topic 11 is part of part two of the substance related and addictive disorders this information is located in chapter 22 of your halter textbook which starts on page 406 and goes through 428 there is additional information in your mcus and all pharmacology textbook particularly chapter 8 which starts on page 56 through 71 the objective for topic 11 include one examine the psychosocial cultural and spiritual influences signs and symptoms age related considerations and evidence-based assessments related to substance and addictive disorders across the lifespan two utilize the nursing process to develop Implement and evaluate a client centered plan of care for clients experiencing substance related or addictive disorders three recognize the safety needs of clients experiencing and toxication or withdraw sub related to substances including alcohol benzodiazapines opioids hallucinogens or dissociative drugs four utii utilize effective therapeutic communication with clients experiencing substance related or addictive disorders five discuss the class classifications therapeutic effects major adverse effects client and family education and nursing considerations of medications used to support safe withdraw detox toxification and sobriety maintenance for clients with substance Related Disorders and six recognize the effective evidence-based techniques and settings that support recovery for clients with substance related and addictive disorders substance use disorders if you recall from topic 10 substance use disorders are not an illness of choice they are complex and include Cravings seeking the substance and using the substance these behaviors often have negative consequences leading to impairments in physical social and occupational functioning substance use disorders are chronic disorders and relapse during periods of sobriety are common substance use disorders are used used to be treated and viewed separately from Psychiatric disorders however with research the current trend is to integrate treatment for substance use disorders and co-occurring psychiatric disorders as we mentioned in topic 10 sometimes we see the use of substance is almost a coping mechanism for an individual or an individual with a particular psychiatric disorder as a review substance use disorder is the pathological use of a substance that leads to a disorder of use the substance the sorry the symptoms rather include impaired control social impairment risky use and physical effects which are the intoxication symptoms and those physical effects are dependent on the type of substance being used additionally we can see tolerance of the substance and withdrawal of the substance the central Concepts to substance use disorder were discussed in topic 10 let's review to ensure you understand understand these Concepts addiction is a chronic medical condition with roots in the environment neurotransmission genetics and life experiences addiction occurs when an individual is unable to obstain from the substance or activity and begins to this begins to cause impairments in their functioning such as physical social and occupational functioning intoxication occurs when individual ingests a substance in excess and that leads to intoxication symptoms the symptoms of intoxication will depend on the substance that was consumed tolerance this occurs when an individual doesn't respond to the substance the way they initially did and needs a higher dose of the substance to achieve the initial response or the high this occurs when the substance has been used routinely over a prolonged period of time overdose can occur when an individual is trying to achieve a high but has developed a tolerance to the substance the dsm5 provides diagnostic criteria for the following classes of psychoactive substances which include alcohol caffeine cannabis hallucinogens inhalant opioids sedatives hypnotics and anxiolytics stimulants and to toac we have discussed alcohol use disorder in topic 10 in topic 11 we will focus on understanding the other substances of abuse psychoactive substances will alter the mind when intoxication occurs there are many psychoactive substances in addition to the specific substances we will cover today many mind altering substances can be naturally occurring substances such as plants and fungi some cultures and religion use those substances in their practices table 22.1 on page 408 and 409 in your halter textbook highlights the most commonly misused drugs this table provides a great overview and we will be taking a closer look at many of those drugs also understand individuals can have nonsubstance addictions that are behavioral addictions and are referred to as process addictions the these can include uh addictions to gaming social media shopping and sexual activity mcus your mcus pharmacology textbook um page 59 through 63 has a table 8.3 of most commonly used illicit drugs this is also another table that is um a great tool for to reference to understand these substances we are first going to take a look at caffeine caffeine uh is the most widely used psychoactive substance in the world and while it is not an official use disorder meaning people do not get diagnosed officially with caffeine use disorder the use of caffeine can create problems uh caffeine as we know is a legal substance that