nursing management of patient with substance abuse disorder.pptx

Disorders due to psychoactive substance use refer to conditions arising from the abuse of alcohol, psychoactive drugs and other chemicals such as volatile solvents. These are classified under F10 in ICD 10.

1. SAROJ LAL JI MEHROTRA GLOBAL NURSING COLLEGE AMRITANSHU CHANCHAL NURSING TUTOR NURSING MANAGEMENT OF PATIENT WITH SUBSTANCE USE DISORDER

2. Substance Use Disorder

3. Introduction Disorders due to psychoactive substance use refer to conditions arising from the abuse of alcohol, psychoactive drugs and other chemicals such as volatile solvents. These are classified under F10 in ICD 10.

4. Terminologies related to addiction Abuse: The use of illegal drugs or the use of prescription or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts. Substance abuse may lead to social, physical, emotional, and job-related problems. Dependence: Substance dependence occurs when a person is physically dependent on a substance such as alcohol, nicotine, drugs, or medication, to the extent that their body adapts to it and develops a tolerance to it, resulting in withdrawal symptoms when they stop using it.

5. Tolerance: It is a state in which after repeated administration, a drug produces a decreased effect, or increasing doses are required to produce the same effect. Withdrawal state: Withdrawal syndrome, also known as discontinuation syndrome, occurs in individuals who have developed physiological dependence on a substance and who discontinue or reduce their use of it.

6. Classification

7. Commonly used psychotropic substance Alcohol Opiods Cannabis Cocaine Amphetamines & Sympatho-mimetics Hallucinogen, for example LSD, Phencyclidine Sedatives & hypnotics for example barbiturate Inhalant for example, volatile solvents Nicotine Caffeine

8. Etiological factors in psychoactive substance use Genetic vulnerability: People with a family history of alcohol abuse are up to 4 times more likely to develop problems with alcohol. Additionally, if you have a parent who has a drug problem, you may be up to 8 times more likely to develop an addiction. Research suggests that alcohol dependence and other substance addiction may be associated with generic variation in 51 different chromosomal region.

9. Biochemical Factors: Role of dopamine and nor-epinephrine have been implicated in cocaine, ethanol and opioids dependence. Abnormalities in alcohol dehydrogenase or in the neurotransmitter mechanism are thought to play a role in alcohol dependence. Neurobiological theories: Drug addicts may have an inborn deficiency of endorphins. According to another neurobiological theory, enzymes produces by a given gene might influence hormones and neurotransmitters, contributing to the development of a personality that is more sensitive to peer pressure.

10. Behavioral Theories Behavioral scientist view drug abuse as the result of conditioning, or cumulative reinforcement from drug use. Drug use cause euphoric experience perceived as rewarding, thereby motivating user to keep taking the drug. Stimuli and setting associated with drug use may themselves becomes reinforcing or may trigger drug craving that can lead to relapse.

11. Psychological factors General rebelliousness Sense of inferiority Poor impulse control Low self esteem Inability to cope with the pressure of living and society Loneliness unmet needs Desire to escape from reality Desire to experiment, a sense of adventure Pleasure seeking Masochism Sexual Immaturity

12. Social factors Religious reasons Peer pressure Urbanization Extended periods of education Unemployment Overcrowding Poor social support Effects of other mass media Substance use is more common in chefs, barmen, executives, salesman, actors, entertainers, army personnel, journalist, medical personal etc.

13. Easy Availability of drugs Taking drugs prescribed by doctors (for examples, Benzodiazepenes dependence) Taking drugs that can be bought legally without prescription Taking drugs that can be obtained from illicit source

14. Risk factors for alcohols Dependence Age: The earlier a person begins drinking, the greater the risk for dependence. People with a history of abuse, family violence, family history of alcoholism, depression and stressful life events are high risk for early drinking. Gender: Studies suggest that women are more vulnerable than men to many of long term consequences of alcoholism like alcohol hepatitis, cirrhosis of liver and brain cell damage by alcohol. History of Abuse: Individuals who were abused as children have a higher risk for substance abuse. They also have worse response to treatment than those without such a history.

15. Consequences of substance abuse Substance abuse commonly leads to physical dependence, psychological dependence or both. It may cause unhealthy lifestyle and such as poor diet. Chronic substance abuse impairs social and occupational functioning, creating and occupational functioning, creating personal, professional, financial and legal problems. Drug use beginning in early adolescence may lead to emotional and behavioral problems, including depression, problems with family relationship, problems with or failure to complete schools and chronic substance abuse problems In pregnant women substance abuse jeopardize fetal well being.

16. IV drug abuse may lead to life threatening complication Psychoactive substance produce negative outcome in many patients, including mal-adaptive behavior, bad trips an even long term psychosis. Illicit street drugs pose added dangers; material used to dilute them can cause toxic or reactions.

17. Alcohol Dependence Syndrome A chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking. A person with this disease also needs to drink greater amounts to get the same effect and has withdrawal symptoms after stopping alcohol use. Alcohol dependence affects physical and mental health, and can cause problems with family, friends, and work. Regular heavy alcohol intake increases the risk of several types of cancer. Also called alcoholism.

