Running head: A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
A Concept Analysis: Substance Withdrawal
Dayle Lauren
Stenberg College
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A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
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A Concept Analysis: Substance Withdrawal
The concept of substance withdrawal is a valid reality in nursing when dealing with any
patient in a mental health setting, given the fact that the majority of those with mentally health
issues have co-existing substance abuse issues (Luoma, Kohlenberg, Hayes, Bunting, & Rye,
2008). This paper will analyze the concept of substance withdrawal by discussion of its defining
characteristics such as the existence of an addiction to a substance, the presence of mood
disorders, and the indicative symptoms of detoxification or withdrawal. As well, the paper will
attempt to highlight relevant nursing interventions to be incorporated into nursing practice.
Substance withdrawal is defined as “symptoms associated with abrupt stopping of
excessive use of alcohol or drugs. Features may include anxiety, tremor, sweating, and vivid and
terrifying visual and sensory hallucinations” ("Substance Withdrawal," 2012). Existing
addiction to substances, whether illicit drugs, alcohol or tobacco products, can result in substance
withdrawal when the ingestion of these substances is suddenly ceased. The autonomic nervous
system that innervates the muscles of the heart, gastrointestinal tract, and glands then becomes
over-reactive and the body enters a state of stress ("Alcohol and Other Substance Use
Withdrawal," 2004). Substantial physiological changes can occur while withdrawing from
substance use, especially in older adults, resulting in nausea, vomiting, diarrhea, dizziness,
increased blood pressure, increased heart rate, or seizures; any of which could lead to further
withdrawal crisis, showing symptoms such as hallucinations, stroke, seizure or coma (“Alcohol
and Other Substance Use Withdrawal”, 2004). If left untreated, a risk for serious complications
and death exists.
It is crucial as a nurse to be able to include appropriate questions and substance use
history in the initial patient intake assessment to establish whether or not the patient has a
A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
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substance abuse or addiction problem to which withdrawal from such will impact their care.
Substance use is implicated in approximately 50% of admitted psychiatric patients (Cooper,
2009). The term ‘dual diagnosis’ is commonly used in reference to patients who experience coexisting mental health and substance use problems (Cooper, 2009). Cooper posits this term is
highly criticized as only focusing on two distinct problems, leading to the possibility of
inappropriate interventions, and seemingly ignores the fact that most of these individuals
experience a multitude of problems that need to be considered (2009). Not all patients will be
forthcoming in admitting to their addiction problems as many people addicted to substances are
in denial about their substance use, or they simply refute any issues in order to avoid stigma or
self-stigma (Luoma et al., 2008). In fact, as stated by Luoma et al., (2008), self-stigma can be
found most extensively within the mentally ill. As further defined by Luoma et al., (2008), selfstigma is characterized by shame, evaluative thoughts, and fear of enacted stigma, as a result of
the individuals’ association with a stigmatized group that “acts as a barrier to the pursuit of
valued life goals” (p. 150, para. 2). Self-stigma in this group is also directly associated with
delays in seeking treatment, lower quality of life and deficits in self-esteem and self-efficacy
(Luoma et al., 2008). In the nursing care of patients with substance-induced disorders such as
intoxication, withdrawal, delirium, dementia, amnesia, psychosis, mood disorder, anxiety
disorder and sexual dysfunction, proper assessment tools and screening methods must be part of
the initial intake in order to implement a preventative and thorough care plan (Townsend, 2011).
A thorough understanding of what substances the patient has been abusing and potentially
withdrawing from is also necessary in order to be able to anticipate withdrawal symptoms and
subsequent treatment options. According to Cooper (2009), “alcohol, tobacco and cannabis are
the most commonly used substances among individuals with a mental health problem...”
