Substance Abuse
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Substance Abuse
o The actual prevalence of substance abuse is difficult to determine
o Detrimental effects of substance abuse include:
 Workplace injuries
 Homicide
 Motor vehicle accidents and fatalities
 Domestic abuse
 Child abuse and neglect
o Affects males and females of all ages, cultures, and socioeconomic groups
o Commonly coexists with (and complicates the treatment) of other psychiatric disorders
 Dual Diagnosis
o Increasing numbers of babies are being born to substance-addicted mothers
o Many people with emotional disorders or mental illness use drugs to self medicate
o Many people abuse a combination of substances
o Substances of abuse may be any chemical used therapeutically or recreationally
o Commonly leads to physical dependence, psychological dependence, or both
Etiology
o Biologic factors
 Genetic vulnerability
 Neurochemical influences
o Psychological factors
 Familial dynamics
 Coping Styles
o Social and environmental factors
Cultural Considerations
o Wine is an integral part of Jewish religious rites
o Some Native Americans tribes use peyote in religious ceremonies
o Certain ethnic groups have genetic traits that either predispose them or protect them from developing alcoholism
o Alcohol abuse plays a part in the 5 leading causes of death for Native Americans
Diagnostic Classes
o Alcohol
o Amphetamines
o Caffeine
o Cannabis
o Cocaine
o Hallucinogens
o Inhalants
o Nicotine
o Opioids
o PCP
o Sedatives, hypnotics, or anxiolytics
Definitions
o Substance abuse – using a drug in a way that is inconsistent with medical or social norms and it is done despite
negative consequences
o Substance dependence – tolerance, withdrawal, and unsuccessful attempts to try to stop using that drug. The
word dependence means it’s a physiological need to use that drug. We use the drug to prevent withdrawal
symptoms
o Intoxication – the use of a substance that results in a maladaptive behavior
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Withdrawal – a set of symptoms you can get when you are not getting the substance that your body is addicted to.
Can range from HA to seizures
o Detoxification – the process of safely withdrawing from that substance. Many people can’t detox by themselves,
on their own.
Onset/Clinical Course
o Typically begins with the first episode of intoxication between 15 and 17 years of age
o More severe difficulties begin in the middle 20s-30s
 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
 Significant interference with functioning at work or school
o Blackout drinking in which the person continues to function but has no conscious awareness of their behavior at
the time nor any later memory of the behavior
o As the person continues to drink, they often develop a tolerance for alcohol; that is, they need more alcohol to
produce the same effect
o After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of
alcohol will intoxicate the person
o During the later course of alcoholism, when the person’s functioning definitely is affected, periods of abstinence or
temporarily controlled drinking occur
Alcohol
o Central nervous system depressant
o Overdose can result in vomiting, unconsciousness, and respiratory depression
o Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake
o Alcohol withdrawal usually peaks on the second day and is over in about 5 days
o Very important to ask when their last drink was. You need to know when the withdrawal symptoms will start
Alcohol Withdrawal
o Withdrawal symptoms include:
 Coarse hand tremors, sweating, elevated pulse, elevated blood pressure, insomnia, anxiety, and nausea or
vomiting
 Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium – called
delirium tremens (DTs)
o Withdrawal symptoms monitored using an assessment tool
Pharmacologic Treatment
o Safe withdrawal from alcohol involves:
 Benzodiazepines to suppress withdrawal symptoms (Ativan, Librium, Valium)
 Vitamin B1 (thiamine) to prevent or to treat Wernicke’s syndrome and Korsakoff’s syndrome
 Thiamine is necessary for metabolism, effects nervous system, circulatory system, GI system.
