Ppt chapter 09-1

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 9

Lifestyle: Substance Abuse


Question

• The use of alcohol, tobacco products, and illicit drugs can seriously complicate drug therapy.

– A. True

– B. False


Answer

• A. True

• Rationale: The use of alcohol, tobacco, and illicit drugs affects the pharmacokinetics and pharmacodynamics of concurrent drug therapy.


Overview

• Lifestyle, diet, and habits are core patient variables that exert one of the most important effects on a patient’s response to drug therapy.

• Substance abuse is the inappropriate and usually excessive self-administration of a drug substance for nonmedical purposes.

• Drug addiction is a complex process involving interactions among the drug, the user, and society.


Dopamine Hypothesis • Scientists are becoming increasingly convinced that a link

exists between the neurotransmitter dopamine and drugs of abuse.

• Dopamine is associated with feelings of pleasure and elation.

• Cocaine use stimulates a surge of dopamine in the addict’s brain.

• Addiction may be a disorder of the brain no different from other forms of mental illness.

• The major drugs of abuse mimic the structures of neurotransmitters.


Factors that Affect Substance Abuse


Physiology

• The physiologic effects of drugs with a high potential for abuse involve the body’s adaptation to the toxic effects of the drugs at the biochemical and cellular levels.

• Several physiologic changes characterize this process: tolerance, physical dependence, and psychological dependence.

• It is important to note that tolerance or physical dependence alone does not imply addiction.


Physiologic Changes

• Tolerance occurs when the body develops a natural resistance to the drug’s physical or euphoric effects.

• Physical dependence occurs when actual changes in body cells cause the body to “need” the drug for homeostasis.

• Psychological dependence involves the compulsive use of a drug. It results from the direct influence of drugs on brain chemistry.


Question

• Cross-tolerance can occur between clonazepam (Klonopin) and meperidine (Demerol).

– A. True

– B. False


Answer

• B. False

• Rationale: Cross-tolerance may occur within a drug class, meaning that tolerance to a drug in a particular class may be transferred to other drugs in the same class. Clonazepam and meperidine are not in the same class of drugs.


Factors Influencing Drug Abuse

• Genetic factors: Certain genes may predispose a person to, or protect the person from, drug abuse.

• Developmental and environmental influences: They can trigger changes in brain hormones, making a person more at risk.

• Personality traits: No absolute addictive personality has been identified.

– Risk traits: low tolerance for frustration, impulsivity, manipulativeness, fears of failure, feelings of inadequacy, resentment, hostility, and anger


Factors Influencing Drug Abuse (cont.)

• Mood disorders: They are more likely to cause substance abuse.

• Availability of drugs: If the substance is more readily available, abuse can occur.

• Drug diversion: It estimated to cost employers and insurance companies $25 billion annually.

• Socioeconomic circumstances: People may use or traffic drugs to escape harsh surroundings of poverty and illiteracy and change their perceptions of reality.


Substance Abuse and the Central Nervous System • Virtually all abused drugs have some effect on the CNS.

• The excessive use, these drugs can have adverse effects when their use leads to dependence.

• Commonly abused drugs that affect the CNS are classified into five main categories:

– CNS depressants

– CNS stimulants (psychoactive drugs)

– Hallucinogens (psychedelic drugs)

– Cannabis

– Miscellaneous drugs


Central Nervous System Stimulants

• The most commonly abused CNS stimulants include cocaine and the amphetamines.

• These CNS stimulants initially increase heart rate and blood pressure, energize muscles, decrease appetite, and cause some degree of mental and physical alertness.

• CNS stimulants produce feelings of self-confidence and induce some degree of euphoria.

• All stimulant drugs pose a risk of both physical and psychological dependence.

• As a general rule, intoxication with stimulant drugs is more dangerous than withdrawal.


Central Nervous System Depressants

• CNS depressants decrease heart rate, respiration, muscular coordination and energy and cause constipation, depression, nausea, vomiting, physical dependence.

• Commonly abused CNS depressants include sedative-hypnotics, alcohol, barbiturates, and benzodiazepines.

• Alcoholism is the number one drug problem in America.

• Abrupt withdrawal from long-term use of sedative-hypnotic drugs should never be attempted because withdrawal symptoms are serious and potentially fatal.


Opioids • Opioids are commonly prescribed to relieve pain,

suppress coughing, enhance anesthetic effect for surgery, and relieve severe diarrhea.

• These narcotic drugs have a high potential for abuse and are extremely addicting both physically and psychologically.

