SUBSTANCE ABUSE

 Substance use/abuse and related disorders are a national

health problem.
 14% of adults meet the criteria for an alcohol-related
disorder and 6.2% of adults meet the criteria for a
substance related disorder other than alcohol or tobacco
Substance Abuse
 Use of drug in a way that is inconsistent with medical or
social norms and despite negative consequence.
 It denotes problem in social, vocational or legal areas of
the persons life.
Substance Dependence
 Includes problem associated with addiction such as
tolerance, withdrawal and unsuccessful attempts to stop
sing the substances.
TYPES OF SUBSTANCE ABUSE
Poly Substance Abuse – abuse of more than one substance.

The DSM-IV-TR lists 11 diagnostic classes of substance abuse:

 Alcohol

 Amphetamines or similarly acting sympathomimetics

 Caffeine

 Cannabis

 Cocaine

 Hallucinogens

 Inhalants

 Nicotine

 Opioids

 Phencyclidine (PCP) or similarly acting drugs

 Sedatives, hypnotics, or Anxiolytics

 Two Groups Categorizes Substance-related
Disorder

1. Those that include disorders of abuse and dependence

2. Substance-induced disorders such as:
Intoxication
Withdrawal
Delirium
Dementia
Psychosis
Mood disorder
Anxiety sexual dysfunction
Sleep disorder
Intoxication
 Is use of a substance that results in maladaptive behavior.

Withdrawal Syndrome
 Refers to the negative psychological and physical
reactions that occur when use of a substance ceases or
dramatically decreases.

Detoxification
 is the process of safely withdrawing from a substance.
 ONSET AND CLINICAL COURSE
 The early course of alcoholism typically begins with the
first episode of intoxication between the 15 and 17 years
of age.
 A pattern of more severe difficulties for people with
alcoholism begins to emerge in the middle 20s to the
middle 30s; these difficulties can be the alcohol related:
 Breakup of a significant relationship
 An arrest for public intoxication or driving while intoxicated
 Evidence of alcohol withdrawal
 Early alcohol-related health problems
 Significant interference with functioning at work or school.
Blackout
 Which is an episode during which the person continues
to function but has no conscious awareness of his or her
behavior at the time nor any later memory of the
behavior.
Tolerance
 He/she needs more alcohol to produce the same effect.

Tolerance Break
 Very small amounts of alcohol will intoxicate the person.

Spontaneous Remission/Natural Recovery

 Alcohol problem can modify or quit drinking on their
own without a treatment program.
RELATED DISORDERS
 Substance-induced disorders such as anxiety, mood
disorders, and dementia are present. Like Delirium
which may be seen in severe alcohol withdrawal. A
clinical care plan for a client receiving treatment for
Drugs and alcohol can lead to legal problems. The
effects on adults who grew up in a home with an
alcoholic parent are discussed as the special needs of
clients with a dual diagnosis of substance use and a
major psychiatric disorder.
 ETIOLOGY
 The exact causes of drug use, dependence, and addiction are not known,
but various factors are thought to contribute to the development of
substance-related disorders.
BIOLOGICAL FACTORS
 Children of alcoholic parents are at higher risk for developing
alcoholism and drug dependence than children of non-alcoholic parents.
 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.
 Adoption studies have shown higher rates of alcoholism in sons of
biologic fathers with alcoholism than in those of nonalcoholic biologic
fathers.
 50% to 60% of the variation in causes of alcoholism was the result of
genetics, with the remainder caused by environmental influences.
 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.
 PSYCHOLOGICAL FACTORS
• Children of alcoholics are four times as likely to develop alcoholism.
• Inconsistency in the parent's 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.
• Some people use alcohol as a coping mechanism or to relieve stress
and tension, increase feelings of power and decrease psychological
pain. High doses of alcohol, actually increase muscle tension and
nervousness.
SOCIAL AND ENVIRONMENTAL FACTORS
• Younger experimenters use substances that carry less social
disapproval such as alcohol and cannabis, whereas older people use
drugs such as cocaine and opioid that are more costly and rate higher
disapproval.
• Alcohol consumption increases in areas where availability increases
and decreases in areas where cost of alcohol are higher because of
increased taxation.
ALCOHOL
Intoxication and Overdose
 Alcohol is a central nervous system depressant that is absorbed
rapidly into the blood stream.

