SUBSTANCE

ABUSE

Substance use/abuse and related disorders are a national health problem. 14% of adults meet the criteria for an alcoholrelated disorder and 6.2% of adults meet the criteria for a substance related disorder other than alcohol or tobacco Substance Abuse Use of drug in a way that is inconsistent with medical or social norms and despite negative consequence. It denotes problem in social, vocational or legal areas of the persons life. Substance Dependence Includes problem associated with addiction such as tolerance, withdrawal and unsuccessful attempts to stop sing the substances.

TYPES OF SUBSTANCE ABUSE

Poly Substance Abuse abuse of more than one substance.

The DSM-IV-TR lists 11 diagnostic classes of substance abuse: Alcohol Amphetamines or similarly acting sympathomimetics Caffeine Cannabis Cocaine Hallucinogens Inhalants Nicotine Opioids Phencyclidine (PCP) or similarly acting drugs Sedatives, hypnotics, or Anxiolytics

Two Groups Categorizes Substancerelated Disorder

1. 2.

Those that include disorders of abuse and dependence Substance-induced disorders such as: Intoxication Withdrawal Delirium Dementia Psychosis Mood disorder Anxiety sexual dysfunction Sleep disorder

Intoxication Is use of a substance that results in maladaptive behavior. Withdrawal Syndrome Refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases.
Detoxification is the process of safely withdrawing from a substance.

ONSET AND CLINICAL COURSE

The early course of alcoholism typically begins with the first episode of intoxication between the 15 and 17 years of age. A pattern of more severe difficulties for people with alcoholism begins to emerge in the middle 20s to the middle 30s; these difficulties can be the alcohol related:

Breakup of a significant relationship An arrest for public intoxication or driving while intoxicated Evidence of alcohol withdrawal Early alcohol-related health problems Significant interference with functioning at work or school.

Blackout Which is an episode during which the person continues to function but has no conscious awareness of his or her behavior at the time nor any later memory of the behavior. Tolerance He/she needs more alcohol to produce the same effect. Tolerance Break Very small amounts of alcohol will intoxicate the person. Spontaneous Remission/Natural Recovery Alcohol problem can modify or quit drinking on their own without a treatment program.

RELATED DISORDERS

Substance-induced disorders such as anxiety, mood disorders, and dementia are present. Like Delirium which may be seen in severe alcohol withdrawal. A clinical care plan for a client receiving treatment for Drugs and alcohol can lead to legal problems. The effects on adults who grew up in a home with an alcoholic parent are discussed as the special needs of clients with a dual diagnosis of substance use and a major psychiatric disorder.

ETIOLOGY

The exact causes of drug use, dependence, and addiction are not known, but various factors are thought to contribute to the development of substance-related disorders. BIOLOGICAL FACTORS Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than children of non-alcoholic parents. Several studies of twins have shown a higher rate of concordance (when one twin has it, the other twin gets it) among identical than fraternal twins. Adoption studies have shown higher rates of alcoholism in sons of biologic fathers with alcoholism than in those of nonalcoholic biologic fathers. 50% to 60% of the variation in causes of alcoholism was the result of genetics, with the remainder caused by environmental influences. The ingestion of mood-altering substances stimulates dopamine pathways in the limbic system, which produces pleasant feelings or a high that is a reinforcing, or positive, experience.

PSYCHOLOGICAL FACTORS

Children of alcoholics are four times as likely to develop alcoholism. Inconsistency in the parent's behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse. Some people use alcohol as a coping mechanism or to relieve stress and tension, increase feelings of power and decrease psychological pain. High doses of alcohol, actually increase muscle tension and nervousness.

SOCIAL AND ENVIRONMENTAL FACTORS

Younger experimenters use substances that carry less social disapproval such as alcohol and cannabis, whereas older people use drugs such as cocaine and opioid that are more costly and rate higher disapproval. Alcohol consumption increases in areas where availability increases and decreases in areas where cost of alcohol are higher because of increased taxation.

ALCOHOL

Intoxication and Overdose Alcohol is a central nervous system depressant that is absorbed rapidly into the blood stream.

