Substance-Related Substance-Related DisordersDisorders

West Coast UniversityWest Coast University

NURS 204NURS 204

OverviewOverview

Addiction to psychoactive substances is a Addiction to psychoactive substances is a worldwide health problemworldwide health problem

Addiction is one of the most serious public Addiction is one of the most serious public health problems in the UShealth problems in the US

Alcohol, by far is the leading substance Alcohol, by far is the leading substance abused by Americansabused by Americans

Epidemiolgy of AlcoholEpidemiolgy of Alcohol

About two-thirds of American adults consume About two-thirds of American adults consume alcohol; about 14% of them develop problems with alcohol; about 14% of them develop problems with dependencedependence

Roughly one-third of all hospital admissions are Roughly one-third of all hospital admissions are related to alcohol abuserelated to alcohol abuse

The divorce rate for couples with and alcoholic The divorce rate for couples with and alcoholic spouse is seven times greater than that for other spouse is seven times greater than that for other couplescouples

Approximately one-half of all traffic accidents are Approximately one-half of all traffic accidents are alcohol relatedalcohol related

Substance-Related DisordersSubstance-Related Disorders

Substance abuse - repeated use of substances Substance abuse - repeated use of substances that is maladaptivethat is maladaptive

Substance dependenceSubstance dependence Tolerance: needing increased amount of a substanceTolerance: needing increased amount of a substance Withdrawal: uncomfortable physiologic and cognitive Withdrawal: uncomfortable physiologic and cognitive

behavioral changesbehavioral changes

Substance intoxication: reversible syndrome of Substance intoxication: reversible syndrome of maladaptive physiologic and behavioral changes maladaptive physiologic and behavioral changes that are due to the effect of a substancethat are due to the effect of a substance

Biopsychosocial TheoriesBiopsychosocial Theories

BiologicBiologic GeneticGenetic PsychologicalPsychological SocioculturalSociocultural Family systemsFamily systems

Populations at RiskPopulations at Risk

TeenagersTeenagers Psychiatric clientsPsychiatric clients WomenWomen General hospital clientsGeneral hospital clients Older AdultsOlder Adults Adult Children of AlcoholicsAdult Children of Alcoholics Health Care ProvidersHealth Care Providers

AlcoholAlcohol

Physical effects: Slurred speech, lack of Physical effects: Slurred speech, lack of coordination, unsteady gait, blackouts, nystagmus coordination, unsteady gait, blackouts, nystagmus flushed face, sense of floating, and anorexiaflushed face, sense of floating, and anorexia

Psychological effects: euphoria, mood lability, Psychological effects: euphoria, mood lability, impaired judgment, sexual inhibition, decreased impaired judgment, sexual inhibition, decreased concentration, aggressive behaviorconcentration, aggressive behavior

Withdrawal effects: Anxiety, agitation, and Withdrawal effects: Anxiety, agitation, and irritability, tremors, tachycardia, hypertension, irritability, tremors, tachycardia, hypertension, diaphoresis, hallucinations, N/V, diarrhea, delirium diaphoresis, hallucinations, N/V, diarrhea, delirium tremenstremens

Wernicke-Korsakoff SyndromeWernicke-Korsakoff Syndrome

Results from a deficiency in vitamin B Results from a deficiency in vitamin B complex (most commonly a thiamine complex (most commonly a thiamine deficiency)deficiency)

Severely impairs cognitive functioningSeverely impairs cognitive functioning Produces peripheral neuropathy, cerebellar Produces peripheral neuropathy, cerebellar

ataxia, confabulation, and myopathiesataxia, confabulation, and myopathies Death can occur if thiamine replacement Death can occur if thiamine replacement

therapy is not initiated immediatelytherapy is not initiated immediately

Effects of AlcoholismEffects of Alcoholism

Alcohol-induced persisting amnestic Alcohol-induced persisting amnestic disorderdisorder

Alcohol encephalopathyAlcohol encephalopathy Fetal alcohol syndromeFetal alcohol syndrome Suicide and alcoholism Suicide and alcoholism

