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Chapter 22

Substance-Related & Addictive


Disorders

Substance Disorders
Substance disorders are not
disorders of choice. They are
complex diseases of the brain
represented by craving, seeking, and
using regardless of consequences
(National Institute on Drug Abuse
[NIDA], 2010). Varcarolis, 2013

Substance-Use Disorders

Alcohol Use Disorder


Alcohol Intoxication
Alcohol Withdrawal
Stimulant Use Disorder
Stimulant Intoxication
Stimulant Withdrawal
Caffeine Intoxication
Caffeine Withdrawal
Not a Substance Use Disorder

Cannabis Use Disorder


Cannabis Intoxication
Cannabis Withdrawal
Cocaine Use Disorder
Cocaine Intoxication
Cocaine Withdrawal
Other Hallucinogen Use Disorder
Other Hallucinogen Intoxication No WD
Inhalant Use Disorder
Inhalant Intoxication No WD

Disorders, cont.

Tobacco Use Disorder


Tobacco Withdrawal
Opioid Use Disorder
Opioid Intoxication
Opioid Withdrawal
Phencyclidine Use Disorder
Phencyclidine Intoxication
No WD

Sedative-, Hypnotic-, or Anxiolytic Dependence Use Disorder


Sedative-, Hypnotic-, or Anxiolytic Intoxication
Sedative-, Hypnotic-, or Anxiolytic Dependence Withdrawal
Other (or Unknown) Substance-Related Disorders
Other (or Unknown) Substance Use Disorder
Other (or Unknown) Substance Intoxication
Other (or Unknown) Substance Withdrawal
Gambling Disorder

Important Definitions
Addiction
Obsession, compulsion, or loss of control with respect to use
of a drug (e.g., alcohol), with genetic, psychosocial, and
environmental factors that influence its development. Use of
the drug continues despite the presence of related problems
and a tendency to relapse after stopping use.
Tolerance
Persons physiological reaction to drug decreases with
repeated administration of same dose
Withdrawal
physiological & psychological changes that occur when blood
and tissue concentrations of drug decrease after heavy
prolonged use of substance
5

Important Definitions, cont.


Intoxication
Maladaptive behavioral or psychological
changes caused by excessive use of a
drug or alcohol.
Synergistic effect
when drugs are taken together, effect of
either or both is intensified or prolonged
Antagonistic effects
when drugs are taken together, effect of
one is inhibited or weakened
6

Drugs of Abuse

Alcohol
MDMA (Ecstasy)
Methamphetamine
LSD (Acid)
Heroin
PCP/Phencyclidine
Prescription Drugs
Steroids (Anabolic)

Marijuana
Fentanyl
Inhalants
Cocaine
Designer Drugs

http://www.drugabuse.gov/drugs-abuse/commonly
-abused-drugs/commonly-abused-drugs-chart
7

The Brain & Drugs


Most drugs of abuse target the
brain's reward system by flooding the
reward circuit with dopamine
Continuous use results in actual
changes in the brain structure and
function of the limbic system

Substance-Use Disorders
Pathological pattern of behavior related
to use of substance characterized by:

Impaired control
social impairment
risky use
pharmacological criteria

Impaired Control
1.

The substance is often taken in larger amounts or over a


longer period than was intended
2. Persistent desire or unsuccessful efforts to cut down or control
use
3. A great deal of time is spent
. Obtaining the substance
. Using the substance
. Recovering from the effects
. In severe substance use disorders, most daily activities
revolve around the substance
4. Craving so strong an urge that the person cannot think of
anything else. Involves reward circuits and classical
conditioning. Tendency to relapse.
10

Social Impairment
5.
6.
7.

Recurrent substance use may result in a failure to fulfil


major role obligations at work, school, or home
Continued substance use despite having persistent or
recurrent social or interpersonal problems
Important social, occupational, or recreational activities
may be given up or reduced because of substance use.
Individual may withdraw from family activities and hobbies
to use substance

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Risky Use
8. Recurrent use in situations in which it is
physically
hazardous (e.g. driving)
9. May continue to use despite knowledge of
having a persistent or recurrent physical or
psychological problem that is likely caused
by the substance

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Pharmacological Criteria
10.Tolerance
11.Withdrawal
Tolerance & withdrawal are present for
those with a substance use disorder as
well as for those taking prescribed
medications as part of medical treatment.
The latter group should not receive a
diagnosis of Substance Use Disorder.

