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Lilley: Pharmacology and the Nursing Process, 7th Edition

Chapter 17: Substance Abuse

Key Points - Downloadable

ANATOMY, PHYSIOLOGY, AND PATHOPHYSIOLOGY OVERVIEW

Substance abuse affects people of all ages, sexes, and ethnic and socioeconomic groups.

Addiction
Loss of control over substance use
Continued use despite associated problems
Tendency to relapse

Intoxication
Development of reversible substance syndrome caused by recurrent use
Clinically significant maladaptive behavior or psychological changes
Results from effect of substance on CNS
Develop during or shortly after use

Tolerance
The need for increased amounts to produce desired effects.

Withdrawal
Development of substance-specific syndrome upon cessation or reduction in heavy prolonged use

Substance ABUSEa maladaptive pattern of use leading to clinically significant impairment or distress,
manifested by one or moreof the following:
o Role responsibility problemswork, school, home
o Impairment in hazardous situations Recurrent legal and IPR problems
o Continued use despite social or interpersonal problems

Substance DEPENDENCEmanifested by 3 or more of the following:
o Presence of tolerance
o Presence of withdrawal
o Reduction/absence of important social, occupational, or recreational activities
o Unsuccessful or persistent desire to cut down or quit
o Increased time spent procuring and using substance
o Substance taken in Iarger amounts/for longer periods than intended
o Continued use despite knowledge of recurrent physical or psychological problems, or that problems
were caused or exacerbated by the substance

Tolerance
The need for increased amounts to produce desired effects.
Withdrawal
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Development of substance-specific syndrome upon cessation or reduction in heavy prolonged
use
Synergistic effects
Combining 2 drugs and the resulting effect is greater than either drug taken alone

Antagonistic effects
Combining two drugs to weaken the effect of one drug

In 2010, the government conducted a survey indicating that some 22.6 million Americans 12 years of age or
older were current illicit drug users.

Nearly 50% of the adult patients seen in many family practice clinics have an alcohol or drug disorder.

Physical dependence and psychological dependence on a substance are chronic disorders with remissions
and relapses, as with any other chronic illness.

Habituation refers to situations in which a patient develops tolerance to a certain drug and may have
mild psychological dependence on it but does not show compulsive dose escalation, drug-seeking
behavior, or major withdrawal symptoms on drug discontinuation.
Physical dependence is a condition characterized by physiologic reliance on a substance, usually
indicated by tolerance to the effects of the substance and development of withdrawal symptoms when
use of the substance is terminated.
Psychological dependence is a condition characterized by strong desires to obtain and use a substance.
Reasons for use
1. Restore health
2. Relieve pain
3. Reduce anxiety
4. Increase energy
5. Improve performance
6. Alleviate depression
7. Deal with loss
8. Increase sense of self-worth
9. Create a feeling of euphoria

Co-Morbidity -
PHARMACOLOGY OVERVIEW
Opioids
Opioid analgesics are synthetic versions of pain-relieving substances that were originally derived from the
opium poppy plant.
Diacetylmorphine (heroin) and opium are classified as Schedule I drugs and are not available in the
United States for therapeutic use.
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Heroin is one of the top 10 most abused drugs in the United States. Others in this opioid category are
codeine, hydrocodone, hydromorphone, meperidine, morphine, and oxycodone.
Opioids work by blocking receptors in the central nervous system, resulting in the perception of pain being
blocked.
The effects of opioids are referred to as narcosis or stupor, involving reduced sensory response, especially
to painful stimuli; opioid analgesics are also referred to as narcotics.
The intended effects are to relieve pain and diarrhea, reduce cough, and induce anesthesia.
Due to the high potential for abuse, opioids are classified as Schedule II controlled substances.
Certain opioid drugs, such as methadone, are themselves used to treat opioid dependence.
The major central nervous system (CNS)-related adverse effects include diuresis, miosis, convulsions,
nausea, vomiting, and respiratory depression.
Many of the non-CNS adverse effects are secondary to the release of histamine.
Many patients require formal detoxification while withdrawal symptoms are occurring.
Certain medications are used to prevent relapse use once initial remission is achieved, but are useful only
when concurrent counseling is provided.
For opioid abuse or dependence, naltrexone, an opioid antagonist, works by blocking the opioid
receptors so that the use of opioid drugs does not produce euphoria.
Another opioid antagonist, naloxone, is used for opioid dependence; it is combined with
buprenorphine (Subutrex) or used alone (Suboxone).

