Addiction & Substance Use Disorder PDF

Addiction & Substance Use Disorder Jessica Grinnell, MSN, RN, CEN [email protected]  Learning Outcomes 1. Compare and contrast the pathophysiology, clinical manifestations, and medical/nursing management of the client experiencing addiction and substance use disorder. 2. E...

Addiction & Substance Use Disorder Jessica Grinnell, MSN, RN, CEN [email protected]  Learning Outcomes 1. Compare and contrast the pathophysiology, clinical manifestations, and medical/nursing management of the client experiencing addiction and substance use disorder. 2. Examine risk factors associated with disorders of behavior (specifically above disorders) across the lifespan and the nursing care directed at reducing these risks. 3. Compare and contrast various diagnostics, medications, treatments and procedures, and the holistic assessment skills used to manage disorders involving behavior. 4. Apply the nursing process as a framework to provide age-appropriate, culturally sensitive care of the client experiencing disorders of behavior. 5. Examine common complications associated with addiction and substance use disorder. 6. Develop teaching strategies appropriate to the client with disorders of behavior. 7. Plan, prioritize, and implement evidenced based nursing care for clients with disorders of behavior using research and best practices. Pre-Class Reading Townsend Chapter (10th 23 edition) Adams Chapter 22 (6 th edition)  Substance Use Disorder Summary of Symptoms Psychoactive Associated with the Substances: A profile Syndromes of Summary Intoxication and Withdrawal Table 23-7 p. 411-412 Table 23-8, p. 413-414 Symptoms of use Symptoms of Therapeutic uses intoxication Symptoms of Symptoms of overdose withdrawal Substance Related Disorders Substance Use Addiction Disorders Intoxication Substance Withdrawal Induced Other disorders caused by Disorders substance use  DSM-5 Diagnostic Criteria for Addiction Use of the Excessive amount substance Attempts to cut of time spent trying Intense craving for interferes with down or control use to procure the the substance ability to fulfill role fail substance or obligations recover from its use The person Tolerance develops, Substance-specific engages in and the amount symptoms occur hazardous activities required to achieve upon when impaired by the desired effect discontinuation of the substance. increases. use (withdrawal). Statistics https://www.northpointwashington.com/blog/percentage-population-struggles-addiction-answer-may-su  Substance Induced Disorders Substance Intoxication Substance Withdrawal Reversible after using a Occurs when patient substance abruptly stops taking a Symptoms substance used regularly over a prolonged period Depends on substance used Substance-specific Directly effect CNS syndrome includes: Disrupt physical & Clinically significant psychological functioning physical signs and Impairs judgment, social, & symptoms Psychological changes, occupational functioning such as disturbances in thinking, feeling, and behavior.  Classes of Psychoactive Substances Sedatives, Hypnotics, Alcohol Caffeine Stimulants & Anxiolytics Hallucinoge Inhalants Opioids Cannabis ns Tobacco  Predisposing Factors Biological Factors Psychological Factors Genetics Developmental influences Apparent hereditary factor, Punitive superego particularly with alcoholism Fixation in oral stage of Biochemistry psychosexual development Changes in brain structure and Personality Factors brain neurochemistry occur in Certain personality traits the process of developing increase a tendency toward addiction addictive behavior Cognitive Factors Irrational thinking patterns are a problem central to addictions  Predisposing Factors Sociocultural Factors Social Learning Children & adolescents are more likely to use substances with parents who provide model for substance use Use of substances may also be promoted within peer group Conditioning Pleasurable effects from substance use act as a positive reinforcement for continued use of substance Cultural & Ethnic Influences Some cultures are more prone to substance abuse than others  Dual Diagnosis Patients may be assigned to a Cognitive & What is it? special program behavioral therapies that targets dual diagnosis A coexisting Program combines Help patients monitor substance and special therapies that moods & thought mental disorder target both patterns that lead to disorders/problems. substance abuse  Nursing Process: Assessment Identify s/s of Substance(s) intoxication & Frequency of use used withdrawal H&P Route of Physical status s/s of Amount used abuse administration Abuse & treatment history  Nursing Process: Assessment Impact on functioning