substance disorders 2011

8/3/2019 Substance Disorders 2011

1/99

2012


2/99

Objectivesy Given relevant questions and case scenarios the

students will be able to :

y 1. Identify major substances of abuse andpatterns of abuse and dependency.

y 2. Describe the signs and symptoms ofintoxication and withdrawal

y 3. Discuss pharmacologic and psychosocialtreatment approaches

y 4. Apply the nursing process to the care ofclients and families experiencing substanceused disorders


3/99

Substance Abuse

y The actual prevalence of substance abuse is difficultto determine

y Detrimental effects of substance abuse include:yWorkplace injuries

y Motor vehicle accidents and fatalities

y

Domestic abuse, homicide, and child abuse andneglect


4/99

y 14% of adults have an alcohol-related disordery 6.2% have a substance-related disorder (excluding

nicotine)y

Adolescent substance abuse is risingy Increasing numbers of babies are being born to

substance-addicted mothersy Half of all persons seeking alcohol-related treatment

have at least one alcoholic parent


5/99


6/99


7/99

Types ofSubstance Abuse

Classes of substances abused:y Alcoholy Amphetamines or similarly acting sympathomimeticsy Caffeiney Cannabisy Cocainey Hallucinogensy Inhalantsy Nicotiney Opioidsy Phencyclidine (PCP) or similarly acting drugsy Sedatives, hypnotics, or anxiolytics


8/99

y Intoxication is use of a substance that results in maladaptivebehavior

y Withdrawal syndrome refers to the negative psychological andphysical reactions that occur when use of a substance ceases or

dramatically decreasesy Detoxification is the process of safely withdrawing from a

substance

y Substance abuse is using a drug in a way that is inconsistentwith medical or social norms and despite negativeconsequences

y Substance dependence includes problems associated withaddiction such as tolerance, withdrawal, and unsuccessfulattempts to stop using the substance


9/99

Onset and Clinical Coursey Typically begins with the first episode of intoxication between

15 and 17 years of agey More severe difficulties begin in the mid-20s to

mid-30sy Alcohol-related breakup of a significant relationshipy An arrest for public intoxication or driving while

intoxicatedy Evidence of alcohol withdrawaly Early alcohol-related health problemsy Significant interference with functioning at work or school


10/99

y Blackout drinking in which the person continues tofunction but has no conscious awareness of his or herbehavior at the time nor any later memory of thebehavior

y

As the person continues to drink, he or she oftendevelops a tolerance for alcohol; that is, he or she needsmore alcohol to produce the same effect

yAfter continued heavy drinking, the person experiences atolerance break, which means that very small amounts of

alcohol will intoxicate the persony The later course of alcoholism, when the persons

functioning definitely is affected, is often characterizedby periods of abstinence or temporarily controlled

drinking


11/99

Etiology

yBiologic factorsyGenetic vulnerabilityy

Neurochemical influencesyPsychological factors

yFamilial dynamicsyCoping styles

ySocial and environmental factors


12/99

Substance-Related Disorders:

Theories and Perspectivesy Classic theory

y Alcoholism as a chronic, progressive disease that follows

a predictable natural historyy Moves away from alcoholism as a problem of flawed character

y Addict is seen as someone in need of help

y Addiction involves biological, psychological, and socialfactors

12


13/99


Theories and Perspectivesy PsychodynamicTheory

y Ego

y

Regulates thinkingy Controls instinctive drives

y Protects against anger, boredom, emptiness, and rage

y Addicts lack mature ego defenses and do not cope well

13


14/99


Theories and Perspectivesy Social and environmental influences

y Peers

y Culturesy Beliefs about the substance may encourage or inhibit use

y Availability

y Cost

14


15/99


Theories and Perspectivesy Genetic factors

y Tendency to become alcoholic is inherited

y Increased vulnerability to addiction to drugs whenfamily history is present

y Does not guarantee development of addiction but increasesrisk

y Substance disorders are not genetic disorders as of current

state of scientific knowledge

15


16/99


Theories and Perspectivesy Substance induced neurobiological changes

y Addiction is a pathological brain disease

y

Dysregulation in complex neural mechanisms of learning andmemory related to quest of rewards and cues that predictthem