18. Properties of Alcohol Alcohol is a clear colored liquid with a strong burning taste. The rate of absorption of alcohol into the bloodstream is more rapid than its elimination. Absorption of alcohol into the bloodstream is slower when food is present in the stomach. A small amount is excreted through urine and a small amount is exhaled. A concentration of 80-100 mg of alcohol per 100 ml of blood is considered intoxicated. A person with 200-250 mg will toxic, sleepy, confused and his thought process will be altered. If blood level is 300 mg/100 ml of blood the person may lose consciousness. A concentration of 500mg/100 ml is fatal. All the symptoms change according to tolerance.

19. Epidemiology in India Alcohol consumption in India amounted to about five billion liters in 2020 and was estimated to reach about 6.21 billion liters by 2024. The increase in consuming these beverages can be attributed to multiple factors including the rising levels of disposable income and a growing urban population among others.

20. Epidemiology worldwide A new report from the World Health Organization (WHO) highlights that 2.6 million deaths per year were attributable to alcohol consumption, accounting for 4.7% of all deaths, and 0.6 million deaths to psychoactive drug use. Notably, 2 million of alcohol and 0.4 million of drug-attributable deaths were among men. Total alcohol per capita consumption in the world population decreased slightly from 5.7 litres in 2010 to 5.5 litres in 2019. The highest levels of per capita consumption in 2019 were observed in the WHO European Region (9.2 litres ) and the Region of Americas (7.5 litres ).

21. ICD10 Criteria for Alcohol Dependence A strong desire to take the substance Difficulty in controlling substance taking behavior A physiological withdrawal state Development of tolerance Progressive neglect of alternative pleasures or interest Persisting with substance use despite clear evidence of the harmful consequences

22. Sign & Symptoms of Alcohol Dependence Minor Complaints Malaise, Dyspepsia, Mood Swing or Depression, Increased incidence of Infection Poor personal Hygiene, Untreated Injuries (Cigarette Burns, Fractures, Bruises) Unusually High tolerance for sedatives and opioids Nutritional deficiency (Vitamins and Minerals) Secretive behavior (may attempt to hide disorder or alcohol supply) Consumption of alcohol-containing products (mouth wash, aftershave, hair spray) Denial Problem Tendency to blame others and rationalize problems

23. Psychiatric Disorders due to Alcohol Dependence Acute intoxication Withdrawal syndrome Alcohol induced amnestic disorder Alcohol induced psychiatric disorder

24. Acute Intoxication Withdrawal Syndrome Alcohol Induced Disorder Alcohol Induced psychiatric Disorder Acute intoxication: Acute intoxication develops during or shortly after alcohol ingestion. It is characterized by clinically significant maladaptive behavior or psychological changes. Example: Inappropriately sexual or aggressive behavior, mood liability, impaired judgment, slurred speech, incoordination, unsteady gait etc In person who have been drinking heavily over a prolonged period of time, any rapid decrease in the amount of alcohol in the body is likely to produce withdrawal symptoms. Withdrawal symptoms begin within 6 to 48 hours and peak about 24 to 35 hours after the last drink. During this period the inhibition of the brain activity caused by alcohol is abruptly reversed. Chronic alcohol abuse associated with thiamine (vitamin B) deficiency is the most frequent cause of amnestic disorders. This conditioned is divided into: Wernicke’s Syndrome Koraskoff’s syndrome Alcohol Induced dementia Alcohol induced mood disorder Suicidal behavior Alcohol induced anxiety disorder Impaired psychosexual function Pathological jealousy Alcoholic seizures Alcoholic hallucinosis

25. Wernicke’s & Koraskoff’s Syndrome WK syndrome involves two different brain disorders that often occur together: Wernicke’s disease and Korsakoff’s psychosis. They result from brain damage associated with AUD, combined with vitamin B1 (thiamine) deficiency. In people with severe AUD, poor nutrition decreases the ability of the gut to absorb thiamine from food and, therefore, increases the chance of developing WK syndrome. Without treatment, WK syndrome can be disabling, produce permanent memory loss, and be life-threatening.

26. Symptoms of Wernicke’s disease include In WK syndrome, damage occurs in a variety of brain regions, most notably the thalamus, hippocampus, hypothalamus, and cerebellum. These areas contribute to a wide range of functions such as vision, movement, language, sleep, memory, and motivation. Confusion Lack of energy, hypothermia, low blood pressure, or coma Lack of muscle coordination that can affect posture and balance and can lead to tremors (i.e., involuntary movements in one or more parts of the body)

27. Vision problems such as abnormal eye movements (e.g., back and forth movements called nystagmus), double vision, misaligned or crossed eyes, and eyelid drooping Although some symptoms of Wernicke’s disease such as muscle and vision problems are reversible with prompt thiamine treatment, other symptoms may respond more slowly or may not be completely reversible. Without prompt treatment, Wernicke’s disease can progress to Korsakoff’s psychosis, which is not reversible.

