SUBSTANCE ABUSE

1. SUBSTANCE ABUSE

2. Cost to Business & Industry • 100 million annually • Alcohol= 500 million lost work days • 40% industrial fatalities • 47% workplace injuries • 50% of motor vehicle fatalities(2005)

3. Effects on society • National health problem • More deaths,illness,accidents,disabilities than any other health problem • 15 million dependent on alcohol • 500,000 between ages 9-12 • 7 million persons between 12-20 binge drink (Narconon,2005)

4. Effects on the family • # of babies born with physiologic & emotional consequences of crack & alcohol ---Increasing at an alarming rate • 43% of US families exposed to alcoholism • 50% persons who seek tx have at least one parent w/ alcoholism hx.

5. Culture and Substance abuse • Attitudes vary in cultures • Muslims – no alcohol consumption • Jewish – use wine for religious rites • Native Americans – use payote (religious ceremonies) • Genetic traits found – predispose or protect • Flushing reaction – Asians

6. Genetics & substance abuse • Variations is structure & activity levels of enzymes involved in metabolism of ETOH • Variations among Asians, Africian Americans and whites • Japanese – enzyme produces faster elimination of alcohol • Native Americans- etoh use –one of five leading causes of death(75% accidents) • Japan – ETOH consumption quadrupled since 1960

7. Effects of addiction • Abuse • Tolerence • Physical dependence - addiction • Psychologic dependence –mind-body connection • Alcoholism – chronic progressive potentially fatal • Blackouts

8. Alcohol and other drugs are associated with: • Up to 50% spousal abuse • 50% traffic accidents • 49% murders • 68% manslaughter charges • 69% drownings • 38% child abuse • 52% rapes • 62% assaults • 20-35% suicides (Johnson-1997)

9. Similarities & DifferencesAlcohol

10. Sedatives /Hypnotics Anxiolytics

11. Stimulants amphetamines/cocaine

12. Opioids: morphine,heroin,meperidine,codeine,hydromorphone,

13. Hallucinogens

14. Pharmacologic treatment substance abuse • Disulfiram(antabuse)-maintain abstinence from alcohol • Teach client to read all labels – avoid any product containing alcohol • Lorazepam(ativan) – for w/d fro etoh Monitor V/S/client safety/assess effectiveness

15. Pharmacologic treatment • Clonidine(catapres) –suppresses opiate withdrawal symptoms –check B/P prior to administration – withhold if hypotensive • Thiamine(vitamin B1) Folic acid (folate), B12 = tx nutritional deficiencies – teach re: proper nutrition; darkened urine may result w/folate.

16. Nursing Dx.:Risk for Injury(etoh withdrawal) r/t environment & individual defenses • Place client close to nursing station (safety a priority) • Seizure precautions(seizures can occur during w/d-prevents injury) • Reorient x4 as necessary(provides reality orientation) • Speak in simple direct concrete language(clients ability to deal with complex or abstract ideas is limited) • Reassure client that bugs,snakes etc. are not real(provides reality orientation – decreases anxiety)

17. Ineffective Health maintenance r/t inability to identify/manage/seek help • Monitor health status,V/S parameters, & behavioral changes, administer meds per protocol (B/P , P,presence or absence of tongue tremors-determine need for medication- use predetermined parameters) • Offer fluids freq –esp.juices,malts, no caffeinated beverages(caffeine increases tremors,malts,juices offer nutrients & fluids)

18. Ineffective health maintenance(cont’d) • Monitor fluid/electrolytes,IV therapy-indicated in severe alcohol withdrawal(clients with ETOH abuse are high risk for fluid/lyte imbalance) • Provide food and nourishing fluids as soon as client can tolerate eating(clients who abuse alcohol often have gastritis or anorexia – important to reestablish nutritional intake)

19. continued • Assist with physical care as necessary(client needs should be met with permitting as much independence as possible for client) • Educate –Alcoholism is a disease that requires long term tx and f/u(detox. deals w physical w/d but not address primary disease of alcoholism) • Administer meds to minimize progression of w/d, complications, & to facilitate sleep(client will be fatigued,requires rest)

20. Dual diagnosis • 50% of persons with substance abuse also have mental disorder (2005) • Need to be treated in special units designated for tx. of dual diagnosis – tx. must focus on both the mental disorder and the substance abuse to be effective.

