New York City Chapter Men In Nursing Conference 2016 an overview (includes specific information regarding marijuana, stimulants, hallucinogens, depressants)

1. Raymond Zakhari, DNP, EdM, ANP-BC, FNP-BC, PMHNP-BC
Department of Internal Medicine in Psychiatry
New York Presbyterian Hospital Weill Cornell
www.RaymondZakhari.com
www.MetroMedicalDirect.com

2.  Definitions
 Drugs, Effects & Consequences
 Statistics
 Professional Responsibilities
 Treatment Options

3.  Dependence: indicates an altered physiologic
state caused by repeated administration of a
drug the cessation of which results in a specific
syndrome

4.  Abuse: use of any drug, usually by self
administration, in a manner that deviates from
approved social or medical patterns
 Misuse: usually applied to prescribed
medications that are not used properly

5.  The repeated and increasing use of a substance
or behavior, when deprived, causes symptoms
of distress, and an irresistible urge to use the
agent or engage in the behavior again despite
consequences (physical, social, legal).

6.  A substance of the specific syndrome that
occurs after stopping or reducing the amount
of substance that has been used regularly over
a prolonged period characterized by
physiological and psychological signs and
symptoms.
 Also called abstinence syndrome or discontinuation
syndrome

7.  A physiological phenomenon which occurs
after repeated consumption of a drug
producing decreased effect despite increasingly
larger doses to achieve the first affect.
 Behavioral tolerance reflects the ability to perform
tasks despite the effects of the drugs

8.  The ability of one drug to be substituted for
another each usually producing the same
physiological and psychological effects
 Benzodiazepines and barbiturates
 Neuro adaptation: Neurochemical changes in the
body that result from the repeated administration of
a drug which accounts for the phenomenon of
tolerance

9.  Friends or family members affected by the
behavior of a substance abuser, facilitating the
abusers addictive behavior, requires the
unwillingness of a family member to accept
addiction as a medical psychiatric disorder,
and denial that a person is abusing the
substance.
 Enabler

10.  A primitive defense mechanism characterized
by an unwillingness to accept ego-dystonic
obvious circumstances.

11.  22 million people older than the age of 12 were
classified as having a substance related
disorder
 10% of the total US population
(National Institute of Drug Abuse 2012)
 21 million (9.3%) people are diagnosed with diabetes
in the United States (CDC 2012)

12.  15 million were dependent on or abuse alcohol
 669,000 people were dependent on or abused
heroin
 4.3 million abused marijuana
 1 million abused cocaine
 2 million were classified as dependent on or
abused pain relievers

13.  Those who use any substance younger than 15
years of age for more likely to become addicted
than those who started at a later age
 Of Adults 21 and older who first tried alcohol
at age 14 or younger
 15% were classified as alcoholics
 3% who first used alcohol at age 21
 Men > Women| Whites > Blacks| Higher Edu.
> Lesser Edu.| Unemployed > employed

14.  It depends on the individual and the
circumstances
 It requires drug availability & social
acceptability
 Likelihood is increased with peer pressure and initial
experimentation experience
 Addiction determinant: is influenced by personality,
individual biology, actions of the drug

15.  From voluntary to compulsive
 Classic theories: substance abuse is a
masturbatory equivalent (heroin users
describes the initial rushes similar to a
prolonged sexual orgasm)
 Defense against anxious impulses or a
manifestation of oral regression
 Disturbed Ego function: inability to deal with
reality (self-medication).

