Chapter 17 Substance Abuse

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Chapter 17Substance Abuse
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• Substance abuse (using a drug in a way that is
  inconsistent with medical or social norms and
  despite negative consequences) is a major concern
  in the U.S.
• 14 of adults have an alcohol-related disorder.
• 6.2 have a substance-related disorder (excluding
  nicotine).
• Adolescent substance abuse is rising.
• Cost in job loss is 100 billion per year
  alcohol alone accounts for 500 million lost days
  of work.

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• Increasing numbers of babies are being born to
  substance-addicted mothers.
• Half of all persons seeking alcohol-related
  treatment have at least one alcoholic parent.

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Types of Substance Abuse

• Substance abuse includes alcohol, prescription
  and OTC medications, and illicit drugs.
  Polysubstance abuse is abuse of more than one
  substance and is common. .
• Alcohol has been a major focus of research, so
  more is known about it
• First intoxication episode occurs at age 15 to 17
  years (first drink may be much earlier).
• Severe difficulties begin to appear in mid-20s to
  mid-30s.

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• Blackouts occur (person continues to function but
  has no memory or awareness of what he or she has
  done).
• There may be cycles of controlled drinking,
  abstinence, drinking problems, and so forth.
• Programs attempting to teach social drinking
  have been failures.
• There are some reports of spontaneous remission
  (quit drinking without treatment).

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• For most, alcoholism is a chronic illness.
  Relapse and repeated treatment are common.
• Tolerance-meaning increased amounts of drug to
  produce the desired effects

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Etiology

• Biologic factors include genetic vulnerability
  and failure of neurotransmitters to signal
  enough. Psychological factors include familial
  tendency (having an alcoholic parent or
  relatives) and social influences for instance,
  there are higher rates of cocaine and opioid use
  in urban areas that have high crime rates, high
  unemployment, substandard schools. There are
  fewer social taboos against alcohol use.

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Cultural Considerations

• Substances can be part of religious or
  spiritual practices.
• Some religions forbid the use of substances.
• Certain ethnic groups have genetic traits that
  protect them from alcoholism or predispose them
  to alcoholism (for instance, flushing among
  Asians, variations in liver metabolism of
  alcohol).

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Types of Substances and Effects of Alcohol

• CNS depressant produces relaxation, loss of
  inhibitions
• Intoxication slurred speech, unsteady gait.
  lack of coordination impaired attention,
  concentration, memory, and judgment
• Overdose vomiting, unconsciousness,
  respiratory depression, hypotension, death
• Withdrawal can be life-threatening
  detoxification under medical supervision is
  needed.
• Withdrawal symptoms coarse hand tremors,
  sweating(diaphoresis), weak, elevated blood
  pressure and pulse, insomnia, anxiety, nausea or
  vomiting

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Alcohol

• Severe or untreated withdrawal transient
  hallucinations, seizures, delirium tremens
  (DTs)-important to monitor vital signs
• Withdrawal can take 2 days to 2 weeks.
• Safe withdrawal or detoxification
  benzodiazepines such as diazepam (Valium),
  chlordiazepoxide (Librium), and lorazepam
  (Ativan) are used to suppress withdrawal
  symptoms. Amount and frequency of doses are based
  on vital signs and severity of symptoms. Often an
  established protocol based on assessment of
  symptoms is used.

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Other Cns Depressants Sedatives, Hypnotics, and
Anxiolytics

• CNS depressants with effects similar to those
  of alcohol include sedatives, hypnotics,
  anxiolytics (benzodiazepines), and barbiturates
  (latter two are often abused).
• In usual doses, they produce drowsiness and
  relieve anxiety. Intoxication slurred speech,
  lack of coordination, unsteady gait, labile mood,
  impaired attention and memory, stupor, or coma.
• Overdose of benzodiazepines is rarely fatal but
  causes lethargy and confusion. Treated with
  gastric lavage, activated charcoal, saline
  cathartic.
• Barbiturates are lethal in overdose, causing
  coma, respiratory depression, cardiac failure,
  and death. Lavage or dialysis is used while
  supporting vital functions

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Sedatives cont

• Withdrawal depends on half-life of drug.
  Shorter-acting drugs produce withdrawal symptoms
  in 6 to 8 hours longer-acting drugs take up to
  a week.
• Withdrawal symptoms include autonomic
  hyperactivity (increased pulse, blood pressure,
  respirations, and temperature), hand tremor,
  insomnia, anxiety, nausea, psychomotor agitation.
  Seizures and hallucinations are rare and occur
  only in severe benzodiazepine withdrawal.
• Detoxification is accomplished by tapering
  (administering decreasing doses) with
  barbiturates, coma and death may ensue if stopped
  abruptly.

