Renee Franquiz MSN, RN

28 million Americans over the age of 12 years used drugs or etoh (13%)

17 million Americans over the age of 12 years abused (7%) – based on DSM-IV criteria

Highest prevalence was among white males, age 18-25, high school only education

Most highly abused substance was alcohol

Source: http://www.oas.samhsa.gov/nsduh.htm (US Dept of Health and Human Services)

In class we touched on some of the reasons illustrated below, and we spoke of social acceptance/indifference, peer pressure, role modeling, taboo makes it tempting, cultural norms, changes in family (supervision of children), access to information (internet), result of Rx treatment

Within the US 14% of adults have had an alcohol dependence or abuse problem at some time in their lives.

3% of individuals older that 12 years need treatment for drug use disorders.

DefinitionTo use in a

wrong or harmful way

DSM-IV Criteria (1 of the following in the past 12 months)Failure to fulfill role

obligationsPhysical hazard/InjuryLegal Issue(s)Behavior continues

despite an awareness that there is a problem

Definition Compulsive chronic

requirement where the need creates distress if unfulfilled

Often involves tolerance – which is an habituation – the increasing need for greater amount or more frequency

DSM-IV Criteria (3 of the following in the past 12 months) Tolerance Withdraw Symptoms A desire to Decrease Unsuccessful attempt

to decrease Increase time spent in

pursuit Sacrifice personal

Involvements Behavior continues

despite an awareness that there is a problem

PhysiologicalBiochemical – Substance combines with neurotransmitters to produce endogenous morphine, which becomes addictive

Biologic – Gene of predisposition Familial tendency, especially for etoh Supported by Twin Studies and

Adoption studies

PsychologicalDevelopmental – Stalled development at one of the stages (Freud, Erikson, Kholberg etc) predisposes to use/abuse

Personality – Individual traits predispose to use/abuse, such as low self-esteem, impulsiveness, inability to delay gratification, antisocial, depressive personality

SocialLearned– Bandura’s Social Learning

Theory. Modeling in the environment (family and peers) results in use/abuse

Operant Conditioning – Skinner, Pavlov Positive reinforcement from the pleasure aspect of use leads to repeat behavior

Cultural – Can fall under “Learned” and relates to etoh – reflected as Values, Norms, Customs and Beliefs of a particular culture

Reasons for use –previously covered

Significance ¼ all ER admits are

substance related 1/3 of all suicides are

substance related ½ of all Homicides

are substance related

PLEASE REVIEW ATI pages 154-157 Intended and Toxic

effects This is material that

will be tested on the exam

First examine and explore yourself How do you feel about drugs, alcohol, and

addiction? This may include reflecting on your own use, or

that of family and friends Negative attitudes about use may lead to disapproval,

intolerance, condemnation Positive attitudes about use may lead to enabling and

boundary issue Maintain Professionalism – your attitude either way

should not factor into the nurse-client relationship Empathy is a must

Anticipate the possibility of manipulation addiction creates a powerful need that if

unfulfilled, lead to significant client distress Pursuit of the substance may trump all

conventional thought

Assessment Review the general mental health history and

physical on pages 142 – 147 in Townsend

History should include Type, Route, Frequency, Amount of Substance

used Patterns of use and have they changed (Shift from

Use to Dependence) Date/Time of last use, abstinence hx (rehab),

withdraw sx Be sure to include

Have you ever used more than you wanted to?Have you wanted to change your use? Cut

down/stop?

