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SUBSTANCE ABUSE/DEPENDENCE
Tolerance- The capacity to absorb a drug continuously or in
large doses without adverse effect; diminution in the response
to a drug after prolonged use
Withdrawal- the syndrome of often painful physical and
psychological symptoms that follows discontinuance of an
addicting substance
Addiction- compulsive physiological need for and use of a
habit-forming substance characterized by tolerance and by
well-defined physiological symptoms upon withdrawal
Craving- to long for; want greatly; desire eagerly
Synergistic effects- used especially of drugs that work
together so the total effect is greater than the sum of the two
Antagonistic effects- A chemical substance that interferes
with the physiological action of another
Substance Abuse: 1 or more
w/in 12 mos
-Inability too fulfill major
obligations
-Participation in hazardous
situations while impaired
-Recurrent legal/interpersonal
problems
-Cont’d use despite recurrent
social/interpersonal problems
Substance Dependence: 3 or
more w/in 12 mos
-Presence of tolerance
-Presence of withdrawal
syndrome
-Substance taken in larger
amts/longer time than intended
-Unsuccessful or persistent desire
to cut down or control use
-Inc’d time spent getting, taking,
recovering from use
-Reduction or absence or
important activities
-Use despite knowledge of
recurrent problems
Alcoholism- compulsion to drink ETOH even when know it’s
harmful; *alcohol- one of most dangerous withdrawals inc
BP, HR, seizures, agitation, insomnia
Classifications of Substances:
CNS stimulants- cocaine, amphetamines
Hallucinogens-LSD, peyote, PCP, mescaline, ecstasy
CNS depressants-ETOH, benzos, barbiturates
Inhalants- volatile solutions, nitrates, anesthetics
MarijuanaOpiates-opium, heroin, morphine
CNS depressants
ETOH: activates GABA (antianxiety), dopamine (pleasure),
endogenous opiods (analgesic), glutamate (amnesiac),
serotonin (inc anxious, aggression), norepi (overrides pleasure
of dopa, then depressant)
-dehydrogenase enzyme- in liver (♂ & ♀) & sometimes
stomach (♂) that helps break down ETOH into acetic acid
then CO2 + H2O
Jellinek’s Types
Alpha- mostly psychological dependence- drink to solve
problems; coping
Beta- mostly social dependence- seen in societies where
heavy drinking is norm
Gamma- most severe form- ↑tol, w/d, dependence, loss of
control, “typical”
Delta- maintenance drinker- psych & physical dependent,
never lose control, drink all the time
Epsilon- binge drinker- “abuse”, can abstain but when
drinkbinge
Zeta- mod drinker who becomes abusive & violent
Benzodiazepines- w/d can be very medically dangerous
BarbituratesAssessment: Ask direct questions: what did you take? When
did you take it? How much did you take? Drinking habits? A
time you drank to much? Do family/friends/MD criticize
drinking? Has ETOH ever caused problems? Blackouts?
Blood Alcohol Level (BAL)- w/ tolerance, behaviors occur @
higher levels, death usually from respiratory depression
1 drink= 12oz beer= 5oz wine= 1oz shot
0.05 1-2 drinks
0.30 15-18 drinks
0.10 5-6 drinks
0.40 20-24 drinks
0.20 10-12 drinks
0.50 25-30 drinks
Withdrawal symptoms: 7-48o most dangerous period;
generally disappear between 48-72o
Early w/d- anxiety, insomnia, tremor, hyper alert appearance,
irritability, easily startled, subjective feeling of internal
shaking, transient hallucinations/visions/nightmares, N&V
Acute w/d- diaphoresis, tachycardia, ↑BP, sleep disorders,
N&V, agitation, seizures, hallucinations, delirium tremens
Tx- prevent seizures & delirium (Librium, Valium, Benzos,
Vit B1, MV); correct fluid & electrolyte imbalance; eval for
disease processes 2o alcoholism
Anabuse-get physically ill if drink while taking but does not
help w/ craving
Campral/revia
Delirium during w/d- rarely occurs, usually result of
medically related problems (pneumonia, nutritional deficit,
HTN, etc), can result in death if underlying cause not tx’d;
generally resolve after 1 wk; clouding of consciousness, ∆’s in
LOC, perceptual disturbances.
