Drugs in substance use disorder_ pharmacology

Pharmacology nursing

1. 1- 5.Complementary A nd Alternative Therapies 8.DRUGS In Substance Use Disorder LORIE ANN S. BALILI RN, CNN, MAN

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5. SUBSTANCE USE DISORDER O ther factors related to substance use disorder: F amily-related risk factors: between 16% and 29% of children who suffer neglect or abuse-physical, sexual, and emotional have tried or use drugs. S ocial risk factors: deviant peer relationships (i.e the adolescent associates with the abuser s and uses drugs to feel accepted), Peer pressure, popularity , and bullying have all been correlated to drug use. G ang affiliation is associated with higher drug use and deliquent behavior. I ndividual risk factors: individual with attention-deficit/ hyperactivity disoder (ADHD) are three times as likely as the general population to use drugs such as nicotine, alcohol, a nd drugs other than cannabis; Depression is associated with alcohol use, particularly among young men. Used more than one drug Cognitive development at the time drugs are introduced plays a major role. Adolescents are in a period of brain development where they are especially vulnerable to stress and risk-seeking behavior. POLYDRUG USE

6. Substance use disorder - Occurs “when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment such as health problems, disability, and failure to meet major responsibilities at work, school, or home.” Neurobiology Drugs that are misused typically increase the availability of dopamine and other neurotransmitters in the limbic system of the brain. Reward circuit a structure that regulates our ability to feel pleasure and other emotions, both positive and negative. The drug interfere with the way neurons in the brain normally send, received, and process information by mimicking the brain own neurotransmitters; however, drugs do not copy neurotransmitters exactly, which results in faulty transmission or excessive stimulation. Most of the drugs facilitates transmission of dopamine in the system, leading to mood elevation or euphoria .

7. S ome drugs increase the availability of other neurotransmitter, such as serotonin and gamma-aminobutyric acid (GABA), but the dopamine’s effect on the reward system appears to be pivotal to substance use disorder. Repeated use of drugs remodels the neural circuitry of the brain cells and reduces the responsiveness of receptors. This decreased the responsiveness leads to tolerance. The need for a larger dose of a drug to obtain the original euphoria. Drug use results in levels of dopamine that do not naturally occur; tolerance also reduces the sense of pleasure from experiences that previously resulted in positive feelings such as food, sex, or relationships. Without drugs, the individual may experience depression, anxiety, and/or irritability.

8. Nonpharmacological Therapy for Substance Use Disorders: Individual And Group Counseling Therapy Description Cognitive behavioral therapy CBT teaches people to recognize and stop negative patterns of thinking and behavior and helps enhance self-control. For instance, therapy might help a person become aware of the stressors, situations, and feelings that lead to substance use so that the person can avoid them or act differently when they occur. Contingency management This approach is based on frequent monitoring of behavior and removal of rewards for drug use and was designed to provide incentives to reinforce positive behavior and help the person remain abstinent from drug use. Motivational enhancement therapy MET helps people with substance use disorders develop internally motivated changes and commit t specific plans to engage in treatment and seek recovery. It is often used early in the process to engage people in treatment. Twelve-step facilitation therapy Seeks to guide and support engagement in 12 steps programs such as alcoholics anonymous or narcotics anonymous.

9. Terminology Related to Substance Use Disorder Term Definition Abstinence Refraining from drug use Craving Strong desire for a drug or for the intoxicating effects of that drug Intoxication A condition that results in disturbance in the level of consciousness, cognition, perception, judgment, affect or behavior, or other psychological functions and responses. Stabilization Acute treatment for substance use disorder involving supervision, observation, support, intensive education and counseling that involves multidisciplinary treatment interventions Tolerance Requiring a significantly increased amount of a drug to achieve the desired effect Withdrawal syndrome A group if symptoms of varying severity that occur upon cessation or reduction of use of a drug that has been taken repeatedly, usually for a prolonged period and/or in high doses; may be accompanied by signs of physiologic disturbances. Remission None of the 11 criteria for substance use disorder for at least 3 months (early remission, 3-13 months; sustained remission, after 12 months) Controlled environment Environment where access to any drug is restricted ( e.g treatment center or halfway house) Impaired control Diminished ability of an individual to control his or her use of a drug in terms of onset, level or termination Social impairment Recurrent drug use despite problems at work or school, interpersonal problems, or the cessation of social and recreational activities. Risky use Recurrent drug use despite the difficulty it is causing ( e.g driving while intoxicated, liver damage) Recovery A process of change through which an individual improves health and wellness, lives a self-directed life, and strive to reach full potentials. Relapse A return to drug use after a period of abstinence often accompanied by reinstatement of substance use disorder.

