Professional Documents
Culture Documents
Substance Disorders
Substance disorders are not
disorders of choice. They are
complex diseases of the brain
represented by craving, seeking, and
using regardless of consequences
(National Institute on Drug Abuse
[NIDA], 2010). Varcarolis, 2013
Substance-Use Disorders
Disorders, cont.
Important Definitions
Addiction
Obsession, compulsion, or loss of control with respect to use
of a drug (e.g., alcohol), with genetic, psychosocial, and
environmental factors that influence its development. Use of
the drug continues despite the presence of related problems
and a tendency to relapse after stopping use.
Tolerance
Persons physiological reaction to drug decreases with
repeated administration of same dose
Withdrawal
physiological & psychological changes that occur when blood
and tissue concentrations of drug decrease after heavy
prolonged use of substance
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Drugs of Abuse
Alcohol
MDMA (Ecstasy)
Methamphetamine
LSD (Acid)
Heroin
PCP/Phencyclidine
Prescription Drugs
Steroids (Anabolic)
Marijuana
Fentanyl
Inhalants
Cocaine
Designer Drugs
http://www.drugabuse.gov/drugs-abuse/commonly
-abused-drugs/commonly-abused-drugs-chart
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Substance-Use Disorders
Pathological pattern of behavior related
to use of substance characterized by:
Impaired control
social impairment
risky use
pharmacological criteria
Impaired Control
1.
Social Impairment
5.
6.
7.
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Risky Use
8. Recurrent use in situations in which it is
physically
hazardous (e.g. driving)
9. May continue to use despite knowledge of
having a persistent or recurrent physical or
psychological problem that is likely caused
by the substance
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Pharmacological Criteria
10.Tolerance
11.Withdrawal
Tolerance & withdrawal are present for
those with a substance use disorder as
well as for those taking prescribed
medications as part of medical treatment.
The latter group should not receive a
diagnosis of Substance Use Disorder.
Substance-Induced Disorders
Overall category includes intoxication,
withdrawal, and other
substance/medication induced mental
disorders (e.g., substance-induced
psychotic disorder, substance-induced
depressive disorder)
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Etiology-Genetics (cont.)
Fraternal twins, who are genetically
different individuals born at the
same time, would be more likely to
differ in their tendencies to develop
alcoholism. In general, researchers
using the twin method have found
these expectations to be true
(Pickens, R.W., Svikis, D.S., McGue,
M., Lykken, D.T., Heston, L.L., &
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Etiology-Genetics (cont.)
Adoption studies may employ a number
of techniques. One is to compare the
histories of children of alcoholics who are
adopted by nonalcoholics and grow up in a
nondrinking environment with the histories
of children of nonalcoholics similarly raised
in a nondrinking environment. If genetic
factors play a role, then the adopted
children of alcoholics should preferentially
develop alcoholism as adults.
Cloninger, C.R. Bohman, M.& Sigvardsson,
S., (1981) found this to be true.
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Etiology (cont.)
Specific genetic markers: Dopamine D2 receptors
are being investigated without evidence to
suggest its role.
To search the human genome for specific genes
related to alcoholism, researchers employ two
experimental techniques. The first, the candidate
gene approach, involves hypothesizing that
particular genes are related to the physiology of
alcoholism and then individually testing these
genes for linkage.
The second approach, scanning of the human
genome, involves characterizing, piece by piece,
the entire length of DNA and finding genes that
relate to alcoholism, without proposing candidate
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genes.
Etiology (cont.)
Alcohol may produce morphine-like
substances in the brain that are responsible
for alcohol addiction
Siggins, G., et al (2004) looked at the effect
of alcohol and a common stress-related
neuropeptide, corticotropin releasing factor
(CRF), on a neurotransmitter called gamma
amino butyric acid (GABA).
Both appear to influence neurotransmission
in the amygdala, the so-called pleasure
center of the brain, by increasing the
transmission of one particular
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neurotransmitter, (GABA).
