1 substance abuse (escalante-saac)

polysubstance abuse

Abuse of more than one substance is termed _

1. Alcohol
2. Amphetamines or Similarly Acting Sympathomimetics
3. Caffeine
4. Cannabis
5. Cocaine
6. Hallucinogens
7. Inhalants
8. Nicotine
9. Opioids
10. Phencyclidine (PCP) or Similarly Acting Drugs
11. Sedatives, Hypnotics, or Anxiolytics

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR)
lists 11 diagnostic classes of substance abuse:

It also categorizes substance-related disorders into two groups: (1) those that include disorders of abuse and dependence and (2) substance-induced disorders such
as intoxication, withdrawal, delirium, dementia, psychosis, mood disorder, anxiety, sexual dysfunction, and sleep disorder.
Intoxication

is use of a substance that results in maladaptive behavior.

Withdrawal syndrome

refers to the negative psychologic and physical reactions that occur when use of a substance ceases or
dramatically decreases.

Detoxification

is the process of safely withdrawing from a substance.

Substance abuse

can be defined as using a drug in a way that is inconsistent with medical or social norms and despite
negative consequences.

ONSET AND CLINICAL COURSE

15 and 17

The early course of alcoholism typically begins with the first episode of intoxication between_ years of
age

blackout

During this time, the person experiences his or her first_, which is an episode during which the person
continues to function but has no conscious awareness of his or her behavior at the time or any later
memory of the behavior

tolerance for alcohol

As the person continues to drink, he or she often develops a_; that is, he or she needs more alcohol to
produce the same effect.

tolerance break

After continued heavy drinking, the person experiences a _, which means that very small amounts of
alcohol intoxicate the person.

substance use

For many people,_ is a chronic illness characterized by remissions and relapses to former levels of use

ETIOLOGY
1. Biologic Factors
-Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are children of nonalcoholic parents. This increased risk is partly
the result of environmental factors, but evidence points to the importance of genetic factors as well.
-Several studies of twins have shown a higher rate of concordance (when one twin has it, the other twin gets it) among identical than fraternal twins.
The ingestion of mood-altering substances stimulates dopamine pathways in the limbic system, which produces pleasant feelings or a high that is a reinforcing, or
positive, experience.
2. Psychologic Factors
Some theorists believe that inconsistency in the parents behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of
maladaptive coping, stormy relationships, and substance abuse. Others hypothesize that even children who abhorred their family lives are likely to abuse substances as
adults because they lack adaptive coping skills and cannot form successful relationships
3. Social and Environmental Factors
-Cultural factors, social attitudes, peer behaviors, laws, cost, and availability all influence initial and continued use of substances
-. In general, younger experimenters use substances that carry less social disapproval such as alcohol and cannabis, whereas older people use drugs such as cocaine and
opioids that are more costly and rate higher disapproval
TYPES OF SUBSTANCES AND TREATMENT
1. Alcohol

central nervous system depressant that is absorbed rapidly into the bloodstream.

relaxation and loss of inhibitions

effects are _.

Intoxication and Overdose

Slurred speech, unsteady gait, lack of coordination, and
impaired attention, concentration, memory, and judgment

With intoxication, there is _. Some people become aggressive or display inappropriate sexual
behavior when intoxicated. The person who is intoxicated may experience a blackout.

Cardiac myopathy
Wernickes encephalopathy
Korsakoffs psychosis
Pancreatitis
Esophagitis
Hepatitis
Cirrhosis
Leukopenia
Thrombocytopenia
Ascites

PHYSIOLOGIC EFFECTS OF LONG-TERM ALCOHOL USE

vomiting, unconsciousness, and respiratory depression.

An overdose, or excessive alcohol intake in a short period, can result in _ This combination can cause
aspiration pneumonia or pulmonary obstruction.

cardiovascular shock and death.

