Substance-Related Disorders

Substance-Related Disorders
Chapter 56 Substance-Related Disorders 1

Learning Objectives Discuss the biologic, sociocultural, behavioral, and intrapersonal theories of the etiology of substance abuse or dependence. Describe the data to be collected for the nursing assessment of a patient with substance abuse or dependence. Describe alcohol dependence, alcohol withdrawal syndrome, medical complications of alcohol dependence, and treatment of alcohol abuse and dependence. Discuss the pathophysiologic effects of frequently abused drugs. Describe disorders associated with substance abuse and dependence. Differentiate between drug abuse treatment and alcohol abuse treatment. Describe the nursing diagnoses and interventions associated with substance abuse and dependence. Discuss populations who present special problems in relation to drug abuse and dependency.

Etiology and Risk Factors
3

Biologic Theory Generally accepted by a majority of the experts in the field of addictionology Proposes that a faulty physiologic process that is not clearly understood contributes to dependence on a specific substance or substances (substance dependence) Widely publicized studies implicate a dopamine gene on human chromosome 11 for transmitting a predisposition for alcoholism from generation to generation This theory is supported by the fact that children have been shown to be four times more likely to become alcoholic if their biologic parent or parents are alcoholic, even when the children are raised apart from the parents in homes where they are not exposed to the excessive use of alcohol. 4

Biologic Theory Medical community considers drug dependency to be a physical illness, like those with the following characteristics Incurability A genetic predisposition A potential to be treated effectively only by total abstinence from the substance that the body cannot handle 5

Sociocultural Theory Suggests that sociocultural factors play a major role in becoming dependent on a drug Many who live in poverty and crime-ridden areas use drugs to relieve the stress inherent in these environments In contrast, individuals with strong religious values prohibiting the excessive use of drugs have lower rates of addiction Among certain subcultures, the use of certain drugs can be a rite of entry into a gang or a badge of honor proving that one has “made it.” What are examples of the sociocultural theory? 6

Behavioral Theory Looks at the triggers for drinking and drug-using behaviors and how these patterns are reinforced Substance abuse is a learned maladaptive way of coping with stress and anxiety Family and peer group role models studied closely for use of substances, along with the beliefs and customs surrounding the use of drugs and alcohol 7

Intrapersonal Theory Addresses personality factors that may predispose person to substance abuse Theorists believe that quality of intrapersonal relationships during critical developmental stages of our lives affects us profoundly If children experience early childhood rejection, increased responsibility, unrealistic expectations, or overprotection, they may develop a dependent type of personality and consequently view themselves as inadequate or failures when attempts to meet their needs fail Individuals may ultimately turn to alcohol or other drugs to numb the anxiety or frustration evoked by self-doubt and the daily stressors of reality. What personality traits do many person who abuse substance have in common? 8

Assessment of the Substance Abuser
9

Health History Interview with patient, family members, significant others; a social assessment; medical records; school or military records Question the patient for most reliable data Important to know when patient ingested the drug and how much was taken to predict the physical withdrawal symptoms Finding the most appropriate balance of support and reality-based confrontation is a highly developed skill that increases the likelihood that patients will continue in the treatment process Many substance abusers have sustained major losses—of jobs, relationships, property, self-esteem, and health. Often they will not seek professional help until they have “hit bottom.” A nonjudgmental and matter-of-fact manner is the least likely to alienate an already defensive patient. Why is it important to know when the patient last ingested the drug and how much? 10

Health History Patterns and consequences of abuse
Abuser describes typical patterns of behavior and a combination of physical or psychological withdrawal symptoms Many have erratic and unprovoked mood swings Life may revolve around obtaining/using substance Many abusers hide the extent of their habit from others and despite efforts to limit use of the substance, have been unsuccessful Blackouts when under influence of substance A few patients may not experience any physical withdrawal symptoms despite a history of prolonged, frequent, and heavy abuse, even of some substances that usually are physically addicting. What are blackouts? 11

Health History Defense mechanisms employed
Denial: patients state that they do not have a problem with drug use despite evidence to the contrary Rationalization: abusers attempt to justify the reasons for their abuse of substances Intellectualization: person focuses only on objective facts as a way of avoiding dealing with unconscious conflicts and the emotions they evoke Projection: shifting blame onto someone/something else What are examples of each type of defense mechanism? 12

Physical Examination Many substance abusers appear malnourished and poorly cared for Evidence of physical trauma: falls, abrasions, or fights Jaundice or discolored sclera of the eyes suggests cirrhosis or other liver problems Hypertension is a critical sign of withdrawal, accompanied by fluid retention in the legs or a protuberant abdomen swollen by liver ascites Anxiety, confusion, irritability, memory loss, tremors, lack of coordination, and other neurologic signs are significant; may be associated with nutritional deficits 13

