SUBSTANCE ABUSE DISORDERS

Why do we need to know about chemical dependency?

Many M/S patients are chemically dependent

Your chances of being in a close relationship with someone who is chemically dependent is great

Our profession holds statistically high users of drugs and alcohol

Substance abuse is not a one person illness.

It affects personal and professional relationships with those associated with the user.

We need to treat user and family and significant other.

SUBSTANCE ABUSE:

Repeated use of chemical substances leading to clinically significant impairment over 12 month period manifested by 1 or more of the following: Inability to fulfill major role obligations at work,

school, or home; Recurrent legal or interpersonal problems; Continued use despite social and interpersonal

problems; and Participation in physically hazardous situations

while impaired such as driving

ADDICTION:

Physical dependence on a substance Repeated compulsive use of substance that

continues in spite of negative consequences physical, social or legal

Characterized by loss of control due to participation in the dependency, whether that dependency is to a substance or to a process

A tendency to relapse into dependency Denial (a defense mechanism) is commonly

used by patients who have problems with abuse and dependency

TOLERANCE:

Increased amounts of substance are needed over period of time to achieve same effect as obtained previously with smaller amounts

CROSS TOLERANCE:

Tolerance to one drug causes tolerance to another drug or class of drugs

WITHDRAWAL:

Unpleasant physical, psychological or cognitive effects resulting from decreasing or stopping use of chemical after regular use for extended period of time.

DEPENDENCY:

Condition in which person has several of the following symptoms for a single 12 month periodNeeds more of substance and more

frequent intervals to achieve same high or desired effect of the substance

Spends significant time obtaining substanceGive up important social or professional

functions to use substance

DEPENDENCY continued:

Has tired at least once to quitExperience difficulty with job, family or

social activities because of use or withdrawal symptoms

Uses substance regardless of problem it causes

Uses substance to avoid withdrawal symptoms

Usually has unsatisfied emotional needs

DUAL DIAGNOSIS:

Means that an individual has both a mental illness, such as depression, as well as a problem with substance abuse

Patients with serious mental illness often have a dual diagnosis of some type of substance abuse

DYSFUNCTIONAL:

Often used to refer to relationships within alcoholic family or work environment

Characterized by dishonesty inability to discuss situation, and covering up for users behaviors

CODEPENDENCE:

Members of a family group or relationship begin to lose own sense of identity and purpose and exist solely for the abuser

Enable abuser by taking responsibility for own actions away from abuser

NON-SUBSTANCE RELATED DEPENDENCY / ADDICTIVE PERSONALITY:

Includes all kinds of addictive behavior May include addiction to food, sex, gambling.

Shopping / spending, or internet use

ETIOLOGICAL THEORIES:

Some believe in existence of addictive personality

Biological theories – some sort of genetic metabolic disorderA person who is alcohol dependent is 3-4

times as likely to come from parents who abused alcohol than a person who did not abuse alcohol

ETIOLOGICAL THEORIES:

Cognitive behavioral theorists – suggest way person perceives high may influence act of becoming high, another word, may start out very innocent, just want to repeat that good feeling!

Psychological theories – the person who abuses substances / processes may have certain personal tendencies including: lower self esteem, lower tolerance for pain or frustration.

SOCIO-CULTURAL THEORIES:

Certain cultures within US, such as:Native American have a high percentage of

members with alcohol dependencyAsian’s have low percentage of dependency

Peer pressure and other sociologic factors can increase likelihood of substance use

SELECTED SUBSTANCES OF ABUSE

ALCOHOL

Use and abuse are present in all walks of life, on all economic levels and in both men and women

Differentiation between social drinker and abuser is the degree of need or compulsion to drink

Decreases a persons life

expectancy an 10-12 years

DELIRIUM TREMENS (DT’S)

Visual hallucinations Tremors Possibly tonic-clonic seizures Elevated blood pressure Elevated heart rate Cardiac dysrhythmias Symptoms 4 – 12 hrs after patient has stopped

drinking and will peak in 24 – 48 hours

FETAL ALCOHOL SYNDROME

Leading known preventable causes of mental retardation and birth defects

Lifelong condition that causes physical and mental disabilities

Abnormal facial features, growth deficiencies, and central nervous system problems

Problems learning, memory, attention span, communication, vision, hearting or a combination of these

What are the symptoms of FAS?