21. Dual Diagnosis CARE PLAN - Noncompliance • Discuss patterns of drug/alcohol use in non-judgmental way(non-judgmental manner increases chance of obtaining data) • Help client to correlate increased use of chemicals with increased psychiatric symptoms(these effects may not be apparent to client) • Educate (factual info –sound basis for problem solving)

22. Dual diagnosis – Ineffective coping • Encourage open expression of feelings(initial step towards dealing constructively with those feelings) • Validate client’s frustrations or anger re dual problem(expression of feelings – may relieve stress & anxiety) • Give positive feedback for abstinence(positive feedback reinforces abstinence behaviors) • Encourage client to record activities,feelings thoughts in a journal(provides a focus for client to yield information that is useful in future planning)

23. Review questions • The nurse would recognize the following as signs of alcohol withdrawal: A. coma, disorientation, hyper vigilance B tremors, sweating,elevated b/p C. increased temperature, lethargy,hypothermia D. talkativeness, hyperactivity, blackouts

24. Which of the followingfoods would the nurse eliminate from the diet of a client with alcohol withdrawal? A. Ice cream B. Milk C. Orange juice D. Regular coffee

25. The nurse includes the following intervention in a plan of care for a client with severe alcohol withdrawal: A. Continuous use of restraints B. Informing the client about alcohol treatment programs C. Remaining with the client when he/she is confused D. Touching the client before saying anything

26. ALCOHOLISM & SUBSTANCE ABUSE IN THE OLDER ADULT • Onset after 50 not uncommon • 30 –60 % of elders in treatment programs began drinking abusively after age 60

27. Risk factors – elder substance abuse • Chronic illness-pain (long term use of Rx. narcotics etc.) • Life stress • Loss • Social isolation • Grief • Depression • Abundance of free time • Money (Atkinson, 2004)

28. Drinking problems fall into two distinct patterns in the older adult • 2/3rds early onset alcoholism • 1/3rd late onset alcoholism (Menniger, 2002) Use screening tool AUDIT(Alcohol Use Disorder Identification Test) for early identification of alcoholism problem in older adults.

29. Psychosocial issues & physiologic changes associates with substance abuse in elderly • Increase risk for falls/injuries • Increase risk –suicide (especially older male,single,caucasian,>65 w/health problems) • Increase vulnerability to infection( r/t decreased immune system from alcohol abuse)

30. Age related problems include: • Difficulty seeking help • Exacerbation of Cardiovascular and GI problems • Increased risk for withdrawal & S/E’s of ETOH & drugs r/t more fragile homeostasis • Ignored by health care system & society • Few age related programs exist • Little research published

31. SUBSTANCE ABUSE IN HEALTH PROFESSIONALS • Higher rates of dependence on controlled substances (Jaffe & Anthony 2005) Problems with Reporting colleagues: • Sensitive issue • Want to avoid conflict • Fear of falsely accusing colleague • Feel guilty

32. Legal /ethical responsibility • Ethical responsibility –report suspicious behaviors to supervisor! • Legal obligation –defends State Nurse Practice Act! • DO NOT try to handle situation alone!

33. Warning signs of abuse • Poor work performance • Frequent absenteeism • Unusual behaviors • Slurred speech • Isolates self from colleagues

34. Specific signs& symptoms of substance abuse Nurse should watch for: • Incorrect drug counts • Controlled substances listed as wasted/contaminated(occurring more frequently) • Client reports of ineffective pain relief • Damages/torn packages of controlled substances

35. Nurse should watch for: • Increased reports of pharmacy errors • Frequently offers trips to pharmacy to obtain controlled substances • Trips to bathroom after contact with controlled substances • Consistently arrives early or departs late from work – no apparent reason

36. CA BRN Diversion Program Rehab -based program • Provides early intervention • Board determines candidacy for program

37. BRN criteria for admission into program: • CA license & residence • No hx. of previous discipline • Has not failed to complete a previous diversion program • No harm to clients has been determined • Problems r/t chemical dependency or mental illness • Willingness to comply with practice restrictions • Not a sex offender

