N241 Chapter 12, 16, 17 W22 (6) PDF

Chapter 12 Central Nervous System Depressants and Muscle Relaxants Copyright © 2020 Elsevier Inc. All Rights Reserved. Copyright © 2020 Elsevier Inc. All Rights Reserved. CNS Depressants 2 Sedatives Drugs that have an inhibitory effect on the CNS to the degree that they reduce: Nervousness Excitabil...

Chapter 12 Central Nervous System Depressants and Muscle Relaxants Copyright © 2020 Elsevier Inc. All Rights Reserved. Copyright © 2020 Elsevier Inc. All Rights Reserved. CNS Depressants 2 Sedatives Drugs that have an inhibitory effect on the CNS to the degree that they reduce: Nervousness Excitability Irritability Copyright © 2020 Elsevier Inc. All Rights Reserved. CNS Depressants (Cont.) Hypnotics Cause sleep Much more potent effect on CNS than sedatives A sedative can become a hypnotic if it is given in large enough doses. 3 4 Copyright © 2020 Elsevier Inc. All Rights Reserved. CNS Depressants (Cont.) Sedative-hypnotics: dose dependent At low doses, calm the CNS without inducing sleep. At high doses, calm the CNS to the point of causing sleep. Classified into three main groups: Barbiturates Benzodiazepines Miscellaneous drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. 5 CNS Depressants: Benzodiazepines Formerly the most commonly prescribed sedative-hypnotic drugs Nonbenzodiazepines are currently more frequently prescribed. Favorable adverse effect profiles, efficacy, and safety when used appropriately 6 Copyright © 2020 Elsevier Inc. All Rights Reserved. CNS Depressants: Benzodiazepines (Cont.) Classified as either: Sedative-hypnotic Anxiolytic (medication that relieves anxiety) 7 Copyright © 2020 Elsevier Inc. All Rights Reserved. Benzodiazepines: Mechanism of Action Depress CNS activity Affect hypothalamic, thalamic, and limbic systems of the brain Benzodiazepine receptors Gamma-aminobutyric acid (GABA) GABA is the primary inhibitory neurotransmitter of the brain, and it serves to modulate CNS activity by inhibiting overstimulation Do not suppress rapid eye movement (REM) sleep as much as barbiturates do Do not increase metabolism of other drugs 8 Copyright © 2020 Elsevier Inc. All Rights Reserved. Benzodiazepines: Drug Effects Calming effect on the CNS Useful in controlling agitation and anxiety Reduce excessive sensory stimulation, inducing sleep Induce skeletal muscle relaxation 9 Copyright © 2020 Elsevier Inc. All Rights Reserved. Benzodiazepines: Indications Sedation Sleep induction Skeletal muscle relaxation Anxiety relief Anxiety-related depression Treatment of acute seizure disorders Treatment of alcohol withdrawal Agitation relief Balanced anesthesia Moderate or conscious sedation Copyright © 2020 Elsevier Inc. All Rights Reserved. Contraindication Drug allergy Narrow-angle glaucoma Pregnancy 10 Benzodiazepines: Adverse Effects Mild and infrequent: Headache Drowsiness Dizziness Cognitive impairment Vertigo Lethargy Fall hazard for older adults “Hangover” effect or daytime sleepiness Contraindications/Adverse Effects Copyright © 2020 Elsevier Inc. All Rights Reserved. 11 Benzodiazepines: Toxicity and Overdose Somnolence Confusion Coma Diminished reflexes Do not cause hypotension and respiratory depression unless taken with other CNS depressants Treatment symptomatic and supportive Flumazenil as an antidote 12 Copyright © 2020 Elsevier Inc. All Rights Reserved. Benzodiazepines: Interactions Azole antifungals, verapamil, diltiazem, macrolide antibiotics, grapefruit juice CNS depressants (alcohol, opioids) Food-drug Interactions Opioids Copyright © 2020 Elsevier Inc. All Rights Reserved. 13 Midazolam (Versed) Most commonly used preoperatively and for moderate sedation Causes amnesia and anxiolysis (reduced anxiety) as well as sedation Normally administered by injection in adults Liquid oral dosage form is also available for children. Copyright © 2020 Elsevier Inc. All Rights Reserved. 