anyone can purchase and it is readily available in the United States caffeine is a stimulant so when it is consumed it's going to increase alertness incre and increase energy however too much caffeine can cause intoxication which can lead to cardiac dys rythmia and elevated blood pressure and this could be fatal caffeine intoxication occurs with consumption of 250 mg of caffeine or more the visual on this slide displays the caffeine amounts in some of the commonly ingested drinks the energy drinks and energy shots that are available um today have very high amounts of caffeine and this can be dangerous especially when consumed by children or adolescent overdose of caffeine is rare and is characterized by fever tacac cardia or braic cardia hypertension initially followed by hypotension and possibly seizures treatment will be supportive and generally include hydration in some cases gastric lavage may be necessary to remove excess caffeine medications like beta blockers or vasopressin could be used to manage blood pressure alterations and heart rate management again overdose is rare uh caffeine certainly has withdrawal symptoms if you drink caffeine routinely and you don't have it you may have experienced these symptoms yourself it often starts with an incredible headache irritability and drowsiness if you've experienced this you can understand how the use of the substance will help to minimize those withdrawal symptoms so if you were experiencing caffeine withdrawal symptoms you would likely consume caffeine and your symptoms would decrease this is true for the withdrawal of any substance and so this can make it easier to understand how challenging the withdrawal period can be for any substance if you yourself have experien a caffeine withdrawal next is cannabis cannabis is a commonly used substance in fact it's the third most commonly used psychoactive drug in the United States it is obtained from hemp plants and is typically smoked but can also be put in food and gummies to ingest orally the active ingredient um is THC which will produce the mind altering effects uh CBD is also another ingredient we see in cannabis and we may have heard of that um however this substance does not lead to the mind altering or intoxication effects cannabis has both hallucinogenic effects as well as depressant properties and the desired effect of the use of cannabis typically includes the desire for Euphoria relaxation and Detachment the def as I mentioned the desired effects are typically Euphoria Detachment and relaxation these effects can be achieved by intoxication of cannabis symptoms of intoxication of cannabis will vary depending on the amount and type of cannabis that is used intoxication symptoms typically include heightened Sensations slowing of time slowed motor responses that can be present for 8 to 12 hours after the use of cannabis so we need to ensure the individual understands not to drive if they are under the influence of cannabis additionally we can see conjuctival redness so the whites of their eyes turn red uh typically they will have an increased appetite potentially dry mouth and tacac cardia occasionally cannabis intoxication can include hallucinations we know that uh occasional use of cannabis is typically safe and does not cause a lot of issue however long-term effects of cannabis use can cause impairments and functioning long-term effects include um chronic lethargy and hedonia so that that decreased motivation and pleasure difficulty concentrating loss of memory and then a motivational syndrome or again um that decrease in motivation cannabis does have withdrawal symptoms um when we have somebody who has consumed cannabis over a prolonged period of time uh we can see that they will develop withdrawal symptoms upon stopping and so we see cannabis tends to have a delayed onset of about one week after stopping the use of cannabis withdraw symptoms are unpleasant but not lifethreatening and include irritability aggression anxiety depressed mood insomnia abdominal pain sweating fever and headache some people Express that cannabis is harmless legalization of cannabis has occurred in many states however addiction to cannabis can and does occur the treatment for cannabis addiction is providing support to the client during the unpleasant withdrawal as well as encouraging the use of adaptive coping mechanisms the nurse should be assessing for underlying anxiety and depression sometimes the use of cannabis is for selfed ation for disorders such as anxiety and depression so sometimes we will see that individuals who are suffering from anxiety and depression will turn to cannabis use to help reduce those symptoms and again that can lead to a problem with the use of cannabis hallucinogens hallucinogens are considered into toxins these include naturally occurring substances in synthetic substances commonly used hallucinogens include lyser lysergic acid diamide um or LSD which is sometimes also referred to as acid U masculine or peyote psilocybin or magic mushrooms and then we have dissociatives uh these are another class of drugs that affect the body in a similar manner as hallucinogens but are technically classified as dissociatives these include uh phencyclidine uh piperine or PCP what it's commonly referred to because PCP is much easier to pronounce