Severity & Specifiers


A broad range from mild to severe;
generally severity is based on # of
symptoms endorsed
mild= 2-3 symptoms
moderate=4-5 symptoms
severe = 6 or more

Substance-Induced Disorders
Overall category includes intoxication,
withdrawal, and other
substance/medication induced mental
disorders (e.g., substance-induced
psychotic disorder, substance-induced
depressive disorder)

15

Criteria for Substance


Intoxication
A. Essential feature is development of a reversible
substance-specific syndrome due to the most recent
ingestion of a substance
B. Significant maladaptive behavioral or psychological
changes associated with intoxication (e.g., belligerence,
mood lability, impaired judgment) that are due to the
effect of the substance on the CNS and develop during
or shortly after use of the substance
C. Symptoms not due to a general medical condition and
not better accounted for by another mental disorder

Etiology - Biological factors


Genetics: apparent hereditary factor, particularly
with alcoholism
Two major methods of investigating the
inheritance of alcoholism are studies of twins
and of adoptees.
Twin studies compare the incidence of
alcoholism in identical twins with the incidence
of alcoholism in fraternal twins. If there is a
genetic component in the risk for alcoholism,
then identical twins, who have identical genes,
would be expected to exhibit similar histories
of developing alcoholism (or not developing
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alcoholism).

Etiology-Genetics (cont.)
Fraternal twins, who are genetically
different individuals born at the
same time, would be more likely to
differ in their tendencies to develop
alcoholism. In general, researchers
using the twin method have found
these expectations to be true
(Pickens, R.W., Svikis, D.S., McGue,
M., Lykken, D.T., Heston, L.L., &
18

Etiology-Genetics (cont.)
Adoption studies may employ a number
of techniques. One is to compare the
histories of children of alcoholics who are
adopted by nonalcoholics and grow up in a
nondrinking environment with the histories
of children of nonalcoholics similarly raised
in a nondrinking environment. If genetic
factors play a role, then the adopted
children of alcoholics should preferentially
develop alcoholism as adults.
Cloninger, C.R. Bohman, M.& Sigvardsson,
S., (1981) found this to be true.
19

Etiology (cont.)
Specific genetic markers: Dopamine D2 receptors
are being investigated without evidence to
suggest its role.
To search the human genome for specific genes
related to alcoholism, researchers employ two
experimental techniques. The first, the candidate
gene approach, involves hypothesizing that
particular genes are related to the physiology of
alcoholism and then individually testing these
genes for linkage.
The second approach, scanning of the human
genome, involves characterizing, piece by piece,
the entire length of DNA and finding genes that
relate to alcoholism, without proposing candidate
20
genes.

Etiology (cont.)
Alcohol may produce morphine-like
substances in the brain that are responsible
for alcohol addiction
Siggins, G., et al (2004) looked at the effect
of alcohol and a common stress-related
neuropeptide, corticotropin releasing factor
(CRF), on a neurotransmitter called gamma
amino butyric acid (GABA).
Both appear to influence neurotransmission
in the amygdala, the so-called pleasure
center of the brain, by increasing the
transmission of one particular
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neurotransmitter, (GABA).

Psychological factors
Lack of tolerance for frustration and
pain
Lack of success in life
Lack of affectionate and meaningful
relationships
Low self-esteem, lack of self-regard
Risk-taking propensity

Sociocultural factors
Social and cultural norms, social
learning (families, peer groups)
Socioeconomic stress
Conditioning: pleasurable effects from
substance use act as a positive
reinforcement for continued use of
substance
Cultural and ethnic influences: some
cultures are more prone to the abuse
of substances than others
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Application of the Nursing


Process
Nurses must begin relationship
development with a substance user
by examining own attitudes and
drinking/substance use habits.

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General Assessment

Two questions of importance


1. In the last year, have you ever drank or used drugs
more than you meant to?
2. Have you felt you wanted or needed to cut down
on your drinking or drug use in the last year?

Details include
. Drugs used

25

Route
Quantity
Time of last use
Usual pattern of use

Assessment Guidelines
for the Chemically Impaired
Assess for withdrawal syndrome
Assess for overdose that warrants medical attention
Assess for suicidal thoughts or other self-destructive
behaviors
Evaluate for physical complications related to drug abuse
Explore interests in doing something about drug or alcohol
problem
Assess patient and family for knowledge of community
resources

26

Assessment
Amount and type of alcohol or drugs
(AOD), including prescription
medication
Method of administration, including
injection, snorting, smoking, or drinking
Physical signs of drug use, such as
needle track marks, emaciation, and
alcohol odor
History and onset of drug use
History of attempts to quit AOD use
History of physical withdrawal
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Assessment (cont.)
Blood and urine drug screens (Positive
drug test results prevents AOD
minimization)
Blood alcohol concentration (BAC) of .
08%, or 80mg/DL constitutes legal
intoxication in all United States.
Use screening assessment tools
Medical problems associated with AOD
in client and family members (e.g. HIV,
TB, Hep B, and Hep C, Hep D (a
combination of B & D, D uses a protein
that B makes)
28