16


17/99


Theories and Perspectivesy Substance induced neurobiological changes

y Brain is unable to maintain proper neurochemical

balancey Inadequate amounts of GABA and dopamine results in

increased anxiety and depression

17


18/99


Theories and Perspectivesy Cultural considerations

y Substance use mores and attitudes tied to predictors of

drinkingy Prevalence of substance-related disorders is higher in

large cities

y Substantial disparity in availability of health care for

minority groups

18


19/99

Cultural Considerationsy Muslims do not drink alcoholy Wine is an integral part of Jewish religious ritesy Some Native American tribes use peyote, a hallucinogen, in religious

ceremoniesy The Japanese do not regard alcohol as a drug, and there are no religious

prohibitions against drinkingy Certain ethnic groups have genetic traits that either predispose them to or

protect them from developing alcoholismy Variations have been found in enzymatic activities among Asians, African

Americans, and whitesy Alcohol abuse plays a part in the five leading causes of death for Native

Americansy Drinking is a major health problem among some Aboriginal people and in

Russia


20/99

yA patient asks the nurse, How would I know if I weredependent on alcohol? The nurse should respond by

telling the patient that dependence is defined by:yA.a compulsion to use the drug.

y B. loss of control over use of the drug.

y C.a physiologic need to use the drug.

y D.continued use despite adverse consequences.


21/99

y Dependence is marked by aphysiologic need for thesubstance.The other options refer to psychological

need.


22/99

yA patient tells the nurse, I could get a good high fromdrinking a six-pack a few months ago. Now I need a

few extra cans to get the same high.T

he nurse shouldassess this phenomenon as related to:

yA.tolerance.

y B.withdrawal.

y C.codependency.y D.abstinence syndrome.


23/99

y Tolerance refers to the need for increasing amounts ofa substance to achieve the same effects.The other

terms are not related to needing more drug to achievethe same effect.


24/99


25/99


26/99

Alcoholy Central nervous system depressant

y Overdose can result in vomiting, unconsciousness,and respiratory depression

y Symptoms of withdrawal usually begin 4 to 12 hoursafter cessation or marked reduction of alcohol intake

yAlcohol withdrawal usually peaks on the second day

and is over in about 5 days


27/99

yWithdrawal symptoms include:y Coarse hand tremors, sweating, elevated pulse and blood

pressure, insomnia, anxiety, and nausea or vomiting

y Severe or untreated withdrawal may progress to transient

hallucinations, seizures, or deliriumcalled deliriumtremens (DTs)

yWithdrawal symptoms are monitored using anassessment tool such as the Clinical Institute Withdrawal

Assessment of Alcohol Scale, Revised (CIWA-AR)y Benzodiazepines used for detoxification

y Lorazepam (Ativan), chlordiazepoxide (Librium), ordiazepam (Valium) suppress the withdrawal symptoms


28/99

Alcoholy Most commonly abused substance

yAbsorbed quickly from stomach and small intestineand metabolized in liver

y In concentrated form, is toxic to nerve cells

y In diluted form, is an irritant to nerve cells

y Chronic alcohol affects all body systems

28


29/99


30/99

AlcoholyWithdrawal associated with neural excitation with

abrupt cessation of the CNS depressant action of

alcohol

30


31/99

AlcoholyWithdrawal can occur within hours of last

consumption

y

Symptoms:y Tremors, internal shakiness

y Hyperarousal, easily startled

y Anxiety

y Tachycardia, elevated B/P

y Hallucinations can occur

31


32/99


33/99

Alcoholy Delirium Tremens (DTs)

y Hallucinations, hyperpyrexia, hypertension, tachycardia,

coarse tremors, nervous system arousaly Early detection is important

33


34/99


35/99


36/99


37/99

AlcoholyWernicke-Korsakoff Syndrome

y Profound memory impairment

y Inability to learn new things

37


38/99

Alcoholy Pharmacotherapy for withdrawal

y Benzodiazepines used to manage alcohol withdrawal

syndromey Clinical Institute Withdrawal Assessment-Alcohol

(CIWA-Ar) used to monitor severity of symptoms

38


39/99

Alcoholy Pharmacotherapy for withdrawal

y Antipsychotics may be needed for hallucinations

y Anticonvulsants may be needed for seizures but is notstandard treatment

39


40/99


41/99

yWithdrawal symptoms in 6 to 8 hours or up to 1 week

y Withdrawal syndrome is characterized by symptoms oppositeof the acute effects of the drug:

