Concept: Addiction
Exemplar: Substance Use Disorder and Neonatal Abstinence Syndrome
Terms:
- Addition
oChronic Medical Condition
- Intoxication
oIn the process of using a substance to excess
- Tolerance
oTakes a higher dose to achieve the initial level of response.
- Withdrawal
oSymptoms that occur when a person stops using a substance.
Substance Use Disorders
- Pathological use of a substance that leads to a disorder of use.
- Symptom groups:
oImpaired control
oSocial impairment
oRisky use
oPhysical effects (i.e., intoxication, tolerance, and withdrawal)
Substances That Lead to Use Disorder
- Alcohol
- Caffeine
- Cannabis
- Hallucinogen
- Inhalant
- Opioid
- Sedative-hypnotic
- Stimulant
- Tobacco
- Other: Process addiction (Gambling, shopping, sex, etc.)
Epidemiology
- Alcohol use disorder
o28.3 million
- Other substances
oTotal SUDs- 40.3 million
oMarijuana: 14.2 million
oOpioids: 2.7 million
Co-morbidity
- Psychiatric comorbidity
oAny combination of two or more substance use disorders and mental
disorders
Risk Factors
- Genetic factors
- Neurobiological factors
- Environmental factors
Clinical Picture
- Caffeine
oMost widely used psychoactive substance in the world
oCan result in intoxication, overdose, and withdrawal.
- Cannabis (Marijuana)
oThird most used psychoactive drug in the United States after alcohol,
and illicit drugs
- Hallucinogens
oCause a profound disturbance in reality.
- Inhalants
oSolvents for glues and adhesives
oPropellants
oThinners
oFuels
Opioid Use Disorder
- Heroin, fentanyl, and prescription drugs
- Opioid intoxication
oCravings result in larger amounts, longer periods of use, increasing
tolerance to its effects.
oResults in significant impairment in life roles, interpersonal conflict,
and puts a person in physically hazardous situations.
- Opioid overdose
oDeath usually due to respiratory arrest
oTreatment: promote breathing; naloxone
- Opioid withdrawal
oMethadone, clonidine, buprenorphine/naloxone
oLofexidine
- Opioid maintenance
oPharmacological
oPsychotherapies
Sedative, Hypnotic, and Antianxiety Medication Use Disorder
- Problematic Substances
oBenzodiazepines
oBenzodiazepine-like drugs
oCarbamates
oBarbiturates
oBarbiturate-like hypnotics
- Overdose: gastric lavage
- Withdrawal: gradual reduction to prevent seizures
Stimulant Use Disorder
- Clinical Picture
oAmphetamine-type, cocaine, or other stimulant drugs
oSecond only to cannabis as the most widely used illicit substances in
the United States
- Withdrawal treatment
oGroup and individual therapy
oPossible diazepam for agitation
o1 to 2 weeks’ cocaine withdrawal requires no inpatient care; no
drugs reduce symptoms.
oDepression treatment once withdrawal is complete (e.g., bupropion)
Other Disorders
- Tobacco
oWithdrawal is distressing.
oWithdrawal treatment
Behavioral therapy
Hypnosis
Nicotine replacement therapies
Bupropion
Varenicline
- Gambling disorders
oGamblers Anonymous (GA)
oPossible treatment
SSRIs
Bupropion (Wellbutrin)
Mood stabilizers
Anticonvulsants
Neonatal Abstinence Syndrome
Maternal Substance Use
- Maternal and fetal effects on drugs
oTobacco
oAlcohol
oMarijuana
oOpioids
oCocaine
oMethamphetamine
- Barriers to treatment
oSocial stigma, labeling, and guilt
oWomen fear losing custody of child and criminal prosecution.
oLack of understanding regarding effects of drugs
oSubstance abuse treatment programs do not address issues affecting
pregnant women.
oLong waiting lists and lack of health insurance present further
barriers to treatment.
- Legal Considerations
oSome states consider in utero exposure to be abuse or neglect.
oHealth care practitioners possibly required to report positive results.
oLegal mandating may impact provider-patient relationship.
