7 Substance Use

Substance Related Disorder

Etiologies of Substance Abuse

Biologic Theories • Recent research findings indicate that genetic factors may be responsible for alcohol abuse and addiction – Research in the late 1950s focused on twins of alcoholic parents who were reared in 3 different environments: • With their own parents • With alcoholic foster parents • With foster parents who did not consume alcohol

• After 25 yrs, the incidence of alcoholism in all 3 groups was almost identical

Interpersonal Theories • focus on the individual with low self-esteem who uses substances to feel a sense of control, reduce anxiety, and thereby feel more competent • Other psychodynamic factors that are associated with alcoholism include: – – – – – – –

Basic depressive personality An intolerance for frustration or pain Lack of success Lack of affectionate and meaningful relationships Low self-esteem Lack of self-regard Tendency toward risk behaviors

Psychologic Theories • Earliest theories focused on a psychoanalytic perspective • View the substance abuser as regressed and fixated at the pregenital, oral level of psychosexual development – The individual seeks satisfaction through oral behaviors that include smoking or drinking

Learning Theories • Drug use develops and is reinforced through the positive effect of mood alterations • Media portrayals of “good times” with ETOH and drugs serve as powerful reinforcing mechanisms for adolescents and young adults • Peer pressure and the need to belong to a group also have positive reinforcing powers

Family Theories • families abuse substance have children enmeshed in these family systems • Boundaries are blurred. • Family secretes and myths used as survival measures • Less communication with children from outside their family system • Parent have strong influence on their children (protect or develop).

Demographic variables • Age: mostly 18-20 • Gender: men > women (illicit drugs men = women (non-prescribed drugs) youth; M = F (illicit drugs) • Tobacco 12-17 years F > M > 21 years M > F Education: illicit drug: university < no university alcohol: university > no university Employment: unemployed > employed

Special Population During pregnancy: • • •

Malformation in fetus Smoking has: 20 – 30% low birth weight 14% preterm, 10% infant death. Alcohol: fetal alcohol syndrome (FAS) (Growth retardation, mental retardation, facial abnormalities, hearing loss)

Adolescents: • Problematic use: experimentation • Cigarettes, alcohol, and marijuana most used. • Smoking and alcohol as a gateway to illicit drugs • Early use of drugs predicts prolonged use and substance dependence later.

Signs of adolescent substance use 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Blood shot, red eyes, droopy eyelid Wearing sunglasses at inappropriate times. Changes in sleep pattern Unexplained periods of changed mood, depression and anxiety Loss of interest Decline in academic performance Loss of motivation Changes in peer groups. Disappearance of money and items of value. Unfamiliar containers of locked boxes.

Impaired Professionals • In USA, 10-20% of nurses have substance abuse problems, 6-8% of RN are impaired due to substance abuse problems. • Why? -High job stress, contact with illness and death, and access to drugs

Epidemiology • Substance abuse is the #1 health problem in the US • The cost of substance abuse has been estimated to be a staggering $238 billion per yr • In the US, about 18% of the population experiences a substance-use d/o at some point in their lives • 51% of pts with mental illness are dependent on an illicit substance

Jordanian Study • Tobacco Smoker: NO: 272 (79%) YES: 73 (21%) OF SMOKER: > 20 cig: 42 (57 %) 10 – 20 cig: 14 (19 %) 1 – 10 cig: 56 (24 %)