Assessment (cont.)
Tolerance (High tolerance suggests that a
client has a history of heavy drinking or
drug use.)
Episodes of uncontrolled drug or alcohol
use, binges, or overdoses
Drug use behavior (e.g., does client use
drugs alone? For sex? To go to work?)
Use of AODs for "self-medication" of painful
and unpleasant emotions
Attempts to hide use
Family dysfunction relative to AOD abuse
29

Assessment Tools
Various assessment tools are
available for determining the extent
of the problem a client has with
substances. Two of the common tools
are:
Michigan Alcoholism Screening Test
(MAST)
CAGE Questionnaire

30

Short Michigan Alcohol


Screening Test
A 13-item questionnaire that requires
a 7th grade reading level, and only a
few minutes to complete. Developed
from the Michigan Alcoholism
Screening Test. Evaluation data
indicate that it is an effective
diagnostic instrument, and does not
have a tendency for false positives,
as does the Michigan Alcoholism
Screening Test. Research
31

CAGE Questionnaire
Have you ever felt you should Cut down
on your drinking?
Have people Annoyed you by criticizing
your drinking?
Have you ever felt bad or Guilty about
your drinking?
Have you ever had a drink first thing in
the morning to steady your nerves (Eyeopener)?
32

CAGE-AID (adapted to include


drugs)
Studies reveal that two "yes" answers to the
CAGE questionnaire will correctly identify 75
percent of the alcoholics who respond to it
and accurately eliminate 96 percent of nonalcoholic. Modifying the CAGE questionnaire
for other drugs involves simply substituting
"drug use" for "drinking" in the first three
questions, and asking for the fourth
question, "Do you use one drug to change
the effects of another drug?" or "Do you
ever use drugs first thing in the morning to
`take the edge off'?"
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Interview Approaches
Manner that encourages
forthrightness: matter of fact,
nonjudgmental
Be prepared for defensiveness:
Genuine concern helps overcome this
Be aware of own feelings and avoid
projecting negative attitudes onto
client
Get accurate information: High
priority
Initially focus on legal drug use:
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Interview Approaches - (contd)


Use nonthreatening language
Problem with drinking
Difficulties with drug use
Problems because of drinking
Using more than intended

35

Nurse-client Relationship

Build trust
Be genuine, empathic
Apply rules consistently
Instill hope
Confront denial
Manage manipulation

36

Alcohol-Related Disorders
Millions of Americans suffer from
alcohol related disorders and 25% of
all hospitalized clients have problems
related to alcohol, therefore nurses
must become familiar with a variety
of alcohol-related crises.

37

Alcohol Use Disorder


Clients who abuse alcohol may present
to emergency rooms in various stages
of intoxication and for a variety of
reasons.
Clients may require treatment for:
alcohol-related illness (e.g., pancreatitis)
symptoms of withdrawal
alcohol-related mood and behavioural
disturbances (e.g., violence, suicidal
depression)
they request assistance in quitting
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Alcohol Intoxication (cont.)


Behavioural manifestations of alcohol
intoxication vary with the blood alcohol level
(BAC). As tolerance develops, more alcohol is
required to produce signs of intoxication.
Most will show signs of intoxication (e.g., ataxia,
slowing) at 100 mg/dL (.10%), but behavioural
and mood changes can occur at lower levels
(remember legal limit is 0.08%).
Acute toxicity - levels of 350 mg/dL or > may
lead to coma, depending on the degree of
physical dependence.
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Alcohol Intoxication (cont.)


Intoxicated clients should be
screened for suicidal and homicidal
ideation.
All intoxicated clients must be
detained in the emergency room
until they are no longer legally drunk.
Clients must be observed for signs
and symptoms of withdrawal.

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Signs of Intoxication & Withdrawal


Alcohol
Large amounts of alcohol consumed quickly or over
time

Alcohol withdrawal
Signs develop within a few hours after cessation
Peaks at 24 to 48 hours

Alcohol withdrawal delirium


Medical emergency
Can result in death, even if treated

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Alcohol Withdrawal
Withdrawal can be fatal.
Withdrawal is precipitated by a
decrease in alcohol consumption and
may be delayed by concomitant use
of benzodiazepines, barbiturates,
and general anesthesia (all crosstolerant with alcohol).

