Download Substance Abuse

Chapter 19
Addiction
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Abuse
• National health problem
• Actual prevalence of substance abuse difficult to
determine
• Detrimental effects
– Costs to business, industry
– Motor vehicle accidents, fatalities
– Prenatal drug exposure
– Increase in violence
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Abuse (cont.)
• Children of alcoholics are four times more likely to
develop problems with alcohol.
• 50% of all traffic violations involve alcohol.
• 20% of suicide victims are alcoholics.
• >30% of alcoholic deaths are suicides or related
accidents involving alcohol.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnostic Classes of Substance Abuse
• Important terms
– Intoxication
– Withdrawal syndrome
– Detoxification
– Substance abuse
– Substance dependence
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Categories of Drugs
•
•
•
•
•
•
•
Alcohol
Sedatives, hypnotics, and anxiolytics
Stimulants
Cannabis
Opioids
Hallucinogens
Inhalants
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Course: Alcoholism
• First episode of intoxication → continuing problems with
alcohol → first blackout → continued drinking →
development of tolerance → tolerance break → continued
drinking → functioning becoming affected → periods of
abstinence/temporary controlled drinking → escalation of
alcohol intake → more problems → subsequent crisis →
continuation of cycle
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Etiology
• Biologic factors
– Genetic vulnerability
– Neurochemical influences
• Psychological factors
– Family dynamics
– Coping styles
• Social, environmental factors
– Culture, social attitudes, peer behaviors
– Laws, cost, availability
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cultural Considerations
• Views variable
– Muslims: no alcohol
– Jewish: wine an integral part of religious rites
– Some Native American tribes: peyote (hallucinogen)
– Japanese: alcohol not a drug
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cultural Considerations (cont.)
• Genetic traits of certain ethnic groups as predisposing to
or protective against alcoholism
• Variations in enzymatic activities among Asians, African
Americans, whites
• Alcohol abuse: a part in the five leading causes of death
for Native Americans
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Alcohol
• CNS depressant: relaxation/loss of inhibitions
• Vomiting, unconsciousness, respiratory depression with
overdose (see Box 19.1)
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Alcohol (cont.)
• Symptoms of withdrawal
– Onset within 4 to 12 hours after cessation or marked
reduction of alcohol intake (see Box 19.2); peaking
on second day; complete in about 5 days
– Benzodiazepines for safe withdrawal
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Is the following statement true or false?
• Alcohol is a central nervous system stimulant.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• False
• Rationale: Alcohol is classified as a central nervous
system depressant.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Sedatives, Hypnotics, and Anxiolytics
• CNS depressants
– Benzodiazepines alone, with oral overdose rarely
fatal; lethargy, confusion
– Barbiturate overdose possibly lethal; coma,
respiratory arrest, cardiac failure, death
• Withdrawal dependent on drug
• Detoxification via drug tapering
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Stimulants (Amphetamines, Cocaine)
• CNS stimulants
• High or euphoric feeling, hyperactivity, hypervigilance;
physiologic signs
• Seizures, coma with overdose
• Onset of withdrawal within hours to several days
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Stimulants (Amphetamines, Cocaine)
(cont.)
• Withdrawal syndrome: dysphoria, fatigue, vivid and
unpleasant dreams, insomnia or hypersomnia, increased
appetite, psychomotor retardation or agitation,
depressive symptoms, including suicidal ideation for
several days
• No pharmacologic treatment for withdrawal
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cannabis (Marijuana)
• Used for psychoactive effects
• Excessive use possibly leads to delirium or cannabisinduced psychotic disorder
• No overdose
• No clinically significant withdrawal syndrome
– Possible symptoms of insomnia, muscle aches,
sweating, anxiety, tremors
• Symptomatic treatment
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Opioids
• CNS depressants; desensitization; euphoria; well-being
• Overdose: coma, respiratory depression, pupil
constriction, unconsciousness, death
– Naloxone as treatment for overdose
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Opioids (cont.)
• Withdrawal:
– Short-acting drugs (i.e., heroin): onset in 6 to 24
hours; peaking in 2 to 3 days and gradually
subsiding in 5 to 7 days
– Longer-acting drugs (i.e., methadone): onset in 2 to
4 days, subsiding in 2 weeks
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hallucinogens
• Reality distortion; symptoms like psychosis
(hallucinations [usually visual], depersonalization)
• No overdose; occurrence of toxic reactions (primarily
psychological)
• PCP toxicity: seizures, hypertension, hyperthermia,
respiratory depression
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hallucinogens (cont.)