Caffeine Substance Freq 0 cups

Coffee No % 107 31

Tea No 62

% 18

1- 5 Cups

213

64

249

73

5 – 10 cups

14

4

24

7

10 – 20 cups

3

1

6

2

Substance

0 times No

%

1-2 No

%

3-9 No

%

10-20 No

%

> 20 No

%

330

95.3

9

2.6

5

1.4

0

0

1

0.3

337 Cocaine Marijuana 339 Stimulants 293

97.7

3

0.9

0

0

2

0.6

2

0.6

98.3

3

0.9

1

0.3

1

0.3

0

0

84.9

17

4.9

12

3.5

9

2.6

13

3.8

Alcohol

Substance

0 times No

%

1-2 No

Hallucinogens 341 98.8 1

%

3-9 No

%

10-20 No

%

> 20 No

%

0.3

0

0

0

0

2

0.6

6.7

10

2.9

3

0.9

3

0.9

Tranquilizers

305 88.4

23

Pain killer

171 49.6

105 30.4

40

11.6 15

4.3

12

3.5

Heroin Inhalants

337 97.7

4

1.2

1

0.3

0

0

1

0.3

313 90.7

15

4.3

7

2

3

.9

6

1.7

11 Classes of Substances with the Potential for Abuse and Dependence • • • • • •

Alcohol Amphetamines Caffeine Cannabis Cocaine Hallucinogens

• • • • •

Inhalants Nicotine Opioids Phencyclidines (PCP) Sedative, hypnotics, or anti-anxiety agents

Differentiating Substance Abuse Versus Substance Dependence

DSM-IV Criteria for Substance Abuse • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 (or more) of the following, occurring within a 12 month period: – 1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home – 2. Recurrent substance use in situations in which it is physically dangerous – 3. Recurrent substance-related legal problems – 4. Continued use despite recurrent social or interpersonal problems

• B. The sx have never met the criteria for substance dependence

DSM-IV Criteria for Substance Dependence • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12 month period: – 1. Presence of tolerance – 2. Presence of withdrawal – 3. Substance is taken in larger amounts/for longer period than intended – 4. Unsuccessful or persistent desire to cut down or control use

DSM-IV Criteria for Substance Dependence (cont) – 5. Increased time in getting, taking, and recovering for the substance – 6. Important social, occupational, or recreational activities are given up or reduced because of substance use – 7. Substance used despite knowledge of recurrent physical or psychologic problems

Physiologic Complications of Alcohol Intoxication and Withdrawal

ETOH Intoxication • • • • •

Slurred speech Incoordination Unsteady gait Drowsiness Decreased BP

Level of alcohol intoxication BAL Consequences (Blood Alcohol Level) 20-50 mg/dl blood No Legal intoxication, some uncoordination, (.02 - .05) potential changes in behavior. 80 – 100 mg/dl blood (.08 - .10)

Legal intoxication, impaired ability to drive, slurred speech, staggered gait, impaired sensory function 100 – 150 mg/dl blood Markedly uncoordination, gross cognitive (.1 - .15) and judgment distortion Above 200 mg/dl blood Notable impaired sensory and motor function ( >.20) Above 300 mg/dl blood Potential for cardiovascular and respiratory ( > .30) collapse, coma, and death can occur,

Alcohol Withdrawal Sx • Tremulousness • Increased psychomotor hyperactivity • Insomnia • Acute anxiety • Tachycardia (120-140 BPM) • HTN • Anorexia • Agitation

• Possible nausea, vomiting, abdominal cramps • Weakness • Craving for alcohol or sedative drugs • Acute hallucinosis • Acute withdrawal delirium—24-72 hrs after last drink

Treatment of Withdrawal • Monitor vital signs as ordered—q 2-3 hrs • Provide quiet, nonstimulating environment • Administer benzodiazepines (drug of choice to treat alcohol withdrawal) as ordered • Frequently orient client • Institute seizure precautions • Administer vitamins as ordered • Accurately record I&O

Neurological Effects • Blackouts – Occur most frequently with excessive use of alcohol – An early sign of alcoholism – Recollection of activities are lost from conscious recall but the individual remains conscious and appears to function normally to those in their environment

Neurological Effects (cont) • Alcohol withdrawal delirium -- delirium tremens (DTs) – Most severe form of alcohol withdrawal – Occurs 24-72 hrs after the last drink – Occurs in heavy drinkers and is manifested by an acute psychotic state – Confusion and disorientation to time and place are common – Other sx include visual and auditory hallucinations that are accusatory and threatening to the pt – Illusions, severe agitation, profuse sweating, tachycardia, tachypnea, and possibly grand mal seizure activity can also occur

Neurological Effects (cont) • Acute alcoholic hallucinosis – Occurs after a prolonged period of drinking – Characterized by threatening auditory hallucinations – Different from DTs in that the individual remains oriented to time and place

