2012

Objectives
y Given relevant questions and case scenarios the

students will be able to : y 1. Identify major substances of abuse and patterns of abuse and dependency. y 2. Describe the signs and symptoms of intoxication and withdrawal y 3. Discuss pharmacologic and psychosocial treatment approaches y 4. Apply the nursing process to the care of clients and families experiencing substance used disorders

Substance Abuse
y The actual prevalence of substance abuse is difficult

to determine y Detrimental effects of substance abuse include: y Workplace injuries y Motor vehicle accidents and fatalities y Domestic abuse, homicide, and child abuse and neglect

y 14% of adults have an alcohol-related disorder y 6.2% have a substance-related disorder (excluding

nicotine) y Adolescent substance abuse is rising y Increasing numbers of babies are being born to substance-addicted mothers y Half of all persons seeking alcohol-related treatment have at least one alcoholic parent

Types of Substance Abuse

Classes of substances abused:

y y y y y y y y y y y

Alcohol Amphetamines or similarly acting sympathomimetics Caffeine Cannabis Cocaine Hallucinogens Inhalants Nicotine Opioids Phencyclidine (PCP) or similarly acting drugs Sedatives, hypnotics, or anxiolytics

y Intoxication is use of a substance that results in maladaptive behavior y Withdrawal syndrome refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases y Detoxification is the process of safely withdrawing from a substance y Substance abuse is using a drug in a way that is inconsistent with medical or social norms and despite negative consequences y Substance dependence includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance

Onset and Clinical Course

y Typically begins with the first episode of intoxication between 15 and 17 years of age y More severe difficulties begin in the mid-20s to mid-30s y Alcohol-related breakup of a significant relationship y An arrest for public intoxication or driving while intoxicated y Evidence of alcohol withdrawal y Early alcohol-related health problems y Significant interference with functioning at work or school

y Blackout drinking in 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 y As the person continues to drink, he or she often develops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect y After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol will intoxicate the person y The later course of alcoholism, when the person s functioning definitely is affected, is often characterized by periods of abstinence or temporarily controlled drinking

Etiology y Biologic factors

y Genetic vulnerability y Neurochemical influences

y Psychological factors
y Familial dynamics y Coping styles

y Social and environmental factors

Substance-Related Disorders: Theories and Perspectives

y Classic theory y Alcoholism as a chronic, progressive disease that follows a predictable natural history
y y y

Moves away from alcoholism as a problem of flawed character Addict is seen as someone in need of help Addiction involves biological, psychological, and social factors

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Substance-Related Disorders: Theories and Perspectives

y Psychodynamic Theory y Ego
y y y

Regulates thinking Controls instinctive drives Protects against anger, boredom, emptiness, and rage

y Addicts lack mature ego defenses and do not cope well

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Substance-Related Disorders: Theories and Perspectives

y Social and environmental influences y Peers y Cultures y Beliefs about the substance may encourage or inhibit use y Availability y Cost

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Substance-Related Disorders: Theories and Perspectives

y Genetic factors y Tendency to become alcoholic is inherited y Increased vulnerability to addiction to drugs when family history is present
y

Does not guarantee development of addiction but increases risk Substance disorders are not genetic disorders as of current state of scientific knowledge

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Substance-Related Disorders: Theories and Perspectives

y Substance induced neurobiological changes y Addiction is a pathological brain disease
y

Dysregulation in complex neural mechanisms of learning and memory related to quest of rewards and cues that predict them

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Substance-Related Disorders: Theories and Perspectives

y Substance induced neurobiological changes y Brain is unable to maintain proper neurochemical balance
y

Inadequate amounts of GABA and dopamine results in increased anxiety and depression

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Substance-Related Disorders: Theories and Perspectives

y Cultural considerations y Substance use mores and attitudes tied to predictors of drinking y Prevalence of substance-related disorders is higher in large cities y Substantial disparity in availability of health care for minority groups