16.  Behavior maintained by
its consequences
 Genetic factors: twin
studies suggested a
component for alcoholism
 Neurochemical factors:
Receptors and Receptor
Systems
 Pathways and
neurotransmitters
comprise the brain
reward circuitry
 Dopamine, GABA,
Opioids

20. SUBSTANCE USE
DISORDER:
 a maladaptive pattern
of use leading to
significant impairment
or distress as
manifested by 2 or more
of the following
occurring within a 12
month period
 Failure to fulfill major role
obligations
 Recurrent use and situations in
which physical hazard may
occur i.e. driving
 Continued use despite having
persistent or recurrent social or
interpersonal problems
exacerbated by effects of the
substance
 Tolerance developed
 Withdrawal
 Increasing use
 Persistent desire or unsuccessful
efforts to cut down
 Giving up important activities
for the substance use
 Continued use despite
knowledge of persistent and

21.  A substance specific
syndrome resulting
from the abrupt
cessation of heavy or
prolonged use of a
substance
 The development of a
syndrome due to the
cessation or reduction
in substance use that
has been heavy
 Syndrome that causes
clinically significant
distress or impairment
 Symptoms are not due
to a general medical
condition or another
mental disorder

22.  Antisocial Personality
Disorder
 Mood Disorders
 Anxiety Disorders
 Suicidality
 Delirium
 Psychosis
 Dementia
 Sleep Disorders
 Sexual Dysfunction
 Amnestic Disorder
 Intoxication
 Flashbacks
 Cognitive impairment
 Encephalopathies

23.  Hashish, Marijuana
 How Consumed: swallowed, smoked
 Effects: euphoria, slowed thinking and reaction
time, confusion, impaired balance and
coordination
 Consequences: cough, frequent respiratory
infections, impaired memory and learning,
increased heart rate, anxiety, panic attacks

24.  Barbiturates, Benzodiazepines, GHB, Rohypnol,
Quaalude
 How Consumed: swallowed, injected
 Effects: reduced anxiety, feeling of well-being, lowered
inhibitions, slowed pulse and breathing, lowered blood
pressure, poor concentration
 Consequences: fatigue, confusion, impaired
coordination, memory, judgment, respiratory
depression and arrest, death

25.  Ketamine, PCP
 How Consumed: Injected, swallowed, smoked, snorted
 Effects: increased heart rate and blood pressure,
impaired motor function, delirium, panic, aggression
 Consequences: memory loss, numbness,
nausea/vomiting, depression

26.  LSD, Mescaline, Mushrooms
 How Consumed: swallowed, smoked
 Effects: increased body temperature, heart rate, blood
pressure, loss of appetite, sleeplessness, numbness,
weakness, tremors, altered states of perception and
feeling, nausea
 Consequences: persisting perception disorder
(flashbacks)

27.  Codeine, heroin, morphine, opium,
Oxycodone, Hydrocodone
 How Consumed: injected, swallowed, smoked,
snorted
 Effects: pain relief, euphoria, drowsiness
 Consequences: nausea, constipation, confusion,
sedation, respiratory depression and arrest,
unconsciousness, coma, death

28.  Amphetamine, cocaine, MDMA, methamphetamine,
nicotine, Ritalin
 How Consumed: injected, smoked, snorted, swallowed
 Effects: increased heart rate, blood pressure,
metabolism, feelings of exhilaration, energy, increased
mental alertness
 Consequences: rapid or irregular heart beat, reduced
appetite, weight loss, heart failure, nervousness,
insomnia

29.  Open-ended questions
 Motivational Interviewing
 BATHE technique
 Obtain releases for/ from all other providers
 Maintain active communication with providers
 Observations: MSE and Physical exam findings

30.  Resist the righting reflex
 Psychological reactivity & Therapeutic Paradox
 Understand your patient’s motivation
 Why would they want to?
 Listen to your patient
 Equal parts of listening & informing
 Empower your patient
 Help in contemplating the how and why

31.  It sounds like you may benefit from talking to
someone
 Provide 2-3 referrals
 Provide the patient with reassurance that you
are referring to a resource you trust

