Substance Related Disorders & Dual Diagnosis

Phyllis M. Connolly, PhD, RN, CS

NURS 127A

Questions to Consider Today 4/20/01

What behaviors indicate that a nurse may be abusing substances?

What is the ego/self theory related to substance abuse?

When is denial a problem? What is the relationship between

childhood sexual abuse and addiction?

Substance Disorders Facts Cost: $144 billion/year in health care and job

loss Alcohol most commonly used Marijuana most commonly used illegal drug 50% auto accidents & homicides involve

alcohol Involved in crime & violence 500,000 deaths from Tobacco-related

disorders One in 10 deaths related to alcohol More die from misuse of legal prescriptions

Impaired Nurses

5% of 2 million nurses in 1984 (ANA) abused substances

8-10% chemically dependent Narcotic addiction 30 X higher than

general population (1987 study) 67% of cases handled by 44 state BRN

(1988)

Signs of Impaired Nursing PracticeJob Performance Changes,

Controlled drug handling

Drug counts incorrect

Excessive errors

Excessive wastage, often not countersigned

Medicine signed out to pt. not in pain

Two strengths of drugs signed out to same pt. Same time

Packaging appears to be tampered

Patient complaints of ineffective pain control

Volunteers to give controlled drugs

General Performance

Medication errors

Poor judgment

Euphoric recall for involvement in unpleasant situations

iIlogical or sloppy charting

Absenteeism, esp. days off

Requesting leave time just before assigned shift

Lateness--elaborate excuses

Job shrinkage

missed deadlines

Signs Impaired Nurse Cont.Behavioral/Personality

changes

Sudden changes in mood

Periods of irritability

Forgetfulness

Wears long sleeves (hot weather)

Socially isolates

Inappropriate behavior

Chronic pain condition

Hx pain treatment with controlled substances

Signs of Use

Alcohol on breath

Constant use of perfumes, mouthwash, breath mints

flushed face, reddened eyes, unsteady gait, slurred speech, hyperactivity

accelerated speech

Increasing family problems interfere with work

Interventions: Impaired Colleagues Reporting required ethical & legal

obligation to supervisor Document in writing; time, date, place

description, & names of those present An advisor with (state nurse

rehabilitation team) Team approach,co-workers, supervisor,

nurse administrator, family member

Prevalence of Substance-Related Disorders

Alcohol abuse– Males– Females

Substance Other drug

dependency

16% 29% 6% 18% 9%

Prevalence Disorder

Dahme, 1998

Classes of Substances with Potential for Abuse and Dependence

Alcohol Amphetamine Caffeine Cannabis Cocaine Hallucinogens

Inhalants Nicotine Opiods Phencyclidines

(PCP) Sedative,

hypnotic,or antianxiety agents

5 General Categories of Substances

CNS depressants,(alcohol, sedative-hypnotics, antianxiety agents,and volatile inhalants

Stimulants (cocaine, amphetamine,caffeine, nicotine**, & related substances)

Opioids including analgesics Hallucinogens including PCP Cannabis Caffeine not considered to cause either dependence or abuse

** Nicotine is currently classified as causing dependence but not abuse

Psychoactive Substances

Drugs or chemicals which alter one or several of:– Perception– Awareness– Consciousness– Thinking– Judgment– Decision making– Insight– Mood– Behavior

Etiological Theories: Substance AbuseBiological Addictive substances activate neurotransmitters in

mesolimbic dopaminergic reward pathway– chronic use blood flow to brain

Genetic predisposition Behavioral--conditioning & homeostasis

– drug craving triggers; self-medicating Psychodynamic

– Unconscious oral needs

– Dependency

– Low self-esteem

– child abuse, physical, sexual

– family conflict (Trauma model, Walker et al. 1998)

DSM-IV Criteria Substance Related Disorders

Substance Dependence

A. Maladaptive pattern 3 or more:

tolerence withdrawal need for more inability to stop using time spent acquiring or

recovering from effects problems, social,

occupational, or recreational Continues use despite

knowledge

Substance Abuse

A. Maladaptive pattern leads to significant impairment or distress as manifested by one or more of:

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

Recurrent use in hazardous situations

Recurrent substance related legal problems

Continued use despite problems

DSM-IV Criteria Substance Related Disorders Cont.Substance Intoxication Development of a substance-

specific syndrome due to a recent ingestion of a substance

Clinically significant maladaptive behavioral or psychological changes due to the effect of the substance on the CNS

Not due to general medical condition and not better accounted for by another mental disorder

Substance Withdrawal Development of a substance-

specific maladaptive behavioral or psychological changes due to the effect of the substance on the CNS

The substance-specific syndrome causes clinically significant distress or impairment

Not due to a general medical condition and not better accounted for by another mental disorder

Substance Dependence

Lack of control over drug use and its increasing importance. At least 3 symptoms in 12 month period.

