3/5/2010

SUBSTANCE ABUSE
DISORDERS

SUBSTANCE RELATED
Disorders that causes
DISORDERS behavioral changes
associated with regular
substance abuse that affects
the central nervous system

DSM-IV TR Signs and Symptoms in a person

Classes of Substance Abuse suffering from Substance related

CNS DEPRESSANTS
disorder
Tremors

Absenteeism
-Alcohol, Benzodiazepines, Inhalants,
Flushed face

Frequent accidents or
injuries
Watery or reddened
Opioids (Narcotics)
eyes

CNS STIMULANTS
Drowsiness

Appearing spaced out

Slurred speech
- Cocaine, Caffeine, Nicotine,
Odor of alcohol on the
Amphetamines, Hallucinogens
Inattention to
breath
appearance

High number of

Increasing isolation
physical complaints

Frequent secretive

Disappearing
disappearances
prescriptions

DEFINITION OF TERMS SUBSTANCE ABUSE

A maladaptive pattern of substance use

Substance Abuse leading to clinically significant impairment

Substance Dependence or distress as manifested by 1 or more of

Intoxication the following:

Tolerance 1. Failure to fulfill major role obligations

Withdrawal 2. Recurrent substance use in hazardous
situations
3. Recurrent substance-related legal
problems
4. Continued use despite problems

1

SUBSTANCE DEPENDENCE

A maladaptive pattern of substance use as
manifested by 3 or more of the following:
1. Tolerance
2. Withdrawal
3. Inability to stop using when wanting to do so
4. Causes social, occupational and recreational
problems
5. Continued use despite knowledge of its
physical and psychological effects
SUBSTANCE TOLERANCE

A need for increased
amounts of the substance to
achieve the desired effects
The first step is admitting you have a
problem
3/5/2010
SUBSTANCE INTOXICATION

The development of substance-
specific syndrome due to a recent
ingestion of a substance

Clinically significant maladaptive
behavioral or psychological
changes due to the effect of the
substance on the CNS
SUBSTANCE WITHDRAWAL

The development of substance-
specific syndrome due to the
cessation of or reduction in the
intake of a substance
ALCOHOL ABUSE

Most commonly abused substance

A CNS Depressant affecting all body
tissues
2
 3/5/2010

ALCOHOLISM
ALCOHOL METABOLISM

THEORY
STRONG ORAL TENDENCIES :
10% - STOMACH
UNRESOLVED NEED FOR
90% - SMALL INTESTINE
ATTACHMENT
EMPTY STOMACH – CAN REACH
AN ATTEMPT TO SATISFY AN BLOODSTREAM WITHIN 20 MINS AFTER
INGESTION
UNCONSCIOUS ORAL NEEDS

SLOW ABSORPTION: BEER (4%) & WINE (12%)
PERSONALITY:
LIQUOR ( 40 – 50%)
DEPENDENT, LOW SELF-ESTEEM,

FOOD ALSO SLOWS ALCOHOL ABSORPTION
PASSIVITY, INTROVERSION
HEREDITY

ALCOHOL METABOLISM ALCOHOL METABOLISM

ALDEHYDE

ALCOHOL IS DISSOLVED IN BODY’S WATER DEHYDROGENASE
AND DISTRIBUTED TO ALL BODY TISSUES Alcohol

THE BODY CAN METABOLIZE 10ML OF Dehydrogenase ACETAL-
H2 LIVER
ALCOHOL ( 1 OUNCE OF WHISKEY OR 1 DEHYDE
BYPASS
GLASS OF BEER) IN 90 MINUTES NORMAL
ENERGY