Psychological factors
Lack of tolerance for frustration and
pain
Lack of success in life
Lack of affectionate and meaningful
relationships
Low self-esteem, lack of self-regard
Risk-taking propensity
Sociocultural factors
Social and cultural norms, social
learning (families, peer groups)
Socioeconomic stress
Conditioning: pleasurable effects from
substance use act as a positive
reinforcement for continued use of
substance
Cultural and ethnic influences: some
cultures are more prone to the abuse
of substances than others
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General Assessment
Details include
. Drugs used
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Route
Quantity
Time of last use
Usual pattern of use
Assessment Guidelines
for the Chemically Impaired
Assess for withdrawal syndrome
Assess for overdose that warrants medical attention
Assess for suicidal thoughts or other self-destructive
behaviors
Evaluate for physical complications related to drug abuse
Explore interests in doing something about drug or alcohol
problem
Assess patient and family for knowledge of community
resources
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Assessment
Amount and type of alcohol or drugs
(AOD), including prescription
medication
Method of administration, including
injection, snorting, smoking, or drinking
Physical signs of drug use, such as
needle track marks, emaciation, and
alcohol odor
History and onset of drug use
History of attempts to quit AOD use
History of physical withdrawal
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Assessment (cont.)
Blood and urine drug screens (Positive
drug test results prevents AOD
minimization)
Blood alcohol concentration (BAC) of .
08%, or 80mg/DL constitutes legal
intoxication in all United States.
Use screening assessment tools
Medical problems associated with AOD
in client and family members (e.g. HIV,
TB, Hep B, and Hep C, Hep D (a
combination of B & D, D uses a protein
that B makes)
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Assessment (cont.)
Tolerance (High tolerance suggests that a
client has a history of heavy drinking or
drug use.)
Episodes of uncontrolled drug or alcohol
use, binges, or overdoses
Drug use behavior (e.g., does client use
drugs alone? For sex? To go to work?)
Use of AODs for "self-medication" of painful
and unpleasant emotions
Attempts to hide use
Family dysfunction relative to AOD abuse
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Assessment Tools
Various assessment tools are
available for determining the extent
of the problem a client has with
substances. Two of the common tools
are:
Michigan Alcoholism Screening Test
(MAST)
CAGE Questionnaire
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CAGE Questionnaire
Have you ever felt you should Cut down
on your drinking?
Have people Annoyed you by criticizing
your drinking?
Have you ever felt bad or Guilty about
your drinking?
Have you ever had a drink first thing in
the morning to steady your nerves (Eyeopener)?
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Interview Approaches
Manner that encourages
forthrightness: matter of fact,
nonjudgmental
Be prepared for defensiveness:
Genuine concern helps overcome this
Be aware of own feelings and avoid
projecting negative attitudes onto
client
Get accurate information: High
priority
Initially focus on legal drug use:
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Nurse-client Relationship
Build trust
Be genuine, empathic
Apply rules consistently
Instill hope
Confront denial
Manage manipulation
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Alcohol-Related Disorders
Millions of Americans suffer from
alcohol related disorders and 25% of
all hospitalized clients have problems
related to alcohol, therefore nurses
must become familiar with a variety
of alcohol-related crises.
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Alcohol withdrawal
Signs develop within a few hours after cessation
Peaks at 24 to 48 hours
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Alcohol Withdrawal
Withdrawal can be fatal.
Withdrawal is precipitated by a
decrease in alcohol consumption and
may be delayed by concomitant use
of benzodiazepines, barbiturates,
and general anesthesia (all crosstolerant with alcohol).
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Delirium Tremens
Alcohol withdrawal that is a medical
emergency - Peaks 24 to 72 hours after
cessation - Usually lasts 2-3 days, but
can up to 10.
Delirium, extreme restlessness & agitation,
tachycardia, diaphoresis, hypertension,
fever (100-103). Grand mal seizures after
heavy use.
Severe disturbance in sensorium
(disorientation and clouding of
consciousness).
Visual or tactile hallucinations.
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Paranoid delusions.
Pain
Burning
Tingling
Prickly sensations of the extremities
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Effects on Body
Alcohol myopathy
Thought to result from vitamin B1
deficiency
Acute: pain, tenderness, and edema in
certain skeletal muscles and muscles of
the thoracic cage
Chronic: gradual wasting and weakness
in skeletal muscles
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Hepatic encephalopathy:
occurs in response to the inability of the
diseased liver to convert ammonia to urea for
excretion; the continued rise in serum
ammonia, if allowed to progress, leads to
coma and eventual death
54
Korsakoffs psychosis
Syndrome of confusion, loss of recent
memory, and confabulation in alcoholic
patients
56
Effects of Long-Term
Polysubstance Abuse on the
Brain
Opiates
Opiates include heroin, morphine,
codeine, Oxycontin, Dilaudid,
methadone, meperidine (Demerol),
Percocet (Oxycodone), and others.