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Stimulants (Amphetamine, Cocaine, and Others)

• Excite the CNS limited clinical use (ADHD) used
  to stay awake, lose weight, feel high
• Cocaine is highly addictive.
• Intoxication and overdose high or euphoric
  feelings, hyperactivity, hypervigilance,
  talkativeness, anxiety, grandiosity,
  hallucinations, repetitive or stereotyped
  behavior, anger, fighting, impaired judgment
• Physiologic effects tachycardia, elevated
  blood pressure, dilated pupils, perspiration or
  chills, nausea, chest pain, confusion, cardiac
  arrhythmias
• Methamphetamine is particularly dangerous,
  highly addictive causes psychotic behavior
  brain damage caused by substances used to make
  it.
• Overdoses can result in seizures and coma
  death is rare.
• Withdrawal occurs within a few hours to several
  days and is not life-threatening dysphoria,
  fatigue, vivid and unpleasant dreams, insomnia or
  hypersomnia, increased appetite, psychomotor
  agitation or retardation (crashing) no medical
  treatment indicated.

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Cannabis (marijuana)

• Derived from the hemp plant tetrahydrocannabinol
  (THC) thought to produce most of the psychoactive
  effects
• Most widely used illicit substance in the U.S.
• Short-term effect of lowering intraocular
  pressure
• Two cannabinoids are currently approved for use
  with nausea and vomiting from cancer
  chemotherapy.
• Intoxification feeling high, lowered
  inhibitions, relaxation, euphoria, increased
  appetite, intoxication, impaired motor
  coordination, judgment, and short-term memory,
  inappropriate laughter, impaired judgment and
  short-term memory, distortions of time and
  perception, conjunctival injection, dry mouth
• Withdrawal No significant clinical withdrawal
  syndrome is identified.

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Opoids

• Prescription analgesics morphine, Demerol,
  codeine, hydromorphone, oxycodone, methadone,
  oxymorphone, hydrocodone, propoxyphene
• Illegal types heroin, normethadone
• Cause euphoria, sense of well-being, relief of
  physical and psychological pain
• Persons abusing these drugs spend a great deal
  of time obtaining them, including criminal
  activity. Health care professionals write their
  own prescriptions or divert drugs from patients
  to themselves.
• Intoxification apathy, lethargy, listlessness,
  impaired judgment, psychomotor retardation or
  agitation, constricted pupils, drowsiness,
  slurred speech, impaired attention and memory
• Overdose can lead to respiratory depression,
  pupillary constriction, unconsciousness, death.

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Opoids cont

• Administration of naloxone (Narcan) reverses
  opioid toxicity.
• Withdrawal (Heroin) anxiety, restlessness,
  aching back and legs, craving for more opioids,
  nausea, vomiting, Pupil dilitation dysphoria,
  lacrimation, rhinorrhea, sweating, diarrhea,
  yawning, fever, insomnia. All cause significant
  distress but require no medical treatment.
• Methadone can be used as a substitute for
  opioids or to reduce symptoms symptoms of
  anxiety, insomnia, dysphoria, anhedonia, and drug
  craving may persist for weeks or months.

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Hallucinogens

• Mescaline, LSD, designer drugs (Ecstasy),
  psilocybin
• Distort perception of reality, cause
  hallucinations and depersonalization, increased
  pulse, blood pressure, and temperature, dilated
  pupils, hyperreflexia
• PCP belligerence, aggression, impulsivity,
  unpredictable behavior
• Intoxification and overdose anxiety,
  depression, paranoid ideation, ideas of
  reference, fear of losing ones mind potentially
  dangerous behavior (belief one can fly),
  sweating, tachycardia, palpitations, blurred
  vision, tremors, lack of coordination
• No withdrawal syndrome, but some report drug
  cravings.
• Can produce flashback episodes that can occur
  for months to 5 years after last ingesting the
  drug

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Inhalents

• Anesthetics, nitrates, organic solvents (glue,
  paint thinner, gasoline, spray paint, correction
  fluid, spray can propellants)
• Vapors are usually inhaled from a soaked rag in
  a bag or directly from the container.
• Effects significant brain damage, peripheral
  nervous system damage, liver disease
• Intoxification and overdose dizziness,
  nystagmus, lack of coordination, slurred speech,
  unsteady gait, tremor, muscle weakness, coma,
  death
• Behavioral symptoms belligerence, aggression,
  apathy, impaired judgment, inability to function
• Acute toxicity causes anoxia, respiratory
  depression, vagal stimulation, arrhythmias
• Treatment support of respiratory and cardiac
  functions until substance is removed
• No withdrawal symptoms, except reported cravings

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• Alcohol Treatment and Prognosis
• Treatment is based on the concept that alcoholism
  and drug addictions are a medical illness
  chronic, progressive, characterized by remissions
  and relapses
• Treatment often based on the Hazelden Clinic
  model
• 12-step program developed by Alcoholics Anonymous
  (AA)-Advocates total abstinence regular
  attendance at meetings is important. The
  alcoholic strives to abstain day at a time.