HOT COFFEE OR “SWEATING IT OUT” DOES SOURCE
NOT INCREASE THE METABOLISM OF
ALCOHOL

LATE STAGE ALCOHOLISM : DECREASE IN ACETIC H20
CO2
TOLERANCE ACID

WOMEN HAVE LOWER ADH ENZYME THAN MEN

ALCOHOL METABOLISM ALCOHOL ACTION

POTENTIATES GABA ACTIVITY AND

ACETALDEHYDE DECREASES GLUTAMATE ACTIVITY ( CNS

– TOXIC TO THE BODY DEPRESSANT)
- A CNS IRRITANT
BEHAVIORAL EFFECTS: THOUGHTS,
- CAN CAUSE LIVER CELL JUDGMENT AND INHIBITION IS LOOSENED/
LOSS AND LIVER CIRRHOSIS DISRUPTED, CLUMSY, CONFUSED,
- DECREASE VITAMINS STUPOROUS
ACTIVATION

LEGAL INTOXICATION: 0.1 TO 0.15% BLOOD
ALCOHOL LEVEL

0.4 – 0.5 % AND ABOVE: COMA,
RESPIRATORY AND CARDIAC ARREST

3
 3/5/2010

Blood Alcohol CLINICAL EFFECTS

levels (%) PHYSIOLOGIC EFFECTS
0.05 Euphoria , dIsinhibition
0.10-0.15 Labile mood, talkative, impaired judgment
0.15-0.20 Decreased motor skills; slurred speech, double
Disinhibition
0.25 vision
0.30 Altered perceptions
Impaired judgment
0.35 Altered equilibrium
0.40 Apathy
Fuzzy thinking
0.40-0.50 Stupor, coma
Respiratory depression
Decreased psychomotor activity

Anxiety and tension are relieved

CNS EFFECTS ALCOHOLISM

Slurred speech, short attention span, loud
PHYSIOLOGICAL EFFECT

talk, memory deficits
LIVER: ALCOHOLIC HEPATITIS AND HEPATIC

Sedation CIRRHOSIS

BLACKOUT GI SYSTEM: ESOPHAGITIS, GASTRITIS &
GASTRIC ULCER, ESOPHAGEAL

ALCOHOL WITHDRAWAL SYNDROME VARICES

Alcoholic hallucinosis OTHER BODY SYSTEMS: PANCREATITIS,
DM, VITAMIN DEFICIENCIES

DELIRIUM TREMENS HYPERTENSION, MI, CLOTTING ABILITY,

WERNICKE-KORSAKOFF SYNDROME HYPERLIPIDEMIA, PERIPHERAL NEURITIS,
IMPOTENCE

ALCOHOLISM ALCOHOLISM

INTOXICATION – CORRELATES W/ BLOOD
WITHDRAWAL:

CONCENTRATION OF ALCOHOL 1. TREMULOUSNESS – 6-8 HRS AFTER CESSATION
- INITIALLY: TALKATIVE; 2. PSYCHOTIC AND PERCEPTUAL SX – 8-12 HRS
GREGARIOUS, WITHDRAWN, 3. SEIZURES – 12 TO 24-36 HRS .
SULLEN, LABILITY OF MOOD 4. ALCOHOL WITHDRAWAL DELIRIUM- 72 HRS
( DELIRIUM TREMENS)
- CAN LEAD TO COMA,
IRRITABILITY, NAUSEA & VOMITING,
RESPIRATORY DEPRESSION PSYCHOMOTOR AGITATION, ANXIETY,
AND DEATH SWEATING, FACE FLUSHING, TACHYCARDIA,
- SUPPRESSED IMMUNE MILD HYPERTENSION, GENERALLY ALLERT
SYSTEM

4
 3/5/2010

ASSESSMENT of ALOHOL
ALCOHOLISM
WITHDRAWAL
STAGE SYMPTOMS
TREATMENT
DISULFIRAM ( ANTABUSE )
Stage 1 6-8 hrs after Tremulousness NALTREXONE HCL (Revia)
ACAMPROSATE
Stage 2 8-12 hrs after Anorexia, Insomnia, CHLORDIAZEPOXIDE (LIBRIUM)
Hallucinations, Anxiety

