402 substance use lecture fall2011

1

SUBSTANCE USE
DISORDERS

N402/511 FALL 2011

Charon Burda MS,PMHNP-BC

Healthy People 2020http://www.healthypeople.gov

 Overarching Goals:
 Increase quality
 Increase years of life
 Eliminate health disparities

 Top 10 Leading Health Indicators/Focus
Areas:
 Mental Health & Mental Disorders
 Substance Abuse

Healthy People 2020:
Substance Abusehttp://www.healthypeople.gov

SHORT TITLE Objective
Adverse ▼ Motor vehicle crashes/injuries
Consequences ▼ Cirrhosis deaths
▼ Drug-induced deaths
▼ Drug-related emergency dept. visits
▼ Alcohol-related emergency dept. visits
▼ Alcohol- & drug-related violence
▼ Lost productivity
Substance Use & ▲ Substance-free youth
Abuse ▼ Adolescent & adult use of illicit substances
▼ Binge drinking
▼ Ave. annual alcohol consumption
▲ Low-risk drinking among adults
▼ Steroid & Inhalant Use-Adol.

Healthy People 2020:
Substance Abusehttp://www.healthypeople.gov

SHORT TITLE Objective
Risk ▲ Peer disapproval of substance use
▲ Perception of risk assoc. w/ sub. abuse
Treatment ▼ Treatment gap for illicit drugs
▲ Treatment in correctional institutions
▲ Treatment for injection drug use
▼ Treatment gap for problem alcohol use
State & Local Efforts Hospital emergency dept. referrals
Community partnerships & coalitions
Administrative license revocation laws
Blood alcohol concentration (BAC) levels for
motor vehicle drivers

K. Fornili, Summer 2010

DHHS: Agencies in RED = those with most influence on
mental health and substance abuse
serviceshttp://www.hhs.gov/about/index.html
 Administration for Children & Families (ACF)
 Administration on Aging (AoA)
 Agency for Healthcare Research & Quality (AHRQ)
 Agency for Toxic Substances & Dz. Registry (ATDSR)
 Centers for Disease Control and Prevention (CDC)
 Centers for Medicare and Medicaid (CMS)
 Food and Drug Administration (FDA)
 Health Resources & Services
Administration (HRSA)
 Indian Health Services (IHS)
 National Institutes of Health (NIH)
 Substance Abuse & Mental Health
Services Administration (SAMHSA)


National Institutes on Health:
http://www.nih.gov/

1. National Institute on
Drug Abuse (NIDA)
http://www.nida.nih.gov/

2. National Institute for
Alcoholism &
Alcohol Abuse
(NIAAA)
http://www.niaaa.nih.gov/

3. National Institute of
Mental Health
(NIMH)
http://www.nimh.nih.gov/


Statistics: National Center on Addiction
and Substance Abuse at Columbia
University
 1 in 4 Americans will have an alcohol or drug problems at some
point in their lives.
 The number of alcohol abusers and addicts holds steady at about
16 to 20 million.
 Half of college students binge drink and/or abuse other drugs and
almost a quarter meet medical criteria for alcohol or drug
dependence.
 In 2007, approximately 204,000 high-school seniors used
marijuana on a daily basis.
 Substance abuse and addiction cost federal, state and local
governments at least $467.7 billion in 2005.
 Girls and women become addicted to alcohol, nicotine and illegal
and prescription drugs, and develop substance-related diseases at
lower levels of use and in shorter periods of time than their male
counterparts.
 Alcohol is involved in as many as 73 percent of all rapes and up to
70 percent of all incidents of domestic violence

Substance Abuse among the Military,
Veterans, and their Families

 ―The ongoing operations in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation
Enduring Freedom) continue to strain military personnel, returning veterans, and their
families. Some have experienced long and multiple deployments, combat exposure,
and physical injuries, as well as post-traumatic stress disorder (PTSD) and traumatic
brain injury (TBI).

 Prescription drug abuse doubled among U.S. military personnel from 2002 to 2005
and almost tripled between 2005 and 2008.

