NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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Lesson 19: Addiction
What is a substance?
Refers to any Drugs, Medication, or Toxins that
share the potential for abuse. Substance use
and substance-related disorders can involve
alcohol, stimulants, cannabis, opioids,
hallucinogens, inhalants, sedatives, hypnotics,
and anxiolytics.
Terminologies
Polysubstance abuse - abuse of more than
one substance
Designer drugs - synthetic substances made
by altering existing medications or formulating
new substances not yet controlled or regulated
by the FDA
Intoxication - use of a substance that results in
maladaptive behavior
Withdrawal syndrome - the negative
psychological and physical reactions that occur
when the use of a substance ceases or
dramatically decreases.
Detoxification - the process of safely
withdrawing from a substance.
Substance Abuse - using a drug in a way that
is inconsistent with medical or social norms and
despite negative consequences.
Substance dependence - includes problems
associated with addiction such as tolerance,
withdrawal, and unsuccessful attempts to stop
using the substance.
Onset and Clinical Course
Alcohol is the substance abused most often.
The early course of alcoholism typically begins
much earlier, with the first episode of
intoxication between 12-14 years of age.
The first evidence of minor alcohol-related
problems is seen in the late teens.
Episodes of "sipping" alcohol may occur at age
8 years or even earlier.
A pattern of more severe difficulties for people
with alcoholism begins to emerge in the mid-20s
to the mid-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, or
significant interference with functioning at work
or school. During this time, the person
experiences his or her first blackout, which is an
episode during which the person continues to
function but has no conscious awareness of his
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or her behavior at the time or any later memory
of the behavior.
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. After continued heavy drinking, the
person experiences a tolerance break, which
means that very small amounts of alcohol
intoxicate the person.
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 of time.
Attempts to quit or cut down result in restless,
anxious, and irritable behavior.
Caffeine, Tobacco, or Nicotine
Are substances that are addictive and are
included in the Diagnostic and Statistical
Manual of Mental Disorders, but are not
considered mental health problems per se.
Addiction to 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.
Substance-Induced Anxiety
Refers to the experience of anxiety symptoms
that are caused by substance use or withdrawal
Can be caused by a wide range of substances,
including alcohol, caffeine, nicotine, cannabis,
cocaine, amphetamines, and opioids. These
substances can directly affect the brain's
neurotransmitters, which can lead to the
development of anxiety symptoms.
Withdrawal from these substances can also
trigger anxiety symptoms, as the brain struggles
to readjust to normal functioning without the
substance.
Substance-Induced Psychosis
A type of psychotic disorder that can occur as a
result of substance use or withdrawal.
It is a serious mental health condition that can
be difficult to treat and may have lasting
consequences.
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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Can be caused by a wide range of substances,
including cannabis, cocaine, amphetamines,
hallucinogens, and alcohol. They can interfere
with the brain's neurotransmitters, leading to
changes in mood, perception, and behavior.
Withdrawal from these substances can also
trigger psychosis, as the brain struggles to
readjust to normal functioning without the
substance.
Etiology
The exact causes of drug use, dependence, and
addiction are unknown, but various factors are
thought to contribute to the development of
substance-related disorders (Boland and
Verduin, 2022)
Much of the research on biologic and genetic
factors has been done on alcohol abuse, but
psychological, social, environmental studies
have examined other drugs as well.
Biological Factors
Genetic
Research has shown that there is a strong
heritability component to addiction, with genetic
factors accounting for up to 50% of an
individual's vulnerability to addiction. Various
genes have been implicated in addiction,
including those that regulate the brain's reward
system, stress response, and impulse control.
For example: children of alcoholic parents are at
higher risk for developing alcoholism and drug
dependence than are children of non-alcoholic
parents.
Neurochemical Influences
Neurotransmitters such as dopamine, serotonin,
and norepinephrine play a critical role in
addiction. These chemicals are involved in
regulating the brain's reward system, which is
activated when we engage in pleasurable
activities such as eating, having sex, or using
drugs.
