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What is important to remember about society and chemicals?
- Drugs are a pervasive part of our society
- Certain mood altering substances are socially acceptable and used moderately by the majority of adults
- Society has developed a relative indifference to an occasional abuse
- ETOH most widely used and misused
- 10% that used ETOH develop problems
- CD is progressive by nature
- Health care providers are at high risk for abuse
What are the three most common chemicals used?
What is the history of ETOH
- Beer and wine used since 6400 BC
- Alchemists of the middle ages believed ETOH answer to many ailments
- Whiskey = water of life
- Prohibition laws of 1920-1930 created a profitable underground market - much like illegal drugs today
What are the incidents of alcoholism in the US today?
- Non-drinkers --> 35% (59 million)
- ETOH users --> 55% (92 million)
- Adult problem drinkers
- 7-10% (17 million)
- These problem drinkers affect 1-4 people (44 million)
- 50+% those with serious mental illness are dependent on/addicted to substances
- Suicide rate 3-4 times rate of general pop
4X more health services, treatment reduces the cost
What are the psychiatric comorbidities of chemical dependency?
50% of people with serious mental illness have a substance use disorder some time in their lives
- Psychiatric disorders associated with substance abuse include
- Acute and chronic cognitive impairment disorders
- Attention deficit disorder (ADD)
- Borderline and antisocial personality disorders
- Anxiety disorders
- Depression --> high risk for suicide
- Eating disorders
- Compulsive behavior
- Disease concept --> Alcoholism is chronic illness. Like other chronic illnesses there is no cure. It can be arrested, but there is a continues progression and may be relapse.
- Alcoholic --> Anyone who repetiteely has multiple problem because of drinking over a period of time
- Pattern of use may vary = daily, weekend, periodic
What is the Genetic theory for alcoholism?
- 1st degree relatives 50% rate of addiction
- Sons more likely than daughters
- Twins adopted at birth
What is the biological theory for alcoholism?
- Drugs interfere w/ neurotransmitters
- ETOH and other CNS depressants act on gamma-aminobutric acid
- Helps explain cross-tolerance effects of ETOH, barbiturates & benzodiazepines
- Cocain dependence associated with deficiency in dopamine and norepinephrine
What is the psychological theory for chemically dependency?
- No known addictive personality
- At first use to feel better, later use to not feel bad
- Self-medicate w/anxiety and or depression
What are some psychological issues seen chemical dependency?
- Intolerance and overwhelmed by frustration and pain
- Lack of success
- Lack of meaningful relationships
- Low self-esteem
- Risk taking propensity
What is the socio-cultural theory of chemical dependency?
Norms of cultural influence when, what and
- how a person uses
- Italians and Jews
- Native americans
- Northern Europeans
- Oriental (possible genetic intolerance)
What is substance abuse?
- Inability to fulfill role expectations
- Participation in hazardous activities while impaired
- Recurring legal or personal problems
- Continued use despite problems
What is substance dependence?
- Tolerance to drug
- Withdrawal syndrome
- Substance taken in increasingly larger amounts for longer periods of time
- Desire to cut down
- More and more time spent getting and using substances
What is tolerance?
Need for higher and higher doses to achieve the desired effect
What is withdrawal?
After a long period of continued use, stopping or reducing drug results in specific physical and psychological signs and symptoms.
What are the overall guidelines in an assessment done on the chemically impaired?
- History of client's past substance abuse
- Medical history
- Psychiatric history
- Psychosocial issues (if abstinent, find out why)
What are some psychological characteristics associated with chemical dependency?
- Low self-esteem
What are two important questions to ask when interviewing someone with a chemical dependency?
1. In the last year, have you drunk or used drugs more than you have meant to?
2. Have you ever felt or needed to cut down on your drug usage in the last year?
What are some assessment tools for Chemical dependency?
- Michigan Alcoholism Screening Test
- Cage Questionnaire (cut down, annoyed, guilty, eye opener: 2+ = dependence)
What are the basics or BAL?
- Legal intoxication --> 0.08% (coma at .40 and death at .5mg% due to resp depression)
- Body burns ETOH at rate of 1 or serving/hr
- Body weight and stomach contents affect rate
BAL can be used to assess:
- Level of intoxication
- Level of tolerance
As tolerance develops, a discrepancy is seen between BAL and expected behavior
What are the phases of Alcoholism?