Fetal Alcohol Syndrome symptoms include Small head, small jaw, and small, flat cheeks Malformed ears Small eyes, poor development of optic nerve,

crossed-eyes Upturned nose, low bridge Small upper mouth structure and teeth Umbilical or diaphragmatic hernia Caved-in chest wall Heart murmurs, heart defects, abnormalities of

large vessels

How is FAS diagnosed?

Based on mother’s history and the appearance of the baby, based on a physical examination by a physician

Treatment for FAS?

Specific drugs for treating the symptoms of withdrawal from alcohol in babies

No treatment for life-long birth defects and retardation

Damage often need developmental follow-up and possibly, long-term treatment and care

Prevention of FAS?

100° preventable – however, requires the followingMother to stop using alcohol before

becoming pregnantWomen should stop drinking immediately if

pregnancy is suspected

KORSAKOFF’S PSYCHOSIS:

Form of amnesia often seen in chronic alcoholics that is characterized by a loss of short-term memory and an inability to learn new skills

Usually disoriented, may present with delirium and hallucinations, and confabulates to conceal the condition

Often traced to degenerative changes in the thalamus as a result of a deficiency of B complex vitamins, especially thiamine and B12

Therapeutic Interventions for Alcohol Abuse and Dependence

Treatment is a slow processSingle most effective treatment is

Alcoholics Anonymous, 12-step program that offers support through others who have stopped drinking

Cognitive behavioral therapy and psychotherapy are also sometimes used

Family therapy

ANTABUSE

Medication that is sometimes prescribed as a deterrent to alcohol

Need full informed consent to start antabuse therapy

Severe reaction will occur if ingest alcohol, chest pain, nausea, vomiting, confusion and other symptoms

Effects last 2-3 weeks after last dose

CAMPRAL

New drug that works on neurotransmitters to alter functions of other brain chemicals that have been affected by long term drinking

REVIA

May decrease alcohol cravings (and opoid drugs) and impulsive behavior

VALIUM AND ATIVAN

Can help prevent symptoms of DT’s during acute withdrawal but are not used long term

Hospitalization may range from in house of 2 weeks or more to step down to halfway houses

To eventual independenceIs typical for patients to seek treatment

multiple times

Assessment of Patient with Alcohol Abuse

CAGE questionnaireHave 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 as an Eye opener to steady your nerves or get rid of a hangover?

Assessment of Patient with Alcohol Abuse continued:

Objective, nonjudgmental approach by nurse is imperative

Self assess your own feelingsUse open ended questions

“when was your last drink” “how much do you drink”

Ask about each substance or behavior separately

Assessment of Patient with Alcohol Abuse continued:

Type of substance Type of compulsive behavior Pattern and frequencyAmountAge of regular useChanges in use patterns Previous withdrawal symptoms

NURSING INTERVENTIONS:

SafetyClosely observe for withdrawal, possibly

even 1-1 observationReorient patientAdequate nutrition and fluid balanceLow stimulation environmentAdminister withdrawal meds PRNEmotional support to patient and family

WHAT IS DETOXIFICATION?Removal of poisonous effects of a substance

ALCOHOL DETOXIFICATION

Process which a heavy drinker’s system is brought back to normal after being used to having alcohol in the body on a continual basis

Precipitous withdrawal from long-term addition without medical management can cause severe health problems and can be fatal

Treatment must be undergone to deal with underlying addiction that caused the alcohol use

DRUG DETOXIFICATION

Used to reduce or relieve withdrawal symptoms while helping the addicted individual adjust to living without drugs

Not meant to treat addition – early step in long-term treatment

Treatment occur in a community program that lasts sever months and takes place in residential atmosphere rather than medical center

WHAT IS REHABILITATION?

