Transcript Psycho-Addictive Disorders

Psycho-Addictive
Disorders
Elisa A. Mancuso RNC, MS, FNS
Professor
 Substance Abuse
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Maladaptive pattern of excessive use
Recurrent use = ↑↑ impairment
Failure to meet role obligations
↑↑ Use with
 Legal, social or interpersonal problems
 Intoxication
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Reversible substance induced syndrome
Slurred speech
Ataxia = ↓ Coordination
↓ Cognition
Poor memory & judgment
↑↑Impulsive behavior
 Substance Dependence
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Cognitive, behavioral & psychological symptoms
Pt. believes substance needed for optimal health
Persistent desire and ↑ time spent to obtain & use
Use ↑ quantities more frequently = Addiction
Unsuccessful attempts to stop using
 Tolerance
– Need ↑↑ amounts to achieve desired effects
 Cross Tolerance
– Pt. tolerant to drug A
– When use drug B (similar to A) has ↓ effect
– Need ↑↑ dose of B
 Withdrawal Syndrome
– Cessation of heavy prolonged use
– Autonomic Hyperactivity
– Hallucinations
– Dementia
– Seizures
 Addiction: Three Cs
– Craving to Compulsive Behavior
– Continued use despite (-) consequences
– Loss of Control
3rd
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ETOH
Major health problem
50% ER visits & 12 million adults ETOH dependent
Teens fastest growing group of alcoholics
↑ 50% risk with alcoholic family member
Parents role model ETOH as coping skill
↑ Predisposition = ↑ Sensitivity
ETOH produces morphine like substances TIQs
– Activate opioid brain receptors = addiction
↓ ETOH Dehydrogenase = ↓ ETOH metabolism
– ETOH goes directly from blood to brain
↓ Self Esteem ↓ Frustration
↑↑ Impulsive & ↑ Immediate Gratification
Peer & media influence = + Reinforcement
– ↓ Inhibitions = ↑ confidence & risky behaviors
Cultural Influences
 Asians
– Lowest ETOH rate 2.5%
– Genetic ETOH intolerance (+) Punishment
 Flushing HA
Palpitations
 Native Americans
Alaska Natives
– Highest ETOH rate 12.5 %
– 5th leading cause of death
– Community oriented culture
 Drinking is group activity
 Irish, German, Russian
– ↑ ETOH use & dependency
– RT Socialization & aggression release
Family Dynamics
 Co-Dependency
– Caretaker derives self worth from others
– Over-functioning takes on all responsibilities
– Enabling behaviors
 Adult Children of Alcoholics 1/8
– Learn dysfunctional family roles
– Secrecy, mistrust, shame and denial of abuse.
– Primary goal is to please parent
– Hero/Caretaker Child
 Take on family responsibilities
 Trying to keep it all together”
– Scapegoat Child
 Act out @ home – Child is focus of conflict
– Lost Child
 Avoid conflict & pain (Escape from family)
 Run away
– Mascot/Clown
 Comic relief to mask sadness
 Truly unhappy
ETOH
 CNS Depressant
– ↓ Anxiety
Relaxation ↓ Inhibitions
– ↓ Judgment Slurred speech
↓ Sleep
 BAC Blood Alcohol Concentration
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0.05 = Euphoria, impairment
0.08 = Intoxication (Legal limit)
0.15-0.2 = ↓ coordination, double vision
0.3 = stupor
0.4 = coma & death
 Absorbed in 5 mins
 Liver detoxifies ETOH (¼ oz) per hour =
– 12 oz. Beer
– 4 oz. Wine
– 1 Shot
Cognitive
Effects
Poor judgment
↓Learning
 ↓ Control
 Impulsive/Abusive Behavior
Seizures
 Blackouts “Fugue-like” state
– Amnesia of events during drinking period