-tx-sedatives (benzos- anticonvulsants); thiamine (vit Bprevents encephalopathy); mag sulfate (reduces postw/d
seizures); anticonvulsant (phenobarb- seizure control); folic
acid & multivit (deficiencies)
Characteristics of abuser: depression, denial, anxiety,
hopelessness, low self esteem
Addicts predictive defense: rationalization, projection, denial
Psychological tx: AA recommended Þ detox1. learn to use free time wisely
2.∆ playgrounds & friends that encourage heavy drinking
3. reestablish ties w/ loved ones
4. learning how to say no to drinks
5. handling stress
6. get help w/ coping skills
Discharge instructions include: 1.when & where; 2.list of
halfway houses; 3.follow up chem. Dependency counselor
(LDAC)
Codependency- enable user to use; a way that family
members satisfy need to feel loved or important & needed;
people define self worth in terms of caring for others w/ the
exclusion of own needs; individuals lack ability to form
intimate relationships w/ others; Alanon & Alateen to break
cycle
Cocaine- acts in brains reward centers to block reuptake of
norepi & dopa; looks like mania- euphoria, hyperstimulus,
hyperalert; faster absorption=better high, shorter duration
Symptoms- tachycardia, dilated pupils, ↑BP, N&V, insomnia;
assaultive, grandiose, ↑energy, impaired judgment; can lead to
psychosis
w/d- beings almost immediately: lethargy, vivid/unpleasant
dreams, depression, apathy, disorientation, intense cravings,
diaphoresis
Opiates- derivatives of Opium: morphine, heroin, codeine,
Fentanyl, Demerol, Oxycontin
symptoms of use: euphoria, lethargy, avolition, drowsiness,
slowed pulse, constricted pupils, flushing of skin on
face/chest/neck, abscesses on arms/legs
w/d- very painful- electric shocks through body; depression,
restlessness, N&V, muscle aches, dilated pupils, diaphoresis,
diarrhea, insomnia, chills, fever
tx: Methadone- bypasses detox from opiates, blocks opiate
receptors; higher long term recovery rate; does not produce
euphoric symptoms; ↓’s cravings & effectiveness of other
opiates
-naltrexone (Trexan, Revia)- ↓’s cravings; blocks euphoric
effects
-clonidine (Catapres)- suppresses w/d symptoms
-buprenorphine (Subutex)- opiate antagonist
-L-α-Acetylmethadol (LAAM)-SeroquelInhalants- dizziness, coordination problems, slurred speech,
weakness, tremor, aggressiveness, apathy, poor judgment;
death from lung/heart complications; long term permanent
neuro ∆’s
Ecstasy (MDMA)- meth derivative, hallucinogen; often laced
w/ LSD, ephedrine; release of serotonin, norepi, dopamine
↑empathy, good feelings, loss of inhibitions
Symptoms: hyper, endless energy, ↑temp, dilated pupils,
muscle rigidity, bruxism (grinding teeth), tachycardia,
tremors, arrhythmias, esophoria (eyes up & in), severe
hyponatremia (renal fail)
-serotonin levels do not return to normal for 3-4 days
-#1 cause of death is hyperthermia & dehydration
Club Drugs (Date Rape Drugs)GHB euphoria, hypersalivation, ↓pain; OD seizures,
coma, death; overuse tx-resistant psychosis
Rohypnol- benzo: ↓anxiety & muscle tension (~10x potent as
Valium)amnesia, LOC
Ketamine- anesth w/o resp dep; hallucinations, dream-like
state
Methamphetamines- release ↑levels dopa, over time natural
levels ↓; extremely pleasurable, CNS effects can last up to 24o,
Meth cycle: rush-high-binge-tweaking-crash-withdrawal
Symptoms- anxiety, nervousness, incessant talking, extreme
moodiness, irritability, purposeless mvmt, picking at sin,
pulling out hair, false sense of confidence/power, violent
behavior, anhedonia (lack of interest in pleasurable activities),
depression
CNS effects- ↑wakefulness, physical activity, respirations;
↓appetite; hyperthermia, euphoria, irritability, insomnia,
confusion, tremors, convulsions, anxiety paranoia,
aggressiveness: ↑HR, BP, irreversible damage to cerebral
vascular system
Prolonged use symptoms similar to schizo: auditory
hallucinations, psychotic behavior, brain damage, insomnia,
paranoia, delusions, mood disturbances; 6-8mos for casual
user to begin to feel satisfied w/ life; 2-3yrs for regular uses
due to depress & “fuzzy head”; tx w/ antidepressants