• Supportive treatment
• No withdrawal syndrome
• Flashbacks possible for few months up to 5 years
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Inhalants
• Intoxication: neurologic, behavioral symptoms
• Acute toxicity
– Anoxia, respiratory depression, vagal stimulation,
dysrhythmias
– Death possible from bronchospasm, cardiac arrest,
suffocation, or aspiration
• No withdrawal or detoxification
• Supportive treatment
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Is the following statement true or false?
• A person who abuses hallucinogens will experience a
withdrawal syndrome on cessation of use.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• False
• Rationale: There is no withdrawal syndrome associated
with hallucinogen use.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Abuse Treatment
• Concept: medical illnesses, chronic, progressive,
characterized by remissions and relapses
• Treatment models:
– Hazelden Clinic model
– 12-step program of Alcoholics Anonymous (AA; see
Box 19.3)
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Abuse Treatment (cont.)
• Individual, group counseling
• Treatment settings
• Pharmacologic treatment: safe withdrawal; prevent
relapse (see Table 19.1)
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Dual Diagnosis
• Substance abuse + another psychiatric illness
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Dual Diagnosis (cont.)
• Successful treatment, relapse prevention strategies (see
Nursing Care Plan)
– Healthy, nurturing, supportive living environments
– Help with fundamental life changes, such as finding
job, abstinent friends
– Connections with other recovering people
– Treatment of comorbid conditions
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Abuse and Nursing Process
Application
• Assessment
– History: chaotic family life, family history, crisis that
precipitated treatment
– General appearance, motor behavior
– Mood, affect: tearful; expressing guilt, remorse;
angry; sullen; quiet; unwilling to talk
– Thought process, content: denial; blaming others;
rationalization
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Abuse and Nursing Process
Application (cont.)
• Assessment (cont.)
– Sensorium, intellectual processes: intact
– Judgment, insight: poor judgment; impulsivity;
ability to control substance use
– Self-concept: low self-esteem; problems with
feelings
– Roles, relationships: often strained
– Physiologic considerations: poor nutrition; sleep
disturbances; liver damage; HIV infection; lung
damage
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Abuse and Nursing Process
Application (cont.)
• Data analysis/nursing diagnoses
– Related to physical health status
– Related to substance use
• Outcome identification
– Abstain from alcohol and drug use.
– Accept responsibility for own behavior.
– Practice non–chemical-coping alternatives.
– Establish an effective after-care plan.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Is the following statement true or false?
• A patient who abuses substances will commonly state
that he or she can control his or her use of the
substance.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• True
• Rationale: Typically, the patient is in denial and
commonly states that he or she can stop using the drug
anytime.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Abuse and Nursing Process
Application (cont.)
• Interventions
– Health teaching for patient, family (see Client Family
Education box)
– Addressing family issues (codependence, shifting
roles)
– Coping skills
• Evaluation
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Elder Considerations
• Approximately 30% to 60% of elders in treatment began
drinking abusively after age 60.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Elder Considerations (cont.)
• Risk factors for late-onset substance abuse in elders:
– Chronic illness causing pain; long-term use of
prescription medications (sedative-hypnotics,
anxiolytics); life stress; loss; social isolation; grief;
depression; an abundance of discretionary time and
money
• Physical problems associated with substance abuse
develop more quickly.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Community-Based Care
• Outpatient treatment
• Freestanding substance abuse treatment facilities
• Self-help programs (AA, Rational Recovery)
• Agency-sponsored aftercare program
• Individual or family counseling
• Clinic or physician’s office
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Mental Health Promotion
• Public awareness, educational advertising
• Early identification of older adults with alcoholism
• The College Drinking Prevention Program
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Abuse in Health Professionals
• Ethical, legal responsibility to report suspicious behavior
to supervisor
• General warning signs
– Poor work performance/frequent absenteeism
– Unusual behavior/slurred speech
– Isolation from peers
• Specific behaviors
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Self-Awareness Issues
• Examine own beliefs, family behavior about alcohol and
drugs.
• Recognize that substance abuse is chronic illness with
relapses, remissions.
• Remain objective, reasonably optimistic.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins