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Chapter 22: Substance Abuse Disorder
Substance use disorder is characterized by craving, seeking, and using regardless of consequences
o Result in change of brain structure and function
o Chronic and relapsing
o Symptoms fall into four groupings: impaired control, social impairment, risky use, physical effects
(intoxication, tolerance, withdrawal)
o Substance ranges from innocuous and innocent-seeming substances such as caffeine to illegal minaltering drugs such as LSD
o Psychoactive substances: alcohol, caffeine, cannabis, hallucinogen, inhalant, opioid, sedative,
hypnotic, stimulant, tobacco
o Process Addictions: behavior or feeling brought by action
 Compulsive actions activate the reward or pleasure pathways in the brain
 Gambling, internet gaming, social media, shopping, sexual activity are also process
addictions
Define substance use, intoxication, tolerance, and withdrawal.
o Addiction: primary, chronic disease of brain reward, motivation, memory, and related circuitry
 Dysregulation in the hedonic (pleasure-seeking) or reward pathway of the brain
 Unable to abstain
 Unable to recognize extent to creating problems in functioning, interpersonal
relationships, emotional responses
 Result in disability or premature death
o Intoxication: process if using a substance to excess
o Tolerance: no longer responses to the drug in the way the person initially responded
 Takes higher doses to achieve same level of response
o Withdrawal: set of physiological symptoms that occur when a person stops using a substance
 The more intense symptom a person has, the more likely the person is to start using the
substance again to avoid the symptoms
Epidemiology
o 9% of U.S. population have substance abuse disorder
o 53% drink alcohol
 Binge drinking: 5 drinks on one occasion on one day in the last month
 Heavy drinking: 5 drinks on one occasion on at least five days on the last month
o 10% use illicit substances (nonmedical or nonprescribed)
 Highest rate aged 18-25
 Marijuana and nonmedical prescription pain relivers are illicit drugs of choice
 Amphetamine/dextroamphetamine and methylphenidate have doubled
o The use of synthetic drugs, e-cigs, and hookah are on the rise among young adults
o Scheduled Drugs
 The lower the schedule number, the higher the potential for abuse
 Schedule I: carry a high potential for abuse and have no acceptable medical use
Heroin and LSD
 Schedule II: high potential for abuse, considered dangerous, available only by
prescription
Methadone, meperidine, methylphenidate
 Schedule III: low-moderate potential for misuse and available by prescription
Testosterone, acetaminophen/codeine, buprenorphine
 Schedule IV: low-risk and available by prescription
Alprazolam, lorazepam, propoxyphene/acetaminophen
 Schedule V: limited quantities of certain narcotics for the treatment of diarrhea,
coughing, pain
Atropine/diphenoxylate, guaifenesin and codeine, pregabalin, available OTC
Comorbidity
o Two or more disorder occurring in the same person at the same time with potential interactions
and exacerbation of symptoms
o Co-occurring disorders: combination of two or more substance use disorders and mental disorders
identified in the DSM-5
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Major depressive disorder, bipolar disorder, and anxiety disorder are twice as as likely to have a
substance use disorder
o Antisocial personality disorder and conduct disorder are commonly assoc. w/ substance abuse
Risk Factors
o Biological
 Alcohol use disorder runs in families
 Monozygotic twins are more likely to share alcohol use problems, mostly male twins
 Substance use disorders such as cannabis, cocaine, and opiates definitely run in
families
o Neurochemical
 Opioids acts on opioid receptors
 People with little natural opioid activity or too much opioid antagonism might be prone
to self-medicating through opioid drugs
 The major neurotransmitters involved in developing substance use disorders are the
opioid, catecholamine, and GABA
 The dopaminergic neurons in the ventral tegmental area are important in the sensation
of reward
o Environmental
 Poverty raises the risk of an unfavorable living environment, lack of parental
supervision, poor educational resources, and impaired support systems
 Increasing stress and anxiety along with lack of negative social ties, contributes to
depression
 Coping mechanisms include drugs and acting out behaviors leading to destructive
consequences and interaction with the legal system
 Adolescents are influenced by peers to engage in substance use
 Alcohol referred to as social lubricant increases in adolescent’s feeling of belonging
 Using alcohol, tobacco, and marijuana at an early age is strongly associated with
coming from a home with low parent to supervision
o Sociocultural
 Substance use creates a sense of community and belonging
 In some cultures, and religions alcohol is not accepted and would be considered
deviant
 Muslim majority countries are against alcohol
in Afghanistan it is illegal for citizens to purchase alcohol but there are still
places for foreigners to drink
 In the U.S. Christians denominations reject the use of alcohol
Caffeine: used as a psychoactive substance
o Half-life of caffeine in the body is 3 to 10 hours; peak concentration is 30 to 60 minutes
o Intoxication: restlessness, nervousness, excitement, agitation, rambling speech, and inexhaustibly
 Physical symptoms: flushed face, diuresis, GI disturbance, muscle twitching,
tachycardia, cardiac arrhythmia
 Symptoms result in impairment of normal areas of functioning
 High doses may result in grand Mal seizures and respiratory failure may cause death
 Excessive us is associated with bipolar disorders, eating disorders, and sleep disorders
o Withdrawal: headache, drowsiness, irritability, and poor concentration
 can experience nausea, vomiting, and muscle aches
 Symptoms occur 12 to 24 hours after last dose, peak in 24 to 48 hours, and resolved
within one week
Cannabis Use Disorder: Marijuana is the most used illegal drug and fourth most common use
psychoactive drug
o Comes from the hemp plant
o A chemical, delta-9 TCH, is responsible for its mind-altering effects
o Hashish: concentrated form of cannabis
o Males are more likely to have this disorder
o Symptoms include museum large amounts over a long period of time, craving, tolerance,
withdrawal
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Individuals with heavy marijuana use may try to quit, cut down, or control its use
Results in problems with work, home life, education, social, and physical well-being
Intoxication: heightens users’ sensations
 Experience brighter colors, see new details, time seems to go slowly
 Higher doses depersonalization and derealization occurs
 Motor skills are impacted for 8 to 12 hours and driving, and use of machinery may be
hazardous
 Physical symptoms: conjunctival injection (red eyes from vessel dilation), increased
appetite, dry mouth, tachycardia
o Withdrawal: within one week of cessation
 Symptoms include irritability, anger, aggression, and anxiety, restlessness, and
depressed mood
 People often use marijuana as they sleep aid, insomnia and disturbing dreams may
ensue without it
 Physical symptoms: abdominal pain, shakiness, sweating, fever, chills, headache
o Treatment
 Drug screens can detect cannabis for up to four weeks after use
 Abstinence and support are the main principles of treatment
 Individual, family, and group therapies can provide support
 Anti-anxiety medication may be useful for short term relief of withdrawal symptoms
Hallucinogen Use Disorder
o Intoxicants causing a profound disturbance in reality
o Associated with flashbacks, panic attacks, psychosis, delirium, mood and anxiety disorders
o Classified as schedule I controlled substances, meaning they have no medical use and carry high
abuse potential
o Found in plants and mushrooms or can be man-made
o Clinically significant impairment or distress within a 12-month period including craving, difficulty
with row obligations, impairment, tolerance
o Intoxication: psychological and behavioral changes; paranoia, impaired judgment, intensification
of perceptions, depersonalization, derealization
 Physical symptoms: pupillary dilation, tachycardia, sweating, palpitations, blurred
vision, tremors, incoordination
 Treatment: talking the patient down, reassuring symptoms are caused by the drug and
will subside
in severe cases antipsychotic (haloperidol) or benzodiazepine (diazepam) can be
used in short term
o Withdrawal: there is no official withdrawal diagnosis. Symptoms are distressing and impair the
individual from normal functioning for weeks, months, or even years
o phencyclidine intoxication: Medical emergency can result in dangerous and violent side effects
 can be belligerent, assaultive, impulsive, and unpredictable
 Physical manifestations include nystagmus, HTN, tachycardia, diminished response to
pain, ataxia, muscle rigidity, seizures, coma, and hyperacusis (sensitivity to sound).
