Mental Health Nursing II
NURS 2310
Unit 8
Substance Abuse
Objective 1
Reviewing definitions of the terms
substance abuse, dependency,
intoxication, and withdrawal
Substance Abuse
A maladaptive pattern of substance
use manifested by recurrent and
significant adverse consequences
related to repeated use of the
substance; any use of substances
that poses significant hazards to
health; leads to clinically significant
impairment or distress occurring
within a 12-month period.
Diagnostic Criteria for Substance Abuse
 Recurrent substance use resulting in a
failure to fulfill major role obligations at
work, school, or home
 Recurrent substance use in situations in
which it is physically hazardous
 Recurrent substance-related legal problems
 Continued substance use despite having
persistent or recurrent social or
interpersonal problems caused or
exacerbated by the effects of the substance
Dependency = a compulsive or chronic
requirement; a need so strong as to
generate physical or psychological distress
if left unfulfilled.
 Physical dependence is evidenced by a
cluster of cognitive, behavioral, and
physiological symptoms indicating
continued use of the substance despite
significant substance-related problems
 Psychological dependence is indicated by
an overwhelming desire to repeat the use
of a particular drug to produce pleasure or
avoid discomfort
Criteria for Substance Dependence
 Evidence of tolerance
– the need for markedly increased amounts of
the substance to achieve intoxication or desired
effects
– markedly diminished effect with continued use
of the same amount of the substance

Evidence of withdrawal symptoms
– the characteristic withdrawal syndrome for the
substance
– the same/similar substance is taken to relieve
or avoid withdrawal symptoms
Criteria for Substance Dependence (cont’d)
 The substance is often taken in larger
amounts or over a longer period than was
intended
 There is a persistent desire or unsuccessful
efforts to cut down or control substance
use
 A great deal of time is spend in activities
necessary to obtain the substance, use the
substance, or recover from its effects
Criteria for Substance Dependence (cont’d)
 Important social, occupation, or
recreational activities are given up or
reduced because of substance use
 The substance use is continued despite
knowledge of having a persistent or
recurrent physical or psychological problem
that is likely to have been caused or
exacerbated by the substance
Intoxication = a physical and mental state of
exhilaration and emotional frenzy or
lethargy or stupor.
Criteria for Substance Intoxication
 The development of a reversible substancespecific syndrome caused by recent
ingestion of or exposure to a substance
 Clinically significant maladaptive behavior
or psychological changes that are due to
the effect of the substance on the CNS and
develop during or shortly after use of the
substance
Withdrawal = the physiological and mental
readjustment that accompanies the
discontinuation of an addictive substance;
usually associated with substance
dependence.
Criteria for Substance Withdrawal
 The development of a substance-specific
syndrome caused by the cessation of or
reduction in heavy and prolonged
substance use
 The substance-specific syndrome causes
clinically significant distress or impairment
Substance Addiction
A compulsive or chronic requirement; the
need is so strong as to generate physical
and/or psychological distress if left
unfulfilled.
Dual Diagnosis
Coexisting substance use disorder and
mental illness.
Nonsubstance Addictions

Codependency
– Exaggerated pattern of learned behaviors,
beliefs, and feelings involving dependence on
others that greatly diminishes self-identity
– Stages of recovery:
 Stage
 Stage
 Stage
 Stage

I (Survival)=letting go of denial
II (Reidentification)=awareness of true self
III (Core Issues)=letting go of control of others
IV (Reintegration)=regaining control of self
Gambling disorder
– Defined as being persistent and leading to
clinically significant impairment or distress
Objective 2
Describing substances commonly
abused in the community
Classes of
Psychoactive Substances
Alcohol
 Cannabis
 Hallucinogens
 Inhalants
 Opioids
 Sedative-hypnotics
 Stimulants

Alcohol
Most commonly abused drug
 Physically addicting

– alcohol becomes integrated into physiologic
processes at the cellular level
– cell becomes dependent on alcohol to carry out
metabolic processes

Constitutes the most life-threatening
withdrawal syndrome in comparison to
other types of commonly abused drugs
Alcohol (cont’d)

Intoxication
– disinhibition of sexual or aggressive impulses
– mood lability
– impaired judgment
– unsteady gait; incoordination

Withdrawal
– coarse tremor of hands, tongue, or eyelids
– nausea or vomiting
– malaise or weakness
– tachycardia, sweating, elevated blood pressure
– transient hallucinations or illusions
– progression to alcohol withdrawal delirium
Alcohol (cont’d)

