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Substance Related Disorders & Dual Diagnosis


Substance Related Disorders & Dual Diagnosis Phyllis M. Connolly, PhD, RN, CS NURS 127A Questions to Consider Today 4/20/01 What behaviors indicate that a nurse may ... – PowerPoint PPT presentation

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Title: Substance Related Disorders & Dual Diagnosis

Substance Related Disorders Dual Diagnosis
  • Phyllis M. Connolly, PhD, RN, CS
  • NURS 127A

Questions to Consider Today 4/20/01
  • What behaviors indicate that a nurse may be
    abusing substances?
  • What is the ego/self theory related to substance
  • When is denial a problem?
  • What is the relationship between childhood sexual
    abuse and addiction?

Substance Disorders Facts
  • Cost 144 billion/year in health care and job
  • Alcohol most commonly used
  • Marijuana most commonly used illegal drug
  • 50 auto accidents homicides involve alcohol
  • Involved in crime violence
  • 500,000 deaths from Tobacco-related disorders
  • One in 10 deaths related to alcohol
  • More die from misuse of legal prescriptions

Impaired Nurses
  • 5 of 2 million nurses in 1984 (ANA) abused
  • 8-10 chemically dependent
  • Narcotic addiction 30 X higher than general
    population (1987 study)
  • 67 of cases handled by 44 state BRN (1988)

Signs of Impaired Nursing Practice
  • Job Performance Changes, Controlled drug handling
  • Drug counts incorrect
  • Excessive errors
  • Excessive wastage, often not countersigned
  • Medicine signed out to pt. not in pain
  • Two strengths of drugs signed out to same pt.
    Same time
  • Packaging appears to be tampered
  • Patient complaints of ineffective pain control
  • Volunteers to give controlled drugs
  • General Performance
  • Medication errors
  • Poor judgment
  • Euphoric recall for involvement in unpleasant
  • iIlogical or sloppy charting
  • Absenteeism, esp. days off
  • Requesting leave time just before assigned shift
  • Lateness--elaborate excuses
  • Job shrinkage
  • missed deadlines

Signs Impaired Nurse Cont.
  • Behavioral/Personality changes
  • Sudden changes in mood
  • Periods of irritability
  • Forgetfulness
  • Wears long sleeves (hot weather)
  • Socially isolates
  • Inappropriate behavior
  • Chronic pain condition
  • Hx pain treatment with controlled substances
  • Signs of Use
  • Alcohol on breath
  • Constant use of perfumes, mouthwash, breath mints
  • flushed face, reddened eyes, unsteady gait,
    slurred speech, hyperactivity
  • accelerated speech
  • Increasing family problems interfere with work

Interventions Impaired Colleagues
  • Reporting required ethical legal obligation to
  • Document in writing time, date, place
    description, names of those present
  • An advisor with (state nurse rehabilitation team)
  • Team approach,co-workers, supervisor, nurse
    administrator, family member

Prevalence of Substance-Related Disorders
  • Alcohol abuse
  • Males
  • Females
  • Substance
  • Other drug dependency
  • 16
  • 29
  • 6
  • 18
  • 9

Dahme, 1998
Classes of Substances with Potential for Abuse
and Dependence
  • Inhalants
  • Nicotine
  • Opiods
  • Phencyclidines (PCP)
  • Sedative, hypnotic,or antianxiety agents
  • Alcohol
  • Amphetamine
  • Caffeine
  • Cannabis
  • Cocaine
  • Hallucinogens

5 General Categories of Substances
  • CNS depressants,(alcohol, sedative-hypnotics,
    antianxiety agents,and volatile inhalants
  • Stimulants (cocaine, amphetamine,caffeine?,
    nicotine, related substances)
  • Opioids including analgesics
  • Hallucinogens including PCP
  • Cannabis
  • ? Caffeine not considered to cause either
    dependence or abuse
  • Nicotine is currently classified as causing
    dependence but not abuse

Psychoactive Substances
  • Drugs or chemicals which alter one or several
  • Perception
  • Awareness
  • Consciousness
  • Thinking
  • Judgment
  • Decision making
  • Insight
  • Mood
  • Behavior

Etiological Theories Substance Abuse
  • Biological
  • Addictive substances activate neurotransmitters
    in mesolimbic dopaminergic reward pathway
  • chronic use ? blood flow to brain
  • Genetic predisposition
  • Behavioral--conditioning homeostasis
  • drug craving triggers self-medicating
  • Psychodynamic
  • Unconscious oral needs
  • Dependency
  • Low self-esteem
  • child abuse, physical, sexual
  • family conflict (Trauma model, Walker et al.

