Transcript Substance related disorders

PSYCHIATRIC NURSING
SUBSTANCE-RELATED
DISORDERS
Substance-Related Disorders
• 2 groups of substance-related disorders:
1. Substance-use disorders (dependence and
abuse).
2. Substance-induced disorders (intoxication,
withdrawal, delirium, dementia, amnesia,
psychosis, mood disorder, anxiety
disorder, sexual dysfunction, and sleep
disorders).
Age (18-24), gender (male more than
female).
• Substance abuse can be defined as
using a drug in a way that is
inconsistent with medical or social
norms and despite negative
consequences
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I. Substance-use disorders
1. Substance abuse: a maladaptive pattern of substance
use manifested by recurrent and significant adverse
consequences related to repeated use of the substance,
as manifested by one (or more) of the following,
occurring within a 12-month period:
A. Recurrent substance use resulting in failure to fulfill
major role at work, school, or home.
B. Recurrent substance use in situations in which it is
physically hazardous.
C. Recurrent substance –related legal problems.
D. Continued substance use despite having persistent or
recurrent social or interpersonal problems.
• And never met criteria for dependence
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I. Substance-use disorders
2. Substance dependence
a) Physical dependence is evidenced by:
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A cluster of cognitive, behavioral, & physiological
symptoms indicating that the individual continues
use of substance even with substance-related
problems.
 As this condition develops, the repeated
administration of the substance is necessary to
prevent the appearance of unpleasant effects.
 Dependence is promoted by Tolerance: the need for
increasing the dose or frequency of the substance in
order to obtain desired effects originally produced
by a lower dose.
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I. Substance-use disorders
b) Psychological dependence: this happens when there is an
overwhelming desire to repeat the use of particular drug to
produce pleasure or avoid discomfort.
• At least three of these characteristics must be present for a
diagnosis of substance dependence :
* evidence of tolerance
* evidence of withdrawal symptoms
* a great deal of time is spent in activities necessary to obtain the
substance
* impairment/reduce of social, occupational, or recreational
activities
* continued substance use despite knowledge that has persistent or
recurrent physical or psychological problems
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Substance-use disorders
• persistent desire or unsuccessful efforts to
cut down or control use of substance
• substance is often taken in larger amounts
or over a longer period than was intended.
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II. Substance-induced disorders
1. Substance intoxication:
Development of a reversible substance-specific
syndrome caused by the recent use or exposure to
substance. Effect of the substance on the CNS. CNS
Symptoms include violence, mood lability, cognitive
impairment, impaired judgment, impaired social or
occupational functioning (e.g. alcohol intoxication,
getting high or wasted).
Different substances may induce similar effects
Substances inducing intoxication
identified in the DSM IV
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Alcohol
Amphetamines
Caffeine
Cannabis
Cocaine
• Inhalants
• Opiates
• Sedatives/hypnotics/anxio
lytics
Clinical picture of intoxication
depends on:
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Substance
Dose
Duration/chronicity
Individual degree of
tolerance
• Time since last dose
Substance-induced disorders
2. Substance withdrawal: the development of
substance–specific syndrome caused by the cessation
of, or reduction in, heavy & prolonged substance use.
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Etiology of substance use disorders
• Biological factors:
a. Genetics (alcoholic children 4 times)
b. Biochemical (e.g. alcohol)
• Psychological factors:
a. Developmental influences
b. Personality factors
• Socio-cultural factors:
a. Social learning (modeling)
b. Conditioning (the effect of substance itself…many
substances create pleasure)
• Cultural and ethnic influences.
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Alcohol abuse and dependence
A profile of the substance
• Alcohol is a natural substance formed by the reaction of
fermenting sugar with yeast spores.
• Alcohol in drinks is known as ethyl alcohol (C2H5OH).
• Sometimes seen in medical records as ETOH.
• Classified as food because it contains calories;
however, it has no nutritional value.
• Examples: beer, wine, whisky
• Alcohol produce depressant effect on the CNS (changes
in behavior and mood).
• Factors that influence alcohol behavioral changes are:
slow consumption, individual size, individual stress or
fatigue, whether the stomach contains food.
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Effects of alcohol on the body
• Peripheral neuropathy.