38. Additional program eligibility: • Must voluntarily request admission • Agree to undergo reasonable Psychiatric/medical examination • Cooperate – provide medical info., authorizations, release liability • Agree in writing to comply to all elements • Not have diverted controlled substances for sale

39. Clients with eating disorders • Underlying emotional conflicts – dealt with by destructive food related behavior

40. Nursing Dx.:Imbalanced nutrition <body requirements r/t intake of nutrients insufficient to meet body needs Assessment characteristics: • Wt loss • Body wt 15% + under ideal body wt. • Denial or loss of appetite,difficulty swallowing • Inability to perceive accurately & respond to internal stimuli r/t hunger or nutritional needs • Epigastric distress,vomiting, • Laxative abuse • Concealing wt’s on body to wt .measurement

41. Anorexia characteristics continued: • Denial of illness or resistance of treatment • Denial of being too thin • Excessive exercise • Multiple related physical problems Interventions must be specific to client physical and emotional problems and degree /severity of wt loss and anorexia

42. Examples of interventions: • If critically malnourished: • Parenteral nutrition through a central catheter may be indicated(adequate nutrition,electrolytes etc. can be provides parenterally,client cannot vomit this type of nutrition) • Tube feedings may be used alone or with oral parenteralnutrition(fortified liquid diets can be provided through tube feedings)

43. Severe anorexia interventions: • Supervise client for specified time(90 minutes – decrease to 30 minutes after tube feeding or remove NG tube after feeding(supervision decreased clients opportunity to vomit or siphon feedings) • Offer client opportunity to eat food orally-use tube feeding if amount consumed is insufficient(client may prefer to eat food orally- however, physical health is priority)

44. Severe malnourishment • If N/G tube is used – be matter-of fact re: insertion/use –DO NOT use as a threat! DO NOT permit client to bargain!(limits & consistency essential in avoiding power struggles and decreasing manipulative behaviors)

45. Interventions for the non- criticallymalnourished client • Initially do not allow client to eat with ither clients or visitors(other clients may repeat family patterns by urging client to eat or providing attention to client for not eating) • Provide structure to mealtime-state limits matter-of-factly (clear limits lets client know what is expected)

46. Interventions continued • Do not bribe,coax,threaten or focus on eating at all! • Withdraw attention if client refuses to eat. • When meal is over remove food without discussion(minimizes client’s secondary gains from not eating- does not reinforce issues of control which are central to client)

47. Interventions continued • Encourage client to seek out staff members after eating to talk about feelings of anxiety or guilt or if urge to vomit exists.(speaking to staff promotes focus on emotional issues rather than food) • Supervise during & after meals start with 90 minutes gradually reduce to 30 minutes.Do not permit use of bathroom until at least 30 minutes after each meal (client may spill,hide or discard food-may use BR to vomit or dispose of concealed food)

48. Interventions continued • Gradually permit client increased choices regarding food, mealtime etc.(develops independence in eating habits) • Monitor I&O in an unobtrusive and matter-of fact manner(minimizes direct attention to eating and removes emotional issues) • Weigh client daily,after client has voided and before morning meal; client should wear only hospital gown(consistency is necessary for accurate comparison of wt.over time) • Observe/record client overt/covert physical activity(client may exercise to excess to control wt.)

49. Review questions:Eating disorders • The nurse should include which of the following interventions in the plan of care for a client with bulimia? (select all that apply) A. Encourage the client to avoid eating except at mealtime. B. Promote a weight gain of 3 to 5 pounds per week. C. Observe the client for one hour after meals. D. Encourage the client to identify foods that trigger a binge. E. Instruct the client to keep laxatives and diuretics in a locked area. F. Inform the client that there are no “forbidden” foods.

50. Review questions The nurse is caring for a client with anorexia nervosa. Even though client has been eating all her meals and snacks her weight is unchanged for one week. Which intervention would be indicated: A. Close Obs.x’s2 hrs. p meals/snacks B.  caloric intake from 1500 –2000 calories C. fluid intake D. Request Rx for antianxiety med from MD