Neurological Effects (cont) • Korsakoff’s syndrome – Occurs after many yrs of excessive etoh intake – An amnestic syndrome caused by deficiency in the B vitamins, including thiamine, riboflavin, and folic acid – Characterized by amnesia, disorientation to time and place, severe peripheral neuropathy— tingling; muscle weakness; sore, burning muscles; parasthesias; and extreme pain on movement – The lower extremities are most often affected

Neurological Effects (cont) • Wernicke’s syndrome – Most frequently occurs simultaneously with Korsakoff’s – Neurologic disease characterized by ataxia, nystagmus, and confusion – Caused by severe vitamin B1 deficiency due to lack of adequate food intake – The early stages respond to large doses of IM thiamine – If the condition is not treated, it can progress to a chronic, severe, irreversible lifetime condition

Medical Complications • Liver is the organ most affected by excessive etoh use • Metabolism of etoh releases excessive amounts of hydrogen into the liver – This inhibits metabolism of fats – The unburned fat becomes deposited into the liver and causes hepatic steatosis

• Alcoholic hepatitis occurs after prolonged etoh abuse—causes hepatocyte necrosis – Sx include anorexia, N&V, malaise, weight loss, fever, abdominal distress, jaundice

Medical Complications (cont) • GI system – Inflammation of the esophagus and stomach – Diarrhea

• CV system – – – –

Elevated BP Cardiomyopathy Arrhythmiasheart failure Risk of CVA

Medical Complications (cont) • GU system – Men • Decrease in erectile capacity • Testicular atrophy

– Women • Amenorrhea • Decrease in ovarian size

Abuse of Other Drugs

Benzodiazepines • Benzos taken in combination with etoh can lead to CNS depression and even death • Benzos that have a rapid onset of action are most likely to have abuse potential— Valium and Xanax • Withdrawal sx are similar to the sx of etoh withdrawal

Opioids • The most widely abused opioid is heroin – Other opioids include morphine, codeine, hydromorphone, meperidine, methadone

• Tolerance to opioids develops rapidly, however tolerance to the respiratory depressant effect does not • Most deaths occur as a result of respiratory depression – The triad of coma, pinpoint pupils, and respiratory depression signal opiate OD – Opiate OD is treated with an opioid anatgonist--Narcan

Withdrawal from Opiates • Withdrawal sx begin 6-8 hrs after the last dose and reach their peak intensity within 48-72 hrs • Sx include: – Myalgia, N&V, Diarrhea – Diaphoresis – Rhinorrhea, Lacrimation – Pupillary dilation – HTN, Tachycardia – Fever and chills

Treatment • Methadone – Rx for morphine and heroin addicts – Methadone is a synthetic opioid given to suppress withdrawal sx – Methadone maintenance is continued until the client can be gradually withdrawn from the methadone

• L-Alpha Acetylmethadol (LAAM) – Alternative to methadone – Effective for up to 3 days

Cocaine • Naturally occurring stimulant • Blocks the reuptake of 5-HT and Da --producing an intense feeling of euphoria • Highly addictive drug • Can be inhaled, smoked or used IV • Intoxication is characterized by extreme irritability, agitation, aggressiveness, impulsive sexual activity, and manic excitement – These sx are followed by withdrawal sx referred to as the “crash”

Crack • Widely available alkalinized form of cocaine • Dependence develops rapidly secondary to 5-7 min high

Withdrawal from Cocaine/Crack • Abrupt withdrawal creates an intense craving for the drug • Clients experience severe depression with SI along with hypersomnolence, fatigue, apathy, and general malaise

Stimulants • Stimulant drugs include caffeine, ephedrine, and amphetamine • Amphetamine is a highly addictive drug • Therapeutic use of amphetamines is restricted to ADHD, narcolepsy, and obesity • The amphetamine that has been called the drug of the 1990’s is “ice,” a pure form of methamphetamine which is inhaled or used IV

Stimulants (cont) • Life threatening effects of amphetamines include cardiac arrest, stroke, and neurological involvement leading to coma and death • Psychologic effects include restlessness, dysphoria, insomnia, irritability, confusion, and panic • Withdrawal sx peak 48-72 hrs after drug is d/c – Most frequent and dangerous sx is depression with SI

Inhalants • Inhalants are drugs that produce quick, temporary feeling high and lightheadedness. • Feeling high last minutes to about an hour • Inhalant abuse, also known as “huffing,” • Types: 5. Solvents: paint thinner, glue 6. Gases: Butane 7. Nitrites.

