Psycho-Addictive Psycho-Addictive DisordersDisorders

Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

ProfessorProfessor

Substance AbuseSubstance Abuse– Maladaptive pattern of excessive use Maladaptive pattern of excessive use – Recurrent use = ↑↑ impairment Recurrent use = ↑↑ impairment – Failure to meet role obligationsFailure to meet role obligations– ↑↑ ↑↑ Use withUse with

Legal, social or interpersonal problemsLegal, social or interpersonal problems

IntoxificationIntoxification– Reversible substance induced syndromeReversible substance induced syndrome– Slurred speechSlurred speech– AtaxiaAtaxia = ↓ Coordination = ↓ Coordination– ↓ ↓ CognitionCognition– Poor memory & judgmentPoor memory & judgment– ↑↑↑↑Impulsive behaviorImpulsive behavior

Substance DependenceSubstance Dependence– Cognitive, behavioral & psychological symptomsCognitive, behavioral & psychological symptoms– Pt. believes substance needed for optimal healthPt. believes substance needed for optimal health– Persistent desire and Persistent desire and ↑ time spent to obtain & use↑ time spent to obtain & use– Use ↑ quantities more frequently = AddictionUse ↑ quantities more frequently = Addiction– Unsuccessful attempts to stop usingUnsuccessful attempts to stop using

ToleranceTolerance– Need ↑↑ amounts to achieve desired effectsNeed ↑↑ amounts to achieve desired effects

Cross ToleranceCross Tolerance – Pt. tolerant to drug A Pt. tolerant to drug A – When use drug B (similar to A) has ↓ effect When use drug B (similar to A) has ↓ effect – Need ↑↑ dose of BNeed ↑↑ dose of B

Withdrawal SyndromeWithdrawal Syndrome– Cessation of heavy prolonged useCessation of heavy prolonged use– Autonomic HyperactivityAutonomic Hyperactivity– HallucinationsHallucinations– DementiaDementia– SeizuresSeizures

ETOHETOH 33rdrd Major health problem Major health problem 50% ER visits & 12 million adults ETOH dependent50% ER visits & 12 million adults ETOH dependent Teens fastest growing group of alcoholicsTeens fastest growing group of alcoholics ↑ ↑ 50% risk with alcoholic family member50% risk with alcoholic family member Parents role model ETOH as coping skillParents role model ETOH as coping skill ↑ ↑ Predisposition = ↑ SensitivityPredisposition = ↑ Sensitivity ETOH produces morphine like substances TIQsETOH produces morphine like substances TIQs

– Activate opioid brain receptors = addictionActivate opioid brain receptors = addiction ↓ ↓ ETOH Dehydrogenase = ↓ ETOH metabolismETOH Dehydrogenase = ↓ ETOH metabolism

– ETOH goes directly from blood to brainETOH goes directly from blood to brain ↓ ↓ Self Esteem ↓ Frustration Self Esteem ↓ Frustration ↑↑ ↑↑ Impulsive & ↑ Immediate GratificationImpulsive & ↑ Immediate Gratification Peer & media influence = + ReinforcementPeer & media influence = + Reinforcement

– ↓ ↓ Inhibitions = ↑ confidence & risky behaviorsInhibitions = ↑ confidence & risky behaviors

Cultural InfluencesCultural Influences AsiansAsians

– Lowest ETOH rate 2.5%Lowest ETOH rate 2.5%– Genetic ETOH intoleranceGenetic ETOH intolerance (+) Punishment (+) Punishment

Flushing Flushing HAHA PalpitationsPalpitations Native AmericansNative Americans

– Highest ETOH rate 12.5 %Highest ETOH rate 12.5 %– 55thth leading cause of death leading cause of death– Community oriented culture Community oriented culture

Drinking is group activity Drinking is group activity Irish, German, ScandinavianIrish, German, Scandinavian

– ↑ ↑ ETOH use & dependencyETOH use & dependency – RT Socialization & aggression releaseRT Socialization & aggression release

