Substance Use Disorders

Chapter 23

Terms• Use

– Drinks alcohol, swallows, smokes, sniffs or injects

• Abuse

– Use for purposes of intoxication or for Rx beyond intended use

• Dependence

– Use despite adverse consequences

• Addiction

– Psychological and behavioral dependence

Terms• Withdrawal

– Adverse physical and psychological symptoms that occur when stop using

• Detoxification

– Process of safely and effectively withdrawing a person from an addictive substance

• Relapse

– Recurrence of alcohol- or drug-dependent behavior in person who had previously been abstinent.

DSM-IV Substance Abuse Disorders

• Alcohol

• Amphetamines

• Cannabis (marijuana)

• Cocaine

• Hallucinogens

• Inhalants

• Nicotine

• Opioids

• Phencyclidine

• Sedative-hypnotics

• Anxiolytics

• Caffeine

DSM-IV

Categories

– Abuse of a substance

– Dependence upon a substance

– Induced by intoxication or withdrawal

– Table 23.1

Epidemiology: Lifetime Prevalence

• Positive lifetime history of heavy alcohol use

– 23.4% of U.S. adults

• Positive lifetime history for drug use

– 15.6% of U.S. adults

Epidemiology• African Americans:

– Lower rates of both licit and illicit substances compared to whites

– Experience more health and legal problems than other groups

– Alcohol-related consequences for males higher than whites

• Latin Americans:– High use of drug among adolescents (High school students

have highest rates of crack-cocaine and heroin use.)

– Differences in prevalence among different groups (Mexican Americans - highest; Cuban Americans - lowest)

Epidemiology

• Asian Americans and Pacific Islanders

• Data are limited.

• Drunkenness is disgraceful.

• Drinking is a male activity.

• Seeking help is a sign of weakness.

• Asian “flushing syndrome”

• Native Americans

• Rates are among the highest.

• Alcohol plays a role in health problems of this group.

Epidemiology

Gender Issues

• Incidence rates of substance abuse and dependence

– 1.7% per year men

– 0.7% per year women

• Males - more likely to abuse drugs and alcohol

• Women - more likely to abuse prescription drugs

• A high number of substance abusers has comorbid mental disorders.

Etiology

Biologic

– Genetic Influence

• Clear evidence that it runs in families

• Controversy about specific gene (allele of D2)

– Neurobiologic

• Through the reward system – medial forebrain bundle (MFB) related to cravings

• Intoxication increases extracellular dopamine.

Etiology: Psychological TheoriesAddictive Personality

– Need to feel self-worth

– Need to have control over the environment

– Need to feel intimate contact

– Need to accomplish something

– Need to eliminate pain or negative feelings

Behavioral Theories– Conduct problems of childhood

– Relationship between conduct problems, hyperactivity, impulsivity and future substance abuse

Etiology: Social Theories

• Peer drug use and affiliation

• Poor interaction skills

• Certain neighborhood characteristics

Alcohol• 90% of Americans have had a drink at some point in their lives.

• 16% have alcoholism.

• The body can metabolize 1 oz of liquor per hour (5 oz glass of wine, 12 oz can of beer).

• Excessive use can adversely affect all body systems (Table 25.5).

• Cerebellar degeneration occurs from increased levels of acetaldehyde (byproduct of alcohol metabolism), causing impaired coordination, unsteady gait, fine tremors.

• REM and chronic sleep disorders may occur.

• Drinking patterns vary.

Biologic Response to ETOH• Membranes permeable to K+ and Cl-, and

closes Na+ & Ca++ channels depression of CNS, adrenergic activity BP and HR

• Acetaldehyde is a byproduct of alcohol metabolism. Large amounts of acetaldehyde combine with dopamine and serotonin to produce a substance that is highly addictive.

Response to ETOH: Alcohol Tolerance

• Rapid metabolism and sedation, motor and anxiolytic effects

• Higher levels of BAL before intoxication

• Locus ceruleus – inhibits action of ethanol and instrumental in tolerance

• During withdrawal, locus ceruleus is hyperactive noradrenergic activity and CNS stimulation

Alcohol Withdrawal Syndrome• Changes in VS

BP and HR

• Diaphoresis

• Adverse GI effects

• CNS side effects– Anxiety

– Restlessness

– Hand tremors or “shakes”

– Disorientation

– Confusion

– Delirium tremens (DTs)

Delirium Tremens• 10 or more years of drinking

• Tachycardia

• Sweating

• Hypertension

• Irregular tremor

• Searing

• Hypertension

• Tremor

• Delusions

• Vivid hallucinations

• Resolves in three to four days

Alcohol-induced Amnestic Disorders

• History of many years of drinking

• Over age of 40

• Onset – sudden or insidious

Alcohol-induced Amnestic Disorders:

Wernicke’s Syndrome• Reversible, caused by diet deficiency of

thiamine

• Marked diplopia (palsy of the third and fourth cranial nerves), hyperactivity and delirium (cortical brain and thalamic lesions), coma

Alcohol-induced Amnestic Disorders Korsakoff’s Psychosis

• Follows Wernicke’s enceophalopathy

• Loss of recent memory and confabulation

• Vulnerable to others

Psychopharmacology

Acute Symptoms of Withdrawal

• Benzodiazepines to produce sedation and

reduce anxiety symptoms

• Diazepam 5-10 mg every two to four hours

• Librium 25-100 mg every four hours

Pharmacology & Nutrition• Disulfiram (Antabuse)

– Agonist

– Inhibits ALDH metabolism and causes nausea and hypotension, severe can cause death

– Occurs 10-20 minutes after ingestion

– Adjunct treatment

• Naltrexone (Trexan)

– Narcotic antagonist

– Reduces cravings for alcohol

• Nutrition and vitamins

Cocaine• 1.5 million Americans use cocaine.

