Substance Abuse Disorders
Chapter 25
Terms
• Use
– drinking alcohol, swallows, smokes, sniffs, or
injects
• Abuse
– use for purposes of intoxication or for Rx beyond
intended use
• Dependence
– use despite adverse consequences
• Addiction
– psychological and behavioral dependence
Terms
• Withdrawal
– Adverse physical and psychological symptoms
that occur when stop using.
• Detoxification
– Process of safely and effectively withdrawing a
person from an addictive substance.
• Relapse
– Recurrence of alcohol- or drug- dependent
behavior who had previously been abstinent.
DSM-IV Substance Abuse
Disorders
• alcohol
• amphetamines
• cannabis
(marijuana)
• cocaine
• hallucinogens
• inhalants
• nicotine
• opioids
• phencyclidine
• sedativehypnotics
• anxiolytics
• caffeine
DSM-IV
Categories
– Abuse of a substance
– Dependence upon a substance
– Induced by intoxication or withdrawal
– Table 25.1
Epidemiology:
Lifetime Prevalence
• Positive lifetime history of heavy alcohol
use
– 23.4% of US adults
• Positive lifetime history for drug use
– 15.6% of US adults
Epidemiology
• African American
– lower rates of both licit and illicit substances compared to
whites
– experience more health and legal problems than other
groups
– alcohol-related consequences for males is higher than
whites
• Latino Americans
– high use of drug among adolescents (HS students have
highest rates of crack-cocaine and heroin use
– Differences in prevalence among different groups (Mexican
Americans - highest; Cuban Americans - lowest)
Epidemiology
• Asian and Pacific
• data are limited
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drunkenness is disgraceful
drinking is a male activity
seeking help is a sign of weakness
Asian “flushing syndrome”
• Native Americans
• rates among the highest
• alcohol plays a in health problems of this group
Epidemiology
Gender Issues
• Incidence rates of substance abuse and dependence
– 1.7% per year men
– 0.7% per year women
• Males - more likely to abuse drugs and alcohol
• Women - more likely to abuse prescription drugs
• High number of substance abusers have comorbid
mental disorders
Etiology
Biologic
– Genetic Influence
• Clear evidence that it runs in families
• Controversy about specific gene (allele of D2)
– Neurobiologic
• Through the reward system -- medial forebrain
bundle (MFB)-related to cravings
• Intoxication increases extracellular dopamine
Etiology: Psychological Theories
Addictive Personality
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need to feel self-worth
need to have control over the environment
need to feel intimate contact
need to accomplish something
need to eliminate pain or negative feelings
Behavioral Theories
– conduct problems of childhood
– relationship between conduct problems, hyperactivity,
impulsivity, and future substance abuse
Etiology: Social Theories
• Peer drug use and affiliation
• Poor interaction skills
• Certain neighborhood characteristics
Alcohol
• 90% of Americans have had a drink at some point in their lives
• 16% have alcoholism
• Body can metabolize 1 oz of liquor per hour - 5 oz glass of wine, 12 oz
can of beer (Table 25.4)
• Excessive use can adversely affect all body systems (Table 25.5)
• Cerebellar degeneration from increased levels of acetaldehyde (byproduct of alcohol metabolism) -- impaired coordination, unsteady
gait, fine tremors
• REM and chronic sleep disorders
• Drinking patterns vary
Biologic Response to ETOH
• Membranes permeable to K+ and Cl-, and
closes Na+ & Ca++ channels  depression of
CNS, adrenergic activity   BP and  HR
• Acetaldehyde is a by-product of alcohol
metabolism. Large amounts of acetaldehyde
combine with dopamine and serotonin to
produce a substance that is highly addictive
Response to ETOH:
Alcohol Tolerance
• Rapid metabolism and  sedation, motor, and
anxiolytic effects
• Higher levels of BAL before intoxication
• Locus ceruleus -- inhibits action of ethanol
and instrumental in tolerance
• During withdrawal, locus ceruleus is
hyperactive  noradrenergic activity and
CNS stimulation
Alcohol Withdrawal Syndrome
• Changes in VS
– BP and  HR
• Diaphoresis
• Adverse GI effects
• CNS side effects
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anxiety
restlessness
hand tremors or “shakes”
disorientation
confusion
delirium tremens (DTs)
Delirium Tremens
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10 or more years of drinking
Tachycardia
Sweating
Hypertension
Irregular tremor
Searing
Hypertension
Tremor
Delusions
Vivid hallucinations
Resolves in 3-4 days
Alcohol-Induced Amnestic
Disorders
• History of many years of drinking
• Over age of 40
• Onset -- sudden or insidious
Alcohol-Induced Amnestic
Disorders:
Wernicke’s Syndrome
• Reversible, caused by diet deficiency of
thiamine
• Marked diplopia (palsy of the 3 and 4
cranial nerves), hyperactivity and
delirium (cortical brain and thalamic
lesions), coma
Alcohol-Induced Amnestic Disorders
Korsakoff’s Psychosis
• Follows Wernicke’s enceophalopathy
• Loss of recent memory and
confabulation
• Vulnerable to others
Psychopharmacology
Acute Symptoms of Withdrawal
• Benzodiazepines to produce sedation
and reduce anxiety symptoms
• Diazepam 5-10 mg every 2-4 hours
• Librium 25-100 mg every 4 hours
Pharmacology & Nutrition
• Disulfiram (Antabuse)
– Agonist
– Inhibits ALDH metabolism and causes nausea and
hypotension, severe can cause death
– Occurs 10-20 minutes after ingestion
– Adjunct treatment
• Naltrexone (Trexan)
– Narcotic antagonist
– Reduces cravings for alcohol
• Nutrition and vitamins
Cocaine
