Substance Abuse Disorders

1. Substance Abuse Disorders Chapter 25

2. Terms • Use • drinking alcohol, swallows, smokes, sniffs, or injects • Abuse • use for purposes of intoxication or for Rx beyond intended use • Dependence • use despite adverse consequences • Addiction • psychological and behavioral dependence

3. Terms • Withdrawal • Adverse physical and psychological symptoms that occur when stop using. • Detoxification • Process of safely and effectively withdrawing a person from an addictive substance. • Relapse • Recurrence of alcohol- or drug- dependent behavior who had previously been abstinent.

4. alcohol amphetamines cannabis (marijuana) cocaine hallucinogens inhalants nicotine opioids phencyclidine sedative-hypnotics anxiolytics caffeine DSM-IV Substance Abuse Disorders

5. DSM-IV Categories • Abuse of a substance • Dependence upon a substance • Induced by intoxication or withdrawal • Table 25.1

6. Epidemiology: Lifetime Prevalence • Positive lifetime history of heavy alcohol use • 23.4% of US adults • Positive lifetime history for drug use • 15.6% of US adults

7. Epidemiology • African American • lower rates of both licit and illicit substances compared to whites • experience more health and legal problems than other groups • alcohol-related consequences for males is higher than whites • Latino Americans • high use of drug among adolescents (HS students have highest rates of crack-cocaine and heroin use • Differences in prevalence among different groups (Mexican Americans - highest; Cuban Americans - lowest)

8. Epidemiology • Asian and Pacific • data are limited • drunkenness is disgraceful • drinking is a male activity • seeking help is a sign of weakness • Asian “flushing syndrome” • Native Americans • rates among the highest • alcohol plays a in health problems of this group

9. Epidemiology Gender Issues • Incidence rates of substance abuse and dependence • 1.7% per year men • 0.7% per year women • Males - more likely to abuse drugs and alcohol • Women - more likely to abuse prescription drugs • High number of substance abusers have comorbid mental disorders

10. Etiology Biologic • Genetic Influence • Clear evidence that it runs in families • Controversy about specific gene (allele of D2) • Neurobiologic • Through the reward system -- medial forebrain bundle (MFB)-related to cravings • Intoxication increases extracellular dopamine

11. Etiology: Psychological Theories Addictive Personality • needto feel self-worth • need to have control over the environment • need to feel intimate contact • need to accomplish something • need to eliminate pain or negative feelings Behavioral Theories • conduct problems of childhood • relationship between conduct problems, hyperactivity, impulsivity, and future substance abuse

12. Etiology: Social Theories • Peer drug use and affiliation • Poor interaction skills • Certain neighborhood characteristics

13. Alcohol • 90% of Americans have had a drink at some point in their lives • 16% have alcoholism • Body can metabolize 1 oz of liquor per hour - 5 oz glass of wine, 12 oz can of beer (Table 25.4) • Excessive use can adversely affect all body systems (Table 25.5) • Cerebellar degeneration from increased levels of acetaldehyde (by-product of alcohol metabolism) -- impaired coordination, unsteady gait, fine tremors • REM and chronic sleepdisorders • Drinking patterns vary

14. Biologic Response to ETOH • Membranes permeable to K+ and Cl-, and closes Na+ & Ca++ channels  depression of CNS, adrenergic activity  BP and  HR • Acetaldehyde is a by-product of alcohol metabolism. Large amounts of acetaldehyde combine with dopamine and serotonin to produce a substance that is highly addictive

15. Response to ETOH: Alcohol Tolerance • Rapid metabolism and  sedation, motor, and anxiolytic effects • Higher levels of BAL before intoxication • Locus ceruleus -- inhibits action of ethanol and instrumental in tolerance • During withdrawal, locus ceruleus is hyperactive  noradrenergic activity and CNS stimulation

16. Alcohol Withdrawal Syndrome • Changes in VS • BP and  HR • Diaphoresis • Adverse GI effects • CNS side effects • anxiety • restlessness • hand tremors or “shakes” • disorientation • confusion • delirium tremens (DTs)

17. Delirium Tremens • 10 or more years of drinking • Tachycardia • Sweating • Hypertension • Irregular tremor • Searing • Hypertension • Tremor • Delusions • Vivid hallucinations • Resolves in 3-4 days

18. Alcohol-Induced Amnestic Disorders • History of many years of drinking • Over age of 40 • Onset -- sudden or insidious

19. Alcohol-Induced Amnestic Disorders: Wernicke’s Syndrome • Reversible, caused by diet deficiency of thiamine • Marked diplopia (palsy of the 3 and 4 cranial nerves), hyperactivity and delirium (cortical brain and thalamic lesions), coma

20. Alcohol-Induced Amnestic Disorders Korsakoff’s Psychosis • Follows Wernicke’s enceophalopathy • Loss of recent memory and confabulation • Vulnerable to others

21. Psychopharmacology Acute Symptoms of Withdrawal • Benzodiazepines to produce sedation and reduce anxiety symptoms • Diazepam 5-10 mg every 2-4 hours • Librium 25-100 mg every 4 hours

