Substance Use Disorders: Neurobiology

Substance Use Disorders

• Identifying the symptoms, using this information aids in assessing clients with substance-related and addictive disorders.
• Recognize what nursing diagnoses and treatments are appropriate for patients dealing with substance-related and addictive disorders.
• Discussing substance-related and addictive ailments is important within the nursing profession.

Neurobiology

• Pleasure response results from stimulating opioid receptors, either naturally or artificially.
• Stimulation of opioid receptors raises dopamine levels, reducing inhibition of dopamine pathways.
• When dopamine levels increase, a memory of this feeling of pleasure may cause cravings.
• After repeated consumption, natural stimulation of opioid receptors ceases.
• Artificial substances bypass the body's natural satiety mechanisms, chronically increasing dopamine levels, leading to desensitization.
• Over time, the substance becomes necessary to maintain normal dopamine levels.

Substance Use Disorder

• Substance use can impair the ability to fulfill role obligations.
• Efforts to cut down or control use are unsuccessful.
• There is an Intense craving for the substance.
• A great amount of time is occupied with trying to get the substance or recover from its consumption.
• Substance use creates challenges in interpersonal relationships or leads to social isolation.
• Engaging in risky activities happens when impaired by the substance.
• Tolerance builds, causing the need for larger amounts to achieve the desired effect.
• Substance-specific symptoms appear when substance use stops.

Substance-Induced Disorders

• Substance intoxication involves the creation of a reversible syndrome of symptoms due to excessive substance use.
• Intoxication from substances directly affects the central nervous system, causing disturbances in physical and psychological functioning.
• Judgment is affected and social and occupational functioning is impaired during substance intoxication.
• Substance withdrawal is identified by the development of symptoms upon abrupt reduction or discontinuation of a substance and are specific to the substance that has been used.
• These symptoms may cause disruption in mental and physical functioning.

Classes of Psychoactive Substances List

• Alcohol
• Caffeine
• Cannabis
• Hallucinogens
• Inhalants
• Opioids
• Sedatives/hypnotics
• Stimulants
• Tobacco

Alcohol Intoxication and Withdrawal

• Alcohol intoxication occurs with blood alcohol levels are between 100 to 200 milligrams per deciliter.
• Alcohol withdrawal occurs within 4 to 12 hours of stopping or reducing heavy and prolonged alcohol use.

Stimulant Use Disorder

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

Stimulant-Induced Disorders

• Amphetamine and cocaine intoxication causes euphoria, impaired judgment, confusion, and changes in vital signs. High doses may cause coma or death.
• Caffeine intoxication happens after consuming more than 250 milligrams, resulting in restlessness and insomnia as common symptoms.
• Amphetamine and cocaine cause withdrawal, which can lead to dysphoria, fatigue, sleep disturbances, and increased appetite.
• Caffeine withdrawal can trigger headache, 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

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

Opioid-Induced Disorders

• Opioid drug half-life determines the duration of intoxication symptoms, usually lasting several hours.
• Early euphoria is followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment.
• Severe opioid intoxication can cause respiratory depression, coma, and death.
• Opioid withdrawal symptoms consist of dysphoria, muscle aches, nausea/vomiting, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, abdominal cramping, diarrhea, yawning, fever, and insomnia.

Opioid Withdrawal Durations

• Short-acting drugs (e.g., heroin) see symptoms onset within 6-8 hours, peaking in 1-3 days, and gradually subsiding in 5-10 days.
• Long-acting drugs (e.g., methadone) cause symptoms within 1-3 days, peaking between days 4-6, and subsiding in 14-21 days.

Nursing Process: Assessment

• Substance use problems can be assessed using various tools.
• These include taking a drug history and assessment, using the Clinical Institute Withdrawal Assessment of Alcohol Scale, or administering the CAGE questionnaire.

Dual Diagnosis

• Those with coexisting substance and mental disorders may be placed in a special program targeting the dual diagnosis.
• Special therapies addressing both the substance and mental health problems are part of the program.

The Chemically Impaired Nurse

• From 10% to 15% of nurses are believed to have a chemical dependency.
• Alcohol is the main abused drug, followed by narcotics.
• If the employee’s source is outside work, high absenteeism may be present.
• The person may rarely miss work when the substance origin is found at work.
• Raising rates of drug wasting, higher errors in narcotic counts, and repeated signing out of medications for other nurses can suggests chemical impairment.
• Poor concentration, struggling to meet deadlines, wrong responses, and poor memory or recall may point to chemical impairment.
• Other signs include relationship problems, irritability, isolating, and giving elaborate excuses for behavior.

