Care for the substance abuse patient

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Week IV, Discussion Post: Care for the Client with a Substance Abuse Diagnosis

Opioids are substances extracted from opium poppy, they are a sophisticated group of prescribed drugs that are used in pain management, especially after significant surgeries. Unfortunately, when these medications are used in an uncontrolled manner, they have adverse addictive effects. These drugs are specifically designed to treat severe pain and are often prescribed following surgery or injury or for health conditions that cause extensive chronic illness such as cancer. At times, when taken in a way other than prescribed by a licensed practitioner, they can cause euphoric and pleasurable effects, making them a high demand on the streets. The death statistics resulting from opioid overdose in the United States between 1999 and 2010 increased exponentially, and it was recorded that in 2010 alone, the number of deaths recorded from opioid overdose was 16,651 deaths (Volkow, Frieden, Hyde, P. & Cha, S., 2014).

In the last 20 years, both therapeutic and illicit opioid use has escalated in the United States (Volkow et al., 2014). The total number of opioid prescriptions dispensed from the United States outpatient retail pharmacies increased from 174.1 million in 2000 to 256.9 million in 2009 (Brown, A.R., 2018). The over-prescription of opioid medications widely contributes to an increase in opioid overdose, and this has had a massive impact on the states. The United States has used more than 1 trillion dollars since the year 2001 to try and contain the pandemic.

The Centers for Disease Control and Prevention estimates that the total "economic burden" of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement. The increase in drugs used by injection has also contributed to the spread of diseases including HIV and hepatitis C. As we have seen throughout the history of medicine, science can be a major part of the solution in such a public health crisis. Expanding access to effective, evidence-based treatments for those with addiction and also less severe substance use disorders is critical, but broader prevention programs and policies are also essential to reduce substance misuse and the pervasive health and social problems caused by it.

Time and again, studies have found that there are high levels of correlation between mental and emotional disorders and addiction. This means that those who suffer from addiction have a higher-than-average likelihood of also suffering from a psychiatric disorder (Coon, Mitterer, & Martini, 2019). That said, it is extremely important for the Psychiatric Mental Health Nurse Practitioner (PMHNP) to recognize both physical and mental exam findings consistent with substance abuse disorder. The earlier a diagnosis is made, the better the prognosis. However, use over periods of years produces physical and psychological findings that make diagnosis much easier. Some examples of physical symptoms and findings that ensue after persistent use include the following:

· Malnutrition, including cachexia, but also obesity (the person may forget to eat, not want to eat, or eat unhealthily because the only thing that makes them feel better is drugs or alcohol).

· Systemic infections including cellulitis, sexually transmitted diseases, HIV, hepatitis B and C, tuberculosis, and bacterial endocarditis (the individual may use dirty needles, have unprotected sex for drugs, live or sleep in filthy crowded areas).

· Elevated blood pressure, tachycardia, chest pain, transient ischemic attacks, restlessness, sweating, and tremors (symptoms consistent of withdrawal).

· Physical damage from administering a drug that involve chronic sinus/nasal problems, worsening bronchitis from marijuana or cocaine smoking, or "track marks" from injection drug use

· The myriad systemic effects of alcoholism, including delirium, liver enlargement or failure, ascites, anemia, thrombocytopenia and bleeding, seizures, trauma, myopathy, and cardiomyopathy (Alcohol damages the liver, which is responsible for filtering out toxins and blood clotting).

· Increased aggression, irritability, personality changes, lethargy, and depression

Every substance has slightly different effects on the brain, but all addictive drugs, including alcohol, opioids, and cocaine, produce a pleasurable surge of the neurotransmitter dopamine in the basal ganglia  This area is responsible for controlling reward and our ability to learn based on rewards. As substance use increases, these circuits adapt. They scale back their sensitivity to dopamine, leading to a reduction in a substance’s ability to produce euphoria or the “high” that comes from using it (Knudson, Abraham, & Roman, 2011). This is known as tolerance, and it reflects the way that the brain maintains balance and adjusts to a new normal, the frequent presence of the substance. However, as a result, users often increase the amount of the substance they take so that they can reach the level of high they are used to. These same circuits control our ability to take pleasure from ordinary rewards like food, sex, and social interaction, and when they are disrupted by substance use, the rest of life can feel less and less enjoyable to the user when they are not using the substance.

Management of alcohol withdrawal is directed at alleviating symptoms and identifying and correcting metabolic derangements. Benzodiazepines are used to control psychomotor agitation and prevent progression to more severe withdrawal. Supportive care, including intravenous fluids, nutritional supplementation, and frequent clinical reassessment including vital signs, is important (Spithoff et al., 2017). Treatment with opioid agonists (methadone or buprenorphine) is the first-line treatment for opioid use disorder (Knudson et al., 2011).

The CDC (2020) recognizes that group therapy has been a core aspect of drug and alcohol addiction recovery for several decades, and it has proven to be very effective. Clients that participate in group therapy have a higher rate of accountability regarding their own behaviors. Motivational interviewing and cognitive behavioral therapies are also remarkably effective on an individualized level (Centers of Disease Control and Prevention, 2020).

Brown, A. R. (2018). A Systematic Review of Psychosocial Interventions in the Treatment of Opioid Addiction. Journal of Social Work Practice in Addictions, 28(4), 135-142. Retrieved from www.practiceinaddictions.com Centers of Disease Control and Prevention. (2020). https://www.cdc.gov/drugoverdose/epidemic/index.html Spithoff, S., Turner, S., Gomes, T., Martins, D., & Singh, S. (2017). First-line medications for alcohol use disorders among public drug plan beneficiaries in Ontario. Canadian family physician Medecin de famille canadien, 63(5), e277–e283. Volkow, N., Frieden, T., Hyde, P., & Cha, S. (2014). Medication-assisted therapies-tackling the opioid overdose epidemic. New England Journal of Medicine, 67(2), 181-187. Retrieved from www.nejm.org