Substance Use Disorders in Nursing

Substance Use Disorders

• Annie Smith, RN-BC, MSN, CNE created these notes
• The objectives are:
  • Identify symptomatology and it's use to assess clients with substance-related and addictive disorders
  • Identify nursing diagnoses and treatments for patients with substance-related and addictive disorders and select appropriate nursing interventions
  • Discuss substance-related and addictive disorders within nursing

Neurobiology

• A pleasure response can be triggered by natural or artificial means by stimulating opioid receptors
• Stimulation of these opioid receptors increases dopamine levels by decreasing inhibition of dopamine pathways
• When dopamine levels increase, it creates a memory that evokes future cravings
• Natural stimulation of opioid receptors will stop after repeated consumption
• Artificial substances can bypass the bodies natural mechanisms that cause chronically elevated dopamine levels leading to desensitization
• With continued use, the substance is needed to maintain normal dopamine levels

Substance Use Disorder

• Use of the substance interferes with fulfilling role obligations
• Attempts to cut down or control the use of the substance fail
• There is an intense craving for the substance
• Excessive time is spent trying to procure the substance or recover from its use
• A person has difficulty with relationships or withdrawing from social situations
• Engaging in activities may become hazardous when impaired by a substance
• Tolerance develops increasing the amount to achieve the desired effect
• Substance-specific symptoms occur upon discontinuation of use

Substance-Induced Disorders

• Substance intoxication involves:
  • Development of a syndrome of symptoms from excessive substance use
  • Direct effect on the central nervous system
  • Disruption in physical and psychological functioning
  • Disturbed judgment affecting social and occupational functioning
• Symptoms occur from abrupt reduction or discontinuation of a substance that has been used
• Symptoms are specific to the substance being used, plus disruption in physical and psychological functioning

Classes of Psychoactive Substances

• Includes 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 mg per deciliter
• Alcohol withdrawal occurs within 4 to 12 hours of heavy and prolonged usage cessation or reduction

Stimulant Use Disorder

• The stimulant substances include:
  • Amphetamines
  • Synthetic stimulants
  • Non-amphetamine stimulants
  • Cocaine
  • Caffeine
  • Nicotine

Stimulant-Induced Disorders

• Amphetamine and cocaine intoxication can produce euphoria, impaired judgment, confusion, and changes in vital signs which can lead to coma or death based on the amount consumed
• Caffeine intoxication will occur after consuming over 250mg, and common symptoms include restlessness and insomnia
• Amphetamine and cocaine withdrawal may cause dysphoria, fatigue, sleep disturbances and increased appetite
• Caffeine withdrawal may include headache, fatigue, drowsiness, irritability, muscle pain and stiffness, as well as nausea and vomiting
• Nicotine withdrawal can include dysphoria, anxiety, difficulty concentrating, irritability, restlessness, and increased appetite

Opioid Use Disorder

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

Opioid-Induced Disorders

• Symptoms are consistent with the half-life of most opioid drugs and last for several hours
• Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment
• Severe opioid intoxication can lead to respiratory depression, coma, and death
• Symptoms of opioid withdrawal include: muscle aches, nausea/vomiting, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, abdominal cramping, diarrhea, yawning, fever, and insomnia
• Withdrawal from short-acting drugs like heroin will ensue 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 will ensue within 1 to 3 days, peak between days 4 and 6, and subside in 14 to 21 days

Nursing Process: Assessment

• Assessment tools are used to determine the extent of the patients substance use issue
• Assessment tools include:
  • Drug history and assessment
  • Clinical Institute Withdrawal Assessment of Alcohol Scale
  • CAGE Questionnaire

Dual Diagnosis

• Clients with a coexisting substance use disorder and mental health disorder are assigned to a program that targets the dual diagnosis
• The program combines special therapies that address both problems

The Chemically Impaired Nurse

• Around 10-15% of nurses are estimated to have the disease of chemical dependency
• Alcohol is the most abused drug; however, narcotics are closely ranked
• High absenteeism is present if the source is outside the work environment, while the opposite is true if the source is at work
• Issues with wasting drugs, high incorrect narcotic counts, and a higher record of signing out drugs for other nurses may be present
• Other signs can include: poor concentration, difficulty meeting deadlines, inappropriate responses, poor memory or recall, problems with relationships, irritability, tendency to isolate, and elaborate excuses for behavior

