Substance Use Class 9 Final Slides

Partnering with Persons who use Substances: Using a Harm Reduction Approach in assessment, treatment planning and intervention Class 9: PPN 303 Promoting Mental Health Course Checking-in PPN 303 – Promoting Mental Health Parking Lot & Making Space Topics of Mental Health and Substance Use can...

Partnering with Persons who use Substances: Using a Harm Reduction Approach in assessment, treatment planning and intervention Class 9: PPN 303 Promoting Mental Health Course Checking-in PPN 303 – Promoting Mental Health Parking Lot & Making Space Topics of Mental Health and Substance Use can be triggering Please make space to acknowledge your needs and if feeling triggered remember to pause and connect to supports. TMU Student Support Resources https://www.torontomu.ca/student-wellbeing/counselling/ Land Acknowledgment "Toronto is in the 'Dish With One Spoon Territory’. The Dish With One Spoon is a treaty between the Anishinaabe, Mississaugas and Haudenosaunee that bound them to share the territory and protect the land. Subsequent Indigenous Nations and peoples, Europeans and all newcomers have been invited into this treaty in the spirit of peace, friendship and respect." The "Dish", or sometimes it is called the "Bowl", represents what is now southern Ontario, from the Great Lakes to Quebec and from Lake Simcoe into the United States. *We all eat out of the Dish, all of us that share this territory, with only one spoon. That means we have to share the responsibility of ensuring the dish is never empty, which includes taking care of the land and the creatures we share it with. Importantly, there are no knives at the table, representing that we must keep the peace. The dish is graphically represented by the wampum pictured below. This was a treaty made between the Anishinaabe and Haudenosaunee after the French and Indian War. Newcomers were then incorporated into it over the years, notably in 1764 with The Royal Proclamation/The Treaty of Niagara. Objectives Describe Foundational aspects of the screening, assessment, treatment planning, and interventions to support people experiencing substance use Introduce Nursing management of intoxication, withdrawal, harm reduction and recovery goals. Concurrent disorders treatment approaches Examine for persons with co-occuring mental health conditions and substance use Explain Key components of integrating a Harm Reduction philosophy to practice and integrating a SBIRT approach to practice  Question What Comes to Mind when you hear the words: Addiction Substance Use Spectrum of Use, Foundational Concepts, Harm Reduction Substance Use Spectrum PPN 303 Why We Need to Increase Substance Use Nursing Capacity Substance use disorders affect a wide range of persons encountered across all practice settings. Early assessment and management promotes substantially better outcomes. Stigma often promotes delayed care. 10 The Foundations of Substance Use Nursing: An appreciation that substance use disorders are a complex interrelated condition that affects the whole person. Understands the bio-psycho-social aspects of substance use disorders. Is able to assess, manage, and provide care for persons in intoxication, withdrawal management, and throughout recovery. Understands treatment models and is knowledgeable about treatment options. Practices within a harm reduction framework 11 What is Harm Reduction? Harm Reduction  Harm reduction is defined as an approach, set of strategies, policy or program designed to reduce substance-related harm without requiring abstinence.  At its core is working together with people who use substances as https://harmreductionto.ca/what-is-harm-reduction partners to: Reduce negative health, social, and economic consequences related to substance use Promote public health, human rights, and social justice. Promotes equity, inclusion, dignity, self- determination, and respect. https://ohrn.org/about-us/ Harm Reduction Theory 14 Opioid Crisis/A View from the Frontlines - Michael https://youtu.be/zleONA ORmYI Kumako Question? What are some of the reasons for use of a substance? Potential Factors That increase Risk of Severity of Use: Concurrent mental Health concern. Self-medication Emotional distress Decreased Coping Childhood abuse Personal or Family History 17 But the Brain & Body is involved as well ! Substances that tend to be more “addictive”: Have a fast onset Can be enhanced by injecting, smoking, crushing, snorting, etc. Have a short half-life (T ½) Leave body quickly—need to keep using But: Medication treatments tend to have slow onset & long T ½ 18 Neurobiology  Process of Developing a Substance Use Disorder Positive Effects of Increased dose First use Experience Shorter intervals between doses Baseline Negative Aspects 1. Use gives of Experience immediate positive effects 2. Effects lessen with PHYSICALLY ILL repeated use, leading to UNABLE TO increased use MAINTAIN ROLE/FUNCTION 3. Attempts to stop use results in LEGAL negative effects CONSEQUENCES Physiological/Psychological States Intoxication Tolerance Withdrawal A need for markedly increased Occurs when reducing or amounts of substance to achieve stopping substance. The direct and immediate intoxication or desired effect. Withdrawal symptom Physiological/Psychological effects of taking substance(s) parameters often are opposite to the induced effects of the A markedly diminished effect with substances continued use of the same amount of a substance. The withdrawal parameters are Effects vary by type, quantity and Note: This criterion is not route of substance use specific and characteristic of considered to be met for those the substance taken. taking opioids solely under appropriate medical supervision. Substance Use & Disorder Substance Use Substance Use disorder The ingestion or administration DSM–5, identified as “a cluster of of psychoactive substances that cognitive, behavioral, and can be beneficial or harmful physiological symptoms indicating depending on the substance that the individual continues using used and the quantity, the substance despite significant frequency, method, and context substance-related problems and harms” of use (Ministry of Health Promotion, 2010; Rassool, Patterns of behavior include impaired 2010). control, social impairment, risky use, and pharmacological criteria 22  DSM 5 Disorders DSM5 Substance Use & Substance Substance SUD Use Induced Categorization Disorders Disorders 10 Substances Intoxication Spectrum of severity: * Mild * Moderate Withdrawal * Severe Substance Use Disorder DSM V A problematic pattern of a substance use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:  Substance often taken in larger amounts or over a longer period than was intended.  Persistent desire or unsuccessful efforts to cut down or control use.  A great deal of time is spent in activities necessary to obtain, use, or recover from effects of substance.  Craving, or a strong desire or urge to use substance.  Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.  Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects.  Important social, occupational, or recreational activities are given up or reduced because of use.  Recurrent use in situations in which it is physically hazardous.  Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.  Tolerance  Withdrawal Spectrum of Severity Mild Moderate Severe 2-3 4-5 6+ symptoms symptoms Symptoms Contributing Factors Risk Factors Internal External Substance Use Disorders 26 Classes of Psychoactive Substances Depressants (i.e. alcohol, benzodiazepine, opioids) Stimulants (i.e. cocaine, crystal Methamphetamine) Hallucinogens (i.e. MDMA, Marijuana) Anabolic Steroids (i.e. Steroids) 27 Opioids  Opium, Heroin non-synthetic, smoked, injection, snorted Prescription Narcotic Pain Medications Morphine, Percocet, oxycontin, Dilaudid, Codeine Opioids Swallow pills, crush, inject, snorted Substances that engage opioid Fentanyl, Car-fentanyl receptors Much more potent, longer duration of action (“Pain killers” – such Fentanyl 80-100 times than morphine as narcotic pain meds Carfentanil 10 000 times more than morphine Highly contaminated street supply or heroin. Intravenous, oral tablets, snort, smoked Kratom Kratom has properties of both opiates and stimulants: Lower doses cause stimulant effects, and higher doses cause opiate effects.  Sedation, drowsiness Slowed breathing Decreased level of consciousness Feelings of calmness/pleasure Opioid Effects (intoxication) If not rousable, trouble breathing, Slurred/slowed speech blue lips/fingernails, call 911 and administer Naloxone Sensation of heavy limbs Overdose Prevention Carry Naloxone Use with Others Test Dose First  Muscle Aches/Pain Cold Sweats/Chills Opioid Stomach cramping/Diarrhea/Vomiting/Nausea Withdrawal Tearing/Runny Nose Effects Agitation/Anxiety Yawning Increased Heart Rate/BP “Flu-like” Intense Craving Anxiety & low mood Restlessness, insomnia ***Rapid loss of tolerance after 4-5 days Goosebumps Copyrights apply Subjective Opiate Withdrawal Scale (SOWS) Clinical Opioid Withdrawal Scale (COWS)  Advil, Tylenol, for pain Over the counter medications in response to Gravol for nausea symptoms: Opioid