Relationships Jobs Finances Self-respect Legal DUI Disorderly conduct Selling/using Emotional Responses  Nursing Process: Assessment Motivational Used for clients with any disorder interviewing Assessment Drug history and assessment Tools used to Clinical Institute Withdrawal Assessment determine of Alcohol Scale (CIWA) Michigan Alcoholism Screening Test extent of (MAST) addiction to CAGE Questionnaire substance  Nursing Process: Assessment The nurse must examine his or her feelings about working with a client who abuses substances. If behaviors are viewed by the nurse as morally wrong, it may be difficult to suppress judgmental feelings. Nurses must begin relationship development with a substance abuser by examining own attitudes and personal experiences with substances. Nursing Process: Outcome Criteria The Client: Has not experienced physical injury Has not caused harm to self or others Accepts responsibility for own behavior Acknowledges association between personal problems and use of substance(s) Demonstrates more adaptive coping mechanisms that can be used in stressful situations (instead of taking substances) Shows no signs or symptoms of infection or malnutrition Exhibits evidence of increased self-worth by attempting new projects without fear of failure and by demonstrating less defensive behavior toward others Verbalizes importance of abstaining from use of substances in order to maintain optimal wellness Nursing Process: Planning/Implementation Risk for injury Denial Ineffective coping Dysfunctional family processes  Nursing Process: Evaluation Has detoxification occurred without complications? Is the client still in denial? Does the client accept responsibility for their own behavior? Have they acknowledged a personal problem with substances? Has a correlation been made between personal problems & the use of substances? Has the client remained substance-free during treatment? Does the client cooperate with treatment? Does the client refrain from manipulative behavior and violation of limits? Is the client able to verbalize motivation toward alternative adaptive coping strategies to substitute for substance use? Has the use of the strategies been demonstrated? Does positive reinforcement encourage repetition of these adaptive behaviors? Has nutritional status been restored? Does the client consume diet adequate for their size & level of activity? Is the client able to discuss the importance of adequate nutrition? Has the client remained free of infection during hospitalization? Is the client able to verbalize the effects of substance abuse on the body?  The Chemically Impaired Nurse Approximately 10 percent of nurses Alcohol is the most suffer from widely abused chemical addiction drug, followed (same as the closely by general narcotics. population).  The Chemically Impaired Nurse: Recognition Clues for recognizing substance impairment in nurses Attendance at work Medication administration Employee characteristics Interpersonal relationships Personality traits Physical appearance Patient pain is not controlled  The Chemically Impaired Nurse: Repercussions State board response May deny, suspend, or revoke a license based on a report of chemical abuse by a nurse Diversionary laws allow impaired nurses to avoid disciplinary action by agreeing to seek treatment The Chemically Impaired Nurse: Suspension Period Successful completion of an inpatient, outpatient, group, or individual counseling treatment program Evidence of regular attendance at nurse support groups or 12- step program Random negative drug screens Employment or volunteer activities The Chemically Impaired Nurse: Peer Assistance Programs Regain Obtain Recognize their accountability necessary impairment within treatment profession  Codependency Dysfunctional Sacrifice their Boundaries relationships own needs blurred Feels Derives self- Commonly responsible for worth from denies that the happiness others problems exist of others  Codependency Releases anxiety in the form of stress-related illnesses, or compulsive behaviors, such as eating, spending, working, or use of substances May have experienced abuse or emotional neglect as a child Outwardly focused on others and know very little about how to direct their lives from their own sense of self  The Codependent Nurse: Classic Characteristics Poor Caretaking Perfectionism Denial communication Self-worth High risk for Need to be in comes from physical and control being needed emotional by others burnout  Treating Codependency: 4 Stages of Recovery Survival Stage Re-identification Stage Core issues Stage Reintegration Stage  Treatment Modalities: Alcoholics Anonymous A major self-help organization for the treatment of alcoholism Based on the concepts of: Peer support Acceptance Understanding from others who have experienced the same problem 12-step program provides specific guidelines on how to attain & maintain sobriety Sees total abstinence as the only cure The person can never safely return to social drinking.  