Related physiological effects
– Wernicke’s encephalopathy
 Severe thiamine deficiency
 Paralysis of the ocular muscles
 Ataxia
 Somnolence, stupor, or death
– Korsakoff’s psychosis
 Confusion
 Loss of recent memory
 Confabulation
 Often occurs in conjunction with Wernicke’s
encephalopathy (“Wernicke-Korsakoff syndrome”)
– Fetal alcohol syndrome
 Physical, mental, behavioral, and learning disabilities
Alcohol (cont’d)

Four phases of progression
– Phase I: The Prealcoholic Phase
 Use of alcohol to relieve everyday stress and tension
– Phase II: The Early Alcoholic Phase
 Characterized by blackouts
 Alcohol becomes requirement as opposed to source of
pleasure or relief
– Phase III: The Crucial Phase
 Loss of control over drinking
 Interference with social and/or occupational function
– Phase IV: The Chronic Phase
 Emotional and physical disintegration
 Life-threatening physical manifestations of both use
and withdrawal symptomology present
Cannabis
Produces an effect similar to that of LSD
 Heightened awareness, distortion of space
and time, heightened sensitivity to sound,
and depersonalization
 May produce paranoia, but not true
hallucinations
 Has sedative effect and is psychologically
addicting
 Chronic use may result in psychosis and
lack of motivation

Cannabis (cont’d)
Second only to alcohol as the most widely
abused drug in the U.S.
 Intoxication

– impaired motor coordination
– euphoria
– anxiety
– sensation of slowed time
– impaired judgment
– increased appetite
– dry mouth
– tachycardia
Hallucinogens
Altered perceptions that are dream-like
 Altered sense of time
 Feelings of special insight
 Emotions are intensified and labile
 Depersonalization
 Adverse reactions include paranoia,
depression, frightening hallucinations, and
acute confusional state

Hallucinogens (cont’d)

Intoxication
– marked anxiety or depression
– ideas of reference
– fear of losing one’s mind
– paranoid ideation
– impaired judgment
– illusions, hallucinations, and depersonalization
– tachycardia, palpitations, tremors
– sweating
– blurred vision
Inhalants
Paint, glue, aerosol sprays, “whiteout”,
gasoline
 Produce mind-altering response
 Drug used most by adolescents due to ready
availability and low cost
 Symptoms include nosebleeds, bloodshot
eyes, infectious lesions around the nose and
mouth, severe disorientation and
unconsciousness
 Chronic use results in progressive brain
damage, asphyxiation, seizures, bone
marrow suppression, cardiac dysrhythmias

Inhalants (cont’d)

Intoxication
– belligerence, assaultiveness, impaired judgment
– dizziness, incoordination, unsteady gait
– slurred speech
– euphoria
– impaired social or occupational functioning
– lethargy, depressed reflexes, psychomotor
retardation
– tremor, generalized muscle weakness
– blurred vision
– stupor or coma
Opioids

Narcotic analgesics
– Sedative effect
– Desensitizes user to physical and psychological
pain
Can cause physiological and psychological
dependence
 Induces sense of euphoria

– Drug’s pleasurable effect on the CNS promotes
abuse

Effects include lethargy, indifference to the
environment
Opioids (cont’d)

Intoxication
– Apathy and dysphoria
– Psychomotor agitation or retardation
– Impaired judgment
– Drowsiness
– Slurred speech
– Impairment in attention or memory
– Can be fatal
 Respiratory depression
 Coma
 Death
Opioids (cont’d)

Withdrawal
– Develops after cessation of, or reduction in,
heavy and prolonged use of an opiate or related
substance
– Dysphoric mood
– Nausea/vomiting/diarrhea
– Muscle aches
– Lacrimation
– Sweating
– Abdominal cramping
– Insomnia
– Fever
Sedative-Hypnotics
Induces varying degrees of CNS depression
 Categories include barbiturates,
nonbarbiturate hypnotics, and antianxiety
agents
 Physiologically and psychologically addicting
 May generate “psychic drive” for continued
use to achieve maximum level of
functioning or feeling of well-being

Sedative-Hypnotics (cont’d)

Intoxication
– slurred speech
– incoordination/unsteady gait
– nystagmus
– impaired memory; stupor/coma

Withdrawal
– diaphoresis; nausea/vomiting
– increased heart rate
– psychomotor agitation; hand tremors; seizures
– insomnia
– hallucinations/illusions
Stimulants
Induces varying degrees of CNS stimulation
 Categories—

