Drugs Mental Health Lecture Note

Substance-Related and Addictive Disorders Substance use disorders are complex diseases of the brain characterized by craving, seeking and use regardless of the price they may pay. Continuous use usually changes brain structure and function. A substance use disorder is a pathological use of a substance that leads to a disorder of usage. Symptoms fall into four groups. • • • • Impaired control Social impairment Risk, use Physical effect Concepts Central to Substance use Disorders Addiction-defined as a primary, chronic disease of brain reward, motivation, and memory. • The individual who is addicted is consistently unable to abstain and also unable to recognize the extent to which the addiction is creating problems in functioning, interpersonal relationships and emotional responses. Intoxication-defined as the development of a reversible syndrome of symptoms following excessive use of a substance. • Symptoms are drug-specific and occur during or shortly after ingestion of the substance. Withdrawal-occurs upon reduction or discontinuation of a substance that has been used regularly over a prolonged period. Tolerance-Individual with substance abuse experience this to the effects of the substance. Tolerance occurs when a person no longer responds to the drug in the way that he/she initially responded. It takes a higher dose to achieve the same level of response. The Drug Enforcement Agency-Drug Classification Nurses administer legal drugs each day, but all drugs (legal and non-legal) are classified. • • • • • Schedule I- high potential for abuse and have no acceptable use (ex. heroin) Schedule II- high potential for abuse, are considered dangerous and are available only by prescription (ex. methadone, methylphenidate (Ritalin)) Schedule III- low to moderate risk for misuse potential and are available only by prescription (ex. buprenorphine (Suboxone)) Schedule IV- drugs are low risk and are available by prescription (ex. alprazolam (Xanax) & lorazepam (Ativan)) Schedule V- drugs contain limited quantities of certain narcotics and are available over the counter (ex. Lomotil & Robitussin AC) Cannabis Cannabis or marijuana is the most widely used, often illegal drug in the world and the most commonly used drug after caffeine, alcohol and nicotine. Psychological tolerance and addiction have been shown to occur. One controversy that exists regarding marijuana is whether it leads to the use of other illicit drugs. With chronic use, it is also associated with a condition called “motivational syndrome.” Symptoms include lethargy, apathy, social and personal deterioration and lack of motivation. Intoxication Symptoms • Impaired motor coordination • Euphoria • Anxiety • Sensation of slowed time • Impaired judgement Social Withdrawal Withdrawal • Anger, aggression • Irritability • Anxiety • Sleep difficulty (disturbing dreams, insomnia) • Decreased appetite • Restlessness • • Depressed mood Physical symptoms (abdominal pain, tremors, sweating, fever, chills, Headache) Opioid Use Disorder This classification of drugs includes opioids, opium derivatives and synthetic substitutes. This classification of drugs includes Heroin, Morphine, Oxycodone, Hydrocodone and Fentanyl. They exert a sedative and analgesic effect. The major medical use for Morphine, Oxycodone and Hydrocodone is pain management. These are often abused because they produce a euphoric sate and desensitize the individual from psychological and physiological pain. In this country we are struggling to deal with an opioid abuse epidemic. Fentanyl is the most common drug today related to overdose deaths. It is 50-100 times stronger than Heroin. Intoxication Symptoms • psychomotor retardation • drowsiness • slurred speech • altered mood • impaired memory and attention • bradycardia • hypotension • hypothermia • meiosis (pinpoint pupils) • intense drowsiness • coma Withdrawal Begins 6-8 hours after last dose. • • • • • • • • • • • • • tachycardia rhinorrhea (runny nose) muscle spasms bone and muscle pain anxiety abdominal cramps vomiting & diarrhea tachycardia hypertension hypothermia mydriasis (enlarged pupils) diaphoresis increased respiratory rate Overdose Death usually stems from respiratory arrest due to respiratory depressant effect of the drug. Three symptoms are strongly suggestive of overdose: respiratory depression, pinpoint pupils and coma. Overdose Treatment Breathing is promoted by aspirating secretions and inserting airway. Mechanical ventilation may be necessary. Naloxone (Narcan), a specific opioid antagonist, which can be administered intramuscularly, subcutaneously or intravenously. Today, it can be also administered by nasal