Substance Related Disorders & Dual Diagnosis

1. Substance Related Disorders & Dual Diagnosis Phyllis M. Connolly, PhD, RN, CS NURS 127A

2. Questions to Consider Today 4/20/01 • What behaviors indicate that a nurse may be abusing substances? • What is the ego/self theory related to substance abuse? • When is denial a problem? • What is the relationship between childhood sexual abuse and addiction?

3. Substance Disorders Facts • Cost: $144 billion/year in health care and job loss • Alcohol most commonly used • Marijuana most commonly used illegal drug • 50% auto accidents & homicides involve alcohol • Involved in crime & violence • 500,000 deaths from Tobacco-related disorders • One in 10 deaths related to alcohol • More die from misuse of legal prescriptions

4. Impaired Nurses • 5% of 2 million nurses in 1984 (ANA) abused substances • 8-10% chemically dependent • Narcotic addiction 30 X higher than general population (1987 study) • 67% of cases handled by 44 state BRN (1988)

5. Job Performance Changes, Controlled drug handling Drug counts incorrect Excessive errors Excessive wastage, often not countersigned Medicine signed out to pt. not in pain Two strengths of drugs signed out to same pt. Same time Packaging appears to be tampered Patient complaints of ineffective pain control Volunteers to give controlled drugs General Performance Medication errors Poor judgment Euphoric recall for involvement in unpleasant situations iIlogical or sloppy charting Absenteeism, esp. days off Requesting leave time just before assigned shift Lateness--elaborate excuses Job shrinkage missed deadlines Signs of Impaired Nursing Practice

6. Behavioral/Personality changes Sudden changes in mood Periods of irritability Forgetfulness Wears long sleeves (hot weather) Socially isolates Inappropriate behavior Chronic pain condition Hx pain treatment with controlled substances Signs of Use Alcohol on breath Constant use of perfumes, mouthwash, breath mints flushed face, reddened eyes, unsteady gait, slurred speech, hyperactivity accelerated speech Increasing family problems interfere with work Signs Impaired Nurse Cont.

7. Interventions: Impaired Colleagues • Reporting required ethical & legal obligation to supervisor • Document in writing; time, date, place description, & names of those present • An advisor with (state nurse rehabilitation team) • Team approach,co-workers, supervisor, nurse administrator, family member

8. Alcohol abuse Males Females Substance Other drug dependency 16% 29% 6% 18% 9% Prevalence of Substance-Related Disorders Disorder Prevalence Dahme, 1998

9. Alcohol Amphetamine Caffeine Cannabis Cocaine Hallucinogens Inhalants Nicotine Opiods Phencyclidines (PCP) Sedative, hypnotic,or antianxiety agents Classes of Substances with Potential for Abuse and Dependence

10. 5 General Categories of Substances • CNS depressants,(alcohol, sedative-hypnotics, antianxiety agents,and volatile inhalants • Stimulants (cocaine, amphetamine,caffeine, nicotine**, & related substances) • Opioids including analgesics • Hallucinogens including PCP • Cannabis  Caffeine not considered to cause either dependence or abuse ** Nicotine is currently classified as causing dependence but not abuse

11. Psychoactive Substances • Drugs or chemicals which alter one or several of: • Perception • Awareness • Consciousness • Thinking • Judgment • Decision making • Insight • Mood • Behavior

12. Etiological Theories: Substance Abuse Biological • Addictive substances activate neurotransmitters in mesolimbic dopaminergic reward pathway • chronic use  blood flow to brain • Genetic predisposition • Behavioral--conditioning & homeostasis • drug craving triggers; self-medicating • Psychodynamic • Unconscious oral needs • Dependency • Low self-esteem • child abuse, physical, sexual • family conflict (Trauma model, Walker et al. 1998)

13. Substance Dependence A. Maladaptive pattern3 or more: tolerence withdrawal need for more inability to stop using time spent acquiring or recovering from effects problems, social, occupational, or recreational Continues use despite knowledge Substance Abuse A. Maladaptive pattern leads to significant impairment or distress as manifested by one or more of: Failure to fulfill major role obligations at work, school, or home Recurrent use in hazardous situations Recurrent substance related legal problems Continued use despite problems DSM-IV Criteria Substance Related Disorders

14. Substance Intoxication Development of a substance- specific syndrome due to a recent ingestion of a substance Clinically significant maladaptive behavioral or psychological changes due to the effect of the substance on the CNS Not due to general medical condition and not better accounted for by another mental disorder Substance Withdrawal Development of a substance-specific maladaptive behavioral or psychological changes due to the effect of the substance on the CNS The substance-specific syndrome causes clinically significant distress or impairment Not due to a general medical condition and not better accounted for by another mental disorder DSM-IV Criteria Substance Related Disorders Cont.