14 Temazepam (Restoril) Intermediate-acting benzodiazepine One of the metabolites of diazepam Normally induces sleep within 20 to 40 minutes Long onset of action, so it is recommended that patients take it about 1 hour prior to going to bed Still an effective hypnotic; however, it has been replaced by newer drugs 15 Copyright © 2020 Elsevier Inc. All Rights Reserved. Nonbenzodiazepine: Ramelteon (Rozerem) Structurally similar to the hormone melatonin works as an agonist at melatonin receptors in the CNS used as hypnotic Not classified as a controlled substance Indicated for patients who have difficulty with sleep onset rather than sleep maintenance 16 Copyright © 2020 Elsevier Inc. All Rights Reserved. Barbiturates First introduced in 1903; were the standard drugs for insomnia and sedation Habit forming; low therapeutic index Only a handful commonly used today partly because of the safety and efficacy of benzodiazepines Copyright © 2020 Elsevier Inc. All Rights Reserved. Site of action: brainstem (reticular formation) 17 Barbiturates: Mechanism of Action By potentiating the action of GABA, nerve impulses traveling in the cerebral cortex are inhibited. Copyright © 2020 Elsevier Inc. All Rights Reserved. Ultrashort acting 18 Barbiturates: Indications Anesthesia for short surgical procedures Anesthesia induction Control of seizures Reduction of intracranial pressure in neurologic patients Short acting Sedation and control of seizures Intermediate acting Sedation and control of seizures Long acting Seizure prophylaxis Contraindications Copyright © 2020 Elsevier Inc. All Rights Reserved. 19 Barbiturates: Contraindications/ Adverse effects Drug allergy Pregnancy Significant respiratory difficulties Severe kidney or liver disease Caution in older adults Adverse Effects Drowsiness, lethargy, vertigo, vasodilation Reduced REM sleep, resulting in: Agitation, Inability to deal with normal stress Copyright © 2020 Elsevier Inc. All Rights Reserved. Barbiturates: Toxicity and Overdose 20 Overdose CNS depression & frequently leads to respiratory depression and subsequent respiratory arrest. Can be therapeutic Anesthesia induction Uncontrollable seizures: “phenobarbital coma” Treatment of overdose Symptomatic and supportive Maintain adequate airway Assisted ventilation or oxygen therapy Fluids Pressor support Activated charcoal Copyright © 2020 Elsevier Inc. All Rights Reserved. Additive effects 21 Barbiturates: Drug Interactions Alcohol, antihistamines, benzodiazepines, opioids, tranquilizers Increased metabolism Reduces anticoagulant response, leading to possible clot formation Copyright © 2020 Elsevier Inc. All Rights Reserved. Prototypical barbiturate Long-acting 22 Phenobarbital Uses: Prevention of generalized tonic-clonic seizures and febrile convulsions Rarely used as sedative No longer recommended as a hypnotic Copyright © 2020 Elsevier Inc. All Rights Reserved. 23 Over-the-Counter Hypnotics Nonprescription sleeping aids often contain antihistamines, which have CNS depressant effect. Doxylamine (Unisom) and diphenhydramine (Sominex), acetaminophen/diphenhydramine (Extra Strength Tylenol PM) As with other CNS depressants, concurrent use of alcohol can cause respiratory depression or arrest. Copyright © 2020 Elsevier Inc. All Rights Reserved. 24 Muscle Relaxants Act to relieve pain associated with skeletal muscle spasms Majority are centrally acting. CNS is the site of action. Similar in structure and action to other CNS depressants Direct acting Act directly on skeletal muscle Closely resemble GABA Copyright © 2020 Elsevier Inc. All Rights Reserved. Muscle Relaxants: Indications Relief of painful musculoskeletal conditions Muscle spasms Management of spasticity of severe chronic disorders (multiple sclerosis, cerebral palsy) Work best when used along with physical therapy 25 Copyright © 2020 Elsevier Inc. All Rights Reserved. 