spray and is now used by first responders. Increased respirations and dilated pupils should happen quickly after administration if administered in time. General treatment includes is a synthetic narcotic opioid, Methadone, to decrease painful symptoms of opiate withdrawal. It also blocks the euphoric effects of opiate drugs such as heroin, morphine and codeine, as well as semisynthetic opioids, oxycodone and hydrocodone. Sedative, Hypnotic or Anxiolytic Use Disorder Drugs in this category are benzodiazepines, all prescription sleeping medications, almost all antianxiety drugs. Intoxication Symptoms • Slurred speech • Incoordination • Impaired thinking • Unsteady gait • Nystagmus Overdose • A comatose state is a dangerous possibility with an overdose Overdose Treatment • Gastric lavage and activated charcoal are the treatment. • If the client is awake after overdosing, prevent loss of consciousness again. Withdrawal Treatment • Gradual reduction of benzodiazepines will prevent seizures and other withdrawal symptoms. Stimulant Use Disorder Amphetamines, cocaine or other stimulant drugs are the second most abused illicit substance in the U.S. These drugs produce a euphoric state in which the individual feels capable of upper human feats. Intoxication Symptoms • Elation • Euphoria • Sensitive, anxious, tense, hypervigilant and angry • Psychotic and aggressive Withdrawal • In the initial phase, the individual feels agitated and anxious with intense cravings for the drug. Following the initial phase, the individual feels depressed and lethargic. It is often called “crashing.” Withdrawal Treatment • Physical symptoms of chills, muscle cramps and aching make the process extremely uncomfortable. The physical symptoms are often severe. • Depression can last for months after physical withdrawal. • Medical detox can help to make this process more tolerable. Alcohol Use Disorder • • • Although alcohol is a sedative/depressant, it causes an initial feeling of euphoria. It exerts a depressant effect on the CNS, resulting in behavioral and mood changes. Like any other mind- altering drug, it has the potential for abuse. At low doses it produces relaxation, lack of concentration and drowsiness. Intoxication Symptoms • The legal definition of intoxication in most states requires a blood concentration of 80 or 100mg ethanol per deciliter, expressed as 0.08-0.10g/d. There may be sexual or aggressive impulses, mood lability, impaired judgment and functioning. Mild to Moderate Withdrawal • Lack of appetite • • • • • • • Insomnia Agitation Impaired cognition Perceptual changes Increase in blood pressure Increase in pulse Increase in body temperature Severe Alcohol Withdrawal This is an emergency situation that results in death in 20% of untreated individuals. This may happen anytime within the first 72 hours. Autonomic hyperactivity may result in: • • • • • • • tachycardia diaphoresis fever anxiety insomnia hypertension visual and tactile delusions & hallucinations are common in alcohol withdrawal syndrome Prevention of alcohol withdrawal syndrome is the goal during withdrawal. Diazepam (Valium) may be used to relieve acute agitation, tremor, impending delirium tremors and hallucinations. Chloradiazepoxide (Librium) may be used to reduce the danger of progress. Once the delirium appears, intravenous lorazepam (Ativan) is used to treat severe symptoms. Nursing Care It is important for the nurse to self-assess because personal views, culture and history can affect feelings towards substance abuse and addictive disorder. Safety is a primary focus of nursing care during intoxication and withdrawal stages. The nurse is to assess for level of orientation. Also, obtain information to determine substance(s), time and amount of last use, length and frequency of use and amount of daily use. Withdrawal Interventions • Keep environment quiet (decrease stimulus) • If necessary, one to one observation (family and/or staff) • Fall precautions • Seizure precautions • • • • Suicidal precautions Frequently orient to reality and surroundings Monitor vital signs Follow the medication regime Long-Term Interventions • Establish rapport and trusting relationship • Set limits to manipulative behavior • Explain the physical effects of substance abuse • Identify with client stressors that precipitate use • Teach coping skills • Positive reinforcement for evidence of delayed gratification Screening Tools • Michigan Alcohol Screening Test (MAST) • CAGE- Questions to ask clients to determine how they view their substance usage • Clinical Institute Withdrawal Assessment Scale (CIWA) • This is a scale to determine the level of detox and if additional medication is needed.