Transcript Chemical Dependency

RNSG 2213
SUBSTANCE-RELATED DISORDERS
DISEASE ENTITIES
&
SUBSTANCE PROFILES
CNS DEPRESSANTS
ALCOHOL
Some Facts
 5-7% of Americans are Alcoholics
 Every alcoholic touches lives of 5 people
 A leading cause of death: from medical
complications, accidents and suicides
 Fetal Alcohol Syndrome most common
cause of mental retardation in children
 Potentiates other CNS depressants
 Alcoholism underreported in women and
older adults
Alcohol: Intoxication
 Metabolism of alcohol is increased in heavy
drinkers
 Women more easily intoxicated than men.
 Effects: CNS depression and Peripheral
vasodilation
 Decreased muscle tension, lowered anxiety level,
disinhibition, impaired judgment, sedation
 Toxic effects: stupor, unconsciousness (including
blackouts), coma, death
Alcohol poisoning s/t large amount consumed
in short period of time
Alcohol Withdrawal
 Usually develops 4-12 hours after cessation or
reduction of alcohol use
 Rebound phenomenon (CNS irritability) as
drug effects wear off:
 increased anxiety, tension, psychomotor activity
 sweats, tremors, tachycardia, increased temp.
and BP
 nausea, vomiting, diarrhea
Alcohol Withdrawal, cont’d
 Withdrawal seizures may occur 7-48 hours after
cessation or reduction
 Alcohol withdrawal delirium (also known as
Delirium Tremens or DTs) may occur 48-72 hours
following cessation or reduction- agitation, terror,
hallucinations
(A Belgian beer is named for this effect)
Alcohol Withdrawal
 Use of validated withdrawal assessment rating
scale assists in objective description of withdrawal
severity
Validated withdrawal
assessment scale:
Clinical Institute
Withdrawal Assessment
for Alcohol (CIWA-Ar)
Alcohol:
Interventions for Withdrawal
 Seizure precautions; anticonvulsants for DT’s
 Suicide assessment and precautions, if necessary
 Medications: for withdrawal
 Benzodiazepines e.g. chlordiazepoxide
(Librium), oxazepam (Serax), diazepam
(Valium). Administration may depend on
withdrawal rating parameters.
Alcohol:
Interventions for Recovery
 Medications to promote abstinence after detox.
 disulfiram (Antabuse) = Aversive Therapy;
produces unpleasant or even harmful effects
when alcohol is consumed or absorbed in any
form (in foods, fluids, cosmetics, medications,
etc.).
 naltrexone (ReVia) – opiate receptor
antagonist-blocks the “high”
 acamprosate (Campral) – reduces cravings
Complications of Alcohol
Dependence: Physiologic
 Esophagitis and gastritis (ulcers, hemorrhage)
 Sexual dysfunction
 Pancreatitis
 Hepatitis
 Leukopenia
 Thrombocytopenia
 Peripheral neuritis with LE numbness, pain
ALCOHOLISM: COMPLICATIONS
 Cirrhosis-liver becomes fibrotic, fatty
 complications include portal
hypertension, ascites, esophageal
varices and hepatic encephalopathy)
Complications of Alcoholism
due to
Thiamine (B1) Deficiency
Wernicke’s Encephalopathy: ataxia, muscle
weakness, nystagmus and confusion
Korsakoff’s Syndrome: memory loss, amnesia,
psychosis
Often appear together = Wernicke-Korsakoff Syndrome
Alcoholic Cardiomyopathy
Result of toxicity + nutritional deficiency
SEDATIVES, HYPNOTICS AND
ANXIOLYTICS
BARBITURATES,
BENZODIAZEPINES
•
•
Commonly prescribed for sleep, anxiety, muscle
spasms, etc.
Also used illicitly, including
• reducing effects of stimulant (esp. amphetamine) abuse
• if other narcotics not available
• by sexual predators
Sedatives, Hypnotics, or Anxiolytics
Abuse and Dependence
 Potentiate each other and alcohol
 Produce physiological dependence
 Produce psychological dependence
 Cross-tolerance and cross-dependence
between CNS depressants
Sedatives, Hypnotics and
Anxiolytics: Dependence
 Withdrawal sx.: anxiety, insomnia, nausea,
seizures
 Overdose and Fatal effects: respiratory
depression, coma, death
Interventions for Sedative W/D
 Quiet, calm environment
 Monitor vital signs
 Taper dose gradually; may take weeks or months
 Seizure precautions
Inhalents
 Inorganic and organic volatile substances-usually
cheap and readily available
 Intoxication: CNS depression- elevated mood
(silly and happy) and excitability, possible
sleepiness and confusion
INHALANTS:
Abuse and Dependence
 Dangerous due to inability to control amount
inhaled
 Use is associated with
 CNS damage
 Respiratory irritation, distress and depression
 GI distress
 Mouth ulcers
 Renal and hepatic damage
 Death from asphyxiation or suffocation
OPIOIDS
 OPIUM and HEROIN
 MORPHINE
 CODEINE
 SYNTHETIC MORPHINE
DERIVATIVES, e.g:
 OXYCODONE (OxyContin)
 HYDROMORPHONE
((Dilaudid)
 HYDROCODONE (Vicodin)
 MEPERIDINE (Demerol)
OPIOID Abuse and Dependence
 Activate endorphins, reduce pain and anxiety
 Many routes of use: po, subcut., IM, IV, inhaled
 IV use is associated with infection, including HIV
and Hepatitis, bacterial endocarditis, and
abscesses
 May be prescribed or illicitly obtained
 Heroin--highest abuse and dependence potential
 CNS effects, including respiratory depression
 GI effects