Family DynamicsFamily Dynamics Co-DependencyCo-Dependency

– Caretaker derives self worth from othersCaretaker derives self worth from others– Over-functioning takes on all responsibilitiesOver-functioning takes on all responsibilities– Enabling behaviorsEnabling behaviors

Adult Children of Alcoholics 1/8 Adult Children of Alcoholics 1/8 – Learn dysfunctional family roles Learn dysfunctional family roles – Secrecy, mistrust, shame and denial of abuse.Secrecy, mistrust, shame and denial of abuse.– Primary goal is to please parentPrimary goal is to please parent– Hero/Caretaker ChildHero/Caretaker Child

Take on family responsibilitiesTake on family responsibilities Trying to keep it all together”Trying to keep it all together”

– Scapegoat ChildScapegoat Child Act out @ home – Child is focus of conflictAct out @ home – Child is focus of conflict

– Lost ChildLost Child Avoid conflict & pain (Escape from family)Avoid conflict & pain (Escape from family) Run awayRun away

– Mascot/ClownMascot/Clown Comic relief to mask sadnessComic relief to mask sadness Truly unhappyTruly unhappy

ETOHETOH CNS DepressantCNS Depressant

– ↓ ↓ Anxiety Anxiety Relaxation Relaxation ↓ Inhibitions ↓ Inhibitions – ↓ ↓ Judgment Judgment Slurred speechSlurred speech ↓ Sleep↓ Sleep

BAC Blood Alcohol ConcentrationBAC Blood Alcohol Concentration– 0.05 = Euphoria, impairment0.05 = Euphoria, impairment– 0.08 = Intoxication (Legal limit)0.08 = Intoxication (Legal limit)– 0.15-0.2 = ↓ coordination, double vision0.15-0.2 = ↓ coordination, double vision– 0.3 = stupor0.3 = stupor– 0.4 = coma & death0.4 = coma & death

Absorbed in 5 minsAbsorbed in 5 mins Liver detoxifies ETOH (¼Liver detoxifies ETOH (¼ oz) oz) per hour =per hour =

– 12 oz. Beer12 oz. Beer– 4 oz. Wine4 oz. Wine– 1 Shot1 Shot

Cognitive EffectsCognitive Effects ↓ ↓ ControlControl Poor judgment Poor judgment ↓Learning↓Learning Impulsive/Abusive BehaviorImpulsive/Abusive Behavior SeizuresSeizures

Blackouts “Fugue-like” stateBlackouts “Fugue-like” state– Amnesia of events during drinking periodAmnesia of events during drinking period– No loss of consciousness during episodeNo loss of consciousness during episode

Wernicke’s EncephalopathyWernicke’s Encephalopathy– Thiamine deficiency→ Grey matter damageThiamine deficiency→ Grey matter damage– Abnormal thinking patterns ↓ MemoryAbnormal thinking patterns ↓ Memory AtaxiaAtaxia

Korsakoff’s PsychosisKorsakoff’s Psychosis (2 (2ndnd to Wernicke’s) to Wernicke’s)– Niacin & Thiamine deficiencyNiacin & Thiamine deficiency– Irreversible cell death & progressive mental Irreversible cell death & progressive mental

deteriorationdeterioration– ConfabulationConfabulation Loss of recent memory Loss of recent memory DiplopiaDiplopia– Somnolence → Stupor → DeathSomnolence → Stupor → Death

Systemic EffectsSystemic Effects CardiovascularCardiovascular

– Autonomic Hyperactivity = Autonomic Hyperactivity = ↑ HR ↑ BP ↑ HR ↑ BP CHFCHF

– Myopathy RT Myopathy RT Vasoconstriction = Chest painVasoconstriction = Chest pain

– Bone Marrow ToxicityBone Marrow Toxicity ↓ ↓ RBCs ↓ WBCs ↓ PltsRBCs ↓ WBCs ↓ Plts