- Early Alcoholic
Describe the phase:
use of ETOH to relieve everyday stress. Tolerance develops
Describe the phase:
- ETOH no longer source of pleasure or relief but is required
- Blackouts occur
- Feels enormous guilt and is defensive about use
- Excessive use of RATIONALIZATION and DENIAL
Describe the phase:
- Person has lost control
- Physiological dependence is evident
- Anger and aggression are common
- Drinking and use are total focus
- Willing to risk losing everything (job, marriage, family, friends, and self-respect) that was important in an effort to keep addiction
Describe the Phase:
- Emotionally and physical disintegration
- Life-threatening physical manifestations evident in every system of the body
- Abstinence results in terrifying tremors, hallucinations, convulsions, severe agitation and panic
- Depression and ideas of suicide are common
What are the effects on the body of chemical dependency?
- Induces a general, non-selective reversible depression on the CNS
- 20% single dose absorbed and into the blood stream through stomach
- Does not have to be digested
- Blood carries it directly into the brain where it acts on the brain's central control areas, slowing down and depressing brain activity
- 80% processed slowing through the upper intestinal tract and blood stream
- Moments after consumed, it can be found in ALL tissues, organs, and secretions of the body.
What do low doses of ETOH have on the body?
- Loss of inhibition and lace of consentration
- Slurred speech
What does intoxication result in?
- Aggression and impaired judgement
- Impaired attention and irritability
- Emotional lability
- Lack of coordination
- Unsteady gait
What happens at after ingesting very high levels of ETOH
- Severe disorientation
- Stupor disorientation
- Stupor anesthsia
What are the effects on metabolism in ETOH use?
- Hyperuricemia --> increased uric acid in blood
What are the effects on gastrointestinal system with ETOH use?
- Increased risk of cancer in oral cavity
- Esophagitis --> inflammation and pain of esophagus due to toxic effects of ETOH due to frequent vomiting
- Malabsorption of nutrients, especially folic acid, Vit B1 (thiamine) and Vit B12
- Ulcers --> gastric and duodenal
What are the basics of gastritis in ETOH use?
- Epigastic distress, N/V and distention
- Breaks down stomach protective mucosal barrier, allowing hydrochloric acid to erode the stomach wall
- Damage to blood vessels may result in hemorrhage
What are the basics of Alcoholic Hepatitis?
- Follows a severe, prolonged bout of drinking with a damaged alcoholic (fatty) lover
- Syndrome of inflammation and necrosis
What are the clinical manifestation of alcoholic hepatitis?
- Enlarged liver and spleen, abdominal pain
- Vomiting and weakness
- Low grade fever, fatigue and jaundice
- Loss of appetite and increased WBC count
- Ascites, increase weight loss with severe cases
What are the basics of pancreatitis with ETOH use?
- Usually 1-2 days after binge
- Symptoms --> constant, severe epigastric pain, N/V and abdominal distention
- Leads o pancreatic insuffieciency
- Resulting in steatorrhea (fatty stool), weight loss, malnutrition and diabetes mellitus
What are the basics of cirrhosis of the liver?
End stage of ETOH disease
Caused by the toxic effects of ETOH on the lever
Widespread destruction of liver cells replaced by fibrosis (scar) tissue symptoms similar to hepatitis
Treatment: abstinence, correction of malnutrition and supportive care to prevent complications
Increased BP through portal circulation results in defective blood flow through cirrhotic liver
excessive serous fluid in the abdominal cavity, occurs in response to portal hypertension
Veins of esophagus become distended due to excessive pressure from defective blood flow through cirrhotic liver
As pressure increases, varicosities can rupture causing hemorrhage and death
Response to the inability of diseased liver to convert ammonia to urea for excretion
- Continued increase in serum ammonia caused by impaired menal
- functioning, apathy, euphoria or depression, sleep disturbance, increase
- confusion and progression to coma and death
Treatment (for all--> abstinence, temporary elimination of protein from diet and reduced intestinal ammonia using neomycin or lactulose
What are some Neurological system affects in ETOH use?