• All opioids affect the CNS and cause cerebral changes, mood changes, confusion, euphoria, and analgesia.

• Regular use of narcotics over several weeks usually results in tolerance to the drug’s effects.

• Withdrawal effects from narcotics induce muscle pain, nausea and vomiting, abdominal cramps, and diarrhea.


Tranquilizers • Certain tranquilizing drugs, known as “date rape” drugs,

have made headlines. They are Rohypnol and gamma-hydroxybutyrate (GHB).

• Rohypnol is 10 times more potent than diazepam (Valium).

• Rohypnol induces slowing of psychomotor performance, muscle relaxation, decreased blood pressure, sleepiness, and amnesia.


Tranquilizers (cont.)

• Some of the adverse effects associated with use of Rohypnol are drowsiness, headaches, memory impairment, dizziness, nightmares, confusion, and tremors.

• GHB is a powerful, rapidly acting CNS depressant.

• Produced naturally by the body in small amounts, the physiologic function of GHB is unclear.


Hallucinogens

• Hallucinogenic drugs have pronounced mental and emotional effects because they distort the way the brain interprets sensory information.

• Included in this category are marijuana, mescaline, psilocybin, lysergic acid diethylamide (LSD), dimethyltryptamine (DMT), and phencyclidine hydrochloride (PCP).

• These drugs can be inhaled, injected, or swallowed.

• They cause a long-lasting reduction in the brain’s supply of serotonin and produce powerful psychic changes.


Inhalants

• The term “inhalants” refers to products that can be abused by inhaling them through the nose or mouth to achieve an intoxicating effect.

• Because they are easily accessible, inexpensive, and easy to conceal, inhalants are some of the first substances abused.

• Effects of inhalant use resemble alcohol inebriation.


Inhalants (cont.)

• The user initially experiences stimulation, a loss of inhibition, and a distorted perception of reality and spatial relations.

• After a few minutes, the senses become depressed, and a sense of lethargy arises as the body attempts to stabilize blood flow to the brain.

• Users also experience headaches, nausea, vomiting, slurred speech, loss of coordination, and wheezing.


Designer Drugs

• These drugs are similar in chemical structure to existing drugs and are developed with relative ease in illegal laboratories.

• They are extremely potent, and when used recreationally, they have addictive capabilities greater than those of existing drugs.

• These drugs can destroys brain cells and much of voluntary muscular movement.


Anabolic Androgenic Steroids • Anabolic androgenic steroids are synthetic formulations of

the male hormone testosterone.

• The abuse of these drugs in men and women is widespread to increase strength and enhance athletic performance.

• Anabolic androgenic steroids also have a dramatic effect on emotions and make the user feel more confident and aggressive.

• Continued use of anabolic androgenic steroids may lead to emotional instability, rage, depression, or psychosis.

• Serious health effects include sex hormone imbalances, changes in secondary sexual characteristics, permanent sterility, hepatic cancer, and myocardial infarction.


Commonly Abused Drugs

• Commonly abused drugs include alcohol, cocaine, heroin, and marijuana.

• The nurse’s role in substance abuse involves having core knowledge related to specific drugs and to abuse prevention.

– Assess for potential or actual abuse.

– Formulate plan of care for the patient who is abusing drugs or is at risk for abuse.


Pharmacokinetics of Alcohol Abuse

• Alcohol, known clinically as ethanol (ETOH), does not require digestion before absorption.

• It is completely absorbed by the stomach and small intestine within 2 hours of ingestion.

• The liver metabolizes alcohol by two different pathways.

• People with chronic alcoholism metabolize alcohol by way of the MEOS, which causes damage to the liver cells.

• Alcohol is excreted in urine by the kidneys, in the breath by the respiratory system, and in sweat by the skin.


Question

• Food in the stomach will _______ the effects of alcohol.

– A. Increase

– B. Decrease

– C. Have no effect


Answer

• B. Decrease

• Rationale: Food in the stomach decreases the effects of alcohol, delays gastric emptying time, and retards absorption from the small intestine.


Pharmacodynamics of Alcohol Abuse

• Alcohol affects many body systems.

• Alcohol is thought to interfere with the transmission of nerve impulses.

• Alcohol sequentially depresses the CNS.


Adverse Effects of Alcohol Abuse

• Alcohol depresses the CNS.

• Alcohol impairs muscular coordination.

• It increases the heart rate and dilates the blood vessels.

• In low doses, alcohol lowers the blood pressure.

• Prolonged alcohol use causes hypertension and cardiovascular damage.

• Alcohol irritates the gastrointestinal (GI) tract.

