CHEMICAL DEPENDENCY: An Overview

1. CHEMICAL DEPENDENCY: An Overview RNSG 2213

2. INTRODUCTION • Substance abuse is not a new problem. • Mood-altering and mind-altering substances have been used throughout human history. • Opium used openly into the 20th century; Freud used Cocaine. • Tribal cultures have e.g. chewed coco leaves, used peyote in religious ceremonies, smoked the “peace pipe.”

3. Illicit Drug Use • Most used illicit drugs world-wide: • Cannabis (#1) • Amphetamines • Cocaine • Opioids (WHO 2004)

4. Introduction • No clear transition from therapeutic to abusive substance use • Use is significantly underreported and effects are often misdiagnosed • Much social stigma attaches to abuse and addiction • Implicated in many accidental deaths, crimes • Severe adverse effects on health, work, relationships and quality of life

5. Introduction: Drugs and U.S. Law • 1914: Harrison Narcotic Act --Opiate prohibition • Alcohol Prohibition in the 1920’s and 1930’s • 1970: Drug Enforcement Agency created; Controlled Substances Act passed • 1987: AMA declared all chemical dependency as disease • 1990: ADA—non discrimination against persons with history of drug/alcohol addiction

6. ADDICTION LIABILITY Highest Lower • cocaine/crack amphetamines • opiates anesthetics (PCP, ketamine) • alcohol nicotine benzodiazepines marijuana

7. (Addiction liability, cont’d) These are non-addicting: • LSD and other hallucinogens • antidepressant drugs • antipsychotic drugs • naltrexone-Trexan

8. DEFINITIONS • Intoxication: Substance-specific CNS effects • Substance Abuse: Recurrent use of a drug which results in adverse effects to oneself or others. (e.g. interpersonal, legal or safety issues) • Addiction: (compulsive use of substance = same as substance dependence; term is now considered judgmental )

9. Definitions, cont’d • Chemical/Substance Dependence: Loss of Control over use, which involves: • Tolerance: Must increase the amount of drug to get the needed effect. • Withdrawal: Refers to psychoactive substance-specific syndrome that occurs when person stops using the drug

10. DSM IV CRITERIA FOR SUBSTANCE DEPENDENCE • Tolerance, Withdrawal • Desires and attempts to cut down • Much time is spent in obtaining drug and recovering from drug • Social and occupational problems result • Substance use continues despite problems caused

11. DSM IV CRITERIA FOR SUBSTANCE WITHDRAWAL • Development of specific symptoms due to cessation of drug • Syndrome causes distress • Symptoms not due to a medical condition

12. Biological Theory: Neurotransmitters of Drug Dependence • Dopamine (DA) –”pleasure pathway” • Serotonin (SER) • Endorphins (END) • GABA/Glutamate (GLU) Theory: heavy drug use decreases response of “brain calming” neuroreceptors (= tolerance)

13. Etiology of Dependence: Biological Theory • Repeated use of a drug results in stimulation of brain’s “reward” or “pleasure” pathwayin mesolimbic system

14. Biological Theory of Dependence cont’d • Repeated use of a drug targets specific brain areas for that drug, with resulting creation of extra receptors and brain’s perception that drug’s stimuli are necessary for survival (cravings)

15. The Addicted Brain Bottom Line: Major sites targeted by addicting drugs (Within medial forebrain, not cortex) are evidence that addictions are not under conscious control

16. Biological Theory, cont’d • Evidence of genetic predisposition for alcoholism. • Example: Allergic response to ETOH in many Southeast Asians • Strong concurrence with bipolar disorder • Twins born to alcoholic parents who are then adopted have 3x rate of adopted children of non-alcoholics.

17. Multivariant Theory: Biology + Learning • Drug dependence results from interaction of the physiological effects of substances on brain areas associated with motivation and emotion, combined with ‘‘learning’’ about the relationship between substances and substance-related cues. • This theory gives support to why relapse may occur even after long period of abstinence. (e.g.: smell of cigarette can cause an ex-smoker to light up)

18. Etiology: Sociocultural Factors • Advertising: “Relief is just a swallow away” • Don’t suffer; take action • Sex differences: Males abuse alcohol and opiates more. Females abuse prescription drugs • Catholics: Highest rate of alcohol abuse • Observant Jews: lowest • Stress • Availability, cost

19. Etiology: Psychological/Psychodynamic Theory • Person who abuses drugs seeks to escape from anxiety or emotional pain. Sees self in a fundamentally negative way.

20. Personality Traits Associated with Chemical Dependence • DENIAL/ anger • Inability to express emotions • High anxiety in interpersonal relations • Emotional immaturity; overdependence • Ambivalence towards authority; rule breaker • Low frustration tolerance; wants instant gratification

21. Personality Traits, continued • Low self-esteem • Feelings of isolation • Perfectionism and compulsiveness • Sex role confusion Are these qualities the cause or the result of drug use?

22. Effects on Family • All family members affected by the substance-dependent member. • Many characteristic behaviors: • Focus becomes on the addict’s behavior • Co-dependency • Care-taking by children • Perpetuation of these dynamics into adulthood • 3 Options: ignore, banish, adapt • Family in need of treatment

23. Assessment • Denial complicates assessment • Use screening tools, e.g. MAST • Careful history: occupational, legal, behavioral alterations • Physical Assessment: substance specific signs and symptoms • Urine and serum drug screens; breathalyzer (alcohol)

24. Short version of Michigan Alcoholism Screening Test (SMAST) > 3 points indicates problem

25. GOALS FOR DETOXIFICATION • American Society of Addiction Medicine lists three immediate goals for detoxification of alcohol and other substances: (1) “to provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug-free”; (2) “to provide a withdrawal that is humane and thus protects the patient’s dignity”

26. Principles of Detoxification Ideal detoxification avoids life-threatening withdrawal signs and symptoms but also avoids intoxication with the withdrawal medications. The goal is not absolute comfort. Objective measures of withdrawal (vital signs, observable findings, withdrawal rating scores)are very useful for monitoring the course of withdrawal and supplementing the subjective data from the client.

27. Nursing Interventions • Examine own attitudes about substance use and dependence Provide: • Safe environment for client in withdrawal • Empathy and acceptance • Hope for recovery • Group therapy: to deal with denial and provide support for change • Medications to treat co-occurring mental illness

28. Client Behaviors and Nursing Interventions • Anger: matter-of-fact approach • Guilt and shame: non-judgmental support; offer positive feedback for help-seeking behaviors • Denial and Avoiding Responsibility: supportive confrontation • Manipulation: Set limits and clear rules. • Cravings: provide support, teaching and encourage talking with peers

29. Interventions: Client Teaching • Disease process • Total abstinence is the goal • Relapse prevention strategies • Recognize and confront own denial • Recognize triggers • “Change people, places and things.” • Often biggest obstacle to abstinence.

30. Interventions • Referrals and Community Resources • Long-term residential rehabilitation is best predictor of abstinence (28 days to 6 months or more) • Halfway House • Outpatient rehabilitation • AA, NA, Rational Recovery • Family counseling • Al-Anon, Nar-Anon, Alateen • Other services: job placement, housing, etc.