Codependency

• Members of a family where chemical dependency exists exhibit dysfunctional behaviors.
• Dysfunctional behavior may also be evident in family units that harbor secrets of abuse, cruelties, or pathological conditions.
• Codependent individuals prioritize other's needs over their own to create a sense of control.
• They derive self-worth from others and feel responsible for others' happiness, while commonly ignoring the problems that exist.

Pharmacotherapy for Alcoholism

• Treatment options include Disulfiram (Antabuse).
• Alcohol withdrawal managed with:
• Benzodiazepines
• Anticonvulsants
• Multivitamin therapy
• Thiamine

Psychopharmacology for Substance Intoxication and Substance Withdrawal

• Other medication options:
• Naltrexone (ReVia)
• Selective serotonin reuptake inhibitors (SSRIs)
• Acamprosate (Campral)
• For Opioids treatment:
• Narcotic antagonists such as Naloxone (Narcan) and Naltrexone (ReVia)
• Buprenorphine
• Methadone
• Clonidine

Gambling Disorder

• The disorder consists of repetitive problematic gambling which intensifies when the individual is under stress.
• The individual may use any means necessary to get money to continue the addiction.
• Gambling behavior most often starts in adolescence.
• Compulsive behaviors rarely appear before young adulthood.
• The disorder follows a chronic course, with waxing and waning periods
• The disorder obstructs with interpersonal relationships, social life, academics, or occupational functioning.

Eating Disorders

• The hypothalamus in the brain regulates the body's ability to identify when it's hungry, not hungry, and when it's full or sated.
• Eating behaviors are affected by society and culture which impacts what is considered a desirable shape.

Body Mass Index (BMI)

• Normal weight is defined as a BMI range of 20 to 24.9.
• A BMI of 30 or more defines obesity.
• Anorexia nervosa manifests as a BMI of 17 or less, and below 15 in extreme instances.

Anorexia Nervosa

• Anorexia is described as a morbid fear of obesity.
• Symptoms include warped body image, preoccupation with food, and rejecting eating.
• Patients undergoing the disorder commonly have weight loss of more than 15% and other symptoms, such as hypothermia, bradycardia, hypotension, edema, lanugo, and variations of metabolic changes.
• Amenorrhea becomes common, and it sometimes precedes significant weight loss.
• Obsession with food and feelings of anxiety and depression are common.

Bulimia Nervosa

• Bulimia nervosa consists of episodic, uncontrolled, rapid consuming of large amounts of food over a short period of time.
• Compensation after binging is self-induced vomiting or misuse of laxatives, diuretics, or enemas, and fasting or extreme exercise.
• Most remain at a normal weight range, with some underweight or slightly overweight, with many dealing with depression, anxiety, and substance abuse.
• Excessive vomiting and laxative or diuretic abuse can lead to dehydration and electrolyte imbalances.

Binge Eating Disorder

• Binge eating disorder is defined, and can further lead to obesity.
• The individual binges on large amounts of food like that of bulimia nervosa.
• Unlike bulimia nervosa, BED does not involve behaviors to rid the body of the excess calories.

Predisposing Factors for Eating Disorders

• Biological, genetics, neuroendocrine and neurochemical influences influence the presence of a disorder.
• Anorexia nervosa is often found among sisters and mothers.
• Abnormalities may be related to hypothalamic dysfunction in anorexia nervosa.
• Bulimia nervosa is possibly connected to the neurotransmitters serotonin and norepinephrine, and anorexia nervosa with high levels of endogenous opioids.
• Family influences may be involved in treatment.

Outcomes for the Patient

• Important outcomes are:
• Achieving and maintaining at least 80% of expected body weight
• Having stable vital signs, blood pressure, and lab results within normal limits
• Verbalizing the importance of enough nutrition

Planning and Implementation

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

Treatment Modalities: Behavior Modification

• Control is a central issue in these disorders.
• The client must perceive that they are in control of the treatment for the program to be successful.
• Success is more easily achievable when the client is allowed to contract for privileges based on weight gain, has input into their plan and can have a clear view of the treatment choices.

Treatment Modalities: Psychopharmacology

• Anxiety and depression can be treated though no medication has been determined to specifically treat eating disorders.
• Anorexia can be treated with Fluoxetine (Prozac), Clomipramine (Anafranil), Cyproheptadine (Pariactin), Chlorpromazine (Thorazine) or Olanzapine (Zyprexa).
• Bulimia may be treated with Fluoxetine (Prozac), Imipramine (Tofranil), Desipramine (Norpramine), Amitriptyline (Elavil), Nortriptyline (Aventyl), or Phenelzine (Nardil).
• Binge eating disorder with obesity, can be treated with Topiramate (Topamax) or Lisdexamfetamine (Vyvanse).