28. Symptoms of Koraskoff’s psychosis include Potentially severe, irreversible memory impairments, including problems forming new memories (called anterograde amnesia) and recalling memories Making up inaccurate stories about events (i.e., confabulation) or remembering events incorrectly Experiencing hallucinations (i.e., seeing or hearing things that are not really there) Repetitious speech and actions Problems with decision-making as well as planning, organizing, and completing tasks Lack of motivation and emotional apathy

29. Complications of alcohol abuse Cardiopulmonary Complications Arrhythemias Essential hypertension Cardiomyopathy Pneumonia Incresed risk for TB Gastrointestinal Complication Chronic Diarrhea Esophagitis Esophageal Cancer Esophageal Ulcer Gastric Ulcer Gastritis GI bleeding Hepatic complication Alcoholic hepatitis Cirrhosis Fatty liver Neurologic complication Alcohol Dementia Alcoholic hallucinosis Alcohol withdrawal delirium Koraskoff’s syndrome Peripheral neuropathy Seizure disorder Sudural hematoma Psychiatric complications 1. Amotivational syndrome Depression Impaird social and Occupational functioning Multiple substance abuse Suicide Other complication Beriberi Fetal alcohol syndrome Hypoglycemia Leg and foot ulcer Prostatistis Deaths due to violence Accidents, suicide and crime Domestic violence

30. Diagnosis Carbohydrate-deficient transferrin (CDT) is a biomarker for chronic alcohol intake of more than 60 g ethanol/d. It has been reported to be superior to conventional markers like gamma- glutamyl transferase (GGT) and mean corpuscular volume MCV). Gamma- glutamyl transferase (GGT) is an enzyme that's mainly found in your liver. Healthcare providers use GGT blood tests to help diagnose liver conditions or to rule out certain medical conditions based on abnormal results from other liver enzyme tests. Testosterone is a male hormone. Its level are low in men with alcoholism. MCV (mean corpuscular volume) measures the average size of your red blood cells. It’s included in a common blood test called a complete blood count (CBC). Considered alongside the results of other tests, an MCV blood test can help your healthcare provider determine if you have anemia, liver disease or other conditions.

31. An electrolyte panel, also known as a serum electrolyte test, is a blood test that measures levels of the body's main electrolytes: Sodium, which helps control the amount of fluid in your body. It also helps your nerves and muscles work properly. Chloride, which also helps control the amount of fluid in your body. Liver function test: Most common liver function test are: Alanine transaminase (ALT).  ALT is an enzyme found in the liver that helps convert proteins into energy for the liver cells. When the liver is damaged, ALT is released into the bloodstream and levels increase. This test is sometimes referred to as SGPT. Aspartate transaminase (AST).  AST is an enzyme that helps the body break down amino acids. Like ALT, AST is usually present in blood at low levels. An increase in AST levels may mean liver damage, liver disease or muscle damage. This test is sometimes referred to as SGOT.

32. An echocardiogram is an ultrasound test that checks the structure and function of your heart. An echo can diagnose a range of conditions including cardiomyopathy and valve disease. There are several types of echo tests, including transthoracic and transesophageal. It has been found that alcohol interferes with the production and function of white blood cells. The number of WBC's decreases (especially neutrophils) which increases the risk of serious infection. Also, the platelet (PLT) production gets impaired resulting in interference with blood clotting.

33. Treatment Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. It denotes a clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on substances of abuse. Detoxification seeks to minimize the physical harm caused by the abuse of substances. Drug used for treatment are: Chlordiazepoxide 80-200 mg/Day, Diazepam 40-80 mg/Day in divided doses. Symptoms of DTs tend to begin soon after you stop drinking alcohol and can happen abruptly. Because of this, it's best to talk to your doctor before stopping alcohol use. They can help you set up a plan to manage your alcohol withdrawal symptoms.

34. Treating Delirium Tremens Delirium tremens treatment begins at the hospital. The treatment aims to help relieve your symptoms, reduce the chance of complications and, if DTs are bad, save your life. Sedatives, usually benzodiazepines, are medications used to treat alcohol withdrawal and DTs. They help calm your excited nervous system. If your symptoms can't be managed with sedatives, your doctor may prescribe anesthesia so you will be completely sedated until your symptoms end. You may also need intravenous fluids with vitamins and minerals to treat dehydration or bring your electrolytes back into balance. Other drugs used in the hospital to treat acute DTs symptoms include: Antipsychotic drugs to help calm you and prevent hallucinations Anticonvulsants to stop seizures Blood pressure medications Drugs to regulate your heartbeat Pain medication

35. Treating Seizure Carbamazepine. Oxcarbazepine (Trileptal, Oxtellar XR) Lamotrigine (Lamictal) Phenytoin (Dilantin) Valproic acid (Depakene) Seizures are usually self limited and treated with a benzodiazepenes. Intravenous phenytoin along with benzodiazepenes may be used in patient who have history of seizures, who have epilespy, or in those with ongoing seizures. Because phenytoin may lower blood pressure, the patient’s blood pressure should be monitored during treatment.

