SUBSTANCE ABUSE DISORDERS DANA BARTLETT, RN, BSN, MSN, MA Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material and textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students. ABSTRACT Substance use in the United States and worldwide is a major health concern requiring specially trained health professionals in primary care, public health and treatment centers for the identification of various categories of substance abuse and its prevention. There is high risk of substance abuse among certain groups in society. Although substance abuse is typically thought of as illicit drug use or chronic alcohol abuse, commonly occurring within marginalized, crime ridden sectors of society, in reality, substance abuse is a wide-spread societal problem involving alcohol, tobacco, prescription and illicit drugs, among many individuals indistinguishable from the general population. Substance abuse is explained according to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1
Continuing Nursing Education Course Director & Planners: William A. Cook, PhD, Director; Douglas Lawrence, MS, Webmaster; Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner Accreditation Statement: This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Credit Designation: This continuing education (CE) activity is credited for 3.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Course Author & Planner Disclosure Policy Statements: It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice for all continuing nursing education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise. Statement of Need: Nurses need to understand varying patterns of substance use and the harm caused by each. As members of the health care team, nurses can assist individuals needing help begin recovery and, hopefully, succeed. Course Purpose: This course is designed to provide nurses and health associates with knowledge about substance abuse and the recommended steps to support patient recovery. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2
Learning Objectives: 1. Identify the diagnostic criteria of a substance abuse disorder. 2. Identify a mechanism of action by which substance abuse occurs. 3. Identify behaviors commonly associated with a substance abuse disorder. 4. Identify signs/symptoms of substance abuse withdrawal. 5. Identify drugs used for treating substance abuse withdrawal. Target Audience: Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Associates Course Author & Director Disclosures: Dana Bartlett, RN, MA, MSN, William S. Cook, PhD, Douglas Lawrence, MS, Susan DePasquale, CGRN, MSN, FPMHNP-BC - all have no disclosures Acknowledgement of Commercial Support: There is no commercial support for this course. Activity Review Information: Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC. Release Date: 9/8/2014 Termination Date: 9/8/2017 Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to self-assess knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3
1. The term dependency used in relation to substance abuse means: a. an intense psychological craving for alcohol or a drug b. physical need for alcohol or a drug that develops over time. c. the need for increasing amounts of alcohol or a drug over time. d. a physical resistance to withdrawal signs and symptoms. 2. One of the central themes of a substance abuse disorder is: a. continued use despite significant substance related problems. b. excessive use of alcohol or an illicit drug. c. a pattern of use of alcohol or a drug that causes medical harm. d. alcohol or drug use that has social consequences. 3. One of the diagnostic criteria for substance abuse disorder is: a. Self-admitted addiction to alcohol or a drug. b. Excessive use of alcohol or a drug for > five years. c. Impaired control relating to use of alcohol or a drug. d. Use of an illicit drug 4. One of the diagnostic criteria for substance abuse disorder is: a. Refusal by the patient to accept professional help. b. Alcohol or drug use that causes medical harm. c. Alcohol or drug use that waxes and wanes. d. Tolerance to alcohol or a drug. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4
5. Substance abuse is thought to be caused and reinforced in part by: a. Changes in neurotransmitters and their receptors. b. Decreased function of the endocrine system. c. Changes in microcirculation. d. Undiagnosed immune system dysfunction. 6. Withdrawal in most patients who have a substance abuse disorder: a. causes significant morbidity and mortality. b. is relatively benign and self-limiting. c. is less serious if the duration of use has been many years. d. typically affects males more than females. 7. One of the serious complications of alcohol withdrawal is: a. Acute renal failure b. Delirium tremens c. Rhabdomyolysis d. Cardiac arrhythmias 8. Withdrawal from benzodiazepines can cause: a. Seizures b. Rhabdomyolysis c. Hepatic damage d. Pulmonary edema nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5
9. Which of the following is the drug of choice for treating alcohol withdrawal? a. Antipsychotics b. Benzodiazepines c. Selective serotonin reuptake inhibitors d. Barbiturates 10. Which of the following drugs are often used to treat opioid withdrawal? a. Benzodiazepines, clonidine, and methadone b. Anti-psychotics, barbiturates, and selective serotonin reuptake inhibitors c. Non-opioid analgesics, propofol, and tri-cyclic anti-depressants d. Buprenorphine/naloxone, clonidine, and methadone nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6
