Substance Related Disorder

Etiologies of Substance Abuse

 Biologic Theories
• Recent research findings indicate that genetic
factors may be responsible for alcohol abuse and
addiction
– Research in the late 1950s focused on twins of
alcoholic parents who were reared in 3 different
environments:
• With their own parents
• With alcoholic foster parents
• With foster parents who did not consume alcohol
• After 25 yrs, the incidence of alcoholism in all 3
groups was almost identical
 Interpersonal Theories
• focus on the individual with low self-esteem who
uses substances to feel a sense of control, reduce
anxiety, and thereby feel more competent
• Other psychodynamic factors that are associated
with alcoholism include:
– Basic depressive personality
– An intolerance for frustration or pain
– Lack of success
– Lack of affectionate and meaningful relationships
– Low self-esteem
– Lack of self-regard
– Tendency toward risk behaviors
 Psychologic Theories
• Earliest theories focused on a
psychoanalytic perspective
• View the substance abuser as regressed and
fixated at the pregenital, oral level of
psychosexual development
– The individual seeks satisfaction through oral
behaviors that include smoking or drinking
 Learning Theories
• Drug use develops and is reinforced through
the positive effect of mood alterations
• Media portrayals of “good times” with
ETOH and drugs serve as powerful
reinforcing mechanisms for adolescents and
young adults
• Peer pressure and the need to belong to a
group also have positive reinforcing powers
 Family Theories
• families abuse substance have children
enmeshed in these family systems
• Boundaries are blurred.
• Family secretes and myths used as survival
measures
• Less communication with children from
outside their family system
• Parent have strong influence on their
children (protect or develop).
 Demographic variables
• Age: mostly 18-20
• Gender: men > women (illicit drugs
men = women (non-prescribed drugs)
youth; M = F (illicit drugs)
• Tobacco 12-17 years F > M
> 21 years M > F
Education: illicit drug: university < no university
alcohol: university > no university
Employment: unemployed > employed
 Special Population
During pregnancy:
• Malformation in fetus
• Smoking has: 20 – 30% low birth weight
14% preterm, 10% infant death.
• Alcohol: fetal alcohol syndrome (FAS)
(Growth retardation, mental retardation,
facial abnormalities, hearing loss)
 Adolescents:
• Problematic use: experimentation
• Cigarettes, alcohol, and marijuana most
used.
• Smoking and alcohol as a gateway to
illicit drugs
• Early use of drugs predicts prolonged
use and substance dependence later.
 Signs of adolescent substance use
1. Blood shot, red eyes, droopy eyelid
2. Wearing sunglasses at inappropriate times.
3. Changes in sleep pattern
4. Unexplained periods of changed mood,
depression and anxiety
5. Loss of interest
6. Decline in academic performance
7. Loss of motivation
8. Changes in peer groups.
9. Disappearance of money and items of value.
10. Unfamiliar containers of locked boxes.
 Impaired Professionals
• In USA, 10-20% of nurses have substance
abuse problems, 6-8% of RN are impaired
due to substance abuse problems.
• Why?
-High job stress, contact with illness and
death, and access to drugs
 Epidemiology
• Substance abuse is the #1 health problem in the
US
• The cost of substance abuse has been estimated to
be a staggering $238 billion per yr
• In the US, about 18% of the population
experiences a substance-use d/o at some point in
their lives
• 51% of pts with mental illness are dependent on
an illicit substance
 Jordanian Study
• Tobacco Smoker: NO: 272 (79%)
YES: 73 (21%)
OF SMOKER: > 20 cig: 42 (57 %)
10 – 20 cig: 14 (19 %)
1 – 10 cig: 56 (24 %)
 Caffeine
Substance Coffee Tea
Freq No % No %
0 cups 107 31 62 18

1- 5 Cups 213 64 249 73

5 – 10 cups 14 4 24 7

10 – 20 cups 3 1 6 2
Substance 0 times 1-2 3-9 10-20 > 20
No % No % No % No % No %

Alcohol 330 95.3 9 2.6 5 1.4 0 0 1 0.3

Cocaine 337 97.7 3 0.9 0 0 2 0.6 2 0.6

Marijuana 339 98.3 3 0.9 1 0.3 1 0.3 0 0
Stimulants 293 84.9 17 4.9 12 3.5 9 2.6 13 3.8
 Substance 0 times 1-2 3-9 10-20 > 20
No % No % No % No % No %
Hallucinogens 341 98.8 1 0.3 0 0 0 0 2 0.6

