Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2590_Библиотеки_им_академика_М_И_Перельмана
.pdf
38
https://t.me/med1917
2: PUBLIC HEALTH GUIDELINES
PREDISPOSING FACTORS
Factors vary among individuals and no one factor can account
entirely for the risk of substance abuse. Studies indicate a high
correlation between substance use and the presence of psychiatric disorders, especially anxiety disorders, depression,
schizophrenia, and eating disorders in females.
A. Genetic.
B. Familial.
C. Environmental.
D. Occupational.
E. Socioeconomic.
F. Cultural.
G. Personality.
H. Life stress.
I. Psychiatric comorbidity.
J. Biological.
K. Social learning and behavioral conditioning.
L. Sexual minority adults identied as being lesbian, gay, or
bisexual.
COMMON COMPLAINTS
Clients’ complaints will be focused on the symptoms of the
problem rather than the substance dependence. The problem
itself will be avoided through use of denial, minimization,
blaming, and projection (all signs of the disease of substance
dependence).
A. Chronic anxiety and tension.
B. Insomnia.
C. Chronic depression.
D. Headaches and/or back pain.
E. Blackouts.
F. Gastrointestinal problems.
G. Tachycardia/palpitations.
H. Frequent falls or minor injuries.
I. Problems with a loved one, problems at work, or with
friends.
OTHER SIGNS AND SYMPTOMS
A. Defensiveness about alcohol/drug use or vagueness with
answers.
B. History of problems with family life, marital relationships,
work, nances, and physical health.
C. Change in spiritual beliefs (stops attending religious
services).
D. Unexplained job changes and multiple trafc accidents.
E. History of impulsive behavior, ghting, or unexplained
falls.
F. Arrest for public drunkenness, driving under the inu-
ence, or illegal activity when alcohol/drugs were involved.
G. Tremors (shakes).
H. Delirium tremens (DTs).
I. Seizures related to drugs.
J. Hallucinations.
K. History of chronic family chaos and instability.
L. Physical indications of chronic alcohol/drug use include
spider angiomas, ruddy nose and face, nasal lesions, bruxism, swollen features, bruises, needle marks/tracks, cutaneous abscesses, malnourishment, anemia, jaundice, and severe
dental problems such as “meth mouth.”
M. Active withdrawal symptoms include nausea and vom-
iting, malaise, weakness, tachycardia, diaphoresis, tremors,
lightheadedness or dizziness, insomnia, irritability, confusion,
perceptual abnormalities or hallucinations (auditory, visual,
or tactile), paresthesia, blurred vision, diarrhea, anorexia,
abdominal cramps, severe depression, severe anxiety, piloerection, fasciculation (muscle twitching), rhinorrhea, fever, elevated blood pressure and pulse, tinnitus, nystagmus, delirium,
or seizures.
N. Overdose symptoms related to drug(s) include seizures,
cardiovascular depression/collapse, and respiratory depression/collapse. Be prepared to provide cardiovascular and
respiratory support and supportive care until transport.
SUBJECTIVE DATA
A. Review the onset, duration, and course of presenting
complaints.
B. Question the client regarding relatives with a history of
alcohol, tobacco, or drug use or problems pertaining to use.
C. When questioning the client, assume some use. Start with
the least invasive questions rst, for example, “At what age
did you rst start drinking?” Then ask about tobacco products, e-cigarettes, over-the-counter (OTC) medications,
prescription medications, marijuana, stimulants, opiates, sedatives, hypnotics, benzodiazepines, barbiturates, hallucinogens, inhalants, steroids, and other drugs.
D. Review use of the following drugs concerning quantity
and type (if cigarettes, brand smoked, e-cigarettes; if alcohol,
type of alcohol: beer, wine, hard liquor) and age at initiation.
Query regarding previous attempts to stop use.
E. Start with the past and proceed to the present with use;
include rst use of the mood-altering substance, amount, and
the last use of the particular substance and amount.
F. Choose evidence-based screening tools and assessments.
The NIDA website has links to multiple tools specic to alcohol and/or drugs and client age, and indicates if the tool is
self-administered or clinician-administered (www.drugabuse
.gov/nidamed-medical-health-professionals/screening-tools
-resources/chart-screening-tools).
1. Assess using the CAGE test. The CAGE (two out of
four) is highly predictive of addiction.
a. Have you ever tried to cut down on your alcohol/
drug use?
b. Do you get annoyed if someone mentions your use
is a problem?
c. Do you ever feel guilty about your use?
d. Do you ever have an “eye-opener” rst thing in the
morning after you have been drinking or using the
night before?
2. Assess the client’s pain and function regularly using
a validated instrument, such as the three-item PEG
Assessment Scale. A 30% improvement in pain and function is considered clinically meaningful. If your client does
not have a 30% improvement in pain and function, consider reducing dose or tapering and discontinuing opioids. Ask the client:
a. What number best describes your pain on average
in the past week? (from 0 = no pain to 10 = pain as bad
as you can imagine)
b. What number best describes how, during the past
week, pain has interfered with your enjoyment of
life? (from 0 = does not interfere to 10 = completely
interferes)
c. What number best describes how, during the past
week, pain has interfered with your general activity?
(from 0 = does not interfere to 10 = completely interferes)
3. Assess for depression using the Patient Health
Questionnaire (PHQ). The PHQ-9 has been validated for
use in primary care settings and can be used to make a
SUBSTANCE USE DISORDERS
https://t.me/med1917
39
tentative diagnosis of depression and to monitor depression
severity and response to treatments in the past 2 weeks. The
PHQ-9 is available at d14rmgtrwzf5a.cloudfront.net/sites/
default/les/les/PatientHealthQuestionnaire9.pdf.
4. The NIDA has two brief online validated adolescent sub-
stance use screening tools to assess for SUD risk among adolescents 12 to 17 years old. The Brief Screener for Tobacco,
Alcohol, and Other Drugs (BSTAD) and the Screening to
Brief Intervention (S2BI) ask clients about the frequency of
past-year use and triage them into one of three levels of SUD
risk: no reported use, lower risk, and higher risk.
a. The BSATD online tool can be accessed at www.dru
gabuse.gov/ast/bstad/#/.
b. The S2BI online tool can be accessed at www.druga
buse.gov/ast/s2bi/#/.