26 Muscle Relaxants: Adverse Effects Extension of effects on CNS and skeletal muscles Euphoria Lightheadedness Dizziness Drowsiness Fatigue Muscle weakness Copyright © 2020 Elsevier Inc. All Rights Reserved. Primarily involve the CNS Toxicity and Management of Overdose No specific antidote or reversal Best treated with conservative supportive measures If taken along with other CNS depressants Adequate airway must be maintained EKG monitoring Fluid management to avoid crystalluria 27 Copyright © 2020 Elsevier Inc. All Rights Reserved. 28 Interactions Caution with other CNS depressants Benzodiazepines Alcohol Copyright © 2020 Elsevier Inc. All Rights Reserved. Baclofen (Lioresal) Cyclobenzaprine (Flexeril) 29 Common Muscle Relaxants Tizanidine (Zanaflex) Carisoprodol (Soma) Methocarbamol (Robaxin) Copyright © 2020 Elsevier Inc. All Rights Reserved. 30Cyclobenzaprine (Flexeril) Centrally acting muscle relaxer Most common used muscle relaxer Can cause marked sedation Copyright © 2020 Elsevier Inc. All Rights Reserved. Obtain Before-thorough history regarding allergies, use of other medications, health history, and medical history. Obtain Baseline vital signs and I&O, including supine and erect blood pressure. Assess Potential disorders and conditions that may be contraindications and for potential drug interactions. 31 Nursing Implications Nursing Implications (Cont.) 32 Give Hypnotics 30 to 60 minutes before bedtime for maximum effectiveness in inducing sleep (depends on drug’s onset). Use caution in older adults. Most benzodiazepines cause REM rebound and a tired feeling the next day. Instruct Patients to avoid alcohol and other CNS depressants. Safety Keep side rails up or use bed alarms. Do not permit smoking. Assist patient with ambulation (especially older adults). Keep call light within reach. Copyright © 2020 Elsevier Inc. All Rights Reserved. Copyright © 2020 Elsevier Inc. All Rights Reserved. Nursing Implications (Cont.) 33 Monitor for therapeutic effects: Increased ability to sleep at night Fewer awakenings Shorter sleep-induction time Few adverse effects, such as “hangover” effects Improved sense of well-being because of improved sleep For muscle relaxants: decreased spasticity, decreased rigidity Chapter 16 Copyright © 2020 Elsevier Inc. All Rights Reserved. Psychotherapeutic Drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. Psychotherapeutic Drugs 36 Used in the treatment of emotional and mental disorders Ability to cope with emotions can range from occasional depression or anxiety to constant emotional distress When emotions significantly affect an individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option. Copyright © 2020 Elsevier Inc. All Rights Reserved. Exact cause of mental disorders not fully understood 37 Psychotherapeutic Drugs (Cont.) Thought to arise from abnormal levels or imbalance of neurotransmitters Dopamine and epinephrine Serotonin and histamine Gamma-aminobutyric acid and acetylcholine 38 Psychotherapeutic Drugs (Cont.) Three main emotional and mental disorders Anxiety Affective disorders Psychoses Copyright © 2020 Elsevier Inc. All Rights Reserved. 39 Types of psychotherapeutic drugs Psychotherapeutic Drugs (Cont.) Anxiolytic drugs Mood-stabilizing drugs Antidepressant drugs Antipsychotic drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. Copyright © 2020 Elsevier Inc. All Rights Reserved. Anxiety 40 Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder (PTSD) Generalized anxiety disorder (GAD) Panic disorder Social phobia (social anxiety disorder) Simple phobia Unpleasant state of mind characterized by a sense of dread and fear May be based on actual anticipated experiences or past experiences May be exaggerated responses to imaginary negative situations Copyright © 2020 Elsevier Inc. All Rights Reserved. 41 Affective Disorders (Mood Disorders) Changes in mood that range from mania (abnormally pronounced emotions) to depression (abnormally reduced emotions) Some patients may exhibit both mania and depression: bipolar disorder (BPD) Copyright © 2020 Elsevier Inc. All Rights Reserved. 