Tranquilizers 305 88.4 23 6.7 10 2.9 3 0.9 3 0.9

Pain killer 171 49.6 105 30.4 40 11.6 15 4.3 12 3.5

Heroin 337 97.7 4 1.2 1 0.3 0 0 1 0.3

Inhalants 313 90.7 15 4.3 7 2 3 .9 6 1.7
11 Classes of Substances with the
Potential for Abuse and
Dependence
• Alcohol • Inhalants
• Amphetamines • Nicotine
• Caffeine • Opioids
• Cannabis • Phencyclidines (PCP)
• Cocaine • Sedative, hypnotics, or
• Hallucinogens anti-anxiety agents
Differentiating Substance Abuse
Versus Substance Dependence
 DSM-IV Criteria for Substance
Abuse
• A. A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by 1 (or more) of the following, occurring
within a 12 month period:
– 1. Recurrent substance use resulting in a failure to fulfill major
role obligations at work, school, or home
– 2. Recurrent substance use in situations in which it is physically
dangerous
– 3. Recurrent substance-related legal problems
– 4. Continued use despite recurrent social or interpersonal
problems
• B. The sx have never met the criteria for substance
dependence
 DSM-IV Criteria for Substance
Dependence
• A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by 3 (or more) of the following,
occurring at any time in the same 12 month
period:
– 1. Presence of tolerance
– 2. Presence of withdrawal
– 3. Substance is taken in larger amounts/for longer
period than intended
– 4. Unsuccessful or persistent desire to cut down or
control use
DSM-IV Criteria for Substance
Dependence (cont)
– 5. Increased time in getting, taking, and
recovering for the substance
– 6. Important social, occupational, or
recreational activities are given up or reduced
because of substance use
– 7. Substance used despite knowledge of
recurrent physical or psychologic problems
Physiologic Complications of
Alcohol Intoxication and
Withdrawal
 ETOH Intoxication
• Slurred speech
• Incoordination
• Unsteady gait
• Drowsiness
• Decreased BP
 Level of alcohol intoxication
BAL Consequences
(Blood Alcohol Level)
20-50 mg/dl blood No Legal intoxication, some uncoordination,
(.02 - .05) potential changes in behavior.