10. Types of substance use Disrorder 01 02 04 ALCOHOL USE DISORDER CANNABIS DISORDER 03 OPIOID DISORDER TOBACCO DISORDER OTHER SUBSTANCE USE DISORDER: Cough and colds products Anabolic-androgenic steroids 05

11. Types of substance use Disrorder Inhibits the effects if GABA, thereby reducing neurotransmission in the brain. S hort-term effects of alcohol use include nausea, vomiting, headaches, slurred speech impaired judgement, memory loss, hangovers, and black outs. L ong term problems associated with heavy drinking includes stomach ailments, heart problems, cancer, brain damage, serious memory loss, immune system compromise and liver cirrhosis. I ncrease the chance of dying from automobile accidents, homicide, and suicide. S pouses and children of person with AUD may face family violence, and children may suffer physical a nd sexual abuse and neglect and may develop psychologcical problems. 01 ALCOHOL USE DISORDER

12. Treatment for AUD 1. Disulfiram - inhibits aldehyde dehydrogenase, the enzyme that involved in metabolizing alcohol. Used in people who are newly abstinent. Administered in tablet form dosage ranges from 125 to 500 mg daily. Should not be taken 12 within 12 hours of alcohol consumption (including mouth wash, cough medicine or eating desserts that containing alcohol or eating foods cooked in alcohol. Should never be used in combination with eliglustat and ritonavir. 2. acamprosate- is a GABA analogue thought to work in the brain to restore the balance between neuronal excitation and inhibition via GABA and glutamate. It should only be used in persons who are abstinent; may be continued through relapse. Usual dosing is 666 mg orally three times per day. Dosing adjusted in kidney disease, and serum creatinine level should be obtained at baseline. Common side effects: includes pain, loss of appetite nausea, diarrhea, dizziness, anxiety, pruritus, depression, insomnia. Patient should be assessed for suicidal ideation before beginning treatment. 3. Naltrexone- is a competitive opioid antagonist with a high affinity for mu receptors. Oral form absorbed through the GI tract undergo up to 40% first pass metabolism. A naloxone challenge test may be done before initiating treatment and the patient is observed for an hour. If no withdrawal is observed, dosing may begin the next day at 50 mg per day for 12 weeks or less.

13. Types of substance use Disrorder Cannabis contains more than 60 related psychoactive chemicals known as Cannabinoids ; the most abundant of these is delta-9-tetrahydrocannabinol (THC) Is the most commonly used recreational drug in the US. Cannabis use disorder is more common among people in their late teens and early 20s. Users report feeling an alteration in their senses and an altered sense of time as well as changes in mood. Other names: Marijuana, blunt, Bud, Dope, Ganja, Grass, Green, Herb, joint, Mary jane, Pot, Reefer, Sinsemilla, Skunk, Smoke, trees and weeds. CANNABIS DISORDER 02 When smoked, THC rapidly crosses the blood brain barrier and binds to cannabinoid receptors in many areas of the brain, overwhelming the endocannabinoid system and making it difficult for the user to respond appropriately to incoming stimuli. Cannabis increases heart rate and may cause hallucination, it can cause problem with balance and coordination and learning ability.

14. T reatment for Cannabis Long term use of cannabis is associated with chronic cough, frequent respiratory infections and exposure to cancer causing compounds because the smoke has many of the same irritating and lung damaging properties as tobacco. The drug has been linked to mental health problems and increased symptoms in persons with schizophrenia. Babies born to women who use cannabis have behavioral issues and problems with attention, memory and problem solving. Many have supported the nationwide legalization of cannabis to treat medical condition; however, rigorous scientific evidence show that the benefits of cannabis outweigh its health risks is limited and does not support approval. Cognitive behavior therapy (CBT) contingency management and Motivational enhancement therapy (MET) may be effective in the treatment of cannabis use disorder; however, no medication are currently approved or indicated for this use.

15. OPIOID USE DISORDER A re controlled substances legally prescribed to treat moderate to severe pain. T hese drugs interact with opioid receptors in the brain and nervous system to reduce pain. I n addition to reducing pain, this receptor inteaction floods the brain’s reward system with dopamine, producing a sense of euphoria and tranquility. S hort term effects of opioid use include drowsiness, mental confusion, nausea, constipation, and dose-dependent respiratory depression. W hen taken with alcohol, users may experience dangerous slowing of heart rate and breathing leading to coma or death. P rescription opioids are also known by numerous street names including vikes, cody, china white, fizzies, M, Demmies, Blue heavens, Juice, Smack, Hillbilly, Heroin and Roxy. The FDA has toughened the safety warnings on opioids including adding a boxed warning about the potentially lethal risks associated with misuse. 03

16. Naloxone- is the drug of choice in the treatment of respiratory depression associated with opioid overdose. I s a short-acting opioid antagonist that competitively attaches to opioid receptors in t he CNS, thereby blocking activation by opioid drugs. Methadone - since 1950s this has been prescribed to treat person’s with OUD. W hen taken as prescribed and combined with couseling and behavioral therapies, administration of this long acting opioid drug is safe and effective. Methadone works by changing the way a person’s brain respond to pain; it is an opioid receptor agonist at the mu receptor and an antagonist at the N-methyl-D- aspartate (NMDA) receptor. Taken daily, it blocks the sense of euphoria and tranquility caused by opioid use and prevents opioid withdrawal craving. Treatment for Opioid disorder