GastrointestinalGastrointestinal– Esophagitis RT VomitingEsophagitis RT Vomiting– Esophageal Varices RT Portal HTNEsophageal Varices RT Portal HTN– Gastritis & Ulcers RT Gastritis & Ulcers RT ↑HCL↑HCL– Malnutrition Malnutrition → → AscitisAscitis– Pancreatitis Pancreatitis → → DM & CADM & CA– Hepatitis & Cirrhosis Hepatitis & Cirrhosis → → Liver FailureLiver Failure

Systemic EffectsSystemic Effects

RespiratoryRespiratory– COPD COPD PN PN– Lung CA RT Lung CA RT ↑↑ Smoking↑↑ Smoking

Skin/SkeletalSkin/Skeletal– ↓↓ ↓↓ Reflexes RT Peripheral Reflexes RT Peripheral

NeuropathyNeuropathy – Muscle weakness = Muscle weakness = ↑↑↑↑ Falls Falls– Skin ulcersSkin ulcers– Spider AngiomasSpider Angiomas

GenitourinaryGenitourinary– ↑↑ ↑↑ Urination RT diuretic action of ETOHUrination RT diuretic action of ETOH– ↑ ↑ FASFAS– ↓ ↓ Sexual PerformanceSexual Performance RT ↓ LibidoRT ↓ Libido

Alcohol Withdrawal Syndrome AWSAlcohol Withdrawal Syndrome AWS Rebound NS HyperirritabilityRebound NS Hyperirritability 11stst Stage (6-8 h after last drink) Stage (6-8 h after last drink)

– ““Morning after jitters”Morning after jitters”– TremorsTremors AnxietyAnxiety C/O “Shaky Inside”C/O “Shaky Inside”– Irritability Irritability ↑ HR↑ HR ↑ BP↑ BP

N & VN & V 22ndnd Stage (24 h no interventions) Stage (24 h no interventions)

– Hallucinations Hallucinations Visual: 3 - 4’ long bugsVisual: 3 - 4’ long bugs Tactile: crawling sensationTactile: crawling sensation Auditory: hear musicAuditory: hear music

– SeizuresSeizures (2-6 during 3-4 h period) (2-6 during 3-4 h period)

Alcohol Withdrawal Syndrome AWSAlcohol Withdrawal Syndrome AWS

33rdrd Stage (48h) Delirium Tremens- DTs Stage (48h) Delirium Tremens- DTs– Acute Medical Condition (20% mortality)Acute Medical Condition (20% mortality)– Dehydration Dehydration →→Fluid & Electrolyte Fluid & Electrolyte

imbalanceimbalance– ↑↑↑↑ Autonomic HyperactivityAutonomic Hyperactivity

↑↑HR ↑BP ↑TempHR ↑BP ↑Temp

– Fatal ArrhythmiasFatal Arrhythmias – Global confusion & unaware of Global confusion & unaware of

environmentenvironment– Vivid Hallucinations & DelusionsVivid Hallucinations & Delusions– ↑↑ ↑↑ Agitation & SeizuresAgitation & Seizures

AWS TherapyAWS Therapy

Detoxification 3-7 daysDetoxification 3-7 days AWS ProtocolsAWS Protocols

– Librium, Valium or Ativan Librium, Valium or Ativan 10-20x dose 10-20x dose initially!initially!

