Download Pharmacology and the Nursing Process, 4th ed. Lilley/Harrington

Chapter 17
Substance Abuse
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Substance Abuse:
Leads to Dependence
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Physical dependence
Psychologic dependence
Habituation
Addiction
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Commonly Abused Substances
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Opioids
Stimulants
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Methamphetamine
Methylenedioxymethamphetamine (MDMA,
“ecstasy”)
Cocaine
Depressants
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

Benzodiazepines
Barbiturates
Marijuana
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Commonly Abused Substances
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Alcohol
Anabolic steroids
Dextromethorphan
Lysergic acid diethylamide (LSD)
Nicotine
Phencyclidine (PCP)
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Opioids
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opium
heroin
(diacetylmorphine)
morphine
codeine
hydromorphone
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hydrocodone
meperidine
oxycodone
propoxyphene
methadone
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Opioids (cont’d)
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Also known as narcotics
Opium and heroin are Schedule I
Most others are Schedule II because of their
high potential for abuse
Often abused because of their ability to
produce euphoria
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Opioids (cont’d)
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Produce analgesia, drowsiness, euphoria,
tranquility, other mood alterations
Affect areas outside the central nervous
system (CNS)
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
Skin, GI tract, GU tract
Normally used to:
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Relieve pain, reduce cough, relieve diarrhea, and
induce anesthesia
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Opioids (cont’d)
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Heroin
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Injected (“mainlining” or “skin popping”)
Sniffed (“snorted”)
Smoked
Causes a brief “rush,” followed by a few hours
of a relaxed, contented state
Large doses can stop respirations
Methadone
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Opioids: Adverse Effects
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Central nervous system
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Diuresis
 Miosis
 Convulsions
 Nausea, vomiting
 Respiratory depression
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Opioids: Adverse Effects (cont’d)
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Non–central nervous system
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Hypotension
 Constipation
 Urinary retention
 Flushing of the face, neck, and upper thorax
 Sweating, urticaria, and pruritus
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Opioid Drug Withdrawal
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Peak period: 1 to 3 days
Duration: 5 to 7 days
Signs
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Drug seeking, mydriasis, diaphoresis, rhinorrhea,
lacrimation, diarrhea, elevated BP and pulse
Symptoms

Intense desire for drug, muscle cramps, arthralgia,
anxiety, nausea, vomiting, malaise
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Opioid Drug Withdrawal: Treatment
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Block opioid receptors so that use of opioid
drugs does not produce euphoria
Naltrexone—an opioid antagonist
Vivitrol—injectable form of naltrexone
Naloxone combined with buprenorphine
(Subutrex) or used alone (Suboxone)
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Stimulants
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Elevation of mood
Reduction of fatigue
Increased alertness
Invigorated aggressiveness
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Stimulants
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Amphetamines
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Methamphetamine
MDMA (“ecstasy”)
cocaine
methylphenidate (Ritalin)
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Methamphetamine
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Stronger effects than other amphetamines
Pill form
Powder form: snorted or injected
Crystallized form:
Also known as “ice,” “crystal,” “glass,” “crystal meth”
 Smokable
 More powerful
 Sales of over-the-counter (OTC) pseudoephedrine
are now regulated

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Methylenedioxymethamphetamine
(MDMA, “ecstasy,” or “E”)
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Usually prepared in secret home laboratories
More calming effects than other amphetamine
drugs
Usually taken by pill
“Raves”
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Cocaine
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From the leaves of the coca plant
Snorted or injected intravenously
Highly addictive—physical and psychologic
dependence
Powdered form
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
Also called “dust,” “coke,” “snow,” “flake,” “blow,”
“girl”
Crystallized form (smoked)

