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Chapter 56
Substance-Related
Disorders
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Learning Objectives
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Discuss the biologic, sociocultural, behavioral, and intrapersonal
theories of the etiology of substance abuse or dependence.
Describe the data to be collected for the nursing
assessment of a patient with substance abuse or dependence.
Describe alcohol dependence, alcohol withdrawal syndrome,
medical complications of alcohol dependence,
and treatment of alcohol abuse and dependence.
Discuss the pathophysiologic effects of frequently abused drugs.
Describe disorders associated with substance abuse and
dependence.
Differentiate between drug abuse treatment and alcohol
abuse treatment.
Describe the nursing diagnoses and interventions associated
with substance abuse and dependence.
Discuss populations who present special problems in
relation to drug abuse and dependency.
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Etiology and Risk Factors
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Biologic Theory
• Generally accepted by a majority of the experts in the
field of addictionology
• Proposes that a faulty physiologic process that is not
clearly understood contributes to dependence on a
specific substance or substances (substance
dependence)
• Widely publicized studies implicate a dopamine gene
on human chromosome 11 for transmitting a
predisposition for alcoholism from generation to
generation
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Biologic Theory
• Medical community considers drug
dependency to be a physical illness, like those
with the following characteristics
• Incurability
• A genetic predisposition
• A potential to be treated effectively only by total
abstinence from the substance that the body cannot
handle
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Sociocultural Theory
• Suggests that sociocultural factors play a major
role in becoming dependent on a drug
• Many who live in poverty and crime-ridden
areas use drugs to relieve the stress inherent
in these environments
• In contrast, individuals with strong religious
values prohibiting the excessive use of drugs
have lower rates of addiction
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Behavioral Theory
• Looks at the triggers for drinking and drugusing behaviors and how these patterns are
reinforced
• Substance abuse is a learned maladaptive way
of coping with stress and anxiety
• Family and peer group role models studied
closely for use of substances, along with the
beliefs and customs surrounding the use of
drugs and alcohol
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Intrapersonal Theory
• Addresses personality factors that may predispose
person to substance abuse
• Theorists believe that quality of intrapersonal
relationships during critical developmental stages of
our lives affects us profoundly
• If children experience early childhood rejection,
increased responsibility, unrealistic expectations, or
overprotection, they may develop a dependent type of
personality and consequently view themselves as
inadequate or failures when attempts to meet their
needs fail
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Assessment of the Substance
Abuser
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Health History
• Interview with patient, family members, significant
others; a social assessment; medical records; school
or military records
• Question the patient for most reliable data
• Important to know when patient ingested the drug and
how much was taken to predict the physical withdrawal
symptoms
• Finding the most appropriate balance of support and
reality-based confrontation is a highly developed skill
that increases the likelihood that patients will continue
in the treatment process
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Health History
• Patterns and consequences of abuse
• Abuser describes typical patterns of behavior and a
combination of physical or psychological withdrawal symptoms
• Many have erratic and unprovoked mood swings
• Life may revolve around obtaining/using substance
• Many abusers hide the extent of their habit from others and
despite efforts to limit use of the substance, have been
unsuccessful
• Blackouts when under influence of substance
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Health History
• Defense mechanisms employed
• Denial: patients state that they do not have a problem with
drug use despite evidence to the contrary
• Rationalization: abusers attempt to justify the reasons for their
abuse of substances
• Intellectualization: person focuses only on objective facts as a
way of avoiding dealing with unconscious conflicts and the
emotions they evoke
• Projection: shifting blame onto someone/something else
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Physical Examination
• Many substance abusers appear malnourished and poorly cared
for
• Evidence of physical trauma: falls, abrasions, or fights
• Jaundice or discolored sclera of the eyes suggests cirrhosis or
other liver problems
• Hypertension is a critical sign of withdrawal, accompanied by fluid
retention in the legs or a protuberant abdomen swollen by liver
ascites
• Anxiety, confusion, irritability, memory loss, tremors, lack of
coordination, and other neurologic signs are significant; may be
associated with nutritional deficits
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Diagnostic Tests
• Blood alcohol study
• Most accurate test available to measure the degree of
intoxication on initiation of treatment for alcohol abuse
• Urine drug screening
• Preferred screening for the recent use of an unknown drug;
commonly with initial laboratory work
• Hair analysis
• Recent addition to methods for detecting abused substances
• It requires sensitive technology but may be very helpful in
monitoring patients for relapse
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Alcohol and Alcoholism
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Alcohol
• Most commonly abused drug in the United States
• According to the American Society of Addiction Medicine,
alcoholism is “a primary, chronic disease with psychosocial and
environmental factors influencing its development and
manifestations. The disease is often progressive and fatal. It is
characterized by continuous or periodic impaired control over
drinking, preoccupation with the drug alcohol, use of alcohol
despite adverse consequences, and distortions in thinking, most
notably denial.”