NURSING MANAGEMENT
Stage 3 2-3 days Seizures, Convulsions SECURE ENVIRONMENT
SUPPLEMENTS: MULTIVITAMINS, B-
Stage 4 2-5 days Excitability, disoriented,
COMPLEX, VITAMIN C, CALCIUM
confused, agitation
AND MAGNESIUM

ALCOHOLISM MANAGEMENT

NALTREXONE HCL
OPIOID RECEPTOR ANTAGONIST
Ask about when was the last intake of
APPROVED IN 1995 (FDA) FOR THE USE OF alcohol and the amount taken
TREATING ALCOHOL DEPENDENT

NO ANTIPSYCHOTICS!
ACTION: INCREASE ABSTINENCE & DECREASE
CRAVING
GIVE ANXIOLYTICS
CONTRAINDICATED FOR THOSE WHO ABUSED
Decrease environmental stimuli
NARCOTIC WITHIN 7 TO 10 DAYS

Monitor VS q1-2hrs

Ensure safety

Re-orient the client

REHABILITATION GROUP THERAPY

Foundation is ABSTINENCE
AVERSION THERAPY
Alcoholics Anonymous
(DISULFIRAM/ANTABUSE)
Al-Anon
-Avoid anything that contains ALCOHOL
Ala-Teen

Live a positive LIFE

MUST: Give up Denial First

5
 3/5/2010

CAGE Questionnaire

Have you ever felt you should CUT

DOWN on your drinking?

Have people ANNOYED you by
criticizing your drinking?

Have you ever felt bad or GUILTY
about your drinking?

Have you ever had a drink first thing in
the morning to steady your nerves or
get rid of a hang-over? (EYE OPENER)
DRUG ABUSE

BARBITURATES BARBITURATES

EX: PHENOBARBITAL
EFFECT

CNS DEPRESSANT BEHAVIORAL: IMPAIRED JUDGEMENT

DURATION OF ACTION: ULTRASHORT INAPPROPRIATE SEXUAL/ AGGRESSIVE
SHORT, BEHAVIOR
INTERMEDIATE MOOD LABILITY
LONG SLURRED SPEECH

METABOLISM: BY LIVER AND INCOORDINATION
EXCRETED THRU KIDNEY UNSTEADY GAIT; SLUGGISHNESS

TO MAINTAIN A STATE OF RELATIVELY NYSTAGMUS
ANXIETY-FREE LIVING IMPAIRMENT IN ATTENTION /MEMORY
STUPOR / COMA

BARBITURATES BARBITURATES

WITHDRAWAL AND DETOXIFICATION
LIFE THREATENING
OVERDOSE:
WITH HALLUCINATIONS, ILLUSIONS, SEIZURES
1 gram – SERIOUS POISONING
MILD SX (400mg): ANXIETY, WEAKNESS,
SWEATING & INSOMNIA 2 TO 10 gram - FATAL
(800mg): ORTHOSTATIC HYPOTENSION,
WEAKNESS, TREMOR &
DRUG INTERACTIONS
SEVERE ANXIETY
ELDERLY: CAN CAUSE EXCITEMENT
SEVERE SX: SEIZURES, DELIRIUM, CARDIAC ARREST
& DEATH
PREGNANCY: FETAL ABNORMALITIES
SYMPTOMS APPEAR IN THE FIRST 3 DAYS OF ABSTINENCE;
WITHDRAWAL : CAN CAUSE DEATH
SEIZURE ON THE 2ND / 3RD DAY
PSYCHOTIC SX: 3RD TO 8TH DAY
DETOXIFICATION: REQUIRES CAUTIOUS &
GRADUAL REDUCTION

6
 3/5/2010

INHALANTS INHALANTS

CATEGORIES:
CNS DEPRESSANTS AND HILARITY

HYDROCARBON SOLVENTS
CROSS THE BLOOD-BRAIN BARRIER QUICKLY
AEROSOL PROPELLANTS
SIDE EFFECT: MOUTH ULCERS
ANESTHETICS GI PROBLEMS