Treatment Modalities for Substance-Related Disorders Support Groups Various groups structured like AA, but Counseling Group Therapy for other substances (ex: Narcotics Anonymous) Alcohol Use Disorder Standard Drink  Alcohol Intoxication Sedative & CNS depressant High doses can cause respiratory depression & death Blood Alcohol Level (BAL) Intoxication BAL is 0.10% to 0.20% Drunk driving limit is 0.08%  Alcohol Use Disorder: Patterns of Use 1 2 3 4 Phase I: Phase II: Phase III: Phase IV: Pre-alcoholic Early The Crucial The Chronic phase alcoholic phase phase phase  Effects of Alcohol on the Body Wernicke’s Peripheral Alcoholic Korsakoff’s encephalopat neuropathy myopathy psychosis hy Alcoholic cardiomyopat Esophagitis Gastritis hy Effects of Alcohol on the Body Pancreatitis Alcoholic Hepatitis Acute Caused by long-term heavy alcohol Usually occurs 1-2 days after a use binge Manifestations: Chronic Enlarged, tender liver Leads to pancreatic insufficiency N/V Lethargy Anorexia Elevated WBC count Fever Jaundice Ascites & Weight loss (severe cases)  Cirrhosis of the liver End-stage alcoholic liver disease Caused by chronic heavy Effects of alcohol use Widespread destruction of liver Alcohol on the cells that are replaced by fibrous (scar) tissue. Body Complications Portal hypertension Ascites Esophageal varices Hepatic encephalopathy  Leukopenia Thrombocytopenia Sexual Dysfunction Effects of Short-term Alcohol on the Enhanced libido Failure of erection Body Long-term Gynecomastia Sterility Impotence Decreased libido Alcohol and Pregnancy Alcohol use during pregnancy can result in fetal alcohol spectrum disorders (FASDs). Fetal alcohol syndrome (FAS) includes problems with learning, memory, attention span, communication, vision, and hearing. Alcohol-related neurodevelopmental disorder Alcohol-related birth defects Fetal Alcohol Syndrome Characteristics Abnormal facial features Small head size Shorter-than-average height Low body weight Poor coordination Hyperactive behavior Difficulty paying attention Poor memory Difficulty in school Learning difficulties Speech and language delays Intellectual disability Poor reasoning skills Sleep and sucking problems as a baby Vision or hearing problems Problems with the heart, kidneys, or bones Alcohol Withdrawal Can occur within 4-12 hours of Minor cessation of or reduction in heavy Withdrawal and prolonged alcohol use Agitation, anorexia, and Delirium hallucinations Tremens Typically occurs 48-72 hours after (DT’s) last drink. Alcohol Withdrawal: Nursing Care Administer Administer vitamins: Monitor fluid magnesium status Thiamine sulfate IV “banana bag” Administration Administration of Seizure of benzodiazepine Precautions anticonvulsants s  Medications for Alcoholism Disulfiram (Antabuse) Naltrexone (ReVia) Acamprosate (Campral) Selective serotonin reuptake inhibitors (SSRIs) Topiramate (Topamax) / Gabapentin (Neurontin) Milk Thistle for Alcohol Liver Damage (Adams Chapter 22, p. 297) Opioid Use Disorder Opioid Use Disorder A profile of the Patterns of use substance Opioids of natural Obtained by origin or derivatives prescription for relief Synthetic opiate-like of a medical problem drugs Use for recreational purposes and obtain by illegal sources Opioid Use Disorder: Effects on the Body CNS effects GI effects Cardiovascular effects Sexual functioning  Opioid Intoxication S/S Initially, euphora Apathy Dysphoira Psychomotor agitation or slowing Impaired judgment Severe intoxication  respiratory depression, coma, and death Usually lasts for several hours  Opioid Withdrawals Short-acting Long-acting Ultra-short drugs (i.e. drugs (i.e. acting heroin) methadone) meperidine Symptom onset Symptom onset Symptoms = 6-8 hours = 1-3 days begin quickly Peak within 1-3 Peak between Peak in 8-12 days 4-6 days hours Gradually Subside in 14- Subside in 4-5 subside in 5-10 21 days days days Opioid Withdrawal Symptoms Lacrimatio Muscle Dysphoria N/V n or aches rhinorrhea Pupillary Piloerectio Abdominal Sweating dilation n cramping Diarrhea Yawning Fever Insomnia  Treatment for Opioids Naloxone (Narcan) & nalmefene (Zurnai) Emergency overdoses Clonidine (Catapres) & lofexidine (Lucemyra) Treat withdrawal symptoms Short & Long-Term Medication Assisted Therapy (MAT) Buprenorphine (Subutex) Suppresses & reduces cravings for opioids Methadone (Methadone, Dolophine) Reduces opioid cravings & withdrawal & blunts or blocks the effects