DSM-IV Criteria Substance Related Disorders
  • Substance Dependence
  • A. Maladaptive pattern 3 or more
  • tolerence
  • withdrawal
  • need for more
  • inability to stop using
  • time spent acquiring or recovering from effects
  • problems, social, occupational, or recreational
  • Continues use despite knowledge
  • Substance Abuse
  • A. Maladaptive pattern leads to significant
    impairment or distress as manifested by one or
    more of
  • Failure to fulfill major role obligations at
    work, school, or home
  • Recurrent use in hazardous situations
  • Recurrent substance related legal problems
  • Continued use despite problems

DSM-IV Criteria Substance Related Disorders Cont.
  • Substance Intoxication
  • Development of a substance- specific syndrome due
    to a recent ingestion of a substance
  • Clinically significant maladaptive behavioral or
    psychological changes due to the effect of the
    substance on the CNS
  • Not due to general medical condition and not
    better accounted for by another mental disorder
  • Substance Withdrawal
  • Development of a substance-specific maladaptive
    behavioral or psychological changes due to the
    effect of the substance on the CNS
  • The substance-specific syndrome causes clinically
    significant distress or impairment
  • Not due to a general medical condition and not
    better accounted for by another mental disorder

Substance Dependence
  • Lack of control over drug use and its increasing
    importance. At least 3 symptoms in 12 month
  • Tolerance
  • Withdrawal
  • Taking larger amounts
  • Inability to reduce use
  • Excess time spent on obtaining drugs
  • Impairment in functioning
  • Continued use despite negative consequences

Dahme, 1998
Key Terms
  • Dependence A drug abuser must take a usual or
    increasing dose of a drug in order to prevent the
    onset of abstinence symptoms/withdrawal
  • Tolerance The need for increasing amounts of a
    substance to achieve the same effects
  • Withdrawal Physical signs and symptoms that
    occur when the addictive substance is reduced or
    withheld (abstinence syndrome)

Key Terms cont.
  • Abuse--Excessive use of a substance that differs
    from societal norms
  • Codependency--stress-related preoccupation with
    an addicted persons life, leading to extreme
    dependence on that person
  • Blackouts--period of time in which the drinker
    functions socially but for which there is no
  • Pharmacodynamic tolerance--occurs when higher
    blood levels are required to produce a given

Coping Styles Contributing to Substance Abuse
  • Rationalization
  • Falsifying an experience by giving a contrived,
    socially acceptable and logical explanation to
    justify an unpleasant experience or questionable
  • Projection
  • Attributing an unconscious impulse, attitude,or
    behavior to someone else (blaming or
  • Denial
  • escaping unpleasant realities by ignoring their

Cognitive Framework Assessing Denial
Is it denial?
Is it a problem?
Do nothing
How is it a problem?
What cognitions are in conflict?
What are alternative means of reducing dissonance?
Forchuk Westwell, 1987
Alcohol Abuse and Culture
  • Norms important role
  • Cultures with ?rate of alcohol abuse may condone
    drunkenness (Irish)
  • Cultures with ? rates appropriate use of small
    amts. Celebrations (Jewish Mediterranean)
  • Condemn altogether (Muslim, Jehovahs Witness,
    and Mormons)
  • China and Japan lower prevalence-negative
    physiological response
  • Native Americans Eskimos ? rates
  • US rates similar to northern European countries

  • Behaviors of individuals in family or social
    system who inadvertently promote continued
    alcohol or drug use. By protecting them from
    consequences of their actions. Examples ignoring
    or making excuses for persons behavior,
    finishing the work of a colleague who is unable
    to function.

CAGE Screening Test Alcoholism
  • 1. Have you ever felt you ought to Cut down on
    your drinking?
  • 2. Have people Annoyed you by criticizing your
  • 3. Have you ever felt bad or Guilty about your
  • 4. Have you ever had a drink first thing in the
    morning to steady your nerves or get rid of a
    hangover? (Eyeopener)

Keltner, p. 530
Alcohol Withdrawal Symptoms First 24 hours
  • Within a few hours, peaks within 24 hrs.
  • Anxiety
  • Insomnia
  • Irritability
  • Internal shaking ? BP, P, diaphoresis

Alcohol Withdrawal Symptoms Sudden to 2-3 days
  • Grandmal convulsive seizures--48 hrs.
  • Delerium tremens (DTS)--72 hrs.
  • ? Medical Emergency Acute pathological state of
    consciousness results from interference with
    brain metabolism

Wernickes Syndrome Korsakoffs Disease
  • Nutritional disorders related to alcoholism
  • Thiamine deficiency
  • Both treated with withdrawal from alcohol and
    vitamin supplements.
  • Improvement can occur in Wernickes syndrome,
    some degree of intellectual and emotional
    impairment remains.
  • Memory impairment is residual in Korsakoffs even
    when slight improvement occurs

Wernickes Syndrome
  • Neuronal and capillary lesions in gray matter of
    brain stem
  • Characterized by delirium, memory loss,
    confabulation, apathy, apprehension, ataxia,
    clouding of consciousness, sometimes coma
  • If not treated early with large doses of
    thiamine, Korsakoffs Disease may develop

Korsakoffs Disease
  • Niacin deficiency in addition to thiamine
  • Degeneration of cerebrum and peripheral nerves
  • Characterized by amnesia, confabulation,
    disorientation, and peripheral neuropathy

