Mental Health Nursing / Clinical

NUR 474
Week 7

Addiction

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Addiction
At the end of the lecture discussion, the students should be able to:
1. Discuss the characteristics, risk factors, and family dynamics prevalent with
substance use disorders.
2. Describe the principles of a 12-step treatment approach for substance use
disorders.
3. Apply the nursing process to the care of clients with substance use issues.
4. Provide education to clients, families, and community members to increase
knowledge and understanding of substance use.

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Polysubstance abuse

• Abuse of more than one substance

Drugs and alcohol can lead to legal

problems. Categories of drugs include:
1. Alcohol Intoxication is use of a substance that
2. Sedatives, hypnotics, and anxiolytics results in maladaptive behavior.
3. Stimulants
4. Cannabis Withdrawal syndrome refers to the
5. Opioids negative psychological and physical
6. Hallucinogens reactions that occur when use of a
7. Inhalants substance ceases or dramatically decreases.

Detoxification is the process of safely

withdrawing from a substance.

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RELATED DISORDERS
 Gambling disorder is a non–substance-related diagnosis.
• It is characterized by problem gambling, spending money one cannot
afford to lose, lying about gambling, getting money from others, and an
inability to refrain from gambling for any specific time. Attempts to quit
or cut down result in restless, anxious, and irritable behavior.
 Caffeine and tobacco or nicotine are substances that are addictive
 Addiction to the internet, noting that some people spend more than
half of their waking hours on the computer and become upset and
irritable if use is limited or curtailed.
 Substances can induce symptoms that are similar to other mental illness
diagnoses, such as anxiety, psychosis, or mood disorders.
 methamphetamine can cause substance-induced psychosis, but the
psychotic symptoms may persist due to damage to the brain.

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The most significant risk factors for alcoholism are having an alcoholic parent,
genetic vulnerability, and growing up in an alcoholic home.

► Routine screening with tools such as the SSI-AOD in a wide variety of settings
(clinics, physicians’ offices, through emergency services) can be used to detect
substance use problems.
► After detoxification, treatment of substance use continues in various outpatient
and inpatient settings.

Approaches are often based on the 12- step philosophy of abstinence, altered
lifestyles, and peer support.

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Biologic Factors
Genetic link
Neurochemical influences on substance use patterns have been
studied primarily in animal research.
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
family dynamics are thought to play a part. Children of alcoholics are
four times as likely to develop alcoholism compared with the general
population. Some theorists believe that 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.
Social and Environmental
Factors Cultural factors, social attitudes, peer behaviors, laws, cost, and availability all
influence initial and continued use of substances.
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 TYPES OF SUBSTANCES AND TREATMENT
Overdose, or excessive alcohol
Alcohol Intoxication and Overdose intake
• Alcohol is a central nervous system • vomiting, unconsciousness, and
depressant that is absorbed rapidly in to the respiratory depression.
bloodstream. • can cause aspiration pneumonia
• Initially, the effects are relaxation and loss or pulmonary obstruction.
of inhibitions. • Alcohol-induced hypotension can
• With intoxication lead to cardiovascular shock
• slurred speech, and death.
• unsteady gait
• lack of coordination
• impaired attention, concentration, memory,
and judgment.
• Some people become aggressive or display
inappropriate sexual behavior when
intoxicated.
• blackout
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Treatment of an alcohol overdose

• gastric lavage or dialysis to remove the

drug,

• support of respiratory and

cardiovascular functioning in an
intensive care unit.

• The administration of central nervous

system stimulants is contraindicated
(Burchum & Rosenthal,2018).

• The physiological effects of repeated

intoxication and long-term use

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Withdrawal and Detoxification
• symptoms of withdrawal usually begin 4 to 12 • Alcohol Withdrawal can be life-
hours after cessation or marked reduction of threatening, detoxification needs to be
alcohol intake. accomplished under medical
supervision.
• Symptoms:
• coarse hand tremors, sweating, elevated • If the client’s withdrawal symptoms are
pulse and blood pressure, insomnia, mild and he or she can abstain from
anxiety, and nausea or vomiting. alcohol, he or she can be treated safely
at home.
• Severe or untreated withdrawal may
progress to transient hallucinations, seizures, • For more severe withdrawal or for
or delirium, called delirium tremens. clients who cannot abstain during
detoxification, a short admission of 3
• Alcohol withdrawal usually peaks on the to 5 days is the most common setting
second day and is over in about 5 days.
• This can vary, however; and withdrawal may
take 1 to 2 weeks.
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 Safe withdrawal is usually accomplished with the
administration of benzodiazepines, such as lorazepam
(Ativan), chlordiazepoxide (Librium), or diazepam
(Valium), to suppress the withdrawal symptoms.

Treatment Settings and Programs

• Clients being treated for intoxication and
withdrawal or detoxification are encountered in a
wide variety of medical settings from emergency
departments to outpatient clinics.
Alcoholics Anonymous (AA)
• medical units in the hospital setting and then
• The self-help group developed
referred to an appropriate outpatient treatment
the 12-step program model for
setting when they are medically stable
recovery

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 Pharmacologic Treatment

Pharmacologic treatment in substance abuse has two

main purposes:
(1) to permit safe withdrawal from alcohol, sedative–
hypnotics, and benzodiazepines and
(2) to prevent relapse.