Hyperthermia and seizure activity may occur
 Treatment: require restraint and a calming medication such as benzodiazepine.
Mechanical cooling may be necessary for severe hyperthermia
Inhalant use disorder
o Volatile hydrocarbons are toxic gases inhaled through the nose or mouth to enter the bloodstream
o These include solvents for glues and adhesives; propellants found in aerosol paint sprays,
hairsprays, and shaving cream; thinners such as paint products and correction fluids; fuels such as
gasoline and propane
o Use for a short period of time; some users continue use despite knowing that this practice is
causing serious problems
o Sudden sniffing death from cardiac arrhythmias may occur with inhalants particularly with butane
and propane
o This disorder is seen in ages 12 to 17
o Intoxication:
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Small doses result in disinhibition and euphoria
High doses cause fearfulness, illusions, auditory and visual hallucinations, and
distorted body image
 Apathy, diminished social and occupational functioning, impaired judgment impulsive
and aggressive behavior accompany intoxication
 Physical responses: nausea, anorexia, nystagmus, depressed reflexes, diplopia
Higher doses can lead to stupor, unconsciousness, amnesia
Delirium, dementia, psychosis are also serious possibilities from inhalant use
 Treatment:
Inhalant intoxication usually does not require treatment
coma, cardiac arrhythmias, bronchospasm do happen
Haloperidol used to manage severe agitation
Opioid Use Disorder
o Misuse with heroin and prescription drugs, is a chronic relapsing disorder
o Cravings result in larger amounts and longer periods of time being devoted to the drug and
increasing tolerance to its effects
o Result impairment in life roles, interpersonal conflict, physical hazardous situation
o Opioid use begins in late teens or early 20s
o Intoxication: psychomotor retardation, drowsiness, slurred speech, altered mood, impaired
memory and attention
o Withdrawal: mood dysphoria, N/V, diarrhea, muscle aches, fever, insomnia,
 Lacrimation, rhinorrhea, pupillary dilation, yawning
 The symptom of piloerection (bristling of hairs) or gooseflesh is the origin of the term
cold turkey for the abstinence syndrome
 Males experience sweating and spontaneous ejaculations
 Morphine, heroin, methadone withdrawal begins 6-8 hrs after the last dose
Intensity reaches during 2nd or 3rd day
 Meperidine withdrawal begins within 8-12 hrs from abstinence and lasts 5 days
o Overdose: death attribute from respiratory arrest d/t respiratory depressant effect of the drug
 Symptoms: unresponsiveness, slow respiration, coma, hypothermia, hypotension,
bradycardia
 Coma, pinpoint pupils, respiratory depression are strongly suggestive of overdose
o Treatment: promoting breathing by aspirating secretions and inserting an airway
 Mechanical ventilation should be used until naloxone can be given IM subcut, or IV
 Increase respirations and pupillary dilation should happen quickly
o General Treatment
 Individual therapy, behavioral therapy, cognitive behavioral therapy, family therapy,
and social skills training
 Methadone: synthetic narcotic opioid; used to decrease the painful symptoms of opiate
withdrawal
blocks euphoric effects
only the spends through an opioid treatment program certified by SAMHSA
will eventually need to be withdrawn due to dependence
in pregnant users a low dose is safe; neonatal withdrawal is usually mild and can
be managed with paregoric
side effects: difficulty breathing, shallow breathing, feel lightheaded, chest pain,
fast or pounding heartbeat; hives, rash, swelling of the face, lips, tongue, or
throat could be serious symptoms; hallucinations or confusion should be
reported
 Buprenorphine: used to reduce or quit use of heroin or other opiates such as pain
relievers like morphine
opioid partial agonist