Addictive substances hijack the brain's reward
system by causing a surge of dopamine, which
leads to feelings of pleasure and reinforces the
behavior.
Over time, the brain becomes less sensitive to
the effects of dopamine, and individuals may
require larger amounts of the substance to
achieve the same high.
Changes in other neurotransmitters, such as
glutamate and GABA, have also been
implicated in addiction.
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Brain Structure
Brain imaging studies have shown that addiction
is associated with structural and functional
changes in various regions of the brain,
including the prefrontal cortex, amygdala, and
striatum.
These changes can affect decision-making,
impulse control, and emotional regulation,
making it more challenging for individuals to quit
using drugs or engaging in addictive behaviors.
For example, chronic drug use has been shown
to lead to a decrease in gray matter volume in
the prefrontal cortex, which is responsible for
executive function.
Psychological Factors
Personality Traits
Research has shown that certain personality
traits can increase an individual's risk of
developing addiction.
For example, individuals who are sensationseeking, impulsive, or have low self-esteem are
more likely to develop addiction. People who
have difficulty coping with stress and negative
emotions may also be more vulnerable to
addiction.
Individuals who have a history of trauma or
abuse may be at increased risk of developing
addiction as a way to cope with emotional pain.
Cognitive Processes
Cognitive processes, such as decision-making,
attention, and learning, play an important role in
addiction.
Individuals with addiction may have cognitive
biases that influence their decision-making,
such as a focus on short-term rewards and a
tendency to discount the potential negative
consequences of their behavior.
They may also have difficulty learning from
negative experiences, leading to continued
substance use or engagement in addictive
behaviors.
Individuals with addiction may have impaired
attention and impulse control, which can make it
difficult to resist cravings and avoid triggers.
Motivations
Motivations for substance use and addictive
behaviors can vary widely.
For some individuals, addiction may be a way to
cope with stress or negative emotions, while for
others, it may be a way to seek pleasure or
enhance social connections. Some individuals
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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may use substances or engage in addictive
behaviors to manage physical pain or other
symptoms of mental health conditions.
Understanding an individual's motivations for
addiction is essential in developing effective
treatment strategies.
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Social and Environmental Factors
Social Factors
Social factors, such as peer pressure, social
norms, and cultural attitudes, can significantly
impact an individual's risk of developing
addiction.
For example, individuals who have friends or
family members who use drugs or engage in
addictive behaviors are more likely to develop
addiction themselves.
Cultural attitudes towards substance use and
addiction can impact an individual's willingness
to seek help for their addiction and can influence
the availability of resources for treatment.
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Environmental Factors
Environmental factors, such as access to drugs
or addictive behaviors, can also play a
significant role in addiction vulnerability.
Individuals who live in areas with high rates of
drug use or who have easy access to drugs are
more likely to develop addiction.
Individuals who experience high levels of stress
or trauma may be more vulnerable to addiction
as a way to cope with these experiences.
Environmental factors such as poverty,
homelessness, and lack of access to healthcare
can also contribute to addiction vulnerability.
Family Dynamics
Family dynamics can also play a significant role
in addiction vulnerability. Individuals who grow
up in homes with parents or siblings who use
drugs or engage in addictive behaviors are more
likely to develop addiction themselves.
Individuals who experience neglect, abuse, or
other adverse childhood experiences may be
more vulnerable to addiction as a way to cope
with these experiences.
Peer Pressure
Peer pressure can also be a significant factor in
addiction vulnerability.
Individuals who feel pressure from their peers to
use drugs or engage in addictive behaviors may
be more likely to do so themselves.
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This can be particularly true for adolescents and
young adults who are still developing their
sense of identity and may feel a need to conform
to peer expectations.
Cultural Consideration
Cultural Attitudes
Cultural attitudes towards substance use and
addiction can impact an individual's willingness
to seek help for their addiction and can influence
the availability of resources for treatment.
For example, in some cultures, addiction may
be stigmatized or viewed as a moral failing
rather than a disease. This can make it difficult
for individuals to seek help for their addiction or
to receive appropriate treatment.
