Substance Use Disorder

Overview

  • Substance Use Disorders are a national health problem with significant prevalence and detrimental effects.

Alcohol Use Disorder: Overview

  • Prevalence in the United States:

    • 16.6 million adults (age ≥ 18 years)

    • 697,000 adolescents (age 12–17 years)

  • Detrimental Effects:

    • Third leading preventable cause of death in the U.S.

    • Associated with absenteeism at work

    • Prenatal exposure risks

    • Increased incidents of violence

Opioid Crisis

  • Statistics:

    • Estimated cause of 130 deaths daily in the United States due to overdose.

    • Affects individuals across gender, race, and age.

  • Department of Health and Human Services (2019) Five-Point Program:

    • Access: Enhancing prevention, treatment, and recovery services.

    • Data: Improving data collection on the epidemic.

    • Pain: Effective pain management strategies.

    • Overdoses: Targeting overdose-reversing drugs.

    • Research: Fostering research on pain and addiction.

Categories of Drugs

  • Drug Categories:

    • Alcohol

    • Sedatives, hypnotics, and anxiolytics

    • Stimulants

    • Cannabis

    • Opioids

    • Hallucinogens

    • Inhalants

Substance Use Disorders Terminology

  • Important Terms:

    • Intoxication: State of being under the influence of a substance.

    • Withdrawal Syndrome: Symptoms that occur when stopping or reducing use.

    • Detoxification: The process of removing toxins, specifically substances, from the body.

    • Substance Abuse: Maladaptive pattern of substance use leading to significant impairment or distress.

    • Substance or Chemical Dependence: Compulsive use and reliance on a substance.

    • Substance Use: The consumption of alcohol or drugs.

Onset and Clinical Course

  • Onset Patterns:

    • Average age for first episode of intoxication occurs in adolescence.

    • Early episodes (e.g., “sipping”) noted as early as 8 years old.

    • More severe difficulties typically emerge during the mid-20s to mid-30s.

    • Elements of tolerance (need for increased quantity) and tolerance breaks.

    • Cycle of abstinence or controlled drinking may lead to crisis situations and escalating use.

  • Nature of Addiction:

    • Substance use identified as a chronic illness characterized by:

    • Remissions and relapses (60% to 90% relapse rates).

    • Highest successful recovery rates achieved through abstinence and high motivation.

    • Instances of spontaneous remission (recovery without treatment).

    • Poor outcomes associated with earlier onset of use.

Related Disorders

  • Comorbid Disorders:

    • Gambling disorder

    • Caffeine and tobacco addictions

    • Substances can induce symptoms similar to those of other mental illnesses.

Etiology (Causes of Substance Use Disorders)

  • Biologic Factors:

    • Genetic vulnerability: Example includes familial predisposition.

    • Neurochemical influences affecting dopamine pathways and reward systems.

  • Psychological Factors:

    • Family dynamics impacting coping and stress management through unhealthy norms.

  • Social and Environmental Factors:

    • Cultural attitudes about substance use (differences in drinking norms by culture).

    • Peer behaviors encouraging or discouraging use, laws regulating substances, costs, and availability.

Cultural Considerations

  • Cultural Attitudes:

    • Attitudes towards alcohol and drugs vary significantly among cultures:

    • Example: Muslims generally prohibit alcohol consumption.

    • Jewish culture integrates wine into religious practices.

    • Certain Native American tribes use peyote in religious ceremonies.

  • Ethnic Genetic Differences:

    • Variations in enzyme genes related to alcohol metabolism.

    • Example: Flushing response, characterized by reddening of the face and neck, indicating possible genetic predisposition to alcoholism.

    • Alcohol abuse is notably linked to deaths among Native Americans and Alaska Natives.

Alcohol

  • Effects & Behaviors:

    • Intoxication:

    • Central nervous system (CNS) depressant leading to relaxation and loss of inhibitions.

    • Symptoms include slurred speech, unsteady gait, lack of coordination, impaired memory and judgment, aggressive behavior, or inappropriate actions.

    • Overdose:

    • Symptoms: Vomiting, unconsciousness, respiratory depression.

    • Treatment Options: Gastric lavage or dialysis, supportive care for respiratory and cardiovascular functions in an intensive care unit.

  • Withdrawal Symptoms:

    • Onset: 4 to 12 hours post-cessation, peaking by day 2, resolved in approximately 5 days.

    • Symptoms: Coarse hand tremors, sweating, insomnia, anxiety, elevated pulse and blood pressure.

    • Severe withdrawal may escalate to transient hallucinations, seizures, or delirium (known as delirium tremens or DTs). Life-threatening conditions requiring treatment with benzodiazepines for safe withdrawal.

Questions & Answers on Alcohol

  • Question #1: Is it true that alcohol is a CNS stimulant?

    • Answer: False; alcohol is classified as a CNS depressant.

Sedatives, Hypnotics, and Anxiolytics

  • Intoxication:

    • Recognized as CNS depressants, symptoms include slurred speech, unsteady gait, labile mood, stupor.

    • Barbiturate overdose can potentially lead to lethal outcomes (coma, respiratory failure).

  • Withdrawal:

    • Onset and symptoms vary based on the drug's half-life; symptoms are typically the opposite of acute effects.

    • Detoxification often managed through drug tapering.

Stimulants (Amphetamines, Cocaine)

  • Effects:

    • Classed as CNS stimulants.