Initial Effects
 Relaxation
 Loss of inhibition
Intoxication Symptoms
 Slurred speech
 Unsteady gait
 Lack of coordination
 Impaired attention
 Concentration
 Memory
 Judgment
 Some people become aggressive or display
inappropriate sexual behavior when intoxicated.
The person who is intoxicated may experience a
blackout.
Overdose
 Vomiting

 Unconscious

 Respiratory depression

Treatment
 Gastric lavage or dialysis to remove drug

 Support for respiratory

 Cardiovascular functioning in an ICU

 WITHDRAWAL AND DETOXIFICATION
Symptoms withdrawal usually begins 4-12hrs. After
cessation. Symptoms include:
 Coarse hand tremors

 Sweating

 Elevated blood pressure and pulse

 Insomnia

 Anxiety

 Nausea and vomiting

 Severe or untreated withdrawal may progress to transient

hallucination, seizure or delirium called Delirium Tremors
( DTs)
Safe withdrawal usually is accomplished with the
administration of benzodiazepines such as lorazepam
(Ativan), chlordiazepoxide (Librium), or diazepam (Valium)
to suppress the withdrawal symptoms.
 PHYSIOLOGIC EFFECTS OFLONG-
TERM ALCOHOL USE
 Cardiac myopathy
 Wernicke’s encephalopathy

 Korsakoff’s psychosis

 Pancreatitis

 Esophagitis

 Hepatitis

 Cirrhosis

 Leukopenia

 Thrombocytopenia

 Ascites
SEDATIVES, HYPNOTIC AND
ANXIOLYTICS
INTOXICATION AND OVERDOSE
Intoxication Symptoms
 Slurred speech
 Lack of coordination

 Unsteady gait

 Labile mood

 Impaired attention/ memory

 Stupor and coma

Treatment
 Includegastric lavage followed by ingestion of active
charcoal and a saline cathartics dialysis can be used if
symptoms are severe.
 WITHDRAWAL AND DETOXIFICATION
Lorazepam – action typically last about 10 hours produce

withdrawal symptoms in 6-8 hours; longer acting medications such

as diazepam may not produce withdrawal symptoms for 1 week.
Withdrawal Syndrome – characterized by symptoms that are
opposite of the acute effects of drug. That is:
 Autonomic hyperactivity (Increased Vital Signs)
 Hand tremor
 Insomnia
 Anxiety
 Nausea
 Psychomotor agitation
Seizures and hallucinations occur only rarely in severe
benzodiazepine withdrawal.
Tapering, or administering decreasing doses of a medication, is

essential with barbiturates to prevent coma and death that will occur
if the drug is stopped abruptly.
STIMULANTS (AMPHETAMINES,
COCAINE, OTHER)
Amphetamines – are drugs that stimulate or
excite the CNS; used by people who wanted to
lose-weight or to stay awake.
Cocaine – highly addictive and a popular
recreational drugs because of the intense and
immediate feeling of euphoria it produces.
Methamphetamine – it is particularly dangerous.
It is highly addictive and causes psychotic
behavior.
 INTOXICATION AND OVERDOSE
Intoxification Effects
 Euphoric feeling

 Hyperactivity

 Hyper vigilance

 Talkativeness

 Anxiety

 Grandiosity

 Hallucination

 Stereotypic/ repetitive behavior

 Anger

 Fighting

 Impaired judgment
Physiologic Effects
Elevated Blood Pressure
 Tachycardia

 Dilated pupils

 Perspiration/ chills

 Nausea

 Chest pain

 Confusion

 Cardiac Dysrrhythmias

 Overdose can result seizures, coma; deaths are rare.

