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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?
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
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)
Signs of Impaired Nursing PracticeJob 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
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
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
Prevalence of Substance-Related Disorders
Alcohol abuse– Males– Females
Substance Other drug
dependency
16% 29% 6% 18% 9%
Prevalence Disorder
Dahme, 1998
Classes of Substances with Potential for Abuse and Dependence
Alcohol Amphetamine Caffeine Cannabis Cocaine Hallucinogens
Inhalants Nicotine Opiods Phencyclidines
(PCP) Sedative,
hypnotic,or antianxiety agents
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
Psychoactive Substances
Drugs or chemicals which alter one or several of:– Perception– Awareness– Consciousness– Thinking– Judgment– Decision making– Insight– Mood– Behavior
Etiological Theories: Substance AbuseBiological 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)
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
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
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
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)
Key Terms cont. Abuse--Excessive use of a substance that
differs from societal norms Codependency--stress-related preoccupation
with an addicted person’s 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
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
Cognitive Framework: Assessing Denial Is it denial?
No ReassessIs it a problem? Yes
Yes No Do nothing
How is it a problem?
What cognitions are in conflict?
What are alternative means of reducing dissonance?
Forchuk & Westwell, 1987
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, Jehovah’s Witness,
and Mormons) China and Japan lower prevalence-negative
physiological response Native Americans & Eskimos rates US rates similar to northern European countries
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 person’s behavior, finishing the work of a colleague who is unable to function.
CAGE Screening Test Alcoholism1. 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
Alcohol Withdrawal Symptoms: First 24 hours
Within a few hours, peaks within 24 hrs. Anxiety Insomnia Irritability “Internal shaking” BP, P, diaphoresis
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
Wernicke’s Syndrome & Korsakoff’s Disease
Nutritional disorders related to alcoholism Thiamine deficiency Both treated with withdrawal from alcohol
and vitamin supplements. Improvement can occur in Wernicke’s
syndrome, some degree of intellectual and emotional impairment remains.
Memory impairment is residual in Korsakoff’s even when slight improvement occurs
Wernicke’s 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, Korsakoff’s Disease may develop
Korsakoff’s Disease
Niacin deficiency in addition to thiamine Degeneration of cerebrum and
peripheral nerves Characterized by amnesia,
confabulation, disorientation, and peripheral neuropathy
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-Wenicke’s Syndrome
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
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 situationsCompton, 1989
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
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
Interventions Alcohol Abuse AA Self-Help Brief Interventions
– Feedback– Responsibility– Advice– Menu– Empathy– Self-efficacy
Moderation-Online Self-Help Motivational interviewing
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
Antecedents to Relapse
Event Cocaine Alcohol
Being around users 87% 40%
Severe craving 67% 25%
Stopping AA/NA 48% 75%
Not expressingfeelings
20% 75%
Major emotionalcrisis
33% 50%
Keltner, p. 538
Stages of Change: Addictive Behaviors
Relapse
Precontemplation
Contemplation
Preparation
Action
Maintenance
Permanent Exit
Prochaska & DiClemente, 1992
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
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
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
Examples of Dual Diagnoses
Axis I Schizophrenia
Alcohol abuse Axis I Major depression
Anxiolytic dependency Axis I Major Depression
Marijuana abuse
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
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
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