Addiction & �Co-Occurring Disorders�Chpt. 31 & 42

Objectives

1. Identify common signs and symptoms of both acute and chronic use of common substances
2. Discuss the patterns of substance use with other mental disorders
3. Differentiate the medications used to prevent alcohol use, relapse, treat opioid overdose, and medication used for opioid maintenance treatment
4. Analyze barriers to treatment of co-occurring disorders and substance use disorders
5. Describe the cycle of recovery and relapse in substance use and co-occurring disorders
6. Apply patient-specific nursing processes for persons with substance use disorders and those who have co-occurring disorders

What is addiction?

Physiologic components

• Dopamine
• The cycle:

• “The continued use of substances despite adverse consequences”; can be a physiological or psychological (or combined) dependence.
• Two categories: substance use disorder and substance-induced disorder
• Occurs when medications used for other health issues/diagnoses cause intoxication, withdrawals, etc.
• Occurs when an individual continues using substance despite cognitive, behavioral, and physiologic symptoms

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Neurotransmitter Pathways

Acetylcholine Pathways

Serotonergic Pathways

Noradrenergic Pathways

Dopamine Pathways

How are pathways created?

Acetylcholine Pathways

Serotonergic Pathways

Noradrenergic Pathways

Dopamine Pathways

Addiction

• What qualifies as a substance in a substance use disorder?
• Any type of substance/drug that changes the brain “circuitry” on a cellular level
• Alcohol, caffeine, cannabis, hallucinogens, inhalants (whippers), opioids, sedative-hypnotics, stimulants (meth), tobacco, gambling
• When does it become an addiction?
• When the changes in the brain lead to pathologic behaviors that occur with repeated relapses and cravings when exposed to drug-related cues (including withdrawal symptoms)

Most abused substances in the United States:

• Alcohol
• Marijuana
• Prescribed Pain Relievers
• Hallucinogens
• Depressants
• Cocaine
• Stimulants
• Inhalants
• Meth
• Heroin

Effects of excessive drinking in Colorado

Alcohol Use Disorder

• DSM-5-TR Diagnostic Criteria: A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
• Alcohol 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 alcohol use.
• A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
• Craving, or a strong desire or urge to use alcohol.
• Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
• Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
• Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
• Recurrent alcohol use in situations in which it is physically hazardous.
• Alcohol 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 alcohol.
• Tolerance, as defined by either of the following:
1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
2. A markedly diminished effect with continued use of the same amount of alcohol.
• Withdrawal, as manifested by either of the following:
• The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal).
• Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Alcohol Use Complications

Acute

Chronic

• Liver disease
• High blood pressure
• Heart disease
• Digestive problems and nutritional deficiencies
• Brain disorders
• Wernicke encephalopathy
• Wernicke-Korsakoff syndrome
• Cancer
• Liver, mouth, throat, esophagus, colon, rectum

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• Sedation/relaxation
• Decreased inhibitions
• Decreased coordination
• Slurred speech
• Nausea/vomiting
• Respiratory depression

Refer to Box 31.1

CAGE Assessment

• Have you ever felt you should Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?

Alcohol Withdrawals

• Mild peripheral edema
• Autonomic hyperactivity (sweating, tachycardia)
• Shakiness/tremors
• Fever
• Chills
• Headache
• Seizure (generalized tonic-clonic)

• Mood symptoms such as anxiety or agitation
• Hallucinations
• Nausea/vomiting/diarrhea
• Insomnia
• Gastritis
• Hematemesis
• Dry mouth
• Puffy, blotchy complexion

CIWA-Ar�Clinical Institute Withdrawal Assessment of Alcohol Scale, revised

1. Nausea/Vomiting
2. Tremor
3. Paroxysmal Sweats
4. Anxiety
5. Agitation
6. Tactile Disturbances
7. Auditory Disturbances
8. Visual Disturbances
9. Headache/Fullness in Head
10. Orientation and Clouding of Sensorium

Scored 0-7, 0 being no symptoms, 7 being the most severe

Alcohol Withdrawal Stages

Treating acute alcohol withdrawals

• Benzodiazepines are generally used to control psychomotor agitation, anxiety, or seizure activity.
• DiazePAM (Valium), LORazepam (Ativan), and chlordiazePOXIDE (Librium) are the most frequently used benzodiazepines.
• Often, hospital protocols will state treatment with PRN benzos begins when CIWA-Ar scores reach 8-10 or higher. Some protocols will also include transfer to the ICU for scores >20.
• Ativan is best for severe liver impairment.
• Consider additional supportive care such as intravenous fluids, nutritional supplementation, fall precautions, seizure precautions, and frequent vital signs.
• There are many vitamin & electrolyte deficiencies with alcohol use because of increased liver disfunction and UOP. Supplemental vitamins are often ordered as scheduled meds.
• Folate (B9, which works with B12), thiamine, Vitamin B6, Vitamin A
• Sodium, potassium, magnesium, calcium, phosphate

