hi guys we're going to talk about
chapter 22 and this is going to really
focus in on substance related and
addictive disorders so when we think
about substance use disorders these are
not disorders of choice they are very
complex diseases of the brain that are
usually characterized by Cravings
seeking and using regardless of any
consequences
continued use can actually change the
brain structure and function substance
use disorder is the pathological use of
a substance that leads to to a disorder
of use so let's just get started here
when we think about substance use
disorder these are symptoms that are
grouped together they usually have
impaired control social impairment risky
use and some of the physical effects
that we're going to get into are
intoxication tolerance and withdrawal so
all of these groups are going to have
all of these symptoms
substances that can lead to use
disorders can fall into remember four
major groupings that impaired control
social impairment risky use and again
those physical effects and the ones that
we're going to look at are listed here
alcohol caffeine cannabis hallucinogens
inhalants opioid sedative hypnotics
stimulants tobacco and we don't want to
forget that gambling is also a very
addictive process so it can also lead to
a disorder
so some of the concepts Central to
Adaptive use disorders we can talk about
addiction and that's defined as a
primary chronic disease of brain reward
motivation memory and related circuitry
they are typically without addiction
unable to abstain from whatever
substance they are addicted to and
they're real those people are unable to
really recognize any functional problems
that may be going on
without treatment addiction is
Progressive and it can lead to
disability or death
intoxication is that excess use of
substance
some of the terminology can vary
depending on the substance that you're
using so anyone using substances may be
considered Under the Influence alcohol
can cause intoxication or cocaine will
make you high so some of that
terminology is just a little bit
different depending on the substance
that's being used
when we think about tolerance an
individual no longer responds to the
substance in the initial way that they
responded so they really need more of
that substance to feel the same response
withdrawal we have symptoms that occur
with when one stops using that substance
so each substance has its own
characteristic withdrawal symptoms we
unfortunately know that the more intense
the symptoms one has the more likely the
person is going to start using again
because the withdrawal symptoms are so
bad they're like nope I'm not doing this
this is too bad I'm just going to get
back on my substance again
so as far as epidemiology the national
survey on drug use and health survey is
conducted annually participants are
typically 12 years and older and they're
randomly selected for an interview then
based on this data they can see about
165 million people use substances within
that last month the actual number of
people with substance use disorder is
about 20.3 million and that includes
about 15 million with an alcohol use
disorder and about 8 million with an
illicit drug disorder
so this again is our epidemiology you
can see
um note the past Year's substance use
disorder this came from a 2018 study and
you can just see the differences in the
numbers there on which substance was
used more heavily
you can think about genetic factors
substance use disorders such as cannabis
cocaine and opioids typically run in
families
as far as neurobiological factors the
major neurotransmitter involved in
developing substance use disorders are
the opioid catecholamine and Gaba
symptoms systems sorry as far as
environmental factors poverty raises the
risk of an unfavorable living
environment lack of Parental supervision
poor educational resources and really an
impaired support system
a cycle of negative environmental events
often begins with disadvantaged
neighborhoods increasing Stress and
Anxiety along with a lack of negative
social ties which really contributes to
depression so the environment is really
a high risk factor depending on kind of
that patient's unfortunate poverty level
so here's our clinical picture we're
just going to go through each of these
and we're caffeine so caffeine is the
most widely used
psychoactive substance in the world
why do individuals use caffeine as an
addiction it increases your alertness
and it decreases your fatigue right I'm
sure all of you or most of your coffee
drinkers I'm not a coffee drinker I'm
more of a Giant Mountain Dew Drinker
um but if I'm tired right I can hit one
of those up and it kind of increases my
alertness and decreases that fatigue so
I can keep going
um this really is an official use