Alcohol induced hypotension can lead to

gastric lavage or dialysis

Treatment of an alcohol overdose is similar to that for any central nervous system depressant:_ to
remove the drug and support of respiratory and cardiovascular functioning in an intensive care unit

Withdrawal and Detoxification

4 to 12 HOURS

Symptoms of withdrawal usually begin_ hours after cessation or marked reduction of alcohol intake.

coarse hand tremors, sweating, elevated pulse and blood

pressure, insomnia, anxiety, and nausea or vomiting.

Symptoms include

delirium tremens (DTs)

Severe or untreated withdrawal may progress to transient hallucinations, seizures, or deliriumcalled _

2 substance abuse (escalante-saac)

second

Alcohol withdrawal usually peaks on the_ day and is over in about 5 days

medical supervision.

detoxification needs to be accomplished under _

3 to 5

If the clients withdrawal symptoms are mild and he or she can abstain from alcohol, he or she can be
treated safely at home. For more severe withdrawal or for clients who cannot abstain during
detoxification, a short admission of_ days is the most common setting.

lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam

(Valium)

Safe withdrawal is usually accomplished with the administration of benzodiazepines such as _to
suppress the withdrawal symptoms.

2. Sedatives, Hypnotics, and Anxiolytics

Intoxication and Overdose
barbiturates, nonbarbiturate hypnotics, and anxiolytics,
particularly benzodiazepines

This class of drugs includes all central nervous system depressants:

Benzodiazepines and barbiturates

_are the most frequently abused drugs in this category

drowsiness and reduce anxiety

In the usual prescribed doses, these drugs cause_, which is the intended purpose.

lurred speech, lack of coordination, unsteady gait, labile mood,

impaired attention or memory, and even stupor and coma.

Intoxication symptoms include s

lethargic and confused

Benzodiazepines alone, when taken orally in overdose, are rarely fatal, but the person is _.

gastric lavage

Treatment includes_ followed by ingestion of activated charcoal and a saline cathartic; dialysis can
be used if symptoms are severe

Barbiturates

_, in contrast, can be lethal when taken in overdose. They can cause coma, respiratory arrest, cardiac
failure, and death. Treatment in an intensive care unit is required using lavage or dialysis to remove
the drug from the system and to support respiratory and cardiovascular function.

Withdrawal and Detoxification

10 ,

Medications such as lorazepam, whose actions typically last about _hours, produce withdrawal
symptoms in 6 to 8 hours; longer-acting medications such as diazepam may not produce withdrawal
symptoms for 1 week

autonomic hyperactivity (increased pulse, blood pressure,

The withdrawal syndrome is characterized by symptoms that are the opposite of the acute effects of the
respirations, and temperature), hand tremor, insomnia, anxiety, drug: that is, Seizures and hallucinations occur only rarely in severe benzodiazepine withdrawal
nausea, and psychomotor agitation.
tapering

Detoxification from sedatives, hypnotics, and anxiolytics is often managed medically by_ the amount of
the drug the client receives over a period of days or weeks, depending on the drug and the amount the
client had been using.

Tapering

_, or administering decreasing doses of a medication, is essential with barbiturates to prevent coma and
death that occur if the drug is stopped abruptly

3. Stimulants (Amphetamines, Cocaine)

Stimulants

are drugs that stimulate or excite the central nervous system.

attention deficit hyperactivity disorder and high potential for

abuse

Stimulants have limited clinical use (with the exception of stimulants used to treat

Amphetamines

(uppers) were popular in the past; they were used by people who wanted to lose weight or to stay
awake.

Cocaine

, an illegal drug with virtually no clinical use in medicine, is highly addictive and a popular recreational
drug because of the intense and immediate feeling of euphoria it produces.

Methamphetamine

is particularly dangerous. It is highly addictive and causes psychotic behavior. Brain damage related to
its use is frequent, primarily as a result of the substances used to make itthat is, liquid agricultural
fertilizer.

Intoxication and Overdose

high or euphoric feeling, hyperactivity, hypervigilance,
talkativeness, anxiety, grandiosity, hallucinations, stereotypic
or repetitive behavior, anger, fighting, and impaired judgment.