– Amphetamines
 Pleasurable euphoria followed by profound
depression/exhaustion; other intoxication effects are
hyperactivity/irritability, combativeness, paranoia,
and affective blunting
 Toxic psychosis occurs in most chronic users; may
be irreversible
 Withdrawal symptoms include dysphoria,
psychomotor retardation, fatigue, insomnia or
hypersomnia, vivid unpleasant dreams, and
increased appetite
Stimulants (cont’d)

Categories (cont’d)—
– Cocaine
 Highly addictive due to intense feelings of euphoria
(only lasts about 30-60 minutes)
 Chronic inhalation results in runny nose/sniffles,
frequent colds, weight loss, and hyperactivity
 Potentially fatal stroke/seizure/heart attack possible
(even with first-time use)
 Withdrawal symptoms include “crashing” (intense,
unpleasant feelings of sadness), fatigue, insomnia or
hypersomnia, increased appetite, agitation,
psychomotor retardation, and possible suicidal
ideation
Stimulants (cont’d)

Categories (cont’d)—
– Synthetic stimulants
– Caffeine
 Most widely used stimulant (readily available)
 Relieves fatigue and increases alertness
 Withdrawal symptoms include headache, muscle
pain/stiffness, fatigue, anxiety, irritability,
depression, impaired psychomotor function
– Nicotine
 Widely used stimulant (readily available)
 Increases alertness
 Withdrawal symptoms include depression, irritability,
insomnia, difficulty concentrating, increased appetite
Objective 3
Exploring psychiatric/mental health
interventions utilized for the
treatment of clients with substance
abuse
Major treatment objectives of substance
recovery include:

Detoxification
– 1st step in the recovery process
– should occur in safe, supportive environment
– may include substitution therapy

Intermediate Care
– identification of causes of dependency

Rehabilitation
– health promotion/maintenance; outside support
– identification of alternative sources of satisfaction
Treatment modalities for substance-related
disorders include:
Client/family education
 Support groups
 Pharmacotherapy
 Counseling
 Group therapy
 Psychopharmacology for substance
intoxication and substance withdrawal

Nursing assessment of clients at risk for alcohol
withdrawal symptoms typically includes the
Clinical Institute Withdrawal Assessment of
Alcohol Scale (CIWA)
 Determines risk and severity of alcohol
withdrawal
 Used in initial assessment and ongoing
monitoring of client’s withdrawal
 Provides parameters for pharmacological
intervention
– Maximum possible score is 67
– Score below 10 is generally indicative of “safe”
withdrawal that does not require medication
Objective 4
Identifying self-help
groups available for
clients with addictions
and alcohol abuse
Alcoholics Anonymous
 Women for Sobriety

– female alcoholics

Al-Anon
– families of alcoholics
Adult Children of Alcoholics (ACOA)
 Narcotics Anonymous
 Fresh Start

– nicotine addiction

Pills Anonymous
– polysubstance addiction
Objective 5
Discussing
medications
used in the
treatment of
substance abuse
to include their
actions and side
effects
Disulfiram (Antabuse)
 Inhibits metabolism of alcohol in the body,
producing an uncomfortable, potentially lifethreatening reaction to alcohol exposure
 Taken daily and lasts in the body for up to
two weeks
Acamprosate (Campral)
 Maintenance of abstinence from alcohol
 Ineffective in clients who have not
undergone detoxification and not achieved
alcohol abstinence prior to initiation
 Concomitant use with psychosocial therapy
Catapres
 Assists heroin abuser through detox
 Non-opiate antihypertensive that partially
blocks withdrawal symptoms, but does not
completely remove unpleasant feelings
associated with withdrawal
Naltrexone (ReVia)
 Does not produce “narcotic high”
 Non-habit forming
 “Replaces” heroin or other opiates by binding
to the same receptors in the brain that
produce feelings of pleasure
Methadone
 Synthetic opioid used for treatment of heroin
addiction
 Given orally and absorbed slowly so that it
does not produce “rush” associated with IV
heroin use
 Alleviates opioid cravings for a short time
 Dose gradually reduced during detoxification,
and client is not told how much of the drug
they are being given
 Use is highly controversial due to “trading
one addiction for another”
Narcan
 Opioid antagonist
 Counteracts dangerous respiratory
depressant effects of heroin or other opiate
overdose
 When given to client under the influence of
an opiate, the individual may experience
acute withdrawal symptoms