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402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
402 substance use lecture fall2011
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402 substance use lecture fall2011

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  • 1. 1SUBSTANCE USEDISORDERSN402/511 FALL 2011 Charon Burda MS,PMHNP-BC
  • 2. Healthy People 2020http://www.healthypeople.gov Overarching Goals:  Increase quality  Increase years of life  Eliminate health disparities Top 10 Leading Health Indicators/Focus Areas:  Mental Health & Mental Disorders  Substance Abuse
  • 3. Healthy People 2020:Substance Abusehttp://www.healthypeople.govSHORT TITLE ObjectiveAdverse ▼ Motor vehicle crashes/injuriesConsequences ▼ Cirrhosis deaths ▼ Drug-induced deaths ▼ Drug-related emergency dept. visits ▼ Alcohol-related emergency dept. visits ▼ Alcohol- & drug-related violence ▼ Lost productivitySubstance Use & ▲ Substance-free youthAbuse ▼ Adolescent & adult use of illicit substances ▼ Binge drinking ▼ Ave. annual alcohol consumption ▲ Low-risk drinking among adults ▼ Steroid & Inhalant Use-Adol.
  • 4. Healthy People 2020:Substance Abusehttp://www.healthypeople.govSHORT TITLE ObjectiveRisk ▲ Peer disapproval of substance use ▲ Perception of risk assoc. w/ sub. abuseTreatment ▼ Treatment gap for illicit drugs ▲ Treatment in correctional institutions ▲ Treatment for injection drug use ▼ Treatment gap for problem alcohol useState & Local Efforts Hospital emergency dept. referrals Community partnerships & coalitions Administrative license revocation laws Blood alcohol concentration (BAC) levels for motor vehicle drivers K. Fornili, Summer 2010
  • 5. DHHS: Agencies in RED = those with most influence on mental health and substance abuse serviceshttp://www.hhs.gov/about/index.html Administration for Children & Families (ACF) Administration on Aging (AoA) Agency for Healthcare Research & Quality (AHRQ) Agency for Toxic Substances & Dz. Registry (ATDSR) Centers for Disease Control and Prevention (CDC) Centers for Medicare and Medicaid (CMS) Food and Drug Administration (FDA) Health Resources & Services Administration (HRSA) Indian Health Services (IHS) National Institutes of Health (NIH) Substance Abuse & Mental Health Services Administration (SAMHSA) K. Fornili, Summer 2010
  • 6. National Institutes on Health: http://www.nih.gov/1. National Institute on Drug Abuse (NIDA) http://www.nida.nih.gov/2. National Institute for Alcoholism & Alcohol Abuse (NIAAA) http://www.niaaa.nih.gov/3. National Institute of Mental Health (NIMH) http://www.nimh.nih.gov/ K. Fornili, Summer 2010
  • 7. Statistics: National Center on Addiction and Substance Abuse at Columbia University 1 in 4 Americans will have an alcohol or drug problems at some point in their lives. The number of alcohol abusers and addicts holds steady at about 16 to 20 million. Half of college students binge drink and/or abuse other drugs and almost a quarter meet medical criteria for alcohol or drug dependence. In 2007, approximately 204,000 high-school seniors used marijuana on a daily basis. Substance abuse and addiction cost federal, state and local governments at least $467.7 billion in 2005. Girls and women become addicted to alcohol, nicotine and illegal and prescription drugs, and develop substance-related diseases at lower levels of use and in shorter periods of time than their male counterparts. Alcohol is involved in as many as 73 percent of all rapes and up to 70 percent of all incidents of domestic violence