Cultural attitudes towards specific substances
or behaviors may impact an individual's risk of
developing addiction
Cultural Values
Cultural values can also impact an individual's
risk of developing addiction.
For example, cultures that place a high value on
conformity or social conformity may be more
likely to have higher rates of addiction among
individuals who feel pressure to conform to
social expectations.
Similarly, cultures that place a high value on
individualism or personal autonomy may be
more likely to have higher rates of addiction
among individuals who prioritize their own
desires over social norms.
Cultural Beliefs and Practices
Cultural beliefs and practices can also impact an
individual's risk of developing addiction.
For example, some cultures may have
traditional practices involving the use of certain
substances or addictive behaviors.
These practices may be seen as socially
acceptable or even encouraged within the
culture.
Additionally, some cultures may have traditional
healing practices that involve the use of
psychoactive substances.
These practices can impact an individual's
attitudes towards substance use and addiction.
Access to Resources
Access to resources for prevention and
treatment can also be impacted by cultural
factors.
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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In some cultures, there may be a lack of
resources for addiction treatment, or the
resources that are available may not be
culturally appropriate or sensitive to the needs
of the community.
Additionally, cultural factors may impact an
individual's willingness to seek help or to
participate in treatment programs.
Types of Substance and Treatment
These are mood-altering substances that have
similarities and differences depending on its
intended effect, intoxication effects, and
withdrawal symptoms.
However, treatment approaches after
detoxification are quite similar.
Alcohol
A Central Nervous System Depressant that is
absorbed rapidly into the bloodstream.
Intoxication and Overdose
Initial effects of alcohol intake include:
o Relaxation
o Loss of inhibitions
Effects during Intoxication:
o Slurred speech
o Unsteady gait
o Lack of coordination
o Impaired attention, concentration,
memory, and judgment.
o Aggressiveness
o Display inappropriate sexual behavior.
o May also experience blackout
Overdose is an excessive alcohol intake for a
short period of time. Effects include:
o Vomiting
o Unconsciousness
o Respiratory depression
▪ Combination of these 3 may
cause Aspiration Pneumonia
or Pulmonary Obstruction.
o Alcohol-induced Hypotension
▪ May lead to Cardiovascular
shock and death.
Treatment
The goal of the treatment is to remove the
substance and support respiratory and
cardiovascular function.
Administration of Central Nervous System
stimulants is contraindicated.
Gastric lavage and dialysis
Long-Term Physiological Effects of Alcohol Use
• Cardiac Myopathy
• Wernicke Encephalopathy
• Korsakoff Psychosis
• Pancreatitis
• Esophagitis
• Hepatitis
• Cirrhosis
• Leukopenia
• Thrombocytopenia
• Ascites
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Withdrawal
Symptoms of withdrawal begin 4 to 12 hours
after cessation or marked reduction of alcohol
intake.
Alcohol withdrawal usually peaks on the second
day and is over in about 5 days; May also take
1 to 2 weeks.
Symptoms include:
o Coarse hand tremors
o Sweating
o Elevated pulse and blood pressure
o Insomnia
o Anxiety
o Nausea or Vomiting
Severe Withdrawal Symptom:
o Transient Hallucinations
o Seizures
o Delirium
Detoxification
Alcohol withdrawal can be life-threatening,
detoxification needs to be accomplished under
medical supervision.
If the client’s withdrawal symptoms are mild, and
they can abstain from alcohol:
o Can be treated safely at home.
If the client’s withdrawal symptoms are mild, and
cannot abstain from alcohol:
o Short admission of 3 to 5 days.
Pharmacologic
management
for
safe
withdrawal includes:
o Benzodiazepines
▪ Lorazepam, Diazepam, and
Chlordiazepoxide.
Withdrawal can be accomplished by:
o Fixed-scheduled dosing also known as
Tapering
o Symptom-triggered dosing
Presence and severity of withdrawal symptoms
determine the amount of medication needed
and the frequency of the administration.