y Autonomic hyperactivity (increased pulse, blood pressure,

respirations, and temperature), hand tremor, insomnia,anxiety, nausea, and psychomotor agitation; seizures andhallucinations occur rarely in severe benzodiazepinewithdrawal

y Detoxification from sedatives, hypnotics, and anxiolytics is

managed by tapering the amount of the drug


42/99

Stimulants (Amphetamines, Cocaine, Others)

y Central nervous system stimulants

y Overdoses can result in seizures and coma

yWithdrawal occurs within hours to several days

yWithdrawal syndrome:

y Dysphoria accompanied by fatigue, vivid and unpleasantdreams, insomnia or hypersomnia, increased appetite, andpsychomotor retardation or agitation; withdrawal

symptoms are referred to as crashing--the person mayexperience depressive symptoms, including suicidalideation, for several days

y Stimulant withdrawal is not treated pharmacologically


43/99

Cannabis (Marijuana)

y Used for its psychoactive effects

y Excessive use of cannabis may produce delirium orcannabis-induced psychotic disorder; overdoses ofcannabis do not occur

yWithdrawal symptoms:

y Insomnia, muscle aches, sweating, anxiety, and

tremorsy Effects are treated symptomatically


44/99

Opioids

y Central nervous system depressants

y Overdose can lead to coma, respiratory depression, pupillaryconstriction, unconsciousness, and death

y Withdrawal:

y Short-acting drugs: begins in 6 to 24 hours; peaks in 2 to 3days and gradually subside in 5 to 7 days

y Longer-acting drugs: begins in 2 to 4 days, subsiding in 2

weeks


45/99

y Withdrawal symptoms:

y Anxiety, restlessness, aching back and legs, cravings,nausea, vomiting, dysphoria, lacrimation, rhinorrhea,sweating, diarrhea, yawning, fever, and insomnia

y Withdrawal does not require pharmacologic intervention

y Administration of naloxone (Narcan) is the treatment ofchoice

y Methadone can be used as a replacement for heroin, serving

to reduce cravings


46/99

Hallu

cinogensy Distort reality and produce symptoms similar to psychosis,

including hallucinations (usually visual) anddepersonalization

y Toxic reactions to hallucinogens (except PCP) are primarilypsychological; overdoses as such do not occur. PCP toxicitycan include seizures, hypertension, hyperthermia, andrespiratory depression

y Hallucinogens can produce flashbacks that may persist for a

few months up to 5 yearsy Treatment is supportive:

y Isolation from external stimuli; physical restraints; (for PCP)medications to control seizures and blood pressure; coolingdevices; mechanical ventilation


47/99

Inhalantsy Inhaled for their effectsy Overdose:

y Anoxia, respiratory depression, vagal stimulation, and dysrhythmiasy Death may occur from bronchospasm, cardiac arrest, suffocation, or

aspiration of the compound or vomitusy People who abuse inhalants may suffer from persistent dementia or

inhalant-induced disorders such as psychosis, anxiety, or mooddisorders even if the inhalant abuse ceases

y Withdrawal symptoms: noney Treatment:

y Supporting respiratory and cardiac functioning until the substance isremoved from the body


48/99

Substance Ab

use T

reatment

y Treatment is based on the concept that alcoholismand drug addiction are medical illnesses: chronic,progressive, characterized by remissions and relapses

y Treatment models include:

y The Hazelden Clinic model

y 12-step program of Alcoholics Anonymous (AA)

y Individual and group counseling


49/99

Tr

eatmentS

ettings and Pr

ogr

amsy Emergency departments

y Medical units

y Extended treatment

y Outpatient treatment

y Clinics offering day and evening programs

y Halfway houses

y Residential settingsy Chemical dependency units in hospitals


50/99

Pharmacologic Treatment

Two main purposes:

yTo permit safe withdrawal from alcohol,

sedative-hypnotics, and benzodiazepinesyTo prevent relapse


51/99

Pharmacologic Treatment (contd)

Safe withdrawal from alcohol involves:

y Benzodiazepines to suppress withdrawal symptomsy

Lorazepam, chlordiazepoxide, and diazepamyVitamin B1 (thiamine) to prevent or to treat