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• Focus is on group experiences involving
  education, problem-solving techniques, cognitive
  techniques to identify and modify faulty
  thinking, coping with life, stress, and other
  people without the use of substances
• Treatment may be as an outpatient or inpatient
  depending on clients circumstances and ability
  to abstain from alcohol or drugs.

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• Safe withdrawal from alcohol includes use of
  vitamin B1 (thiamine) supplements to prevent or
  treat Wernicke-Korsakoffs syndrome, folic acid,
  multivitamins, cyanocobalamin (vitamin B12) for
  nutritional deficiencies.
• Alcohol withdrawal managed with benzodiazepines

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• Disulfiram (Antabuse) to help client abstain from
  alcohol-causes dangerous reaction if taken with
  alcohol methadone as a substitute for heroin
  Naltrexone (ReVia) to block effects of opioids
  and reduce cravings for alcohol Clonidine
  (Catapres) to suppress opiate withdrawal-check
  blood presure Bromocriptine (Parlodel) to
  decrease cocaine cravings

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Dual Diagnosis (Substance Abuse and Major Mental
Illness)

• Traditional treatment programs have little
  success
• Impaired cognitive abilities
• Avoidance of all drugs is emphasized.
• Concept of limited recovery is acceptable in
  mental health, but there is no such thing with
  substance abuse.

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• Lifelong abstinence may seem impossible for
  client who lives day to day.
• Difficult to determine whether behavior is due to
  substance abuse or mental illness

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Application of the Nursing Process Substance
Abuse-DsmIV-symptoms of abuse

• Denial is a major component of substance abuse,
  so identifying clients can be difficult. Several
  screening devices are available. Detoxification
  is a priority.

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• Assessment
• History chaotic family life, family history,
  crisis that precipitated treatment
• General appearance and motor behavior depends on
  physical health likely to be fatigued, anxious
• Mood and affect may be tearful, expressing guilt
  and remorse angry, sullen, quiet, unwilling to
  talk
• Thought processes and content users often
  minimize substance use, blame others for
  problems, rationalize their behavior, say they
  can quit on their own

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• Sensorium and intellectual processes usually
  alert and oriented intellectual abilities intact
  (unless neurologic deficits from long-term
  alcohol or inhalants)
• Judgment and insight poor judgment while
  intoxicated and due to cravings for substance
  insight usually limited
• Self-concept low self-esteem, feels inadequate
  at coping with life
• Roles and relationships strained relationships
  and problems with role fulfillment due to
  substance use

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• Physiologic considerations may have trouble
  eating and sleeping HIV risk if IV drug user
• Other health problems associated with substance
  use-liver damage hepatitis pancreatitis-check
  glucose

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• Data Analysis
• Nursing diagnoses related to physical health
  vary with the client. Common diagnoses for
  clients with substance use include
• Ineffective Denial
• Ineffective Role Performance
• Interrupted Family Processes
• Ineffective Coping

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• Outcomes
• The client will
• Abstain from alcohol/drugs.
• Express feelings openly and directly.
• Accept responsibility for own behavior.
• Practice nonchemical alternatives to deal with
  stress or difficult situations.
• Establish an effective aftercare plan.

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• Intervention
• Providing health teaching for client and
  family-wife of an alcoholic-Try to maintain a
  normal home environment
• Addressing family issues codependence- EXcheck
  to see if the alcoholic got home if not they go
  out looking for them, changes in roles
• Promoting coping skills

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Evaluation

• Successful outcomes are based on abstinence.
• Community-based care is important in both
  treatment and follow-up
• Self-help groups
• Aftercare programs
• Individual or family counseling

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Substance Abuse in Health Professionals

• A growing problem
• Reporting suspicious behavior to a supervisor is
  crucial, though most hesitate to do so.
• General warning signs poor work performance,
  frequent absenteeism, unusual behavior, slurred
  speech, isolation from peers

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• Specific behaviors drug count errors, excessive
  wasting of controlled substances, reports of
  ineffective pain relief from clients, damaged or
  torn drug packaging, pharmacy error reports,
  unexplained behavior (absent from unit, many
  trips to bathroom, coming early or staying late
  for no reason)

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Self-Awareness Issues

• Examine own beliefs and/or family behavior about
  alcohol and drugs
• Recognize that substance abuse is a chronic
  illness with relapses and remissions
• Nurse must be objective and reasonably optimistic.