G. If the client admits drinking or drug use, ascertain specic
amounts and the last use of each substance. Has the client ever
needed the use of naloxone for overdose or been hospitalized?
H. Determine whether the client experiences suicidal ideation
and whether there is a history of attempts (see Chapter 22,
“Psychiatric Guidelines”).
PHYSICAL EXAMINATION
A. Check temperature (if indicated), pulse, respirations,
blood pressure, and height and weight to calculate body mass
index.
B. Inspect:
1. Observe general appearance, dress, grooming, breath
odor, wasted appearance, attitude, sad affect, psychomotor retardation, or tremors.
2. Conduct a dermal examination for spider angiomas,
bruises, track marks, color, pallor, rash, jaundice, petechiae, and gynecomastia in males (hallucinogens).
3. Examine the eyes for sclera color and features, pupil
size, and reactivity.
4. Inspect the nasal mucosa for erythema, edema, spider
telangiectasis, and discharge; look for septal lesions or perforation, deviation, and polyps.
5. Inspect the mouth/pharynx: oral lesions, poor dental
hygiene, erythema, and teeth for uneven surfaces, tooth
decay, and gum erosion.
C. Palpate:
1. Palpate the neck and thyroid.
2. Palpate the axilla and groin for lymphadenopathy.
3. Palpate the abdomen; note hepatomegaly/tenderness.
D. Percuss:
1. Percuss the chest; note pulmonary consolidation.
2. Percuss the abdomen for hepatosplenomegaly.
E. Auscultate:
1. Auscultate the heart for murmur, new S4 gallop, single
S2, and arrhythmias.
2. Auscultate the lungs for rales, effusion, and consolidation.
F. Perform neurologic examination/mental status.
DIAGNOSTIC TESTS
Intravenous drug use contributes strongly to the spread of AIDS, hepatitis B and hepatitis C, and other infectious diseases. Consider evaluation
for sexually transmitted infections.
A. Blood alcohol level.
B. Cotinine level (nicotine, where available).
C. Urine drug screen.
D. Complete blood count with differential.
E. Platelet count.
F. HIV or hepatitis.
G. Antinuclear antibody, erythrocyte sedimentation rate, and
rheumatoid factor.
H. Electrolytes.
I. Liver panel:
1. Elevated liver enzymes can also be attributed to over-
use of acetaminophen (Tylenol), found in combination
with opiates.
J. Blood cultures (fever).
K. Bone density studies:
1. Clients who have been drinking for years should have
bone density studies done as alcohol increases the risk of
osteoporosis.
DIFFERENTIAL DIAGNOSES
A. Chronic pain syndrome.
B. Anxiety.
C. Depression.
PLAN
A. General interventions:
1. Discuss your concerns about alcohol, nicotine, or drug
use and discuss addiction treatment with the client.
2. Principles of Drug Addiction Treatment:
a. Everyone entering treatment receives a clinical
assessment. A complete assessment of an individual is needed to help treatment professionals offer
the type of treatment that best suits the client. The
assessment also helps program counselors work with
the person to design an effective treatment plan.
Although clinical assessment continues throughout
a person’s treatment, it starts at or just before a person’s admission to a treatment program. The assessment includes:
i. Cultural issues around use of alcohol or drugs.
ii. Effects of drug or alcohol use on the person’s life.
iii. Medical history.
iv. Current medical problems or needs.
v. Current medications (including pain
medication).
vi. Mental health issues or behavioral problems.
vii. Family and social issues and needs.
viii. Legal or nancial problems.
ix. Educational background and needs.
x. Current living situation and environment.
xi. Employment history, stability, problems, and
needs.
xii. School performance, problems, and needs, if
relevant.
xiii. Previous treatment experiences or attempts to
quit drug or alcohol use.
b. More than three decades of scientic research show
that treatment can help drug-addicted individuals stop
drug use, avoid relapse, and successfully recover their
lives. Based on this research, 13 fundamental principles that characterize effective drug abuse treatment
have been developed. These principles are detailed
in NIDA’s Principles of Drug Addiction Treatment: A
Research-Based Guide. The guide also describes different types of science-based treatments and provides
answers to commonly asked questions.
40
https://t.me/med1917
2: PUBLIC HEALTH GUIDELINES
i. Addiction is a complex but treatable disease
that affects brain function and behavior. Drugs
alter the brain’s structure and how it functions,
resulting in changes that persist long after drug
use has ceased. This may help explain why abusers are at risk of relapse even after long periods of
abstinence.
ii. No single treatment is appropriate for every-
one. Matching treatment settings, interventions,
and services to an individual’s particular problems
and needs is critical to their ultimate success.
iii. Treatment needs to be readily available. Because
drug-addicted individuals may be uncertain about
entering treatment, taking advantage of available
services the moment people are ready for treatment
is critical. Potential clients can be lost if treatment is
not immediately available or readily accessible.
iv. Effective treatment attends to multiple needs
of the individual, not just theri drug abuse. To be
effective, treatment must address the individual’s
drug abuse and any associated medical, psychological, social, vocational, and legal problems.
v. Remaining in treatment for an adequate
period of time is critical. The appropriate duration
for an individual depends on the type and degree
of their problems and needs. Research indicates that
most addicted individuals need at least 3 months in
treatment to signicantly reduce or stop their drug
use and that the best outcomes occur with longer
durations of treatment.
vi. Counseling—individual and/or group—and
other behavioral therapies are the most commonly
used forms of drug abuse treatment. Behavioral
therapies vary in their focus and may involve
addressing a client’s motivations to change, building skills to resist drug use, replacing drug-using
activities with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships.
vii. Medications are an important element of treat-
ment for many clients, especially when combined
with counseling and other behavioral therapies.