36. Psychosis For hallucinations or extremely aggressive behavior, antipsychotic drugs, particularly haloperidol, may be administered. Koraskoff’s psychosis is caused y severe vitamin B1deficieny, which cannot be replaced orally. Rapid and immune injection of the Vitamin B thiamin is necessary. Symptomatic treatment may involve respiratory support, fluid replacement, IV glucose to prevent hypoglycemia, correction of hypothermia or acidosis, and emergency measures for trauma, infection or GI bleeding.

37. Medication Three drug are specifically approved to treat alcohol dependence: Naltrexone: For oral dosage form (tablets): For alcohol use disorder: AcamprostateAdults—50 milligrams (mg) once a day. Children—Use and dose must be determined by your healthcare provider. For opioid use disorder: Adults—At first, 25 milligrams (mg) (one-half tablet) once a day. If no withdrawal side effects occur, you may take 50 mg (one tablet) once a day. Children—Use and dose must be determined by your healthcare provider. Disulfiram Other type of medications such as antidepressant may also be used to treat patient with alcoholism

38. Naltrexone This medication is used to prevent people who have been addicted to certain drugs (opiates) from taking them again. It is used as part of a complete treatment program for drug abuse (such as compliance monitoring, counseling, behavioral contract, lifestyle changes). This medication must not be used in people currently taking opiates, including methadone. Doing so can cause sudden withdrawal symptoms. Naltrexone  belongs to a class of drugs known as opiate antagonists. It works in the brain to prevent opiate effects (such as feelings of well-being, pain relief). It also decreases the desire to take opiates. Teach your family or household members about the signs of an opioid overdose and how to treat it. This medication is also used to treat alcohol abuse. It can help people drink less alcohol or stop drinking altogether. It also decreases the desire to drink alcohol when used with a treatment program that includes counseling, support, and lifestyle changes.

39. Common side effects may include Common symptoms Serious side effect Nausea Sleepiness Headache Dizziness Vomiting Decreased appetite Painful joints Muscle cramps Cold symptoms Trouble sleeping Toothache Severe reactions at the site of injection, including: intense pain; tissue death for which surgery may be required; swelling, lumps, or hardness; scabs, blisters, or open wounds. Liver damage or hepatitis, including; stomach area pain lasting more than a few days; dark urine; yellowing of the whites of your eyes tiredness. Serious allergic reactions, including: skin rash; swelling of face, eyes, mouth, or tongue; trouble breathing or wheezing; chest pain; feeling dizzy or faint. Pneumonia Depressed mood

40. Acamprosate Acamprosate calcium is a prescription medication that helps people who are dependent on alcohol to abstain from drinking it. It is used along with psychosocial support and helps to prevent the cravings and urge to drink alcohol that people with alcohol use disorder experience. Drinking alcohol alters the balance of the chemical messengers or neurotransmitters in your brain. Acamprosate is thought to work by helping to restore the balance of these neurotransmitters. It's thought that it primarily works by decreasing the excessive excitation that accompanies alcohol dependence. Initial dose: 333 mg orally 3 times a day Maintenance dose: 333 to 666 mg orally 3 times a day

41. Common side effects of acamprosate include Accidental injury Asthenia Pain Anorexia Diarrhea Flatulence Nausea Anxiety Depression Dizziness Dry mouth Insomnia Paresthesia Pruritus Sweating

42. Disulfiram Disulfiram  is a medication used to support the treatment of chronic alcoholism by producing an acute sensitivity to ethanol (drinking alcohol). Disulfiram works by inhibiting the enzyme  aldehyde dehydrogenase, causing many of the effects of a hangover to be felt immediately following alcohol consumption. Disulfiram plus alcohol, even small amounts, produces flushing, throbbing in the head and neck, a throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating, thirst, chest pain, palpitation,  dyspnea , hyperventilation, fast heart rate, low loo pressure, fainting, marked uneasiness, weakness, vertigo, blurred vision, and confusion. In severe reactions there may be respiratory depression, cardiovascular collapse, abnormal heart rhythms, heart attack, acute congestive heart failure, unconsciousness, convulsions, and death.

43. Flushing (warmth, redness, or tingly feeling); Sweating, increased thirst, swelling, rapid weight gain Nausea, severe vomiting Neck pain, throbbing headache, blurred vision Chest pain, shortness of breath (even with mild exertion) Fast or pounding heartbeats or fluttering in your chest Confusion, weakness, spinning sensation, feeling unsteady A light-headed feeling, like you might pass out.

44. Eye pain or sudden vision loss Confusion, unusual thoughts or behavior or Liver problems nausea, upper stomach pain, itching, tired feeling, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes).

