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Addiction Disorders: Tolerance, Withdrawal & Comorbidity

This chapter explores the concepts of tolerance, withdrawal, comorbidity, and the general assessment and signs of intoxication with various addictive substances. It also discusses the effects of central nervous system stimulants, opiates, marijuana, hallucinogens, inhalants, club drugs, and date rape drugs. Assessment guidelines for the chemically impaired and potential nursing diagnoses are provided.

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Addiction Disorders: Tolerance, Withdrawal & Comorbidity

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  1. Chapter 18 Addictive Disorders

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

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

  8. 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

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

  10. Fine-motor tremors Diaphoresis Diarrhea Hallucinations and delusions

  11. 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

  12. Cocaine and Crack • Extracted from leaf of coca bush • 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

  13. Opiates Morphine Heroin Codeine Fentanyl Methadone Meperidine

  14. Marijuana (Cannabis sativa) • Indian hemp plant • Tetrahydrocannabinol (THC) is active ingredient • Depressant and hallucinogenic properties • Usually smoked • Desired effects – euphoria, detachment, relaxation • Long-term effects – lethargy, anhedonia, difficulty concentrating, loss of memory

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

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

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

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

  19. 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

  20. 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

  21. 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

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

  23. Health Teaching and Health Promotion • Primary prevention – health teaching FRAMES • Feedback of personal risk • Responsibility of the patient • Advice to change • Menu of ways to reduce substance use • Empathetic counseling • Self-efficacy or optimism of the patient

  24. Intervention Strategies Continued • Relapse prevention • Self-help groups for patient and family • 12-Step programs • Residential programs • Intensive outpatient programs • Outpatient drug-free programs and employee assistance programs

  25. Pharmacological Interventions Treatment of Alcoholism • Naltrexone (ReVia) • Reduces or eliminates alcohol craving • Acamprosate (Campral) • Helps client abstain from alcohol • Topiramate (Topamax) • Works to decrease alcohol cravings • Disulfiram (Antabuse) • Alcohol-disulfiram reaction causes unpleasant physical effects

  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. Evaluation • Increased time in abstinence • Decreased denial • Acceptable occupational functioning • Improved family relationships • Ability to relate comfortably to other individuals

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