Care for the Client with a Substance Use Diagnosis

Care for the Client with a Substance Use Diagnosis

 

Initial Post

In a Word document, address the following prompts:

• Elaborate on etiology, stressors, problems of addiction, dependence, and relapse in the U.S. currently.
• Discuss potential objective physical and mental examination findings when examining a client with a substance abuse issues with rationales.
• Discuss the neurobiological mechanism that underlies the addictive behavior reinforcing properties.
• What are the first-line pharmacotherapy and psychotherapy interventions with implications for monitoring (for alcohol and for opioid abuse).

Post your completed Word document to this discussion forum.

Use APA format with reference list (two to three books and/or articles).

Reply Posts

Reply to at least two of your peers. In your replies, write a maximum two paragraphs for each reply with two to three sentences each that synthesizes one to two pieces of research.

Please refer to the Grading Rubric for details on how this activity will be graded.

The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria which exceed expectations

 

 

First Reply

Shannon Schaal

Substance abuse is defined as the hazardous or harmful use of psychoactive substances, including alcohol and illicit drugs (World Health Organization, 2020). Substance abuse is characterized by overindulgence in an addictive substance. From 1999 to 2016, over 630,000 people have died from a drug overdose (Centers for Disease Control and Prevention, 2020). Substance abuse has become an epidemic in the United States. Increased numbers of individuals are dying every day due to overdoses. Approximately 66% of all drug overdose deaths in 2016 involved an opioid (Centers for Disease Control and Prevention, 2020). Barry, Sherman, and McGinty (2018) report that opiate overdoses are the leading cause of injury related death in the United States and contribute to reversals in life expectancy gains. On average, 115 Americans die daily from an opioid overdose (Centers for Disease Control and Prevention, 2020). Access to drugs is becoming easier and easier. Individuals are beginning drug use at younger ages. Drug addiction can destroy a person’s life. Substance abuse can lead to poor family dynamics, domestic violence, child abuse, vehicle accidents, loss of employment, and even death. The purpose of this discussion is to review the etiology of substance dependence, discuss objective physical and mental examination findings for a substance abuse patient, and discuss the neurobiological mechanism that underlies addictive behavior. This discussion will also review first-line pharmacological and psychotherapeutic interventions for substance abuse.

There are multiple factors that contribute to the etiology of substance use disorders including psychodynamic factors, genetic factors, and neurochemical factors. Sadock, Sadock, and Ruiz (2014) report that addiction has been described as a “brain disease”, and that the critical processes that transform voluntary drug-using behavior to compulsive drug use are changes in the structure and neurochemistry of the brain of the drug user. Drug availability, social acceptability, and peer pressures may be the major determinants of initial drug use; however, other factors such as personality and individual biology play a key role in how the effects of a given drug are perceived and the degree to which repeated drug use produces changes in the central nervous system (Sadock et al., 2014). Other factors, including the particular actions of the drug, may be primary determinants of whether drug use progresses to drug dependence, whereas still others may be important influences on the likelihood that drug use (1) leads to adverse effects or (2) leads to successful recovery from dependence (Sadock et al., 2014). As with treatment for other chronic diseases, treatment for addiction does not offer a cure. The chronic nature of addiction means that for some people relapse, or a return to drug use after an attempt to stop, can be part of the process (National Institute on Drug Abuse, 2020). Recent drug relapse statistics show that more than 85% of individuals relapse and return to drug use within the year following treatment (American Addiction Centers, 2020). Researchers estimate that more than two thirds of individuals in recovery relapse within weeks to months of beginning addiction treatment (American Addiction Centers, 2020). These statistics reinforce the importance of addiction treatment programs and access to treatment.