• Excess alcohol consumption inhibits antidiuretic hormone and therefore increases urine production.


Alcohol: Drug Interactions

• Alcohol has no nutritional value, and it interferes with the absorption of vitamins and minerals.

• Alcohol can affect iron absorption, folate activities, and platelets.


Cocaine Abuse

• Cocaine is derived from the leaves of Erythroxylon coca.

• Cocaine is usually administered orally, intravenously, or by nasal insufflation.

• Treatment for cocaine addiction is difficult because of the extreme physical and psychological dependence associated with its use.


Cocaine Abuse (cont.)

• Pharmacokinetics

– Cocaine is rapidly absorbed into the bloodstream.

– Onset, peak, and duration vary with route of administration.

– Cocaine is extensively metabolized in the liver and the blood.


Cocaine Abuse (cont.)

• Pharmacodynamics

– Cocaine has pronounced effects on the central and peripheral nervous systems.

– It causes hypertension, tachycardia, and vasoconstriction.

– It interferes with serotonin uptake and dopamine reuptake.


Adverse Effects of Cocaine Abuse • Adverse reactions to cocaine include the following:

– CNS: agitation, anxiety, excitement, paranoid psychosis, and seizures

– Cardiovascular: atrioventricular arrhythmias, severe hypertension, cardiomyopathy, coronary and peripheral vasoconstriction

– Pulmonary: pneumothorax, pulmonary edema, and respiratory arrest

– Metabolic: disseminated intravascular coagulation, hepatotoxicity, hyperthermia, renal failure, and rhabdomyolysis

– Complications of nasal inhalation: anosmia, nasal mucosal atrophy, nasal septal necrosis, and rhinorrhea


Opioid Abuse

• Heroin is the most abused opioid in the United States.

• It is a synthetically manufactured drug that possesses morphine-like pharmacologic activity.

• It has a poor oral availability; therefore, abusers often begin by smoking the drug.

• Pure heroin is very expensive and dangerously powerful.


Opioid Abuse (cont.)


– The rate of heroin’s absorption by the bloodstream depends on the method of administration.

– The effects of injected heroin persist for approximately 4 to 6 hours.

– Most heroin is converted to morphine and excreted by the kidneys.


Opioid Abuse (cont.)


– Heroin acts on the body in a manner similar to that of other opioids.

– The abuser feels relaxed, carefree, and somewhat dreamy.


Adverse Effects of Opioid Abuse

• The pathophysiologic effects of heroin are similar to those of other opioids.

• An overdose of heroin may result in severe respiratory depression, pulmonary edema, coma, and possibly death.

• Some pathophysiologic effects specific to IV heroin use include infection with human immunodeficiency virus (HIV) or hepatitis.


Marijuana Abuse

• The most commonly abused psychedelic drug is marijuana.

• The major ingredient of marijuana is 9-tetrahydrocannabinol (THC).

• The THC concentration in the average marijuana cigarette has increased substantially during the past 3 decades.

• A typical marijuana cigarette delivers a dose of THC ranging from 2.5 mg to 5 mg.


Marijuana Abuse (cont.)

• Pharmacotherapeutics

– An oral form of marijuana is used for anorexia, nausea, and vomiting.


– The systemic availability is based on the route of administration.

– THC is metabolized in the liver and excreted by the kidneys.


Marijuana Abuse (cont.)


– The mechanism of action of THC is unknown, but it does have antiemetic properties.

– THC produces minor cognitive effects.


Adverse Effects of Marijuana Abuse

• Some of the adverse effects of THC include decreased myocardial oxygen supply, increased heart rate, and impaired fertility.

• Cannabinoid receptors are concentrated most heavily in the cerebellum and hippocampus.

• Although smoking marijuana is often thought to be relatively safe compared with smoking tobacco, the smoke is virtually identical in both cases.

• Tolerance to the effects of marijuana develops quite slowly.


Hallucinogen Abuse

• Although often associated with the 1960s, LSD and PCP are still used.

• LSD is taken orally, and PCP can be taken orally, smoked, or injected.

• Tolerance develops with continued use of these drugs.

• No specific withdrawal syndrome is associated with these drugs.


Hallucinogen Abuse (Cont.)


– Dependent on the route and dosage of the drug

– PCP is rapidly metabolized in the liver and excreted in the kidneys.


– The mechanism of action is unclear.

– Alterations in sensory perception occur.

– Sensory input is also enhanced.


Adverse Effects of Hallucinogen Abuse

• Subjective effects and mood changes are quite variable with LSD.

