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Chemical Dependence: Substance Abuse

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Authors:    David Tilton (RN, BSN) , Susan Tilton (BSB BSMT)

Purpose/Goals

Chemical dependence is a topic rife with confusion in our society. This is also true amongst those who provide care to clients who find their bodies, minds, and quality of life shattered on the jagged shoals of substance misuse. While philosophical debates rage in areas such as whether or not chemical dependency is or is not a disease we can agree upon the ill effects manifested in the health of those afflicted, and share strategies to recognize and provide care to those who misuse or overuse substances.

Objectives

On completion of this educational activity, the learner will be able to:

  • Discuss a basic definition of chemical dependency.
  • Describe three signs/symptoms that would indicate a need to consider chemical dependency in a client.
  • Provide an overview of the brain response system associated with chemical dependency.
  • Name three common groupings for chemicals of abuse.
  • Outline one method of brief intervention used in dealing with chemical dependency.

Introduction

While misuses of psychoactive chemicals or recreational substances make for a smashing hit movie, observations gathered over time provide a tremendous amount of useful information concerning both chemicals and patterns of dependence and abuse.

 

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Scope of Problem

Chemical dependence afflicts the old and the young, all economic levels, all cultural divisions. Around forty percent of all hospital admissions are influenced in some manner by chemical dependency or substance abuse (Weaver & Jarvis, 2009).

Overutilization of any substance can lead to undesirable effects. Tendencies to overuse some manner of chemicals may be unduly influenced by inborn molecular genetic predispositions. Of concurrent importance is the presence of individualized behavioral rewards for using a given substance.

Dependence on a chemical or substance, according to the Diagnostic and Statistical Manual of the American Psychiatric Association consists of groupings of recognizable physiologic, cognitive, and behavioral symptoms that demonstrate that an individual is using on a continuing basis a substance that causes significant problems for that person. Dependence can be on a prescription medication, a recognized drug of abuse, or other substances that can be taken into the body (DSM-IV-TR. 2000).

The difference between Substance Dependence (aka Chemical Dependence) and Substance Abuse (aka Drug Abuse) can be subtle, and there is considerable room for overlap between the diagnostic criteria. For the purpose of this discussion we will concentrate on the key areas that differentiate dependence from abuse in the DSM Diagnostic Criteria, namely the presence in chemical dependence of the components of; 1) Tolerance, 2) Avoidance of withdrawal, and 3) Persistent compulsive use. The presence of these factors in conjunction with negative consequences (physical, social, occupational, psychological) related directly to the use of the chemical in question paint a clear diagnostic picture of the presence of medically significant dependency for that individual.

Chemical Dependence Definitions
 
Definition:Chemical Dependence(often referred to as addiction)
Presence of tolerance to the substance
Avoidance of withdrawal symptoms
Consumption in larger amounts than intended
Persistent use despite negative consequences
 
 
 Social
 Occupational
 Psychological
 Physical
 
Definition:Substance Abuse
Recurrent use over a 12 month period despite:
 
 Use creates physically hazardous situations
 Use creates legal problems
 Use creates negative social and interpersonal consequences
 
Definition:ChemicalIntoxication
Reversible substance-specific syndrome, due to recent ingestion, resulting in behavioral or psychological maladaption
 
Definition: Tolerance
When the same amount of substance results in diminished effect,
or,
When increased amounts of substance are needed to achieve a former (desired) result
 
Definition: Withdrawal
Substance-specific reaction (either physical or psychological) to cessation of intake of a substance previously ingested
(Moses, 2009)


Illegal substances are those whose possession or use is deemed by federal or state statue to violate a judicial regulation or decision. Illicit substances are those whose use may or may not violate a specific law yet are considered wrong or unacceptable by prevailing social customs or standards. Illegal or illicit substances can, and frequently are, the subjects of chemical dependence, and tend to be the items tracked by law enforcement and health advocacy groups whenever usage statistics are cited. Not all substances that cause significant detrimental symptoms are illicit or illegal. Chemical dependence can be present to a legitimate and legal substance of use (i.e. alcohol, prescription pharmaceuticals, over the counter medications). It is important as a health professional to be constantly aware that dependency is not limited to what are frequently referred to as "drugs of abuse". Aunt Millie's special cough elixir with its high composition alcohol base and other special ingredients can also be the source of negative consequences of chemical dependency, which require identification and treatment.
 

Case Study: Gemina

Gemina is a 70 y/o type 2 diabetic female one day post ankle surgery. Her surgery was done using a regional anesthetic in order to decrease the possibility of complications. Other than oral hypoglycemics she is on no routine prescription medication, and indicates that the only over the counter items she regularly takes are an older adult liquid multivitamin complex four times a day and a nighttime sleep elixir which has the active ingredient diphenhydramine. In the admission notes, it indicates that the client brought both OTC's with her to presurgery admission despite being instructed that hospital policy prevent their use during her stay, and became upset and argumentative with the admissions staff when they were sent home with the client's family. The client reports that she uses no recreational substances and is an adamant non-drinker.