INTRODUCTION Substance abuse is an enormous problem in the United States, and even the small sample of statistics outlined below illustrates its widespread and deeply injurious effects. A 2102 report issued by the U.S. White House Office of National Drug Control Policy states that, for the period from 2000-2006, drug users in the United States spent $100 billion each year on cocaine, heroin, marijuana, and methamphetamine. 1 In 2011, nonmedical use of pharmaceuticals was involved in greater than 1.4 million emergency department encounters. Additionally, emergency department encounters was reported to be 505,224 for the use of cocaine, 455,668 for the use of marijuana, 258,482 for the use of heroin, and 159,840 for the use of amphetamines, methamphetamine, and other psychostimulants. 2 Alcohol use is the third leading cause of death in the United States. 3 Approximately 17 million American adults and 855,000 adolescents in the United States have an alcohol use disorder. 4 Tobacco use is the leading cause of preventable death in the United States. 5 Substance abuse is typically thought of as illicit drug use or chronic abuse of alcohol, and it is often assumed that substance abuse is nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7
primarily an issue for those living on or near the fringe of society and a problem characterized by aberrant behavior and crime. Yet substance abuse is a problem that also involves the use of legal substances such as alcohol and tobacco, prescription drugs such as benzodiazepines and opioids; moreover, people who are substance abusers are often indistinguishable from the general population. This module will discuss substance abuse involving cocaine, opioids, amphetamines/stimulants, sedative/hypnotics, and alcohol. Note that this module uses the terms substance abuse and substance abuse disorder, not addiction or addict. Both of the former terms are still in common use and there are many professional journals that have the word addiction as part of their title. But addiction is not a recognized diagnostic term, and the word addict has negative connotations and tends to focus attention on the behavior and character of the individual. The term dependency is also frequently used when referring to substance abuse. Dependency refers to the physical need for a drug or substance that develops over time and it is just one part of the clinical picture of substance abuse. Part of the commonly accepted definition of a drug is a substance that will and is intended to, affect the structure or function of the body. 6 A drug is also defined as a substance intended for the cure, diagnosis, mitigation, prevention, or treatment of a disease. 6 Almost all the classes of drugs that are involved in substance abuse disorders have some legitimate, albeit occasionally limited medical use, and alcohol has in the past been used medicinally. However, alcohol is almost never used as a drug anymore. The illicit forms of cocaine, opioids, and stimulants are obviously produced without quality control, and nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8
there are many well-documented cases of dangerous contaminants and adulterants being added to them. For practical purposes, when discussing substance abuse disorders, alcohol is considered a substance and all of the rest are considered drugs. WHAT IS SUBSTANCE ABUSE? The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists more than 20 separate substance use disorders, 7 and a partial list is provided in Table 1. Table 1: DSM-5 Substance Abuse Disorders Alcohol Use Disorder Cannabis Use Disorder Inhalant Use Disorder Opioid use Disorder Phencyclidine Use Disorder Sedative, Hypnotic, or Anxiolytic Use Disorder Stimulant Use Disorder Other (or Unknown) Substance Abuse Disorder Other Hallucinogen Use Disorder Each of the substance abuse disorders has its specific features, but the DSM-5 does point out that all substance abuse disorders are characterized by a central theme: The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. 7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9
This can be expanded by noting that the person who has a substance abuse disorder exhibits the following: 1) has a constant craving for, and preoccupation with the drug; 2) uses more of the drug than is necessary to become intoxicated; 3) has a decreased interest in, and motivation for, normal life activities; 4) develops a tolerance to the drug so that there is a need for increasingly larger doses and more frequent use; 5) develops neurological changes that result in craving and dependency, and; 6) develops withdrawal signs and symptoms if the drug cannot be obtained. All of these are further explained by the DSM-5 in the diagnostic criteria of substance abuse. These criteria are divided into five categories. 7 1. Impaired control: Impaired control is one of the hallmarks of a substance abuse disorder. Someone with a substance abuse disorder finds that over time she/he is taking larger amounts of the drug of substance, despite expressed intentions to cut down or stop use. The life of a person with a substance abuse disorder slowly begins to revolve around drug or substance use, and daily activities become focused on obtaining, using, and recovering from use. The individual s desire for the drug or substance, the craving, becomes intense and unmanageable. 2. Social impairment: The second diagnostic criterion of substance abuse disorder is social impairment. Because of impaired control and the priority on obtaining and using the drug or substance, the substance nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10
abuser cannot function at home, at work, or in other areas of attachment and responsibility. The consequences of the substance abuse are often quite serious; e.g., divorce, loss of job and income, estrangement and isolation from friends and family, or homelessness. However, despite these consequences, some substance abusers cannot or will not change. 3. Risky use: A person who has a substance abuse disorder will continue to use the drug or substance even if doing so involves significant and obvious risks to health and life. He/she may do some very risky things to obtain the drug and get high. 4. Tolerance: A substance abuse disorder is characterized by tolerance. Tolerance is defined as the need for increasingly higher amounts of the drug or substance to achieve the desired effect or a decreased effect from the usual dose or amount. Tolerance is a complicated phenomenon that involves changes in the central nervous system (CNS) and the degree of tolerance developed varies widely from individual to individual 5. Withdrawal: Withdrawal is the final diagnostic criterion of substance abuse disorders. Withdrawal is defined as specific signs and symptoms that occur when someone with a substance abuse disorder abruptly discontinues or greatly decreases use. The seriousness of withdrawal depends on the drug or substance that has been used and the pattern and duration of use. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11
