chapter 17 substance abuse copyright © 2014 by mosby, an imprint of elsevier inc

Chapter 17

Substance Abuse

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Physical dependence Psychologic dependence Habituation Addiction

Substance Abuse: Leads to Dependence

2Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Opioids Stimulants

Methamphetamine Methylenedioxymethamphetamine (MDMA,

“ecstasy”) Cocaine

Depressants Benzodiazepines Barbiturates Marijuana

Commonly Abused Substances


Alcohol Anabolic steroids Dextromethorphan Lysergic acid diethylamide (LSD) Nicotine Phencyclidine (PCP)

Commonly Abused Substances


Opioids

opium heroin

(diacetylmorphine) morphine codeine hydromorphone

hydrocodone meperidine oxycodone propoxyphene methadone

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 5

Also known as narcotics Opium and heroin are Schedule I Most others are Schedule II because of their

high potential for abuse Often abused because of their ability to

produce euphoria

Opioids (cont’d)


Produce analgesia, drowsiness, euphoria, tranquility, other mood alterations

Affect areas outside the central nervous system (CNS) Skin, GI tract, GU tract

Normally used to: Relieve pain, reduce cough, relieve diarrhea, and

induce anesthesia

Opioids (cont’d)


Heroin Injected (“mainlining” or “skin popping”) Sniffed (“snorted”) Smoked

Causes a brief “rush,” followed by a few hours of a relaxed, contented state

Large doses can stop respirations Methadone

Opioids (cont’d)


Central nervous system Diuresis Miosis Convulsions Nausea, vomiting Respiratory depression

Opioids: Adverse Effects


Non–central nervous system Hypotension Constipation Urinary retention Flushing of the face, neck, and upper thorax Sweating, urticaria, and pruritus

Opioids: Adverse Effects (cont’d)


Peak period: 1 to 3 days Duration: 5 to 7 days Signs

Drug seeking, mydriasis, diaphoresis, rhinorrhea, lacrimation, diarrhea, elevated BP and pulse

Symptoms Intense desire for drug, muscle cramps, arthralgia,

anxiety, nausea, vomiting, malaise

Opioid Drug Withdrawal


Block opioid receptors so that use of opioid drugs does not produce euphoria

Naltrexone—an opioid antagonist Vivitrol—injectable form of naltrexone Naloxone combined with buprenorphine

(Subutrex) or used alone (Suboxone)

Opioid Drug Withdrawal: Treatment


Elevation of mood Reduction of fatigue Increased alertness Invigorated aggressiveness

Stimulants


Amphetamines Methamphetamine MDMA (“ecstasy”)

cocaine methylphenidate (Ritalin)

Stimulants


Stronger effects than other amphetamines Pill form Powder form: snorted or injected Crystallized form:

Also known as “ice,” “crystal,” “glass,” “crystal meth” Smokable More powerful Sales of over-the-counter (OTC) pseudoephedrine

are now regulated

Methamphetamine


Usually prepared in secret home laboratories More calming effects than other amphetamine

drugs Usually taken by pill “Raves”

Methylenedioxymethamphetamine (MDMA, “ecstasy,” or “E”)


From the leaves of the coca plant Snorted or injected intravenously Highly addictive—physical and psychologic

dependence Powdered form

Also called “dust,” “coke,” “snow,” “flake,” “blow,” “girl”

Crystallized form (smoked) Also called “crack,” “freebase rocks,” “rock”

Cocaine


Stimulants: Adverse Effects

CNS Restlessness Syncope (fainting) Tremor Hyperactive reflexes Talkativeness Irritability Insomnia Fever Euphoria

Confusion Aggression Increased libido Anxiety Delirium Paranoid

hallucinations Suicidal or homicidal

tendencies


Cardiovascular Headache Chilliness Pallor or flushing Palpitations Tachycardia Cardiac dysrhythmias Anginal pain Hypertension or hypotension Circulatory collapse




Gastronintestinal Dry mouth Metallic taste Anorexia Nausea Vomiting Diarrhea Abdominal cramps

Fatal hyperthermia


Death results from: Convulsions Coma Cerebral hemorrhage

May occur during periods of intoxication or withdrawal

Stimulant Overdose


Peak period: 1 to 3 days Duration: 5 to 7 days Signs

Social withdrawal, psychomotor retardation, hypersomnia, hyperphagia

Symptoms Depression, suicidal thoughts and behavior,

paranoid delusions No specific pharmacologic treatments

Stimulant Withdrawal


Drugs that relieve anxiety, irritability, and tension

Used to treat seizure disorders and induce anesthesia

Two main pharmacologic classes: Benzodiazepines (flunitrazepam) Barbiturates

Marijuana (“pot,” “grass,” “weed”)

Depressants


CNS Drowsiness, sedation, loss of coordination,

dizziness, blurred vision, headaches, and paradoxical reactions

Gastronintestinal Nausea, vomiting, constipation, dry mouth, and

abdominal cramping Pruritus and skin rash “Amotivational” syndrome

Depressants: Adverse Effects


Peak period 2 to 4 days for short-acting drugs 4 to 7 days for long-acting drugs

Duration 4 to 7 days for short-acting drugs 7 to 12 days for long-acting drugs

Signs Increased psychomotor activity; agitation;

hyperthermia; diaphoresis; delirium; convulsions; elevated BP, pulse rate, and temperature; others

Depressants Withdrawal


Symptoms Anxiety, depression, euphoria, incoherent thoughts,

hostility, grandiosity, disorientation, hallucinations, suicidal thoughts

Treatment involves tapering of the drug over a course of a 7 to 10 or 10 to 14 days

Depressants Withdrawal (cont’d)


Classroom Response Question

Which drug will the nurse anticipate administering to a patient experiencing benzodiazepine overdose?