42 Psychosis Severe emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in activities of daily living Hallmark: loss of contact with reality Examples Schizophrenia Depressive and drug-induced psychoses Anxiolytic Drugs Benzodiazepines 43 Copyright © 2020 Elsevier Inc. All Rights Reserved. Reduce anxiety by reducing overactivity in central nervous system (CNS). Depress activity in the brainstem and limbic system. Used to treat alcohol withdrawal, insomnia, and muscle spasms as well as adjunct for depression Alprazolam (Xanax) Diazepam (Valium) Lorazepam (Ativan) 44 Copyright © 2020 Elsevier Inc. All Rights Reserved. Benzodiazepines: Adverse Effects Benzodiazepines’ adverse effects are an overexpression of their therapeutic effects Decreased CNS activity, sedation Hypotension Drowsiness, loss of coordination, dizziness, headaches Nausea, vomiting, dry mouth, constipation Others Copyright © 2020 Elsevier Inc. All Rights Reserved. 45 Benzodiazepines Overdose Dangerous when taken with other sedatives or alcohol Treatment is generally symptomatic and supportive. Flumazenil (Romazicon) may be used to reverse benzodiazepines’ effects. Copyright © 2020 Elsevier Inc. All Rights Reserved. 46 Benzodiazepines Interactions Alcohol and CNS depressants can result in additive CNS depression and even death. More likely to occur in patients with renal or hepatic compromise 47 Copyright © 2020 Elsevier Inc. All Rights Reserved. Alprazolam (Xanax) Most commonly used as an anxiolytic Indicated for GAD, short-term relief of anxiety symptoms, panic disorder, and anxiety associated with depression Adverse effects: confusion, ataxia, headache, and others Interactions: alcohol, oral contraceptives, and others Copyright © 2020 Elsevier Inc. All Rights Reserved. 48 Miscellaneous Anxiolytic Buspirone (Buspar) Unknown mechanism of action Administered on a scheduled basis Lacks sedative properties and dependency potential as other benzodiazepines Adverse effects Paradoxical anxiety Blurred vision Headache Nausea Copyright © 2020 Elsevier Inc. All Rights Reserved. 49 MoodStabilizing Drugs Used to treat bipolar illness Lithium carbonate and lithium citrate Other drugs may be used in combination with lithium Benzodiazepines Antipsychotic drugs Antiepileptic drugs Dopamine receptor agonists Lithium 50 Drug of choice for the treatment of mania It is thought to potentiate serotonergic neurotransmission Narrow therapeutic range: acute mania—lithium serum level of 1 to 1.5 mEq/L; maintenance serum levels should range between 0.6 and 1.2 mEq/L. Levels exceeding 1.5 to 2.5 mEq/L begin to produce toxicity, including gastrointestinal (GI) discomfort, tremor, confusion, somnolence, seizures, and possibly death. Keeping the sodium level in the normal range (135 to 145 mEq/L) helps to maintain therapeutic lithium levels. Copyright © 2020 Elsevier Inc. All Rights Reserved. 51 Copyright © 2020 Elsevier Inc. All Rights Reserved. Adverse effects Most serious adverse effect is cardiac dysrhythmia. Lithium Other effects: drowsiness, slurred speech, epilepsy-type seizures, choreoathetotic movements (involuntary wavelike movements of the extremities), ataxia (generalized disturbance of muscular coordination), and hypotension Long-term treatment may cause hypothyroidism. 53 Copyright © 2020 Elsevier Inc. All Rights Reserved. Antidepressant Drugs Indicated for major depressive disorders Other indications: Dysthymia (chronic low-grade depression) As adjunct for schizophrenia Eating disorders Personality disorders Various medical conditions Migraine headaches Chronic pain/sleep disorders Premenstrual syndrome Hot flashes associated with menopause Copyright © 2020 Elsevier Inc. All Rights Reserved. Antidepressants Increase the levels of neurotransmitter concentration in CNS Requires at least 6 weeks of therapy with adequate doses to be able to fully evaluate results May require upward titration of dosages over several weeks Should be used in conjunction with psychotherapy Higher risk of