Considering these diagnostic criteria, the picture of a substance abuser begins to emerge. Drug or substance use is compulsive and causes intense craving. Acquisition and use can become the sole focus of that person s life, and recovery from highs can be lengthy and debilitating. Other areas of life suffer and may be completely neglected, and the substance abuser may lose his/her home, friends and family, and job. The health risks and social and personal consequences of the abuse are clear, but the substance abuser feels compelled to continue and will frequently take ever-increasing risks to get the drug and get high. The substance abuser may express a desire to stop use, but the desire to continue is intense and discontinuation is discouraged because of withdrawal signs and symptoms - further reinforcement for continued drug or substance abuse. DRUGS AND SUBSTANCES THAT ARE ABUSED Certain drugs and substances have strong potential for abuse while others do not, and it is not clear why. Drugs such as cocaine and heroin and substances such as alcohol are intensely psychoactive - using cruder terms, they provide a powerful high - and this is certainly one of the reasons for why they are the agents of choice for people who develop a substance abuse disorder. However, the pleasures of intoxication cannot fully explain substance abuse, and research has shown that continued and excessive use of these harmful agents causes changes in the central nervous system, changes that both cause and reinforce substance abuse. Of course, there are many people who take illicit or prescription drugs and/or drink alcohol that do not develop a substance abuse disorder, and these individual responses to commonly abused drugs and substances further complicate the efforts at understanding substance abuse. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12
The mechanism of action, the signs and symptoms of acute intoxication, and the medical consequences of long-term use of alcohol, amphetamines/stimulants, cocaine, opioids, and sedativehypnotics will be discussed in this section. The mechanisms of action by which alcohol and these drugs cause substance abuse disorder and the withdrawal syndromes associated with each one will be discussed in separate sections. Alcohol Aside from tobacco, alcohol is the most commonly abused psychoactive drug in our society. There are many types of alcohol, e.g., ethylene glycol, isopropyl, but the one that is most often consumed for its intoxicating effects is ethanol. The exact mechanisms by which ethanol alters consciousness and causes tolerance and withdrawal are not completely understood. But it is thought that these effects are due to ethanol changing the activity of two neurotransmitters and their receptors: a major inhibitory neurotransmitter called gamma aminobutyric acid (GABA) and a subtype of the major excitatory neurotransmitter glutamate called N- methyl-d-aspartate (NDMA). Gamma aminobuytric acid acts as an inhibitory neurotransmitter by increasing intracellular chloride concentration and decreasing intracellular potassium concentration. This hyperpolarizes the cells and makes them less able to respond. N- methyl-d-aspartate increases the movement of calcium and sodium across cell membranes, and this increases the cells ability to respond to a stimulus and depolarize. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13
Ethanol binds to receptors that are associated with GABA and NDMA receptors on cell membranes in the CNS. This binding increases the affinity of GABA for GABA receptors and it decreases the affinity of NDMA for DMA receptors. The result is increased inhibition and decreased excitation. However, when large amounts of alcohol are abused chronically the body responds by decreasing the number, sensitivity, and function of GABA receptors and increases the number, sensitivity, and function of NDMA receptors. 11 This effect explains alcohol intoxication as well as tolerance to alcohol, e.g., the need for larger amounts of alcohol to produce the same effect; and, it explains withdrawal, the clinical state that is produced when alcohol intake is stopped. Intoxication is caused by increased inhibition and decreased excitation in the CNS. Tolerance occurs because of the effect of chronic alcohol intake on the neurotransmitter receptors. Furthermore, when the intake of alcohol is stopped, withdrawal is caused because there are large numbers of highly active NDMA receptors that can respond to NDMA and a greatly decreased number of GABA receptors that can respond to GABA. Alcohol intoxication is characterized primarily by CNS depression and impairment. Someone who has ingested an excess amount of ethanol will be drowsy, may be ataxic (incoordination of movement), have impaired judgment, decreased impulse control, and slurred speech. Extreme intoxication can cause coma, hypoglycemia, hypotension, respiratory depression, and death. Long-term use is associated with liver disease, heart failure, brain atrophy, gastritis and ulcers, anemia, and various cancers; it is particularly dangerous to the unborn child. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14