42

Alcohol Withdrawal (cont.)


Signs of withdrawal (see CIWA-AR)
include:
tremor, anxiety, sleeplessness,
restlessness, sleep disturbances, and
elevation of pulse and blood pressure.
May report transient, poorly formed
hallucinations, illusions, or vivid
nightmares.
Nausea & vomiting may also be present.
Symptoms usually begin within the first 12
hours of abstinence, and peak within 24 to
72 hours of cessation, or reduction in,
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heavy and prolonged alcohol use.

Alcohol Withdrawal (cont.)


Degree of withdrawal S&S is
commensurate with the degree of
physical dependence, and length of
time substance has been abused.
Withdrawal S&S can last up to 1
week - can be longer if complicated
by Delirium Tremens.
44

Delirium Tremens
Alcohol withdrawal that is a medical
emergency - Peaks 24 to 72 hours after
cessation - Usually lasts 2-3 days, but
can up to 10.
Delirium, extreme restlessness & agitation,
tachycardia, diaphoresis, hypertension,
fever (100-103). Grand mal seizures after
heavy use.
Severe disturbance in sensorium
(disorientation and clouding of
consciousness).
Visual or tactile hallucinations.
45
Paranoid delusions.

Effects of Alcohol on the body


Peripheral neuropathy characterized
by:
Peripheral nerve damage

Pain
Burning
Tingling
Prickly sensations of the extremities

46

Effects on Body
Alcohol myopathy
Thought to result from vitamin B1
deficiency
Acute: pain, tenderness, and edema in
certain skeletal muscles and muscles of
the thoracic cage
Chronic: gradual wasting and weakness
in skeletal muscles

47

Effects on Body (cont.)


Alcoholic cardiomyopathy general
deterioration of the heart muscle
ischemia leads to heart failure
(symptoms include dyspnea,
peripheral edema & arrhythmias)
Effect of alcohol on the heart is an
accumulation of lipids in the
myocardial cells, resulting in
enlargement and a weakened
condition.
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Effects on Body (cont.)


Esophagitis
Inflammation and pain in the esophagus
occur because of the toxic effects of
alcohol on the esophageal mucosa and
because of frequent vomiting associated with
alcohol abuse.
Gastritis
Effects of alcohol on the stomach include
inflammation of stomach lining characterized
by epigastric distress, nausea, vomiting &
distention
49

Effects on Body (cont.)


Pancreatitis
Chronic: leads to pancreatic insufficiency
resulting in steatorrhea, malnutrition,
weight loss, and diabetes mellitus
Alcoholic hepatitis
Often follows a severe prolonged bout of
drinking and is usually superimposed on an
already damaged liver; characterized by a
syndrome of inflammation and necrosis

50

51

52

Effects on Body (cont.)


Cirrhosis of the liver
The end-stage of alcoholic liver disease and
believed to be caused by the direct toxic effect
of alcohol on the liver. There is widespread
destruction of liver cells, which are replaced by
fibrous (scar) tissue.
Portal hypertension: elevation of blood pressure
through the portal circulation - results from
defective blood flow through cirrhotic liver
Ascites: a condition in which an excessive
amount of serous fluid accumulates in the
abdominal cavity; occurs in response to portal
hypertension
53

Cirrhosis of the liver (cont.)


Esophageal varices:
veins in the esophagus become distended
because of excessive pressure from defective
blood flow through the cirrhotic liver

Hepatic encephalopathy:
occurs in response to the inability of the
diseased liver to convert ammonia to urea for
excretion; the continued rise in serum
ammonia, if allowed to progress, leads to
coma and eventual death
54

Effects on Body (cont.)


Leukopenia - Production, function, and
movement of white blood cells impaired
Thrombocytopenia - Platelet production
& survival impaired as a result of toxic
effects of alcohol
Sexual dysfunction
In the short term, enhanced libido and
failure of erection common
Long-term effects include gynecomastia,
sterility, impotence, decreased libido
55

Effects on Body (cont.)


Wernickes encephalopathy
Most serious form of thiamine (Vit B1)
deficiency in alcoholic patients, and
damage to the thalamus, hypothalamus
and cerebral atrophy

Korsakoffs psychosis
Syndrome of confusion, loss of recent
memory, and confabulation in alcoholic
patients
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Effects of Alcoholism on the


Brain

Hemorrhagic necrosis of hypothalamus (A) and of mamillary bodies (B) in client


with alcoholism. 1 and 2, Wernicke's encephalopathy with damage to the
periaqueductal grey region.
Courtesy of Dr. Richard E. Powers, Director, University of Alabama at Birmingham, Brain Resource
Program. (From Keltner NL, Folks DG, Palmer CA, Powers RE: Psychobiological foundations of
psychiatric care, St. Louis, 1998, Mosby.)
57

Effects of Long-Term
Polysubstance Abuse on the
Brain

A, Normal brain. B, Brain of a person with alcoholism (40-years old).