• Alcohol is referred to as a “drug” in this definition, reflecting the
thinking of most health care professionals. It is a drug with
addictive qualities similar to those of other abused drugs
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Alcoholism
• Chronic use involves the regular daily ingestion of large quantities
of alcohol, regular heavy drinking only on weekends, or binges of
heavy drinking followed by long periods of abstinence
• Physical addiction occurs when alcohol becomes integrated into
physiologic processes at the cellular level
• Cell becomes dependent on alcohol for metabolic processes; if
alcohol is no longer available, the cell goes into “shock” and is unable
to compensate for the loss quickly
• Alcohol withdrawal syndrome begins after the individual stops or
decreases the amount ingested
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Alcohol Withdrawal Syndrome
• Involves physiologic and behavioral symptoms
that begin when the individual’s blood alcohol
level drops
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Alcohol Withdrawal Syndrome: Stages
• First stage: early withdrawal
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Occurs within 6 to 12 hours after the last drink
Symptoms: anxiety, agitation, then irritability
If the patient does not drink, tremors
Blood pressure, pulse, and temperature rise
Sweating, nausea, vomiting, and diarrhea
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Alcohol Withdrawal Syndrome:
Stages
• Second stage: major withdrawal
• Begins with seizures and hallucinations; can advance to lifethreatening delirium tremens (or DTs)
• Occurs after about 3 days (sometimes less) without alcohol
and can be predicted from extreme elevations in temperature,
pulse, and blood pressure
• Patient typically becomes disoriented and confused
• Hallucinations are often visual and “animal” in nature
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Medical Complications
• Cirrhosis of the liver, pancreatitis, gastrointestinal
bleeding, Wernicke’s encephalopathy, Korsakoff’s
psychosis, and fetal alcohol syndrome
• Wernicke’s encephalopathy
• Due to vitamin B1 (thiamine) deficiency
• Symptoms: delirium, confabulation, unsteady gait,
apprehension, altered levels of consciousness that can
proceed to coma
• If not properly treated with vitamins, Korsakoff’s psychosis
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Medical Complications
• Korsakoff’s psychosis
• Thiamine and niacin deficiencies: degeneration of
the cerebrum and the peripheral nervous system
• Symptoms: amnesia, confabulation, disorientation,
and peripheral neuropathies
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Medical Complications
• Fetal alcohol syndrome
• A medical complication of great concern
• If woman drinks to excess throughout pregnancy, unborn child
at risk for low birth weight, mental retardation, growth
deficiencies, heart defects, facial malformations, learning
disabilities, and hyperactivity
• Recent controversy has arisen over whether maternal
alcoholism constitutes child abuse and is thus reportable under
child protection statutes
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Treatment for Alcohol Abuse
• Active family involvement in the treatment of alcohol
abuse is critical to the effectiveness of treatment
outcomes
• Alcoholism affects everyone in the family system
• Produces predictable patterns of individual behavior or
changes in roles that may significantly handicap
various family members in getting their needs met
• Codependent
• Those who enable are codependent; their behavior is highly
structured around managing and adapting to the substance
abuser’s dysfunctional behavior
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Treatment for Alcohol Abuse
• Family and peer pressure and confrontation critical in
inducing alcoholic to seek treatment
• Through participation in a 12-step self-help support
group for the significant others of substance abusers,
called Al-Anon and Al-Ateen, spouses, children, friends,
and co-workers can learn how to cope with issues and
avoid enabling the alcoholic so it becomes harder for
him/her to continue a destructive pattern of drinking
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Treatment for Alcohol Abuse
• Intervention
• A planned, structured meeting by family and friends to confront
the alcoholic, who is brought into the meeting without prior
notification about the intervention
• Led by a specially trained interventionist who helps those
involved in the process to prepare by writing down the ways
that the person’s alcohol abuse affects them personally
• Participants read their letters aloud to the alcohol abuser
• The end of each letter requests the alcoholic to get help
• After intervention the user will go unhappily, but voluntarily,
