Care of the Patient with an Addictive Personality

Chapter 36Chapter 36

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Addiction

• Addictive behavior patterns can impede the patient’s recovery from an acute illness.

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Care of the Patient with an Addictive Personality

• The treatment of patients with addictive behaviors is an important concern for nurses.

• Definition of Addiction (pg.1158) Excessive use or abuse Display of psychological disturbance Decline in social and economic function Uncontrollable consumption indicating dependence

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Addiction

• 44% of adolescents who start drinking at the age of 14 or younger, will develop alcoholism

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• Addictive Personality A person who exhibits a pattern of compulsive and

habitual use of a substance or practice to cope with psychic pain from conflict and anxiety

Common traits• Low stress tolerance• Dependency• Negative self-image• Feelings of insecurity• Depression

Care of the Patient with an Addictive Personality

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Stages of Dependence

• Early Stages A tolerance to substance is developed. User may decrease or stop to prove he or she can. Family and friends comment about the user’s

overinvolvement with drug. User may have legal problems or may drive while

intoxicated. User may miss work or school or show up late

frequently. Mood swings, decreased self-esteem, shame, guilt,

remorse, resentment, and irritability may occur. Financial difficulties arise; spending for drug use. Recovery may occur without treatment.

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Stages of Dependence

• Middle Stage User is moderately impaired. The user uses just to “feel normal.” Family relationships weaken. Physical health declines. Job loss is common. Social isolation increases. Very few in this stage recover without treatment Abstinence brings on signs and symptoms of

withdrawal.

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Stages of Dependence

• Late Stage Dependent user displays severe impairment in all

areas of function. Use is continuous in an attempt to avoid emotional

and physical pain. Medical problems worsen; user neglects personal

hygiene. User may be suicidal or homicidal. User is manipulative, denies his or her problems, and

has poor problem-solving ability and impaired judgment.

User is usually unemployed and may be homeless. People in this stage will not improve without

treatment.

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Alcohol Abuse and Alcoholism

• Alcoholism is a U.S health problem that is surpassed only by heart disease and cancer.

• Contributing factors Genetic: 30% to 50% chance that the son of an

alcoholic man will develop alcoholism. Deficiencies in hepatic enzymes necessary to

metabolize alcohol in some people• Many Asians, American Indians, and Eskimos have

these deficiencies.

• Most teenagers have their first drink between the ages of 12 and 15 years.

• Alcohol is often referred to as a gateway drug.

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Alcohol

• CNS depressant

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Alcohol Abuse and Alcoholism

• Etiology and Pathophysiology Alcohol is a central nervous system depressant. Stimulating effect occurs because the first areas of the

brain affected are those that govern self-control. Alcohol poisoning may occur from rapid,

large-quantity consumption. Alcohol does not require digestion. Alcohol has a diuretic effect. Prolonged use has a toxic effect on intestinal mucosa

causing decreased absorption of thiamine (B1), folic acid and vitamin B12

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Figure 36-1 Limbic system

Limbic system.

(Illustration by Lee Hoffman.)

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Alcohol Abuse and Alcoholism

• Disorders Associated with Alcoholism Fetal alcohol syndrome

• Frequently seen in newborns whose mothers drank heavily during pregnancy

• Congenital anomaly Mental retardation Growth disorders Wide-set eyes Malformed body parts Spontaneous abortion or stillborn

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Alcohol Abuse and Alcoholism

• Disorders Associated with Alcoholism (continued) Alcohol withdrawal syndrome

• Seen in a person who has developed physiologic dependence and quits drinking

• At risk Older adults, people who have suffered DTs before,

malnourished people, and those suffering with another acute illness and seizures

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Alcohol Abuse and Alcoholism

• Disorders Associated with Alcoholism (continued) Alcohol withdrawal syndrome (continued)

• Signs and symptoms Usually occur 6 to 48 hours after the last drink May last for 3 to 5 days Diaphoresis, tachycardia, hypertension, tremors,

nausea/vomiting, anorexia, restlessness, disorientation, hallucinations

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Alcohol Abuse and Alcoholism

• Disorders Associated with Alcoholism (continued) Delirium tremens

• Acute psychotic reaction to withdrawal of alcohol. Usually occurs 1 to 4 days after alcohol cessation. Lasts 2 days to 1 week

• Result of excessive alcohol consumption over a long period of time

• Signs and symptoms Increased activity to extreme agitation Disorientation; fear/panic Hallucinations; elevated temperature

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Delirium Tremens

• Page 1161

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Alcohol Abuse and Alcoholism

