Substance Use Disorders PDF

Substance Use Disorders Emma Mangano, DNP, PMHNP-BC Objectives Define substance use disorder ► Identify personal beliefs and attitudes about substance use and how these impact your role as nurse in caring for people who use substances ► Define “dual diagnosis” and discuss implications for psychiat...

Substance Use Disorders Emma Mangano, DNP, PMHNP-BC Objectives Define substance use disorder ► Identify personal beliefs and attitudes about substance use and how these impact your role as nurse in caring for people who use substances ► Define “dual diagnosis” and discuss implications for psychiatric nursing care ► Describe general principles that guide nursing assessment and intervention with patients at risk for substance withdrawal ► Identify withdrawal symptoms of different substances of abuse ► 2 Substance Use Disorder: A Brain Disorder ► All addicting substances affect the dopamine pathways associated with the reinforcing effect of the substance ► Dopamine levels spike much higher and for a longer time than any natural reward such as food or sex ► With repeated use over time, the brain no longer responds to natural rewards ► Repeated exposure seems to alter neurons permanently 3 Classification of Substances ► Alcohol ► CNS Depressants such as benzodiazepines, sleeping aids (zolpidem) ► Inhalants such as solvents, aerosol sprays, gases, nitrates ► Opioids such as oxycodone, fentanyl, heroin ► Stimulants such as cocaine ► Amphetamines (prescribed and unprescribed) ► Hallucinogens such as LSD, PCP 4 Drug Scheduling ► Schedule I: no accepted medical use and high potential for abuse ► Schedule II: high abuse potential and considered dangerous ► Schedule III: moderate to low risk of dependence and abuse ► Schedule IV: low risk of abuse and dependence ► Schedule V: lower risk for abuse potential than IV; often used for antidiarrheal, antitussive, and analgesic purposes https://www.dea.gov/drug-information/drug-scheduling 5 SAMHSA 2020 National Survey on Drug Use and Health ► 50% of people >12yo used alcohol in the past month ► 44.4% of those who drank were classified as binge drinkers, this was highest among young adults (18-25yo) ► 3.4% of those >12yo misused opioids; of the 9.5 million who misused – 9.3 million was from prescription pain relievers. ► 14.5% of the population had a SUD in the past year (alcohol > illicit drug > alcohol and illicit drug use) ► Almost ten percent of the population had a co-occurring mental illness and substance use https://www.samhsa.gov/data/sites/default/files/2021-10/2020_NSDUH_Highlights.pdf 6 Overall Physical Assessment ► Signs of trauma, abuse, chronic housing instability, malnutrition ► Ask about vein care and wounds ► ► • • “How do you take care of your veins?” “Where do you feel comfortable going if you notice a wound or abscess?” If the patient has a wound, may need a wound care consult • • • Avoid the use of stigmatizing language (track marks, junkie) Ask about injection practices- where does the patient get the water for injection? Are they skin popping? Or using veins in their neck or groin? If the patient is using drugs intranasally check nares for signs of infection 7 Alcohol Use Disorder A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring within a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 7. Important social, occupational, or recreational activities given up or reduced because of use 2. There is a persistent desire or unsuccessful efforts to cut down or control use. 8. Recurrent use in situations in which it is physically hazardous. 3. A great deal of time is spent in activities to obtain, use, or recover from effects of alcohol. 9. Use is continued despite knowledge of having a physical or psychological problem caused by alcohol. 4. Craving or strong desire/urge to use alcohol. 10. Tolerance: a. Need for increased amounts to achieve desired effects b. Diminished effect with same amount 5. Recurrent use results in a failure to fulfill major role obligations. 11. Withdrawal: a. Withdrawal syndrome b. Alcohol (or benzo) is taken to relieve or avoid withdrawal symptoms 6. Continued use despite social or interpersonal problems from effects of alcohol. 