- Care management by interprofessional team
- Screening
oFirst prenatal visit
oPast and present use
oInclude prescription and herbal substances.
oNonjudgmental approach
o4 Ps plus tool
oToxicology testing
Urine
Meconium
Hair
- Assessment
oAdditional assessment related to conditions more likely in women
with substance abuse issues
oInfections
HIV
Hepatitis
Syphilis
Common STI’s
oUltrasounds
Gestational age
- Interventions
oMedical management
Education
Consequences of drug use
Monitoring
Treatment programs
oNursing interventions
Low threshold for pain requires additional approaches to
management.
Decreased involvement with infant requires advice and
education.
Considerations for breastfeeding related to infant exposure.
Neonatal Abstinence Syndrome
- NAS
oTerm used to describe the set of behaviors exhibited by infants
exposed to opioids in utero.
- Symptoms include:
oIrritability
oHigh-pitched cry
oHypertonicity, hyperactivity.
oPoor feeding
oVomiting, diarrhea
oUncoordinated, frantic sucking
oFever and diaphoresis
oTachypnea and nasal stuffiness
oDisrupted sleep patterns
- Early identification is key.
- Symptoms present within hours or up to two weeks later.
- Related to the type, amount, length of drug use.
- Infants assessed using one of several standardized rating scales.
- Nursing care focuses on:
oTreating presenting signs
oDecreasing stimuli
oProviding adequate nutrition and hydration
oPromoting mother-infant attachment
- Breastfeeding?
- Severe signs treated with medications (typically tapered opioids)
Alcohol Use Disorder
- Epidemiology
oAlmost twice the prevalence among adult men than adult women
oAmerican Indians/Alaska Natives (12.1%) have the highest rates;
disproportionately affected by alcohol problems.
- Comorbidity
oBipolar disorders
oSchizophrenia
oAntisocial personality disorder
oMajor depressive disorder
- Risk Factors
oGenetics
oNeurobiology
oSocial
oCultural
- Type of problematic Drinking
oBinge drinking
oHeavy Drinking
- Alcohol intoxication
oLegal definition of intoxication in most states
Blood concentration of 80 or 100 mg/dL
Often expressed as 0.08 to 0.10 g/dL
- Alcohol withdrawal
- Cognitive disturbances
oWernicke-Korsakoff syndrome
- Fetal Alcohol Syndrome
- Systemic Effects
oPeripheral neuropathy
oAlcoholic myopathy and cardiomyopathy
oEsophagitis, gastritis, and pancreatitis
oAlcoholic hepatitis
oCirrhosis of the liver
oLeukopenia
oThrombocytopenia
oCancer (especially head and neck)
Screening Tools
- SBIRT: Screening, Brief Intervention, and Referral to Treatment
- AUDIT: Alcohol Use Disorders Identification Test
- CAGE: 4 questions to identify alcohol abuse
- CAGE-AID: Same questions as CAGE but adds drug use with alcohol.
- T-ACE: Tolerance, Annoyance, Cut down, Eye-opener.
Nursing Process
- Assessment
oFamily assessment (codependence)
oSelf-assessment
- Nursing Diagnosis
- Outcomes identification
- Planning
oIdentifying problem
oSetting a goal
oDetermining the interventions that will accomplish the goal
- Implementation
oPromoting safety and sleep (1st line interventions)
oReintroduce good nutrition and hydration.
oSupport for self-care (hygiene)
oExploring harmful thoughts and spiritual distress
- Health Teaching and health Promotion
oPrevention against genetic vulnerability
oPublic classes
Treatment Modalities
- Pharmacotherapy
oDisulfiram
oNaltrexone
oBenzodiazepines
- Psychotherapy
- Motivational Interviewing
Care Continuum for Substance Use Disorders
- Detoxification (detox)
- Rehabilitation
- Halfway houses
- Other housing
- Partial hospitalization program
- Intensive outpatient programs
- Outpatient treatment
- Alcoholics Anonymous (AA)
- Relapse prevention
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