• Alcoholic myopathy.
• Wernicke’s encephalopathy (ataxia, opthalmoparesis, short
memory loss)
• Korsakoff’s psychosis (sever memory loss, apathy, quick
change)
• Alcoholic cardiomyopathy.
• Esophagitis.
• Pancreatitis.
• Cirrhosis or hepatic encephalopathy (cause by acetaldehyde).
• Leukopenia.
• Thrombocytopenia.
• Sexual dysfunction.
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Patterns of alcohol use/abuse
• People use alcoholic beverages to enhance
the flavor of food with meals, at social
gatherings to encourage relaxation &
friendliness among the guests, & to promote
celebration at special occasions such as
weddings & birthdays.
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Alcohol intoxication
• BAL (blood alcohol level) 0.08 or 0.1 g/dl- legal definition
• Intoxication occurs at blood alcohol levels between 100-200
mg/dl.
• Death has been reported at levels ranging from 400-700 mg/dl.
• Symptoms of intoxication:
a. Mood lability
b. Impaired judgment
c. Incoordination
d. Unsteady gait
e. Flushed face
f. Slurred speech
g. Nystagmus (uncontrolled movement of the eyes )
h. Impaired social or occupational functioning
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Alcohol withdrawal
• Occurs within 4 –12 hours of cessation of or reduction in
heavy and prolonged alcohol use.
• Symptoms of withdrawal:
a. Nausea or vomiting b. Malaise or weakness
c. Tachycardia
d. Sweating
e. Headache
f. Insomnia
g. Increased blood pressure
h. Coarse tremor of hands, tongue, or eyelids
i. Anxiety, depressed mood or irritability
j. Transient hallucinations or illusions
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Sedative, hypnotic, or anxiolytic abuse
and dependence
A profile of the substance
• All these substances are capable of inducing varying
degrees of CNS depression, from relief of anxiety to
anesthesia, coma, & even death.
1. The effects of CNS depressants are additive with one
another and with the behavioral state of the user.
2. CNS depressants are capable of producing
physiological & psychological dependence to
achieve maximum level of functioning or feeling of
well-being.
3. Cross-tolerance & cross-dependence may exist
between different CNS depressants.
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Categories of CNS depressants
• Barbiturates:
a . Pentobarbital–street name (yellow jackets)
b . Amobarbital–blue angels
• Nonbarbiturate hypnotics:
a. Triazolam–sleepers b. Flurazepam–sleepers
c. Chloral hydrate–Peter, Mickey
• Antianxiety agents:
a. Diazepam (Valium )
b. Alprazolam (Xanax)
c. Lorazepam (Ativan )
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Effects on the body
• CNS: depression of CNS from sedation to death.
• Sleep & dreaming: decrease the amount of sleep
time spent in dreaming.
• Cardiovascular: hypotension , decreased cardiac
output & decrease cerebral blood flow.
• Respiratory depression.
• Decreased body temperature.
• Produce jaundice: (stimulate the production of
liver enzymes).
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Patterns of use/abuse
1) CNS depressants prescribed by physicians
as treatment for anxiety or insomnia, &
then, independently, the individual increases
the dose or frequency to produce the desired
effect.
2) Use of substances that were obtained
illegally. The initial objective is to achieve
euphoria.
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Sedative, hypnotic, or anxiolytic
intoxication
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Mood lability
Impaired judgment
Inappropriate sexual or aggressive behavior
Impaired social or occupational functioning
Incoordination
Unsteady gait
Impaired attention or memory
Slurred speech
Stupor or coma
Sedative, hypnotic, or anxiolytic
withdrawal
• Short-acting anxiolytics (lorazepam or oxazepam)
may produce Sx. within 6-8 hrs of decreasing blood
levels. Longer half-lives (diazepam) may not
develop Sx. for more than a wk, peaking during 2nd
wk, & decrease in wk 3-4.
• Symptoms include:
a. Sweating.
b.Tachycardia (HR>100).
c. Hand tremor.
d. Insomnia.
e. Nausea or vomiting. f. Hallucinations.
g. Illusions.
h. Agitation & anxiety.
