Chapter 018

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Transcript Chapter 018

Addictive Disorders
CHAPTER 18
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Overview
 Addiction to psychoactive substances
is a worldwide health problem
 Addiction is one of the most serious
public health problems in the US
 Alcohol, by far is the leading substance
abused by Americans
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Tolerance and Withdrawal
Tolerance
• Person’s physiological reaction to drug
decreases with repeated administration
of same dose
Withdrawal
• Psychological changes occur when
blood and tissue concentrations of
drug decrease after heavy prolonged
use of substance
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Synergistic and Antagonistic
• Synergistic effect – when drugs are
taken together, effect of either or both
is intensified or prolonged
• Antagonistic effects – when drugs are
taken together, effect of one is
inhibited or weakened
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Comorbidity
• Psychiatric comorbidity – 6 out of 10
people affected by substance-abuse
disorder also affected by mental health
disorder
• Medical comorbidity – alcohol-related
medical problems are the comorbidities
most commonly seen in medical
settings
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Etiology
• Biological factors
– Specific effects on neurotransmitter systems
• Psychological factors
– Lack of tolerance for frustration and pain
– Lack of success in life
– Lack of affectionate and meaningful relationships
– Low self-esteem, lack of self-regard
– Risk-taking propensity
• Sociocultural factors
– Social and cultural norms
– Socioeconomic stress
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Epidemiolgy of Alcohol
 About two-thirds of American adults consume
alcohol; about 14% of them develop problems
with dependence
 Roughly one-third of all hospital admissions
are related to alcohol abuse
 The divorce rate for couples with and alcoholic
spouse is seven times greater than that for
other couples
 Approximately one-half of all traffic accidents
are alcohol related
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General Assessment
•
Two questions of importance
1. In the last year, have you ever drank or used
drugs more than you meant to?
2. Have you felt you wanted or needed to cut down
on your drinking or drug use in the last year?
•
Details include
– Drugs used
• Route
• Quantity
• Time of last use
• Usual pattern of use
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Psychological Changes
• Denial
• Depression
• Anxiety
• Dependency
• Hopelessness
• Low self-esteem
• Various psychiatric disorders
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Alcohol
 Physical effects: Slurred speech, lack of
coordination, unsteady gait, blackouts,
nystagmus flushed face, sense of floating, and
anorexia
 Psychological effects: euphoria, mood lability,
impaired judgment, sexual inhibition,
decreased concentration, aggressive behavior
 Withdrawal effects: Anxiety, agitation, and
irritability, tremors, tachycardia, hypertension,
diaphoresis, hallucinations, N/V, diarrhea,
delirium tremens
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Signs of Intoxication
and Withdrawal
• Alcohol poisoning
– Large amounts of alcohol consumed quickly or
over time
• Alcohol withdrawal
– Signs develop within a few hours after cessation
– Peaks at 24 to 48 hours
• Alcohol withdrawal delirium
– Medical emergency
– Can result in death, even if treated
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Wernicke-Korsakoff Syndrome
 Results from a deficiency in vitamin B
complex (most commonly a thiamine
deficiency)
 Severely impairs cognitive functioning
 Produces peripheral neuropathy, cerebellar
ataxia, confabulation, and myopathies
 Death can occur if thiamine replacement
therapy is not initiated immediately
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Effects of Alcoholism
 Alcohol-induced persisting amnestic
disorder
 Alcohol encephalopathy
 Fetal alcohol syndrome
 Suicide and alcoholism

norepinephrine =

GABA leads to risk of seizure
BP, HR
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CAGE Questionaire
 Consist of four questions
 Have you ever felt you should cut down on
your drinking?
 Have people annoyed you by criticizing
your drinking
 Have you ever felt bad or guilty about your
drinking?
 Have you ever had a drink first thing in the
morning to steady nerves or get rid of a
hangover (eye-opener)?