suicide among both adult and pediatric population 54 Copyright © 2020 Elsevier Inc. All Rights Reserved. Tricyclic antidepressants 55 Antidepressants (Cont.) Monoamine oxidase inhibitors (MAOIs) Second-generation antidepressants SSRIs Serotonin-norepinephrine reuptake inhibitors (SNRIs) Copyright © 2020 Elsevier Inc. All Rights Reserved. Tricyclic Antidepressants (TCA) Have largely been replaced by SSRIs as first-line antidepressant drugs Considered second line For patients who fail with SSRIs or other newer generation antidepressants As adjunct therapy with newer generation antidepressants Amitriptyline (Elavil) 57 Tricyclic Antidepressants MOA Block reuptake of neurotransmitters, causing accumulation at the nerve endings It is thought that increasing concentrations of neurotransmitters corrects abnormally low levels that lead to depression. Indications Depression Childhood enuresis (imipramine) OCDs (clomipramine) Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia Increased appetite is an effect of TCAs; therefore, TCAs are sometimes used to treat anorexia nervosa. Copyright © 2020 Elsevier Inc. All Rights Reserved. Sedation Impotence Orthostatic hypotension Older patients Dizziness, postural hypotension, constipation, delayed micturition, edema, muscle tremors Tricyclic Antidepressants Adverse Effects 59 Tricyclic Antidepressants: Overdose 60 Lethal: 70% to 80% die before reaching the hospital. CNS and cardiovascular systems are mainly affected. No specific antidote Decrease drug absorption with activated charcoal. Speed elimination by alkalinizing urine. Manage seizures and dysrhythmias. Provide basic life support. Death results from seizures or dysrhythmias. Contraindications known drug allergy, pregnancy, and recent myocardial infarction Copyright © 2020 Elsevier Inc. All Rights Reserved. 62 Copyright © 2020 Elsevier Inc. All Rights Reserved. Monoamine Oxidase Inhibitors (MAOIs) Nonselective: isocarboxazid (Marplan) Rarely used for depression Used for Parkinson’s disease Disadvantage potential to cause hypertensive crisis when taken with tyramine Copyright © 2020 Elsevier Inc. All Rights Reserved. 63 Ingestion of foods or drinks with tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death MAOIs and Tyramine Avoid foods that contain tyramine! Aged, mature cheeses (cheddar, bleu, Swiss) Smoked, pickled, or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) Yeast extracts Red wines Italian broad beans (fava beans) Copyright © 2020 Elsevier Inc. All Rights Reserved. Second-Generation Antidepressants Fewer adverse effects than TCAs and MAOIs Very few drug–drug or drug–food interactions Still take about 4 to 6 weeks to reach maximum clinical effectiveness Now considered first-line drugs for depression Mechanism of action: inhibition of serotonin reuptake and possible effects on norepinephrine and dopamine reuptake 64 Second-Generation Antidepressants Indications Adverse Effects Depression insomnia (partly caused by reduced rapid eye movement sleep), weight gain, and sexual dysfunction BPD, obesity, eating disorders, OCD, panic attacks or disorders, social anxiety disorder, PTSD, premenstrual dysphoric disorder Common symptoms Copyright © 2020 Elsevier Inc. All Rights Reserved. 66 SecondGeneration Antidepressants: Serotonin Syndrome Delirium Agitation Tachycardia Sweating Myoclonus (muscle spasms) Hyperreflexia Shivering Course tremors Extensor plantar muscles (sole of foot) response More severe symptoms Hyperthermia Seizures Rhabdomyolysis Renal failure Cardiac dysrhythmias Disseminated intravascular coagulation Copyright © 2020 Elsevier Inc. All Rights Reserved. 67 Second-Generation Antidepressants Interactions Highly protein bound Need 2- to 5-week “washout” when changing classes of antidepressants that include MAOIs Increase risk of Serotonin Syndrome Avoid herbal products, particularly St. John’s wort Copyright © 2020 Elsevier Inc. All Rights Reserved. 