Substance AbuseCh. 95 Med/Surg Nursing 2013
Substance Abuse • Drug-substance that activates the pleasure center of the brain* • Used as a response to stress, low self-esteem, obsessed with food, work, sex, gambling • Addictions know no racial, religious, age, gender or socioeconomic barriers • Nursing care requires PATIENCE
Chemical Abuse and Chemical Dependency • APA definition-“maladaptive pattern of substance use leading to clinically significant impairment or distress” with one or more of the following in a 12 month period: • Failure to fulfill role obligations • Use that presents danger to self or others • Recurrent use-related legal problems* • Continued use
Chemical Abuse and Chemical Dependency • Drugs that are abused include: alcohol, marijuana, cocaine, methamphetamines, MD prescribed medications, etc.
Chemical Abuse and Chemical Dependency • Chemical Dependency (substance dependence) as defined by the APA as those listed above including at least 3 of the following in a 12 month period:. • 1. Tolerance-need more of the drug to produce desired effect • 2. Withdrawal-occurs when they stop using, must take the drug or alcohol to avoid these symptoms • 3. Use larger amounts of the drug • 4. Would like to cut down or quit but can’t • 5. Spend time, energy and money to obtain the drug • 6. Give up their former “important things” in life in order to use the drug • 7. Continued use of the drug regardless of its effect on the body (spiritually, mentally, interpersonal relationships) • Chemical dependencies are often combined with other behaviors such as gambling
Chemical Abuse and Chemical Dependency • Dx Tools: DIS-specific for alcohol; ASI-determines degree of addiction to any drug • Chemical dependency can lead to mental disorders, sexual dysfunction, cirrhosis of the liver, organic brain damage, and pancreatitis
Chemical Abuse and Chemical Dependency • Causes: • Several theories • Physical Factors Theory: excessive consumption is the most immediate cause of addiction • Use substances to escape from life or to feel better • Genetic Theory: could possibly be based on direct biologic transmission or as a learned childhood behavior
Chemical Abuse and Chemical Dependency • Emotional and Psychological Theory: use to escape from stress, or d/t low self-esteem, dissatisfaction with life, low tolerance for frustration, self-destructive tendencies, co-existing mental illness • Need the drug to feel good about life
Chemical Abuse and Chemical Dependency • Dual Disorders: • Mental illness combined with chemical dependency (MI/CD) • Mentally ill clients are usually depressed • May use drugs to ease the pain or commit suicide • May experience auditory hallucinations (hear voices) and use chemicals to make the “voices” go away • What the client don’t realize is that alcohol, sedatives, and narcotics are depressants and this accelerates the already depressed client’s mood
Nature • Progressive Nature: psychological cause • 1. Use to feel better, the drugs temporarily relieves the feelings of low self-worth and stress • 2. Use to keep from feeling bad, need increased amounts to stop feeling sick or depressed, the body needs the drug • 3. Lose control-small amounts of the chemical causes illness or severe intoxication • Blackouts occur with excessive use • Need medical attention to save their life!
Nature • **Defense Mechanisms-most commonly used • Denial • Rationalization • Projection
Nature • Management of Dependency • 1. Recognition • 2. Intervention • 3. Treatment-must be STRUCTURED!! • 4. Recovery
Nursing care measures • Nursing care can be on an outpatient basis, ECF, special treatment centers and clinics, and hospitals • Insurance companies may not reimburse for a substance abuse Dx so the client may be listed under another Dx (medical)
Identification of the Chemically Dependent Person • Use defense mechanisms regularly • Be aware of withdrawal sx: tremors, anxiety, agitation
Nursing Assessment • Interview Process-see questions to ask on pg. 1633 • Dealing With an Intoxicated Person in the Healthcare Facility • CHALLENGING • Must confirm the drug used by laboratory tests • Monitor LOC!! • Obtain a thorough history • Determine when alcohol or drug was last used • Document ALL information
Dx tests • Dx test ordered by Md: blood alcohol test (do not prep site with alcohol) and urine toxicity (U-tox) which will determine the drugs used • If a visitor is intoxicated-do not allow them into the room, notify the charge nurse, supervisor or security
Detoxification and Recovery • Detoxification-process of removing a drug and its physiologic effects from the person’s body • May take days depending on the drug used, amount, level of dependence, liver and kidney function • Provide comfort and SAFETY during withdrawal • Use sedation and emotional support to allow rest and recuperation • Detoxification must occur before long-term CD treatment can occur
Motivation for CD Treatment • Person wants to stop • Don’t want to rely on the drug • Want to cut down on the drug but it is not possible-must stop! • May be court ordered and they will be angry because they may not want to stop • Need strong peer pressure to stop
Detox Center • Usually escorted by the police • Under medical supervision while in the center • Need supportive care and referral to continuing therapy after detox.
