Substance Use Disorder PDF

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. Examine Explain Concurrent disorders treatment a...

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. Examine Explain Concurrent disorders treatment approaches for persons with co-occuring mental health conditions and substance use 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 partners to: • Reduce negative health, social, and https://harmreductionto.ca/what-is-harm-reduction economic consequences related to substance use • Promote public health, human rights, and social justice. • Promotes equity, inclusion, dignity, selfdetermination, and respect. https://ohrn.org/about-us/ Harm Reduction Theory 14 Opioid Crisis/A View from the Frontlines Michael Kumako https://youtu.be/zleONA ORmYI 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 1. Use gives immediate positive effects 2. Effects lessen with repeated use, leading to increased use 3. Attempts to stop use results in negative effects Shorter intervals between doses Baseline Increased dose Positive Effects of Experience First use Process of Developing a Substance Use Disorder - Negative Aspects of Experience PHYSICALLY ILL UNABLE TO MAINTAIN ROLE/FUNCTION LEGAL CONSEQUENCES Physiological/Psychological States Intoxication The direct and immediate Physiological/Psychological effects of taking substance(s) Tolerance A need for markedly increased amounts of substance to achieve intoxication or desired effect. A markedly diminished effect with continued use of the same amount of a substance. Effects vary by type, quantity and route of substance use Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision. Withdrawal Occurs when reducing or stopping substance. Withdrawal symptom parameters often are opposite to the induced effects of the substances The withdrawal parameters are specific and characteristic of the substance taken. Substance Use & Disorder Substance Use Substance Use disorder • The ingestion or administration of psychoactive substances that can be beneficial or harmful depending on the substance used and the quantity, frequency, method, and context of use • DSM–5, identified as “a cluster of • (Ministry of Health Promotion, 2010; Rassool, 2010). • cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems and harms” Patterns of behavior include impaired control, social impairment, risky use, and pharmacological criteria 22 DSM5 Substance Use & SUD Categorization DSM 5 Disorders Substance Use Disorders Substance Induced Disorders 10 Substances Intoxication Spectrum of severity: * Mild * Moderate * Severe Withdrawal 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. ▪ ▪ ▪ Important social, occupational, or recreational activities are given up or reduced because of use. ▪ ▪ Tolerance 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 . 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. Withdrawal Spectrum of Severity Mild Moderate Severe 2-3 symptoms 4-5 symptoms 6+ Symptoms Contributing Factors Internal Risk Factors 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 Opioids Substances that engage opioid receptors (“Pain killers” – such as narcotic pain meds or heroin. Prescription Narcotic Pain Medications • Morphine, Percocet, oxycontin, Dilaudid, Codeine • Swallow pills, crush, inject, snorted Fentanyl, Car-fentanyl • Much more potent, longer duration of action • Fentanyl 80-100 times than morphine • Carfentanil 10 000 times more than morphine • Highly contaminated street supply • 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. Opioid Effects Sedation, drowsiness (intoxication) Slowed breathing If not rousable, trouble breathing, blue lips/fingernails, call 911 and administer Naloxone Decreased level of consciousness Feelings of calmness/pleasure Slurred/slowed speech Sensation of heavy limbs Overdose Prevention Carry Naloxone Use with Others Test Dose First Muscle Aches/Pain Opioid Withdrawal Effects “Flu-like” Cold Sweats/Chills Stomach cramping/Diarrhea/Vomiting/Nausea Tearing/Runny Nose Agitation/Anxiety Yawning Increased Heart Rate/BP 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 Opioid Withdrawal Symptom Management Approach Over the counter medications in response to symptoms: Gravol for nausea Rest, fluids, warm shower, supportive measures Imodium for stomach upset RX medications based on severity of symptoms/anticipated more severe withdrawal suboxone (buprenorphine) in small doses to mitigate/prevent severity of withdrawal course. Clonidine Supportive counselling Partial opiate that relieves opiate withdrawal symptoms for full 24 hours Buprenorphine + Naloxone (Suboxone) Often combined with naloxone (to discourage people from injecting) 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 Overdose Risk Escalating Tolerance & Withdrawal Pain related Syndromes Constipation **non-bulk forming laxatives!!