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Cultural Considerations
y Muslims do not drink alcohol y Wine is an integral part of Jewish religious rites y Some Native American tribes use peyote, a hallucinogen, in religious y y y y y

ceremonies The Japanese do not regard alcohol as a drug, and there are no religious prohibitions against drinking Certain ethnic groups have genetic traits that either predispose them to or protect them from developing alcoholism Variations have been found in enzymatic activities among Asians, African Americans, and whites Alcohol abuse plays a part in the five leading causes of death for Native Americans Drinking is a major health problem among some Aboriginal people and in Russia

y A patient asks the nurse, How would I know if I were

dependent on alcohol? The nurse should respond by telling the patient that dependence is defined by: y A.a compulsion to use the drug. y B. loss of control over use of the drug. y C.a physiologic need to use the drug. y D.continued use despite adverse consequences.

y Dependence is marked by a physiologic need for the

substance. The other options refer to psychological need.

y A patient tells the nurse, I could get a good high from

drinking a six-pack a few months ago. Now I need a few extra cans to get the same high. The nurse should assess this phenomenon as related to: y A.tolerance. y B.withdrawal. y C.codependency. y D.abstinence syndrome.

y Tolerance refers to the need for increasing amounts of

a substance to achieve the same effects. The other terms are not related to needing more drug to achieve the same effect.

Alcohol
y Central nervous system depressant y Overdose can result in vomiting, unconsciousness,

and respiratory depression y Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake y Alcohol withdrawal usually peaks on the second day and is over in about 5 days

y Withdrawal symptoms include: y Coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting y Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium called delirium tremens (DTs) y Withdrawal symptoms are monitored using an

assessment tool such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) y Benzodiazepines used for detoxification
y Lorazepam (Ativan), chlordiazepoxide (Librium), or

diazepam (Valium) suppress the withdrawal symptoms

Alcohol y Most commonly abused substance

y Absorbed quickly from stomach and small intestine

and metabolized in liver y In concentrated form, is toxic to nerve cells y In diluted form, is an irritant to nerve cells y Chronic alcohol affects all body systems

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Alcohol
y Withdrawal associated with neural excitation with

abrupt cessation of the CNS depressant action of alcohol

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Alcohol
y Withdrawal can occur within hours of last

consumption
y Symptoms:
y y y y y

Tremors, internal shakiness Hyperarousal, easily startled Anxiety Tachycardia, elevated B/P Hallucinations can occur

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Alcohol
y Delirium Tremens (DTs) y Hallucinations, hyperpyrexia, hypertension, tachycardia, coarse tremors, nervous system arousal y Early detection is important

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Alcohol
y Wernicke Encephalopathy y Thiamine deficiency y Symptoms:
y

Ataxia, delirium, palsy of 6th cranial nerve

y If not treated, may develop into Wernicke-Korsakoff

Syndrome

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Alcohol
y Wernicke-Korsakoff Syndrome y Profound memory impairment y Inability to learn new things

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Alcohol
y Pharmacotherapy for withdrawal y Benzodiazepines used to manage alcohol withdrawal syndrome y Clinical Institute Withdrawal Assessment-Alcohol (CIWA-Ar) used to monitor severity of symptoms

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Alcohol
y Pharmacotherapy for withdrawal y Antipsychotics may be needed for hallucinations y Anticonvulsants may be needed for seizures but is not standard treatment

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Sedatives, Hypnotics, and Anxiolytics

y Central nervous system depressants y Benzodiazepines alone, when taken orally in

overdose, are rarely fatal, but the person will be lethargic and confused y Barbiturates, in contrast, can be lethal when taken in overdose. They can cause coma, respiratory arrest, cardiac failure, and death

y Withdrawal symptoms in 6 to 8 hours or up to 1 week y Withdrawal syndrome is characterized by symptoms opposite of the acute effects of the drug:
y Autonomic hyperactivity (increased pulse, blood pressure,

respirations, and temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitation; seizures and hallucinations occur rarely in severe benzodiazepine withdrawal y Detoxification from sedatives, hypnotics, and anxiolytics is managed by tapering the amount of the drug

