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Summary Notes
Introduction
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Substance abuse is not a new problem
Alcohol and Opium used openly into the 20th century
Freud used Cocaine
Tribes have chewed coco leaves, smoked the “Peace pipe”
In 1914, passed the Harrison Narcotic Act
Prohibition in the 1920=s and 1930=s
Statistics
 Alcohol
 7% of Americans are Alcoholics
 Every alcoholic touches lives of 5 people
 Factor in 50% of MVA=s
 One third of private plane accidents
 One third to one half of drownings
 Alcoholism underreported in women
Addiction Liability
 Highest
 cocaine/crack
 opiates
 alcohol
 barbituates
 nicotine
 Lower
 amphetamines
 benzodiazepines
 Anesthetics
 *PCP, Ketamine
 marijuana
These are non-addicting:
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caffeine
LSD and other hallucinogens
antidepressant drugs
antipsychotic drugs
naltrexone-trexan
Neurotransmitters of Addiction
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Dopamine (DA)
Serotonin (SER)
Endorphins (END)
GABA/Glutamate (GLU) Theory emphasizes deficiencies
Areas of Brain
 Medial Forebrain Bundle
 Ventral tegmental area
 Lateral hypothalamus
 Nucleus accumbens
 Frontal Cortex
 Bottom Line: Major site of addicting drugs (MFB, not Cortex) is evidence that
addictions are not under conscious control
Definitions
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Abuse: Purposeful use of a drug which results in adverse effects to oneself or
other
Addiction: Primary Physiologic focus
Chemical Dependency: Refers to the bio-psycho-social mode; of this problem
Dependence: Loss of Control
Tolerance: Increase the amount of drug to get the needed effect
Withdrawal: Refers to psychoactive substance-specific syndrome that occurs
after cessation of the drug
DSM IV
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Criteria for substance Dependence
 Tolerance, Withdrawal
 Desire and attempts to cut down
 Time spent in obtaining drug
 Important social and occupational time is giving up for substance
 Substance used despite knowledge of problems caused
Criteria for Substance abuse
Criteria for Substance intoxication
Criteria for substance withdrawal
 Development of specific symptoms due to cessation of drug
 Syndrome causes distress
 Symptoms not due to a medical condition
Etiology: Biological
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Evidence of genetic tendency among alcoholics
Strong concurrence with bipolar Dis.
Twins born to alcoholic parents who are adopted: 3x rate of adopted children of
non-alcoholics
Allergic response in orientals decrease rate; Indians very high
“Good Chemical” Hypothesis
Hypothesis that addicts have difficulty producing “good chemical”
Anyone who takes opiates or cocaine can create extra receptors for good
chemicals, thus causing craving
New treatment has been developed for this
Etiology: Sociocultural
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Advertising: Relief is just a swallow
Don’t suffer; take action
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Sex difference:
Males abuse alcohol and opiates more.
prescription drugs
Catholics: Highest rate of alcohol abuse
Jews: lowest
High levels of stress and availability
Females abuse
Etiology: Psychological
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Freud: Oral dependent type; coffee, etc.
Gold: Cycle: Conflict, anxiety. Feelings of powerlessness, self-deprecation, and
low self-esteem, then substance abuse
Bradshaw: describes a person as feeling “Shame Based.” He believes that
during childhood the pt. has a core of feeling “BAD.” Uses drugs for pain.
Etiology: Family
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Bradshaw believes that these families are enmeshed
People play out different roles
 Alcoholic
 Co-dependent
 Hero
 Lost child
 Mascot
 Scapegoat
Jaffe and Stanton: Family in which one parent is overly involved with addict and
other is punitive, inaccessible, distant, or absent.
Attention is focused on addict’s behavior
Illness effects entire family
3 options: Ignore, Banish, Adapt
Jellinek: 4 Phases of Abuse
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1. Prealcoholic: Social drug use, control, occasional use for stress reduction
2. Early: First blackout, sneaking drinks, preoccupational with drug, gulping,
loss of control
3. Middle: impossible to stop drinking. Social/work problems.
Late: Drinking all day, benders, physical dependence
Personality Traits & CD
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DENIAL/anger/overdependency
Inability to express emotions
High anxiety in interpersonal relations
Emotional immaturity
Ambivalence towards authority
Low frustration tolerance
Traits and CD
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Grandiosity
Low self-esteem
Feelings of isolation
Perfectionism and compulsiveness
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Sex role confusion
CD person’s emotional growth is stunted. Will be same age dry as when became
addicted.
