Chapter 18

1. Addictive Disorders Chapter 18

2. Overview • Addiction to psychoactive substances is a worldwide health problem • Addiction is one of the most serious public health problems in the US • Alcohol, by far is the leading substance abused by Americans

3. Tolerance and Withdrawal Tolerance • Person’s physiological reaction to drug decreases with repeated administration of same dose Withdrawal • Psychological changes occur when blood and tissue concentrations of drug decrease after heavy prolonged use of substance

4. Synergistic and Antagonistic • Synergistic effect– when drugs are taken together, effect of either or both is intensified or prolonged • Antagonistic effects–whendrugs are taken together, effect of one is inhibited or weakened

5. Comorbidity • Psychiatric comorbidity– 6 out of 10 people affected by substance-abuse disorder also affected by mental health disorder • Medical comorbidity– alcohol-related medical problems are the comorbidities most commonly seen in medical settings

6. Etiology • Biological factors • Specific effects on neurotransmitter systems • Psychological factors • Lack of tolerance for frustration and pain • Lack of success in life • Lack of affectionate and meaningful relationships • Low self-esteem, lack of self-regard • Risk-taking propensity • Sociocultural factors • Social and cultural norms • Socioeconomic stress

7. Epidemiolgy of Alcohol • About two-thirds of American adults consume alcohol; about 14% of them develop problems with dependence • Roughly one-third of all hospital admissions are related to alcohol abuse • The divorce rate for couples with and alcoholic spouse is seven times greater than that for other couples • Approximately one-half of all traffic accidents are alcohol related

8. General Assessment • Two questions of importance • In the last year, have you ever drank or used drugs more than you meant to? • Have you felt you wanted or needed to cut down on your drinking or drug use in the last year? • Details include • Drugs used • Route • Quantity • Time of last use • Usual pattern of use

9. Psychological Changes Denial Depression Anxiety Dependency Hopelessness Low self-esteem Various psychiatric disorders

10. Alcohol • Physical effects: Slurred speech, lack of coordination, unsteady gait, blackouts, nystagmus flushed face, sense of floating, and anorexia • Psychological effects: euphoria, mood lability, impaired judgment, sexual inhibition, decreased concentration, aggressive behavior • Withdrawal effects: Anxiety, agitation, and irritability, tremors, tachycardia, hypertension, diaphoresis, hallucinations, N/V, diarrhea, delirium tremens

11. Signs of Intoxication and Withdrawal • Alcohol poisoning • Large amounts of alcohol consumed quickly or over time • Alcohol withdrawal • Signs develop within a few hours after cessation • Peaks at 24 to 48 hours • Alcohol withdrawal delirium • Medical emergency • Can result in death, even if treated

12. Wernicke-Korsakoff Syndrome • Results from a deficiency in vitamin B complex (most commonly a thiamine deficiency) • Severely impairs cognitive functioning • Produces peripheral neuropathy, cerebellar ataxia, confabulation, and myopathies • Death can occur if thiamine replacement therapy is not initiated immediately

13. Effects of Alcoholism • Alcohol-induced persisting amnestic disorder • Alcohol encephalopathy • Fetal alcohol syndrome • Suicide and alcoholism • norepinephrine = BP, HR • GABA leads to risk of seizure

14. CAGE Questionaire • Consist of four questions • Have you ever felt you should cut down on your drinking? • Have people annoyed you by criticizing your drinking • Have you ever felt bad or guilty about your drinking? • Have you ever had a drink first thing in the morning to steady nerves or get rid of a hangover (eye-opener)?

15. Nursing Implications • Monitor the patient’s vital signs and behavior • Seek a physician’s order for a benzodiazepine to decrease withdrawal symptoms • Close observation • Promote sleep and rest • Institute seizure precautions • Encourage fluids

16. Pharmacology Treatment • Benzodiazepines: Valium, Ativan and Librium for withdrawal symptoms • Disulfiram (Antabuse): inhibits Acetaldehyde Dehydrogenase • Alcohol-disulfiram reaction causes unpleasant physical effects • Naltrexone (ReVia, Trexan): block the need to ingest alcohol. Vivitrol-IM (monthly) • Opiate antagonist. Blocks euphoric reinforcement produced by substance and prevents craving

17. Pharmacology Treatment • Acamprosate – (Camprol): Stabilizes N-Methyl-D-Aspartate (NMDA) receptor causing decrease of glutamatergic/excitatory system • Topiramate (Topamax): actions on glutamatergic system to decrease alcohol cravings • SSRI’s: may decrease drinking in late onset alcoholism

18. A nurse is assigned the care of four patients detoxifying from alcohol. The patient with which symptom would be the nurse’s highest priority?

