Week 13 MHD Substance Related Addictive Disorders 2024-2025 Student PDF

SUBSTANCE-RELATED AND ADDICTIVE DISORDERS NURS 1028 Chapter 26 1  ADDICTION Addiction, a chronic, relapsing, and treatable medical condition, is the leading preventable cause of death, disability, and disease globally. It is a d...

SUBSTANCE-RELATED AND ADDICTIVE DISORDERS NURS 1028 Chapter 26 1  ADDICTION Addiction, a chronic, relapsing, and treatable medical condition, is the leading preventable cause of death, disability, and disease globally. It is a disease of the brain and not an expression of moral character. Like other chronic diseases, addiction often involves cycles of relapse and remission. Addiction, substance disorder or dependency interchangeable. Misuse is use of any illegal drug or legal drug for purposes other than which it was intended, or in excess such as alcohol beyond legal limit. Individuals affected with addiction are often alienated and isolated from both their family and communities. Substances, when taken in excess, have in common the direct activation of the brain reward system (i.e., pleasurable effect). Stimulation of the reward pathway occurs in part through increasing extracellular dopamine concentrations in the limbic regions. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. 2  DSM-5 DIAGNOSIS CRITERIA Disorders related to taking of substances of abuse and includes two categories: SUDs and substance-induced disorders (substance intoxication, substance withdrawal, and other substance/medication-induced mental disorders). 1. Substance-Use Disorders (SUD) The diagnosis of SUD is substance specific (e.g., alcohol, opioid, or tobacco use disorder). It is based on a pathologic pattern of 11 behaviours grouped into: Impaired control Social impairment Risky use Pharmacologic categories Occurs in a range of severity from mild to severe: Mild: The presence of two or three symptoms Moderate: Presence of four to five symptoms Severe: Presence of six or more symptoms Changes in severity may be observed across time 3  OPIOID USE DISORDER CRITERIA A minimum of 2-3 criteria is required for a mild substance use disorder diagnosis, while 4-5 is moderate, and 6-7 is severe (APA, 2013). Opioid Use Disorder is specified instead of Substance Use Disorder, if opioids are the drug of abuse. Note: A printable checklist version is linked below 1. Taking the opioid in larger amounts and for longer than intended 2. Wanting to cut down or quit but not being able to do it 3. Spending a lot of time obtaining the opioid 4. Craving or a strong desire to use opioids 5. Repeatedly unable to carry out major obligations at work, school, or home due to opioid use 6. Continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use 7. Stopping or reducing important social, occupational, or recreational activities due to opioid use 8. Recurrent use of opioids in physically hazardous situations 9. Consistent use of opioids despite acknowledgment of persistent or recurrent physical or psychological difficulties from using opioids 10.*Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount. (Does not apply for diminished effect when used appropriately under medical supervision) 11.*Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal (Does not apply when used appropriately under medical supervision) 4  DSM-5 DIAGNOSIS CRITERIA 2. Substance-Induced Disorders Substance Intoxication: Development of a reversible substance-specific syndrome due to the recent ingestion of (or exposure to) a substance. The maladaptive behaviours associated with intoxication (e.g., belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) are due to the direct physiologic effects of the substance on the central nervous system. Significant risk for adverse effects (e.g., accidents, general medical complications, disruption in social and family relationships, vocational or financial difficulties, and legal problems). Substance Withdrawal: Development of a substance-specific maladaptive behavioural change that is due to the cessation, or reduction, of heavy and prolonged substance use. May cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, and as a result, most individuals will experience craving to readminister the substance to reduce the discomforting symptoms. 