Opioid Intoxication
 Initial euphoria
 Followed by apathy, dysphoria, psychomotor
agitation or retardation
 Pupillary constriction
 Drowsiness (“nodding”), slurred speech
 Impaired judgment, memory and concentration
Opioid Overdose
 Pinpoint pupils
 Clammy skin
 Respiratory depression
 Coma (pupils will dilate
secondary to anoxia)
 Death rapidly follows coma
TX of Overdose:
Narcotic antagonist:
naloxone (Narcan)
Opioid Withdrawal
Very uncomfortable but rarely dangerous:
• Dysphoria, anxiety, cravings
• Sweating and chills, piloerection
• Lacrimation, rhinorrhea
• GI distress (anorexia, n/v, cramping, diarrhea)
• Muscle aches, bone pain
• Restlessness
• Tremors
• Sleep disturbances
Interventions for
Opioid Withdrawal
 Primarily supportive care
 Treat symptomatically
 Specific pharmacotherapy:
 clonidine-for n/v/diarrhea
 buprenorphine (Buprenex) –reduces pain and
discomfort
Example of clinical
assessment tool for
opiate withdrawal
(COWS)
Interventions for
Opioid Dependence
Medications which Promote Abstinence:
 Maintenance Pharmacotherapy to reduce cravings
and block the “high” :
 naltrexone (Trexan, ReVia)
 methadone –requires enrollment in
maintenance program (federally controlled
supervision)
CNS STIMULANTS
CNS STIMULANTS
 Cocaine
 Amphetamines: prescribed or illicit
 Non-amphetamine stimulants
 Caffeine
 Nicotine
STIMULANTS: Intoxication
 Various Effects:
 Increased alertness, arousal and endurance
 Decreased need for food and sleep
 HR and BP
Stimulants: Neurobiology
Different for different drugs:
 facilitate norepinephrine, dopamine activity
 nicotinic receptor agonists
 adenosine receptor antagonists
STIMULANTS: COCAINE
Intoxication
 Blocks dopamine reuptake esp. in nucleus accumbens
(“pleasure center”)
 IV or intranasal route; Crack (dilute) form is smoked
 Rapid Effects and Rapidly metabolized:
 Intense euphoria
 Increased mental alertness
 Increased motor and cardiac activity
 Increased muscle strength
Stimulants: Cocaine Dependence
 Psychological dependence is even more
severe than physical dependence; cravings
are intense
Stimulants: AMPHETAMINES
Intoxication and Dependence
 Often are prescribed, widely abused
 Methamphetamine: Slower metabolic effects,
often mixed with cocaine (cheaper)
 Routes: IV, intranasal, po, smoked
 Immediate intense pleasure, lasting high
 “Crash” occurs as drug effects wear off
 Intense cravings promote frequent, repetitive
use
 Damage to teeth, gums
STIMULANTS: WITHDRAWAL AND
COMPLICATIONS
 Toxic effects: Hallucinations and paranoid
delusions
 Severe hypertension, cardiac ischemia
 Withdrawal: severe agitation, anxiety, depression
 Death from cardiac arrhythmias, seizures, suicide,
respiratory collapse, stroke
STIMULANTS:
Treatment of Overdose
• Induce vomiting, diuretics
• Administer IM antipsychotic for drug-induced
psychosis/agitation
HALLUCINOGENS
HALLUCINOGENS
 Natural or synthetic substances
 Effects vary from enhancement of sensory stimuli to
loss of reality and hallucinations (Psychotic
symptoms)
 Effects highly unpredictable
HALLUCINOGENS: CANNABINOLS
(MARIJUANA and Related)
 Not strictly a hallucinogen
 Most widely used illegal drug in US
 Active Ingredient: THC (delta-9-tetrahydrocannbinol
 Detectable in blood and urine for up to 4 weeks
 Smoked or ingested
 Hashish-resinous form
 “Medical marijuana” antiemetic and for chronic pain
 Legal RX: drobinol (Marinol)
 Plant form legal in some states
CANNABIS: INTOXICATION
 Euphoria, relaxation, disinhibition
 Alteration in sensory and time perception
 Increased appetite
 Anxiety
 Tachycardia and Hypotension
CANNABIS: DEPENDENCE
 ?Physical?
 Psychological- tolerance
CANNABIS: COMPLICATIONS AND
ADVERSE EFFECTS
 Impaired memory, concentration
 Apathy and loss of motivation (heavy users)
 Pulmonary compromise
 ?Reduced female, male hormones and sperm count?
 Paranoia and panic
 Flashbacks
HALLUCINOGENS:
LYSERGIC ACID DIETHYLAMIDE
(LSD)
 Semisynthetic-binds to serotonin receptors
 LSD Intoxication:
 Episodic and binge use common
 Effects last up to 12 hours
 Synesthesia experiences-blending of sensory
perceptions
LSD: ADVERSE EFFECTS
 Hypertension and tachycardia
 Acute psychosis: delusions, paranoia
 Flashbacks
 Panic
HALLUCINOGENS:
PHENCYCLIDINE (PCP)
• Synthetic anesthetic
 PCP Intoxication:
 Euphoria and relaxation
 PCP Adverse Effects:
 Ataxia, vomiting
 Agitation, violent outbursts, catatonia
 Severe elevations in HR and BP
HALLUCINOGENS: LSD and PCP
Overdose and Fatal effects; Complications
 Psychotic break (persisting psychosis)
 Perceptual distortions cause client to harm self/suicide
or others
 Cardiac arrest
 PCP-seizures
HALLUCINOGENS: LSD and PCP
 Psychological tolerance
 Frequent users-cravings
 No physiologic dependence
LSD and PCP
 Treatment of Acute Intoxication or Overdose
 Diazepam (Valium) for seizures [PCP], paranoia and
panic
 IM haloperidol (Haldol) for agitation and aggression
Comparison Chart