Download ADDICTIVE DISORDERS PP 1

Chapter 16
Addictive Disorders
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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Concept of Addiction
• Addiction is a brain disease, evolving over
time, occurring because of individuals
voluntarily taking drugs
– Repeated use causes uncontrollable and
compulsive drug craving, seeking, and use
that destroys functioning
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Concept of Addiction
• Abuse: use of substance that falls outside
of medical necessity, resulting in adverse
effects to user and others
• Dependence (addiction) occurs when
tolerance to drug occurs and amounts
increase to avoid withdrawal
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Operational Definition of Addiction:
The Three C’s
• Behavior motivated by emotions ranging
along lines of craving to compulsive
spectrum
• Continued use despite adverse
consequences to health, mental status,
relationships, occupation and finances
• Loss of control
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Addictive Disorders:
Prevalence and Comorbidity
• Prevalence
– Lifetime prevalence of substance use
disorders in U.S. is 14.6%
– Alcohol: most common; 8.5% of population
– Illicit drugs: decreased use of marijuana,
cocaine and heroin over past decade and
increased use of club drugs, prescription pain
medications, amphetamines,
benzodiazepines, and anabolic steroids
– Nicotine use: estimated 46 million Americans
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Addictive Disorders:
Prevalence and Comorbidity
• Comorbidity
– At least 50% people with serious mental
illness have substance use disorder as well
(dual diagnosis)
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Addictive Disorders:
Prevalence and Comorbidity
• Medical comorbidity
– Alcohol-related problems affect all organ
systems (neurological, GI, cardiovascular)
– Cocaine abusers: extreme weight loss,
malnutrition, myocardial infarctions, stroke
– Nicotine abusers develop chronic lung
disease, coronary heart disease, and stroke
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Addictive Disorders:
Prevalence and Comorbidity
– Intravenous drug users develop infections,
sclerosing of veins, hepatitis, and HIV
– Intranasal drug users develop perforated
nasal septum
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Biological Theory Related to
Addictive Disorders
• Genetics
– Believed to account for 40%-60% of personal
vulnerability to addiction
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Biological Theory Related to
Addictive Disorders
• Effects of addictive substances on brain
– Abusive substances affect dopamine systems
and directly or indirectly affect limbic system
– Over time, dopamine receptors/dopamine
levels decrease and individual needs more of
abusive substance in order to keep dopamine
level normal
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Biological Theory Related to
Addictive Disorders
• Cross-tolerance occurs with opioid drugs,
alcohol, benzodiazepines, barbiturates
– Affect central nervous system, causing
depressant effect
• Cocaine and amphetamines act on
dopamine and serotonin
– Affect central nervous system, causing
stimulation
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Other Theories Related to
Addictive Disorders
• Psychological theories
– Psychodynamic factors: lack of tolerance for
frustration and pain, impulsiveness, lack of
success in life, lack of affectionate and
meaningful relationships, low self-esteem,
and strong propensity for risk taking
• Cultural considerations
– Differences recognized among cultural groups
• Asian cultures: low rate of alcohol abuse
• Native Americans, Alaska Natives: high rates of
alcohol abuse
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Special Populations Related to
Addictive Disorders
• Pregnant women
– Alcohol is neurotoxic; affects fetal brain
development
• Fetal alcohol syndrome (FAS) and fetal alcohol
spectrum disorders
– Smoking related to low-birth-weight babies,
increased risk of congenital abnormalities
– Opiate use in mother causes withdrawal in
babies
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Special Populations Related to
Addictive Disorders
• Chemically impaired nurses
– Addiction rate is 32%-50% higher than
general population
– Important to report abusing nurse to nurse
manager for appropriate intervention and
referral to treatment program
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Substance Abuse
• DSM-IV-TR defines as maladaptive
pattern of substance use leading to
clinically significant impairment or distress
– Inability to fulfill life roles
– Participation in hazardous activities when
under influence
– Recurrent legal/interpersonal problems
– Continued use despite consequences
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Substance Dependence
• DSM-IV-TR defines as maladaptive
pattern of substance use leading to
clinically significant impairment
– Presence of tolerance: need for higher doses
– Presence of withdrawal: specific physical and
psychological symptoms when stopping use
– Unsuccessful attempts to cut down
– Increased time spent obtaining substances
– Reduced time in normal activities
– Substance use despite consequences
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Common Effects of Substance Use
• Flashbacks: transitory recurrences of
perceptual disturbance caused by earlier
use of hallucinogenic drug
• Codependence: over-responsible
behaviors often exhibited by family
members of substance user
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Common Effects of Substance Use
• Synergistic effects: combining two drugs
with similar actions (depression or
stimulation of CNS) intensifies effects
• Antagonistic effects: combining drugs to
counterbalance effects
– Combining CNS depressant (opioid) with CNS
stimulant (cocaine)
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Nursing Process:
Assessment Guidelines
• Determine history of patient’s use
– Number of drugs taken, pattern of use,
dosage
– Previous treatment for substance abuse
– Presence of blackouts, delirium, seizures,
withdrawal symptoms
• Review history for comorbid illness
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Nursing Process:
Assessment Guidelines
• Review psychiatric history for comorbid
disorders
• Determine psychosocial issues
– Effect of use on patient’s life functioning
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Nursing Process:
Assessment Guidelines
• Initial screening: use of two questions
– In past year, have you ever drunk or used
drugs more than you meant to?
– Have you felt you wanted to cut down on
drinking or drug use in past year?
