Transcript Substance Related Disorders & Dual Diagnosis

Substance Related Disorders &
Dual Diagnosis
Phyllis M. Connolly, PhD, RN, CS
NURS 127A
Questions to Consider Today 4/20/01
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What behaviors indicate that a nurse
may be abusing substances?
What is the ego/self theory related to
substance abuse?
When is denial a problem?
What is the relationship between
childhood sexual abuse and addiction?
Substance Disorders Facts
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Cost: $144 billion/year in health care and job
loss
Alcohol most commonly used
Marijuana most commonly used illegal drug
50% auto accidents & homicides involve
alcohol
Involved in crime & violence
500,000 deaths from Tobacco-related
disorders
One in 10 deaths related to alcohol
More die from misuse of legal prescriptions
Impaired Nurses
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5% of 2 million nurses in 1984 (ANA)
abused substances
8-10% chemically dependent
Narcotic addiction 30 X higher than
general population (1987 study)
67% of cases handled by 44 state BRN
(1988)
Signs of Impaired Nursing Practice
Job Performance Changes,
Controlled drug handling
Drug counts incorrect
Excessive errors
Excessive wastage, often not
countersigned
Medicine signed out to pt. not
in pain
Two strengths of drugs signed
out to same pt. Same time
Packaging appears to be
tampered
Patient complaints of
ineffective pain control
Volunteers to give controlled
drugs
General Performance
Medication errors
Poor judgment
Euphoric recall for
involvement in unpleasant
situations
iIlogical or sloppy charting
Absenteeism, esp. days off
Requesting leave time just
before assigned shift
Lateness--elaborate excuses
Job shrinkage
missed deadlines
Signs Impaired Nurse Cont.
Behavioral/Personality
changes
Sudden changes in
mood
Periods of irritability
Forgetfulness
Wears long sleeves (hot
weather)
Socially isolates
Inappropriate behavior
Chronic pain condition
Hx pain treatment with
controlled substances
Signs of Use
Alcohol on breath
Constant use of
perfumes, mouthwash,
breath mints
flushed face, reddened
eyes, unsteady gait,
slurred speech,
hyperactivity
accelerated speech
Increasing family
problems interfere with
work
Interventions: Impaired
Colleagues
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Reporting required ethical & legal
obligation to supervisor
Document in writing; time, date, place
description, & names of those present
An advisor with (state nurse
rehabilitation team)
Team approach,co-workers, supervisor,
nurse administrator, family member
Prevalence of Substance-Related
Disorders
Prevalence
 Alcohol abuse
– Males
– Females
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Substance
Other drug
dependency
Disorder
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16%
29%
6%
18%
9%
Dahme, 1998
Classes of Substances with Potential
for Abuse and Dependence
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Alcohol
Amphetamine
Caffeine
Cannabis
Cocaine
Hallucinogens
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Inhalants
Nicotine
Opiods
Phencyclidines
(PCP)
Sedative,
hypnotic,or
antianxiety agents
5 General Categories of Substances
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CNS depressants,(alcohol, sedative-hypnotics,
antianxiety agents,and volatile inhalants
Stimulants (cocaine, amphetamine,caffeine,
nicotine**, & related substances)
Opioids including analgesics
Hallucinogens including PCP
Cannabis
 Caffeine not considered to cause either dependence or abuse
** Nicotine is currently classified as causing dependence but not abuse
Psychoactive Substances
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Drugs or chemicals which alter one or
several of:
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Perception
Awareness
Consciousness
Thinking
Judgment
Decision making
Insight
Mood
Behavior
Etiological Theories: Substance
Abuse
Biological
 Addictive substances activate neurotransmitters in
mesolimbic dopaminergic reward pathway
– chronic use  blood flow to brain
 Genetic predisposition
 Behavioral--conditioning & homeostasis
– drug craving triggers; self-medicating
 Psychodynamic
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Unconscious oral needs
Dependency
Low self-esteem
child abuse, physical, sexual
family conflict (Trauma model, Walker et al. 1998)
DSM-IV Criteria Substance
Related Disorders
Substance Dependence Substance Abuse
A. Maladaptive pattern 3 A. Maladaptive pattern leads
to significant impairment
or more:
or distress as manifested
 tolerence
by one or more of:
 withdrawal
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need for more
inability to stop using
time spent acquiring or
recovering from effects
problems, social,
occupational, or recreational
Continues use despite
knowledge
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Failure to fulfill major role
obligations at work, school, or
home
Recurrent use in hazardous
situations
Recurrent substance related
legal problems
Continued use despite
problems
DSM-IV Criteria Substance Related
Disorders Cont.
