Chapter 17 Substance Abuse Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Physical dependence  Psychologic dependence  Habituation  Addiction Substance Abuse: Leads to Dependence 2Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Opioids  Stimulants  Methamphetamine  Methylenedioxymethamphetamine (MDMA, “ecstasy”)  Cocaine  Depressants  Benzodiazepines  Barbiturates  Marijuana Commonly Abused Substances 3Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Alcohol  Anabolic steroids  Dextromethorphan  Lysergic acid diethylamide (LSD)  Nicotine  Phencyclidine (PCP) Commonly Abused Substances 4Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Opioids  opium  heroin (diacetylmorphine)  morphine  codeine  hydromorphone  hydrocodone  meperidine  oxycodone  propoxyphene  methadone Copyright © 2014 by Mosby, an imprint of Elsevier Inc.5

 Also known as narcotics  Opium and heroin are Schedule I  Most others are Schedule II because of their high potential for abuse  Often abused because of their ability to produce euphoria Opioids (cont’d) 6Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Produce analgesia, drowsiness, euphoria, tranquility, other mood alterations  Affect areas outside the central nervous system (CNS)  Skin, GI tract, GU tract  Normally used to:  Relieve pain, reduce cough, relieve diarrhea, and induce anesthesia Opioids (cont’d) 7Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Heroin  Injected (“mainlining” or “skin popping”)  Sniffed (“snorted”)  Smoked  Causes a brief “rush,” followed by a few hours of a relaxed, contented state  Large doses can stop respirations  Methadone Opioids (cont’d) 8Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Central nervous system  Diuresis  Miosis  Convulsions  Nausea, vomiting  Respiratory depression Opioids: Adverse Effects 9Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Non–central nervous system  Hypotension  Constipation  Urinary retention  Flushing of the face, neck, and upper thorax  Sweating, urticaria, and pruritus Opioids: Adverse Effects (cont’d) 10Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Peak period: 1 to 3 days  Duration: 5 to 7 days  Signs  Drug seeking, mydriasis, diaphoresis, rhinorrhea, lacrimation, diarrhea, elevated BP and pulse  Symptoms  Intense desire for drug, muscle cramps, arthralgia, anxiety, nausea, vomiting, malaise Opioid Drug Withdrawal 11Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Block opioid receptors so that use of opioid drugs does not produce euphoria  Naltrexone—an opioid antagonist  Vivitrol—injectable form of naltrexone  Naloxone combined with buprenorphine (Subutrex) or used alone (Suboxone) Opioid Drug Withdrawal: Treatment 12Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Elevation of mood  Reduction of fatigue  Increased alertness  Invigorated aggressiveness Stimulants 13Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Amphetamines  Methamphetamine  MDMA (“ecstasy”)  cocaine  methylphenidate (Ritalin) Stimulants 14Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Stronger effects than other amphetamines  Pill form  Powder form: snorted or injected  Crystallized form:  Also known as “ice,” “crystal,” “glass,” “crystal meth”  Smokable  More powerful  Sales of over-the-counter (OTC) pseudoephedrine are now regulated Methamphetamine 15Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Usually prepared in secret home laboratories  More calming effects than other amphetamine drugs  Usually taken by pill  “Raves” Methylenedioxymethamphetamine (MDMA, “ecstasy,” or “E”) 16Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 From the leaves of the coca plant  Snorted or injected intravenously  Highly addictive—physical and psychologic dependence  Powdered form  Also called “dust,” “coke,” “snow,” “flake,” “blow,” “girl”  Crystallized form (smoked)  Also called “crack,” “freebase rocks,” “rock” Cocaine 17Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Stimulants: Adverse Effects  CNS  Restlessness  Syncope (fainting)  Tremor  Hyperactive reflexes  Talkativeness  Irritability  Insomnia  Fever  Euphoria  Confusion  Aggression  Increased libido  Anxiety  Delirium  Paranoid hallucinations  Suicidal or homicidal tendencies Copyright © 2014 by Mosby, an imprint of Elsevier Inc.18