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Nursing Process:
Assessment Guidelines
• Use of CAGE-AID (adapted to include
drugs) screening tool
– C: Have you ever felt need to cut down
– A: Have people annoyed you by criticizing
your use?
– G: Have you ever felt guilty about use?
– E: Have you ever felt need for an eye opener
in morning?
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Nursing Process:
Assessment Guidelines
• Further initial assessment
– Neurological changes: determine brain injury
– Urine toxicology screen or blood alcohol level
(BAL): help determine type/amount of
substances
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Nursing Process:
Assessment Guidelines
• Psychological changes
– Use of defense mechanisms common: denial,
projection, rationalization
– Characteristic thought processes: all-or-none
thinking, selective attention
– Common behaviors: conflict minimization,
avoidance, passivity, and manipulation
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Complications of Substance Use:
Intoxication with CNS Depressants
• Common symptoms of intoxication from
drugs that are CNS depressants (alcohol,
BZAs, barbiturates)
– Slurred speech, incoordination, unsteady gait,
drowsiness, decreased blood pressure,
impaired judgment
• Treatment of intoxication/overdose
– Treated symptomatically: maintain
airway/circulation, induce vomiting, administer
flumazenil (Romazicon) for BZA overdose
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Complications of Substance Use:
Withdrawal from CNS Depressants
• Symptoms are similar to that of alcohol
– Alcohol withdrawal
• Increased alertness, irritability, feelings of “shaking
inside,” presence of illusions, seizures can occur
within 7-48 hours
– Alcohol withdrawal delirium
• Anxiety, insomnia, delirium
• Autonomic hyperactivity: increased vital signs
(temperature, pulse, blood pressure, respirations)
• Disorientation, perceptual disturbances, delusions
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Treatment Approaches for Alcohol/CNS
Depressant Withdrawal
• Sedation
– Use of BZAs in gradually decreasing dosages:
chlordiazepoxide (Librium)
• Seizure prevention
– Anticonvulsants: gabapentin (Neurontin)
• Prevention of Wernicke’s encephalopathy
– Thiamine (vitamin B1)
• Decrease in autonomic hyperactivity
– Beta blockers: propranolol (Inderal)
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Complications of Substance Use:
Intoxication with CNS Stimulants
• Cocaine and amphetamines
– Intoxication: increased vital signs, nausea and
vomiting, insomnia, assaultive behavior,
euphoria, increased energy, paranoia
– Overdose: myocardial infarction, stroke,
coma, death
• Treatment of overdose
– Treatment is symptomatic: maintain airway,
circulation, prevent cardiovascular events
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Effects of Abusive Substances
• Cocaine: produces fleeting high followed
by period of deep depression; effects on
body include anesthesia and stimulation
• Methamphetamine: produces excessive
stimulation; affects brain cells containing
dopamine
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Effects of Abusive Substances
• Nicotine: stimulant, depressant, or
tranquilizer
• Opiates: produce CNS depression
• Marijuana: depressant and hallucinogenic
• Hallucinogens: LSD, PCP
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Effects of Abusive Substances
• Inhalants
– Produce CNS depression similar to alcohol
– Also cause liver, brain damage
• Rave, “club drugs,” and date rape drugs
– Ecstasy (MDMA): produces CNS stimulation
and causes hallucinations
• Also produces hyperthermia, heart failure, kidney
failure, death from severe dehydration
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Effects of Abusive Substances
– Flunitrazepam (Rohypnol) and
hydroxybutyric acid (GHB)
• Used as date rape drugs, similar effects of
BZAs, also cause amnesia
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Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnoses
– Imbalanced nutrition: less than body
requirements, Deficient fluid volume,
Disturbed thought processes, Acute or
Chronic confusion, Hopelessness, Situational
low self-esteem, Ineffective coping
• Outcomes identification
– Remain free from injury while withdrawing
from substances, attend treatment programs,
have stable group of friends, demonstrate
coping without substances
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Nursing Process:
Planning and Implementation
• Planning care dependent on patient’s
social status, income, ethnic background,
gender, age, substance use history, and
current condition
– Goal: abstinence from abusive substances
• Implementation directed toward selfresponsibility and referral to specific
addiction treatment program
– Treatment can take place in inpatient or
outpatient setting
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Nursing Communication Guidelines for
Patients with Substance Abuse
• Accepting, nonjudgmental approach
important for therapeutic relationship
• Substance abuse intervention for resistant
addict may be used by nurse to help
patient willingly engage in treatment
– Significant others become involved in this
treatment approach; specific evidence about
patient’s substance use/abuse is presented
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Health Teaching and Promotion for
Patient Who Is Substance Abuser
• Focus is relapse prevention
• Strategies of relapse prevention
– Keep program simple, encourage use of
notebook/journaling
– Use cognitive-behavioral principles to
increase coping
– Encourage patient to join relapse prevention
group
– Encourage patient to enhance personal
insight through therapy
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Treatment for Substance Abuse:
Psychotherapy and Other Modalities
• Psychotherapy
– Assists patient in identifying and using
alternative coping mechanisms instead of
reliance on substances
• Self-help groups for patient and family
– 12-step programs most effective
• Alcoholics Anonymous (AA) for the patient
• Al-Anon and Alateen for family members
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Nursing Process: Evaluation
• Treatment outcomes are evaluated
– Increased length of time in abstinence
– Decreased denial
– Acceptable occupational, social functioning
– Ability to use coping strategies
– Attendance at 12-step support group program
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