Delana Frazier RN. BSN. FNP-S Texas Woman’s University

Denton Campus College of NursingFall 2009

IntroductionAddictive behavior is a repeated satisfied or calming feeling

when one repeatedly fulfills a desire. Physiological factors include raising brain levels of dopamine. Psychological factors evolve from positive feedback provided

by pleasurable sensations. Social/behavioral factors include the following: Ex: Smoking

becomes a habit and intrinsic part of daily activities. Ex: Smoking can be used as self-medication to reduce

unpleasant sensations that occur with tobacco withdrawal or stress.

Epidemiology

By the 8th grade teenagers in Texas.52% of adolescents have consumed alcohol. 41% have smoked cigarettes.20% have used marijuana.

Most people begin smoking as adolescents. Among youths who smoke, the average age of initiation is 12.5 years of age.

http://www.gdcada.org/statistics/teens.htm

Smoking and tobacco is the 4th leading indicator.

Substance abuse is the 5th leading indicator. (Healthy People (2010)

Pathogenesis of Teenage AddictionAddictive behaviors can be an increase or a

decrease in the reaction to stimulant or depressant introduced in the body.

Smoking has nicotine it suppresses the central nervous system (CNS) a smokers calming effect. Smoking addiction leads to alcohol use.

Alcohol is also a CNS suppressant. Alcohol use leads to marijuana use.

Progression of Teenage AddictionMarijuana is a CNS suppressant it affects the

limbic system making the person not care about their actions and becomes mellow. Use of marijuana leads to elicit street drugs Extacy and cocaine even heroin.

Methamphetamine (Meth) is prescription or street drug CNS stimulant but is highly addictive and needs to have increase amount over time to maintain the desired effect.

After one has used Meth they usually progress to heroin or ‘Cheese”. Cheese is a combination of heroin Tylenol PM and Xanax.

Risk factors for Addictive BehaviorsThe etiology of addictive behaviors is vulnerability

or lack of education and lack of self control. The following elements cloud good decision making by the teenager.

StressFeeling of worthlessness Early aggressive behaviorLack of parental supervisionPeer pressure Exposure to substance abuseDrug availabilityPoverty

Teenager DecisionsThere have been as many as 22 teenagers in

Collin county alone since 2007 deaths from over dose to cheese.

Teenagers are influenced by their environment. The teenager who has a parent who smokes or drinks and a peer who smokes influences the teenager’s choices.

A personal experience with one teenager found at a Rave party unresponsive. EMS brought him to ER. I was his nurse. We were blessed he lived.

Clinical Presentation of Teenage Addiction

Addictive behaviors are individual and are influenced by the family, peer pressure, school, and the community.

Warning Signs for drug/chemical addiction They have sleepiness and difficult to stay awake. Poor gradesStrange hoursUnusual behavioral patterns often represent clues to

the problem. A tendency toward secrecy or lack of inhibition is

sometimes observed. The lack of appropriate inhibition may display itself as a

lack of respect for others or a tendency toward vulgarity.

When the teenager is causing financially and physically damage to the family start to try to help the teenager and seek medical assistance.

Clinical Presentation of Teenage Addiction

Smoking the teenager wants to appear to be “cool.” (Ferguson, L. A. 2009)

Warning Signs for SmokingFor Parents the warning signs. • They smell of smoke. They recently acquired a lighter.

Burn holes in their cloths. They desire to have breath mints, and open windows. They have frequent excuses to go outside. The single most important thing to preventing a teen from smoking is just talk to them.

For the ProviderTake time to screen the teenager when they are in the

office for treatment. Take your time so to develop a relationship and trust. Always approach a teenager in a non-judgmental way. Offer to help the teenager to stop smoking and a plan. Make sure they know that when they decide on a date to stop to make sure they know to call you so you can insure a plan.

Treatment for Addictive BehaviorTeenage Drug/chemical addiction:• If prevention fails, early intervention is the next

hope. During the early stages of drug or alcohol experimentation, calm and honest dialog are helpful and a referral to or consultation with an addiction specialist is advisable.

• Once the adolescent is firmly addicted, an aggressive treatment program must begin with medical intervention.

• In Patient treatment is the most successful treatment.

Parents guide to cheese.

http://www.dallasnews.com/sharedcontent/dws/news/longterm/stories/cheese.b67ba6.html

Smoking Cessation GuidelinesSmoking Cessation GuidelinesThere has not been an update by the Surgeon

General on these guidelines since of May 2008. Please go to the following site which gives the full update (over 200 pages): http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf

“The goal of these recommendations is that clinicians strongly recommend the use of effective tobacco dependence counseling and medication treatments to their patients who use tobacco, and that health systems, insurers, and purchasers assist clinicians in making such effective treatments available.” (pg. vi)

Treatment for Addictive Behavior

Teenage Smoking: Surgeons General 5A’sAsk: Ask about tobacco use at every encounter:

Identify and document tobacco use status for every patient at every visit.

Advise: Advise all smokers to quit: Use strong, clear, and

personalized manner, urge every tobacco user to quit.Assess: Identify smokers willing to make a quit attempt:

Is the tobacco user willing to make a quit attempt at this time?Assist: Aid the patient in quitting: Offer medication and provide or

refer for counseling or additional treatment to help the patient quit. If unwilling quit address tobacco dependence and willingness to quit at next clinic visit.

(Surgeons General 2009)

Treatment for Addictive BehaviorSmoking Cessation

Arrange: Schedule follow-up contact: Arrange for frequent follow-up visits (first should be

soon after the quit date) or phone contacts to assess cessation.

At each contact, ask patients if they’ve quit, provide positive reinforcement, and if smoking has resumed remind them that relapse is common and that it can be used as a learning experience and not as a sign of failure.