Initial Effects

Relaxation Loss of inhibition Slurred speech Unsteady gait Lack of coordination Impaired attention Concentration Memory Judgment

Intoxication Symptoms

Some people become aggressive or display inappropriate sexual behavior when intoxicated. The person who is intoxicated may experience a blackout. Overdose Vomiting Unconscious Respiratory depression Treatment Gastric lavage or dialysis to remove drug Support for respiratory Cardiovascular functioning in an ICU

WITHDRAWAL AND DETOXIFICATION

Symptoms withdrawal usually begins 4-12hrs. After cessation. Symptoms include: Coarse hand tremors Sweating Elevated blood pressure and pulse Insomnia Anxiety Nausea and vomiting Severe or untreated withdrawal may progress to transient hallucination, seizure or delirium called Delirium Tremors ( DTs) Safe withdrawal usually is accomplished with the administration of benzodiazepines such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium) to suppress the withdrawal symptoms.

PHYSIOLOGIC EFFECTS OFLONGTERM ALCOHOL USE

Cardiac myopathy Wernickes encephalopathy Korsakoffs psychosis Pancreatitis Esophagitis Hepatitis Cirrhosis Leukopenia Thrombocytopenia Ascites

SEDATIVES, HYPNOTIC AND ANXIOLYTICS

INTOXICATION AND OVERDOSE Intoxication Symptoms
Slurred speech Lack of coordination Unsteady gait Labile mood Impaired attention/ memory Stupor and coma

Treatment

Include gastric lavage followed by ingestion of active charcoal and a saline cathartics dialysis can be used if symptoms are severe.

WITHDRAWAL AND DETOXIFICATION Lorazepam action typically last about 10 hours produce withdrawal symptoms in 6-8 hours; longer acting medications such as diazepam may not produce withdrawal symptoms for 1 week. Withdrawal Syndrome characterized by symptoms that are opposite of the acute effects of drug. That is: Autonomic hyperactivity (Increased Vital Signs) Hand tremor Insomnia Anxiety Nausea Psychomotor agitation Seizures and hallucinations occur only rarely in severe benzodiazepine withdrawal. Tapering, or administering decreasing doses of a medication, is essential with barbiturates to prevent coma and death that will occur if the drug is stopped abruptly.

STIMULANTS (AMPHETAMINES, COCAINE, OTHER)

Amphetamines are drugs that stimulate or excite the CNS; used by people who wanted to lose-weight or to stay awake. Cocaine highly addictive and a popular recreational drugs because of the intense and immediate feeling of euphoria it produces. Methamphetamine it is particularly dangerous. It is highly addictive and causes psychotic behavior.

INTOXICATION AND OVERDOSE Intoxification Effects Euphoric feeling Hyperactivity Hyper vigilance Talkativeness Anxiety Grandiosity Hallucination Stereotypic/ repetitive behavior Anger Fighting Impaired judgment

Physiologic Effects
Elevated Blood Pressure Tachycardia Dilated pupils Perspiration/ chills Nausea Chest pain Confusion Cardiac Dysrrhythmias Overdose can result seizures, coma; deaths are rare.

Treatment

CHLORPROMAZINE (Thorazine) antipsychotic, control hallucination, lower Blood Pressure, relieves nausea.

WITHDRAWAL AND DETOXIFICATION

Occurs with in the few hours to several days after cessation of the drugs and is not life-threatening Dysphoria Fatigue Vivid Unpleasant dreams Insomnia/ Hypersomnia Increase appetite Psychomotor retardation/ agitation

CANNABIS (MARIJUANA)
Cannabis Sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and for oil fro its seeds. Marijuana refers to the upper leaves, flowering tops and stems of the plant. Two Cannabinoids used to treat N/V from cancer chemotheraphy. 1. Dronabinol (Marinol) 2. Nabilone ( Cesamet)

INTOXICATION AND OVERDOSE

Cannabis begins to act less than 1minute after inhalation. Effects usually occur in 20-30min. And last at least 2-3hours.

Symptoms of Intoxication

Impaired motor coordination Inappropriate laughter Impaired judgment Short term-memory Distortion of time and perception Anxiety Dysphoria Social withdrawal

Physiologic Effects Increased appetite Conjunctival injection (Bloodshot Eyes) Dry mouth Hypotension Tachycardia WITHDRAWAL AND DETOXIFICATION Withdrawal Symptoms
Muscle ache Sweating Anxiety Tremors

OPIOIDS

Are popular drugs of abuse because they desensitize the user to both physiologic and psychological pain and induce the sense of euphoria and well-being. Opioids compounds include both potent prescription analgesic such as:

Morphine Meperidine ( Demerol ) Codeine Hydromorphone

Oxycodone Methadone Oxymorphone Hydrocodone Propoxyphene and illegal substance such as Heroin Normethadone

INTOXICATION AND OVERDOSE It may develops soon after the initial euphoria feeling; symptoms includes: Apathy Lethargy List lessens Impaired judgment Psychomotor retardation/ agitation Constricted pupils Drowsiness Slurred speech Impaired attention and memory

In severe intoxication can lead to: Coma Respiratory depression Papillary constriction Unconsciousness Death Administration of NALOXONE (Narcan ) opioid antagonist is the treatment of choice because it reverses all signs of opioid toxicity.