32. Reflective
Listening
Validate &
Affirm
Explore a Menu
of Options
Explore the
Pro’s and
Con’s
Where are they on the SOC continuum?
Ask permissionSet an
Agenda
Ambivalence
is Normal
Resist the
Righting Reflex
Consider life balance
High Risk Situations
Explore
Coping
Create
Discrepancy
Readiness to
Change?
What is the
motivation
Abstinence
Violation
Effect
Empathy
Promote Self-
Efficacy
Use Rulers
What’s
Next?
Listen for and try to do these
things:

33.  Abstinence vs. harm reduction
 Detoxification
 Outpatient
 Intensive Outpatient
 Inpatient
 28/ 30-day
 Long-term residential
 Half-way house
 Anonymous meetings

34. Relapse Prevention Model
Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct

35.  High Risk Situations
 Self-Efficacy
 Abstinence Violation Effect (AVE)
Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct

36. Craving
mediated
by
Expectancies
For immediate
effect
Rationalization,
Denial, and
apparently
irrelevant
decisions
Lifestyle imbalance
(Shoulds> wants) Desire for
indulgence or
immediate
gratification (I
owe myself)
Precursors to High Risk
Situations

37. High Risk
Situation
Coping
Response
No Coping
Response
Increased Self-
Efficacy
Decreased
Self-Efficacy
Decreased
probability of
relapse
Lapse
Abstinence
Violation
Effect
Relapse
Cognitive Behavior Model
of the Relapse Process

38. Negative Emotional State (35%)
Interpersonal Conflict (16%)
Social Pressure (20%)
Cummings, Gordon, & Marlatt 1980; Marlatt & Gordon 1980

39. Functionality in
Family, Work,
and Community

40. Brain changes in addiction help explain
continued drug abuse and relapse.

41. Relapse Rates for Drug Addiction
are Similar to Other Chronic Medical
Conditions
0
10
20
30
40
50
60
70
80
90
100
Drug
Dependence
Type I
Diabetes
Hypertension Asthma
40to60%
30to50%
50to70%
50to70%
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October
PercentofPatientsWhoRelapse

42. Drug Abuse Treatment Can Work
• No single treatment is
appropriate for all
individuals.
• Treatment needs to be
readily available.
• Treatment must attend to
multiple needs of the
individual, not just drug use.
• Multiple courses of
treatment may be required
for success.
• Remaining in treatment for
an adequate period of time is
critical for treatment
effectiveness.

43. 0
2
4
6
8
10
Pre During Post
Treatment Research Institute
Outcome In Diabetes
Conclusion: Treatment Successful!

44. 0
2
4
6
8
10
Pre During Post
Treatment Research Institute
Outcome In Addiction
(Incorrect) conclusion: Treatment NOT successful!

45. Intake Processing /
Assessment
Treatment Plan
Pharmacotherapy
Continuing Care
Clinical and Case
Management
Self-Help / Peer
Support Groups
Behavioral
Therapy and
Counseling
Substance Use
Monitoring
Detoxification
Child Care
Services
Vocational
Services
Medical
Services
Educational
ServicesAIDS / HIV
Services
Family
Services
Financial
Services
Legal
Services
Mental Health
Services
Housing /
Transportation
Services
Services to Match Needs

46. Treatment should target factors associated
with criminal behavior.
 Criminal thinking
 Antisocial values
 Anger/hostility
 Problem solving
 Conflict resolution skills
 Attitudes toward school/work
 Mental health problems
 Family functioning
 Barriers to care
 Alcohol/drug problems

47. DRUG ABUSE
Depression
Attention Deficit Disorder
Conduct Disorders
Bipolar Disorder
Post-Traumatic Stress Disorder

48.  Methadone
 Naltrexone
 Buprenorphine

49.  www.al-anon.alateen.org
 www.alcoholics-anonymous.org
 www.na.org
 www.nida.nih.gov
 www.samhsa.gov
 www.niaaa.nih.gov
 www.fadaa.org

50. Raymond Zakhari, NP
Twitter: @RZakhari
#AddictCareNYC
www.RaymondZakhari.com