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CNS stimulant abuse and dependence
A profile of the substance
• The CNS stimulants are identified by the behavioral
stimulation & psychomotor agitation that they induce.
• Induce stimulation by augmentation of
neurotransmitters, or by direct action on the cellular
activity.
• The most prevalent and widely used stimulants are
caffeine & nicotine.
• When used in moderation, these stimulants tend to
relieve fatigue & increase alertness.
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Categories of CNS stimulants
 Amphetamines:
a. Dextroamphetamine–street name (Dexies )
b. Methamphetamine (Meth, speed, ice)
 Nonamphetamine stimulants:
a. Pemoline
b. Phentermine
c. Benzphetamine d. Phendimetrazine
 Cocaine (crack, lady, snow)
 Caffeine (java, cocoa)
 Nicotine (weeds, chaw)
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Patterns of use/abuse
1. Using the substance for the appetitesuppressant effect in an attempt at
weight control.
2. The daily user may take large or small
doses & may use the drug several times
a day. Chronic users tend to depend on
CNS stimulants to feel more powerful,
more confident, & more decisive
(vital).
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Effects on the body
• CNS: CNS stimulation (tremor, anorexia, insomnia,
agitation, increased motor activity). Increased
alertness & decreased fatigue from amphetamines,
nonamphetamines, & cocaine. Chronic use results in
paranoia, hallucinations, aggressive behavior.
• Cardiovascular/pulmonary: hypertension,
tachycardia, cardiac arrhythmias, vasoconstriction
(MI), pulmonary hemorrhage, chronic bronchiolitis,
& pneumonia.
 GI & renal: constipation, contraction of the bladder
sphincter, diuretic effect (caffeine), diarrhea
(nicotine), anorexia, increase body temperature
(amphetamines).
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• CNS stimulant intoxication: euphoria, anxiety,
tension, anger, stereotyped behaviors, impaired
judgment. Pupillary dilation, tachy- or
bradycardia, nausea, vomiting, chills, muscular
weakness, respiratory depression, chest pain,
coma. Hypo- or hypertension, restlessness,
nervousness, GI disturbance.
• CNS stimulant withdrawal: dysphoria, unpleasant
dreams, insomnia or hypersomnia, increased
appetite & wt gain, retardation, agitation,
depressive symptoms, nausea, vomiting, fatigue,
muscles pain & stiffness.
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Inhalant abuse and dependence
A profile of the substance
• Aliphatic & aromatic hydrocarbons found in
substances such as fuels, solvents, adhesives, & paint
thinners.
• Examples: gasoline, varnish remover, airplane glue, &
spray paint.
Patterns of use/abuse:
• Highest use seen from 12-25 years. Less common after
age 35 yrs.
• Children may use inhalants several times a wk, often
on weekends & after school.
• Adults may use the substance at varying times during
each day.
• Methods of using include huffing & bagging.
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Effects on the body
• CNS: central & peripheral nerve damage,
generalized weakness, peripheral
neuropathy, cerebral atrophy, whitematter lesions.
• GI: abdominal pain, nausea, vomiting,
rash around nose and mouth, unusual
breath odors.
• Renal & respiratory: chronic renal
failure, respiratory depression leading to
death.
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Inhalant intoxication
Two or more of the following signs are present:
* Dizziness
* Blurred vision or diplopia
* Incoordination
* Stupor or coma
* Slurred speech
* Muscle weakness
* Unsteady gait
* Psychomotor retardation
* Lethargy
* Tremor
* Depressed reflexes * Euphoria
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Opioid abuse and dependence
A profile of the substance
• The term OPIOID refers to a group of
compounds that includes opium (juice),
opium derivatives, & synthetic substitutes.
• Opioids exert both a sedative & an
analgesic effect (relief of pain, Tx. of
diarrhea, & relief of coughing).
• Methods of administration of opioid drugs
include oral, smoking, S/C, I/M, I/V.
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Categories of opioids
Opioids of natural Morphine
origin
Codeine
street name
(White staff)
Cody, syrup
Opioid derivatives Heroin
Horse, Harry
Hydromorphone Lords, little D
Synthetic opiatelike drugs
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Meperidine
Methadone
Fentanyl
Doctors
Dollies
China girl
Patterns of use / abuse
1. Obtain the drug by prescription from
physician for relief of a medical
problem then increase dose, justifying
this behavior as Sx. treatment.