For example, methadone and buprenorphine are
effective in helping individuals addicted to heroin
or other opioids stabilize their lives and reduce
their illicit drug use. Also, for persons addicted to
nicotine, a nicotine replacement product (nicotine
patches or gum) or an oral medication (bupropion
or varenicline) can be an effective component of
treatment when part of a comprehensive behavioral
treatment program.
viii. An individual’s treatment and services plan
must be assessed continually and modied as necessary to ensure it meets their changing needs.
A client may require varying combinations of services and treatment components during the course
of treatment and recovery. In addition to counseling
or psychotherapy, a client may require medication,
medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and
legal services. For many clients, a continuing care
approach provides the best results, with treatment
intensity varying according to a person’s changing
needs.
ix. Many drug-addicted individuals also have
other mental disorders. Because drug abuse and
addiction—both of which are mental disorders—
often co-occur with other mental illnesses, clients
presenting with one condition should be assessed
for the other(s). When these problems co-occur,
treatment should address both (or all), including the
use of medications as appropriate.
x. Medically assisted detoxication is only the
rst stage of addiction treatment and by itself does
little to change long-term drug abuse. Although
medically assisted detoxication can safely manage
the acute physical symptoms of withdrawal, detoxication alone is rarely sufcient to help addicted
individuals achieve long-term abstinence. Thus, clients should be encouraged to continue drug treatment following detoxication.
xi. Treatment does not need to be voluntary to
be effective. Sanctions or enticements from family,
employment settings, and/or the criminal justice
system can signicantly increase treatment entry,
retention rates, and the ultimate success of drug
treatment interventions.
xii. Drug use during treatment must be monitored
continuously, as lapses during treatment do occur.
Knowing their drug use is being monitored can be
a powerful incentive for clients and can help them
withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use,
signaling a possible need to adjust an individual’s
treatment plan to better meet their needs.
xiii. Treatment programs should assess clients for
presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, as well as
provide targeted risk reduction counseling to help
clients modify or change behaviors that place
them at risk of contracting or spreading infectious
diseases. Targeted counseling specically focused
on reducing infectious disease risk can help clients
further reduce or avoid substance-related and other
high-risk behaviors. Treatment providers should
encourage and support HIV screening and inform
clients in whom highly active antiretroviral therapy
(HAART) has proven effective in combating HIV,
including among drug-abusing populations.
c. At each ofce visit, provide support to help prevent
relapse. If relapse occurs, encourage the client to try
again immediately.
d. Consider signing a contract with the client to stop
smoking, drinking, or using drugs.
e. Verify abstinence by urine drug screen and pill
counts at each visit.
f. Assess potential for suicide with every ofce visit.
g. If possible, obtain conrmation of the client’s absti-
nence from a family member.
h. Stress the importance of 12-step meetings such as
Alcoholics Anonymous (AA), Cocaine Anonymous
(CA), and Narcotics Anonymous (NA).
i. Have the client sign a written release of information
so that you can speak with a rehabilitation counselor. If
the client is willing, refer to an alcohol and drug treatment facility or smoking-cessation program, after initial assessment and differential diagnosis are made.
j. Treat physical/laboratory ndings as indicated.
SUBSTANCE USE DISORDERS
https://t.me/med1917
41
k. Identify potential withdrawal symptoms from ces-
sation of stimulants, such as caffeine intake reduction,
alcohol, and drug use.
l. If malnourished, discuss dietary needs and
treatment.
B. Client teaching: See Client Teaching Guide for Chapter 22,
“Psychiatric Guidelines.”
1. Educate the client about the impact of alcohol, tobacco,
and drugs on physical/emotional health. Provide information for the client to read at home.
2. Educate the client about safe disposal of medications.
a. Many communities have drug take-back programs;
some pharmacies have mail-back programs and disposal kiosks for unused/expired medicines.
b. Almost all medicines, except those on the Food and
Drug Administration (FDA) ush list, can be thrown
into household trash, including prescription and OTC
drugs in pills, liquids, drops, patches, creams, and
inhalers.
i. Mix medications with an unappealing sub-
stance, such as dirt or kitty litter, place in a sealed
container such as a zip-locking bag, and dispose in
the household trash.
ii. Mark out or scratch out personal information
on used prescription bottles before placing them in
the household trash.
iii. The fentanyl adhesive patch, even after used,
contains a lot of medication and therefore ushing
the patch is recommended for disposal.
C. Pharmaceutical therapy:
1. The CDC Guideline for Prescribing Opioids for chronic
pain recommends optimization of nonopioid pharmacotherapy and nonpharmacologic therapy, rather than a trial
of opioids. The principles of chronic pain treatment using
nonopioid treatments are noted in Exhibit 2.1.
2. The CDC’s Guideline for Prescribing Opioids for Chronic
Pain was published in March 2016 and can be accessed
at www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.
htm. The guideline provides 12 recommendations on
appropriate prescribing of prescription opioids and other
treatment options to improve pain management and client
safety. The guideline is not intended for clients who are on
active cancer treatment, palliative care, or end-of-life care.
a. Nonpharmacologic therapy and nonopioid phar-
macologic therapy are preferred for chronic pain.
Clinicians should consider opioid therapy only if
expected benets for both pain and function are anticipated to outweigh risks to the client. If opioids are
used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy,
as appropriate.
b. Before starting opioid therapy for chronic pain, cli-
nicians should establish treatment goals with all clients, including realistic goals for pain and function,
and should consider how opioid therapy will be discontinued if benets do not outweigh risks. Clinicians
should continue opioid therapy only if there is clinically meaningful improvement in pain and function
that outweighs risks to client safety.
c. Before starting and periodically during opioid ther-
apy, clinicians should discuss with the client the known
risks and realistic benets of opioid therapy and client
and clinician responsibilities for managing therapy.
d. When starting opioid therapy for chronic pain, cli-
nicians should prescribe immediate-release opioids
instead of extended release/long-acting (ER/LA) opioids (ER/LA opioids include methadone, transdermal
fentanyl, and ER versions of opioids).
e. When opioids are started, clinicians should prescribe
the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should
carefully reassess evidence of individual benets and
risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/d, and should
avoid increasing dosage to ≥90 MME/d or carefully
justify a decision to titrate dosage to ≥90 MME/d.
f. Long-term opioid use often begins with treatment
of acute pain. When opioids are used for acute pain,
clinicians should prescribe the lowest effective dose
of immediate-release opioids and should prescribe no
greater quantity than needed for the expected duration
of pain severe enough to require opioids. Three days
or less will often be sufcient; more than 7 days will
rarely be needed.
g. Clinicians should evaluate the benets and harms
with clients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians
should evaluate the benets and harms of continued
therapy with clients every 3 months or more frequently.
