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Transcript
SUBSTANCE ABUSE Emiliya Mullayeva Molloy College Case Description • Jake is a 15 year old, suspect of recently abusing prescription drugs. He is brought in his mother for evaluation. She describes his behavior as erratic and worse on weekends. He can be very hyperactive or sluggish. He has consistently completed his school work in the past and maintained a C + average. His mother feels he has gotten involved with the “wrong crowed” and she can no longer reach him. Jake does not see any problems and is annoyed with his mother. He denies drug use but acknowledges that his peers are involved with “some stuff” but can not or will not explain further. History of present Illness • 15 year old male presents hyperactive/sluggish and erratic behavior. Past Medical History • Normal vaginal delivery without any complications • Birth weight: 8 bls 4 oz. Hight 21” • Past History: appendectomy age 10 • No serious illnesses • Up-to-date immunizations and prior health checkups Family History • Father well and alive History of smoking Mother no serious medical illnesses Two siblings 10 yr and 5 yr well and healthy Mother 40 yr college graduate, works as P/T in private office, full time Father 47 yr college graduate, works full-time as an MRI tech in the hospital There is no family history of alcohol or drugs abuse in the family, no mental illnesses. Physical examination Pupils 3mm, PERLA Apical Pulse-88 Respiratory rate-20 breath/min Blood Pressure-108/60 Weight-145lbs Height 5 ft 6 inch BMI 23.4 Temp-97.7 F (tympanic); No signs of physical abuse noted. Mental Status examination • • • • • • • • • • • • AAO x 3 (time, person and place) Maintained a good eye contact Appearance: Well groomed and nourished. Speech: clear Mood: Anxious Affect: congruent Gate: stable Thought process: linear Thought content: appropriate Impulse control: fair Insight/Judgment: fair Sensorium: grossly intact Is Jake medically stable? • There is no evidence of acute intoxication or withdrawals noted at this time. • No tremors, hallucinations (tactile/visual) • No diaphoresis, agitation, confusion (DT’s) • No ataxia, miosis, mydriasis, rinorrhea • No flash skin, chills, body aches, diarrhea or piloerrection (hair standing up on arms or goose bumps). Screening tools • COWS - Clinical Opiate Withdrawal Scale • CIWA – Clinical Institute Withdrawal • Assessment for Alcohol. • CAGE – Alcohol and Drug Abuse assessment Clinical Decision making • Jake is medically stable, no ER needed at this time. • Refer Jake to the Psychiatrist for the full evaluation. • Also refer him to the substance abuse counselor for the evaluation as well. Interview the mother • Behavior patterns of her son: sleeping, taking showers, school attendance and homework. If Jake recently changed his friends suddenly? Any compulsive behavior? Anger or depressive mood? Any extra curriculum activities? • Have you ever smell alcohol or cigarettes on Jake’s breath or cloth? • Ask the mother to sign consent for Jake’s interview. Interviewing Jake Past/present suicide attempts/ideations or plans? Do you experiment drugs? If yes/Why? Do you have trouble with sleeping at night? Trouble with concentration? What is your daily routine? Do you have compulsive behavior, such as compulsive spending, cutting, internet or eating disorder? Do you have a good relationship with your mother/father? Do you have a significant other? Describe your relationship? Social History • Jake is lately isolating himself in his room. • His Growth and Developmental milestones were WNL according to his mom. • Jake doing poorly in school this year, interacts poorly with his family and friends • Exposed to peer pressure, hanging out with the “wrong crowed”. Facts on Substance Abuse in Teenage • Teens are making the decision to abuse prescription medicines based on misinformation. In fact, many people think that abusing prescription drugs is safer than abusing illicit drugs. • Prescription drugs can have dangerous short – and long – term health consequences when used incorrectly or by someone other than for whom they were intended. Facts continue • Teens tend to abuse substances that are inexpensive and easy to obtain. • Prescription medications commonly misused: opioids used for treatment of pain and include hydrocodone and oxycodone), stimulants (treatment of attention-deficit/hyperactivity disorder-ADHD, such as methylphenidate and amphetamine), tranquilizers (benzodiazepines and minor tranq. as meprobamate and carisoprodol), and sedatives (barbiturates and chloral hydrate). Also steroids: testosterone, Stanzolol( Winstrol). Facts continue Misuse, of drugs can lead to notable risks. It’s include the potential for physical or psychological dependence and overdose. • Physical dependence result from withdrawal intolerance. • Addiction: 1 Repeated use of drugs, compulsive seeking (psychological depend.) 