Mental health & crisis management 7 APRIL qui z

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Substance related disorders Dual Diagnosis Concurrent disorders

Week 10

Key Terms

Use

Drinks alcohol, swallows, smokes, sniffs or injects

Abuse-harmful use

Using a legal/illegal substance in the not prescribed way/not intended way

Dependence

Use despite adverse consequences

Addiction

A chronic often relapsing brain disease that causes compulsive substance seeking and use

Withdrawal

Adverse physical and psychological symptoms that occur when use has stopped

Detoxification

Process of safely and effectively withdrawing a person from an addictive substance

Relapse

Recurrence of alcohol- or drug- dependent behaviour in person who had previously been abstinent

Intoxication

The development of aa reversible substance-specific syndrome due to the recent ingestion of (or exposure to) a substance

Clarification: Addiction/Substance use disorder interchangeable*

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Herie, M., Godden, T., Shenfield, J. & Kelly, C. (2010). Addiction an information guide. Retrieved from https://www.camh.ca/-/media/files/guides-and-publications/addiction-guide-en.pdf?la=en&hash=F1BFB1ED194D54A9FCF892116BFE745818169A56

Introduction – What is addiction/ substance use disorder?

Link: https://www.youtube.com/watch?v=LNk8J5AFsFg

Addiction

The term “addiction” is commonly used in such a “vague way”, there have been many attempts to define it more clearly

The following provides a good definition for addiction

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors. . . . It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving (Savage et al., 2003)

Source: Herie, M., Godden, T., Shenfield, J. & Kelly, C. (2010). Addiction an information guide. Retrieved from https://www.camh.ca/-/media/files/guides-and-publications/addiction-guide-en.pdf?la=en&hash=F1BFB1ED194D54A9FCF892116BFE745818169A56

Distinguishing Between an Addiction and Compulsive Behaviour

Addiction must include three elements:

biological, psychological, and social (see Figure 18.1)

Compulsive behaviours do not have the biological element,

only the psychological and the social

Without the biological risk different concerns for policy and practice are present

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

The Process of Addiction Development

Addiction development

No contact

Experimentation

Integrated use

Excessive use

Addiction (with features of tolerance and withdrawal)

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Substance Classifications

Alcohol

Caffeine

Cannabis

Hallucinogens

Inhalants

Opioids

Sedatives

Hypnotics

Anxiolytics

Tobacco

Other substances

Epidemiology

Prevalence of alcohol use for Canadians over age 15 years is 78%

Drug use by youth 15 to 24 years of age is higher than for adults 25 years and over

Binge drinking among Canadian men is ranked as the highest in the world

Of the three categories of pharmaceuticals, opioid pain relievers were the most commonly used in 2017

Overall smoking prevalence has fallen to 15% of the population

The rate of death due to alcohol for Indigenous people in Canada is twice that of the general population

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Epidemiology/ Comorbidity

The combination of a psychiatric comorbidity and substance use disorder is called a concurrent disorder

Of those with Anxiety Disorders, 24% have concurrent substance use disorders

27% of people with Major Depressive Disorder have concurrent disorders

47% of those with Schizophrenia have concurrent disorders

56% of those with Bipolar Disorders experience a concurrent disorder

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Medical Comorbidities

Wernicke’s (alcoholic) encephalopathy: an acute and reversible condition

Korsakoff’s syndrome: a chronic condition with a recovery rate of only about 20%

Fetal Alcohol Spectrum Disorder

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Etiology

Characterized by use, abuse, and physical and psychological dependence, and also by certain behaviours:

Loss of control of substance consumption

Continued substance use despite associated problems

Cravings and a tendency to relapse after efforts to change behaviour

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

The Brain & Addiction

The most complex body organ, the brain, is impacted by substance use in 3 central areas:

The brain stem

This controls basic bodily functions, including breathing, sleeping, and heart rate

The cerebral cortex

This controls executive functions, such as decision-making, planning, and sensory information processing

The limbic system

This is the body’s emotional reward circuitry and controls our ability to experience pleasure and motivation for survival sustaining activities, which is activated by drugs of abuse (NIDA, 2014)

Source: Drugabuse.com. (2013). What causes addiction? Retrieved from https://drugabuse.com/causes-of-addiction

Neurotransmitters

The main systems that seem to be involved in substance abuse are the endorphin, catecholamine (especially dopamine), serotonin, endocannabinoid, and GABA systems

Cocaine, amphetamines, and lesser stimulants increase levels of norepinephrine, serotonin, and dopamine

Opioid drugs act on endorphin receptors with a secondary effect on dopamine

Alcohol and other CNS depressants will act on GABA receptors and, as a result, increase the bioavailability of glutamate, norepinephrine, and dopamine

Hallucinogens act to varying degrees on serotonin, whereas marijuana acts on endocannabinoids

Dopamine

The brain registers all pleasures in the same way, whether they originate with a psychoactive drug, a monetary reward, or a satisfying meal

In the brain, pleasure has a distinct signature: the release of the neurotransmitter dopamine in the nucleus accumbens, a cluster of nerve cells lying underneath the cerebral cortex (see illustration)

