Chapter 5 Drugs of Abuse Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Context of Drug Abuse  Cultural considerations  Definitions  Drug misuse  Drug abuse  Drug addiction  Dependence  Physical dependence 2 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Neurobiology of Addictive Drugs  Mesolimbic system: the “pleasure center” or brain reward system, an ancient system that creates the sensation of pleasure for certain behaviors necessary for survival, such as eating and sexual behavior  Dopamine  Other neurotransmitters 3 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Terminology of Drug Abuse  Tolerance  Craving  Cue-induced craving  Abstinence  Relapse 4 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Overview of Addictive States  Intoxication: state of being influenced or affected by a drug or other toxic substance  Detoxification: treating an intoxicated patient to diminish or remove drugs or their effects from the body 5 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Overview of Addictive States (Cont.)  Withdrawal syndrome: group of signs and symptoms that occurs in physically dependent persons when drug use is stopped. The symptoms are often opposite the effects the drug produced before it was withdrawn.  Cessation and maintaining abstinence: treatment with other drugs may be used to decrease craving and prevent withdrawal syndrome. 6 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Stimulants  Nicotine  Most rapidly addicting of the drugs of abuse  Side effects/adverse reactions: marked cardiovascular stimulation and increased myocardial oxygen consumption, general CNS stimulation, increased respiratory rate and tremors, increased alertness and arousal, increased GI secretions and smooth-muscle tone, and promotion of relaxation and relief of anxiety 7 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Nicotine  Psychological dependency  Withdrawal symptoms may occur within the first few hours after stopping smoking, peak in 24 to 48 hours, and last from a few weeks to several months.  After withdrawal subsides, cue-induced craving may cause smoking relapse.  Treatment: nicotine replacement therapy (NRT) or other smoking cessation agents are recommended for all tobacco users in addition to behavioral and support therapies. 8 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Nicotine Replacement Agents  Gum  Lozenges  Patch  Nasal spray  Inhaler 9 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Smoking Cessation  Bupropion (Zyban): atypical (heterocyclic) antidepressant  Varenicline (Chantix)  Nortriptyline (Aventyl, Pamelor) and clonidine (Catapres) 10 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Nursing Process: Nicotine  Assessment  Nursing diagnoses  Planning  Nursing interventions  Patient teaching  Evaluation 11 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Stimulants (Cont.)  Cocaine  Schedule II drug under the Controlled Substances Act  Side effects/adverse reactions: At usual doses, cocaine produces euphoria and increased energy and alertness as well as peripheral adrenaline-like actions.  Chronic use: Impairment of concentration and memory, irritability and mood swings, paranoia, and depression 12 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Cocaine  Cocaine psychosis  Acute cocaine toxicity  Emergency management  Cognitive-behavioral therapies  Disulfiram (Antabuse)  Modafinil (Provigil)  Topiramate (Topamax)  Ondansetron (Zofran) 13 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Stimulants (Cont.)  Amphetamines  Synthetic drugs  Schedule II drug of the Controlled Substance Act  May be used therapeutically as CNS stimulants  More often initially used a cheaper alternative to cocaine  Effects  Drug interactions 14 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Amphetamines  Amphetamines  Side effects/adverse reactions: Initial effects of increased alertness, improved performance, relief of fatigue, anorexia, and increased heart rate and blood pressure  Long-term use: irritability, anxiety, paranoia, and hostile and violent behaviors  Toxic reactions  “Bath salts”  Treatment 15 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Stimulants (Cont.)  Caffeine  Most widely used psychoactive substance in the world  Used to promote alertness and to alleviate fatigue  Safe in most people  “Energy” drinks  Side effects/adverse reactions: Insomnia, irritability, anxiety, muscle twitching, confusion, chest pain, tachycardia, dysrhythmias  Treatment 16 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Depressants  Alcohol  Most widely consumed substance of abuse in the United States  Side effects/adverse reactions: Wernicke’s encephalopathy, Korsakoff’s psychosis  Alcohol withdrawal: chlordiazepoxide (Librium) or lorazepam (Ativan)  Rehabilitation and sustained abstinence: disulfiram (Antabuse), naltrexone (ReVia, Depade), naltrexone extended release (Vivitrol), acamprosate (Campral), ondansetron (Zofran), topiramate (Topamax) 17 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Depressants (Cont.)  Sedative-hypnotics  Barbiturates, benzodiazepines, and barbiturate- like drugs  Pharmacokinetics and pharmacodynamics  Side effects/adverse reactions  Tolerance  Withdrawal  Treatment 18 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Depressants (Cont.)  Opioids  Effects: analgesia, drowsiness, slurred speech, and detachment from the environment  Signs of overdose of opioids: pinpoint pupils, clammy skin, depressed respiration, coma, and death, if not treated 19 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Depressants (Cont.)  Opioids  Treatment Overdose  Naloxone (Narcan) Withdrawal symptoms  Methadone (Dolophine), clonidine (Catapres), buprenorphine (Buprenex) Opioid antagonist  Naltrexone (oral ReVia, injectable Vivitrol) 20 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Other Drugs of Abuse  Cannabis  Psychedelic drugs  Inhalants  Volatile solvents  Aerosols  Anesthetic agents  Nitrites 21 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Special Needs of Drug-Abusing Patients  Surgical patients  Drug interactions  Pain management: Addictive treatment is not priority when patient is in pain.  Develop written agreement with patient 22 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Chemical Impairment in Health Professionals  Serious concern  10% to 20% of nurses have substance abuse problem.  3% to 6% demonstrate impaired practice because of drugs.  Contributing factors  Characteristics  Management 23 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Practice Question #1 A patient who smoked 1 pack of cigarettes a day for 2 years abruptly stopped smoking 2 days ago. The nurse performing an assessment on the patient identifies manifestations of nicotine withdrawal as including A.increased appetite and blood pressure. B.restlessness and increased blood pressure. C.depression and decreased blood pressure. D.nausea, confusion, and seizures. 24 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Practice Question #2 The nurse is aware that physical and psychological dependence on caffeine has been found with chronic use of what dosage per day? A.100 mg B.200 mg C.300 mg D.500 mg 25 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Practice Question #3 The nurse performing an assessment on a patient identifies the manifestations of cocaine use, which include A.fatigue and hallucinations. B.agitation and cardiac dysrhythmias. C.shock and hypotension. D.shallow respirations and pallor. 26 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Practice Question #4 A patient with a known opioid addiction is to have surgery. In planning the patient’s postoperative pain management, the nurse will A.withhold opioid medications. B.treat the addiction before managing pain. C.provide pain management as needed. D.anticipate that the patient will experience less pain. 27 Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.