– Thiamine (IM)Thiamine (IM) – Cyanocobalamine (Vit B12)Cyanocobalamine (Vit B12)– Niacin (Vit B6) Niacin (Vit B6) Folic Acid Folic Acid – IV GlucoseIV Glucose– ß Blockers: ß Blockers:

Propanonol (Inderal) Clonidine (Catapres)Propanonol (Inderal) Clonidine (Catapres)– Dilantin or Mg SO4 Dilantin or Mg SO4 – NO Mellaril or Haldol for hallucinationsNO Mellaril or Haldol for hallucinations

(↑↑ Seizures)(↑↑ Seizures)– Tryptophan & Trophamine Tryptophan & Trophamine – Odansetron (Zofran)Odansetron (Zofran)

AWS NursingAWS NursingPrimary Priority = Assessment! V/S & LOCPrimary Priority = Assessment! V/S & LOC Monitor Pt’s response to therapyMonitor Pt’s response to therapy Pt. Safety = Pt. Safety = √ S/S of depression & √ S/S of depression &

suicidesuicide Calm, quiet environmentCalm, quiet environment Provide uninterrupted periods of restProvide uninterrupted periods of rest Firm limits & consistent supportFirm limits & consistent support Reorient to realityReorient to reality Confront denial, rationalization, Confront denial, rationalization,

projectionprojection Monitor visitorsMonitor visitors

MedicationsMedications Antabuse (Disulfiram)Antabuse (Disulfiram)

Aversion TherapyAversion Therapy –Blocks oxidation of ETOH Blocks oxidation of ETOH –↑ ↑ Pt sensitivityPt sensitivity–↑ ↑ HA ↑ HR N & V Flushing HA ↑ HR N & V Flushing

–Chest Pain → DeathChest Pain → Death Naltrexone HCL (ReVia)Naltrexone HCL (ReVia)

Opioid antagonist = Opioid antagonist = ↓ ETOH ↓ ETOH cravingcraving

Can not be used with narcotics Can not be used with narcotics for 7-10 daysfor 7-10 days

TherapyTherapy

12 Step Programs: AA NA CA12 Step Programs: AA NA CA– Life-long commitmentLife-long commitment– Attain & Maintain sobriety Attain & Maintain sobriety

Peer group & sponsorPeer group & sponsor– Accept ETOH dependency as Accept ETOH dependency as

illnessillness– Develop adaptive coping skills Develop adaptive coping skills – ↑↑ ↑↑ Self-EsteemSelf-Esteem

HallucinogensHallucinogens LSDLSD: Acid, Purple Haze Big D: Acid, Purple Haze Big D MescalineMescaline: Peyote, Half-Moon: Peyote, Half-Moon PCPPCP: Angel dust (lipophilic): Angel dust (lipophilic) KetamineKetamine: Special K: Special K MarijuanaMarijuana: Pot, Weed, Grass, Joint, MJ: Pot, Weed, Grass, Joint, MJ Dronabinol (Marinol) & Nabilone (Cesamet)Dronabinol (Marinol) & Nabilone (Cesamet)

– used for Chemo induced N & Vused for Chemo induced N & V ActionAction

– Alter mood & perception of time & spaceAlter mood & perception of time & space– Alter cognitive function = insight into life?Alter cognitive function = insight into life?– SynesthesiaSynesthesia = altered visual/auditory = altered visual/auditory

“ “ Hear Colors” “See Music”Hear Colors” “See Music”– Paranoia , Hallucinations & IllusionsParanoia , Hallucinations & Illusions– Bad Trips = fear of losing one’s mind Bad Trips = fear of losing one’s mind ↑ suicide↑ suicide – ↑↑ ↑↑ Aggression & ↑↑ Physical StrengthAggression & ↑↑ Physical Strength (PCP) (PCP)– Flashbacks (up to 5 -15 years)Flashbacks (up to 5 -15 years)

StimulantsStimulants Amphetamines: Ecstasy, MDMA, AmylnitrateAmphetamines: Ecstasy, MDMA, Amylnitrate

– Ice “Crank” smokeable form of methamphetamineIce “Crank” smokeable form of methamphetamine– Euphoria lasts 12 -30 h Euphoria lasts 12 -30 h ↑ violence ↑ strength↑ violence ↑ strength

Cocaine: CokeCocaine: Coke– Crack “Rock” smokeable form of cokeCrack “Rock” smokeable form of coke– Onset 6-7 secs, High 2-5 min, Severe crash Onset 6-7 secs, High 2-5 min, Severe crash → ↑↑ use→ ↑↑ use