 Alcohol abuse is the most prevalent problem and one which poses a significant health
risk. A study of Army soldiers screened 3 to 4 months after returning from deployment
to Iraq showed that 27 percent met criteria for alcohol abuse and were at increased
risk for related harmful behaviors (e.g., drinking and driving, using illicit drugs). And
although soldiers frequently report alcohol concerns, few are referred to alcohol

Drugs of abuse
 Nicotine
 Alcohol
 Marijuana (cannabis)
 Heroin/opiods
 Stimulants: Cocaine, Amphetamines, Methamphetamines
 Hallucinogens: LSD, mescaline, psilocybin
 Club drugs: MDMA (ecstacy)
 PCP
 Anabolic steroids
 Inhalants
 Prescription medications (opioid pain relievers, stimulants, CNS
depressants/benzodiazepines)

DSM-IV-TR Criteria –
Substance Abuse
10

 A maladaptive pattern leading to significant
distress or impairment with one or more of
the following in a 12-month period:
 Recurrent failure to fulfill major obligations
 Recurrent physically hazardous behavior

 Recurrent substance-related legal problems

 Continued use despite social problems

 Symptoms have never met dependence
criteria

DSM-IV-TR Criteria –
11 Substance Dependence
 Three or more of the following at the
same time in a 12-month period:
 Tolerance
 Withdrawal
 More ingested than intended
 Desire or unsuccessful attempts to reduce use
 Much time involved with substances
 Reduced time spent on other important
activities
 Continued use despite physical or
psychological problems

• American Society of Addiction Medicine
12
defines alcoholism as:

Other Definitions of Addiction
– A primary, chronic disease with
genetic,psychosocial, and environmental factors
influencing its development and manifestations.

---The disease is often progressive and fatal. It is
characterized by continuous or periodic: impaired
control over drinking, preoccupation with the
drug alcohol, use of alcohol despite adverse
consequences, and distortions in thinking, most
notably denial.‖

Etiology of Substance Use
Disorders
13

 Pathologic condition characterized by
measurable changes in physiology and
neurobiology

 Genetic predisposition in some individuals

 Environmental precipitants

Genetic Factors Associated With
Alcohol Dependence
14

• 3 to 4 times higher risk in close relatives of people
with alcohol dependence. Higher risk associated with:
– Greater number of affected relatives
– Closer genetic relationships
– Severity of alcohol-related problems in
affected relative(s)
• Significantly higher risk in monozygotic twin than
dizygotic twin of a person with alcohol dependence
• 3- to 4-fold increase in risk in adopted children with a
natural parent who is alcohol dependent despite being
raised by adoptive parents without the disorder

(American Psychiatric Association, 2000.)

NIDA: Addiction changes the brain

Dopamine Reward Pathway

The VTA-nucleus
accumbens pathway is
activated by all drugs
of dependence
including alcohol

This pathway is
important not only in
drug dependence, but
Nucleus
accumbens
also in essential
physiological
behaviors such as
eating, drinking,
Ventral tegmental area
sleeping, and sex
(VTA)

http://www.youtube.com/watch?v=at3Sg6qvgTE

Therapeutic Alliance
18

 The therapist-patient relationship is a
critical component of all treatment
modalities
 Work to establish a positive alliance at
the beginning of treatment
 Promote a positive therapeutic alliance
 Minimize or avoid negative reactions
 Avoid confrontation
 Convey a high degree of empathy,
confidence, and hope

Underlying Principles:
 People are people first (not disorder);
 People are deserving of
 Respect; and
 Access to Services;

 Recovering people & their families need to be involved in
their treatment & recovery;
 People can and do RECOVER;
 Optimism is important;
 Long-term support needed;

• System philosophy should ensure that
―Any door is the right door‖;

Underlying Principles:
• Treatment plans should be client-centered &
individualized;

• Maximum feasible degree of integration: ―Least
restrictive environment that best meets needs‖
• Culturally competent services that match community’s
diversity:
 Age;

 Gender & Sexual Preference;

 Race & Ethnicity;