2. Use the opioid drugs for recreational
purposes & obtain them from illegal
sources.
• Opioids may be used alone or in
combination with stimulants or other
drugs to enhance the euphoric effect.
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Effects on the body
• CNS: euphoria, mood changes, mental clouding,
pain reduction, drowsiness, pupillary constriction,
antitussive response, respiratory depression, nausea
& vomiting.
• GI: therapeutic effect in the treatment of severe
diarrhea. Constipation & fecal impaction with
chronic use.
• Cardiovascular: relieve pulmonary edema & pain
of cardiac infarction (morphine). Hypotension at
high doses (direct action on heart or opioid-induced
histamine release).
• Sexual functioning: decreased sexual pleasure
(from heroin). Retarded ejaculation, impotence, &
orgasm failure.
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Opioid intoxication
Symptoms include:
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Initial euphoria followed by…
Apathy
Dysphoria
Impaired judgment
Agitation or retardation
Pupillary constriction (or dilation)
Slurred speech
Impaired attention or memory
Respiratory depression, coma, & even death (with
severe intoxication)
Opioid withdrawal
Symptoms occur within 6-12 hrs,
peaking in 1-3days, & subside in 5-7
days:
* Dysphoric mood
* Sweating
* Nausea or vomiting
* Insomnia
* Muscle aches
* Diarrhea
* Pupillary dilation
* Fever
* Abdominal cramping * Piloerection
* Rhinorrhea or lacrimation
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Hallucinogen abuse and dependence
A profile of the substance
• Hallucinogenic substances are capable
of distorting an individual’s perception
of reality; they have the ability to alter
sensory perception (“mind expanding”).
• Some are produced synthetically; others
are natural products of plants and fungi.
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Categories of hallucinogens
Naturally occurring Mescaline (half moon )
hallucinogens
Psilocybin & psilocyn
Synthetic
compounds
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Phencyclidine (Peace pill)
Lysergic acid diethylamide
[LSD] (acid, big D,
cupcakes)
Effects on the body
* Nausea and vomiting * Chills
* Pupil dilation
* Increased V/S
* Mild dizziness
* Loss of appetite
* Sweating
* Insomnia
* Paranoia, panic
* Euphoria
* Fear of losing control * Derealization
* Sense of slowing of time
* Heightened body awareness
* Heightened response to color & sounds
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Hallucinogen intoxication
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Marked anxiety or depression
Ideas of reference
Fear of losing one’s mind
Paranoid ideation
Depersonalization
Illusions & hallucinations
Pupillary dilation
Blurred vision
Tremors & incoordination
Palpitations
Cannabis abuse and dependence
A profile of the substance
• Is second only to alcohol as the most widely
abused drug.
• It occurs naturally in the plant Cannabis sativa.
• Cannabis products are usually smoked, can also
be taken orally.
• It produces CNS depression.
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Cannabinoids (cannabis category)
Cannabis
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Marijuana
Mary Jane
Hay
Texas tea
Composed of
dried leaves,
stems, &
flowers of
the plant.
Hashish
Ganja
Bhang
Hash
Derived from
the flowering
tops of the
plant.
Patterns of use/abuse
• Many people incorrectly regard cannabis as
substance of low abuse potential; this false
belief has promoted use of this substance by
some individuals who believe it is harmless.
• Tolerance, although it tends to decline
rapidly, does occur with chronic use.
• Marijuana is the MOST WIDELY USED
illicit drug among high school students.
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Effects on the body
• Cardiovascular: Tachycardia, hypotension,
decreased myocardial oxygen supply, &
increased oxygen demand.
• Respiratory: Laryngitis, bronchitis, cough,
hoarseness, lung damage & cancer,
bronchodilatation.
• CNS: Euphoria, relaxed inhibitions,
disorientation, depersonalization, sensory
alterations, impaired recent memory &
judgment, tremor, muscle rigidity,
conjunctival redness.