produces effects such as euphoria or respiratory depression but effects are
weaker
FDA has approved the following schedule III buprenorphine products some
contain naloxone: Subutex, bunavail, suboxone, zubsolv, probuphine
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Side effects: N/V, constipation, muscle aches and cramps, insomnia, irritability,
fever
only used after abstaining from opioids for 12 to 24 hours and in the early stages
of opioid withdrawal
 Naltrexone: indicated for prevention of relapse to opioid dependence following opioid
detoxification
ReVia is given once a month
if a person using naltrexone relapses and uses the misuse drug, naltrexone
blocks the euphoric and sedative effects
Side effects: weakness, tiredness, insomnia, increased thirst, anxiety,
nervousness, restlessness, irritability, Lightheadedness, fainting, muscle or joint
aches, decrease sex drive, impotence, or difficulty having an orgasm
10. Sedative, Hypnotic, and Antianxiety Medication Use Disorder
o Drugs in this category include benzodiazepines, benzodiazepine-like drugs, carbamates,
barbiturates, barbiturate-like hypnotics
o Craving is a typical feature
o A curse in males slightly more often than females
o Highest among 18- to 29-year-olds
o Intoxication: Solar speech, incoordination, unsteady gait, nystagmus, impaired thinking
 Coma is a dangerous possibility with this class of drugs
 Inappropriate aggression and sexual behavior, mood fluctuation, and impaired
judgement
o Overdose treatment: Gastric lavage, activated charcoal, vital sign monitoring
 Pts awake after overdosing should be kept awake to prevent loss of consciousness
 if unconscious, IV fluid line should be established
 Endotracheal tube may be required provide patent airway and mechanical ventilation
can be used
o Withdrawal: Gradual reduction of benzodiazepines will prevent seizures and other symptoms
 Barbiturate withdrawal Can be aided by using a long-acting barbiturate such as
phenobarbital
11. Stimulant Use Disorder
o Amphetamine-type, cocaine, or other stimulant drugs are second only to cannabis as the most
widely used illicit substances in the US
o produce euphoric feeling and high energy
o long distance truckers, student studying for exams, soldiers in wartime, athletes in competition use
these drugs
o Both genders are affected equally
o IV stimulants use is greater in males
o Intoxication: feel superhuman while using stimulants; feel elated, euphoric, sociable;
hypervigilant, sensitive, anxious, tense, angry
 physical symptoms: chest pain, cardiac arrhythmias, high or low blood pressure,
tachycardia or bradycardia, respiratory depression, dilated pupils, perspiration, chills,
N/V, weight loss, psychomotor agitation or retardation, weakness, confusion, seizures,
coma
o Withdrawal: happens within few hours to several days
 Symptoms: tiredness, vivid nightmares, increased appetite, insomnia or hypersomnia,
and psychomotor retardation or agitation
 functionality is impaired
 depression and suicidal thoughts are the most serious side effects
 Treatment:
Amphetamines inpatient setting
a. Individual, family, group therapy
b. antipsychotics may be prescribed
c. if there is no psychosis diazepam is useful in treating agitation and
hyperactivity
d. Depression is treated with bupropion (antidepressant)
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One-to-two-week cocaine withdrawal period is distinct b/c There are no
physiological disturbances
a. first approach is outpatient setting
b. patient experience fatigue, mood changes, disturbed sleep, craving, and
depressionthere are no drugs to reduce the intensity of these
symptoms
c. intense craving associated with cocaine withdrawal may require
hospitalization
d. Unscheduled urine drug testing is usually warranted
12. Tobacco Use Disorder
o Craving, persistent, and recurrent use, and tolerance are all symptoms of tobacco use disorder
o Dependence happens quickly