disorder but it can still result in
intoxication overdose and withdrawal
so when we think about caffeine
intoxication this usually occurs with
greater than 250 milligrams of
consumption so those of you that have
those high energy drinks that's two of
those and then you can have that
intoxication feeling some of the
behavioral symptoms that you might
notice are restlessness nervousness
excitement maybe that rambling speech
where you just are talking super fast
some of the physical symptoms might be a
flushed face Maybe diuresis GI
disturbances such as kind of nausea
belly aches and tachycardic
high doses can cause Grand mouth
seizures respiratory failure and even
death so a lot of people don't think
about caffeine in that way but
understand really high doses can be very
serious
when you think about caffeine withdrawal
this is associated with medical problems
excuse me and there's really no
intervention that's needed symptoms can
occur within 12 to 24 hours after
consumption and the peak is usually
about 24 to 48 hours symptoms could
include headache drowsiness maybe some
irritability so I think if you can think
about that time if you've had that time
or opportunity to maybe cut out your
caffeine in about a day or two I know
I've experienced it I start getting that
headache I get a little more irritable
because I'm I just have that little bit
of addiction to that caffeine
when we think about cannabis or
marijuana this is the most widely used
drug in the world it is legalized in
some states synthetically for the use of
nausea and vomiting that is associated
with chemo for cancer
more states are becoming more widely
open with cannabis so you just have to
know which of those States is widely
using it other synthetic cannaboids
um are K2 or spice can be associated
with toxic doses
it is the fourth most commonly used
psychoactive drug in the U.S after
caffeine alcohol and nicotine
cannabis intoxication we can think about
the heightened Sensations Sensations are
barely very heightened they see things
in brighter colors new details of common
stimuli time seems to go much more
slower
and motor skills are impaired for about
8 to 12 hours
cannabis withdrawal typically occurs
within about one week of cessation some
of the behavioral symptoms that we might
see are anger irritability maybe some
anxiety
some of the physical symptoms may
include abdominal pain sweating fever
chills and even headache as far as
treatment
abstinence and support is our main
principle we can think about individual
family and group therapies to help
Provide support we also need to just be
aware as health care providers that drug
scheme screens can detect cannabis for
up to four weeks after use
hallucinogens cause a very profound
disturbance in reality there are two
categories we can think about classic
and disassociative drugs the first one
is that we're going to talk about is our
classic which are hallucinogen
Classics which are LSD so other
terminology might be acid maybe Boomers
significant psychological and behavioral
changes occur with this when they're on
this paranoia Illusions maybe some
hallucinations even some of the physical
symptoms that we could think about are
pupillary dilation
tachycardia sweating and Tremors and
treatment is usually trying to just talk
that patient down reassuring them that
the symptoms are going to subside
sometimes in severe cases we may have to
administer Haldol or Valium and very
short-term periods
um dissociative drugs
um for hallucinogens are our PCP
um otherwise known as either angel dust
Sherman's Zoom or some of the other
lingo that I've heard of
um it this is a medical emergency if
you're in a PCP intoxication your
patient is in a medical emergency that
they could result in very violent side
effects they can be very belligerent
they can be very assaultive or impulsive
as far as treatment these patients
typically are unable to be talked down
so we will have to restrain most of
these patients that are in a PCP
intoxication
as far as hallucinogen withdrawal
there's no official withdrawal diagnosis
they will re-experience symptoms
while intoxicated so that
re-experiencing of perceptual symptoms
may actually prevent normal function for
weeks months are even years
inhalants are there are toxic gases that
are inhaled through the nose or mouth
and then enter into our bloodstream
common household products include
solvents for glues and adhesives
propellants maybe paint spray or paint
spray aerosol hair sprays shaving cream
some of our thinners might be paint
products Correctional fluid and then
fuels is the last one gasoline and
propane so these are all different
um items that people can inhale in order
to get that high feeling
it can cause failure in major life roles