Intoxication from stimulants develops rapidly; effects include the _.

tachycardia, elevated blood pressure, dilated pupils,

perspiration or chills, nausea, chest pain, confusion, and
cardiac dysrhythmias.

Physiologic effects include

seizures and coma

Overdoses of stimulants can result in_; deaths are rare

chlorpromazine

Treatment with_ (Thorazine), an antipsychotic, controls hallucinations, lowers blood pressure, and
relieves nausea (Lehne, 2006).

Withdrawal and Detoxification

Withdrawal from stimulants occurs within a few hours to several days after cessation of the drug and is
not lifethreatening.
Marked dysphoria

_ is the primary symptom and is accompanied by fatigue, vivid and unpleasant dreams, insomnia or
hypersomnia, increased appetite, and psychomotor retardation or agitation.

crashing

Marked withdrawal symptoms are referred to as _; the person may experience depressive symptoms,
including suicidal ideation, for several days.

4. Cannabis (Marijuana)
Cannabis sativa

is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and for oil from its
seeds. It has become widely known for its psychoactive resin.

cannabinoids

This resin contains more than 60 substances, called _, of which #-9tetrahydrocannabinol is thought to
be responsible for most of the psychoactive effects

Marijuana

refers to the upper leaves, flowering tops, and stems of the plant; hashish is the dried resinous exudate
from the leaves of the female plant.

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Cannabis

is most often smoked in cigarettes (joints), but it can be eaten.

lowering intraocular pressure

Research has shown that cannabis has shortterm effects of_, but it is not approved for the treatment of
glaucoma. It also has been studied for its effectiveness in relieving the nausea and vomiting
associated with cancer chemotherapy and the anorexia and weight loss of AIDS. Currently, two
cannabinoids, _, have been approved for treating nausea and vomiting from cancer chemotherapy.

dronabinol (Marinol) and nabilone (Cesamet)

Intoxication and Overdose
less than 1 minute

Cannabis begins to act _after inhalation. Peak effects usually occur in 20 to 30 minutes and last at least
2 to 3 hours.

lowered inhibitions, relaxation, euphoria, and increased

appetite.

Users report a high feeling similar to that with alcohol, _

impaired motor coordination, inappropriate laughter, impaired

judgment and short-term memory, and distortions of time and
perception.

Symptoms of intoxication include _. Anxiety, dysphoria, and social withdrawal may occur in some
users.

conjunctival injection (bloodshot eyes), dry mouth,

hypotension, and tachycardia.

Physiologic effects, in addition to increased appetite, include ._Excessive use of cannabis may produce
delirium or, rarely, cannabis-induced psychotic disorder, both of which are treated
symptomatically

Withdrawal and Detoxification

Although some people have reported withdrawal symptoms of muscle aches, sweating, anxiety, and
tremors, no clinically significant withdrawal syndrome is identified
5. Opioids
Opioids

are popular drugs of abuse because they desensitize the user to both physiologic and psychologic pain
and induce a sense of euphoria and well-being.

morphine, meperidine (Demerol), codeine, hydromorphone,

oxycodone, methadone, oxymorphone, hydrocodone, and
propoxyphene as well as illegal substances such as heroin and
normethadone.

Opioid compounds include both potent prescription analgesics such as _

Intoxication and Overdose

apathy, lethargy, listlessness, impaired judgment, psychomotor Opioid intoxication develops soon after the initial euphoric feeling; symptoms include
retardation or agitation, constricted pupils, drowsiness, slurred
speech, and impaired attention and memory.
coma, respiratory depression, pupillary constriction,
unconsciousness, and death.

Severe intoxication or opioid overdose can lead to

naloxone

Administration of_ (Narcan), an opioid antagonist, is the treatment of choice because it reverses all
signs of opioid toxicity.
Naloxone is given every few hours until the opioid level drops to nontoxic; this process may take days

Withdrawal and Detoxification

anxiety, restlessness, aching back and legs, and cravings for
more opioids

Initial symptoms are _ (Jaffe & Strain, 2005).