  • 8. Substance Abuse among the Military, Veterans, and their Families ―The ongoing operations in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) continue to strain military personnel, returning veterans, and their families. Some have experienced long and multiple deployments, combat exposure, and physical injuries, as well as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). Prescription drug abuse doubled among U.S. military personnel from 2002 to 2005 and almost tripled between 2005 and 2008. Alcohol abuse is the most prevalent problem and one which poses a significant health risk. A study of Army soldiers screened 3 to 4 months after returning from deployment to Iraq showed that 27 percent met criteria for alcohol abuse and were at increased risk for related harmful behaviors (e.g., drinking and driving, using illicit drugs). And although soldiers frequently report alcohol concerns, few are referred to alcohol
  • 9. Drugs of abuse Nicotine Alcohol Marijuana (cannabis) Heroin/opiods Stimulants: Cocaine, Amphetamines, Methamphetamines Hallucinogens: LSD, mescaline, psilocybin Club drugs: MDMA (ecstacy) PCP Anabolic steroids Inhalants Prescription medications (opioid pain relievers, stimulants, CNS depressants/benzodiazepines)
  • 10. DSM-IV-TR Criteria – Substance Abuse10  A maladaptive pattern leading to significant distress or impairment with one or more of the following in a 12-month period:  Recurrent failure to fulfill major obligations  Recurrent physically hazardous behavior  Recurrent substance-related legal problems  Continued use despite social problems  Symptoms have never met dependence criteria
  • 11. DSM-IV-TR Criteria –11 Substance Dependence  Three or more of the following at the same time in a 12-month period:  Tolerance  Withdrawal  More ingested than intended  Desire or unsuccessful attempts to reduce use  Much time involved with substances  Reduced time spent on other important activities  Continued use despite physical or psychological problems
  • 12. • American Society of Addiction Medicine12 defines alcoholism as: Other Definitions of Addiction – A primary, chronic disease with genetic,psychosocial, and environmental factors influencing its development and manifestations. ---The disease is often progressive and fatal. It is characterized by continuous or periodic: impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.‖
  • 13. Etiology of Substance Use Disorders13  Pathologic condition characterized by measurable changes in physiology and neurobiology  Genetic predisposition in some individuals  Environmental precipitants
  • 14. Genetic Factors Associated With Alcohol Dependence14 • 3 to 4 times higher risk in close relatives of people with alcohol dependence. Higher risk associated with: – Greater number of affected relatives – Closer genetic relationships – Severity of alcohol-related problems in affected relative(s) • Significantly higher risk in monozygotic twin than dizygotic twin of a person with alcohol dependence • 3- to 4-fold increase in risk in adopted children with a natural parent who is alcohol dependent despite being raised by adoptive parents without the disorder (American Psychiatric Association, 2000.)
  • 15. NIDA: Addiction changes the brain
  • 16. Dopamine Reward Pathway The VTA-nucleus accumbens pathway is activated by all drugs of dependence including alcohol This pathway is important not only in drug dependence, but Nucleusaccumbens also in essential physiological behaviors such as eating, drinking, Ventral tegmental area sleeping, and sex (VTA)http://www.youtube.com/watch?v=at3Sg6qvgTE
  • 17. Our Role as Nurse17
  • 18. Therapeutic Alliance18  The therapist-patient relationship is a critical component of all treatment modalities  Work to establish a positive alliance at the beginning of treatment  Promote a positive therapeutic alliance  Minimize or avoid negative reactions  Avoid confrontation  Convey a high degree of empathy, confidence, and hope
  • 19. Underlying Principles: People are people first (not disorder); People are deserving of  Respect; and  Access to Services; Recovering people & their families need to be involved in their treatment & recovery; People can and do RECOVER;  Optimism is important;  Long-term support needed;• System philosophy should ensure that ―Any door is the right door‖;