and interpersonal relationships
cardiac arrhythmias is a is a big thing
they can have that sudden sniffing death
right they sniff something they inhale
something they go into a cardiac
arrhythmia that could actually cause
death
inhalant intoxication really depends on
the substance but generally they're
going to have that disinhibitation
disinhibition and Euphoria they may have
some fearfulness Illusions Auditorium
visual hallucinations impaired judgment
impulsive aggressive and some of the
physical symptoms that you might see are
nausea anorexia diplopia super
unconsciousness and Amnesia especially
in some very high doses as far as
treatment there is no treatment it's
self-limited
um they will come off of that high in a
few hours to a few weeks again depending
on the substance
everyone has heard about opioids
especially the opioid misuse
particularly heroin or prescription
drugs and this is a chronic relapsing
Disorder so our patients get an opioid
because they have a craving for it that
craving they become tolerant to it so
they need larger amounts which just
increases our intolerance and it's this
vicious circle that our patients can go
through it can cause very significant
life roles and interpersonal impairment
as far as opioid intoxication drowsiness
Tacoma slurred speech impaired memory
pupillary constriction impaired judgment
and social functioning and we but we can
give naloxone IV to relieve some of
those toxic effects
when we think about opioid withdrawal
this occurs after cessation of heavy use
symptoms may include mood dysphoria GI
symptoms muscle aches fever insomnia
other classic symptoms include
lacrimation rhinorrhea and then
pupillary dilation right because we're
coming off of it
morphine heroin methadone is usually a
six to eight hour after the last dose
with one week of use when we're coming
off of it
meperidamine or Demerol is usually 8 to
12 hours to about five days for that
withdrawal
opioid overdose death usually results
from respiratory arrest due to
respiratory depressant effect of the
drug
so we're going to really need to do a
lot of respiratory support and then give
that naloxone
as far as general treatment
individual family behavioral therapies
can be helpful in managing use
pharmacological treatment is methadone
bupary norefine and naloxone
the methadone just decreases those
painful symptoms of withdrawal
sedative hypnotic and anti-anxiety
medications so these can include our
benzos benzo like drugs carbamates
barbiturates and barbavituate like drugs
it could also include our club drugs
sorry club drugs like um the date rape
drug
it can also include prescriptive sleep
medication and maybe even anti-anxiety
medications
the craving is a typical feature with
significant tolerance and then
withdrawal can develop once they stop
taking it
as far as intoxication we're going to
see symptoms like slurred speech
impaired thinking coma can be a very
dangerous possibility
when we're thinking overdose treatments
gastric lavage is what has to happen we
have to get that substance out of their
system so we'll use that activated
charcoal monitor the vital signs and get
that substance out as soon as we can
withdrawal really again depends on the
degree and timing of the specific
substance a treatment could be gradual
reduction of whatever the substance is
to prevent seizures so especially with
our benzos we want to just gradually
reduce those benzos
stimulants ah cocaine Coke crack snow
blow sniff whatever you want to call it
and other amphetamines crank ice speed
uppers
um are what we're talking about when
we're thinking about our stimulants this
is the second most widely used drug
euphoric feeling and high energy they
feel much more awake they're super alert
they're confident and they're very
energetic
increased use plus Cravings plus
tolerance equals of course your
decreased function in those major life
roles
stimulant intoxication they feel
superhuman they are elated they are
euphoric and they are very sociable
Unfortunately they are also a hyper
Vigilant sensitive anxious and also
tense
some of the physical symptoms we may see
they may complain of chest pain they may
have higher low blood pressure
tachycardic or bradycardic respiratory
depression weakness confusion and maybe
even coma
as far as stimulant withdrawal that
usually begins a few hours to days after
they've stopped the substance and it can
include fatigue though it may have very
Vivid nightmares depression and then
that's where suicide may come play a
role in this is that withdrawal
as far as treatment
in patients setting is usually necessary
individual family group therapies can be
helpful
antipsychotics are useful in treating
agitation and hyperactivity and our
antidepressants may be prescribed once