Signs and Symptoms of Withdrawal
Treatment of Withdrawal
Alcohol
Rarely are there any pure alcoholics anymore.
Polysubstance abuse is much more common.
As many as one third of the hospital beds in a general hospital have alcoholic pts. in
them who do not mention their own alcoholism.
Areas that are common are Orthopedics, medicine, ER.
Onset of withdrawal B 6 to 8 hours after last drink.
Early Symptoms
1. Irritability, anxiety.
2. Insomnia
3. Tremors
4. Mild tachycardia
Symptoms of 6 to 96 hrs.
1. Withdrawal Seizures B 7-48 hrs.
2. Hallucinations B 48 to 72 hrs.
Symptoms of 3 to 14 days
1. Delirium Tremens B confusion, disorientation, visual hallucinations, tachycardia,
hyper-hypo-tension, extreme tremors, diaphoresis, and fever
Treatment
Assessment
1. Questions about drinking need to take into account that the pt. will downplay his
drinking.
Ask very specific questions; like How much do you drink? When was your last drink?
2. Close assessment of vital signs very important.
3. Tachycardia and increase in BP very important signs in monitoring withdrawal. Need
more meds.
4. Consult lab work for other drugs and problems, like anemia or lack of magnesium,
etc.
Planning
1. Administer Librium or Tranzene according to protocol and VS.
2. Administer high vitamin, high carbohydrate drink as ordered.
3. Administer B-vitamins Esp. Thiamine B maybe need magnesium also.
4. Continue to assess VS, sensorium, orientation, tremors, and irritability.
5. Maintain a calm, quiet environment.
6. Bed rest may be needed.
7. Pt. may be very down on himself. Be careful not to encourage or disagree.
Listening is very important.
8. Show acceptance, matter-of-fact response.
Signs and Symptoms of Drug Withdrawal
1. Opioids:
Tremors, spasms, abd pain, nausea and vomiting. Goose bumps, sweating, chills,
hypertension, increased respirations, tachycardia, anxiety, irritability, drug
craving, depression
TX Use methadone to decrease withdrawal symptoms.
2. Sedatives, anxiolytics:
Nausea, diarrhea, tremors, diaphoresis, unstable BP, sleep disturbance,
restlessness, impaired cognition seizures.
TX Need to withdraw slowly. Very long and difficult withdrawal.
Treatment for Drug Dependence
Medication
Disulfiram/ antabuse
Action: causes an adverse reaction to alcohol.
Concept: Keep alcoholic from drinking impulsively.
Teach
Symptoms of reaction are severe and easily triggered.
Symptoms include flushing, nausea, vomiting, thirst, diaphoresis, dyspnea,
hyperventilation, throbbing headache. Severe symptoms are MI, coma, convulsions and
death.
Dose: 500 mg each morning for two weeks, then 250 mg.
Pt. must avoid alcohol in all forms; both external and internal.
All cough medications, mouth washes, nail polish remover, vanilla extract, caffeine.
Treatment Issues
1. Assess for suicidal ideation.
2. Assess your own feelings about drug abusers.
3. Group treatment is essential. AA/NA is essential. Gives CD person feeling of
acceptance.
4. Pt. and family education to see CD as a disease not as a weakness.
5. Intervening in denial. May need to confront the denial directly. May take the form
of grandiose statements. “I know I’ll never drink again.” Better to talk about “One
day at a time.”
6. Problems of dependency B and avoiding responsibility. Very important for nurses to
make clear to pt. his sobriety is his/her responsibility. Don’t become too codependent or over responsible for the patient.
7. Pts often very angry and manipulative. Set clear rules and stick with them.
8. Pt. may need to attend a meeting every day after discharge. 90 meetings in 90
days.
9. Pt. needs a sponsor in AA.
Social Support
1. May need a whole new lifestyle. New friends and recreation. May need a halfway
house.
2. Family counseling essential. Al-anon.
The Reward Center B Handout
Antipsychotics
*Sedative/Hypnotics
*Inhalants
Thorazine
Haldol
Mellaril
Trilafon
Prolixin
Navane
Stelazine
etc.