2. Loss of control. 3. Use despite negative consequences. Facts continue • All of these medications offer pleasant, euphoric sensations. Stimulants offer improved focus, decreased need for sleep, and reduced appetite and can contribute to weight loss. They are attractive to teens juggling academic and extracurricular activities. • Steroids can improve physical appearance and users may report feelings of invincibility. Consequences of Prescription Substance Abuse Opiate meds may lead to rapid tolerance and if abused consistently can lead to opiate withdrawal when stopped abruptly. Symptoms of opioids misuse: resp. depression and death. Drowsiness, miosis, and constipation. This side effects can be made worse when prescription drugs are abused in combination with other substances including alcohol or benzodiazepines, both of which can slow breathing. When abused, may be taking in inappropriate doses or by routes of administration that change the way the drugs act in the body, risking overdose. Example: OxyContin crushed and inhale the pills, a 12-hour dose hits their central nrvous system all at once – which increases their risk of addiction and overdose. Opiate withdrawals: mydriasis, rinorrhea,flash skin, piloerrection, chills, body aches, GI upset/diarrhea, lethargy. Consequences continue • Stimulants such as Adderall-Dextroamphetamine, RitalinMethylphenidate. Increase blood pressure and heart rate, open up the pathway of the respiratory system, which can increase alertness, attention and energy. Overdose of stimulants can cause anxiety, panic, tremors irregular heartbeat, restlessness, dangerously high body temp, and even heart attack. People who stop taking stimulants after some time may suffer from fatigue and depression. Toxic effect of high dose include: seizure, violent behavior, high risk behavior ( sexual promiscuity, motor vehicle accidents), cardiac rhythm disturbances, strokes, disease related to IV use (Hep C, HIV), and lung disease related to the injection of the inert materials that are components of the Ritalin tablets. Extremely addictive, but no physical dependency. Consequences continue • Benzodiazepines and barbiturates are CNS depressant medications. Slow down activity in the brain. People can feel drowsy or calm , an effect that is helpful for those suffering from anxiety or sleep disorders. It can cause confusion and slowed breathing. Stopping their use suddenly after long –term use can cause seizures, because the brain cells become overactive. Behavioral Warning Signs • • • • • • • • Loss of enthusiasm and signs of depression Withdrawal from normal activities Truancy and unexplained drop in grades Irritability and overreaction to criticism Unusual requests for money Decreased interest in appearance Unexplained changes in friends Frequent nasal or sinus infections Why might teens use drugs? • • • • • • • • • • • • • To enhance pleasure To have fun To vary their conscious experience To self medicate As a way to cope with trauma To relieve anxiety, depression, insomnia To relieve pain To Promote and enhance social interaction To stimulate artistic creativity and performance To rebel To improve physical/mental performance To fend off withdrawal To lose weight Consequences continue • Adolescence is a time of significant growth and change including the development of cognitive functioning. The abuse of any substance during adolescence poses additional risks to physical, psychological and cognitive development. Identifying Abuse • Peer pressure, depression, a history of physical, sexual or emotional abuse, and a history of parental drug abuse. • Screening parents and teens for potential substance abuse may help to identify those at risk. Rapid Assessment • Screen tool for assessing teens at risk for substance abuse. The CAGE questionnaire, usually used for assessing alcohol abuse, can be use to assess drug abuse too. • C=have you ever thought you should Cut down on your drug use? • A=have people Annoyed you by being critical about your drug use? • G=have you ever felt Guilty about your drug use? • E=have you ever used drugs first thing in the morning as an Eye opener or to get the day started? Rapid Assessment continue • Any “yes” answer to