Amphetamines/stimulants Amphetamines and stimulants act by directly stimulating the adrenergic nerve endings. This causes a release into the synapses of norepinephrine and dopamine, neurotransmitters that stimulate the peripheral α receptors and β receptors. Acute intoxication causes anxiety, diaphoresis, hypertension, mydriasis, and tachycardia. More serious effects such as dysrhythmias, hallucinations, hyperthermia, myocardial ischemia, myocardial infarction, psychosis, seizures, stroke, and rhabdomyolysis are possible, as well. Long-term effects of amphetamine and stimulant use include aortic and mitral valve regurgitation, cardiomyopathy vasculitis, cardiomyopathy, pulmonary hypertension, and permanent damage to the dopaminergic and serotonergic neurons. Amphetamines and stimulants can be taken as tablets, injected, smoked, or insufflated (snorted). Probably the most commonly abused amphetamine is methamphetamine. Methamphetamine is commercially produced (Desoxyn ), and it has labeled uses for the treatment of patients who have exogenous obesity or attention deficit disorder with hyperactivity disorder. Methamphetamine is lipid-soluble and crosses the blood-brain barrier more easily than the parent compound amphetamine, making it a more powerful drug. The great majority of the methamphetamine involved in substance abuse is illicitly produced, and this form of the drug is commonly called crank or speed. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15
Cocaine Cocaine causes the release and blocks the re-uptake of the neurotransmitters dopamine, epinephrine, norepinephrine, and serotonin. These actions produce a hyper-adrenergic state, and the common signs and symptoms of cocaine intoxication are agitation, anxiety, chest pain, diaphoresis, hypertension, hyperthermia, mydriasis, tachycardia, and tachypnea. Cocaine also acts to stabilize the cardiac membrane by an effect on the sodium channels in the myocardium, and it bocks the movement of potassium through cardiac membrane ion channels. Blockade of the sodium channels produces cardiac membrane stabilization, typically called the quinidine-like effect. This can cause a prolonged QRS and cardiac dysrhythmias. Blockade of the potassium ion channels can cause QTc prolongation and cardiac dysrhythmias, as well. Cocaine abuse has also been associated with serious medical problems affecting essentially every organ system: acute angle-closure glaucoma, aortic dissection, coronary artery vasospasm, dystonic reactions, intestinal infarction, myocardial infarction, pneumothorax, pulmonary infarction, rhabdomyolysis, seizures, stroke, and transient ischemic attack. Long-term effects of cocaine abuse include atherosclerosis, cardiomyopathy, endocarditis, malnutrition, and behavior that can be characterized as virtually identical to personality disturbances, paranoia, and schizophrenic syndromes. Cocaine can be ingested, applied to mucous membranes, insufflated, smoked, or injected. As mentioned previously, there are many well- nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16
documented cases of dangerous contaminants and adulterants being added to cocaine, and these can cause significant harm. Opioids The opioids are a class of drugs that are derived from chemical modification of an opiate, an opiate being one of several alkaloids that are derived directly from the opium poppy. In common practice the term opioid is the one used for all drugs that have similar structure and clinical effects including, but not limited to, buprenorphine, codeine, dextromethorphan, fentanyl, heroin, hydrocodone, methadone, morphine, oxycodone, and propoxyphene. In the United States all of these drugs except for heroin are commercially produced and are commonly prescribed. In the United States, heroin is classified as a Schedule 1 drug. A Schedule 1 drug is defined as a drug: 1) with a high potential for abuse; 2) that has no currently accepted medical use; and, 3) for which there is a lack of accepted safety for use of the drug while under medical supervision. Heroin is commercially available in other countries and is used for treating people who have severe, intractable pain. The opioids act by binding to and stimulating opioid receptors in the brain, spinal cord, and peripheral sites. Opioid receptor stimulation causes the cells to become hyperpolarized and thus less active and less able to respond to stimuli. As with alcohol and other drugs discussed in this module, chronic use of opioids affects the function and activity of neurotransmitters and their receptors, and this causes tolerance and the potential for a withdrawal syndrome. The nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17
therapeutic effects of the opioids are analgesia and an anti-tussive effect. Constipation, drowsiness, nausea, and vomiting are common side effects of the opioids. Opioid intoxication is characterized by ataxia, central nervous system depression, euphoria, hypotension, miosis, respiratory depression, and slurred speech. With profound intoxication coma, hypoxic seizures, hypoxic brain injury, pulmonary edema, and respiratory arrest are possible. Propoxyphene intoxication can cause myocardium sodium channel blockade and arrhythmias. Long-term effects of opioid abuse include heart valve infections, infectious diseases such as hepatitis B and C and HIV (human immunodeficiency virus) that occur with intravenous use, arthritis, collapsed and sclerotic veins, malnutrition, and a depressed immune system. Opioids can be taken as tablets, injected, smoked, or insufflated. As mentioned previously, there are many well-documented cases of dangerous contaminants and adulterants being added to illicit opioids (typically injectable heroin) and these can cause significant harm. Sedative-hypnotics The sedative-hypnotics are a group of drugs that are used to treat anxiety and/or agitation (sedatives) or to induce sleep (hypnotics). There are many drugs that are classified as sedatives or hypnotics, but the sedative-hypnotics that are most often involved in substance abuse disorders are the benzodiazepines and the barbiturates. Table 2A lists the commonly available sedative-hypnotics. Flunitrazepam is not commercially available in the United States but it is included here because of its highly publicized status as the date rape drug, also known as roofies. Midazolam is an injectable benzodiazepine nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18