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Nursing Implications
 Monitor the patient’s vital signs and
behavior
 Seek a physician’s order for a
benzodiazepine to decrease withdrawal
symptoms
 Close observation
 Promote sleep and rest
 Institute seizure precautions
 Encourage fluids
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Pharmacology Treatment
 Benzodiazepines: Valium, Ativan and
Librium for withdrawal symptoms
 Disulfiram (Antabuse): inhibits
Acetaldehyde Dehydrogenase
 Alcohol-disulfiram reaction causes unpleasant
physical effects
 Naltrexone (ReVia, Trexan): block the need
to ingest alcohol. Vivitrol-IM (monthly)
 Opiate antagonist. Blocks euphoric reinforcement
produced by substance and prevents craving
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Pharmacology Treatment
 Acamprosate – (Camprol): Stabilizes NMethyl-D-Aspartate (NMDA) receptor
causing decrease of
glutamatergic/excitatory system
 Topiramate (Topamax): actions on
glutamatergic system to decrease
alcohol cravings
 SSRI’s: may decrease drinking in late
onset alcoholism
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• A nurse is assigned the care of four
patients detoxifying from alcohol. The
patient with which symptom would be
the nurse’s highest priority?
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a. Fine-motor tremors
b. Diaphoresis
c. Diarrhea
d. Hallucinations and delusions
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Central Nervous System
Stimulants
Common signs of stimulant abuse
– Dilation of the pupils
– Dryness of the oronasal cavity
– Excessive motor activity
Cocaine and crack
Caffeine and nicotine
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Cocaine and Crack
• Extracted from leaf of coca plant, found in
Bolivia and Peru.
• When smoked, takes effect in 4 to 6 seconds; a
5- to 7-minute high follows, then a deep
depression
• Two main effects on body
– Anesthetic
– Stimulant
• Produces imbalance in neurotransmitters
• Withdrawal symptoms include
– Depression, paranoia, lethargy, anxiety, insomnia,
nausea, vomiting, sweating, chills
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Cocaine
 Stimulant and decreases appetite.
 Ingredient in Coca-cola until 1903.
 Used as a local anesthetic.
 Develop tolerance
 Intoxication
 Similar to alcohol withdrawal: sweating, dilated
pupils, psychomotor agitation, increase BP and
HR, high fever, arrythmias, seizures,
hallucinations
 The “Post-Coke” Blues
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Pharmacological Treatment
 Diazepan (Valium)
 Phenobarbital
 Imipramine hydrochloride (Tofranil)
 Propranolol (Inderal)
 Bromocriptine (Parlodel)
 Amantadine (Symmetrel)
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Opiates
 Physical effects: pinhole pupils, skin
picking, sleepiness, anorexia
 Psychological effects: Anxiety,
impaired cognition, delirium, euphoria
 Withdrawal effects: lacrimation,
rhinorrhea, excessive sweating,
yawning, tachycardia, fever, insomnia,
muscle aches, craving, N/V, dilated
pupils, chills
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Opiates
• Morphine
• Heroin
• Codeine
• Fentanyl
• Methadone
• Meperidine
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Pharmacological Interventions
Treatment of Opioid Addiction
• Methadone (Dolophine)
– Synthetic opiate blocks craving for and effects of heroin
• LAAM (l-α-acetylmethadol)
– An alternative to methadone
• Naltrexone (ReVia)
– Antagonist that blocks euphoric effects of opioids
• Clonidine (Catapres)
– Effective somatic treatment when combined with
naltrexone
• Buprenorphine (Subutex)
– Blocks signs and symptoms of opioid withdrawal
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Nursing Implication
• Monitor vital signs
• Close observation
• Offer fluids and light food as tolerated
• Keep environment nondistracting and soothing
• Methadone (dolophine) maintenance
• Levomethadyl (Orlaam) administered 3 times a
week
• Clonodine: reduces autonomic hyperactivity
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Barbiturates and
Sedatives/Hypnotics
 Physical effects: Drowsiness, fatigue,
orthostatic hypotension, anorexia, slurred
speech, ataxia, seizure, dizziness