  • 20. Underlying Principles:• Treatment plans should be client-centered & individualized;• Maximum feasible degree of integration: ―Least restrictive environment that best meets needs‖• Culturally competent services that match community’s diversity:  Age;  Gender & Sexual Preference;  Race & Ethnicity; INTEGRATED Mental Health and Addictions Treatment  Not sequential Summer 2010
  • 21.  1. ADDICTION IS FUNDAMENTALLY ABOUT COMPULSIVE BEHAVIOUR 2. COMPULSIVE DRUG SEEKING IS INITIATED OUTSIDE OF CONSCIOUSNESS 3. ADDICTION IS ABOUT 50%HERITABLE AND COMPLEXITYABOUNDS 4. MOST PEOPLE WITH ADDICTIONS WHO PRESENT FOR HELP HAVE OTHER PSYCHIATRIC PROBLEMS AS WELL 5. ADDICTION IS A CHRONIC RELAPSING DISORDER IN THE MAJORITY OF PEOPLE WHO PRESENT FOR HELP
  • 22. 10 things con’t 6. DIFFERENT PSYCHOTHERAPIES APPEAR TO PRODUCE SIMILAR TREATMENT OUTCOMES 7. ‘COME BACK WHEN YOU’RE MOTIVATED’ IS NO LONGER AN ACCEPTABLE THERAPEUTIC RESPONSE 8. THE MORE INDIVIDUALIZED AND BROAD-BASED THE TREATMENT A PERSON WITH ADDICTION RECEIVES, THE BETTER THE OUTCOME 9. EPIPHANIES ARE HARD TO MANUFACTURE 10. CHANGE TAKES TIME
  • 23. Screening and Assessment23
  • 24. At-Risk Drinking24 Per WeekPer Occasion Men >14 drinks >4 drinks Women >7 drinks >3 drinks Elders >7 drinks >1 drink
  • 25. CAGE25  Have you ever felt you ought to Cut Down on your drinking?  Have people Annoyed you by criticizing your drinking.  Have you ever felt bad or Guilty about your drinking  Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang over (Eye-Opener)  * one or more yes responses are indicative of problem drinking and further screening should be done
  • 26. Single Alcohol Screening Question26  When was the last time you had more than …  Women: 4 drinks in one day?  Men: 5 drinks in one day?  Positive response = within the past 3 months  Sensitivity and specificity are 86% for hazardous drinking, alcohol abuse, or alcohol dependenceVinson, 2000; Vinson, (Williams & 2004)
  • 27. Assessment27 Quantity and frequency of alcohol use Other drug use: benzos, opioids, street drugs (pot and cocaine), OTC drugs Consequences of Use: family, health, legal, work, driving while impaired Co-occurring disorders: depression, anxiety, psychosis, suicide, PTSDT Withdrawal symptoms: anxiety, tremor, hand shake. ―Does a drink make you feel better.‖ Hx of seizures Previous treatment attempts. What worked? What didn’t work? Readiness to change
  • 28. Physical Assessment & Exam 28 BEHAVIORAL: Hyperactivity, anxiety, aggressive violent behavior, paranoia, grandiosity, euphoria, reduced inhibition, drowsiness, sedation COGNITIVE: memory and learning impairment Decreased concentration, impaired judgment• SKIN: Tracking (needle marks, local abscesses• (MRSA), scars from previous abscesses, wound botulism, jaundice, rhinophyma, palmer erythema, cigarette burns, spider nevi• HEENT: Evidence of head trauma, conju.• nctivitis, constricted pupils, nasal irritation, erosion or abscess of nasal septum, periodontal disease, hoarseness, swollen parotids, alcohol on breathMuhrer, JC.,(2010).Detecting and Dealing with Substance Abuse Disorders in Primary Care. The Journal for Nurse Practitioners 6(8) September 2010. 597-604
  • 29. Physical Assessment29 CARDIOVASCULAR: Murmur (cardiomyopathy), arrhythmias, severe hypertension, findings of subacute bacterial endocarditis PULMONARY: Tachypnea, signs of pneumonia (community acquired aspiration) COPD, clubbing CHEST: Gynecomastia Abdomen: Hepatomegaly, ascites, epigastric tenderness, heme positive stools, signs of pancreatitis GENITOURINARY: decreased testicular size MUSCULOSKELETAL: Red, swollen joints, gout, septic arthritis, SXS osteomyelitis, skeletal infections in unusual locations (sternoclavicular, vertebral) fractures NEUROLOGICAL: slurred speech, impaired motor coordination , tremor, slowed reflexes, peripheral neuropathy, evidence of stroke Muhrer, JC.,(2010).Detecting and Dealing with Substance Abuse Disorders in Primary Care. The Journal for Nurse Practitioners 6(8) September 2010. 597-604.