– No loss of consciousness during episode
 Wernicke’s Encephalopathy
– Thiamine deficiency→ Grey matter damage
– Abnormal thinking patterns ↓ Memory
Ataxia
 Korsakoff’s Psychosis (2nd to Wernicke’s)
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Niacin & Thiamine deficiency
Irreversible cell death & progressive mental deterioration
Confabulation Loss of recent memory
Diplopia
Somnolence → Stupor → Death
Systemic Effects
 Cardiovascular
– Autonomic Hyperactivity = ↑ HR ↑ BP CHF
– Myopathy RT
 Vasoconstriction = Chest pain
– Bone Marrow Toxicity
 ↓ RBCs ↓ WBCs ↓ Plts
 Gastrointestinal
– Esophagitis RT Vomiting
– Esophageal Varices RT Portal HTN
– Gastritis & Ulcers RT ↑HCL
– Malnutrition → Ascitis
– Pancreatitis → DM & CA
– Hepatitis & Cirrhosis → Liver Failure
Systemic Effects
 Respiratory
– COPD
PN
– Lung CA RT ↑↑ Smoking
 Skin/Skeletal
– ↓↓ Reflexes RT Peripheral Neuropathy
– Muscle weakness = ↑↑ Falls
– Skin ulcers
– Spider Angiomas
 Genitourinary
– ↑↑ Urination RT diuretic action of ETOH
– ↑ FAS
Alcohol Withdrawal Syndrome AWS
 Rebound NS Hyperirritability
 1st Stage (6-8 h after last drink)
– “Morning after jitters”
– Tremors Anxiety C/O “Shaky Inside”
– Irritability ↑ HR
↑ BP
N&V
 2nd Stage (24 h no interventions)
– Hallucinations
 Visual: 3 - 4’ long bugs
 Tactile: crawling sensation
 Auditory: hear music
– Seizures (2-6 during 3-4 h period)
Alcohol Withdrawal Syndrome AWS
 3rd Stage (48h) Delirium Tremens- DTs
– Acute Medical Condition (20% mortality)
– Dehydration →Fluid & Electrolyte imbalance
– ↑↑ Autonomic Hyperactivity
 ↑HR
↑BP
↑Temp
– Fatal Arrhythmias
– Global confusion & unaware of environment
– Vivid Hallucinations & Delusions
– ↑↑ Agitation & Seizures
AWS Therapy
 Detoxification 3-7 days
 AWS Protocols
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Librium, Valium or Ativan 10-20x dose initially!
Thiamine (IM)
Cyanocobalamine (Vit B12)
Niacin (Vit B6)
Folic Acid
IV Glucose
ß Blockers:
 Propanonol (Inderal) Clonidine (Catapres)
– Dilantin or Mg SO4
NO Mellaril or Haldol for hallucinations
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– Tryptophan & Trophamine
– Odansetron (Zofran)
AWS Nursing
Primary Priority = Assessment! V/S & LOC
 Monitor Pt’s response to therapy
 Pt. Safety = √ S/S of depression & suicide
 Calm, quiet environment
 Provide uninterrupted periods of rest
 Firm limits & consistent support
 Reorient to reality
 Confront denial, rationalization, projection
 Monitor visitors
Medications
 Antabuse (Disulfiram)
 Aversion Therapy
–Blocks oxidation of ETOH
–↑ Pt sensitivity
–↑ HA ↑ HR N & V Flushing
–Chest Pain → Death
 Naltrexone HCL (ReVia PO, Vivitrol IM)
 Opioid antagonist = ↓ ETOH craving
 Can not be used with narcotics for 7-10
days
 Acamprosate (Campral)
 ↓ ETOH cravings
Therapy
 12 Step Programs: AA NA CA
– Life-long commitment
– Attain & Maintain sobriety
 Peer group & sponsor
– Accept ETOH dependency as illness
– Develop adaptive coping skills
– ↑↑ Self-Esteem
Hallucinogens
LSD: Acid, Purple Haze Big D
Mescaline: Peyote, Half-Moon
PCP: Angel dust (lipophilic)
Ketamine: Special K
Marijuana: Pot, Weed, Grass, Joint, MJ
Dronabinol (Marinol) & Nabilone (Cesamet)
– used for Chemo induced N & V
 Action
– Alter mood & perception of time & space
– Paranoia , Hallucinations & Illusions
– Alter cognitive function = insight into life?
