Mental Health Nursing II NURS 2310 Unit 8 Substance Abuse

Objective 1 Reviewing definitions of the terms substance abuse, dependency, intoxication, and withdrawal

Substance Abuse A maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to repeated use of the substance; any use of substances that poses significant hazards to health; leads to clinically significant impairment or distress occurring within a 12-month period.

Diagnostic Criteria for Substance Abuse Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home Recurrent substance use in situations in which it is physically hazardous Recurrent substance-related legal problems Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

Dependency = a compulsive or chronic requirement; a need so strong as to generate physical or psychological distress if left unfulfilled. Physical dependence is evidenced by a cluster of cognitive, behavioral, and physiological symptoms indicating continued use of the substance despite significant substance-related problems Psychological dependence is indicated by an overwhelming desire to repeat the use of a particular drug to produce pleasure or avoid discomfort

Criteria for Substance Dependence Evidence of tolerance – –the need for markedly increased amounts of the substance to achieve intoxication or desired effects – –markedly diminished effect with continued use of the same amount of the substance Evidence of withdrawal symptoms – –the characteristic withdrawal syndrome for the substance – –the same/similar substance is taken to relieve or avoid withdrawal symptoms

Criteria for Substance Dependence (cont’d) The substance is often taken in larger amounts or over a longer period than was intended There is a persistent desire or unsuccessful efforts to cut down or control substance use A great deal of time is spend in activities necessary to obtain the substance, use the substance, or recover from its effects

Criteria for Substance Dependence (cont’d) Important social, occupation, or recreational activities are given up or reduced because of substance use The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

Intoxication = a physical and mental state of exhilaration and emotional frenzy or lethargy or stupor. Criteria for Substance Intoxication The development of a reversible substance- specific syndrome caused by recent ingestion of or exposure to a substance Clinically significant maladaptive behavior or psychological changes that are due to the effect of the substance on the CNS and develop during or shortly after use of the substance

Withdrawal = the physiological and mental readjustment that accompanies the discontinuation of an addictive substance; usually associated with substance dependence. Criteria for Substance Withdrawal The development of a substance-specific syndrome caused by the cessation of or reduction in heavy and prolonged substance use The substance-specific syndrome causes clinically significant distress or impairment

Substance Addiction A compulsive or chronic requirement; the need is so strong as to generate physical and/or psychological distress if left unfulfilled. Dual Diagnosis Coexisting substance use disorder and mental illness.

Nonsubstance Addictions Codependency – –Exaggerated pattern of learned behaviors, beliefs, and feelings involving dependence on others that greatly diminishes self-identity – –Stages of recovery:   Stage I (Survival)=letting go of denial   Stage II (Reidentification)=awareness of true self   Stage III (Core Issues)=letting go of control of others   Stage IV (Reintegration)=regaining control of self Gambling disorder – –Defined as being persistent and leading to clinically significant impairment or distress

Objective 2 Describing substances commonly abused in the community

Classes of Psychoactive Substances Alcohol Cannabis Hallucinogens Inhalants Opioids Sedative-hypnotics Stimulants

Alcohol Most commonly abused drug Physically addicting – –alcohol becomes integrated into physiologic processes at the cellular level – –cell becomes dependent on alcohol to carry out metabolic processes Constitutes the most life-threatening withdrawal syndrome in comparison to other types of commonly abused drugs

Alcohol (cont’d) Intoxication – –disinhibition of sexual or aggressive impulses – –mood lability – –impaired judgment – –unsteady gait; incoordination Withdrawal – –coarse tremor of hands, tongue, or eyelids – –nausea or vomiting – –malaise or weakness – –tachycardia, sweating, elevated blood pressure – –transient hallucinations or illusions – –progression to alcohol withdrawal delirium

Alcohol (cont’d) Related physiological effects – –Wernicke’s encephalopathy   Severe thiamine deficiency   Paralysis of the ocular muscles   Ataxia   Somnolence, stupor, or death – –Korsakoff’s psychosis   Confusion   Loss of recent memory   Confabulation   Often occurs in conjunction with Wernicke’s encephalopathy (“Wernicke-Korsakoff syndrome”) – –Fetal alcohol syndrome   Physical, mental, behavioral, and learning disabilities