that is used for pre-operative sedation. It is seldom a drug of choice for abuse but it is included here because it is well known and often used. The non-benzodiazepine hypnotics (Table 2B) have a similar mechanism of action as the benzodiazepines. The barbiturates, listed in Table 3, were at one time the drugs of choice for treating anxiety/agitation or for inducing sleep, but the benzodiazepines have been shown to have similar effectiveness for those purposes and a superior safety profile. The barbiturates are now used to help induce pre-operative sedation or for the treatment of seizure disorders. The short-acting barbiturate butalbital is available in prescription analgesics, compounded in various combinations with acetaminophen, aspirin, caffeine, and codeine. These drugs are almost always used and abused in tablet or capsule from, but injectable preparations are available. Table 2A: Benzodiazepines Alprazolam (Xanax ) Chlordiazepoxide (Librium ) Clonazepam (Klonopin ) Diazepam (Valium ) Flunitrazepam (Rohypnol ) Flurazepam (Dalmane ) Lorazepam (Ativan ) Midazolam (Versed ) Oxazepam (Serax ) Temazepam (Restoril ) Triazolam (Halcion ) nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19
Table 2B: Non-Benzodiazepine Hypnotics Eszopiclone (Lunesta ) Zaleplon (Sonata ) Zolpidem (Ambien ) Table 3: Barbiturates Amobarbital (Amytal ) Butalbital Pentobarbital (Nembutal ) Phenobarbital (Luminal ) Primidone (Mysoline ) Secobarbital (Seconal ) Thiopental (Pentothal ) The mechanism of action differs slightly for the three different categories, but essentially all these drugs act by binding to specific receptors that are part of the GABA receptor complex. This binding increases the affinity of GABA for GABA receptors and, as explained previously, this increases the inhibitory effect of GABA in the CNS. Intoxication with a sedative-hypnotic causes ataxia, CNS depression of varying degrees, from mild drowsiness to coma, hypotension, slurred speech, and respiratory depression. Death is caused by respiratory depression. The barbiturates, compared to the benzodiazepines and the non-benzodiazepine hypnotics, will produce more severe effects: if nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20
very large amounts are ingested coma and respiratory depression may last for days. Compared to alcohol, cocaine, amphetamine/stimulants, and opioids, the long-term medical consequences of sedative-hypnotic abuse are relatively mild. Perhaps the biggest risks are the potential for dependency and development of substance abuse. And although acute intoxication and the long-term medical consequences of alcohol, cocaine, amphetamines/stimulants, and opioids are much more severe, the sedative-hypnotic withdrawal from the benzodiazepines and the barbiturates is comparatively more severe and can be life threatening. THE CAUSES OF SUBSTANCE ABUSE There is no single cause of substance abuse, and despite many years of research there are still no answers to the most pressing questions about substance abuse. Why do some people make the use and acquisition of alcohol, illicit drugs, or certain prescription medications the sole focus of their lives? Also, why do some people continue to abuse substances despite obvious and severe consequences? Although the term is no longer preferred, another way of asking this question is, why do some people become addicts while others do not? There has been a vast amount of effort and research directed towards uncovering the root cause(s) of substance abuse disorders. Biological, psychological, and sociological reasons for these afflictions have all been advanced, and strong arguments can be made for each of these as major contributors to the genesis of, and continued presence of, substance abuse disorders. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21
Current thinking is that there is no single cause of substance abuse disorders, and that substance abuse involves complex neuropsychological phenomena that are behaviorally expressed within a social context. However, although there has been much research, more work needs to be done. Much of the published literature involves animal experiments or a single drug, and it is clear that the true basis for substance abuse disorders is not known. Substance abuse: the process Substance abuse is a multi-factorial process, and the nuances of how biology, psychology and sociology contribute to it have not been sorted out. However, although it is not entirely clear what causes substance abuse, there is very strong evidence about how substance abuse develops in, and affects, the neurologic system. Substance abuse involves changes in several areas of the brain and in neurotransmitters, but perhaps the most important part of the brain that is affected by substance abuse is the reward system. Drugs of abuse stimulate areas of the brain that are involved with very pleasurable survival behaviors such as eating, sex, and bonding. When these areas of the brain (there are several, but the mesolimbic pathway is considered to be the most important) are stimulated, they receive a surge in the neurotransmitter dopamine. Dopamine is a neurotransmitter that is found in the areas of the brain that control emotion, motivation, and pleasure, and increases in dopamine levels of the CNS have many effects and one of them is the experience of pleasure. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22
