Transcript 2 Substance Use-M

Stimulants
STIMULANTS
• Intoxication (acute)
– psychological and physical signs
– euphoria, enhanced vigor, gregariousness,
hyperactivity, restlessness, interpersonal sensitivity,
anxiety, tension, anger, impaired judgment, paranoia
– tachycardia, papillary dilation, HTN, N/V, diaphoresis,
chills, weight loss, chest pain, cardiac arrhythmias,
confusion, seizures, coma
STIMULANTS
(cont.)
• Chronic intoxication
– affective blunting, fatigue, sadness, social
withdrawal, hypotension, bradycardia, muscle
weakness
• Withdrawal
– not severe but have exhaustion with sleep
(crash)
– treat with rest and support
Cocaine
• Route: nasal, IV or smoked
• Has vasoconstrictive effects that may outlast use
and increase risk for CVA and MI (obtain EKG)
• Can get rhabdomyolsis with compartment
syndrome from hypermetabolic state
• Can see psychosis associated with intoxication
that resolves
• Neuroadaptation: cocaine mainly prevents
reuptake of DA
Treatment - Stimulant Use
Disorder (cocaine)
• CD treatment including support, education,
skills, CA
• Pharmacotherapy
– No medications FDA-approved for treatment
– If medication used, also need a psychosocial
treatment component
Amphetamines
• Similar intoxication syndrome to cocaine but usually
longer
• Route - oral, IV, nasally, smoked
• No vasoconstrictive effect
• Chronic use results in neurotoxicity possibly from
glutamate and axonal degeneration
• Can see permanent amphetamine psychosis with
continued use
• Treatment similar as for cocaine but no known
substances to reduce cravings
• Neuroadaptation
– inhibit reuptake of DA, NE, SE - greatest effect on DA
Treatment – Stimulant Use
Disorder (amphetamine)
• CD treatment: including support, education,
skills, CA
• No specific medications have been found
helpful in treatment although some early
promising research using atypical
antipsychotics (methamphetamine)
Tobacco
Tobacco
• Most important preventable cause of death /
disease in USA
• 25%- current smokers, 25% ex smokers
• 20% of all US deaths
• 45% of smokers die of tobacco induced disorder
• Second hand smoke causes death / morbidity
• Psychiatric pts at risk for Nicotine dependence75%-90 % of Schizophrenia pts smoke
Tobacco (cont.)
• Drug Interactions
– induces CYP1A2 - watch for interactions when start or stop
(ex. Olanzapine)
• No intoxication diagnosis
– initial use associated with dizziness, HA, nausea
• Neuroadaptation
– nicotine acetylcholine receptors on DA neurons in ventral
tegmental area release DA in nucleus accumbens
• Tolerance
– rapid
• Withdrawal
– dysphoria, irritability, anxiety, decreased concentration,
insomnia, increased appetite
Treatment – Tobacco Use
Disorder
• Cognitive Behavioral Therapy
• Agonist substitution therapy
– nicotine gum or lozenge, transdermal patch, nasal
spray
• Medication
– bupropion (Zyban) 150mg po bid,
– varenicline (Chantix) 1mg po bid
Hallucinogens
HALLUCINOGENS
• Naturally occurring - Peyote cactus (mescaline);
magic mushroom(Psilocybin) - oral
• Synthetic agents – LSD (lysergic acid diethyamide) oral
• DMT (dimethyltryptamine) - smoked, snuffed, IV
• STP (2,5-dimethoxy-4-methylamphetamine) –oral
• MDMA (3,4-methyl-enedioxymethamphetamine)
ecstasy – oral
MDMA (XTC or Ecstacy)
• Designer club drug
• Enhanced empathy, personal insight, euphoria,
increased energy
• 3-6 hour duration
• Intoxication- illusions, hyperacusis, sensitivity of
touch, taste/ smell altered, "oneness with the
world", tearfulness, euphoria, panic, paranoia,
impairment judgment
• Tolerance develops quickly and unpleasant side
effects with continued use (teeth grinding) so
dependence less likely
MDMA (XTC or Ecstacy)cont.
• Neuroadaptation- affects serotonin (5HT), DA, NE
but predominantly 5HT2 receptor agonists
• Psychosis
– Hallucinations generally mild
– Paranoid psychosis associated with chronic use
– Serotonin neural injury associated with panic, anxiety,
depression, flashbacks, psychosis, cognitive changes.
• Withdrawal – unclear syndrome (maybe similar to
mild stimulants-sleepiness
and depression due to 5HT depletion)
Cannabis
CANNABIS
• Most commonly used illicit drug in America
• THC levels reach peak 10-30 min, lipid soluble; long half life of 50
hours
• IntoxicationAppetite and thirst increase
Colors/ sounds/ tastes are clearer
Increased confidence and euphoria
Relaxation
Increased libido
Transient depression, anxiety, paranoia
Tachycardia, dry mouth, conjunctival injection
Slowed reaction time/ motor speed
Impaired cognition
Psychosis
CANNABIS (cont.)
• Neuroadaptation
– CB1, CB2 cannabinoid receptors in brain/ body
– Coupled with G proteins and adenylate cyclase to CA
channel inhibiting calcium influx
– Neuromodulator effect; decrease uptake of GABA and
DA
• Withdrawal - insomnia, irritability, anxiety, poor
appetite, depression, physical discomfort
CANNABIS (cont.)