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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Addiction Research Foundation Clinical
Institute Withdrawal Assessment for
Alcohol, Revised. (for the assessment tool,
please refer to page 361 of the ninth edition of
the book)
The use of an assessment tool such as the
Clinical Institute Withdrawal Assessment of
Alcohol Scale.
o Patients on symptom-triggered dosing
receive medication based on this
scale.
o Patients on fixed-scheduled dosing
receive additional doses based on this
scale.
A score of less than 8 indicates mild
withdrawal.
A score of 8 to 15 indicates moderate
withdrawal.
A score of 15 or above indicates severe
withdrawal.
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Sedatives, Hypnotics, and Anxiolytics
Drugs that are Central Nervous System
stimulants such as:
o Barbiturates
o Nonbarbiturate hypnotics
o Anxiolytics,
particularly
benzodiazepines.
Most frequently abused drugs: Barbiturates and
Benzodiazepines.
Effects of the drugs, intoxication, and withdrawal
symptoms are similar to alcohol.
Intended purpose:
o Reduce anxiety, with drowsiness as a
side effect.
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Intoxication and Overdose
Benzodiazepines when taken orally in
overdose is rarely fatal.
The effect however is that the person becomes
lethargic and confused.
Treatment includes gastric lavage followed by
ingestion of activated charcoal and a saline
cathartic.
Dialysis can be used for severe symptoms.
Symptoms improve as the drug is excreted.
Barbiturates when taken in orally in overdose
is fatal.
Effects include:
o Comatose
o Respiratory arrest
o Cardiac failure
o Death
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Treatment in the ICU is required using gastric
lavage or dialysis to remove the drug from the
system and to support respiratory and cardiac
function.
Withdrawal
Onset of withdrawal symptoms depends on the
half-life of the drug.
Benzodiazepines such as Lorazepam which
typically lasts about 10 hours, produce
withdrawal symptoms in 6 to 8 hours.
Withdrawal syndrome is characterized by
symptoms that are opposite of the acute effects
of the drug – autonomic hyperactivity such as:
o Elevated pulse, blood pressure,
respiration, and temperature.
o Hand tremor
o Insomnia
o Anxiety
o Nausea
o Psychomotor agitation
Seizures and hallucinations occur rarely.
Detoxification
Detoxification is often medically managed by
tapering the amount of the drug the client
receives over a period of time.
Tapering is essential for barbiturates to prevent
coma and death that may occur if the drug is
stopped abruptly.
Stimulants
These are drugs that stimulate or excite the
Central Nervous System and have limited
clinical use and a high potential for abuse.
Amphetamines, in the past, were used by
people who want to lose weight quickly or stay
awake.
Cocaine is illegal, has no clinical use in
medicine, but is highly addictive and a popular
recreational drug because of the intense and
immediate feeling or euphoria it produces.
Methamphetamines is highly addictive and
causes psychotic disorder and brain damage
Intoxication and Overdose
Intoxication develops rapidly. Effects include:
o High or euphoric feeling
o Hyperactivity
o Hypervigilance
o Talkativeness
o Anxiety
o Grandiosity
o Hallucinations
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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o Stereotypic or repetitive behavior
o Anger and fighting
o Impaired judgment
Physiological effects include:
o Tachycardia
o Elevated blood pressure
o Dilated pupils
o Perspirations or chills
o Nausea
o Chest pain
o Confusion
o Cardiac dysrhythmias
Overdose can result in seizure and comatose.
Death used to be rare. However, deaths
associated with these stimulants are increasing.
Withdrawal and Detoxification
Withdrawal occurs within a few hours to several
days after cessation of the drug and is not lifethreatening.
Marked dysphoria is the primary withdrawal
symptom, associated with:
o Fatigue
o Vivid and unpleasant dreams
o Insomnia or hypersomnia
o Increased appetite
o Psychomotor retardation or agitation
Marked withdrawal symptoms are referred to as
crashing;
o The
person may
experience
depressive symptoms such as suicidal
ideation
Stimulant withdrawal is not treated
pharmacologically
Cannabis
Cannabis sativa is the hemp plant, and is wildly
cultivated for its fiber used to make rope and
cloth, and for oil from its seeds.