uh ketamine we'll hear ketamine on the streets called Special K and Salvia Salvia is often used by shamans and it's a plant uh note that ketamine is a medication that can be prescribed and is commonly used um for anesthesia in the hospital settings uh additionally there is a lot of research being done on the use of ketamine for specific mental illnesses uh which we don't go into detail in this course about um just understand there is much upand cominging research on the use of ketamine to treat uh psychiatric illnesses if we think about um hallucinogens really the desired effect for for using these types of stem substances as to achieve a disturbance in reality uh so again hallucinogens you can expect that there's going to be a disturbance in reality hence the name hallucinogens think about you know hallucinations so these substances are often used periodically with time set aside for use as functioning decreases significantly with the use of the um substance intoxication symptoms include very intense perception so this includes sound and visual perceptions are very intensified as you can see um on the slide the picture there is very colorful and intense and those are some of the symptoms we associate with huc hallucinogens additionally hallucinations Illusions paranoia depersonalization derealization uh we can see cesia which is a term that refers to quote seen sounds or quote hearing colors so again alteration in um sensory perception there additionally intoxication is going to increase Vital Signs blood pressure elevation is commonly seen in the intoxication of dissociatives like PCP and ketamine fucin don't cause physical dependence necessarily uh so therefore we don't see significant withdrawal symptoms for the individual who is frequently using hallucinogens we would want to focus our attention on decreasing the psychological desire for the drug uh and digging in a little deeper on maybe why they have such desire to use the substance again is this a specific coping mechanism um that they're using the substance for the problem with uh hallucinogens that we need to be aware of is caring for the client who's intoxicated uh with a hallucinogen or dissociative drug um safety can be a concern and should be a priority when a client is hallucinating or having impaired perceptions safety is a concern we want to ensure our therapeutic communication to talk the individual down and ensure least to most restrictive treatment the paranoia and hallucinations can be decreased with the use of medications which could include the administration of an anticho such as haloperidol or a benzo dipine such as diazapam these medications would be used short term just to help decrease the effects of the substance uh PCP intoxication this specific um drug can cause very dangerous and violent Behavior to the person who is intoxicated with the substance uh therefore we want to ensure our own safety when caring for this client um we would do that by ensuring a low stimuli environment providing observation from a safe distance and again we're going to consider the use of medications um to decrease their symptoms again it would be the antis psychotic the benzodiazapine um as well as seclusion or restraint may be necessary for the client intoxicated with PCP so PCP intoxication you should think very dangerous violent Behavior can occur with that again not always but the the risk is there inhalent use disorder is when an individual inhales Violet hydrocarbons which are toxic gases through their nose or mouth to achieve a high this can be through sniffing bagging or huffing the substances um that are used are common household substances such as glues and adhesives aerosol paints and sprays paint thinner gasoline or propane inhalent use disorder is more common among young individuals or adolescents as these substances are are easily available and legal to purchase at the local hardware store individuals who use inhalant typically use them shortterm and veryy periodically however addiction to inhalence does occur uh there is a television show called Intervention on A&E and they have aired individuals who are addicted to inhalence um there's also some various YouTube videos out there uh regarding people who are addicted to inhalence and it can be very very serious the thing that is important to know about inhalant is that um sudden sniffing death can occur and this happens when the toxin causes cardiac arrhythmias that lead to death and we could have a person who has inhaled um this substance several times uh and just achieved the high but no cardiovascular effects and then you know they could inhale it another time and have sudden sniffing death so don't really know when that's going to occur however we do know it is more common with substances that contain butane or propane ano anoxia is also a potential problem with the use of inhalent um and this can lead to seizures and permanent brain damage or death as well intoxication symptoms associated with inhalence include disinhibition and Euphoria apathy impaired judgment impaired coordination and hallucinations at times we will see the individual will have increased anxiety and aggressive behaviors uh other physical symptoms include nausea decreased appetite nagus diplopia um and decreased reflexes when used shortterm or