There are several objective physical and mental examination findings which can indicate the presence of a substance use disorder. Mersy (2013) reports that physical exam findings that can suggest the presence of a substance use disorder include tremor (suggestive of withdrawal from alcohol or opiates), odor of alcohol on breath, enlarged or tender liver, nasal irritation (suggestive or snorting substances), labile blood pressure or tachycardia (suggestive of intoxication or withdrawal from multiple substances), presence of hepatitis B or C, or presence of HIV infection (suggestive of possible needle sharing). Mental examination findings suggestive of a substance use disorder include insomnia, history of frequent trauma, frequent absences from work/school, sexual dysfunction, and presence of other mental health disorders (Mersy, 2013). A high prevalence of additional psychiatric disorders is found among persons seeking treatment for substance abuse; and some studies have shown that up to 50% of those suffering from addiction have a comorbid psychiatric disorder (Sadock et al., 2014). Additionally, positive results on various screening tools can be suggestive of the presence of a substance use disorder.

Understanding the neurobiological mechanism is critical in understanding addiction. Researchers have identified particular neurotransmitters and neurotransmitter receptors involved with most substances of abuse. The major neurotransmitters involved in developing substance abuse and substance dependence are the opioid, catecholamine (particularly dopamine), and GABA systems (Sadock et al., 2014). Even in a person with completely normal receptor function and neurotransmitter concentration, the long-term use of a particular substance of abuse may eventually modulate receptor systems in the brain so that the presence of the substance in needed to maintain homeostasis (Sadock et al., 2014).

There are various pharmacological treatments available for substance use disorders. Saxon, Strain, and Peavy (2020) report that first-line pharmacological treatment for patients with an opioid use disorder include treatment with an opioid agonist or an opioid antagonist. Examples of these medications include methadone, subutex, and suboxone. The use of methadone requires close monitoring. Most patients using methadone are required to visit clinics daily to receive dosage administration. Subutex and suboxone are available by prescription. Medications used during alcohol withdrawal include benzodiazepines, phenobarbital, anticonvulsants, clonidine, and beta blockers (Sadock et al., 2014). Most clinicians choose benzodiazepines for safety (Sadock et al., 2014). Patients withdrawing from alcohol should be monitored for the duration of detoxification, which is typically five to seven days for most patients. If detoxification from alcohol has been completed and the patient does not have a comorbid mental health condition, little evidence favors prescribing psychotropic medications for the treatment of alcoholism (Sadock et al., 2014). However, certain medications can be prescribed to blunt the rewarding effects of drinking and decrease alcohol cravings. These medications include naltrexone and campral.

There are various psychotherapeutic treatments available for substance use disorders. Dickerson et al. (2018) report that motivational interviewing is one of the best studied evidence-based treatments for substance use disorders. Motivational interviewing is described as a directive, client-centered counselling style for eliciting behavior change by helping clients to explore and resolve ambivalence (Rollnick & Miller, 2013). Another effective psychotherapy method for treatment of substance use disorders is cognitive behavioral therapy (CBT). Easton, Crane, and Mandel (2018) report that CBT utilizes social learning theory, classical conditioning, and operant conditioning to help individuals acquire healthier, prosocial behaviors to replace established maladaptive behaviors. Easton et al. (2018) further report that ample evidence across several randomized controlled trials supports the effectiveness of CBT at decreasing alcohol and drug use. Research indicates an enhanced treatment outcome and longer period of recovery with the combined treatment of motivational interviewing and cognitive behavioral therapy when compared with either treatment alone (Khattra et al. 2017)

 

