Substance Use Disorders

Substance Use Disorders

• Annie Smith, RN-BC, MSN, CNE presents this information.

Objectives

• Identify the symptomatology to assess clients with substance-related and addictive disorders.
• Recognize nursing diagnoses and treatments for patients with substance-related and addictive disorders to select the appropriate nursing interventions.
• Discuss substance-related and addictive disorders within the nursing profession.

Neurobiology

• Stimulating opioid receptors triggers a pleasure response naturally or artificially.
• Increased dopamine levels result from the stimulation of opioid receptors, decreasing inhibition of dopamine pathways.
• A memory of this pleasant feeling is created when dopamine levels rise and may be triggered as “cravings”.
• Natural stimulation of opioid receptors stops after repeated consumption.
• Artificial substances evade the body's natural satiety mechanisms, resulting in chronically elevated dopamine levels, which desensitizes.
• Consequently, the substance is needed to maintain normal dopamine levels.

Substance Use Disorder

• Using substances interferes with the ability to fulfill role obligations.
• Attempts to cut down or control use fail, often leading to an intense craving.
• People spend much time trying to get the substance or recover from its use.
• Using substances can cause relationship difficulties or social isolation.
• People engage in hazardous activities when impaired by the substance.
• Tolerance develops, and the amount required to achieve the desired effect increases.
• Substance-specific symptoms occur upon discontinuation of use.

Substance-Induced Disorders

• Includes substance intoxication and withdrawal
• Development of a reversible syndrome of symptoms after excessive use of a substance.
• Results in a direct effect on the central nervous system.
• Manifests as disruption in physical and psychological functioning.
• Judgement is disturbed, and social and occupational functioning are impaired.
• Symptoms are specific to the substance that the person used.
• Substance withdrawal is the development of symptoms that occurs upon abrupt reduction or discontinuation of a substance.

Classes of Psychoactive Substances

• Include alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics, stimulants, and tobacco

Alcohol Intoxication and Withdrawal

• Alcohol intoxication occurs at blood alcohol levels between 100 and 200 milligrams per deciliter.
• Alcohol withdrawal occurs within 4 to 12 hours of cessation or a reduction in heavy and prolonged alcohol use.

Stimulant Use Disorder

• Includes:
• Amphetamines
• Synthetic stimulants
• Non-amphetamine stimulants
• Cocaine
• Caffeine
• Nicotine

Stimulant-Induced Disorders

• Intoxication from amphetamine and cocaine produces euphoria, impaired judgment, confusion, and changes in vital signs, which can result in a coma or death, depending on the amount consumed.
• Caffeine intoxication usually occurs following consumption in excess of 250 milligrams, displaying restlessness and insomnia as the most common symptoms.

Stimulant-Induced Disorders: Withdrawal

• Amphetamine and cocaine withdrawal may result in dysphoria, fatigue, sleep disturbances, and increased appetite.
• Caffeine withdrawal may include headaches, fatigue, drowsiness, irritability, muscle pain and stiffness, nausea, and vomiting.
• Nicotine withdrawal may include dysphoria, anxiety, difficulty concentrating, irritability, restlessness, and increased appetite.

Opioid Use Disorder

• Includes:
• Opioids of natural origin
• Opioid derivatives
• Synthetic opiate-like drugs

Opioid-Induced Disorders

• Symptoms of intoxication are consistent with the half-life of most opioid drugs and usually last for several hours.
• Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment.
• The risk of severe opioid intoxication can lead to respiratory depression, coma, and death.
• Symptoms of opioid withdrawal include dysphoria, muscle aches, nausea/vomiting, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, abdominal cramping, diarrhea, yawning, fever, and insomnia.

Opioid-Induced Disorders: Withdrawal Timelines

• Withdrawal from short-acting drugs, like heroin, shows symptoms that occur within 6 to 8 hours, peak within 1 to 3 days, and gradually subside in 5 to 10 days.
• Withdrawal from long-acting drugs, like methadone, shows symptoms that occur within 1 to 3 days, peak between days 4 and 6, and subside in 14 to 21 days.

Nursing Process: Assessment

• Assessment tools available for determining the extent of the problem that a client has with substances include:
• Drug history and assessment
• Clinical Institute Withdrawal Assessment of Alcohol Scale
• CAGE Questionnaire

Dual Diagnosis

• Clients with coexisting substance and mental disorders may be assigned to a program that targets the dual diagnosis.
• The program combines special therapies that target both problems.

The Chemically Impaired Nurse

• It is estimated that 10% to 15% of nurses suffer from the disease of chemical dependency.
• Alcohol is the most widely abused drug, followed closely by narcotics.
• High absenteeism could be apparent if the person's source is outside the work area.
• Alternatively, the person may rarely miss work if the substance source is at work.
• Increase in "wasting" of drugs, higher incidences of incorrect narcotic counts, and signing out drugs for other nurses may be present.
• Displays poor concentration, difficulty meeting deadlines, inappropriate responses, and poor memory or recall.
• Exhibits issues with relationships.
• Shows irritability, a tendency to isolate, and elaborates excuses for behavior.

Codependency

• Defined by dysfunctional behaviors evident among family members of a chemically dependent person, or who harbor secrets of physical or emotional abuse, cruelties, or pathological conditions.
• Codependent people sacrifice their needs for others' fulfillment to achieve control.
• Self-worth is derived from others.
• People feel responsible for the happiness of others.
• Commonly denies that problems exist.