– Synesthesia = altered visual/auditory
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 “ Hear Colors” “See Music”
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Bad Trips = fear of losing one’s mind ↑ suicide
↑↑ HR ↑↑ BP ↑↑ Temp
Dilated Pupils
↑↑ Aggression & ↑↑ Physical Strength (PCP)
Flashbacks (up to 5 -15 years)
Stimulants
 Amphetamines: Ecstasy, MDMA, Amylnitrate
– Ice “Crank” smokeable form of methamphetamine
– Euphoria lasts 12 -30 h ↑ violence ↑ strength
 Cocaine: Coke
– Crack “Rock” smokeable form of coke
– Onset 6-7 secs, High 2-5 min, Severe crash → ↑↑ use
 Caffeine
 Action
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↑↑ DA ↑↑ NE ↑↑ 5-HT
↑ Alertness
↑Endurance
↑Elation
Euphoria
↑↑ Self-Esteem ↑↑Assertiveness ↑ Sexuality
Verborrhea
Tolerance in hours – days
Vasoconstriction = ↑ HR ↑ BP ↑ Temp Arrhythmias
 Withdrawal
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Tobacco
Respiratory depression
Dilated pupils
Fatigue Vivid Dreams
↑↑ Appetite
Psychomotor retardation
Crashing = Suicidal Ideation Psychosis
↑↑ Tremors
Opioids
Morphine MSO4
Hydromorphone
Codeine
Oxycodone
Heroin
Hydrocodone
Action
– Euphoria ↓↓ Pain Perception ↑↑ Passivity
– ↓ Anxiety & ↓ ↓ Aggression = Apathy
– ↓ Hunger ↓ Thirst ↓ Libido
– Pin point Pupils
↓↓ Respirations
– Rapid weak pulse
 Withdrawal (5-14 days)
– Watery eyes
Rhinitis
Anxiety
– Yawning
Sneezing
Tremors
– Abdominal spasms
– Restlessness
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Opioid Withdrawal Meds
Buprenorphine HCL (Subutex)
Buprenorphine HCL & Naloxone HCL
(Suboxone)
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Alternative to methadone
Outpatient Detox (Controlled)
Avoids going through withdrawal symptoms
Ethical issues
↑↑↑ Risk of abuse with Suboxone
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Sedatives, Hypnotics & Anxiolytics
Brevital, Seconal
Restoril, Halcion
Valium, Xanax, Ativan, Rohypnol ‘Roffis”
Gamma Hydroxybutrate (GHB):
–G
Liquid X
Georgia Homeboy
 Action
– Relaxation & well being = Sense of Calm
– ↓↓ HR ↓↓ BP
↓↓ RR
– ↓↓ Muscle spasms & ↑↑ Sleep
– ↓↓ Coordination = Ataxia
Mental Impairment
– Quick temper ↓↓ Patience & tolerance
– ↑↑ Dose = ↓↓ Anxiety → Sedation → Coma → Death
Impaired Nursing Practice
1/8 Nurses are addicted = impacts their
practice.
 1/5 are chemically dependent
 45,000 Alcoholic RNs
 Narcotic addiction is 30x > public
 50-70% due to inadequate pain
management for work related injury.
 Hx of ETOH or substance abuse in family.
Warning Signs of Abuse
 Poor judgment & work performance
– Errors in charting & ↓↓ Pt. care
– ↑Accidents/incidents during shift
 Inaccurate med counts
– ↑↑ vial breakage & waste
 Volunteers to work extra shifts & give meds.
– ↑ Reports from Pt of unrelieved pain
 ↑↑ Absenteeism (after many days off)
 Leaves floor frequently
– Spends ↑↑ time in bathroom
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ETOH breath
Reddened eyes
Hyperactivity
Apathetic
Flushed face
Unsteady Gait
Irritability
Nursing Interventions
 Document RN behavior, Pt or
medication incidents objectively.
 Approach colleague with compassion
 Express concern for her health and Pt’s
safety.
 Remain in touch with colleague
 Notify supervisor to report impaired
colleague
– Ethical & legal obligation
– Facilitates RN to obtain EAP services, RX
– Protects the public!
Peer Assistance Program PAP
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Established in 1982 by ANA
RN voluntarily submits license during program (5 years)
Facilitates impaired nurses to recognize their illness.
Maintain confidentiality & obtain needed RX.
Regain accountability within profession.
Contract
– Method of RX, work guidelines, spot drug testing and quarterly
evaluations.
 Work site monitor √ progress during treatment.
 If unsuccessful refer to the State Board of Nursing,
– Office of Professional Discipline (OPD).
– Any Pt. harm or criminal charges
 Narcotics taken (Federal Law) & theft of property
 FL 2009 Law
– Hx of abuse
– Unable to reapply for license for 15 years!
Statewide Peer Assistance for Nurses
(SPAN)
 Voluntary participation with PAP.
 SPAN Advocate
– Mentor maintains weekly contact for 1:1
counseling and support.
 Weekly support group meetings
– With other impaired nurses.
 Open ended participation
– Encouraged to stay active c PAP program
 Evolve into sponsors for their colleagues.
 Terminated for non-participation
– PAP notified.