NCP Hallucinogen Phencyclidine and Cannabis Related Disorders

DSM-IV

HALLUCINOGEN-RELATED/induced DISORDERS

292.89 Hallucinogen intoxication

292.81 Intoxication delirium

292.89 Hallucinogen persisting perception disorder (flashbacks)

292.89 Hallucinogen-induced anxiety disorder

292.84 Hallucinogen-induced mood disorder

PHENCYCLIDINE (OR PHENCYCLIDINE-LIKE)/induced DISORDERS

292.89 Phencyclidine intoxication

292.81 Intoxication delirium

292.11 Induced psychotic disorder with delusions

292.12 Induced psychotic disorder with hallucinations

CANNABIS-RELATED/induced DISORDERS

292.89 Cannabis intoxication

292.81 Intoxication delirium

292.89 Cannabis-induced anxiety disorder

Hallucinogenic substances can distort an individual’s perception of reality, altering sensory perception, and inducing hallucinations. For this reason, these substances are referred to as “mind expanding.” They are highly unpredictable in the effects they may induce each time they are used, and adverse reactions, including “flashbacks,” can recur at any time, even without current use of the drug. Hallucinogens have been used as part of religious ceremonies and at social gatherings by Native Americans for more than 2000 years. Therapeutic uses for LSD have been proposed; however, more research is required. At this time, no real evidence speaks to the safety and efficacy of LSD in humans.

Of the drugs that produce mood and perceptual changes varying from sensory illusions to hallucinations, the most popular and well-known are ergot and related compounds (LSD, morning glory seeds), phenyl alkylamines (mescaline, “STP,” and MDMA or “Ecstasy”), and indole alkaloids (DMT).

A separate classification of drugs includes phencyclidine (PCP, “angel dust,” HOG) and similarly acting compounds such as ketamine (Ketalar) and the thiophene analogue of phencyclidine (TCP). Although these drugs have an entirely different chemical structure, they can have similar hallucinogenic effects and therefore are included here.

Additionally, cannabis (marijuana, hashish, synthetic THC) also produces an altered state of awareness accompanied by feelings of relaxation and mild euphoria and is often used in conjunction with other substances.

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 is thought to have 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 for behavior.

Certain personality traits may play an important part in the development and maintenance of dependence. Characteristics that have been identified include impulsivity, negative self-concept, weak ego, low social conformity, neuroticism, and introversion. Substance abuse has also been associated with antisocial personality and depressive response styles.

Biological

A genetic link is thought to be involved in the development of substance abuse disorders. Although statistics are currently inconclusive, hereditary factors are generally accepted to be a factor in the abuse of substances. Research is currently being done into the role biochemical factors play in the problems of substance abuse.

Family Dynamics

A predisposition to substance use disorders is found in the dysfunctional family system. Often one parent is absent or is an overpowering tyrant, and/or another parent is weak and ineffectual. Substance abuse may be evident as the primary method of relieving stress. The child has negative role models and learns to respond to stressful situations in like manner. However, parents may be average, normal individuals with children who succumb to overwhelming peer pressure and become involved with drugs.

In the family the effects of modeling, imitation, and identification on behavior can be observed from early childhood onward. Peer influence may exert a great deal of influence also. Cultural factors may help to establish patterns of substance use by attitudes of acceptance of such use as a part of daily or recreational life.

CLIENT ASSESSMENT DATA BASE

Factors that can affect the kind of reaction (positive or negative) experienced by the hallucinogen user include individual circadian rhythms (fatigue), previous drug-taking experience, personality, mood, and expectations. Concurrent use of alcohol/other drugs can compound symptoms/reactions. One’s educational level can also cause different perceptions.