19. Fine-motor tremors Diaphoresis Diarrhea Hallucinations and delusions

20. Central Nervous System Stimulants Common signs of stimulant abuse • Dilation of the pupils • Dryness of the oronasal cavity • Excessive motor activity Cocaine and crack Caffeine and nicotine

21. Cocaine and Crack • Extracted from leaf of coca plant, found in Bolivia and Peru. • When smoked, takes effect in 4 to 6 seconds; a 5- to 7-minute high follows, then a deep depression • Two main effects on body • Anesthetic • Stimulant • Produces imbalance in neurotransmitters • Withdrawal symptoms include • Depression, paranoia, lethargy, anxiety, insomnia, nausea, vomiting, sweating, chills

22. Cocaine • Stimulant and decreases appetite. • Ingredient in Coca-cola until 1903. • Used as a local anesthetic. • Develop tolerance • Intoxication • Similar to alcohol withdrawal: sweating, dilated pupils, psychomotor agitation, increase BP and HR, high fever, arrythmias, seizures, hallucinations • The “Post-Coke” Blues

23. Pharmacological Treatment • Diazepan (Valium) • Phenobarbital • Imipramine hydrochloride (Tofranil) • Propranolol (Inderal) • Bromocriptine (Parlodel) • Amantadine (Symmetrel)

24. Opiates • Physical effects: pinhole pupils, skin picking, sleepiness, anorexia • Psychological effects: Anxiety, impaired cognition, delirium, euphoria • Withdrawal effects: lacrimation, rhinorrhea, excessive sweating, yawning, tachycardia, fever, insomnia, muscle aches, craving, N/V, dilated pupils, chills

25. Opiates Morphine Heroin Codeine Fentanyl Methadone Meperidine

26. Pharmacological Interventions Treatment of Opioid Addiction • Methadone (Dolophine) • Synthetic opiate blocks craving for and effects of heroin • LAAM (l-α-acetylmethadol) • An alternative to methadone • Naltrexone (ReVia) • Antagonist that blocks euphoric effects of opioids • Clonidine (Catapres) • Effective somatic treatment when combined with naltrexone • Buprenorphine (Subutex) • Blocks signs and symptoms of opioid withdrawal

27. Nursing Implication Monitor vital signs Close observation Offer fluids and light food as tolerated Keep environment nondistracting and soothing Methadone (dolophine) maintenance Levomethadyl (Orlaam) administered 3 times a week Clonodine: reduces autonomic hyperactivity

28. Barbiturates and Sedatives/Hypnotics • Physical effects: Drowsiness, fatigue, orthostatic hypotension, anorexia, slurred speech, ataxia, seizure, dizziness • Psychological effects: Euphoria, irritability, anxiety, poor memory and understanding, delirium, depressed mood, violence • Withdrawal effects: N/V, generalized malaise, tachycardia, excessive sweating, anxiety, irritablity, ortho hypotension, insomnia, seizures, coarse tremors

29. Amphetamines • Physical effects: anorexia, arrhythmia, restlessness, tremors, dizziness, generalized tonic-clonic seizures, dry mouth, dilated pupils, hyperactive reflexes, tachycardia • Psychological effects: Labile affect, anxiety, delirium, euphoria, violence, hallucinations, irritability • Withdrawal effects: Depression, fatigue, agitation, suicidal thought, paranoia, insomnia or hypersomnia, disorientation

30. Nursing Implication • Promote sleep and rest • Monitor vital signs • Monitor suicidal ideation • Antidepressant, if ordered • Remain with a frightened or disoriented patient • Orient the patient to reality

31. Marijuana (Cannabis sativa) • Indian hemp plant • Tetrahydrocannabinol (THC) is active ingredient • THC is stored in the fatty tissues (especially in the brain and reproductive system) • THC can be detected in the body for up to 6 weeks • Depressant and hallucinogenic properties

32. Marijuana (Cannabis sativa) • Usually smoked • Desired effects – euphoria, detachment, relaxation • Long-term effects – lethargy, anhedonia, difficulty concentrating, loss of memor • Analgesic effect • Effective against nausea and vomiting • Treat weight loss • Marinol (Dronabinol) is a synthetic THC approved by the FDA for anorexia.