periodically there's not significant withdrawal symptoms however additional complications associated with the use of inhalant uh include significant irritation to the nasal cavity or to the oral mucosa and the lining of the trachea from inhaling the toxic substance and obviously uh there would be risk for lung damage with frequent use of inhalent treatment for an individual who is currently intoxicated with an inhalent would focus on ABC's uh paying particular attention to their respiratory and cardiovascular um system and intervening accordingly opioid use has been an increasing problem in the United States particularly with heroin and the misuse of prescription drugs like oxy codone fentanyl is another opioid that is very potent and can lead to overdose if too much is used uh other opioids of misuse include hydrocodone Codine and morphine as a nurse you will likely be administering these medications for pain management again opioids can be prescribed however we must understand that these should be used shortterm only as they can become very addictive and uh the body does become physically dependent on the drug Additionally the client will build tolerance to the opioid requiring more of the drug to get the same effect intoxication symptoms of opioids include a general slowdown in movement drowsiness slurred speech impaired memory physical and symptoms can include pinpoint pupils and decreased bowel sounds resp rate and blood pressure may be slightly lower with intoxication overdose symptoms of opioids can be life-threatening as high doses of opioids will result in respiratory depression additional overdose symptoms include unresponsiveness hypothermia hypotension and brto cardia the three quote classic symptoms of Overdose are pinpoint pupils respiratory depression which is a low respiratory rate uh and coma or decreased level of Consciousness so those are the three classic overdose symptoms if opioid overdose is suspected the nurse should prepare to support the airway this can include opening the airway and using um a bagging method or um Consulting your team for um insertion of an endotracheal tube for mechanical ventilation the nurse will also prepare to administer nxone or Naran as it is the opioid antagonist and can help to reverse the overdose effects uh understand that nxone can be given im subq IV or intranasal and that it is short acting so it is likely going to need to be repeated so usually giving more than one dose of mexone to an over opioid overdose opioid withdrawal this is a very unpleasant time for the individual who is addicted to opioids withdrawal symptoms include mood disturbances extreme body aches nausea vomiting diarrhea lacrimation which is watery eyes and Rhino which is a runny nose we can see pupil dilation and pyo erection which are goosebumps the time frame of when to expect withdraw symptoms to start really depends on the specific opioid they were addicted to but generally is going to start about 6 to 8 hours after the last use if madine is the drug of choice um it's going to take a little longer as that drug has a longer halflife so usually with M paradine addiction we won't see withdraw symptoms start until about 8 to 10 hour 8 to 12 hours after the last use opioid withdrawal tends to Peak around the third day of withdrawal and should begin to subside after about one week so it's important to understand opioid withdrawal is not life-threatening uh like alcohol withdrawal but it is a very very very unpleasant time for the individual and this makes it very challenging for the individual to get through the withdrawal as they know using the substance would reduce these unpleasant feelings they're experiencing so medications can be used to help decrease the withdrawal symptoms uh methadone is one of the medications that can be used this is actually an opioid uh so it's used as substitution the therapy it's going to really help decrease the withdrawal symptoms um and block the euphoric effects of opioids this medication has to be prescribed very cautiously again it is an opioid um only programs with specific certification can dispense this medication and the client must understand at some point they will have to be we off the methadone and this can be a very challenging process as well for the individual um so while it can be very effective and helping to decrease the withdrawal symptoms the medication itself has potential um challenges with use uh clonidine is an alpha agonis anti-hypertensive this medication has been shown uh to be useful in decreasing opioid withdrawal symptoms uh as well as anxiety symptoms associated with the opioid withdrawal penine this is an opioid uh partial Agonist and we need to understand that this can be used during the excuse me withdrawal State or the maintenance phase of opioid use when used during the withdrawal process we um have to see that the individual has abstained from op opioid use for at least 12 hours so usually this will not be started until about um 12 to 24 hours after the last opioid use and again it can help to decrease some of those withdrawal symptoms and also help to reduce Cravings in that maintenance phase of opioid addiction um and nxone this medication can be used for uh long-term management of opioid use disorder as it's going to block euphoric effects of