Chapter Chapter 6 Substance Use Assessment PDF

# Chapter 6 Substance Use Assessment ## Alcohol Use and Abuse - High incidence of occurrence across patient care settings - Many patients will have significant history of drinking that has impact on their health status. - Alcohol consumption has dose-related effects: the more you drink, th...

# Chapter 6 Substance Use Assessment ## Alcohol Use and Abuse - High incidence of occurrence across patient care settings - Many patients will have significant history of drinking that has impact on their health status. - Alcohol consumption has dose-related effects: the more you drink, the higher the risk. - Morbidity and mortality data reflect adverse consequences of excessive alcohol use. - A high number of medications are classified as alcohol interactive. - Alcohol dependence increases the risk for ED visits, ICU admissions, and sepsis. - Binge drinking associated with increasing health risks. ## Defining Illicit Drug Use - Seven categories of illicit drug use - Marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type drugs used nonmedically. - 12 years and older show highest prevalence. - Illicit drug use has serious consequences for - health, relationships, and future jobs, school, and career. ## Prescription Drug Abuse and Opioid-Related Deaths - Increased rate of deaths from drug overdose as opposed to motor vehicle accidents - Contributing factors to Rx abuse and Opioid crisis: - Increase in Rx for pain medication - Marketing strategies to promote medications - Misrepresentation of “addictive” nature - Combination addictions-drinking and taking alcohol-interactive medications ## Diagnosing Substance Abuse - Gold standard of diagnosis is well defined in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) - Alcohol problems underdiagnosed both in primary care settings and in hospitals - Excessive alcohol use often unrecognized until patients develop serious complications ## Developmental Competence: Adolescents - Effect of alcohol on decreasing brain development and maturity - Associated risk between alcohol use and other high-risk behaviors leading to - sexual high-risk. - academic problems in school. - injuries from trauma. - continuation of alcohol disease in later life. ## Developmental Competence: Pregnancy - Dangers to mother as well as to fetus - Development of Fetal Alcohol Spectrum - Potential adverse consequences of alcohol use to fetus are well known. - Physical deformities as well as learning and behavioral problems - No amount of alcohol has been determined safe for pregnant women. - All women who are contemplating pregnancy or who are pregnant should be screened for alcohol use, and abstinence should be recommended. ## Developmental Competence: Aging Adult - An increasing number of older adults are drinking. - Characteristics that increase risks associated with alcohol use: - Decrease in body's metabolic functions (liver, water, and renal) leading to increased bioavailability - Muscle mass decline leads to increased concentration in the body. - Effects of polypharmacy may interact with alcohol. - Increases risk for cognitive decline - Drinking alcohol increases risk for falls, depression, and gastrointestinal problems. ## Subjective Data - Data collected by examiner asking questions - If patient is currently intoxicated or going through substance withdrawal, collecting any history data is difficult and unreliable. - However, when sober, most people are willing and able to give reliable data, provided that the setting is private, confidential, and nonconfrontational. - Ask about alcohol use - Do you sometimes drink beer, wine, or other alcoholic beverages? - If the answer is yes, then ask screening question about heavy drinking days, such as "How many times in the past year have you had five or more drinks a day (for men) or four or more drinks a day (for women)? - Use screening tools. - Identify problem drinking. - Require further assessment. ## AUDIT Questionnaire - Quantitative format uses numbers to identify a response. - Three domains: alcohol consumption, drinking behavior or dependence, and adverse consequences (Maximum score: 40) - Useful in primary care with adolescents and older adults - Relatively free of gender and cultural bias - AUDIT-C: shorter form for acute and critical care units (maximum score: 12) - The AUDIT will help detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders. - Helpful with emergency department (ED) and trauma patients because it is sensitive to current as opposed to past alcohol problems. ## Standard Clinical Diagnostic Criteria - Determine whether there is a maladaptive pattern of alcohol use causing clinically significant impairment or distress. - Ask, "In the past 12 months: - has your drinking repeatedly caused or contributed to the following?" - Risk for bodily harm, relationship trouble, role failure, and/or run-ins with law - "Have you not been able to stick to drinking limits, or have you repeatedly gone over them?” - Shown tolerance, signs of withdrawal, kept drinking despite problems, spent a lot of time drinking or anticipating or recovering and/or spent less time on other matters or activities that had been important or pleasurable - Ask about use of illicit substances: - "Do you sometimes take illicit drugs or street drugs, such as marijuana, cocaine, hallucinogens, narcotics?" - If yes, ask, “When was last time you used drugs, and how much did you take that time?" ## TWEAK Questions - Screening women for alcohol problems - TWEAK questions help identify at-risk drinking in women, especially