• Treatment
-Detox and rehab
-Behavioral model
-No pharmacological treatment but may
treat other psychiatric symptoms
PCP
PHENACYCLIDINE ( PCP)
"Angel Dust"
• Dissociative anesthetic
• Similar to Ketamine used in anesthesia
• Intoxication: severe dissociative reactions – paranoid
delusions, hallucinations, can become very agitated/ violent
with decreased awareness of pain.
• Cerebellar symptoms - ataxia, dysarthria, nystagmus (vertical
and horizontal)
• With severe OD - mute, catatonic, muscle rigidity, HTN,
hyperthermia, rhabdomyolsis, seizures, coma and death
PCP cont.
• Treatment
– antipsychotic drugs or BZD if required
– Low stimulation environment
– acidify urine if severe toxicity/coma
• Neuroadaptation
– opiate receptor effects
– allosteric modulator of glutamate NMDA receptor
• No tolerance or withdrawal
Inhalants
• Inhalants are drugs that produce quick,
temporary feeling high and lightheadedness.
• Feeling high last minutes to about an hour
• Inhalant abuse, also known as “huffing,”
• Types:
1. Solvents: paint thinner, glue
2. Gases: Butane
3. Nitrites.
Are they harmful?
• Short-term
1. Impaired physical coordination
2. Impaired mental judgment (confusion,
hallucination, delusion of persecution)
3. Irritation to breathing passage
4. May block the breathing center secondary
to CNS depression
5. Oxygen deprivation that lead to
unconsciousness …coma…DEATH
• Long term:
1. Tolerance
2. Permanent brain damage manifested
by: poor memory, extreme mood
swing, tremors, seizures, cardiac
arrhythmia, and respiratory depression
3. Glaucoma and blindness
4. Damage to liver and kidney
Treatment Modalities
Individual Therapy
• Indicated for clients with substance related d/os
who have:
– High levels of anxiety
– Inadequate coping mechanisms
– Low tolerance for frustration
• Problems with individual therapy:
– Clients continually test the bond between therapist and
client
– Therapist must be aware of several occurrences during
the process of therapy including:
• Possibility of relapse
• The onset of depression
• Refusal to continue therapy
Group therapy
• In a group setting, clients with similar experiences
and problems can confront and support each other
in a safe environment
• Groups work best when there are ground rules
established
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Sobriety
Regular attendance
Willingness to share experiences and confront defenses
Confidentiality
Family Therapy
• Provides opportunities to learn healthy ways
of interacting with one another and of
solving problems
• Provides a structure in which the entire
family can be educated about alcoholism as
a disease
Behavioral Therapy
• Relaxation techniques
• Biofeedback
• Use in combination with other models of
counseling and assertiveness therapy
• Approaches: assertiveness and aversive
therapy (teaching negative association)
Antabuse and Naltrexone Antagonist
• Disulfiram (Antabuse)
– Inhibits the enzyme aldehyde dehydrogenase, thus
blocking the oxidation of alcohol and allowing
acetaldehyde to accumulate in the blood
• When clients take Antabuse and ingest even a
small amount of alcohol, they become very sick
– Sx include: flushing, feelings of heat in the face, chest,
and upper limbs, pallor, hypotension, nausea,
palpitations, dizziness, blurred vision
Relapse prevention
• Teaching the client to identify the situations
in which relapse in expected.
• Enabling the client to make life style
changes including living area, shopping
place, and selection of friends and living
with family
Harm reduction
•
•
1.
2.
A techniques to change a pattern of use.
example include:
Driver program
Smoking cigarettes with low tar and
nicotine
Changing The Conversation
Program
1.
2.
3.
4.
5.
There is “ no wrong door” to treatment
Invest for results
Commit to quality
Change attitudes
Build partnership
Prognosis
• Sobriety is the goal for complete recovery from
substance abuse and dependence
• The course of substance dependence is variable
– It is usually chronic, lasting years with periods of heavy
intake and partial or full remission
• During the first 10 months after the onset of
remission, one is particularly vulnerable to relapse
• Most clients relapse a minimum of 3-4 times
before they attain sobriety
The Nursing Process
Assessment
• Screening instruments
– CAGE
• Have you ever felt you ought to Cut down on your
drinking?
• Have people Annoyed you by criticizing your
drinking?
• Have you ever felt Guilty about your drinking?
• Have you ever had a drink first thing in the morning
to steady your nerves or get rid of a hangover (Eye
opener)?
– Positive response to 2 of the 4 items of the
CAGE indicates a potential problem with
alcohol
Assessment (cont)
• Laboratory tests
– A comprehensive urine drug screen
– Other common laboratory tests useful in the
diagnosis of alcohol abuse include:
• Blood alcohol level (BAL)
• GGT—rises in response to ETOH ingestion; 6080% of individuals with chronic ETOH abuse will
have an increased GGT
• MCV—elevated in 35% of individuals who are
heavy drinkers
Nursing Diagnoses
• Coping, ineffective individual
• Denial, ineffective
• Family processes, altered
• Nutrition, altered
• Thought processes, altered
• Trauma, risk for
• Violence, risk for
(See also appendix)
Nursing intervention
1.
2.
3.
4.
Maintain patent airway and life threatening situation
Maintain safety of the client and others.
Observe for additional S&S for overdose
Assess for psychological and physiological sing and
symptoms for withdrawal and drug interaction.
5. Initiate therapeutic intervention to treat withdrawal
symptoms
6. Provide emotional support for client and family.
7. Support nutrition and nutrients consumption
8. Provide carbohydrate intake, vitamin, minerals.
9. Support client and family to acknowledge denial and
deception
10. Teach family about substance use
11. Encourage client and family to engage in AA’s