Alcohol Overdose

Treatment:

• Pump stomach
• Symptomatic treatment

• Unconsciousness
• Vomiting
• Seizure
• Trouble breathing
• Slow heart rate
• Clammy skin
• No gag reflex
• Low body temperature

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Pharmaceuticals used to reduce alcohol use

• Antabuse (Disulfiram)
• Used as an adjunct therapy to help deter and prevent individuals from drinking.
• Will give a negative reaction; can make some people get pretty sick if they drink alcohol (even colognes or hand sanitizers).
• Vivitrol, Revia, or Depade (Naltrexone)
• Can help maintain abstinence by reducing the appeal of alcohol and interfering with the tendency to want to drink more.
• Also used for opioids.
• Campral (Acamprosate)
• Help maintain abstinence by letting someone feel drunk, but not the “fun” parts of being drunk. Reduces the appeal.

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Marijuana Use In Colorado

Cannabis Use Disorder

• DSM-5-TR Diagnostic Criteria: A problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
• Cannabis 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 cannabis use.
• A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects.
• Craving, or a strong desire or urge to use cannabis.
• Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home.
• Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis.
• Important social, occupational, or recreational activities are given up or reduced because of cannabis use.
• Recurrent cannabis use in situations in which it is physically hazardous.
• Cannabis 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 cannabis.
• Tolerance, as defined by either of the following:
1. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect.
2. A markedly diminished effect with continued use of the same amount of cannabis.
• Withdrawal, as manifested by either of the following:
• The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria set for cannabis withdrawal).
• Cannabis (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Marijuana Use Complications

Acute

Chronic

• Amotivational syndrome
• Cause cognitive deficits
• Inability to concentrate
• Impaired memory
• Sleep disorders
• Lung damage (smoking)
• May precipitate psychosis
• Associated with suicidal thoughts and behavior

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• Euphoria or dysphoria
• Relaxation/drowsiness
• Heightened/distorted perception of color and sound
• Poor physical coordination
• Time and spatial perception distortion
• Unusual body sensations
• Dry mouth
• Dysarthria
• Increased appetite
• Increased heart rate
• Reddened eyes
• Lability
• Disorientation

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Marijuana Withdrawals

• Shakiness/tremors
• Sweating
• Fever
• Chills
• Headache

• Mood symptoms such as irritability, restlessness, and anger
• Gastrointestinal symptoms
• Stomachache
• Nausea
• Nervousness or anxiety
• Sleep difficulty
• Decreased appetite or weight loss
• Depressed mood

Marijuana Overdose

Treatment:

• Symptomatic treatment

• Extreme anxiety or panic attacks
• Psychotic reactions
• Decreased judgement
• Tachycardia
• Chest pain
• Severe shaking/seizures
• Pale skin color
• Unresponsiveness
• High blood pressure

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Who likes seafood?

Overdose Deaths in �Colorado from Opioids

Overdose Deaths in America

Opioid Use Disorder

• DSM-5-TR Diagnostic Criteria: A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
• Opioids are 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 opioid use.
• A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
• Craving, or a strong desire or urge to use opioids.
• Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
• Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
• Important social, occupational, or recreational activities are given up or reduced because of opioid use.
• Recurrent opioid use in situations in which it is physically hazardous.
• Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
• Tolerance, as defined by either of the following:
1. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
2. A markedly diminished effect with continued use of the same amount of an opioid.
• Withdrawal, as manifested by either of the following:
• The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal).
• Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.
• Note: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

Opioid Use Complications

Acute

Chronic

• Breathing problems during sleep
• Hyperalgesia
• Immunosuppression
• Chronic constipation
• Bowel obstruction
• Tooth decay
• Neuroendocrine dysfunction

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• Drowsiness
• Mental fog
• Sedation
• Nausea/vomiting
• Low respirations/heart rate
• Overdose/death

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CAGE-AID Assessment

• Have you ever felt you should Cut down on your drug use?
• Have people Annoyed you by criticizing your drug use?
• Have you ever felt bad or Guilty about your drug use?
• Have you ever had drugs first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?