Pharmacotherapy for Alcoholism

• Can use Disulfiram (Antabuse)
• For alcohol withdrawal, can use:
• Benzodiazepines
• Anticonvulsants
• Multivitamin therapy
• Thiamine
• Other medications that can be used are:
• Naltrexone (ReVia)
• Selective serotonin reuptake inhibitors (SSRIs)
• Acamprosate (Campral)
• Opioids
• Narcotic antagonists:
• Naloxone (Narcan)
• Naltrexone (ReVia)
• Buprenorphine
• Methadone
• Clonidine

Gambling Disorder

• Shows persistent and recurrent problematic gambling behavior that intensifies when under stress.
• The individual may use any means required to obtain money to continue the addiction as the need to gamble increases.
• Gambling behavior typically begins in adolescence, but compulsive behaviors mostly occur after young adulthood.
• Generally runs a chronic course, with periods of waxing and waning.
• The disorder interferes with interpersonal relationships, social, academic, or occupational functioning.

Eating Disorders

• This information is presented by Annie Smith, RN-BC, MSN, CNE from Morgan and Townsend- Chapter 21.

Objectives: Eating Disorders

• Identify and differentiate among several eating disorders.
• Describe symptomatology associated with anorexia nervosa, bulimia nervosa, and obesity and use the information in patient assessment.
• Identify predisposing factors to the development of eating disorders.
• Formulate nursing diagnoses and outcomes of care for patients with eating disorders and describe appropriate interventions for behaviors associated with eating disorders.

Introduction: Eating Disorders

• The hypothalamus contains the appetite regulation center in the brain.
• This regulates the body's ability to recognize when it is hungry, not hungry, and sated.
• Eating behaviors are influenced by society and culture.
• Historically, society and culture have influenced the perception of a desirable human body.

Body Mass Index (BMI)

• A normal weight range is a BMI of 20 to 24.9.
• Obesity is defined as a BMI of 30 or greater.
• Anorexia nervosa shows a BMI of 17 or lower, or less than 15 in extreme cases.

Anorexia Nervosa

• Characterized by a morbid fear of obesity
• Symptoms include gross distortion of body image, preoccupation with food, and refusal to eat.
• Weight loss is extreme (usually more than 15% of expected weight).
• Other symptoms include hypothermia, bradycardia, hypotension, edema, lanugo, and metabolic changes.
• Amenorrhea is typical and can precede significant weight loss.
• The person may show an obsession with food.
• Feelings of anxiety and depression are common.

Bulimia Nervosa

• An episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period of time (bingeing)
• Followed by inappropriate compensatory behaviors to rid the body of excess calories (self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
• Fasting or excessive exercise may also occur.
• Most patients with bulimia are within a normal weight range; some are slightly underweight, and some are slightly overweight.
• Depression, anxiety, and substance abuse are not uncommon.
• Excessive vomiting, and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalances.

Binge Eating Disorder

• The DSM-5 identifies binge eating disorder (BED) as an eating disorder that can lead to obesity.
• The individual binges on large amounts of food, similar to bulimia nervosa.
• BED is different from bulimia nervosa because the individual does not engage in behaviors to rid the body of excess calories.

Eating Disorders: Biological Influences

• Genetics: A hereditary predisposition to eating disorders has been hypothesized.
• Anorexia nervosa is more common among sisters and mothers of those with the disorder than it is among the general population.
• Neuroendocrine abnormalities
• There has been speculation about a hypothalamic dysfunction in anorexia nervosa.
• Neurochemical influences
• Bulimia nervosa may be associated with the neurotransmitters serotonin and norepinephrine.
• Anorexia nervosa may be associated with high levels of endogenous opioids.

Eating Disorders: Family Influences

• Historically, family dynamics were heavily considered as factors, but there is insufficient evidence to support these claims.
• Family members should be involved in treatment rather than blamed for the issue.

Outcomes: The Patient

• Achieving/maintaining at least 80% of expected body weight.
• Maintain normal vital signs, blood pressure, and laboratory serum studies.
• Verbalize the importance of adequate nutrition.

Planning and Implementation

• Hospitalization may be needed in cases of malnutrition, dehydration, severe electrolyte imbalance, a cardiac arrhythmia or severe bradycardia, hypothermia, hypotension, and suicidal ideation.

Treatment Modalities: Behavior Modification

• Issues of control are central to the etiology of these disorders.
• Client should perceive they are in control of treatment for the program to be successful.
• Success may be seen when clients contract for privileges based on weight gain, have input into the care plan, and see the treatment choices clearly.

Treatment Modalities: Psychopharmacology

• There are no medications specifically indicated for eating disorders.
• Various medications have been prescribed for associated symptoms, such as anxiety and depression.

Medications for Anorexia Nervosa

• Fluoxetine (Prozac)
• Clomipramine (Anafranil)
• Cyproheptadine (Pariactin)
• Chlorpromazine (Thorazine)
• Olanzapine (Zyprexa)

Medications for Bulimia Nervosa

• Fluoxetine (Prozac)
• Imipramine (Tofranil)
• Desipramine (Norpramine)
• Amitriptyline (Elavil)
• Nortriptyline (Aventyl)
• Phenelzine (Nardil)

Medications for Binge Eating Disorder with Obesity

• Topiramate (Topamax)
• Lisdexamfetamine (Vyvanse)