If benets do not outweigh harms of continued opioid
therapy, clinicians should optimize other therapies and
work with clients to taper opioids to lower dosages or
to taper and discontinue opioids.
h. Before starting and periodically during continua-
tion of opioid therapy, clinicians should evaluate risk
factors for opioid-related harms. Clinicians should
incorporate into the management plan strategies to
mitigate risk, including considering naloxone when
factors that increase the risk of opioid overdose, such
as history of overdose, history of SUD, higher opioid
dosages (≥50 MME/d), or concurrent benzodiazepine
use, are present.
i. Clinicians should review the client’s history of con-
trolled substance prescriptions using state prescription
drug monitoring program (PDMP) data to determine
whether the client is receiving opioid dosages or dangerous combinations that put them at high risk of
overdose. Clinicians should review PDMP data when
starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging
from every prescription to every 3 months.
j. When prescribing opioids for chronic pain, clini-
cians should use urine drug testing before starting opioid therapy and consider urine drug testing at least
annually to assess for prescribed medications as well
as other controlled prescription drugs and illicit drugs.
k. Clinicians should avoid prescribing opioid pain
medication and benzodiazepines concurrently whenever possible.
l. Clinicians should offer or arrange evidence-based
treatment (usually medication-assisted treatment
with buprenorphine or methadone in combination
with behavioral therapies) for clients with opioid use
disorder.
3. Opioid antagonist: Depending on the state, friends, fam-
ily members, and others in the community may give naloxone
42
CS263451
April 27, 2016
https://t.me/med1917
2: PUBLIC HEALTH GUIDELINES
EXHIBIT 2.1 Nonopioid Therapy
NONOPIOID TREATMENTS
FOR CHRONIC PAIN
PRINCIPLES OF CHRONIC PAIN TREATMENT
Patients with pain should receive treatment that provides the greatest benefit. Opioids are not the first-line therapy for
chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Evidence suggests that nonopioid
treatments, including nonopioid medications and nonpharmacological therapies can provide relief to those suffering
from chronic pain, and are safer. Effective approaches to chronic pain should:
Use nonopioid therapies to the extent possible
Identify and address co-existing mental health
conditions (e.g., depression, anxiety, PTSD)
Focus on functional goals and improvement, engaging
patients actively in their pain management
Use disease-specific treatments when available (e.g.,
triptans for migraines, gabapentin/pregabalin/duloxetine
for neuropathic pain)
Consider interventional therapies (e.g.,
corticosteroid injections) in patients who fail
standard non-invasive therapies
Use multimodal approaches, including
interdisciplinary rehabilitation for patients who have
failed standard treatments, have severe functional
deficits, or psychosocial risk factors
NONOPIOID MEDICATIONS
MEDICATION
Acetaminophen Small
NSAIDs Small-moderate Cardiac, GI, renal First-line analgesic, COX-2 selective NSAIDs less GI toxicity
Gabapentin/pregabalin Small-moderate Sedation, dizziness, ataxia First-line agent for neuropathic pain; pregabalin approved for fibromyalgia
Tricyclic antidepressants and
serotonin/norepinephrine
reuptake inhibitors
Topical agents (lidocaine,
capsaicin, NSAIDs)
MAGNITUDE OF
BENEFITS
Small-moderate
Small-moderate
HARMS COMMENTS
Hepatotoxic, particularly at
higher doses
TCAs have anticholinergic
and cardiac toxicities;
SNRIs safer and better
tolerated
Capsaicin initial flare/
burning, irritation of
mucus membranes
First-line analgesic, probably less effective than NSAIDs
First-line for neuropathic pain; TCAs and SNRIs for fibromyalgia, TCAs for
headaches
Consider as alternative first-line, thought to be safer than systemic
medications. Lidocaine for neuropathic pain, topical NSAIDs for localized
osteoarthritis, topical capsaicin for musculoskeletal and neuropathic pain
LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html
(continued)
EXHIBIT 2.1 Nonopioid Therapy (continued )
https://t.me/med1917
RECOMMENDED TREATMENTS FOR COMMON CHRONIC
PAIN CONDITIONS
SUBSTANCE USE DISORDERS
43
Low back pain
Self-care and education in all patients; advise
patients to remain active and limit bedrest
Nonpharmacological treatments: Exercise, cognitive
behavioral therapy, interdisciplinary rehabilitation
Medications
•First-line: acetaminophen, non-steroidal anti inflammatory
drugs (NSAIDs)
•Second-line: Serotonin and norepinephrine reuptake inhibitors
(SNRIs)/tricyclic antidepressants (TCAs)
Migraine
Preventive treatments
•Beta-blockers
•TCAs
•Antiseizure medications
•Calcium channel blockers
•Non-pharmacological treatments (Cognitive behavioral
therapy, relaxation, biofeedback, exercise therapy)
•Avoid migraine triggers
Acute treatments
•Aspirin, acetaminophen, NSAIDs (may be combined
with caffeine)
•Antinausea medication
•Triptans-migraine-specific
Osteoarthritis
Nonpharmacological treatments: Exercise, weight
loss, patient education
Medications
•First-line: acetaminophen, oral NSAIDs, topical NSAIDs
•Second-line: Intra-articular hyaluronic acid, capsaicin
(limited number of intra-articular glucocorticoid injections
if acetaminophen and NSAIDs insufficient)
Fibromyalgia
Patient education: Address diagnosis, treatment,
and the patient’s role in treatment
Nonpharmacological treatments: Low-impact aerobic
exercise (e.g., brisk walking, swimming, water
aerobics, or bicycling), cognitive behavioral therapy,
biofeedback, interdisciplinary rehabilitation
Medications
•FDA-approved: Pregabalin, duloxetine, milnacipran
•Other options: TCAs, gabapentin
Neuropathic pain
Medications: TCAs, SNRIs, gabapentin/pregabalin,
topical lidocaine
LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html
44
https://t.me/med1917
2: PUBLIC HEALTH GUIDELINES
to someone who has overdosed. Some states require a prescription; in other states, pharmacies may distribute naloxone in an outpatient setting without a prescription. There are
three FDA-approved formulations of naloxone:
a. Intravenous (IV) injectable: professional training
required for administration.
b. Autoinjectable Evzio: prelled autoinject device
that makes it easy for families or emergency personnel
to inject naloxone quickly into the outer thigh. Once
activated, the device provides verbal instructions to
the user describing how to deliver the medication, similar to automated debrillators.