they've gone through that withdrawal
period
so I just really liked this box in your
book talks about the stimuli
intoxication and short-term what's going
on and then as they're withdrawing off
of it you can see some of those symptoms
as well so I think you can see as they
withdrawal if they're becoming more
anxious more irritable right they may
just be like this isn't worth it and
they just get back on that substance so
that's where those withdrawal symptoms
can be very indicative of why they
continue to keep going back to it
tobacco these are cigarettes cigars can
be smokeless can be snuffed or chewed
um Cravings that persistence recurrence
and tolerance are all symptoms
dependence can happen very quickly with
these substances cigarettes are the most
widely used intended effects are usually
for relaxation decreased anxiety some of
the long-term effects can be on the
cardiovascular and respiratory systems
smokeless can affect that oral mucus
mucosa though
as far as tobacco withdrawals again they
can be irritable depressed difficulty
concentrating maybe even Restless this
can happen days after cessation
the heart rate though once they do have
that cessation can decrease 5 to 12
beats per minute within that first year
of quitting a lot of times our patients
May gain four to seven pounds so again
that might be the reason why they get
back on it as far as treatment we can do
behavioral therapy recognizing those
Cravings we can also think about
nicotine replacement therapy the Patches
gum things like that
all right so let's move into a little
bit of alcohol
um this is usually a sedative creating
an initial feeling of euphoria
usually related to decreased inhibitions
um severity is really based on the
number of DSM-5 symptoms so if we have
mild
alcoholism it's going to be two to three
symptoms on that DSM-5 moderates four to
five and then severe is five or more
so when we think about alcohol use
disorder there are two different types
of problematic drinking binge drinking
refers to drinking too much alcohol too
quickly heavy drinking is characterized
by drinking too much too often
eight or more drinks in a week
constitute heavy drinking for women men
who drink more than 14 drinks in a week
are considered heavy drinkers
so what is
um a standard drink
standard drinks are defined per National
Institute of Health as any drink that
contains about
0.6 fluid ounces or 14 grams of pure
alcohol so you can see that each of
these drinks pictured are different
sizes but each contains approximately
the same amount of alcohol and that's
what's considered a standard drink
when is drinking in moderation too much
so if we're drinking in moderation but
now we're borderline too much maybe
we're taking a medication that interacts
with our alcohol
maybe we're managing a medical condition
that can be made worse by drinking
if you're under the age of 21 even in
moderation that's too much for most for
all states if you're recovering from
alcohol use disorder even one drink is
too much
and then obviously if you're pregnant or
could be pregnant then drinking in
moderation is too much
so alcohol intoxication these are
symptoms that are based on the blood
alcohol level 80 to 100
MGS per DL are the 0.08 to 0.10 is our
blouse blood alcohol
limit or above plummet so for thinking
about
um two drinks
um that's that 20 Megs per Dill
0.02 is our two drinks we may see some
slow Motor Performance maybe a little
altered mood maybe that Euphoria is in
play but we will have some decreased
thinking
three drinks you can see there is 0.05
we have impaired judgment again more
Euphoria maybe some lower alertness at
this point four drinks is going to put
us at that lower limit of our blood
alcohol content
0.08 altered speech impaired judgment
poor self-control
five drinks puts us at 0.10 slurred
speech poor coordination slowed thinking
and then if we are having more than five
drinks we just have that potential of
the 0.40 impaired Vital Signs and and
even possible death
according to the National Institute on
alcohol abuse and alcoholism men consume
more than four drinks on any day or more
for the 14 drinks per week for women if
it's three drinks per day or more than
seven drinks per week then we're
concerned about that heavy drinking
alcohol withdrawal Tremors shakes lack
of appetite nausea vomiting increased
blood pressure you could see those about
eight to ten hours after cessation
and then as far as withdrawal seizures
this can occur 12 to 24 hours after
cessation these can be tonic clonic
Valium may be given when we think about
withdrawal withdrawal delirium this is a
medical emergency this could happen
within the first 72 hours delusions
hallucinations could result in very
unpredictable Behavior so we need to