8 Alcohol Withdrawal ► Cessation or reduction in use that has been heavy and prolonged ► Two or more of the following: • • • • • • • • Autonomic hyperactivity Increased hand tremor Insomnia Nausea or vomiting Hallucinations or illusions Psychomotor agitation Anxiety Seizures 9 Alcohol Withdrawal - Assessment ► Clinical Institute Withdrawal Assessment for Alcohol (CIWA) ► Brief Alcohol Withdrawal Scale Protocol (BAWS) ► Richmond Agitation Sedation Scale (RASS) *Watch Vital Signs* 10 Alcohol Withdrawal - Treatment ► Benzodiazepine • • • • Chlordiazepoxide Diazepam Lorazepam Oxazepam ► Non-benzodiazepine • Phenobarbital 11 Opiate Use Disorder A problematic patter of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following in 12 months: 1. Opioids are taken in larger amounts or over a longer period than was intended. 7. Important social, occupational, or recreational activities given up due to use. 2. There is a persistent desire or unsuccessful effort to cut down on use. 8. Recurrent use in situations in which it is physically hazardous. 3. Great deal of time is spent in activities to obtain, use or recover from the effects of opiates. 9. Continued use despite knowledge of having a physical or psychological problem caused by use. 4. Craving or a strong desire to use. 10. Tolerance, defined by: a. Need for increased amounts to achieve effect b. Diminished effect with use of the same amount. 5. Recurrent use resulting in a failure to fulfill major obligations. 6. Continued use despite recurrent social or interpersonal problems caused by use. 11. Withdrawal: a. Opioid withdrawal syndrome b. Opioids taken to relieve/avoid withdrawal. 12 Opioid Withdrawal ►Presence of either of the following: • • Cessation of (or reduction in) opioid use that has been heavy and prolonged Administration of an opioid antagonist after a period of opioid use ► Three (or more) of the following after cessation: • • • • • • • • • Dysphoric mood Nausea or vomiting Muscle aches Lacrimation or rhinorrhea Pupillary dilation, piloerection, or sweating Diarrhea Yawning Fever Insomnia 13 Opioid Withdrawal - Assessment ► Clinical Opiate Withdrawal Scale (COWS) ► Clinical Institute Narcotic Assessment (CINA) 14 Opioid Withdrawal - Treatment ► Buprenorphine (partial opioid agonist): first line treatment ► Methadone (full opioid agonist) ► Clonidine (alpha-2 adrenergic agonist) ► Taper vs maintenance 15 From the Surgeon General https://addiction.surgeongeneral.gov/sites/default/files/SG-Postcard.jpg 16 Management of Other Substances ► Cocaine • • Blocks dopamine reuptake  euphoria, psychomotor agitation Cocaine “crash” – depleted of neurotransmitters; low mood and risk for suicide ► Cannabis • • • THC active ingredient Withdrawal can cause someone to be irritable, anxious Cannabis hyperemesis syndrome 17 Using Therapeutic Language Stigmatizing vs Compassionate Addict Individual who uses substances Needy or attention-seeking Individuals coming to be seen that have a physical or psychiatric concern Drug-seeking behavior Individual that is in pain or physical withdrawal Clean or Dirty Used or Unused 18 Nursing Assessment ► SBIRT method • • • Screening Brief intervention Referral to treatment https://www.samhsa.gov/sbirt 19 Important Screening Information ► Alcohol Use Disorder Identification Test (AUDIT) • Identifies hazardous alcohol use or alcohol use disorder • • Not useful in determining risky drinking ► CAGE questionnaire Quick indicator of candidacy for standardized interview for alcohol use disorder ► Transtheoretical model • Identifies readiness to change harmful behaviors 20 Interaction Leading into Assessment ► ► Individuals who use substances are more than their drug use • Obtain the facts: patients are experts in their own lives, listen • • • ► Goal is to address the reason that they have been admitted/presented in the first place, which may not be related to their substance use How is your patient feeling- physically, mentally, emotionally, scared of punishments, worried about being judged and not having their pain being addressed What substances are they taking? How often? When did they last use? When do they anticipate they will start to go into withdrawal? Ask about HIV and HCV status Substance use can meet important needs for patients, and we don’t know the whole story 21 Examples of Interview Approaches & Attitudes Use manner that encourages forthrightness—matter-of-fact, nonjudgmental approach • Be careful and aware of personal biases ► Be prepared for defensiveness—genuine concern helps overcome this ► Be aware of own feelings and avoid projecting negative attitudes onto patient ► Get accurate information—a high priority is to ask patient to state date and time of last drink, drug use ► Initially focus on legal drug use—caffeine, nicotine ► 22 Examples of Nonthreatening Language • • • • “Problem with drinking” “Difficulties with drug use” “Problems because of drinking” “Using