• LSD produces adrenergic effects: hypertension, hyperpnea, tachycardia, hyperthermia, pupillary dilation, and hyperreflexia.

• Diaphoresis, salivation, lacrimation, nausea, and vomiting may also occur.

• Dopaminergic and anticholinergic effects on the body occur with PCP use.

• PCP can cause severe psychoses, seizures, respiratory depression, intracerebral hemorrhage, hyperpyrexia, and death.


Inhalant Abuse

• Inhalants are volatile chemicals and gases that produce behavioral effects.

• Commonly abused inhalants include model glue, spray paint and hair spray propellants, cleaning solvents, gasoline, and kerosene.

• Long-term inhalant abuse can cause permanent CNS, hepatic, renal, and bone marrow damage.


Inhalant Abuse (cont.)


– Inhalants are rapid-acting substances.

– The duration of the effect depends on the substance used.


– Inhaling volatile chemicals and gases produces a short-lived, mild intoxication.

– These agents produce a sense of exhilaration and light-headedness.


Adverse Effects of Inhalant Abuse

• Psychological dependence can develop, but physical dependence is rare.

• Tolerance to the substance can develop over time.

• Toxicities depend on the properties of the individual solvents.

• Abuse of inhalants has been implicated in severe brain damage, cancer, neuropathies, kidney failure, liver damage, respiratory failure, and cardiac arrest.


Health Status

• When the nurse suspects that a patient may be abusing substances, a physical, psychological, and functional health assessment is performed.

• Substance abuse screening may be easily incorporated into a health habits survey.

• At this time, also ask the patient about any family history of substance abuse.

• During the physical assessment, convey a nonjudgmental attitude, which may encourage the patient to communicate.


Life Span • Pregnancy

– An estimated 10% of infants are exposed to illicit drugs during the gestational period.

– Drug use and abuse during pregnancy have been linked to several maternal and fetal complications.

• Infancy

– Exposure to drugs can cause problems at birth and for the first 3 to 4 months of life.

• Childhood

– Prenatal alcohol exposure can lead to cognitive deficits and behavior problems.


Life Span (cont.)

• Adolescence

– The greatest physical and emotional changes occur during adolescence, which can lead to substance abuse.

• Older Adulthood

– Changes that occur in older adults may put them at risk for substance abuse.

– Substance abuse may be difficult to recognize due to chronic medical conditions.


Environment and Culture

• Environment

– Former substance abusers are at risk for relapse.

– Environmental triggers may produce intense desire for the drug even after years of recovery.

• Culture

– Some populations exhibit an unusual response after consuming ethanol.

– These people have a genetic deficiency that leads to an accumulation of ethanol.


Nursing Diagnoses and Outcomes

• Ineffective Denial related to impaired ability to accept consequences of behavior

– Desired outcome: The patient will acknowledge an alcohol or substance abuse problem.

• Risk for Other-Directed Violence related to drug or alcohol abuse

– Desired outcome: The patient will demonstrate control of behavior with assistance from others.


Nursing Diagnoses and Outcomes (cont.)

• Ineffective Health Maintenance related to substance abuse

– Desired outcome: The patient will identify barriers to health maintenance.

• Self-Concept Disturbance related to self-destructive behavior (substance abuse)

– Desired outcome: The patient will appraise self-situations in a realistic manner.


Maximizing Recovery

• Initial nursing interventions in acutely intoxicated patients are generally directed toward preventing life-threatening and debilitating effects.

• These nursing interventions evolve from the specific physiologic and psychological effects of the particular substance.

• Physical or psychological withdrawal symptoms may follow abrupt cessation of a substance.

• Physiologic symptoms associated with drug withdrawal may be treated with various pharmacotherapies.


Minimizing Relapse

• For alcohol, cocaine, or narcotic abusers, treatment is lifelong, and relapses do occur.

• Psychotherapy, support groups, and administration of withdrawal and anticraving drugs may help prevent relapse.


Providing Patient and Family Education

• After identifying a substance abuse problem, intervene by assisting the patient and family to develop ways to prevent substance abuse.

• Help family members identify their feelings and responses to the substance abuse problem and cope with these feelings.

• This is also an opportune time to teach the family more about the hazards of substance abuse.


Ongoing Assessment and Evaluation

• Health consequences of substance abuse are usually manifested by changes in physiologic and behavioral functioning.

• Nurses and other health care professionals have a community responsibility to provide information about substance abuse.

• Recovery is lifelong and requires total abstinence from the abused substance.

Ppt chapter 09-1

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