Diagnostic Tests Blood alcohol study Urine drug screening
Most accurate test available to measure the degree of intoxication on initiation of treatment for alcohol abuse Urine drug screening Preferred screening for the recent use of an unknown drug; commonly with initial laboratory work Hair analysis Recent addition to methods for detecting abused substances It requires sensitive technology but may be very helpful in monitoring patients for relapse A blood alcohol level above 0.3% requires treatment for overdose; at concentrations of over 0.4%, death is likely. Legal intoxication is determined when a person’s blood alcohol level reaches what level? Drugs that are most likely to be identified with a urine drug screen include amphetamines, barbiturates, benzodiazepines, cocaine, “crack,” the opiates, marijuana, PCP, LSD, opioid analgesics, sedatives, and stimulants. Depending on the length of the hair, substance use can be detected for up to 1 year after only 2 or 3 days of use. 14

Alcohol and Alcoholism
15

Alcohol Most commonly abused drug in the United States
According to the American Society of Addiction Medicine, alcoholism is “a primary, chronic disease with psychosocial and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.” Alcohol is referred to as a “drug” in this definition, reflecting the thinking of most health care professionals. It is a drug with addictive qualities similar to those of other abused drugs Simple intoxication from alcohol usually lasts less than 12 hours and is followed by the unpleasant experience of a hangover beginning about 4 to 6 hours after the last drink. What are typical symptoms of alcohol intoxication? 16

Alcoholism Chronic use involves the regular daily ingestion of large quantities of alcohol, regular heavy drinking only on weekends, or binges of heavy drinking followed by long periods of abstinence Physical addiction occurs when alcohol becomes integrated into physiologic processes at the cellular level Cell becomes dependent on alcohol for metabolic processes; if alcohol is no longer available, the cell goes into “shock” and is unable to compensate for the loss quickly Alcohol withdrawal syndrome begins after the individual stops or decreases the amount ingested 17

Alcohol Withdrawal Syndrome
Involves physiologic and behavioral symptoms that begin when the individual’s blood alcohol level drops 18

Alcohol Withdrawal Syndrome: Stages
First stage: early withdrawal Occurs within 6 to 12 hours after the last drink Symptoms: anxiety, agitation, then irritability If the patient does not drink, tremors Blood pressure, pulse, and temperature rise Sweating, nausea, vomiting, and diarrhea 19

Alcohol Withdrawal Syndrome: Stages
Second stage: major withdrawal Begins with seizures and hallucinations; can advance to life-threatening delirium tremens (or DTs) Occurs after about 3 days (sometimes less) without alcohol and can be predicted from extreme elevations in temperature, pulse, and blood pressure Patient typically becomes disoriented and confused Hallucinations are often visual and “animal” in nature Alcohol withdrawal is the most life-threatening withdrawal syndrome in comparison to those associated with other types of commonly abused drugs, even heroin. What advice should the nurse give an alcoholic who wants to quite drinking? 20

Medical Complications
Cirrhosis of the liver, pancreatitis, gastrointestinal bleeding, Wernicke’s encephalopathy, Korsakoff’s psychosis, and fetal alcohol syndrome Wernicke’s encephalopathy Due to vitamin B1 (thiamine) deficiency Symptoms: delirium, confabulation, unsteady gait, apprehension, altered levels of consciousness that can proceed to coma If not properly treated with vitamins, Korsakoff’s psychosis 21

Korsakoff’s psychosis Thiamine and niacin deficiencies: degeneration of the cerebrum and the peripheral nervous system Symptoms: amnesia, confabulation, disorientation, and peripheral neuropathies 22

Fetal alcohol syndrome A medical complication of great concern If woman drinks to excess throughout pregnancy, unborn child at risk for low birth weight, mental retardation, growth deficiencies, heart defects, facial malformations, learning disabilities, and hyperactivity Recent controversy has arisen over whether maternal alcoholism constitutes child abuse and is thus reportable under child protection statutes 23

Treatment for Alcohol Abuse
Active family involvement in the treatment of alcohol abuse is critical to the effectiveness of treatment outcomes Alcoholism affects everyone in the family system Produces predictable patterns of individual behavior or changes in roles that may significantly handicap various family members in getting their needs met Codependent Those who enable are codependent; their behavior is highly structured around managing and adapting to the substance abuser’s dysfunctional behavior 24