Withdrawal Rest, fluids, warm Symptom shower, supportive measures Imodium for stomach upset Management Approach suboxone (buprenorphine) in small doses to mitigate/prevent RX medications based severity of withdrawal on severity of course. symptoms/anticipated more severe withdrawal Clonidine Supportive counselling  Partial opiate that relieves opiate withdrawal symptoms for full 24 hours Buprenorphin Often combined with naloxone (to discourage people e+ Naloxone from injecting) (Suboxone) Does not cause high Safer than methadone (very low risk of overdose) Possible side effects: Nausea, constipation, sedation Client should avoid taking other sedatives (like alcohol or benzodiazepines) Methadone Full agonist opiate that relieves opiate withdrawal symptoms for full 24 hours and used in maintenance therapy Prescribed by specialty Physicians with CPSO guidelines Sedation and drowsiness common side effect Possible side effects: Nausea, constipation, sedation Strict guidelines on take home doses and missed doses. Opioid Withdrawal Considerations Withdrawal = Loss of tolerance = High risk of overdose Offer OAT for withdrawal or longer term as options Pregnant persons should not stop abruptly Opioids: Health Impacts Escalating Tolerance & Overdose Risk Pain related Syndromes Withdrawal Constipation Withdrawal related miscarriage risk during Intravenous route related **non-bulk forming Pregnancy risk for laxatives!!** No Metamucil/high fibre **Do not stop cold turkey Hep C, HIV exposure, skin if pregnant** refer to infections/abscesses Recommend laxaday/PEG specialist Medication Options for Opioid use Disorder Pharmacotherapeutic Options Opioid Agonist Injectable Safe Opioid Supply Therapy (OAT) OAT (SOS) Injectable Suboxone Methadone Kadian Dilaudid hydromorphone dissolving tablet ‘Orange” drink ‘Partial agonist 24hr coverage 24 hrs coverage Full agonist Label Me Person Lived Experience – Stephanie Bertrand https://youtu.be/OhFO-iL ZXKE  Slows the central nervous system Slows mental processes Depressants Decreased alertness Slows heart rate while intoxicated Fast heart rate in withdrawal Common depressants: Alcohol Benzos Sedatives/Tranquilizers  Alcohol 10 drinks a week for biologically female bodies, with no more than 2 drinks a day most days 15 drinks a week for biologically male bodies, with no more than 3 341mL(5%alc) = 43mL(40% alc) = 83mL drinks a day most days (12%alc) https://www.camh.ca/-/media/files/canadas-low-risk-guidelin es-pdf.pdf Problematic Drinking Versus Alcohol Dependence Objective Measures Problematic Drinking Alcohol Dependence Number of Male – More than 14 More than 40-60 per Drinks/Week Female – More than 9 week Drinks Moderately Often Rarely (Fewer than 4/Day) Tolerance Mild Marked Withdrawal No Often Symptoms Neglect of Major No Yes Responsibilities Socially Stable Usually Not Often Screening for Alcohol Problems TAKE A COMPREHENSIVE PATIENT HISTORY Ask about alcohol use Ask about the number of drinks/week Explore the maximum amount consumed on any one day in the past three months Ask how many bottles & what size are consumed per week Ask about the previous weeks drinking pattern if patient is vague Ask about other drug use as it is not uncommon for heavy drinking and polysubstance use to co-exist. Ask if the patient has ever been hospitalized or required medication for alcohol withdrawal  Morning Relief Drinking Tremor Alcohol Withdrawal Sweating Anxiety Seizures, risk increases with previous history of seizures Delirium Tremens - severe Withdrawal is common when consuming more than 40 drinks per week. The Three Stages of Alcohol Withdrawal MINOR INTERMEDIATE MAJOR Autonomic Hyperactivity Autonomic Hyperactivity: Delirium Tremens: -Nausea/Vomiting Seizures Severe agitation, gross -Coarse Tremor Dysrhythmias (Atrial Fibrillation, tremulousness, global -Sweating Supraventricular, confusion,disorientation, auditory, tactile,visual hallucinations, -Tachycardia Ventricular Tachycardia) psychomotor & autonomic -Hypertension Hallucinations (Auditory/Visual) hyperactivity (hypertension, fever…etc.) Symptoms tend to appear within Withdrawal Seizures usually occur Typically occur 5-6 days after 6-12 hours of last drink between 12-72 hours after drinking severe, untreated withdrawal has stopped Symptoms usually resolve within Seizure Protocol: 20mg Valium Sudden death can occur 48-72 hours q1hr x 3 doses min Alcohol Withdrawal Symptom Management Approach Symptom triggered approach using low dose Diazepam 10mg – 20mg for CIWA>10 Or Lorazepam 2mg Medications to Help with Cravings/Relapse Naltexone Acamprosate Disulfiram (Revia) – (Campral) - (Antabuse) - anti-craving anti-craving Deterant Alcohol: Health Impacts Throat and Stomach Liver Impacts: Escalating Related Impacts: Tolerance & Cardiac Impacts Cirrhosis Withdrawal Esophageal Varices , Reflux Concurrent Anxiety, Cognitive Impacts, Injuries Depression Wernicke Korsakoffs MVA, Alcohol Withdrawal: When to send to ER  Escalating symptoms of tremor/shakiness, disorientation, sweating, hallucinations  Symptoms are not getting better BENZODIAZEPINES Lorazepam (Ativan) Diazepam (Valium) Temazepam Alprazolam (Xanax) 53  Benzodiazepines commonly prescribed drugs Controversy around the most appropriate use and effectiveness of benzodiazepines Most common indications are for: - Anxiety Disorders (Panic Disorder, Generalized Anxiety Disorder) - Mood Disorders (Depression) Indications for Benzodiazepines - Sleep Disorders (Insomnia) Alcohol withdrawal & Seizure Disorders Monitoring the Discontinuation of Benzodiazepines 1.) Do not abruptly stop taking if have been taking for several months/years unless there is a medically sound reason such as serious complications that warrant immediate discontinuation Due to increased risk of seizure 2.) Withdrawal regimens for tapering off benzodiazepines should be slow and gradual with support of primary physician/NP Benzodiazepine Withdrawal Considerations Xanax is long acting Often Benzos found in more potent benzo that fentanyl has higher likelihood of severe withdrawal. 56 Benzodiazepine Withdrawal considerations May be happening “silently” if folks whose primary substance of concern is not benzo – ie, came in for help for X, but forgot to mention they usually Slow Taper Preferred regularly take benzos OR did not know that their fentanyl or other substance had benzo in it or knew but never really experienced how much the benzo part of the drug was affecting them.  Increase central nervous Examples: system activity Effects: Wakefulness, Cocaine/Crack Cocaine euphoria, decreased appetite, aggression, rapid heart rate, Methamphetamine (crystal, Stimulants elevated body temperature, crystal meth, meth, ice, crank, “Uppers” agitation, paranoia, delusions, glass, chalk). hallucinations Psychoactive bath salts Refer to medical care if client is very agitated (may need benzodiazepines), delusional (may need antipsychotics), or hyperventilating and experiencing severe sweating and convulsions (may indicate an overdose) Stimulants – Indicators of Stimulant Use BEHAVIORAL PHYSIOLOGICAL Using BZDs/opioids/alcohol (depressants) to Increased BP/HR/Temp ’come down’ off stimulants Rapid Speech/Movements Increased Alertness Cardiac Irregularities Restlessness/Irritable/Assaultive Mydriasis Euphoria Nausea/Vomiting Weight Loss Grandiose/Increased Confidence Decreased Appetite/Sleep Insomnia Paranoia Dental Problems Delusions/Hallucinations Seizures (Auditory/Tactile/Visual) Cocaine/Crystal Meth May be smoked, snorted, orally ingested, injected or used on mucous membranes Smoking– effects within 30 seconds Injecting – effects within 1-2 minutes Snorting – effects within 3-5 minutes Crystal meth effects last usually 6-12 hours, and may last up to 24 hours Stimulants: Health Impacts Accidental Cardiac Events Overdose Psychosis/Paranoia MI Contaminated Supply Route Related Harms Mood Dysregulation IV related Snorting – nasal peforation Perforated Septum Perforated Palate  Stimulant Withdrawal “Crash” Fatigue Agitation/irritability Mood Swings Cravings Strong cravings Paranoia, anxiety, fatigue, sleep disturbances, suicidality, itching 66 Stimulant Withdrawal Supportive measures Symptoms Management Approach Paranoia Refer to medical care if client is very anxious, fearful, or worried that people are trying to kill them/Paranoia Suicidality Tobacco 18% of Canadians (4.9 million) 15yrs or older are current smokers. As high as 40-90% in special populations Average cigarettes smoked per day =15.0 Tobacco is the #1 cause of preventable death in Canada. Smoking cessation counseling is one of the most cost effective interventions a clinician can perform. 