Chemical Dependency

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

Pharmacokinetic of Alcohol

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

Opioid: Heroine

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

The End