Substance

Abuse

2/3 of the adult pop. in US consume ETOH on a reg. basis

2.4 million of US po. >12yoa need RX for drug disorders

-an additional 13 million need RX for ETOH disorders

alcohol is the #1 drug problem in US

americans spend 197 million/day on ETOH

3/4 of all HS seniors report being drunk @least once

TOP

3

ABUSED
SUBSTANCES

1) ETOH

2) nicotine

3) caffeine

TOP

5

most abused

controlled & illicit

substances

1) cocaine

2) heroine

3) marijuana

4) xanax

5) valium

ETIOLOGY

of

ETOH ABUSE

BIOLOGICAL:

specific effects on the neurotransmitter systems

PSYCHOLOGICAL:

-lack of tolerance

-lack of success in life

-lack of affectionate & meaningful relationships

-low self-esteem

-lack of self regard

-risk taking propensity

SOCIOCULTURAL:

social & cultural norms.

socioeconomic stress

Family:

hx of acoholism in fam

cognitive behavioral:

comorbidities

ADDICTION

a behavioral pattern of drug abuse characterized by overwhelming involvement w/use of drug(s) (complusive use) & securing its supply

*addiction & dependence ARE NOT the same

*addicition is often used when dependence is meant

3 characteristics

of

addiction

1) loss of control over substance consumption= complusive use

2) substance use despite asst. problems

3) Tendency to RELASPE

SUBSTANCE
ABUSE

the repeated use of ETOH or other drugs leading to functional problems

DOES NOT include: complusive use= addiction

person/client does not have withdrawl s/sx that accompany substance abuse

SUBSTANCE
DEPENDENCE

continued use of ETOH or other drugs despite  neg. consequences

ex. significant function problems in daily life

TOLERANCE

person's physiological response to drug decreases w/repeated administration of same dose.

WITHDRAWAL

psychological changes that occur when blood & tissue concentrations of drug decreasea after heavy prolonged use of substance.

SYNERGESTIC

EFFECT

when drugs are taken together, effect of either both is intensified or prolonged

ANTAGONISTIC

EFFECTS

when drugs are taken together, one is inhibited or weakened

COMORBIDITIES

of

SUBSTANCE
ABUSE

psychatric comorbidity:

6/10 people affected by substance-abuse disorder also are  affected by a mental health disorder.

medical comorbidity:

ETOH related medical problems are the comborbidities most commonly seen in medical settings.

CROSS-TOLERANCE

a person dependent on 1 substance requires increased doses of another substance in the same general drug catergory

EX.

tolerance to ETOH requires higher doses of another CNS depressant (like a benzo) to achieve a buzz.

INTOXICATON

occurs after drinking excessive amounts of ETOH

pt may be flush, decreased level of LOC, slurred speech, mood changes, irritable, impaired attn. span.

RELASPE

a term used to desribe someone who has returned to active addictive behavior.

PSYCHOLOGICAL CHANGES

with

SUBSTANCE

ABUSE

Denial

Depression

Anxiety

Dependence

Hopelessness

Low self-esteem

Various psychiatric  disorders

SIGNS

of

INTOXICATION

and

WITHDRAWAL

Alcohol poisoning

Alcohol withdrawal

Alcohol withdrawal delirium

ALCOHOL POISONING

Large amounts of alcohol consumed quickly or over time

early s/sx:

tremor, anxiety

ALCOHOL WITHDRAWAL

Signs develop w/in a few hours after cessation

Peaks @24-48 hours

s/sx:

anorexia, anxiety, insomnia

ALCOHOL WITHDRAWAL DELIRIUM

MEDICAL EMERGENCY!!!!

Can result in death, even if RX.

s/sx:

confusion, fright, diaphoretic, anxiety, clouded consciousness, fever, increased HR & B/P, hallucinations, paranoid, agitated, 10% mortality rate.

NSG:

keep reorienting, give warm support & enviro>

ETOH

effects

on

the

body

IMMEDIATE:

Acute intoxication

High doses

CHRONIC USE:

Gastro system= anemia & risk of thrombocytopenia

Cardiovascular system= heart weakenss, doesn't pump as efficently

Blackouts= lack of O2 to brain

Reproductive system= FAS

Central nervous system=

-Wernicke's Encephalopathy:

acute stage of confusion (delirium)

-Korsakoff's psychosis:

chronice cognitive impairment; dementia= not reversible.

ETOH

Collaborative Care

Seizures

Aspiration pnx.

