Transcript CHEMICAL DEPENDENCY: An Overview

CHEMICAL
DEPENDENCY:
An Overview
RNSG 2213
INTRODUCTION
 Substance abuse is not a new problem.
 Mood-altering and mind-altering substances
have been used throughout human history.
 Opium used openly into the 20th century;
Freud used Cocaine.
 Tribal cultures have e.g. chewed coco leaves,
used peyote in religious ceremonies, smoked
the “peace pipe.”
Illicit Drug Use
 Most used illicit drugs world-wide:
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Cannabis (#1)
Amphetamines
Cocaine
Opioids
(WHO 2004)
Introduction
 No clear transition from therapeutic to abusive
substance use
 Use is significantly underreported and effects
are often misdiagnosed
 Much social stigma attaches to abuse and
addiction
 Implicated in many accidental deaths, crimes
 Severe adverse effects on health, work,
relationships and quality of life
Introduction: Drugs and
U.S. Law
 1914: Harrison Narcotic Act --Opiate prohibition
 Alcohol Prohibition in the 1920’s and 1930’s
 1970: Drug Enforcement Agency created;
Controlled Substances Act passed
 1987: AMA declared all chemical dependency
as disease
 1990: ADA—non discrimination against
persons with history of drug/alcohol addiction
ADDICTION LIABILITY
Highest
 cocaine/crack
 opiates
 alcohol
Lower
amphetamines
anesthetics
(PCP, ketamine)
nicotine
benzodiazepines
marijuana
(Addiction liability, cont’d)
These are non-addicting:
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LSD and other hallucinogens
antidepressant drugs
antipsychotic drugs
naltrexone-Trexan
DEFINITIONS
 Intoxication: Substance-specific CNS
effects
 Substance Abuse: Recurrent use of a
drug which results in adverse effects to
oneself or others. (e.g. interpersonal, legal
or safety issues)
 Addiction: (compulsive use of substance
= same as substance dependence; term is
now considered judgmental )
Definitions, cont’d
 Chemical/Substance Dependence:
Loss of Control over use, which involves:
 Tolerance: Must increase the amount of
drug to get the needed effect.
 Withdrawal: Refers to psychoactive
substance-specific syndrome that occurs
when person stops using the drug
DSM IV CRITERIA FOR
SUBSTANCE DEPENDENCE
 Tolerance, Withdrawal
 Desires and attempts to cut down
 Much time is spent in obtaining drug
and recovering from drug
 Social and occupational problems
result
 Substance use continues despite
problems caused
DSM IV CRITERIA FOR
SUBSTANCE WITHDRAWAL
 Development of specific symptoms due
to cessation of drug
 Syndrome causes distress
 Symptoms not due to a medical
condition
Biological Theory:
Neurotransmitters of Drug
Dependence
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Dopamine (DA) –”pleasure pathway”
Serotonin (SER)
Endorphins (END)
GABA/Glutamate (GLU) Theory: heavy
drug use decreases response of “brain
calming” neuroreceptors (= tolerance)
Etiology of Dependence:
Biological Theory
 Repeated use of a drug results in
stimulation of brain’s “reward” or “pleasure”
pathway in mesolimbic system
Biological Theory of Dependence
cont’d
 Repeated use of a drug targets
specific brain areas for that drug,
with resulting creation of extra
receptors and brain’s perception
that drug’s stimuli are necessary for
survival (cravings)
The Addicted Brain
Bottom Line: Major sites targeted by addicting drugs
(Within medial forebrain, not cortex) are evidence that
addictions are not under conscious control
Biological Theory, cont’d
 Evidence of genetic predisposition for
alcoholism.
 Example: Allergic response to ETOH in many
Southeast Asians
 Strong concurrence with bipolar disorder
 Twins born to alcoholic parents who are then
adopted have 3x rate of adopted children of
non-alcoholics.
Multivariant Theory:
Biology + Learning
 Drug dependence results from interaction of
the physiological effects of substances on
brain areas associated with motivation and
emotion, combined with ‘‘learning’’ about the
relationship between substances and
substance-related cues.
 This theory gives support to why relapse
may occur even after long period of
abstinence. (e.g.: smell of cigarette can
cause an ex-smoker to light up)
Etiology: Sociocultural
Factors
 Advertising: “Relief is just a swallow away”
 Don’t suffer; take action
 Sex differences: Males abuse alcohol and
opiates more. Females abuse prescription
drugs
 Catholics: Highest rate of alcohol abuse
 Observant Jews: lowest
 Stress
 Availability, cost
Etiology:
Psychological/Psychodynamic
Theory
 Person who abuses drugs seeks to
escape from anxiety or emotional pain.
Sees self in a fundamentally negative
way.
Personality Traits Associated
with Chemical Dependence
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DENIAL/ anger
Inability to express emotions
High anxiety in interpersonal relations
Emotional immaturity; overdependence
Ambivalence towards authority; rule
breaker
 Low frustration tolerance; wants instant
gratification
Personality Traits, continued
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Low self-esteem
Feelings of isolation
Perfectionism and compulsiveness
Sex role confusion
Are these qualities the cause or the result of drug use?
Effects on Family
 All family members affected by the
substance-dependent member.
 Many characteristic behaviors:
 Focus becomes on the addict’s behavior
 Co-dependency
 Care-taking by children
 Perpetuation of these dynamics into
adulthood
 3 Options: ignore, banish, adapt
 Family in need of treatment
Assessment
 Denial complicates assessment
 Use screening tools, e.g. MAST
 Careful history: occupational, legal,
behavioral alterations
 Physical Assessment: substance specific
signs and symptoms
 Urine and serum drug screens;
breathalyzer (alcohol)
Short version of Michigan Alcoholism Screening Test
(SMAST)
> 3 points indicates problem
GOALS FOR
DETOXIFICATION
 American Society of Addiction
Medicine lists three immediate goals for
detoxification of alcohol and other
substances: (1) “to provide a safe
withdrawal from the drug(s) of
dependence and enable the patient to
become drug-free”; (2) “to provide a
withdrawal that is humane and thus
protects the patient’s dignity”
Principles of Detoxification
 Ideal detoxification avoids life-threatening
withdrawal signs and symptoms but also avoids
intoxication with the withdrawal medications.
The goal is not absolute comfort.
 Objective measures of withdrawal (vital signs,
observable findings, withdrawal rating scores)
are very useful for monitoring the course of
withdrawal and supplementing the subjective
data from the client.
Nursing Interventions
 Examine own attitudes about substance
use and dependence
Provide:
 Safe environment for client in withdrawal
 Empathy and acceptance
 Hope for recovery
 Group therapy: to deal with denial and provide
support for change
 Medications to treat co-occurring mental illness
Client Behaviors and
Nursing Interventions
 Anger: matter-of-fact approach
 Guilt and shame: non-judgmental support;
offer positive feedback for help-seeking
behaviors
 Denial and Avoiding Responsibility:
supportive confrontation
 Manipulation: Set limits and clear rules.
 Cravings: provide support, teaching and
encourage talking with peers
Interventions:
Client Teaching
 Disease process
 Total abstinence is the goal
 Relapse prevention strategies
 Recognize and confront own denial
 Recognize triggers
 “Change people, places and things.”
 Often biggest obstacle to abstinence.
Interventions
 Referrals and Community Resources
 Long-term residential rehabilitation is best predictor
of abstinence (28 days to 6 months or more)
 Halfway House
 Outpatient rehabilitation
 AA, NA, Rational Recovery
 Family counseling
 Al-Anon, Nar-Anon, Alateen
 Other services: job placement, housing, etc.