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CH 22 Substance-Related and Addictive Disorders
Practicum In Psychiatric Mental Health Nursing (NUR 334)
University of Rhode Island
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SUBSTANCE DISORDERS
→ Substance disorders are complex diseases of the brain characterized by craving, seeking, and using regardless of consequences → continuous substance use results in alteration in function and structure of brain reward/pleasure center → affected system- limbic system is same affected in anxiety, depression, and schizophrenia (more than half of substance abuse pts have co-occurring mental disorder) → 20% of nurses struggle with a substance abuse problem → 71% of nurses treated for a SUD are employed and sober after 5 years
Substance Use Disorder: a pathological use of a substance that leads to a disorder of use, intoxication, and withdrawal if the substance is taken away Addiction: primary, chronic disease of brain reward, motivation, memory, and related circuitry; dysregulation in hedonic (pleasure seeking) pathway of brain Intoxication: when a person is in the process of using a substance to excess Tolerance: needing increasing amounts of a substance to receive the desired result or finding that using the same amount over time results in a much-diminished affect Withdrawal: a set of physiological symptoms that begin to occur as the concentration of the chemical decreases in an individual’s bloodstream SBIRT⇒ S(creening) B(rief) i(intervention) R(errral) T(o treatment) SMART goal setting⇒ S(pecific) M(easurable) A(chievable) R(ealistic) T(ime bound)
The American Psychiatric Association identifies these substance use disorders⇒ ● Alcohol ● Caffeine ● Cannabis ● Hallucinogens
● Inhalants ● Opioids ● Sedatives, hypnotics, anxiolytics ● Stimulants ● Tobacco (nicotine) ● Anabolic steroids ● Designer drugs ○ MDMA ○ K2 ○ Bath salts ○ GHB ○ Ketamine Behavioral Addictions/ Process addictions: ● Gambling ● Internet gaming ● Social media use ● Shopping ● Sex
Neurobiological Factors -psychoactive substances and certain behaviors can hijack the reward pathway circuit (the nucleus accumbens and the ventral tegmental area which are activated by dopamine) releasing as much as 10 times the amount of dopamine as usual -over time the release of dopamine becomes more important than the reward pathway circuit and the inhibitory function of the frontal cortex is cancelled by the brain leading to craving -the brain response to the imbalance by producing less receptors attempting to reach homeostasis leading to tolerance
Risk Factors Combination of Biological, Psychological, and Social Factors
- hx of chronic stress, trauma, abuse
- poverty
- financial obligations
- low socioeconomic/ educational status
- genetic vulnerability (30-50% increase risk)
- impulsivity
- hx of mood, psychotic, personality disorders, ADHD
- lack of meaningful social support
bradycardia Overdose can be lethal (withdrawal cannot) ALCOHOL mood/behavior changes, reduced coordination, speech impairment, trouble walking, reduction in alertness, impaired judgement, N/V, hypothermia, hypotension, bradycardia, bradypnea
(2-4 days after last drink) Restlessness, irritability, anorexia, tremor, insomnia, impaired cognitive functions, mild perceptual changes, trembling of hands and arms, sweating, tachycardia (above 100), HTN (above 140/90), N/V, hypersensitivity to noise, auditory/visual hallucinations, pyrexia (over 101F), grand mal seizures/tonic-clonic, delirium tremens, infections, hypoglycemia, GI bleeding, hepatic failure, cardiomyopathy, pancreatitis, encephalopathy, death TREATMENT→ benzodiazepines, antipsychotics, fluids, ICU admission possible
STIMULANTS Increased energy, decreased appetite, mental alertness, tachycardia, HTN, dilated pupils, irregular heart beat, chest pains, panic attacks , cocaine bugs (skin sensation), depression, increased risk of heart attack
Depression, hypersomnia, insomnia, fatigue, anxiety, irritability, poor concentration, psychomotor retardation, increased appetite, paranoia, drug craving
Treatment Opioid overdose→ give Narcan Alcohol overdose→ Conscious: induce vomiting w/ Ipecac, administer activated charcoal
Coma/ Unconsciousness: maintain airway, gastric lavage, IV fluids, flumazenil IV, hemodialysis Alcohol withdrawal continued: ⇒ severe autonomic instability with high mortality rate if not treated→ 15-40%; past history of delirium tremens major predictor for future episodes ⇒ seizures→ several hours-2 days after last drink, generalized tonic-clonic seizures (time seizure, cushion head, place on side in recovery position when seizure stops)
ASSESSMENT hint→ how much do you drink everyday? A gallon? A pint? 5 glasses? Alcohol Use Complications→ *thiamine: vitamin B-1 helps brain cells produce energy for sugar Wernicke’s Encephalopathy ● Serious form of thiamine deficiency ● Paralysis of ocular muscles ● Diplopia ● Ataxia ● Somnolence ● Can be fatal Korsakoff psychosis ● Confusion - ● Loss of recent memory ● Leads to alcoholic dementia ● Often happens in pts with wenicke’s encephalopathy
Medications: alcohol→ 1. Disulfiram (Antabuse) a. maintenance treatment b. ingesting alcohol while taking a medication produces a toxic reaction that causes intense N/V, headache, sweating, flushed skin, respiratory difficulties, and confusion c. must be taken consistently for alcohol aversion to be consistent d. Do not take 12 hrs after ingesting alcohol e. Abstain from drinking for at least 2 weeks after stopping medication f. Do not use products containing alcohol (cough medicine, mouthwashes) g. Use wrist ID
OPIOIDS
○ falls ● Genitourinary ○ Sexual dysfunction ○ Infertility ○ Abnormal menses ○ Decreased testosterone ● Urine toxicology ● Pregnancy status
Medications opiates→ 1. Methadone hydrochloride for treatment a. AGONIST b. Sedation side effect c. Safe during pregnancy/ breastfeeding d. Regulated federally (opioid treatment programs) e. Limited access in non-urban areas f. Long halflife 8-59 h g. No ceiling effect, can be abused, take home doses not likely h. Effective relief from withdrawal 2. Buprenorphine for treatment (subutex, oral buprenex, injectable suboxone) a. PARTIAL AGONIST b. Administered through opioid treatment programs or w/in outpt clinics c. Requires prescribers to have an additional license→ trained physicians d. Long half life 24-60 h e. Hard to abuse, take home doses likely f. Lower risk of fatal overdose g. Preferred treatment of pts w/ higher risk of toxicity 3. Naltrexone hydrochloride for treatment (trexan, vivitrol) a. ANTAGONIST b. Long acting c. N/V/D side effect d. Administered via oupt services 4. Clonidine or ativan for withdrawal positive COWS 5. Thiamine, folic acid, multivitamins for withdrawal 6. Narcan (naloxone) for OVERDOSE a. ANTAGONIST b. Reverse opioid effects; can be used for cocaine too c. IN, IM, IV, SQ
d. 30 min half life e. Onset of action w/in 2 minutes f. Indicated for unconscious pt, RR <8, g. Rescue breathing, CPR as indicated
CH 22 Substance-Related and Addictive Disorders
Course: Practicum In Psychiatric Mental Health Nursing (NUR 334)
University: University of Rhode Island
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