Restore to health or normal life by training and therapy – restore to a former condition

Getting back on your feet, finding your old self again, learning to live a normal life, the way – before alcohol took over

Need to be strong to stay off the booze of course – always about changing life

SIGNS & SYMPTOMS OF ALCOHOL INTOXICATION

Glazed eyesSmell on breath PupilsUnsteady gaitUnusual behavior for the patient, passive

aggressive, violent

NICOTINE:

Cigarettes, cigars, and smokeless tobacco

Experts believe the single most difficult addition to overcome

OPIOIDS:

Heroin Prescription opiodsCan be injected, smoked or inhaled

BARBITURATES:

Ingested orally and injectedPentathol, phenobarbitalSedatives, hypnotics

BENZODIAZEPINES:

ValiumMany have replaced earlier used

barbituratesCan be taken orally or injected

AMPHETAMINES:

Crystal meth which is a growing substance use / abuse problem affecting families and society

Can be taken orally, injected IV or smoked

COCAINE:

Can be injected, smoked or inhaled nasally

CANNABIS:

Marijuana or hashishCan be smoked or eaten

INHALANTS

Nitrous oxide and solvents that are sniffed, huffed or bagged

Often young teenagers or young children to use lighter fluid, paint, paint thinners, and gasoline (or other easily accessed household substances) to get high

Highly toxic substances that are potentially lethal

PSYCHEDELICS: LSD

Usually ingested orally, can be injected or smokedSymptoms include:

Sleeplessness Increased heart rate Increased blood pressure Loss of appetite Powerful hallucinogenic

Very addictive- Provides a mental escape

Bath Salts

A synthetic, stimulant powder product that contains amphetamine-like chemicals, including mephedrone, which may have a high risk for overdose.

"Agitation, paranoia, hallucinations, chest pain, suicidality”

Signs and Symptoms of drug abuse and dependence

Very similar as those s/s of alcohol abuse

Read, watery eyesRunny noseHostile behaviorParanoiaNeedle tracts on arms or legs

Therapeutic interventions for drug abuse and dependence

Narcotics anonymous

Group therapy

Psychotherapy

Meth programs

Nursing interventions for drug abuse and dependence

Essentially the same as for those who are alcohol dependent

Remember nurses and doctors can not “fix” the patient who is chemically dependent

Desire to be chemically free needs to come from within the patient themselves

The chemically impaired nurse

Nurses have 32 – 50% increased rate of chemical dependency than general population. Access! When clinically impaired nurse is on duty patient may have increase complaints of pain, with little relief of pain meds, patients may ask more often for pain med. You may also see inaccurate narcotic counts, frequent vial breakage may also occur.

Indication evident in the chemically impaired nurse

Changing life style to focus activities that encourage substance use

Inconsistency between statements and actions Increase irritability Projecting blame Isolating self from social contacts Deteriorating physical appearance Tardiness or absences Depression

PRIORITIES OF NURSE

WHO IS A WITNESS OR SUSPECTS CHEMICALLY IMPAIRED COLLEAGUE

Ethically and legally remove nurse from patient care

Clear accurate documentation by co-worker is vital

Report to nurse managerImpaired nurse should be allowed

referral to treatment programReport to state board of nursing

Withdrawal Symptoms

Alcohol-increase in VS, psychosis, seizures LSD-no withdrawal symptoms Crystal Meth-increased sleeping, depression Heroin-muscle pain, cramps in abdomen,

increased yawning Cigarettes-craving, nervous/anxious,

increased appetite, irritable Caffeine-irritability, headache, jittery Marijuana-no withdrawal symptoms