Psycho-Addictive Disorders

1. Psycho-Addictive Disorders Elisa A. Mancuso RNC, MS, FNS Professor

2. Substance Abuse Maladaptive pattern of excessive use Recurrent use = ↑↑ impairment Failure to meet role obligations ↑↑ Use with Legal, social or interpersonal problems Intoxification Reversible substance induced syndrome Slurred speech Ataxia = ↓ Coordination ↓ Cognition Poor memory & judgment ↑↑Impulsive behavior

3. Substance Dependence Cognitive, behavioral & psychological symptoms Pt. believes substance needed for optimal health Persistent desire and ↑ time spent to obtain & use Use ↑ quantities more frequently = Addiction Unsuccessful attempts to stop using Tolerance Need ↑↑ amounts to achieve desired effects Cross Tolerance Pt. tolerant to drug A When use drug B (similar to A) has ↓ effect Need ↑↑ dose of B Withdrawal Syndrome Cessation of heavy prolonged use Autonomic Hyperactivity Hallucinations Dementia Seizures

4. ETOH 3rd Major health problem 50% ER visits & 12 million adults ETOH dependent Teens fastest growing group of alcoholics ↑ 50% risk with alcoholic family member Parents role model ETOH as coping skill ↑ Predisposition = ↑ Sensitivity ETOH produces morphine like substances TIQs Activate opioid brain receptors = addiction ↓ ETOH Dehydrogenase = ↓ ETOH metabolism ETOH goes directly from blood to brain ↓ Self Esteem ↓ Frustration ↑↑ Impulsive & ↑ Immediate Gratification Peer & media influence = + Reinforcement ↓ Inhibitions = ↑ confidence & risky behaviors

5. Cultural Influences Asians Lowest ETOH rate 2.5% Genetic ETOH intolerance (+) Punishment Flushing HA Palpitations Native Americans Highest ETOH rate 12.5 % 5th leading cause of death Community oriented culture Drinking is group activity Irish, German, Scandinavian ↑ ETOH use & dependency RT Socialization & aggression release

6. Family Dynamics Co-Dependency Caretaker derives self worth from others Over-functioning takes on all responsibilities Enabling behaviors Adult Children of Alcoholics 1/8 Learn dysfunctional family roles Secrecy, mistrust, shame and denial of abuse. Primary goal is to please parent Hero/Caretaker Child Take on family responsibilities Trying to keep it all together” Scapegoat Child Act out @ home – Child is focus of conflict Lost Child Avoid conflict & pain (Escape from family) Run away Mascot/Clown Comic relief to mask sadness Truly unhappy

7. ETOH CNS Depressant ↓ Anxiety Relaxation ↓ Inhibitions ↓ Judgment Slurred speech ↓ Sleep BAC Blood Alcohol Concentration 0.05 = Euphoria, impairment 0.08 = Intoxication (Legal limit) 0.15-0.2 = ↓ coordination, double vision 0.3 = stupor 0.4 = coma & death Absorbed in 5 mins Liver detoxifies ETOH (¼ oz) per hour = 12 oz. Beer 4 oz. Wine 1 Shot

8. Cognitive Effects ↓ Control Poor judgment ↓Learning Impulsive/Abusive Behavior Seizures Blackouts “Fugue-like” state Amnesia of events during drinking period No loss of consciousness during episode Wernicke’s Encephalopathy Thiamine deficiency→ Grey matter damage Abnormal thinking patterns ↓ Memory Ataxia Korsakoff’s Psychosis (2nd to Wernicke’s) Niacin & Thiamine deficiency Irreversible cell death & progressive mental deterioration Confabulation Loss of recent memory Diplopia Somnolence → Stupor → Death