Late in the evening Gemina begins complaining of anxiety and uncontrollable "shivering". On examination, she is diaphoretic and tachycardic. Her BP is 164/90, P 112, R 22, Temp 99.1. Her Blood Sugar, which was checked immediately by the nurse, is 83.
 
Resolution:

Review of admission paperwork and questioning of Gemina along with a phone call to her family reveal that the OTC substances the client compulsively imbibes both have a high alcohol content that is not listed as an "active" ingredient. The older adult liquid multivitamin complex she takes four times daily is meant for once daily, and the sleep aid, elixir bottle stays at her bedside in case she has "difficulty sleeping" and needs a second or third dose during the night.

Gemina is diagnosed with withdrawal secondary to alcohol dependence and given supportive acute care with extended follow-up.
 


 

Brain Reward in Chemical Dependency

Chemical dependence occurs in the brain. Brain reward is a term used to describe the recognition of, desire for, and drive to continue the use of a substance even after the person consciously realizes detrimental effect accompanies its use. The brain closely regulates the interplay of chemicals affecting the ongoing balancing acts of daily life. A key player in this ongoing and at times frantic juggle of biochemistry is the brain's reward system, the mesolimbic dopamine system. Research into brain chemistry is showing that brain reward can be triggered when a substance stimulates dopamine production in the mesolimbic system. Dopamine produced in this manner consequently affects an array of neurochemical and neurohormone messengers dependent on individual factors such as prevalent demands and functional imbalances. This helps explain why certain ingested chemicals are problematic to one person while not desired by another. For example, cravings for amphetamines rather than heroin even after being exposed to both. The uniqueness of the needs for balancing individual brain chemistry plays a role in what triggers the brain reward response (Erickson, 2009).

Closely allied to the neurochemical brain reward response are the cognitive behavioral effects of chemical dependency. The correct chemical trigger at the proper time for the right person can nudge the brain chemistry and make our thoughts and feelings regarding unpleasant life circumstances better, at least for a time. So closely linked are the behavioral rewards of chemical dependency to the biochemical brain reward system that there is no clear differentiation. Even after negative consequences of substance misuse become evident in a dependant person's life and health, the person clings to their chemicals of choice, hoping perhaps for better future results and fearing what life would be without the support of their chemical helpers.

Chemicals with a greater probability of leading to dependency have been grouped into four major classes (Parren, 2009):

Sedative-Hypnotics - Depressant substances such as alcohol, barbiturates, benzodiazepines
Stimulants - Such as caffeine, cocaine, methamphetamine, nicotine
Opioids - Such as heroin and prescription opioid analgesics
"Other" drugs - Substances with high potential for dependence that do not fit readily into the other main groupings such as hallucinogens, psychedelics, dissociative anesthetics, cannabinoidsChemicals in these general high dependence groupings provoke the release of dopamine (either directly or indirectly) from the brain resulting in the brain reward response. Differences in what triggers the brain reward response and how sensitive each person is to that reward once triggered contributes toward the level of risk for chemical dependence, what is sometimes referred to as the abuse potential (Parren, 2009).
 
Discussion Point: Seeking Dissociation

Those caught in the web of chemical addiction have an expansive range of motivations. Some become enmeshed while seeking relief from physical pain, others while seeking more energy, greater creativity or perhaps enhanced pleasure. Others may be looking for the emotional relief brought by a sense of numbness or a change of sensations. Often, awareness of any primary motivation for continued chemical use past the point of negative life consequences will be absent (e.g., "I don't know why I became hooked, it just happened!").

Please be aware that one of the strong underlying primary motivations related to situations that develop into chemical dependency is that of dissociation or escape, the shifting of the way that individual feels about themselves, their life, and their frustrations, both related to specific or general situations.

Homework Assignment: When working with a chemical dependency client set aside a brief interval to contemplate the following;
 

"What is the primary benefit this person achieves from their chemical of choice?"
 

Many people are able to control their use of substances with the potential for abuse and not experience sustained or serious consequences from occasional responsible use. The experience of those who become burdened with chemical dependence can be thought of as an abnormal level of response (brain reward) which leads to a desire for more of the substance and continuing increases in both the frequency of use and the amount of the chemical needed for effect. In conjunction with the substance ingestion or resulting from consequences of the substance use, negative consequences arise giving the health professional diagnostic clues on which to home in (Weaver & Jarvis, 2009).
 

Diagnostic Evidences

The best situation is the client who approaches their care provider with concerns about substances they are taking and consequences they are experiencing. Yes, this does happen! Chemical dependency scenarios are not confined to what is portrayed on TV dramas. Frequently people find themselves in uncomfortable situations regarding prescription pain medications, social drinking, recreational substances, and so on. Often they voice concerns to health care providers that they have never voiced to anyone else, even their families, about adverse circumstances, they are facing or unusual cravings that concern them.