 Vitamin B12 (cyanocobalamin) or folic acid for nutritional deficiencies
Wernicke-Korsakoff Syndrome
o These usually aren’t reversible…
o Wernicke’s encephalopathy
 An inflammatory, hemorrhagic, degenerative, condition of the brain; characterized by lesions in several
parts of the brain
 Double vision, involuntary rapid movements of eyes, paralysis of eyes, lack of muscular coordination,
decreased mental function, peripheral neuropathy
 Caused by thiamine deficiency
o Korsakoff’s syndrome (psychosis)
 A form of amnesia characterized by a loss of short-term memory and an ability to learn new skills; usually
disoriented, may present with delirium, hallucinations, and confabulates to conceal the condition
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Can often be traced to a degenerative change in the thalamus as a result of a deficiency of B complex
vitamins – especially thiamine and B12
Medical Complications of Alcoholism
o Gastritis
o Cirrhosis
o Pancreatitis
o Diabetes
o Malnutrition
o Esophageal varices
o Peripheral neuropathy
Sedatives, Hypnotics, and Anxiolytics
o Central nervous system depressants
 Barbiturates, nonbarbiturate hypnotics, and anxiolytics
o Benzodiazepines alone, when taken orally in overdose
 Romazicon given for overdose
o Barbiturates, in contrast, can be lethal when taken in overdose; they can cause coma, respiratory arrest, cardiac
failure, and death
o Withdrawal symptoms occur in 6 to 8 hours or up to 1 week, depending on the half-life of the drug
o Withdrawal syndrome is characterized by symptoms opposite of the acute effects of the drug:
 Autonomic hyperactivity (increased pulse, blood pressure, respirations, & temperature), hand tremor,
insomnia, anxiety, nausea, and psychomotor agitation
 Seizures and hallucinations occur rarely in benzodiazepine withdrawal
o Detoxification is managed by tapering
 To prevent seizures
Stimulants: Amphetamines, Cocaine, Methamphetamine, etc.
o Central nervous system stimulants
o Overdoses can result in seizures and coma
o Withdrawal occurs within hours to several days
o Withdrawal syndrome:
 Dysphoria accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased
appetite, psychomotor retardation or agitation, and depressive symptoms including suicidal ideation for
several days
o Stimulant withdrawal is not treated pharmacologically
 Psychological withdrawal is more severe than physiologic withdrawal
 Looks a lot like paranoid schizophrenia
 Formication – the feeling like there are bugs or whatever crawling under your skin. Also called “coke
bugs”
Cannabis (Marijuana)
o Used for its psychoactive effects
o Excessive use of cannabis may produce delirium or cannabis-induced psychotic disorder; overdoses do not occur
o Withdrawal symptoms:
 Insomnia, muscle aches, sweating, anxiety, and tremors
o Effects are treated symptomatically
Opioids (narcotics)
o Central nervous system depressants
 Demerol, morphine, heroine, oxycontin, methadone
o Overdose can lead to coma, respiratory depression, pupillary constriction, unconsciousness, and death
o Withdrawal:
 Short-acting drugs begin in 6 to 24 hours, peak in 2 to 3 days, and gradually subside in 5 to 7 days
 Longer-acting drugs begin in 2 to 4 days, subsiding in 2 weeks
o Withdrawal symptoms:
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 Withdrawal does not require pharmacologic intervention
 Administration of Narcan is the treatment of choice for overdose
 Methadone can be used as a replacement for heroin, serving to reduce cravings
 These have the least complicated withdrawal symptoms
Hallucinogens
o Distort reality and produce symptoms similar to psychosis including hallucinations (usually visual) and
depersonalization
 Shrooms, LSD, mescaline, ecstasy
 Synesthia – blending of all the senses
o Toxic reactions to hallucinogens (except PCP) are primarily psychological; overdoses as such do not occur; PCP
toxicity can include seizures, hypertension, hyperthermia, and respiratory depression
o Hallucinogens can produce flashbacks which may persist from a few months to 5 years
 “Bad trip”
o Treatment is supportive:
 Isolation from external stimuli; physical restraints; for PCP, medications to control seizures and blood
pressure; cooling devices; mechanical ventilation
Inhalants
o Inhaled for their effects
o Overdose:
 Anoxia, respiratory depression, vagal stimulation, dysrhythmias
 Death may occur from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or
vomitus
 People who abuse inhalants may suffer from persistent dementia or inhalant-induced disorders such as
psychosis, anxiety, or mood disorders even if the inhalant abuse ceases
o Withdrawal symptoms: none
o Treatment:
 Support respiratory and cardiac functioning until the substance is removed from the body
 May present with mouth ulcers, confusion, ataxia
Substance Abuse Treatment
o Treatment based on concept that alcoholism/drug addiction are medical illnesses: chronic, progressive, and
characterized by remissions and relapses
o Settings
 Emergency department/medical or chemical dependency unit
 Outpatient/extended treatment
 Halfway houses
o Programs
 AA/NA
 Individual and group counseling
Pharmacologic Treatment
o Has 2 main purposes:
 To permit safe withdrawal from alcohol, sedative/hypnotics, and benzodiazepines
 Prevent relapse
o Relapse Prevention