9. Systemic Effects Cardiovascular Autonomic Hyperactivity = ↑ HR ↑ BP CHF Myopathy RT Vasoconstriction = Chest pain Bone Marrow Toxicity ↓ RBCs ↓ WBCs ↓ Plts Gastrointestinal Esophagitis RT Vomiting Esophageal Varices RT Portal HTN Gastritis & Ulcers RT ↑HCL Malnutrition → Ascitis Pancreatitis → DM & CA Hepatitis & Cirrhosis → Liver Failure

10. Systemic Effects Respiratory COPD PN Lung CA RT ↑↑ Smoking Skin/Skeletal ↓↓ Reflexes RT Peripheral Neuropathy Muscle weakness = ↑↑ Falls Skin ulcers Spider Angiomas Genitourinary ↑↑ Urination RT diuretic action of ETOH ↑ FAS ↓ Sexual Performance RT ↓ Libido

11. Alcohol Withdrawal Syndrome AWS Rebound NS Hyperirritability 1st Stage (6-8 h after last drink) “Morning after jitters” Tremors Anxiety C/O “Shaky Inside” Irritability ↑ HR ↑ BP N & V 2nd Stage (24 h no interventions) Hallucinations Visual: 3 - 4’ long bugs Tactile: crawling sensation Auditory: hear music Seizures (2-6 during 3-4 h period)

12. Alcohol Withdrawal Syndrome AWS 3rd Stage (48h) Delirium Tremens- DTs Acute Medical Condition (20% mortality) Dehydration →Fluid & Electrolyte imbalance ↑↑ Autonomic Hyperactivity ↑HR ↑BP ↑Temp Fatal Arrhythmias Global confusion & unaware of environment Vivid Hallucinations & Delusions ↑↑ Agitation & Seizures

13. AWS Therapy Detoxification 3-7 days AWS Protocols Librium, Valium or Ativan 10-20x dose initially! Thiamine (IM) Cyanocobalamine (Vit B12) Niacin (Vit B6) Folic Acid IV Glucose ß Blockers: Propanonol (Inderal) Clonidine (Catapres) Dilantin or Mg SO4 NO Mellaril or Haldol for hallucinations (↑↑ Seizures) Tryptophan & Trophamine Odansetron (Zofran)

14. AWS Nursing Primary Priority = Assessment! V/S & LOC Monitor Pt’s response to therapy Pt. Safety = √ S/S of depression & suicide Calm, quiet environment Provide uninterrupted periods of rest Firm limits & consistent support Reorient to reality Confront denial, rationalization, projection Monitor visitors

15. Medications Antabuse (Disulfiram) Aversion Therapy Blocks oxidation of ETOH ↑ Pt sensitivity ↑ HA ↑ HR N & V Flushing Chest Pain → Death Naltrexone HCL (ReVia) Opioid antagonist = ↓ ETOH craving Can not be used with narcotics for 7-10 days

16. Therapy • 12 Step Programs: AA NA CA • Life-long commitment • Attain & Maintain sobriety • Peer group & sponsor • Accept ETOH dependency as illness • Develop adaptive coping skills • ↑↑ Self-Esteem

17. Hallucinogens LSD: Acid, Purple Haze Big D Mescaline: Peyote, Half-Moon PCP: Angel dust (lipophilic) Ketamine: Special K Marijuana: Pot, Weed, Grass, Joint, MJ Dronabinol (Marinol) & Nabilone (Cesamet) used for Chemo induced N & V Action Alter mood & perception of time & space Alter cognitive function = insight into life? Synesthesia = altered visual/auditory “ Hear Colors” “See Music” Paranoia , Hallucinations & Illusions Bad Trips = fear of losing one’s mind ↑ suicide ↑↑ Aggression & ↑↑ Physical Strength (PCP) Flashbacks (up to 5 -15 years)