Caregivers and family members should practice administration technique using the trainer injector that is supplied with the product before
naloxone is needed.
c. Narcan Nasal Spray: prelled, needle-free device
that requires no assembly and is sprayed into one nostril while the client lies on their back.
d. Dosing:
i. Adults: 0.4 to 2 mg IV, intramuscularly (IM), or
subcutaneously, up to a total dose of 10 mg; doses
may be repeated every 2 to 3 minutes, as needed.
In emergency settings, clinical practice guidelines
recommend 0.4 to 2 mg IV; alternatively, 0.4 to 0.8
mg may be given by IM or subcutaneous injection
if systemic perfusion is adequate. Repeat doses as
needed to attain desired response.
ii. Children and adolescents 5 to 17 years or weigh-
ing more than 20 kg: 2 mg IV or IO is recommended
for total reversal of narcotic effect (Pediatric Advanced
Life Support [PALS] recommendation); may require
repeated doses to prevent recurrent apnea. The
FDA-approved labeling recommends an initial dose
of .01 mg/kg IV, IM, or subcutaneously; may repeat
dose every 2 to 3 minutes until sufcient response.
iii. Infants and children younger than 5 years or
weighing 20 kg or less: .1 mg/kg/dose IV or IO is recommended for total reversal of narcotic effect (PALS
recommendation); may require repeated doses to
prevent recurrent apnea. The FDA-approved labeling recommends an initial dose of 0.01 mg/kg/dose
IV, IM, or subcutaneously; may repeat dose every 2
to 3 minutes until sufcient response.
iv. Neonates: 0.1 mg/kg/dose IV is recommended
by clinical practice guidelines and may require
repeated doses to prevent recurrent apnea. If IV
access is not available, IM administration is acceptable. The FDA-approved labeling recommends 0.01
mg/kg/dose IV, IM, or subcutaneously every 2 to 3
minutes until the desired response is obtained.
v. Intranasal dosage (Narcan Nasal Spray): NOTE:
Restrict use of the 2-mg nasal spray to opioiddependent clients expected to be at risk of severe
opioid withdrawal in situations where there is a low
risk for accidental or intentional opioid exposure by
household contacts
1) Adults, adolescents, children, infants, and
neonates: Spray, which delivers 2 mg or 4 mg
of naloxone, by intranasal administration. Seek
immediate medical attention after administration of the rst dose. If additional doses are
available, dose may be repeated in alternate
nostrils every 2 to 3 minutes as needed if the
desired response is not attained or if the client relapses into respiratory depression. Each
device contains a single dose. Family or caregiver should monitor the client closely until
emergency medical personal arrive. Pediatric
clients should continue to be monitored for at
least 24 hours after administration.nel arrive.
Pediatric clients should continue to be monitored for at least 24 hours after administration.
4. Nicotine replacement:
a. Consider nicotine replacement for those who smoke
more than one pack of cigarettes per day or who smoke
their rst cigarette within 30 minutes of waking. Stress
that there is no smoking while using the nicotine patch.
b. Nicotine patch: Nicoderm (dosing based on more
than 10 cigarettesper day habit):
i. 21 mg/QD for 6 weeks (14 mg QD × 6 weeks for
<10 cigarettesper day) then
ii. 14 mg/QD for 2 weeks (7 mg QD × 6 weeks for
<10 cigarettesper day) then
iii. 7 mg/QD for 2 weeks (only for more than 10
cigarettesper day habit).
c. Nicotine gum:
i. 2 to 4 mg of nicotine gum per hour with a maxi-
mum of 24 pieces per day for up to 12 weeks.
d. Nicotine lozenges:
i. 2 to 4 mg every 1 to 2 hours for 6 weeks.
ii. 2 mg every 2 to 4 hours for 3 weeks.
iii. 2 mg every 4 to 8 hours for 3 weeks.
5. Nonnicotine therapy:
a. Adults: bupropion (Zyban, Wellbutrin) 150 ER mg
daily for 3 days, then increase to 150 mg ER twice
daily. Treat for 7 to 12 weeks. The client may continue
to smoke during the rst 2 weeks of starting medication. This medication should not be given to clients
with seizure disorders.
b. Varenicline (Chantix): Start at .5 mg/d for the rst 3
days, then for the next 4 days .5 mg BID. After the rst
7 days, the dose is 1 mg BID × 11 weeks.
i. Encourage the client to choose a stop date for
smoking and start the Chantix 1 to 2 weeks before
this stop date.
ii. The client should be encouraged to quit even if
they have relapses.
iii. Instruct the client that the most common side
effects of Chantix are insomnia, vivid or strange
dreams, and nausea. Advise that side effects are
usually transient.
iv. Warn the client regarding potential side effects
of mood swings, aggression, homicidal thoughts,
psychosis, anxiety, and panic disorder, which may
occur on rare occasions.
v. See package inserts or the Physicians’ Desk
Reference for detailed instructions.
6. Detoxication and methadone maintenance
should be performed by specially licensed and trained
professionals.
7. Disulram (Antabuse) therapy is not recommended.
Clients who consume alcohol after taking Antabuse can
become extremely ill.
8. Refer the client to a physician or specialist if they are
experiencing withdrawal; consider admission to rehabilitation center for detoxication and treatment.