 Cardiovascular  Headache  Chilliness  Pallor or flushing  Palpitations  Tachycardia  Cardiac dysrhythmias  Anginal pain  Hypertension or hypotension  Circulatory collapse Stimulants: Adverse Effects 19Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Stimulants: Adverse Effects  Gastronintestinal  Dry mouth  Metallic taste  Anorexia  Nausea  Vomiting  Diarrhea  Abdominal cramps  Fatal hyperthermia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.20

 Death results from:  Convulsions  Coma  Cerebral hemorrhage  May occur during periods of intoxication or withdrawal Stimulant Overdose 21Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Peak period: 1 to 3 days  Duration: 5 to 7 days  Signs  Social withdrawal, psychomotor retardation, hypersomnia, hyperphagia  Symptoms  Depression, suicidal thoughts and behavior, paranoid delusions  No specific pharmacologic treatments Stimulant Withdrawal 22Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Drugs that relieve anxiety, irritability, and tension  Used to treat seizure disorders and induce anesthesia  Two main pharmacologic classes:  Benzodiazepines (flunitrazepam)  Barbiturates  Marijuana (“pot,” “grass,” “weed”) Depressants 23Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 CNS  Drowsiness, sedation, loss of coordination, dizziness, blurred vision, headaches, and paradoxical reactions  Gastronintestinal  Nausea, vomiting, constipation, dry mouth, and abdominal cramping  Pruritus and skin rash  “Amotivational” syndrome Depressants: Adverse Effects 24Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Peak period  2 to 4 days for short-acting drugs  4 to 7 days for long-acting drugs  Duration  4 to 7 days for short-acting drugs  7 to 12 days for long-acting drugs  Signs  Increased psychomotor activity; agitation; hyperthermia; diaphoresis; delirium; convulsions; elevated BP, pulse rate, and temperature; others Depressants Withdrawal 25Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Symptoms  Anxiety, depression, euphoria, incoherent thoughts, hostility, grandiosity, disorientation, hallucinations, suicidal thoughts  Treatment involves tapering of the drug over a course of a 7 to 10 or 10 to 14 days Depressants Withdrawal (cont’d) 26Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question Which drug will the nurse anticipate administering to a patient experiencing benzodiazepine overdose? A.flumazenil B.naltrexone C.Vivitrol D.flunitrazepam Copyright © 2014 by Mosby, an imprint of Elsevier Inc.27

 More accurately known as ethanol (ETOH)  Causes CNS depression by dissolving in lipid membranes in the CNS  Few legitimate uses of ethanol and alcoholic beverages  Used as a solvent for many drugs Alcohol (Ethanol) 28Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 CNS depression  Respiratory stimulation or depression  Vasodilation, producing warm, flushed skin  Increased sweating  Diuretic effects Ethanol: Drug Effects 29Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Nutritional and vitamin deficiencies (especially B vitamins)  Wernicke’s encephalopathy  Korsakoff’s psychosis  Polyneuritis  Nicotinic acid deficiency encephalopathy  Seizures  Alcoholic hepatitis, progressing to cirrhosis  Cardiomyopathy Effects of Chronic Ethanol Ingestion 30Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Fetal alcohol syndrome (FAS)  Craniofacial abnormalities  CNS dysfunction  Prenatal and postnatal growth retardation Effects of Chronic Ethanol Ingestion (cont’d) 31Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Signs and symptoms  Elevated blood pressure, pulse rate, and temperature  Insomnia  Tremors  Agitation  Classified as mild, moderate, and severe Ethanol Withdrawal 32Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A patient with a diagnosis of delirium tremens is admitted to the acute care facility. Which finding does the nurse expect upon assessment of the patient? A.Hyperthermia B.Hypotension C.Bradycardia D.Somnulence Copyright © 2014 by Mosby, an imprint of Elsevier Inc.33

