Transcript Substance Abuse

Med/Surg Nursing
2013
 Drug-substance
that activates the pleasure
center of the brain*
 Used as a response to stress, low selfesteem, obsessed with food, work, sex,
gambling
 Addictions know no racial, religious, age,
gender or socioeconomic barriers
 Nursing care requires PATIENCE
 APA
definition-“maladaptive pattern of
substance use leading to clinically significant
impairment or distress” with one or more of
the following in a 12 month period:
 Failure to fulfill role obligations
 Use that presents danger to self or others
 Recurrent use-related legal problems*
 Continued use
 Drugs
that are abused include: alcohol,
marijuana, cocaine, methamphetamines, MD
prescribed medications, etc.

Chemical Dependency (substance dependence) as defined by
the APA as those listed above including at least 3 of the
following in a 12 month period:.
 1. Tolerance-need more of the drug to produce desired
effect
 2. Withdrawal-occurs when they stop using, must take the
drug or alcohol to avoid these symptoms
 3. Use larger amounts of the drug
 4. Would like to cut down or quit but can’t
 5. Spend time, energy and money to obtain the drug
 6. Give up their former “important things” in life in order
to use the drug
 7. Continued use of the drug regardless of its effect on the
body (spiritually, mentally, interpersonal relationships)
 Chemical dependencies are often combined with other
behaviors such as gambling
 Dx
Tools: DIS-specific for alcohol; ASIdetermines degree of addiction to any drug
 Chemical dependency can lead to mental
disorders, sexual dysfunction, cirrhosis of the
liver, organic brain damage, and pancreatitis
 Causes:
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Several theories
Physical Factors Theory: excessive consumption is
the most immediate cause of addiction
Use substances to escape from life or to feel
better
Genetic Theory: could possibly be based on
direct biologic transmission or as a learned
childhood behavior
 Emotional
and Psychological Theory: use to
escape from stress, or d/t low self-esteem,
dissatisfaction with life, low tolerance for
frustration, self-destructive tendencies, coexisting mental illness
 Need the drug to feel good about life
 Dual
Disorders:
 Mental illness combined with chemical
dependency (MI/CD)
 Mentally ill clients are usually depressed
 May use drugs to ease the pain or commit suicide
 May experience auditory hallucinations (hear
voices) and use chemicals to make the “voices” go
away
 What the client don’t realize is that alcohol,
sedatives, and narcotics are depressants and this
accelerates the already depressed client’s mood
 Progressive
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Nature: psychological cause
1. Use to feel better, the drugs temporarily relieves the
feelings of low self-worth and stress
2. Use to keep from feeling bad, need increased
amounts to stop feeling sick or depressed, the body
needs the drug
3. Lose control-small amounts of the chemical causes
illness or severe intoxication
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Blackouts occur with excessive use
Need medical attention to save their life!
 **Defense
Mechanisms-most commonly
used
 Denial
 Rationalization
 Projection
 Management
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1.
2.
3.
4.
of Dependency
Recognition
Intervention
Treatment-must be STRUCTURED!!
Recovery
 Nursing
care can be on an outpatient basis,
ECF, special treatment centers and clinics,
and hospitals
 Insurance companies may not reimburse for a
substance abuse Dx so the client may be
listed under another Dx (medical)
 Use
defense mechanisms regularly
 Be aware of withdrawal sx: tremors, anxiety,
agitation
 Interview
Process-see questions to ask on
pg. 1633
 Dealing With an Intoxicated Person in the
Healthcare Facility
CHALLENGING
 Must confirm the drug used by laboratory tests
 Monitor LOC!!
 Obtain a thorough history
 Determine when alcohol or drug was last used
 Document ALL information
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 Dx
test ordered by Md: blood alcohol test (do
not prep site with alcohol) and urine toxicity
(U-tox) which will determine the drugs used
 If a visitor is intoxicated-do not allow them
into the room, notify the charge nurse,
supervisor or security
 Detoxification-process
of removing a drug
and its physiologic effects from the
person’s body
 May take days depending on the drug
used, amount, level of dependence, liver
and kidney function
 Provide comfort and SAFETY during
withdrawal
 Use sedation and emotional support to
allow rest and recuperation
 Detoxification must occur before longterm CD treatment can occur
 Person
wants to stop
 Don’t want to rely on the drug
 Want to cut down on the drug but it is not
possible-must stop!
 May be court ordered and they will be angry
because they may not want to stop
 Need strong peer pressure to stop
 Usually
escorted by the police
 Under medical supervision while in the
center
 Need supportive care and referral to
continuing therapy after detox.