Substance Intoxication Substance Withdrawal
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Development of a substancespecific syndrome due to a
recent ingestion of a
substance
Clinically significant
maladaptive behavioral or
psychological changes due
to the effect of the substance
on the CNS
Not due to general medical
condition and not better
accounted for by another
mental disorder
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Development of a substancespecific maladaptive
behavioral or psychological
changes due to the effect of
the substance on the CNS
The substance-specific
syndrome causes clinically
significant distress or
impairment
Not due to a general medical
condition and not better
accounted for by another
mental disorder
Substance Dependence
Lack of control over drug use and its increasing
importance. At least 3 symptoms in 12 month
period.
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Tolerance
Withdrawal
Taking larger amounts
Inability to reduce use
Excess time spent on obtaining drugs
Impairment in functioning
Continued use despite negative consequences
Dahme, 1998
Key Terms
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Dependence: A drug abuser must take a
usual or increasing dose of a drug in order to
prevent the onset of abstinence
symptoms/withdrawal
Tolerance: The need for increasing amounts
of a substance to achieve the same effects
Withdrawal: Physical signs and symptoms
that occur when the addictive substance is
reduced or withheld (abstinence syndrome)
Key Terms cont.
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Abuse--Excessive use of a substance that
differs from societal norms
Codependency--stress-related preoccupation
with an addicted person’s life, leading to
extreme dependence on that person
Blackouts--period of time in which the drinker
functions socially but for which there is no
memory
Pharmacodynamic tolerance--occurs when
higher blood levels are required to produce a
given effect
Coping Styles Contributing to
Substance Abuse Maintenance
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Rationalization
– Falsifying an experience by giving a contrived, socially
acceptable and logical explanation to justify an unpleasant
experience or questionable behavior
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Projection
– Attributing an unconscious impulse, attitude,or behavior to
someone else (blaming or scapegoating)
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Denial
– escaping unpleasant realities by ignoring their existence
Cognitive Framework: Assessing
Denial
Is it denial?
Is it a problem?
Yes
No
Yes
No
Reassess
Do nothing
How is it a problem?
What cognitions are in conflict?
What are alternative means of
reducing dissonance?
Forchuk & Westwell, 1987
Alcohol Abuse and Culture
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Norms important role
Cultures with rate of alcohol abuse may condone
drunkenness (Irish)
Cultures with  rates appropriate use of small amts.
Celebrations (Jewish & Mediterranean)
Condemn altogether (Muslim, Jehovah’s Witness,
and Mormons)
China and Japan lower prevalence-negative
physiological response
Native Americans & Eskimos  rates
US rates similar to northern European countries
Enabling
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Behaviors of individuals in family or
social system who inadvertently
promote continued alcohol or drug use.
By protecting them from consequences
of their actions. Examples: ignoring or
making excuses for person’s behavior,
finishing the work of a colleague who is
unable to function.
CAGE Screening Test
Alcoholism
1. Have you ever felt you ought to Cut
down on your drinking?
2. Have people Annoyed you by criticizing
your drinking?
3. Have you ever felt bad or Guilty about
your drinking?
4. Have you ever had a drink first thing in
the morning to steady your nerves or
get rid of a hangover? (Eyeopener)
Keltner, p. 530
Alcohol Withdrawal Symptoms:
First 24 hours
Within a few hours, peaks within 24 hrs.
 Anxiety
 Insomnia
 Irritability
 “Internal shaking”  BP, P, diaphoresis
Alcohol Withdrawal Symptoms:
Sudden to 2-3 days
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Grandmal convulsive seizures--48 hrs.
Delerium tremens (DTS)--72 hrs.
–  Medical Emergency Acute pathological
state of consciousness results from
interference with brain metabolism
Wernicke’s Syndrome &
Korsakoff’s Disease
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Nutritional disorders related to alcoholism
Thiamine deficiency
Both treated with withdrawal from alcohol
and vitamin supplements.
Improvement can occur in Wernicke’s
syndrome, some degree of intellectual and
emotional impairment remains.