Are they harmful? • Short-term 2. Impaired physical coordination 3. Impaired mental judgment (confusion, hallucination, delusion of persecution) 4. Irritation to breathing passage 5. May block the breathing center secondary to CNS depression 6. Oxygen deprivation that lead to unconsciousness …coma…DEATH

• Long term: • Tolerance • Permanent brain damage manifested by: poor memory, extreme mood swing, tremors, seizures, cardiac arrhythmia, and respiratory depression • Glaucoma and blindness • Damage to liver and kidney

Treatment Modalities

Individual Therapy • Indicated for clients with substance related d/os who have: – High levels of anxiety – Inadequate coping mechanisms – Low tolerance for frustration

• Problems with individual therapy: – Clients continually test the bond between therapist and client – Therapist must be aware of several occurrences during the process of therapy including: • Possibility of relapse • The onset of depression • Refusal to continue therapy

Group therapy • In a group setting, clients with similar experiences and problems can confront and support each other in a safe environment • Groups work best when there are ground rules established – – – –

Sobriety Regular attendance Willingness to share experiences and confront defenses Confidentiality

Family Therapy • Provides opportunities to learn healthy ways of interacting with one another and of solving problems • Provides a structure in which the entire family can be educated about alcoholism as a disease

Behavioral Therapy • Relaxation techniques • Biofeedback • Use in combination with other models of counseling and assertiveness therapy • Approaches: assertiveness and aversive therapy (teaching negative association)

Antabuse and Naltrexone Antagonist • Disulfiram (Antabuse) – Inhibits the enzyme aldehyde dehydrogenase, thus blocking the oxidation of alcohol and allowing acetaldehyde to accumulate in the blood

• When clients take Antabuse and ingest even a small amount of alcohol, they become very sick – Sx include: flushing, feelings of heat in the face, chest, and upper limbs, pallor, hypotension, nausea, palpitations, dizziness, blurred vision

Relapse prevention • Teaching the client to identify the situations in which relapse in expected. • Enabling the client to make life style changes including living area, shopping place, and selection of friends and living with family

Harm reduction • •

A techniques to change a pattern of use. example include: 3. Driver program 4. Smoking cigarettes with low tar and nicotine

Changing The Conversation Program 1. 2. 3. 4. 5.

There is “ no wrong door” to treatment Invest for results Commit to quality Change attitudes Build partnership

Prognosis • Sobriety is the goal for complete recovery from substance abuse and dependence • The course of substance dependence is variable – It is usually chronic, lasting years with periods of heavy intake and partial or full remission

• During the first 10 months after the onset of remission, one is particularly vulnerable to relapse • Most clients relapse a minimum of 3-4 times before they attain sobriety

The Nursing Process

Assessment • Screening instruments – CAGE • Have you ever felt you ought to Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt Guilty about your drinking? • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?

– Positive response to 2 of the 4 items of the CAGE indicates a potential problem with alcohol

Assessment (cont) • Laboratory tests – A comprehensive urine drug screen – Other common laboratory tests useful in the diagnosis of alcohol abuse include: • Blood alcohol level (BAL) • GGT—rises in response to ETOH ingestion; 6080% of individuals with chronic ETOH abuse will have an increased GGT • MCV—elevated in 35% of individuals who are heavy drinkers

Nursing Diagnoses • • • • • • •

Coping, ineffective individual Denial, ineffective Family processes, altered Nutrition, altered Thought processes, altered Trauma, risk for Violence, risk for (See also appendix)

Nursing intervention • • • • • • • • • • •

Maintain patent airway and life threatening situation Maintain safety of the client and others. Observe for additional S&S for overdose Assess for psychological and physiological sing and symptoms for withdrawal and drug interaction. Initiate therapeutic intervention to treat withdrawal symptoms Provide emotional support for client and family. Support nutrition and nutrients consumption Provide carbohydrate intake, vitamin, minerals. Support client and family to acknowledge denial and deception Teach family about substance use Encourage client and family to engage in AA’s