7 substance use

8/14/2019 7 Substance Use

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Substance Related Disorder


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Etiologies of Substance Abuse


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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


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Interpersonal Theories

focus on the individual with low self-esteem whouses substances to feel a sense of control, reduceanxiety, 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


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Psychologic Theories

Earliest theories focused on a

psychoanalytic perspective

View the substance abuser as regressed andfixated at the pregenital, oral level of

psychosexual development

The individual seeks satisfaction through oralbehaviors that include smoking or drinking


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Learning Theories

Drug use develops and is reinforced throughthe positive effect of mood alterations

Media portrayals of good times withETOH and drugs serve as powerfulreinforcing mechanisms for adolescents andyoung adults

Peer pressure and the need to belong to agroup also have positive reinforcing powers


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Family Theories families abuse substance have children

enmeshed in these family systems

Boundaries are blurred.

Family secretes and myths used as survivalmeasures

Less communication with children from

outside their family system Parent have strong influence on their

children (protect or develop).


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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


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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)


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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.


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Signs of adolescent substance use1. Blood shot, red eyes, droopy eyelid

2. Wearing sunglasses at inappropriate times.

3. Changes in sleep pattern

4. Unexplained periods of changed mood,

depression and anxiety5. Loss of interest

6. Decline in academic performance

7. Loss of motivation

8. Changes in peer groups.

9. Disappearance of money and items of value.

10. Unfamiliar containers of locked boxes.


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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


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Epidemiology

Substance abuse is the #1 health problem in theUS

The cost of substance abuse has been estimated tobe a staggering $238 billion per yr

In the US, about 18% of the populationexperiences a substance-use d/o at some point in

their lives 51% of pts with mental illness are dependent onan illicit substance


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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 %)


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Caffeine

62 18107 310 cups

6 23 110 20 cups

24 714 45 10 cups

249 73213 641- 5 Cups

Tea

No %

Coffee

No %

Substance

Freq


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3.8132.693.5124.91784.9293Stimulants

000.310.310.9398.3339Marijuana

0.620.62000.9397.7337Cocaine

0.31001.452.6995.3330Alcohol

%No%No%No%No%No

> 2010-203-91-20 timesSubstance


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1.76.93274.31590.7313Inhalants

0.31000.311.2497.7337Heroin

3.5124.31511.64030.410549.6171Pain killer

0.930.932.9106.72388.4305Tranquilizers

0.6200000.3198.8341Hallucinogens

%No%No%No%No%No

> 2010-203-91-20 timesSubstance

11 Cl f S b i h h


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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


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Differentiating Substance Abuse

Versus Substance Dependence


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DSM-IV Criteria for Substance

Abuse A. A maladaptive pattern of substance use leading toclinically 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


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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


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Dependence (cont)5. Increased time in getting, taking, and

recovering for the substance

6. Important social, occupational, orrecreational activities are given up or reduced

because of substance use

7. Substance used despite knowledge ofrecurrent physical or psychologic problems


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Physiologic Complications ofAlcohol Intoxication and

Withdrawal


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ETOH Intoxication

Slurred speech

Incoordination

Unsteady gait

Drowsiness

Decreased BP


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Level of alcohol intoxication

Potential for cardiovascular and respiratory

collapse, coma, and death can occur,

Above 300 mg/dl blood

( > .30)

Notable impaired sensory and motor functionAbove 200 mg/dl blood

( >.20)

Markedly uncoordination, gross cognitive

and judgment distortion

100 150 mg/dl blood

(.1 - .15)

Legal intoxication, impaired ability to drive,slurred speech, staggered gait, impaired

sensory function

80 100 mg/dl blood(.08 - .10)

No Legal intoxication, some uncoordination,

potential changes in behavior.

20-50 mg/dl blood

(.02 - .05)

ConsequencesBAL

(Blood Alcohol Level)


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Alcohol Withdrawal Sx

Tremulousness

Increased psychomotorhyperactivity

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

delirium24-72 hrs after

last drink


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Treatment of Withdrawal

Monitor vital signs as orderedq 2-3 hrs

Provide quiet, nonstimulating environment

Administer benzodiazepines (drug of choice totreat alcohol withdrawal) as ordered

Frequently orient client

Institute seizure precautions Administer vitamins as ordered

Accurately record I&O


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Neurological Effects

Blackouts

Occur most frequently with excessive use of

alcoholAn 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


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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 acutepsychotic state

Confusion and disorientation to time and place arecommon

Other sx include visual and auditory hallucinations thatare accusatory and threatening to the pt

Illusions, severe agitation, profuse sweating,tachycardia, tachypnea, and possibly grand mal seizure

activity can also occur


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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


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Neurological Effects (cont) Korsakoffs 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 totime and place, severe peripheral neuropathy

tingling; muscle weakness; sore, burningmuscles; parasthesias; and extreme pain onmovement

The lower extremities are most often affected


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Neurological Effects (cont) Wernickes syndrome