Courtesy of Dr. Richard E. Powers, Director, University of Alabama at
Birmingham, Brain Resource Program. (From Keltner NL, Folks DG,
Palmer CA, Powers RE: Psychobiological foundations of psychiatric care,
St. Louis, 1998, Mosby.)
58

Intoxication, Withdrawal, &


Overdose
Any client presenting with altered
mental status, including confusion,
depression, stupor, psychosis, or
excitation, should be screened for
drugs of abuse (including alcohol).
Toxicity (possibly related to
overdose) from "legitimate" drugs
should also be considered.
59

Opiates
Opiates include heroin, morphine,
codeine, Oxycontin, Dilaudid,
methadone, meperidine (Demerol),
Percocet (Oxycodone), and others.
(Clients who have alcohol
intoxication may appear drowsy,
sometimes euphoric, tranquil, or
dulled.) Must assess carefully
Opiate users rarely present for
treatment of intoxication per se.
60

Opiates
Intoxication:
Constricted pupils, decreased
respiration, drowsiness, decreased blood
pressure, slurred speech, psychomotor
retardation, impaired judgment

61

Opiates - Withdrawal
Opiate withdrawal is an acute state
caused by cessation or dramatic
reduction of use of opiate drugs that
has been heavy and prolonged
(several weeks or longer).

62

Opiate Withdrawal (cont.)


These drugs can cause physical
dependence, which means that the
body reduces production of its own
natural opioids (endorphins and
enkephalins) and begins to rely on
the drug to manage the functions of
these natural brain chemicals.

63

Opiate Withdrawal (cont.)


Withdrawal symptoms begin 6-8 hours after last
dose, and though uncomfortable, are not lethal.

Anxiety, insomnia, sweating, rhinorrhea,


yawning, and lacrimation are early withdrawal
signs.

These progress to tremors, piloerection,


irritability.

Later, abdominal and muscle cramping, bone


pain, chills, diarrhea, and vomiting may occur.

About 24 hours after the last dose, pulse, blood


pressure, and temperature rise. Symptoms of
withdrawal peak at about 48-72 hours after the
last dose.
64

Opiate Withdrawal (cont.)


Clients exhibiting observable,
objective signs of withdrawal (e.g.,
elevated vital signs, dilated pupils,
sweating) may require inpatient
detoxification with methadone and/or
alleviation of autonomic instability
with clonidine.
Severe dehydration may require fluid
and electrolyte replacement.
65

Opiate Withdrawal (cont.)


Note: physical dependence is not
addiction, which is defined as
compulsive use of a substance despite
negative consequences.
Pain clients who use opiates as
prescribed for long periods of time can
develop physical dependence.
However, because they don't have the
psychological attachment to the drug
seen in addiction, withdrawal symptoms
are often less distressing.
66

Opiate Withdrawal
Complications
The biggest complication is return to drug
use.
Most opiate overdose deaths occur in
people who have just withdrawn or
detoxed. Because withdrawal reduces a
previously-developed tolerance, recently
withdrawn addicts can overdose on a
much smaller dose than they used to take
daily.
Addicts should be warned about this
possibility.
67

Opiates & Overdose


Overdose with opiates constitutes a
medical emergency as respiratory
depression and coma may result.
Induction of emesis (if client is alert)
and reversal of the opiate effect with
Narcan (naloxone), (if client is drowsy or
comatose) are standard parts of
treatment of opiate overdose.
Comatose clients require airway
management, possibly including
ventilation.
68

Opiate Withdrawal
Complications
Addicts withdrawing from opiates
should be assessed for depression
and other mental illnesses.

