Psycho-Addictive Disorders

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Psycho-Addictive Disorders

• Elisa A. Mancuso RNC, MS, FNS
• Professor

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• Substance Abuse
• Maladaptive pattern of excessive use
• Recurrent use ?? impairment
• Failure to meet role obligations
• ?? Use with
• Legal, social or interpersonal problems
• Intoxification
• Reversible substance induced syndrome
• Slurred speech
• Ataxia ? Coordination
• ? Cognition
• Poor memory judgment
• ??Impulsive behavior

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• Substance Dependence
• Cognitive, behavioral psychological symptoms
• Pt. believes substance needed for optimal health
• Persistent desire and ? time spent to obtain
  use
• Use ? quantities more frequently Addiction
• Unsuccessful attempts to stop using
• Tolerance
• Need ?? amounts to achieve desired effects
• Cross Tolerance
• Pt. tolerant to drug A
• When use drug B (similar to A) has ? effect
• Need ?? dose of B
• Withdrawal Syndrome
• Cessation of heavy prolonged use
• Autonomic Hyperactivity
• Hallucinations
• Dementia
• Seizures

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ETOH

• 3rd Major health problem
• 50 ER visits 12 million adults ETOH dependent
• Teens fastest growing group of alcoholics
• ? 50 risk with alcoholic family member
• Parents role model ETOH as coping skill
• ? Predisposition ? Sensitivity
• ETOH produces morphine like substances TIQs
• Activate opioid brain receptors addiction
• ? ETOH Dehydrogenase ? ETOH metabolism
• ETOH goes directly from blood to brain
• ? Self Esteem ? Frustration
• ?? Impulsive ? Immediate Gratification
• Peer media influence Reinforcement
• ? Inhibitions ? confidence risky behaviors

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Cultural Influences

• Asians
• Lowest ETOH rate 2.5
• Genetic ETOH intolerance () Punishment
• Flushing HA Palpitations
• Native Americans
• Highest ETOH rate 12.5
• 5th leading cause of death
• Community oriented culture
• Drinking is group activity
• Irish, German, Scandinavian
• ? ETOH use dependency
• RT Socialization aggression release

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Family Dynamics

• Co-Dependency
• Caretaker derives self worth from others
• Over-functioning takes on all responsibilities
• Enabling behaviors
• Adult Children of Alcoholics 1/8
• Learn dysfunctional family roles
• Secrecy, mistrust, shame and denial of abuse.
• Primary goal is to please parent
• Hero/Caretaker Child
• Take on family responsibilities
• Trying to keep it all together
• Scapegoat Child
• Act out _at_ home Child is focus of conflict
• Lost Child
• Avoid conflict pain (Escape from family)
• Run away
• Mascot/Clown
• Comic relief to mask sadness
• Truly unhappy

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ETOH

• CNS Depressant
• ? Anxiety Relaxation ? Inhibitions
• ? Judgment Slurred speech ? Sleep
• BAC Blood Alcohol Concentration
• 0.05 Euphoria, impairment
• 0.08 Intoxication (Legal limit)
• 0.15-0.2 ? coordination, double vision
• 0.3 stupor
• 0.4 coma death
• Absorbed in 5 mins
• Liver detoxifies ETOH (¼ oz) per hour
• 12 oz. Beer
• 4 oz. Wine
• 1 Shot

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Cognitive Effects

• ? Control Poor judgment ?Learning
• Impulsive/Abusive Behavior Seizures
• Blackouts Fugue-like state
• Amnesia of events during drinking period
• No loss of consciousness during episode
• Wernickes Encephalopathy
• Thiamine deficiency? Grey matter damage
• Abnormal thinking patterns ? Memory Ataxia
• Korsakoffs Psychosis (2nd to Wernickes)
• Niacin Thiamine deficiency
• Irreversible cell death progressive mental
  deterioration
• Confabulation Loss of recent memory Diplopia
• Somnolence ? Stupor ? Death

