Chemical Dependency

1. Chemical Dependency

2. Presence of substance abuse or dependency AND a Mental Health Diagnosis (Axis I or Axis II) 50% of clients with severe mental illness also have substance abuse problems Increases revolving door syndrome Crisis Admission Stabilization Discharge Substance abuse Poor prognosis Dual Diagnosis

3. Along with heart disease and cancer Ranks as one of the leading causes of death and disability in the United States Premature death 2 to 4 times higher Homicides 50% alcohol related Suicides 25% alcohol related Accidental Death 47% alcohol related Drownings 34% alcohol related Falls 28% alcohol related Alcoholism

4. Psychodynamic Easily succumb to the escape More phobic Stereotypical characteristic (the result of alcoholism or the cause?) Feelings of Inferiority Dependency, low self-esteem, introversion Biological Theory Genetic Predisposition Children of alcoholics are at greater risk even when raised in an alcohol free environment Can take steps to minimize risk Recognize family predisposition Avoid the use of alcohol and drugs Theories for Substance Dependence

5. Pharmacokinetic of Alcohol

6. Hepatic Function Primary metabolism is in the liver Increased hepatic drug-metabolizing enzymes Hasten alcohol metabolism Fat accumulates in the liver because it’s primary use is no longer for energy Alcohol accumulates in the liver increasing cell death Vitamins can not be activated Respiratory Depression Tolerance to Respiratory depressing effects does notdevelop The more alcohol an individual drinks the more likelyrespiratory depression (regardless of needing more alcohol to get a buzz) Results in deaths of long-term pharmacodynamically tolerant drinkers Alcohol: Tolerance Disease and Respiratory Depression

7. Alcohol: Unlike other drugs does not mimic a single neurotransmitter A small fat soluble molecule Alcohol enters the cell membrane of neurons Changes the properties Receptors are located on cell membranes Cell membranes control the release of neurotransmitters Alcohol Unlike other drugs effects all parts of the brain and all neurotransmitters Some of the Neurotransmitters effected Glutamate Muscle relaxation, discoordination and Black outs Dopamine Excitement and stimulation GABA Anxiety reduction Endorphins Kills pain and leads to endorphin”high” Alcohol: a Chemical BOMB!

8. Cerebral Intoxication Depresses psychomotor activity Relieves anxiety and tension Increases ability to socialize Decreases self- imposed social barriers REBOUND: how it starts and ends First depresses psychomotor activity relieves anxiety and tension Second effects wear off greater tension and anxiety rebound psychomotor activity Third drinker consumes more alcohol to regain anxiety free state Presenting complaints Nervousness (anxiety) Depression Alcohol: The Central Nervous System

9. The Liver Decrease liver cell function Increase in ammonia High lab value Hepatic encephalopathy (brain damage) Increase in bilirubin Increase in female hormones Pancreatitis Diabetes Peripheral Nervous System Thiamine deficiency contributes to peripheral neuritis (paresthesia in distal extremities) Alcohol and Medical Problems

10. Cause: Malabsorption syndrome Irritation of the intestinal lining Deficiency in vitamin absorption Especially B vitamins and B1 (Thiamine) Amnesia Delirium Peripheral neuropathy Must replace Thiamine Give parenterally at first then orally Delirium will become a permanent Dementia if Thiamine remains deficient Wernecke- Korsakaff Syndrome

11. Neuro: CNS irritation, tremulousness, nervousness, unsteady gait, difficulty concentrating. Exaggerated startle reflex Alcohol Withdrawal

12. MH: Anxiety, sleep disturbance, craving for alcohol and other drugs, hallucinations. Delirium tremens (DTs) GI: N&V diarrhea, anorexia CV: tachycardia, high BP, profuse perspiration Alcohol Withdrawal

13. CIWA Clinical Institute Withdrawal Assessment • Some of the CIWA measurements include: • Pulse and blood pressure measurements • Nausea and vomiting incidences including frequency and severity • Tactile disturbances which have a wide range from feeling a pins and needles sensation to itching to severe or continuous hallucinations • Tremor severity, if any • Visual and auditory disturbances • Sweating • Anxiety and agitation which may be noted from mild to serious panic attack mode • Orientation or disorientation levels • Each symptoms is scored and a TOTAL score can warrant prn medication