Cocaine, heroin, etc. stimulate a direct release of dopamine or prevent its breakdown and, crudely put, the more dopamine the higher the level of pleasure. Alcohol, and the drugs that are involved in substance abuse disorders, cause a higher brain dopamine level than do natural rewards such as food or sex. This surge in dopamine and the intensity of the experience - the high - is especially strong when it is caused by drugs of abuse and the information about that experience gets stored and remembered: the drug is associated with pleasure. However, with succeeding exposures to these drugs, the dopamine surge become less and less, and the dopamine levels go lower and lower below normal baseline as less is produced. There is a reduction in dopamine receptors as well. The result is that the person who is chemically dependent gets less of a high each time he/she use the drug and he/she feels less happy when they are not intoxicated, which leads to more drug seeking, and a vicious cycle because the chemically dependent person has now developed a tolerance. 8 Addicts have a term that is called chasing the dragon. It means that there is no high like the first high, and science is proving that to be correct. There is also evidence that the faster the increases in dopamine concentration in the brain (which occurs with early, heavy drug use and with certain drugs such as cocaine) the stronger the reinforcing effect of the drug. Even worse, long-term use of addictive drugs produces long-lasting changes in brain structure that make the person who has a substance abuse disorder susceptible to relapse months and years after successful rehabilitation and abstinence; a phenomenon that partially explains the high relapse rate in people who nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23
have had a substance abuse disorder and they are chemically dependent. Also, these changes in brain structure make the brain less able to react to the weaker pleasure stimuli such as food, sex, bonding, etc. However, it has been shown that increases in brain dopamine concentrations caused by drugs of abuse happen to people who become addicted and to people who do not, so the short-term increase in dopamine cannot explain the development of chemical dependency. It may be that there is a difference in the dopamine circuits between those who are chemically dependent and those who are not. The chemically dependent person may have a particularly weak circuit that doesn t respond to normal pleasurable activities so she/he needs strong levels of stimulation to feel good, and there is supporting evidence for this idea in the literature. It is also possible that people who develop a substance abuse disorder have a biological susceptibility to drugs of abuse. Their brains react to drugs by decreasing the numbers of dopamine receptors and decreasing the amount of dopamine released, thus inhibiting their ability to feel pleasure. This may not happen to people who do not develop a substance abuse disorder. TREATMENT APPROACHES AND WITHDRAWAL Treatment for substance abuse disorders is a process as complex as the disorders themselves. There are many treatment approaches, some which have strong supporting evidence in the medical literature and some that do not. It does seem clear though that early interventions are more likely to be successful. If someone has had a nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24
substance abuse disorder for a relatively brief period of time the chances for him/her successfully discontinuing use are much greater. However, regardless of the specifics of any approach to treating substance abuse disorders the process must involve the following: 1) stopping the use of alcohol and or the drug; 2) if possible, administer the patient an equivalent drug that has a more limited potential for dependency and tolerance; 3) manage the physical signs and symptoms of withdrawal; and, 4) provide psychiatric and social support. Treatment for substance abuse must be a fluid process and be able to change over time. The patient at times will have a need for medical support, rehabilitation, and continuing care, and there are a myriad of personal, social, legal, and medical issues to address. Withdrawal defined Discontinuation of alcohol or one of the drugs discussed in this module will cause withdrawal. Withdrawal is a group of characteristic signs and symptoms of varying severity, which occur after cessation or reduction of use of a psychoactive substance. Withdrawal happens when someone has taken the psychoactive substance in high doses for a prolonged period of time. 9 The intensity and duration of withdrawal depends on many factors. For some people and for certain drugs the withdrawal process is quite uncomfortable, but it is self-limiting and poses no serious risk. But for certain individuals and with some drugs, the withdrawal process can be dangerous. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25
Alcohol withdrawal The pathophysiology of alcohol withdrawal is not completely understood, but the primary mechanism is thought to be adaptation and insensitivity of the CNS to GABA and NDMA. 10 In response to chronic alcohol ingestion and its effects on GABA and NDMA, the body decreases the number, sensitivity, and function of the GABA receptors and increases the number, sensitivity, and function of NDMA receptors. 11 When someone who chronically abuses alcohol stops drinking, the stimulation and inhibition respectively of the GABA and NDMA receptors is removed and the patient experiences an intense excitatory state which explains, in part, the signs and symptoms of alcohol withdrawal syndrome. Alcohol withdrawal syndrome usually starts within six hours or so after cessation of drinking, but the onset may be delayed for several days. It is possible for withdrawal to occur even if the patient still has a relatively high alcohol level. 10 The signs and symptoms of alcohol withdrawal syndrome are primarily cardiac, neurologic, and gastrointestinal and can be mild to severe. Commonly noted signs and symptoms include agitation, anxiety, depression, elevated blood pressure and heart rate, fever, insomnia, nausea, and tremors. 10,11 Patients may present with a relatively mild to moderate clinical picture. However, there are three serious complications of alcohol withdrawal syndrome that are possible: 1) withdrawal seizures; 2) alcoholic hallucinations, and; 3) delirium tremens. Withdrawal seizures affect approximately 10% of all patients with an alcohol withdrawal syndrome. 11 They typically occur within 12-24 hour after the last drink is consumed; they are usually single seizures or nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26
