Transcript Chemical Dependency

Chemical Dependency
Dual Diagnosis
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Presence of substance
abuse or dependency
AND a Mental Health
Diagnosis (Axis I or Axis II)
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50% of clients with severe
mental illness also have
substance abuse problems
Increases revolving door
syndrome
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Crisis
Admission
Stabilization
Discharge
Substance abuse
Poor prognosis
Alcoholism
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Along with heart disease
and cancer
Ranks as one of the leading
causes of death and
disability in the United
States
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Premature death
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Homicides
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47% alcohol related
Drownings
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25% alcohol related
Accidental Death
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50% alcohol related
Suicides
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2 to 4 times higher
34% alcohol related
Falls
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28% alcohol related
Theories for Substance Dependence
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Psychodynamic
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Easily succumb to the
escape
More phobic
Stereotypical characteristic (the
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Biological Theory
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result of alcoholism or the cause?)
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Feelings of Inferiority
Dependency, low selfesteem, introversion
Genetic Predisposition
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Children of alcoholics are
at greater risk even when
raised in an alcohol free
environment
Can take steps to minimize
risk
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Recognize family
predisposition
Avoid the use of alcohol
and drugs
Pharmacokinetic of Alcohol
Alcohol: Tolerance Disease and
Respiratory Depression
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Hepatic Function
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Primary metabolism is in
the liver
Increased hepatic drugmetabolizing enzymes
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Respiratory Depression
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Hasten alcohol metabolism
Fat accumulates in the liver
because it’s primary use is
no longer for energy
Alcohol accumulates in the
liver increasing cell death
Vitamins can not be
activated
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Tolerance to Respiratory
depressing effects does not
develop
The more alcohol an
individual drinks the more
likely respiratory depression
(regardless of needing
more alcohol to get a buzz)
Results in deaths of longterm pharmacodynamically
tolerant drinkers
Alcohol: a Chemical BOMB!
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Alcohol:
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Unlike other drugs does not
mimic a single neurotransmitter
A small fat soluble molecule
Alcohol enters the cell
membrane of neurons
Changes the properties
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Receptors are located on cell
membranes
Cell membranes control the
release of neurotransmitters
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Alcohol
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Unlike other drugs effects all
parts of the brain and all
neurotransmitters
Some of the Neurotransmitters
effected
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Glutamate
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Dopamine
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Excitement and stimulation
GABA
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Muscle relaxation,
discoordination and Black outs
Anxiety reduction
Endorphins
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Kills pain and leads to
endorphin”high”
Alcohol: The Central Nervous System
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Cerebral Intoxication
Depresses psychomotor activity
Relieves anxiety and tension
Increases ability to socialize
Decreases self- imposed social
barriers
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REBOUND: how it starts
and ends
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First
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Second
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effects wear off
greater tension and anxiety
rebound psychomotor activity
Third
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depresses psychomotor
activity
relieves anxiety and tension
drinker consumes more
alcohol to regain anxiety free
state
Presenting complaints
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Nervousness (anxiety)
Depression
Alcohol and Medical Problems
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The Liver
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Decrease liver cell function
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Increase in ammonia
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High lab value
Hepatic encephalopathy
(brain damage)
Increase in bilirubin
Increase in female
hormones
Pancreatitis
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Diabetes
Peripheral Nervous System
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Thiamine deficiency
contributes to peripheral
neuritis (paresthesia in
distal extremities)
Wernecke- Korsakaff Syndrome
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Cause: Malabsorption
syndrome
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Irritation of the intestinal
lining
Deficiency in vitamin
absorption
Especially B vitamins and
B1 (Thiamine)
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Amnesia
Delirium
Peripheral neuropathy
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Must replace Thiamine
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Give parenterally at first
then orally
Delirium will become a
permanent Dementia if
Thiamine remains deficient
Alcohol Withdrawal
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Neuro: CNS irritation,
tremulousness,
nervousness, unsteady
gait, difficulty
concentrating.
Exaggerated startle
reflex
Alcohol Withdrawal
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MH: Anxiety, sleep
disturbance, craving for
alcohol and other
drugs, hallucinations.