more than intended” 23 SUDs Assessment ► When was the first time you used X? ► When was the last time you used? ► How much are you currently using? ► What route did you use? ► What is the longest period of sobriety you have had? How were you successful? ► Assess for withdrawal symptoms ► Assess for readiness to change 24 Stages of Change: Meeting the Patient Where They Are ► Pre-contemplation: ask if it is okay to talk about drug use, if it is not okay, they stop ► Contemplation: talk about options, abstinence isn’t the only behavior change (example- ask if they want to talk to the substance use consult service) ► Preparation: support behavior change (example- provide directions to NEX, MAT) ► Action: congratulate any small change (example- no use for 10 years and/or not using and driving and/or going to the syringe exchange once) ► Maintenance: provide encouragement for continued goal ► Relapse: know that relapse is a possibility/probability (on average, individuals relapse 7 times before successfully stopping) https://www.verywellmind.com/the-stages-of-change-model-of-overcoming-addiction-21961 25 Milieu Management ► ► ► ► Safety • • Drug-free environment Suicide prevention Structure • Active, meaningful schedule Balance • Confrontation with support Limit setting • Protects patient from self and others ► Norms ► Environmental modification 26 Development of a Treatment Plan ► While in the hospital • Develop a clear plan and agreement – “We ask that you do not use while you are in the hospital, we will plan to manage your withdrawal with buprenorphine.” – “If you feel the urge to use could you let nursing staff know so we can address symptoms?” – “If you do use, please let us know, this will help the treatment team know why there may be a change in your mental status.” – “Sometimes it is our protocol to conduct room searches, restrict visitors, ask that you do not leave the unit, or ask for daily tox screens.” 27 Development of a Treatment Plan ► Post hospitalization • This is unique to every patient, and depends on what their behavior change goal is: – Someone who wants to stop using Detox or medication assisted treatment (buprenorphine, methadone, vivitrol) Inpatient or outpatient programs NA/AA meetings, helpful for some but not the answer for everyone – Someone who wants to reduce use Set specific goals (i.e. only use on weekends, with other people, or after going to the needle exchange) Budget money for use per day or per week Keep a calendar to remember when drugs were used Discuss PrEP (Pre-Exposure Prophylaxis) Always carry Narcan Supervised or Safe Injection Sites 28 Nurse-Patient Relationship ►Build trust, Be genuine, empathic ►Discuss natural consequences of drinking, drug use and the need for total abstinence ►Create a concrete plan for recovery; offer hope for longterm recovery ► Group work ► Educate regarding diagnosis; need to take one day at a time ► Providing physical and nutritional needs ► Helping patient become involved in groups such as AA and NA and families with Alanon 29 Discharge Planning ► Prevention of opioid overdose • Discharge with Narcan and training ► Educational materials ► Referrals • Inpatient or outpatient treatment ► Resources 30 Recovery Groups in the Community ► Alcohol Use • • • 12-step program groups • Narcotics Anonymous Alcoholics Anonymous (AA or Al-Anon) (for patients and partners) Alateen (for children/teenagers of alcoholic parents) ► Drug Use 31 Carry, Administer, Co-prescribe Knowing how to use naloxone and keeping it within reach can save a life. Previous US Surgeon General Dr. Jerome Adams issued an advisory on April 5, 2018 recommending that more Americans carry naloxone. http://store.samhsa.gov/shin /content//SMA16- 4742/SMA164742.pdf 32 References ► American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders (5th ed. Text revised). Substance-related and Addictive Disorders. https://doi.org/10.1176/appi.books.9780890425787.x16_Substance_Related_Disorders ► Keltner, N. & Steele, D. (2019). Psychiatric Nursing (8th ed.). Elsevier ► Lindner, B. K., Gilmore, V. T., Kruer, R. M., Alvanzo, A. A., Chen, E. S., Murray, P., Niessen, T., Perrin, K., Rastegar, D. A., Young, S., & Jarrell, A. S. (2019). Evaluation of the Brief Alcohol Withdrawal Scale Protocol at an Academic Medical Center. Journal of Addiction Medicine, 13(5), 379–384. https://doi.org/10.1097/ADM.0000000000000510 ► Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). Highlights for the 2020 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/2021-10/2020_NSDUH_Highlights.pdf 33