14. Withdrawal: Misery and Risk of Death Medications to assist with symptoms: Clonidine (Catapress) Thiamine (vitamin B1) Lactulose Decreases ammonia levels Medication is used to prevent DTs and seizures: Benzodiazepines Chlordiazepoxide (Librium) Lorazepam (Ativan) Diazepam (Valuim) Disulfram (Antabuse) Aversive Therapy Will become ill if the person drinks Sweating, flushed face, N&V, dyspnea palpitations, dizzy weakness, Naltrexone hydrochloride (ReVia) Opioid receptor antagonist Decreases pleasurable affects Must wear a medical alert bracelet Acomprosate (Campral) Corrects the balance between neuronal inhibition and excitation altered by alcohol Does not prevent relapse Medications: Alcohol

15. Opioid: Heroine

16. Opium, Heroine Codeine hydromorphone (Dilaudid) meperidine (Demerol) methadone (Dolophine) hydrocodone (Vicodin) oxycodone (Oxycontin) Opioids (Narcotics)

17. Progressive symptoms: Pinpoint pupils (mitosis) Stuporous and sleeps Skin is wet and warm Coma and respiratory depression Skin becomes cold and clammy Pupils dilate Death Narcotic antagonist Naloxone (Narcan) Given IV push Client responds in a few minutes May have to administer again Blocks neuroreceptors Affected by opioids Overdose: Opioids

18. Withdrawal can be fatal if unassisted Neuro: leg spasms (kicking the habit). Tremor, restlessness, MH: Anxiety Opioid Withdrawal

19. GI: diarrhea and vomiting Other: yawning, rhinorrhea, sweating chills, piloerection (goose bumps), bone pain Opioid Withdrawal

20. Treated Symptomatically Catapress (Clonidine) can be helpful Naltrexone hydrochloride (ReVia) Opioid receptor antagonist Decreases pleasurable affects Must wear a medical alert bracelet Withdrawal from Opioids

21. Cheap and readily available Hydrocarbon solvents Gasoline and glue Aerosol propellants Spray cans Anesthetic gasses Chloroform, nitrous oxide Death Amount inhaled can not be controlled Asphyxiation, suffocation and choking Brain Damage Frontal lobe Cerebellar Hippocampal Diminished problem solving Ataxia Dementia Inhalants

23. Cocaine Blocks dopamine re-uptake Euphoria, alertness, Psychological dependence Increased strength Sexual stimulation Intense paranoia Hypertension Tachycardia (can cause death) Decreased inhibitions Death: metabolic and respiratory acidosis; prolonged seizures Crack Less expensive way of using cocaine Stimulants

24. Epidemic Physical addiction Names: speed, meth, crystal, crank or ice Longer high than cocaine Causes anorexia and insomnia Rebound Paranoid Hallucinations Violent rages Long-term use Damages Dopaminergic system Use to avoid feeling bad Methamphetamine

25. Mescaline (peyote) North American Native Indian Religious practice protected by law Taken orally Action Probably the norepinephrine synapses Lasts 12 hours Psilocybin and Psilocin (mushrooms) Hallucinations Hypertension Increased temperature Involuntary movements Lasts 8 hours Lysergic Acid Diethylamide (LSD) Binds to serotonin receptors Causes a blending of senses (smelling a color or tasting a sound) Increase in blood pressure Tachycardia Trembling Dilated pupils Flashbacks Anxiety Paranoia Acute panic Psychotic Breaks Individuals have killed themselves Hallucinogens

26. Delt-9- tetrahydrocannabinol (THC) Varies in strength depending on soil conditions and climate Changed to metabolites and stored in fatty tissue (remains in the body for 6 weeks) Detected in blood and urine for 3 days to 4 weeks Effects last 2 to 4 hours Effects Sense of well-being Alters perception Euphoria Antiemetic Impairs balance and stability Problems Amotivational Bronchitis Memory impairment May increase anxiety Marijuana

