SUBSTANCE ABUSE AND DEPENDENCE: An Overview

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SUBSTANCE ABUSE AND DEPENDENCE An
Overview

• RNSG 2213

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INTRODUCTION

• Substance abuse is not a new problem.
• Mood-altering and mind-altering substances have
  been used throughout human history.
• Opium used openly into the 20th century Freud
  used Cocaine.
• Tribal cultures have e.g. chewed coca leaves,
  used peyote in religious ceremonies, smoked the
  peace pipe.

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• Which legal drug is the
• most widely used?

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Illicit Drug Use

• Most used illicit drugs world-wide
• Cannabis (1)
• Amphetamines ( synthetic stimulants) greatest
  increase
• Cocaine
• Opioids
• World Health Organization
  2010
• www.who.int_substanceabuse/
  facts.htm

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Illicit Drugs A Global Issue

• Economics
• Crime
• Health
• Effects on young people
• Environmental effects

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Illegal Drugs U.S.A.

• CDC www.cdc.gov (2010 report)
• Persons in U.S. gt 12 y/o who in past month
• used illegal drug(s) 8
• used Marijuana 6.1
• non-medical use of a psychotherapeutic agent
  2.5
  
• (CDC Statistics from 2008)

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Introduction

• No clear transition from therapeutic to abusive
  substance use
• Use is significantly underreported and effects
  are often misdiagnosed
• Much social stigma attaches to abuse and
  addiction
• Implicated in many accidental deaths, crimes
• Severe adverse effects on health, work,
  relationships and quality of life

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Co-Morbidity with other Mental Disorders
Dual Diagnosis

• Shared Risk Factors
• Genetic factors
• Environmental factors
• Similar brain regions affected
• Drugs can change the brain
• Drug use can induce mental illness
• Mental disorders may lead to drug use
  (self-medication)

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Co-Morbidity With Mental D/O
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Vegetable compound Alcohol content 18

The Bayer Co.s best-seller
Laudanum 50 opium/50 alcohol
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Introduction Drugs and U.S. Law

• 1914 Harrison Narcotics Act Prohibition of
  non-doctor-prescribed opiates
• Alcohol Prohibition in the 1920s and 1930s
• 1970 Drug Enforcement Agency created Controlled
  Substances Act passed
• 1987 AMA declared all chemical dependency as
  disease
• 1990 ADAnon discrimination against persons with
  history of drug/alcohol addiction

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ADDICTION LIABILITY

• Highest Lower
• cocaine/crack ? amphetamines
• opiates ? anesthetics
• nicotine (PCP, ketamine)
• alcohol ? benzodiazepines
  
  ? marijuana

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DEFINITIONS

• Intoxication Substance-specific CNS effects
• Substance Abuse Recurrent use of a drug which
  results in adverse effects to oneself or others.
  (e.g. interpersonal, legal or safety issues)
• Addiction (compulsive use of substance same as
  substance dependence term is sometimes
  considered judgmental )
  

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Definitions, contd

• Chemical/Substance Dependence Loss of Control
  over use, which involves
• Tolerance Must increase the amount of drug to
  get the needed effect.
• Withdrawal Refers to psychoactive
  substance-specific syndrome that occurs when
  person stops using the drug

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Definitions Matching

1. Client 1 states morphine for cancer pain is not
   working Dr. writes order for increased dose.
2. Client 2 smokes some marijuana and feels
   mellow, eats junk food.
3. Most nights, Client 3 drinks a 6-pack of beer and
   falls asleep in front of TV. (Spouse is not
   happy.)
4. While waiting for more cocaine to be delivered,
   Client 4 feels very depressed, anxious and is
   desperate to feel good again.

• A. Substance abuse
• B. Substance withdrawal
• C. Tolerance
• D. Substance dependence
• E. Substance intoxication

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DSM IV CRITERIA FOR SUBSTANCE DEPENDENCE

• Tolerance, Withdrawal
• Desires and attempts to cut down
• Much time is spent in obtaining drug and
  recovering from drug
• Social and occupational problems result
• Substance use continues despite problems caused

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DSM IV CRITERIA FOR SUBSTANCE WITHDRAWAL

• Development of specific symptoms due to cessation
  of drug
• Syndrome causes distress
• Symptoms not due to a medical condition

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Biological Theory Neurotransmitters of Addiction

• Dopamine (DA) reward pathway
• Serotonin (SER)
• Endorphins (END)
• GABA/Glutamate (GLU) Theory heavy drug use
  decreases response of brain calming
  neuroreceptors ( tolerance)

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Etiology of Addiction Biological Theory

• Repeated use of a drug results in stimulation of
  brains reward pathway

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Biological Theory of Addiction contd

• Repeated use of a drug targets specific brain
  areas for that drug, with resulting creation of
  extra receptors and brains perception that
  drugs stimuli are necessary for survival
  (?cravings)

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Biological Theory, contd

• Genetic predisposition
• Examples -Allergic response to ETOH in many
  Southeast Asians
• -Twins born to alcoholic
  parents who are then adopted have 3x rate of
  becoming alcoholic than children of
  non-alcoholics who are then adopted.