 Antabuse – alcohol and studies being done for cocaine addiction
 Campral – new one for alcohol
 Methadone – used for heroine
 ReVia – opioid antagonist sometimes used to treat overdose
 Catapres – lessen effects of withdrawal
 Zofran – using in young males that are at high risk for alcohol dependence, also treatment for meth
addiction, they’re doing studies to see these effects
o Off-Label Uses
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Nursing Process
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Antabuse – use for cocaine addiction
Provigil – can become addictive itself
Inderal – alcohol withdrawal
Topamax – alcohol withdrawal
The nurse may encounter patients with substance problems in various settings unrelated to mental health
 Seeking treatment of medical problems related to alcohol use
 Withdrawal symptoms may develop while in the hospital for surgery or an unrelated condition
 Be alert to the possibility of substance use in these situations and be prepared to make appropriate
referrals
Assessment
 History: chaotic family life, family history, crisis that precipitated treatment
 General appearance/motor behavior: depends on physical health; likely to be fatigued, anxious
 Mood/affect: may be tearful (expressing guilt and remorse), angry, sullen, quiet, unwilling to talk
 Thought process/content: minimize substance use, blame others, rationalize behavior, say can quit on
their own
 Sensorium/intellectual processes: alert and oriented; intellectual abilities intact (unless neurologic deficits
from long-term alcohol or inhalants)
 Judgment/insight: poor judgment while intoxicated and due to cravings for substance; insight limited
 Self-concept: low self-esteem, feels inadequate coping with life
 Roles/relationships: strained relationships and problems with role fulfillment due to substance use
 Physiologic considerations: may have trouble eating, sleeping; HIV risk if IV drug user
Data analysis
 Nursing diagnoses common to physical health needs:
 Diarrhea
 Risk for injury
 Risk for infection
 Activity intolerance
 Self-care deficits
 Excess fluid volume
 Imbalanced nutrition: less than body requirements
 Nursing diagnoses common to psychosocial health needs:
 Ineffective denial
 Ineffective coping
 Ineffective role performance
 Ineffective family process
Outcomes
 The patient will:
 Abstain from alcohol/drugs
 Express feelings openly and directly
 Accept responsibility for own behavior
 Practice non chemical alternatives to deal with stress or difficult situations
 Establish an effective aftercare plan
Interventions
 Adequate pharmacological treatment
 Monitoring of vital signs
 Control nausea and vomiting
 Assess fluid and electrolyte balance
 Assess nutritional status
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 Provide safe environment
 Assess for suicide potential
 Encourage participation in groups
 Do not reinforce feelings of worthlessness
 Help to see relapse as opportunity for learning
 Be firm and consistent –manipulation
 Set limits – demanding
 Enforce rules, help strengthen impulse control –acting out
 Place responsibility on patient – dependency
 Help patient make realistic self-appraisals and expectations – superficiality
o Evaluation
 Is the patient abstaining from substances?
 Is the patient more stable in their role performance?
 Does the patient have improved interpersonal relationships?
 Is the patient experiencing increased satisfaction with quality of life?
Elder Considerations
o Estimates are that 30% to 60% of elders in treatment began drinking abusively after age 60
o Risk factors for late-onset substance abuse in elders:
 Chronic illness that causes pain; long-term use of prescription medication (sedative-hypnotics,
anxiolytics); life stress; loss; social isolation; grief; depression; an abundance of discretionary time and
money
o Elders may experience physical problems associated with substance abuse more quickly
Mental Health Promotion
o Public awareness and educational advertising
o Early identification of older adults with alcoholism
o The College Drinking Prevention Program
Substance Abuse in Health Professionals
o Higher rates of dependence on controlled substances
o Ethical and legal responsibility to report suspicious behavior
o Texas Peer Assistance Program for Nurses (TPAPN)
 Texas Peer Assistance Program for Nurses
 Available for LVNs and RNs of Texas whose practice has been impaired due to the effects of psychiatric or
substance abuse disorders
 Operates under state legislation, Chapter 467, Texas Health and Safety Code & NPA of Texas
 A project of the Texas Nurses Foundation
 TPAPN’s Mission
 Offer nurses life-renewing opportunities for recovery from substance use and psychiatric
disorders
 Integrate nurses back into the profession, thus
 Protect the public, and
 Promote professional accountability
 TPAPN Serves in Two Complementary Ways
 As a voluntary, confidential & non-punitive alternative to BON investigation emphasizing
rehabilitation & monitoring of nurses’ practice/recovery; and
 As a voluntary & non-confidential option under BON licensure discipline emphasizing
rehabilitation & monitoring of nurses’ practice/recovery
 TPAPN Serves to…
 Keep good nurses with bad diseases who are motivated to find and maintain recovery while
helping them to return to safe nursing practice – most often improved nursing practice.