opioids so if the client was going to use opioids and was on nrex Zone they would not um obtain the high that they were looking to achieve with the use of NR Zone um additionally uh like I said bupren forine and methadone can be continued um to use after the withdrawal to promote continued abstinence of opioid use uh the client with opioid addiction will also benefit from psychological therapies such as individual therapy cognitive behavioral therapy or family therapy for the management of their disorder there is also Narcotics Anonymous and this is a 12-step program that is designed similar to AA for alcoholics and has been shown very useful for opioid addiction the next class of substances we will look at are the CNS depressants or central nervous system depressants these substances include alcohol which was discussed in topic 10 benzodiazapines and barbituates also known as the sedatives hypnotics and anti-anxiety drugs again many of these drugs may be prescribed um and they can become misused as we have discussed previously benzodiazapine should be used shortterm to prevent addiction sedatives and hypnotics should also be used um short term intoxication symptoms of these drugs are similar to those of alcohol since they all are depressing the central nervous system therefore we may the um just a general slowdown of the body and this can result in slurred speech unstead gate impaired cordination impaired thinking withdrawal symptoms of CNS depressants again if we think about um you know what's happening to the brain the brain has been dep in a depressed state for an extended period of time so when we take this substance away the central nervous system becomes excited and and it can result in autonomic hyperactivity Tremors agitation anxiety and insomnia seizures can also occur if a client has used these substances longterm and these are prescribed substances we should ensure that they are gradually weaned off of the substance rather than stopping them cold turkey overdose of CNS depressants can occur and it can be life-threatening as it will lead to cardiovascular or respiratory depression coma and potentially death overdose treatment depends on the route and time the substance was taken can include gastric lavage or activated charcoal for Orly ingested substances if the client is awake we want to try to intervene quickly and keep them awake um if the client loses Consciousness the nurse will want to ensure Airway and breathing uh also initiate IV access to administer fluids and if the overdose is from a benzo dipene prepare for the administration of flumazenil um again this can overcome the sedative effects of the benzo oene um flumazenil is only beneficial for benzodiazapines and understand that Ben or flumazenil is given IV and again the dose may have to be repeated overall for overdose of C s depressants abcc should be the priority ensuring frequent Vital Signs and cardiac monitoring as well as monitoring um for seizures that can occur with [Music] overdose stimulant use disorder includes uh the substances that are amphetamine type as well as cocaine these are commonly abused drugs in the United States we are going to take a closer look at some of the stimulant drugs on the next few slides but in general stimulants are used to produce a euphoric feeling increase and increase energy in an individual intoxication of a stimulant is going to speed up the central nervous system which can result in the following symptoms increased energy increased socialization decreased appetite Dil of piples uh we can see dryness or irritation of the nasal cavity if the substance is snorted like in the use of cocaine we may also uh note increased motor activity and a variation in Vital Signs so sometimes we'll see that heart rate and blood pressure increase and sometimes it will decrease additionally cardiac arrhythmias can occur and we should monitor for those long-term use of stimulants pose a risk for addition complications weight loss is a significant problem as appetite remains decreased for a prolonged period of time chest pain and irregular heartbeat may occur delusions and hallucinations are possible in fact tactile hallucinations that alter feelings um on the skin are commonly seen with prolonged methamphetamine use uh we can also see it with cocaine use you will notice the individual has a lot of scabs over their skin and this is likely from picking at those Sensations that they're feeling the sensations are often referred to as bugs crawling um and on page 416 in your halter textbook um box 22.2 points out these intoxication and withdrawal symptoms of stimulants crack and cocaine is extracted from the leaf of a cocoa Bush crack is often smoked whereas cocaine is typically snorted and will produce a high Feeling by altering the neurotransmitters withdrawal is very unpleasant for the individual who is withdrawing from Cracker cocaine symptoms include depression paranoia lethargy anxiety insomnia chills nausea and vomiting and sweaty there is more information on crack and cocaine in the muc mucin um pharmacology textbook on page 60 within table 8.3 as mentioned the withdrawal of crack and cocaine is very unpleasant typically the individual will go through free three phases the crash phase um this is where we have suddenly taken away the stimulant and