Family and peer pressure and confrontation critical in inducing alcoholic to seek treatment Through participation in a 12-step self-help support group for the significant others of substance abusers, called Al-Anon and Al-Ateen, spouses, children, friends, and co-workers can learn how to cope with issues and avoid enabling the alcoholic so it becomes harder for him/her to continue a destructive pattern of drinking 25

Intervention A planned, structured meeting by family and friends to confront the alcoholic, who is brought into the meeting without prior notification about the intervention Led by a specially trained interventionist who helps those involved in the process to prepare by writing down the ways that the person’s alcohol abuse affects them personally Participants read their letters aloud to the alcohol abuser The end of each letter requests the alcoholic to get help After intervention the user will go unhappily, but voluntarily, directly from the intervention into a treatment program that has been arranged in advance in the event of that outcome The use of this strategy has come under criticism because the user confronted in this way often feels coerced into treatment. How do proponents of the use of intervention justify the consequences it may have? 26

Detoxification Usually in an inpatient hospital Vital signs are monitored frequently Initially, patients do not participate in group therapy because of their physical status Rest and nutrition are emphasized Anxiolytics (benzodiazepine) are most often used, but also hypnotics (phenobarbital, chloral hydrate) IV magnesium sulfate is used to prevent seizures in rare cases Fluids encouraged to combat dehydration, and vitamin replacement therapy is instituted 27

Rehabilitation Once medically stable, patient referred to inpatient or outpatient program, depending on needs and resources Inpatient program lasts about 28 days; includes highly structured scheduling of drug education films and presentations; increasingly confrontational individual, group, and family therapy; recreational and occupational therapy; milieu therapy; and introduction to Alcoholics Anonymous (AA) Commonly, patients referred to partial hospitalization programs and outpatient therapy as well as other community resources Less common is an extended residential program that may last 1 to 2 years 28

Alcoholics Anonymous Nonprofit, worldwide organization of alcoholics who meet anonymously in small groups to assist each other in staying sober Uses a strong spiritual base, which is controversial, and a 12-step program involving discussions and written exercises designed around each of the 12 steps to keep the alcoholic from relapsing Members identify another participant of the same sex to act as their sponsor Community service work to focus outside oneself What are the 12 steps of the 12-step program? 29

Rehabilitation Trend is toward using more nontraditional treatment approaches The teaching of stress management; social skills training; behavioral approaches to marital therapy; and matching clients with a therapist whose style matches personality type Other factors in developing homogeneous small groups are styles of thinking (abstract versus concrete thinkers), sex role–related issues, ethnicity, and age Cost containment has stimulated the development of many new types of outpatient programs for the treatment of alcoholism. What treatment programs may an alcoholic be referred to? 30

Relapse prevention Assists patients to identify triggers of substance use Person then actively avoids these people and places Other coping strategies also developed that can be used if the person encounters a trigger Aftercare and recovery Assists alcoholics who have completed a treatment program successfully to make a gradual transition back into the community with the support necessary to prevent relapses Relapse prevention is a key component in the treatment of persons with substance abuse or dependence. What services are provided by Adult Children of Alcoholics and Codependents Anonymous? 31

Medications Disulfiram (Antabuse) Metronidazole (Flagyl) Naltrexone hydrochloride (Trexan) Antidepressants Amitriptyline (Elavil) Desipramine (Norpramin) Fluoxetine (Prozac) Angiotensin-converting enzyme (ACE) inhibitors such as enalapril maleate (Vasotec) The treatment team may recommend the use of disulfiram (Antabuse) to assist the alcoholic who is highly motivated to remain sober but recognizes that poor impulse control may increase the odds of relapse. Inhibits the metabolism of alcohol in the body, producing an uncomfortable, potentially life-threatening reaction to exposure to alcohol. Research efforts continue to attempt to identify other types of drugs that could assist alcoholics to go through withdrawal more comfortably and avoid relapse. How is Flagyl used to help the alcohol abuser? 32

Other Psychoactive Substances
Stimulants Amphetamines Cocaine Crack Depressants Sedatives Hypnotics Anxiolytics Amphetamines usually are used orally or intravenously on a daily basis or on binges. They are psychologically addictive; the dose is gradually increased over time to produce the euphoria (or “high”) that is extremely pleasurable. Cocaine produces an intense feeling of euphoria that usually lasts only 30 to 60 minutes; however, the substance remains in the brain for about 10 days after use. "Crack" is a hardened form of cocaine that is smoked. It produces a tremendously addicting, short-acting psychological euphoria that is quickly followed by “crashing,” which stimulates continued cravings and use. The cravings are so intense that the user will do almost anything to obtain more of the drug, often resorting to violence if thwarted. How may depressants be obtained? 33