protect themselves from what they
believe are genuine dangers how can we
treat those deliriums diazepam Valium
for agitation Tremor hallucination
that'll help keep those patients or
sorry chlorodized
Chlor diazepoxide will help keep our
patient out of danger so alcohol
withdrawal can be very serious depending
on how heavy of a drinker they are so
just being aware of that
the other thing I just want to talk
about is where Nikki korsakov syndrome
this is cognitive disturbances that can
happen
people with heavy use of alcohol can
suffer from short-term memory
disturbances one reducing memory problem
is Wernicke's alcohol
encephalopathy which is an acute and
reversible condition usually
characterized by altered gait vestibular
dysfunction confusion and ocular
motility abnormalities
when we think about
Korsakoff syndrome this is a chronic
condition with a recovery rate of only
about 20 percent
so the patho really behind those these
two problems is a thiamine deficiency
because of poor nutrition associated
with alcohol use or malabsorption of
nutrients
treatment for Wernicke or sorry Wernicke
will respond rapidly to large doses of
IV thiamine two to three times a day for
one to two weeks corsicoff is also
treated with thiamine for about three to
twelve months so just being aware of
that cognitive disturbance syndrome that
you can get with over alcohol use
fetal alcohol syndrome is
um unfortunately the leading cause of
intellectual disabilities those this is
alcohol during pregnancy that just
inhibits that uterine growth and
postnatal development we can see
microcephaly craniofacial malformations
limb defects and even heart defects and
so I just grabbed this picture from your
book you can see some of the different
facial malformations that can be seen
that you can recognize pretty quickly
for a baby that may have fetal alcohol
syndrome
as far as systemic effects peripheral
neuropathy they may complain of pins and
needles in that lower extremity because
of numbness
alcohol myopathy is decreasing muscle
mass or they may have a lot of muscle
weakness
alcoholic
cardiomyopathy is again that decrease in
muscle tone around the heart they can
have fatigue shortness of breath maybe
some edematous legs and feet
esophagitis is comes from vomiting
gastritis is that nausea and vomiting
and then pancreatitis is severe
abdominal pain nausea vomiting that
usually will subside with cessation
alcoholic hepatitis is that inflamed
liver a lot of times genetics can play a
role for with that
as far as cirrhosis of the liver this is
Progressive eventually to
non-functioning liver you can see
jaundice ascites legodemum
leukopenias that decrease wbcs due to
cirrhosis so we have to really indicate
to our patients that cessation is their
best alternative
thrombocytopenia or low platelet counts
due to against cirrhosis bruising
particular rash prolonged bleeding can
be a problem
and then we have noticed that cancer
especially of the head and the neck
breast liver and colorectal can come as
a systemic effect with alcohol use
disorder
so let's apply the nursing process
so when we think about the nursing
process and we talk about assessment
there are several screening tools that
we can think about the first one is
expert screening brief intervention and
referral to treatment this really
identifies at-risk substance abuse
patients for those early interventions
the other your book also listed audit
which is an alcohol use disorder
identification test
cage there's four questions that can
identify alcohol abuse and those four
questions are listed in your book kjd
and then T Ace or other screening tools
so when we think about assessment and
we've done our screening tools we're
going to assess for we're going to
assess the family
is part of our assessment process we
want to evaluate the individual
holistically background pattern of abuse
are there any mental health symptoms and
then we're going to look at that family
assessment and codependence so
codependence is that the family exhibits
overly responsible behaviors the
individual self-worth of caring for
others to the exclusion of their own
needs so if you're purchasing alcohol
your your canceling plans because you
think your spouse is going to get
intoxicated and they may need you that's
being codependent so please understand
what codependence means
um especially with alcohol use disorder
self-assessment alcohol use is
self-inflicted and the nurses should
really be careful assessing personal
thoughts opinions and feelings right why
don't you just stop right this is
self-inflicted it's an addiction they a
lot of times they can't just stop so
making sure as nurses that we're really
assessing our own self thoughts opinions
and feelings
um once we've done our assessment we're