Delirium tremens (DTs)
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GI: N&V diarrhea,
anorexia
CV: tachycardia,
high BP, profuse
perspiration
CIWA
Clinical Institute Withdrawal
Assessment
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Some of the CIWA measurements include:
Pulse and blood pressure measurements
Nausea and vomiting incidences including frequency and severity
Tactile disturbances which have a wide range from feeling a pins and
needles sensation to itching to severe or continuous hallucinations
Tremor severity, if any
Visual and auditory disturbances
Sweating severity
Anxiety and agitation which may be noted from mild to serious panic
attack mode
Orientation or disorientation levels
Each symptoms is scored and a TOTAL score can warrant prn
medication
Medications: Alcohol
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Withdrawal: Misery and Risk of
Death
Medications to assist with
symptoms:
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Clonidine (Catapress)
Thiamine (vitamin B1)
Lactulose
Disulfram (Antabuse)
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Medication is used to prevent
DTs and seizures:
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Benzodiazepines
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Chlordiazepoxide (Librium)
Lorazepam (Ativan)
Diazepam (Valuim)
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Will become ill if the person
drinks
Sweating, flushed face, N&V,
dyspnea palpitations, dizzy
weakness,
Naltrexone hydrochloride
(ReVia)
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Aversive Therapy
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Decreases ammonia levels
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Opioid receptor antagonist
Decreases pleasurable affects
Must wear a medical alert
bracelet
Acomprosate (Campral)
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Corrects the balance between
neuronal inhibition and
excitation altered by alcohol
Does not prevent relapse
Barbiturate Withdrawal
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Common Barbiturates:
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secobarbital (Seconal)
amobarbital (Amytal)
phenobarbital (Luminal)
Street names: yellows,
jackets, reds, blues
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Lethal: at slightly higher
than therapeutic doses:
Respiratory Depression
Withdrawal is often
severe and can cause
death; begins 8-12
hours after the last
dose; need cautious
gradual withdrawal
(10% per day)
Barbiturate Withdrawal
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Neuro: (causes CNS
depression)
Withdrawal results in a
rebound:
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muscle twitching
tremor, progressive
weakness
convulsions
delirium
Barbiturate Withdrawal
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MH: Anxiety, insomnia
GI: Nausea and
vomiting
CV: orthostatic
hypotension, dizziness
May continuing to give
Barbiturate and
decrease by 10% per
day.
Opioid: Heroine
Opioids (Narcotics)
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Opium, Heroine
Codeine
hydromorphone
(Dilaudid)
meperidine (Demerol)
methadone (Dolophine)
hydrocodone (Vicodin)
oxycodone (Oxycontin)
Overdose: Opioids
Progressive symptoms:
1.
Pinpoint pupils (mitosis)
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Stuporous and sleeps
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Skin is wet and warm
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Coma and respiratory
depression
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Skin becomes cold and
clammy
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Pupils dilate
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Death
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Narcotic antagonist
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Naloxone (Narcan)
Given IV push
Client responds in a few
minutes
May have to administer
again
Blocks neuroreceptors
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Affected by opioids
Opioid Withdrawal
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Withdrawal can be fatal
if unassisted
Neuro: leg spasms
(kicking the habit).
Tremor, restlessness,
MH: Anxiety
Opioid Withdrawal
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GI: diarrhea and
vomiting
Other: yawning,
rhinorrhea, sweating
chills, piloerection
(goose bumps), bone
pain
Withdrawal from Opioids
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Treated
Symptomatically
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Naltrexone hydrochloride
(ReVia)
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Catapress (Clonidine)
can be helpful
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Opioid receptor
antagonist
Decreases pleasurable
affects
Must wear a medical
alert bracelet
Inhalants
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Cheap and readily available
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Hydrocarbon solvents
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Aerosol propellants
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Spray cans
Chloroform, nitrous oxide
Death
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Brain Damage
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Anesthetic gasses
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Gasoline and glue
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Amount inhaled can not be
controlled
Asphyxiation, suffocation
and choking
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Frontal lobe
Cerebellar
Hippocampal
Diminished problem solving
Ataxia
Dementia
Stimulants
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Cocaine
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Blocks dopamine re-uptake
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Euphoria, alertness,
Psychological dependence
Increased strength
Sexual stimulation
Intense paranoia
Hypertension
Tachycardia (can cause death)
Decreased inhibitions
Death: metabolic and
respiratory acidosis; prolonged
seizures
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Crack
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Less expensive way of using
cocaine
Methamphetamine
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Epidemic
Physical addiction
Names: speed, meth,
crystal, crank or ice
Longer high than
cocaine
Causes anorexia and
insomnia
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Rebound
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Paranoid
Hallucinations
Violent rages
Long-term use
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Damages Dopaminergic
system
Use to avoid feeling bad
Hallucinogens
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Mescaline (peyote)
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Action
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Religious practice protected
by law
Taken orally
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Probably the norepinephrine
synapses
Lasts 12 hours
Psilocybin and Psilocin
(mushrooms)
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Lysergic Acid Diethylamide (LSD)
North American Native Indian
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Hallucinations
Hypertension
Increased temperature
Involuntary movements
Lasts 8 hours
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Binds to serotonin receptors
Causes a blending of senses
(smelling a color or tasting a sound)
Increase in blood pressure
Tachycardia
Trembling
Dilated pupils
Flashbacks
Anxiety
Paranoia
Acute panic
Psychotic Breaks
Individuals have killed themselves
Marijuana
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Delt-9- tetrahydrocannabinol