It became widely known for its psychoactive
resin. The resin contains 60 substances called
cannabinoids.
Delta-9-tetrahydrocannabinol is thought to be
responsible for most of the psychoactive effects.
Marijuana refers to the upper leaves, flowering
tops, and stems.
Hashish refers to the dried resinous exudate
from the leaves of the female plant.
Cannabis is often smoked and can be eaten.
In the USA, many states may have legalized
medical marijuana use, recreational use, both,
or neither
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Research has shown that it has short-term
effects of lowering intraocular pressure, but is
not approves for the treatment of glaucoma
2 cannabinoids, Dronabinol and Nabilone, have
been approved for treating nausea and vomiting
from cancer chemotherapy
Cannabis-related drugs have shown promise in
the control of seizures
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 effects similar to alcohol:
o High feeling
o Lowered inhibitions
o Relaxation
o Euphoria
o Increased appetite
Intoxication effects include:
o Impaired motor coordination
o Impaired judgment and short-term
memory
o Distortions of time and perception
o Anxiety, dysphoria, and social
withdrawal may occur sometimes.
Physiological effects include:
o Conjunctival injection or bloodshot
eyes
o Dry mouth
o Hypotension
o Tachycardia
Excessive use may cause:
o Delirium
o Cannabis-induced psychotic disorder
o Both can be treated symptomatically
Withdrawal and Detoxification
No clinically significant withdrawal syndrome is
identified. Although some users report:
o Muscle aches
o Sweating
o Anxiety
o Tremors
Opioids
These are popular drugs of abuse because they
desensitize the user both physiological and
psychological pain and induce a sense of
euphoria and well-being.
Opioid compounds include potent prescription
analgesics and illegal substances.
Potent prescription drugs include:
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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o Morphine
o Meperidine
o Codeine
o Hydromorphone
o Oxycodone
o Methadone
o Oxymorphone
o Hydrocodone
o Propoxyphene
Illegal substances include:
o Heroin
o Illicitly produced fentanyl
o Normethadone
Fentanyl is a synthetic opioid used in clinical
settings for anesthesia. It is 50 to 100 times
more potent than morphine.
Illicitly produced fentanyl is thought to be
responsible for the dramatic increase in deaths
from an opioid overdose.
People who abuse opioids spend a great deal of
time in obtaining the drug. Either by engaging in
illegal activities. HCWs often write prescriptions
for themselves or divert prescribed pain
medications for clients to themselves.
Intoxication and Overdose
Opioid intoxication develops soon after the initial
euphoric feeling. Symptoms include:
o Apathy
o Lethargy
o Listlessness
o Impaired judgment
o Psychomotor retardation or agitation
o Constricted pupils
o Drowsiness
o Slurred speech
o Impaired attention and memory
Opioid overdose can lead to:
o Comatose
o Respiratory depression
o Pupillary constriction
o Unconsciousness
o Death
Treatment includes the administration of
Naloxone, an opioid antagonist, as it reverses
all the signs of opioid toxicity.
Naloxone is given every few hours until the
opioid level drops to nontoxic. This process
takes a few process
Higher doses of Naloxone are needed today
because of the synthetic opioid commonly used
today.
Withdrawal and Detoxification
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Opioid withdrawal develops when drug intake
ceases or decreases markedly, or can be
precipitated by the administration of opioid
antagonists.
Initial symptoms are:
o Anxiety
o Restlessness
o Aching back and legs
o Cravings for more opioids
Symptoms may progress to:
o Nausea and vomiting
o Dysphoria
o Lacrimation
o Rhinorrhea
o Sweating
o Diarrhea
o Yawning
o Fever
o Insomnia
Symptoms of opioid withdrawal cause
significant distress, but does not require
pharmacologic management.
Short acting drugs such as heroin produce
withdrawal symptoms in 6 to 24 hours; peak in
2 to 3 days and gradually subsides in 5 to 7
days.
Longer acting drug such as methadone may not
produce significant withdrawal symptoms for 2
to 4 days, and symptoms may take 2 weeks to
subside.