    • Intoxication Symptoms: Euphoria, hyperactivity, elevated blood pressure, chest pain, confusion, agitation.

    • Overdose Symptoms: Seizures, coma.

  • Withdrawal:

    • Onset: hours to several days post-ceasing use.

    • Primary symptom: marked dysphoria, commonly termed “crashing”; typically not treated pharmacologically.

Cannabis (Marijuana)

  • Uses:

    • Both psychoactive effects and medical applications noted.

  • Intoxication Symptoms:

    • Lowered inhibitions, relaxation, euphoria, increased appetite, with motor control and judgment impairment.

    • Risk of cannabis-induced psychotic disorders.

  • Withdrawal:

    • Generally not associated with clinically significant withdrawal syndromes but may have mild symptoms (muscle aches, sweating, anxiety, tremors).

Opioids

  • Effects:

    • Opioids induce desensitization to pain, promote euphoria and overall well-being. Symptoms of intoxication include:

    • Apathy, lethargy, listlessness, impaired judgment, and reduced respiration rate leading to potential coma.

    • Overdose Treatment: Administer naloxone to counteract overdose effects.

  • Withdrawal Symptoms:

    • Manifestations include nausea, vomiting, dysphoria, sweating, and insomnia with onset dependent on drug type.

    • Short-acting opioids (e.g., heroin) show withdrawal onset of 6-24 hours, peaking 2-3 days later; subsides within 5-7 days. Long-acting (e.g., methadone) show onset of 2-4 days with a longer subsidence period.

Hallucinogens

  • Effects:

    • Cause reality distortion, producing symptoms similar to psychosis (hallucinations, depersonalization).

    • Physical symptoms may include increased pulse and blood pressure with dilated pupils.

  • Intoxication Symptoms:

    • Maladaptive behavioral and psychological changes; no overdose reported but can result in toxic psychological reactions (PCP toxicity may include seizures, hypertension, or respiratory depression).

  • Withdrawal:

    • There is typically no formal withdrawal syndrome, but cravings may occur, and flashbacks can occur for varying durations.

Inhalants

  • Effects:

    • Intoxication from inhalants leads to neurologic and behavioral symptoms.

    • Acute toxicity can result in significant, life-threatening conditions including anoxia, respiratory depression, and potential death from various causes.

  • Withdrawal:

    • No set withdrawal syndrome noted; however, cravings may persist; treatment often focuses on symptomatic relief.

Questions & Answers on Hallucinogens

  • Question #2: Can a person abusing hallucinogens experience withdrawal syndrome?

    • Answer: False; no withdrawal syndrome is associated with hallucinogen use.

Substance Abuse Treatment

  • Concept:

    • Recognized as a medical illness characterized by progression, chronic state, remissions, and relapses.

  • Treatment Models:

    • Hazelden Clinic model.

    • 12-step program of Alcoholics Anonymous (AA).

  • Methods:

    • Individual and group counseling, pharmacologic treatments focus on managing withdrawal and cravings (specific medications detailed see Table 19.1).

Dual Diagnosis

  • Definition:

    • Co-occurrence of substance abuse with another psychiatric illness; approximately 75% of individuals with severe mental illness also present with substance use disorders.

  • Successful Treatments:

    • Employing relapse prevention strategies:

    • Healthy living environments, assistance with life changes like employment, fostering connective relationships with others in recovery.

    • Comprehensive treatment of comorbid conditions.

Substance Use Disorders and Nursing Process Application

  • Assessment:

    • History must include chaotic family life and crises contributing to treatment.

    • Observations on general appearance, mood, motor behavior, thought process, self-concept, and physiological considerations regarding health impacts.

  • Data Analysis & Outcome Identification:

    • Key focus areas on physical health status; desired outcomes include stable abstinence from substances, responsible behavior acknowledgment, emotion management, and effective aftercare planning.

Questions & Answers on Substance Use Disorder

  • Question #3: Do clients abusing substances often claim control over their substance use?

    • Answer: True; clients in denial frequently assert they can stop any time they choose.

Nursing Actions and Education

  • Actions:

    • Clients and families receive health education and substance abuse information.

    • Family dynamics addressed (codependence, enabling, and shifting family roles).

    • Focus on promoting coping skills tailored to recovery needs.

Age-Related Considerations in Substance Use

  • Children and Adolescents:

    • Notably, 10% of alcohol is consumed by individuals aged 12-20; college student drinking is prevalent and problematic.

  • Older Adults:

    • 30% to 60% of older adults in substance abuse treatment report initiating drinking after age 60; risk factors for late-onset primarily include chronic illness, chronic medication use, life stressors, and isolation.

Community-Based Care

  • Options:

    • Outpatient treatment facilities, individual or family counseling, and various recovery programs (e.g., AA, Rational Recovery).

Mental Health Promotion

  • Strategies:

    • Initiatives aimed at public awareness, advertising education, early identification of at-risk older adults, and targeted programs such as the College Drinking Prevention Program.

Substance Use Disorder in Health Professionals

  • Ethical Responsibility:

    • Legal obligations require reporting of suspicious behavior in peers, with characteristic red flags including diminished work performance, social isolation, and unusual behaviors (e.g. slurred speech).

Self-Awareness Issues

  • Considerations for Health Professionals:

    • Examining personal beliefs regarding substance use, recognizing the chronic nature of substance abuse, and maintaining open and objective perspectives for client interaction.