DISSOCIATIVE DISORDERS- disturbances in the
normally well-integrated continuum of consciousness,
memory, identity & perception
Dissociation- creative survival technique allows enduring
“hopeless: no conscious awareness; circumstances to preserve
some areas of healthy fxning; originates in childhood as result
of chronic unpredictable trauma; each trauma shapes alternate
personality
Each personality: has unique identity; perform different fxns;
holds different memories & feelings; Freudian repression
Psych trauma can ∆ structures because of high levels of
glucocorticoids & other stress hormones: hippocampus
(memory) is smaller; deficits in verbal recalls
-tx- trend is not to tx; address depression & symptoms but not
the disorder
Classifications:
Depersonalization disorder- persistent or recurrent alteration
in perception of self while reality testing remains intact
Dissociative Amnesia- inability to recall important personal
information, often of traumatic or stressful nature, that is too
pervasive to be explained by ordinary forgetfulness
Dissociative Fugue- sudden, unexpected travel away from
customary locale & inability to recall one’s identity & info
about some or all of the past; rarely assume whole new
identity; lead simple unassuming lives
Dissociative Identity Disorder- presence of two or more
distinct personality states that recurrently take control of
behavior
-alternate personality or subpersonality- has own pattern of
perceiving, relating to & thining about the self & environment
PERSONALITY DISORDERS- Axis II dx: when
personality traits are inflexible & maladaptive & cause
significant functional impairment or subjective distress; blame
others for all problems; have little insight into self & lack
ability to see impact on those around them
Personality: patterns acquired in early childhood, become
lifelong patterns: Attitudes; Beliefs; Desires; Values;
Behaviors; Judgments; Goals; Accomplishments
4 common characteristics:
1 .inflexible & maladaptive response to stress
2. disability in working & capacity to love; lack trust,
compassion, feelings
3. ability to evoke interpersonal conflict; “drama queens”
4. capacity to “gent under the skin”; good at reading you &
manipulating/influencing
-tx: usually NOT tx’d: occasionally pharm for aggressionlitium, anticonvulsants, SSRI’s
Causes:
Environmental influences: single traumatic event vs. chronic
trauma; abuse at early age is common
Biological determinants: individual tolerance to stimulation or
stress; genetic predisposition (link to relatives w/ schizo);
effect of psychosocial stressors effecting inc in intensity of
neurotransmitters to stress
Borderline personality disorder- most commonly seen
disorder in psych units because of suicide attempt; splitting;
self-mutilation; self destructive behavior; rarely feel
satisfaction of needs; h/o leaving fxn’l relationships;
aggression is paired w/ need to destroy; quit jobs that are
going well; seek meeting overwhelming needs though
relationships; frantic avoidance of abandonment- drawn to
nurturing, approving, supportive; unstable/intense
relationships; cannot get enough to satisfy; boundary issues;
impulsive acts; separation anxiety
-document clearly to keep license safe
-tx-SSRI’s for anger & depression; carbamazepine for
dyscontrol & self-harm; low dose antipsychotics for cognitive
disturbance (paranoia, magical thinking, illusions); dialectical
therapy
Psychodynamic issues- many have periods of dissociation;
-purpose of therapy is to focus on healing qualities of
“corrective relationship”, can correct & readjust maladaptive
learning; teach responsibility/coping; need consistency,
nurturing, reliability, tolerance
Freudian:
repression-pushing feeling/memory down
undoing – repetition of event, seeing it happen w/ different
ending
regression –going backwards to childhood behavior
consolidation- reconstituting personalities
Nursing assessment:
What is presenting problem? Client’s emotional state? How is
client handling behavior? What is pattern of employment? Is
client suicidal? Does client have any meaningful
relationships? How would client like to see problem resolve?