pregnant women. - Tolerance: how many drinks can you hold? Or how many drinks does it take to make you feel high? - Worry: have close friends or relatives complained about your drinking? - Eye-opener: do you sometimes take a drink in morning when you first get up? - Amnesia: has a friend or family member told you about things you said but could not remember? - Kut down: do you sometimes feel the need to cut down? ## SMAST-G Questionnaire - Screening aging adults - Use the SMAST-G questionnaire for older adults who report social or regular drinking of any amount of alcohol. - Older adults have specific emotional responses and physical reactions to alcohol. - 10 questions with yes/no responses that address these factors. - Two or more “yes” questions indicate alcohol problem. ## Advise and Assist (Brief Intervention) - Consequences of substance abuse are so debilitating and destructive to patients and their families that a short statement of assistance and concern is given here. - If your assessment has determined the patient to have at-risk drinking or illicit substance use, state your conclusion and recommendation clearly. ## Objective Data: Clinical Laboratory Data (1 of 2) - Less sensitive and specific than self-report questionnaires but help to corroborate subjective data - Serum protein, gamma glutamyl transferase (GGT): commonly used biochemical marker of alcohol drinking - Occasional alcohol drinking will not raise this measure, but chronic heavy drinking will. Be aware that nonalcoholic liver disease also can increase GGT levels in the absence of alcohol. - Carbohydrate-deficient transferring (CDT) - Gender issue-higher levels seen in healthy females thus combining it with GGT may improve accuracy - Serum aspartate aminotransferase (AST) - Enzyme found in high concentrations in heart and liver ## Objective Data: Clinical Laboratory Data (2 of 2) - Mean corpuscular volume (MCV) index of red blood cell size - MCV is not sensitive enough to use as only biomarker. - Can detect earlier drinking after long period of abstinence - Direct biomarker phosphatidylethanol(Peth) - Sensitive indicator used to evaluate abstinence - Breath alcohol analysis detects any amount of alcohol in end of exhaled air following a deep inhalation until all ingested alcohol is metabolized. - This measure can be correlated with blood alcohol concentration (BAC) and is the basis for a legal interpretation of drinking. ## Clinical Institute Withdrawal Assessment Scale (CIWA) - Most sensitive scale for objective measurement of withdrawal - 10 measured criteria with individual scoring to arrive at a composite score - Includes vital signs and oxygen saturation - Individual subscales include 7 criteria with the exception of Orientation which includes 4 criteria. - Based on continued assessment provides trended results to determine level of monitoring that is needed. - Score of 0 to 7 can monitor every 4 hours. - All scores below 8 for 72 hours, you can discontinue. ## Clinical Signs of Substance-Abuse Disorders -“Substances” refers to non-medical agents taken to alter mood or behavior. - Intoxication: maladaptive behavioral changes due to effects on CNS from substance - Abuse: daily or recurrent use such that impairment and decreased functioning has occurred leading to ongoing problems - Dependence: physiological reliance - Tolerance: requires more to get the desired effect - Withdrawal: cessation of substance leads to physiological effects ## Question 1 - The nurse is assessing a patient who has been abusing opiates for 4 years. The patient says, “I can quit anytime I want.” The nurse should interpret this statement to be a sign that this individual 1. may be in denial of needing help or having a problem with opiates. 2. is ready to quit and can do so with little intervention. 3. is motivated to enter rehabilitation. 4. should not be trusted because this individual is not of sound mind. ## Answer to Question 1 - The correct answer is 1. Most patients will deny needing help for substance abuse and may believe they can stop at any time. - Option 2 is incorrect because the patient may be ready to quit but will most likely need the support of health care and family to succeed. - Option 3 is incorrect because, based on the statement “I can quit anytime I want,” this patient is not likely to be motivated to quit. - Option 4 is incorrect because patients with substance-abuse issues are considered capable of making decisions for themselves unless a mental status examination proves otherwise. ## Question 2 - The nurse is caring for a patient in the ED who has been a patient many times before in the ED. In fact, this is the patient's second overdose in 1 month. The nurse says, “Here we go again. I don't know why we bother with this guy, because he will be back out there as soon as he is discharged”. The nurse 1. is not being professional and cannot give unbiased care. 2. is obligated to provide care. 3. is not obligated to provide care. 4. must find a way to come to terms with the way he or she feels about these types of issues and work on ways to deal with them. ## Answer to Question 2 - The correct answer is 4. The nurse should examine the way he or she feels about these issues to provide nonjudgmental care for substance-abusing patients. - Option 1 is true; however, the nurse will not have the option to not administer care in this situation. - Option 2 is true, but it is not the best answer because it does not encourage the nurse to examine his or her values. - Option 3 is incorrect because the nurse must provide care in this situation.