Families and friends may also be the ones to bring a dependency concern up to the affected individual or to a trusted health care provider. The perceptions and concerns voiced by someone who knows the individual well should always be considered as a potential, needing follow up.

Both acute symptoms and chronic health consequences of chemical dependence can also bring the matter to the awareness of the health care system. Presenting symptoms can vary greatly depending on the individual and the substance involved.
 

Sedative-Hypnotics

Among the chemical dependency groups, substances whose primary mode of action is a depressant effect have been gathered under the heading of Sedative-Hypnotics. Alcohol, benzodiazepines and barbiturates all belong to this category. Nonbarbiturate nonbenzodiazepine sedative-hypnotics are also included, such as buspirone, chloral hydrate, carisoprodol, and gamma-hydroxybutyrate (GHB).

Sedative-hypnotic use is common. Benzodiazepines for therapeutic use are one of the most frequently prescribed pharmaceuticals in the world. The wide availability by prescription for legitimate use creates ample opportunity to maintain an established long-duration chemical dependence.

The use of sedative-hypnotics also tends to accompany chemical dependency to both stimulants and opioids. Frequently in these individuals no dependency is present to a sedative-hypnotic, the depressant chemical is simply a tool used to help offset side-effects or withdrawal symptoms created by the substance they are dependent on (Cooper, 2009).

Chief amongst the sedative-hypnotic chemicals of dependence is alcohol, which is licit (socially accepted), and possesses predictable central nervous system depressant effects. Roughly two-thirds of Americans drink alcohol with around one in ten using it to significant abuse. Excessive alcohol use has been identified as the third leading preventable cause of death amongst Americans and comprises of a large number of emergency room visits each year (Gold & Aronson, 2009).
 
Alcohol Use Prevalence in the United States in 2004
 
  • Alcohol dependence = 2 to 9 percent of population
  • Risky drinking = 4 to 29 percent of population
  • Harmful drinking = 0.3 to 10 percent of population
(Gold, & Aronson, 2009)

Acute indicators, which may signal the presence of an alcohol or other depressant chemical dependence, range from suspicious circumstances in an accident to obvious disinhibition from the CNS depressant effect. Blood levels for acute use symptoms may be an effective tool to aid a person to realize that they have a problem that requires treatment.

Chronic physical symptoms specific to alcohol dependence range widely and are dependent to areas of physiologic vulnerability specific to each individual. They may include effects of chronic use such as the following (Cohagan, & Worthington, 2007);

Neurologic - Korsakoff psychosis, Wernicke encephalopathy, peripheral neuropathy, dementia resulting to structural changes in the brain
Psychiatric - Anxiety or depressive disorders
Immunologic - Neutrophil function suppression
Gastrointestinal - Liver cirrhosis, peptic ulcer disease, pancreatitis
Obstetric - Fetal alcohol syndrome, mental retardation, fetal deformities
Endocrine - Male testicular atrophy, impotence, gynecomastia

Assessment for alcohol or other depressant dependence requires personal history information in order to determine the presence of chemical use patterns and any negative consequences that may be related to use. Information either from the client or from family members is helpful, and often clients are very forthcoming concerning substance use as long as questions are framed in an open and nonjudgmental manner.

Even when being fully cooperative, clients frequently underestimate their own substance use. Tools such as the CAGE alcohol-screening questionnaire can help the health provider to gain the clearest understanding possible. A single positive response for any of the CAGE four questions is considered as suggestive of an alcohol dependence problem. Two or more positive responses increase probability of a dependence problem to around 90-percent. Please remember when using the CAGE tool that it is best utilized when not preceded by questions concerning types or numbers of drinks consumed.
 
CAGE Questionnaire for Alcohol Use Screening
 
C-Has anyone ever felt you should Cut down on your drinking?
A -Have people Annoyed you by criticizing your drinking?
G -Have you ever felt Guilty about your drinking?
E -Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
(Cohagan, & Worthington, (2007)

Making a dependency diagnosis with any of the sedative-hypnotics only requires meeting the criteria discussed earlier: tolerance, avoidance of withdrawal, consumption greater than intended and negative consequences of use. Health practitioners do not actually need to quantify consumption amounts to detail; however, learning amount of typical intake during both "normal" and "binge" episodes can be very helpful in both risk assessment for chronic health concerns and later in counseling for dependency.
 