For clients whose primary substance is alcohol, vitamin

B1 (thiamine) is often prescribed to prevent or to treat
Wernicke– Korsakoff syndrome, which are neurologic
conditions that can result from heavy alcohol use.
Cyanocobalamin (vitamin B12) and folic acid are often
prescribed for clients with nutritional deficiencies.

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 Sedatives, Hypnotics, and Anxiolytics
• (Barbiturates, Nonbarbiturate hypnotics, and Anxiolytics, particularly
benzodiazepines)
• This class of drugs includes all central nervous system depressants

Intoxication and Overdose

• Intoxication symptoms
• slurred speech, lack of coordination, unsteady gait, labile mood,
impaired attention or memory, and even stupor and coma.

Treatment
• gastric lavage followed by ingestion of activated charcoal and a saline
cathartic;
• dialysis

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 Withdrawal and Detoxification

• Medications such as lorazepam, with actions that typically last about 10

hours, produce withdrawal symptoms in 6 to 8 hours; longer acting
medications, such as diazepam, may not produce withdrawal symptoms for 1
week.

• The withdrawal syndrome symptoms :

• autonomic hyperactivity (increased pulse, blood pressure, respirations, and
temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor
agitation.
• Seizures and hallucinations occur only rarely in severe benzodiazepine
withdrawal (Tamburin et al., 2017).

• Detoxification from sedatives, hypnotics, and anxiolytics is often medically

managed by tapering 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
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 Stimulants
Stimulants are drugs that stimulate or
excite the central nervous system and have
limited clinical use and a high potential for
abuse.

• Amphetamines
• Cocaine

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Intoxication and Overdose
• Intoxication from stimulants develops Overdoses of stimulants can result in
rapidly; seizures and coma; deaths are rare
• Intoxication effects include: the high (Iannucci & Weiss, 2017).
or euphoric feeling, hyperactivity,
hypervigilance, talkativeness, anxiety,
grandiosity, hallucinations, stereotypic Treatment with chlorpromazine
(Thorazine), an antipsychotic, controls
or repetitive behavior, anger, fighting,
hallucinations, lowers blood pressure,
and impaired judgment. and relieves nausea (Burchum &
• Physiological effects include Rosenthal, 2018).
tachycardia, elevated blood pressure,
dilated pupils, perspiration or chills,
nausea, chest pain, confusion, and
cardiac dysrhythmias

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 Withdrawal and Detoxification

Withdrawal from stimulants occurs within a few hours

to several days after cessation of the drug and is not life-
threatening.

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.

Marked withdrawal symptoms are referred to as

“crashing”; the person may experience depressive
symptoms, including suicidal ideation, for several days.
Stimulant withdrawal is not treated pharmacologically

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Cannabis

• 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.

• This resin contains more than 60
substances, called cannabinoids, of
which δ-9-tetrahydrocannabinol 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 (Hall &
Degenhardt, 2017).
Cannabis is often smoked in cigarettes
(joints), and it can also be eaten.

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Intoxication and Overdose

• Cannabis begins to act less than 1 minute after

inhalation.

• Peak effects usually occur in 20 to 30 minutes

and last at least 2 to 3 hours.

• Users report a high feeling similar to that with

alcohol, lowered inhibitions, relaxation,
euphoria, and increased appetite.

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 Symptoms of intoxication:

• impaired motor coordination, inappropriate

laughter, impaired judgment and short-term
memory, and distortions of time and perception.
• Anxiety, dysphoria, and social withdrawal may
occur in some users.

Physiological effects:
• in addition to increased appetite, include
conjunctival injection (bloodshot eyes), dry mouth,
hypotension, and tachycardia.
• Excessive use of cannabis may produce delirium or
rarely, cannabis-induced psychotic disorder, both of
which are treated symptomatically.
• Overdoses of cannabis do not occur.

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Withdrawal and Detoxification

Although some people have reported

withdrawal symptoms of muscle aches,
sweating, anxiety, and tremors, no
clinically significant withdrawal
syndrome is identified.

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Opioids

Opioids are popular drugs of abuse because they

desensitize the user to both physiological and
psychological pain and induce a sense of euphoria
and well being.

Opioid compounds: morphine, meperidine

(Demerol), codeine, hydromorphone, oxycodone,
methadone, oxymorphone, hydrocodone, and
propoxyphene as well as illegal substances such as
heroin, illicitly produced fentanyl, and
normethadone.

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Intoxication and Overdose

Opioid intoxication develops soon after the initial

euphoric feeling;
Symptoms: apathy, lethargy, listlessness, impaired
judgment, psychomotor retardation or agitation,
constricted pupils, drowsiness, slurred speech, and
impaired attention and memory.