  • Commonly observed in chronic brain syndrome
  • Person cannot recall specific aspects of an event
  • Fills in with relevant imaginary information
  • Face-saving device, protects self-esteem
  • Compensates for memory loss
  • Due to lack of access to stored information and
    lack of new input
  • Inability to form new associations
  • Loss of capacity for introspection and judgment
    of truth
  • Frequently observed in Korsakoff-Wenickes

Potential Nursing Diagnoses Substance Abuse
  • Altered nutrition
  • Risk for fluid volume deficit
  • Altered thought processes
  • Sensory/perceptual alterations auditory-visual
  • Sleep pattern disturbance
  • Altered health maintenance
  • Self-care deficit
  • Noncompliance
  • Hopelessness
  • Helplessness
  • Self-esteem disturbance
  • ? risk violence to self and others
  • Anxiety
  • Ineffective individual coping

Self-Care Deficit
  • Ego functioning which does not handle painful
    affects or maximize protective activity
  • Interventions
  • Provide alternative ways to handle or tolerate
    painful emotions--stress management
  • Furnish structured supportive environment
  • Increase awareness of unsatisfactory protective
  • Teach skills to recognize respond to
    health-threatening situations

Compton, 1989
Pharmacological Interventions Alcohol Abuse
  • Disulfiram (Antabuse)--negative aversive
  • inhibits breakdown of acetaldehyde--toxic to
    body if alcohol is ingested causes
    sweating,flushing, ? pulse, ? BP, headache,
    nausea, vomiting, palpitations, dyspnea, tremor,
    and/or weakness. May cause arrhythmias, MI,
    cardiac failure, seizures, coma, and death

Elements of Detoxification Process
  • Secure environment
  • Sedation
  • Supplements

Pharmacological Interventions Alcohol Abuse Cont.
  • Naltrexone hydrochloride (ReVia)--opiod receptor
  • Increases abstinence and reduces alcohol craving
    in combination with comprehensive treatment plan
  • May cause liver toxicity at high doses
  • Contraindicated for patients who abused narcotics
    within 7-10 days

Interventions Alcohol Abuse
  • AA Self-Help
  • Brief Interventions
  • Feedback
  • Responsibility
  • Advice
  • Menu
  • Empathy
  • Self-efficacy
  • Moderation-Online Self-Help
  • Motivational interviewing

Opioid Abuse Signs Symptoms
  • CNS Effects
  • sedation
  • euphoria
  • mood changes
  • mental clouding
  • pain reduction
  • pinpoint pupils
  • decreased respiratory rate
  • GI Effects
  • chronic constipation
  • Cardio Vascular
  • Hypotension
  • Sexual Functioning
  • Decreased libido
  • retarded ejaculation
  • impotence
  • orgasm failure
  • Detoxification
  • Clonidine (Catapress)

Townsend, 1996, p. 374
Antecedents to Relapse
Keltner, p. 538
Stages of Change Addictive Behaviors
Permanent Exit
Prochaska DiClemente, 1992
Treatment of Substance-Related Disorders
  • Trusting therapeutic relationship, nurse
  • Detox residential treatment
  • Behavioral model disease model
  • Rehabilitation
  • Abstinence
  • Motivation
  • Medications
  • Alcohol-Librium, Valium, Ativan
  • Opioid--Narcan
  • Methadone
  • Family education
  • Treatment of comorbid medical psychiatric
  • Group treatment
  • Confrontation
  • Personal responsibility
  • Conscience development
  • Self-help
  • Life-style issues

Percent of Population (15 -54) 1991 With
Substance Abuse Disorder, Mental, or Both in
Substance Abuse Dependence 12
Both Disorders 13.7
Only Mental Disorder 21.4
Dahme, 1998, p. 288
Etiology Dual Diagnosis
  • Generally mental illness first
  • Heredity
  • Biological factors
  • Self-medicating
  • Substance abuse first
  • Brain chemistry altered
  • Guilt, depression, altered self-esteem
  • Personality disorders

Examples of Dual Diagnoses
  • Axis I Schizophrenia
  • Alcohol abuse
  • Axis I Major depression
  • Anxiolytic dependency
  • Axis I Major Depression
  • Marijuana abuse

Treatment Dual Diagnosis
  • Multidisciplinary
  • Case management
  • Individual therapy
  • Group therapy
  • Skills training
  • Education groups
  • Vocational counseling
  • Referrals to community resources
  • Self-help groups
  • Five-step model

Therapeutic Tasks Dual Diagnosis
  • Establish therapeutic alliance
  • Help patient evaluate costs and benefits of
    continued substance abuse
  • Individualize goals for change include harm
    reduction as alternative to abstinence
  • Help build an environment and lifestyle
    supportive of abstinence
  • Acknowledge recovery long-term process

Jefferson, 1998, p. 517
Outcomes Treatment Major Depression and Alcohol
  • Short Term
  • Verbalizes plans for future
  • Sleeps 6-8 hrs/night
  • Eats 3 balanced meals/day
  • Recognizes and describes problems with alcohol
    and depression
  • Plans to live with non substance user friend
  • Long Term
  • Practices abstinence from alcohol
  • Attends self-help groups
  • Attends outpatient treatment
  • Medication compliant
  • Lives in halfway house or non substance user