5  NON-SUBSTA NCE -RELATED DISORDE RS Ranges of other repetitive behaviours have been postulated to form part of the addiction-related disorder spectrum: Gambling disorder Not yet recognized by DSM-5: Internet gaming addiction Sex addiction Exercise addiction This Photo by Unknown Author is licensed under CC Shopping addiction BY-SA Praill (2017) states, “The World Health Organization (WHO) will confirm what parents have been saying for years – excessive time spent playing video games is a real problem. WHO plans to make obsessive video game playing a mental health disorder in 2018” (para. 1). 6  ETIOLOGY Biological Theory Physical Environmental Stressors Example: Sleep deprivation and toxic work conditions Genetics Prenatal and postnatal stress (potential to change genetic expression) Addicted Neonate (drugs) Fetal Alcohol Spectrum Disorder Increased Levels of Dopamine Reward system by sending signals to the limbic system Gender (male = female) 7  ETIOLOGY Biological Theory Physical Environmental Stressors Example: Sleep deprivation and toxic work conditions Genetics Prenatal and postnatal stress (potential to change genetic expression) Addicted Neonate (drugs) Fetal Alcohol Spectrum Disorder (FAS) Increased Levels of Dopamine FAS Features: Small eyes, Reward system by sending signals to the exceptionally thin upper lip, a limbic system short upturned nose, and a Gender (male = female) smooth skin surface between the nose and upper lip 8  ETIOLOGY Psychological Theory Social Theory Mental Health Disorders Peer Influences Unstable Home and Family Age = young exposure Life/Conflict Geographical Disrupted care during infancy Access and availability to and adverse childhood substances experiences Income Trauma/ Abuse (i.e., physical, emotional and Ability to pay for sexual) substances 9  INTE RDIS CI PLI NA RY TREATMENT Purpose: The adaptation in the brain that results from chronic substance exposure is long lasting; therefore, addiction interventions must also reflect its chronic (and relapsing) nature. No single treatment is appropriate for everyone. Treatment varies depending on the type of addiction and the characteristics of the clients. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society. Addiction Treatment Programs Goals Stabilizing the client’s condition Altering the course of the substance-related disorder as well as the client’s overall functioning Improving the client’s quality of life…but clients have to be emotionally ready Improving all areas of life affected by addiction (e.g., employment, interpersonal relationships, interface with the law/criminal justice system, physical health) Improving all levels of adaptive functioning Preventing relapse to substance use Multimodal Treatment Education: Addiction is a bona fide disease including its causes, consequences, approaches to, and the options for, interdisciplinary treatment. Harm Reduction: May be an interim step toward abstinence. Therapeutic Alliance: “Helping alliance” between the nurse and the patient is a key ingredient for treatment success. 10  HARM REDUCTION Set of practical strategies and ideas aimed at reducing negative consequences associated with drug use and move towards abstinence. Harm reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs. Examples for Drug Addiction: SAFE NEEDLE AND SYRINGE EXCHANGE PROGRAMS NAXOLONE (NARCAN) PROGRAMS Examples for Alcohol Addiction: HANDING OFF KEYS AND PHONES TO LOVED ONES WHEN DRINKING ARRANGING RIDES IN ADVANCE TO AVOID DRIVING INTOXICATED LOGGING OUT OF PUBLIC SOCIAL MEDIA ACCOUNTS BEFORE DRINKING 11  THERAPEUTIC ALLIANCE This therapeutic alliance ideally builds a foundation of empathy, mutual respect, and trust; provides hope for recovery; and begins at the very first meeting with the patient. Nurses should aim to establish rapport and create a positive alliance with the In order to establish a therapeutic alliance, the nurse should aim to minimize or avoid premature and inappropriate confrontations, judgment, negative interactions, advice without permission, and other approaches not congruent with motivation-based techniques. Potential of negative bias and stereotyping of people, perhaps stemming from their own particular background, psychodynamics, or their own losses or experiences with addiction. For the ethical professional, it is important to make the effort of processing any unresolved conflicts and losses in her/his own life and to successfully work through any related issues. 