Stimulants (Amphetamines, Cocaine, Others)

y Central nervous system stimulants y Overdoses can result in seizures and coma y Withdrawal occurs within hours to several days y Withdrawal syndrome: y Dysphoria accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation; withdrawal symptoms are referred to as crashing --the person may experience depressive symptoms, including suicidal ideation, for several days y Stimulant withdrawal is not treated pharmacologically

Cannabis (Marijuana)
y Used for its psychoactive effects y Excessive use of cannabis may produce delirium or

cannabis-induced psychotic disorder; overdoses of cannabis do not occur y Withdrawal symptoms: y Insomnia, muscle aches, sweating, anxiety, and tremors y Effects are treated symptomatically

Opioids
y Central nervous system depressants y Overdose can lead to coma, respiratory depression, pupillary constriction, unconsciousness, and death y Withdrawal:
y Short-acting drugs: begins in 6 to 24 hours; peaks in 2 to 3

days and gradually subside in 5 to 7 days y Longer-acting drugs: begins in 2 to 4 days, subsiding in 2 weeks

y Withdrawal symptoms:
y Anxiety, restlessness, aching back and legs, cravings,

nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia y Withdrawal does not require pharmacologic intervention y Administration of naloxone (Narcan) is the treatment of choice y Methadone can be used as a replacement for heroin, serving to reduce cravings

Hallucinogens
y Distort reality and produce symptoms similar to psychosis, including hallucinations (usually visual) and depersonalization y Toxic reactions to hallucinogens (except PCP) are primarily psychological; overdoses as such do not occur. PCP toxicity can include seizures, hypertension, hyperthermia, and respiratory depression y Hallucinogens can produce flashbacks that may persist for a few months up to 5 years y Treatment is supportive: y Isolation from external stimuli; physical restraints; (for PCP) medications to control seizures and blood pressure; cooling devices; mechanical ventilation

Inhalants
y Inhaled for their effects y Overdose:

aspiration of the compound or vomitus y People who abuse inhalants may suffer from persistent dementia or inhalant-induced disorders such as psychosis, anxiety, or mood disorders even if the inhalant abuse ceases y Withdrawal symptoms: none y Treatment: y Supporting respiratory and cardiac functioning until the substance is removed from the body

y Anoxia, respiratory depression, vagal stimulation, and dysrhythmias y Death may occur from bronchospasm, cardiac arrest, suffocation, or

Substance Abuse Treatment

y Treatment is based on the concept that alcoholism

and drug addiction are medical illnesses: chronic, progressive, characterized by remissions and relapses y Treatment models include: y The Hazelden Clinic model y 12-step program of Alcoholics Anonymous (AA) y Individual and group counseling

Treatment Settings and Programs

y Emergency departments y Medical units y Extended treatment y Outpatient treatment y Clinics offering day and evening programs y Halfway houses y Residential settings y Chemical dependency units in hospitals

Pharmacologic Treatment

Two main purposes: y To permit safe withdrawal from alcohol, sedative-hypnotics, and benzodiazepines y To prevent relapse

Pharmacologic Treatment (cont d)

Safe withdrawal from alcohol involves:

y Benzodiazepines to suppress withdrawal symptoms
y Lorazepam, chlordiazepoxide, and diazepam

y Vitamin B1 (thiamine) to prevent or to treat

Wernicke s syndrome and Korsakoff s syndrome y Cyanocobalamin (vitamin B12) and folic acid for nutritional deficiencies

Pharmacologic Treatment (cont d)

Relapse prevention involves: y Disulfiram (Antabuse) y Methadone y Naltrexone (ReVia) y Clonidine (Catapres) y Odansetron (Zofran)