Appropriate treatment of such


disorders can reduce the risk of
relapse, and antidepressant
medications should not be withheld
with the idea that the depression is
only related to withdrawal and not a
pre-existing condition.
69

Treatment Approaches
Basic treatment approaches used for
managing opiate withdrawal include:
treating the symptoms of the withdrawal
with appropriate medications on an asneeded basis.
replace the client's drug of choice with, a
long-acting, cross-tolerant substitute, such
as methadone, levomethadyl
treating with an opioid antagonist, such as
naltrexone,
treating with an agonist/antagonist, e.g.
70
Suboxone, or partial agonist - Subutex

Rapid opiate detoxification


(ROD)
A treatment option for opiate
withdrawal, the ROD method is
reported to be faster and to cause
less physical discomfort than
traditional forms of opiate
detoxification.
The treatment is typically performed
in a hospital or private clinic setting.
71

Rapid opiate detoxification


(ROD)
Naltrexone, an opiate antagonistic that
blocks opiate receptors and reverses
the effects of opiates, is administered
to trigger the withdrawal response.
Clonidine is given simultaneously to
ease the symptoms of withdrawal.
The client is anesthetized throughout
the three to four hour procedure, and
withdrawal occurs while the client
sleeps.
Vital signs are monitored closely and a
ventilator may be employed.
72

Opiate Treatment
Approaches
Longer term treatment is
recommended for most addicts
following withdrawal.
This can include self-help groups, like
Narcotics Anonymous or SMART
Recovery, out-patient counseling,
intensive out-patient treatment
(partial hospitalization), or in-patient
treatment.
73

Treatment Approaches,
cont.
It is important to note that methadone withdrawal
treatment differs from a methadone maintenance
program, in which clients who are unwilling to give
up opiates are prescribed methadone as a legal,
long-term substitute for their drug of choice.
Treatment goals should be discussed with the client
and recommendations for care made accordingly.
If an opiate addict has withdrawn repeatedly only to
relapse repeatedly, methadone maintenance or
suboxone is strongly recommended.
74

Opiates-IV use
It should be noted that intravenous
drug users are at risk for such
diseases as endocarditis, hepatitis,
and human immunodeficiency virus
infection and should be offered
appropriate screening.

75

Central Nervous System


Depressants
Drugs in this category cover a wide
gamut, including barbiturates and
benzodiazepines, as well as alcohol
CNS Depressants & Intoxication
As in the case of opiates, clients who are
intoxicated on these agents rarely seek
treatment. Such clients appear drunk,
possibly giddy, and disinhibited or violent in
early phases of intoxication and
uncoordinated and slowed in later stages.
76

CNS Depressants & WD


Treatment of withdrawal consists of
medical support and detoxification
with a long-acting drug to which the
client is cross-tolerant (particularly a
long-acting benzodiazepine or
barbiturate).
In reliable clients, mild withdrawal
may be treated on an out-patient
basis using a benzodiazepine.

77

Treatment of overdose
Mainly supportive (e.g., airway protection).
Romazicon (flumazenil) may be given to reverse the
effects of benzodiazepines, but it must be used with
caution, as clients who are physically dependent on
benzodiazepines may develop seizures following the
use of this agent.
It cannot be given to reverse the effects of
barbiturates. There is NO ANTIDOTE to reverse
Barbiturate toxicity.

78

Cocaine and Crack


Extracted from leaf of coca bush
When smoked, takes effect in 4 to 6 seconds; a
5- to 7-minute high follows, then a deep depression
Two main effects on body
Anesthetic
Stimulant

Produces imbalance in neurotransmitters

79

Central Nervous System Stimulants


Common signs of stimulant abuse
Dilation of the pupils
Dryness of the oronasal cavity
Excessive motor activity

Cocaine and crack


Caffeine and nicotine

80

Central Nervous System


Stimulants

Stimulants are both prescribed and those


substances that are illicit. (also includes caffeine
& nicotine.)
Mild intoxication includes euphoria and feelings of
increased ability and self-confidence. Dilated
pupils and adrenergic stimulation occur.
Increased sexual behaviour, irritability, emotional
lability & violence may be seen.
Severe intoxication may result in psychotic
behavior, such as repetitive motions, paranoia,
ideas of reference, and hallucinations.
Autonomic hyperactivity, resulting in extremely
elevated pulse & blood pressure, may be life
threatening. Evidence of toxicity is characterized
81
by convulsions, tachycardia, hypertension,
chest

CNS Stimulants &


Withdrawal
Treatment is directed toward managing the
effects of adrenergic stimulation (e.g.,
tachycardia, seizures, and psychotic
symptoms).
Stimulants are sympathomimetic agents
(mimic effects of epinephrine & dopamine);
the increased blood pressure resulting from
their use predisposes to aortic dissection and
ischemic events.

82

CNS Stimulants &


Withdrawal
Clients withdrawing from central
nervous system stimulants may
develop extreme fatigue,
hyperphagia, and hypersomnia.
Severe depression and suicidal
ideation are common, and such
clients should be evaluated and
protected if necessary.