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Systemic Effects

• Cardiovascular
• Autonomic Hyperactivity ? HR ? BP CHF
• Myopathy RT
• Vasoconstriction Chest pain
• Bone Marrow Toxicity
• ? RBCs ? WBCs ? Plts
• Gastrointestinal
• Esophagitis RT Vomiting
• Esophageal Varices RT Portal HTN
• Gastritis Ulcers RT ?HCL
• Malnutrition ? Ascitis
• Pancreatitis ? DM CA
• Hepatitis Cirrhosis ? Liver Failure

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Systemic Effects

• Respiratory
• COPD PN
• Lung CA RT ?? Smoking
• Skin/Skeletal
• ?? Reflexes RT Peripheral Neuropathy
• Muscle weakness ?? Falls
• Skin ulcers
• Spider Angiomas
• Genitourinary
• ?? Urination RT diuretic action of ETOH
• ? FAS
• ? Sexual Performance RT ? Libido

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Alcohol Withdrawal Syndrome AWS

• Rebound NS Hyperirritability
• 1st Stage (6-8 h after last drink)
• Morning after jitters
• Tremors Anxiety C/O Shaky Inside
• Irritability ? HR ? BP N V
• 2nd Stage (24 h no interventions)
• Hallucinations
• Visual 3 - 4 long bugs
• Tactile crawling sensation
• Auditory hear music
• Seizures (2-6 during 3-4 h period)

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Alcohol Withdrawal Syndrome AWS

• 3rd Stage (48h) Delirium Tremens- DTs
• Acute Medical Condition (20 mortality)
• Dehydration ?Fluid Electrolyte imbalance
• ?? Autonomic Hyperactivity
• ?HR ?BP ?Temp
• Fatal Arrhythmias
• Global confusion unaware of environment
• Vivid Hallucinations Delusions
• ?? Agitation Seizures

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AWS Therapy

• Detoxification 3-7 days
• AWS Protocols
• Librium, Valium or Ativan 10-20x dose initially!
• Thiamine (IM)
• Cyanocobalamine (Vit B12)
• Niacin (Vit B6) Folic Acid
• IV Glucose
• ß Blockers
• Propanonol (Inderal) Clonidine (Catapres)
• Dilantin or Mg SO4
• NO Mellaril or Haldol for hallucinations
• (?? Seizures)
• Tryptophan Trophamine
• Odansetron (Zofran)

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AWS Nursing

• Primary Priority Assessment! V/S LOC
• Monitor Pts response to therapy
• Pt. Safety v S/S of depression suicide
• Calm, quiet environment
• Provide uninterrupted periods of rest
• Firm limits consistent support
• Reorient to reality
• Confront denial, rationalization, projection
• Monitor visitors

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Medications

• Antabuse (Disulfiram)
• Aversion Therapy
• Blocks oxidation of ETOH
• ? Pt sensitivity
• ? HA ? HR N V Flushing
• Chest Pain ? Death
• Naltrexone HCL (ReVia)
• Opioid antagonist ? ETOH craving
• Can not be used with narcotics for 7-10 days

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Therapy

• 12 Step Programs AA NA CA
• Life-long commitment
• Attain Maintain sobriety
• Peer group sponsor
• Accept ETOH dependency as illness
• Develop adaptive coping skills
• ?? Self-Esteem

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Hallucinogens

• LSD Acid, Purple Haze Big D
• Mescaline Peyote, Half-Moon
• PCP Angel dust (lipophilic)
• Ketamine Special K
• Marijuana Pot, Weed, Grass, Joint, MJ
• Dronabinol (Marinol) Nabilone (Cesamet)
• used for Chemo induced N V
• Action
• Alter mood perception of time space
• Alter cognitive function insight into life?
• Synesthesia altered visual/auditory
• Hear Colors See Music
• Paranoia , Hallucinations Illusions
• Bad Trips fear of losing ones mind ? suicide
• ?? Aggression ?? Physical Strength (PCP)
• Flashbacks (up to 5 -15 years)