CDC Excessive Alcohol Use Definitions
 
  • Heavy Drinking = More than two drinks per day for men, more than one drink per day for women
  • Binge Drinking = Five or more drinks during a single occasion for men, four or more drinks during a single occasion for women
  • Excessive Drinking = Includes BOTH heavy and binge drinking
 
  • A standard drink is defined as;
    • 0.5 ounces of pure alcohol (1.2 tablespoons or 13.7 grams)
    • 1.5 ounces of distilled (80 proof) spirits or distilled liquor (e.g. rum, vodka, gin, whiskey)
    • 5 ounces of wine
    • 8 ounces of malt liquor
    • 12 ounces of regular beer or wine cooler
(CDC, Alcohol and Public Health, 2008)

Withdrawal symptoms are a red flag for any health professional that chemical dependency is an issue. An awareness of some key aspects of alcohol withdrawal is therefore essential in order to recognize and supply the best support and treatment.
 
Alcohol Withdrawal Characteristics
 
  • "The Shakes" 12 to 24 hours (times are approx., i.e., can begin manifesting within 6 hours) after the last drink. Tremor may be accompanied by anxiety, headache, tachycardia, diaphoresis, insomnia, or anorexia, and reflect an over-excitation of the CNS.
  
  • "Rum Fits" 24 to 72 hours after last drink. Generalized seizures may manifest, as may alcoholic hallucinations. Untreated alcohol withdrawal seizures progress to delirium tremens in about one-third of clients.
 
  • "DT's" 3 to 5 days after last drink. Delirium tremens (DT) is a condition characterized by fever, disorientation, and visual hallucinations. DT's are regarded as a medical emergency and warrant inpatient treatment.
(Cohagan, & Worthington, 2007), (Hoffman, & Weinhouse, 2009)

In our focus on alcohol as the most prevalent of the sedative-hypnotic chemicals of the dependence group please be aware that one of the commonly observed characteristics of alcohol dependence is a loss of control by the user concerning behaviors associated with alcohol use. This can be manifested in such things as drinking their alcohol more quickly than circumstances might dictate, or gulping their very first drink. Other indicators might include showing concern or worry when events interfere with planned drinking opportunities, or using alcohol as a primary mechanism to release stress. Frequent thoughts or talk about drinking and when they will be able to engage in their next drink can also be an indication of need to assess for dependence.

Blood alcohol levels may not be of great assistance in determining a diagnosis of alcohol dependence. The presence of detectable alcohol by breath test or in the bloodstream does not present the requisite information to determine the pattern of use present. Other laboratory tests may supply a clearer picture of use patterns (Gold, & Aronson, 2009).
 
  • MCV or Mean Corpuscular Volume - Macrocytosis (MCV of between 100 and 110 fL in the complete blood count) is frequently associated with a pattern of alcohol use indicative of dependence. Regular ingestion of 80 grams of alcohol each day (equivalent to one bottle of wine) leads to this change in around 90-percent of individuals. Abstaining from alcohol allows the body to resolve macrocytosis within two to four months.
  • Liver studies - A number of characteristic liver changes accompany consistent and extended alcohol use. Abnormalities in serum aspartate and alanine aminotransferases as well as gammaglutamyl transferase (GGT) are commonly associated with alcohol dependence or abuse.
  • Serum Carbohydrate-deficient Transferrin (CDT) - is an intriguing blood assay that can be of great use identifying chronic heavy alcohol use. This test is actually a better biomarker for alcohol consumption than either MCV or GGT as its sensitivity for significant alcohol intake is between 60 to 70-percent while its specificity is between 80 to 90-percent. A rising CDT concentration can be an indication of relapse during treatment.
It is important for the health professional to remember that the presence of other chemicals in the sedative-hypnotic group will also tend to resemble alcohol intoxication. The use of both laboratory screening tools and interview skills are important. In cases of severe impairment, the following studies are recommended (Cooper, 2009):
 
  • Complete blood count (CBC)
  • Arterial blood gas (ABG)
  • Chemistry profile with glucose
  • Toxicology screen
    • Suspected intentional exposures should always include; Alcohol, Salicylate, and Acetaminophen
    • Quantitative serum drug concentration levels are recommended for clients with serious toxicity symptoms

Stimulants

Stimulant use as a dependence issue is often an exercise in polysubstance use. While the stimulant dependent person will often have their favorite substance, many imbibe whatever is at hand that can be utilized to achieve the goal of renewed energy, a boost, or simply to help them maintain a feeling of control. Stimulants range from licit items such as caffeine, heavily sugared energy drinks, cigarettes, and even over-the-counter (OTC) decongestants, to illicit and illegal substances such as cocaine or methamphetamines.

Suspicion of stimulant use and perhaps dependence should occur on observing any of the following; an elevated mood in circumstances where that would not be warranted, an unusual level of alertness, reports of increased energy often accompanied with insomnia, and atypical weight loss similar to anorexia (Divadeenam, K., 2008).