- Sleep disturbances
- Peripheral neuropathy
- Cerebellar degeneration
- Wernicke's encephalopathy
- Korsafoffs psychosis
thiamine deficiency with ocular muscle paralysis dilopia, ataxia, somnolence, stupor and death
confusion, loss of recent memory w/ confabulation
Wernicke-Korsakoff's Syndrome or Dementia
S/S --> Wide based gait, ataxia, confusion, coma, death
Tends to be permanent: 1/3rd rule
Hypomagnessemia --> Give Mag sulfate to increase seizure threshold and increase body's ability to use B1
Cardiovascular basics of excess ETOH use
- Hypertension, tachycardia w/ withdrawal
- Decreased cardia mechanical function
- accumulation of lipids in myocardial cells result in enlarged and weakened condition
- clinical findings relate to CHF or arrhythmia
- Symptoms: decreases exercise tolerance, tachycardia, dyspnea, edema, palpitations
- TREATMENT --> abstinence and treatment of CHF symptoms
- Production and function and survival impaired
- At high risk for infection
- Abstinence rapidly reverses this deficiency
How does ETOH use effect the respiratory system?
Impaired diffusion and increased lung infection (cilia get drunk too!)
How does ETOH use affect the Genitourinary system?
Increase urinary excretion of potassium and magnesium
- Sexual dysfunction
- Enhanced libido and erection failure (short term)
- Sterility, impotence and decreased libido (long term)
How does ETOH use effect the musculoskeletal system?
Myopathy --> results in Vit B deficiency that also contributes to peripheral neuropathy
Acute: Pain, tenderness and edema after excess ETOH ingestion + increase enzymes
Chronic: gradual wasting and weakness. Neither pain, tenderness or elevated muscle enzymes in acute myopathy.
Multiple drug and ETOH dependency can result in simultaneous withdrawal syndromes with bizarre clinical picture and problems for safe withdrawal
S/S of withdrawal
Early signs appear 6-8 hrs after last drink
Peak after 24-48 hours and rapidly disappear unless progression to withdrawal delirium
With delirium patient usually terrified, confused and anxious
Pulse and BP elevated
Grand mal seizures in 7-48 hrs
Panic may occur when patient realized bottle is not available
May be argumentative, hostile, demanding as a way to deal with intense anxiety, shame and guilt
Withdrawal needs to be monitored to prevent progression to delirium
What are the signs and symptoms of delirium?
- Anxiety and tremor
- Anorexia and insomnia
- Hyper-alert and jerky movement
- Irritability and startle easily
- Subjective stress --> shaking inside
- May have vivid nightmares, poorly formed hallucinations or illusions
Describe withdrawal treatment
- Treatment use of sedatives control overactive of sympathetic nervous system
- Pulse and BP should be checked hourly for 8-12 hours and then q 4 for 48 hours
- Pulse is a good indicator of progression through withdrawal
- See Alcoholism protocol
What are the basics of withdrawal delirium?
- Medical emergency w/ 20% mortality
- Death due to MI, fat emobili, peripheral vascular collapse, hyperthermia or aspiration pneumonia
- 48-72 hours, peaks at 3 days
- Consistent and frequent orientation to time and place
- Do NOT use physical restraints
ETOH withdrawal VS ETOH withdrawal delirium
- Withdrawal delirium
- Medical emergency that can reult in death
- Delirium peaks at 2-3 days after cessation of ETOH and lasts 2-3 days
- S/S: -->
- Tachycardia, diaphoresis, elevated BP
- Disorientation and clouding of consciousness
- Visual or tactile hallucinations
- Hyperexcitability to lethargy
- Paranoid delusions, agitation
- Fever (100-103)
What are some other CNS depressants?
Tranquilizing relief of anxiety to anesthesia, coma and even death
- Nonbarbiturate hypnotics
- Antianxiety agents (benzodiazepines)
What are the principles of CNS depressants?
- Effects additive with one another
- No specific antagonist (coffee)
- Low doses initially produce excitation by reliving inhibition and induced feeling of euphoria
- Produce physiological and psychological dependence
- cross tolerance --> less response to others
- cross dependence --> helpful with withdrawal
- Pattern of use:
- Sedative use increase with age
- Tranquilizer used more by women
- ETOH used more by men
- Effects on the body:
- General depressant effect
- All areas of the body --> brain, nerves, muscles, heart
- Reduces rate of metabolism
What are the common signs of stimulant abuse?