so depression is very common in this phase and the individual should be monitored for suicidal ideation additionally we'll see anxiety and agitation as well as intense cravings for the substances present this phase lasts about 4 days the next phase is where we will see the client is very unmotivated and not wanting to do anything again think um depression and potential for suicide this phase can last up to 10 weeks making relapse and use of the substance very common the third phase is that for an extended period of time even years the client could struggle with intermittent cravings for the drug treatment is typically outpatient setting however some will require impatient settings for support through the intense Cravings there are no specific medications used to treat crack and C cocaine withdraw methamphetamines are another commonly used stimulant drug this substance is highly addictive it can be smoked or injected methampetamine can cause significant alterations to the brain leading to brain damaging effects and intoxication and chronic use can resemble psychosis of schizophrenia long-term use can cause Parkinson like symptoms um this is due to the changes in the dopamine levels associated with methylamphetamine use prolonged use can cause significant damage to the teeth and most long-term users will eventually lose all of their teeth skin infections occur related to the picking of the skin caused by the altered Sensations that we discussed earlier lung disease or um kidney and liver damage can occur as well as stroke um are additional potential risks associated with long-term methamphetamine use the withdrawal from methamphetamine is similar to the withdrawal um of crack and cocaine however impatient treatment usually is required if severe agitation is present diazapam might be used for agitation uh depression and suicidal ideation are the most serious side effects of stimulant withdrawal and the need for an anti-depressant should be assessed buproprion or well Butrin is an anti-depressant that has been shown useful for stimulant addict tobacco use disorder includes the addiction to anything with nicotine in it the substance can be smoked chewed or inhaled it is highly addictive and is typically socially acceptable um used to be that everyone smoked even in the hospitals the doctors would smoke you'd have ashes in every room that is not the case today now that we know the potential um complications that can occur from smoking or even secondhand smoke uh nicotine is legal to purchase if the person is of age which that age can vary from state to state typically it is 18 years or 21 years or older um stopping the use of tobacco can be very challenging for the client uh withdraw symptoms include irritability anxiety insomnia and a strong urge and desire to use the substance withdrawal treatment can include the use of medications to help decrease Cravings uh such as buproprion or uh verin vereline or chanics is the brand name additionally individuals can use nicotine patches gum or lines to supply some nicotine that will help reduce the cravings and then they can gradually taper off those products as indicated to wean themselves from the nicotine VAP or electronic cigarettes are fairly new uh these were originally marketed as a safe alternative to smoking cigarettes however recent Research indicates otherwise the manufacturing um of the chemicals that are used and Vapes allow flavoring to the chemicals which really targets those young people um when we have these really desirable flavors present uh we know through research now there is risk for lung and brain injury with the use of vaping uh the chemicals that are used in Vapes can include nicotine or even THC both of which can be addictive and overall vaping should not be considered a safe alternative to smoking club drugs these include stimulate stimulated amphetamines uh such as MDMA which is also known as ecstasy X or Molly MDA tends to be our love drug mde is known as Eve bass salts Flaka these drugs really are a combination of stimulants and hallucinogens the purpose of these drugs is just to get a significant High um they get their overall name is CL club drugs because they're often used um in the clubs group settings like that they may produce hallucinogenic effects um they are usually used periodically and don't tend to produce physical dependency or withdrawal symptoms therefore uh we have discussed several different treatments for the specific substances of abuse this slide provides a review of General substance addiction treatment for you to review um again we talked more about some of the medications that are used for withdrawing from specific substances uh just understand that anyone who has an addictive disorder should be involved in some kind of psycho therapy as well so that can include um individual therapy group therapy cognitive therapy motivational interviewing um and then some of the specific recovery models are listed on that slide for review understand that families of addicts are also impacted by the individual's Disorder so family therapy should be encouraged um so that each family member can understand the disorder and the role they have taken on in the disorder and how to best help the individual who is struggling with the addictive Disorder so that wraps up topic 11