Hallucinogens LSD (lysergic acid diethylamide, or “acid”) PCP (phencyclidine, or “angel dust”) MDMA (3,4-methylenedioxymethamphetamine, known as “ecstasy” or “Adam”) Marijuana LSD is not physically addicting but can produce physical symptoms of altered perceptions that are dreamlike, often with an altered sense of time and feelings that one has attained special insight. PCP (phencyclidine) differs from other hallucinogens in that abusers experience a psychotic state similar to that observed in schizophrenics. What are the affects of MDMA? Marijuana causes heightened awareness, distortion of space and time, heightened sensitivity to sound, and sometimes depersonalization. 34

Narcotics (opioids) Heroin Morphine Oxycodone (OxyContin) Hydrocodone Pentazocine (Talwin) Methadone Meperidine (Demerol) 35

Inhalants Paint, glue, aerosol sprays, typing correction fluid, and gasoline Designer drugs Synthetic drugs especially designed to sidestep categorization with any of the drugs identified as illegal in the United States They are usually placed in a plastic bag or other container that is then placed over the nose and mouth and inhaled. Symptoms appearing in the individual under the influence of the drug depend on the substance inhaled and include nosebleeds, bloodshot eyes, infectious lesions around the nose and mouth, and severe disorientation or unconsciousness. What are the risks of using inhalants? 36

Disorders Associated with Substance Abuse
Human immunodeficiency virus disease (HIVD), which leads to acquired immunodeficiency syndrome (AIDS) Those who have/are predisposed to, serious psychiatric illness may present with active mental disorder Fetuses carried by mothers who are physically addicted to an opioid are born addicted and also may experience developmental delays and a prolonged lack of the capacity to feel pleasure even after they have been successfully weaned from the abused drug Clients with chronic pain also vulnerable to drug abuse 37

Treatment for Substance Abuse
Treatment similar to alcohol detoxification/rehabilitation Narcotics Anonymous (NA) structured much like AA Often inpatient treatment programs place recovering addicts with alcoholics for educational and therapy groups Family involvement in the process is very important Al-Anon is the support group for family members or significant others of a substance-abusing person It is recommended that members of the family begin attending meetings as soon as they realize that the person is using some type of drug A booming area of research is the identification of alternative treatments and medications that will help drug abusers detoxify more comfortably from the chemicals that they are addicted to and reduce the risks of relapse. How may the legal system influence an abuser to seek treatment? 38

Detoxification Complex because of the likelihood of polysubstance abuse and the uncertainty of what to expect when two or more drugs are mixed together Inpatient hospitalization recommended for safety However, some individuals who have been using drugs that are primarily psychologically addicting may not demonstrate many physical symptoms but rather experience intense psychological cravings 39

Medications Methadone Clonidine (Catapres) Naloxone (Narcan)
Used in the treatment of heroin addicts Clonidine (Catapres) A nonopiate antihypertensive drug that partially blocks withdrawal symptoms Naloxone (Narcan) An opioid antagonist that counteracts the dangerous respiratory depressant effects of heroin or other opiate overdose What are the most typical side effects of methadone? Clonidine does not completely remove the unpleasant feelings accompanied by heroin withdrawal. 40

Rehabilitation Client participates in NA at least some of the time
Based on the 12 steps of AA, except that the word “alcohol” is replaced by “drugs” in all of the literature, and the case histories used for reading assignments are about other addicts in recovery Many private health care systems are opening day treatment programs for substance abusers as insurance reimbursement for long-term inpatient programs becomes less available 41

Aftercare and Recovery
Recovering abusers offered opportunity to participate in a support group provided by a hospital Many of the same people who went through treatment at the same time participate Relationships built during this time of crisis are often intense; thus, groups can be helpful in preventing relapse Clients hoped to continue regular participation in NA groups on an ongoing basis Some do well in halfway houses, which allow for a new living environment surrounded by other recovering addicts during the difficult transition back into the community 42

Methadone Maintenance
For patients who have experienced multiple relapses into heroin abuse after treatment who may have sustained permanent damage to chemical receptor sites in the brain, which decreases their ability to resist relapse The person goes to a methadone clinic daily or 3 times/week to receive medication for next 24 to 72 hours May continue this indefinitely, often for many years The controversy over methadone maintenance has resulted in the frequent use of naltrexone (Trexan) as an alternative A single dose may be administered in liquid form or in a diskette dissolved in juice, and the person is carefully observed by clinic staff members to ensure that the medication is actually taken and not hoarded in any way. How does naltrexone (Trexan) work to help prevent the use of heroin? 43

