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Substance AbuseSubstance AbuseThe actual prevalence of substance abuse is difficult to determineDetrimental effects of substance abuse include:Workplace injuriesHomicideMotor vehicle accidents and fatalitiesDomestic abuseChild abuse and neglectAffects males and females of all ages, cultures, and socioeconomic groupsCommonly coexists with (and complicates the treatment) of other psychiatric disordersDual DiagnosisIncreasing numbers of babies are being born to substance-addicted mothersMany people with emotional disorders or mental illness use drugs to self medicateMany people abuse a combination of substancesSubstances of abuse may be any chemical used therapeutically or recreationallyCommonly leads to physical dependence, psychological dependence, or bothEtiologyBiologic factorsGenetic vulnerabilityNeurochemical influencesPsychological factorsFamilial dynamicsCoping StylesSocial and environmental factorsCultural ConsiderationsWine is an integral part of Jewish religious ritesSome Native Americans tribes use peyote in religious ceremoniesCertain ethnic groups have genetic traits that either predispose them or protect them from developing alcoholismAlcohol abuse plays a part in the 5 leading causes of death for Native AmericansDiagnostic ClassesAlcoholAmphetaminesCaffeineCannabisCocaineHallucinogensInhalantsNicotineOpioids PCPSedatives, hypnotics, or anxiolytics DefinitionsSubstance abuse – using a drug in a way that is inconsistent with medical or social norms and it is done despite negative consequencesSubstance dependence – tolerance, withdrawal, and unsuccessful attempts to try to stop using that drug. The word dependence means it’s a physiological need to use that drug. We use the drug to prevent withdrawal symptomsIntoxication – the use of a substance that results in a maladaptive behaviorWithdrawal – a set of symptoms you can get when you are not getting the substance that your body is addicted to. Can range from HA to seizuresDetoxification – the process of safely withdrawing from that substance. Many people can’t detox by themselves, on their own. Onset/Clinical CourseTypically begins with the first episode of intoxication between 15 and 17 years of ageMore severe difficulties begin in the middle 20s-30sAlcohol-related breakup of a significant relationshipAn arrest for public intoxication or driving while intoxicatedEvidence of alcohol withdrawalEarly alcohol-related health problemsSignificant interference with functioning at work or schoolBlackout drinking in which the person continues to function but has no conscious awareness of their behavior at the time nor any later memory of the behaviorAs the person continues to drink, they often develop a tolerance for alcohol; that is, they need more alcohol to produce the same effect After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol will intoxicate the personDuring the later course of alcoholism, when the person’s functioning definitely is affected, periods of abstinence or temporarily controlled drinking occurAlcoholCentral nervous system depressantOverdose can result in vomiting, unconsciousness, and respiratory depressionSymptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intakeAlcohol withdrawal usually peaks on the second day and is over in about 5 daysVery important to ask when their last drink was. You need to know when the withdrawal symptoms will startAlcohol WithdrawalWithdrawal symptoms include:Coarse hand tremors, sweating, elevated pulse, elevated blood pressure, insomnia, anxiety, and nausea or vomitingSevere or untreated withdrawal may progress to transient hallucinations, seizures, or delirium – called delirium tremens (DTs)Withdrawal symptoms monitored using an assessment tool Pharmacologic TreatmentSafe withdrawal from alcohol involves:Benzodiazepines to suppress withdrawal symptoms (Ativan, Librium, Valium)Vitamin B1 (thiamine) to prevent or to treat Wernicke’s syndrome and Korsakoff’s syndromeThiamine is necessary for metabolism, effects nervous system, circulatory system, GI system. Vitamin B12 (cyanocobalamin) or folic acid for nutritional deficienciesWernicke-Korsakoff SyndromeThese usually aren’t reversible… Wernicke’s encephalopathyAn inflammatory, hemorrhagic, degenerative, condition of the brain; characterized by lesions in several parts of the brainDouble vision, involuntary rapid movements of eyes, paralysis of eyes, lack