• 1.5 million Americans use cocain
• Men have a higher rate than women
• Stimulant -- made from leaves of coca plant
• Sudden burst of alertness, energy, and selfconfidence
• High lasts 10-20 minutes, then let down
• Crack cocaine -- street drug form, highly
addictive
Biologic Effects of Cocaine
• Increases the release and blockage of the reuptake
of norepinephrine, serotonin and dopamine
• Dopamine -- euphoria and psychotic symptoms
(prolactin levels-contributes to sexual dysfunction and secondary
sexual characteristics)
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 Norepinephrine -- tachycardia, hypertension,
dilated pupils, and body temp
•  Serotonin -- sleep disturbances, anorexia
• Long term use -- depletion of dopamine
Cocaine
• Intoxication
– CNS stimulation followed by depression
– Increasing doses -- restlessness  tremors and
agitation  convulsions  CNS depression
– Death -- respiratory failure
• Withdrawal
– Norepinephrine depletion causes person to sleep
12-18 hours
– Then, sleep disturbances with rebound REM,
anergia, decreased libido, depression, suicidality,
anhedonia, poor concentration and cocaine
craving
Treatment of Cocaine Craving
• Antidepressants
• Anticonvulsants
• Dopamine agonists
Others
• Amphetamines -- Stimulant
– block reuptake of norepinephrine and dopamine, not as
strong effect on serotonin (as cocaine does)
– Effect peripheral nervous system
• Cannabis -- Relaxant
– Stored in fat tissue for weeks
– Amotivational syndrome
• Hallucinogens -- LSD
– Phencyclidine (PCP) angel dust
–  awareness and detachment
– hallucinations/destructive behavior (adrenergic )
Opiates -- Narcotics
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Any substance that binds to the opioid receptor
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Cause CNS depression, sleep or stupor, and analgesia
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Major -- heroin, codeine, and meperidine
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Act on Delta and Mu receptors and depress the CNA
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Types
– agonist -- increases CNS effects
– antagonist -- block CNS effects
– mixed agonist-antoagonist
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Effects of opiates
– pleasure
– relief of pain
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Cause tolerance and physical dependence
Opiate Treatment
• Antagonist -- block CNS effects,
Naloxone (Narcan)
• Detox -- gradual reduction over several
days
• Methadone maintenance treatment
– Opiate that satisfies craving, but no
subjective high (See Table 25.7)
• Naltrexone -- see Drug Profile
Other Substances
• Sedatives-Hypnotics and Anxiolytics
– Abuse of prescription drugs
– See Table 25.8
• Inhalants
– Cause euphoria, sedation, emotional lability, impaired
judgment
– Result in respiratory depression
– Found in common household products
• Nicotine
• Caffeine
Nursing Management
Assessment
• Denial
• Countertransference (Table 25.11)
• Codependence (Figure 25.2)
– Maladaptive learned pattern of coping
– Roles in family
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Chief enabler
Dependent
Hero
Scapegoat
Lost child
Mascot
Nursing Diagnoses
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Risk for Injury
Disturbed Thought Processes
Anxiety
Risk for Ineffective Management of
Therapeutic Regimen, Ineffective Denial
• Altered Nutrition
Motivation for Change
• Key predictor of whether an individual will
change their substance abuse
• Involves recognizing problem, searching for a
way to change, and then changing
• Motivational interviewing seeks to elicit selfmotivational statement from patients,
supports behavioral change, and creates a
discrepancy between the patient’s goals and
continued alcohol and other drug use.
Guidelines for Therapeutic Relationship
• Encourage honest expression of feelings
• Listen and express caring
• Hold individual responsible for behavior
• Provide consequences for negative behavior
and talk about specific, objectionable actions
• Do not compromise own values, monitor
reaction
• Communicate to team
Reality Confrontation
• Therapeutic strategy that promotes the
person’s experience of the natural
consequences of one’s behavior.
• Learning from previous behavior
• Guidelines for establishing interactions
(See Table 25.10 and Therapeutic
Dialogue)
Special Considerations
• HIV and substance abuse
– high risk for HIV among IV drug users
– dual diagnosis of chemical dependency and HIV
requires extremely careful assessment,
intervention
– patients often experience intense feelings of
uselessness
• Harm-reduction strategies
– community health intervention replacing moral and
criminal approach -- needle exchange programs,
designated driver
Special Considerations (cont)
Pregnancy and substance abuse
• Detrimental effects on pregnancy
• Several clinical issues facing mothers
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feelings of guilt and shame
difficulties being a single parent
care and responsibility of raising children early sobriety
lack of access to treatment facilities
anger and blame from caregivers
need for parenting skills
potential for child abuse and neglect
lack of medical and other health care services
Interventions
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12-step program (Table 25.13)
Cognitive therapy
Psychoeducation groups
Behavioral interventions
Group therapy and early recovery
Individual therapy
Family therapy
Interventions
• Nursing Care Plan 25.1
• Depend upon the stage of treatment