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l OM oAR cP SD | 59 67 6 29 Alcoholism - Mark Klimek Alcoholism (And All Abuse) Psychodynamics/Psychological Factors of Abuse (Alcoholism)

You can use these problems with almost all types of abuse.Side note: bullied at work for instance by a senior nurse-never say you always talk as I

1 st

Problem in Abuse: Denial

• In absence of physiological, safety or comfort issue, we target psychological as top priority • If given four psychological abuse-related problems, denial is top one • Denial is the refusal to accept the reality of their problem • How do you treat denial in abuse? Confront.

• You confront denial by pointing out to the person the difference between what

they say and what they do.

• E.g you say that you are not a child abuser but your children are under child aid

custody- this is confronting them

• Goal is for them to see a real picture of themselves and see themselves as they

are.

• Confrontation is not very high power; it will not result in immediate results but

may let them notice that they do have a problem.

• “You say you’re not an alcoholic, but its ten o’clock in the morning and you are

drunk” etc.• How do you treat denial in loss? Support the denial of loss and grief.

• Denial is the first stage of loss and grief.
• DENIAL is a acceptable healthy reaction to a loss. You don’t confront it but YOU

SUPPORT IT.

• DABDA – denial, anger, bargaining, depression, acceptance
• Supportive quotes – they get patient to talk more, “tell me more/how”; allowing

denial to continue 2 nd

Problem in Abuse: Dependency/Co-Dependency

• Co-dependency – significant other derives positive self-esteem from doing things for or making decisions for the abuser.

• Abuser asks person to do task (dependency), person acts and feels good about

themselves for helping abuser (Co dependency).

• The abuser gets no responsibility and continues to abuse the partner while the

partner receives positive self-esteem.

• They are both using each other for something good, symbiotic relationship that is

pathological.• Treating Dependency and Co-Dependency

• Set limits and enforce them – set limits on what is allowed and what is not and

enforce them ▪ I.e. what will the co-dependent do for the dependent? What is reasonable? Negotiate and enforce agreement.

• Work on self-esteem of co-dependent person
• To be successful in treating dependency, from what source must the co-

dependent person’s self esteem flow? From themselves and what they can do and not meeting the needs of dependent people.

rd

Problem in Abuse: Manipulation

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• Manipulation is when the abuser gets SO to do things for him and her that are not in the best interest of the SO; the nature of the act is dangerous or harmful to the significant other • There is some similarity between dependency and manipulation – tell the difference by looking to see what they are being asked to do (nature of the act)

• Harmless task? Co-dependent
• Harmful task? Manipulated

• Treating manipulation

• Set limits and enforce them
• Start saying NO

▪ Easier to treat than co-dependency because nobody likes being manipulated and people like being co-dependent (self-esteem) ▪ People who are co-dependent would rather have their self-esteem than their safety

In manipulation- the codependent is not important.

Wernicke-Korsakoff (Alcoholism Induced Dementia) • Psychosis induced by vitamin B1 (thiamine) deficiency – loses touch with reality-

INSANITY

• Symptom: Amnesia with confabulation (making up stores).

• Psychosis due to brain damage and is permanent
• Referred to as a form of dementia (dementia refers to loss of touch with reality

due to brain damage)

• You can’t confront them because they cant differentiate between real and their

imagination

• What do you do? Redirect them into activities that they can do.

• Vitamin B1 is necessary for the metabolism of alcohol to occur; without B1, alcohol you drink stays in bloodstream and raises to toxic levels and crosses the blood brain barrier and results in damage • If you have a diet high in B1 and you drink excessively, you will metabolize alcohol and it will not build to toxic levels in any great amount in you will not end up with brain damage (dementia) • Need as co-enzyme to enter pyruvic acid cycle • Characteristics of Wernicke-Korsakoff

• Disease is entirely preventable – requires B1 vitamin
• Disease is arrestable – can be stopped from getting worse by increasing B1 in

the diet (not necessarily to stop drinking!!l)

• Disease is irreversible – can’t reverse memory lost

• Goal with dementia: maintain current memory, rate of deterioration will decrease; not improve/get better/re-gain memory

Antabuse Disulfiram- Disulfiram is a drug used to support the treatment of chronic alcoholism by producing an acute sensitivity to ethanol • Treatment with aversion therapy (gut hatred- for example we want people with alcohol to start hating aclohol – patient associates something that you want them to stop doing with a very negative experience • **it works better in theory compared to reality