 INTEGRATED Mental Health and Addictions Treatment
 Not sequential
Summer 2010

 1. ADDICTION IS FUNDAMENTALLY ABOUT COMPULSIVE
BEHAVIOUR

 2. COMPULSIVE DRUG SEEKING IS INITIATED OUTSIDE OF
CONSCIOUSNESS

 3. ADDICTION IS ABOUT 50%HERITABLE AND COMPLEXITYABOUNDS

 4. MOST PEOPLE WITH ADDICTIONS WHO PRESENT FOR HELP HAVE
OTHER PSYCHIATRIC PROBLEMS AS WELL

 5. ADDICTION IS A CHRONIC RELAPSING DISORDER IN THE
MAJORITY OF PEOPLE WHO PRESENT FOR HELP

10 things con’t

 6. DIFFERENT PSYCHOTHERAPIES APPEAR TO PRODUCE
SIMILAR TREATMENT OUTCOMES

 7. ‘COME BACK WHEN YOU’RE MOTIVATED’ IS NO LONGER AN
ACCEPTABLE THERAPEUTIC RESPONSE

 8. THE MORE INDIVIDUALIZED AND BROAD-BASED THE
TREATMENT A PERSON WITH ADDICTION RECEIVES, THE
BETTER THE OUTCOME

 9. EPIPHANIES ARE HARD TO MANUFACTURE

 10. CHANGE TAKES TIME

At-Risk Drinking
24

Per WeekPer Occasion

Men >14 drinks >4 drinks

Women >7 drinks >3 drinks

Elders >7 drinks >1 drink

CAGE
25

 Have you ever felt you ought to Cut Down
on your drinking?
 Have people Annoyed you by criticizing
your drinking.
 Have you ever felt bad or Guilty about your
drinking
 Have you ever had a drink first thing in the
morning to steady your nerves or get rid of
a hang over (Eye-Opener)
 * one or more yes responses are indicative of problem drinking and
further screening should be done

Single Alcohol Screening Question
26

 When was the last time you had more
than …
 Women: 4 drinks in one day?
 Men: 5 drinks in one day?
 Positive response = within the past 3
months
 Sensitivity and specificity are 86% for
hazardous drinking, alcohol abuse, or
alcohol dependenceVinson, 2000; Vinson,
(Williams &
2004)

Assessment
27

 Quantity and frequency of alcohol use
 Other drug use: benzos, opioids, street drugs (pot and
cocaine), OTC drugs
 Consequences of Use: family, health, legal, work,
driving while impaired
 Co-occurring disorders: depression, anxiety, psychosis,
suicide, PTSDT
 Withdrawal symptoms: anxiety, tremor, hand shake.
―Does a drink make you feel better.‖ Hx of seizures
 Previous treatment attempts. What worked? What didn’t
work?
 Readiness to change

Physical Assessment & Exam
28

 BEHAVIORAL: Hyperactivity, anxiety, aggressive violent behavior,
paranoia, grandiosity, euphoria, reduced inhibition, drowsiness,
sedation
 COGNITIVE: memory and learning impairment
Decreased concentration, impaired judgment
• SKIN: Tracking (needle marks, local abscesses
• (MRSA), scars from previous abscesses, wound botulism, jaundice,
rhinophyma, palmer erythema, cigarette burns, spider nevi
• HEENT: Evidence of head trauma, conju.
• nctivitis, constricted pupils, nasal irritation, erosion or abscess of
nasal septum, periodontal disease, hoarseness, swollen parotids,
alcohol on breath

Muhrer, JC.,(2010).Detecting and Dealing with Substance Abuse Disorders in Primary Care.
The Journal for Nurse Practitioners 6(8) September 2010. 597-604

Physical Assessment
29

 CARDIOVASCULAR: Murmur (cardiomyopathy), arrhythmias, severe
hypertension, findings of subacute bacterial endocarditis
 PULMONARY: Tachypnea, signs of pneumonia (community acquired
aspiration) COPD, clubbing
 CHEST: Gynecomastia Abdomen: Hepatomegaly, ascites, epigastric
tenderness, heme positive stools, signs of pancreatitis
 GENITOURINARY: decreased testicular size
 MUSCULOSKELETAL: Red, swollen joints, gout, septic arthritis, SXS
osteomyelitis, skeletal infections in unusual locations
(sternoclavicular, vertebral) fractures
 NEUROLOGICAL: slurred speech, impaired motor coordination ,
tremor, slowed reflexes, peripheral neuropathy, evidence of stroke

 Muhrer, JC.,(2010).Detecting and Dealing with Substance Abuse Disorders in Primary
Care. The Journal for Nurse Practitioners 6(8) September 2010. 597-604.

Lab testing for substance
30
abuse
 BAC- blood alcohol  How long substances can be
detected:
content (range is 0-  * Alcohol: 3 to 10 hours
500)  * Amphetamines: 24 to 48 hours
* Barbiturates: up to 6 weeks
 Toxicology screen- 

* Benzodiazepines: up to 6
urine

weeks
 * Cocaine: 2 to 4 days; up to 10
to
22 days with heavy use
 * Codeine: 1 to 2 days
 * Heroin: 1 to 2 days
 * Hydromorphone: 1 to 2 days
 * Methadone: 2 to 3 days
 * Morphine: 1 to 2 days
 * Phencyclidine (PCP): 1 to 8
days
 * Tetrahydrocannabinol (THC): 6

Stages of change and motivational
interviewing

 Stages of change:  Motivational
 Precontemplation interviewing:
 Contemplation  Helps patients move further
along the continuum of
 Preparation change (e.g., from believing
Action they have no problem, to
considering making a change,


 Maintenance to actually making changes,
to maintaining those
changes)
 Focused on internally
motivated change
 Non confrontational style
 Help patients resolve
ambivalence about stopping
substance use

SBIRT
 ｷSBIRT stands for Screening, Brief Intervention, Referral to
Treatment.
 ｷSBIRT is a comprehensive, integrated, public health approach
to the delivery of early intervention and treatment services for
people with substance use disorders and those at-risk of
developing them.
 ｷPrimary care, trauma centers, emergency departments, and
other health care settings provide opportunities to intervene
BEFORE more severe consequences of substance misuse
occur.