12  INTE RDIS CI PLI NA RY TREATMENT Principles of Matching Treatment: Clients are matched to the most appropriate level of care based on availability along with the assessment of their condition and comorbidities and with respect to the individuals’ preferences. Outpatient Services Partial Hospitalizations Low-Intensity Residential Services Medically Managed Intensive Inpatient Services Screening: used to identify patients who are likely to have an SUD as determined by their responses to certain key questions. CAGE Questionnaire: 1. Have you ever felt you needed to Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt Guilty about drinking? 4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover? Brief Intervention: Time-limited (i.e., 5 to 20 minutes), client-centred counselling designed to reduce substance use. There is good evidence, for example, that patients who do not meet the diagnostic criteria for alcohol use disorders but are exceeding safe drinking limits can be supported and helped through brief intervention. Referral: Based on screening results and data collected through counselling (assessment and documenting all forms of substance use, willingness to quit, and risk related to continued use) helps health care professionals decide if an individual should be admitted or referred to other community services in the course of their treatment plan. 13  CLASSES OF SUBSTANCES Frequency of drinking alcohol increases with age, income, and education just as smoking and illicit drug use decreases across these variables. Alcohol is second only to tobacco in its prevalence of addiction in Canada. Alcohol Wine – Beer – Hard Liquor Tobacco Nicotine Caffeine Coffee – tea – soft drinks Cannabis Legalized and regulated in Canada Marijuana (MJ) Hallucinogens Magic Mushrooms – Ketamine (Special K) – Bath Salts LSD (Acid) – PCP (Angel Dust) 14  CLASSES OF SUBSTANCES Inhalants Substances that are considered legal and inexpensive. These drugs are popular among teens because they are cheap and legal. Glue – paint – nitrous oxide Opioids Heroin – Codeine – Fentanyl Sedative, Hypnotic, and Anxiolytic Benzodiazepines (Anti-anxiety): Diazepam (Valium) Alprazolam (Xanax) – Lorazepam (Ativan) Barbiturates: Phenobarbital Antidepressant: Celelxa – Prozac – Paxil – Zoloft Stimulants Amphetamines – Cocaine – Adderall 15  WHAT I S THE IMAGE OF THE ELEPHANT FOR? Carfentanil is an opioid NOT for humans!!! It is used by veterinarians for very large animals like elephants. It is not for human use. It is approximately 100 times more toxic than fentanyl and 10,000 times more toxic than morphine. This means carfentanil can be deadly in extremely small amounts. 16  NURSING ASSESS MENT Obtain history from client and support persons. Assess for level of motivation for treatment (can improve treatment engagement). Identify reason for admission: Readiness for change Denial, not ready for change and an indication of guilt Identify the type of substance the person has been using, the amount, frequency, method of administration and the length of time the substance has been abused. Note of any suicidal ideation or interest, with drained symptoms. A baseline physical and emotional nursing assessment is done to determine admission status and provide baseline from which to determine progress towards an expected outcome. An individual’s treatment and services plan must be assessed continually and modified as necessary, to ensure that it meets his or her changing needs. Assessment phase helps begin to build a trusting nurse-client relationship. 17  NURSING ASSESS MENT CAGE Screening Tests 0 or 1 = Low risk for drinking 2 or 3 = High suspicion of alcoholism 4 = Diagnosis for alcoholism Canada’s Low-Risk Alcohol Drinking Guidelines Reduction of long-term health risks can be achieved by drinking no more than: 10 drinks a week for women, with no more than 2 drinks a day most days 15 drinks a week for men, with no more than 3 drinks a day most days Drug Abuse Screening Tool (DAST) Uses of 10 Questions Example Question: Have you neglected your family because of your use of drugs? Score of > 6/10 = Intensive Assessment and referral 18  OBJECTIVE DATA Jaundice Needle tracks Tremors Cellulitis Peripheral neuropathy Rapid weight loss Hypertension Changes in pupil size Tachycardia Confusion Nausea and