• Will force them to immediately associate task with negative experience

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• How long does it take for it to reach a therapeutic level (onset)? Two weeks • How long after you stop it can you safely drink again (duration of effectiveness)? Two weeks; it is in system for two weeks after last pill is taken • During the time that you are starting to take the pill, they take you in to a half-way house for the time being so that you aren’t drinking during start-up • If a patient refuses to take medication anymore, they must know that they can’t drink for two weeks and could be hospitalized if they drink • Otherwise, remain on it for rest of life

Teaching:

Avoid all forms of alcohol to avoid nausea, vomiting and death

• Includes insect repellant, aftershave, mouthwash(even just swishing/spit), elixirs

(OTC medications), vanilla extract (must be cooked), alcohol-based hand sanitizers, alcohol swabs, perfumes, colognes, vinaigrette)

Overdose vs. Withdrawal

• Every abused drug is generally a stimulant or a depressant (neither – not abused)

• Follow the following questions when answering Overdose questions:

• Is the drug an upper (stimulant) or a downer(depressant)?

Stimulants (Uppers) • Caffeine, cocaine, PCP/LSD (psychedelic hallucinogens), methamphetamines, ADHD medications (Ritalin, Adderall)

Signs/symptoms:

➢ Things go UP-> Euphora, Tachycardia, restlessness, irritability, borborygami, diaarehea, +3-4 reflexes, agitation ➢ HIGH RISK FOR SEZIUERES- keep suction ready Depressants (Downers) • Anything else not listed above is downers– there are 135+ • Symptoms: Bradycardia, lethargic, constricted pupils, flaccidity, docility (decrease in violence symptomology scale) • Worst down symptom – respiratory arrest (ambu-bag)

• Is the question talking about overdose/intoxication or withdrawal?
• Overdose – Too much upper? Everything goes up. Too much downer?

Everything goes down.➢ Withdrawal – You don’t have enough of the drug (i.e. too little upper, you will go down or too little downer, will go up) ➢ In general: downer overdose looks like upper withdrawal & upper overdose looks like downer withdrawal ➢ Consider direction – if patient goes up, pick suctioning machine for seizure. If patient is going down, pick ambu-bag for respiratory arrest.

Drug Addiction in the Newborn

• Is the drug an upper or downer?

• ALWAYS ASSUME INTOXICATION OF THE INFANT IN BIRTH

• Depends upon the time frame in the question – 24-hour time frame

o < 24 hours: Always assume intoxication, not withdrawal at birth.

• > 24 hours: If it has been longer than 24 hours since birth, assume withdrawal.

• Can answer the direction – up or down? Up – seizures. Down – respiratory arrest.

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• Note when they say the last drug use – if they indicate when it has been used at an older point, note time and consider 24-hour interval.• If last drink 36 hours ago, baby is withdrawing at birth. If they say alcoholic mother gives birth to baby, assume intoxicated.• Example: Mother addicted to a downer drug, and baby withdrawing after 36 hours. They are going up (because they are withdrawing from down).Options: Shrill high pitched cry, exaggerated startle, difficult to console, respiratory depression, difficulty aroused, sezuire risk

• Would not have respiratory depression or low core temperature.

Alcohol Withdrawal Syndrome vs. Delirium Tremens Both are not the same!!!

• AWS always precedes DT but DT does not always follow AWS Alcohol Withdrawal Syndrome • Alcoholics all go through AWS – 24 hours after last drink

• Alcohol is a depressant, will start to see everything go up with withdrawal
• Tachycardia, jittery, irritable, hypertensive
• Not fatal

• Will be a lower priority; they are a stable sick person • Not dangerous to themselves or others – no indication to restrain

• Treatment:

• Semi-private anywhere on unit – stable, not dangerous, may have roommates
• Up ad lib (can go where they would like to go)
• Regular diet
• No restraints – not dangerous
• Anti-hypertensive – lower BP (BP goes up when withdrawing from downer)
• Tranquilizer – they are going up
• Vitamin B1 – alcohol metabolism

Delirium Tremens • Delirium tremens is less common (few go through) and occurs 72 hours after last drink • Will be a higher priority; unstable, life-threatening syndrome, 18% fatal • Dangerous to themselves or others – indication to restrain

• Treatment:

• Private near nurses’ station
• NPO or clear liquids – seizure may cause aspiration, using suctioning
• Restricted bed rest – no bathroom privileges- provide bedpan or urinal
• MUST Restrain – dangerous, require vest or two-point leather

▪ Check q15m ▪ Neurovascular check and rotate restraints minimum q2h

• Anti-hypertensive – lower BP (BP goes up when withdrawing from downer)
• Tranquilizer – because everything is going up
• Vitamin B1 – alcohol metabolism

Aminoglycosides