going to identify some of those outcomes
and then start planning and a lot of
that's going to be immediate detox and
stabilization abstinence if they're
actively drinking what's their
motivation for treatment and then making
sure that all of those are essential to
that patient-centered
as far as implementation we want to
promote safety and sleep that's the
first line intervention safe environment
observing for those withdrawal symptoms
reorienting them back to time place in
person and then allowing them to just
get a really good restful sleep
reintroducing good nutrition and
hydration severely compromised nutrition
due to choosing the substance versus
sustenance we want to help support body
systems and that neurological function
so they may be very malnourished because
they've chosen their substance over food
so reintroducing that good nutrition we
want to support their self-care and
hygiene this is going to increase their
self-esteem because they've probably
neglected themselves for a long period
of time
and then we want to make sure we're
obviously exploring any harmful thoughts
and spiritual distress making sure our
patients are safe
some of the health teaching and health
promotion that we can consider
prevention against genetic vulnerability
remember genetics accounts for about 40
to 60 percent of someone's risk
prevention may be the best answer right
so if you know you have a risk of
um opioid use prevention needs to be the
best answer teach the patient to
recognize indications of relapse or
factors that could contribute to relapse
encouraging communication techniques
going to public classes those 12-step
programs especially for our alcoholics
can be very helpful
and then after we've done our full
nursing process we definitely have to
evaluate those interventions that we've
implemented assess the effectiveness of
that treatment plan making sure we're
using objective data to check whether
those nursing actions worked
some of the treatment modalities
pharmacotherapy focus on treatment for
alcohol use the first one there is
dysulfurum or antabuse so again that's
for use for maintenance relapse
prevention aversion therapy for alcohol
use disorder
um naloxone again
um or sorry that's not naloxone
Naltrexone
is withdrawal relapse prevention
decreased pleasurable feelings and
Cravings if we give that and then the
last one is our benzos and that can just
help with our withdrawal
as far as motivational interviewing this
is an approach based on the trans
theoretical or stages of change therapy
or Theory it has gained popularity and
use as a brief long-term and
supplementary intervention particularly
in treatment of substance use disorders
it uses a person-centered approach to
just really strengthen the motivation
for change
as far as care can't Continuum
continuity of care occurs through a
Continuum so when we think about
detoxification or detox this is when an
individual quits using the substance
they're going to think about
Rehabilitation medically monitoring and
with an inpatient program
short-term rehab
um has learned lost skills long-term
rehab learns new skills as far as
halfway houses these are residential
treatments extended sobriety getting a
case management assistant integrating
new life skills back into their rep
repertoire
other housing we can have Community
reintegration that's not really part of
their treatment plan
partial hospitalization are those
intense treatments without 24-hour care
five days a week for six to eight hours
intensive outpatients treatment our
structured scheduled treatment groups
Outpatient Treatment is the least
intensive form of treatment and it's
really based off of that individual's
means and then alcoholics on
um we can think about
Alcoholics Anonymous that's that 12-step
program individuals learn how to be
sober through support systems most areas
have around-the-clock meetings
Al Anon are for friends and families
that are worried about someone with a
drinking problem
alatine or peer support groups for
teenagers who are struggling with the
effects of someone else's problem
drinking naranon are our family and
friends who are concerned about
addiction with drug problems not related
really to alcohol and then Gamblers
Anonymous is also another group that's
out there
relapse prevention is the last care
Continuum right we want to make sure
that we are preventing them from
relapsing advances in technology have
expanded options for maintaining
long-term sobriety applications for
smartphones for example offer a way to
monitor behavioral patterns for relapse
cues
and that concludes chapter
22. if you have any questions you can
shoot me an email or we will chat about
it in class thanks guys
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