Activity/Rest

Insomnia, fatigue

Disturbances of sleep/wakefulness

Hyperactivity (LSD, mescaline, PCP)

Circulation

Diastolic BP decreased (cannabis, high-dose PCP)

Hypertension, hypertensive crisis (low- to moderate-dose PCP)

Tachycardia/palpitations; possible dysrhythmias (high-dose PCP)

Ego Integrity

Euphoria, anxiety, suspiciousness, paranoia (PCP psychosis)

Substance abuse as the primary method of coping

Highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, low self-concept; depersonalization, weak superego, possibly resulting in absence of guilt feelings for behavior or self-reproach, excessive guilt, fearfulness

Moods reflect depression or anxiety

Preoccupation with the idea that brain is destroyed and/or will not return to a normal state

Food/Fluid

Increased appetite (cannabis)

Nausea/vomiting, increased salivation

Neurosensory

Blurred vision, altered depth perception

Dizziness, headache (LSD)

Flashback (spontaneous transitory recurrence of a drug-induced experience [LSD] in a drug-free state) often associated with fatigue, emotional stress, and other drug use (especially alcohol, marijuana)

“Bad trips” (self-limiting and confined to period of intoxication)

LSD: Three kinds: (1) bad body trip (e.g., “my body is purple”), (2) bad environment trip (e.g., visual distortions so real the person thinks he or she is going crazy), (3) bad mind trip (e.g., unexpected subconscious material bursts forth into consciousness, as in, “I’m responsible for my mother’s death.”)

PCP: Aggravates any underlying psychopathology

Cannabis: Rare; however, when occurs, panic attacks are usually seen

Pupillary dilation, catatonic staring (LSD, PCP, mescaline); vertical and horizontal nystagmus, lack of convergence (PCP)

Muscle incoordination/tremors, spasms, or increased muscle strength may be noted with PCP (the anesthetic effect deadens pain perception), deep-tendon reflexes increased (low- to moderate-dose PCP) or depressed (high-dose PCP), opisthotonos (body-arching spasm)

Level of Consciousness: Usually responsive; coma may occur (especially if intracranial hemorrhage occurs with PCP); slurred speech, mutism

Mental Status: Perceptual changes, e.g., sensation of slowed time, perceptions enhanced (colors richer, music more profound, smells and tastes heightened), synesthesia (merging of senses, colors are “heard” or sounds are “seen”), changes in body image, hallucinations (usually visual), depersonalization

Delirium with clouded state of consciousness (sensory misperception, disorientation, memory impairment, difficulty in sustaining attention, disordered stream of thought, psychomotor activity); delusions, illusions, hallucinations (rare with cannabis intoxication); may occur within 24 hours after use or following recovery days after PCP taken

Delusions occurring in a normal state of consciousness; may persist beyond 24 hours after cessation of hallucinogen use (persecutory delusions can follow cannabis use immediately or may occur during the course of cannabis intoxication)

Mood: Euphoria/dysphoria; anxiety, emotional lability, apathy, grandiosity

Behavioral Findings: May include assaultiveness, bizarre behavior, impulsivity, unpredictability, belligerence, impaired judgment, paranoid ideation, panic attacks

Seizure activity (high-dose PCP)

Pain/Discomfort

Decreased awareness of pain

Sudden intense chest pain or persistent chest discomfort (if drug is smoked)

Respiration

Decreased rate/depth of respiration (PCP, heavy cannabis use)

Rhonchi, gurgling sounds

Safety

Participation in high-risk behaviors

History of accidental injuries

Diaphoresis

Conjunctival redness/infection (cannabis)

Assaultive behavior (PCP psychosis), risk to self (impaired judgment/acting on altered perceptions)

Temperature elevated

Social Interactions

Sense of “happy sociability,” friendliness (intoxication)

Dysfunctional family system—an overbearing, tyrannical, absent, or weak and ineffectual parent

Overwhelming peer pressure leading to drug involvement

Impaired social or occupational functioning may be seen with drug use/tolerance (fights, loss of friends, absence from work, loss of job, or legal difficulties)

Teaching/Learning

Concurrent use of other drugs, including alcohol

Family history of substance abuse

DIAGNOSTIC STUDIES

Drug Screen/Urinalysis: To identify drug(s) being used.

Other Screening Studies (e.g., Hepatitis, HIV, TB): Depend on general conditions, individual risk factors, and care setting.

Addictive Severity Index (ASI): To assess substance abuse and determine treatment needs.

NURSING PRIORITIES

1. Protect client/others from injury.

2. Promote physiological/psychological stability.

3. Provide appropriate referral and follow-up.

4. Support client/family in Intervention (confrontation) process for decision to stop using drugs.

DISCHARGE GOALS

1. Homeostasis achieved.

2. Complications prevented/resolved.

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

4. Participation in drug rehabilitation program.

5. Plan in place to meet needs after discharge.