EXAMPLES: ANOREXIA
GASOLINE, VARNISH REMOVER, PAINT CONFUSION
THINNERS, GLUES, LIGHTER FLUID,
HEADACHE
RUBBER CEMENT, CLEANING FLUID,
SPRAY PAINT ATAXIA

OPIOIDS OPIOIDS (NARCOTICS)

opium, morphine,
codeine, heroin,
METABOLISM: morphine is metabolized in the
hydromorphine, liver & excreted by the kidneys
demerol &
EFFECTS: STIMULATING OPIOID RECEPTORS
methadone SITES( increasing pain threshold ) &

ADMINISTERED THRU: ENDORPHINES AGONISTS ( blocks pain &
swallowed, smoked, effect on mood )
snorted, injected,
“mainlined”

OPIOIDS ( NARCOTICS ) STIMULANTS

OVERDOSE: respiratory depression, stuporous
CAFFEINE

then sleep, wet and warm skin, coma, cold

NICOTINE
and clammy skin, dilated pupils, death

ANTAGONIST : Naloxone, Nalorphine (Nalline)
AMPHETAMINES

ELDERLY & PREGNANCY : babies suffer
COCAINE
withdrawal sxs

SPECIFIC DRUGS: Methadone (to prevent
withdrawal sxs); Heroin (synthetic drug);
Codeine ( cough suppressant)

7

STIMULANTS

CAFFEINE
Effects: decrease fatigue, increase alertness
& enhance sense of well-being
Complications: nervousness, increase in
blood pressure, increase level of anxiety,
increase gastric acidity
Withdrawal: headaches, marked fatigue or
drowsiness, anxiety or depression, irritability,
muscle tension and nausea, vomiting
STIMULANTS

AMPHETAMINES
AMPHETAMINE
Effect: alertness, euphoria, self-confidence
& increased sex drive – hypervigilance,
grandiose, agitated & irritable
Methamphetamine – “ICE”, “ECSTACY”
Complications: increased cardiac &
respiratory rates & blood pressure

Chronic use: paranoia, auditory & tactile
hallucinations, motor disturbances, poor
memory, tachycardia, arrhythmias,
hypertension, death
STIMULANTS

COCAINE
euphoria, increased
energy, mental
alertness, self-
confidence &
increased sexual
arousal, talkative,
playful
3/5/2010
STIMULANTS

NICOTINE
Effects: feelings of alertness, increases
blood pressure & heart rate, increases
irritability & decreases appetite
Complications: lung disease, cancer of the
lung & cardiovascular disease
Withdrawal: craving, anxiety, restlessness,
decreased concentration, overeating,
irritability, frustration, constipation and
headaches
STIMULANTS
WITHDRAWAL: exhaustion, fatigue, excessive
sleep, unpleasant dreams, enhanced appetite &
depression; suicidal ideation
OVERDOSE: euphoria, hyperactivity,
hypervigilance, talkativeness, anxiety, anger,
fighting & impaired judgment

MDMA ( Ecstacy)- can cause death when combined
with high level of physical activity (increased body
temp.,hypertension, muscle breakdown & kidney
failure)
STIMULANTS
COCAINE

rebound dysphoria
“crash”-
unpleasant feeling
and takes more
cocaine to
overcome
dysphoria
8
 3/5/2010

STIMULANTS STIMULANTS

With increased use,

there is progressive
COCAINE
tolerance of the positive COMPLICATIONS: cardiac & cerebral infarcts,
effect while the perforation of nasal septum, pulmonary
damage, hepatitis (IV use)
negative effects steadily
intensify WITHDRAWAL: severe craving, depression, fatigue
irritability, vivid & unpleasant dreams, insomnia or
hypersomnia
OVERDOSE: euphoria, grandiosity, anger,
elevated BP, chills, nausea & vomiting,seizure,
respiratory depression, cardiac arrhythmias,
death