45. Psychotherapies Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT) is based on the idea that harmful patterns of thought that lead to self-destructive behavior can be unlearned. In CBT, the therapist helps the patient make permanent changes to how they think about situations, which will affect their responses. The Royal College of Psychiatrists shows how a therapist using CBT will treat their patient. In this instance, the therapist works to reframe the way a patient responds to five different areas: The situation (specific triggers that precipitate problematic drinking) Thoughts (thoughts that lead to drinking) Emotions (what the patient specifically feels, what their mood is) Physical feelings (rising temperature, clenched fists, sexual arousal) Behavior (alcohol use)

46. In CBT, every detail about what leads the patient to drinking creates a picture for the therapist. They can then navigate through it to find the psychological reasons behind the alcohol abuse. CBT works well on its own or in combination with other therapies. The goal is to help people understand their disorder and find positive coping techniques they can use throughout recovery.

47. Dialectical behavioral therapy (DBT) is a form of CBT. It focuses on helping clients build a life that is worth living through the use of two opposed tools: change and acceptance. DBT looks at the problem of addiction and finds solutions, which it does by considering the patient’s social/environmental interactions and experiences. DBT’s substance-related goals include: Decreasing substance abuse Reducing the physical discomfort of abstinence Reducing cravings and triggers for use Avoiding opportunities and triggers associated with use Reducing behaviors that lead to use Increasing reinforcement of healthy behaviors, friends and activities This approach helps clients move away from harmful coping behaviors and begin using healthier patterns of coping when they encounter emotionally stressful situations. People with alcohol use disorders are more likely to have mental health disorders, and DBT can be an especially effective therapy in these situations. It shows clients how they can untangle connections between a stressful situation and their behavior, which paves the way for clarity in thinking and action.

48. Family Intervention Motivational Interview Group Therapy Aversive Conditioning: Shock or chemical Induced vomiting Relapse Prevention Technique Cue exposure technique

49. Alcoholic anonymous Alcoholics Anonymous (AA) is a worldwide organization designed to help former alcoholics support one another throughout their recovery journey while maintaining their sobriety. The organization was founded in 1935 by Dr. Bob Smith and Bill Wilson in Akron, Ohio. Today, AA groups can be found in cities across the United States and around the world. Meetings are open to people of all races, ages, and genders, including the family members of recovering alcoholics. Individuals who attend AA groups are committed to stop abusing alcohol and remain sober. The meetings offer a multitude of ways to support ongoing recovery, like an effective 12-step program designed to treat alcoholism. The 12 traditions of AA were intended to stabilize the program and keep it freed from outside influences. Since the organization is considered a mutual-aid fellowship, it is run by former alcoholics who help those currently in recovery.

50. AL-Anon In the organization's own words, Al-Anon is a "worldwide fellowship that offers a program of recovery for the families and friends of alcoholics, whether or not the alcoholic recognizes the existence of an alcohol-related problem or seeks help." Alateen "is part of the Al-Anon fellowship designed for the younger .

51. Nursing management Assessment and monitoring.  Conducting a comprehensive assessment of the patient’s alcohol withdrawal symptoms and closely monitoring vital signs, including heart rate, blood pressure, and respiratory rate. Seizure prevention.  Implementing preventive measures, such as the administration of appropriate medications (e.g., benzodiazepines), to prevent seizures, a potential complication of alcohol withdrawal syndrome (AWS). Delirium tremens (DT) prevention.  Identifying patients at high risk for delirium tremens and implementing interventions, including pharmacological support, to manage symptoms and reduce the risk of severe complications. Fluid and electrolyte balance.  Monitoring and maintaining adequate fluid intake and electrolyte balance to prevent dehydration and address any imbalances caused by AWS. Pharmacologic support.  Administering medications, such as benzodiazepines or anticonvulsants, to manage alcohol withdrawal symptoms, including anxiety, agitation, insomnia, and tremors.

52. Psychological support.  Providing psychological support, counseling, and behavioral interventions to address the emotional and psychological challenges associated with AWS, including cravings, depression, anxiety, and mood disturbances. Nutritional support.  Ensuring proper nutrition and addressing any nutritional deficiencies caused by alcohol abuse and poor dietary habits. Safety measures.  Implementing safety protocols to prevent self-harm, falls, or accidents during the withdrawal process, including close observation and removing any potentially harmful objects from the patient’s environment. Education and relapse prevention.  Providing education on the consequences of alcohol abuse, promoting awareness of triggers and coping strategies, and offering relapse prevention strategies to support long-term recovery. Discharge planning  Collaborating with the patient, family, and support networks to develop a comprehensive discharge plan that includes appropriate follow-up care, referrals to rehabilitation programs or support groups, and ongoing monitoring of the patient’s progress in managing AWS and maintaining sobriety.