o Common: cigarettes
o Higher in males and begin use before age 18
o Withdrawal: distressing; irritability, anxiety, depression, difficulty concentrating, restlessness,
insomnia
 HR decreases 5-12 bpm after cessation
 Within 1st year after smoking cessation, weight increased by 4-7 lb
 Treatment:
Behavioral therapy teaches patient to recognize cravings and respond to them
appropriately
Hypnosis
nicotine replacement therapies: gum, lozenges, nasal sprays, patches
non-nicotine therapy: bupropion (reduces craving), clonidine (decreases
sympathetic activity and reduces withdrawal symptoms), Varenicline (provide
some nicotine effects to ease withdrawal and blocks nicotine effects from
cigarettes if smoking is resumed)
13. Gambling Disorder: Compulsive activity that causes economic problems and disturbances in personal,
social, occupational functioning
o preoccupy with behavior, experience increased desire to gamble, lie to conceal the extent of the
problem
o rely on others to pay off debts and gamble to recoup losses
o common among males
o stress and depression may increase this behavior
o treatment: gamblers anonymous is a 12-step program modeled on alcoholic anonymous
 involves public confession, peer pressure, peer counselors who are reformed gamblers
 Hospitalization removes patient from gambling environment
 SSRI's, bupropion, mood stabilizers, anticonvulsants such as topiramate may be helpful
 second generation antipsychotics have been used in the treatment of gambling disorder
 naltrexone is given to individuals with severe symptoms of gambling disorder
14. Alcohol use disorder: sedative, creates feeling of euphoria
o Types of problematic drinking
 Binge drinking: drinking too much alcohol quickly
Women: >4 drinks within 2 hrs
Men: >5 drinks within 2 hrs
 Heavy drinking: drinking too much, too often
Women: >8 drinks in a week
Men: >14 drinks in a week
o Alcohol Intoxication
 The legal definition of intoxication in most states requires a blood concentration of 80
or 100 mg/dL
 quicker ingestion results in higher levels of blood alcohol
o Alcohol withdrawal
 occurs after reducing or quitting alcohol after heavy and prolonged use
 shakes or jitters begins 6 to 8 hours after alcohol cessation
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Agitation, lack of appetite, N/V, insomnia, impaired cognition, mild perceptual
changes
 Chlordiazepoxide is useful for tremulousness and agitation
 Psychotic and perceptual symptoms begin 8 to 10 hours. If patient begins to experience
psychosis it is considered a medical emergency because of the risks of
unconsciousness, seizures, and delirium
 Lorazepam or Chlordiazepoxide given PO and IM and tapered over 5-7 days
 Withdrawal seizures: occur within 12-24 hrs after cessation
Generalized and tonic-clonic seizures
Diazepam given IV is a common treatment for withdrawal seizures
 Alcohol withdrawal delirium: (delirium tremens) medical emergency that result in
death; happen with the first 72 hrs
Autonomic hyperactivity may result in tachycardia, diaphoresis, fever, anxiety,
insomnia, and HTN
Delusions and visual and tactile hallucinations are common
Oral diazepam relief acute agitation, tremor, impending or acute delirium
tremens, hallucinosis
Seclusion may be necessary
Dehydration occurs; corrected by giving fluids
Alcohol-Induced Persisting Amnestic Disorder
 Wernicke-Korsakoff Syndrome
Wernicke’s encephalopathy, acute and reversible condition
a. Alter gay, vestibular dysfunction, confusion, several ocular motility
abnormalities; sluggish reaction to light and anisocoria
Korsakoff’s syndrome, chronic condition with recovery rate of 20%
a. Response rapidly to large doses of IV thiamine 2-3x/daily for 1-2
weeks
b. Treatment of thiamine for 3-12 months
c. Never fully recover although cognitive improvement may occur
Connection btw the two is thiamine deficiency, caused by poor nutrition assoc.