SUBSTANCE USE DISORDERS
https://t.me/med1917
45
FOLLOW-UP
A. Make a follow-up appointment weekly. Make contact with
the referral source (smoking cessation program, alcohol/
drug rehabilitation program) before the next follow-up visit
to check on the client’s progress. At the weekly visit, question
the client regarding compliance.
B. Order blood alcohol, urine drug screen, or nicotine level
(as appropriate) with every ofce visit while on outpatient
treatment and throughout the year following treatment.
C. Once positive change is seen, the client can be seen
monthly. Discuss changes the client has made, past relapses,
circumstances under which they occurred, and any special
concerns.
D. Refer to the medical diagnosis for other applicable
follow-up recommendations.
CONSULTATION/REFERRAL
A. Refer clients with drug and/or alcohol dependence to a
community mental health center that has an outpatient alcohol/drug rehabilitation program or to a specialist in the
community who deals frequently with substance abuse/
dependence.
1. Substance Abuse and Mental Health Services
Administration (SAMHSA): Search for alcohol, drug, or
mental health treatment facilities around the country, condentially and anonymously located in your area.
2. National Helpline 1-800-662-HELP (4357) for treatment
referral and information 24/7.
3. Behavioral Health Treatment Locator: ndtreatment.sa
mhsa.gov/.
4. Medication-Assisted Treatment (MAT) for Substance
Use Disorders, SAMHSA Opioid Treatment Program
Directory: dpt2.samhsa.gov/treatment/.
5. Buprenorphine Practitioner Locator: www.samhsa.go
v/medication-assisted-treatment/practitioner-program-d
ata/treatment-practitioner-locator.
B. Planning a family intervention to confront the client
is best done with the help of an experienced mental health
professional.
C. Have referral numbers close at hand so that the client’s
moment of motivation is not lost.
INDIVIDUAL CONSIDERATIONS
A. Pregnancy:
1. Substance-dependent pregnant clients frequently avoid
early prenatal care for fear of identication and reprisal.
2. Cocaine use is associated with abruptio placenta and
preterm labor. Consider drug screen for emergent admissions of clients in preterm labor and abruption.
3. Notify the hospital nursery personnel/neonatologist
before delivery to closely monitor the newborn for neonatal abstinence syndrome.
4. Nicotine/smoking use is associated with intrauter-
ine growth restriction, preterm delivery, and bleeding in
pregnancy.
5. Nicotine-dependent pregnant clients should be encour-
aged to stop smoking without pharmacologic treatment.
The nicotine patch should be used during pregnancy only
if the increased likelihood of smoking cessation, with its
potential benets, outweighs the risk of nicotine replacement and potential concomitant smoking. Similar factors
should be considered in lactating individuals.
6. Pregnant clients who use alcohol, tobacco, or drugs
should always be classied as substance-dependent rather
than substance-abusive.
B. Pediatrics:
1. Infants of smokers have increased risk of sudden infant
death syndrome (SIDS).
2. The diagnosis of substance dependence is more dif-
cult to make in children younger than 18 years. If there is
any indication of substance dependence, children should
be referred to a pediatrician who deals specically with
this problem.
3. Consider drug use when alienation of friends and fam-
ily, falling grades, and isolation occur.
4. “Hufng” is common with gasoline, glues, aerosol
sprays, and spray paints.
5. The use of synthetic cannabinoid products is on the
rise in the adolescent population. K2, Spice, and bath
salts and others are available in tobacco stores, gas stations, over the internet, and in other small shops. These
products can be very harmful. They are not detected on
routine toxicology drug screens. Be aware of illicit drug
use if clients present with change in behavior, depression,
paranoid delusion, and aggressive behaviors. Educate the
client and family regarding the toxic use of these OTC
substances. Stress to the client that these are abusive substances that can potentially be fatal. Stress cessation of use
and refer to specialist.
C. Adults:
1. Alcohol:
a. With females, tolerance can be established by asking
the question, “How many drinks does it take to make you
high?” More than two drinks indicates some tolerance.
b. In considering a diagnosis of alcohol dependence,
consider the following diagnostic ndings: hypertension; nonspecic EKG changes; cardiomyopathy; palpitations; increased mean cell volume; decreased red
blood cell count; low platelet count; increased alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactic dehydrogenase, gamma-glutamyl
transpeptidase, and alkaline phosphatase; type IV
hyperlipoproteinemia; gout; and adult-onset diabetes
mellitus.
D. Geriatrics:
1. In this population, consumption of as little as 1 oz/d
can indicate a problem.
2. Pain medications and benzodiazepines, along with
multiple medications for health problems, may create a
substance abuse problem.
E. Partners/Family members:
1. For fear of retribution, the family may remain silent
about the problem, even if accompanying the client to the
healthcare visit.
2. Some studies by corporate business show that, per
capita, businesses spend more money on the care of family members of substance-dependent clients than on the
employee.
3. Refer family members of alcoholics/drug addicts to
Al-Anon, Nar-Anon, Co-Dependents Anonymous, or
Adult Children of Alcoholics (ACOA) meetings.
4. Discuss availability and administration of Narcan.
RESOURCES
Adult Children of Alcoholics: 562-595-7830; www.adultchildren.org
Al-Anon Family Group Headquarters, Inc. (Al-Anon and Alateen):
888-4AL-ANON (meeting information line); Spanish website: www.
al-anon.alateen.org/inicio
Alcoholics Anonymous: 212-870-3400; www.aa.org
Cocaine Anonymous World Services (CAWSO): 800-347-8998; www.