68 Fluoxetine (Prozac) Prototypical SSRI Indications: depression, bulimia, OCD, panic disorder, and premenstrual dysphoric disorder Contraindications: known drug allergy and concurrent MAOI therapy Adverse effects: anxiety, dizziness, drowsiness, insomnia, and others Antidepressants: Nursing Implications 69 Antidepressants Inform patients -several weeks to see therapeutic effects. Monitor & assess for suicidal tendencies, and provide support. Assist older adult and weakened patients with ambulation and other activities because falls may occur because of drowsiness or postural hypotension. Monitor for adverse effects and discuss with patients. Encourage patients to wear medication ID badges naming the drugs being taken. With MAOIs, instruct patients and family foods to avoid and s/s of HTN crisis. Therapeutic Outcomes For antidepressants Improved sleep patterns and nutrition Increased feelings of self-esteem & interest in self and appearance & daily activities Decreased feelings of hopelessness & less depressive or suicidal thoughts or ideations Copyright © 2020 Elsevier Inc. All Rights Reserved. Copyright © 2020 Elsevier Inc. All Rights Reserved. 70 Antipsychotics Drugs used to treat serious mental illness Drug-induced psychoses, schizophrenia, and autism Also used to treat extreme mania (as an adjunct to lithium), BPD, depression that is resistant to other therapy, certain movement disorders (e.g., Tourette’s syndrome), and certain other medical conditions (e.g., nausea, intractable hiccups) Have been known as tranquilizers or neuroleptics Copyright © 2020 Elsevier Inc. All Rights Reserved. Antipsychotics (Cont.) Conventional, or first-generation: phenothiazines Second-generation Atypical antipsychotics 71 72 Antipsychotics Mechanism of Action Copyright © 2020 Elsevier Inc. All Rights Reserved. Block dopamine receptors in the brain (limbic system, basal ganglia), areas associated with emotion, cognitive function, motor function Dopamine levels in the CNS are decreased. Result: tranquilizing effect in psychotic patients Copyright © 2020 Elsevier Inc. All Rights Reserved. 73 Positive and Negative Symptoms of Schizophrenia Positive symptoms: hallucinations, delusions, and conceptual disorganization Negative symptoms: apathy, social withdrawal, blunted affect, poverty of speech, and catatonia All antipsychotics show efficacy in improving the positive symptoms of schizophrenia. Conventional drugs are less effective in managing negative symptoms. Atypical antipsychotics have improved efficacy in treating both positive and negative symptoms. Copyright © 2020 Elsevier Inc. All Rights Reserved. 74 Antipsychotic Drugs Indications Psychotic illness, most commonly schizophrenia Anxiety and mood disorders Copyright © 2020 Elsevier Inc. All Rights Reserved. Agranulocytosis and hemolytic anemia 75 Antipsychotic Drugs Adverse Effects Drowsiness EPS Involuntary muscle symptoms similar to those of Parkinson’s disease Akathisia (distressing muscle restlessness) Acute dystonia (painful muscle spasms) Treated with benztropine (Cogentin) and trihexyphenidyl (Artane) https://youtu.be/2xfu-d_aYWs Copyright © 2020 Elsevier Inc. All Rights Reserved. 76 Antipsychotic Drugs Adverse Effects Con’t Tardive dyskinesia (TD) Involuntary contractions of oral and facial muscles Choreoathetosis (wavelike movements of extremities) Occurs with continuous long-term antipsychotic therapy Valbenazine (Ingrezza) used to treat tardive dyskinesia in adults https://youtu.be/FUr8ltXh1Pc Metabolic Syndrome Copyright © 2020 Elsevier Inc. All Rights Reserved. Indications: long-term treatment of psychosis 77 Haloperidol (Haldol) Contraindications: hypersensitivity, Parkinson’s disease, and in patients taking large amounts of CNS depressants Oral, intramuscular, intravenous Useful in treating patients with schizophrenia who were nonadherent with their drug regimen Copyright © 2020 Elsevier Inc. All Rights Reserved. Atypical Antipsychotics Clozapine (Clozaril) Risperidone (Risperdal) Quetiapine (Seroquel) Aripiprazole (Abilify) 78 Copyright © 2020 Elsevier Inc. All Rights Reserved. 