Nursing ImplicationsNursing Implications

Monitor the patient’s vital signs and behaviorMonitor the patient’s vital signs and behavior Seek a physician’s order for a Seek a physician’s order for a

benzodiazepine to decrease withdrawal benzodiazepine to decrease withdrawal symptomssymptoms

Close observationClose observation Promote sleep and restPromote sleep and rest Institute seizure precautionsInstitute seizure precautions Encourage fluidsEncourage fluids

CAGE QuestionaireCAGE Questionaire

Consist of four questionsConsist of four questions Have you ever felt you should cut down on your Have you ever felt you should cut down on your

drinking?drinking? Have people annoyed you by criticizing your Have people annoyed you by criticizing your

drinkingdrinking Have you ever felt bad or guilty about your Have you ever felt bad or guilty about your

drinking?drinking? Have you ever had a drink first thing in the Have you ever had a drink first thing in the

morning to steady nerves or get rid of a morning to steady nerves or get rid of a hangover (eye-opener)?hangover (eye-opener)?

Pharmacology TreatmentPharmacology Treatment

Benzodiazepines: Valium and Librium for Benzodiazepines: Valium and Librium for withdrawal symptomswithdrawal symptoms

Disulfiram (Antabuse): inhibits Acetaldehyde Disulfiram (Antabuse): inhibits Acetaldehyde DehydrogenaseDehydrogenase

Naltrexone (Re Via, Trexan): block the need Naltrexone (Re Via, Trexan): block the need to ingest alcoholto ingest alcohol

Barbiturates and Barbiturates and Sedatives/HypnoticsSedatives/Hypnotics

Physical effects: Drowsiness, fatigue, orthostatic Physical effects: Drowsiness, fatigue, orthostatic hypotension, anorexia, slurred speech, ataxia, hypotension, anorexia, slurred speech, ataxia, seizure, dizzinessseizure, dizziness

Psychological effects: Euphoria, irritability, anxiety, Psychological effects: Euphoria, irritability, anxiety, poor memory and understanding, delirium, poor memory and understanding, delirium, depressed mood, violencedepressed mood, violence

Withdrawal effects: N/V, generalized malaise, Withdrawal effects: N/V, generalized malaise, tachycardia, excessive sweating, anxiety, tachycardia, excessive sweating, anxiety, irritablity, ortho hypotension, insomnia, seizures, irritablity, ortho hypotension, insomnia, seizures, coarse tremorscoarse tremors

Nursing ImplicationNursing Implication

Monitor vital signsMonitor vital signs Close observationClose observation Promote sleep and restPromote sleep and rest Offer fluids and light foods as toleratedOffer fluids and light foods as tolerated Administer medication, if ordered, to wean Administer medication, if ordered, to wean

the patientthe patient Institute seizure precautionsInstitute seizure precautions

OpioidsOpioids

Physical effects: pinhole pupils, skin picking, Physical effects: pinhole pupils, skin picking, sleepiness, anorexiasleepiness, anorexia

Psychological effects: Anxiety, impaired Psychological effects: Anxiety, impaired cognition, delirium, euphoriacognition, delirium, euphoria

Withdrawal effects: lacrimation, rhinorrhea, Withdrawal effects: lacrimation, rhinorrhea, excessive sweating, yawning, tachycardia, excessive sweating, yawning, tachycardia, fever, insomnia, muscle aches, craving, fever, insomnia, muscle aches, craving, N/V, dilated pupils, chillsN/V, dilated pupils, chills

Nursing ImplicationsNursing Implications

Monitor vital signsMonitor vital signs Close observationClose observation Offer fluids and light food as toleratedOffer fluids and light food as tolerated Keep environment nondistracting and Keep environment nondistracting and

soothingsoothing Methadone maintenance as orderedMethadone maintenance as ordered