Symptoms that develop as withdrawal progresses include nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever and insomnia.
6 to 24

Short-acting drugs such as heroin produce withdrawal symptoms in_ hours; the symptoms peak in 2 to
3 days and gradually subside in 5 to 7 days.

2 to 4 days

Longer-acting substances such as methadone may not produce significant withdrawal symptoms for
_days, and the symptoms may take 2 weeks to subside.

Methadone

can be used as a replacement for the opioid, and the dosage is then decreased over 2 weeks

Withdrawal symptoms such as anxiety, insomnia, dysphoria, anhedonia, and drug craving may persist for weeks or months.
6. Hallucinogens

are substances that distort the users perception of reality and produce symptoms similar to psychosis,
including hallucinations (usually visual) and depersonalization.

increased pulse, blood pressure, and temperature; dilated

pupils; and hyperreflexia.

Hallucinogens also cause

mescaline, psilocybin, lysergic acid diethylamide, and

designer drugs such as Ecstasy.

Examples of hallucinogens are

Intoxication and Overdose

anxiety, depression, paranoid ideation, ideas of reference, fear
of losing ones mind, and potentially dangerous behavior such
as jumping out a window in the belief that one can fly

Hallucinogen intoxication is marked by several maladaptive behavioral or psychologic changes:

Physiologic symptoms include sweating, tachycardia, palpitations, blurred vision, tremors, and lack of coordination. PCP intoxication often involves
belligerence, aggression, impulsivity, and unpredictable behavior.
psychologic

Toxic reactions to hallucinogens (except PCP) are primarily_;

Psychotic reactions are managed best by isolation from external stimuli; physical restraints may be necessary for the safety of the client and others. PCP toxicity
can include seizures, hypertension, hyperthermia, and respiratory depression. Medications are used to control seizures and blood pressure. Cooling devices such as
hyperthermia blankets are used, and mechanical ventilation is used to support respirations
Withdrawal and Detoxification
No

_ withdrawal syndrome has been identified for hallucinogens, although some people have reported a
craving for the drug.

flashbacks, which are transient recurrences of perceptual

disturbances like those experienced with hallucinogen use.

Hallucinogens can produce _.These episodes occur even after all traces of the hallucinogen are gone and
may persist for a few months up to 5 years.

7. Inhalants

are a diverse group of drugs that include anesthetics, nitrates, and organic solvents that are inhaled for

4 substance abuse (escalante-saac)

their effects.
The most common substances in this category are aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint.
Most of the vapors are inhaled from a rag soaked with the compound, from a paper or plastic bag, or directly from the container. Inhalants can cause significant brain
damage, peripheral nervous system damage, and liver disease.
Intoxication and Overdose
dizziness, nystagmus, lack of coordination, slurred speech,
unsteady gait, tremor, muscle weakness, and blurred vision.

Inhalant intoxication involves

Stupor and coma can occur. Significant behavioral symptoms are belligerence, aggression, apathy, impaired judgment, and inability to function.
anoxia, respiratory depression, vagal stimulation, and
dysrhythmias.

Acute toxicity causes

Death

may occur from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomitus

Treatment consists of supporting respiratory and cardiac functioning until the substance is removed from the body. There are no antidotes or specific medications to
treat inhalant toxicity.
Withdrawal and Detoxification
no

There are _withdrawal symptoms or detoxification procedures for inhalants as such, although frequent
users report psychologic cravings.

persistent dementia or inhalant-induced disorders such as

psychosis, anxiety, or mood disorders

People who abuse inhalants may suffer from_ even if the inhalant abuse ceases.