18. Stimulants Amphetamines: Ecstasy, MDMA, Amylnitrate Ice “Crank” smokeable form of methamphetamine Euphoria lasts 12 -30 h ↑ violence ↑ strength Cocaine: Coke Crack “Rock” smokeable form of coke Onset 6-7 secs, High 2-5 min, Severe crash → ↑↑ use CaffeineTobacco Action ↑↑ DA ↑↑ NE ↑↑ 5-HT ↑ Alertness ↑Endurance ↑Elation Euphoria ↑↑ Self-Esteem ↑↑Assertiveness ↑ Sexuality Verborrhea Tolerance in hours – days Vasoconstriction = ↑ HR ↑ BP ↑ Temp Arrhythmias Withdrawal Respiratory depression Dilated pupils ↑↑ Tremors Fatigue Vivid Dreams ↑↑ Appetite Psychomotor retardation Crashing = Suicidal Ideation Psychosis

19. Methamphetamine

20. Methamphetamine Facial Effects

21. Meth Aging

22. Crank Bugs

23. Opioids Morphine MSO4 Codeine Heroin Action Euphoria ↓↓ Pain Perception↑↑ Passivity ↓ Anxiety & ↓ ↓ Aggression = Apathy ↓ Hunger ↓ Thirst ↓ Libido Pin point Pupils ↓↓ Respirations Rapid weak pulse Withdrawal (5-14 days) Watery eyes Rhinitis Yawning Sneezing Tremors Abdominal spasms

24. Sedatives, Hypnotics & Anxiolytics Brevital, Seconal Restoril, Halcion Valium, Xanax, Ativan, Rohypnol ‘Roffis” Gamma Hydroxybutrate (GHB): G Liquid X Georgia Homeboy Action Relaxation & well being = Sense of Calm ↓↓ HR ↓↓ BP ↓↓ RR ↓↓ Muscle spasms & ↑↑ Sleep ↓↓ Coordination = Ataxia Mental Impairment Quick temper ↓↓ Patience & tolerance ↑↑ Dose = ↓↓ Anxiety → Sedation → Coma → Death

25. Impaired Nursing Practice 1/8 Nurses are addicted = impacts their practice. 1/5 are chemically dependent 45,000 Alcoholic RNs Narcotic addiction is 30x > public 50-70% due to inadequate pain management for work related injury. Hx of ETOH or substance abuse in family. ↑↑ Social stigma against femaleaddicts

26. Warning Signs of Abuse Poor judgment & work performance Errors in charting & ↓↓ Pt. care ↑Accidents/incidents during shift Inaccurate med counts ↑↑ vial breakage & waste Volunteers to work extra shifts & give meds. ↑ Reports from Pt of unrelieved pain ↑↑ Absenteeism (after many days off) Leaves floor frequently Spends ↑↑ time in bathroom ETOH breath Flushed face Reddened eyes Unsteady Gait Hyperactivity Irritability/Apathetic

27. Nursing Interventions Document RN behavior, Pt or medication incidents objectively. Approach colleague with compassion Express concern for her health and Pt’s safety. Remain in touch with colleague Notify supervisor to report impaired colleague Ethical & legal obligation Facilitates RN to obtain EAP services, RX Protects the public!

28. Peer Assistance Program PAP Established in 1982 by ANA RN voluntarily submits license during program (5 years) Facilitates impaired nurses to recognize their illness. Maintain confidentiality & obtain needed RX. Regain accountability within profession. Contract Method of RX, work guidelines, spot drug testing and quarterly evaluations. Work site monitor √ progress during treatment. If unsuccessful refer to the State Board of Nursing, Office of Professional Discipline (OPD). Any Pt. harm or criminal charges Narcotics taken (Federal Law) & theft of property FL 2009 Law Hx of abuse Unable to reapply for license for 15 years!

29. Statewide Peer Assistance for Nurses (SPAN) Voluntary participation with PAP. SPAN Advocate Mentor maintains weekly contact for 1:1 counseling and support. Weekly support group meetings With other impaired nurses. Open ended participation Encouraged to stay active c PAP program Evolve into sponsors for their colleagues. Terminated for non-participation PAP notified.