Treatment
• CHLORPROMAZINE (Thorazine) – antipsychotic, control
hallucination, lower Blood Pressure, relieves nausea.
WITHDRAWAL AND DETOXIFICATION
Occurs with in the few hours to several days after cessation
of the drugs and is not life-threatening
 Dysphoria

 Fatigue

 Vivid

 Unpleasant dreams
 Insomnia/ Hypersomnia

 Increase appetite

 Psychomotor retardation/ agitation

CANNABIS (MARIJUANA)
Cannabis Sativa – is the hemp plant that is widely
cultivated for its fiber used to make rope and
cloth and for oil fro its seeds.
Marijuana – refers to the upper leaves, flowering
tops and stems of the plant.
Two Cannabinoids used to treat N/V from cancer
chemotheraphy.
1. Dronabinol (Marinol)
2. Nabilone ( Cesamet)
 INTOXICATION AND OVERDOSE
 Cannabis begins to act less than 1minute after inhalation.
Effects usually occur in 20-30min. And last at least 2-3hours.

Symptoms of Intoxication
 Impaired motor coordination
 Inappropriate laughter
 Impaired judgment
 Short term-memory
 Distortion of time and perception
 Anxiety
 Dysphoria
 Social withdrawal
Physiologic Effects
 Increased appetite
 Conjunctival injection (Bloodshot Eyes)
 Dry mouth
 Hypotension
 Tachycardia

WITHDRAWAL AND DETOXIFICATION

Withdrawal Symptoms
 Muscle ache
 Sweating
 Anxiety
 Tremors
OPIOIDS
 Are popular drugs of abuse because they desensitize the user to
both physiologic and psychological pain and induce the sense of
euphoria and well-being. Opioids compounds include both potent
prescription analgesic such as:
• Morphine
• Meperidine ( Demerol )
• Codeine
• Hydromorphone
• Oxycodone
• Methadone

• Oxymorphone

• Hydrocodone

 Propoxyphene and illegal substance such as

• Heroin

• Normethadone
 INTOXICATION AND OVERDOSE
 It may develops soon after the initial euphoria
feeling; symptoms includes:
 Apathy

 Lethargy

 List lessens

 Impaired judgment

 Psychomotor retardation/ agitation

 Constricted pupils

 Drowsiness

 Slurred speech

 Impaired attention and memory

In severe intoxication can lead to:
 Coma

 Respiratory depression

 Papillary constriction

 Unconsciousness

 Death

 Administration of NALOXONE
(Narcan ) opioid antagonist is the
treatment of choice because it reverses
all signs of opioid toxicity.
 WITHDRAWAL AND DETOXIFICATION
Initial Symptoms
 Anxiety

 Restlessness

 Aching back and legs

Symptoms develop as withdrawal progress includes:

 Nausea

 Vomiting

 Dysphoria

 Lacrimation

 Rhinorrhea

 Sweating

 Diarrhea

 Yawning

 Fever

 Insomnia
  Short-acting drugs such as heroin produce
withdrawal symptoms in 6-24 hrs. symptoms
peak in 2-3days and gradually subside in 5-
7days.
 Longer- acting substances such as methadone
may not produce significant withdrawal
symptoms for 2-4days and the symptoms may
take 2weeks to subside
Methadone – used as replacement for the opioid
and the dosage is decreased aver 2weeks.
HALLUCINOGENS
 Substances that distort the user’s perception of
reality and produce symptoms similar to
psychosis including hallucinations (usually
visual) and depersonalization.
It Causes:
 Increased pulse

 Blood pressure

 Temperature

 Dilated pupils

 Hyperreflexia
 INTOXICATION
 Marked by several maladaptive behavioral
Psychological Changes:
 Anxiety

 Depression

 Paranoid ideation

 Ideas of reference

Fear losing one’s mind

Physiologic symptoms
 Sweating

 Tachycardia

 Palpation

 Blurred vision

 Tremors

 Lack of coordination

WITHDRAWAL AND DETOXIFICATION

 No withdrawal syndrome has been identified foe hallucinogen.
INHALANTS
 Are a diverse group of drugs including anesthetics,
nitrates, and organic solvents that are inhaled for
their effects. Most common substances:
 Aliphatic and aromatic hydrocarbons