53. Nursing Diagnosis: Ineffective Denial Related to: Personal vulnerability Lack of control over substance use The threat of unpleasant reality  Inadequate emotional support Previously ineffective coping skills  Learned response patterns Personal or family value systems Cultural factors

54. As evidenced by: Delay in seeking or refusal to seek medical consult Uses manipulation to avoid responsibility for self Does not admit the impact of the condition on life Projects blame and responsibility for problems Does not perceive personal relevance of symptoms Minimizes symptoms Uses dismissive comments and gestures when addressing the condition Expected Outcomes: The patient will report awareness of the substance abuse problem The patient will verbalize acceptance of responsibility for their behavior The patient will engage in the planning and implementation of the treatment regimen related to substance abuse

55. Ineffective Coping Related to: Negative role modeling Inadequate preparation for stress Inadequate sense of control  Inadequate social support Ineffective stress relief strategies Previous ineffective coping skills substituted with substance use

56. As evidenced by: Impaired problem-solving skills Impaired adaptive behavior Decreased ability to handle stress Impaired ability to meet role expectations Inadequate follow-through with goal-directed behavior Inadequate problem resolution Verbalization of inability to cope Expected Outcomes: The patient will recognize instances that cause increased stress and a desire to use substances The patient will use appropriate coping and problem-solving skills in place of substance use

57. Powerlessness Related to: Failed attempts at recovery Substance addiction with or without periods of abstinence Lifestyle of helplessness Inadequate knowledge to manage a situation Inadequate motivation to improve one’s situation

58. As evidenced by: Ineffective recovery attempts Statements of inability to stop behavior or requests for help Expresses doubt about role performance Continuous thinking about drug or alcohol use Alteration in occupational, personal, and social life Feelings of anger or guilt Verbalizes a lack of self-control Passivity or nonparticipation in treatment Expected Outcomes: The patient will verbalize areas where they have control over their substance abuse The patient will participate in the therapeutic regimen and group peer support

59. Opioids Abuse In the last few decades, the use of opioids has increased markedly world over. India, surrounded on both sides by routes of illicit transport, namely Golden Triangle (Burma, Thailand, Laos) and Golden Crescent (Iran, Afghanistan, Pakistan) is particularly affected. The most important dependence producing derivatives are morphine and heroine. The commonly abused opioid in our country are heroin (brown Sugar, Smack) and synthetic preparations like pethidine , fortwin and tidigesic . The drugs that are injected through needle are heroin, buprenorphine and pentazocine . Though most opiates users had begun chasing heroin they gradually shifted to needle use. These injecting drug user have become a high risk group for HIV infection.

60. Acute intoxication It is characterized by apathy, bradycardia, hypotension, respiratory depression, subnormal temperature and pinpoint pupils. Later delayed reflexes, thready pulse and coma can occur.

61. Withdrawal Syndrome Narcotic withdrawal rarely produces a life threatening situation. Common symptoms include watery eyes, running nose, yawning, loss appetite, irritability, tremors, sweating, cramps, nausea, diarrhea, insomnia, raised body temperature, piloerection (Goosebumps) and anorexia. Withdrawal symptoms begin within 12 hours of the last dose, peak in 24 to 36 hours and disappear in 5 to 6 days.

62. Complications Complications due to illicit drug use: Parkinsonism, peripheral neuropathy, transverse myelitis Complication due to intravenous use: Skin infections, thrombophlebitis, pulmonary embolism, endocarditis, septicemia, AIDS, Viral hepatitis and tetanus Involvement in criminal activities

63. Treatment Treatment of opioid overdose: Opioid overdose can be treated with narcotic antagonists, for example, naloxone, naltrexone. Detoxification : Withdrawal symptoms can be managed by methadone, clonidine, naltrexone, buprenorphine etc. Maintenance therapy: After the detoxification phase is over, the patient is maintained on one of the following regimens: Methadone maintenance Opioids antagonist Psychological methods like individual psychotherapy, behavior therapy, group therapy and family therapy

64. Cannabis Use Disorder

65. Cannabis is derived from hemp plant, cannabis sativa. The dried leaves and flowering tops are often referred to as ganja or marijuana. The raisin of the plant is referred to as ganja or marijuana. The resin of the plant is referred to a hashish. Bhang is a drink made from cannabis. Cannabis is either smoked or taken in liquid form.

66. Acute intoxication The intoxicating effects of marijuana include relaxation, sleepiness, and mild euphoria (getting high). Smoking marijuana leads to fast and predictable signs and symptoms. Eating marijuana can cause slower, and sometimes less predictable, effects. Marijuana can cause undesirable side effects, which increase with higher doses. These side effects include: Decreased short-term memory Dry mouth Impaired perception and motor skills Red eyes More serious side effects include panic, paranoia, or acute psychosis, which may be more common with new users or in those who already have a psychiatric disease.

67. Withdrawal Symptoms They are mostly found in the first 72-96 hours and include increased salivation, hyperthermia, insomnia, decreased appetite and loss of weight.

68. Complications They are mostly found in the first 72-96 hours and include increased salivation, hyperthermia, insomnia, decreased appetite and loss of weight. Complication: Transient or short-lasting psychiatric disorder such as acute anxiety, paranoid psychosis, hysterical fugue like states, hypomania, schizophrenia Amotivational Syndrome Memory Impairment Treatment Supportive & Symptomatic treatment

69. Cocaine use Disorder Cocaine is a controlled illicit, highly addictive stimulant drug that is usually either insufflated (snorted), injected, or smoked in its freebase form (crack). Cocaine use is normally occasional, with the majority of users not meeting the criteria for cocaine use disorder. Cocaine use disorder is a pattern of cocaine use leading to clinically significant impairment or distress, defined by presence of at least 2 of 11 symptoms during a 12-month period.