ca.org
46
https://t.me/med1917
2: PUBLIC HEALTH GUIDELINES
Co-Dependents Anonymous (CoDA®): 888-444-2359; www.coda.org
Drug-Free Workplace: 1-800-WORKPLACE (967-5752)
Dual Recovery Anonymous (DRA) Central Service Ofce: 913-991-2703;
www.draonline.org
Marijuana Anonymous World Services: 800-766-6779;
www.marijuana-anonymous.org
National Association for Children of Alcoholics (NACoA): 888-554-
COAS; www.nacoa.org
National Families in Action (NFIA): 404-248-9676; www
.nationalfamilies.org
National Institute on Drug Abuse (NIDA): www.drugabuse.gov
NIDA for Teens: teens.drugabuse.gov
National Suicide Prevention Lifeline: 1-800-273-TALK (8255)
Nicotine Anonymous: 877-879-6422; www.nicotine-anonymous.org
Parents, Families and Friends of Lesbians and Gays (PFLAG): 202-467-
8180; www.pag.org
Substance Abuse and Mental Health Services Administration (SAMHSA):
www.samhsa.gov
Veteran’s Crisis Line: 1-800-273-TALK (8255)
Women for Sobriety, Inc.: 215-536-8026; www.womenforsobriety.org
BIBLIOGRAPHY
Busse, J. (Ed.). (2017).National pain center. The 2017 Canadian guideline for
opioids for chronic non-cancer pain. http://nationalpaincentre.mcma
ster.ca/documents/Opioid%20GL%20for%20 CMAJ_01may2017.pdf
Centers for Disease Control and Prevention. (n.d). Assessing benets and
harms of opioid therapy. https://www.cdc.gov/ drugoverdose/pdf/
Assessing_Benets_Harms_of_Opioid_Therapy-a.pdf
Centers for Disease Control and Prevention. (2016, April). Nonopioid treat-
ments for chronic pain, principles of chronic pain treatment. https://www.
cdc.gov/drugoverdose/pdf/nonopioid_treatments-a.pdf
Centers for Disease Control and Prevention, Ofce on Smoking and Health,
National Center for Chronic Disease Prevention and Health Promotion.
(2019, February 6). Smoking & tobacco use, fast facts. https://www.cdc.go
v/tobacco/data_statistics/fact_sheets/fast_facts/index.htm
Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for
prescribing opioids for chronic pain—United States, 2016. MMWR
Recommendations Reports, 65(No. RR-1), 1–49. https://doi.org/10.155
85/mmwr.rr6501e1
Ewing, J. A. (1984). Detecting alcoholism. The CAGE questionnaire.
Journal of the American Medical Association, 252(14), 1905–1907. https://
doi.org/10.1001/jama.1984.03350140051025
Hardy, S. (2013). Prevention and management of depression in primary
care. Nursing Standard (Royal College of Nursing (Great Britain): 1987),
27(26), 51–56. https://doi.org/10.7748/ns2013.02.27.26.51.e7240. https
://rcni.com/nursing-standard/evidence-and-practice/clinical, quiz 58
National Institute on Drug Abuse. (2018a, June). Commonly abused drugs. https
://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts
National Institute on Drug Abuse. (2018b, June). Commonly abused
prescription drugs chart. www.drugabuse.gov/drugs-abuse/
commonly-abused-drugs-charts
National Institute on Drug Abuse. (2018c, April). Opioid overdose rever-
sal with naloxone (Narcan, Evzio). https://www.drugabuse.gov/
related-topics/opioid-overdose-reversal-naloxone-narcan-evzio
National Institute on Drug Abuse. (2018d, June). Screening and assessment
tools chart. https://www.drugabuse.gov/nidamed-medical-
health-professionals/screening-tools-resources/chart-screening-tools
National Institute on Drug Abuse. (2019, May). Screening tools
for adolescent substance use. https://www.drugabuse.gov/
nidamed-medical-health-professionals/screening-tools-resources/
screening-tools-for-adolescent-substance-use
Novo Nordisk. (2018, October). Highlights of prescribing information,
Saxenda (liraglutide). https://www.novo-pi.com/saxenda.pdf
O’Malley, P. A. (2012). Baby boomers and substance abuse: The curse of
youth again in old age: Implications for the clinical nurse specialist.
Clinical Nurse Specialist, 26(6), 305–307. https://doi.org/10.1097/NU
R.0b013e318272f7a6
PDR | Prescriber’s Digital Reference. (2019). Naloxone hydrochlo-
ride injection (0.4mg/mL) drug information. https://www.pdr.net/
drug-summary/Naloxone-Hydrochloride-Injection--0-4-mg-mL--
naloxone-hydrochloride-777
Saha, S., Wilson Deanne, J., & Adger, R. J. (2012). K2, spice, and bath salts
drugs of abuse commercially available. Contemporary Pediatrics, 29(10),
22–28. http://www.contemporarypediatrics.com/
SAMHSA. (2014). What is substance abuse treatment? A booklet for families.
HHS publications, 14-4126. https://store.samhsa.gov/system/les/
sma14-4126.pdf
SAMHSA:, Medley., G, Lipari., N, R., Bose, J., Cribb, RTI International:.,
S, D., Kroutil, L. A., & McHenery, G. (2016, October). Sexual orien-
tation and estimates of adult substance use and mental health: Results
from the 2015 national survey on drug use and health. National survey on drug use and health NSDUH data review https://www.samhs
a.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/
NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm
U.S. Department of Health&Human,Services. (2016). E-cigarette use among
youth and young adults: A report of the surgeon general. https://e-cigarettes.
surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdf
U.S. Department of Health and Human Services. (2019, February). Ofce
of the surgeon general opioid overdose prevention. https://www.hhs.gov/
surgeongeneral/priorities/opioids-and-addiction/opioids-overdose
-prevention/index.html
U.S. Food and Drug Administration. (2019, May 30). Disposal of
unused medicines: What you should know. https://www.fda.gov/d
rugs/safe-disposal-medicines/disposal-unused-medicines-whatyou-should-know#Medicines_recommended
Wendell, A. D. (2013). Overview and epidemiology of substance abuse in
pregnancy. Clinical Obstetrics and Gynecology, 56(1), 91–96. https://doi
.org/10.1097/GRF.0b013e31827feeb9
VIOLENCE: CHILDREN
A.DEFINITION
The denitions of sexual abuse, childhood abuse, and the age of
children included in statistics change with each state in the
United States. Any family member, friend, or stranger can perpetrate abuse; however, fathers, mothers’ boyfriends, female
babysitters, and mothers are the most common perpetrators
of abuse. Nonaccidental injury/abuse may result in serious
physical or emotional harm and may result in failure to thrive
(FTT), delayed developmental progress, or death.