- Dilation of pupils
- Dryness of the oral-nasal cavity
- Excessive motor activity
What are the basics of cocaine and crack?
Extracted from the leaf of coco bush
When smoked, it takes effect in 4-6 seconds. A 5-7 min high follows, then a deep depression.
- 2 main effects on the body
Produces imbalance in neurotransmitters (dopamine and norephinepherine)
Withdrawal symptoms include --> Depression, paranoia, lethargy, anxiety, insomnia, nausea, vomiting, sweating, chills
Nicotine --> can act as a stimulant, depression, tranquilizer
What are the basis of Marijuana?
- THC (active ingredient) has depressant and hallucinogenic properties
- Most widely used illicit drug in US, overdose and withdrawal rare (cravings)
- Tolerance lost rapidly
- Used for 5000 years in China and India
- Reduce nausea w/chemo and MS
- Reduce intraocular pressure w/glaucoma
- Appetite stimulant w/ AIDS wasting
What are some Hallucinogens?
- Lyserigic acid diethylamide (LSD or acid)
- Mescaline (peyote) used in religious rites of Native American Religion for the 2000 years. Best cure for ETOHism
- Psilocybin (magic mushroom)
- Phencyclidine piperidine (PCP, angel dust, horse traquilizer, peace pill)
What are some volatile solvents used as inhalants?
- Spray paint
- cigarette lighter fluid
- propellant gases used in aerosols
What is involved in the self-assessment by the nurse for CNS depressants and stimulants?
Examine your own attitudes, feelings, and belief about addicts and addictions. This may include examining your own use, use by your family members, or friends' use of addictive substances
Avoid disapproval, intolerance, condemnation, or lack of emotional reaction to client
Develop empathy and the ability to manage manipulation behaviors and avoid power struggles with the clients
What are the basic of the chemically impaired nurse?
- 50% higher than general public
- Usually overachievers who have doubts about the only adequacy
- Each of us responsibility
- Direct confrontation usually not helpful
- Report to supervisor
- The wrong choice --> do nothing!!
- Without intervention the potential for client harm increases
- 10-20% of practicing nurses are chemically dependent
What are the co-workers responsibilities when they suspect a chemically dependent coworker?
- *Clear documentation (date, times, events, consequences)
- *Report facts to nurse manager
- *Nurse manager then takes facts to nursing admin
If no action is taken by nursing manager and co-workers behavior continues, take facts to the next level in the chain of command
What are the basics of co-dependence in addiction?
- Exists separate from addiction
- Valuing oneself by what one does, looks like or has rather than by who one is
- Overly responsible behavioral in relationship building and maintenance --> doing for others what they could just as well do for themselves and often at ones own expense
- Thee behaviors seen in general pop, especially women and nurse
What is involved in the assessment of chemically impaired clients?
- Suicidal or homicidal thoughts or plans
- Overdose needing immediate medical attention
- withdrawal symptoms
- physical complications
- clients interest in treating addiction
- clients and families knowledge of community resources
- Inhibits impulsive drinking
- Taken daily but can last up to a week
- Must be aware of foods, RX and skin prep with ETOH
What are the physical reactions to Antabuse?
- Facial flushing and sweating
- Headache and neck pain
- Tachycardia and resp distress
- Serious drop in BP and N/V
What Psychopharmacology is involved in the treatment of opioid addiction?
- Dolophine (methadone) --> synthetic opiate blocks craving for and effects of heroin, only med currently approved to treat pregnant opioid addiction
- LAAM (L-α-acetylmethadol) --> alternative to methadone
Naltrexone (Trexan, Revia) --> Antagonist that blocks euphoria effects of opioids
Clonidine (Catapres) --> Nonopioid suppressor of opioid withdrawal symptoms, effective somatic treatment when combined with naltrexone
What is included in the evaluation of a client who chemically dependent?
- Increased time in abstinence
- Decreased denial
- Aceptance occupational functioning
- Improves family relationships
- Ability to relate comfortably to other individuals
What is important to remember about Alcoholics (like heroine addicts) that mature out of their addiction?
Only 2-3% become abstinent each ear
What are some factors associated with remission?
- Finding a substitute
- Aversive event related to using
- Finding a source of hope or self-esteem
- Obtaining new social supports