17. T obacco use disorder When smoked, nicotine is absorbed from the lungs into the pulmonary venous circulation. It then enters the arterial circulation and moves quickly to the brain. Once across the blood brain barrier, nicotine stimulates the release of dopamine, norepinephrine, GABA, glutamate, and endorphins, resulting in stimulation and pleasure and a reduction in stress and anxiety. These sensations fuel the brain’s reward circuit. 04 Quitting is difficult. Persons attempting to quit experience irritability, anger, anxiousness, difficulty thinking, cravings, and increased in hunger. Support is very important part of the process and is often combined with pharmacologic measures. CBT is a goal-directed and problem-focused therapy designed to help the person with TUD identify negative thought patterns and inaccurate beliefs to learn new ways of coping and develop new ways of thinking. 1. Nicotine replacement drugs-sold as a gum , patch, spray, inhaler, or lozenge-mimic the nicotine effects of tobacco by binding to nicotine receptors in the CNS Treatment for TUD

18. Treatment for TUD 2. Bupropion -an antidepressant drug , increases level of dopamine and norepinephrine in the brain, mimicking the effects of nicotine. I t is also has some neuronal nicotinic receptor-blocking activity, reducing reinforcement from the brain’s reward circuit. W hen used for smoking cessation, the dosage is 150 mg ER or once daily for 3 days. T reatment should continue for 7 to 12 weeks; however, ongoing treatment for a year has shown benefit. 3. Vernicline- is a partial alpha-4-beta-2 receptor agonist that stimulates dopamine activty in the brain but not to the extent of nicotine, thereby reducing craving and withdrawal. D osing begins 1 week before an identified quit date at 0.5 mg daily for 3 days.

19. O ther substance use disorder Dextromethorpan- ana antitussive that can be purchase without a prescription. U sing DXM is known on the street as “robotripping” or “skittling”. W hen taken in higher-than recommended amounts, users may experience euphoria, dissociative effects, or hallucination. P romethazine-codeine cough syrup- can result in relaxation and euphoria when taken in higher that recommended amounts; when combined with soda it is referred to as syrup, sizzurp, purple drank, Barre, or lean. C ough and cold products Anabolic-androgenic steroids Is synthetic agent used to treat conditions caused by low levels of testosterone in the body, such as delayed puberty, hypogonadism, and cachexia related to chronic disease drugs. This have used to enhance athletic and sexual performances and physical appearance in all age groups.

20. Short term effects of AAS use include headache acne, fluid retention in the hands and feet, oily skin, yellowing of the skin and whites of the eyes, aggression, extreme mood swings, anger, paranoid jealousy, extreme irritability, delusions, impaired judgement, and infection at the injection site. Withdrawal from AAS use may lead to mood swings, fatigue, restlessness, loss of appetite and decrease sex drive. Nurses must be alert when caring for persons withdrawing from AAS use because withdrawal may cause depression lasting up to a year, which can result in suicide attempts.

21. S pecial Needs Of Patients With Substance Use Disorder N urses should be laert for signs and symptoms of drug interactions with pain medication or anesthesia and for signs of withdrawal W hen patients experience pain, the goal is to treat the pain. A ddressing substance use disorder is not a priority when a patient is in pain. W hen patient acknowledge substance use disorder, it is importantn to determine which drug is used and the amount taken each day. R espiratory changes in persons with TUD make introduction of endotracheal and suction tubes more difficult and increase the risk for postoperative respiratory problems. S urgical patients P ain management

22. N urses take care of others before themselves N urses may enter nondisciplinary programs designed for evaluation and treatment, allowing nurses to maintain their licences. The Nurse With Substance Use Disorder I dentified as job stress, the emotional demands of nursing, long hours and shift rotations, and easy access to drugs. N urses internalize their feelings tom stay in control during the crisis and have little to no time to decompress. discrepancies in controlled- drug handling and records may indicate drug diversion, the deliberate redirecting of a drug from a patient or facility to the employee for personal use. I t is important for nurses to identify pateints who misuse drugs and to intervene. K nowledge of the most commly used drugs and their treatment is critical to sustained remision and promotion of healthy lifestyle C ontributing factor C haracteristics Management Signs and symptoms of substance use disorder

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27. Resources Online Journals: https://www.reliasmedia.com/articles/44548-joint-commission-ids-five-high-alert-meds https://www.registerednursing.org/nclex/dosage-calculations/ https://parents-life.com/teratogens-in-pregnancy/ https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf E-Books: Burchun and Rosenthal (2019). Lehne’s pharmacology for nursing care. 10th Edition. St. Louis, Missouri: Elsevier. Edmund, M.W (2016). Introduction to Clinical Pharmacology 8 th ed. St. Louis, Missouri: Elsevier. Ford, S.M. (2018). Roach’s Introductory: Clinical pharmacology. 11th Edition. Philadelphia, Pennsylvania: Wolters Kluwer. Hayes, Kee, and McCuistion (2015). Pharmacology: a patient-centered nursing process approach. 8 th Edition. St, Louis, Missouri: Saunders, Elsevier. Hodgson and Kisior (2019). Saunders nursing drug handbook 2019. 27th Edition. St. Louis, Missouri: Elsevier. Lapham, R. (2016). Drug calculations for nurses: A Step-by-step approach. 4 th Edition. Boca Raton, Florida: CRC Press