Alcohol (cont’d) Four phases of progression – –Phase I: The Prealcoholic Phase   Use of alcohol to relieve everyday stress and tension – –Phase II: The Early Alcoholic Phase   Characterized by blackouts   Alcohol becomes requirement as opposed to source of pleasure or relief – –Phase III: The Crucial Phase   Loss of control over drinking   Interference with social and/or occupational function – –Phase IV: The Chronic Phase   Emotional and physical disintegration   Life-threatening physical manifestations of both use and withdrawal symptomology present

Cannabis Produces an effect similar to that of LSD Heightened awareness, distortion of space and time, heightened sensitivity to sound, and depersonalization May produce paranoia, but not true hallucinations Has sedative effect and is psychologically addicting Chronic use may result in psychosis and lack of motivation

Cannabis (cont’d) Second only to alcohol as the most widely abused drug in the U.S. Intoxication – –impaired motor coordination – –euphoria – –anxiety – –sensation of slowed time – –impaired judgment – –increased appetite – –dry mouth – –tachycardia

Hallucinogens Altered perceptions that are dream-like Altered sense of time Feelings of special insight Emotions are intensified and labile Depersonalization Adverse reactions include paranoia, depression, frightening hallucinations, and acute confusional state

Hallucinogens (cont’d) Intoxication – –marked anxiety or depression – –ideas of reference – –fear of losing one’s mind – –paranoid ideation – –impaired judgment – –illusions, hallucinations, and depersonalization – –tachycardia, palpitations, tremors – –sweating – –blurred vision

Inhalants Paint, glue, aerosol sprays, “whiteout”, gasoline Produce mind-altering response Drug used most by adolescents due to ready availability and low cost Symptoms include nosebleeds, bloodshot eyes, infectious lesions around the nose and mouth, severe disorientation and unconsciousness Chronic use results in progressive brain damage, asphyxiation, seizures, bone marrow suppression, cardiac dysrhythmias

Inhalants (cont’d) Intoxication – –belligerence, assaultiveness, impaired judgment – –dizziness, incoordination, unsteady gait – –slurred speech – –euphoria – –impaired social or occupational functioning – –lethargy, depressed reflexes, psychomotor retardation – –tremor, generalized muscle weakness – –blurred vision – –stupor or coma

Opioids Narcotic analgesics – –Sedative effect – –Desensitizes user to physical and psychological pain Can cause physiological and psychological dependence Induces sense of euphoria – –Drug’s pleasurable effect on the CNS promotes abuse Effects include lethargy, indifference to the environment

Opioids (cont’d) Intoxication – –Apathy and dysphoria – –Psychomotor agitation or retardation – –Impaired judgment – –Drowsiness – –Slurred speech – –Impairment in attention or memory – –Can be fatal   Respiratory depression   Coma   Death

Opioids (cont’d) Withdrawal – –Develops after cessation of, or reduction in, heavy and prolonged use of an opiate or related substance – –Dysphoric mood – –Nausea/vomiting/diarrhea – –Muscle aches – –Lacrimation – –Sweating – –Abdominal cramping – –Insomnia – –Fever

Sedative-Hypnotics Induces varying degrees of CNS depression Categories include barbiturates, nonbarbiturate hypnotics, and antianxiety agents Physiologically and psychologically addicting May generate “psychic drive” for continued use to achieve maximum level of functioning or feeling of well-being

Sedative-Hypnotics (cont’d) Intoxication – –slurred speech – –incoordination/unsteady gait – –nystagmus – –impaired memory; stupor/coma Withdrawal – –diaphoresis; nausea/vomiting – –increased heart rate – –psychomotor agitation; hand tremors; seizures – –insomnia – –hallucinations/illusions