directly from the intervention into a treatment program that has
been arranged in advance in the event of that outcome
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Treatment for Alcohol Abuse
• Detoxification
• Usually in an inpatient hospital
• Vital signs are monitored frequently
• Initially, patients do not participate in group therapy because of
their physical status
• Rest and nutrition are emphasized
• Anxiolytics (benzodiazepine) are most often used, but also
hypnotics (phenobarbital, chloral hydrate)
• IV magnesium sulfate is used to prevent seizures in rare cases
• Fluids encouraged to combat dehydration, and vitamin
replacement therapy is instituted
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Treatment for Alcohol Abuse
• Rehabilitation
• Once medically stable, patient referred to inpatient or
outpatient program, depending on needs and resources
• Inpatient program lasts about 28 days; includes highly structured
scheduling of drug education films and presentations; increasingly
confrontational individual, group, and family therapy; recreational
and occupational therapy; milieu therapy; and introduction to
Alcoholics Anonymous (AA)
• Commonly, patients referred to partial hospitalization programs
and outpatient therapy as well as other community resources
• Less common is an extended residential program that may last 1
to 2 years
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Treatment for Alcohol Abuse
• Alcoholics Anonymous
• Nonprofit, worldwide organization of alcoholics who meet
anonymously in small groups to assist each other in staying
sober
• Uses a strong spiritual base, which is controversial, and a 12step program involving discussions and written exercises
designed around each of the 12 steps to keep the alcoholic
from relapsing
• Members identify another participant of the same sex to act as
their sponsor
• Community service work to focus outside oneself
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Treatment for Alcohol Abuse
• Rehabilitation
• Trend is toward using more nontraditional treatment
approaches
• The teaching of stress management; social skills training;
behavioral approaches to marital therapy; and matching
clients with a therapist whose style matches personality
type
• Other factors in developing homogeneous small
groups are styles of thinking (abstract versus
concrete thinkers), sex role–related issues, ethnicity,
and age
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Treatment for Alcohol Abuse
• Relapse prevention
• Assists patients to identify triggers of substance use
• Person then actively avoids these people and places
• Other coping strategies also developed that can be used if the
person encounters a trigger
• Aftercare and recovery
• Assists alcoholics who have completed a treatment program
successfully to make a gradual transition back into the
community with the support necessary to prevent relapses
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Treatment for Alcohol Abuse
• Medications
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Disulfiram (Antabuse)
Metronidazole (Flagyl)
Naltrexone hydrochloride (Trexan)
Antidepressants
• Amitriptyline (Elavil)
• Desipramine (Norpramin)
• Fluoxetine (Prozac)
• Angiotensin-converting enzyme (ACE) inhibitors
such as enalapril maleate (Vasotec)
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Other Psychoactive Substances
• Stimulants
• Amphetamines
• Cocaine
• Crack
• Depressants
• Sedatives
• Hypnotics
• Anxiolytics
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Other Psychoactive Substances
• Hallucinogens
• LSD (lysergic acid diethylamide, or “acid”)
• PCP (phencyclidine, or “angel dust”)
• MDMA
(3,4-methylenedioxymethamphetamine, known as
“ecstasy” or “Adam”)
• Marijuana
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Other Psychoactive Substances
• Narcotics (opioids)
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Heroin
Morphine
Oxycodone (OxyContin)
Hydrocodone
Pentazocine (Talwin)
Methadone
Meperidine (Demerol)
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Other Psychoactive Substances
• Inhalants
• Paint, glue, aerosol sprays, typing correction fluid,
and gasoline
• Designer drugs
• Synthetic drugs especially designed to sidestep
categorization with any of the drugs identified as
illegal in the United States
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Disorders Associated with
Substance Abuse
• Human immunodeficiency virus disease (HIVD), which leads to
acquired immunodeficiency syndrome (AIDS)
• Those who have/are predisposed to, serious psychiatric illness
may present with active mental disorder
• Fetuses carried by mothers who are physically addicted to an
opioid are born addicted and also may experience developmental
