Week 13 Drug Misuse and Drug DIversion Lecture Slides PDF

Substance Misuse Drug Diversion NUR 2303 – Week 13 Housekeeping Questions from last week Substance Misuse Physical dependence Psychological dependence Habituation Addiction Commonly Misused Substances Opioids Stimulants heroin racemic amphetamine...

Substance Misuse Drug Diversion NUR 2303 – Week 13 Housekeeping Questions from last week Substance Misuse Physical dependence Psychological dependence Habituation Addiction Commonly Misused Substances Opioids Stimulants heroin racemic amphetamine codeine phosphate dextroamphetamine hydrocodone methamphetamine hydromorphone Cocaine meperidine hydrochloride Depressants morphine Benzodiazepines fentanyl Barbiturates oxycodone Marihuana  Alcohol Anabolic steroids dextromethorphan hydrobromide Commonly Misused Lysergic acid diethylamide (LSD) Substances Methamphetamine Methylenedioxymethamphetamine (ecstasy, molly) Nicotine Phencyclidine (PCP) Opioids Also known as narcotics Intended drug effects: relieve pain, reduce cough, relieve diarrhea, and induce anaesthesia High potential for misuse and psychological dependency; promote relaxation and euphoria Opioids Heroin (diacetylmorphine) Injected (“mainlining” or “skin popping”) Sniffed (“snorted”) Smoked Causes a brief “rush” followed by a few hours of a relaxed, contented state Large doses can stop respirations. One of 10 most misused drugs in Canada Opioids: Adverse Effects CNS Drowsiness Diuresis Miosis (pupillary constriction) Convulsions Nausea, vomiting Respiratory depression Opioids: Adverse Effects Non-CNS Hypotension Constipation Decreased urinary retention Flushing of the face, neck, and upper thorax Sweating, urticaria, and pruritus Opioid Drug Withdrawal Peak period 1 to 3 days Duration 5 to 7 days Signs Drug seeking, mydriasis (pupil dilation), diaphoresis, rhinorrhea (runny nose), lacrimation (tear secretion or production), vomiting, diarrhea, insomnia, elevated blood pressure (BP) and pulse Symptoms Intense desire for drug, muscle cramps, arthralgia, anxiety, nausea, malaise Opioid Drug Withdrawal: Treatment Block opioid receptors so that use of opioid drugs does not produce euphoria. naltrexone hydrochloride, an opioid antagonist methylnaltrexone bromide (Relistor®), an injectable form of naltrexone naloxone combined with buprenorphine hydrochloride (Suboxone®) or with hydromorphone hydrochloride (Targin®) Stimulants Elevation of mood Reduction of fatigue Increased alertness Invigorated aggressiveness Stimulants Amphetamines Cocaine methylphenidate hydrochloride dextroamphetamine sulphate Methamphetamine methylenedioxymethamphetamine Bath salts Methamphetamine Stronger effects than other amphetamines Pill form Powder form: snorted or injected Crystallized form Also known as “ice,” “crystal,” “glass,” “crystal meth” Smokable; more powerful form Sales of over-the-counter ephedrine, pseudoephedrine, and red phosphorus are now restricted to be beyond the counter in pharmacies only. Methylenedioxymethamphetamine Also known as “ecstasy” and “E” Usually prepared in secret home laboratories More calming effects than other amphetamine drugs Usually taken by pill “Raves” Cocaine From the leaves of the coca plant Snorted or injected intravenously Highly addictive—physical and psychological dependence Powdered form Also called “dust,” “coke,” “snow,” “flake,” “blow,” “girl” Crystallized form (smoked) Also called “crack,” “freebase rocks,” “rock”, “candy”  Restlessness Confusion Syncope Aggression (fainting) Increased libido Tremor Anxiety Stimulants: Hyperactive Delirium reflexes Adverse Effects Talkativeness Paranoid hallucinations Irritability Suicidal or Insomnia homicidal Fever tendencies Euphoria Stimulants: Adverse Effects Headache Gastrointestinal Chilliness Dry mouth Metallic taste Pallor or flushing Anorexia Palpitations Nausea Tachycardia Vomiting Diarrhea Cardiac dysrhythmias Abdominal cramps Anginal pain Fatal hyperthermia Hypertension or hypotension Circulatory collapse Stimulant Overdose Death results from Convulsions Coma Cerebral hemorrhage May occur during periods of intoxication or withdrawal Stimulant Withdrawal Peak period 1 to 3 days Duration 5 to 7 days Signs Social withdrawal, psychomotor retardation, hypersomnia, hyperphagia Symptoms Depression, suicidal thoughts and behaviour, paranoid delusions No specific pharmacological treatments Depressants Drugs that relieve anxiety, irritability, and tension when used as intended Also used to treat seizure disorders and induce anaesthesia Two main pharmacologic classes Benzodiazepines Barbiturates Marihuana (“pot,” “grass,” “weed”) flunitrazepam (Rohypnol®): not legally available in Canada; known as “roofies” Depressants Benzodiazepines and barbiturates: increase the action of gamma-aminobutyric acid, an amino acid in the brain, which inhibits nerve transmission in the CNS Results in sedation, muscle relaxation, and relief of anxiety Marihuana (δ-9-trans-tetrahydrocannabinol) Benzodiazepines and Barbiturates Benzodiazepines: anxiety, to induce sleep, to sedate, and to prevent seizures Barbiturates: sedatives and anticonvulsants and to induce anaesthesia Depressants: Adverse Effects CNS Drowsiness, sedation, loss of coordination, dizziness, blurred vision, headaches, and paradoxical reactions Gastrointestinal Nausea, vomiting, constipation, dry mouth, and abdominal cramping Pruritus and skin rash Marihuana: “amotivational” syndrome Depressants: Withdrawal Peak period 2 to 4 days for short-acting drugs 4 to 7 days for long-acting drugs Duration 4 to 7 days for short-acting drugs 7 to 12 days for long-acting drugs Signs