Dual Diagnosis Client with both substance abuse and another psychiatric illness Traditional treatment programs have little success:
y Impaired abilities to process abstract concepts y Avoidance of all psychoactive drugs may not be possible y Substance abuse has no limited recovery concept as do psychiatric

illnesses y Lifelong abstinence may seem impossible to the client with a chronic mental illness y The use of alcohol and other drugs can precipitate psychotic behavior

Application of the Nursing Process: Substance Abuse

The nurse may encounter clients with substance problems in various settings unrelated to mental health. y Seeking treatment of medical problems related to alcohol use y Withdrawal symptoms may develop while in the hospital for surgery or an unrelated condition Be alert to the possibility of substance use in these situations and be prepared to recognize their existence and to make appropriate referrals.

Application of the Nursing Process: Substance Abuse (cont d)

Assessment y History: chaotic family life, family history, crisis that precipitated treatment y General appearance and motor behavior: depends on physical health; likely to be fatigued, anxious y Mood and affect: may be tearful, expressing guilt and remorse; angry, sullen, quiet, unwilling to talk

Application of the Nursing Process: Substance Abuse (cont d)

Assessment (cont d) y Thought processes and content: minimize substance use, blame others for problems, rationalize their behavior, say they can quit on their own y Sensorium and intellectual processes: alert and oriented; intellectual abilities intact (unless neurologic deficits from long-term alcohol or inhalants) y Judgment and insight: poor judgment while intoxicated and due to cravings for substance; insight limited

Application of the Nursing Process: Substance Abuse (cont d)

Assessment (cont d) y Self-concept: low self-esteem, feels inadequate at coping with life y Roles and relationships: strained relationships and problems with role fulfillment due to substance use y Physiologic considerations: may have trouble eating and sleeping; HIV risk if IV drug user

Application of the Nursing Process: Substance Abuse (contd) Data Analysis Nursing diagnoses common to physical health needs include:
y y y y y y y

Imbalanced Nutrition: Less Than Body Requirements Risk for Infection Risk for Injury Diarrhea Excess Fluid Volume Activity Intolerance Self-Care Deficits

Application of the Nursing Process: Substance Abuse (cont d)

Data Analysis (cont d) Nursing diagnoses common to psychosocial health needs include:
y Ineffective Denial y Ineffective Role Performance y Interrupted Family Processes: Alcoholism y Ineffective Coping

Application of the Nursing Process: Substance Abuse (cont d)

Outcomes
The client will: y Abstain from alcohol/drugs y Express feelings openly and directly y Accept responsibility for own behavior y Practice nonchemical alternatives to deal with stress or difficult situations y Establish an effective after-care plan

Application of the Nursing Process: Substance Abuse (cont d)

Intervention y Providing health teaching for client and family y Addressing family issues: y Codependence y Changes in roles y Promoting coping skills

Application of the Nursing Process: Substance Abuse (contd)

Evaluation Is the client abstaining from substances? Is the client more stable in his or her role performance? Does the client have improved interpersonal relationships? Is the client experiencing increased satisfaction with quality of life?

Elder Considerations
y Estimates are 30% to 60% of elders in treatment began

drinking abusively after age 60 y Risk factors for late-onset substance abuse in elders include: y Chronic illness that causes pain; long-term use of prescription medication (sedative-hypnotics, anxiolytics); life stress; loss; social isolation; grief; depression; an abundance of discretionary time and money y Elders may experience physical problems associated with substance abuse more quickly

Community-Based Care
y Outpatient treatment y Freestanding substance abuse treatment facilities y Self-help programs such as AA and Rational Recovery y Agency-sponsored after-care program y Individual or family counseling y Clinic or physician s office

Mental Health Promotion

y Public awareness and educational advertising y Early identification of older adults with

alcoholism y The College Drinking Prevention Program

Substance Abuse in Health Professionals

y Higher rates of dependence on controlled

substances y Ethical and legal responsibility to report suspicious behavior to a supervisor