 TPAPN serves…
 RNs and LVNs of Texas with at least one of the following diagnoses:
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Substance Use Disorders (SUDS)
 Substance abuse
 Substance dependency
 (Alcoholism, prescription drug abuse or dependence, illicit drug abuse or
dependence like cocaine, marijuana, crystal meth, opioids, etc.)
 Psychiatric Disorders
o Anxiety disorders
o Bipolar disorder
o Major depression
o Schizophrenia
o Schizoaffective disorder
 Note: 8% of all TPAPN participants are psychiatric only
How Does TPAPN Work?
 Holds nurses accountable for working a recovery program and obtaining appropriate support
 Must demonstrate good recovery for a minimum of 2 yrs (3 yrs of APN)
 Must demonstrate safe nursing practice by working as a nurse for at least 1 year of their
participation
 Nurses should not have to lose jobs or licenses without first being offered the opportunity for
education, treatment, and recovery for chronic, progressive, and potentially fatal diseases
 However, nurses whose psychiatric illness or substance use prevents them from practicing
nursing safely must be referred to the BON
Substance Abuse
o Classic Signs
 Changes in behaviors & practice usually seen before physical changes are seen
 Co-workers observe pattern/change over time- deterioration
 Work is often the last thing “to go”
 High level of functioning before “hitting bottom”
 May justify use (abuse) through RX meds
 Increasingly isolated over time
 Denial!
 At work, but not “on the job”
o Other Warning Signs
 Incorrect drug counts
 Excessive controlled substances listed as wasted or contaminated
 Reports by patients of ineffective pain relief from medications especially if relief had been adequate
previously
 Damaged or torn packaging on controlled substances
 Unexplained absences from the unit
 Trips to the bathroom after contact with controlled substances
 Consistent early arrivals at or late departures from work for no apparent reason
Psychiatric Impairment
o Signs
 Chronic, depressed mood, lack of focus, crying…
 Difficulty completing tasks
 Increased absenteeism
 Mood swings – cyclical in nature
 Hyperactivity, grandiosity, pressured speech…
 Attention & memory deficits
 Anxiety that impairs practice, memory, etc.
 Rage or disruptive behaviors
 Bizarre (as in psychotic) behaviors
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Why Nurses are at risk
o Genetic predisposition: individual (brain) susceptibility to substances of abuse
o Environmental & Socio-cultural influences
 Family of origin (environment) e.g., development of adult children of alcoholic (enabling) personalities
 Cultural values, e.g., Western culture/medicine: Expectation for immediate gratification, pain relief. Our
stressful habits & poor self-care are to be remedied by better pills…
 Unique Work Stressors, combined with access to controlled substances
o Myth of Immunity: “I’m a nurse, not some uneducated loser on the street!”
o Myth of Perfectionism: “I can do it all – and I have to do it all perfectly!”
o Low self-esteem & poor self-care: Nurses end up meeting everyone else’s needs but their own!
o Enabling by co-workers & administration: We may assume all is “OK” or fear confronting nurse until its too late
Requirements of Participation
o Qualified assessment  psychiatrist
o Appropriate treatment
o Ongoing self-help group support
o Random drug testing
o Payment of participation &/or Board Order Fees
o Released to RTW – by Treatment Provider & TPAPN
o Demonstrate minimum 12 months safe practice
o Minimum 2 year participation with compliance
o Usually 1 relapse allowed before
BON
o 2 full participations typically permitted
Self-Awareness Issues
o Examine own beliefs and/or family behavior about alcohol and drugs
o Recognize that substance abuse is a chronic illness with relapses and remissions
o Nurse must be objective and reasonably optimistic