Mental Health Mental Health Nursing IINursing II

NURS 2310NURS 2310

Unit 8Unit 8

Substance AbuseSubstance Abuse

Objective 1Objective 1

Reviewing definitions of the terms substance abuse,

dependency, intoxication, and withdrawal

Substance Abuse

A maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to repeated use of the substance; any use of substances that poses significant hazards to health; leads to clinically significant impairment or distress occurring within a 12-month period.

Diagnostic Criteria for Substance Abuse Recurrent substance use resulting in a

failure to fulfill major role obligations at work, school, or home

Recurrent substance use in situations in which it is physically hazardous

Recurrent substance-related legal problems

Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

Dependency = a compulsive or chronic requirement; a need so strong as to generate physical or psychological distress if left unfulfilled.

Physical dependence is evidenced by a cluster of cognitive, behavioral, and physiological symptoms indicating continued use of the substance despite significant substance-related problems

Psychological dependence is indicated by an overwhelming desire to repeat the use of a particular drug to produce pleasure or avoid discomfort

Criteria for Substance Dependence Evidence of tolerance

– the need for markedly increased amounts of the substance to achieve intoxication or desired effects

– markedly diminished effect with continued use of the same amount of the substance

Evidence of withdrawal symptoms– the characteristic withdrawal syndrome

for the substance– the same/similar substance is taken to

relieve or avoid withdrawal symptoms

Criteria for Substance Dependence (cont’d)

The substance is often taken in larger amounts or over a longer period than was intended

There is a persistent desire or unsuccessful efforts to cut down or control substance use

A great deal of time is spend in activities necessary to obtain the substance, use the substance, or recover from its effects

Criteria for Substance Dependence (cont’d)

Important social, occupation, or recreational activities are given up or reduced because of substance use

The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

Intoxication = a physical and mental state of exhilaration and emotional frenzy or lethargy or stupor.

Criteria for Substance Intoxication The development of a reversible

substance-specific syndrome caused by recent ingestion of or exposure to a substance

Clinically significant maladaptive behavior or psychological changes that are due to the effect of the substance on the CNS and develop during or shortly after use of the substance

Withdrawal = the physiological and mental readjustment that accompanies the discontinuation of an addictive substance; usually associated with substance dependence.

Criteria for Substance Withdrawal The development of a substance-specific

syndrome caused by the cessation of or reduction in heavy and prolonged substance use

The substance-specific syndrome causes clinically significant distress or impairment

Substance Addiction

A compulsive or chronic requirement; the need is so strong as to generate

physical and/or psychological distress if left unfulfilled.

Dual Diagnosis

Coexisting substance use disorder and mental illness.

Nonsubstance Addictions Codependency

– Exaggerated pattern of learned behaviors, beliefs, and feelings involving dependence on others that greatly diminishes self-identity

– Stages of recovery: Stage I (Survival)=letting go of denial Stage II (Reidentification)=awareness of true self Stage III (Core Issues)=letting go of control of

others Stage IV (Reintegration)=regaining control of self

Gambling disorder– Defined as being persistent and leading to

clinically significant impairment or distress

Objective 2Objective 2

Describing substances commonly abused in the

community

Classes ofPsychoactive Substances

Alcohol Cannabis Hallucinogens Inhalants Opioids Sedative-hypnotics Stimulants

Alcohol

Most commonly abused drug Physically addicting

– alcohol becomes integrated into physiologic processes at the cellular level

– cell becomes dependent on alcohol to carry out metabolic processes

Constitutes the most life-threatening withdrawal syndrome in comparison to other types of commonly abused drugs

Alcohol (cont’d) Intoxication

– disinhibition of sexual or aggressive impulses– mood lability– impaired judgment– unsteady gait; incoordination

Withdrawal– coarse tremor of hands, tongue, or eyelids– nausea or vomiting– malaise or weakness– tachycardia, sweating, elevated blood

pressure– transient hallucinations or illusions– progression to alcohol withdrawal delirium

Alcohol (cont’d) Related physiological effects

– Wernicke’s encephalopathy Severe thiamine deficiency Paralysis of the ocular muscles Ataxia Somnolence, stupor, or death