• Disorders Associated with Alcoholism (continued) Korsakoff’s psychosis and Wernicke’s encephalopathy

• Brain disorders seen in chronic alcoholics Korsakoff’s psychosis

• Short-term memory loss• Disorientation; muttering delirium• Insomnia• Hallucinations• Polyneuritis• Painful extremities

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Alcohol Abuse and Alcoholism

• Disorders Associated with Alcoholism (continued) Wernicke’s encephalopathy

• Associated with thiamine deficiency.• Memory loss• Aphasia• Involuntary eye movement and double vision• Lack of muscle coordination.• Disorientation with confabulation

Fills in memory gaps with inappropriate words

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Assessment

• Subjective Data Normal using or drinking pattern Date and time of the last drink or use of a drug Specific substance and the quantity used Complaints of nausea, indigestion, sleep disturbance,

or pain Normal dietary patterns Presence of any disease requiring treatment with

prescribed medications Regular use of over-the-counter drugs Drug allergies

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Assessment

• Objective Data Height, weight, vital signs, and physical assessment Presence of tremors Skin conditions

• Especially on the forearms, backs of hands, and insteps• Acne-like facial rash

Frequent sniffing, stuffy nose, or harsh nonproductive cough

Tachycardia, hypertension, petechiae, and neuropathies

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Diagnostic Tests

• Blood and urine tests will screen for toxins.• Some foods can cause a false-positive reading in a

urine screen (poppy seeds).• Alcoholism

Liver enzymes, hypoglycemia, blood protein levels, and magnesium

• Hepatitis and HIV

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Nursing Diagnosis

• Nursing diagnoses and interventions for the patient with an addiction include emotional needs as well as physical needs. Denial, ineffective Coping, ineffective

Refer to table 35-4 on page 1163 for further nursing diagnosis. Be able to apply a diagnosis if given information.

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Nursing Interventions

• Detoxification Removal of poisonous effects of a substance from a

patient A controlled setting where the patient can be closely

observed and treated for complications…focus is SAFETY.

• Medication to reduce withdrawal symptoms Chlordiazepoxide (Librium) Naltrexone (ReVia) Medicate according to the amount of withdrawal symptoms

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Nursing Interventions

• Detoxification (continued) Monitor for cardiorespiratory distress.

• Continuous cardiac monitoring; vital signs Maintain therapeutic communication.

• Simple explanations; speaking in a calm voice Reorient as needed.

• Disorientation may occur, especially at night. Provide physical care as needed. Encourage proper nutrition. Reduce environmental stimuli Allow patient to ambulate to ease “nervousness.”

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Rehabilitation• Group Therapy

Provides a caring, emotionally supportive atmosphere Helps patient see the relationship between substance

abuse and negative consequences in his or her life

• Alcoholics Anonymous International nonprofit organization Abstinent alcoholics helping other alcoholics to become

and stay sober through group support, shared experiences, and faith in a power greater than themselves

12 step based program Antabuse (disulfiram): aversion therapy see pg.1164

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Alcoholics Anonymous

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Alcoholics Anonymous

• 12 step based program see box 36-2 pg.1165

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Antabuse (disulfiram)

• Causes facial flushing, nausea, tachycardia, dyspnea, dizziness and confusion…considered “aversion therapy”

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Rehabilitation

• Residential Treatment Centers Provide detoxification without direct medical

intervention Provide close physical monitoring by trained nurses,

counselors, and recovered peers After detoxification, the patient is placed in a

drug- and alcohol-free residence Goal: to rebuild social skills that do not involve drug

use Length of stay 1 to 6 months Ability-to-pay basis

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Rehabilitation

• Pain Management It can involve the use of addicting substances. Nursing interventions require not only careful

assessment of pain but also observation for developing patterns of drug-seeking behavior.

Encouraging the patient to practice and use nonchemical interventions to ease pain will reduce the risk of chemical dependency for relief.

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Drug Abuse

• Just say NO !!!

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Drug Abuse

• Illegal Drugs “Street drugs” Sold to users by illegal drug dealers

• Manufactured without strict controls• Illegally obtained prescription drugs• Drugs not approved for use in the United States

• Prescription or Over-the-Counter Drugs When a person takes drugs for other than

recommended medical reasons or more than recommended dosage

Many commonly abused drugs act on the limbic system of the brain…may cause permanent damage.