A. flumazenil

B. naltrexone

C. Vivitrol

D. flunitrazepam


More accurately known as ethanol (ETOH) Causes CNS depression by dissolving in lipid

membranes in the CNS Few legitimate uses of ethanol and alcoholic

beverages Used as a solvent for many drugs

Alcohol (Ethanol)


CNS depression Respiratory stimulation or depression Vasodilation, producing warm, flushed skin Increased sweating Diuretic effects

Ethanol: Drug Effects


Nutritional and vitamin deficiencies (especially B vitamins) Wernicke’s encephalopathy Korsakoff’s psychosis Polyneuritis Nicotinic acid deficiency encephalopathy

Seizures Alcoholic hepatitis, progressing to cirrhosis Cardiomyopathy

Effects of Chronic Ethanol Ingestion


Fetal alcohol syndrome (FAS) Craniofacial abnormalities CNS dysfunction Prenatal and postnatal growth retardation

Effects of Chronic Ethanol Ingestion (cont’d)


Signs and symptoms Elevated blood pressure, pulse rate, and

temperature Insomnia Tremors Agitation

Classified as mild, moderate, and severe

Ethanol Withdrawal



A patient with a diagnosis of delirium tremens is admitted to the acute care facility. Which finding does the nurse expect upon assessment of the patient?

A. Hyperthermia

B. Hypotension

C. Bradycardia

D. Somnulence


Benzodiazepines are the treatment of choice diazepam (Valium), lorazepam (Ativan), or

chlordiazepoxide (Korsakoff’s psychosis) Dosage and frequency depend on severity

For severe withdrawal, monitoring in an intensive care unit is recommended

Ethanol Withdrawal Treatment


disulfiram (Antabuse) Acetaldehyde syndrome

naltrexone acamprosate (Campral)

Newest treatment Counseling

Individual Alcoholics Anonymous

Treatment for Alcoholism



Which statement does the nurse include when teaching a patient about disulfiram (Antabuse) therapy?

A.“Disulfiram (Antabuse) will cure your alcoholism if you take it as directed.”

B.“If you drink alcohol after taking disulfiram (Antabuse), your blood pressure will get very high.”

C.“You cannot drink alcohol for at least 3 or 4 days after taking disulfiram (Antabuse).”

D.“If you miss a dose of disulfiram (Antabuse), double the dose the next time it is due.”


Many smoke to “calm nerves” Releases epinephrine, which creates

physiologic stress rather than relaxation Tolerance develops Physical and psychologic dependency Withdrawal symptoms occur if stopped No therapeutic uses 200 known poisons present in cigarette smoke

Nicotine


Transient stimulation of autonomic ganglia Followed by more persistent depression of all

autonomic ganglia CNS and respiratory stimulation, followed by

CNS depression Increased heart rate and BP Increased bowel activity

Nicotine:Drug Effects


Manifested by cigarette craving Irritability, restlessness, decreased heart rate and BP

Cardiac symptoms resolve in 3 to 4 weeks, but cigarette craving may persist for months or years

Nicotine Withdrawal


Treatments provide nicotine without the carcinogens in tobacco : Nicotine transdermal system (patch) Nicotine polacrilex (gum) Inhalers Nasal spray

Nicotine Withdrawal Treatment


bupropion (Zyban) may be prescribed to aid in smoking cessation First nicotine-free prescription medicine to treat

nicotine dependence varenicline (Chantix)

Stimulates nicotine receptors

Nicotine Withdrawal Treatment



The nurse is explaining the differences between transdermal nicotine and nicotine gum programs. Which statement by the nurse is correct?

A. “The nicotine patch will give you quick relief from cravings.”

B. “Chewing the gum rapidly will release an immediate dose of nicotine.”

C. “It seems that patients have better treatment compliance with the gum than the patch.”

D. “The dose of nicotine in the gum is approximately twice the dose the average smoker receives in one cigarette.”


Assessments should include nonjudgmental and open-ended questions about substance abuse

Be observant for clues to substance abuse so as to avoid withdrawal symptoms

The most dangerous substances in terms of withdrawal are CNS depressants such as barbiturates, benzodiazepines, and alcohol

Establish therapeutic rapport, and use empathy toward the patient

Nursing Implications


Assessment tools for substance abuse CAGE Alcoholism Screening Test Adapted to

Include Drugs (CAGE-AID) Substance Abuse Subtle Screening Inventory

(SASSI) Michigan Alcoholism Screening Test Geriatric

version (MAST-G) Problem Oriented Screening Instrument for

Teenagers (POSIT)

Nursing Implications (cont’d)


Patient safety is of utmost importance at all times during patient care but especially when the patient is experiencing the signs and symptoms of withdrawal

Provide monitoring and support as needed throughout the withdrawal process

Educate the patient and family members or significant others about the recovery process

Emphasize that recovery is lifelong

Nursing Implications (cont’d)


chapter 17 substance abuse copyright © 2014 by mosby, an imprint of elsevier inc

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substance abuse copyright

euphoria opioids contd

pruritus opioids

anesthesia opioids contd

respiratory depression

malaise opioid drug

adverse effects contd