(Clients who have alcohol
intoxication may appear drowsy,
sometimes euphoric, tranquil, or
dulled.) Must assess carefully
Opiate users rarely present for
treatment of intoxication per se.
60
Opiates
Intoxication:
Constricted pupils, decreased
respiration, drowsiness, decreased blood
pressure, slurred speech, psychomotor
retardation, impaired judgment
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Opiates - Withdrawal
Opiate withdrawal is an acute state
caused by cessation or dramatic
reduction of use of opiate drugs that
has been heavy and prolonged
(several weeks or longer).
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Opiate Withdrawal
Complications
The biggest complication is return to drug
use.
Most opiate overdose deaths occur in
people who have just withdrawn or
detoxed. Because withdrawal reduces a
previously-developed tolerance, recently
withdrawn addicts can overdose on a
much smaller dose than they used to take
daily.
Addicts should be warned about this
possibility.
67
Opiate Withdrawal
Complications
Addicts withdrawing from opiates
should be assessed for depression
and other mental illnesses.
Treatment Approaches
Basic treatment approaches used for
managing opiate withdrawal include:
treating the symptoms of the withdrawal
with appropriate medications on an asneeded basis.
replace the client's drug of choice with, a
long-acting, cross-tolerant substitute, such
as methadone, levomethadyl
treating with an opioid antagonist, such as
naltrexone,
treating with an agonist/antagonist, e.g.
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Suboxone, or partial agonist - Subutex
Opiate Treatment
Approaches
Longer term treatment is
recommended for most addicts
following withdrawal.
This can include self-help groups, like
Narcotics Anonymous or SMART
Recovery, out-patient counseling,
intensive out-patient treatment
(partial hospitalization), or in-patient
treatment.
73
Treatment Approaches,
cont.
It is important to note that methadone withdrawal
treatment differs from a methadone maintenance
program, in which clients who are unwilling to give
up opiates are prescribed methadone as a legal,
long-term substitute for their drug of choice.
Treatment goals should be discussed with the client
and recommendations for care made accordingly.
If an opiate addict has withdrawn repeatedly only to
relapse repeatedly, methadone maintenance or
suboxone is strongly recommended.
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Opiates-IV use
It should be noted that intravenous
drug users are at risk for such
diseases as endocarditis, hepatitis,
and human immunodeficiency virus
infection and should be offered
appropriate screening.
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Treatment of overdose
Mainly supportive (e.g., airway protection).
Romazicon (flumazenil) may be given to reverse the
effects of benzodiazepines, but it must be used with
caution, as clients who are physically dependent on
benzodiazepines may develop seizures following the
use of this agent.
It cannot be given to reverse the effects of
barbiturates. There is NO ANTIDOTE to reverse
Barbiturate toxicity.
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Hallucinogens
Clients who take hallucinogens (LSD,
Mescaline, Psilocybin, khat, other designer
drugs, etc.) most commonly seek treatment
for confusional states, psychosis, or
flashbacks.
Such individuals become frightened of the
disorganization and sense of loss of control
caused by the drug, fearing that they are
losing their mind.
These clients should not be left alone, should
be allowed to rest in a quiet environment, and
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should be reassured that the strange
Designer Drugs
Common drugs
Ecstasy - also called MDMA, Adam, yaba, XTC
MDA love
MDE Eve
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Hallucinogen Intoxication
Intoxication: Pupils dilated, tachycardia, palpitations,
diaphoresis, tremors, incoordination, elevated temp,
pulse, respiration.
In severe cases, a benzodiazepine may help the client to
relax.
Antipsychotic agents & drugs with anticholinergic
properties (e.g., Thorazine) should be avoided because
they can add to the delirium.
These clients require close observation, and sometimes
restraints (only if they are a danger to self or others) until
the drug is eliminated.
87
Hallucinogens
Some clients, usually those with underlying psychiatric
disorders, continue to display psychotic symptoms after
the drug has been cleared from the body.
They may require hospitalization and treatment with
psychotropic agents.
Other clients have "flashbacks" or brief periods of
perceptual distortion or depersonalization that mirror the
drug experience.