1. Physical abuse: iniction of pain/harm producing
injuries, including skeletal fractures, skin (e.g., burns), and
central nervous system injuries (e.g., abusive head trauma
[AHT] and shaken baby syndrome [SBS]/shaking-impact
syndrome).
2. Sexual abuse: inappropriate exposure; fondling; sexual
stimulation; coercion; oral, genital, buttock, and breast
contact; anal or vaginal penetration; foreign-body insertion; and sharing obscene images and making use of child
pornography photos or videos.
3. Emotional abuse: rejection, lack of affection or stim-
ulation, ignoring, dominating, intimidating, describing
the child negatively, blaming the child, and verbal abuse
(belittle, yell, threats of severe punishment) resulting in
impaired psychological growth and development.
4. Child neglect: isolation; starvation; lack of medical care;
inadequate supervision; failure to provide love, affection,
and emotional support; and failure to enroll/attend school.
INCIDENCE
A. Childhood abuse occurs worldwide; the exact incidence is
not known. It occurs across all cultures and at all racial, socioeconomic, and educational levels.
B. In the United States, approximately 700,000 to 1.25 million
children are abused or neglected annually.
C. Approximately 3.6 million refer`rals are made to child pro-
tective agencies (CPS), involving more than 6.6 million children (a referral can include multiple children), for child abuse
and/or neglect reported annually.
D. Up to 2,500 children die of inicted injuries annually in the
United States.
VIOLENCE: CHILDREN
https://t.me/med1917
47
E. Sexual abuse is underreported, underrecognized, and
undertreated.
F. Approximately one in six boys are sexually abused before
the age of 16 years.
G. More than 15 million children live with families in which
partner violence occurs at least once a year. Seven million
children live in families in which severe partner violence
occurs. Witnessing domestic violence is associated with
experiencing physical abuse and witnessing physical abuse
of a sibling.
PATHOGENESIS
A. Society, lack of parenting skills, the home environment,
substance abuse, and untreated mental illness are all factors
that contribute to abuse.
PREDISPOSING FACTORS
A. Children:
1. Minority children.
2. Disabled or medically fragile children:
a. Congenital anomalies.
b. Mental retardation.
c. Handicapped.
d. Speech or language disorders.
e. Learning disabilities.
f. Chronic medical illness.
g. Hyperactive.
h. Adopted children/stepchildren.
i. Poor bonding.
3. Unwanted child.
4. Age of children (physical abuse):
a. Younger than 1 year.
b. Children younger than 3 years.
B. Parental factors:
1. Young or single parents.
2. Distant or absent extended family.
3. Low educational level of parents.
4. Parents' lack of understanding of children’s needs,
child development, and parenting skills.
5. Unrealistic expectations for the child.
6. Nonbiological, transient caregivers in the home (e.g.,
parent’s partner).
7. Acute or chronic instability and stress in the family:
a. Loss of employment.
b. Divorce/death.
c. Drug/alcohol abuse.
d. Parents with a history of abuse/neglect as a child
(learned behavior).
e. Presence of psychiatric illness.
f. Poverty.
g. Criminal history.
h. Parental thoughts and emotions that tend to sup-
port or justify maltreatment behaviors.
C. Sexual abuse risk factors:
1. Male:
a. Younger than 13 years.
b. Non white.
c. Low socioeconomic status.
d. Not living with the biological father.
e. Disabled.
2. Female:
a. Young age between 7 and 14 years.
b. Absence of a parent.
c. Appearance of isolation, depression, or loneliness.
COMMON COMPLAINTS
A. Oral/facial injuries:
1. Oropharyngeal sexually transmitted infections: sexual
abuse.
2. Lip/tongue lacerations.
3. Missing or fracture teeth.
4. Black eyes.
5. Nasal perforation/septal deviation.
6. Skull fracture.
7. Maxillary/mandibular fracture.
8. Traumatic alopecia.
9. Retinal hemorrhage.
10. Hearing loss/tympanic injury.
B. Burns (6%−20% of injuries):
1. Cigarette burns (pathognomonic for child abuse).
2. Scalding/immersion.
3. Caustic exposure.
4. Branding.
5. Microwave burns.
6. Stun-gun burns.
C. Fractures (second most common injury).
D. Bruises (most common type of injury).
E. Lacerations.
F. Bites.
G. Force-feeding/“bottle jamming”/forced ingestion (water,
salt, pepper, poisons).
H. Starvation.
I. Sexual abuse:
1. Difculty with bowel movements.
2. Urinary tract infections.
3. Vaginal infections, itching, or discharge.
4. Complains of stomachaches.
5. Headaches.
6. Vaginal or rectal bleeding.
7. Difculty walking or sitting.
J. Behavioral signs:
1. Loss of appetite/eating disorder.
2. Clinging, withdrawn, or aggressive.
3. Nightmares, disturbed sleep pattern, and fear of the
dark.
4. Regression (e.g., bedwetting, thumb sucking, and
crying).
5. Poor grades/school attendance.
6. Expression of interest or affection inappropriate for the
child’s age.
7. Intercourse or masturbation or other sexual acting out.
8. Self-injurious behavior (e.g., cutting, biting, and pull-
ing out hair).
OTHER SIGNS AND SYMPTOMS
A. A caregiver’s refusal to allow an interview of the child
alone in the examination room is considered a “red ag” for
abuse.
B. The history is inconsistent, changes with repeated ques-
tioning, conicts with other family members/caregivers who
are interviewed, is implausible, or there is a total lack of history (e.g., “I don’t know how it happened”).
C. History is inconsistent with the child’s developmental
ability/stage.
D. Caregiver behaviors that may indicate abuse include
delay in seeking care, argumentativeness, lack of emotional
response, inappropriateness, or violence.
E. Radiographs should be obtained for a history of “soft,”
easily broken bones.
Соседние файлы в папке Библиотека им академика М.И. Перельмана