Substitution of methadone during detoxification
reduces symptoms to no worse than a mild case
of flu.
Withdrawal symptoms such as anxiety,
insomnia, dysphoria, anhedonia, and drug
craving may persist for weeks or months.
Hallucinogens
Substances that distort the user's perception of
reality and produce symptoms similar to
psychosis, including hallucinations (usually
visual) and depersonalization.
Can also cause increased pulse, blood
pressure, and temperature; dilated pupils; and
hyperreflexia.
Examples include mescaline, psilocybin,
lysergic acid diethylamide, and "designer drugs"
such as ecstasy. Phencyclidine (PCP) is also
included.
Intoxication and Overdose
Maladaptive behavioral or psychological
changes: anxiety, depression, paranoid
ideation, ideas of reference, fear of losing one’s
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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mind, and potentially dangerous behaviors such
as jumping out a window in the belief that one
can fly.
Physiological symptoms: sweating, tachycardia,
palpitations, blurred vision, tremors, and lack of
coordination
PCP intoxication often involves belligerence,
aggression, impulsivity, and unpredictable
behavior.
Toxic reactions to hallucinogens (except PCP)
are primarily psychological; overdoses as such
do not occur.
Psychotic reactions are managed best by
isolation from external stimuli; physical
restraints may be necessary for the safety of the
client and others.
PCP toxicity can include seizures, hypertension,
hyperthermia, and respiratory depression.
Medications are used to control seizures and
blood pressure. Cooling devices such as
hyperthermia blankets are used, and
mechanical ventilation is used to support
respirations.
Withdrawal and Detoxification
No withdrawal syndrome has been identified for
hallucinogens, though some people have
reported a craving for the drug. Hallucinogens
can produce flashbacks, which are transient
recurrences of perceptual disturbances like
those experienced with hallucinogen use. These
episodes occur even after all traces of the
hallucinogen are gone and may persist for a few
months up to 5 years.
Inhalants
A diverse group of drugs that include
anesthetics, nitrates, and organic solvents that
are inhaled for their effects.
The most common substances are aliphatic and
aromatic hydrocarbons found in gasoline, glue,
paint thinner and spray paint.
Less
frequently
used
halogenated
hydrocarbons include cleaners, correction
fluids, spray can propellants, and other
compounds containing esters, ketones, and
glycols.
Inhalants can cause significant brain damage,
peripheral nervous system damage, and liver
disease.
Intoxification and Overdose
Inhalant intoxication involves dizziness,
nystagmus, lack of coordination, slurred
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speech, unsteady gait, tremors, muscle
weakness, and blurred vision. Stupor and coma
can occur.
Behavioral
symptoms:
belligerence,
aggression, apathy, impaired judgment, and
inability to function.
Acute toxicity: anoxia, respiratory depression,
vagal stimulation, and dysrhythmias.
Death may occur from bronchospasm, cardiac
arrest, suffocation, aspiration of the compound,
or vomitus.
Treatment consists of supporting respiratory
and cardiac functioning until the substance is
removed from the body. There are no antidotes
or specific medications to treat inhalant toxicity.
Withdrawal and Detoxification
There are no withdrawal symptoms or
detoxification procedures for inhalants as such,
though frequent users report psychological
cravings. People who abuse inhalants may
suffer from persistent dementia or inhalantinduced disorders, such as psychosis, anxiety,
or mood disorders even if the inhalant abuse
ceases. These disorders are all treated
symptomatically.
Treatment and Prognosis
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Today, treatment for substance use is
available in a variety of community settings,
not all of which involve health professionals
Alcoholics Anonymous (AA) was founded in
the 1930s by alcoholics. This self-help
group developed the 12-step program
model for recovery
o Based on the philosophy that total
abstinence is essential and that
alcoholics need the help and
support of others to maintain
sobriety
Many treatment programs, regardless of
setting, use the 12-step approach and
emphasize participation in AA.
They also include individual counseling and
a wide variety of groups.