A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
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(Cooper, 2009, p. 253). Understanding why a person is dependent or uses substances is essential
for developing a progressive treatment program, and approaching a therapeutic relationship with
the right strategies in mind. Some of the theories that abound as to why those with mental health
issues use substances are stated as being due to the same reasons that anyone else in the
community would do so, as an attempt to alleviate mental health symptoms, as a method of
coping, or to reduce side effects of medication (Cooper, 2009). When substance abuse becomes
a factor in the development of a treatment plan for a patient, nursing interventions will expand to
include such considerations as assessment of the patient’s level of disorientation, obtaining
necessary lab tests, instituting proper safety precautions, developing a trusted nurse-patient
relationship, conveying an attitude of acceptance toward patient and educating patient in order to
correct any misconceptions surrounding substance abuse, setting limits and boundaries on
manipulative behaviours, encouraging the patient to openly express feelings, fears and anxieties,
and reviewing family history, support and relationships to further educate on substance use,
misuse, withdrawal and offer support for the patient, and ongoing monitoring and assessment of
nutritional intake (Townsend, 2011). Interventions of the substance abusing patient should be
based on their beliefs and understanding surrounding substance abuse, according to Cooper
(2009). Cooper proposes the use of Osher and Kofoed’s four-stage model of treatment for
individuals with co-existing problems: this model builds up the treatment plan with the following
phases: engagement, motivation, active treatment and relapse prevention (2009). During the
engagement stage, the therapeutic relationship is built on empathy, non-judgmental approach and
understanding, and non-confrontational respect (Cooper, 2009). The motivational stage
encompasses motivational interview processes, in which a non-confrontational approach is used
to further explore the patient’s ambivalence and motivation to change (Cooper, 2009). Thirdly,
A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
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Cooper explains that the active treatment stage can only take place and progress if the goals are
realistic and set by the patient: the nurse can assist in this phase where needed, to ensure that the
goals are realistic and achievable in order to prevent feelings of self-worthlessness or failure
(2009). The relapse prevention phase includes a strong educational element, with information
and counseling for the patient in how to recognize early warning signs of relapse, management of
their anxiety and effective coping skills training (Cooper, 2009). This phase will likely continue
outside of the in-patient setting and must therefore take into consideration the available resources
in the community and patient environment. This may entail making referrals or advocating for
proper housing, financial assistance, ongoing counseling and therapy, or further evaluation and
monitoring. Many provincial and federal programs exist that the nurse must be privy to in order
to establish a thorough relapse prevention plan that will follow the patient out of the care unit,
such as mentoring and sponsorship in 12 step programs within the community, monitoring by
social workers and community support workers, and follow up by psychiatrists and regular
physicians. It is not effective nursing for the nurse to simply treat the symptoms of substance
withdrawal without consideration of the underlying addiction; approaching the patient as
someone with a substance abuse issue in a respectful and dignified and caring manner offers the
patient the best opportunity for a successfully maintained period of abstinence (Fernandez,
2009).
Mood disorders are another characteristic that define the concept of substance
withdrawal. Studies in the past two decades have shown that “the prevalence of co-occurring
Axis I and Axis II disorders in substance abuse patients is high” (Franken & Hendriks, 2001, p.
30). Specifically, Franken & Hendriks, (2001) posit that mood disorders and anxiety are the
most prevalent comorbid disorder in this population of patients, with over half (70%) of this
A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
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group having lifelong mood disorders identified; therefore, a variety of screening methods must
exist by way of psychiatric interviews and semi-structured or structured interviews. Psychiatric
symptoms are commonly confounded by underlying detoxification symptoms, and therefore
psychopathological screening methods are stressed in all admittance procedures (Franken &
Hendriks, 2001). Mood disorders can be a result of many underlying factors, such as biological,
physiological, or as side effects of medications (Townsend, 2011). In methamphetamine users,
depression and other psychiatric symptoms are highly correlated with intensity of
methamphetamine cravings (Nakama, Chang, Cloak, Jiang, Alicata, & Haning, 2008). Nursing
care plans that address the concept of substance withdrawal must therefore also take into
consideration the underlying mood disorders or anxiety that exist within the substance dependent
patient. Interventions should include assessment and monitoring of the patient’s mood, the
stimulation levels of their environment, the establishment of monitoring and intervention
techniques/protocol for handling escalation levels in high-risk or violent patients, ongoing
observation of any disturbed thought processes, monitoring of sleep patterns, the administration
of proper medications, and the teaching of coping mechanisms (Townsend, 2011). Mood
changes in the substance-abusing patient may also be acute as their bodies become devoid of
their substance of choice, leaving their emotions to feel ‘raw’ and exposed: frequently, substance
abuse is a method of coping, and once this coping method is absent, the patient may develop
acute symptoms of mood disorders; ongoing assessment according to Townsend is therefore
necessary, as this will aid in setting realistic goals with the patient suffering from withdrawal
symptoms in order to help them deal with fluctuating anxiety levels (2011).
Likely the most pronounced characteristic of the substance withdrawal concept is the
presence of detoxification or withdrawal symptoms. These can present themselves in a myriad
A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
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of different ways, dependent on what substance or substances the patient has been abusing.
Common withdrawal symptoms manifest from abuse of tobacco, alcohol, medications or street
drugs; equivocally prevalent among mentally ill individuals, as cited earlier by Luoma et al,
(2008). Many of the withdrawal symptoms experienced can present as dementia, psychosis,
mood changes, seizures and tremors, often being mistaken for other mental illnesses ("Alcohol
and Other Substance Use Withdrawal," 2004). Furthermore, the signs and symptoms of alcohol
withdrawal can easily be misdiagnosed as electrolyte imbalance, pain or infection (Riddle, Bush,
Tittle, & Dilkhush, 2010). Patients who are experiencing withdrawal symptoms from alcohol
may likely require benzodiazepines to help with the symptom management as their bodies are
struggling with adjusting to a sudden cessation of substances (“Alcohol and Other Substance Use
Withdrawal”, 2004). Riddle et al., (2010) illustrate the fact that the treatment of symptoms
seems to be more beneficial than scheduled doses of medications for the detoxing patient,
resulting in less medication for less time. For a patient addicted to psychotropic medications,
withdrawal from these medications will require a slow, gradual tapering in order to prevent
unwanted and uncomfortable and potentially dangerous withdrawal symptoms ("Alcohol and
Other Substance Use Withdrawal," 2004). The withdrawal process will require much support
and understanding from the nursing staff, an open and honest therapeutic relationship built on
trust and respect, as well as a strong, holistic approach to treatment of all comorbid presentations
of substance withdrawal (Cooper, 2009). Modalities such as counseling and therapy should also
become part of the treatment plan, such as implementation of Barker’s Tidal Model, or the use of
techniques such as Psychodrama, in order to assist the patient in dealing with underlying issues
that exacerbate their substance abuse.