15. Substance Dependence Lack of control over drug use and its increasing importance. At least 3 symptoms in 12 month period. • Tolerance • Withdrawal • Taking larger amounts • Inability to reduce use • Excess time spent on obtaining drugs • Impairment in functioning • Continued use despite negative consequences Dahme, 1998

16. Key Terms • Dependence: A drug abuser must take a usual or increasing dose of a drug in order to prevent the onset of abstinence symptoms/withdrawal • Tolerance: The need for increasing amounts of a substance to achieve the same effects • Withdrawal: Physical signs and symptoms that occur when the addictive substance is reduced or withheld (abstinence syndrome)

17. Key Terms cont. • Abuse--Excessive use of a substance that differs from societal norms • Codependency--stress-related preoccupation with an addicted person’s life, leading to extreme dependence on that person • Blackouts--period of time in which the drinker functions socially but for which there is no memory • Pharmacodynamic tolerance--occurs when higher blood levels are required to produce a given effect

18. Coping Styles Contributing to Substance Abuse Maintenance • Rationalization • Falsifying an experience by giving a contrived, socially acceptable and logical explanation to justify an unpleasant experience or questionable behavior • Projection • Attributing an unconscious impulse, attitude,or behavior to someone else (blaming or scapegoating) • Denial • escaping unpleasant realities by ignoring their existence

19. Cognitive Framework: Assessing Denial Is it denial? Yes No Reassess Is it a problem? Yes No Do nothing How is it a problem? What cognitions are in conflict? What are alternative means of reducing dissonance? Forchuk & Westwell, 1987

20. Alcohol Abuse and Culture • Norms important role • Cultures with rate of alcohol abuse may condone drunkenness (Irish) • Cultures with  rates appropriate use of small amts. Celebrations (Jewish & Mediterranean) • Condemn altogether (Muslim, Jehovah’s Witness, and Mormons) • China and Japan lower prevalence-negative physiological response • Native Americans & Eskimos  rates • US rates similar to northern European countries

21. Enabling • Behaviors of individuals in family or social system who inadvertently promote continued alcohol or drug use. By protecting them from consequences of their actions. Examples: ignoring or making excuses for person’s behavior, finishing the work of a colleague who is unable to function.

22. CAGE Screening Test Alcoholism 1. Have you ever felt you ought to Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt bad or Guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eyeopener) Keltner, p. 530

23. Alcohol Withdrawal Symptoms: First 24 hours Within a few hours, peaks within 24 hrs. • Anxiety • Insomnia • Irritability • “Internal shaking”  BP, P, diaphoresis

24. Alcohol Withdrawal Symptoms: Sudden to 2-3 days • Grandmal convulsive seizures--48 hrs. • Delerium tremens (DTS)--72 hrs. •  Medical Emergency Acute pathological state of consciousness results from interference with brain metabolism

25. Wernicke’s Syndrome & Korsakoff’s Disease • Nutritional disorders related to alcoholism • Thiamine deficiency • Both treated with withdrawal from alcohol and vitamin supplements. • Improvement can occur in Wernicke’s syndrome, some degree of intellectual and emotional impairment remains. • Memory impairment is residual in Korsakoff’s even when slight improvement occurs

26. Wernicke’s Syndrome • Neuronal and capillary lesions in gray matter of brain stem • Characterized by delirium, memory loss, confabulation, apathy, apprehension, ataxia, clouding of consciousness, sometimes coma • If not treated early with large doses of thiamine, Korsakoff’s Disease may develop

27. Korsakoff’s Disease • Niacin deficiency in addition to thiamine • Degeneration of cerebrum and peripheral nerves • Characterized by amnesia, confabulation, disorientation, and peripheral neuropathy

28. Confabulation • Commonly observed in chronic brain syndrome • Person cannot recall specific aspects of an event • Fills in with relevant imaginary information • Face-saving device, protects self-esteem • Compensates for memory loss • Due to lack of access to stored information and lack of new input • Inability to form new associations • Loss of capacity for introspection and judgment of truth • Frequently observed in Korsakoff-Wenicke’s Syndrome