Severe intoxication or opioid overdose can lead to

coma, respiratory depression, pupillary constriction,
unconsciousness, and death.
Administration of naloxone (Narcan), an opioid
antagonist, is the treatment of choice because it reverses
all signs of opioid toxicity.

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Withdrawal and Detoxification Pharmacologic Treatment
Opioid withdrawal develops when drug intake
ceases or decreases markedly, or it can be • Methadone, a potent synthetic opiate,
precipitated by the administration of an opioid is used as a substitute for heroin in
antagonist. Initial symptoms are anxiety, some maintenance programs.
restlessness, aching back and legs, and cravings
for more opioids. • The client takes 1 daily dose of
methadone
Symptoms that develop as withdrawal progresses
include nausea, vomiting, dysphoria, lacrimation, • Levomethadyl is a narcotic analgesic
rhinorrhea, sweating, diarrhea, yawning, fever, with the only purpose of treating
and insomnia. opiate dependence.

Symptoms of opioid withdrawal cause • Buprenorphine/naloxone (Suboxone)

significant distress, but do not require is a combination drug used for opiate
pharmacologic intervention to support life or maintenance and to decrease opiate
bodily functions. cravings.

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 Hallucinogens

Hallucinogens are substances that distort the

user’s perception of reality and produce
symptoms similar to psychosis, including
hallucinations (usually visual) and
depersonalization.

Hallucinogens also cause increased pulse,

blood pressure, and temperature; dilated
pupils; and hyperreflexia

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Treatment of toxic reactions
Withdrawal and Detoxification
Psychotic reactions are managed best by • No withdrawal syndrome has been
isolation from external stimuli; physical identified for hallucinogens.
restraints may be necessary for the safety of
the client and others. • Hallucinogens can produce
flashbacks, which are transient
recurrences of perceptual disturbances
PCP toxicity can include seizures, like those experienced with
hypertension, hyperthermia, and respiratory hallucinogen use.
depression.
These episodes occur even after all traces
Medications are used to control seizures and of the hallucinogen are gone and may
blood pressure. Cooling devices such as persist for a few months up to 5 years.
hyperthermia blankets are used, and
mechanical ventilation is used to support
respirations (Burchum & Rosenthal, 2018).
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 Inhalants

Inhalants are a diverse group of drugs that

include anesthetics, nitrates, and organic
solvents that are inhaled for their effects.

The most common substances in this category

are aliphatic and aromatic hydrocarbons
found in gasoline, glue, paint thinner, and
spray paint.

Inhalants can cause significant brain damage,

peripheral nervous system damage, and liver
disease

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Intoxication and Overdose
Treatment
Inhalant intoxication involves dizziness, nystagmus, • supporting respiratory and cardiac
lack of coordination, slurred speech, unsteady gait, functioning until the substance is
tremor, muscle weakness, and blurred vision. removed from the body.
• no antidotes or specific medications
Stupor and coma can occur. Significant behavioral to treat inhalant toxicity.
symptoms are belligerence, aggression, apathy,
impaired judgment, and inability to function. Acute
toxicity causes anoxia, respiratory depression, vagal Withdrawal and Detoxification
stimulation, and dysrhythmias. • no withdrawal symptoms or
detoxification procedures for
Death may occur from bronchospasm, cardiac arrest, inhalants
suffocation, or aspiration of the compound or vomitus • People who abuse inhalants may
(Howard, Bowen, & Garland, 2017). suffer from persistent dementia or
inhalant-induced disorders, such as
psychosis, anxiety, or mood
disorders even if the inhalant abuse
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 Data Analysis

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Review Questions:
• Select the appropriate interventions for caring for the client in alcohol
withdrawal.
A. Monitor vital signs
B. Provide stimulation in the environment
C. Maintain NPO status
D. Provide reality orientation as appropriate
E. Address hallucinations therapeutically

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Review Questions
• Johnette is reviewing her lessons in Pharmacology. She is aware that
the general classification of drugs belonging to the opioid category is
analgesic and:
A. depressant.
B. hallucinogenic.
C. stimulant.
D. tranquilizing.

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 References:

Videbeck, Shiela. 2020. Psychiatric Mental Health Nursing, 8th Edition.

Aoki, Y., Wehage, S. L., & Talalay, P. (2017). Quantification of skin erythema response to
topical alcohol in alcohol-tolerant East Asians. Skin Research & Technology, 23(4), 593–
596.
Bertron, J. L., Seto, M., & Lindsley, C. W. (2018). DARK classics in chemical neuroscience:
Phencyclidine (PCP). ACS Chemical Neuroscience, 9(10), 2459–2474.

Burchum, J. R., & Rosenthal, L. D. (2018). Lehne’spharmacology for nursing care (10th
ed.). St. Louis, MO: Elsevier.
Cooper, S., Robison, A. J., & Mazei-Robison, M. S. (2017). Reward circuitry in addiction.
Neurotherapeutics, 14(3), 697–697.

Crèvecoeur-MacPhail, D., Cousins, S. J., Denering, L., Kim, T., & Rawson, R. A. (2018).
Effectiveness of extended release naltrexone to reduce alcohol cravings and behaviors
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