22. Pharmacology & Nutrition • Disulfiram (Antabuse) • Agonist • Inhibits ALDH metabolism and causes nausea and hypotension, severe can cause death • Occurs 10-20 minutes after ingestion • Adjunct treatment • Naltrexone (Trexan) • Narcotic antagonist • Reduces cravings for alcohol • Nutrition and vitamins

23. Cocaine • 1.5 million Americans use cocain • Men have a higher rate than women • Stimulant -- made from leaves of coca plant • Sudden burst of alertness, energy, and self-confidence • High lasts 10-20 minutes, then let down • Crack cocaine -- street drug form, highly addictive

24. Biologic Effects of Cocaine • Increases the release and blockage of the reuptake of norepinephrine, serotonin and dopamine • Dopamine -- euphoria and psychotic symptoms (prolactin levels-contributes to sexual dysfunction and secondary sexual characteristics) •  Norepinephrine -- tachycardia, hypertension, dilated pupils, and body temp •  Serotonin -- sleep disturbances, anorexia • Long term use -- depletion of dopamine

25. Cocaine • Intoxication • CNS stimulation followed by depression • Increasing doses -- restlessness  tremors and agitation  convulsions  CNS depression • Death -- respiratory failure • Withdrawal • Norepinephrine depletion causes person to sleep 12-18 hours • Then, sleep disturbances with rebound REM, anergia, decreased libido, depression, suicidality, anhedonia, poor concentration and cocaine craving

26. Treatment of Cocaine Craving • Antidepressants • Anticonvulsants • Dopamine agonists

27. Others • Amphetamines -- Stimulant • block reuptake of norepinephrine and dopamine, not as strong effect on serotonin (as cocaine does) • Effect peripheral nervous system • Cannabis -- Relaxant • Stored in fat tissue for weeks • Amotivational syndrome • Hallucinogens -- LSD • Phencyclidine (PCP) angel dust •  awareness and detachment • hallucinations/destructive behavior (adrenergic )

28. Opiates -- Narcotics • Any substance that binds to the opioid receptor • Cause CNS depression, sleep or stupor, and analgesia • Major -- heroin, codeine, and meperidine • Act on Delta and Mu receptors and depress the CNA • Types • agonist -- increases CNS effects • antagonist -- block CNS effects • mixed agonist-antoagonist • Effects of opiates • pleasure • relief of pain • Cause tolerance and physical dependence

29. Opiate Treatment • Antagonist -- block CNS effects, Naloxone (Narcan) • Detox -- gradual reduction over several days • Methadone maintenance treatment • Opiate that satisfies craving, but no subjective high (See Table 25.7) • Naltrexone -- see Drug Profile

30. Other Substances • Sedatives-Hypnotics and Anxiolytics • Abuse of prescription drugs • See Table 25.8 • Inhalants • Cause euphoria, sedation, emotional lability, impaired judgment • Result in respiratory depression • Found in common household products • Nicotine • Caffeine

31. Nursing ManagementAssessment • Denial • Countertransference (Table 25.11) • Codependence (Figure 25.2) • Maladaptive learned pattern of coping • Roles in family • Chief enabler • Dependent • Hero • Scapegoat • Lost child • Mascot

32. Nursing Diagnoses • Risk for Injury • Disturbed Thought Processes • Anxiety • Risk for Ineffective Management of Therapeutic Regimen, Ineffective Denial • Altered Nutrition

33. Motivation for Change • Key predictor of whether an individual will change their substance abuse • Involves recognizing problem, searching for a way to change, and then changing • Motivational interviewing seeks to elicit self-motivational statement from patients, supports behavioral change, and creates a discrepancy between the patient’s goals and continued alcohol and other drug use.

34. Guidelines for Therapeutic Relationship • Encourage honest expression of feelings • Listen and express caring • Hold individual responsible for behavior • Provide consequences for negative behavior and talk about specific, objectionable actions • Do not compromise own values, monitor reaction • Communicate to team

35. Reality Confrontation • Therapeutic strategy that promotes the person’s experience of the natural consequences of one’s behavior. • Learning from previous behavior • Guidelines for establishing interactions (See Table 25.10 and Therapeutic Dialogue)

36. Special Considerations • HIV and substance abuse • high risk for HIV among IV drug users • dual diagnosis of chemical dependency and HIV requires extremely careful assessment, intervention • patients often experience intense feelings of uselessness • Harm-reduction strategies • community health intervention replacing moral and criminal approach -- needle exchange programs, designated driver

37. Special Considerations (cont) Pregnancy and substance abuse • Detrimental effects on pregnancy • Several clinical issues facing mothers • feelings of guilt and shame • difficulties being a single parent • care and responsibility of raising children early sobriety • lack of access to treatment facilities • anger and blame from caregivers • need for parenting skills • potential for child abuse and neglect • lack of medical and other health care services

38. Interventions • 12-step program (Table 25.13) • Cognitive therapy • Psychoeducation groups • Behavioral interventions • Group therapy and early recovery • Individual therapy • Family therapy

39. Interventions • Nursing Care Plan 25.1 • Depend upon the stage of treatment