29. Potential Nursing Diagnoses: Substance Abuse • Altered nutrition • Risk for fluid volume deficit • Altered thought processes • Sensory/perceptual alterations: auditory-visual • Sleep pattern disturbance • Altered health maintenance • Self-care deficit • Noncompliance • Hopelessness • Helplessness • Self-esteem disturbance •  risk violence to self and others • Anxiety • Ineffective individual coping

30. Self-Care Deficit Ego functioning which does not handle painful affects or maximize protective activity • Interventions • Provide alternative ways to handle or tolerate painful emotions--stress management • Furnish structured supportive environment • Increase awareness of unsatisfactory protective behaviors • Teach skills to recognize & respond to health-threatening situations Compton, 1989

31. Pharmacological Interventions: Alcohol Abuse • Disulfiram (Antabuse)--negative aversive • inhibits breakdown of acetaldehyde--toxic to body: if alcohol is ingested causes sweating,flushing,  pulse,  BP, headache, nausea, vomiting, palpitations, dyspnea, tremor, and/or weakness. May cause arrhythmias, MI, cardiac failure, seizures, coma, and death

32. Elements of Detoxification Process • Secure environment • Sedation • Supplements

33. Pharmacological Interventions: Alcohol Abuse Cont. • Naltrexone hydrochloride (ReVia)--opiod receptor antagonist • Increases abstinence and reduces alcohol craving in combination with comprehensive treatment plan • May cause liver toxicity at high doses • Contraindicated for patients who abused narcotics within 7-10 days

34. Interventions Alcohol Abuse • AA Self-Help • Brief Interventions • Feedback • Responsibility • Advice • Menu • Empathy • Self-efficacy • Moderation-Online Self-Help • Motivational interviewing

35. CNS Effects sedation euphoria mood changes mental clouding pain reduction pinpoint pupils decreased respiratory rate GI Effects chronic constipation Cardio Vascular Hypotension Sexual Functioning Decreased libido retarded ejaculation impotence orgasm failure Detoxification Clonidine (Catapress) Opioid Abuse: Signs & Symptoms Townsend, 1996, p. 374

36. Antecedents to Relapse Keltner, p. 538

37. Stages of Change: Addictive Behaviors Relapse Permanent Exit Maintenance Precontemplation Contemplation Action Preparation Prochaska & DiClemente, 1992

38. Trusting therapeutic relationship, nurse Detox & residential treatment Behavioral model & disease model Rehabilitation Abstinence Motivation Medications Alcohol-Librium, Valium, Ativan Opioid--Narcan Methadone Family education Treatment of comorbid medical & psychiatric disorders Group treatment Confrontation Personal responsibility Conscience development Self-help Life-style issues Treatment of Substance-Related Disorders

39. Percent of Population (15 -54) 1991 With Substance Abuse Disorder, Mental, or Both in Lifetime Substance Abuse Dependence 12% Both Disorders 13.7% Only Mental Disorder 21.4% Dahme, 1998, p. 288

40. Etiology: Dual Diagnosis • Generally mental illness first • Heredity • Biological factors • Self-medicating • Substance abuse first • Brain chemistry altered • Guilt, depression, altered self-esteem • Personality disorders

41. Examples of Dual Diagnoses • Axis I Schizophrenia Alcohol abuse • Axis I Major depression Anxiolytic dependency • Axis I Major Depression Marijuana abuse

42. Treatment: Dual Diagnosis • Multidisciplinary • Case management • Individual therapy • Group therapy • Skills training • Education groups • Vocational counseling • Referrals to community resources • Self-help groups • Five-step model

43. Therapeutic Tasks: Dual Diagnosis • Establish therapeutic alliance • Help patient evaluate costs and benefits of continued substance abuse • Individualize goals for change; include harm reduction as alternative to abstinence • Help build an environment and lifestyle supportive of abstinence • Acknowledge recovery long-term process Jefferson, 1998, p. 517

44. Outcomes Treatment: Major Depression and Alcohol Abuse • Short Term • Verbalizes plans for future • Sleeps 6-8 hrs/night • Eats 3 balanced meals/day • Recognizes and describes problems with alcohol and depression • Plans to live with non substance user friend • Long Term • Practices abstinence from alcohol • Attends self-help groups • Attends outpatient treatment • Medication compliant • Lives in halfway house or non substance user friend