CaffeineCaffeine TobaccoTobacco ActionAction

– ↑↑ ↑↑ DA ↑↑ NE ↑↑ 5-HT DA ↑↑ NE ↑↑ 5-HT – ↑ ↑ AlertnessAlertness ↑Endurance↑Endurance ↑Elation ↑Elation Euphoria Euphoria– ↑↑ ↑↑ Self-Esteem ↑↑Assertiveness ↑ Sexuality Self-Esteem ↑↑Assertiveness ↑ Sexuality

VerborrheaVerborrhea– Tolerance in hours – daysTolerance in hours – days– Vasoconstriction = ↑ HR ↑ BP ↑ Temp ArrhythmiasVasoconstriction = ↑ HR ↑ BP ↑ Temp Arrhythmias

WithdrawalWithdrawal– Respiratory depressionRespiratory depression Dilated pupilsDilated pupils ↑↑ ↑↑

TremorsTremors– Fatigue Fatigue Vivid Dreams Vivid Dreams ↑↑ Appetite↑↑ Appetite– Psychomotor retardationPsychomotor retardation– Crashing = Suicidal IdeationCrashing = Suicidal Ideation PsychosisPsychosis

MethamphetamineMethamphetamine

Methamphetamine Methamphetamine Facial EffectsFacial Effects

Meth AgingMeth Aging

Crank BugsCrank Bugs

OpioidsOpioids Morphine MSO4Morphine MSO4 CodeineCodeine HeroinHeroin ActionAction

– Euphoria Euphoria ↓↓ Pain Perception↓↓ Pain Perception ↑↑ ↑↑ PassivityPassivity

– ↓ ↓ Anxiety & ↓ ↓ Aggression = ApathyAnxiety & ↓ ↓ Aggression = Apathy– ↓ ↓ Hunger ↓ Thirst ↓ LibidoHunger ↓ Thirst ↓ Libido– Pin point PupilsPin point Pupils ↓↓ Respirations ↓↓ Respirations – Rapid weak pulseRapid weak pulse

Withdrawal Withdrawal (5-14 days)(5-14 days)– Watery eyes Watery eyes RhinitisRhinitis– Yawning Yawning Sneezing Sneezing TremorsTremors– Abdominal spasmsAbdominal spasms

Sedatives, Hypnotics & AnxiolyticsSedatives, Hypnotics & Anxiolytics Brevital, SeconalBrevital, Seconal Restoril, HalcionRestoril, Halcion Valium, Xanax, Ativan, Rohypnol ‘Roffis”Valium, Xanax, Ativan, Rohypnol ‘Roffis” Gamma Hydroxybutrate (GHB): Gamma Hydroxybutrate (GHB):

– G G Liquid X Liquid X Georgia HomeboyGeorgia Homeboy

Action Action – Relaxation & well being = Sense of CalmRelaxation & well being = Sense of Calm– ↓↓ ↓↓ HR HR ↓↓ BP ↓↓ BP ↓↓ RR ↓↓ RR– ↓↓ ↓↓ Muscle spasms & ↑↑ SleepMuscle spasms & ↑↑ Sleep– ↓↓ ↓↓ Coordination = AtaxiaCoordination = Ataxia Mental ImpairmentMental Impairment– Quick temper ↓↓ Patience & toleranceQuick temper ↓↓ Patience & tolerance– ↑↑ ↑↑ Dose = ↓↓ Anxiety → Sedation → Coma → Dose = ↓↓ Anxiety → Sedation → Coma →

DeathDeath

Impaired Nursing PracticeImpaired Nursing Practice

1/8 Nurses are addicted = impacts their 1/8 Nurses are addicted = impacts their practicepractice..