vomiting Smell of drugs on Upper abdominal pain person and clothing 19  LAB DIAGNOSTICS Blood Alcohol Concentration: BAC is.0.05%, that means 50 milligrams of alcohol in 100 millitres of blood. Liver Function Tests (GGT) and (AST): Alcohol, medications and cirrhosis Gamma-Glutamyl Transferase (GGT) : Detect liver disease Aspartate Aminotransferase (AST): Detect liver damage Mean Corpuscular Volume (MCV): Anemia due to persistent drinking Uric Acid: Alcohol dehydrates and therefore kidneys and excrete alcohol instead of uric acid. Triglycerides: Alcohol is high in calories and sugar and has a particularly potent effect on triglycerides. Urea: Urea synthesis is an essential metabolic liver function that plays a key regulatory role in nitrogen homeostasis, nitrogen is a building block that make up the proteins in your hair, muscles, skin and other important tissues. Urine Drug Screens: Marijuana (THC), Cocaine (COC), Opiates (OPI), Amphetamines (AMP), Phencyclidine (Angel Dust), MDMA (Ecstasy). 20  MANAGEMENT OF INTOX ICATION AND WI THDRAWAL Intoxication: The result of being under the influence of, and responding to, the acute effects of alcohol and/or other substances of abuse. Symptoms vary from one individual to another and vary from one substance to another. Symptoms: Inappropriate behaviour; actions; impaired judgement; liability of mood; impaired social and/or work-related function. Detoxification: A process under the care of a health provider, individuals are systematically withdrawn from addictive substances in either an inpatient or outpatient setting. Helps protects the client’s dignity and prepare the client for ongoing treatment their SUD. Give enough of the abused substance to alleviate withdrawal symptoms. Gradually the substance is decreased over a period of days. Important to recognize that detoxification is not the treatment of the SUD. It is only the management of withdrawal symptoms. 21  WITHDRAWAL SYM PTOMS FROM ALCOHOL Determine AWS Stage Stage I: Hyperactivity Stage II: Hallucinations and seizure activity Stage III: DTs, confusion, fever and anxiety Withdrawal begins within Symptoms of AWS hours of abstinence or Seizures decreased alcohol consumption Hypertension, tachycardia, diaphoresis May last 4-5 days Increased hand tremor Treatment Ativan, Serax, anti- seizure medications (to Insomnia alleviate symptoms of Agitation withdrawal) DT (delirium tremens) Vitamin B1, Folic Acid, B12 supplements 22  WITHDRAWAL SYMPTOMS FROM OPIOIDS Tearing Withdrawal begins in 4-6 hrs. (e.g., heroin) – lasts 5 days Rhinorrhea Buprenorphine more potent (25 - 40 Yawning times) and longer lasting analgesic than morphine) withdrawal 1-3 days Irritability and can lasts weeks Pain Catapres (clonidine) is the Loss of appetite medication of choice for treatment of opioid use withdrawal Confusion Note. Monitor for orthostatic hypotension 23 WIT H D RAWAL SYMPTO MS F R OM C N S D EPR ESSAN T S Insomnia Lasts 3 to 7 days for short- Increased anxiety acting (hypnotics used for sleep) drugs (e.g., Increased temperature, benzodiazepines) pulse, respirations 3 to 6 months for long- Fine tremors acting (sedatives used for GI upset anxiety) drugs (e.g., Muscle aches phenobarbital) 24  NURSING DIA GNOS IS Risk for injury related to hallucinations, acute Intoxication evidenced by confusion, disorientation, inability to identify potentially harmful situations. Altered health maintenance related to inability to identify, manage or seek out help to maintain health, evidenced by various physical symptoms, exhaustion, sleep disturbances, Ineffective denial related to weak, under-developed ego, evidenced by lack of insight, rationalization of problems, blaming others, failure to accept responsibility for his behaviour. Ineffective individual coping related to impairment of adaptive behaviour and problem-solving abilities, evidenced by use of substances as coping mechanisms. Acute confusion related to exhaustion Anxiety related to physical symptoms Dysfunctional family process related to lack of insight Risk for suicide related to withdrawal symptoms Knowledge deficit related to failure to accept responsibility for behaviour 25  NURSING I NTERVENTIONS DURING A CUTE INTOXI CATION Type Substance Use Class To determine which substance client is abusing, assess the signs and symptoms vary with the substance and dosage. Acute