WITHDRAWAL AND DETOXIFICATION Initial Symptoms Anxiety Restlessness Aching back and legs Symptoms develop as withdrawal progress includes: Nausea Vomiting Dysphoria Lacrimation Rhinorrhea Sweating Diarrhea Yawning Fever Insomnia

Short-acting drugs such as heroin produce withdrawal symptoms in 6-24 hrs. symptoms peak in 2-3days and gradually subside in 5-7days. Longer- acting substances such as methadone may not produce significant withdrawal symptoms for 2-4days and the symptoms may take 2weeks to subside Methadone used as replacement for the opioid and the dosage is decreased aver 2weeks.

HALLUCINOGENS
Substances that distort the users perception of reality and produce symptoms similar to psychosis including hallucinations (usually visual) and depersonalization. It Causes: Increased pulse Blood pressure Temperature Dilated pupils Hyperreflexia

INTOXICATION Marked by several maladaptive behavioral Psychological Changes: Anxiety Depression Paranoid ideation Ideas of reference Fear losing ones mind Physiologic symptoms Sweating Tachycardia Palpation Blurred vision Tremors Lack of coordination WITHDRAWAL AND DETOXIFICATION No withdrawal syndrome has been identified foe hallucinogen.

INHALANTS
a diverse group of drugs including anesthetics, nitrates, and organic solvents that are inhaled for their effects. Most common substances: Aliphatic and aromatic hydrocarbons Glue Paint thinner Spray paint It can cause: Brain damage Peripheral nervous system damage Liver disease
Are

INTOXICATION AND OVERDOSE Inhalants intoxication involves: Dizziness Nystagmus Lack of coordination Slurred speech Unsteady gait Tremor Muscle weakness Blurred vision

Behavioral symptoms: Belligerence Aggression Apathy Impaired judgment Inability to function Acute toxicity causes: Anoxia Respiratory depression Vagal stimulation Dysrrhythmias

Treatment: Consist of supporting respiratory and cardiac functioning until the substance is removed from the body. WITHDRAWAL AND DETOXIFICATION People who abuse inhalants may suffer from persistent dementia or inhalant-induced disorder such as psychosis, anxiety or mood disorder even if the inhalant abuse ceases.

TREATMENT AND PROGNOSIS

Until 1970s, organized treatment programs and clinics for substance abuse was scarce. The user was advised to pull yourself together and get control of your problem. Founded in 1949, the Hazelden Clinic in Minnesota is the noted exception; because of its success, many programs are based on Hazelden model of treatment. Alcoholic Anonymous was founded in the 1930s by alcoholics. This self help group developed the 12-step program model for recovery which is based on the philosophy that total abstinence is essential and alcoholics need the help and support of others to maintain sobriety.

Twelve Steps of Alcoholics Anonymous We admitted we were powerless over alcohol - that our lives had become unmanageable. Came to believe that a Power greater than ourselves could restore us to sanity. Made a decision to turn our will and our lives over to the care of God as we understood Him. Made a searching and fearless moral inventory of ourselves. Admitted to God, to ourselves and to another human being the exact nature of our wrongs. Were entirely ready to have God remove all these defects of character. Humbly asked Him to remove our shortcomings. Made a list of all persons we had harmed, and became willing to make amends to them all. Made direct amends to such people wherever possible, except when to do so would injure them or others. Continued to take personal inventory and when we were wrong promptly admitted it. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

PHARMACOLOGIC TREATMENT
Have two main purposes: To permit safe withdrawal from alcohol, sedative/hypnotics, and benzodiazepines To prevent relapse. For clients whose primary substance is alcohol, vitamin B1 (thiamine) often is prescribed to prevent or treat Wernickes syndrome and Korsakoffs syndrome, which are neurologic conditions that can result from heavy alcohol use. Cyanocobalamin (vitamin B12) and folic acid often are prescribed for clients with nutritional deficiencies. Alcohol withdrawal usually is managed with a benzodiazepine anxiolytic agent, which is used to suppress the symptoms of abstinence. The most common used benzodiazepines are lorazepam, chlordiazepoxide, and diazepam. Disulfiram (Antabuse) may be prescribed to help to deter clients from drinking.