Tolerance Withdrawal Taking larger amounts Inability to reduce use Excess time spent on obtaining drugs Impairment in functioning Continued use despite negative consequences

Dahme, 1998

Key Terms

Dependence: A drug abuser must take a usual or increasing dose of a drug in order to prevent the onset of abstinence symptoms/withdrawal

Tolerance: The need for increasing amounts of a substance to achieve the same effects

Withdrawal: Physical signs and symptoms that occur when the addictive substance is reduced or withheld (abstinence syndrome)

Key Terms cont. Abuse--Excessive use of a substance that

differs from societal norms Codependency--stress-related preoccupation

with an addicted person’s life, leading to extreme dependence on that person

Blackouts--period of time in which the drinker functions socially but for which there is no memory

Pharmacodynamic tolerance--occurs when higher blood levels are required to produce a given effect

Coping Styles Contributing to Substance Abuse Maintenance Rationalization

– Falsifying an experience by giving a contrived, socially acceptable and logical explanation to justify an unpleasant experience or questionable behavior

Projection– Attributing an unconscious impulse, attitude,or behavior to

someone else (blaming or scapegoating) Denial

– escaping unpleasant realities by ignoring their existence

Cognitive Framework: Assessing Denial Is it denial?

No ReassessIs it a problem? Yes

Yes No Do nothing

How is it a problem?

What cognitions are in conflict?

What are alternative means of reducing dissonance?

Forchuk & Westwell, 1987

Alcohol Abuse and Culture

Norms important role Cultures with rate of alcohol abuse may condone

drunkenness (Irish) Cultures with rates appropriate use of small amts.

Celebrations (Jewish & Mediterranean) Condemn altogether (Muslim, Jehovah’s Witness,

and Mormons) China and Japan lower prevalence-negative

physiological response Native Americans & Eskimos rates US rates similar to northern European countries

Enabling

Behaviors of individuals in family or social system who inadvertently promote continued alcohol or drug use. By protecting them from consequences of their actions. Examples: ignoring or making excuses for person’s behavior, finishing the work of a colleague who is unable to function.

CAGE Screening Test Alcoholism1. Have you ever felt you ought to Cut

down on your drinking?

2. Have people Annoyed you by criticizing your drinking?

3. Have you ever felt bad or Guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eyeopener)

Keltner, p. 530

Alcohol Withdrawal Symptoms: First 24 hours

Within a few hours, peaks within 24 hrs. Anxiety Insomnia Irritability “Internal shaking” BP, P, diaphoresis

Alcohol Withdrawal Symptoms: Sudden to 2-3 days Grandmal convulsive seizures--48 hrs. Delerium tremens (DTS)--72 hrs.

– Medical Emergency Acute pathological state of consciousness results from interference with brain metabolism

Wernicke’s Syndrome & Korsakoff’s Disease

Nutritional disorders related to alcoholism Thiamine deficiency Both treated with withdrawal from alcohol

and vitamin supplements. Improvement can occur in Wernicke’s

syndrome, some degree of intellectual and emotional impairment remains.

Memory impairment is residual in Korsakoff’s even when slight improvement occurs

Wernicke’s Syndrome

Neuronal and capillary lesions in gray matter of brain stem

Characterized by delirium, memory loss, confabulation, apathy, apprehension, ataxia, clouding of consciousness, sometimes coma

If not treated early with large doses of thiamine, Korsakoff’s Disease may develop

Korsakoff’s Disease

Niacin deficiency in addition to thiamine Degeneration of cerebrum and

peripheral nerves Characterized by amnesia,

confabulation, disorientation, and peripheral neuropathy

Confabulation

Commonly observed in chronic brain syndrome Person cannot recall specific aspects of an event Fills in with relevant imaginary information Face-saving device, protects self-esteem Compensates for memory loss Due to lack of access to stored information and lack of new

input Inability to form new associations Loss of capacity for introspection and judgment of truth Frequently observed in Korsakoff-Wenicke’s Syndrome