AmphetaminesAmphetamines

Physical effects: anorexia, arrhythmia, Physical effects: anorexia, arrhythmia, restlessness, tremors, dizziness, generalized restlessness, tremors, dizziness, generalized tonic-clonic seizures, dry mouth, dilated pupils, tonic-clonic seizures, dry mouth, dilated pupils, hyperactive reflexes, tachycardiahyperactive reflexes, tachycardia

Psychological effects: Labile affect, anxiety, Psychological effects: Labile affect, anxiety, delirium, euphoria, violence, hallucinations, delirium, euphoria, violence, hallucinations, irritabilityirritability

Withdrawal effects: Depression, fatigue, agitation, Withdrawal effects: Depression, fatigue, agitation, suicidal thought, paranoia, insomnia or suicidal thought, paranoia, insomnia or hypersomnia, disorientationhypersomnia, disorientation

Nursing ImplicationNursing Implication

Promote sleep and restPromote sleep and rest Monitor vital signsMonitor vital signs Monitor suicidal ideationMonitor suicidal ideation Antidepressant, if orderedAntidepressant, if ordered Remain with a frightened or disoriented Remain with a frightened or disoriented

patientpatient Orient the patient to realityOrient the patient to reality

CannabisCannabis

Derived from an Indian hemp plant Derived from an Indian hemp plant (Cannabis sativa)(Cannabis sativa)

Marijuana contains psychoactive substance Marijuana contains psychoactive substance (delta 6-3,4-tetrahydrocannabinol)(delta 6-3,4-tetrahydrocannabinol)

THC is stored in the fatty tissues (especially THC is stored in the fatty tissues (especially in the brain and reproductive system)in the brain and reproductive system)

THC can be detected in the body for up to 6 THC can be detected in the body for up to 6 weeks.weeks.

CannabisCannabis

Analgesic effectAnalgesic effect Effective against nausea and vomitingEffective against nausea and vomiting Treat weight lossTreat weight loss Dronabinol is a synthetic THC approved by Dronabinol is a synthetic THC approved by

the FDA.the FDA.

CannabisCannabis

Physical effects: slowed speech, slowed Physical effects: slowed speech, slowed reflexes, red eyes, dry mouth, increased reflexes, red eyes, dry mouth, increased appetite, lower testosterone, 70% more appetite, lower testosterone, 70% more benzopyrene (major cancer causing benzopyrene (major cancer causing chemical, emphysema).chemical, emphysema).

Psychological effects: apathy, reduced Psychological effects: apathy, reduced inhibition, altered stated of awarenessinhibition, altered stated of awareness

Withdrawal effects: Anxiety and restlessnessWithdrawal effects: Anxiety and restlessness

Nursing ImplicationNursing Implication

Help patient with memory loss to fill in gaps Help patient with memory loss to fill in gaps of informationof information

Attend to self-care needs that a lethargic or Attend to self-care needs that a lethargic or apathetic patient may have neglectedapathetic patient may have neglected

CocaineCocaine

Extracted from the leaves of the coca plant, Extracted from the leaves of the coca plant, found in Bolivia and Peru.found in Bolivia and Peru.

Stimulant and decreases appetite.Stimulant and decreases appetite. Ingredient in Coca-cola until 1903. Ingredient in Coca-cola until 1903. Used as a local anesthetic.Used as a local anesthetic. Not physically addicting by psychologically Not physically addicting by psychologically

addicting.addicting. Develop toleranceDevelop tolerance

Cocaine IntoxicationCocaine Intoxication

Similar to alcohol withdrawal: sweating, Similar to alcohol withdrawal: sweating, dilated pupils, psychomotor agitation, dilated pupils, psychomotor agitation, increase BP and HR, high fever, arrythmias, increase BP and HR, high fever, arrythmias, seizures, hallucinations seizures, hallucinations

The “Post-Coke” BluesThe “Post-Coke” Blues

Cocaine TreatmentCocaine Treatment

Diazepan (Valium) Diazepan (Valium) PhenobarbitalPhenobarbital Imipramine hydrochloride (Tofranil)Imipramine hydrochloride (Tofranil) Propranolol (Inderal)Propranolol (Inderal) Bromocriptine (Parlodel)Bromocriptine (Parlodel) Amantadine (Symmetrel)Amantadine (Symmetrel)