Also called “crack,” “freebase rocks,” “rock”
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Stimulants: Adverse Effects
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CNS
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Restlessness
 Syncope (fainting)
 Tremor
 Hyperactive reflexes
 Talkativeness
 Irritability
 Insomnia
 Fever
 Euphoria
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Confusion
 Aggression
 Increased libido
 Anxiety
 Delirium
 Paranoid
hallucinations
 Suicidal or homicidal
tendencies
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Stimulants: Adverse Effects
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Cardiovascular
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Headache
 Chilliness
 Pallor or flushing
 Palpitations
 Tachycardia
 Cardiac dysrhythmias
 Anginal pain
 Hypertension or hypotension
 Circulatory collapse
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Stimulants: Adverse Effects
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Gastronintestinal
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Dry mouth
 Metallic taste
 Anorexia
 Nausea
 Vomiting
 Diarrhea
 Abdominal cramps

Fatal hyperthermia
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Stimulant Overdose
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Death results from:
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Convulsions
Coma
Cerebral hemorrhage
May occur during periods of intoxication or
withdrawal
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Stimulant Withdrawal
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Peak period: 1 to 3 days
Duration: 5 to 7 days
Signs
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Symptoms
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Social withdrawal, psychomotor retardation,
hypersomnia, hyperphagia
Depression, suicidal thoughts and behavior,
paranoid delusions
No specific pharmacologic treatments
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Depressants
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Drugs that relieve anxiety, irritability, and
tension
Used to treat seizure disorders and induce
anesthesia
Two main pharmacologic classes:
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Benzodiazepines (flunitrazepam)
Barbiturates
Marijuana (“pot,” “grass,” “weed”)
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Depressants: Adverse Effects
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CNS
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Gastronintestinal
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Drowsiness, sedation, loss of coordination,
dizziness, blurred vision, headaches, and
paradoxical reactions
Nausea, vomiting, constipation, dry mouth, and
abdominal cramping
Pruritus and skin rash
“Amotivational” syndrome
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Depressants Withdrawal
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Peak period
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Duration
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2 to 4 days for short-acting drugs
4 to 7 days for long-acting drugs
4 to 7 days for short-acting drugs
7 to 12 days for long-acting drugs
Signs
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Increased psychomotor activity; agitation;
hyperthermia; diaphoresis; delirium; convulsions;
elevated BP, pulse rate, and temperature; others
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Depressants Withdrawal (cont’d)
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Symptoms
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Anxiety, depression, euphoria, incoherent thoughts,
hostility, grandiosity, disorientation, hallucinations,
suicidal thoughts
Treatment involves tapering of the drug over a
course of a 7 to 10 or 10 to 14 days
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Classroom Response Question
Which drug will the nurse anticipate administering to a
patient experiencing benzodiazepine overdose?
A.
B.
C.
D.
flumazenil
naltrexone
Vivitrol
flunitrazepam
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Alcohol (Ethanol)
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More accurately known as ethanol (ETOH)
Causes CNS depression by dissolving in lipid
membranes in the CNS
Few legitimate uses of ethanol and alcoholic
beverages
Used as a solvent for many drugs
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Ethanol: Drug Effects
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CNS depression
Respiratory stimulation or depression
Vasodilation, producing warm, flushed skin
Increased sweating
Diuretic effects
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Effects of Chronic Ethanol
Ingestion
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Nutritional and vitamin deficiencies (especially
B vitamins)
Wernicke’s encephalopathy
 Korsakoff’s psychosis
 Polyneuritis
 Nicotinic acid deficiency encephalopathy
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
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Seizures
Alcoholic hepatitis, progressing to cirrhosis
Cardiomyopathy
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Effects of Chronic Ethanol
Ingestion (cont’d)
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Fetal alcohol syndrome (FAS)
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Craniofacial abnormalities
CNS dysfunction
Prenatal and postnatal growth retardation
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Ethanol Withdrawal
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Signs and symptoms
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Elevated blood pressure, pulse rate, and
temperature
 Insomnia
 Tremors
 Agitation
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Classified as mild, moderate, and severe
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Classroom Response Question
A patient with a diagnosis of delirium tremens is admitted to
the acute care facility. Which finding does the nurse expect
upon assessment of the patient?
A.
B.
C.
D.
Hyperthermia
Hypotension
Bradycardia
Somnulence
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Ethanol Withdrawal Treatment
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Benzodiazepines are the treatment of choice
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diazepam (Valium), lorazepam (Ativan), or
chlordiazepoxide (Korsakoff’s psychosis)
Dosage and frequency depend on severity
For severe withdrawal, monitoring in an
intensive care unit is recommended
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Treatment for Alcoholism
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disulfiram (Antabuse)
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naltrexone
acamprosate (Campral)