What is client’s physical condition or status? What behaviors
or defenses does client exhibit? (manipulation, splitting,
projection, withdrawal, angry/hostile/violent, paranoia,
demanding. What substances are abused? How much? When
was the last? Has client ever been arrested/convicted of crime?
Nursing interventions: difficult because clients have
experienced series of difficult relationships, tendency to blame
& attack others; lack insight into own behavior
CLUSTER A: ODD OR ECCENTRIC
Paranoid- feel betrayed by others; reluctant to share info;
hypervigilant; jealous; unwillingness to forgive; rarely contact
med system; suspect w/o basis; preoccupied w/ thoughts of
loyalty; reluctant to confide; bears grudges; perceive attacks;
recurrent suspicions; usually very intelligent & persuasive;
drawn to quasi-political groups
Schizoid- difficulty in expressing emotion; on periphera y of
society; avoid relationships; lack affect; lack social awareness;
like being alone, shy introverted; energized by own ideas;
reclusive, avoidant, uncooperative
Schizotypal- ideas of reference, cognitive/perceptual
distortions, socially inept; very similar to schizo but fxn’l &
distortions for only short periods
CLUSTER B: DRAMATIC-EMOTIONAL STYLES
Antisocial personality disorder- “conduct disorder” in pts
<18yrs; charming; intent to deceive; impulsive; neglect
responsibilities to others; lie, steal, cheat; indifferent to own
pain & pain of others; no moral boundaries; manipulative;
aggressive; drawn to high risk jobs
Histrionic personality disorder- dramatic presentation;
glamboyant; seductive; preoccupied w/ appearance; overly
concerned w/ impressing others; highly impaired
relationships; seek situations that are immediately gratifying;
depression/suicidal when admiration is withdrawn; seekds
attention; shallow
-tx- MAOI’s for atypical depression; tx comorbid PD’s (BPD
common); no effective therapy
Narcissistic personality disorder- need for admiration;
exploit others to meed needs; feel superior & omnipotent; do
not tolerate mistakes in self or others; swing between feeling
superior & inferior/vulnerable; fantasies of success, power,
intelligence & beauty; exploitive, grandiose, disparaging,
rageful, inc’d sensitivity to rejection & criticism
-tx- cognitive & behavioral; group; no specific meds
CLUSTER C- ANXIOUS-FEARFUL STYLE
Dependent- cling, follow others advice, will do anything to
remain attached, ruminate about abandonment, greater risk for
anxiety & mood disorders, feel incapable of survival if left
alone; difficulty initiating projects b/c lack of confidence;
unrealistically occupied w/ being left alone
Avoidant-shy, avoid conflict, avoid social situations, feel
inadequate, hypersensitive to criticism, emotionally &
physically isolated, long for relationships but fear of
disapproval keeps them from participation; hypersensitive to
negative evaluation
-tx- social skills training, desensitization, CBT, MAOI’s may
help social anxiety, Bezo’s may help panic episodes
Obsessive-compulsive