68 Hallucinogens Marijuana. - (THC, Cesamet) PCP  Mushrooms  Alter sensory perceptions and cause changes in thoughts and feelings Hallucinogens Examples: LSD Dextromethorphan MDMA (ecstasy, E, X, molly, love drug) Psilocybin (mushrooms, shrooms, magic mushrooms) Ketamine (K, special K, super C, green, cat valium) Mescaline (peyote, mesc, cactus, moon, buttons) Phencyclidine (PCP, angel dust, dust, peace pills, ozone, embalming fluid)  Variable response across persons Risk for first episode psychosis for Hallucinogens some Key Points Withdrawal effects are variable and often protracted but not a medical risk consideration Steroids Performance Enhancing Body Building This Photo by Unknown Author is licensed under CC BY-SA SBIRT Screening, Brief Intervention, Referral to Treatment SBIRT Screen all clients Screening Use a validated short tool Not a diagnosis It is a flag for need to further assess Brief Intervention Provide Info & Support Brief MI or Goal exploration Referral to Referral and connection to support Treatment Service Navigation Support Purpose of Screening Formal process of testing to identify whether an individual may have a mental health or substance use disorder that warrants a more comprehensive assessment including an assessment of suicidal ideation and behaviour. Means to quickly assess clients in all care settings Useful for baseline measurements (Health Canada, 2002) 75 Universal Screening Questions for Substance Use Disorders 1. Have you ever had any problems related to your use of alcohol or other substances? (Yes/no) 2. Has a relative, friend, doctor or other health worker been concerned about your drinking or other drug use or suggested cutting down? (Yes/no) 3. Have you ever said to another person "No, I don't have [an alcohol or drug] problem, when around the same time, you questioned yourself and FELT, "Maybe I do have a problem?" (Yes/no) Scoring: A positive response to any one question should indicate the need for further investigation using a validated assessment tool (Health Canada, 2002) 76 Screening- CAGE- AID C Have you ever felt that you need to cut down on your alcohol/substance use? Yes = 1 point No = 0 point A Have people Annoyed you by criticizing your alcohol or substance use? Yes = 1 point No = 0 point G Have you ever felt bad or Guilty about your alcohol or substance use? Yes = 1 point No = 0 point E Have you ever had a drink or used substances first thing in the morning Yes = 1 point to steady your nerves or to get rid of a hangover (Eye opener)? No = 0 point Interpretation: One or more "yes" responses is regarded as a positive screening test, indication possible substance use concer and need for further evaluation. MOTIVATIONAL GOAL OPEN DIALOGUE INTERVIEWING EXPLORATION Brief Intervention Referral to Treatment Supervised Central Access Co-ordinated Connex Ontario Consumption (intake) Access Sites All Substance Withdrawal Toronto wide Toronto Public Use services Management substance use Health 'The across Ontario Services services Works' 1-866-366-9513 1-855-505-5045 Parkdale Queen West CHC South Riverdale CHC  STAGES OF CHANGE MODEL 81 The Stages of Change  The transtheoretical model of change has been utilized to categorize behaviour change  It is a non-linear model  For every person the process of change is unique  Provides the clinician with an understanding of how to engage the client in dialogue that is appropriate for where the person is within the model’s framework  The clinician can then respond and work collaboratively with the individual (Prochaska and82 DiClemente, 1984) What stage is your client in? Important to make sure you and your client are working in the same stage of change Conflict in therapeutic relationships is sometime caused by therapist working on different goal than client Need to assess client’s readiness for change at each session 83 The Stages of Change Assessing and Listening for Readiness to Change - Ask: 1) Tell me about your substance use? 2) What concerns do you have about your use of substance X? Assessing and Listening for Precontemplation - Ask: 1) Tell me about a typical day, where does your substance use fit in? 2) What are the reasons that you take substance X? Assessing and Listening for Contemplation – Ask: 1) What are the pros and cons of substance use from your perspective? 2) Create a decisional balance sheet: “What do you like/hate about substance X?” Supporting the Person in Preparation - Consider: 1) Review decisional balance sheet: discuss medications, counseling options 2) Explore harm reduction strategies: review coping strategies 84DiClemente, 1984) (Prochaska and The Stages of Change Supporting the Person in Action - Consider: 1) Remember that change is a process not an event 2) Plan for slips and lapses Supporting the Person in Maintenance – Consider: 1) Review accomplishments and provide positive reinforcement 2) Talk about ongoing harm reduction strategies and barriers Relapse Prevention – Plan: 1) Safety planning: identify triggers and coping strategies, support systems, dealing with different levels of distress 2) Chain analysis after relapse 85 (Prochaska and DiClemente, 1984) 86