NCP Depressants Barbiturates, Nonbarbiturates, Hypnotics and Anxiolytics, Opioids

DSM-IV

SEDATIVE-, HYPNOTIC-, OR ANXIOLYTIC-INDUCED DISORDERS

292,89 Sedative, hypnotic, or anxiolytic intoxication

292.0 Sedative, hypnotic, or anxiolytic withdrawal

292.81 Intoxication delirium

292. 84 Induced mood disorder

OPIOID-RELATED DISORDERS

292.89 Opioid intoxication

292.81 Intoxication delirium

292.0 Opioid withdrawal

(For further listings, consult DSM-IV.)

CNS depressants are drugs that slow down the central nervous system. They are usually divided into four types: barbiturates, antianxiety agents, sedative-hypnotics, and narcotics (opioids such as morphine, heroin).

CNS depressants prescribed for symptoms of anxiety, depression, and sleep disturbances are among the most widely used and abused drugs. These drugs are very likely to be abused when the underlying conditions remain untreated. Sometimes these drugs are used in conjunction with stimulants, with the user developing a pattern of taking a stimulant to be “up,” then needing the depressant drug to “come down.”

Several principles apply to all CNS depressants: (1) The effects are interactive and cumulative with one another and with the behavioral state of the user; (2) there is no specific antagonist that will block the action of these drugs; (3) low doses produce an initial excitatory response; (4) they are capable of producing physiological and psychological dependency; and (5) cross-tolerance and cross-dependence may exist between various CNS depressants. Although the margin of safety of these drugs is great, they have a characteristic syndrome of withdrawal that can be very severe.

This plan of care addresses acute intoxication/withdrawal and is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.

ETIOLOGICAL THEORIES

Psychodynamics

Individuals who abuse substances fail to complete tasks of separation-individuation, resulting in underdeveloped egos. The person has a highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, and low self-esteem. The superego is weak, resulting in absence of guilt feelings. Underlying psychiatric status must be assessed, as these individuals may use stimulants for varying self-medication reasons.

Psychostructural factors (e.g., personality) are seen as significant. The defect is believed to precede the addiction, with the ego structure breaking down and the substance being used as a maladaptive coping mechanism. Characteristics that have been identified include impulsivity, negative self-concept, weak ego, low social conformity, neuroticism, and introversion.

Biological

A genetic link is thought to be involved in the development of substance use disorders. Although statistics are currently inconclusive, hereditary factors are generally accepted to be a factor in the abuse of substances.

Family Dynamics

There is an apparent predisposition to substance abuse disorders in the dysfunctional family system. Factors such as the absence of a parent or a parent who is an overpowering tyrant or weak and ineffectual, and the use of substances as the primary method of relieving stress, appear to contribute to this dysfunction. These role models have a negative influence, and the child learns to handle stress in like manner. However, parents may be average, normal individuals with children who succumb to overwhelming peer pressure and become involved with drugs. Cultural factors such as acceptance of the use of alcohol and other drugs may also influence the individual’s choice.

CLIENT ASSESSMENT DATA BASE

Data depend on stage of withdrawal and concurrent use of alcohol/other drugs.

Activity/Rest

General malaise

Interference with sleep pattern, insomnia (withdrawal)

Lethargy, drowsiness, somnolence

Yawning

Circulation

Pulse usually slowed; tachycardia (suggests withdrawal syndrome); irregular pulse (atrial fibrillation, ventricular dysrhythmias)

Hypotension

Ego Integrity

Substance use for stress management

Feelings of helplessness, hopelessness, powerlessness

Underdeveloped ego; highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, and low self-esteem

Weak superego, with absence of guilt feelings

Psychostructural factors (e.g., personality) are seen as significant with substance use/abuse (maladaptive coping mechanisms)

Elimination

Diarrhea, occasionally constipation

Food/Fluid

Nausea/vomiting

Neurosensory

Twitching

Mental Status: Confusion, concentration, and memory problems; impaired judgment with some affective change; alterations in consciousness may exist, from extreme agitation to coma; slurred speech

Behavior: Mood swings, lack of motivation, aggression, combativeness (related to general “disinhibiting” effect of the drug, loss of impulse control), dysphoric mood (withdrawal)

Temporary psychosis with acute onset of auditory hallucinations and paranoid delusions (unexplained neuropsychiatric presentation may be indicative of drug use)

Psychomotor activity may be increased

Hypersensitivity (e.g., anxiety, tremors, hypotension, irritability, restlessness, and seizure activity)

Pupils small/pinpoint constriction (opiates), dilated (barbiturates); reaction to light slowed; horizontal gaze, nystagmus, lack of convergence

Gait unsteady/staggering, loss of coordination, positive Romberg’s sign

Pain/Discomfort

Headache, abdominal pain/severe cramping

Muscle aches

Deep muscle/bone pain (methadone abusers)

Respiration

Continuous rhinorrhea, excessive lacrimation, sneezing

Respiratory depression (overdose)

Increased respiratory rate (withdrawal syndrome)

Safety

Hot/cold flashes; diaphoresis

Thermoregulation instability with hyperpyrexia, hypothermia possible

Skin: Piloerection (“gooseflesh”); puncture wounds on arms, hands, legs, under tongue, indicating injection drug use

Social Interactions

Dysfunctional family of origin system

Dysfunctional patterns of interaction with family/others

Teaching/Learning

Preexisting physical/psychological conditions

Family history of substance use/abuse

History of chronic condition/disease process

Concurrent use of other drugs, including alcohol

DIAGNOSTIC STUDIES

Drug Screen: Identifies drug(s) being used.

STD Screening: To determine presence of HIV, hepatitis B, etc.

Other Screening Studies: Depend on general condition, individual risk factors, and care setting.

Addiction Severity Index (ASI): Produces a problem-severity profile, which indicates areas of treatment needs.

NURSING PRIORITIES

1. Achieve physiological stability.

2. Protect client from injury.

3. Provide appropriate referral and follow-up.

4. Promote family involvement in the withdrawal/rehabilitation process.

DISCHARGE GOALS

1. Homeostasis achieved.

2. Complications prevented/resolved.

3. Abstinence from drug(s) initiated/maintained on a day-to-day basis.

4. Attends rehabilitation program, group therapy (e.g., Narcotics Anonymous).

5. Plan in place to meet needs after discharge.