 Isolated
from the substance-oriented
environment
 Recovering abusers usually organize the
program; group therapy
 May be gender specific and focus on male
or female problems
 Goals-address physical and emotional
problems and understand the cycle of
dependence, then they begin the “true”
recovery
 Complete
 Lab
medical work up
work
 Blood chemistry levels to determine vitamin
deficiencies, lipid levels, uric acid levels
 U-tox
 Determine withdrawal behavior-may still ask for the
drug even though they don’t have symptoms
 Must experience withdrawal symptoms-n/v,
tremors, diaphoresis, agitation, anxiety,
hallucinations, h/a, confusion for drugs to be
initiated
 May have medical problems such as esophageal
varices, brain damage, CHF, dyspnea
 Reassess the client at a minimum of q. 1 hour
 Body
is denied access to the drug
 Withdrawal occurs-mild to severe
 Depends on the drug, how much was used
and for how long
 Present with psychological and medical
problems
 **An injury can precipitate withdrawal
 Alcohol
withdrawalmost dangerous
 Often combined
with other drugs
 Detox begins within
72 hours of last
ingestion
 Suicide risk
increases
 TREMORS!!
 Agitation, anxiety
 Diaphoresis
 Delusions
 HTN,
tachycardia,
hyperthermia
 N/V, anorexia
 Seizures
 Hypoglycemia
 Dilated pupils
 Confusion
 Blackouts
 Cardiac arrest
 May cause FAS in
pregnant women
 CD
clients are usually malnourished
 Baseline weight
 May need nutritional supplements
 Refeeding Syndrome
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CHO’s must be given very carefully
This may include dextrose IV solutions, tubefeeding mixtures and liquid dietary supplements!
 Substance
abuser, alcoholic dependent,
chemically dependent or polysubstance
abuser, most people are codependent (live
with others that abuse)
 **Active interventions must occur or
addiction continues!
 12-steps-NA
or AA; teach that the disease is
incurable and is considered to be in
remission
 The
goal is what “Linehan” calls the wise
mind, a midway point between being totally
rational and totally emotional
 They
will need intensive counseling
 Will need to provide support, not encourage
the behavior
 Family recovery can begin even if use
continues*
 Chemically
dependent person needs detox or
intensive CD treatment
 AA and other groups must continue for at
least 2 years
 Public
health problem
 Contributes to over 100,000 deaths/year
 MADD
 DARE
 FAS
 If you drink to often/to much, there are
negative consequences**
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S/S:
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Chronic alcoholics are at risk for suicide
Blood alcohol levels are important to detox programs
Chronic alcoholism can lead to dementia, amnesia,
sleep disorders and psychotic symptoms including
delusions and hallucinations*
Legal level varies state to state
Generally between 0.08-0.10 g/dl
At 0.3 g/dl-person vomits, and may become
aggressive or be in a stupor
At 0.4 g/dl-coma can occur
At 0.5 g/dl-severe respiratory distress and death can
occur
It takes 3-5 glasses of 4 oz wine/hour to reach a BAC
level of 0.08 g/dl(depending on food consumption)
Nurses may draw blood alcohol levels-DON’T USE
ALCOHOL TO CLEAN SITE!!
 S/S:
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CNS depressant
slurred speech
unsteady gait
behavioral changes
confusion
Chronic abusers have may have swollen nose,
spidery veins and thickened and reddened palms
 AST,
ALT, LDH, ALP AND THE GGTP/SCCT
may be used to evaluate liver function
 The GGTP/SGGT is elevated in 75% of
chronic alcoholics
 Thiamine and folate levels are low
\
 RBC’s are often low
 Lipids and uric acid levels may be
increased
 Dietary
Deficiencies-vitamin B1, B9
 Untreated thiamine deficiencies may lead to
severe neurologic disorder called WernickeKorsakoff syndrome. S/S: dementia, ataxia,
somnolence, diplopia, horizontal nystagmus,
mortality rate from this disease is high
 Cirrhosis of the liver and Hepatitis
 Client has malnutrition and decreased
intestinal ability to absorb medications*
 Laennec’s cirrhosis r/t chronic alcohol abuse
 Hepatits C is a result from chronic alcohol
abuse
 Esophageal
varices
 Gastritis
 Gastric
ulcers
 kidney disorders
 CAD
 Sexual impotence-decreased desire/ability to
perform during sex*
 FAS
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Detox and f/u, must have support
program
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Autonomic hyperactivity
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Tachy over 100
Nervous
TREMORS!
insomnia, vivid nightmares
diaphoresis
flushed face
anorexia/nausea
Neuronal excitement
 Sensory-perceptual disturbances
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Severe toxic state is DT’s
S/s include delusions and vivid auditory, visual and
tactile hallucinations called alcohol hallucinosis which
may last from a few days to several weeks
 Vomiting may be present
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Position on side!
Family disease
 the alcoholic family have these characteristics:
 control
 perfectionism
 mistrust of others
 Tension
 Members may have low self esteem!
 overuse defense mechanisms
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 Codependent
is often the person the
alcoholic blames for the entire problem!