HallucinogesHallucinoges

Physical effects: Hyperactive reflexes, tachycardia, labile Physical effects: Hyperactive reflexes, tachycardia, labile mood, anorexia, hypertension, dizzinessmood, anorexia, hypertension, dizziness Lysergic acid diethylamide (LSD): anxiety, sleep disturbance, Lysergic acid diethylamide (LSD): anxiety, sleep disturbance,

tremors, and dilated pupilstremors, and dilated pupils Phecyclidne (PCP): slurred speech, blank stare, irritability, seizures, Phecyclidne (PCP): slurred speech, blank stare, irritability, seizures,

nystagmus, violence, ataxia, delirium, depression, fatigue, memory nystagmus, violence, ataxia, delirium, depression, fatigue, memory loss, poor impulse controlloss, poor impulse control

Peyote used in religious ritualsPeyote used in religious rituals Psilocybin “magic mushroomsPsilocybin “magic mushrooms””

Psychological effects: euphoria, restlessness, Psychological effects: euphoria, restlessness, suspiciousness, hallucinationsuspiciousness, hallucination

Withdrawal effects: No physical withdrawal symptoms for Withdrawal effects: No physical withdrawal symptoms for LSD, PCP: depression, lethargy, cravingLSD, PCP: depression, lethargy, craving

InhalantsInhalants

Physical effects: dizziness and Physical effects: dizziness and lightheadedness lightheadedness

Psychological effects: euphoria and Psychological effects: euphoria and excitementexcitement

Withdrawal effects: noneWithdrawal effects: none

NicotineNicotine

Psychoactive stimulating substance found in Psychoactive stimulating substance found in tobacco.tobacco.

Occupies the receptors for acetylcholine in Occupies the receptors for acetylcholine in both dopamine and serotonin neural both dopamine and serotonin neural pathwayspathways

Associated with cancer, heart disease, Associated with cancer, heart disease, emphysema, hypertension and deathemphysema, hypertension and death

CaffeineCaffeine

Acts acts as a stimulantActs acts as a stimulant Found in coffee, tea, and chocolateFound in coffee, tea, and chocolate 64 mg in instant coffee, 112 mg in filtered 64 mg in instant coffee, 112 mg in filtered

coffee, 40 mg in tea, 7 mg chocolate, 40 mg coffee, 40 mg in tea, 7 mg chocolate, 40 mg cola drinks, 80 mg in Red Bullcola drinks, 80 mg in Red Bull

Diuretic, increases cholesterol and LDLDiuretic, increases cholesterol and LDL Withdrawal symptoms: irritability and Withdrawal symptoms: irritability and

headachesheadaches

Treatment ApproachesTreatment Approaches

PharmacologicalPharmacological DetoxificationDetoxification In-facility treatmentIn-facility treatment Specialty hospital careSpecialty hospital care Residential rehabilitationResidential rehabilitation Extended residential careExtended residential care Outpatient (Day) treatmentOutpatient (Day) treatment Self-help groupsSelf-help groups Twelve-step programs (AA)Twelve-step programs (AA)

Dual Diagnosis ChallengesDual Diagnosis Challenges

Psychiatric clients are vulnerable to Psychiatric clients are vulnerable to substance use and abusesubstance use and abuse

Treatment must address both problemsTreatment must address both problems Specialized treatment programsSpecialized treatment programs

InterventionsInterventions

Confrontation strategiesConfrontation strategies EducationEducation Referral and self-help groupsReferral and self-help groups Lifestyle changeLifestyle change Family – Al-nonFamily – Al-non

Relapse PreventionRelapse Prevention

Relapse is commonRelapse is common Recognize symptoms of relapseRecognize symptoms of relapse Relapse prevention groupsRelapse prevention groups Levels of addiction preventionLevels of addiction prevention

Primary: education programsPrimary: education programs Secondary: early identification of and Secondary: early identification of and

intervention intervention Tertiary: rehabilitationTertiary: rehabilitation

Outcome CriteriaOutcome Criteria

Abstinence from alcohol and drugsAbstinence from alcohol and drugs CopingCoping Decision-makingDecision-making Impulse controlImpulse control

Maintaining Therapeutic Maintaining Therapeutic OptimismOptimism

Substance abuse is a chronic relapsing Substance abuse is a chronic relapsing condition.condition.