79 Atypical Antipsychotics Mechanism of Action Advantageous properties over conventional drugs Block specific dopamine receptors: dopamine-2 (D2) receptors Also block specific serotonin receptors: serotonin 2 (5-HT2) receptors This is responsible for their improved efficacy and safety profiles. 80 Copyright © 2020 Elsevier Inc. All Rights Reserved. Risperidone (Risperdal) Indication: schizophrenia, including negative symptoms Adverse effects: minimal EPS at therapeutic dosages of 1 to 6 mg/day Risperdal Consta: long-acting injectable form; lasts approximately 2 weeks Invega Sustenna: long-acting injection; lasts 1 month Copyright © 2020 Elsevier Inc. All Rights Reserved. 81 Antipsychotics: Nursing Implications Assessment perform and document a thorough nursing history and mental status examination CV, cerebrovascular, neurologic, GI, GU, renal, hepatic, and hematologic functioning Weight gain may occur Suicidal ideation, orthostatic changes in BP, EPS, confusion, headache, GI upset, abnormal muscle movements, rashes, and dry mouth Drug interactions Avoid alcohol and other CNS depressants with these medications. Long-term haloperidol therapy- EPS Monitor liver and renal function studies, CBC, and UA before and during therapy. May cause drowsiness, dizziness, or fainting; change positions slowly. Therapeutic Outcomes For antipsychotics Improved mood and affect Alleviation of psychotic symptoms and episodes Decreased hallucinations, paranoia, delusions, garbled speech, and inability to cope Chapter 17 Substance Use Disorder Copyright © 2020 Elsevier Inc. All Rights Reserved. Copyright © 2020 Elsevier Inc. All Rights Reserved. Affects people of all ages, sexes, ethnic, and socioeconomic groups 83 Substance Abuse Leads to: Physical dependence Psychologic dependence Habituation Addiction Commonly Abused Substances 84 Opioids: Synthetic versions of pain-relieving substances Heroin: One of the most commonly abused opioids Codeine Hydrocodone Hydromorphone Morphine Oxycodone Copyright © 2020 Elsevier Inc. All Rights Reserved. 85 Copyright © 2020 Elsevier Inc. All Rights Reserved. Also known as narcotics Opioids: Mechanism of Action Bind to specific opioid pain receptors in brain and cause an analgesic response, the reduction of pain sensation The ability to produce euphoria is one reason for potential of abuse. Effects primary centered in CNS 86 Copyright © 2020 Elsevier Inc. All Rights Reserved. Intended drug effects of opioids: Relieve pain Reduce cough Relieve diarrhea Induce anesthesia Opioids: Indications Certain opioid drugs are used to treat opioid dependence. Methadone Goal Relapse rates are often high; the drug can be abused. 87 Copyright © 2020 Elsevier Inc. All Rights Reserved. CNS: Diuresis Miosis Convulsions Opioids: Adverse Effects Nausea, vomiting Respiratory depress Non-CNS: Hypotension Constipation Urinary retention Flushing Urticaria/pruritus Copyright © 2020 Elsevier Inc. All Rights Reserved. 88 Opioid: Drug Withdrawal Peak period: 1 to 3 days Duration: 5 to 7 days Signs/Symptoms Drug seeking, mydriasis, diaphoresis, rhinorrhea, lacrimation, elevated blood pressure (BP), and pulse, muscle cramps, arthralgia, anxiety,n/v/d, yawning, insomnia 89 Copyright © 2020 Elsevier Inc. All Rights Reserved. Many patients require a formal detoxification program. Management of Withdrawal, Toxicity, and Overdose Most common cause of death with opioids is respiratory depression. Naloxone is an opioid antagonist used in opioid overdose. Now standard with first responders 90 Copyright © 2020 Elsevier Inc. All Rights Reserved. Relapse Prevention Naltrexone Works by blocking the opioid receptors so that the use of opioid drugs do not produce euphoria Must be 1 week free from opioids to begin this therapy 91 Alcohol (Ethanol) More accurately known as ethanol (ETOH) Causes CNS depression by dissolving in lipid membranes in the CNS