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Etiology Biology Learning

• Drug dependence results from interaction of the
  physiological effects of substances on brain
  areas associated with motivation and emotion,
  combined with learning about the relationship
  between substances and substance-related cues.
• This theory gives support to why relapse may
  occur even after long period of abstinence.
  (e.g. smell of cigarette can cause an ex-smoker
  to light up)

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Multivariant Theory Scenario

• J. was in recovery x 4 months from dependence on
  alcohol. This week at work had been stressful,
  then on Thursday his dog got hit by a car and had
  to be euthanized. On Friday, he started drinking
  again at a downtown bar near his office. After 3
  days of inebriation he called his AA sponsor.
  Together they discussed the events leading up to
  his relapse. He recalled his usual pattern was
  binge drinking on weekends, with a stop at the
  liquor store on Friday after work. He had been
  passing by the bar on his way home on Friday. The
  combination of the sound of people having fun,
  and it being Friday after work, triggered his
  relapse. J. recognized that, since drinking was
  the way he relaxed and dealt with stress, this
  time he put himself in the wrong place at the
  wrong time.

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Etiology Sociocultural Factors

• Advertising
• Cultural and religious values
• Sex differences Males abuse alcohol and opioids
  more. Females abuse prescription drugs
• Availability, cost

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Etiology Psychological/Psychodynamic Theory

• Fundamentally negative view of self
• Substances used to escape from anxiety or
  emotional pain.

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Personality Traits Associated with Substance
Dependence

• DENIAL/ anger
• Inability to express emotions
• High anxiety in interpersonal relations
• Emotional immaturity
• Ambivalence towards authority rule breaker
• Low frustration tolerance wants instant
  gratification

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Personality Traits, continued

• Low self-esteem
• Feelings of isolation
• Overdependence/lack of autonomy
• Perfectionism and compulsiveness
• Sex role confusion

Are these qualities the cause or the result
of drug use?
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Effects on Family

• All family members affected by the
  substance-dependent member.
• Many characteristic behaviors
• Focus of family life the addicts behavior
• Co-dependency
• Care-taking by children
• Perpetuation of these dynamics into adulthood
• Family in need of treatment

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http//www.youtube.com/watch?vmwq0wxZg87g
http//www.youtube.com/watch?vu0ugTOXv0Y4
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ASSESSMENT

• Denial complicates assessment
• Use screening tools, e.g. MAST
• Careful history occupational, legal, behavioral
  alterations
• Physical Assessment substance specific signs and
  symptoms
• Urine and serum drug screens breathalyzer
  (alcohol)

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Short version of Michigan Alcoholism Screening
Test (SMAST)
gt 3 points indicates problem
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INTERVENTIONS DETOXIFICATION

• American Society of Addiction Medicine lists
  three immediate goals for detoxification of
  alcohol and other substances (1) to provide a
  safe withdrawal from the drug(s) of dependence
  and enable the patient to become drug-free (2)
  to provide a withdrawal that is humane and thus
  protects the patients dignity

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Principles of Detoxification

• Avoids life-threatening withdrawal signs and
  symptoms but also avoids intoxication with the
  withdrawal medications.
• The goal is not absolute comfort.
• Objective measures of withdrawal (vital signs,
  observable findings, withdrawal rating scores)
  are very useful for monitoring the course of
  withdrawal and supplementing the subjective data
  from the client.

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Nursing and Milieu Interventions

• Examine own attitudes about substance use and
  dependence
• Provide
• Safe environment for client in withdrawal
• Empathy and acceptance
• Hope for recovery
• Group therapy to deal with denial and provide
  support for change
• Treatment for co-occurring mental illness

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Client Behaviors and Nursing Interventions for

• Anger matter-of-fact approach
• Guilt and shame non-judgmental support offer
  positive feedback for help-seeking behaviors
• Denial and Avoiding Responsibility supportive
  confrontation
• Manipulation set limits and clear rules.
• Cravings provide support, teaching and encourage
  talking with peers.

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Nurse-Client Communication Effective?/Ineffective
?

1. Client You all are a bunch of do-gooders who
   are getting paid to act like you care but you
   dont.
2. Client I want to talk to the dr. now! This
   dose he ordered is ridiculousit wont do
   anything for my headache. I know the amount I
   need.
3. Client I feel like Ive let my whole family
   down by drinking again.
4. Client You have never used drugs, so you cannot
   possibly understand my situation.

• Nurse Your bad attitude is sabotaging your
  treatment.
• Nurse Right now this is what the dr. ordered
  for your headache.
• Nurse I feel for you. Alcohol does terrible
  things to a family.
• Nurse That may be true. But I can see that you
  are having a rough time.

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Interventions Client and Family Teaching

• Disease process
• Total abstinence is the goal
• Relapse is part of recovery
• Relapse prevention strategies
• Recognize and confront own denial
• Recognize triggers
• Change people, places and things.
• Often biggest obstacle to abstinence.

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Relapse Prevention/Recovery

• Client I dont know why I started using again,
  I guess I just cant stay clean.
• Client Ever since I stopped drinking, my
  friends say Im no fun.
• Client I started drinking again because my
  boyfriend stressed me out.

1. Nurse Write down everything you remember about
   that day. Triggers may not always be obvious.
2. Nurse Its time to consider who your friends
   really are.
3. Nurse ________________

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Interventions Referrals and Community Resources

• Long-term residential rehabilitation is best
  predictor of abstinence (28 days to 6 months or
  more)
• Halfway House
• Outpatient rehabilitation
• AA, NA, Rational Recovery
• Family counseling
• Al-Anon, Nar-Anon, Alateen
• Other services job placement, housing, etc.

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Legal-Ethical The Chemically Dependent Nurse

• Required to report impaired colleague to Board of
  Nursing
• Nursing resources in TX
• TPAPN (Texas Peer Assistance Program for Nurses)
  www.tpapn.org

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Addiction Recovery Awareness