Substance Abuse: Symptoms, Treatment & Detoxification - PDF

Substance Abuse ​ Intoxication: the use of a substance that results in maladaptive behavior ​ Withdrawal: The negative reactions that occur when the use of a substance ceases or dramatically decreases CNS Depressants ​ Types of CNS Depressants: ○​ Alcohol ○​ Sedativ...

Substance Abuse ​ Intoxication: the use of a substance that results in maladaptive behavior ​ Withdrawal: The negative reactions that occur when the use of a substance ceases or dramatically decreases CNS Depressants ​ Types of CNS Depressants: ○​ Alcohol ○​ Sedatives ○​ Hypnotics ○​ Anxiolytics Alcohol ​ Signs of Intoxication: ○​ Relaxation and loss of inhibitions ○​ Slurred speech ○​ Unsteady gait ○​ Lack of coordination ○​ Impaired attention, concentration, memory, and judgement ○​ Aggression ○​ Inappropriate sexual behavior ○​ Blackout ​ Signs of Overdose: ○​ Unconsciousness ○​ Vomiting ○​ Respiratory depression ○​ Aspiration pneumonia ○​ Pulmonary obstruction ○​ Alcohol-induced hypotension ​ Leads to cardiovascular shock and death ​ Chronic Effects on the Body: ○​ Cardiac myopathy ​ Disease of the heart that inhibits perfusion ○​ Wernicke encephalopathy ​ Neurologic emergency that results from thiamine (B1) deficiency ○​ Korsakoff psychosis ​ Syndrome of confusion, loss of recent memory, and confabulation in alcoholics ​ Usually a complication of Wernicke encephalopathy  ○​ Pancreatitis ​ Amylase & Lipase labs will be elevated ○​ Esophagitis ○​ Hepatitis ​ Inflammation of the liver ○​ Cirrhosis ​ Scarring of the liver tissue ​ AST/ALT labs will be elevated ○​ Leukopenia ​ Low levels of WBC (leukocytes) in the blood ​ High susceptibility to infection ○​ Thrombocytopenia ​ Low levels of platelets in the blood ○​ Ascites​ ​ Build up of fluid in the abdomen ○​ Wernicke encephalopathy and Korsakoff’s psychosis are the most dangerous adverse effects ​ Withdrawal and Detoxification: ○​ Symptoms: ​ Hand tremors ​ Sweating ​ Elevated HR & BP ​ Insomnia ​ Anxiety ​ Nausea ​ Vomiting ○​ Severe symptoms: ​ Hallucinations ​ Delirium ​ Seizures ​ Seizure precautions include padding the side/head rails and setting up suction ○​ Withdrawal symptoms typically occur within 4-12 hours after their last drink of alcohol, peaks on the second day, and is usually over within 5 days ​ Withdrawal Treatment: ○​ Benzodiazepines ​ Suppress withdrawal symptoms ​ Lorazepam ​ Chlordiazepoxide ​ Diazepam  ○​ Disulfiram (Antabuse) ​ Administered to deter patients from drinking ​ Educate patient on not coming in contact with ANY alcohol ○​ Mouthwash, lotion, vanilla, vinegar, perfume, cough syrup, etc ​ If pt has taken this, and ingested alcohol, expect flushing, throbbing headache, diaphoresis, nausea, and vomiting Sedative/Hypnotics/Anxiolytics ​ Main examples of this include barbiturates and benzodiazepines ​ Effects, intoxication symptoms, and withdrawal symptoms resemble alcohol ​ Benzodiazepine O.D: ○​ Rarely fatal when taken orally, but cause lethargy and confusion ○​ Treatment: gastric lavage, activated charcoal, saline, and dialysis for severe cases ​ Barbiturates O.D: ○​ Coma, respiratory depression, cardiac failure, death ○​ Treatment is ICU admission, dialysis, or mechanical ventilation ​ Signs of Intoxication: ○​ Slurred speech ○​ Lack of coordination ○​ Unsteady gait ○​ Labile, unpredictable mood ○​ Impaired attention or memory ○​ Stupor (unconsciousness) ○​ Coma ​ If intoxication is suspected, immediately assess vital signs and respiratory status ​ Withdrawal and Detoxification: ○​ Remember to taper off barbiturates, NEVER abruptly stop ○​ The detoxification depends on the half-life of the medication ​ Always ask what medication & what time taken ○​ Short-acting drugs (i.e. Lorazepam) withdrawal symptoms within 6-8 hours ○​ Long-acting drugs (i.e. Diazepam) withdrawal symptoms may take up to a week ○​ Symptoms: ​ Increased heart rate ​ Hypertension ​ Increased respirations and temp ​ Hand tremor ​ Insomnia ​ Anxiety  ​ Nausea ​ Psychomotor agitation ○​ Severe symptoms: ​ Seizures ​ Hallucination Stimulants ​ Such as cocaine & methamphetamine ​ Methamphetamine abuse can cause psychotic behavior and brain damage ​ Signs of Intoxication: ○​ Typical Effects: ​ High or euphoric feeling ​ Hyperactivity ​ Hypervigilance ​ Talkativeness ​ Anxiety ​ Grandiosity (a sense of superiority) ​ Hallucinations ​ Stereotypic or repetitive behavior ​ Anger ​ Fighting ​ Impaired judgement ○​ Physiologic Effects: ​ Tachycardia ​ Hypertension ​ Dilated pupils ​ Perspiration ​ Chills ​ Nausea ​ Chest pain ​ Confusion ​ Cardiac dysrhythmias ​ Stimulant Overdose: ○​ Seizures ○​ Coma ○​ Death ​ Withdrawal and Detoxification: ○​ Dysphoria ○​ Fatigue ○​ Vivid and unpleasant dreams  ○​ Insomnia or hypersomnia ○​ Increased appetite ○​ Psychomotor retardation or agitation ○​ Suicidal ideation ​ There is no pharmacologic treatment for withdrawal or detox ​ Detoxing from stimulants is AKA crashing ​ Symptoms start within hours to days after stopping use Cannabis ​ Signs of Intoxication: ○​ Impaired motor coordination ○​ Inappropriate laughter ○​ Impaired judgement ○​ Short term memory ○​ Distortions of time & perception ○​ Anxiety, dysphoria, and social withdrawal ​ Physiological Effects: ○​ Increased appetite ○​ Conjunctival injection (bloodshot eyes) ○​ Dry mouth ○​ Hypotension ○​ Tachycardia ​ Excessive use of cannabis may produce delirium or cannabis induced psychotic disorder ○​ Both are treated symptomatically ​ Cannabis overdoses do not occur ​ 1 minute after inhalation, peaks about 20-30 minutes, and lasts for 2-3 hours ​ Withdrawal and Detoxification: ○​ Muscle aches ○​ Sweating ○​ Anxiety ○​ Tremors Opioids ​ Relieve physical and mental pain ​ Includes morphine, demerol, oxycodone, methadone, etc. ​ Synthetic fentanyl is way more potent ​ If symptoms of intoxication or withdrawal are present, obtain a drug screen immediately, and get a drug history, including the time taken and amount of last use ○​ Intoxication starts when the euphoria hits ​ Signs of Intoxication:  ○​ Symptoms: ​ Euphoria ​ Apathy ​ Lethargy ​ Listlessness ​ Impaired judgement ​ Psychomotor retardation or agitation ​ Constricted pupils ​ Drowsiness ​ Slurred speech ​ Impaired attention & memory ○​ Severe Symptoms: ​ Coma ​ Respiratory depression ​ Pupillary constriction ​ Unconsciousness ​ Death ​ Withdrawal and Detoxification: ○​ Anxiety ○​ Aching back and legs ○​ Nausea ○​ Vomiting ○​ Lacrimation ○​ Sweating ○​ Yawning ○​ Insomnia ○​ Restlessness ○​ Cravings for more opioids ○​ Dysphoria ○​ Rhinorrhea ○​ Diarrhea ○​ Fever ​ Short-acting opioids withdrawals happen within 6-24 hours, peak in 2-3 days, and subsides over 5-7 days ​ Long-acting opioids withdrawals start within 2-4 days, and takes up to 2 weeks to subside ​ Opioid cravings can last for 2-3 months ​ Opioid Intoxication Treatment: ○​ Naloxone (Narcan): ​ Opioid antagonist ​ Reverses all signs of opioid toxicity  ​ Every few hours until opioid levels drop to non-toxic ​ This process may take days depending on dosage, and stronger opioids may require extra doses ​ Synthetic opioids may require higher doses ○​ Methadone: ​ Can be used to reduce symptoms of withdrawal, or as a replacement for opioids ​ Dosage can be decreased to taper the patient off of opioids ​ Helps the patient to abstain from opiods (heroin) Hallucinogens ​ Examples of this include PCP & ecstasy ​ Intoxication and Overdose: ○​ Behavioral/Psychological Changes: ​ Anxiety ​ Depression ​ Paranoid ideation ​ Ideas of reference (certain things are directed at them) ​ Fear of losing one's mind ​ Potentially dangerous behaviors - like jumping out of a window with belief they can fly ○​ Physiological Symptoms: ​ Sweating ​ Tachycardia ​ Palpitations ​ Blurred vision ​ Tremors ​ Lack of coordination ○​ PCP intoxication includes: ​ Belligerence ​ Aggression ​ Impulsivity ​ Unpredictable behavior ○​ PCP toxicity includes: ​ Seizures (need medications to treat) ​ Hypertension (need medications to treat) ​ Hyperthermia (use cooling blankets to treat) ​ Respiratory depression (may require mechanical ventilation) ○​ Death occurs from the actions caused by hallucinations ​ Treatment:  ○​ Toxic reactions (except PCP) are psychological, overdose does not occur ○​ Drugs are not direct cause of death ○​ Isolate the patient from external stimuli ○​ Use restraints if required, to ensure safety for self and others ​ Withdrawal and Detoxification: ○​ Talk the patient down and reassure them that they’re safe ○​ There are no known withdrawal symptoms over than drug cravings ○​ Hallucinogens can cause flashbacks, that may last up to 5 years Inhalants ​ Ex: spray paint, gas, duster ​ Can cause brain damage and liver disease ​ Intoxication and Overdose: ○​ Intoxication Symptoms: ​ Dizziness ​ Nystagmus ​ Lack of coordination ​ Slurred speech ​ Unsteady gait ​ Tremor ​ Muscle weakness ​ Blurred vision ​ Stupor ​ Coma ○​ Behavioral Symptoms: ​ Belligerence ​ Aggression ​ Apathy ​ Impaired judgement ​ Inability to