1. CHEMICAL DEPENDENCY: An Overview
RNSG 2213

2. 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 coco leaves, used peyote in religious ceremonies, smoked the “peace pipe.”

3. Illicit Drug Use Most used illicit drugs world-wide: Cannabis (#1)
Amphetamines
Cocaine
Opioids
(WHO 2004)

4. 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

5. Introduction: Drugs and U.S. Law
1914: Harrison Narcotic Act --Opiate prohibition
Alcohol Prohibition in the 1920’s and 1930’s
1970: Drug Enforcement Agency created; Controlled Substances Act passed
1987: AMA declared all chemical dependency as disease
1990: ADA—non discrimination against persons with history of drug/alcohol addiction

6. ADDICTION LIABILITY Highest Lower cocaine/crack amphetamines
opiates anesthetics
(PCP, ketamine)
alcohol nicotine benzodiazepines
marijuana

7. (Addiction liability, cont’d)
These are non-addicting:
LSD and other hallucinogens
antidepressant drugs
antipsychotic drugs
naltrexone-Trexan

8. 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 now considered judgmental )

9. Definitions, cont’d
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

10. 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

11. 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

12. Biological Theory: Neurotransmitters of Drug Dependence
Dopamine (DA) –”pleasure pathway”
Serotonin (SER)
Endorphins (END)
GABA/Glutamate (GLU) Theory: heavy drug use decreases response of “brain calming” neuroreceptors (= tolerance)

13. Etiology of Dependence: Biological Theory
Repeated use of a drug results in stimulation of brain’s “reward” or “pleasure” pathway in mesolimbic system

14. Biological Theory of Dependence cont’d
Repeated use of a drug targets specific brain areas for that drug, with resulting creation of extra receptors and brain’s perception that drug’s stimuli are necessary for survival (cravings)

15. The Addicted Brain
Bottom Line: Major sites targeted by addicting drugs
(Within medial forebrain, not cortex) are evidence that addictions are not under conscious control

16. Biological Theory, cont’d
Evidence of genetic predisposition for alcoholism.
Example: Allergic response to ETOH in many Southeast Asians
Strong concurrence with bipolar disorder
Twins born to alcoholic parents who are then adopted have 3x rate of adopted children of non-alcoholics.

17. Multivariant Theory: 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)

18. Etiology: Sociocultural Factors
Advertising: “Relief is just a swallow away”
Don’t suffer; take action
Sex differences: Males abuse alcohol and opiates more. Females abuse prescription drugs
Catholics: Highest rate of alcohol abuse
Observant Jews: lowest
Stress
Availability, cost

19. Etiology: Psychological/Psychodynamic Theory
Person who abuses drugs seeks to escape from anxiety or emotional pain. Sees self in a fundamentally negative way.

20. Personality Traits Associated with Chemical Dependence
DENIAL/ anger
Inability to express emotions
High anxiety in interpersonal relations
Emotional immaturity; overdependence
Ambivalence towards authority; rule breaker
Low frustration tolerance; wants instant gratification

21. Personality Traits, continued
Low self-esteem
Feelings of isolation
Perfectionism and compulsiveness
Sex role confusion
Are these qualities the cause or the result of drug use?

22. Effects on Family
All family members affected by the substance-dependent member.
Many characteristic behaviors:
Focus becomes on the addict’s behavior
Co-dependency
Care-taking by children
Perpetuation of these dynamics into adulthood
3 Options: ignore, banish, adapt
Family in need of treatment

23. 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)

24. Short version of Michigan Alcoholism Screening Test (SMAST)
> 3 points indicates problem

25. GOALS FOR 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 patient’s dignity”

26. Principles of Detoxification
Ideal 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.

27. Nursing 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
Medications to treat co-occurring mental illness

28. Client Behaviors and Nursing Interventions
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

29. Interventions: Client Teaching
Disease process
Total abstinence is the goal
Relapse prevention strategies
Recognize and confront own denial
Recognize triggers
“Change people, places and things.”
Often biggest obstacle to abstinence.

30. 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.