Assessment Labs (Acute Evaluation)

Complete Blood Count (CBC) – Concerns for infection, anemia, thrombocytopenia

Complete Metabolic Panel (CMP) – Concerns for Electrolyte Imbalance, Liver Function, Nutritional Deficits

Urine Analysis (U/A) – Concerns for infection, Renal Impairment

Toxicology Screen – Can do as U/A or Blood Blood Alcohol Level (BAL) – Legal Limit 0.08%

(80g/dl)Unable to discharge client until BAL < 100g/dl,

unless they are being transported by someone else

Life Threatening BAL > 350 g/dl – 400g g/dl - All depends on the individuals tolerance

Assessment Tools Please familiarize yourself with these tools

TextbookMAST (Michigan Alcohol Screening Test)CIWA (Clinical Institute Withdraw Assessment)

ATIMAST (As Above)..\MAST.pdfAddiction Severity Index

..\Addiction Severity Index.pdfRecovery Attitude and Treatment Evaluator

(unable to provide d/t copyright – for purchase only)

Drug Abuse Screen Test (DAST)..\DAST.pdfCAGE-AID..\CAGE-AID.pdf

Analysis and Diagnosis Consider any Nursing Dx you have data to

support Due to the breath of impact that substance abuse

has, the list of nursing dx could be quite exhaustive (physical, psychological, social, cognitive)

Key Dx associated with Substance Abuse Ineffective Coping Denial Impaired Nutrition Risk for Injury Disturbed Thought Process Suicide You likely could add at least 10 more!

Analysis Consider that 50% of people with a serious mental

illness have a substance use disorder some time on their lives.

Disorders associated with substance abuse include: Acute and chronic cognitive impairment Attention deficit disorder Anxiety Borderline personalities Depression Eating disorders/compulsivity

Therefore, carefully consider Dual-Diagnosis when assessing a client with Substance Aubse

Plan Physiologic health and safety first – Prioritize

ABCs if applicable. Then move on to Psych/Soc

Aim of psycho-social treatment is self responsibility

Match the types of treatment with client needs: “Fit” between client and resource Type/Severity of addiction Age Physiologic Health Neuropsychological Health Location/ length of program and ability of client to

attend Finances

Implementation

Safety During the Acute Phase of Detoxification Close Observation – 1:1, usually with a UAP (High risk

for seizures, delirium (psychosis), falls, vomit/aspiration)

+/- Restraints - review restraint video in ATI online Frequent VS assessment – rapidly changing condition Safe Environment – Bed low, No objects in the room

that patient could harm themselves with or throw Seizure Precautions – Padded side rails, tongue blade,

Oxygen, Suction, IV access, PRN orders for antiepileptic drugs (usually Benzodiazepines)

Low Sensory Stimulation (Visual, Auditory, Tactile) Provide for foods, fluids, elimination

Self Help Step programs (AA, NA, GA, Al-Anon)

Peer Driven, Faith Based Emphasize Self Responsibility

Counseling Individual

Educate – About addictions, treatment goals Cognitive behavioral therapy Emphasize Self-Responsibility

Family Educate – About addictions, codependency, relapse Support groups

Groups Clients with similar diagnosis meet under the

supervision of a professional to discuss issues Inpatient or Outpatient

Psychopharmacology Alcohol Withdraw

Benzodiazepines – controls agitation and seizures Antiepileptics – Controls seizures Thiamine – Nutritional replacement Ensure IV access at all times

Alcohol Abstinence Antabuse – Inhibits ETOH metabolism,

Acetaldehyde accumulates and causes serious illness

Opioid Reversal Agent – Narcan (Action is immediate); No

concern if given and no narcotic on board Withdraw – Methadone, Buprenorphine (less side

effects than Methadone

Increased time in abstinence Decreased denial Acceptable occupational functioning Improved family relationships Ability to relate to other individuals

10-20% of practicing nurses are chemically dependent in their personal lives

Access to Controlled Substances presents opportunity/temptation

RN license is in jeopardy of suspension or revocation by the Board of Nursing

Signs Physical/Behavioral signs of impairment Work Absenteeism; Frequent breaks from the unit Missing Controlled Substances from the unit Abusers patients report poor pain control (abuser taking

the meds instead of administering) Abuser frequently offers to help other nurses and

medicate their patients (abuser takes the meds instead of administering)

Co-worker’s Responsibilities: Document Report facts to immediate supervisor Confront your co-worker – that’s a good discussion