Wernickes syndrome and Korsakoffs syndrome

y Cyanocobalamin (vitamin B12) and folic acid for

nutritional deficiencies


52/99

Pharmacologic Treatment (contd)

Relapse prevention involves:

yDisulfiram (Antabuse)

yMethadone

yNaltrexone (ReVia)

yClonidine (Catapres)

yOdansetron (Zofran)


53/99

Dual DiagnosisClient with both substance abuse and another

psychiatric illnessTraditional treatment programs have little success:y

Impaired abilities to process abstract conceptsy Avoidance of all psychoactive drugs may not be possibley Substance abuse has no limited recovery concept as do psychiatric

illnessesy Lifelong abstinence may seem impossible to the client with a chronic

mental illnessy T

he use of alcohol and other drugs can precipitate psychotic behavior


54/99

Application of the Nursing Process: Substance Abuse

The nurse may encounter clients with substance problems invarious settings unrelated to mental health.

y Seeking treatment of medical problems related to alcoholuse

y Withdrawal symptoms may develop while in the hospitalfor surgery or an unrelated condition

Be alert to the possibility of substance use in these situationsand be prepared to recognize their existence and to makeappropriate referrals.


55/99

Application of the Nursing Process:

Substance Abuse (contd)Assessmenty History: chaotic family life, family history, crisis that

precipitated treatmenty General appearance and motor behavior: depends

on physical health; likely to be fatigued, anxiousy Mood and affect: may be tearful, expressing guilt

and remorse; angry, sullen, quiet, unwilling to talk


56/99


Substance Abuse (contd)Assessment (contd)y Thought processes and content: minimize substance use,

blame others for problems, rationalize their behavior, say

they can quit on their owny Sensorium and intellectual processes: alert and oriented;

intellectual abilities intact (unless neurologic deficits fromlong-term alcohol or inhalants)

y Judgment and insight: poor judgment while intoxicated anddue to cravings for substance; insight limited


57/99


Substance Abuse (contd)Assessment (contd)

y Self-concept: low self-esteem, feels inadequate at

coping with life

y Roles and relationships: strained relationships andproblems with role fulfillment due to substance use

y

Physiologic considerations: may have trouble eatingand sleeping; HIV risk if IV drug user


58/99

Data AnalysisNursing diagnoses common tophysicalhealth needs

include:y Imbalanced Nutrition: Less Than Body Requirementsy Risk for Infectiony Risk for Injuryy Diarrheay

Excess Fluid VolumeyActivity Intolerancey Self-Care Deficits

Application of the Nursing Process:Substance Abuse (contd)Application of the Nursing Process:Substance Abuse (contd)


59/99


Substance Abuse (contd)Data Analysis (contd)

Nursing diagnoses common topsychosocialhealth needs include:

y Ineffective Denial

y Ineffective Role Performance

y

Interrupted Family Processes: Alcoholismy Ineffective Coping


60/99


Substance Abuse (contd)OutcomesThe client will:y

Abstain from alcohol/drugsy Express feelings openly and directlyyAccept responsibility for own behaviory Practice nonchemical alternatives to deal with stress

or difficult situationsy Establish an effective after-care plan


61/99


Substance Abuse (contd)InterventionyProviding health teaching for client and familyyAddressing family issues:

yCodependenceyChanges in roles

yPromoting coping skills


62/99

EvaluationIs the client abstaining from substances?

Is the client more stable in his or her roleperformance?

Does the client have improved interpersonalrelationships?

Is the client experiencing increased satisfactionwith quality of life?

Application of the Nursing Process:Substance Abuse (contd)Application of the Nursing Process:Substance Abuse (contd)


63/99

Elder Considerationsy Estimates are 30% to 60% of elders in treatment began

drinking abusively after age 60y Risk factors for late-onset substance abuse in elders

include:y Chronic illness that causes pain; long-term use of

prescription medication (sedative-hypnotics,anxiolytics); life stress; loss; social isolation; grief;depression; an abundance of discretionary time and

moneyy Elders may experience physical problems associated with

substance abuse more quickly


64/99


65/99

Mental Health Pr

omotion

yPublic awareness and educational advertising

y

Early identification of older adults withalcoholism

yThe College Drinking Prevention Program


66/99

Substance Abuse in Health

Pr

ofessionals

yHigher rates of dependence on controlledsubstances

yEthical and legal responsibility to reportsuspicious behavior to a supervisor


67/99

Substance Abuse in Health

Professionals (contd)Warning signs of abuse include:y Poor work performance, frequent absenteeism, unusual behavior, slurred speech,