70. Withdrawal Syndrome Cocaine can increase levels of dopamine in the brain. This can cause a person to experience: Extreme happiness and energy Mental alertness Irritability Paranoia

71. Treatment Management of intoxication: Amyl nitrite is an antidote; diazepam or propanolol is also used. For withdrawal symptoms: Antidepressants ( imipramine or amitryptyline ) and psychotherapy.

72. Amphetamine

73. Amphetamine Use Disorder Amphetamines are drugs. They can be legal or illegal. They are legal when they are prescribed by a health care provider and used to treat health problems such as obesity, narcolepsy, or attention deficit hyperactivity disorder (ADHD). Using amphetamines can lead to addiction. Amphetamines are illegal when they are used without a prescription to get high or improve performance. In this case, they are known as street, or recreational drugs, and using them can lead to addiction. This article describes this aspect of amphetamines.

74. Illegal amphetamines come in different forms: Pills and capsules Powder and paste Crystal Liquid They can be used in different ways: Swallowed Dabbed onto the gums Inhaled through the nose (snorted) Injected into a vein (shooting up) Smoked

75. Harmful effects of Amphetamine use disorder Appetite decrease and weight loss Heart problems such as fast heart rate, irregular heartbeat, increased blood pressure, and heart attack High body temperature and skin flushing Memory loss, problems thinking clearly, and stroke Mood and emotional problems such as aggressive or violent behavior, depression, and suicide Ongoing hallucinations and inability to tell what is real Restlessness and tremors Skin sores Sleep problems Tooth decay (meth mouth) Death

76. LSD (Lysergic Acid Diethylamide) LSD is a powerful hallucinogen, and was first synthesized in 1938. it presumably produces its effect by acting on 5-HT levels in brain. A common pattern of LSD use is ‘trip’.

77. Side Effects Aside from the changes it causes in consciousness and perception, LSD can cause other side effects, including: Synesthesia (e.g., “hearing” colors) Dissociation Impaired depth perception Panic attacks Flashbacks Depression Increased heart rate Increased blood pressure Delusions Dry mouth Visual hallucinations Tremors Anxiety

78. Treatment modalities Inpatient rehab programs require patients to live at the facility full-time for a period of 30–90 days while receiving treatment. This intensive atmosphere allows patients to focus 100% of their energy on recovery and provides a supportive network of clinicians, staff, and other patients in various stages of their own recovery. The intensive inpatient experience is not for everyone, and many people opt to receive substance abuse treatment on an outpatient basis. Outpatient programs vary in duration and intensity of the services provided. Programs may last 3–6 months. Some require patients to attend treatment session once per week, while others require 3 or 4 sessions per week, with sessions lasting anywhere from 1 to 4 hours.

79. Barbiturate Use Disorder

80. Barbiturates are a group of drugs in the class of drugs known as sedative-hypnotics, which generally describes their sleep-inducing and anxiety-decreasing effects. Barbiturates can be extremely dangerous because the correct dose is difficult to predict. Even a slight overdose can cause coma or death. Barbiturates are also addictive and can cause a life-threatening withdrawal syndrome.

81. Adverse Effects In general, barbiturates can be thought of as so-called brain relaxers. Alcohol is also a brain relaxer. The effects of barbiturates and alcohol are very similar, and when combined can be lethal. In small doses, the person who misuses barbiturates feels drowsy, disinhibited and intoxicated. In higher doses, the user staggers as if drunk, develops slurred speech, and is confused. At even higher doses, the person is unable to be aroused (coma) and may stop breathing. Death is possible.

82. Symptoms of withdrawal or abstinence include tremors, difficulty sleeping, and agitation. These symptoms can become worse, resulting in life-threatening symptoms, including hallucinations, high temperature, and seizures.

83. Treatment The treatment of barbiturate abuse or overdose is generally supportive. The amount of support required depends on the person’s symptoms. If the person is drowsy but awake and can swallow and breathe without difficulty, the treatment may consist of just watching the person closely. If the person is not breathing, a breathing machine is used to ensure the person can breathe well until the drugs have worn off.

84. Most people receive a liquid form of activated charcoal to bind to any drugs in their stomach. This may be done by placing a tube into the stomach (through the nose or mouth) or by having the person drink it. Most people are admitted to the hospital or are observed in the emergency department for a number of hours, and sometimes may need to be admitted to the hospital for further monitoring and treatment. Other treatments depend on the specific situation.