of opioids Naltrexone (Vivitrol) Sedatives, Hypnotics, & Anxiolytic Use Disorder  Sedative, Hypnotic, & Anxiolytic Use Disorder Varying degrees of CNS depression Highly addictive Causes dependence & withdrawal syndrome Barbiturates Non-barbiturate hypnotics Antianxiety agents Patterns of Use: Often used in combination or alcohol Synergistic with alcohol & overdose can occur Sedative, Hypnotic, & Anxiolytic Use Disorder Patterns of Use Effects on the Body Sleep & dreaming Respiratory depression Cardiovascular effects Renal function Hepatic effects Body temperature Sexual functioning  Sedative/Hypnotic-Induced Disorder Intoxication Withdrawal CNS depressant  Symptoms depend on the Disinhibition & half-life of the drug the pt aggressiveness  coma & is withdrawing from death Severe withdrawal from CNS depressants can be life-threatening Patients need to be tapered off these medications Stimulant Use Disorder Stimulant Use Disorder Profile of the substance Psychomotor stimulants induce stimulation by augmentation or potentiation of the neurotransmitters norepinephrine, epinephrine, or dopamine. General cellular stimulants (caffeine and nicotine) exert their action directly on cellular activity. Examples: Amphetamines Synthetic stimulants Non-amphetamine stimulants Cocaine  Stimulant Use Disorder Patterns of use CNS stimulant use is usually characterized by either episodic or chronic daily or near-daily use. Often, patients have a pattern of “uppers” and “downers” Effects on the body CNS effects Cardiovascular/pulmonary effects Gastrointestinal and renal effects Sexual function  Stimulant Intoxication Amphetamine and cocaine intoxication: S/S: Euphoria, impaired judgment, confusion, and changes in vital signs (even coma or death, depending on amount consumed). Caffeine intoxication usually occurs following consumption in excess of 250 mg. Restlessness and insomnia are the most common symptoms.  Stimulant Withdrawal Amphetamine and cocaine withdrawal may result in dysphoria, fatigue, sleep disturbances, and increased appetite. Withdrawal from caffeine may include headache, fatigue, drowsiness, irritability, muscle pain and stiffness, and nausea and vomiting. Withdrawal from nicotine may include dysphoria, anxiety, difficulty concentrating, irritability, restlessness, and increased appetite.  Treatment for Stimulants Intoxication: Minor tranquilizers Major tranquilizers Anticonvulsants Antidepressants Withdrawal is not the medical emergency we have with CNS depressants  Inhalant Use Disorder Aliphatic and aromatic hydrocarbons found in substances, such as fuels, solvents, adhesives, aerosol propellants, and paint thinners Historical aspects Use for altered consciousness or for religious rituals dates back to ancient times Patterns of use Huffing Bagging Inhaled through mouth or nose  Inhalant Use Disorder: Effects on the Body CNS effects Respiratory effects GI effects Renal system effects  Inhalant Intoxication Develops during or shortly after use of or exposure to volatile inhalants Symptoms: Dizziness, ataxia, muscle weakness Euphoria, excitation, disinhibition Nystagmus, blurred or double vision Slurred speech, lethargy Psychomotor retardation, hypoactive reflexes Stupor or coma  Hallucinogen Use Disorder Patterns of use of A profile of the Historical hallucinogens substance aspects is usually episodic Naturally Used throughout occurring history in many hallucinogens cultures for Synthetic religious and compounds mystical Patterns of use experiences, Use is usually including in episodic Aztec, Mexican Indian, and Hindu ceremonies  Hallucinogens: Effects on the Body Physiological Psychological Nausea/vomiting Heightened response to Chills color, sounds, body Pupil dilation Distorted vision Increased blood Sense of slowed time pressure, pulse Fear of control loss Loss of appetite Magnified feelings Insomnia Paranoia, panic Sweating, trembling Euphoria, peace Elevated blood sugar Depersonalization Decreased respirations Derealization Increased libido  Hallucinogen Intoxication Intoxication occurs during or shortly after using the drug. Symptoms include perceptual alteration, depersonalization, de-realization, tachycardia, and palpitations. Symptoms of phencyclidine (PCP) intoxication include belligerence and aggressiveness leading to assault and may proceed to seizures or coma. General effects of MDMA (Ecstasy) include increased heart rate, blood pressure, and body temperature; dehydration; confusion; insomnia; and paranoia.  