Myocardial infarction

Injuries: MVA, gunshots, falling

Hypothermia/hyperthermia: fall/pass out in snow bank

Gastrointestinal bleeding

BLOOD ALCOHOL LEVEL

(BAL)

PEAK: w/in 50mins-3hrs after heavy drinking

LEGAL definition: Maine 0.08g/dL

COMA: occurs if BAL of 0.4g/dL

CNS

STIMULANTS

COMMON s/sx of stimulant ABUSE:

-dilation of pupils

-dryness of the oronasal cavity

-excessive motor activity

-insomnia

-impaired judgement

-increased HR & B/P

-may see twitching

depression; body trying to reg.neurotransmitters

EX.

cocaine & crack

caffeine (coffee, tea, soda)  & nicotine=as addictive as heroine.

COCAINE

&

CRACK

-extracted from the leaf of the coca bush

-when smoked takes effect in 4-6secs; a deep 5-7mins of high follows, then a deep depression.

TWO MAIN EFFECTS ON BODY:

1) anesthia= blocks electrical impulses in nerve cells.

2) stimulant= violent behavior & sexual arousal; imbalance of norepinephrine.

*BOTH produce imbalance in neurotransmitters.

WITHDRAWAL s/sx:

Depression

Paranoia

Lethargy

Anxiety

Insomnia

N/V

Sweating

Chills

OPIATES

*Morphine

*Heroin

*Codeine

*Fentanyl

*Methadone-synthetic opiod

*Meperidine

SE:

pupils constricted, decreased RR & B/P, drowsiness, psychomotor retardation, impaired judgement.

NSG:

obs. for resp. depression, coma, convulsions.

MARIJUANA

(cannabis sativa)

Indian hemp plant

Tetrahydrocannibal (THC) is active ingredient

Depressant & hallucinogenic properties

Usu. smoked

Desired effects: euphoria, detachment, relaxation

Lon-term effects: lethargy, anhedonia, diff. concentrating, loss of memory.

overdose=panic

perception intensified, time delay, heightened sensitivity to stimuli.

HALLUCINOGENS

*Lysergic acid diethylamide= LSD or acid

*Mescaline= peyote

*Psilocybin= magic mushrooms

*Phencyclidine piperidine= PCP, angel dust, horse tranq, peace pill.

addictive, alter mental state, good slowing of time, images of intense colors, visions, sound. Taken oral, IV, sniffed, smoked.

 SE: can cause severe anxiety & paranoia, blank stare, twitching, rigid muscles, chronic jerking of muscles, suicidal ideation, dulls thinking, lethargy, poor memory.

NSG: reassure, provide safe enviro, reduce stimuli. 

INHALANTS

(VOLATILE SOLVENTS)

Spray glue

Glue

Cigarette lighter fluid

Propellant gases used in aerosols

Popular amongst teens

Can damage lungs & oral cavity

CLUB DRUGS

COMMON:

Ecstasy (MDMA, Adam, yaba, XTC, MDA= "love", MDE= "eve"

Produce subjective effects resembeling stimulants & hallucinogens.

DATE RAPE DRUGS

*Fluitrazepam (Rohypnol or Rooofies)

*Gamma hydroxybutyric acid (GHB)

Rapidly produce:

-disinhibiton

-relaxation

-anterograde amnesia

-ETOH potentiates effects

ROOFIES: rapid disinhibition, relaxation of sexuality & retrograde amnesia: do not remember anything.

GENERAL ASSESSMENT

of

Client

with SUBSTANCE ABUSE

2 IMPORTANT QUESTIONS:

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 past year?

DETAILS include:

-Drugs use:

Route

Quanity

Time of last use

Usu. pattern of use

assessment:

role/relationship

health perception/health management

interview (tips)

ASSESSMENT GUIDLINES

for the

CHEMICALLY IMPAIRED

* assess for withdrawal syndrome

* assess for overdose that warrants medical attn.

* assess for suicidal thoughts or other self destructive behaviors

* eval. for physical complications r/t drug abuse

* explore interests in doing something about drug or alcohol problem

* assess pt & family for knowledge of community resources.

SCREENING TOOLS

MAST: Michigan alcohol screening test

CIWA-Ar: alcohol withdrawal assessment scoring guidelines

CAGE questionnaire: acronym of 4 questions w/drinking

1) Cut back (have you thought about doing)?

2) Annoyed friends/fam w/drinking?

3) Guilt about drinking?

4) Eye opener; drink 1st thing in the am to steady nerves/get rid of hangover?