1/5 are chemically dependent1/5 are chemically dependent 45,000 Alcoholic RNs45,000 Alcoholic RNs Narcotic addiction is 30x > publicNarcotic addiction is 30x > public 50-70% due to inadequate pain 50-70% due to inadequate pain

management for work related injury.management for work related injury. Hx of ETOH or substance abuse in family.Hx of ETOH or substance abuse in family. ↑↑ ↑↑ Social stigma against femaleSocial stigma against female addictsaddicts

Warning Signs of AbuseWarning Signs of Abuse Poor judgment & work performancePoor judgment & work performance

– Errors in charting & Errors in charting & ↓↓ Pt. care↓↓ Pt. care– ↑↑Accidents/incidents during shiftAccidents/incidents during shift

Inaccurate med countsInaccurate med counts – ↑↑↑↑ vial breakage & wastevial breakage & waste

Volunteers to work extra shifts & give meds.Volunteers to work extra shifts & give meds.– ↑ ↑ Reports from Pt of unrelieved painReports from Pt of unrelieved pain

↑↑ ↑↑ Absenteeism (after many days off)Absenteeism (after many days off) Leaves floor frequentlyLeaves floor frequently

– Spends Spends ↑↑ time in bathroom ↑↑ time in bathroom ETOH breathETOH breath Flushed faceFlushed face Reddened eyesReddened eyes Unsteady GaitUnsteady Gait Hyperactivity Hyperactivity Irritability/ApatheticIrritability/Apathetic

Nursing InterventionsNursing Interventions Document RN behavior, Pt or Document RN behavior, Pt or

medication incidents objectivelymedication incidents objectively.. Approach colleague with compassion Approach colleague with compassion Express concern for her health and Express concern for her health and

Pt’s safety.Pt’s safety. Remain in touch with colleagueRemain in touch with colleague Notify supervisor to report impaired Notify supervisor to report impaired

colleaguecolleague– Ethical & legal obligationEthical & legal obligation– Facilitates RN to obtain EAP services, RX Facilitates RN to obtain EAP services, RX – Protects the public!Protects the public!

Peer Assistance Program PAPPeer Assistance Program PAP Established in 1982 by ANAEstablished in 1982 by ANA RN voluntarily submits license during program (5 RN voluntarily submits license during program (5

years)years) Facilitates impaired nurses to recognize their illness.Facilitates impaired nurses to recognize their illness. Maintain confidentiality & obtain needed RX.Maintain confidentiality & obtain needed RX. Regain accountability within profession.Regain accountability within profession. ContractContract

– Method of RX, work guidelines, spot drug testing and Method of RX, work guidelines, spot drug testing and quarterly evaluations.quarterly evaluations.

Work site monitor Work site monitor √ √ progress during treatment.progress during treatment. If unsuccessful refer to the State Board of Nursing, If unsuccessful refer to the State Board of Nursing,

– Office of Professional Discipline (OPD).Office of Professional Discipline (OPD). – Any Pt. harm or criminal chargesAny Pt. harm or criminal charges

Narcotics taken (Federal Law) & theft of Narcotics taken (Federal Law) & theft of propertyproperty

FL 2009 Law FL 2009 Law – Hx of abuseHx of abuse– Unable to reapply for license for 15 years!Unable to reapply for license for 15 years!

Statewide Peer Assistance for Nurses (SPAN)Statewide Peer Assistance for Nurses (SPAN)

Voluntary participation with PAP.Voluntary participation with PAP. SPAN AdvocateSPAN Advocate

– Mentor maintains weekly contact for 1:1 Mentor maintains weekly contact for 1:1 counseling and support.counseling and support.

Weekly support group meetingsWeekly support group meetings – With other impaired nurses.With other impaired nurses.

Open ended participationOpen ended participation– Encouraged to stay active c PAP programEncouraged to stay active c PAP program

Evolve into sponsors for their Evolve into sponsors for their colleagues.colleagues.

Terminated for non-participationTerminated for non-participation– PAP notified.PAP notified.