function ○​ Acute Toxicity: ​ Anoxia ​ Respiratory depression ​ Vagal stimulation ​ Dysrhythmias ​ Death related to: ​ Bronchospasm ​ Cardiac arrest ​ Suffocation ​ Aspiration of the compound or vomit  ○​ There are no medications for inhalant abuse ○​ To treat overdose: support respiratory and cardiac system ​ Withdrawal and Detoxification: ○​ No known withdrawal symptoms - though some report psychological cravings ○​ No detoxification procedures ○​ May experience inhalant-induced disorders such as: ​ Psychosis ​ Dementia ​ Anxiety ​ Mood disorders ○​ Treat inhalant-induced disorders symptomatically Overall Substance Abuse Treatments ​ 12-Step Programs: ○​ The ONLY requirement for membership is a desire to stop drinking/using ​ Remind the patient of this ​ Does not always have to be god-centered ​ Treatment Settings: ○​ Intoxication and withdrawal/detoxification can take place in the ER, outpatient clinics, or inpatient ​ Pharmacologic Treatments: ○​ Alcohol: ​ Vitamin B1 (Thiamine) ​ For Wernicke Encephalopathy ​ Benzodiazepines ​ For withdrawal treatment ​ Barbiturates ​ For Benzodiazepine resistant cases of alcohol withdrawal ​ Disulfiram (Antabuse) ​ To prohibit alcohol abuse in alcoholics ​ Educate the patient on using NO alcohol ○​ Opioids: ​ Methadone ​ To taper the patient off of heroin ​ Naloxone ​ Reversal agent for overdose ​ Buprenorphine ​ Can be given with naloxone ​ Sublingual ​ Clonidine (Catapres)  ​ Combats side effects of withdrawal ​ Naltrexone ​ Reduces opioid cravings ​ Usually a monthly injection Dual Diagnosis ​ Patient with a psychiatric illness who also abuses substance ​ There’s limited treatment success ​ Key elements to address: ○​ Require healthy, nurturing, and supportive living environments ○​ Need assistance with fundamental life changes (finding a job/other abstinent friends) ○​ Connections with other recovering people are helpful for recovery ○​ Require treatment of comorbid conditions ○​ Overall, the goal is to help the patient with support groups and to provide relapse prevention education Caring for Patients with Substance Use Problems ​ Denial & Rationalization ○​ Usually the 1st response ○​ Be sure to respond with therapeutic communication ​ Priority Steps: ○​ 1st: Detox ○​ 2nd: Based on physical needs (safety, nutrition, fluids, elimination, & sleep) ○​ ALWAYS remember therapeutic communication ○​ ALWAYS remember that the 1st step for working relationships with our patients, is to build rapport ​ CAGE Questionnaire Screening Tool: ○​ Used to assess the patients addiction, as well as their knowledge of their addiction ​ C: Have you ever felt you should Cut down on your drinking? ​ A: Have people Annoyed you by criticizing your drinking? ​ G: Have you ever felt bad or Guilty about your drinking? ​ E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye opener) ​ Assessment Data: ○​ History (trauma, treatment, etc) ○​ General appearance & motor behavior (tremors, cleanliness, etc) ○​ Mood & affect (restlessness, posture, etc) ○​ Thought process & content (what stage are they in in this process?) ○​ Sensorium & intellectual processes  ○​Judgement & insight (do they connect the consequences to the substance?) ○​Self-concept (how is their self-esteem?) ○​Roles & relationships (have they maintained relationships?) ○​Physiological considerations (nutrition, sleep, liver disease, HIV, or lung disorders? ​ Data Analysis & Priorities ○​ What makes your patient different? ○​ What puts your patient at risk? ​ Outcome Identification ○​ Goals: ​ Verbalizing addiction ​ Coping skills ​ Aftercare treatments ​ Actions: ○​ Providing health teaching for the patient & family ​ Educate family on addiction ​ Educate the patient on “all or nothing”, and that they can not “dabble” in their substances after recovery ​ Debunk false knowledge & myths about addiction ​ Discourage codependency or enabling from family ○​ Addressing family issues ​ Teach the importance on understanding relapse ○​ Promoting coping skills ​ Identify issues and how to solve them ​ Encourage safe distractions like hobbies, exercise, etc ​ Educate them to focus on the present and future, NOT the past ○​ Evaluation ​ Did they achieve complete abstinence? Substance Abuse in Health Professionals ​ It is our responsibility to report, regardless of relationship ​ General warning signs: ○​ Incorrect drug counts ○​ Excessive wastes ○​ Documented break-through medications ○​ Medication errors ○​ Patient reporting pain, especially after documented medications