The presentation for evaluation in office or emergency department with chest pain, tachypnea, abdominal pain, nausea, and headaches may indicate stimulant use. The long-term use of stimulants tends to show characteristic dependency indicators such as substance tolerance, and may also be manifested in weight loss as well as mood and mental instabilities such as heightened impulsivity, irritability, aggressiveness, hallucinations and even delusional thinking. The characteristics of stimulant dependence and overuse can be summarized as follows:
 
Stimulant Intoxication Mental Status Examination
 
  • Attitude – Tense
  • Psychomotor Activity - Agitated, restless
  • Speech – Talkative
  • Mood/ Affect - Good, euphoric, labile
  • Thought content or processes - Flight of ideas, paranoia, grandiosity, hypersexuality, hallucinations, homicidal ideation
  • Orientation - Confused, delirium
  • Insight or judgment – Impaired
  • Memory - Varies, while small amounts of stimulants may improve alertness and task focus, heavy or prolonged use is detrimental to memory and can lead to coma
(Divadeenam, 2008)

A similar examination of an individual with long-standing stimulant use or stimulant dependence who has been without their substance of choice can also be characterized into a recognizable pattern.
 
Stimulant Withdrawal Mental Status Examination
  • Behavior – Sedated
  • Psychomotor Activity – Retarded
  • Speech – Nonspontaneous
  • Mood/ Affect - Depressed, irritable
  • Thought content or processes - Linear at times with suicidal content and substance cravings, homicidal potential as well as paranoia is often present
  • Orientation - Close to normal
  • Insight or judgment – Variable
  • Memory - Likely to be impaired due to sleep deprivation and fatigue
(Divadeenam, 2008)

A clinical history that encompasses substance use is an important tool in establishing the presence of stimulant dependence. It has been suggested that the sequence of topics discussed can play a role in obtaining more and better information when chemical dependence is suspected. By preference, a layered substance questioning strategy has been recommended.
 
Substance Use Interview Sequence
 
  • First, ask concerning socially accepted substances such as nicotine or caffeine. This helps to establish a level of comfort for the client regarding questions about substance use.
  • Next, inquire about alcohol. Be sure to specifically ask about wine, beer, and whiskey as many clients will not consider beer to be "alcohol", which some only associate with hard liquor.
  • Inquire concerning use of over-the-counter drugs including caffeine pills, dextromethorphan and pseudoephedrine products, and "energy" products.
  • Finally ask concerning illicit drug use. The client should be prepared by this time, having a sense that the practitioner is collecting information in a non-judgmental fashion for the purpose of helping.
    • Marijuana is often regarded by users as a substance with little social stigma, so should be the first illicit substance asked about.
    • Following that should be questions about cocaine and heroin use, as well as prescription pain medication use.
  • Be sure to ask clear questions concerning the quantity of each substance used as well as frequency of use.
  • Please be aware, studies with alcohol abusers indicate that clients dealing with dependence issues are more open to discussion of them than most providers believe.
(Weaver, & Jarvis, 2009), (Gold, & Aronson, 2009)

Physical examination results may indicate suspicion of stimulant dependence especially when cocaine or methamphetamines have been the substance of choice. The presence of signs of metabolic acceleration or excitation such as being hyperthermic, tachycardic, and hypertensive are all suggestive of acute stimulant use. A manifestation of seizure activity in the absence of seizure history is also a diagnostic indicator to suspect stimulant use.

Laboratory screening for substances of abuse can be very helpful in these individuals. It is also important to conduct generalized electrolyte studies along with glucose levels as stimulants play havoc with these metabolic processes.
 

Opioids

Narcotic is a generalized term that may incorporate a variety of classes of chemicals who share the properties of enhancing sleep and decreasing pain. Opioid chemicals consist of a more narrow range of pharmaceutical grade or street drug level substances than the general term narcotic. The common relationship opioids have with each other is that they either are derived from or chemically resemble active metabolites obtained from the opium poppy. Both prescription pain relievers and illicit opioids are chemicals that may be associated with dependence and as with the category stimulants, it is often not a single drug of choice involved but rather whatever related item is currently available. Therefore while the chemically dependent individual may have a drug of preference, it is important to inquire about related substances they have taken in the past as well as what they are currently utilizing, to get a better clinical picture.
 
Some of the more common Opioids
Natural Opioids (aka Opiates)Synthetic Opioids
  • Opium
  • Morphine
 
  • Codeine
  • Oxycodone (OxyContin)
  • Meperidine (Demerol)
  • Fentanyl (Sublimaze)
  • Hydromorphone (Dilaudid)
  • Methadone
  • Propoxyphene (Darvon)
  • Pentazocine (Talwin)
  • Nalbuphine (Nubain)
  • Butorphanol (Stadol)
  • Heroin, perhaps the most abused opioid of all, is semisythetic and may be found in either category depending on the definitions used by various information sources.
(Opioids and Related Disorders, 2009), (Habal, 2008)

Pharmacologic pain management has relied extensively on opioid narcotics. This makes professional healthcare the number one means of initial exposure to a substance that in a few individuals triggers the brain reward system and sets up a cycle that may lead toward chemical dependence. Awareness of the potential for developing a dependency is crucial to the delivery of care, as is the early identification of dependency before negative consequences creates irreparable damage.

Chemical dependence to an opioid follows the diagnostic pattern outlined in the DSM-IV. The establishment of a tolerance to the substance leads to a higher dosage being required in order to achieve the desired effect. Active avoidance of feelings or symptoms associated with stopping the use of the substance, and a continuing persistence of usage despite evidence of growing negative consequences are also needed to establish a dependence diagnosis.

Please be aware! Substance abuse and chemical dependency are not the same thing and recognition with follow-up needs to be congruent with the individual client. Quantities of use in the opioid groupings cannot be utilized as a definitive diagnostic differential between abuse and dependence as individuals who ingest opioids for the purpose of abuse typically use them less frequently, and may also use lesser single dosages than do those who have developed tolerance in an ongoing dependency (Opioids and Related Disorders 2009).

Signs of recent opioid use include facial flushing which is the result of vascular changes induced by the drug, and the presence of drowsiness or lethargy that is unusual in that person or not congruent with the current situation. Dry mouth and slurred speech along with a positive affect or mood and seeming indifference to pain are symptoms that can support the suspicion of active opioid use. Complaints concerning constipation can also provide suspicion of both current and ongoing opioid use as this side effect is consistent across the spectrum of therapeutic as well as non-therapeutic usage.

In clients who have developed a dependency for opioids it can quite literally be true that the amounts of drug they are taking could kill another person who is opioid naive (e.g., has never before been exposed to them). Opioid tolerance can develop quickly and regular users adjust by incrementally increasing the amounts taken, at times to staggering quantities. The manner in which our metabolism adjusts can create a situation where in the dependent person only feels "normal" when they actively have adequate opioids in their system. This means that a disruption in supply of the desired chemical can have significant effect on emotional, physical, and mental problem solving abilities.

Symptoms of opioid withdrawal are a red flag that opioid dependency may be a factor. Withdrawal begins in as little as six to eight hours from the time that an effective drug level leaves the system, and depending on the opioid currently being used can last from several days to an extended withdrawal of six months or longer. Methadone withdrawal symptoms for example are notoriously prolonged. In part this is due to the extended half-life of the drug and the length of time it takes for the built-up metabolites of methadone to clear the system.

High on the list of withdrawal symptoms with which a client may present to a physician's office, clinic or emergency department is insomnia. Sleeping difficulties are frequently accompanied by generalized feelings of anxiety and a loss of interest in activities or functions that they would normally enjoy.

So well recognized are the symptoms associated with stopping the use of an opioid that the DSM-IV paints a clear picture of what manifestations to be aware of in order to confirm or rule out withdrawal.
 
Opioid Withdrawal
 
  • Opioid-specific withdrawal syndrome: Three or more of the following symptoms which are not due to another known condition and which develop after abstinence from or reducing the amount of an opioid;
    • Insomnia (often accompanied by fatigue),
    • Dysphoric (negative) mood,
    • Nausea or vomiting,
    • Muscle aches,
    • Runny nose or watery eyes,
    • Dilated pupils,
    • Sweating with or without fever
    • Diarrhea,
    • Yawning (with or without reports of fatigue)
  • Please note that in order to be used as diagnostic evidence the withdrawal symptoms must cause significant distress, and that restlessness and anxiety such as that seen in opioid withdrawal may be seen in withdrawal from sedatives, hypnotics, and anxiolytic chemicals.
(Opioids and Related Disorders, 2009)

Diagnostic procedures in the acute setting rely heavily on clinician experience and clinical interview. Laboratory drug screening is a good confirmation of suspicion for opioid presence yet will not replace the depth of information that comes from a thorough diagnostic workup and interview. One interview tool that has been shown to be useful is the RAFFT questionnaire for substance abuse.
 
RAFFT Questionnaire
 
  • R (relax) - Does the client drink or take drugs to Relax, improve a self-image, or to fit in?
  • A (alone) - Does the client ever drink or take drugs while Alone?
  • F (friends) - Do any close Friends drink or use drugs?
  • F (family) - Does a close Family member have a problem with alcohol or drugs?
  • T (trouble) - Has the client ever gotten into Trouble for drinking or taking drugs?
(Weaver & Jarvis, 2009)

 

Brief Intervention in Chemical Dependency

Chemical dependency whenever suspected is a problem that must be addressed. It is important to inform the client of concerns in a clear and caring way. Options for treatment can be offered and while some clients will adamantly deny that there is a problem a surprising number show relief when it is out in the open and no longer a hidden burden they must bear in secret.