A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
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In summary, substance withdrawal is a concept that has far reaching implications in
mental health treatment. The three characteristics outlined in this paper (existence of an
addiction, co-morbid mood disorders, and symptoms of withdrawal or detoxification), and the
fact that the concept of substance withdrawal would not exist without these characteristics,
further validates the existence of substance withdrawal as a substantial consideration in nursing
diagnoses. A prudent and effective nurse must be sure to then consider the effects and
implications of substance withdrawal in any mental health patient as a highly possible reality,
and should therefore develop and implement their care plan with this concept in mind, as a
means of creating the most progressive, effective and respectful approach to their mental health
care and wellbeing. Methods of intervention when considering the concept of substance
withdrawal within the nursing process would be highly strategic, broad and detailed in order to
properly consider all causal factors surrounding the patient’s diagnosis. This is only possible
with a thorough understanding of appropriate and pertinent mental health and addiction
modalities, the appropriate and most effective means of intervention based on the individual’s
needs, beliefs and values, communication, understanding, respect, therapy, and ongoing support.
The treatment plan for any patient in which the nurse must consider the concept of substance
withdrawal should encompass motivational interviewing techniques, cognitive–behavioral
therapy or other effective therapeutic modalities, a strong yet achievable relapse prevention plan,
a holistic and respectful harm reduction plan, and monitored and regimented medication
management plan; in short, a well-rounded and holistic and humanistic approach to care
(Cooper, 2009).
A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
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References
Best practices: alcohol and other substance use withdrawal. (2004). Retrieved from
http://www.agingincanada.ca/BEST_7.PDF
Cooper, P. D. (2009). The person who experiences mental health and substance use problems. In
P. Barker (Ed.), Psychiatric and Mental Health Nursing: The craft of caring (2nd ed., pp.
252-261). London, United Kingdom: Edward Arnold (Publishers) Ltd.
Fernandez, J. (2009, August). Nurse-led detox in primary care. Journal of Community Nursing,
23, 18-22. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010393233&site=eho
st-live
Franken, I. H., & Hendriks, V. M. (2001). Screening and diagnosis of anxiety and mood
disorders in substance abuse patients. The American Journal on Addictions, 10, 30-39.
Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=4318692&site=ehostlive
Luoma, J. B., Kohlenberg, B. S., Hayes, S. C., Bunting, K., & Rye, A. K. (2008, April).
Reducing self-stigma in substance abuse through acceptance and commitment therapy:
Model, manual development, and pilot outcomes. Addiction Research and Theory, 16,
149-165. http://dx.doi.org/10.1080/16066350701850295
Nakama, H., Chang, L., Cloak, C., Jiang, C., Alicata, D., & Haning, W. (2008). Association
between psychiatric symptoms and craving in methamphetamine users. The American
Journal on Addiction, 17, 441-446. http://dx.doi.org/10.1080/10550490802268462
A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
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Riddle, E., Bush, J., Tittle, M., & Dilkhush, D. (2010, June). Alcohol withdrawal: Development
of a standing order set. Critical Care Nurse, 30, 38-47.
http://dx.doi.org/10.4037/ccn2010862
Substance withdrawal. (2012). In Mental health glossary. Retrieved from
http://www.theroyal.ca/en/mental-health-at-the-royal/mental-health-glossary/
Townsend, M. C. (2011). Nursing diagnoses in psychiatric nursing: Care plans and
psychotropic medications (8th ed.). Philadelphia, PA: F.A. Davis Company.
A CONCEPT ANALYSIS: SUBSTANCE WITHDRAWAL
Grade
Graded on
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58.00 / 60.00
Friday, 1 February 2013, 7:09 AM
Vicki Hammond
Evaluation Criteria – Written Assignment: Thank you for such an interesting
paper. The topic is quite relevant in that the issue of substance misuse and
withdrawal is prevalent in all areas of nursing. In terms of APA my suggestion is
to avoid the run on paragraphs, as it can be distracting to the reader. Overall you
have done an excellent job, with a fairly complex subject and great selection of
references!
Content (85%) 50 / 51
Introduction, Adherence to topic discussed, depth of topic
Evidence of critical thought and synthesis of ideas &development of ideas
Feedback
comments
Relevance to psychiatric nursing
Conclusion
Structure and Scholarly Presentation (15%) 8 / 9
Length 2000 words, identification of topic to be discussed
Organization, APA format adhered to (quotations, citations, references)
Reference list (appropriate, comprehensive, congruent)
Grammar (spelling, punctuation, sentence structure)