CINA: clinical institute narcotic assessment

COWS: clinical opiate withdrawal scale

Potential NSG DX:

Imbalanced nutrition: < 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

OUTCOMES IDENTIFIED

WITHDRAWAL:

-flluid balance

-neurological status: consciousness

-distorted thought self-control

INTIAL & ACTIVE RX:

-risk control: ETOH abuse

-risk control: drug abuse

-substance addiction consequences

HEALTH MAINTENANCE:

-knowledge: substance abuse control

-family coping

-hygiene, nutrition, keeping appts.

IMPLEMENTATION

AIM OF RX:

self responsibility

(not always compliant; want them to be responsible)

CHALLENGE:

-physiological

-psychological

-sociocultural processes

THE NURSE'S ROLE

PRIMARY PREVENTION:

-schools, YMCA

SECONDARY PREVENTION:

-early identification

TERTIARY PREVENTION:

-support groups; AA

SOCIAL ACTIVISM:

-RX not detention

Health Teaching

&

Health promotion

PRIMARY PREVENTION: Health teaching frames

-Feedback of personal risk

-Responsibilty of the pt.

-Advice to change

-Menu of ways to reduce substance abuse use

-Empathetic counseling

-Self-efficacy or optimism of the pt.

INTERVENTION STRATEGIES

Relaspe prevention:want client to learn from relaspe

Self-help groups

12 step programs

Residential programs; Betty Ford: 30 days

Intensive outpt. programs

Outpt. drug-free programs & employee assistance programs

What didn't work last time? So, over time can lengthen periods of being sober, w/less relaspes.

TREATMENT MODALITIES

Self- help groups

Individual, group, & family therapy

Pharmacotherapy

Cognitive behavioral therapy

-pos. coping skills

-specific skill training

-behavior change

Alternative therapies

*some are sponsored by hospital or outpt basis.

SUBSTANCE ABUSE

PHARMACOLOGICAL INTERVENTIONS

TX

of

ALCOHOLISM

* Naltrexone (Revia)

* Acamprosate (Campral)

* Topiramate (Topamax)

* Dissulfiram (Antabuse)

meds should not be given until s/sx are seen

do not overhydrate; give anticonvulsants

cross dependent sedatives as well; lower electrolytes mag, K+, Na+.

Naltrexone (Revia)

Reduces or eliminates ETOH craving

low toxicity

Acamprosate (Campral)

Helps client abstain from ETOH

quit drinking; reduces neurotransmission > inhibits transmission.

Topiramate (Topamax)

Works to decrease ETOH cravings

Inhibits the release of Dopamine

Disulfiram (Antabuse)

ETOH-disulfiram reaction causes unpleasant physical effects; produces vomiting > prevents implusive drinking.

PHARMACOLOGICAL INTERVENTIONS

TX of

OPIOID ABUSE

* Methadone (Dolophine)

* LAAM (l-a-acetylmethadol)

* Naltrexone (Revia)

* Clonidine (Catapres)

* Buprenorphine (Subutex)

Opioid pharm tx:

Methedone (Dolophine)

Highly addicting; when stopped abruptly produces w/drawal s/sx. Gets pts out of illegal culture & psycho tx.

-synthetic opiate blocks craving for & effects of heroin.

given outpt.

opioid pharm tx:

LAAM (l-a-acetylmethadol)

an alternative to methadone

given outpt.

opioid pharm tx:

Naltrexone (Revia)

antagonist that blocks euphoric effects of opioids

low SE & low toxicity

opioid pharm tx:

Clonidine (Catapres)

nonopioid suppressor

Effective somatic TX when combined w/Naltrexone

opioid pharm tx:

Buprenorphine (Subutex)

Blocks s/sx of opioid withdrawal

Also, Suboxone

NSG EVALUATION

Want to see:

Increase in abstinence

Decreased denial

Acceptable Occupational Functioning

Ability to relate comfortably to other individuals

Read labels; no ETOH in food or OTC meds, herbal tinctures.

FAMILY EFFECTS

with pt

of

SUBSTANCE ABUSE

Chaos, disorganized

Denial

Children of abuse

Anger/alienation

Codependency:

-behaviors

-depression & low self-esteem

Education

Dual dx common

Tx ea. separately

Chemically Impaired Practice:

50% higher rate in Nursing

Due to:

Specialities

S/sx of this:

taking too much OT, always in BR, never around, pt's complain of too much pain, isolating themselves, not social, physical appearance, tardy, always want the narcotic keys, depressed.

*nurses have more access

*nurses have stressful jobs