Transcript Alcohol
Substance Use Disorders Chapter 23 Terms • Use – Drinks alcohol, swallows, smokes, sniffs or injects • Abuse – Use for purposes of intoxication or for Rx beyond intended use • Dependence – Use despite adverse consequences • Addiction – Psychological and behavioral dependence Terms • Withdrawal – Adverse physical and psychological symptoms that occur when stop using • Detoxification – Process of safely and effectively withdrawing a person from an addictive substance • Relapse – Recurrence of alcohol- or drug-dependent behavior in person who had previously been abstinent. DSM-IV Substance Abuse Disorders • Alcohol • Nicotine • Amphetamines • Opioids • Cannabis (marijuana) • Phencyclidine • Cocaine • Sedativehypnotics • Hallucinogens • Anxiolytics • Inhalants • Caffeine DSM-IV Categories – Abuse of a substance – Dependence upon a substance – Induced by intoxication or withdrawal – Table 23.1 Epidemiology: Lifetime Prevalence • Positive lifetime history of heavy alcohol use – 23.4% of U.S. adults • Positive lifetime history for drug use – 15.6% of U.S. adults Epidemiology • African Americans: – Lower rates of both licit and illicit substances compared to whites – Experience more health and legal problems than other groups – Alcohol-related consequences for males higher than whites • Latin Americans: – High use of drug among adolescents (High school students have highest rates of crack-cocaine and heroin use.) – Differences in prevalence among different groups (Mexican Americans - highest; Cuban Americans - lowest) Epidemiology • Asian Americans and Pacific Islanders • Data are limited. • Drunkenness is disgraceful. • Drinking is a male activity. • Seeking help is a sign of weakness. • Asian “flushing syndrome” • Native Americans • Rates are among the highest. • Alcohol plays a role in health problems of this group. Epidemiology Gender Issues • Incidence rates of substance abuse and dependence – 1.7% per year men – 0.7% per year women • Males - more likely to abuse drugs and alcohol • Women - more likely to abuse prescription drugs • A high number of substance abusers has comorbid mental disorders. Etiology Biologic – Genetic Influence • Clear evidence that it runs in families • Controversy about specific gene (allele of D2) – Neurobiologic • Through the reward system – medial forebrain bundle (MFB) related to cravings • Intoxication increases extracellular dopamine. Etiology: Psychological Theories Addictive Personality – Need to feel self-worth – Need to have control over the environment – Need to feel intimate contact – Need to accomplish something – Need to eliminate pain or negative feelings Behavioral Theories – Conduct problems of childhood – Relationship between conduct problems, hyperactivity, impulsivity and future substance abuse Etiology: Social Theories • Peer drug use and affiliation • Poor interaction skills • Certain neighborhood characteristics Alcohol • 90% of Americans have had a drink at some point in their lives. • 16% have alcoholism. • The body can metabolize 1 oz of liquor per hour (5 oz glass of wine, 12 oz can of beer). • Excessive use can adversely affect all body systems (Table 25.5). • Cerebellar degeneration occurs from increased levels of acetaldehyde (byproduct of alcohol metabolism), causing impaired coordination, unsteady gait, fine tremors. • REM and chronic sleep disorders may occur. • Drinking patterns vary. Biologic Response to ETOH • Membranes permeable to K+ and Cl-, and closes Na+ & Ca++ channels depression of CNS, adrenergic activity BP and HR • Acetaldehyde is a byproduct of alcohol metabolism. Large amounts of acetaldehyde combine with dopamine and serotonin to produce a substance that is highly addictive. Response to ETOH: Alcohol Tolerance • Rapid metabolism and sedation, motor and anxiolytic effects • Higher levels of BAL before intoxication • Locus ceruleus – inhibits action of ethanol and instrumental in tolerance • During withdrawal, locus ceruleus is hyperactive noradrenergic activity and CNS stimulation Alcohol Withdrawal Syndrome • Changes in VS – BP and HR • Diaphoresis • Adverse GI effects • CNS side effects – Anxiety – Restlessness – Hand tremors or “shakes” – Disorientation – Confusion – Delirium tremens (DTs) Delirium Tremens • 10 or more years of drinking • Tachycardia • Sweating • Hypertension • Irregular tremor • Searing • Hypertension • Tremor • Delusions • Vivid hallucinations • Resolves in three to four days Alcohol-induced Amnestic Disorders • History of many years of drinking • Over age of 40 • Onset – sudden or insidious Alcohol-induced Amnestic Disorders: Wernicke’s Syndrome • Reversible, caused by diet deficiency of thiamine • Marked diplopia (palsy of the third and fourth cranial nerves), hyperactivity and delirium (cortical brain and thalamic lesions), coma Alcohol-induced Amnestic Disorders Korsakoff’s Psychosis • Follows Wernicke’s enceophalopathy • Loss of recent memory and confabulation • Vulnerable to others Psychopharmacology Acute Symptoms of Withdrawal • Benzodiazepines to produce sedation and reduce anxiety symptoms • Diazepam 5-10 mg every two to four hours • Librium 25-100 mg every four hours Pharmacology & Nutrition • Disulfiram (Antabuse) – Agonist – Inhibits ALDH metabolism and causes nausea and hypotension, severe can cause death – Occurs 10-20 minutes after ingestion – Adjunct treatment • Naltrexone (Trexan) – Narcotic antagonist – Reduces cravings for alcohol • Nutrition and vitamins Cocaine • 1.5 million Americans use cocaine. • Men have a higher rate than women. • Stimulant – made from leaves of coca plant • Sudden burst of alertness, energy and selfconfidence • High lasts 10-20 minutes, then let down • Crack cocaine – street drug form, highly addictive Biologic Effects of Cocaine • Increases the release and blockage of the reuptake of norepinephrine, serotonin and dopamine • Dopamine – euphoria and psychotic symptoms (prolactin levels - contribute to sexual dysfunction and secondary sexual characteristics) • Norepinephrine – tachycardia, hypertension, dilated pupils and body temp • Serotonin – sleep disturbances, anorexia • Long-term use – depletion of dopamine Cocaine • Intoxication – CNS stimulation followed by depression – Increasing doses – restlessness tremors and agitation convulsions CNS depression – Death – respiratory failure • Withdrawal – Norepinephrine depletion causes person to sleep 12-18 hours. – Then, sleep disturbances with rebound REM, anergia, decreased libido, depression, suicidality, anhedonia, poor concentration and cocaine craving Treatment of Cocaine Craving • Antidepressants • Anticonvulsants • Dopamine agonists Others • Amphetamines – Stimulant – Block reuptake of norepinephrine and dopamine, not as strong effect on serotonin (as cocaine does) – Effect peripheral nervous system • Cannabis – Relaxant – Stored in fat tissue for weeks – Amotivational syndrome • Hallucinogens – LSD – Phencyclidine (PCP) angel dust – awareness and detachment – hallucinations/destructive behavior (adrenergic ) Opiates – Narcotics • Any substance that binds to the opioid receptor • Cause CNS depression, sleep or stupor, and analgesia • Major – heroin, codeine and meperidine • Act on Delta and Mu receptors and depress the CNA • Types – Agonist – increases CNS effects – Antagonist – block CNS effects – Mixed agonist-antagonist • Effects of opiates – Pleasure – Relief of pain • Cause tolerance and physical dependence Opiate Treatment • Antagonist – block CNS effects, Naloxone (Narcan) • Detox – gradual reduction over several days • Methadone maintenance treatment – Opiate that satisfies craving, but no subjective high (See Table 25.7) • Naltrexone – see Drug Profile Other Substances • Sedatives-hypnotics and Anxiolytics – Abuse of prescription drugs – See Table 25.8 • Inhalants – Cause euphoria, sedation, emotional lability, impaired judgment – Result in respiratory depression – Found in common household products • Nicotine • Caffeine Nursing Management Assessment • Denial • Countertransference • Codependence • Maladaptive learned pattern of coping – Roles in family • Chief enabler • Dependent • Hero • Scapegoat • Lost child • Mascot Nursing Diagnoses • Risk for injury • Disturbed thought processes • Anxiety • Risk for ineffective management of therapeutic regimen, ineffective denial • Altered nutrition Motivation for Change • Key predictor of whether an individual will change his/her substance abuse • Involves recognizing problem, searching for a way to change and then changing • Motivational interviewing seeks to elicit selfmotivational statement from patients, supports behavioral change and creates a discrepancy between the patient’s goals and continued alcohol and other drug use. Guidelines for Therapeutic Relationship • Encourage honest expression of feelings. • Listen, and express caring. • Hold individual responsible for behavior. • Provide consequences for negative behavior, and talk about specific, objectionable actions. • Do not compromise own values; monitor reaction. • Communicate to the team. Reality Confrontation • Therapeutic strategy that promotes the person’s experience of the natural consequences of one’s behavior • Learning from previous behavior • Guidelines for establishing interactions Special Considerations • HIV and substance abuse – High risk for HIV exists among IV drug users. – Dual diagnosis of chemical dependency and HIV requires extremely careful assessment and intervention. – Patients often experience intense feelings of uselessness. • Harm-reduction strategies – Community health intervention replacing moral and criminal approach (needle exchange programs, designated driver) Special Considerations (cont.) Pregnancy and substance abuse • Detrimental effects on pregnancy • Several clinical issues facing mothers – Feelings of guilt and shame – Difficulties being a single parent – Care and responsibility of raising children early sobriety – Lack of access to treatment facilities – Anger and blame from caregivers – Need for parenting skills – Potential for child abuse and neglect – Lack of medical and other health care services Interventions • 12-step program • Cognitive therapy • Psychoeducation groups • Behavioral interventions • Group therapy and early recovery • Individual therapy • Family therapy Interventions • Nursing Care Plan 23.1 • Depend upon the stage of treatment