33. Marijuana (Cannabis sativa) • Physical effects: slowed speech, slowed reflexes, red eyes, dry mouth, increased appetite, lower testosterone, 70% more benzopyrene (major cancer causing chemical, emphysema). • Psychological effects: apathy, reduced inhibition, altered stated of awareness • Withdrawal effects: Anxiety and restlessness

34. Salvia • Salvia divinorum: large green leaves, hollow square stems, and white flowers. • Can be chewed, can drink the extracted juices, or smoked through water pipes and inhaled. • Hallucinatory experience, paranoia and loss of physical coordination • Users feel giddiness and disorientation. • Sometimes used in combination with other substances, such as alcohol.

35. Nursing Implication • Help patient with memory loss to fill in gaps of information • Attend to self-care needs that a lethargic or apathetic patient may have neglected

36. Hallucinogens • Lysergic acid diethylamide (LSD or acid) • Mescaline (peyote) • Psilocybin (magic mushroom) • Phencyclidine piperidine (PCP, angel dust, horse tranquilizer, peace pill)

37. Hallucinogens • Physical effects: Hyperactive reflexes, tachycardia, labile mood, anorexia, hypertension, dizziness • Lysergic acid diethylamide (LSD): anxiety, sleep disturbance, tremors, and dilated pupils • Phecyclidne (PCP): slurred speech, blank stare, irritability, seizures, nystagmus, violence, ataxia, delirium, depression, fatigue, memory loss, poor impulse control • Psychological effects: euphoria, restlessness, suspiciousness, hallucinations • Withdrawal effects: No physical withdrawal symptoms for LSD, PCP: depression, lethargy, craving

38. Inhalants • Volatile solvents • Spray paint • Glue • Cigarette lighter fluid • Propellant gases used in aerosols

39. Inhalants • Physical effects: dizziness and lightheadedness • Psychological effects: euphoria and excitement • Withdrawal effects: none

40. “Bath Salt” • “Bath Salt” Methylenedioxypyrovalerone (MDPV) • Agitation • Paranoia • Hallucinations • Chest pain • Suicidality

41. Nicotine • Psychoactive stimulating substance found in tobacco. • Extremely addictive • Occupies the receptors for acetylcholine in both dopamine and serotonin neural pathways (acts on brain reward mechanisms) • Associated with cancer, heart disease, emphysema, hypertension and death

42. Smoking • 1 cigarette = 14 mins. • 10 pack = 2hours 20 mins • 20 pack = 4 hours 40 mins • If you smoke 20 a day, which is the norm, for 20 years of your life, you will take 3 years, and 10 months off your life !!!!

43. Smoking Cessation • Varenicline (Chantix) partial agonist at nicotinic receptors • Bupropion (Zyban) increase dopamine to decrease cravings • Transdermal patch – steady levels of nicotine, desensitizes receptors to relieve craving.

44. Caffeine • Acts as a stimulant • Found in coffee, tea, and chocolate • 64 mg in instant coffee, 112 mg in filtered coffee, 40 mg in tea, 7 mg chocolate, 40 mg cola drinks, 80 mg in Red Bull • Diuretic, increases cholesterol and LDL • Withdrawal symptoms: irritability and headaches

45. Club Drugs • Common drugs • Ecstasy - also called MDMA, Adam, yaba, XTC • MDA – “love” • MDE – “Eve” • Produce subjective effects resembling stimulants and hallucinogens

46. Date Rape Drugs • Flunitrazepam (Rohypnolor “roofies”) • Gamma hydroxybutyric acid (GHB) • Rapidly produce • Disinhibition • Relaxation of voluntary muscles • Anterograde amnesia

47. Assessment Guidelinesfor the Chemically Impaired • Assess for withdrawal syndrome • Assess for overdose that warrants medical attention • Assess for suicidal thoughts or other self-destructive behaviors • Evaluate for physical complications related to drug abuse • Explore interests in doing something about drug or alcohol problem • Assess patient and family for knowledge of community resources

48. Potential Nursing Diagnoses • Imbalanced nutrition: less than 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

49. Outcomes Identification • Withdrawal • Fluid balance • Neurological status: consciousness • Distorted thought self-control • Initial and active drug treatment • Risk control – alcohol use • Risk control – drug use • Substance addiction consequences • Health maintenance • Knowledge: substance abuse control • Family coping

50. Implementation • Aim of treatment – self-responsibility • Challenge – matching patients with types of treatment related to various needs • Physiological • Psychological • Sociocultural processes