of muscular coordination, decreased mental function, peripheral neuropathyCaused by thiamine deficiencyKorsakoff’s syndrome (psychosis)A form of amnesia characterized by a loss of short-term memory and an ability to learn new skills; usually disoriented, may present with delirium, hallucinations, and confabulates to conceal the conditionCan often be traced to a degenerative change in the thalamus as a result of a deficiency of B complex vitamins – especially thiamine and B12Medical Complications of AlcoholismGastritisCirrhosisPancreatitisDiabetesMalnutritionEsophageal varices Peripheral neuropathySedatives, Hypnotics, and AnxiolyticsCentral nervous system depressantsBarbiturates, nonbarbiturate hypnotics, and anxiolytics Benzodiazepines alone, when taken orally in overdoseRomazicon given for overdoseBarbiturates, in contrast, can be lethal when taken in overdose; they can cause coma, respiratory arrest, cardiac failure, and deathWithdrawal symptoms occur in 6 to 8 hours or up to 1 week, depending on the half-life of the drugWithdrawal syndrome is characterized by symptoms opposite of the acute effects of the drug:Autonomic hyperactivity (increased pulse, blood pressure, respirations, & temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitationSeizures and hallucinations occur rarely in benzodiazepine withdrawalDetoxification is managed by tapering To prevent seizuresStimulants: Amphetamines, Cocaine, Methamphetamine, etc.Central nervous system stimulantsOverdoses can result in seizures and comaWithdrawal occurs within hours to several daysWithdrawal syndrome:Dysphoria accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, psychomotor retardation or agitation, and depressive symptoms including suicidal ideation for several daysStimulant withdrawal is not treated pharmacologicallyPsychological withdrawal is more severe than physiologic withdrawalLooks a lot like paranoid schizophrenia Formication – the feeling like there are bugs or whatever crawling under your skin. Also called “coke bugs”Cannabis (Marijuana)Used for its psychoactive effectsExcessive use of cannabis may produce delirium or cannabis-induced psychotic disorder; overdoses do not occurWithdrawal symptoms:Insomnia, muscle aches, sweating, anxiety, and tremorsEffects are treated symptomaticallyOpioids (narcotics)Central nervous system depressantsDemerol, morphine, heroine, oxycontin, methadoneOverdose can lead to coma, respiratory depression, pupillary constriction, unconsciousness, and deathWithdrawal:Short-acting drugs begin in 6 to 24 hours, peak in 2 to 3 days, and gradually subside in 5 to 7 daysLonger-acting drugs begin in 2 to 4 days, subsiding in 2 weeksWithdrawal symptoms:Withdrawal does not require pharmacologic interventionAdministration of Narcan is the treatment of choice for overdoseMethadone can be used as a replacement for heroin, serving to reduce cravingsThese have the least complicated withdrawal symptomsHallucinogensDistort reality and produce symptoms similar to psychosis including hallucinations (usually visual) and depersonalizationShrooms, LSD, mescaline, ecstasySynesthia – blending of all the senses Toxic reactions to hallucinogens (except PCP) are primarily psychological; overdoses as such do not occur; PCP toxicity can include seizures, hypertension, hyperthermia, and respiratory depressionHallucinogens can produce flashbacks which may persist from a few months to 5 years“Bad trip”Treatment is supportive:Isolation from external stimuli; physical restraints; for PCP, medications to control seizures and blood pressure; cooling devices; mechanical ventilationInhalantsInhaled for their effectsOverdose:Anoxia, respiratory depression, vagal stimulation, dysrhythmias Death may occur from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomitus People who abuse inhalants may suffer from persistent dementia or inhalant-induced disorders such as psychosis, anxiety, or mood disorders even if the inhalant abuse ceasesWithdrawal symptoms: noneTreatment:Support respiratory and cardiac functioning until the substance is removed from the bodyMay present with mouth ulcers, confusion, ataxiaSubstance Abuse TreatmentTreatment based on concept that alcoholism/drug addiction are medical illnesses: chronic, progressive, and characterized by remissions and relapsesSettingsEmergency department/medical or chemical dependency unitOutpatient/extended treatmentHalfway housesProgramsAA/NAIndividual and