Opioid Overdose

Treatment:

• Naloxone

• Unconscious
• Pinpoint pupils
• Slow, shallow breathing
• Vomiting
• Blue/grey skin (lips and fingertips)
• Snoring/gurgling sounds

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Opioid Withdrawals

• Dilated pupils
• Body aches
• Nausea/vomiting/diarrhea
• Shakiness/twitching
• Yawning
• Sweating
• Fever

• Restlessness
• Sleep disturbances
• Rebound hyperexcitability
• Rhinorrhea
• Lacrimation
• Piloerection
• Anxiety/irritability
• Depression/dysphoria

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Opioid use detoxification and treatment

• Initially, opioids will be gradually stopped over a few days to a few weeks by administering substitute drugs to prevent severe physical symptoms of withdrawal
• Methadone (Dolophine)
• It is a synthetic opiate and is physiologically addicting, but it helps satisfy the opioid cravings without severe effects of heroin
• It is controlled by a physician and available in tablet form so no more IV drug use risks
• Buprenorphine
• Relieves drug cravings without producing the same intense “high”, similar to Methadone
• Sublingual
• Subutex (buprenorphine-only): safe for pregnant women
• Buprenorphine and Naloxone (Bunavail, Suboxone, Zubsolv)
• Maintenance treatment of opioid addiction; Naloxone helps protect the patient from overdose
• Sublingual
• NalTRExone
• Competitively inhibits the action of opioid drugs and blocks the intoxicating effects of opioids
• Cannot be used at the same time as opioids as withdrawal symptoms may appear
• CANNOT be used as a rescue drug (sound alike drug)

Co-Occurring Disorders

• Mental disorders and substance use disorders are two different and primary mental disorders. However, someone can have both of these disorders at the same time.
• Some mental disorders come from long-term substance use, while others predispose individuals to begin using substances.
• Typical comorbid mental disorders: psychotic, anxiety, mood, or personality disorders
• Patients with co-occurring diagnoses use their substance of choice to experience fleeting moments of joy and escape, even though doing so will prompt a decline in their overall function and worsen their psychiatric symptoms.

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Which comes first?

The Relapse Cycle

In the relapse cycle, reemerging psychiatric symptoms lead to ineffective coping strategies, increased anxiety, substance use to avoid painful feelings, averse consequences, and attempted abstinence until psychiatric symptoms reemerge and the cycle repeats itself

Chemical dependency and nursing

• Estimated prevalence: 6-8%
• Risk factors include:
• Access/availability of drugs
• Training in the administration of IV drugs
• Working conditions (shortages, inadequate ratios, shift rotations, shifts >8hrs, increased OT)
• Risk of loss of license
• Peer assistance programs

• Signs of chemical dependency in nursing:
• Mood swings
• Noncompliance with acceptable policies and procedures
• Deteriorating appearance/performance
• Sloppy/illegible charting
• Alcohol/marijuana smell
• Forgetfulness/poor judgement
• Lying
• High achievement
• Patient complaints of care

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Treatment and Recovery

• Involves a partnership between the health care team, the individual, and any social systems
• Medication adherence
• Education
• Support
• Relapse: an expected part of recovery

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Using the Transtheoretical Model

Relapse prevention

• Stable and safe place to live
• Specific, individualized plan for managing stressful times
• Making informed, healthy choices to support physical and emotional well-being
• Purposeful and meaningful daily activities
• Relationships and social networks
• Support for meeting spiritual needs and finding a sense of meaning in life
• Independence, income, and resources to participate in society

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Nursing Management

• What is our priority of care for any patient who has substance use disorder?
• Safety
• whether the person will be withdrawing, and how severe
• Therapeutic relationship
• Between us and the patient
• Between the patient and themselves and others
• Why? To encourage recovery

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Nursing Management

• Motivational Interviewing
• Harm Reduction
• Brief Intervention
• Therapeutic Interactions
• Cognitive Interventions
• Cognitive Behavioral Interventions
• Coping Skills Enhancement

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• Group Therapy
• Individual Therapy
• Family Therapy
• Peer Support Self-Help Groups
• 12-Step Programs
• Education and administration of medications used to help substance use

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FRAMES

What are some harm reduction interventions?

• Naloxone distribution programs
• Needle exchange
• Designated driver campaigns
• Condoms in school

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Think about the nursing code of ethics… which applies here?

• Beneficence & non-maleficence
• Beneficence is providing positive benefits and removing harmful conditions
• Non-maleficence is avoiding causing harm to patients; weighing every action against the risks, benefits, and consequences of that action
• Also justice & autonomy
• Treating each patient impartially and fairly, regardless of circumstances
• Nurse performs their duties using professional & critical judgement; patient gets to control their care

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Barriers to treatment

• Stigma (for anyone… including HCP who may have substance abuse problem)
• Health issues (homelessness, health hazards, provider frustration)
• Education
• Adherence
• Environment (codependent friends)
• Denial of substance use
• Manipulative behavior

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28 Days Case Study

• What is the chief complaint?
• What questions would you ask during history taking?
• Is the diagnosis of severe alcohol use disorder accurate?
• What requirements does the client meet that supports this diagnosis (DSM-5)?
• What treatment plan would you outline?
• What are the expected outcomes?