 Psychological effects: Euphoria, irritability,
anxiety, poor memory and understanding,
delirium, depressed mood, violence
 Withdrawal effects: N/V, generalized
malaise, tachycardia, excessive sweating,
anxiety, irritablity, ortho hypotension,
insomnia, seizures, coarse tremors
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Amphetamines
 Physical effects: anorexia, arrhythmia,
restlessness, tremors, dizziness,
generalized tonic-clonic seizures, dry
mouth, dilated pupils, hyperactive reflexes,
tachycardia
 Psychological effects: Labile affect, anxiety,
delirium, euphoria, violence, hallucinations,
irritability
 Withdrawal effects: Depression, fatigue,
agitation, suicidal thought, paranoia,
insomnia or hypersomnia, disorientation
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Nursing Implication
 Promote sleep and rest
 Monitor vital signs
 Monitor suicidal ideation
 Antidepressant, if ordered
 Remain with a frightened or disoriented
patient
 Orient the patient to reality
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Marijuana (Cannabis sativa)
• Indian hemp plant
• Tetrahydrocannabinol (THC) is active
ingredient
 THC is stored in the fatty tissues
(especially in the brain and reproductive
system)
 THC can be detected in the body for up to
6 weeks
 Depressant and hallucinogenic properties
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Marijuana (Cannabis sativa)
• Usually smoked
• Desired effects – euphoria, detachment,
relaxation
• Long-term effects – lethargy, anhedonia,
difficulty concentrating, loss of memor
 Analgesic effect
 Effective against nausea and vomiting
 Treat weight loss
 Marinol (Dronabinol) is a synthetic THC
approved by the FDA for anorexia.
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Marijuana (Cannabis sativa)
 Physical effects: slowed speech,
slowed reflexes, red eyes, dry mouth,
increased appetite, lower testosterone,
70% more benzopyrene (major cancer
causing chemical, emphysema).
 Psychological effects: apathy, reduced
inhibition, altered stated of awareness
 Withdrawal effects: Anxiety and
restlessness
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Salvia
 Salvia divinorum: large green leaves, hollow
square stems, and white flowers.
 Can be chewed, can drink the extracted
juices, or smoked through water pipes and
inhaled.
 Hallucinatory experience, paranoia and loss
of physical coordination
 Users feel giddiness and disorientation.
 Sometimes used in combination with other
substances, such as alcohol.
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Nursing Implication
 Help patient with memory loss to fill in
gaps of information
 Attend to self-care needs that a
lethargic or apathetic patient may have
neglected
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Hallucinogens
• Lysergic acid diethylamide (LSD or acid)
• Mescaline (peyote)
• Psilocybin (magic mushroom)
• Phencyclidine piperidine (PCP, angel
dust, horse tranquilizer, peace pill)
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Hallucinogens
 Physical effects: Hyperactive reflexes, tachycardia,
labile mood, anorexia, hypertension, dizziness
 Lysergic acid diethylamide (LSD): anxiety, sleep
disturbance, tremors, and dilated pupils
 Phecyclidne (PCP): slurred speech, blank stare, irritability,
seizures, nystagmus, violence, ataxia, delirium, depression,
fatigue, memory loss, poor impulse control
 Psychological effects: euphoria, restlessness,
suspiciousness, hallucinations
 Withdrawal effects: No physical withdrawal
symptoms for LSD, PCP: depression, lethargy,
craving
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Inhalants
• Volatile solvents
– Spray paint
– Glue
– Cigarette lighter fluid
– Propellant gases used in aerosols
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Inhalants
 Physical effects: dizziness and
lightheadedness
 Psychological effects: euphoria and
excitement
 Withdrawal effects: none
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“Bath Salt”
 “Bath Salt”
Methylenedioxypyrovalerone (MDPV)
 Agitation
 Paranoia
 Hallucinations
 Chest pain
 Suicidality
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Nicotine
 Psychoactive stimulating substance
found in tobacco.