Clients being treated for intoxication and
withdrawal
or
detoxification
are
encountered in a wide variety of medical
settings from emergency departments to
outpatient clinics.
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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If the client cannot remain sober during
outpatient treatment, then inpatient
treatment may be required.
Acamprosate
(Campral)
Pharmacologic Treatment
Drug
Nursing
Considerations
Dosage
Alcohol Withdrawal Drugs
Lorazepam
2–4 mg every
(Ativan)
2–4 hours
PRN
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Chlordiazepoxide
(Librium)
50–100 mg,
repeat in 2–4
hours if
necessary;
not to exceed
300 mg/day
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Maintains abstinence from alcohol
Disulfiram
500 mg/day
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(Antabuse)
for 1–2
weeks, then
250 mg/day
Maintains abstinence from heroin
Methadone
Up to 120
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(Dolophine)
mg/day for
maintenance
Maintains abstinence from opiates
Levomethadyl
60–90
mg •
(Orlaam)
three times a
week
for
maintenance
Monitor VS
Monitor
effectiveness
May cause
dizziness or
drowsiness
Monitor VS
Monitor
effectiveness
May cause
dizziness or
drowsiness
Teach client to
read labels to
avoid products
with alcohol
May cause
nausea and
vomiting
Do not take drug
on consecutive
days; take-home
doses are not
permitted
Buprenorphine/
4/1 mg–24/6 •
May
cause
naloxone
mg daily for
orthostatic
(Suboxone)
maintenance
hypotension,
sedation
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Avoid
CNS
depressants
Blocks the effects of opiates; reduces alcohol cravings
Naltrexone
350
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Client may not
(ReVia, Trexan)
mg/week,
respond
to
divided into
narcotics used
three doses
to treat cough,
for
opiatediarrhea,
or
blocking
pain;
effect;
50 •
Take with food
mg/day for up
or milk
to 12 weeks •
May
cause
for alcohol
headache,
cravings
restlessness, or
irritability
Suppresses opiate withdrawal symptoms
Clonidine
0.1 mg every •
Take
blood
(Catapres)
6 hours PRN
pressure before
each dose
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Withhold if client
is hypotensive
Suppresses alcohol cravings
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666 mg three
times daily
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Monitor
for
diarrhea,
vomiting,
flatulence, and
pruritis
Vitamins and Supplements
Thiamine
100 mg/day
(vitamin B1)
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Folic acid (folate)
1–2 mg/day
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Cyanocobalamin
(vitamin B12)
25–250
µg/day
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Teach
client
about
proper
nutrition
Teach
client
about
proper
nutrition
Teach
client
about
proper
nutrition
Dual Diagnosis
The client with both substance abuse and
another psychiatric illness is said to have a dual
diagnosis.
Dual diagnosis clients who have schizophrenia,
schizoaffective disorder, or bipolar disorder
present the greatest challenge to health care
professionals.
It is estimated that 50% of people with a
substance abuse disorder also have mental
health diagnoses.
Traditional methods for treatment of major
psychiatric illness or primary substance abuse often
have limited success
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Clients with a major psychiatric illness may have
impaired abilities to process abstract concepts.
Substance abuse has no limited recovery
concept.
The use of alcohol and other drugs can
precipitate psychotic behavior
Clients with a dual diagnosis (substance use
and mental illness) present challenge that
traditional settings cannot meet.
Several key elements that need to be addressed
include healthy, nurturing, supportive living
environments
Clients identified the need for stable housing,
positive social support, using prayer or relying
on a higher power, participation in meaningful
activity, eating regularly, getting sufficient sleep,
and looking presentable as important
components of relapse prevention
Application of the Nursing Process
Assessment
History
General Appearance and Motor Behavior
Mood and Affect
ALAS, BACO, BALLESCAS, OGA, PUNZALAN
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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Thought Process and Content
Sensorium and Intellectual Processes
Judgment and Insight
Self-Concept
Roles and Relationships
Physiological Considerations
History
Clients with a parent or other family members
with substance abuse problems may report a
chaotic family life, though this is not always the
case
Physical Problems or Development of
Withdrawal Symptoms
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.