 Source: U Maryland School of Medicine

 http://www.youtube.com/watch?v=orChO5Pbuoc&feature=related

 http://www.youtube.com/watch?v=J-acGrReypg&feature=related

INTOXICATION AND WITHDRAWAL

 The nurse should be
able to recognize the
signs and symptoms of:
 substance
INTOXICATION and
 substance WITHDRAWAL

 And the nursing
management of both
conditions

Alcohol
Alcohol Beer, wine, liquor, etc.
MOA Effects of relaxation by stimulating the GABA
receptors.

Effect Sedation, decreased inhibition, relaxation,
slurred speech, nausea

Overdose effect respiratory depression, cardiac arrest

Withdrawal effect Tremors, increased temp, pulse, blood
pressure, delirium tremens

Prolonged Effect Weight loss, malnutrition, paranoid ideation,
thought disturbance, stereotypical
movements, amnestic disorder (Wernicke’s
syndrome & Korsakoff’s psychosis) Alcohol
destroys brain cells, particularly binge
drinking.

Pharmacologic Treatment of
Alcohol Withdrawal

Medications Purpose

Benzodiazepines (Ativan, Administered when elevated HR, BP, T,
Valium; Librium) presence of Tremors to prevent delirium
tremens.

Disulfiram (Antabuse) Deters individuals from drinking by causing
aversive reactions

Acamprosate Deters individuals from drinking by
decreasing cravings

Opiates

Opiates Heroin and prescription narcotics
MOA Stimulate opioid receptors
Effect produce analgesia, euphoria, relaxation, constipation,
constricted pupils

Overdose effect Overdose can lead to respiratory depression, coma
and death. Antidote Narcan.

Withdrawal very uncomfortable and includes flu like symptoms,
effect anorexia, stuffy or runny nose, dilated pupils
(photophobia), piloerection and intense cravings.
Prolonged Effect Criminal behavior to obtain drugs, risk infection
related to needle use

Pharmacologic Management of
Opioid withdrawal
 Opioid substitution
 Methadone (Agonist)

 Buprenorphine (Partial Agonist)

 Naltrexone (Antagonist)
 Non-Opioid Symptom Relief
 Clonidine (tremor, agitation)

 Dicyclomine (GI symptoms)

 Cyclobenzaprine (muscle cramps)

Sedatives, Hypnotics,
Anxiolytics

Sedatives, hypnotics, Barbituates: amytal, Nembutal, seconal,
anxiolytics phenobarbital; Benzo’s: Ativan, Xanax, etc.
MOA Stimulating the GABA receptors
Effect Euphoria, sedation, reduced libido, emotional
lability, impaired judgement
Overdose effect Respiratory depression, cardiac arrest

Withdrawal effect Anxiety rebound and agitation, hypertension,
tachycardia, sweating, hyperpyrexia,
insomnia, delirium, seizure

Prolonged Effect Often used with alcohol/ risk infection related to
needle use

Stimulants

Stimulants amphetamines, methamphetamine and cocaine.
MOA Stimulate dopamine and norepinephrine receptors.
Effect heightened attention, euphoria, energy; decreased
apetite, insomnia, dilated pupils, tremors, paranoia,
aggressiveness, Physiologically depress appetite and
cause increased T,HR and BP.
Overdose effect Cardiac arrhythmias/arrest, increased or decreased
BP, respiratory depression, seizure, psychosis, coma,
death
Withdrawal Withdrawal symptoms very uncomfortable and can
effect precipitate acute depressive episode and suicidal
ideation.
Prolonged Effect Methamphetamine damages dopamine axons resulting
in significant defects in thinking, cognitive functions
and motor skills.

Hallucinogens

Hallucinogens LSD, Club Drugs (ecstasy+/-, GHB, psilocybin,
mescaline
MOA Stimulate serotonin receptors and cause distorted
perception and heightened sense of awareness
Effect illusions and hallucinations. Mood and judgment
impaired. Physical effects include increased T, HR
and BP.