several seizures occurring within a short period of time, and they are self-limiting. 10,11 Alcoholic hallucinations (sometimes called alcoholic hallucinosis) are usually visual, but auditory and tactile hallucinations are possible. Alcoholic hallucinations are self-limiting and usually resolve within 24-48 hours. 10 It is important to note that alcoholic hallucinations are a separate phenomenon from delirium tremens. Delirium tremens, typically called the DTs, is a specific alcohol withdrawal syndrome complication. It affects approximately 5% of all patients who are going through alcohol withdrawal syndrome. 10 The DTs are more likely to occur if the patient 1) has had DTs before, 2) has been a long-time alcohol abuser, 3) is greater than age 30, 4) is experiencing alcohol withdrawal and has a high blood alcohol level, 5) has a concurrent illness, and 6) the onset of alcohol withdrawal is delayed. 10 Delirium tremens produces a clinical picture essentially identical to mild to moderate alcohol withdrawal syndrome, but the intensity of the signs and symptoms is much more intense. Patients who have DTs have severe agitation, confusion and disorientation, diaphoresis, fluid and electrolyte losses, hallucinations, fever, hypertension, and tachycardia. Delirium tremens has a mortality rate of approximately 5%. 10 Patients who succumb are those who are elderly and/or have significant co-morbidities. Factors that have been correlated with an increased risk of developing complicated alcohol withdrawal include: 12 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27
The use of alcohol within the past 30 days or a measurable blood alcohol level Previous episodes of alcohol withdrawal A history of alcohol withdrawal seizures A history of DTs A history of blackouts caused by alcohol ingestion Prior admission to an alcohol rehabilitation program The use of alcohol and a CNS depressant drug such as a benzodiazepine within the past 90 days The use of alcohol and a substance of abuse within the past 90 days A blood alcohol level > 200 mg/dl Evidence of autonomic hyperactivity, e.g., diaphoresis, tachycardia. Opioid withdrawal The pathophysiology of opioid withdrawal is incompletely understood, but it is thought to be similar to other withdrawal syndromes, i.e., continued excessive use of an opioid causes changes to neurotransmitters and their receptors; in the case of opioids, GABA and noradrenaline. 13 When the opioid is discontinued the changes in circulating levels of neurotransmitters and the altered function of the receptors are no longer inhibited by the opioid, resulting in the clinical picture of withdrawal. Opioid withdrawal begins 6-12 hours after last use and the severity of the signs and symptoms will peak within 24 to 48 hours. 14 The clinical course of opioid withdrawal syndrome often follows the progression outlined below, starting from the last time the opioid was used. 14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28
6-12 hours: Diaphoresis, lacrimation, mydriasis, rhinorrhea, yawning 12-18 hours: Anxiety, insomnia, irritability, nausea 18-24 hours: Abdominal cramps, anorexia, piloerection, restlessness, tremor > 24 hours: Chills, diarrhea, hyperthermia, muscle spasms, severe insomnia, tachycardia The severity of opioid withdrawal can be evaluated by using the Clinical Opiate Withdrawal Scale (COWS). 14 The use of COWS can help clinicians make an objective assessment of the severity of withdrawal and it also involves patient input. Table 4: Clinical Opiate Withdrawal Scale 1. Resting heart rate: a. 0-80 beats/min or below b. 1-81-100 beats/min c. 2-101-120 beats/min d. 4 - > 120 beats/min 2. Sweating over the past 30 minutes, not caused by ambient temperature or physical activity: a. 0 - No chills or flushing b. 1 - Subjective reporting of chills or flushing c. 2 - Observed flushing or moistness on the face d. 3 Diaphoresis on the brow or face e. 4 Sweat streaming from the face 3. Restlessness: a. 0 - able to sit still b. 1 Reports difficulty sitting still, but can do so c. 3 Frequent shifting or extraneous movements of arms/legs nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29
4. GI upset within past 30 minutes: a. 0 - No GI symptoms b. 1 - Stomach cramps c. 2 - Nausea or loose stools d. 3 - Vomiting or diarrhea e. 5 - Multiple episodes of diarrhea or vomiting 5. Anxiety or irritability: a. 0 - None b. 1 - Patient reports increasing anxiousness or irritability c. 2 - Patient is obviously anxious or irritable d. 4 - Patient is anxious/irritable and difficult to assess 6. Bone or joint aches: a. 0 - absent b. 1 - Mild, diffuse discomfort c. 2 - Patient reports severe, diffuse aching of muscles, joints d. 4. - Patient is rubbing joints or muscles and cannot sit still 7. Tremor: observation of outstretched arms a. 0 - No tremor b. 1 - Tremor can be felt but not observed c. 2 - Slight tremor observed d. 4 - Gross tremor or muscle twitching 8. Yawning: a. 0 - No yawning b. 1 - Yawning once or twice during assessment c. 2 - Yawning three or more times during assessment d. 4 - Yawning several times a minute 9. Pupils size: a. 0 - Pupils normal sized for room light or pinned b. 1 - Pupils possibly (?) than normal size for room light c. 2 - Pupils moderately dilated d. 4 - Pupils are dilated to the point that only the rim of the iris is visible nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30