Depending on their overall health status and any
health problems resulting from substance use,
clients may appear physically ill.
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.
Irritability is common because clients are newly
free of substances.
Thought Process and Content
Clients are likely to minimize their substance
use, blame others for their problems, and
rationalize their behavior.
Focus their attention on finances, legal issues,
or employment problems as the main source of
difficulty rather than their substance use.
Sensorium and Intellectual Processes
Clients generally are oriented and alert unless
they are experiencing lingering effects of
withdrawal.
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Self-Concept
Clients generally have low self-esteem, which
they may express directly or cover with
grandiose behavior.
They do not feel adequate to cope with life and
stress without the substance and are often
uncomfortable around others when not using.
Roles and Relationships
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Judgment and Insight
Clients are likely to have exercised poor
judgment, especially while under the influence
of the substance.
Difficulty acknowledging their behavior while
using or may not see loss of jobs or relationships
as connected to the substance use.
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Clients usually have experienced many
difficulties with social, family, and occupational
roles. Absenteeism and poor work performance
are common
Relationships in the family are often strained.
Clients may be angry with family members who
were instrumental in bringing them to treatment
or who threatened loss of a significant
relationship.
Physiological Considerations
Many clients have histories of poor nutrition
(using rather than eating) and sleep
disturbances that persist beyond detoxification
Liver damage, Hepatitis, HIV infection from drug
use.
Data Analysis
Dysfunctional Family Processes: Alcoholism
Imbalanced Nutrition: Less than body
requirements.
Ineffective Denial
Ineffective Coping
Outcome Identification
The client will abstain from alcohol and drug
use.
The client will express feelings openly and
directly.
The client will verbalize acceptance of
responsibility for his or her own behavior.
The client will practice nonchemical alternatives
to deal with stress or difficult situations.
The client will practice nonchemical alternatives
to deal with stress or difficult situations.
Intervention
Substance abuse is an illness.
Dispel myths about substance abuse.
ALAS, BACO, BALLESCAS, OGA, PUNZALAN
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NCM 76. Psychiatric Nursing
2nd Semester, SY 2022-2023
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Prescribed medication can be an abused
substance.
Abstinence from substances is not a matter of
willpower.
Feedback from family about relapse signs, for
example, a return to previous maladaptive
coping mechanisms, is vital.
Any alcohol, whether beer, wine, or liquor, can
be an abused substance.
Addressing Family Issues
○ Alcoholism (and other substance
abuse) is often called a family illness.
○ Codependence is a maladaptive
coping pattern on the part of family
members or others resulting from a
prolonged relationship with the person
who uses substances.
Characteristics of Codependence
Poor relationship skills
Excessive anxiety
Worry
Compulsive behaviors
Resistance to change.
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Set realistic goals such as staying sober today
Evaluation
The effectiveness of substance abuse treatment
is based heavily on the client’s abstinence from
substances. In addition, successful treatment
should result in more stable role performance,
improved interpersonal relationships, and
increased satisfaction with quality of life.
Promoting Coping Skills
The nurse can help clients focus on the present,
not the past. It is not helpful for clients to dwell
on past problems and regrets.
The nurse can encourage clients to set
attainable goals such as, “What can I do today
to stay sober?” instead of feeling overwhelmed
by thinking “How can I avoid substances for the
rest of my life?” Clients need to believe that they
can succeed.
Characteristics of Codependence
Codependent Behavior: Enabling
Codependent behaviors have also been
identified in health care professionals when they
make excuses for a client’s behavior or do
things for clients that clients can do for
themselves.
Addressing Family Issues
Children of alcoholics:
○ Inability to trust
○ An extreme need to control,
○ An excessive sense of responsibility,
and denial of feelings; these
characteristics persist into adulthood.
Without support and help to understand and cope,
many family members may develop substance
abuse problems of their own, thus perpetuating the
dysfunctional cycle
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Nursing Interventions
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
ALAS, BACO, BALLESCAS, OGA, PUNZALAN
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