w/ alcohol use or malabsorption
 Blackouts
Caused by excessive consumption of alcohol followed by episodes of amnesia
Person engages in behaviors, perform complicated tasks, appears normal
This phenomenon is due to alcohol's ability to block the consolidation of new
memories into ones through the hippocampus and related temporal lobe
structures
Fetal Alcohol Syndrome: leading cause of intellectual disability
 During pregnancy inhibits intrauterine growth and postnatal development resulting
microcephaly, craniofacial malformation, limb and heart defects
 Features: low nasal bridge, minor ear abnormalities, indistinct philtrum, micrognathia,
thin upper lip, flat midface and short nose, short palpebral fissures, epicanthal folds
Systemic Effects
 Peripheral Neuropathy: damage to the peripheral nervous system
Feeling of pins and needles in the lower extremities
Numbness, muscle weakness, sensitivity to touch, burning
 Alcoholic Myopathy: muscle weakness and myonecrosis (muscle damage)
Recovery is possible if alcohol is avoided
 Alcoholic Cardiomyopathy: weaken and thin the muscles of the heart leading to
enlargement and eventual heart failure
fatigue, shortness of breath, edema of the legs and feet
 Esophagitis: inflammation of the esophagus
Vomiting related to alcohol overuse is also contributory to this condition
Result from heavy drinkingdistended esophageal veins, at risk for bursting
resulting in medical emergency
 Gastritis: alcohol irritates and erodes the mucosal stomach lining
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N/V, loss of appetite, belching, bloating
lead to ulcers and bleeding
Pancreatitis: result from excessive drinking, more than 5 years
Abdominal pain, nausea, vomiting
chronic conditionmalnutrition, weight loss, diabetes mellitus
alcoholic hepatitis: diseased and inflamed liver
symptoms appetite changes, dry mouth, weight loss, pain or swelling in the
abdomen, jaundice, fever, confusion, fatigue, N/V
Cirrhosis of the liver: liver is replaced by scar tissue which blocks the blood flow
through the liver
Symptoms: easy bruising, bleeding, pruritus, jaundice, ascites, leg edema,
weight loss, confusion, petechiae, testicular atrophy
Leukopenia: cause low WBCs
Symptoms: periodontitis, gingivitis, fatigue, weakness, fever, abdominal pain
Thrombocytopenia: low platelet count
Symptoms: purpura, petechiae, prolonged bleeding
Platelet count increases 2-5 days after abstaining from alcohol
Cancer
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15. Nursing Process
o Assessment
 Living with someone who is uses alcohol or other substances is a source of stress and
requires family system adjustments
 Codependence: cluster of behaviors originally identified through research involving the
families of alcohol patients
people who are codependent often exhibit responsible behavior
o Advance Practice Interventions
 Psychotherapy
CBT and motivational interviewing
Destructive and negative thinking patterns play into the development of
maladaptive behavioral patterns
cognitive behavioral therapy helps patients explore thinking patterns
Motivational Interviewing: uses a person center approach to strength motivation
for change
a. Precontemplation, need assistance in admitting there is a problem
b. if they acknowledged a problem, contemplation, they may still not be
ready to commit to addressing it
c. goal is to develop awareness and commitment
d. preparation getting ready
e. action, changing take place in an early treatment
f. maintenance stage: ongoing commitment to recovery program
g. without continuing action, the individual will likely return to the
previous behavior, relapse
16. The Care Continuum for Substance Use Disorders
o Detoxification: quits using psychoactive substance; accompanied by uncomfortable and fatal side
effects caused by withdrawal
o Rehabilitation: provide intensive and specialized care for individuals with biomedical or
psychiatric comorbid conditions
o Halfway houses: offer residential treatment in a substance-free communal or family environment
that provides opportunities for independent growth
 Focus is on extending the period of sobriety
o Other housing, partial hospitalization program, intensive outpatient program, outpatient treatment,
Alcoholics Anonymous, relapse prevention