Treatment consists of reassurance that if the client
refrains from drug use, flashbacks will not persist.
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Phencyclidine
Phencyclidine (PCP) may mimic
depressants, stimulants,
hallucinogens, or analgesics,
depending on the drug dose.
Clients may be brought to ED
because of bizarre behavior such as
posturing or staring into space or
psychotic, unstable or violent.
Nystagmus, hypertension, and
drooling in a client presenting
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Inhalants
Volatile solvents
Spray paint
Glue
Cigarette lighter fluid
Propellant gases used in aerosols
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Issues in Recovery
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Pharmacological Interventions
Treatment of Alcoholism
Naltrexone (ReVia)
Reduces or eliminates alcohol craving
Acamprosate (Campral)
Helps client abstain from alcohol
Topiramate (Topamax)
Works to decrease alcohol cravings
Disulfiram (Antabuse)
Alcohol-disulfiram reaction causes unpleasant
physical effects
94
Pharmacological Interventions
Treatment of Opioid Addiction
Methadone (Dolophine)
Synthetic opiate blocks craving for and effects of heroin
LAAM (l--acetylmethadol)
An alternative to methadone
Naltrexone (ReVia)
Antagonist that blocks euphoric effects of opioids
Clonidine (Catapres)
Effective somatic treatment when combined with naltrexone
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Hallucinogens
Diazepam
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Dual Diagnosis
The presence of at least one
psychiatric disorder in addition to a
substance abuse or dependency
problem
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Comorbidity
Psychiatric Comorbidity - 51% of
people with a serious mental illness
are dependent on or addicted to an
illicit drug.
People with comorbidity often have
chronic medical, social, and
emotional problems.
98
Treatment Issues
Treat mental illness, then substance
abuse
or
Treat substance abuse, then mental
illness
Result: Inadequate treatment
Integrated programs provide holistic
treatment
100
Family Functioning
Substance abuse is a family problem
Dysfunctional family patterns
Ineffective communication
Codependency/enabling
Adult children of alcoholics
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Powerlessness
Self-esteem, chronic
low
Sensory perception,
disturbed
Sexual dysfunction
Sleep patterns,
disturbed
Social isolation
Spiritual distress
Thought processes,
disturbed
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Outcome
Identification/Planning
Based on the assessment data, select
outcomes appropriate to the nursing diagnoses
Reduce or eliminate alcohol or drug use
Improve quality of life through abstinence
Improve quality of family life
104
Outcomes Identification,
cont.
Withdrawal
Fluid balance
Neurological status: consciousness
Distorted thoughts
Health maintenance
Knowledge: substance abuse control
Family coping
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Nursing Interventions
Assessment
Establish trust using empathy,
nonjudgmental attitude
Involve client in outcome
identification
Monitor symptoms: mental illness,
substance withdrawal, medication
effects, side effects
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Relapse prevention
Self-help groups for patient and family
12-Step programs
Residential programs
Intensive outpatient programs
Outpatient drug-free programs and
employee assistance programs
Implementation
Two phases of treatment
interventions:
1. Crisis intervention
2. Long-term abstinence
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Implementation
Aim of treatment self-responsibility
Challenge matching patients with types
of treatment related to various needs
Physiological
Psychological
Sociocultural processes
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Evaluation
111
Milieu Management
Enforce rules and set limits
Education groups regarding mental
illness, substances, medications
Other groups: Stress management,
assertiveness, community living skills
Flexible assignments to groups
Gentle supportive confrontation
Encourage attendance at self-help
groups
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Milieu Management
Safety
Drug-free environment
Suicide prevention
Structure
Balance
Limit setting
Environmental modification
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Problems Affecting
Program Development
Heterogeneous population: Group
treatment difficult
Decide which issues can be handled in
large group versus small group versus
individually
Flexibility necessary in assigning groups
Open-ended treatment necessary
Staff must deal with manipulation,
conflict
Education programs must be
structured, concrete, simplified,
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Continuum of Care
Precontemplation
Express concern about client, symptoms
Contemplation
Discuss positive and negative aspects of
substance use, periods of abstinence,
psychological symptoms
Help client consider trial of abstinence
Preparation
Affirm significance of treatment
Goal setting
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Maintenance
Anticipate and discuss difficulties
Provide support
Relapse
Express concern
Discuss what can be learned from relapse
Provide support and encouragement
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