Therapeutic Community • Isolated from the substance-oriented environment • Recovering abusers usually organize the program; group therapy • May be gender specific and focus on male or female problems • Goals-address physical and emotional problems and understand the cycle of dependence, then they begin the “true” recovery
Immediate Detox TX • Complete medical work up • Lab work • Blood chemistry levels to determine vitamin deficiencies, lipid levels, uric acid levels • U-tox • Determine withdrawal behavior-may still ask for the drug even though they don’t have symptoms • Must experience withdrawal symptoms-n/v, tremors, diaphoresis, agitation, anxiety, hallucinations, h/a, confusion for drugs to be initiated • May have medical problems such as esophageal varices, brain damage, CHF, dyspnea • Reassess the client at a minimum of q. 1 hour
Withdrawal SX • Body is denied access to the drug • Withdrawal occurs-mild to severe • Depends on the drug, how much was used and for how long • Present with psychological and medical problems • **An injury can precipitate withdrawal
Withdrawal SX • Alcohol withdrawal-most dangerous • Often combined with other drugs • Detox begins within 72 hours of last ingestion • Suicide risk increases • TREMORS!! • Agitation, anxiety • Diaphoresis • Delusions • HTN, tachycardia, hyperthermia • N/V, anorexia • Seizures • Hypoglycemia • Dilated pupils • Confusion • Blackouts • Cardiac arrest • May cause FAS in pregnant women
Nutrition and General Health • CD clients are usually malnourished • Baseline weight • May need nutritional supplements • Refeeding Syndrome • CHO’s must be given very carefully • This may include dextrose IV solutions, tube-feeding mixtures and liquid dietary supplements!
Long-Term F/U and Treatment • Substance abuser, alcoholic dependent, chemically dependent or polysubstance abuser, most people are codependent (live with others that abuse) • **Active interventions must occur or addiction continues!
Inpatient or Outpatient Tx. • 12-steps-NA or AA; teach that the disease is incurable and is considered to be in remission
Dialectical Behavioral Therapy • The goal is what “Linehan” calls the wise mind, a midway point between being totally rational and totally emotional
Family Counseling • They will need intensive counseling • Will need to provide support, not encourage the behavior • Family recovery can begin even if use continues*
After-Care • Chemically dependent person needs detox or intensive CD treatment • AA and other groups must continue for at least 2 years
Alcohol Abuse and Dependence • Public health problem • Contributes to over 100,000 deaths/year • MADD • DARE • FAS • If you drink to often/to much, there are negative consequences**
Alcoholism • S/S: • Chronic alcoholics are at risk for suicide • Blood alcohol levels are important to detoxprograms • Chronic alcoholism can lead to dementia, amnesia, sleep disorders and psychotic symptoms including delusions and hallucinations* • Legal level varies state to state • Generally between 0.08-0.10 g/dl • At 0.3 g/dl-person vomits, and may become aggressive or be in a stupor • At 0.4 g/dl-coma can occur • At 0.5 g/dl-severe respiratory distress and death can occur • It takes 3-5 glasses of 4 oz wine/hour to reach a BAC level of 0.08 g/dl(depending on food consumption) • Nurses may draw blood alcohol levels-DON’T USE ALCOHOL TO CLEAN SITE!!
Alcohol Abuse and Dependence • S/S: • CNS depressant • slurred speech • unsteady gait • behavioral changes • confusion • Chronic abusers have may have swollen nose, spidery veins and thickened and reddened palms
S/s of Alcoholism • AST, ALT, LDH, ALP AND THE GGTP/SCCT may be used to evaluate liver function • The GGTP/SGGT is elevated in 75% of chronic alcoholics • Thiamine and folate levels are low \ • RBC’s are often low • Lipids and uric acid levels may be increased
disorders resulting from Alcohol Abuse • Dietary Deficiencies-vitamin B1, B9 • Untreated thiamine deficiencies may lead to severe neurologic disorder called Wernicke-Korsakoff syndrome. S/S: dementia, ataxia, somnolence, diplopia, horizontal nystagmus, mortality rate from this disease is high • Cirrhosis of the liver and Hepatitis • Client has malnutrition and decreased intestinal ability to absorb medications* • Laennec’s cirrhosis r/t chronic alcohol abuse • Hepatits C is a result from chronic alcohol abuse
Other disorders • Esophageal varices • Gastritis • Gastric ulcers • kidney disorders • CAD • Sexual impotence-decreased desire/ability to perform during sex* • FAS
Treatment • Detox and f/u, must have support program
STAGES OF WITHDRAWAL • Autonomic hyperactivity • Tachy over 100 • Nervous • TREMORS! • insomnia, vivid nightmares • diaphoresis • flushed face • anorexia/nausea • Neuronal excitement • Sensory-perceptual disturbances • Severe toxic state is DT’s • S/s include delusions and vivid auditory, visual and tactile hallucinations called alcohol hallucinosis which may last from a few days to several weeks • Vomiting may be present • Position on side!