80 – 100 mg/dl blood Legal intoxication, impaired ability to drive,

(.08 - .10) slurred speech, staggered gait, impaired
sensory function
100 – 150 mg/dl blood Markedly uncoordination, gross cognitive
(.1 - .15) and judgment distortion
Above 200 mg/dl blood Notable impaired sensory and motor function
( >.20)
Above 300 mg/dl blood Potential for cardiovascular and respiratory
( > .30) collapse, coma, and death can occur,
 Alcohol Withdrawal Sx
• Tremulousness • Possible nausea,
• Increased psychomotor vomiting, abdominal
hyperactivity cramps
• Insomnia • Weakness
• Acute anxiety • Craving for alcohol or
• Tachycardia (120-140 sedative drugs
BPM)
• Acute hallucinosis
• HTN
• Acute withdrawal
• Anorexia
delirium—24-72 hrs after
• Agitation
last drink
 Treatment of Withdrawal
• Monitor vital signs as ordered—q 2-3 hrs
• Provide quiet, nonstimulating environment
• Administer benzodiazepines (drug of choice to
treat alcohol withdrawal) as ordered
• Frequently orient client
• Institute seizure precautions
• Administer vitamins as ordered
• Accurately record I&O
 Neurological Effects
• Blackouts
– Occur most frequently with excessive use of
alcohol
– An early sign of alcoholism
– Recollection of activities are lost from
conscious recall but the individual remains
conscious and appears to function normally to
those in their environment
 Neurological Effects (cont)
• Alcohol withdrawal delirium -- delirium tremens
(DTs)
– Most severe form of alcohol withdrawal
– Occurs 24-72 hrs after the last drink
– Occurs in heavy drinkers and is manifested by an acute
psychotic state
– Confusion and disorientation to time and place are
common
– Other sx include visual and auditory hallucinations that
are accusatory and threatening to the pt
– Illusions, severe agitation, profuse sweating,
tachycardia, tachypnea, and possibly grand mal seizure
activity can also occur
 Neurological Effects (cont)
• Acute alcoholic hallucinosis
– Occurs after a prolonged period of drinking
– Characterized by threatening auditory
hallucinations
– Different from DTs in that the individual
remains oriented to time and place
 Neurological Effects (cont)
• Korsakoff’s syndrome
– Occurs after many yrs of excessive etoh intake
– An amnestic syndrome caused by deficiency in
the B vitamins, including thiamine, riboflavin,
and folic acid
– Characterized by amnesia, disorientation to
time and place, severe peripheral neuropathy—
tingling; muscle weakness; sore, burning
muscles; parasthesias; and extreme pain on
movement
– The lower extremities are most often affected
 Neurological Effects (cont)
• Wernicke’s syndrome
– Most frequently occurs simultaneously with
Korsakoff’s
– Neurologic disease characterized by ataxia,
nystagmus, and confusion
– Caused by severe vitamin B1 deficiency due to
lack of adequate food intake
– The early stages respond to large doses of IM
thiamine
– If the condition is not treated, it can progress to
a chronic, severe, irreversible lifetime condition
 Medical Complications
• Liver is the organ most affected by excessive etoh
use
• Metabolism of etoh releases excessive amounts of
hydrogen into the liver
– This inhibits metabolism of fats
– The unburned fat becomes deposited into the liver and
causes hepatic steatosis
• Alcoholic hepatitis occurs after prolonged etoh
abuse—causes hepatocyte necrosis
– Sx include anorexia, N&V, malaise, weight loss, fever,
abdominal distress, jaundice
 Medical Complications (cont)
• GI system
– Inflammation of the esophagus and stomach
– Diarrhea
• CV system
– Elevated BP
– Cardiomyopathy
– Arrhythmiasheart failure
– Risk of CVA
 Medical Complications (cont)
• GU system
– Men
• Decrease in erectile capacity
• Testicular atrophy
– Women
• Amenorrhea
• Decrease in ovarian size
Abuse of Other Drugs
 Benzodiazepines
• Benzos taken in combination with etoh can
lead to CNS depression and even death
• Benzos that have a rapid onset of action are
most likely to have abuse potential—
Valium and Xanax
• Withdrawal sx are similar to the sx of etoh
withdrawal
 Opioids
• The most widely abused opioid is heroin
– Other opioids include morphine, codeine,
hydromorphone, meperidine, methadone
• Tolerance to opioids develops rapidly, however
tolerance to the respiratory depressant effect does
not
• Most deaths occur as a result of respiratory
depression
– The triad of coma, pinpoint pupils, and respiratory
depression signal opiate OD
– Opiate OD is treated with an opioid anatgonist--Narcan
 Withdrawal from Opiates
• Withdrawal sx begin 6-8 hrs after the last dose and
reach their peak intensity within 48-72 hrs
• Sx include:
– Myalgia, N&V, Diarrhea
– Diaphoresis
– Rhinorrhea, Lacrimation
– Pupillary dilation
– HTN, Tachycardia
– Fever and chills
 Treatment
• Methadone
– Rx for morphine and heroin addicts
– Methadone is a synthetic opioid given to suppress
withdrawal sx
– Methadone maintenance is continued until the client
can be gradually withdrawn from the methadone
• L-Alpha Acetylmethadol (LAAM)
– Alternative to methadone
– Effective for up to 3 days
 Cocaine
• Naturally occurring stimulant
• Blocks the reuptake of 5-HT and Da --producing
an intense feeling of euphoria
• Highly addictive drug
• Can be inhaled, smoked or used IV
• Intoxication is characterized by extreme
irritability, agitation, aggressiveness, impulsive
sexual activity, and manic excitement
– These sx are followed by withdrawal sx referred to as
the “crash”
 Crack
• Widely available alkalinized form of
cocaine
• Dependence develops rapidly secondary to
5-7 min high
Withdrawal from Cocaine/Crack
• Abrupt withdrawal creates an intense
craving for the drug
• Clients experience severe depression with
SI along with hypersomnolence, fatigue,
apathy, and general malaise
 Stimulants
• Stimulant drugs include caffeine, ephedrine, and
amphetamine
• Amphetamine is a highly addictive drug
• Therapeutic use of amphetamines is restricted to
ADHD, narcolepsy, and obesity
• The amphetamine that has been called the drug of
the 1990’s is “ice,” a pure form of
methamphetamine which is inhaled or used IV
 Stimulants (cont)
• Life threatening effects of amphetamines include
cardiac arrest, stroke, and neurological
involvement leading to coma and death
• Psychologic effects include restlessness,
dysphoria, insomnia, irritability, confusion, and
panic
• Withdrawal sx peak 48-72 hrs after drug is d/c
– Most frequent and dangerous sx is depression with SI
 Inhalants
• Inhalants are drugs that produce quick,
temporary feeling high and lightheadedness.
• Feeling high last minutes to about an hour
• Inhalant abuse, also known as “huffing,”
• Types:
5. Solvents: paint thinner, glue
6. Gases: Butane
7. Nitrites.
Are they harmful?
• Short-term
2. Impaired physical coordination
3. Impaired mental judgment (confusion,
hallucination, delusion of persecution)
4. Irritation to breathing passage
5. May block the breathing center secondary
to CNS depression
6. Oxygen deprivation that lead to
unconsciousness …coma…DEATH
• Long term:
• Tolerance
• Permanent brain damage manifested
by: poor memory, extreme mood
swing, tremors, seizures, cardiac
arrhythmia, and respiratory depression
• Glaucoma and blindness
• Damage to liver and kidney
Treatment Modalities
 Individual Therapy
• Indicated for clients with substance related d/os
who have:
– High levels of anxiety
– Inadequate coping mechanisms
– Low tolerance for frustration
• Problems with individual therapy:
– Clients continually test the bond between therapist and
client
– Therapist must be aware of several occurrences during
the process of therapy including:
• Possibility of relapse
• The onset of depression
• Refusal to continue therapy
 Group therapy
• In a group setting, clients with similar experiences
and problems can confront and support each other
in a safe environment
• Groups work best when there are ground rules
established
– Sobriety
– Regular attendance
– Willingness to share experiences and confront defenses
– Confidentiality
 Family Therapy
• Provides opportunities to learn healthy
ways of interacting with one another and of
solving problems
• Provides a structure in which the entire
family can be educated about alcoholism as
a disease
 Behavioral Therapy
• Relaxation techniques
• Biofeedback
• Use in combination with other models of
counseling and assertiveness therapy
• Approaches: assertiveness and aversive
therapy (teaching negative association)
Antabuse and Naltrexone Antagonist