83

Marijuana (Cannabis sativa)


Indian hemp plant - Tetrahydrocannabinol (THC)
is active ingredient
Depressant and hallucinogenic properties
Usually smoked
Desired effects euphoria, detachment,
relaxation
Long-term effects lethargy, anhedonia, difficulty
concentrating, loss of memory
Toxicity may be attributed to other toxic
substances found in Cannabis. Symptoms may
include paranoia, psychotic behavior, respiratory
illnesses, lung cancer, reproductive problems.
84

Hallucinogens
Clients who take hallucinogens (LSD,
Mescaline, Psilocybin, khat, other designer
drugs, etc.) most commonly seek treatment
for confusional states, psychosis, or
flashbacks.
Such individuals become frightened of the
disorganization and sense of loss of control
caused by the drug, fearing that they are
losing their mind.
These clients should not be left alone, should
be allowed to rest in a quiet environment, and
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should be reassured that the strange

Designer Drugs
Common drugs
Ecstasy - also called MDMA, Adam, yaba, XTC
MDA love
MDE Eve

Produce subjective effects resembling


stimulants and hallucinogens

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Hallucinogen Intoxication
Intoxication: Pupils dilated, tachycardia, palpitations,
diaphoresis, tremors, incoordination, elevated temp,
pulse, respiration.
In severe cases, a benzodiazepine may help the client to
relax.
Antipsychotic agents & drugs with anticholinergic
properties (e.g., Thorazine) should be avoided because
they can add to the delirium.
These clients require close observation, and sometimes
restraints (only if they are a danger to self or others) until
the drug is eliminated.

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Hallucinogens
Some clients, usually those with underlying psychiatric
disorders, continue to display psychotic symptoms after
the drug has been cleared from the body.
They may require hospitalization and treatment with
psychotropic agents.
Other clients have "flashbacks" or brief periods of
perceptual distortion or depersonalization that mirror the
drug experience.
Treatment consists of reassurance that if the client
refrains from drug use, flashbacks will not persist.

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Phencyclidine
Phencyclidine (PCP) may mimic
depressants, stimulants,
hallucinogens, or analgesics,
depending on the drug dose.
Clients may be brought to ED
because of bizarre behavior such as
posturing or staring into space or
psychotic, unstable or violent.
Nystagmus, hypertension, and
drooling in a client presenting
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Phencyclidine & Treatment


Autonomic instability and seizures may also
occur with PCP, so clients require frequent
observation with measurements of vital
signs to ensure that immediate medical
management can occur.
Some clinicians also recommend
acidification of the urine.
Some individuals develop a prolonged
psychosis after ingesting PCP, and require
hospitalization, since the phenomenon may
last weeks to months.
90

Date Rape Drugs


Flunitrazepam (Rohypnol or roofies)
Gamma hydroxybutyric acid (GHB)
Rapidly produce
Disinhibition
Relaxation of voluntary muscles
Anterograde amnesia

91

Inhalants
Volatile solvents
Spray paint
Glue
Cigarette lighter fluid
Propellant gases used in aerosols

92

Issues in Recovery

Confrontation denial is significant


Personal responsibility
Conscience development
Lifestyle changes

93

Pharmacological Interventions
Treatment of Alcoholism
Naltrexone (ReVia)
Reduces or eliminates alcohol craving

Acamprosate (Campral)
Helps client abstain from alcohol

Topiramate (Topamax)
Works to decrease alcohol cravings

Disulfiram (Antabuse)
Alcohol-disulfiram reaction causes unpleasant
physical effects
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Pharmacological Interventions
Treatment of Opioid Addiction
Methadone (Dolophine)
Synthetic opiate blocks craving for and effects of heroin

LAAM (l--acetylmethadol)
An alternative to methadone

Naltrexone (ReVia)
Antagonist that blocks euphoric effects of opioids

Clonidine (Catapres)
Effective somatic treatment when combined with naltrexone

Buprenorphine (Subutex) (see also Suboxone)


Blocks signs and symptoms of opioid withdrawal. Only
recommended for 1st few days

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Pharmacological Interventions (contd)


Stimulants
Dopaminergics
Anticonvulsants
TCAs
Tyrosine, phenylalanine

Hallucinogens
Diazepam

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Dual Diagnosis
The presence of at least one
psychiatric disorder in addition to a
substance abuse or dependency
problem

97

Comorbidity
Psychiatric Comorbidity - 51% of
people with a serious mental illness
are dependent on or addicted to an
illicit drug.
People with comorbidity often have
chronic medical, social, and
emotional problems.

98

Which Comes First?