Dopamine release in the nucleus accumbens is so consistently tied with pleasure that neuroscientists refer to the region as the brain’s pleasure center

Source: Drugabuse.com. (2013). What causes addiction? Retrieved from https://drugabuse.com/causes-of-addiction

Helpguide.org. (2019). Understanding addiction: How addiction hijacks your brain. Retrieved from https://www.helpguide.org/harvard/how-addiction-hijacks-the-brain.htm

Dopamine

All drugs of abuse, from nicotine to heroin, cause a particularly powerful surge of dopamine in the nucleus accumbens

Addictive drugs provide a shortcut to the brain’s reward system by flooding the nucleus accumbens with dopamine

The hippocampus provides memories of this rapid sense of satisfaction, and the amygdala creates a conditioned response to certain stimuli

Source: Drugabuse.com. (2013). What causes addiction? Retrieved from https://drugabuse.com/causes-of-addiction

Helpguide.org. (2019). Understanding addiction: How addiction hijacks your brain. Retrieved from https://www.helpguide.org/harvard/how-addiction-hijacks-the-brain.htm

Tolerance

Over time, of using substances the brain adapts in a way that actually makes the sought-after substance or activity less pleasurable

Addictive drugs and behaviors provide a shortcut, flooding the brain with dopamine and other neurotransmitters

Addictive drugs, for example, can release 2 to 10 times the amount of dopamine that natural rewards do, and they do it more quickly and more reliably

In a person who becomes addicted, brain receptors become overwhelmed

Source: Helpguide.org. (2019). Understanding addiction: How addiction hijacks your brain. Retrieved from https://www.helpguide.org/harvard/how-addiction-hijacks-the-brain.htm

Tolerance

The brain responds by producing less dopamine or eliminating dopamine receptors—an adaptation similar to turning the volume down on a loudspeaker when noise becomes too loud

As a result of these adaptations, dopamine has less impact on the brain’s reward center

People who develop an addiction find that, in time, the desired substance no longer gives as much pleasure

Therefore, take more of it to obtain the same dopamine “high” because the brain has adapted—an effect known as tolerance

Source: Helpguide.org. (2019). Understanding addiction: How addiction hijacks your brain. Retrieved from https://www.helpguide.org/harvard/how-addiction-hijacks-the-brain.htm

Psychological factors

Fundamental to this perspective is the belief that people will repeat any behaviour that brings pleasure or reward and will discontinue any behaviour that brings them discomfort or punishment

If a drug brings pleasure or relief in a stressful situation, reduces anxiety or fear, or provides status or popularity in an insecure or lonely situation, its use will become a repeated behaviour

This is what the treatment process attempts to accomplish in terminating an individual's misuse or abuse of a substance

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Psychological factors

Another prominent psychological theory is personality theory

Human personality traits have been grouped into five categories: extraversion, agreeableness, conscientiousness, emotional stability and openness to experience

Of these five, it is the extraversion trait that has been most closely associated with excessive substance use, particularly the attribute of impulsivity

The literature generally shows personality does not predict illness, with research continuing in this area

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Psychological factors

A third long-established psychological perspective on addiction is based in psychodynamic theory

This view arises from the early work of Freud, although Freud, himself, did not devote much attention to addiction in his extensive writings, despite his own drug dependency to tobacco and cocaine

Freud stated that alcoholism may be due to the inability to successfully resolve issues among the three components of the self: the id or instinctual striving for at times pleasure and at other times pain relief, the superego or conscience, and the ego or coping component of the person

Failure of the ego to resolve issues between conscience and basic instincts can lead to maladaptive coping responses, including use of psychoactive drugs

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Psychological factors

A fourth perspective is attachment theory, which focuses on long-term emotional bonds

The core idea of attachment theory is that primary caregivers who are available and responsive to an infant's needs allow the child to develop a sense of security, which some label as love, enabling the child to explore their environment in a confident manner, knowing that they are protected

Children who are securely attached as infants tend to develop stronger self-esteem and are more sociable and self-reliant as they grow older

Attachment theory views addiction as an attempt to fill the empty space left by the lack of a secure attachment due to deprivation during childhood, including painful, rejecting, or shaming relationships

Excessive drug use, then, is seen as an individual's attempt to self-repair psychological deficits and fill an emptiness from childhood

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Common question: Why do people keep ‘using’?

Substance use/ abuse can be hard to change

One thing that makes change so difficult is that the immediate effects of substance use tend to be positive

People may feel good, have more confidence and forget about problems

People may come to rely on the effects of substances to bring short-term relief from difficult or painful feelings

Biological and psychological

theories combined

Common question: Why do people keep ‘using’?