 Must understand that alcoholics have a bad
disease but are not bad people*
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Antabuse-used for aversion therapy when the alcoholic is
unable to maintain sobriety
*Loading dose is 500 mg/day for 2 weeks followed by a
daily maintenance dose of about 250 mg
*If the person drinks while taking Antabuse, they become
ill d/t the buildup of acetaldehyde; s/s: flushing, h/a,
dyspnea, hypotension, nausea, tremors, thirst
Do NOT give Antabuse within 12 hours of alcohol ingestion
Naltrexone-Blocking agent used to treat opioid abuse and
as adjunct treatment for alcoholism
Decreases subjective effects of alcohol, which results in
the person drinking less
Don’t use this drug if the client has hepatitis or liver
failure
Must be completely detoxified from coexisting opioids
before beginning treatment
 Includes
barbiturates and antianxiety drugs such
as benzo’s
 Barbiturates
 Amobarbital/Amytal
 Secobarbital/Seconal
 Benzodiazepines
 Alprazolam/Xanax*
 Chlordiazepoxide/Librium
 Diazepam/Valium
 Lorazepam/Ativan
 Others
 Delirium
 Depression
 Slurred
speech
 Amnesia, irreversible dementia
 Respiratory depression
 WITHDRAWAL
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SEIZURES
ANTIDOTE FOR OD-flumazenil/Romazicon
 Date-rape
drug
 Sx of abuse
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Labile
Incontinent
Coma
seizures
 Withdrawal
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Similar to DT’s but vitals are often normal or only
slightly elevated
 Made
from hemp plant and used as
hallucinogens
 SX of abuse
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Dreamy state, characterized by euphoria
Perception of space and time may be distorted
Can induce psychological and physical
dependence!
 Withdrawal
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Diarrhea, ptsosis, rhinorrhea
 heroin
 morphine
 meperidine
HCL (Demerol)
 hydromorphone (Dilaudid)
 Symptoms of Abuse/narcotic intoxication s/s:
drowsiness/coma, slurred speech, bradypnea,
depression, suicide risk
 Withdrawal: sore throat, rhinorrhea, insomnia,
diaphoresis, dilated pupils; more severe: Gi
discomfort, joint and muscle pains
 Naloxone/Narcan is the antidote for narcotic
overdose**
 Naltrexone-before
use, the client must go
through detox from opiates
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Originally developed as a treatment for narcotic
addiction
 Must wait 7 days prior to administration
 If addicted to methadone-must wait 10 days
prior to tx.
 Methadone-opiate analgesic used for the tx
of heroin-dependent individuals, used as a
substitute for heroin-does not produce a
“high”
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Powder is mixed in at least 120 ml of OJ to mask
the taste and dosage of drug
Do well on therapy as long as they don’t continue
to use other drugs
 Can
precipitate withdrawal even if client not
completely detoxified*
 Mood
elevators and appetite depressants and
they combat drowsiness and simple fatigu
 Street
names “ecstasy”, “crystal meth”
 S/S of abuse: euphoria, confusion, anger,
poor judgement
 Withdrawal: depression, paranoid
psychosis, nightmares, increased appetite
 Tweaking
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Meth user who has not slept for days and is in
acute withdrawal
 Use
cocaine to feel better*
 Symptoms of abuse:
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Sexual dysfunction
Sleep disorders
Delirium and mood and anxiety disorders
Hallucinations
Withdrawal
intensive care or 1:1 staffing!
 Stimulant
 Abuse
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Euphoric and stimulant effects
Appear emotionally unstable
Induces psychosis, including hallucinations and a
feeling of being liberated from space and time
 Withdrawal
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Drowsy
Hallucinations
Lethargy
Mild depression
 Not
believed to cause actual or physical
dependence, but produce psychological
dependence and mild tolerance
 LSD/Mescaline and Mushroom
Auditory hallucinations and intense visual
hallucinations
 Objects may appear larger-macropsia or smallermicropsia
Phencyclidine Hydrochloride
hallucinogens developed as an animal anesthetic
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 Volatile
substances are CNS depressants that
when inhaled produce altered states of
consciousness and varied degrees of
intoxication
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Boppers, gluey, locker room, moon gas, poppers
and is very dangerous
Causes addiction
Death can result from sudden cardiac arrest,
suffocation, burns or aspiration of vomitus
Derive from testosterone
 Promote growth of muscle and increase lean
body mass
 Take steroids intermittently
 Side effects: liver damage, cancer, edema,
fatigue and insomnia
 May experience mood lability and paranoia
 Death can occur
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 Found
in cigarettes and snuff
 Smokers have a higher than normal risk of
cancer of the stomach, kidney, pancreas,
bladder, or skin
 Nicotine also contributes to heart and blood
vessel disorders
 Cigarette smoke binds with hemoglobin to
diminish the bloods oxygen carrying capacity
reducing tissue oxygenation
 Verenicline tartrate/Chantix is a nicotine
receptor antagonist
 Found
in coffee, tea, chocolate, soft drinks
 CNS stimulant
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Does not reverse alcohols intoxicating or
depressant effects and may actually add to
depression*
 Heart
rate increases and may become
irregular
 Aggravation of cystic breast disease
 Available
without a RX
 Can be abused if taken in large doses and
more frequently than normal
Pregnant Women: drugs, alcohol, caffeine and
nicotine can complicate pregnancy
 Babies are preterm, subject to physical and or
mental disorders
 Adolescents: Peer pressure and low self-esteem
are problems, cigarette smoking and alcohol are
on the rise
 Older Adults: Seniors may “double dose”,
attempt suicide with medications and may
overuse antacids
 Nurses: Drugs are available in healthcare
facilities, 50% more likely to become chemically
dependent than the general population
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