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Stimulants

• Amphetamines Ecstasy, MDMA, Amylnitrate
• Ice Crank smokeable form of methamphetamine
• Euphoria lasts 12 -30 h ? violence ? strength
• Cocaine Coke
• Crack Rock smokeable form of coke
• Onset 6-7 secs, High 2-5 min, Severe crash ? ??
  use
• Caffeine Tobacco
• Action
• ?? DA ?? NE ?? 5-HT
• ? Alertness ?Endurance ?Elation Euphoria
• ?? Self-Esteem ??Assertiveness ? Sexuality
  Verborrhea
• Tolerance in hours days
• Vasoconstriction ? HR ? BP ? Temp
  Arrhythmias
• Withdrawal
• Respiratory depression Dilated pupils ??
  Tremors
• Fatigue Vivid Dreams ?? Appetite
• Psychomotor retardation
• Crashing Suicidal Ideation Psychosis

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Methamphetamine
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Methamphetamine Facial Effects
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Meth Aging
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Crank Bugs
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Opioids

• Morphine MSO4
• Codeine
• Heroin
• Action
• Euphoria ?? Pain Perception ?? Passivity
• ? Anxiety ? ? Aggression Apathy
• ? Hunger ? Thirst ? Libido
• Pin point Pupils ?? Respirations
• Rapid weak pulse
• Withdrawal (5-14 days)
• Watery eyes Rhinitis
• Yawning Sneezing Tremors
• Abdominal spasms

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Sedatives, Hypnotics Anxiolytics

• Brevital, Seconal
• Restoril, Halcion
• Valium, Xanax, Ativan, Rohypnol Roffis
• Gamma Hydroxybutrate (GHB)
• G Liquid X Georgia Homeboy
• Action
• Relaxation well being Sense of Calm
• ?? HR ?? BP ?? RR
• ?? Muscle spasms ?? Sleep
• ?? Coordination Ataxia Mental Impairment
• Quick temper ?? Patience tolerance
• ?? Dose ?? Anxiety ? Sedation ? Coma ? Death

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Impaired Nursing Practice

• 1/8 Nurses are addicted impacts their practice.
• 1/5 are chemically dependent
• 45,000 Alcoholic RNs
• Narcotic addiction is 30x gt public
• 50-70 due to inadequate pain management for work
  related injury.
• Hx of ETOH or substance abuse in family.
• ?? Social stigma against female addicts

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Warning Signs of Abuse

• Poor judgment work performance
• Errors in charting ?? Pt. care
• ?Accidents/incidents during shift
• Inaccurate med counts
• ?? vial breakage waste
• Volunteers to work extra shifts give meds.
• ? Reports from Pt of unrelieved pain
• ?? Absenteeism (after many days off)
• Leaves floor frequently
• Spends ?? time in bathroom
• ETOH breath
• Flushed face
• Reddened eyes
• Unsteady Gait
• Hyperactivity
• Irritability/Apathetic

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Nursing Interventions

• Document RN behavior, Pt or medication incidents
  objectively.
• Approach colleague with compassion
• Express concern for her health and Pts safety.
• Remain in touch with colleague
• Notify supervisor to report impaired colleague
• Ethical legal obligation
• Facilitates RN to obtain EAP services, RX
• Protects the public!

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Peer Assistance Program PAP

• Established in 1982 by ANA
• RN voluntarily submits license during program (5
  years)
• Facilitates impaired nurses to recognize their
  illness.
• Maintain confidentiality obtain needed RX.
• Regain accountability within profession.
• Contract
• Method of RX, work guidelines, spot drug testing
  and quarterly evaluations.
• Work site monitor v progress during treatment.
• If unsuccessful refer to the State Board of
  Nursing,
• Office of Professional Discipline (OPD).
• Any Pt. harm or criminal charges
• Narcotics taken (Federal Law) theft of property
• FL 2009 Law
• Hx of abuse
• Unable to reapply for license for 15 years!

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Statewide Peer Assistance for Nurses (SPAN)

• Voluntary participation with PAP.
• SPAN Advocate
• Mentor maintains weekly contact for 11
  counseling and support.
• Weekly support group meetings
• With other impaired nurses.
• Open ended participation
• Encouraged to stay active c PAP program
• Evolve into sponsors for their colleagues.
• Terminated for non-participation
• PAP notified.