Memory impairment is residual in
Korsakoff’s even when slight improvement
occurs
Wernicke’s Syndrome
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Neuronal and capillary lesions in gray
matter of brain stem
Characterized by delirium, memory
loss, confabulation, apathy,
apprehension, ataxia, clouding of
consciousness, sometimes coma
If not treated early with large doses of
thiamine, Korsakoff’s Disease may
develop
Korsakoff’s Disease
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Niacin deficiency in addition to thiamine
Degeneration of cerebrum and
peripheral nerves
Characterized by amnesia,
confabulation, disorientation, and
peripheral neuropathy
Confabulation
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Commonly observed in chronic brain syndrome
Person cannot recall specific aspects of an event
Fills in with relevant imaginary information
Face-saving device, protects self-esteem
Compensates for memory loss
Due to lack of access to stored information and lack of new
input
Inability to form new associations
Loss of capacity for introspection and judgment of truth
Frequently observed in Korsakoff-Wenicke’s Syndrome
Potential Nursing Diagnoses:
Substance Abuse
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Altered nutrition
Risk for fluid volume deficit
Altered thought processes
Sensory/perceptual alterations: auditory-visual
Sleep pattern disturbance
Altered health maintenance
Self-care deficit
Noncompliance
Hopelessness
Helplessness
Self-esteem disturbance
 risk violence to self and others
Anxiety
Ineffective individual coping
Self-Care Deficit
Ego functioning which does not handle painful
affects or maximize protective activity
 Interventions
– Provide alternative ways to handle or tolerate
painful emotions--stress management
– Furnish structured supportive environment
– Increase awareness of unsatisfactory protective
behaviors
– Teach skills to recognize & respond to healththreatening situations
Compton, 1989
Pharmacological Interventions:
Alcohol Abuse
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Disulfiram (Antabuse)--negative
aversive
– inhibits breakdown of acetaldehyde--toxic
to body: if alcohol is ingested causes
sweating,flushing,  pulse,  BP,
headache, nausea, vomiting, palpitations,
dyspnea, tremor, and/or weakness. May
cause arrhythmias, MI, cardiac failure,
seizures, coma, and death
Elements of Detoxification
Process
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Secure environment
Sedation
Supplements
Pharmacological Interventions:
Alcohol Abuse Cont.
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Naltrexone hydrochloride (ReVia)-opiod receptor antagonist
– Increases abstinence and reduces alcohol
craving in combination with comprehensive
treatment plan
– May cause liver toxicity at high doses
– Contraindicated for patients who abused
narcotics within 7-10 days
Interventions Alcohol Abuse
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AA Self-Help
Brief Interventions
– Feedback
– Responsibility
– Advice
– Menu
– Empathy
– Self-efficacy
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Moderation-Online Self-Help
Motivational interviewing
Opioid Abuse: Signs & Symptoms
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CNS Effects
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sedation
euphoria
mood changes
mental clouding
pain reduction
pinpoint pupils
decreased respiratory
rate
GI Effects
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Cardio Vascular
– Hypotension
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Sexual Functioning
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Decreased libido
retarded ejaculation
impotence
orgasm failure
Detoxification
– Clonidine (Catapress)
– chronic constipation
Townsend, 1996, p. 374
Antecedents to Relapse
Event
Cocaine Alcohol
Being around users 87%
40%
Severe craving
67%
25%
Stopping AA/NA
48%
75%
Not expressing
feelings
Major emotional
crisis
20%
75%
33%
50%
Keltner, p. 538
Stages of Change: Addictive Behaviors
Relapse
Permanent Exit
Maintenance
Precontemplation
Contemplation
Action
Preparation
Prochaska &
DiClemente, 1992
Treatment of Substance-Related
Disorders
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Trusting therapeutic
relationship, nurse
Detox & residential
treatment
Behavioral model &
disease model
Rehabilitation
– Abstinence
– Motivation
Medications
– Alcohol-Librium,
Valium, Ativan
Opioid--Narcan
– Methadone
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Family education
Treatment of comorbid
medical & psychiatric
disorders
Group treatment
– Confrontation
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Personal responsibility
Conscience development
Self-help
Life-style issues
Percent of Population (15 -54) 1991
With Substance Abuse Disorder, Mental,
or Both in Lifetime
Substance
Abuse
Dependence
12%
Both
Disorders
13.7%
Only Mental
Disorder
21.4%
Dahme, 1998, p. 288
Etiology: Dual Diagnosis
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Generally mental illness first
– Heredity
– Biological factors
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Self-medicating
Substance abuse first
– Brain chemistry altered
– Guilt, depression, altered self-esteem
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Personality disorders
Examples of Dual Diagnoses
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Axis I Schizophrenia
Alcohol abuse
Axis I Major depression
Anxiolytic dependency
Axis I Major Depression
Marijuana abuse
Treatment: Dual Diagnosis
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Multidisciplinary
Case management
Individual therapy
Group therapy
Skills training
Education groups
Vocational counseling
Referrals to community resources
Self-help groups
Five-step model
Therapeutic Tasks: Dual
Diagnosis
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Establish therapeutic alliance
Help patient evaluate costs and benefits of
continued substance abuse
Individualize goals for change; include harm
reduction as alternative to abstinence
Help build an environment and lifestyle
supportive of abstinence
Acknowledge recovery long-term process
Jefferson, 1998, p. 517
Outcomes Treatment: Major
Depression and Alcohol Abuse
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Short Term
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Verbalizes plans for future
Sleeps 6-8 hrs/night
Eats 3 balanced meals/day
Recognizes and describes problems with alcohol and
depression
– Plans to live with non substance user friend
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Long Term
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Practices abstinence from alcohol
Attends self-help groups
Attends outpatient treatment
Medication compliant
Lives in halfway house or non substance user friend