PLEASE READ THE TREATMENT AND PROGNOSIS :)

Assessment
*History
-Clients with a parent or other family members with substance abuse problems may report a chaotic family life, although this is not always the case. They generally
describe some crisis that precipitated entry into treatment, such as physical problems or development of withdrawal symptoms while being treated for another condition
*GENERAL APPEARANCE AND MOTOR BEHAVIOR
1. Reveals appearance and speech to be normal.
2. Appear anxious, tired, and disheveled if they have just completed a difficult course of detoxification.
3. Clients are somewhat apprehensive about treatment, resent being in treatment, or feel pressured by others to be there.
*Mood and Affect
1. Some clients are sad and tearful, expressing guilt and remorse for their behavior and circumstances. 2. Others may be angry and sarcastic or quiet and sullen, unwilling
to talk to the nurse. Irritability is common because clients are newly free of substances.
3. Clients may be pleasant and seemingly happy, appearing unaffected by the situation, especially if they are still in denial about the substance use.*
*Thought Process and Content
1. Clients are likely to minimize their substance use, blame others for their problems, and rationalize their behavior.
2. They may believe they cannot survive without the substance or may express no desire to do so. 3. They may focus their attention on finances, legal issues, or
employment problems as the main source of difficulty rather than their substance use.
4. They may believe that they could quit on their own if they wanted to, and they continue to deny or minimize the extent of the problem.
*Sensorium and Intellectual Processes
1. Oriented and alert unless they are experiencing lingering effects of withdrawal. I
2. ntellectual abilities are intact unless clients have experienced neurologic deficits from long-term alcohol use or inhalant use.
*Judgment and Insight
1. Exercised poor judgment, especially while under the influence of the substance.
2. Judgment may still be affected: clients may behave impulsively such as leaving treatment to obtain the substance of choice.
3. Insight usually is limited regarding substance use.
4. Clients may have difficulty acknowledging their behavior while using or may not see loss of jobs or relationships as connected to the substance use. They may still
believe they can control the substance use.
*Self-Concept
1. Clients generally have low self-esteem, which they may express directly or cover with grandiose behavior.
2. They do not feel adequate to cope with life and stress without the substance and often are uncomfortable around others when not using.
3. They often have difficulty identifying and expressing true feelings; in the past, they have preferred to escape feelings and to avoid any personal pain or difficulty with
the help of the substance.
*Roles and Relationships
1. Clients usually have experienced many difficulties with social, family, and occupational roles. 2. Absenteeism and poor work performance are common.
3. Clients may be angry with family members who were instrumental in bringing them to treatment or who threatened loss of a significant relationship.
*Physiologic Considerations
1. Many clients have a history of poor nutrition (using rather than eating) and sleep disturbances that persist beyond detoxification.
2. They may have liver damage from drinking alcohol, hepatitis or HIV infection from intravenous drug use, or lung or neurologic damage from using inhalants.
Data Analysis Each client has nursing diagnoses specific to his or her physical health status. These may include the following:
Imbalanced Nutrition: Less Than Body Requirements
Risk for Infection
Risk for Injury
Diarrhea
Excess Fluid Volume
Activity Intolerance
Self-Care Deficits
Nursing diagnoses commonly used when working with clients with substance use include the following:
Ineffective Denial
Ineffective Role Performance
Dysfunctional Family Processes: Alcoholism
Ineffective Coping
Outcome Identification
Treatment outcomes for clients with substance use may include the following:
The client will abstain from alcohol and drug use.
The client will express feelings openly and directly.
The client will verbalize acceptance of responsibility for his or her own behavior.
The client will practice nonchemical alternatives to deal with stress or difficult situations.

5 substance abuse (escalante-saac)

The client will establish an effective after-care plan.
Interventions:
*Providing Health Teaching for Client and Family
*Addressing Family Issues
-Codependence is a maladaptive coping pattern on the part of family members or others that results from a prolonged relationship with the person who uses substances.
Characteristics of codependence are poor relationship skills, excessive anxiety and worry, compulsive behaviors, and resistance to change.
*Promoting Coping Skills
Points to Consider When Working with Clients and Families with Substance Abuse Problems
Remember that substance abuse is a chronic, recurring disease for many people, just like diabetes or heart disease.
Examine substance abuse problems in your own family and friends even though it may be painful.
Approach each treatment experience with an open and objective attitude