group counselingPharmacologic TreatmentHas 2 main purposes:To permit safe withdrawal from alcohol, sedative/hypnotics, and benzodiazepinesPrevent relapseRelapse PreventionAntabuse – alcohol and studies being done for cocaine addictionCampral – new one for alcoholMethadone – used for heroine ReVia – opioid antagonist sometimes used to treat overdoseCatapres – lessen effects of withdrawalZofran – using in young males that are at high risk for alcohol dependence, also treatment for meth addiction, they’re doing studies to see these effectsOff-Label UsesAntabuse – use for cocaine addictionProvigil – can become addictive itselfInderal – alcohol withdrawalTopamax – alcohol withdrawalNursing ProcessInfoThe nurse may encounter patients with substance problems in various settings unrelated to mental healthSeeking treatment of medical problems related to alcohol useWithdrawal symptoms may develop while in the hospital for surgery or an unrelated conditionBe alert to the possibility of substance use in these situations and be prepared to make appropriate referralsAssessmentHistory: chaotic family life, family history, crisis that precipitated treatmentGeneral appearance/motor behavior: depends on physical health; likely to be fatigued, anxiousMood/affect: may be tearful (expressing guilt and remorse), angry, sullen, quiet, unwilling to talkThought process/content: minimize substance use, blame others, rationalize behavior, say can quit on their ownSensorium/intellectual processes: alert and oriented; intellectual abilities intact (unless neurologic deficits from long-term alcohol or inhalants)Judgment/insight: poor judgment while intoxicated and due to cravings for substance; insight limitedSelf-concept: low self-esteem, feels inadequate coping with lifeRoles/relationships: strained relationships and problems with role fulfillment due to substance usePhysiologic considerations: may have trouble eating, sleeping; HIV risk if IV drug userData analysisNursing diagnoses common to physical health needs:DiarrheaRisk for injuryRisk for infectionActivity intoleranceSelf-care deficitsExcess fluid volumeImbalanced nutrition: less than body requirementsNursing diagnoses common to psychosocial health needs:Ineffective denialIneffective copingIneffective role performanceIneffective family processOutcomesThe patient will:Abstain from alcohol/drugsExpress feelings openly and directlyAccept responsibility for own behaviorPractice non chemical alternatives to deal with stress or difficult situationsEstablish an effective aftercare planInterventionsAdequate pharmacological treatmentMonitoring of vital signsControl nausea and vomitingAssess fluid and electrolyte balanceAssess nutritional statusProvide safe environmentAssess for suicide potentialEncourage participation in groupsDo not reinforce feelings of worthlessnessHelp to see relapse as opportunity for learningBe firm and consistent –manipulationSet limits – demandingEnforce rules, help strengthen impulse control –acting outPlace responsibility on patient – dependencyHelp patient make realistic self-appraisals and expectations – superficialityEvaluationIs the patient abstaining from substances?Is the patient more stable in their role performance?Does the patient have improved interpersonal relationships?Is the patient experiencing increased satisfaction with quality of life?Elder ConsiderationsEstimates are that 30% to 60% of elders in treatment began drinking abusively after age 60Risk factors for late-onset substance abuse in elders:Chronic illness that causes pain; long-term use of prescription medication (sedative-hypnotics, anxiolytics); life stress; loss; social isolation; grief; depression; an abundance of discretionary time and moneyElders may experience physical problems associated with substance abuse more quicklyMental Health PromotionPublic awareness and educational advertisingEarly identification of older adults with alcoholismThe College Drinking Prevention ProgramSubstance Abuse in Health ProfessionalsHigher rates of dependence on controlled substancesEthical and legal responsibility to report suspicious behavior Texas Peer Assistance Program for Nurses (TPAPN)Texas Peer Assistance Program for NursesAvailable for LVNs and RNs of Texas whose practice has been impaired due to the effects of psychiatric or substance abuse disordersOperates under state legislation, Chapter 467, Texas Health and Safety Code & NPA of TexasA project of the