10. Runny nose or tearing: Not accounted for by allergy or cold: a. 0 - Not present b. 1 - Nasal stuffiness or unusually moist eyes c. 2 - Nose running or tearing d. 4 - Nose constantly running or tears streaming down cheeks 11. Gooseflesh skin: a. 0 - Absent b. 3 - Skin piloerection can be felt or hair standing up on arms c. 5 - Prominent piloerection A score of 5-12 is considered mild; 13-24 is moderate; 25-36 is moderately severe, and; > 36 is severe. Benzodiazepine withdrawal The benzodiazepines are comparatively old drugs; they are commonly prescribed and commonly abused, and the most of the medical literature regarding sedative-hypnotic withdrawal has been about benzodiazepines. Benzodiazepine intoxication is typically mild to moderate in severity but paradoxically, withdrawal from benzodiazepines can produce severe signs and symptoms and can be life-threatening. 15 As with other alcohol and the other drugs discussed in this module, chronic use of a benzodiazepine changes the affinity of receptors for a specific neurotransmitter (GABA in the case of benzodiazpines), causing a compensatory change in the number, function, and activity of these receptors. When someone who has been chronically using or nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31
abusing a benzodiazepine stops taking the drug, the inhibitory effect of GABA is removed, causing excess CNS excitation. Withdrawal from benzodiazepines occurs when use of the drug is abruptly stopped or tapering of the drug is done too quickly, 15 but mild withdrawal can occur even if the drug is slowly tapered. 16 The onset of signs and symptoms depends on the half-life of the particular benzodiazepine. The withdrawal syndrome may begin within 24-48 hours after cessation of the drug, but if the benzodiazepine has a long half-life (> 24 hours) it may be several weeks before signs and symptoms are observed. 15,17 The severity and duration of the withdrawal syndrome appears to be related to the duration of use/abuse and how quickly the drug was stopped. However, severe withdrawal reactions can occur even after short-term use at low doses. 17 The benzodiazepine withdrawal syndrome is characterized by agitation, anxiety, dysphoria, insomnia, irritability, muscle tremors, and restlessness. Other, less common signs and symptoms include abnormal sensory perceptions, delirium, parathesias, tinnitus, psychotic symptoms, persistent headaches, myoclonic jerks, and seizures. 16,18 The prevalence of seizures has been estimated to be 2.5%-8%. 16 They are usually self-limiting, but deaths have been reported in association with seizures caused by benzodiazepines. 19 The benzodiazepines that have short (< 1 hours) half-lives such as diazepam and lorazepam are more likely to cause withdrawal seizures, 17,20 and seizures are more likely to occur during withdrawal if the prescribed dose is high and the duration of use is long. 17,20 The risk of withdrawal seizures is also increased by other factors that are nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32
common to the population of substance abusers such a concomitant alcohol use. 17 Amphetamine/stimulant withdrawal Compared to the amount of literature published about alcohol withdrawal and opioid withdrawal there is little data about amphetamine/stimulant withdrawal and much of the research has been on methamphetamine. The medical effects of methamphetamine withdrawal appear to be relatively benign and well tolerated, and several sources identify an acute phase and a sub-acute phase. 21,22 The acute phase lasts approximately 7 to 10 days and the signs and symptoms may include diaphoresis, headache, muscle and joint pain, and mild, self-limiting gastrointestinal distress. 21 Psychological effects during the acute phase include anxiety, depression, an increased appetite and an increased need for sleep, and craving for the drug. Psychosis during the acute phase of withdrawal is relatively common. Patients who have a long history of methamphetamine use, have more severe depressive symptoms, and are significantly older than other users, are more likely to have persistent and severe psychotic symptoms. 23 The sub-acute phase lasts approximately to weeks and is characterized by a gradual decrease in the number and intensity of symptoms. 21 Craving may persist for up to five weeks. 22 Cocaine withdrawal Cocaine withdrawal rarely causes serious medical harm or consequences, and most patients simply have mild, self-limiting signs nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33
and symptoms such as chills, non-specific musculo-skeletal pain, and tremor. 24 However, the psychological effects of cocaine withdrawal can be intense and debilitating. Patients may experience significant levels of anxiety, depression, fatigue, inability to concentrate, insomnia, and intense drug cravings. 24 The duration of cocaine withdrawal is typically one to two weeks. 24 TREATMENT FOR SUBSTANCE ABUSE Amphetamine/stimulant abuse and withdrawal and cocaine abuse and withdrawal are considered to be relatively mild and self-limiting and treated with symptomatic/supportive care. 22, 24-26. Benzodiazepine abuse and withdrawal is treated by slowly tapering the use of the drug, administering a long-acting benzodiazepine, and providing symptomatic/supportive care. 15,16 Antihistamines, antipsychotics, beta-blockers, selective serotonin reuptake inhibitors, and tricyclic anti-depressants have been used to treat benzodiazepine withdrawal, but they have not been shown to be superior to benzodiazepines. 15,16 There has been some evidence supporting the use of carbamazepine to treat benzodiazepine withdrawal, but a review considered the data for its use for this purpose insufficient. 27 The optimum rate for tapering has not been determined and it may take weeks to years to successfully withdraw a patient from a benzodiazepine. 28 Treatment of alcohol abuse and withdrawal has been well studied. The basic approach is to: 1) make sure the patient is undergoing alcohol withdrawal by ruling out alternative diagnoses, and; 2) provide symptomatic/supportive care. 10 Symptomatic/supportive care should nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34