27. All family members are affected Treatment for the family is important Problems: Rescuing or Enabling Making excuses for the person addicted Doing things that the person should have done Lying Effects on the Family

28. Co-dependent Set of behaviors that maintain the addiction Does not hold the person addicted responsible for their behavior Spouse may also be a child of an alcoholic and used to a certain pattern of behavior Takes on roles out of necessity (control) Behaviors are integrated and resistive to change Difficult to alter when the individual stops using Change Hold the person who was addicted responsible Re-assign roles and responsibilities within the family Sacrifice of income Change in job to be in a drug free environment Decrease stress Maintaining an alcohol and drug free home Family and Relapse

29. Interview Approaches Encourage Honesty genuine concern for the client Matter of Fact Non-judgmental Avoid words like: Addict Alcoholic State: Problems with drinking Difficulties with drug use Using more than intended Tools to Screen for Alcoholism Michigan Alcohol Screening Test (MAST) CAGE Questionnaire Inpatient Chemical Dependency Assessments every 4 hours or more often Form to complete which is quantified (given a score) BP and heart rate are important Tremors, lacrimation, rhinorhea and cravings PRN medication is given based on the score. The Nurse is very busy with assessments and administration of medications Assessment

30. Attempts to address: Narcissistic DENIAL and Faulty Thinking (Cognitive Distortions) i.e. better than others “I can do my job when drinking, when other people can not.” “I can stop after just one drink.” Tendency to break the rules: “I can have a drink and drive because I can handle it when others can not.” The relationship with the alcohol or drug being the most important relationship Ineffective behaviors increase the chance of relapse. Establish trust by expressing empathy and providing a safe environment. Assist in establishing new goals and directions. Assist the client in identifying ineffective behaviors and replace with new coping skills. Confrontation of DENIAL (telling the client what is observed and how it may differ from what is said) The Nurse Patient Relationship

31. Observe and protect the environment Must remain drug-free Suicide prevention Intervening with aggression Urine drug screens Structured and predictable schedule Familiar and comfortable with structure (i.e. plan their day in order to use alcohol or drug) Confrontation of Behavior Penetrate denial and defensiveness Requires Balance Sensitivity to confront while protecting the client’s self esteem Limit Setting Manipulation and splitting can occur (remember: the relationship with the drug or alcohol is more important than other relationships) Milieu Management

32. 12 Step Programs • Best Known • Alcoholics Anonymous (AA) • Narcotics Anonymous (NA) • Both Have a religious influence • Starts with: • Admitting powerlessness over alcohol (drugs) • The 12 Steps Confront • Denial • Narcissism • Cognitive Distortions • Problems with relationships

33. Relapse • Being around other users • Severe Cravings • Stopping attendance of AA or NA meetings • Client does not meet the GOAL of attending 90 meetings in 90 days • GOAL: In 90 days the client will go to one meeting each day • Not expressing feelings • Going through a major emotional crisis

34. Addiction and Health Care Professionals • Most common areas of employment: • Operating Room • Emergency Room • Intensive Care Unit • Many times these are our best and brightest • (cognitive distortion: I can do my job having taken this drug when others can not) • How do you know? • Client is still in pain after pain medication is given and documented • Narcotic medication count errors (hospitals checks statistics on every nurse) • What do you do when your colleague asks: • I have been so busy. I already wasted that medication I did not use, do you mind witnessing it for me? • (remember: the relationship with the drug or alcohol is more important than other relationships)

35. Texas Peer Assistance Program for Nurses (TPAPN): GOALS • Identify nurses experiencing • mental health or • alcohol/drug problems • that have been or are likely to be job impairing. • Assist these nurses in obtaining appropriate treatment. • Monitor the nurse's return to the work force. • Educate employers and nursing colleagues • about the negative effects of addiction/mental illness in the work place • and the potential for rehabilitation and return to productive work. • http://www.texasnurses.org/displaycommon.cfm?an=1&subarticlenbr=107

36. The End