Few legitimate uses of ethanol and alcoholic beverages Used as a solvent for many drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. Systemic uses of ethanol: treatment of methyl alcohol and ethylene glycol intoxication (e.g., from drinking automotive antifreeze solution) Copyright © 2020 Elsevier Inc. All Rights Reserved. CNS depression 92 Ethanol: Drug Effects Respiratory stimulation or depression Vasodilation, producing warm, flushed skin Increased sweating Diuretic effects 93 Copyright © 2020 Elsevier Inc. All Rights Reserved. Nutritional and vitamin deficiencies (especially B vitamins) Wernicke’s encephalopathy Effects of Chronic Ethanol Ingestion Korsakoff’s psychosis Polyneuritis Nicotinic acid deficiency encephalopathy Seizures Alcoholic hepatitis, progressing to cirrhosis Cardiomyopathy 94 Effects of Chronic Ethanol Ingestion (Cont.) Copyright © 2020 Elsevier Inc. All Rights Reserved. Fetal alcohol syndrome (FAS) Craniofacial abnormalities CNS dysfunction Prenatal and postnatal growth retardation 95 Copyright © 2020 Elsevier Inc. All Rights Reserved. Intensifies sedative effects of medications that work in the CNS Alcohol Interactions Interacts with antibiotic metronidazole Hepatotoxicity with acetaminophen Increase bioavailability of blood thinner warfarin 96 Copyright © 2020 Elsevier Inc. All Rights Reserved. Ethanol Withdrawal Signs and symptoms Elevated blood pressure, pulse rate, and temperature Insomnia Tremors Agitation Classified as mild, moderate, and severe 97 Copyright © 2020 Elsevier Inc. All Rights Reserved. Benzodiazepines are the treatment of choice Dosage and frequency depend on severity Ethanol Withdrawal Treatment For severe withdrawal, monitoring in an intensive care unit is recommended. Disulfiram (Antabuse) Acetaldehyde syndrome Naltrexone Acamprosate (Campral) Newest treatment Counseling Individual Alcoholics anonymous Copyright © 2020 Elsevier Inc. All Rights Reserved. 98 Nicotine Many smoke to “calm nerves.” Releases epinephrine, which creates physiologic stress rather than relaxation Tolerance develops Physical and psychologic dependency Withdrawal symptoms occur if stopped No therapeutic uses 200 known poisons present in cigarette smoke. Copyright © 2020 Elsevier Inc. All Rights Reserved. Nicotine: Drug Effects 99 Transient stimulation of autonomic ganglia Followed by more persistent depression of all autonomic ganglia CNS and respiratory stimulation followed by CNS depression Increased heart rate and BP Increased bowel activity Nicotine: no known therapeutic uses Nicotine is medically significant because of its addictive and toxic properties. Nicotine Adverse Effects/Withdrawal Symptoms Adverse Effects Primarily affect the CNS Large doses produce tremors and even convulsions. Respiratory stimulation commonly occurs. Increase heart rate and blood pressure. Increase tone and motor activity of bowel. Withdrawal Manifested by cigarette craving Irritability, restlessness, decreased heart rate, and BP Cardiac symptoms resolve in 3 to 4 weeks, but cigarette craving may persist for months or years. Copyright © 2020 Elsevier Inc. All Rights Reserved. 101 Treatments Nicotine: Withdrawal Treatment provide nicotine without the carcinogens Nicotine transdermal system (patch) Nicotine polacrilex (gum) Inhalers Nasal spray Medications Bupropion (Zyban): may be prescribed to aid in smoking cessation First nicotine-free prescription medicine to treat nicotine dependence Varenicline (Chantix) Stimulates nicotine receptors Copyright © 2020 Elsevier Inc. All Rights Reserved. 102 Nursing Implications Nonjudgmental and open-ended questions about substance abuse. The most dangerous substances in terms of withdrawal are CNS depressants such as barbiturates, benzodiazepines, and alcohol. Assessment tools for substance abuse CAGE Patient safety-especially when withdrawal process. Provide monitoring and supportwithdrawal process. Educate-recovery process & Emphasize that recovery is lifelong.