• Men have a higher rate than women.

• Stimulant – made from leaves of coca plant

• Sudden burst of alertness, energy and self-confidence

• High lasts 10-20 minutes, then let down

• Crack cocaine – street drug form, highly addictive

Biologic Effects of Cocaine• Increases the release and blockage of the reuptake

of norepinephrine, serotonin and dopamine

Dopamine – euphoria and psychotic symptoms (prolactin levels - contribute to sexual dysfunction and secondary sexual characteristics)

Norepinephrine – tachycardia, hypertension, dilated pupils and body temp

Serotonin – sleep disturbances, anorexia

• Long-term use – depletion of dopamine

Cocaine• Intoxication

– CNS stimulation followed by depression

– Increasing doses – restlessness tremors and agitation convulsions CNS depression

– Death – respiratory failure

• Withdrawal– Norepinephrine depletion causes person to sleep 12-18 hours.

– Then, sleep disturbances with rebound REM, anergia, decreased libido, depression, suicidality, anhedonia, poor concentration and cocaine craving

Treatment of Cocaine Craving

• Antidepressants

• Anticonvulsants

• Dopamine agonists

Others• Amphetamines – Stimulant

– Block reuptake of norepinephrine and dopamine, not as strong effect on serotonin (as cocaine does)

– Effect peripheral nervous system

• Cannabis – Relaxant – Stored in fat tissue for weeks

– Amotivational syndrome

• Hallucinogens – LSD– Phencyclidine (PCP) angel dust

awareness and detachment

– hallucinations/destructive behavior (adrenergic )

Opiates – Narcotics• Any substance that binds to the opioid receptor

• Cause CNS depression, sleep or stupor, and analgesia

• Major – heroin, codeine and meperidine

• Act on Delta and Mu receptors and depress the CNA

• Types

– Agonist – increases CNS effects

– Antagonist – block CNS effects

– Mixed agonist-antagonist

• Effects of opiates

– Pleasure

– Relief of pain

• Cause tolerance and physical dependence

Opiate Treatment• Antagonist – block CNS effects, Naloxone

(Narcan)

• Detox – gradual reduction over several days

• Methadone maintenance treatment

– Opiate that satisfies craving, but no subjective high (See Table 25.7)

• Naltrexone – see Drug Profile

Other Substances• Sedatives-hypnotics and Anxiolytics

– Abuse of prescription drugs

– See Table 25.8

• Inhalants– Cause euphoria, sedation, emotional lability, impaired judgment

– Result in respiratory depression

– Found in common household products

• Nicotine

• Caffeine

Nursing ManagementAssessment

• Denial

• Countertransference

• Codependence

• Maladaptive learned pattern of coping

– Roles in family

• Chief enabler

• Dependent

• Hero

• Scapegoat

• Lost child

• Mascot

Nursing Diagnoses

• Risk for injury

• Disturbed thought processes

• Anxiety

• Risk for ineffective management of therapeutic regimen, ineffective denial

• Altered nutrition

Motivation for Change

• Key predictor of whether an individual will change his/her substance abuse

• Involves recognizing problem, searching for a way to change and then changing

• Motivational interviewing seeks to elicit self-motivational statement from patients, supports behavioral change and creates a discrepancy between the patient’s goals and continued alcohol and other drug use.

Guidelines for Therapeutic Relationship

• Encourage honest expression of feelings.

• Listen, and express caring.

• Hold individual responsible for behavior.

• Provide consequences for negative behavior, and talk about specific, objectionable actions.

• Do not compromise own values; monitor reaction.

• Communicate to the team.

Reality Confrontation

• Therapeutic strategy that promotes the person’s experience of the natural consequences of one’s behavior

• Learning from previous behavior

• Guidelines for establishing interactions

Special Considerations• HIV and substance abuse

– High risk for HIV exists among IV drug users.

– Dual diagnosis of chemical dependency and HIV requires extremely careful assessment and intervention.

– Patients often experience intense feelings of uselessness.

• Harm-reduction strategies

– Community health intervention replacing moral and criminal approach (needle exchange programs, designated driver)

Special Considerations (cont.)

Pregnancy and substance abuse

• Detrimental effects on pregnancy

• Several clinical issues facing mothers– Feelings of guilt and shame

– Difficulties being a single parent

– Care and responsibility of raising children early sobriety

– Lack of access to treatment facilities

– Anger and blame from caregivers

– Need for parenting skills

– Potential for child abuse and neglect

– Lack of medical and other health care services

Interventions• 12-step program

• Cognitive therapy

• Psychoeducation groups

• Behavioral interventions

• Group therapy and early recovery

• Individual therapy

• Family therapy

Interventions

• Nursing Care Plan 23.1

• Depend upon the stage of treatment