Cannabis Use Disorder This Photo by Unknown Author is licensed under CC BY-SA A profile of the substance Marijuana Hashish Historical aspects Products of Cannabis sativa have been used therapeutically for nearly 5,000 years. Patterns of use 22.2 million Americans aged 12 years or older are current illicit users of marijuana. Represents almost 8.4 percent of population ages 12 years and older As of November 2023  Cannabis: Effects on the body Cardiovascul Respiratory Reproductive ar Sexual CNS functioning  Cannabis: Intoxication S/S: Impaired motor coordination Euphoria Anxiety Sensation of slowed time Impaired judgment Conjunctival injection Increased appetite Dry mouth Tachycardia Impairment of motor skills lasts for 8-12 hours  Cannabis Withdrawal Starts within a week following cessation of use Symptoms: Irritability, anger, or aggression Nervousness, restlessness, or anxiety Sleep difficulty (e.g., insomnia, disturbing dreams) Decreased appetite or weight loss Depressed mood Physical symptoms, such as abdominal pain, tremors, sweating, fever, chills, or headache  Treatment for Hallucinogens & Cannabinols Benzodiazepin Antipsychotics es Nicotine Generally Effects last considered a 30 min – CNS hours stimulant  Nicotine: Effects on the Body Increased Light Relaxation Increased HR alertness headedness Increased Blood Increased Increased risk of Reduces Pressure metabolism heart attack appetite Chronic lung Convulsions Muscle tremors infections/diseas with high doses es Nicotine Withdrawal & Treatment Withdrawal Treatment Agitation Patches/Gum Weight gain Bupropion (Zyban) Anxiety Varenicline (Chantix) Headache Extreme Cravings Britton’s Rx Awareness Story Thank you! Any Questions? References  Adams, M. P., Holland, N., & Urban, C. Q. (2019). Pharmacology for nurses: A pathophysiologic approach (6th ed.). Pearson.  Addiction Policy Forum (2022). DSM-5 criteria for addiction simplified. Retrieved September 20, 2024, from https://www.addictionpolicy.org/post/dsm-5-facts-and-figures  American Society of Addiction Medicine. (2019). Definition of addiction. Retrieved September 20, 2024, from https://www.asam.org/quality-care/definition-of-addictionNational Institute of Mental Health. (2024). Substance use and co-occurring mental disorders. National Institute of Health. Retrieved September 20, 2024, from https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health  Goldblatt, M. J., Herbstman, B., & Maltsberger, J. T. (2014). Superego distortions and self-attack. The Scandinavian Psychoanalytic Review, 37(1), 15 – 23. Retrieved September 24, 2024, from , http://dx.doi.org/10.1080/01062301.2014.891797  Hasin, D. S., O’Brien, C. P., Auriacombe, M., Borges, G., Bucholz, K., Budney, A., Compton, W. M., Crowley, T., Ling, W., Petry, N. M., Schuckit, N., & Grant, B. F. (2013). DSM-5 criteria for substance use disorders: recommendations and rationale. American Journal of Psychiatry, 170(8), 834 – 851. Retrieved September 22, 2024, from https://doi.org/10.1176/appi.ajp.2013.12060782  Lehigh University. (n.d.). What is a standard drink? [Image]. Retrieved September 22, 2024, from https://studentaffairs.lehigh.edu/content/what-standard-drink  Morgan, K. I., & Townsend, M. C. (2021). Davis advantage for psychiatric mental health nursing (10th ed.). F. A. Davis.  National Center for Drug Abuse Statistics. (2023). Drug use among youth: Facts & statistics. Retrieved September 20, 2024, from https://drugabusestatistics.org/teen-drug-use/  National Institute on Drug Abuse. (2023). Medications for opioid overdose, withdrawal, & addiction [Infographic]. National Institute of Health. Retrieved September 24, 2024, from https://nida.nih.gov/research-topics/opioids/medications-opioid-overdose-withdrawal-addiction-infographic  Northpoint Washington. (2017). Statistics on substance abuse [Image]. Retrieved September 20, 2024, from https://www.northpointwashington.com/blog/percentage-population-struggles-addiction-answer-may-surprise/  Procon.org. (2023). Legal medical & recreational marijuana states [Image]. Retrieved September 25, 2024, from https://marijuana.procon.org/legal-recreational-marijuana-states-and-dc/  Singhal, N. (2024). Stigma, prejudice and discrimination against people with mental illness. American Psychiatric Association. Retrieved September 24, 2024, from https://www.psychiatry.org/patients-families/stigma-and-discrimination  Torrise, B. (2024). What is a substance use disorder? American Psychiatric Association. Retrieved September 21, 2024, from https://www.psychiatry.org/patients-families/addiction-substance-use-disorders/what-is-a-substance-use-disorder  U.S. Food and Drug Administration. (2024). FDA approves first nalmefene hydrochloride auto-injector to reverse opioid overdose [News Release]. Retrieved September 24, 2024, from https://www.fda.gov/news-events/press-announcements/fda-approves-first-nalmefene-hydrochloride-auto-injector-reverse-opioid-overdose