Stimulants
The abuse of stimulants is related to their ability to cause elevation of mood, reduction of fatigue, a
sense of increased alertness, and invigorating aggressiveness.
Amphetamine is a stimulant drug that is commonly abused. Three classes of amphetamine exist: salts of
racemic amphetamine, dextroamphetamine, and methamphetamine.
Methamphetamine has a much stronger effect on the CNS than the other two classes of amphetamine.
Multiple slight chemical variants of amphetamine are referred to as designer drugs, which have
psychoactive properties along with their stimulant properties.
Another synthetic amphetamine derivative is methylenedioxymethamphetamine (MDMA, ecstasy, or
E); it tends to have more calming effects than other amphetamine drugs.
Marijuana and alcohol are commonly listed as additional drugs of abuse in those admitted for treatment of
methamphetamine abuse.
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Cocaine also produces strong CNS stimulation and was originally classified as a narcotic. However,
unlike the opioid analgesics, cocaine does not normally induce a state of narcosis or stupor and is
therefore more correctly categorized as a stimulant drug.
Cocaine tends to give a temporary illusion of limitless power and energy but afterward leaves the user
feeling depressed, edgy, and craving more. Crack is a smokable form of cocaine that has been chemically
altered. Cocaine and crack are highly addictive.
Stimulants work by releasing biogenic amines from their storage sites in the nerve terminals, primarily
norepinephrine, resulting in stimulation of the CNS, as well as cardiovascular stimulation, increasing blood
pressure and heart rate and possibly inducing cardiac dysrhythmias.
The most common therapeutic use for stimulants is in treating attention deficit disorder or attention deficit
hyperactivity disorder. Stimulants also are used in preventing or reversing fatigue and sleep (such as in
narcolepsy) and in stimulating the respiratory center.
CNS-related adverse effects, an extension of the therapeutic effects of stimulants, are restlessness,
syncope (fainting), dizziness, tremor, hyperactive reflexes, talkativeness, tenseness, irritability,
weakness, insomnia, fever, and sometimes euphoria.
Death due to poisoning or toxic levels is usually a result of convulsions, coma, or cerebral hemorrhage and
may occur during periods of intoxication or withdrawal.

Depressants
Depressants are drugs that relieve anxiety, irritability, and tension and are also used to treat seizure disorders
and induce anesthesia.
The two main pharmacologic classes of depressant are benzodiazepines and barbiturates.
Benzodiazepines and barbiturates work by increasing the action of gamma-aminobutyric acid (GABA);
the alteration of GABA action in the CNS results in relief of anxiety, sedation, and muscle relaxation.
The CNS is the primary area of the body adversely affected by these drugs.
Benzodiazepines are used primarily therapeutically to relieve anxiety, to induce sleep, to sedate, and
to prevent seizures.
Ingestion of benzodiazepines together with alcohol or barbiturates can be lethal; death is typically due to
respiratory arrest.
A benzodiazepine used as a recreational drug is flunitrazepam, known as roofies among young people; it
creates a sleepy, relaxed, drunken feeling that lasts 2 to 8 hours. Girls and women around the country have
reported being raped after being involuntarily sedated with roofies, which were often slipped into their
drinks by their attackers.
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Abrupt withdrawal of benzodiazepines when they have been taken for prolonged periods has resulted
in autonomic withdrawal symptoms, seizures, delirium, rebound anxiety, myoclonus (involuntary
muscle contractions), myalgia, and sleep disturbances.
Barbiturates are used as sedatives and anticonvulsants and to induce anesthesia.
Barbiturates and benzodiazepines are commonly implicated in suicides, especially in combination with
alcohol.
Long-term ingestion of excessive amounts of benzodiazepines or barbiturates is a major social and medical
problem.
Another depressant that is neither a benzodiazepine nor a barbiturate is marijuana.
Controversial medical uses for marijuana include treatment of chronic pain, reduction of nausea and
vomiting associated with cancer treatment, and appetite stimulation in those with wasting syndromes, such
as patients with cancer or AIDS.

Alcohol
Alcohol, more accurately known as ethanol, causes CNS depression. A new hypothesis is that it causes
local disordering in the lipid matrix of the brain, termed membrane fluidization.
The therapeutic value of alcohol is extremely limited. Ethanol is an excellent solvent for many drugs and is
commonly used as a vehicle for medicinal mixtures. When applied topically to the skin, ethanol acts as a
coolant. Ethanol is the most popular skin disinfectant; however, isopropyl alcohol is most often used on the
skin and is not drinkable.
Long-term excessive ingestion of ethanol is associated with serious neurologic and mental disorders, such as
seizures. Nutritional and vitamin deficiencies can result in Wernickes and nicotinic acid deficiency
encephalopathy, Korsakoffs psychosis, and polyneuritis.
When consumed on a regular basis in large quantities, ethanol produces a constellation of dose-related
negative effects such as alcoholic hepatitis or its progression to cirrhosis.
Moderate amounts of ethanol may stimulate or depress respirations. Large amounts produce dangerous
or lethal depression of respiration. Although circulatory effects of ethanol are relatively minor, acute severe
alcoholic intoxication may cause cardiovascular depression.
Teratogenic effects can be devastating and are caused by the direct action of ethanol, which inhibits
embryonic cellular proliferation early in gestation.
Alcohol can intensify the sedative effects of any medications that work in the CNS.
Signs and symptoms of withdrawal may vary depending on the individuals usage pattern, the preferred type
of ethanol, and the presence of comorbidities and can be life threatening.
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Disulfiram (Antabuse), used in treatment of alcoholism, works by altering the metabolism of alcohol.
Patients know that if they are to avoid the devastating experience of acetaldehyde syndrome, they cannot
drink for at least 3 or 4 days after taking disulfiram.
Acamprosate is used to maintain abstinence from alcohol in patients who are abstinent when starting the
drug and who have additional psychosocial support.

