Substance Related Disorders

1
Substance Related Disorders Dual Diagnosis

• Phyllis M. Connolly, PhD, RN, CS
• NURS 127A

2
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?

3
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

4
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)

5
Signs of Impaired Nursing Practice

• Job 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

6
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

7
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

8
Prevalence of Substance-Related Disorders
Disorder
Prevalence

• Alcohol abuse
• Males
• Females
• Substance
• Other drug dependency

• 16
• 29
• 6
• 18
• 9

Dahme, 1998
9
Classes of Substances with Potential for Abuse
and Dependence

• Inhalants
• Nicotine
• Opiods
• Phencyclidines (PCP)
• Sedative, hypnotic,or antianxiety agents

• Alcohol
• Amphetamine
• Caffeine
• Cannabis
• Cocaine
• Hallucinogens

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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

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Psychoactive Substances

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

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Etiological Theories Substance Abuse

• Biological
• 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)

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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

14
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

15
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
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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)

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Key Terms cont.

• Abuse--Excessive use of a substance that differs
  from societal norms
• Codependency--stress-related preoccupation with
  an addicted persons 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

18
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

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Cognitive Framework Assessing Denial
Is it denial?
No
Reassess
Yes
Is it a problem?
Yes
No
Do nothing
How is it a problem?
What cognitions are in conflict?
What are alternative means of reducing dissonance?
Forchuk Westwell, 1987
20
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, Jehovahs Witness,
  and Mormons)
• China and Japan lower prevalence-negative
  physiological response
• Native Americans Eskimos ? rates
• US rates similar to northern European countries

21
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 persons behavior,
  finishing the work of a colleague who is unable
  to function.

22
CAGE Screening Test Alcoholism

• 1. 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
23
Alcohol Withdrawal Symptoms First 24 hours

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

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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

25
Wernickes Syndrome Korsakoffs Disease

• Nutritional disorders related to alcoholism
• Thiamine deficiency
• Both treated with withdrawal from alcohol and
  vitamin supplements.
• Improvement can occur in Wernickes syndrome,
  some degree of intellectual and emotional
  impairment remains.
• Memory impairment is residual in Korsakoffs even
  when slight improvement occurs

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Wernickes 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, Korsakoffs Disease may develop

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Korsakoffs Disease

• Niacin deficiency in addition to thiamine
• Degeneration of cerebrum and peripheral nerves
• Characterized by amnesia, confabulation,
  disorientation, and peripheral neuropathy

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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-Wenickes
  Syndrome

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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

30
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 situations

Compton, 1989
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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

32
Elements of Detoxification Process

• Secure environment
• Sedation
• Supplements

33
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

34
Interventions Alcohol Abuse

• AA Self-Help
• Brief Interventions
• Feedback
• Responsibility
• Advice
• Menu
• Empathy
• Self-efficacy
• Moderation-Online Self-Help
• Motivational interviewing

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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
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Antecedents to Relapse
Keltner, p. 538
37
Stages of Change Addictive Behaviors
Relapse
Permanent Exit
Maintenance
Precontemplation
Contemplation
Action
Preparation
Prochaska DiClemente, 1992
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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

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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
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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

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Examples of Dual Diagnoses

• Axis I Schizophrenia
• Alcohol abuse
• Axis I Major depression
• Anxiolytic dependency
• Axis I Major Depression
• Marijuana abuse

42
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

43
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
44
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