1. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 0

2. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 1 Chapter 24 Chemically Mediated Responses and Substance-Related Disorders

3. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 2

4. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 3 The CAGE Questionnaire Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye- opener)? Scoring: Two “yes” answers indicate probable alcohol abuse and warrant further assessment.

5. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 4 Figure 24-5 The Stuart Stress Adaptation Model as related to substance abuse.

6. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 5 Primary Nursing Diagnoses Related to Chemically Mediated Responses Acute confusion Ineffective coping Dysfunctional family processes: alcoholism Disturbed sensory perception

7. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 6 Primary Medical Diagnoses Related to Chemically Mediated Responses Substance use disorders Substance dependence Substance abuse Substance-induced disorders Substance intoxicationPsychotic disorder Substance withdrawalMood disorder DeliriumAnxiety disorder DementiaSexual dysfunction Amnestic disorderSleep disorder

8. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 7 Evidence-Based Treatments for Chemically Mediated Responses Disorder: Alcohol use disorder Treatment: Cognitive behavioral treatments help patients shape and adapt to their life circumstances. 12-step treatment may be as effective as cognitive behavioral treatments. Therapist characteristics may have a stronger effect on outcome than type of treatment. Lower intensity treatment for a longer duration may be an effective treatment strategy.

9. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 8 Evidence-Based Treatments for Chemically Mediated Responses (Cont.) Alcohol use disorder (cont.) There appears to be little difference in outcome between inpatient and outpatient treatment. Naltrexone is effective in preventing full-blown relapses in alcoholics who have had a “slip” after achieving abstinence.

10. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 9 Evidence-Based Treatments for Chemically Mediated Responses (Cont.) Disorder: Substance use disorders Treatment: The nicotine patch and nicotine gum significantly increase nicotine abstinence. Maintenance treatment using methadone for heroin dependence is effective. LAAM, a longer-acting opioid, also is effective.

11. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 10 Principles of Alcohol Detoxification The long-acting benzodiazepines are the drugs of choice because they effectively reduce signs and symptoms of withdrawal, prevent seizures, and have a better margin of safety than other drugs. A symptom-triggered dosing regimen is preferred over fixed-schedule dosing because it is effective, requires less medication, and appears to prevent seizures as well as fixed schemes. The use of a withdrawal assessment tool such as the CIWA-AR is recommended for medication determinations because it reduces overmedication caused by patient overreporting of symptoms or fixed regimes, and undermedication resulting from staff reluctance to treat.

12. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 11 Principles of Alcohol Detoxification (Cont.) A fixed schedule, with prn dosing, may be used on a unit where the staff members have no training in the use of a withdrawal assessment tool. Although neither magnesium nor thiamine reduces seizures, administration of thiamine is recommended to prevent Wernicke disease and Wernicke-Korsakoff syndrome.

13. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 12 Principles of Motivational Counseling Express empathy through reflective listening. Develop discrepancy between the patient’s goals or values and current behavior. Avoid argument and direct confrontation. Roll with resistance. Support self-efficacy.

14. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 13 Decisional Balance Grid Old Behavior New Behavior Pros/Benefits Like the taste of alcohol Helps me to relax Pros/Benefits Better relationship with spouse No more DWIs Cons/Costs Costs a lot of money Led to DWI—costly, embarrassing, and inconvenient Cons/Costs Will miss my drinking friends Don’t know how to have fun without it

15. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 14 Figure 24-7 A model of change in substance use disorders. (Modified from Prochaska J, DiClemente C: Towards a comprehensive model of change. In Miller W, Heather N, editors: Treating addictive behaviors: process of change, New York, 1986, Plenum.)

16. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 15 Treatment Stages and Interventions for Dually Diagnosed Patients Engagement—Intervene in crises, help with practical living problems, establish rapport with family members, demonstrate caring and support, listen actively Persuasion—Help to analyze pros and cons of substance use, educate patient and family, arrange peer-group discussions, expose patient to double- trouble self-help groups, adjust medication, persuade patient to comply with medication regimen

17. Copyright © 2005 Mosby, Inc. All rights reserved. Slide 16 Treatment Stages and Interventions for Dually Diagnosed Patients (Cont.) Active treatment—Help to change thinking patterns, friends, habits, behaviors, and living situations as necessary to support goals; teach social skills; encourage patient to develop positive social supports through double-trouble self-help groups; enlist family support of changes; monitor urine and breath for substances; offer medications Relapse prevention—Reinforce abstinence, compliance, and behavioral changes; identify risk factors and help to practice preventive strategies; encourage continued involvement in double-trouble groups; continue lab monitoring