Nicotine
The medical significance of nicotine grows out of its toxicity, presence in tobacco, and propensity for
eliciting dependence in its users.
Smoking releases epinephrine, a hormone that creates physiologic stress in the smoker rather than
relaxation; apparent calming effects may be related to the increased deep breathing.
Large doses of nicotine can produce tremors, convulsions, and respiratory stimulation.
The cardiovascular effects of nicotine are an increase in heart rate and blood pressure. The effects of
nicotine on the gastrointestinal system are largely due to parasympathetic stimulation, which results in
increased tone and motor activity of the bowel and vomiting.
The use of tobacco is addictive; most users develop tolerance and need greater amounts. Smokers become
physically and psychologically dependent and will suffer withdrawal.
Smoking cessation leads to nicotine withdrawal. An often-overlooked problem in hospitalized patients is
nicotine withdrawal, which manifests as irritability, restlessness, and a decrease in heart rate and blood
pressure.
Nicotine formulated into drug products may reduce cravings and promote smoking cessation.
Varenicline (Chantix), newer for smoking cessation, has shown better efficacy than bupropion.

NURSING PROCESS
Assessment
The purpose of a substance abuse assessment is to determine whether substance abuse exists, to evaluate the
relationship between the abuse and other health concerns, and to begin the implementation of an effective
health promotion and health restoration plan.
Question all patients about the use and misuse of substances because addiction may be encountered in all
clinical specialties. Abuse/misuse of substances/prescription medications may need to be assessed in other
family members as well.
A thorough patient assessment and history must include specific questions about the substance(s), duration
of abuse, related physical and mental health concerns, and withdrawal.
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Valid and reliable assessment tools are available to nurses and health care professionals for use with patients
suspected of drug or substance abuse. The goal of screening for alcohol and other drug abuse or addiction is
to identify patients who have or are at risk for developing alcohol or drug-related problems and to further
engage them in discussion.
Assessment of opioid abuse includes determination of the route being used for drug delivery since
intravenous drug use may cause health concerns such as HIV/AIDS or hepatitis.
Opioid withdrawal includes seeking the drug from more than one prescriber, mydriasis, rhinorrhea,
diaphoresis, piloerection, lacrimation, diarrhea, insomnia, and elevated blood pressure and pulse rate.
Assessment of CNS stimulant abuse requires careful questioning about and observation for adverse effects,
toxicity, and withdrawal signs and symptoms.
CNS stimulant withdrawal includes social isolation or withdrawal, psychomotor retardation, and
hypersomnia.
Abuse of CNS depressants is manifested by a decrease in vital signs and mental functioning; therefore,
frequent monitoring of vital signs and neurologic status is needed for safe care.
CNS depressant withdrawal includes increased psychomotor activity; agitation; muscular weakness;
hyperthermia; diaphoresis; delirium; convulsions; elevated blood pressure, pulse rate, and temperature; and
eyelid tremors.
Ethanol withdrawal produces varying degrees of signs and symptoms depending on the specific blood
alcohol level. Delirium tremens is characterized by hypertensive crisis, tachycardia, and hyperthermia and
may be life threatening.

I mplementation
The nurse helps to meet the patients basic needs and teaches the patient, family, and/or significant others
about addiction and its effect on the entire family.
Nursing interventions involve maximizing all of the therapeutic plans and minimizing those factors
contributing to the abusive behaviors.
Substance withdrawal is treated with a multimodal approach that includes pharmacologic and
nonpharmacologic interventions.
The family will also be in need of treatment and therapeutic support; the caring, empathic, supportive, and
educative responses by nurses will convey acceptance to the patient and family and help in the overall
process of recovery and rehabilitation.

Evaluation
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Patient safety is of utmost importance when the patient is experiencing signs and symptoms of withdrawal.
Patients may enter life-threatening situations within a period of a day or two.
Evaluation of the recovery and rehabilitation process is important, including monitoring of the therapeutic
effects of the treatment regimen and monitoring for any physiologic and/or psychological ill effects from the
withdrawal of the abused substance.