delays and a prolonged lack of the capacity to feel pleasure even
after they have been successfully weaned from the abused drug
• Clients with chronic pain also vulnerable to drug abuse
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Treatment for Substance Abuse
• Treatment similar to alcohol detoxification/rehabilitation
• Narcotics Anonymous (NA) structured much like AA
• Often inpatient treatment programs place recovering addicts with
alcoholics for educational and therapy groups
• Family involvement in the process is very important
• Al-Anon is the support group for family members or significant others
of a substance-abusing person
• It is recommended that members of the family begin attending
meetings as soon as they realize that the person is using some type
of drug
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Detoxification
• Complex because of the likelihood of polysubstance
abuse and the uncertainty of what to expect when two
or more drugs are mixed together
• Inpatient hospitalization recommended for safety
• However, some individuals who have been using drugs
that are primarily psychologically addicting may not
demonstrate many physical symptoms but rather
experience intense psychological cravings
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Medications
• Methadone
• Used in the treatment of heroin addicts
• Clonidine (Catapres)
• A nonopiate antihypertensive drug that partially
blocks withdrawal symptoms
• Naloxone (Narcan)
• An opioid antagonist that counteracts the dangerous
respiratory depressant effects of heroin or other
opiate overdose
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Rehabilitation
• Client participates in NA at least some of the time
• Based on the 12 steps of AA, except that the word “alcohol” is
replaced by “drugs” in all of the literature, and the case
histories used for reading assignments are about other addicts
in recovery
• Many private health care systems are opening day
treatment programs for substance abusers as
insurance reimbursement for long-term inpatient
programs becomes less available
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Aftercare and Recovery
• Recovering abusers offered opportunity to participate in a support
group provided by a hospital
• Many of the same people who went through treatment at the same
time participate
• Relationships built during this time of crisis are often intense; thus,
groups can be helpful in preventing relapse
• Clients hoped to continue regular participation in NA groups on an
ongoing basis
• Some do well in halfway houses, which allow for a new living
environment surrounded by other recovering addicts during the
difficult transition back into the community
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Methadone Maintenance
• For patients who have experienced multiple relapses into heroin
abuse after treatment who may have sustained permanent
damage to chemical receptor sites in the brain, which decreases
their ability to resist relapse
• The person goes to a methadone clinic daily or 3 times/week to
receive medication for next 24 to 72 hours
• May continue this indefinitely, often for many years
• The controversy over methadone maintenance has resulted in the
frequent use of naltrexone (Trexan) as an alternative
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Care of the Person with a
Substance Disorder
• Assessment
• Thorough assessment is the initial step
• Data can help identify and prioritize problems that
must be addressed to maximize the likelihood that
the patient will remain sober
• Problems seen in substance abusers of any kind
include denial, poor impulse control, high risk for
injury, high risk for relapse, guilt, and low selfesteem
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Care of the Person with a
Substance Disorder
• Interventions
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Regular physical assessment
Administration of appropriate medications
Teaching patients about actions and consequences
Providing adequate nutrition
Reassurance and support
Assisting in processing the meaning of client’s substance
abuse and planning for a future without continued use of that
substance
• Work toward penetrating patient’s denial without further
damaging the individual’s self-esteem
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Care of the Person with a
Substance Disorder
• Interventions
• Teaching stress management and practicing these new skills
with patients can greatly increase the odds that they will not
relapse after discharge
• Patient must be taught to recognize symptoms that often lead
to relapse
• Act as a good role model in handling feelings, participating
appropriately in meetings, and communicating to the patient in
a way that supports the program
