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Dual Diagnosis
Presence of substance abuse or dependency
AND a Mental Health Diagnosis (Axis I or Axis II)
50% of clients with severe mental illness also have substance abuse problems
Increases revolving door syndrome
– Crisis– Admission– Stabilization – Discharge– Substance abuse
Poor prognosis
Alcoholism
Along with heart disease and cancer
Ranks as one of the leading causes of death and disability in the United States
Premature death – 2 to 4 times higher
Homicides– 50% alcohol related
Suicides– 25% alcohol related
Accidental Death– 47% alcohol related
Drownings– 34% alcohol related
Falls– 28% alcohol related
Theories for Substance Dependence
Psychodynamic– Easily succumb to the
escape– More phobic– Stereotypical characteristic (the
result of alcoholism or the cause?) Feelings of Inferiority Dependency, low self-
esteem, introversion
Biological Theory– Genetic Predisposition
Children of alcoholics are at greater risk even when raised in an alcohol free environment
– Can take steps to minimize risk
Recognize family predisposition
Avoid the use of alcohol and drugs
Alcohol: Tolerance Disease and Respiratory Depression
Hepatic Function– Primary metabolism is in
the liver– Increased hepatic drug-
metabolizing enzymes Hasten alcohol metabolism
– Fat accumulates in the liver because it’s primary use is no longer for energy
– Alcohol accumulates in the liver increasing cell death
– Vitamins can not be activated
Respiratory Depression– Tolerance to Respiratory
depressing effects does not develop
– The more alcohol an individual drinks the more likely respiratory depression (regardless of needing more alcohol to get a buzz)
– Results in deaths of long-term pharmacodynamically tolerant drinkers
Alcohol: a Chemical BOMB!
Alcohol: – Unlike other drugs does not
mimic a single neurotransmitter– A small fat soluble molecule– Alcohol enters the cell
membrane of neurons– Changes the properties
Receptors are located on cell membranes
Cell membranes control the release of neurotransmitters
Alcohol– Unlike other drugs effects all
parts of the brain and all neurotransmitters
Some of the Neurotransmitters effected
– Glutamate Muscle relaxation,
discoordination and Black outs– Dopamine
Excitement and stimulation– GABA
Anxiety reduction– Endorphins
Kills pain and leads to endorphin”high”
Alcohol: The Central Nervous System
Cerebral Intoxication Depresses psychomotor activity Relieves anxiety and tension Increases ability to socialize Decreases self- imposed social
barriers
REBOUND: how it starts and ends
– First depresses psychomotor
activity relieves anxiety and tension
– Second effects wear off greater tension and anxiety rebound psychomotor activity
– Third drinker consumes more
alcohol to regain anxiety free state
– Presenting complaints Nervousness (anxiety) Depression
Alcohol and Medical Problems
The Liver– Decrease liver cell function
Increase in ammonia– High lab value – Hepatic encephalopathy
(brain damage) Increase in bilirubin Increase in female
hormones
Pancreatitis– Diabetes
Peripheral Nervous System– Thiamine deficiency
contributes to peripheral neuritis (paresthesia in distal extremities)
Wernecke- Korsakaff Syndrome
Cause: Malabsorption syndrome
– Irritation of the intestinal lining
– Deficiency in vitamin absorption
– Especially B vitamins and B1 (Thiamine)
Amnesia Delirium Peripheral neuropathy
Must replace Thiamine– Give parenterally at first
then orally– Delirium will become a
permanent Dementia if Thiamine remains deficient
Alcohol Withdrawal
Neuro: CNS irritation, tremulousness, nervousness, unsteady gait, difficulty concentrating. Exaggerated startle reflex
Alcohol Withdrawal
MH: Anxiety, sleep disturbance, craving for alcohol and other drugs, hallucinations. Delirium tremens (DTs)
GI: N&V diarrhea, anorexia
CV: tachycardia,
high BP, profuse perspiration
CIWA Clinical Institute Withdrawal
Assessment
Some of the CIWA measurements include: Pulse and blood pressure measurements Nausea and vomiting incidences including frequency and severity Tactile disturbances which have a wide range from feeling a pins and
needles sensation to itching to severe or continuous hallucinations Tremor severity, if any Visual and auditory disturbances Sweating Anxiety and agitation which may be noted from mild to serious panic