Potential Nursing Diagnoses: Substance Abuse Altered nutrition Risk for fluid volume deficit Altered thought processes Sensory/perceptual alterations: auditory-visual Sleep pattern disturbance Altered health maintenance Self-care deficit Noncompliance Hopelessness Helplessness Self-esteem disturbance risk violence to self and others Anxiety Ineffective individual coping

Self-Care Deficit

Ego functioning which does not handle painful affects or maximize protective activity

Interventions– Provide alternative ways to handle or tolerate

painful emotions--stress management– Furnish structured supportive environment– Increase awareness of unsatisfactory protective

behaviors– Teach skills to recognize & respond to health-

threatening situationsCompton, 1989

Pharmacological Interventions: Alcohol Abuse Disulfiram (Antabuse)--negative

aversive– inhibits breakdown of acetaldehyde--toxic

to body: if alcohol is ingested causes sweating,flushing, pulse, BP, headache, nausea, vomiting, palpitations, dyspnea, tremor, and/or weakness. May cause arrhythmias, MI, cardiac failure, seizures, coma, and death

Elements of Detoxification Process Secure environment Sedation Supplements

Pharmacological Interventions: Alcohol Abuse Cont. Naltrexone hydrochloride (ReVia)--

opiod receptor antagonist– Increases abstinence and reduces alcohol

craving in combination with comprehensive treatment plan

– May cause liver toxicity at high doses– Contraindicated for patients who abused

narcotics within 7-10 days

Interventions Alcohol Abuse AA Self-Help Brief Interventions

– Feedback– Responsibility– Advice– Menu– Empathy– Self-efficacy

Moderation-Online Self-Help Motivational interviewing

Opioid Abuse: Signs & Symptoms

CNS Effects – sedation– euphoria– mood changes– mental clouding– pain reduction– pinpoint pupils– decreased respiratory

rate

GI Effects– chronic constipation

Cardio Vascular– Hypotension

Sexual Functioning– Decreased libido– retarded ejaculation– impotence– orgasm failure

Detoxification– Clonidine (Catapress)

Townsend, 1996, p. 374

Antecedents to Relapse

Event Cocaine Alcohol

Being around users 87% 40%

Severe craving 67% 25%

Stopping AA/NA 48% 75%

Not expressingfeelings

20% 75%

Major emotionalcrisis

33% 50%

Keltner, p. 538

Stages of Change: Addictive Behaviors

Relapse

Precontemplation

Contemplation

Preparation

Action

Maintenance

Permanent Exit

Prochaska & DiClemente, 1992

Treatment of Substance-Related Disorders Trusting therapeutic

relationship, nurse Detox & residential

treatment Behavioral model & disease

model Rehabilitation

– Abstinence

– Motivation Medications

– Alcohol-Librium, Valium, Ativan

Opioid--Narcan

– Methadone

Family education Treatment of comorbid

medical & psychiatric disorders

Group treatment– Confrontation

Personal responsibility Conscience development Self-help Life-style issues

Percent of Population (15 -54) 1991 With Substance Abuse Disorder, Mental, or Both in Lifetime

Substance Abuse Dependence 12%

Both Disorders 13.7%

Only Mental Disorder 21.4%

Dahme, 1998, p. 288

Etiology: Dual Diagnosis

Generally mental illness first– Heredity– Biological factors

Self-medicating Substance abuse first

– Brain chemistry altered– Guilt, depression, altered self-esteem

Personality disorders

Examples of Dual Diagnoses

Axis I Schizophrenia

Alcohol abuse Axis I Major depression

Anxiolytic dependency Axis I Major Depression

Marijuana abuse

Treatment: Dual Diagnosis

Multidisciplinary Case management Individual therapy Group therapy Skills training Education groups Vocational counseling Referrals to community resources Self-help groups Five-step model

Therapeutic Tasks: Dual Diagnosis

Establish therapeutic alliance Help patient evaluate costs and benefits of

continued substance abuse Individualize goals for change; include harm

reduction as alternative to abstinence Help build an environment and lifestyle

supportive of abstinence Acknowledge recovery long-term process

Jefferson, 1998, p. 517

Outcomes Treatment: Major Depression and Alcohol Abuse Short Term

– Verbalizes plans for future– Sleeps 6-8 hrs/night– Eats 3 balanced meals/day– Recognizes and describes problems with alcohol and

depression– Plans to live with non substance user friend

Long Term– Practices abstinence from alcohol– Attends self-help groups– Attends outpatient treatment– Medication compliant– Lives in halfway house or non substance user friend