 Glue

 Paint thinner

 Spray paint

It can cause:
 Brain damage

 Peripheral nervous system damage

 Liver disease
 INTOXICATION AND OVERDOSE
Inhalants intoxication involves:
 Dizziness

 Nystagmus

 Lack of coordination

 Slurred speech

 Unsteady gait

 Tremor

 Muscle weakness

 Blurred vision
Behavioral symptoms:
 Belligerence

 Aggression

 Apathy

 Impaired judgment

 Inability to function

Acute toxicity causes:

 Anoxia

 Respiratory depression

 Vagal stimulation

 Dysrrhythmias
Treatment:
Consist of supporting respiratory and cardiac
functioning until the substance is removed
from the body.
WITHDRAWAL AND DETOXIFICATION
 People who abuse inhalants may suffer from
persistent dementia or inhalant-induced
disorder such as psychosis, anxiety or mood
disorder even if the inhalant abuse ceases.
TREATMENT AND PROGNOSIS
 Until 1970’s, organized treatment programs and clinics for
substance abuse was scarce.
 The user was advised to “pull yourself together” and “get
control of your problem.”
 Founded in 1949, the Hazelden Clinic in Minnesota is the
noted exception; because of its success, many programs
are based on Hazelden model of treatment.
Alcoholic Anonymous was founded in the 1930’s by
alcoholics. This self help group developed the 12-step
program model for recovery which is based on the
philosophy that total abstinence is essential and alcoholics
need the help and support of others to maintain sobriety.
Twelve Steps of Alcoholics Anonymous
 We admitted we were powerless over alcohol - that our lives had become
unmanageable.
 Came to believe that a Power greater than ourselves could restore us to sanity.

 Made a decision to turn our will and our lives over to the care of God as we
understood Him.
 Made a searching and fearless moral inventory of ourselves.

 Admitted to God, to ourselves and to another human being the exact nature of our
wrongs.
 Were entirely ready to have God remove all these defects of character.

 Humbly asked Him to remove our shortcomings.

 Made a list of all persons we had harmed, and became willing to make amends to
them all.
 Made direct amends to such people wherever possible, except when to do so would
injure them or others.
 Continued to take personal inventory and when we were wrong promptly admitted it.

 Sought through prayer and meditation to improve our conscious contact with God as
we understood Him, praying only for knowledge of His will for us and the power to
carry that out.
 Having had a spiritual awakening as the result of these steps, we tried to carry this
message to alcoholics and to practice these principles in all our affairs.
PHARMACOLOGIC TREATMENT
Have two main purposes:
 To permit safe withdrawal from alcohol, sedative/hypnotics, and
benzodiazepines
 To prevent relapse.