Nembutal
Tuinal
Seconal
Placidyl
Miltown
Alcohol
Quaalude
Noctec
Dalmane
Restoril
Halcion
etc.
Liquid Paper
Paint
Gasoline
Glue
etc.
*Minor
Tranquilizers
Librium
Valium
Serax
Tranxene
Xanax
Centrax
Paxipam
Soma
Ativan
Restoril
Dalmane
Halcion
Limbitrol
Meprobamate
etc.
*Stimulants
Amphetamines
Benzedrine
Dexadrine
Desoxyn
Ecstasy
Ice
Tenuate
Ritalin
Cylert
Cocaine
Crack
etc.
Antidepressants
*Narcotics/Opiates
Elavil
Sinequan
Tofranil
Vivactyl
Prozac
Nardil
Desyrel
Pamelor
etc.
Codeine
Demerol
Dilaudid
Percodan
Talwin
Morphine
Vicodin
Darvon
Heroin
Methadone
etc.
*Hallucinogens
LSD
Mescaline
PCP
Ecstasy
Mushrooms
etc.
*Cannabinoids
Marijuana
Hashish
THC
etc.
*Addictive or Stimulates
The Reward Center
W. Loving, M.D.
Antipsychotic and antidepressants are
listed to show that there are drugs
that affect the brain yet do not
stimulate The Reward Center and are
not addictive.
If you are on pain medicines
(narcotics/opiates) by a doctor - tell
the doctor you are addiction prone;
ask the doctor not to refill the
prescription without a good reason;
tell your sponsor and loved ones you
are on the medicine; give the bottle of
pills to someone else to give it to you
as directed; get off of it soon; go to
more
meetings;
contact
your
treatment center if necessary.
The 12 step program is very
helpful in recovery.
Good Luck
 1990 William Loving, MD.
Reproduction Authorized
Phases of Alcohol Dependency
Jellinek proposed the 4 phases of alcoholism, which has since been generalized to
describe dependency on other chemicals as well. These phases may assist the nurse in
determining the degree to which chemicals are used.
Phase 1 Prealcoholic phase: characterized by social drinking, control over drinking
behavior, occasional alcohol use for stress reduction; at later stages of this
phase, frequent drinking related to stress reduction.
Phase 2 Early alcoholic phase: begins with the first blackout; characterized by
sneaking drinks, preoccupation with drinking, gulping drinks, avoidance of
reference to drinking, frequent blackouts and loss of control of drinking.
Phase 3 Middle alcoholic phase: it is impossible for the person to stop after one
drink; characterized by gross physical and psychological changes, chain
drinking, maintenance of supply, resentments, some attempts at seeking help,
attempts at abstinence, family changes, work-related problems, social decay,
aggressive behavior, extravagance, alibis for behaviors; life revolves around
alcohol.
Phase 4 Late alcoholic phase: drinking begins in the morning and continues all day;
characterized by benders, physical dependence, ethical deterioration, paranoid
thinking, alcoholic jealousies, indefinable fears, religious need, severe liver and
brain damage.
Personality Characteristics Associated with Persons Experiencing the Stressors
Associated with Chemical Dependency
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Note:
Angry over dependency
Inability to express emotions adequately
High anxiety in interpersonal relationship
Emotional immaturity
Ambivalence toward authority
Low frustration tolerance
Grandiosity
Low self-esteem
Feelings of isolation
Perfectionism and compulsiveness
Sex role confusion
There is no research data to support the theory of a “pre-addictive” personality.
(Above personality characteristics are those observed after chemical dependency is
apparent.)
Therapeutic Interventions:
Medication (Aversion)
Disulfiram (Antabuse) p 24-48 alcohol-free hours, 120-500 mg/day.
Appears to inhibit liver enzymes which degrade alcohol
tachycardia, hypotension, syncope, MI, CHF
Tx: maintain BP, treat s/s shock, O2, antihistamines.
TEACH!
Narcotic Antagonist
Naltrexone (Trexan) 50-100 mg/day
Narcotic antagonist - blocks effects of opiates by competing for the same receptor sites.
After patient detoxed, may begin p 7-10 d. If not detoxed, will experience acute opiate
withdrawal (Narcan challenge).
In an emergency: patient will require higher doses of opiate analgesics and will experience
greater and prolonged respiratory depression.