attack mode Orientation or disorientation levels
Each symptoms is scored and a TOTAL score can warrant prn medication
Medications: Alcohol
Withdrawal: Misery and Risk of Death
Medications to assist with symptoms:
– Clonidine (Catapress)– Thiamine (vitamin B1) – Lactulose
Decreases ammonia levels Medication is used to prevent
DTs and seizures:– Benzodiazepines
Chlordiazepoxide (Librium) Lorazepam (Ativan) Diazepam (Valuim)
– Disulfram (Antabuse) Aversive Therapy
– Will become ill if the person drinks
– Sweating, flushed face, N&V, dyspnea palpitations, dizzy weakness,
– Naltrexone hydrochloride (ReVia)
Opioid receptor antagonist Decreases pleasurable affects Must wear a medical alert
bracelet– Acomprosate (Campral)
Corrects the balance between neuronal inhibition and excitation altered by alcohol
Does not prevent relapse
Opioids (Narcotics)
Opium, Heroine Codeine hydromorphone
(Dilaudid) meperidine (Demerol) methadone (Dolophine) hydrocodone (Vicodin) oxycodone (Oxycontin)
Overdose: Opioids
Progressive symptoms:
1. Pinpoint pupils (mitosis)
2. Stuporous and sleeps
3. Skin is wet and warm
4. Coma and respiratory depression
5. Skin becomes cold and clammy
6. Pupils dilate
7. Death
Narcotic antagonist– Naloxone (Narcan)– Given IV push– Client responds in a few
minutes– May have to administer
again– Blocks neuroreceptors
Affected by opioids
Opioid Withdrawal
Withdrawal can be fatal if unassisted
Neuro: leg spasms (kicking the habit). Tremor, restlessness,
MH: Anxiety
Opioid Withdrawal
GI: diarrhea and vomiting
Other: yawning, rhinorrhea, sweating chills, piloerection (goose bumps), bone pain
Withdrawal from Opioids
Treated Symptomatically
Catapress (Clonidine) can be helpful
– Naltrexone hydrochloride (ReVia)
Opioid receptor antagonist
Decreases pleasurable affects
Must wear a medical alert bracelet
Inhalants
Cheap and readily available– Hydrocarbon solvents
Gasoline and glue– Aerosol propellants
Spray cans– Anesthetic gasses
Chloroform, nitrous oxide Death
– Amount inhaled can not be controlled
– Asphyxiation, suffocation and choking
Brain Damage– Frontal lobe– Cerebellar– Hippocampal
– Diminished problem solving– Ataxia– Dementia
Stimulants
Cocaine– Blocks dopamine re-uptake
Euphoria, alertness, Psychological dependence Increased strength Sexual stimulation
– Intense paranoia– Hypertension– Tachycardia (can cause death)– Decreased inhibitions
– Death: metabolic and respiratory acidosis; prolonged seizures
Crack– Less expensive way of using
cocaine
Methamphetamine
Epidemic Physical addiction Names: speed, meth,
crystal, crank or ice Longer high than
cocaine Causes anorexia and
insomnia
Rebound– Paranoid– Hallucinations– Violent rages
Long-term use– Damages Dopaminergic
system– Use to avoid feeling bad
Hallucinogens
Mescaline (peyote)– North American Native Indian
Religious practice protected by law
Taken orally– Action
Probably the norepinephrine synapses
Lasts 12 hours Psilocybin and Psilocin
(mushrooms)– Hallucinations– Hypertension– Increased temperature– Involuntary movements– Lasts 8 hours
Lysergic Acid Diethylamide (LSD)
– Binds to serotonin receptors– Causes a blending of senses
(smelling a color or tasting a sound)– Increase in blood pressure– Tachycardia– Trembling– Dilated pupils– Flashbacks
– Anxiety – Paranoia– Acute panic– Psychotic Breaks– Individuals have killed themselves
Marijuana
Delt-9- tetrahydrocannabinol (THC)
Varies in strength depending on soil conditions and climate
Changed to metabolites and stored in fatty tissue (remains in the body for 6 weeks)
Detected in blood and urine for 3 days to 4 weeks
Effects last 2 to 4 hours
Effects– Sense of well-being– Alters perception– Euphoria– Antiemetic– Impairs balance and
stability
– Problems Amotivational Bronchitis Memory impairment May increase anxiety
Effects on the Family
All family members are affected
Treatment for the family is important
Problems: Rescuing or Enabling
– Making excuses for the person addicted
– Doing things that the person should have done
– Lying
Family and Relapse
Co-dependent– Set of behaviors that maintain
the addiction– Does not hold the person
addicted responsible for their behavior