Codependency

• Codependency is defined by dysfunctional behaviors within members of family of the chemically dependent, and among family members who harbor secrets of abuse or pathological conditions
• Codependent people forgo their well-being for the well-being of others, for a sense of control
• A person derives self-worth from others, feels responsible for others' happiness, and commonly denies problems exist

Pharmacotherapy for Alcoholism

• Includes Disulfiram (Antabuse), Benzodiazepines, Anticonvulsants, Multivitamin therapy, and Thiamine
• Used for Alcohol withdrawal

Psychopharmacology For Substance Intoxication and Substance Withdrawal

• Medications utilized include:
  • Naltrexone (ReVia)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Acamprosate (Campral)
  • Opioids:
    • Naloxone (Narcan)
    • Naltrexone (ReVia)
    • Buprenorphine
    • Methadone
    • Clonidine

Gambling Disorder

• Persistent and recurrent problematic gambling behavior that intensifies when a person is under stress
• To fulfil the need to gamble, the individual may use any means to get money to appease the addiction
• Gambling typically begins in adolescence
• The disorder usually follows a chronic course with periods of waxing and waning
• Gambling can impact relationships, social interactions, school, and work

Eating disorders

• Are commonly eating disorders

Objectives

• Identify and differentiate among eating disorders
• Describe symptomatology relating to anorexia, bulimia, and obesity to use for patient assessment
• Identify predisposing factors in the development of eating disorders
• Formulate nursing diagnoses to care for eating disorders and how to act in caring for them

Eating Disorders: Introduction

• The hypothalamus hosts the appetite regulation center in the brain
• It regulates to recognize when hungry, not hungry, and when sated
• Eating behaviors are influenced by society and culture
• Historically, society and culture have influenced what is considered desirable in the human body

Body Mass Index

• Healthy weight range is a BMI of 20-24.9
• Obesity is indicated with a BMI of 30 or greater
• Anorexia nervosa has a BMI indicated at 17 or lower; with anorexia being extreme at less than 15

Anorexia Nervosa

• Characterized by a morbid fear of obesity
• Includes gross distortion of the body image, preoccupation with food, and refusal to eat
• Extreme weight loss includes losing 15% of expected weight
• Signs will commonly show hypothermia, bradycardia, hypotension, edema, lanugo, and metabolic changes
• Amenorrhea is typical and may even precede significant weight loss; and individuals will have an obsession of food
• It's common to have feelings of anxiety and depression

Bulimia Nervosa

• Bulimia nervosa is uncontrolled, compulsive, rapid ingestion of large quantities of food over a period of time (bingeing)
• An episode will immediately follow with inappropriate compensatory behaviors to rid the body of excess calories or misusing laxatives, diuretics, or enemas
• It's common to occur in fasting or increased exercise
• It appears that most patients with bulimia are within normal weight or they're slightly underweight and sometimes show as overweight
• Depression, anxiety, and substance abuse are not rare
• Excessive vomiting, laxative, or diuretic abuse can show with electrolyte and dehydration imbalances

Binge Eating Disorder

• Diagnosed as an eating disorder from binge eating leading to obesity
• The person binges on large amounts of food as in bulimia
• Binge eating differs because someone does not partake in attempts to get rid of excess calories

Predisposing Factors

• Hereditary predisposition is theorized. Where anorexia nervosa is prominent among sisters and mothers
• There is speculation for primary hypothalamus dysfunction in anorexia
• Bulimia has shown that the neurotransmitters (serotonin and norepinephrine) can be affected
• Anorexia nervosa has also been shown to display an impact with elevated levels of endogenous opioids

Family Influences

• Family influences were believed as prominent factors with no signs that support these claims. Instead, family should be involved in treatment

Outcomes

• It is important to show a minimum of 80% of expected body weight
• To establish the importance of lab serums and blood pressure, demonstrating safe care with nutritional balance
• Having vital signs within normal parameters
• Verbalizes the importance of healthy nutrition

Planning and Implementation

• Hospitalization is needed in cases of:
  • Malnutrition, dehydration, severe electrolyte imbalance, cardiac arrhythmia or severe bradycardia, hypothermia, hypotension, and suicidal ideation

Treatment Modalities: Behavior Modification

• Central issues involve the root and etiology of the behavior
• Creating the opportunity for control to promote proper treatment options

Treatment Modalities: Psychopharmacology

• There are no medications that are specified for usage
• Medications utilized include -Anxiety and depression relief and or antipsychotics