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Chapter 22 Substance Related and Addictive Disorders
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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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