the questions below should be investigated. • Answering “yes” to two or more questions suggests the need for additional assessment into potential drug and/or alcohol problems. • These tools can help to start the conversation to identify potential risky behaviors. Have the teen complete the questionnaire in the room without the presence of the parents to begin the confidentiality process. Let the teen know that sexual health matters are confidential, lifethreatening behavior may have to be. Assessment continue • During a physical exam, several signs and symptoms may alert you to the possibility of drug use. Sudden weight loss or gain and eye signs may provide clues. • Sedative abuse and hypnotics may cause nystagmus; opioid abuse causes miosis. Stimulants and opioid withdrawal can lead to mydriasis. Diagnostic lab test • Urine drug screen may confirm suspected drug abuse, but accurate results depend on when the drug was taken and how fast it’s metabolized. • Blood test • Hair analysis is noninvasive and has a larger window of detection than a urine drug screen ( up to 6-9 month). Treatment • Counseling and detoxification are the first steps toward treatment. Then, intensive residential treatment followed by long-term outpatient care and support (aftercare). • Encourage teen to begin an open discussion with parents, school guidance, counselor, or other trusted adult about sex, drugs, depression, or other concerns. • Continue to educate teens about the negatives of drugs use with each visit in a nonthreatening manner, and offer information on getting help. • AA, NA, CA self help meetings. Family Education • Educate parents about the proper storage and disposal of prescription meds and remind them to keep drugs and alcohol out of reach of all children, regardless of age. • Medications should not be disposed into water sources. Meds. Can be harmful to the environment, humans when they enter the water system via toilets and water drains. • Advise parents to dispose of meds in the trash by removing them from their original containers, crushing them , into a kitty litter, spoiled foods, or coffee grounds. Some communities have the dropof centers. Limit your child exposure to PG-13 movies and avoid Rrated movies. Remove TV from child’s bedroom. Turn off TV during evening meals. • Warning signs: depression, low self –esteem. • Feel like they don’t fit in and are not popular with the mainstream • Frequently feel sluggish and have difficulty sleeping • Aggressive and rebellious attitude toward authority figures Education continue • Educate Jake about medical aspects of chemical dependency. Explain the danger of the combination drugs and drugs with alcohol. Example: Acetaminophen, a component of many combination opioid products, can cause potentially fatal liver damage in high doses. Nonsteroidal antiinflammatory drugs combined with opioids can cause gastrointestinal bleeding and renal damage, etc. Safety standards. Information and Support “Smart Moves, Smart Choices: A prescription Drug Abuse Education Program”. http://www.nasn.org “The Current State of Teenage Drug Abuse: Trend Toward Prescription Drugs” http://www.nyhealth.gov/publications/1064.p df [email protected] Information and Support • • • • • After School Alliance Parents-The Anti-Drug Queens Outreach Program Center National Suicide Prevention Lifeline 1-800-273-TALK is a crisis hotline that can help with many problems, not just suicide. • Treatment referral Helpline 1-800-662-HELP • Offered by Substance Abuse and Mental Health Services Administration-refers callers to treatment facilities, support groups, and other local organizations that can provide help for their specific needs. References Victor C. Strusburger, MD(2010) Policy Statement-Children, Adolescents, Substance Abuse, and the Media American academy of Pediatrics, • 126;791 Retrieved from htt://www.pediatrics.aapublications.org on February 10,2012 S. Schepis and k.Suchitra, PhD (2008) Characterizing Adolescent Prescription Misusers: A Population-Based Study,47:7 J. American Academy Child Adolesc. Psychiatry. Retrieve from http://www.JAACAP.COM on February 10,2012. Jennifer R. Havens, PhD, Christoper E. RN,BSN (2011) Nonmedical Prescription Drug Use in a Nartionally Representative Sample of Adolescents, vol165(no3). ARCHPediatric Adolesc Medical Association Retrieve from http://www.ARCHPEdIATRICS.COM on February 10,2012. Susan Simmons, PhD,RN,ARNP-BC (2010) Teens and Prescription Drugs A Potentially dangerous combination, vol 42. Nursing, Retrieve from http://www.NURSING.com on February 10,2012.