** No Metamucil/high fibre Recommend laxaday/PEG Withdrawal related miscarriage risk during Pregnancy **Do not stop cold turkey if pregnant** refer to specialist Intravenous route related risk for Hep C, HIV exposure, skin infections/abscesses Medication Options for Opioid use Disorder Pharmacotherapeutic Options Opioid Agonist Therapy (OAT) Suboxone Methadone dissolving tablet ‘Partial agonist 24 hrs coverage ‘Orange” drink 24hr coverage Full agonist Injectable OAT Injectable hydromorphone Safe Opioid Supply (SOS) Kadian Dilaudid Label Me Person Lived Experience – Stephanie Bertrand https://youtu.be/OhFOiLZXKE 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 341mL(5%alc) = (12%alc) 43mL(40% alc) = 83mL https://www.camh.ca/-/media/files/canadas-low-riskguidelines-pdf.pdf 15 drinks a week for biologically male bodies, with no more than 3 drinks a day most days Problematic Drinking Versus Alcohol Dependence Objective Measures Problematic Drinking Alcohol Dependence Number of Drinks/Week Male – More than 14 Female – More than 9 More than 40-60 per week Drinks Moderately (Fewer than 4/Day) Often Rarely Tolerance Mild Marked Withdrawal Symptoms No Often Neglect of Major Responsibilities No Yes 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 Alcohol Withdrawal Tremor 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 -Nausea/Vomiting -Coarse Tremor -Sweating -Tachycardia -Hypertension Autonomic Hyperactivity: Seizures Dysrhythmias (Atrial Fibrillation, Supraventricular, Ventricular Tachycardia) Hallucinations (Auditory/Visual) Delirium Tremens: Severe agitation, gross tremulousness, global confusion,disorientation, auditory, tactile,visual hallucinations, psychomotor & autonomic hyperactivity (hypertension, fever…etc.) Symptoms tend to appear within 6-12 hours of last drink Withdrawal Seizures usually occur between 12-72 hours after drinking has stopped Typically occur 5-6 days after severe, untreated withdrawal Symptoms usually resolve within 48-72 hours Seizure Protocol: 20mg Valium q1hr x 3 doses min Sudden death can occur 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 (Revia) – anti-craving Acamprosate (Campral) anti-craving Disulfiram (Antabuse) Deterant Alcohol: Health Impacts Liver Impacts: Cirrhosis Escalating Tolerance & Withdrawal Cognitive Impacts, Wernicke Korsakoffs Throat and Stomach Related Impacts: Esophageal Varices , Reflux Injuries MVA, Cardiac Impacts Concurrent Anxiety, Depression 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) Indications for Benzodiazepines - Mood Disorders (Depression) - 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 o 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 Often Benzos found in fentanyl Xanax is long acting more potent benzo that has higher likelihood of severe withdrawal. 56 Benzodiazepine Withdrawal considerations Slow Taper Preferred 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 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 system activity Stimulants “Uppers” • Effects: Wakefulness, euphoria, decreased appetite, aggression, rapid heart rate, elevated body temperature, agitation, paranoia, delusions, hallucinations • 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) Examples: • Cocaine/Crack Cocaine • Methamphetamine (crystal, crystal meth, meth, ice, crank, glass, chalk). • Psychoactive bath salts Stimulants – Indicators of Stimulant Use BEHAVIORAL PHYSIOLOGICAL Using BZDs/opioids/alcohol (depressants) to ’come down’ off stimulants Increased BP/HR/Temp 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 (Auditory/Tactile/Visual) Seizures 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 Cardiac Events MI Accidental Overdose Contaminated Supply Mood Dysregulation Psychosis/Paranoia Route Related Harms • 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 Symptoms Management Approach Supportive measures 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) Hallucinogens Key Points • Variable response across persons • Risk for first episode psychosis for some • 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 Screening Brief Intervention Referral to Treatment • • • • Screen all clients Use a validated short tool Not a diagnosis It is a flag for need to further assess • Provide Info & Support • Brief MI or Goal exploration • Referral and connection to support • 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 Yes = 1 point No = 0 point ever had a drink or used substances first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? Interpretation: One or more "yes" responses is regarded as a positive screening test, indication possible substance use concer and need for further evaluation. MOTIVATIONAL INTERVIEWING GOAL EXPLORATION Brief Intervention OPEN DIALOGUE Referral to Treatment Connex Ontario • All Substance Use services across Ontario Central Access (intake) • Withdrawal Management Services • 1-866-366-9513 Co-ordinated Access • Toronto wide substance use services • 1-855-505-5045 Supervised Consumption Sites • Toronto Public Health 'The Works' • 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 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 (Prochaska and 84DiClemente, 1984) 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 (Prochaska and DiClemente, 1984) 85