Second Reply

Priscilla Asonye

According to National Survey on Drug Use and Health (2018) (NSDUH, in 2017, about 19.7 million American adults aged (12 and older battled a substance use disorder with almost 74% suffering from alcohol use disorder and about 38% battled illicit drug use disorder. In 2017, about 8.5million American adults were reported to have suffered from both a mental health disorder and a substance use disorder, or co-occurring disorders with drug abuse and addiction costing American society more than $740billion annually in lost workplace productivity, healthcare expenses, and crime-related cost National Institute on Drug Abuse (2017)
Etiology:
Both the Substance Abuse and Mental Health Service Administration (SAMHSA) and the National Institutes of Health(NIH) similarly describe addiction as a long- term and relapsing condition characterized by the individual compulsively seeking and using drugs despite adverse consequences. Presently the prevailing view regarding prediction of whether an individual will become addicted to substance is that interaction of the person’s unique biology and environment both influence how the drug will impact a person’s susceptibility to becoming addicted National Institute on Drug Abuse (NIDA (2018) According to NIDA (2018), Biological factors impacting addiction accounts for between 40%-60% of an individual’s risk for addition, this includes, genes and epigenetics, gender, ethnicity and stage of development, home environment, family dynamics, friends and school. According to NIDA (2018) people get addicted to drugs for many reasons but one of the major factors behind why drugs are so addictive is the rewarding, euphoric high they bring about as drugs have the potential to significantly impact the systems in the brain relating to pleasure and motivation and making it difficult for other natural pleasures to compare. Dopamine is one of the brain chemicals often discussed in the addictive power of substances. Scientist believe that when a rewarding event occurs, the brain releases dopamine to signal the experience and encourage repetition. Dopamine tells the brain that the experience of using a drug is important and should be repeated and programed the brain to remember the people, place, things associated with the use, so it will be easier for the person to repeat the situation. With repetition, these burst of dopamine tells the brain to value drugs more than natural reward, and the brain adjust so that the reward circuit becomes less sensitive to natural rewards. This can make a person feel depressed or emotionally “flat” at a time they are not using drug NIDA (2018) Over time, the desire for drug becomes a learned reflex- so that the person can be triggered to use by people, place, and things that are alike to their drug use just as someone might get hungry driving by sight or smell of food NIDA (2018).
Discuss potential objective physical and mental examination finding s when examining a client with a substance abuse issues with rationale
According to Johnson and Vanderhoef (2016) substance abuse or dependence produces many physical symptoms which are usually a result of sequelae of use or abuse and depending on whether if the patient is in the intoxicating or withdrawal stages. Physical finding related to alcohol/substance use disorders include drastic weight loss or gain, changes in appearance and or hygiene, dilated or constricted pupils, red eyes, slurred speech/problem with motor coordination HEENT, poor oral health Johnson & Vanderhoef (2016)
Specifically, patients going through alcohol cessation or reduction in substance use has been heavy or prolonged are known to exhibit the following symptoms, within several hours or days of reduction or cessation of substance intake: hand tremor, insomnia, sweating, increase heart rate and increased BP due to autonomic hyperreflexia Johnson and Vanderhoef (2016) Patient also exhibits behavior such as hallucination or illusions, psychomotor agitation, anxiety and may have seizure also due to autonomic hyperreflexia. For other street drugs and opioids, different drug use result to different behaviors for example, stimulants: agitation, anxiety, irritability, mood swings and elevated mood. Opioids: mood swing, aggression, disinhibition, impaired cognition, slurred speech and psychomotor slowing etc. Johnson &Vanderhoef (2016)

Discuss the neurobiological mechanisms that underlies the addictive behavior reinforcing properties. Positive rewards of reinforcement result in the social rewards commonly associated with drug use such as disinhibition, euphoric mood, and anxiety reduction. Drug- specific alterations in the normal level and function of neurotransmitters occur as the body adapts to the chronic presence of the substance of abuse. Neuroadaptive process becomes very significant when the person tops substance use. Neuroadaptive change may be more enduring in some person, possibly lasting for years, thus increasing their potential for relapse. This concept helps to explain why, after a long period of sobriety, a person who return to substance abuse often picks up at the same level they stop. Johnson & Vanderhoef (2016)

What are the first line pharmacotherapy and psychotherapy intervention with implications for monitoring (for alcohol and for opioid abuse. According to Johnson and Vanderhoef (2016) pharmacological treatments are symptom specific. E.g. for acute alcohol withdrawal (detox agents replace uncontrolled use of substance with slow tapering of controlled substance such as benzoes are scheduled and gradually used to minimized neuroadaptive rebound.
Also polytherapy is newer approach that matches drugs required for safe and effective withdrawal with neurotransmitter deficiet created by the substance use. Medication used are SSRI, Opioid antagonist (naltrexone, anti –seizure meds such as tegretol and valproic acid, adrenergic medication and anti- craving medication such as naltrexone and multimodality treatment possibly for life time treatment often required Johnson and Vanderhoef (2016)