Overdose effect Hallucinations, paranoia, psychosis, aggression, CVA,
seizures, malignant hyperthermia

Withdrawal No known
effect
Prolonged Effect Flashbacks after termination of use

Inhalants

Inhalants Includes any chemical that can be inhaled such as
household cleaners, gas, solvents, glue,
automotive and industrial agents, aerosol sprays
MOA

Effect Causes short term sense of dizziness, euphoria and
altered sensation. O2 deprivation
Overdose effect CNS Depression, coma, convulsions

Withdrawal Similar to alcohol but milder ie. Anxiety, tremors,
effect hallucinations, and sleep disturbance

Prolonged Effect serious and permanent neurological damage and
death.

Treatment
42

23.48 million
Americans
needed
treatment in
2004

(National Survey on Drug Use and Health, 2004)

Access to Treatment
43

2.33 million (9.9%)
received treatment

440,000 (1.9%) tried but
could not get treatment

19.92 million (84.8%) felt 790,000 (3.4%) did not
no need for treatment try to get treatment

Goals of Treatment
44

 Engage, motivate, and retain the patient in
treatment
 Provide education about addiction
 Reduce intensity and frequency of
substance use
 Prevent relapse to substance use
 Improve areas of life affected by addiction
(e.g., employment, interpersonal
relationships)
 Improve the patient’s quality of life

Evaluating Treatment Outcome
45

 Abstinence should not be the only measure
 Harm or Symptom Reduction in
 Substance Use
 Physical health
 Occupational functioning
 Interpersonal functioning
 Legal problems, public health and safety
 Overall Quality of Life
 Improvement in comorbid psychiatric
disorders
 Patient satisfaction and quality of life

Treatment Modalities
46

PSYCHOTHERAPY AND SELF-HELP APPROACHES
• Individual Psychotherapy
• Group Psychotherapy
• Cognitive Behavioral Therapy
• Alcoholics Anonymous and Twelve-Step Groups
• Motivational Enhancement Therapy and
Motivational Interviewing
• Family Therapy
• Psychodynamic Therapy
• Pharmacotherapy

Treatment facilities in
Maryland
 http://maryland-adaa.org/resource/

AA and Twelve-Step Groups
48

 Founded in 1935
 A worldwide organization with over 2.2 million
members
 Structured around the Twelve Steps
 Peer-led
 Only requirement to join is a desire to stop drinking
 There are similar groups nationwide for other
substances and issues (e.g., Cocaine Anonymous,
Narcotics Anonymous, Overeaters Anonymous,
Gamblers Anonymous, Nicotine Anonymous)

AA and Twelve-Step Groups
49

 Advantages:  Disdvantages:
 Social peer support network Group members may insist on
 Free abstinence as only measure
 Offered in most urban and of success
suburban areas
 Meeting held several times
per day/week Group members may
 Sponsor system available 24 discourage psychotropic
hours/day medication for co-occurring
 WEBSITE to find meetings disorders
and other information:
http://www.alcoholics-
anonymous.org

FDA-Approved Pharmacotherapies for
Alcohol Dependence
50

 Inhibits aldehyde dehydrogenase
Disulfiram (Antabuse®)
 When alcohol consumed, results
in nausea, dizziness, headache,
flushing
 Decreases desire to drink
 Poor tolerability profile, low
efficacy
Naltrexone (ReVia®)  Opioid antagonist
 Binds to opioid receptors, thus blocking
alcohol reward pathways
 Black box warning regarding hepatotoxicity
FDA = US Food and Drug Administration.
Antabuse is a registered trademark of Odyssey Pharmaceuticals, Inc.
ReVia is a registered trademark of the DuPont Merck Pharmaceutical Company
(O’Connor, 1998.)

FDA-Approved Pharmacotherapies for
Alcohol Dependence
51

Acamprosate (Campral®)  Indicated for maintenance of
abstinence from alcohol in
patients abstinent at treatment
initiation
 Renally cleared; contraindicated
in severe renal disease

FDA = US Food and Drug Administration.
Campral is a registered trademark of Merck Santé

Methadone maintenance
(heroin/opioid dependence)
52

 Methadone
t1/2 = 24-46 hours- once a day
dosing possible

Good oral bioavailability

• 45-90% of patients in treatment for
one year discontinue illicit opioid use
(J Health Sci Behav 29:214-226, 1988)

The Role of Buprenorphine
53
in Opioid Treatment
 Partial Opioid Agonist
 Produces a ceiling effect at higher doses
 Has effects of typical opioid agonists—these
effects are dose dependent up to a limit
 Binds strongly to opiate receptor and is long-
acting
 Safe
and effective therapy for opioid
maintenance and detoxification

402 substance use lecture fall2011

402 substance use lecture fall2011

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402 substance use lecture fall2011