 Extremely addictive
 Occupies the receptors for acetylcholine
in both dopamine and serotonin neural
pathways (acts on brain reward
mechanisms)
 Associated with cancer, heart disease,
emphysema, hypertension and death
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Smoking
 1 cigarette = 14 mins.
 10 pack = 2hours 20 mins
 20 pack = 4 hours 40 mins
 If you smoke 20 a day, which is the
norm, for 20 years of your life, you will
take 3 years, and 10 months off your
life !!!!
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Smoking Cessation
 Varenicline (Chantix) partial agonist at
nicotinic receptors
 Bupropion (Zyban) increase dopamine
to decrease cravings
 Transdermal patch – steady levels of
nicotine, desensitizes receptors to
relieve craving.
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Caffeine
 Acts as a stimulant
 Found in coffee, tea, and chocolate
 64 mg in instant coffee, 112 mg in filtered
coffee, 40 mg in tea, 7 mg chocolate, 40
mg cola drinks, 80 mg in Red Bull
 Diuretic, increases cholesterol and LDL
 Withdrawal symptoms: irritability and
headaches
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Club Drugs
• Common drugs
– Ecstasy - also called MDMA, Adam, yaba,
XTC
– MDA – “love”
– MDE – “Eve”
• Produce subjective effects resembling
stimulants and hallucinogens
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Date Rape Drugs
• Flunitrazepam (Rohypnol or “roofies”)
• Gamma hydroxybutyric acid (GHB)
• Rapidly produce
– Disinhibition
– Relaxation of voluntary muscles
– Anterograde amnesia
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Assessment Guidelines
for the Chemically Impaired
• Assess for withdrawal syndrome
• Assess for overdose that warrants medical
attention
• Assess for suicidal thoughts or other selfdestructive behaviors
• Evaluate for physical complications related to
drug abuse
• Explore interests in doing something about
drug or alcohol problem
• Assess patient and family for knowledge of
community
resources
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Potential Nursing Diagnoses
• Imbalanced nutrition: less than body
requirements
• Disturbed thought processes
• Disturbed sleep patterns
• Ineffective health maintenance
• Hopelessness
• Risk for suicide
• Risk for other-directed violence
• Ineffective airway clearance
• Ineffective breathing pattern
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Outcomes Identification
• Withdrawal
– Fluid balance
– Neurological status: consciousness
– Distorted thought self-control
• Initial and active drug treatment
– Risk control – alcohol use
– Risk control – drug use
– Substance addiction consequences
• Health maintenance
– Knowledge: substance abuse control
– Family coping
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Implementation
• Aim of treatment – self-responsibility
• Challenge – matching patients with
types of treatment related to various
needs
– Physiological
– Psychological
– Sociocultural processes
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Health Teaching and
Health Promotion
• Primary prevention – health teaching
FRAMES
– Feedback of personal risk
– Responsibility of the patient
– Advice to change
– Menu of ways to reduce substance use
– Empathetic counseling
– Self-efficacy or optimism of the patient
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Intervention Strategies
Continued
• Relapse prevention
• Self-help groups for patient and family
• 12-Step programs
• Residential programs
• Intensive outpatient programs
• Outpatient drug-free programs and
employee assistance programs
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Evaluation
• Increased time in abstinence
• Decreased denial
• Acceptable occupational functioning
• Improved family relationships
• Ability to relate comfortably to other
individuals
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Dual Diagnosis Challenges
 Psychiatric clients are vulnerable to
substance use and abuse
 Treatment must address both problems
 Relapse is common
 Levels of addiction prevention
 Primary: education programs
 Secondary: early identification of and
intervention
 Tertiary: rehabilitation
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