– Korsakoff’s psychosis Confusion Loss of recent memory Confabulation Often occurs in conjunction with Wernicke’s

encephalopathy (“Wernicke-Korsakoff syndrome”)

– Fetal alcohol syndrome Physical, mental, behavioral, and learning

disabilities

Alcohol (cont’d) Four phases of progression

– Phase I: The Prealcoholic Phase Use of alcohol to relieve everyday stress and

tension

– Phase II: The Early Alcoholic Phase Characterized by blackouts Alcohol becomes requirement as opposed to

source of pleasure or relief

– Phase III: The Crucial Phase Loss of control over drinking Interference with social and/or occupational

function

– Phase IV: The Chronic Phase Emotional and physical disintegration Life-threatening physical manifestations of both

use and withdrawal symptomology present

Cannabis Produces an effect similar to that of

LSD Heightened awareness, distortion of

space and time, heightened sensitivity to sound, and depersonalization

May produce paranoia, but not true hallucinations

Has sedative effect and is psychologically addicting

Chronic use may result in psychosis and lack of motivation

Cannabis (cont’d) Second only to alcohol as the most

widely abused drug in the U.S. Intoxication

– impaired motor coordination– euphoria– anxiety– sensation of slowed time– impaired judgment– increased appetite– dry mouth– tachycardia

Hallucinogens Altered perceptions that are dream-

like Altered sense of time Feelings of special insight Emotions are intensified and labile Depersonalization Adverse reactions include paranoia,

depression, frightening hallucinations, and acute confusional state

Hallucinogens (cont’d) Intoxication

– marked anxiety or depression– ideas of reference– fear of losing one’s mind– paranoid ideation– impaired judgment– illusions, hallucinations, and

depersonalization– tachycardia, palpitations, tremors– sweating– blurred vision

Inhalants Paint, glue, aerosol sprays, “whiteout”,

gasoline Produce mind-altering response Drug used most by adolescents due to

ready availability and low cost Symptoms include nosebleeds,

bloodshot eyes, infectious lesions around the nose and mouth, severe disorientation and unconsciousness

Chronic use results in progressive brain damage, asphyxiation, seizures, bone marrow suppression, cardiac dysrhythmias

Inhalants (cont’d) Intoxication

– belligerence, assaultiveness, impaired judgment

– dizziness, incoordination, unsteady gait– slurred speech– euphoria– impaired social or occupational functioning– lethargy, depressed reflexes, psychomotor

retardation– tremor, generalized muscle weakness– blurred vision– stupor or coma

Opioids Narcotic analgesics

– Sedative effect– Desensitizes user to physical and

psychological pain Can cause physiological and

psychological dependence Induces sense of euphoria

– Drug’s pleasurable effect on the CNS promotes abuse

Effects include lethargy, indifference to the environment

Opioids (cont’d) Intoxication

– Apathy and dysphoria– Psychomotor agitation or retardation– Impaired judgment– Drowsiness– Slurred speech– Impairment in attention or memory– Can be fatal

Respiratory depression Coma Death

Opioids (cont’d) Withdrawal

– Develops after cessation of, or reduction in, heavy and prolonged use of an opiate or related substance

– Dysphoric mood– Nausea/vomiting/diarrhea– Muscle aches– Lacrimation– Sweating– Abdominal cramping– Insomnia– Fever

Sedative-Hypnotics Induces varying degrees of CNS

depression Categories include barbiturates,

nonbarbiturate hypnotics, and antianxiety agents

Physiologically and psychologically addicting

May generate “psychic drive” for continued use to achieve maximum level of functioning or feeling of well-being

Sedative-Hypnotics (cont’d) Intoxication

– slurred speech– incoordination/unsteady gait– nystagmus– impaired memory; stupor/coma

Withdrawal– diaphoresis; nausea/vomiting– increased heart rate– psychomotor agitation; hand tremors;

seizures– insomnia– hallucinations/illusions

Stimulants Induces varying degrees of CNS

stimulation Categories—

– Amphetamines Pleasurable euphoria followed by profound

depression/exhaustion; other intoxication effects are hyperactivity/irritability, combativeness, paranoia, and affective blunting