Increased psychomotor activity; agitation; muscular weakness; hyperthermia; diaphoresis; delirium; convulsions; elevated BP, pulse rate, and temperature; others Depressants: Withdrawal Symptoms Anxiety, depression, euphoria, incoherent thoughts, hostility, grandiosity, disorientation, hallucinations, suicidal thoughts Treatment involves tapering of the drug over the course of 7 to 10 days or 10 to 14 days. Alcohol More accurately known as ethanol Causes CNS depression by dissolving in lipid membranes in the CNS Few legitimate uses of ethanol and alcoholic beverages Used as a solvent for many drugs Systemic uses of ethanol: treatment of methyl alcohol and ethylene glycol intoxication (e.g., from drinking automotive antifreeze solution) Ethanol: Drug Effects CNS depression Respiratory stimulation or depression Vasodilation, producing warm flushed skin Increased sweating Diuretic effects Effects of Chronic Ethanol Ingestion Nutritional and vitamin deficiencies (especially B vitamins) Wernicke’s encephalopathy Korsakoff’s psychosis Polyneuritis Nicotinic acid deficiency encephalopathy Seizures Alcoholic hepatitis, progressing to cirrhosis Cardiomyopathy Effects of Chronic Ethanol Ingestion Fetal alcohol spectrum disorder (FASD) Pregnant women should be educated about the effects of alcohol consumption. FASD is characterized by: Craniofacial abnormalities CNS dysfunction Prenatal and postnatal growth retardation Ethanol: Withdrawal Signs and symptoms Elevated blood pressure, pulse rate, and temperature Insomnia Tremors Agitation Classified as mild, moderate, or severe Question A patient with a diagnosis of delirium tremens is admitted to the acute care facility. Which finding does the nurse expect upon assessment of the patient? A. Hyperthermia B. Hypotension C. Bradycardia D. Somnolence Ethanol: Withdrawal Treatment Benzodiazepines are the treatment of choice diazepam (Valium®) Dosage and frequency depend on severity. acamprosate calcium For severe withdrawal, monitoring in a Critical Care Unit is recommended. Treatment of Alcoholism disulfiram (Antabuse®) (no longer manufactured in Canada) Acetaldehyde syndrome naltrexone acamprosate calcium Newest treatment Counselling Individual Alcoholics Anonymous Nicotine Many smoke to “calm nerves.” Releases epinephrine, which creates physiological stress rather than relaxation Tolerance develops Physical and psychological dependency Withdrawal symptoms occur if stopped. No therapeutic uses Two hundred known poisons are present in cigarette smoke. Nicotine: Drug Effects Transient stimulation of autonomic ganglia Followed by more-persistent depression of all autonomic ganglia CNS and respiratory stimulation followed by CNS depression Increased heart rate and BP Increased bowel activity Nicotine: Drug Effects Nicotine found in nature (i.e., tobacco plants) has no known therapeutic uses. Nicotine is medically significant because of its addictive and toxic properties. Nicotine Withdrawal Manifested by cigarette craving Irritability, restlessness, decreased heart rate and BP Cardiac symptoms resolve in 3 to 4 weeks, but cigarette craving may persist for months or years. Nicotine: Withdrawal Treatment Treatments provide nicotine without the carcinogens in tobacco. Nicotine transdermal system (patch) nicotine polacrilex (gum) Inhalers Nasal spray Nicotine: Withdrawal Treatment bupropion hydrochloride (Zyban®): may be prescribed to aid in smoking cessation First nicotine-free prescription medication to treat nicotine dependence varenicline tartrate (Champix®) Stimulates nicotine receptors Nursing Implications Assessments should include nonjudgemental and open-ended questions about substance abuse. Be observant for clues to substance misuse so as to avoid withdrawal symptoms. The most dangerous substances in terms of withdrawal are CNS depressants such as barbiturates, benzodiazepines, and alcohol. Establish therapeutic rapport, and use empathy toward the patient. Nursing Implications Assessment tools for substance misuse: CAGE Alcoholism Screening Test Adapted to Include Drugs (CAGE- AID) Substance Abuse Subtle Screening Inventory (SASSI) Michigan Alcoholism Screening Test Geriatric version (MAST-G) Problem Oriented Screening Instrument for Teenagers (POSIT) Nursing Implications Patient safety is important at all times during patient care but especially when the patient is experiencing the signs and symptoms of withdrawal. Provide monitoring and support as needed throughout the withdrawal process. Educate the patient and family members or significant others about the recovery process. Emphasize that recovery is lifelong. Drug Diversion What is it? How does it harm clients? Risks for staff who are diverting? Risks for non-diverting staff? Which environments might increase the risks of drug diversion? Drug Diversion Red flags? Careful investigations, non-threatening communication, confidential Drug testing Negative drug test results not filed on HR database ‘Watchlist’ Crucial conversations Assistance programs for employees increase client safety Nurses’ Health Program (NHP) Voluntary and confidential professional health programs are highly effective in both protecting the public and aiding recovery. NHP offers a proven approach to the assessment and treatment of substance use and/or mental health disorders. Recognizes these disorders as illnesses and takes a non-punitive approach that reduces stigma and focuses on recovery. With support and opportunity for education, treatment, and recovery, nurses can continue or return to safe nursing practice. Wrap-up Questions? Final exam blueprint Week 14: Final Exam