Texas Nurses FoundationTPAPN’s MissionOffer nurses life-renewing opportunities for recovery from substance use and psychiatric disordersIntegrate nurses back into the profession, thusProtect the public, andPromote professional accountabilityTPAPN Serves in Two Complementary WaysAs a voluntary, confidential & non-punitive alternative to BON investigation emphasizing rehabilitation & monitoring of nurses’ practice/recovery; andAs a voluntary & non-confidential option under BON licensure discipline emphasizing rehabilitation & monitoring of nurses’ practice/recoveryTPAPN Serves to…Keep good nurses with bad diseases who are motivated to find and maintain recovery while helping them to return to safe nursing practice – most often improved nursing practice.TPAPN serves…RNs and LVNs of Texas with at least one of the following diagnoses:Substance Use Disorders (SUDS)Substance abuseSubstance dependency(Alcoholism, prescription drug abuse or dependence, illicit drug abuse or dependence like cocaine, marijuana, crystal meth, opioids, etc.)Psychiatric DisordersAnxiety disordersBipolar disorderMajor depressionSchizophreniaSchizoaffective disorderNote: 8% of all TPAPN participants are psychiatric onlyHow Does TPAPN Work?Holds nurses accountable for working a recovery program and obtaining appropriate supportMust demonstrate good recovery for a minimum of 2 yrs (3 yrs of APN)Must demonstrate safe nursing practice by working as a nurse for at least 1 year of their participationNurses should not have to lose jobs or licenses without first being offered the opportunity for education, treatment, and recovery for chronic, progressive, and potentially fatal diseasesHowever, nurses whose psychiatric illness or substance use prevents them from practicing nursing safely must be referred to the BONSubstance AbuseClassic SignsChanges in behaviors & practice usually seen before physical changes are seenCo-workers observe pattern/change over time- deteriorationWork is often the last thing “to go”High level of functioning before “hitting bottom”May justify use (abuse) through RX medsIncreasingly isolated over timeDenial!At work, but not “on the job”Other Warning SignsIncorrect drug countsExcessive controlled substances listed as wasted or contaminatedReports by patients of ineffective pain relief from medications especially if relief had been adequate previouslyDamaged or torn packaging on controlled substancesUnexplained absences from the unitTrips to the bathroom after contact with controlled substancesConsistent early arrivals at or late departures from work for no apparent reasonPsychiatric ImpairmentSignsChronic, depressed mood, lack of focus, crying…Difficulty completing tasksIncreased absenteeismMood swings – cyclical in natureHyperactivity, grandiosity, pressured speech…Attention & memory deficitsAnxiety that impairs practice, memory, etc.Rage or disruptive behaviorsBizarre (as in psychotic) behaviorsWhy Nurses are at riskGenetic predisposition: individual (brain) susceptibility to substances of abuseEnvironmental & Socio-cultural influencesFamily of origin (environment) e.g., development of adult children of alcoholic (enabling) personalitiesCultural values, e.g., Western culture/medicine: Expectation for immediate gratification, pain relief. Our stressful habits & poor self-care are to be remedied by better pills…Unique Work Stressors, combined with access to controlled substancesMyth of Immunity: “I’m a nurse, not some uneducated loser on the street!”Myth of Perfectionism: “I can do it all – and I have to do it all perfectly!”Low self-esteem & poor self-care: Nurses end up meeting everyone else’s needs but their own!Enabling by co-workers & administration: We may assume all is “OK” or fear confronting nurse until its too lateRequirements of ParticipationQualified assessment psychiatristAppropriate treatmentOngoing self-help group support Random drug testing Payment of participation &/or Board Order FeesReleased to RTW – by Treatment Provider & TPAPNDemonstrate minimum 12 months safe practiceMinimum 2 year participation with complianceUsually 1 relapse allowed before BON2 full participations typically permittedSelf-Awareness IssuesExamine own beliefs and/or family behavior about alcohol and drugsRecognize that substance abuse is a chronic illness with relapses and remissionsNurse must be objective and reasonably optimistic ................
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