isolation from peersy Incorrect drug counts

y Excessive controlled substances listed as wasted or contaminatedy Reports by clients of ineffective pain relief from medications, especially if relief

had been adequate previouslyy Damaged or torn packaging on controlled substancesy Increased reports of pharmacy errory Consistent offers to obtain controlled substances from pharmacyy Unexplained absences from the unit

y Trips to the bathroom after contact with controlled substancesy Consistent early arrivals at or late departures from work for no apparent reason


68/99

Substance-Related

Disorders Across the Life Spany Effects of addiction on the family

y Denial and rationalization

y U

nwritten rule:y Dont talk, dont trust, dont feel

68


69/99

Substance-Related

Disorders Across the Life Spany Effects of addiction on the family

y Codependency:

y External focus on something or someone that cannot becontrolled become an obsessive focus

y Results in neglect of other important responsibilities to selfand others

69


70/99

Substance-Related

Disorders Across the Life Spany Maternal-Infant Issues

y Use of substances during pregnancy poses risk to fetus

y Fetal Alcohol Syndrome (FAS)

y Cocaine use increases risk of placenta abruption, pretermlabor, spontaneous abortion, ruptured uterus, andintrauterine growth retardation

y Infant at risk for poor parenting, abuse, and neglect

70


71/99

Substance-Related

Disorders Across the Life Spany Childhood and adolescence

y Risk factors

y Familial history

y Fetal exposure to alcohol or drugs

y Parental psychopathology

y May try drugs or alcohol to experience pleasurable

feelings or to cope with stress

71


72/99

Substance-Related

Disorders Across the Life SpanyAdulthood

y Addiction most likely to appear

y

No generic pattern of progression applies to all whobecome substance dependent

72


73/99

Substance-Related

Disorders Across the Life SpanyAdulthood

y Substance use may increase to cope with greaterresponsibilities of adulthood

y Divorce

y Death of a spouse or child

y Loss of job

73


74/99

Substance-Related

Disorders Across the Life Spany Older adulthood

y Myth to assume substance abuse does not occur

y Complex set of factors:

y Problems with even low intake due to increased sensitivity toalcohol

y Many late onset alcoholics do not develop physiologicaldependence

74


75/99

Substance-Related

Disorders Across the Life Spany Older adulthood

y Complex set of factors:y Increased cognitive impairment can interfere with self-

monitoring

y Fewer activities make detection more difficult

75


76/99


77/99


78/99


79/99


80/99


81/99


82/99


83/99


84/99


85/99

Treatment and Recoveryy Nature and general course of substance use disorders

must be understood

y No known cure to addiction

85


86/99

Treatment and Recoveryy Recovery is a process

y Combination of behavioral, pharmacologic, and socialservice interventions

y Assess clients readiness to change behaviors

y Development of emotional maturity

y Awareness of relapse cues

86


87/99


88/99


89/99


90/99


91/99

Treatment and Recoveryy Pharmacologic and complementary therapies

y Antabuse (disulfiram)

y ReVia (naltrexone)

y Methadone or long-acting Methadone (LAAM)

y 12-step groups (AA, NA, MA)

91


92/99


93/99


94/99


95/99


96/99

The Role of the Nursey The Generalist Nurse

y Includes 24-hour monitoring of clients physical andmental status concerning withdrawal

y Other responsibilities:

y Psychoeducation

y Administering medication

96


97/99

The Role of the Nursey The Advanced-Practice Psychiatric Nurse

y Treatment based on advanced educational and clinicalexpertise

97


98/99

The Role of the Nursey The Advanced-Practice Psychiatric Nurse

y Major responsibilities:

y Collaborating with other clinicians to provide holistic care

y Prescribing psychotropic agents as allowed by state regulation

y Providing psychotherapy and health education

98


99/99

S

elf-Awar

enessI

ssu

es

yExamine own beliefs and/or family behaviorabout alcohol and drugs

yRecognize that substance abuse is a chronicillness with relapses and remissions

yBe objective and reasonably optimistic

substance disorders 2011

Documents