The effects of substances can make problems seem less important, or make it seem easier to talk and to be with others

People may come to believe that they cannot function or make it through the day without a particular substance

Continued substance use, especially heavy use, can cause changes in the body and brain. If people develop physical dependence and then stop using, they may experience distressing symptoms of withdrawal

Biological and psychological

theories combined

PICTURE: http://www.bing.com/images/search?view=detailV2&id=1FCC36EFC65069422FAD141F6FA29517BBA98F8D&thid=OIP.yl-O3Ej977f5epjkTI_p-QHaFb&mediaurl=http%3A%2F%2Fwww.soulshepherding.org%2Fwp-content%2Fuploads%2F2010%2F05%2FCycle-of-Addiction.png&exph=889&expw=1214&q=addiction+cycle&selectedindex=0&adlt=strict&ajaxhist=0&vt=0

Clinical course of addiction

Research suggests, most patients struggling with addictions will have one or more relapses during their process of recovery

Substance related reminders: smells, sounds, sights, or thoughts

Treatments focus on identifying triggers and possible reasons for current cravings and using this as an outcome measure to signal of possible relapse

Highly stigmatized!

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Personal reflection

What stigmas are attached to addiction?

PICTURE: http://www.bing.com/images/search?view=detailV2&id=E8B7D5DD9E96C127FB684808D394466DF1524AD2&thid=OIP.4rzKxRYkDqmLu6_KgAydoAHaFj&mediaurl=http%3A%2F%2Fmooc.employid.eu%2Fwp-content%2Fuploads%2F2017%2F03%2FReflection.jpg&exph=768&expw=1024&q=personal+reflection&selectedindex=6&adlt=strict&ajaxhist=0&vt=0&eim=1,6

Stigma of addiction/ substance use

Stigma is another reason why the rates of substance use problems may be higher than studies suggest

Stigma marks substance use problems as “shameful” and makes people want to hide their addiction

Stigma also affects the families of people with addiction

It makes them hide the problem or pretend it isn’t there at a time when families need support

What can we do about stigma?

One simple way you can help is to choose to talk about “people with substance use problems” rather than about “addicts,” “alcoholics,” “junkies”

Try this approach whether you are talking about another person or about yourself

When you do this, you put the person ahead of the problem

You are giving the person with an addiction the support and understanding it takes to recover

Application of the nursing process

Application of the Nursing Process

Screening

CAGE

Acute Withdrawal Assessment

Clinical Institute Withdrawal for Alcohol (CIWA-AR)

Clinical Opiate Withdrawal Score (COWS)

Family assessment

Codependence

Self-assessment

Assessment

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

CAGE screening

The four questions to be asked in the screening process are remembered by the mnemonic CAGE:

Have you felt you ought to Cut down on your drinking, substance use, or behaviour?

Have people Annoyed you by criticizing your drinking, substance use, or behaviour?

Have you felt Guilty about your drinking, substance use, or behaviour?

Have you had a drink (or used another substance or behaviour) first thing in the morning to steady your nerves or get yourself going for the day (an Eye-opener)?

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Acute Assessment Process

Assess for:

Acute intoxication

Severe or major withdrawal syndrome

Overdose of a drug or alcohol that warrants immediate medical attention

Suicidal thoughts or other self-destructive behaviours

Physical complications related to drug abuse

Motivation to change

Knowledge of community resources for alcohol and drug treatment

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Assessment of Readiness to Change

The Transtheoretical Model of Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Nursing diagnosis

Outcomes identification

Planning

Identifying problem

Setting a goal

Determining the interventions that will accomplish the goal

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Implementation - care continuum for substance abuse

Detoxification (detox)

Rehabilitation

Halfway houses

Other housing

Partial hospitalization

Intensive outpatient (IOP) treatment

Outpatient treatment

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Levels of prevention

Primary – eg., alcohol labelling policy; cigarette taxation

Secondary – eg., harm reduction practices (supervised injection sites, managed alcohol program); relapse prevention support

Tertiary – detox and recovery/rehabilitation programs

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Implementation

Motivational interviewing

Counselling (individual and family)

Relapse prevention support

Psychobiological interventions

Pharmacological

Health teaching and health promotion

Evaluation

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Motivational Interviewing

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Establish rapport

Set the agenda

Assess readiness to change

Sharpen the focus

Identify ambivalence

Elicit self-motivating statements

Handle resistance

Shift focus and transition

Dual Diagnosis/Concurrent Disorders

Drug use problems and mental health: Comorbidity explained

Link: https://www.youtube.com/watch?v=5RbEotf0jqI

Dual Diagnosis (Concurrent Disorders)

An individual suffers from one substance-related disorder and a mental health disorder

Many possible combinations

Most complex and difficult clinical scenarios in health care

Likely to be stigmatized, socially marginalized, experience high degrees of relational problems, and are likely to be involved in the criminal justice system

Tend to fall through the cracks

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Dual Diagnosis (Concurrent Disorders)

Epidemiology

50% of persons with addiction also suffer from a mental disorder

20% of persons with mental illness also suffer from substance-related disorders

Affect young and old adults

18.5% prevalence of concurrent disorders

Co-occurrence is strongly associated with antisocial and challenging behaviour, legal involvement, and risk of suicide or self injurious behaviours

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Treatment Approaches

Screening should include both substance-related disorders, and other mental health disorders

No single approach or set of interventions

Treatment of each disorder simultaneously

Treatment matching

Indications for hospitalization

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.