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Cannabis intoxication
Symptoms of intoxication include:
• Impaired motor coordination
• Euphoria & anxiety
• Sensation of slowed time
• Impaired judgment
• Dry mouth
• Increased appetite
• Tachycardia
• Conjunctival injection
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Cannabis withdrawal
The symptoms of withdrawal appear only
when individuals abruptly stop taking high
doses of cannabis. Symptoms of cannabis
withdrawal include:
• Irritability
• Restlessness
• Insomnia
• Anorexia
• Mild nausea
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Application of the
nursing process
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Assessment
• In the pre-introductory phase of relationship development,
the nurse must examine his/her feelings about working with
a client who abuses substances.
• The role that alcohol or other substances has played in the
life of the nurse will affect the way in which he/she
approaches interaction with substance-abusing client.
• Unless nurses understand & accept their own attitudes &
feelings, they cannot be empathetic toward clients’
problems.
• Michigan Alcoholism Screening Test (MAST) is one of
the most useful assessment tools for drug abuse patients.
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Diagnosis
Possible nursing diagnoses for clients with
substance-related disorders:
• Ineffective denial related to weak, underdeveloped ego
evidenced by “ I don’t have a problem with (substance).
I can quit any time I want to”
• Ineffective coping related to inadequate coping skills &
weak ego evidenced by use of substances as a coping
mechanism
• Risk for infection related to malnutrition & altered
immune condition
• Risk for suicide related to depressed mood (withdrawal
from CNS stimulants )
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Outcome
• Has not caused harm to self or others
• Demonstrates more adaptive coping
mechanisms that can used in stressful
situations (instead of taking substances)
• Shows no signs or symptoms of infection or
malnutrition
• Verbalizes importance of abstaining from
use of substances in order to maintain
optimal wellness
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Planning
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Detoxification:
provide a safe & supportive environment.
administer substitution therapy as ordered.
Intermediate care:
provide explanations of physical symptoms.
promote understanding & identify the causes of substance
dependency.
 provide education & assistant in course of treatment to client
& family.
• Rehabilitation:
 assist client to identify alternative sources of satisfaction.
 provide support for health promotion & maintenance.
 promote participation in outpatient support system.
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Client/family education
• Nature of the illness:
* effects of substance on the body.
* ways in which use of substance affects life.
• Management of the illness:
* relaxation techniques.
* problem-solving skills.
* the essentials of good nutrition.
• Support services:
* financial assistance.
* legal assistance.
* one-to-one support person.
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Psychopharmacology for
substance intoxication &
substance withdrawal:
SUBSTITUTION THERAPY
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Alcohol
• Benzodiazepines, Librium, Serax, Valium, &
Xanax are THE MOST COMMONLY
USED agents for substitution therapy in
alcohol withdrawal.
• Anticonvulsant therapy (Carbamazepine,
Gabapentin) for management of withdrawal
seizures.
• Multivitamin therapy, in combination with daily
thiamine, is required to prevent neuropathy,
confusion, & encephalopathy.
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Opioids
• Opioid intoxication is treated with narcotic
antagonists such as naloxone, naltrexone, or
nalmefene.
• For withdrawal, methadone is given on the
1st day to suppress the symptoms.
• Buprenorphine is less powerful than
methadone, but is considered safer and
causes fewer side effects.
• Clonidine also has been used to suppress
opiate withdrawal symptoms.
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Depressants
• Substitution therapy for CNS
depressant withdrawal (particularly
barbiturates) is most commonly with
long-acting barbiturate phenobarbital
(Luminal).
• Long-acting benzodiazepines are
commonly used for substitution
therapy when the abused substance is
a nonbarbiturate CNS depressant.
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Stimulants
• Treatment of intoxication begins with minor
tranquilizers such as chlordiazepoxide
(Librium), & progresses to major tranquilizers
such as haloperidol (Haldol).
• Treatment of withdrawal is usually aimed at
reducing drug craving & managing severe
depression.
• Desipramine has been especially successful
with symptoms of cocaine withdrawal &
abstinence (self-control).
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Hallucinogens and cannabinols
• Substitution therapy is not required with
these drugs.
• When adverse reactions occur (anxiety
or panic), benzodiazepines (diazepam)
may be prescribed to prevent harm to
the client or others. Psychotic reactions
may be treated with antipsychotic
medications.
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