85. General Nursing Intervention for a patient with acute drug Intoxication Nursing Problem Priorities The following are the nursing priorities for patients with substance abuse: Ensure safety and monitor for withdrawal symptoms Provide education on substance abuse and its effects Assist in developing coping skills and relapse prevention strategies Facilitate access to appropriate treatment programs and resources Support the patient’s physical and emotional well-being Address any co-occurring mental health issues Encourage participation in support groups or counseling

86. Nursing Assessment Assess for the following subjective and objective data: Physical signs such as dilated or constricted pupils, bloodshot eyes, slurred speech, or unsteady gait Behavioral changes, such as mood swings, irritability, changes in sleep patterns, or decreased motivation or productivity Social and occupational dysfunction, as observed through poor work or school performance, strained relationships, or isolation from social activities Observable signs of intoxication or withdrawal, including tremors, sweating, restlessness, or agitation Neglecting personal hygiene or a decline in grooming habits Strained or damaged relationships with loved ones due to substance use Elevated liver enzymes or positive drug screenings

87. Reports from family members, friends, or other caregivers regarding the patient’s substance use or related behaviors. Nursing Diagnosis Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with substance abuse based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

88. Nursing Goals Goals and expected outcomes may include: The client will verbalize awareness of the relationship between substance abuse and the current situation. The client will verbalize acceptance of responsibility for their own behavior. The client will identify ineffective coping behaviors/consequences, including the use of substances as a method of coping. The client will admit the inability to control their drug habit and surrender to powerlessness over addiction. The client will verbalize acceptance of the need for treatment and awareness that willpower alone cannot control abstinence. The client will demonstrate active participation in the program. The client will regain and maintain a healthy state with a drug-free lifestyle. The client will demonstrate progressive weight gain toward the goal with normalization of laboratory values and the absence of signs of malnutrition.

89. The client will verbalize understanding of the effects of substance abuse and reduced dietary intake on nutritional status. The client will demonstrate behaviors, and lifestyle changes to regain and maintain an appropriate weight. The client will identify feelings and underlying dynamics for the negative perception of self. The client will verbalize acceptance of self as is and an increased sense of self-worth. The client will set goals and participate in realistic planning for lifestyle changes necessary to live without drugs. The client will identify ineffective coping behaviors and consequences. The client will initiate and plan for necessary lifestyle changes. The client will take action to change self-destructive behaviors/alter behaviors that contribute to the partner’s/significant other’s addiction. The client will verbally acknowledge the effects of drug use on sexual functioning/reproduction.

90. Levels of prevention of substance use disorder Primary Prevention : Reduction of over prescribing by doctors Identification and treatment of family members who may be contributing to the drug abuse. Introduction of social changes is likely to affect drinking pattern in the population as a whole. This is made possible by: Putting up the price of alcohol and alcohol or beverages Controlling or abolishing the advertising of alcoholic drinks Control on sales Restricting availability and lessening social deprivation

91. Secondary Prevention Early detection and counselling Brief intervention in primary care Motivational interviewing which involves providing feedback to the patient on personal risks that alcohol poses, together with a number of option for change A full assessment of current medical psychological and social problems. Assessment also includes ascertaining whether alcoholism is the primary or secondary problem. For example a patient with diabetic neuropathy may be using alcohol to numb pain. Detoxification with benzodiazepenes

92. Tertiary prevention Specific measures: Alcohol deterrent therapy Supportive psychotherapy, behavior counselling, individual psychotherapy etc Agencies such as (AA) Alcohol anonymous, AL-Anon, AL- Ateen etc Some practical issues under relapse prevention include: Motivation enhancement, including education about health consequences of alcohol abuse Identifying high risk situation and developing strategies to deal with them Drink refusal skills Detailing with faulty cognition Handling negative mood states Time management Anger management Financial management

93. Follow up care The client will verbalize understanding of the effects of substance abuse and reduced dietary intake on nutritional status. The client will demonstrate behaviors, and lifestyle changes to regain and maintain an appropriate weight. The client will identify feelings and underlying dynamics for the negative perception of self. The client will verbalize acceptance of self as is and an increased sense of self-worth. The client will set goals and participate in realistic planning for lifestyle changes necessary to live without drugs. The client will identify ineffective coping behaviors and consequences. The client will initiate and plan for necessary lifestyle changes. The client will take action to change self-destructive behaviors/alter behaviors that contribute to the partner’s/significant other’s addiction. The client will verbally acknowledge the effects of drug use on sexual functioning/reproduction.

94. Discuss the importance of timely, recommended follow-up visits Use the same diagnosis for substance use at each follow-up Coordinate care between behavioral health and primary care physicians Share progress notes and updates Include the diagnosis for substance use Reach out to patients who cancel appointment and assist them with rescheduling as soon as possible Consider telemedicine visit when in-person visits are not available Use the same diagnosis for substance use disorder at each follow up (a non-mental illness diagnosis code will not fulfill this measure)

95. Schedule follow-up appointments as soon as possible, particularly those patients recently discharged from the ED Train patients and staff on the “Teach Back Method” to ensure patients and caregivers review and understand discharge instructions and the next steps in their care for follow-up Encourage the patient to bring their discharge paperwork to their first appointment Educate the patient about the importance of follow-up and adherence to treatment recommendations Outreach patients who cancel appointment and assist them with rescheduling as soon as possible