Toxic psychosis occurs in most chronic users; may be irreversible

Withdrawal symptoms include dysphoria, psychomotor retardation, fatigue, insomnia or hypersomnia, vivid unpleasant dreams, and increased appetite

Stimulants (cont’d) Categories (cont’d)—

– Cocaine Highly addictive due to intense feelings of

euphoria (only lasts about 30-60 minutes) Chronic inhalation results in runny

nose/sniffles, frequent colds, weight loss, and hyperactivity

Potentially fatal stroke/seizure/heart attack possible (even with first-time use)

Withdrawal symptoms include “crashing” (intense, unpleasant feelings of sadness), fatigue, insomnia or hypersomnia, increased appetite, agitation, psychomotor retardation, and possible suicidal ideation

Stimulants (cont’d) Categories (cont’d)—

– Synthetic stimulants– Caffeine

Most widely used stimulant (readily available) Relieves fatigue and increases alertness Withdrawal symptoms include headache, muscle

pain/stiffness, fatigue, anxiety, irritability, depression, impaired psychomotor function

– Nicotine Widely used stimulant (readily available) Increases alertness Withdrawal symptoms include depression,

irritability, insomnia, difficulty concentrating, increased appetite

Objective 3Objective 3

Exploring psychiatric/mental health interventions utilized for the treatment of clients

with substance abuse

Major treatment objectives of substance recovery include:

Detoxification– 1st step in the recovery process– should occur in safe, supportive environment– may include substitution therapy

Intermediate Care– identification of causes of dependency

Rehabilitation– health promotion/maintenance; outside support– identification of alternative sources of

satisfaction

Treatment modalities for substance-related disorders include:

Client/family education Support groups Pharmacotherapy Counseling Group therapy Psychopharmacology for substance

intoxication and substance withdrawal

Nursing assessment of clients at risk for alcohol withdrawal symptoms typically includes the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA)

Determines risk and severity of alcohol withdrawal

Used in initial assessment and ongoing monitoring of client’s withdrawal

Provides parameters for pharmacological intervention– Maximum possible score is 67– Score below 10 is generally indicative of

“safe” withdrawal that does not require medication

Objective 4Objective 4

Identifying self-help groups available for

clients with addictions and alcohol abuse

Alcoholics Anonymous Women for Sobriety

– female alcoholics Al-Anon

– families of alcoholics Adult Children of Alcoholics (ACOA) Narcotics Anonymous Fresh Start

– nicotine addiction Pills Anonymous

– polysubstance addiction

Objective 5Objective 5

Discussing medications used in the treatment of substance abuse to include their actions and side effects

Disulfiram (Antabuse) Inhibits metabolism of alcohol in the body,

producing an uncomfortable, potentially life-threatening reaction to alcohol exposure

Taken daily and lasts in the body for up to two weeks

Acamprosate (Campral) Maintenance of abstinence from alcohol Ineffective in clients who have not undergone

detoxification and not achieved alcohol abstinence prior to initiation

Concomitant use with psychosocial therapy

Catapres Assists heroin abuser through detox Non-opiate antihypertensive that

partially blocks withdrawal symptoms, but does not completely remove unpleasant feelings associated with withdrawal

Naltrexone (ReVia) Does not produce “narcotic high” Non-habit forming “Replaces” heroin or other opiates by

binding to the same receptors in the brain that produce feelings of pleasure

Methadone Synthetic opioid used for treatment of

heroin addiction Given orally and absorbed slowly so that

it does not produce “rush” associated with IV heroin use

Alleviates opioid cravings for a short time

Dose gradually reduced during detoxification, and client is not told how much of the drug they are being given

Use is highly controversial due to “trading one addiction for another”

Narcan Opioid antagonist Counteracts dangerous respiratory

depressant effects of heroin or other opiate overdose

When given to client under the influence of an opiate, the individual may experience acute withdrawal symptoms