Care of the Person with a Substance Disorder
Assessment Thorough assessment is the initial step Data can help identify and prioritize problems that must be addressed to maximize the likelihood that the patient will remain sober Problems seen in substance abusers of any kind include denial, poor impulse control, high risk for injury, high risk for relapse, guilt, and low self-esteem 44

Interventions Regular physical assessment Administration of appropriate medications Teaching patients about actions and consequences Providing adequate nutrition Reassurance and support Assisting in processing the meaning of client’s substance abuse and planning for a future without continued use of that substance Work toward penetrating patient’s denial without further damaging the individual’s self-esteem What is the biggest issue to be addressed at first that most substance abusers possess? 45

Interventions Teaching stress management and practicing these new skills with patients can greatly increase the odds that they will not relapse after discharge Patient must be taught to recognize symptoms that often lead to relapse Act as a good role model in handling feelings, participating appropriately in meetings, and communicating to the patient in a way that supports the program 46

Populations of Substance Abusers
47

Older Adults Older adults more likely to abuse over-the-counter and prescription sleeping pills, pain medications, or tranquilizers Misuse is seldom for recreational purposes among this age-group Because of a decreased ability to metabolize and eliminate alcohol or drugs from the body, older adults who do abuse drugs over extended periods may experience significant medical problems as a result 48

Older Adults Consequences of alcohol abuse: malnutrition, cirrhosis of the liver, bone thinning, gastritis, poor memory, decreased cognitive ability to process new information If the person combines alcohol with any other medication that has central nervous system depressant effects, there is serious danger of oversedation, impaired responses, or respiratory depression Abuse in the older adult population usually diagnosed by the family physician as a result of complaints related to the psychological or physical effects of alcohol abuse, such as memory impairment or insomnia 49

Older Adults Treatment of alcoholism in older adults is similar to that of younger individuals except that the period of withdrawal must be more closely monitored and occur more slowly because of physical fragility Rehabilitation groups and educational programs should be structured to permit processing information more slowly to allow for cognitive slowing for this age-group Cognitive changes may be more pronounced because of the neurologic effects of chronic use of alcohol or other drugs, or both. 50

Adolescents One in four adolescents are involved in substance abuse
The younger the age at onset of drug use, the greater is the risk for significant interference in the physical and psychological development of the individual Developmental issues of this age-group also contribute to the adolescent’s vulnerability Identification with peer group is an important aspect of feeling accepted Average adolescents view themselves as omnipotent and deny the likelihood of negative consequences of their behaviors It is estimated that one in four adolescents becomes involved in substance abuse. What developmental tasks are adolescents establishing? 51

Adolescents Substance abuse symptom of family issues
Family history of substance abuse, or the adolescent may fall in with the “wrong crowd” of other young people Entry into treatment is a result of a crisis situation, revealing the severity of drug use and parental insistence Rehabilitation requires that treatment be modified to meet needs of this age-group How is the use of drugs linked to the risk of HIV infection? 52

The Dually Diagnosed Patients diagnosed with a serious psychiatric illness and have a substance abuse problem Usually have psychiatric illnesses of depression, schizophrenia, or bipolar illness Mental retardation and organic brain disease also included in medical problems identified as presenting special concerns in the event of a concurrent substance abuse problem Chronic drug or alcohol abuse may exacerbate an already fragile neurophysiology, producing psychiatric symptoms What may cause toxic psychosis to occur more frequently? 53

The Dually Diagnosed People with chronic psychiatric problems require special teaching and supervision in the event of substance relapse The approach to rehabilitation must be modified to adapt to this special population Each patient’s ability to comprehend the abstract ideas from the 12-step process of AA will vary What could happen to patients taking anxiolytic or antidepressant agents with alcohol? 54

Peer Assistance Programs
Offer a supportive alternative to health professionals (physicians, dentists, nurses) who become addicted to a substance instead of taking immediate disciplinary action Referrals are made by the individuals themselves or their employers and peers With the help of representatives of the program, information is gathered to support an intervention to get the person into treatment and recovery 55

Goals of an intervention for a nurse Assist the nurse whose practice is impaired to receive treatment Protect the public from an untreated nurse Help recovering nurse reenter nursing in a systematic, planned, and safe way Assist in monitoring the continued recovery of the nurse for a period of time 56

Usually, there is also at least a 2-year period after diagnosis and onset of treatment in which the nurse is required to attend AA or NA groups regularly, participate in peer support groups, meet routinely with identified support person, and undergo random urine drug screens to ensure that he or she has not relapsed The information regarding each nurse involved is kept confidential and, if they successfully complete the requirements of the program, will never become part of the licensing board’s records. What happens if the nurse is unable to comply with the process? 57

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