  • 30. Lab testing for substance30 abuse  BAC- blood alcohol  How long substances can be detected: content (range is 0-  * Alcohol: 3 to 10 hours 500)  * Amphetamines: 24 to 48 hours * Barbiturates: up to 6 weeks  Toxicology screen-  * Benzodiazepines: up to 6 urine  weeks  * Cocaine: 2 to 4 days; up to 10 to 22 days with heavy use  * Codeine: 1 to 2 days  * Heroin: 1 to 2 days  * Hydromorphone: 1 to 2 days  * Methadone: 2 to 3 days  * Morphine: 1 to 2 days  * Phencyclidine (PCP): 1 to 8 days  * Tetrahydrocannabinol (THC): 6
  • 31. Stages of change and motivationalinterviewing Stages of change:  Motivational Precontemplation interviewing: Contemplation  Helps patients move further along the continuum of Preparation change (e.g., from believing Action they have no problem, to considering making a change, Maintenance to actually making changes, to maintaining those changes)  Focused on internally motivated change  Non confrontational style  Help patients resolve ambivalence about stopping substance use
  • 32. SBIRT  キSBIRT stands for Screening, Brief Intervention, Referral to Treatment.  キSBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for people with substance use disorders and those at-risk of developing them.  キPrimary care, trauma centers, emergency departments, and other health care settings provide opportunities to intervene BEFORE more severe consequences of substance misuse occur.  Source: U Maryland School of Medicine http://www.youtube.com/watch?v=orChO5Pbuoc&feature=related http://www.youtube.com/watch?v=J-acGrReypg&feature=related
  • 33. INTOXICATION AND WITHDRAWAL The nurse should be able to recognize the signs and symptoms of: substance INTOXICATION and substance WITHDRAWAL And the nursing management of both conditions
  • 34. AlcoholAlcohol Beer, wine, liquor, etc.MOA Effects of relaxation by stimulating the GABA receptors.Effect Sedation, decreased inhibition, relaxation, slurred speech, nauseaOverdose effect respiratory depression, cardiac arrestWithdrawal effect Tremors, increased temp, pulse, blood pressure, delirium tremensProlonged Effect Weight loss, malnutrition, paranoid ideation, thought disturbance, stereotypical movements, amnestic disorder (Wernicke’s syndrome & Korsakoff’s psychosis) Alcohol destroys brain cells, particularly binge drinking.
  • 35. Pharmacologic Treatment ofAlcohol Withdrawal Medications Purpose Benzodiazepines (Ativan, Administered when elevated HR, BP, T, Valium; Librium) presence of Tremors to prevent delirium tremens. Disulfiram (Antabuse) Deters individuals from drinking by causing aversive reactions Acamprosate Deters individuals from drinking by decreasing cravings
  • 36. OpiatesOpiates Heroin and prescription narcoticsMOA Stimulate opioid receptorsEffect produce analgesia, euphoria, relaxation, constipation, constricted pupilsOverdose effect Overdose can lead to respiratory depression, coma and death. Antidote Narcan.Withdrawal very uncomfortable and includes flu like symptoms, effect anorexia, stuffy or runny nose, dilated pupils (photophobia), piloerection and intense cravings.Prolonged Effect Criminal behavior to obtain drugs, risk infection related to needle use
  • 37. Pharmacologic Management ofOpioid withdrawal Opioid substitution  Methadone (Agonist)  Buprenorphine (Partial Agonist) Naltrexone (Antagonist) Non-Opioid Symptom Relief  Clonidine (tremor, agitation)  Dicyclomine (GI symptoms)  Cyclobenzaprine (muscle cramps)
  • 38. Sedatives, Hypnotics,Anxiolytics Sedatives, hypnotics, Barbituates: amytal, Nembutal, seconal, anxiolytics phenobarbital; Benzo’s: Ativan, Xanax, etc. MOA Stimulating the GABA receptors Effect Euphoria, sedation, reduced libido, emotional lability, impaired judgement Overdose effect Respiratory depression, cardiac arrest Withdrawal effect Anxiety rebound and agitation, hypertension, tachycardia, sweating, hyperpyrexia, insomnia, delirium, seizure Prolonged Effect Often used with alcohol/ risk infection related to needle use
  • 39. StimulantsStimulants amphetamines, methamphetamine and cocaine.MOA Stimulate dopamine and norepinephrine receptors.Effect heightened attention, euphoria, energy; decreased apetite, insomnia, dilated pupils, tremors, paranoia, aggressiveness, Physiologically depress appetite and cause increased T,HR and BP.Overdose effect Cardiac arrhythmias/arrest, increased or decreased BP, respiratory depression, seizure, psychosis, coma, deathWithdrawal Withdrawal symptoms very uncomfortable and caneffect precipitate acute depressive episode and suicidal ideation.Prolonged Effect Methamphetamine damages dopamine axons resulting in significant defects in thinking, cognitive functions and motor skills.