• Disulfiram (Antabuse)
– Inhibits the enzyme aldehyde dehydrogenase, thus
blocking the oxidation of alcohol and allowing
acetaldehyde to accumulate in the blood
• When clients take Antabuse and ingest even a
small amount of alcohol, they become very sick
– Sx include: flushing, feelings of heat in the face, chest,
and upper limbs, pallor, hypotension, nausea,
palpitations, dizziness, blurred vision
 Relapse prevention
• Teaching the client to identify the situations
in which relapse in expected.
• Enabling the client to make life style
changes including living area, shopping
place, and selection of friends and living
with family
 Harm reduction
• A techniques to change a pattern of use.
• example include:
3. Driver program
4. Smoking cigarettes with low tar and
nicotine
 Changing The Conversation
Program
1. There is “ no wrong door” to treatment
2. Invest for results
3. Commit to quality
4. Change attitudes
5. Build partnership
 Prognosis
• Sobriety is the goal for complete recovery from
substance abuse and dependence
• The course of substance dependence is variable
– It is usually chronic, lasting years with periods of heavy
intake and partial or full remission
• During the first 10 months after the onset of
remission, one is particularly vulnerable to relapse
• Most clients relapse a minimum of 3-4 times
before they attain sobriety
The Nursing Process
 Assessment
• Screening instruments
– CAGE
• Have you ever felt you ought to Cut down on your
drinking?
• Have people Annoyed you by criticizing your
drinking?
• Have you ever felt Guilty about your drinking?
• Have you ever had a drink first thing in the morning
to steady your nerves or get rid of a hangover (Eye
opener)?
– Positive response to 2 of the 4 items of the
CAGE indicates a potential problem with
alcohol
 Assessment (cont)
• Laboratory tests
– A comprehensive urine drug screen
– Other common laboratory tests useful in the
diagnosis of alcohol abuse include:
• Blood alcohol level (BAL)
• GGT—rises in response to ETOH ingestion; 60-
80% of individuals with chronic ETOH abuse will
have an increased GGT
• MCV—elevated in 35% of individuals who are
heavy drinkers
 Nursing Diagnoses
• Coping, ineffective individual
• Denial, ineffective
• Family processes, altered
• Nutrition, altered
• Thought processes, altered
• Trauma, risk for
• Violence, risk for
(See also appendix)
 Nursing intervention
• Maintain patent airway and life threatening situation
• Maintain safety of the client and others.
• Observe for additional S&S for overdose
• Assess for psychological and physiological sing and
symptoms for withdrawal and drug interaction.
• Initiate therapeutic intervention to treat withdrawal
symptoms
• Provide emotional support for client and family.
• Support nutrition and nutrients consumption
• Provide carbohydrate intake, vitamin, minerals.
• Support client and family to acknowledge denial and
deception
• Teach family about substance use
• Encourage client and family to engage in AA’s