The power of a therapeutic relationshipThe power of a therapeutic relationship Talk to people in recovery.Talk to people in recovery. Talk to clients about spirituality.Talk to clients about spirituality. Find mentors.Find mentors. Take care of yourself!Take care of yourself!

Review QuestionReview Question

Ten hours after admission to the ICU following an auto accident, a client begins to exhibit mild tachycardia, irritability, and tremors. Three hours later the client has a grand mal seizure. The staff suspect that the client has A. Undetected internal bleeding. B. Korsakoff's syndrome. C. Alcohol withdrawal syndrome. D. Wernicke's encephalopathy.

Review QuestionReview Question

The nurse is taking the history of a psychiatric client suspected of abusing alcohol. Which assessment question is best to ask? A. When was your last drink? B. Do you drink regularly? C. Who are your drinking partners? D. Are you experiencing blackouts?

Review QuestionReview Question

Which is the priority intervention for a client admitted with acute alcohol intoxication? A. Place the client in seizure precaution.

B. Restrain the client when restless and agitated.

C. Darken the room. D. Monitor vital signs frequently.

Review QuestionReview Question

The nurse anticipates that a client who has sedative The nurse anticipates that a client who has sedative hypnotic dependence will experience withdrawal hypnotic dependence will experience withdrawal symptoms. The nurse should assess for the onset symptoms. The nurse should assess for the onset of which set of symptoms? of which set of symptoms? A.A. Nausea and vomiting, sweating, anxiety, and Nausea and vomiting, sweating, anxiety, and

coarse tremorscoarse tremors

B.B. Runny nose, diarrhea, yawningRunny nose, diarrhea, yawning

C.C. Depression, restlessness, disorientationDepression, restlessness, disorientation

D.D. Craving, hypersomnia, irritabilityCraving, hypersomnia, irritability

Review QuestionReview Question

An adolescent client presented to the emergency room An adolescent client presented to the emergency room after ingesting LSD that produced a bad trip. The drug’s after ingesting LSD that produced a bad trip. The drug’s effects wore off after 10 hours. What health teaching effects wore off after 10 hours. What health teaching should be provided to the client before discharge?should be provided to the client before discharge?

1.1. Information about the risks of narcotic useInformation about the risks of narcotic use

2.2. Information about the risks of cocaine useInformation about the risks of cocaine use

3.3. Information about the carcinogenic effects of Information about the carcinogenic effects of marijuanamarijuana

4.4. Information about flashbacks Information about flashbacks

Review QuestionReview Question

Which of the following treatment approaches Which of the following treatment approaches would be most appropriate in helping a client would be most appropriate in helping a client maintain long-term smoking cessation?maintain long-term smoking cessation?

1.1. Bupropion (Zyban)Bupropion (Zyban)

2.2. Nicotine patchNicotine patch

3.3. Nicotine gumNicotine gum

4.4. Counseling Counseling

Review QuestionReview Question

The nurse anticipates that a client who has The nurse anticipates that a client who has sedative hypnotic dependence will experience sedative hypnotic dependence will experience withdrawal symptoms. The nurse should assess withdrawal symptoms. The nurse should assess for the onset of which set of symptoms? for the onset of which set of symptoms?

1.1. Nausea and vomiting, sweating, anxiety, and Nausea and vomiting, sweating, anxiety, and coarse tremorscoarse tremors

2.2. Runny nose, diarrhea, yawningRunny nose, diarrhea, yawning

3.3. Depression, restlessness, disorientationDepression, restlessness, disorientation

4.4. Craving, hypersomnia, irritability Craving, hypersomnia, irritability