Mental illness precedes substance
abuse
Heredity, biologic factors predispose to
substance problems
Use substances to self-medicate psychotic
symptoms
Relieve side effects of antipsychotics

Substance abuse precedes mental


illness
Chemicals can induce psychiatric problems,
alter dopamine system, increase positive
symptoms of schizophrenia, lead99 to guilt,
depression, altered self-esteem

Treatment Issues
Treat mental illness, then substance
abuse
or
Treat substance abuse, then mental
illness
Result: Inadequate treatment
Integrated programs provide holistic
treatment
100

Family Functioning
Substance abuse is a family problem
Dysfunctional family patterns
Ineffective communication
Codependency/enabling
Adult children of alcoholics

101

Potential Nursing Diagnoses

102

Imbalanced nutrition: less than body requirements


Disturbed thought processes
Disturbed sleep patterns
Ineffective health maintenance
Hopelessness
Risk for suicide
Risk for other-directed violence
Ineffective airway clearance
Ineffective breathing pattern

Useful NANDA Diagnoses


Anxiety
Communication, verbal,
impaired
Coping, ineffective
Family processes,
interrupted
Helplessness
Injury, risk for
Knowledge, deficient
Noncompliance
Parenting, impaired

Powerlessness
Self-esteem, chronic
low
Sensory perception,
disturbed
Sexual dysfunction
Sleep patterns,
disturbed
Social isolation
Spiritual distress
Thought processes,
disturbed
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Outcome
Identification/Planning
Based on the assessment data, select
outcomes appropriate to the nursing diagnoses
Reduce or eliminate alcohol or drug use
Improve quality of life through abstinence
Improve quality of family life

Priorities of care for clients with substance use


disorders are as follows:
Maintain safety of client and others
Maintain abstinence
Assume responsibility for own behavior

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Outcomes Identification,
cont.
Withdrawal

Fluid balance
Neurological status: consciousness
Distorted thoughts

Initial and active drug treatment


Risk control alcohol use
Risk control drug use
Substance addiction consequences

Health maintenance
Knowledge: substance abuse control
Family coping
105

Nursing Interventions
Assessment
Establish trust using empathy,
nonjudgmental attitude
Involve client in outcome
identification
Monitor symptoms: mental illness,
substance withdrawal, medication
effects, side effects
106

Nursing Interventions (contd)


Teach
Effects of ETOH and drugs
Results of combining ETOH and other drugs
Signs of relapse of mental illness and
substance abuse
Relapse prevention strategies

Support medication compliance


Provide assistance with interferences to
compliance
Teach side effect management
107

Intervention Strategies, cont.

108

Relapse prevention
Self-help groups for patient and family
12-Step programs
Residential programs
Intensive outpatient programs
Outpatient drug-free programs and
employee assistance programs

Implementation
Two phases of treatment
interventions:
1. Crisis intervention
2. Long-term abstinence

109

Implementation
Aim of treatment self-responsibility
Challenge matching patients with types
of treatment related to various needs
Physiological
Psychological
Sociocultural processes

110

Evaluation

111

Increased time in abstinence


Decreased denial
Acceptable occupational functioning
Improved family relationships
Ability to relate comfortably to other
individuals

Milieu Management
Enforce rules and set limits
Education groups regarding mental
illness, substances, medications
Other groups: Stress management,
assertiveness, community living skills
Flexible assignments to groups
Gentle supportive confrontation
Encourage attendance at self-help
groups
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Milieu Management
Safety

Drug-free environment
Suicide prevention

Structure

Active, meaningful schedule

Balance

Confrontation with support

Limit setting

Protects client from self and others

Environmental modification

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Problems Affecting
Program Development
Heterogeneous population: Group
treatment difficult
Decide which issues can be handled in
large group versus small group versus
individually
Flexibility necessary in assigning groups
Open-ended treatment necessary
Staff must deal with manipulation,
conflict
Education programs must be
structured, concrete, simplified,
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Continuum of Care
Precontemplation
Express concern about client, symptoms

Contemplation
Discuss positive and negative aspects of
substance use, periods of abstinence,
psychological symptoms
Help client consider trial of abstinence

Preparation
Affirm significance of treatment
Goal setting
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Continuum of Care - (contd)


Action
Encourage and support adaptive actions
and remaining in recovery, despite
discomforts

Maintenance
Anticipate and discuss difficulties
Provide support

Relapse
Express concern
Discuss what can be learned from relapse
Provide support and encouragement
116

Health Teaching & Health Promotion


Primary prevention health teaching
FRAMES
Feedback of personal risk
Responsibility of the patient
Advice to change
Menu of ways to reduce substance use
Empathetic counseling
Self-efficacy or optimism of the patient
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