Phase Intoxication and Detoxification Maintaining the client’s vital functions, ensuring their safety, and easing discomfort. Rehabilitation Caregiver help the client acknowledge their substance abuse problem and find alternative ways to cope with stress and help the client to achieve recovery and stay free of substance use. 26  NURSING I NTERVENTIONS DURING A CUTE INTOXI CATION Continuously monitor the client's vital signs and urine output. Watch for complications of overdose and withdrawal. Maintain a safe and quiet environment. Take appropriate measures to prevent suicide attempts and assaults. Remove harmful objects from the room, and use restraints only if you suspect the client might harm himself or others. Approach the client in a non - threatening way; limit sustained eye contact, which they may perceive it as threatening. Institute seizure precautions. Administer IV fluids to increase circulatory volume. Give medications as ordered (e.g., Ativan or Haldol). Monitor and record the clients effectiveness. 27  NURSING INTERVENTIONS DURING WITHDRAWAL Administer medications as ordered, to decrease withdrawal symptoms, monitor and record their effectiveness. Maintain a quiet and safe environment, because excessive noise may agitate the client. 28  N U R SI NG I NT ERV EN TI O NS P OST W IT H D R AWAL Carefully monitor and promote adequate nutrition. Administer drugs carefully to prevent hoarding. Check the client’s mouth to ensure that he has swallowed oral medication. Closely monitor visitors who might supply the client with drugs/alcohol. Refer the client for rehabilitation as appropriate; provide a list of available resources. Encourage family members to seek help regardless of whether the client seeks it. Develop personal self awareness and an understanding and positive attitude towards the client. Control reactions to the behaviours, commonly associated during psychological dependence (i.e., manipulation, anger, frustration, and alienation). Motivation = Readiness (Does it remain after withdrawal as it did before?) Set limits when dealing with demanding manipulative behaviour. 29  INTERVENTIONS Psychosocial Interventions Motivational Interviewing Cognitive-Behavioural Therapy Twelve-Step Programs Group Therapy Family Therapy Pharmacotherapy Methadone/Narcan Relapse Prevention Toxicology Testing/Drug Screening 30  NURSING I NTERVENTIONS FOR THE FAMILY Education Family members should educate themselves about addiction, including why addiction is considered a chronic disorder. Educating helps to recognize potential triggers and bad influences. Clear the residence/home of any alcohol or stimulants/intoxicants. Set boundaries. Encourage the person to take up some healthy habits to avoid triggers (exercise and participate in activities that keep the mind busy). Keep communication open with the person and be patient. Be honest and non-judgmental with the person. Work to rebuild trust in relationships is a vital part of recovery. 31  NURSING I NTERVENTIONS FOR THE FAMILY Post Rehabilitation The person may need to attend meetings regularly as part of an outpatient rehab program or a support group. Person will need to continue focusing on their sobriety and avoiding stressors that may cause them to relapse. It’s important not to mistake this period of essential self-care as selfishness…do not take it personally. Recovery Process As the person’s recovery progresses; focus on mending other aspects of their life (including relationships, work, and hobbies). Expect to develop a routine after rehab. Most rehab facilities maintain firm schedules so patients can build habits that contribute to substance-free lives. Studies show that people are more likely to drink or use drugs when they are hungry, angry, lonely, or tired. 32  DISCHARGE CRITERIA Maintains abstinence. Admits to being dependent on substance. Demonstrates increased self-esteem. Developed better coping mechanisms. Expresses knowledge of continual progress towards recovery. Verbalizes realistic goals. Attends support and recovery groups. Reduce, identify, and manage negative emotional states (i.e., the acronym HALT warns not to become too Hungry, too Angry, too Lonely, or too Tired). 33  REFERENCES Kunyk, D., Peternelj-Taylor, C., & Austin, W. (2022). Psychiatric and mental health nursing for Canadian practice (5th ed.). Wolters Kluwer. 34