Assess nicotine replacement therapy use and problems. Consider referral to more intensive program.(Uphold, C. R. & Graham, M. V. 2003)

Pharmacotherapeutics First 5 Nicotine Replacement Treatment

Smoking treatment:

The 5 A’s should be used with all adolescent teens.

There are 2 options besides counseling for teens: nicotine gum and patches, although trials using other therapies (Bupropion, Clonidine Nortriptyline) have been shown to be effective in teens. (NPPR, Fall, 2009)

Pharmacotherapeutics First 5 Nicotine Replacement Treatment

Five first-line: Nicotine gum Nicotine patch Nicotine nasal spray Nicotine inhaler Nicotine lozenge Bupropion SR (Zyban) Varenicline (Chantix)Category C: Buproprion and VareniclineCategory D: Nicotine gum, patch, nasal spray,

inhaler (CDC 2009)

Pharmacotherapeutics Available: Nicotine gum • exclusively as an over-the-counter medication • 2 mg and 4 mg (per piece) doses.

Dosage: • 2 mg gum initially for patients smoking < 25 cigarettes/d • 4 mg for smoker > 25 cigarettes/day or failed with 2 mg • not exceed 30 pieces per day for using 2 mg strength • not exceed 20 pieces per day for using 4 mg strength

Duration: • Usually for first few months of quit attempt • Should tailor the dosage and duration of the therapy to fit the need of each patient.

Pharmacotherapeutics

Adverse effects:

Mouth soreness, hiccups, dyspepsia and jaw ache.

Instructions: Patient should refrain from smoking while using the gum. Chew slowly until a “peppery” taste emerges, then

“parked” slowly between cheek and gum to facilitate nicotine absorption through the oral mucosa.

Gum should be intermittently chewed and parked for about 30 minutes. (NPPR, Fall, 2009)

First 5 Nicotine Replacement Treatment Patch

Nicoderm and Habitrol

4then 2then 2

21/2414/247/24

Prostep 4Then 4

22/2411/24

Nicotrol 4then 2then 2

15/1610/165/16

Brand Duration (WEEKS)

Dosage (mg/h)

Available: Both as an over the counter and a prescription medication patch.Duration/Dosage: ( McPhee, 2009, P. 9 )

Question #1J.J is an 18 year old male presents to the clinic alone and has

insurance because he is still a senior in the high school. “I want to get the patch to help stop smoking.” He says he has smoked for 1 year. He smokes between 18-20 cigarettes daily and does most of his smoking at work. He works at Market Street as a grocery boy. He smokes everyday even when he is ill. His parents are aware he smokes and borrows cigarettes from them. He smokes his first cigarette in the morning before getting out of bed. He says he has tried to cut down on his smoking from 25 cigarettes a day. Given the drug information what would you give J.J to help him stop smoking?

A. First he must establish a quit date then 2 weeks before start him on Buproprion 150mg pill daily for two weeks.

B. 2 mg gum initially for patients smoking < 25 cigarettes/d, not exceed 30 pieces per day for using 2 mg strength.

C. 4 mg for smoker > 25 cigarettes/day or failed with 2 mg, not exceed 20 pieces per day for using 4 mg strength

Question #2

Given the medication information when writing the prescription for J.J. you tell him to chew the gum for 30 minutes until you have a “peppery flavor. Then you park the gum. He asks you where do I park this gum?

A.You tell him to stick it in the first handicapped parking space in the parking lot by the door of the clinic.

B.You tell him to place the gum between the cheek and gums for 30 minutes.

C.You tell him he is to chew it for 30 minutes and sick it behind his right ear.

PICO Question:Teenagers with addictive behaviors, how does

outpatient therapy compared to inpatient therapy affect the ability to successfully eliminate their addictive behavior?

A.The treatment of drug/ chemical addictive behaviors for teenagers are to be referred for inpatient treatment.

B.As a health care provider we can successfully treat teenagers for tobacco addictive behaviors in a out patient setting.

Government Assistive Programs for Referral

• For more information, contact the Phoenix Academy at 214-999-1044, ext. 3156, or www.phoenixhouse.org; or the Nexus Recovery Center at 214-321-0156 or www.nexusrecovery.org.

• For information about the public mental health and substance abuse treatment system, contact ValueOptions at 1-888-800-6799 or www.valueoptions.com/northstar.

• The Texas Department of State Health Services operates a toll-free hotline to locate services at 1-877-9NODRUG (877-966-3784), or go to www.tcada.state.tx.us/treatment/index.shtml.

• The Greater Dallas Council on Alcohol and Drug Abuse provides referrals at 214-522-8600 or www.gdcada.org.

ConclusionNo single factor determines patterns of tobacco use. These

patterns are the results of complex interactions f multiple factors, such as socioeconomic status, cultural characteristics, acculturation, stress, biological elements, targeted advertising, price of tobacco products, and varying capacities of communities to mount effective tobacco control initiatives.

Our society needs surveillance and prevention research are needed on the changing cultural, psychosocial, and environmental factors that influence drug addiction or tobacco use to improve our understanding of racial/ethnic patterns and identify strategic control opportunities. (CDC, 2009)

References Adelman W.P. (2006). Tobacco Use Cessation for Adolescents. Adolescent Medicine

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CDC. Tobacco Use Among U.S. Racial/Ethnic Minority Groups: A report of the Surgeon General 2007 Retrieved September 21, 2009 from http://profiles.nlm.nih.gov/NN/B/C/M/C/ Ferguson, L. A. (2009), Adolescent Smoking: A lethal Addiction. The Journal for Nurse

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Hill. Uphold, C. R. & Graham, M. V. (2003). Clinical Guidelines in Family practice ( 4th. Ed.) Gainesville, Florida: Barmarrae Books, Inc.