Methadone, a potent synthetic opiate, is used as a substitute for heroin in some maintenance programs. Levomethadyl is a narcotic analgesic whose only purpose is the treatment of opiate dependence. Naltrexone (ReVia) is an opiod antagonisy often used to treat overdose. Clonidine (Catapres) is an alpha-2-adrenergic agonist used to treat hypertension. Odansentron (Zofran), a 5-HT3 antagonist that blocks the vagal stimulation effects of serotonin in the small intestine, is used as an antiemetic.

Dual Diagnosis

Client with both substance abuse and another psychiatric illness is said to have a dual diagnosis. It is estimated that 50% of people with a substance abuse disorder also have a mental health diagnosis. Traditional methods of treatment for major psychiatric illness or primary substance abuse often have little success in these clients for the following reasons:

Clients with a major psychiatric illness may have impaired abilities to process abstract concepts; this is a major barrier in substance abuse programs. Substance use treatment emphasizes avoidance of all psychoactive drugs. This may not be possible for the client who needs psychotropic drugs to treat his or her mental illness. The concept of limited recovery is more acceptable in the treatment of psychiatric illnesses, but substance abuse has no limited recovery concept. The notion of lifelong abstinence, which is central to substance use treatment, may seem overwhelming and impossible to the client who lives day to day with a chronic mental illness. The use of alcohol and other drugs can precipitate psychotic behavior; this makes it difficult for professionals to identify whether symptoms are the result of active mental illness or substance abuse.

Symptoms of Substance Abuse Denial of problems Minimizes use of substance Rationalization Blaming others for problems Anxiety Irritability Impulsivity Feelings of guilt and sadness or anger and resentment Poor judgment Limited insight Low self-esteem Ineffective coping strategies Difficulty expressing genuine

feelings Impaired role performance Strained interpersonal relationships Physical problems such as sleep disturbances and inadequate nutrition

CLIENT AND FAMILY TEACHING: CLIENTS WITH SUBSTANCE ABUSE

Substance abuse is an illness Dispel myths about substance abuse Abstinence from substances is not a matter of willpower Any alcohol whether beer, wine, or liquor, can be an abused substance Prescribed medication can be an abused substance Feedback from family about a return to previous maladaptive coping mechanism is vital Continued participation in an aftercare program is important

NURSING INTERVENTIONS FOR CLIENTSWITH SUBSTANCE ABUSE

Health teaching for the client and family Dispel myths surrounding substance abuse Decrease codependent behaviors among family members Make appropriate referrals for family members Promote coping skills Role-play potentially difficult situations Focus on the here-and-now with clients Set realistic goals such as staying sober today

APPLICATION OF NURSING PROCESS

GENERAL APPEARANCE AND MOTOR BEHAVIOR Assessment of general appearance and behavior usually reveals appearance and speech to be normal. Clients may appear anxious, tired, and disheveled if they have just completed a difficult course of detoxification. MOOD AND AFFECT Wide ranges of mood and affect are possible. Some clients are sad and tearful, expressing guilt and remorse for their behavior and circumstances. Others may be angry and sarcastic or quiet and sullen, unwilling to talk to the nurse. Irritability is common because clients are newly free of substances.

THOUGHT PROCESS AND CONTENT During assessment of thought process and content, clients are likely to minimize their substance use, blame others for their problems, and rationalize their behavior. They may think they cannot survive without the substance or may express no desire to do so. SENSORIUM AND INTELLECTUAL PROCESSES Clients generally are oriented and alert unless they are experiencing lingering effects of withdrawal. Intellectual abilities are intact unless clients have experienced neurologic deficits from long-term alcohol use or inhalant use. JUDGMENT AND INSIGHT Clients are likely to have exercised poor judgment especially while under the influence of the substance. Judgment may still be affected: clients may behave impulsively such as leaving treatment to obtain the substance of choice. Insight usually is limited regarding substance use.

SELF-CONCEPT Clients generally have low self-esteem, which they may express directly or cover with grandiose behavior. ROLES AND RELATIONSHIPS Clients usually have experienced many difficulties with social, family, and occupational roles. Absenteeism and poor work performance are common. PHYSIOLOGIC CONSIDERATIONS Many clients have a history of poor nutrition (using rather than eating) and sleep disturbances that persist beyond detoxification. They may have liver damage from drinking alcohol, hepatitis or HIV infection.