Family Considerations • Family disease • the alcoholic family have these characteristics: • control • perfectionism • mistrust of others • Tension • Members may have low self esteem! • overuse defense mechanisms
Codependent or Enabler • Codependent is often the person the alcoholic blames for the entire problem! • Must understand that alcoholics have a bad disease but are not bad people*
Medication Therapy • Antabuse-used for aversion therapy when the alcoholic is unable to maintain sobriety • *Loading dose is 500 mg/day for 2 weeks followed by a daily maintenance dose of about 250 mg • *If the person drinks while taking Antabuse, they become ill d/t the buildup of acetaldehyde; s/s: flushing, h/a, dyspnea, hypotension, nausea, tremors, thirst • Do NOT give Antabuse within 12 hours of alcohol ingestion • Naltrexone-Blocking agent used to treat opioid abuse and as adjunct treatment for alcoholism • Decreases subjective effects of alcohol, which results in the person drinking less • Don’t use this drug if the client has hepatitis or liver failure • Must be completely detoxified from coexisting opioids before beginning treatment
Sedatives, hypnotics and anxiolytic drugs • Includes barbiturates and antianxiety drugs such as benzo’s • Barbiturates • Amobarbital/Amytal • Secobarbital/Seconal • Benzodiazepines • Alprazolam/Xanax* • Chlordiazepoxide/Librium • Diazepam/Valium • Lorazepam/Ativan • Others
Symptoms of abuse • Delirium • Depression • Slurred speech • Amnesia, irreversible dementia • Respiratory depression • WITHDRAWAL • SEIZURES • ANTIDOTE FOR OD-flumazenil/Romazicon
GHB • Date-rape drug • Sx of abuse • Labile • Incontinent • Coma • seizures • Withdrawal • Similar to DT’s but vitals are often normal or only slightly elevated
Cannabis-related drugs • Made from hemp plant and used as hallucinogens • SX of abuse • Dreamy state, characterized by euphoria • Perception of space and time may be distorted • Can induce psychological and physical dependence! • Withdrawal • Diarrhea, ptsosis, rhinorrhea
Opiates and opiate agonists • heroin • morphine • meperidine HCL (Demerol) • hydromorphone (Dilaudid) • Symptoms of Abuse/narcotic intoxication s/s: drowsiness/coma, slurred speech, bradypnea, depression, suicide risk • Withdrawal: sore throat, rhinorrhea, insomnia, diaphoresis, dilated pupils; more severe: Gi discomfort, joint and muscle pains • Naloxone/Narcan is the antidote for narcotic overdose**
Agonist and drug replacement therapy • Naltrexone-before use, the client must go through detox from opiates • Originally developed as a treatment for narcotic addiction • Must wait 7 days prior to administration • If addicted to methadone-must wait 10 days prior to tx. • Methadone-opiate analgesic used for the tx of heroin-dependent individuals, used as a substitute for heroin-does not produce a “high” • Powder is mixed in at least 120 ml of OJ to mask the taste and dosage of drug • Do well on therapy as long as they don’t continue to use other drugs • Can precipitate withdrawal even if client not completely detoxified*
Cns-stimulants Amphetamines • Mood elevators and appetite depressants and they combat drowsiness and simple fatigu • Street names “ecstasy”, “crystal meth” • S/S of abuse: euphoria, confusion, anger, poor judgement • Withdrawal: depression, paranoid psychosis, nightmares, increased appetite • Tweaking • Meth user who has not slept for days and is in acute withdrawal
Cocaine • Use cocaine to feel better* • Symptoms of abuse: • Sexual dysfunction • Sleep disorders • Delirium and mood and anxiety disorders • Hallucinations Withdrawal intensive care or 1:1 staffing!
Khat • Stimulant • Abuse • Euphoric and stimulant effects • Appear emotionally unstable • Induces psychosis, including hallucinations and a feeling of being liberated from space and time • Withdrawal • Drowsy • Hallucinations • Lethargy • Mild depression
Hallucinogens • Not believed to cause actual or physical dependence, but produce psychological dependence and mild tolerance • LSD/Mescaline and Mushroom • Auditory hallucinations and intense visual hallucinations • Objects may appear larger-macropsia or smaller-micropsia Phencyclidine Hydrochloride hallucinogens developed as an animal anesthetic