– Spouse may also be a child of an alcoholic and used to a certain pattern of behavior
– Takes on roles out of necessity (control)
– Behaviors are integrated and resistive to change
Difficult to alter when the individual stops using
Change– Hold the person who was
addicted responsible– Re-assign roles and
responsibilities within the family– Sacrifice of income
Change in job to be in a drug free environment
Decrease stress– Maintaining an alcohol and
drug free home
Assessment
Interview Approaches– Encourage Honesty
genuine concern for the client– Matter of Fact
Non-judgmental– Avoid words like:
Addict Alcoholic
– State: Problems with drinking Difficulties with drug use Using more than intended
Tools to Screen for Alcoholism– Michigan Alcohol Screening Test
(MAST)– CAGE Questionnaire
Inpatient Chemical Dependency Assessments every 4 hours or more often
– Form to complete which is quantified (given a score)
BP and heart rate are important Tremors, lacrimation, rhinorhea and
cravings– PRN medication is given based on
the score. – The Nurse is very busy with
assessments and administration of medications
The Nurse Patient Relationship
Attempts to address: Narcissistic DENIAL and Faulty Thinking
(Cognitive Distortions) i.e. better than others
– “I can do my job when drinking, when other people can not.”
– “I can stop after just one drink.” Tendency to break the rules:
– “I can have a drink and drive because I can handle it when others can not.”
The relationship with the alcohol or drug being the most important relationship
Ineffective behaviors increase the chance of relapse.
Establish trust by expressing empathy and providing a safe environment.
Assist in establishing new goals and directions.
Assist the client in identifying ineffective behaviors and replace with new coping skills.
Confrontation of DENIAL (telling the client what is observed and how it may differ from what is said)
Milieu Management
Observe and protect the environment
– Must remain drug-free– Suicide prevention– Intervening with aggression– Urine drug screens
Structured and predictable schedule
– Familiar and comfortable with structure
(i.e. plan their day in order to use alcohol or drug)
Confrontation of Behavior– Penetrate denial and
defensiveness– Requires Balance
Sensitivity to confront while protecting the client’s self esteem
Limit Setting– Manipulation and splitting can
occur (remember: the relationship
with the drug or alcohol is more important than other relationships)
12 Step Programs
Best Known– Alcoholics Anonymous (AA) – Narcotics Anonymous (NA)
Both Have a religious influence
Starts with:– Admitting powerlessness over alcohol (drugs)
The 12 Steps Confront Denial Narcissism Cognitive Distortions Problems with relationships
Relapse
Being around other users Severe Cravings Stopping attendance of AA or NA meetings
– Client does not meet the GOAL of attending 90 meetings in 90 days
GOAL: In 90 days the client will go to one meeting each day
Not expressing feelings Going through a major emotional crisis
Addiction and Health Care Professionals
Most common areas of employment: – Operating Room– Emergency Room– Intensive Care Unit– Many times these are our best and brightest
(cognitive distortion: I can do my job having taken this drug when others can not)
How do you know?– Client is still in pain after pain medication is given and documented– Narcotic medication count errors (hospitals checks statistics on
every nurse) What do you do when your colleague asks:
– I have been so busy. I already wasted that medication I did not use, do you mind witnessing it for me?
(remember: the relationship with the drug or alcohol is more important than other relationships)
Texas Peer Assistance Program for Nurses (TPAPN): GOALS
Identify nurses experiencing – mental health or– alcohol/drug problems
that have been or are likely to be job impairing. Assist these nurses in obtaining appropriate treatment. Monitor the nurse's return to the work force. Educate employers and nursing colleagues
– about the negative effects of addiction/mental illness in the work place – and the potential for rehabilitation and return to productive work.
http://www.texasnurses.org/displaycommon.cfm?an=1&subarticlenbr=107