 Benzodiazepines are the treatment of choice  diazepam (Valium), lorazepam (Ativan), or chlordiazepoxide (Korsakoff’s psychosis)  Dosage and frequency depend on severity  For severe withdrawal, monitoring in an intensive care unit is recommended Ethanol Withdrawal Treatment 34Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 disulfiram (Antabuse)  Acetaldehyde syndrome  naltrexone  acamprosate (Campral)  Newest treatment  Counseling  Individual  Alcoholics Anonymous Treatment for Alcoholism 35Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question Which statement does the nurse include when teaching a patient about disulfiram (Antabuse) therapy? A.“Disulfiram (Antabuse) will cure your alcoholism if you take it as directed.” B.“If you drink alcohol after taking disulfiram (Antabuse), your blood pressure will get very high.” C.“You cannot drink alcohol for at least 3 or 4 days after taking disulfiram (Antabuse).” D.“If you miss a dose of disulfiram (Antabuse), double the dose the next time it is due.” Copyright © 2014 by Mosby, an imprint of Elsevier Inc.36

 Many smoke to “calm nerves”  Releases epinephrine, which creates physiologic stress rather than relaxation  Tolerance develops  Physical and psychologic dependency  Withdrawal symptoms occur if stopped  No therapeutic uses  200 known poisons present in cigarette smoke Nicotine 37Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Transient stimulation of autonomic ganglia  Followed by more persistent depression of all autonomic ganglia  CNS and respiratory stimulation, followed by CNS depression  Increased heart rate and BP  Increased bowel activity Nicotine: Drug Effects 38Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Manifested by cigarette craving  Irritability, restlessness, decreased heart rate and BP  Cardiac symptoms resolve in 3 to 4 weeks, but cigarette craving may persist for months or years Nicotine Withdrawal 39Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Treatments provide nicotine without the carcinogens in tobacco :  Nicotine transdermal system (patch)  Nicotine polacrilex (gum)  Inhalers  Nasal spray Nicotine Withdrawal Treatment 40Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 bupropion (Zyban) may be prescribed to aid in smoking cessation  First nicotine-free prescription medicine to treat nicotine dependence  varenicline (Chantix)  Stimulates nicotine receptors Nicotine Withdrawal Treatment 41Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question The nurse is explaining the differences between transdermal nicotine and nicotine gum programs. Which statement by the nurse is correct? A.“ The nicotine patch will give you quick relief from cravings.” B.“Chewing the gum rapidly will release an immediate dose of nicotine.” C.“It seems that patients have better treatment compliance with the gum than the patch.” D.“The dose of nicotine in the gum is approximately twice the dose the average smoker receives in one cigarette.” Copyright © 2014 by Mosby, an imprint of Elsevier Inc.42

 Assessments should include nonjudgmental and open-ended questions about substance abuse  Be observant for clues to substance abuse so as to avoid withdrawal symptoms  The most dangerous substances in terms of withdrawal are CNS depressants such as barbiturates, benzodiazepines, and alcohol  Establish therapeutic rapport, and use empathy toward the patient Nursing Implications 43Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Assessment tools for substance abuse  CAGE Alcoholism Screening Test Adapted to Include Drugs (CAGE-AID)  Substance Abuse Subtle Screening Inventory (SASSI)  Michigan Alcoholism Screening Test Geriatric version (MAST-G)  Problem Oriented Screening Instrument for Teenagers (POSIT) Nursing Implications (cont’d) 44Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Patient safety is of utmost importance at all times during patient care but especially when the patient is experiencing the signs and symptoms of withdrawal  Provide monitoring and support as needed throughout the withdrawal process  Educate the patient and family members or significant others about the recovery process  Emphasize that recovery is lifelong Nursing Implications (cont’d) 45Copyright © 2014 by Mosby, an imprint of Elsevier Inc.