For clients whose primary substance is alcohol, vitamin B1 (thiamine) often is

prescribed to prevent or treat Wernicke’s syndrome and Korsakoff’s
syndrome, which are neurologic conditions that can result from heavy alcohol
use.
Cyanocobalamin (vitamin B12) and folic acid often are prescribed for clients
with nutritional deficiencies.
Alcohol withdrawal usually is managed with a benzodiazepine anxiolytic agent,
which is used to suppress the symptoms of abstinence. The most common
used benzodiazepines are lorazepam, chlordiazepoxide, and diazepam.
Disulfiram (Antabuse) may be prescribed to help to deter clients from drinking.
Methadone, a potent synthetic opiate, is used as a
substitute for heroin in some maintenance programs.
Levomethadyl is a narcotic analgesic whose only
purpose is the treatment of opiate dependence.
Naltrexone (ReVia) is an opiod antagonisy often used
to treat overdose.
Clonidine (Catapres) is an alpha-2-adrenergic agonist
used to treat hypertension.
Odansentron (Zofran), a 5-HT3 antagonist that blocks
the vagal stimulation effects of serotonin in the
small intestine, is used as an antiemetic.
Dual Diagnosis
 Clientwith both substance abuse and another psychiatric illness is said
to have a dual diagnosis. It is estimated that 50% of people with a
substance abuse disorder also have a mental health diagnosis.
Traditional methods of treatment for major psychiatric illness or primary
substance abuse often have little success in these clients for the
following reasons:
 Clients with a major psychiatric illness may have impaired abilities to process
abstract concepts; this is a major barrier in substance abuse programs.
 Substance use treatment emphasizes avoidance of all psychoactive drugs. This
may not be possible for the client who needs psychotropic drugs to treat his or
her mental illness.
 The concept of “limited recovery” is more acceptable in the treatment of
psychiatric illnesses, but substance abuse has no limited recovery concept.
 The notion of lifelong abstinence, which is central to substance use treatment,
may seem overwhelming and impossible to the client who lives “day to day”
with a chronic mental illness.
 The use of alcohol and other drugs can precipitate psychotic behavior; this
makes it difficult for professionals to identify whether symptoms are the
result of active mental illness or substance abuse.
Symptoms of Substance Abuse
 Denial of problems
 Minimizes use of substance
 Rationalization
 Blaming others for problems
 Anxiety
 Irritability
 Impulsivity
 Feelings of guilt and sadness or
anger and resentment
 Poor judgment
 Limited insight
 Low self-esteem
 Ineffective coping strategies
 Difficulty expressing genuine
feelings
 Impaired role performance
 Strained interpersonal
relationships
 Physical problems such as sleep
disturbances and inadequate
nutrition
CLIENT AND FAMILY TEACHING:
CLIENTS WITH SUBSTANCE ABUSE
 Substance abuse is an illness
 Dispel myths about substance abuse
 Abstinence from substances is not a matter of willpower
 Any alcohol whether beer, wine, or liquor, can be an
abused substance
 Prescribed medication can be an abused substance
 Feedback from family about a return to previous
maladaptive coping mechanism is vital
 Continued participation in an aftercare program is
important
NURSING INTERVENTIONS FOR
CLIENTSWITH SUBSTANCE ABUSE
 Health teaching for the client and family
 Dispel myths surrounding substance abuse
 Decrease codependent behaviors among family
 members
 Make appropriate referrals for family members
 Promote coping skills
 Role-play potentially difficult situations
 Focus on the here-and-now with clients
 Set realistic goals such as staying sober today
APPLICATION OF NURSING PROCESS
GENERAL APPEARANCE AND MOTOR BEHAVIOR
 Assessment of general appearance and behavior usually
reveals appearance and speech to be normal. Clients may
appear anxious, tired, and disheveled if they have just
completed a difficult course of detoxification.
MOOD AND AFFECT
 Wide ranges of mood and affect are possible. Some
clients are sad and tearful, expressing guilt and remorse
for their behavior and circumstances. 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.
THOUGHT PROCESS AND CONTENT
 During assessment of thought process and content, clients are
likely to minimize their substance use, blame others for their
problems, and rationalize their behavior. They may think they
cannot survive without the substance or may express no desire
to do so.
SENSORIUM AND INTELLECTUAL PROCESSES
 Clients generally are oriented and alert unless they are
experiencing lingering effects of withdrawal. Intellectual
abilities are intact unless clients have experienced neurologic
deficits from long-term alcohol use or inhalant use.
JUDGMENT AND INSIGHT
 Clients are likely to have exercised poor judgment especially
while under the influence of the substance. Judgment may still
be affected: clients may behave impulsively such as leaving
treatment to obtain the substance of choice. Insight usually is
limited regarding substance use.
SELF-CONCEPT
 Clients generally have low self-esteem, which they may
express directly or cover with grandiose behavior.
ROLES AND RELATIONSHIPS
 Clients usually have experienced many difficulties with
social, family, and occupational roles. Absenteeism and
poor work performance are common.
PHYSIOLOGIC CONSIDERATIONS
 Many clients have a history of poor nutrition (using
rather than eating) and sleep disturbances that persist
beyond detoxification. They may have liver damage
from drinking alcohol, hepatitis or HIV infection.