Substance Abuse in Health Professionals (cont d)

Warning signs of abuse include:
y Poor work performance, frequent absenteeism, unusual behavior, slurred speech, y y y y y y y y y

isolation from peers Incorrect drug counts Excessive controlled substances listed as wasted or contaminated Reports by clients of ineffective pain relief from medications, especially if relief had been adequate previously Damaged or torn packaging on controlled substances Increased reports of pharmacy error Consistent offers to obtain controlled substances from pharmacy Unexplained absences from the unit Trips to the bathroom after contact with controlled substances Consistent early arrivals at or late departures from work for no apparent reason

Substance-Related Disorders Across the Life Span

y Effects of addiction on the family y Denial and rationalization y Unwritten rule:
y

Don t talk, don t trust, don t feel

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Substance-Related Disorders Across the Life Span

y Effects of addiction on the family y Codependency:
y

External focus on something or someone that cannot be controlled become an obsessive focus Results in neglect of other important responsibilities to self and others

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Substance-Related Disorders Across the Life Span

y Maternal-Infant Issues y Use of substances during pregnancy poses risk to fetus
y y

Fetal Alcohol Syndrome (FAS) Cocaine use increases risk of placenta abruption, preterm labor, spontaneous abortion, ruptured uterus, and intrauterine growth retardation Infant at risk for poor parenting, abuse, and neglect

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Substance-Related Disorders Across the Life Span

y Childhood and adolescence y Risk factors
y y y

Familial history Fetal exposure to alcohol or drugs Parental psychopathology

y May try drugs or alcohol to experience pleasurable

feelings or to cope with stress

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Substance-Related Disorders Across the Life Span

y Adulthood y Addiction most likely to appear y No generic pattern of progression applies to all who become substance dependent

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Substance-Related Disorders Across the Life Span

y Adulthood y Substance use may increase to cope with greater responsibilities of adulthood
y y y

Divorce Death of a spouse or child Loss of job

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Substance-Related Disorders Across the Life Span

y Older adulthood y Myth to assume substance abuse does not occur y Complex set of factors:
y

Problems with even low intake due to increased sensitivity to alcohol Many late onset alcoholics do not develop physiological dependence

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Substance-Related Disorders Across the Life Span

y Older adulthood y Complex set of factors:
y

Increased cognitive impairment can interfere with selfmonitoring Fewer activities make detection more difficult

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Treatment and Recovery

y Nature and general course of substance use disorders

must be understood y No known cure to addiction

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Treatment and Recovery

y Recovery is a process y Combination of behavioral, pharmacologic, and social service interventions y Assess client s readiness to change behaviors y Development of emotional maturity y Awareness of relapse cues

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Treatment and Recovery

y Pharmacologic and complementary therapies y Antabuse (disulfiram) y ReVia (naltrexone) y Methadone or long-acting Methadone (LAAM) y 12-step groups (AA, NA, MA)

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The Role of the Nurse

y The Generalist Nurse y Performs nursing assessment:
y y y

Takes vital signs Monitors client s response to treatment Provides safe and therapeutic environment

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The Role of the Nurse

y The Generalist Nurse y Includes 24-hour monitoring of client s physical and mental status concerning withdrawal y Other responsibilities:
y y

Psychoeducation Administering medication

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The Role of the Nurse

y The Advanced-Practice Psychiatric Nurse y Treatment based on advanced educational and clinical expertise

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The Role of the Nurse

y The Advanced-Practice Psychiatric Nurse y Major responsibilities:
y y y

Collaborating with other clinicians to provide holistic care Prescribing psychotropic agents as allowed by state regulation Providing psychotherapy and health education

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Self-Awareness Issues

y Examine own beliefs and/or family behavior

about alcohol and drugs y Recognize that substance abuse is a chronic illness with relapses and remissions y Be objective and reasonably optimistic