risk category
Explained guidelines and specific recommendations
Discussed medical consequences
Connected drinking habits to specific problems (BP)
- Enhance motivation clinician strategies
- Reasons patient IDed for wanting to reduce drinking
Used readiness for change ruler
Jill IDs blood pressure and recent fall as consequences
Jill IDs other harmful consequences
Use
Ingestion, smoking, sniffing, or injection of mind-altering substance
Misuse*
Use of prescribed drugs in a way that deviates from expected use
Abuse*
Use of a substance in a way that deviates from approved social or medical patterns
Tolerance*
Pattern in which higher doses are needed to achieve same effect
Withdrawal*
Symptoms occurring when substance is no longer used
Physical dependence***
Physiological effects of multiple episodes of substance use
Behavioral dependence*
Substance-seeking activities and related evidence of pathological use (cravings, mood changes related to use)
Hazardous/risky/harmful use***
Lesser form of substance use, does not meet criteria for substance use disorder,
but intervention is warranted
Addiction***
Continued use despite adverse consequences, deprivation of substance causes sig. distress and an irresistible urge to use
Substance use disorder***
Occurs when individual continues using substance despite cog, behavioral, and physiological symptoms. Substance use disorder occurs when there is an underlying change in brain circuitry that may persist after detox
SBIRT
Screening
Brief Interview
Refer to treatment
Risky drinking - Healthy men under age 65
- more than 4 drinks in a day
- more than 14 drinks a week
For all healthy women and healthy men over age 65
- more than 3 drinks in a day AND
- more than 7 drinks in a week
Pyramid of alcohol use
1: 3-7% drinkers with an alcohol use disorder
2: 10-15% hazardous drinkers
3: 35-40% low-risk drinkers
4: 40% abstainers
What part of pyramid does CAGE target
Rank 1: alcohol use disorder
What part of pyramid does AUDIT target
Rank 2: hazardous drinkers
Brief intervention steps
- raise the subject
- provide feedback
- enhance motivation
- negotiate and advise
Enhance motivation considerations
Assess readiness for change (use rulers)
Explore pros and cons
Develop discrepancy
Elicit their reasons for change
Audit questions
- How often do you have a drink containing alcohol
- How many drinks containing alcohol do you have on a typical day when you are drinking
- Wo often do you have 5 or more drinks on one occasion
AUDIT positive scoring
Men – 4 or more
Women – 3 or more
Older adults – 3 or more
8 or above suggests AUD
CAGE
C – thought to cut down on you drinking or durg use
A – have people annoyed you by criticizing your drinking or drug use
G – have you felt bad or guilty about your drinking or durg use
E – Have you ever had a drink or used drugs first thing in the morning? (Eye-opener)
DAST scoring
1-2: low level of risk – monitor, reassess later
3-5: moderate level of risk – further investigation needed
6-8: substantial risk – intensive assessment needed
4 microskills of motivational interviewing
OARs
O - open-ended questions
A – affirmations
R – reflections
S – summarize
Assumptions to avoid with regards to stages of behavior change
- That person’s health should be primary motivation
- That patients are either motivated to change or not
- That now is the right time to consider change
- That change needs a tough approach/discipline that the patient lacks
- That patient should seize this opportunity with an expert
- That consultation was a failure if patient decides not to change
Rulers (2)***
Readiness ruler
Confidence ruler
Effective elements of Brief Intervention (FRAMES)***
Feedback Responsibility Advice Menu Empathic Counseling Self-efficacy
Substance Use Disorder dx criteria***
Substance use disorder qualifiers
Problematic pattern of substance use leading to clinically sig. impairment or distress w/n a 12 month period
Manifested by 2 or more qualifiers
- substance taken in large amounts
- persistent desire/unsuccessful effort to cut down
- significant amount of time spent trying to obtain the substance
