1. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 1 Chapter 16 Addictive Disorders

2. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 2 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

3. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 3 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

4. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 4 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

5. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 5 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

6. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 6 Addictive Disorders: Prevalence and Comorbidity Comorbidity –At least 50% people with serious mental illness have substance use disorder as well (dual diagnosis)

7. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 7 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

8. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 8 Addictive Disorders: Prevalence and Comorbidity –Intravenous drug users develop infections, sclerosing of veins, hepatitis, and HIV –Intranasal drug users develop perforated nasal septum

9. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 9 Biological Theory Related to Addictive Disorders Genetics –Believed to account for 40%-60% of personal vulnerability to addiction

10. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 10 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

11. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 11 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

12. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 12 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

13. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 13 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

14. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 14 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

15. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 15 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

16. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 16 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

17. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 17 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

18. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 18 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)

19. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 19 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

20. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 20 Nursing Process: Assessment Guidelines Review psychiatric history for comorbid disorders Determine psychosocial issues –Effect of use on patient’s life functioning

21. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 21 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?

22. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 22 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?

23. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 23 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

24. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 24 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

25. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 25 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

26. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 26 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

27. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 27 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 B 1 ) Decrease in autonomic hyperactivity –Beta blockers: propranolol (Inderal)

28. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 28 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

29. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 29 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

30. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 30 Effects of Abusive Substances Nicotine: stimulant, depressant, or tranquilizer Opiates: produce CNS depression Marijuana: depressant and hallucinogenic Hallucinogens: LSD, PCP

31. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 31 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

32. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 32 Effects of Abusive Substances –Flunitrazepam (Rohypnol) and hydroxybutyric acid (GHB) Used as date rape drugs, similar effects of BZAs, also cause amnesia

33. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 33 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

34. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 34 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 self- responsibility and referral to specific addiction treatment program –Treatment can take place in inpatient or outpatient setting

35. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 35 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

36. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 36 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

37. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 37 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

38. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 38 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