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Populations of Substance Abusers
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Older Adults
• Older adults more likely to abuse over-the-counter and
prescription sleeping pills, pain medications, or
tranquilizers
• Misuse is seldom for recreational purposes among this
age-group
• Because of a decreased ability to metabolize and
eliminate alcohol or drugs from the body, older adults
who do abuse drugs over extended periods may
experience significant medical problems as a result
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Older Adults
• Consequences of alcohol abuse: malnutrition, cirrhosis of the liver,
bone thinning, gastritis, poor memory, decreased cognitive ability
to process new information
• If the person combines alcohol with any other medication that has
central nervous system depressant effects, there is serious danger
of oversedation, impaired responses, or respiratory depression
• Abuse in the older adult population usually diagnosed by the
family physician as a result of complaints related to the
psychological or physical effects of alcohol abuse, such as
memory impairment or insomnia
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Older Adults
• Treatment of alcoholism in older adults is similar to that
of younger individuals except that the period of
withdrawal must be more closely monitored and occur
more slowly because of physical fragility
• Rehabilitation groups and educational programs should
be structured to permit processing information more
slowly to allow for cognitive slowing for this age-group
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Adolescents
• One in four adolescents are involved in substance abuse
• The younger the age at onset of drug use, the greater is the risk
for significant interference in the physical and psychological
development of the individual
• Developmental issues of this age-group also contribute to the
adolescent’s vulnerability
• Identification with peer group is an important aspect of feeling
accepted
• Average adolescents view themselves as omnipotent and deny
the likelihood of negative consequences of their behaviors
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Adolescents
• Substance abuse symptom of family issues
• Family history of substance abuse, or the adolescent
may fall in with the “wrong crowd” of other young
people
• Entry into treatment is a result of a crisis situation,
revealing the severity of drug use and parental
insistence
• Rehabilitation requires that treatment be modified to
meet needs of this age-group
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The Dually Diagnosed
• Patients diagnosed with a serious psychiatric illness
and have a substance abuse problem
• Usually have psychiatric illnesses of depression,
schizophrenia, or bipolar illness
• Mental retardation and organic brain disease also
included in medical problems identified as presenting
special concerns in the event of a concurrent
substance abuse problem
• Chronic drug or alcohol abuse may exacerbate an
already fragile neurophysiology, producing psychiatric
symptoms
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The Dually Diagnosed
• People with chronic psychiatric problems
require special teaching and supervision in the
event of substance relapse
• The approach to rehabilitation must be
modified to adapt to this special population
• Each patient’s ability to comprehend the
abstract ideas from the 12-step process of AA
will vary
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Peer Assistance Programs
• Offer a supportive alternative to health professionals
(physicians, dentists, nurses) who become addicted to
a substance instead of taking immediate disciplinary
action
• Referrals are made by the individuals themselves or
their employers and peers
• With the help of representatives of the program,
information is gathered to support an intervention to
get the person into treatment and recovery
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Peer Assistance Programs
• Goals of an intervention for a nurse
• Assist the nurse whose practice is impaired to
receive treatment
• Protect the public from an untreated nurse
• Help recovering nurse reenter nursing in a
systematic, planned, and safe way
• Assist in monitoring the continued recovery of the
nurse for a period of time
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Peer Assistance Programs
• Usually, there is also at least a 2-year period
after diagnosis and onset of treatment in which
the nurse is required to attend AA or NA groups
regularly, participate in peer support groups,
meet routinely with identified support person,
and undergo random urine drug screens to
ensure that he or she has not relapsed
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