(THC)
Varies in strength depending on
soil conditions and climate
Changed to metabolites and
stored in fatty tissue (remains in
the body for 6 weeks)
Detected in blood and urine for
3 days to 4 weeks
Effects last 2 to 4 hours
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Effects
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Sense of well-being
Alters perception
Euphoria
Antiemetic
Impairs balance and
stability
Problems
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Amotivational
Bronchitis
Memory impairment
May increase anxiety
Effects on the Family
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All family members are
affected
Treatment for the family
is important
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Problems: Rescuing or
Enabling
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Making excuses for the
person addicted
Doing things that the
person should have
done
Lying
Family and Relapse
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Co-dependent
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Set of behaviors that maintain
the addiction
Does not hold the person
addicted responsible for their
behavior
Spouse may also be a child of
an alcoholic and used to a
certain pattern of behavior
Takes on roles out of necessity
(control)
Behaviors are integrated and
resistive to change
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Difficult to alter when the
individual stops using
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Change
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Hold the person who was
addicted responsible
Re-assign roles and
responsibilities within the family
Sacrifice of income
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Change in job to be in a drug
free environment
Decrease stress
Maintaining an alcohol and
drug free home
Assessment
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Interview Approaches
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Encourage Honesty
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Matter of Fact
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Addict
Alcoholic
Problems with drinking
Difficulties with drug use
Using more than intended
Tools to Screen for Alcoholism
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Non-judgmental
State:
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Inpatient Chemical Dependency
Assessments every 4 hours or
more often
Michigan Alcohol Screening Test
(MAST)
CAGE Questionnaire
Form to complete which is
quantified (given a score)
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Avoid words like:
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genuine concern for the client
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BP and heart rate are important
Tremors, lacrimation, rhinorhea and
cravings
PRN medication is given based on
the score.
The Nurse is very busy with
assessments and administration of
medications
The Nurse Patient Relationship
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Attempts to address:
Narcissistic
DENIAL and Faulty Thinking
(Cognitive Distortions) i.e.
better than others
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Tendency to break the rules:
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“I can do my job when drinking,
when other people can not.”
“I can stop after just one drink.”
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Establish trust by expressing
empathy and providing a safe
environment.
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Assist in establishing new goals
and directions.
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Assist the client in identifying
ineffective behaviors and
replace with new coping skills.
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Confrontation of DENIAL (telling
the client what is observed and
how it may differ from what is
said) p526 Keltner
“I can have a drink and drive
because I can handle it when
others can not.”
The relationship with the
alcohol or drug being the most
important relationship
Ineffective behaviors increase
the chance of relapse.
Milieu Management
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Observe and protect the
environment
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Familiar and comfortable with
structure
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(i.e. plan their day in order to use
alcohol or drug)
Confrontation of Behavior
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Must remain drug-free
Suicide prevention
Intervening with aggression
Urine drug screens
Structured and predictable
schedule
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Penetrate denial and
defensiveness
Requires Balance
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Sensitivity to confront while
protecting the client’s self
esteem
Limit Setting
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Manipulation and splitting can
occur
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(remember: the relationship
with the drug or alcohol is
more important than other
relationships)
12 Step Programs
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Best Known
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Alcoholics Anonymous (AA)
Narcotics Anonymous (NA)
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Starts with:
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Both Have a religious influence
Admitting powerlessness over alcohol (drugs)
The 12 Steps Confront
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Denial
Narcissism
Cognitive Distortions
Problems with relationships (Box 35-7; p530 Keltner)
Relapse
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Being around other users
Severe Cravings
Stopping attendance of AA or NA meetings
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Client does not meet the GOAL of attending 90
meetings in 90 days
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GOAL: In 90 days the client will go to one meeting each
day
Not expressing feelings
Going through a major emotional crisis
Addiction and Health Care
Professionals
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Most common areas of employment:
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Operating Room
Emergency Room
Intensive Care Unit
Many times these are our best and brightest
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not)
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How do you know?
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Client is still in pain after pain medication is given and documented
Narcotic medication count errors (hospitals checks statistics on
every nurse)
What do you do when your colleague asks:
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I have been so busy. I already wasted that medication I did not use, do
you mind witnessing it for me?
 (remember: the relationship with the drug or alcohol is more important than
other relationships)
Texas Peer Assistance Program for
Nurses (TPAPN): GOALS
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Identify nurses experiencing
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mental health or
alcohol/drug problems
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Assist these nurses in obtaining appropriate treatment.
Monitor the nurse's return to the work force.
Educate employers and nursing colleagues
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that have been or are likely to be job impairing.
about the negative effects of addiction/mental illness in the work place
and the potential for rehabilitation and return to productive work.
http://www.texasnurses.org/displaycommon.cfm?an=1&subarticlenbr=107
The End