HALLUCINOGEN/
HALLUCINOGENS
CANNABINOLS

LSD; mescaline, PCP; psilocybin

MARIJUANA-most widely used illegally

EFFECTS: vivid visual images, altered
perceptions and a sensation of slowed time,
EFFECTS: Euphoria
euphoria, labile emotions, hostility &
Increased hunger
depression

COMPLICATIONS: “ bad trip” (psychotic state, Dilated Pupils
perceptual changes, flashbacks, increased Conjunctival irritation
heart rate & BP, stroke, death

OVERDOSE: anxiety, ideas of reference, Dry Mouth
intensification of perception, Sore throat
depersonalization, illusion, physiological
changes, death

MANAGEMENT NURSING MANAGEMENT

NURSE-PATIENT RELATIONSHIP
MILIEU

POSITIVE MOTIVATORS
SAFETY : DRUG-FREE ENVIRONMENT, SUICIDE,
TRUSTING RELATIONSHIP
INAPPROPRIATE SEXUAL BEHAVIOR ETC.
GENUINENESS
STRUCTURE: SCHEDULE, NORMS, OPENNESS,
EMPATHY & SAFE ENVIRONMENT
FEEDBACK, CONFRONTATION
FEELINGS OF HOPE
LIMIT SETTING: RECOGNIZING STILL
GROUP THERAPY
ADDICTED MIND, DRUG SCREENS
PERSONAL RESPONSIBILITY
ALCOHOLIC & NARCOTICS ANONYMOUS
CONSCIENCE DEVELOPMENT
LIFSTYLE ISSUES

9
 3/5/2010

SUMMARY of DRUG SUMMARY OF OPIOID

INTOXICATION INTOXICATION
Depressants Stimulants
Constricted pupils

Drowsiness
Dilated pupils
Decreased respirations

Hypotension
Euphoria

Impairment of memory,
Hypertension

Drowsiness
attention, judgment, and
Insomnia
Hypotension
social or occupational
Paranoia, hallucinations,
functioning
Psychomotor retardation
delusions

Incoordination and
Tachycardia
Slurred speech
unsteady gait

Potential for violence

Irritability

Slurred speech

SUMMARY OF HALLUCINOGEN SUMMARY

INTOXICATION Intoxication Withdrawal

Dilated pupils CNS Depressant Depressant Stimulating

Agitation and belligerence -Sedative Effect Effect

Bizarre behavior Hypnotics *PIN-POINT
-Narcotics PUPILS

Diaphoresis
(Heroine)

Elevated VS
CNS STIMULANT Stimulating Depressant

Hallucinations, Paranoia Effect Effect
-Amphetamine

Seizures *DILATED
-Cocaine

Tachycardia -Hallucinogens PUPILS
(Cocaine)

Sample Questions

CNS DEPRESSANT
You are monitoring a client during alcohol

-Physical Dependence withdrawal. Which of the following would
alert you for potential for withdrawal
-Psychological Dependence
delirium?

CNS STIMULANT
A. hypotension, ataxia, hunger
-Psychological Dependence
B. Stupor, agitation, muscular rigidity
C. Hypotension, coarse tremors, agitation
D. Hypertension, changes in LOC,
hallucinations

10
 3/5/2010

Sample Questions Sample Questions

The basic needs that will require the most
attention during the early detoxification Addiction to marijuana causes the following
period are the following: effects EXCEPT:

A. rest and nutrition A. euphoria

B. comfort and hygiene B. conjunctival irritation
C. safety and security C. synesthesia
D. recreation and elimination D. increased hunger

Sample Questions

“ALWAYS BE A
Rick was admitted to the ER. Upon
assessment of the ER nurse, he was found BLESSING TO OTHERS”
to be on drugs, with pinpoint pupils and a
RR of 9 per minute. Rick is likely to be
suffering from:

A. cocaine intoxication ‘
B. heroine intoxication
C. cocaine withdrawal
D. heroine withdrawal

11