  • 40. Hallucinogens Hallucinogens LSD, Club Drugs (ecstasy+/-, GHB, psilocybin, mescaline MOA Stimulate serotonin receptors and cause distorted perception and heightened sense of awareness Effect illusions and hallucinations. Mood and judgment impaired. Physical effects include increased T, HR and BP. Overdose effect Hallucinations, paranoia, psychosis, aggression, CVA, seizures, malignant hyperthermia Withdrawal No known effect Prolonged Effect Flashbacks after termination of use
  • 41. InhalantsInhalants Includes any chemical that can be inhaled such as household cleaners, gas, solvents, glue, automotive and industrial agents, aerosol spraysMOAEffect Causes short term sense of dizziness, euphoria and altered sensation. O2 deprivationOverdose effect CNS Depression, coma, convulsionsWithdrawal Similar to alcohol but milder ie. Anxiety, tremors, effect hallucinations, and sleep disturbanceProlonged Effect serious and permanent neurological damage and death.
  • 42. Treatment42 23.48 million Americans needed treatment in 2004 (National Survey on Drug Use and Health, 2004)
  • 43. Access to Treatment43 2.33 million (9.9%) received treatment 440,000 (1.9%) tried but could not get treatment 19.92 million (84.8%) felt 790,000 (3.4%) did not no need for treatment try to get treatment
  • 44. Goals of Treatment44  Engage, motivate, and retain the patient in treatment  Provide education about addiction  Reduce intensity and frequency of substance use  Prevent relapse to substance use  Improve areas of life affected by addiction (e.g., employment, interpersonal relationships)  Improve the patient’s quality of life
  • 45. Evaluating Treatment Outcome45  Abstinence should not be the only measure  Harm or Symptom Reduction in  Substance Use  Physical health  Occupational functioning  Interpersonal functioning  Legal problems, public health and safety  Overall Quality of Life  Improvement in comorbid psychiatric disorders  Patient satisfaction and quality of life
  • 46. Treatment Modalities46 PSYCHOTHERAPY AND SELF-HELP APPROACHES • Individual Psychotherapy • Group Psychotherapy • Cognitive Behavioral Therapy • Alcoholics Anonymous and Twelve-Step Groups • Motivational Enhancement Therapy and Motivational Interviewing • Family Therapy • Psychodynamic Therapy • Pharmacotherapy
  • 47. Treatment facilities inMaryland http://maryland-adaa.org/resource/
  • 48. AA and Twelve-Step Groups48  Founded in 1935  A worldwide organization with over 2.2 million members  Structured around the Twelve Steps  Peer-led  Only requirement to join is a desire to stop drinking  There are similar groups nationwide for other substances and issues (e.g., Cocaine Anonymous, Narcotics Anonymous, Overeaters Anonymous, Gamblers Anonymous, Nicotine Anonymous)
  • 49. AA and Twelve-Step Groups49  Advantages:  Disdvantages:  Social peer support network Group members may insist on  Free abstinence as only measure  Offered in most urban and of success suburban areas  Meeting held several times per day/week Group members may  Sponsor system available 24 discourage psychotropic hours/day medication for co-occurring  WEBSITE to find meetings disorders and other information: http://www.alcoholics- anonymous.org
  • 50. FDA-Approved Pharmacotherapies for Alcohol Dependence50  Inhibits aldehyde dehydrogenase Disulfiram (Antabuse®)  When alcohol consumed, results in nausea, dizziness, headache, flushing  Decreases desire to drink  Poor tolerability profile, low efficacy Naltrexone (ReVia®)  Opioid antagonist  Binds to opioid receptors, thus blocking alcohol reward pathways  Black box warning regarding hepatotoxicity FDA = US Food and Drug Administration. Antabuse is a registered trademark of Odyssey Pharmaceuticals, Inc. ReVia is a registered trademark of the DuPont Merck Pharmaceutical Company (O’Connor, 1998.)
  • 51. FDA-Approved Pharmacotherapies for Alcohol Dependence51 Acamprosate (Campral®)  Indicated for maintenance of abstinence from alcohol in patients abstinent at treatment initiation  Renally cleared; contraindicated in severe renal disease FDA = US Food and Drug Administration. Campral is a registered trademark of Merck Santé
  • 52. Methadone maintenance (heroin/opioid dependence)52  Methadone t1/2 = 24-46 hours- once a day dosing possible Good oral bioavailability • 45-90% of patients in treatment for one year discontinue illicit opioid use (J Health Sci Behav 29:214-226, 1988)
  • 53. The Role of Buprenorphine53 in Opioid Treatment  Partial Opioid Agonist  Produces a ceiling effect at higher doses  Has effects of typical opioid agonists—these effects are dose dependent up to a limit  Binds strongly to opiate receptor and is long- acting  Safe and effective therapy for opioid maintenance and detoxification
  • 54. Drugs and alcohol kill

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