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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
• Nicotine
• Amphetamines
• Opioids
• Cannabis
(marijuana)
• Phencyclidine
• Cocaine
• Sedativehypnotics
• Hallucinogens
• Anxiolytics
• Inhalants
• 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 Theories
Addictive 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 selfconfidence
• 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 Management
Assessment
• 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 selfmotivational 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