Acute, follow-up, and ongoing maintaining therapies are all essential in the treatment of chemical dependency. Acute medical interventions are focused on the specific medical needs of the individual right at the time of diagnosis. The consensus of the medical and mental health community however is that acute treatment alone is rarely enough. Virtually every client with a chemical dependency diagnosis benefits from consistent follow-up treatment and lasting support to maintain a chemical dependence-free life.

Several treatment modalities exist for follow-up treatment of chemical dependency. Individual factors such as time, expense, personality and available support must all be factored in to the decision-making process. The therapeutic regimen known as Brief Intervention has gathered a growing following amongst practitioners due to its well-documented efficacy amongst chemical dependency clients, especially in the subset of problem alcohol behaviors.

Brief intervention is a strategy that utilizes short-duration sessions, which can begin at the time of admission. Brief intervention can be woven into treatment planning and for use at the bedside through the course of medical recovery, and form an integrated strategy throughout follow-up office visits or referrals. The techniques involved often take around five minutes or less, which make it a prized therapeutic method useful to even the busiest health professional. The ability to hold a meaningful session during a routine office visit, for example, makes for a happy client and clinician.

Brief intervention sessions focus on finding and emphasizing the specific motivation that will work for that particular client. These short yet structured sessions continue over a regular schedule until the client is motivated to take positive actions to change the behavior that supports their chemical dependency. While brief intervention has shown good success, it must then be followed up with a structured support system that focuses on maintenance of the person vulnerable to chemical dependency.

FRAMES is an acronym that has been used for the separate elements incorporated in Brief Intervention sessions (Weaver & Jarvis, 2009).
 
The FRAMES of Brief Intervention
 
  • Feedback - Give Feedback on the risks and negative consequences of substance use based on thorough assessment
  • Responsibility - Help the client take Responsibility for changing
  • Advice - Give clear Advice on what behavior(s) must change
  • Menu - Offer a Menu of options for making the change with focus on the client's involvement in decision making
  • Empathy - Express Empathy for the ambivalence and difficulty that is present when making changes
  • Self-efficacy - Evoke Self-efficacy to foster commitment and confidence (Self-Efficacy is one's personal ability to produce a desired result or effect)
(Weaver & Jarvis, 2009)

 

Feedback

Promoting awareness of the negative consequences of chemical dependency is the purpose of feedback in brief intervention. Utilize laboratory results such as abnormal liver function tests or connect chemical use to encounters with law enforcement, job loss, and family problems. Pull from your client's life to find the correct feedback that captivates their attention to the dependency problem and solidify the link that it is their dependency behaviors that are putting their happiness at risk. The use of a daily journal or self-monitoring diary can be of assistance in this phase.

Responsibility

This is about the client. This is about the client's life, the client's behaviors. Personal responsibility is the core concept to their control of their life and happiness. Work to clarify goals that are important to your client. Goals should be reasonable and achievable. Anticipate the client will need assistance to form realistic, incremental goals.

Advice

Offer clear suggestions on reaching personal goals that are important to your client. Support here consists of suggestions and encouragement as well as providing the opportunity for the client to voice their concerns and frustrations in a climate free of condemnation.

Menu

Offer options on how to reach newly set goals. Be aware that some helps, methods or means to obtain those goals will be unknown to your client. Allow the opportunity for your client to discuss and consider what strategies appeal to them and their circumstances. Reinforce the concept of personal choice and personal responsibility in their personal treatment. Should there be concerns that too many options may overwhelm the client, carefully consider which two or three to promote and offer information on.

Empathy

The pivotal component to success in brief intervention therapy revolves around empathy. Utilize skillful listening to offer suggestions or responses that validate client's feelings while supporting their efforts toward success. Be ever vigilant not to smother a client's progress by imposing your own life experiences or values onto them.

Self-efficacy

Success in any given venture centers on the belief that it can be achieved. Self-efficacy is about building up your client' sense of ability to succeed in this task. Promote optimism, celebrate incremental success, and assist your client to maintain a clear vision of the positive gains that will be achieved once their dependency is under control. Specific helps consist of strategies such as assisting the setting of early, easily accomplished goals and eliciting or reinforcing self-motivating statements.
 
Case Study: Margaret
Margaret is a 26 y/o female, married, with two children ages 3 and 5.

She was admitted for trauma workup after driving through the front window of a convenience store in an SUV. To first responders she presented with slowed responses and slurred speech though no odor of alcohol was present. Of immediate concern was the possibility of head trauma, which was later ruled out. Blood alcohol was negative. Present to toxicology screening was benzodiazepines for which she has a valid prescription due to generalized anxiety disorder.

In the back seat of the SUV at the time of the accident were both children, safely secured in car seats.
During the admission interview with the emergency room nurse, Margaret, reveals that she has come to depend on her prescription medication, Ativan, to help her feel "normal". Recently her medication has ceased to be effective and her general practitioner unwilling to increase her dosage. She has been "borrowing" from her mother's Valium, which she indicates her mother rarely uses. The interview also indicates that Margaret values the health and safety of her children very highly and would never willingly put them at risk for danger.
Assignment: Initiating the FRAMES Component - Feedback

Using the Feedback component of Brief Intervention, what awareness could you offer to Margaret concerning a behavior that is putting her happiness at risk.