Most frequently occurs simultaneously withKorsakoffs

Neurologic disease characterized by ataxia,nystagmus, and confusion

Caused by severe vitamin B1 deficiency due tolack of adequate food intake

The early stages respond to large doses of IMthiamine

If the condition is not treated, it can progress toa chronic, severe, irreversible lifetime condition


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Medical Complications

Liver is the organ most affected by excessive etohuse

Metabolism of etoh releases excessive amounts ofhydrogen into the liver This inhibits metabolism of fats

The unburned fat becomes deposited into the liver andcauses hepatic steatosis

Alcoholic hepatitis occurs after prolonged etohabusecauses hepatocyte necrosis Sx include anorexia, N&V, malaise, weight loss, fever,

abdominal distress, jaundice


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Medical Complications (cont)

GI systemInflammation of the esophagus and stomach

Diarrhea CV system

Elevated BP

Cardiomyopathy

Arrhythmiasheart failure

Risk of CVA


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Medical Complications (cont)

GU system

Men

Decrease in erectile capacity Testicular atrophy

Women

Amenorrhea

Decrease in ovarian size


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Abuse of Other Drugs


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Benzodiazepines

Benzos taken in combination with etoh can

lead to CNS depression and even death

Benzos that have a rapid onset of action aremost likely to have abuse potential

Valium and Xanax

Withdrawal sx are similar to the sx of etohwithdrawal


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Opioids

The most widely abused opioid is heroin

Other opioids include morphine, codeine,

hydromorphone, meperidine, methadone

Tolerance to opioids develops rapidly, howevertolerance 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


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Withdrawal from Opiates

Withdrawal sx begin 6-8 hrs after the last dose andreach their peak intensity within 48-72 hrs

Sx include:

Myalgia, N&V, Diarrhea

Diaphoresis

Rhinorrhea, Lacrimation

Pupillary dilationHTN, Tachycardia

Fever and chills


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Treatment

Methadone

Rx for morphine and heroin addicts

Methadone is a synthetic opioid given to suppresswithdrawal 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


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Cocaine

Naturally occurring stimulant

Blocks the reuptake of 5-HT and Da --producingan intense feeling of euphoria

Highly addictive drug Can be inhaled, smoked or used IV

Intoxication is characterized by extremeirritability, agitation, aggressiveness, impulsivesexual activity, and manic excitement These sx are followed by withdrawal sx referred to as

the crash


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Crack

Widely available alkalinized form of

cocaine

Dependence develops rapidly secondary to5-7 min high


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Withdrawal from Cocaine/Crack

Abrupt withdrawal creates an intense

craving for the drug

Clients experience severe depression withSI along with hypersomnolence, fatigue,

apathy, and general malaise


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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 1990s is ice, a pure form of

methamphetamine which is inhaled or used IV


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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


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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.


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Are they harmful?

Short-term2. 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 depression6. Oxygen deprivation that lead to

unconsciousness comaDEATH


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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


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Treatment Modalities


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Individual Therapy

Indicated for clients with substance related d/oswho have: High levels of anxiety

Inadequate coping mechanisms

Low tolerance for frustration Problems with individual therapy:

Clients continually test the bond between therapist andclient

Therapist must be aware of several occurrences duringthe process of therapy including:

Possibility of relapse

The onset of depression

Refusal to continue therapy


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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


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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


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Behavioral Therapy

Relaxation techniques

Biofeedback

Use in combination with other models ofcounseling and assertiveness therapy

Approaches: assertiveness and aversive

therapy (teaching negative association)


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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


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Relapse prevention

Teaching the client to identify the situations

in which relapse in expected.

Enabling the client to make life stylechanges including living area, shopping

place, and selection of friends and living

with family


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Harm reduction

A techniques to change a pattern of use.

example include:

3. Driver program

4. Smoking cigarettes with low tar and

nicotine


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Changing The Conversation

Program1. There is no wrong door to treatment

2. Invest for results

3. Commit to quality

4. Change attitudes

5. Build partnership


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Prognosis

Sobriety is the goal for complete recovery fromsubstance 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 ofremission, one is particularly vulnerable to relapse

Most clients relapse a minimum of 3-4 timesbefore they attain sobriety


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The Nursing Process


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Assessment

Screening instrumentsCAGE

Have you ever felt you ought to Cut down on yourdrinking?

Have people Annoyed you by criticizing yourdrinking?

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 (Eyeopener)?

Positive response to 2 of the 4 items of theCAGE indicates a potential problem with

alcohol


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Assessment (cont)

Laboratory tests

A comprehensive urine drug screen

Other common laboratory tests useful in thediagnosis of alcohol abuse include:

Blood alcohol level (BAL)

GGTrises in response to ETOH ingestion; 60-

80% of individuals with chronic ETOH abuse willhave an increased GGT

MCVelevated in 35% of individuals who are

heavy drinkers


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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


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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 anddeception

Teach family about substance use

E li d f il i AA

7 substance use

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