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Drug Abuse• CNS Depressants( pgs.1166-1167 ) serious problems may result

from sudden withdrawal from CNS depressants such as seizures… Alcohol Sedative-hypnotic medications

• Barbiturates: phenobarbital, Seconal• Benzodiazepines: flurazepam (Dalmane), diazepam

(Valium), flunitrazepam (Rohypnol:date-rape drug)

• Opioid Analgesics pg.1167 Heroin: highly addictive, withdrawal symptoms: tachycardia, dilated

pupils, diaphoresis, HTN, body-aches…see pg.1167 Morphine Methadone Narcan (naloxone) : used to treat opioid overdose

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Rohypnol • The “date-rape” drug

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Drug Abuse

• CNS Stimulants (pgs.1167-1170) Caffeine: coffee, tea, chocolate, soft drinks

Nicotine: tobacco : abrupt cessation may cause withdrawal symptoms…see page 1168

Cocaine: crack (mixed with baking soda and smoked); powder (snorted) overdose may cause cardio-respiratory distress and seizures. Cravings may persist for prolonged periods !!

Amphetamines• Methylphenidate (Ritalin)• Methamphetamine (can be made with household

chemicals)• May cause dopamine depletion resulting in parkinsonian-

like symptoms.

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Drug Abuse

• Hallucinogens pgs.1168-1170 PCP LSD MDMA (ecstasy): causes release of the

neurotransmitter serotonin until it is depleted from the brain cells.

Ketamine Mescaline and psilocybin

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Effect of Ecstasy on the brain

Brain scans: non drug-user (left); ecstasy (MDMA) user (right). ,

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Drug Abuse

• Cannabis Marijuana, hemp Amotivational cannabis syndrome :( page 1170) ,

causes decreased goal directed activities, abrupt mood swings, irritability, decline in self-care etc… REVERSES WITH ABSTNENCE !!!!

THC : active ingredient, fat soluble: may accumulate in the body up to a month or longer after last use. Could cause a person to test positive on a drug screen

• Inhalants – seems to be more popular with “younger” crowd Huffing Glue, lighter fluid, cleaning fluids, paint

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Chemically Impaired Nurses

• Thirty-seven states have programs that offer chemically impaired nurses treatment and rehabilitation in order to keep their license.

• Impaired nurses become illogical and careless in charting and performance of duties.

• They may steal medication and report spillage.• Peer assistance programs are usually under the

jurisdiction of the state board of nursing. Contract agreement

• This requires the nurse to undergo treatment and monitoring for a certain period of time.

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Chemically Impaired Nurses

• Healthcare Integrity and Protection Data Bank (HIPDB) or (HIPB) Nursing boards and health agencies are required to

report any actions against a health care provider, supplier, or practitioner.

Provides incentive for nurses to enter treatment and avoid any FINAL action that is mandatory to report to HIPDB

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Chemically Impaired Nurses

• Warning Signs Alcoholism

• Irritability, mood swings• Elaborate excuses for behavior• Unkempt appearance• Blackouts (temporary amnesia)• Impaired motor coordination, slurred speech, flushed

face, bloodshot eyes• Numerous injuries, burns, bruises, etc., with vague

explanation• Smell of alcohol on breath or excessive use of

mouthwash, mints, etc.

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Chemically Impaired Nurses

• Warning Signs (continued) Drug addiction

• Rapid changes in mood and/or performance• Frequent absence from unit; frequent use of restroom• Works a lot of overtime; arrives early and stays late• Increased somatic complaints requiring prescriptions of

pain medications• Consistently signs out more or larger amounts of

controlled drugs than anyone else; excessive wasting of drugs

• defensiveness

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Chemically Impaired Nurses• Warning Signs (continued)

Drug addiction (continued)• Increased isolation from others• Patients report that pain medication is not effective or of not

receiving medication• Excessive discrepancies in signing and documenting

procedures of controlled substances

As “addiction” worsens, the nurse may become defensive if questioned. We are obligated to report our suspicions to the supervisor if we suspect a coworker of chemical dependency!!!!

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Chemically Impaired Nurses

• Warning Signs (continued) Mental health disorder

• Depressed, lethargic, unable to focus or concentrate• Makes many mistakes at work• Erratic behavior or mood swings• Inappropriate or bizarre behavior or speech• May also exhibit some of the same or similar

characteristics as chemically dependent nurse

It is the duty of every nurse to uphold the standards of the profession. Report observations objectively to supervisor if you suspect a nurse may be “under the influence.”

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TPAPN : Texas Peer Assistance Program for Nurses

• Voluntary : a nurse has the right to NOT participate• Created as a non-punishing, confidential alternative

to reporting RNs/LVNs to the Texas BON.• Offers opportunities for recovery from chemical

dependency and mental illness.• Maintains confidentiality consistent to state and

federal laws.• A nurse without a record may self refer to TPAPN• Toll free (800) 288 - 5528