Summary

Chemical dependency is the use or overuse of a substance which can be licit, illicit or illegal and has; 1) created a tolerance due to its continued use, 2) provokes active avoidance of withdrawal symptoms associated with decreasing or stopping its use, 3) is being consumed in larger amounts than therapeutic use warrants, and 4) has by persistent use created negative consequences in the life of the user in the realms of social, occupational, physical, or psychological functioning.

Brain reward is a system of neurochemical feedback governed by the mesolimbic dopamine response. Triggering of the brain reward prompts each of us to respond favorably to the presence of preferred chemicals that may be unique to each of us. Behavioral rewards are also a huge factor in the overuse of recreational, prescription or street drugs so it is important to consider what primary benefit is being achieved in your client's chemical dependence.

Individuals enmeshed in the web of chemical dependence may find themselves drawn to different groups of substances depending on behavioral rewards and how their brain reward system responds. General groupings of chemicals that have a greater risk for dependence are; 1) Sedative-Hypnotics, 2) Stimulants, 3) Opioids, and 4) Other Drugs that do not readily fall into the major three categories. When clients present with aspects of tolerance, avoidance of withdrawal, high levels of consumption in a particular chemical grouping, or negative life consequences not readily associated to another known event then chemical dependency should be considered.

Acute medical treatment followed by structured follow-up using a system such as Brief Intervention are important steps in helping the client to regain a life free of the bonds of chemical dependency.

We are all affected by chemical dependency. Be it in a family member, a client, or in ourselves. The burden placed on society as a whole by the impact of chemical dependency is horrific. By sharing what we know and have observed we can, as health professionals be more alert and provide earlier therapeutic interventions with better outcomes for those snared in the web of chemical dependency.

References

Centers for Disease Control and Prevention. (2008). Alcohol and Public Health. Retrieved December 29, 2009, from Web site: http://www.cdc.gov/alcohol/terms.htm#excessive.

Cohagan, A. & Worthington, R. (2007). Alcohol and Substance Abuse Evaluation. eMedicine.com. Retrieved December 27, 2009, from Web site: http://emedicine.medscape.com/article/805084-overview.

Cooper, JS., (2009). Toxicity Sedative-Hypnotics. eMedicine.com. Retrieved December 27, 2009, from Web site: http://emedicine.medscape.com/article/818430-overview.

Divadeenam, K., (2008). Stimulants. eMedicine.com. Retrieved December 27, 2009, from Web site: http://emedicine.medscape.com/article/289007-overview.

DSM-IV-TR. (2000). Diagnostic and Statistical Manual of Mental Disorders - 4th Ed. Washington, DC. American Psychiatric Association. ISBN 0-89042-024-6. STAT!Ref Online Electronic Medical Library. Retrieved December 26, 2009, from Web site: http://online.statref.com.proxy.heal-wa.org
/document.aspx?fxid=37&docid=88
.

Erickson, CK. (2009). Addiction is a Brain Disease, What is the Evidence? Recovery Today. Retrieved December 28, 2009, from Web site: http://www.recoverytoday.net/Mar09/erickson_print.html

Gold, MS. & Aronson, MD. (2009). Screening for and Diagnosis of Alcohol Problems. In: Hirsch MS (Ed.) UpToDate 17.3. Waltham, MA.

Habal, R. (2008). Toxicity Heroin. eMedicine.com. Retrieved December 27, 2009, from Web site: http://emedicine.medscape.com/article/166464-overview

Hoffman, RS. & Weinhouse, GL. (2009). Management of Moderate and Severe Alcohol Withdrawal Syndromes. In: Hirsch MS (Ed.) UpToDate 17.3. Waltham, MA.

Moses, S. (2009). Chemical Dependency. Family Practice Notebook.com. Retrieved December 24, 2009, from Web site: http://www.fpnotebook.com/Psych/CD/ChmclDpndncy.htm

National Center for Health Statistics. (2008). Health, United States 2008 with Chartbook. Hyattsville, MD. 2009.

Opioids and Related Disorders. (2009). Found in: Encyclopedia of Mental Disorders. Retrieved January 16, 2010 , from Web site: http://www.minddisorders.com/Ob-Ps/Opioids-and-related-disorders.html

Parran, TV. (2009). Prescription Drug Abuse. In: Hirsch MS (Ed.) UpToDate 17.3. Waltham, MA.

Weaver, MF. & Jarvis, MAE. (2009). Overview of the Recognition and Management of the Drug Abuser. In: Hirsch MS (Ed.) UpToDate 17.3. Waltham, MA.