Stimulants Induces varying degrees of CNS stimulation Categories— – –Amphetamines   Pleasurable euphoria followed by profound depression/exhaustion; other intoxication effects are hyperactivity/irritability, combativeness, paranoia, and affective blunting   Toxic psychosis occurs in most chronic users; may be irreversible   Withdrawal symptoms include dysphoria, psychomotor retardation, fatigue, insomnia or hypersomnia, vivid unpleasant dreams, and increased appetite

Stimulants (cont’d) Categories (cont’d)— – –Cocaine   Highly addictive due to intense feelings of euphoria (only lasts about minutes)   Chronic inhalation results in runny nose/sniffles, frequent colds, weight loss, and hyperactivity   Potentially fatal stroke/seizure/heart attack possible (even with first-time use)   Withdrawal symptoms include “crashing” (intense, unpleasant feelings of sadness), fatigue, insomnia or hypersomnia, increased appetite, agitation, psychomotor retardation, and possible suicidal ideation

Stimulants (cont’d) Categories (cont’d)— – –Synthetic stimulants – –Caffeine   Most widely used stimulant (readily available)   Relieves fatigue and increases alertness   Withdrawal symptoms include headache, muscle pain/stiffness, fatigue, anxiety, irritability, depression, impaired psychomotor function – –Nicotine   Widely used stimulant (readily available)   Increases alertness   Withdrawal symptoms include depression, irritability, insomnia, difficulty concentrating, increased appetite

Objective 3 Exploring psychiatric/mental health interventions utilized for the treatment of clients with substance abuse

Major treatment objectives of substance recovery include: Detoxification – –1 st step in the recovery process – –should occur in safe, supportive environment – –may include substitution therapy Intermediate Care – –identification of causes of dependency Rehabilitation – –health promotion/maintenance; outside support – –identification of alternative sources of satisfaction

Treatment modalities for substance-related disorders include: Client/family education Support groups Pharmacotherapy Counseling Group therapy Psychopharmacology for substance intoxication and substance withdrawal

Nursing assessment of clients at risk for alcohol withdrawal symptoms typically includes the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) Determines risk and severity of alcohol withdrawal Used in initial assessment and ongoing monitoring of client’s withdrawal Provides parameters for pharmacological intervention – –Maximum possible score is 67 – –Score below 10 is generally indicative of “safe” withdrawal that does not require medication

Objective 4 Identifying self-help groups available for clients with addictions and alcohol abuse

Alcoholics Anonymous Women for Sobriety – –female alcoholics Al-Anon – –families of alcoholics Adult Children of Alcoholics (ACOA) Narcotics Anonymous Fresh Start – –nicotine addiction Pills Anonymous – –polysubstance addiction

Objective 5 Discussing medications used in the treatment of substance abuse to include their actions and side effects

Disulfiram (Antabuse) Inhibits metabolism of alcohol in the body, producing an uncomfortable, potentially life- threatening reaction to alcohol exposure Taken daily and lasts in the body for up to two weeks Acamprosate (Campral) Maintenance of abstinence from alcohol Ineffective in clients who have not undergone detoxification and not achieved alcohol abstinence prior to initiation Concomitant use with psychosocial therapy

Catapres Assists heroin abuser through detox Non-opiate antihypertensive that partially blocks withdrawal symptoms, but does not completely remove unpleasant feelings associated with withdrawal Naltrexone (ReVia) Does not produce “narcotic high” Non-habit forming “Replaces” heroin or other opiates by binding to the same receptors in the brain that produce feelings of pleasure

Methadone Synthetic opioid used for treatment of heroin addiction Given orally and absorbed slowly so that it does not produce “rush” associated with IV heroin use Alleviates opioid cravings for a short time Dose gradually reduced during detoxification, and client is not told how much of the drug they are being given Use is highly controversial due to “trading one addiction for another”

Narcan Opioid antagonist Counteracts dangerous respiratory depressant effects of heroin or other opiate overdose When given to client under the influence of an opiate, the individual may experience acute withdrawal symptoms