- important activities are given up or reduced
- continued use despite recurrent social or interpersonal problems
- recurrent use despite failure to fulfill major role obligations
- recurrent use of alcohol in situations which are hazardous
- use despite knowledge that physical problem is caused by substance
- tolerance, withdrawal, cravings
Standard drink and NIAA guidelines***
12 oz (5%) beer
8-9 oz malt liquor (7%)
5 oz wine (12%)
1.5 oz (40%)
alcohol Withdrawal syndrome (4)
Tremors
Seizures
Elevated temp, pulse, BP
Delirium tremens
Wernicke encephalopathy
Cause
Caused by thiamine deficiency (treated by administering vitamin B)
Wernicke encephalopathy
s/s
(5)
Visual impairments Ataxia Hypotension Confusion Coma
Korsakoff amnestic syndrome
Cause
Multi-organ infovlentme caused by long term alcohol use
Primary problem is difficulty acquiring new info and inability in retrieving memories
Korsakoff amnesic syndrome
s/s
Attention deficit Disorientation Visual impairments Amnesia Use of confabulatio
S/s delirium tremens
Seizures, hallucination, disorientation, fever, high blood pressure, heavy sweating
CIWA scoring
for monitoring severity of alcohol withdrawal symptoms
0-9: absent or minimal withdrawal (PRN med)
10-19: mild-moderate (scheduled + prn)
20+: severe withdrawal (hourly eval)
35+: consider ICU xfer
When can delirium tremens occur
Anytime during first week after last drink
relapse prevention medication
disulfiram
naltrexone
opioid effects
Euphoria Sedation Analgesia Constipation Constricted pupils
Opioid Withdrawal syndrome
Rebound hyperexcitability restlessness Irritability Nausea Diarrhea Goose flesh Dilated pupils Increased BP Increased HR
Dysphoria, Pupillary dilation Piloerection Yawning Muscle aches Lacrimation Rhinorrhea Nausea Fever Sweating Vomiting Diarrhea
opioid addiction Maintenance tx
Methadone therapy with behavioral therapy and counseling
Naltrexone
Buprenorphine
Initial onset and duration opioid withdrawal
8-12 h after last use of short-acting opiods
1-3 days after last use for longer acting
Severe symptoms peak between 48-72 hrs
Symptoms abate in 7-10 days for short acting opioids
Methadone duration can be several weeks
Disulfiram:
Class
MOA
Considerations
Anti-alcoholic agent, enzyme inhibitor
Inhibits metabolism of alcohol, accumulated concentration oaf acetaldehyde – sickness
Only for very motivated patients
Take daily
NO alcohol
Do not administer until 12 hrs after alcohol use
Naltrexone: Class Indication MOA Consideration
Opiod antagonist
Narcotic or alcohol dependence
Blocks opioid receptors – reduced craving
Cannot be used with opioid analgesics
Naloxone: Class Indication Route Onset Consideration
Opioid antagonist
Rescue drug to reverse opioid OD
IV, IM, intranasal
2-5 minutes
Rescue breathing while you wait for effect!
Methadone: Class MOA Indication Administration Half-life SE Education
Opioid agonist
Occupies opioid receptors without the subjective high,
Can satisfy craving
Maintenance tx
-dosed daily in conjunction with consueling
15 to 30 hours
Sedation
Respiratory depression
Constipation
Impaired cognition
Take as prescribed Avoid alcohol Take with food while lying quietiely to minimize nausea Eat small frequent meals Avoid driving if dizzy Use mild laxative
Assessment
Substance use history -frequency, duration, binge -hx withdrawal -consequences of use -loss of control -desire/efforts to decrease/control use -preoccupation with use -social vocational or recreational activities affected by use Asses denial of problem Assess for physiological complications Assess motivation for change Assess co-dependence
Interventions
Therapeutic interactions Monitor for SE SBIRT (BI specifically) CBT Psychoeducation Coping skills enhancement (25.13) Refer to group therapy and early recovery Refer to individual and family therapy Harm-reduction strategies 12 step program (25.14)
Therapeutic relationship
- establish trust and rapport
- encourage hones expression
- listen
- caring
- hold individual responsible
- provide consistent consequences
- communicate tx plan
- monitor own reactions
- confrontation
