Transcript CHEMICAL DEPENDENCY: An Overview

SUBSTANCE ABUSE
AND DEPENDENCE:
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 coca leaves,
used peyote in religious ceremonies, smoked
the “peace pipe.”
Which legal drug is the
most widely used?
Illicit Drug Use
 Most used illicit drugs world-wide:
 Cannabis (#1)
 Amphetamines (& synthetic stimulants)
*greatest increase
 Cocaine
 Opioids
World Health Organization 2010
www.who.int_substanceabuse/facts.htm
Illicit Drugs:
A Global Issue
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Economics
Crime
Health
Effects on young people
Environmental effects
Illegal Drugs: U.S.A.
 CDC www.cdc.gov (2010 report):
Persons in U.S. > 12 y/o who in past month:
 used illegal drug(s)
8%
 used Marijuana
6.1%
 non-medical use of a psychotherapeutic
agent
2.5%
(CDC Statistics from 2008)
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
Co-Morbidity with other
Mental Disorders:
Dual Diagnosis
 Shared Risk Factors
 Genetic factors
 Environmental factors
 Similar brain regions affected
 Drugs can change the brain
 Drug use can induce mental illness
 Mental disorders may lead to drug use
(“self-medication”)
Co-Morbidity With Mental D/O
“Vegetable
compound”
Alcohol content
=18%
The Bayer Co.’s
best-seller
Laudanum = 50% opium/50% alcohol
Introduction: Drugs and
U.S. Law
 1914: Harrison Narcotics Act – Prohibition of
non-doctor-prescribed opiates
 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
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cocaine/crack
opiates
nicotine
alcohol
Lower
 amphetamines
 anesthetics
(PCP, ketamine)
 benzodiazepines
 marijuana
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
sometimes 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
Definitions Matching
1.
2.
3.
4.
Client 1 states morphine
for cancer pain is not
working: Dr. writes
order for increased dose.
Client 2 smokes some
marijuana and feels
“mellow,” eats junk food.
Most nights, Client 3
drinks a 6-pack of beer
and falls asleep in front
of TV. (Spouse is not
happy.)
While waiting for more
cocaine to be delivered,
Client 4 feels very
depressed, anxious and is
desperate to feel “good”
again.
A.
Substance abuse
B.
Substance withdrawal
C.
Tolerance
D.
Substance dependence
E.
Substance intoxication
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
Addiction
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Dopamine (DA) –”reward pathway”
Serotonin (SER)
Endorphins (END)
GABA/Glutamate (GLU) Theory: heavy
drug use decreases response of “brain
calming” neuroreceptors (= tolerance)
Etiology of Addiction:
Biological Theory
 Repeated use of a drug results in stimulation of
brain’s “reward” pathway
Biological Theory of Addiction 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)
Biological Theory, cont’d
 Genetic predisposition
 Examples: -Allergic response to ETOH in
many Southeast Asians
-Twins born to alcoholic parents
who are then adopted have 3x rate of
becoming alcoholic than children of nonalcoholics who are then adopted.
Etiology:
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)
Multivariant Theory Scenario
J. was in recovery x 4 months from dependence on alcohol.
This week at work had been stressful, then on Thursday his
dog got hit by a car and had to be euthanized. On Friday, he
started drinking again at a downtown bar near his office.
After 3 days of inebriation he called his AA sponsor.
Together they discussed the events leading up to his
relapse. He recalled his usual pattern was binge drinking on
weekends, with a stop at the liquor store on Friday after
work. He had been passing by the bar on his way home on
Friday. The combination of the sound of people having “fun,”
and it being Friday after work, triggered his relapse. J.
recognized that, since drinking was the way he relaxed and
dealt with stress, this time he put himself in “the wrong place
at the wrong time.”
Etiology:
Sociocultural
Factors
 Advertising
 Cultural and religious values
 Sex differences: Males abuse alcohol
and opioids more. Females abuse
prescription drugs
 Availability, cost
Etiology:
Psychological/Psychodynamic
Theory
 Fundamentally negative view of self
 Substances used to escape from anxiety
or emotional pain.
Personality Traits Associated
with Substance Dependence
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DENIAL/ anger
Inability to express emotions
High anxiety in interpersonal relations
Emotional immaturity
Ambivalence towards authority; rule
breaker
 Low frustration tolerance; wants instant
gratification
Personality Traits, continued
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Low self-esteem
Feelings of isolation
Overdependence/lack of autonomy
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 of family life = the addict’s behavior
 Co-dependency
 Care-taking by children
 Perpetuation of these dynamics into
adulthood
 Family in need of treatment
http://www.youtube.com/watch?v=mwq0wxZg87g
http://www.youtube.com/watch?v=u0ugTOXv0Y4
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
INTERVENTIONS:
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
 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 and Milieu
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
 Treatment for co-occurring mental illness
Client Behaviors and
Nursing Interventions for:
 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.
Nurse-Client Communication:
Effective?/Ineffective?
1.
2.
3.
4.
Client: “You all are a bunch
of do-gooders who are
getting paid to act like you
care but you don’t. “
Client: “I want to talk to the
dr. now! This dose he
ordered is ridiculous—it
won’t do anything for my
headache. I know the
amount I need.”
Client: “I feel like I’ve let my
whole family down by
drinking again.”
Client: “You have never
used drugs, so you cannot
possibly understand my
situation.”
1.
Nurse: “Your bad attitude
is sabotaging your
treatment.”
2.
Nurse: “Right now this is
what the dr. ordered for
your headache.”
3.
Nurse: “I feel for you.
Alcohol does terrible
things to a family.”
4.
Nurse: “That may be true.
But I can see that you are
having a rough time.”
Interventions:
Client and Family Teaching
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Disease process
Total abstinence is the goal
Relapse is part of recovery
Relapse prevention strategies
 Recognize and confront own denial
 Recognize triggers
 “Change people, places and things.”
 Often biggest obstacle to abstinence.
Relapse
Prevention/Recovery
1.
2.
3.
Client: “I don’t know why I
started using again, I guess I
just can’t stay clean.”
1.
Nurse: “Write down
everything you remember
about that day. Triggers may
not always be obvious.”
2.
Nurse: “It’s time to consider
who your friends really are.”
3.
Nurse: ________________
Client: “Ever since I stopped
drinking, my friends say I’m
no fun.”
Client: “I started drinking
again because my boyfriend
stressed me out.”
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.
Legal-Ethical: The
Chemically Dependent Nurse
 Required to report impaired colleague to
Board of Nursing
 Nursing resources in TX:
 TPAPN (Texas Peer Assistance Program for
Nurses) www.tpapn.org
Addiction Recovery Awareness