Acetaldehyde syndrome
Newest treatment
Counseling

Individual
 Alcoholics Anonymous
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Classroom Response Question
Which statement does the nurse include when teaching a
patient about disulfiram (Antabuse) therapy?
A. “Disulfiram (Antabuse) will cure your alcoholism if you
take it as directed.”
B. “If you drink alcohol after taking disulfiram (Antabuse),
your blood pressure will get very high.”
C. “You cannot drink alcohol for at least 3 or 4 days after
taking disulfiram (Antabuse).”
D. “If you miss a dose of disulfiram (Antabuse), double the
dose the next time it is due.”
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Nicotine
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Many smoke to “calm nerves”
Releases epinephrine, which creates
physiologic stress rather than relaxation
Tolerance develops
Physical and psychologic dependency
Withdrawal symptoms occur if stopped
No therapeutic uses
200 known poisons present in cigarette smoke
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Nicotine:
Drug Effects
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Transient stimulation of autonomic ganglia
Followed by more persistent depression of all
autonomic ganglia
CNS and respiratory stimulation, followed by
CNS depression
Increased heart rate and BP
Increased bowel activity
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Nicotine Withdrawal
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Manifested by cigarette craving
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Irritability, restlessness, decreased heart rate and BP
Cardiac symptoms resolve in 3 to 4 weeks, but
cigarette craving may persist for months or
years
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Nicotine Withdrawal Treatment
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Treatments provide nicotine without the
carcinogens in tobacco :

Nicotine transdermal system (patch)
 Nicotine polacrilex (gum)
 Inhalers
 Nasal spray
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Nicotine Withdrawal Treatment

bupropion (Zyban) may be prescribed to aid in
smoking cessation
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First nicotine-free prescription medicine to treat
nicotine dependence
varenicline (Chantix)

Stimulates nicotine receptors
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Classroom Response Question
The nurse is explaining the differences between
transdermal nicotine and nicotine gum programs. Which
statement by the nurse is correct?
A. “The nicotine patch will give you quick relief from cravings.”
B. “Chewing the gum rapidly will release an immediate dose of
nicotine.”
C. “It seems that patients have better treatment compliance
with the gum than the patch.”
D. “The dose of nicotine in the gum is approximately twice the
dose the average smoker receives in one cigarette.”
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Nursing Implications
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Assessments should include nonjudgmental
and open-ended questions about substance
abuse
Be observant for clues to substance abuse so
as to avoid withdrawal symptoms
The most dangerous substances in terms of
withdrawal are CNS depressants such as
barbiturates, benzodiazepines, and alcohol
Establish therapeutic rapport, and use empathy
toward the patient
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Nursing Implications (cont’d)
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Assessment tools for substance abuse
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CAGE Alcoholism Screening Test Adapted to Include
Drugs (CAGE-AID)
Substance Abuse Subtle Screening Inventory
(SASSI)
Michigan Alcoholism Screening Test Geriatric
version (MAST-G)
Problem Oriented Screening Instrument for
Teenagers (POSIT)
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Nursing Implications (cont’d)
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Patient safety is of utmost importance at all
times during patient care but especially when
the patient is experiencing the signs and
symptoms of withdrawal
Provide monitoring and support as needed
throughout the withdrawal process
Educate the patient and family members or
significant others about the recovery process
Emphasize that recovery is lifelong
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