Explain trends in substance abuse and prevention programs.
Discuss characteristics, risk factors, and family dynamics of substance use disorders.
Describe 12-step treatment approach.
Develop a plan of care for clients with substance use issues.
Educate clients, families, and community members.
Discuss the nurse’s role in dealing with the chemically impaired professional.
Evaluate personal feelings and attitudes toward clients and families with substance use disorders.
Introduction to Substance Use Disorders
Substance use disorders are a national health problem.
More than 16.6 million adult Americans have an alcohol use disorder.
Nearly 88,000 people die from alcohol-related causes each year.
Alcohol-related death is the third leading preventable cause of death in the United States.
30% of driving fatalities are alcohol related.
Worldwide, 3 million deaths result from harmful alcohol use annually.
Alcohol is a causal factor in more than 200 disease and injury conditions.
Absenteeism at work is higher for employees who have alcohol-related problems.
The number of infants suffering from prenatal exposure to alcohol or drugs is increasing.
Chemical abuse results in increased violence.
Approximately 8.7 million children aged 17 years of age or younger live with a parent who has a substance use disorder.
Children of alcoholics are more likely to develop problems with alcohol.
The increased use of opioids in the United States has prompted the identification of an “opioid crisis.”
An estimated 130 deaths occur daily in the United States from an opioid overdose.
The Department of Health and Human Services initiated a five-point program to address this crisis in 2019, including access, data, pain management, overdose reversal, and research improvements.
Illicit fentanyl, fentanyl analogs, methamphetamine, and cocaine are driving the overdose epidemic.
Types of Substance Abuse
Categories of drugs include alcohol, sedatives, hypnotics, anxiolytics, stimulants, cannabis, opioids, hallucinogens, and inhalants.
Polysubstance abuse: Abuse of more than one substance.
Designer drugs (club drugs): Synthetic substances made by altering existing medications or formulating new substances not yet controlled or regulated by the FDA.
Intoxication: Use of a substance that results in maladaptive behavior.
Withdrawal syndrome: Negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases.
Detoxification: The process of safely withdrawing from a substance.
Substance abuse: Using a drug in a way that is inconsistent with medical or social norms and despite negative consequences.
Substance dependence: Includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance.
Substance use includes both abuse and dependence.
Onset and Clinical Course
The average age for an initial alcohol intoxication episode is during adolescent years.
The first episode of intoxication occurs between 12 and 14 years of age; minor alcohol-related problems are seen in the late teens.
Episodes of "sipping" alcohol may occur at age 8 years or even earlier.
More severe difficulties for people with alcoholism begin to emerge in the mid-20s to the mid-30s.
Blackout: An episode during which the person continues to function but has no conscious awareness of their behavior at the time or any later memory of the behavior.
Tolerance: Needing more alcohol to produce the same effect.
Tolerance break: Very small amounts of alcohol intoxicate the person.
Substance use is a chronic illness characterized by remissions and relapses to former levels of use.
Relapse rates range from 60% to 80%.
Spontaneous remission or natural recovery: People with alcohol-related problems can modify or quit drinking on their own without a treatment program.
Poor outcomes have been associated with an earlier age at onset, longer periods of substance use, and the coexistence of a major psychiatric illness.
With extended use, the risk of mental and physical deterioration and infectious disease increases.
Related Disorders
Gambling disorder is a non–substance-related diagnosis.
Caffeine and tobacco or nicotine are addictive substances but are not considered mental health problems per se.
Substance-induced anxiety, substance-induced psychosis, and so forth are symptoms that are similar to other mental illness diagnoses.
Etiology of Substance Use Disorders
Biologic factors:
Children of alcoholic parents are at higher risk.
Genetic vulnerability.
About 40% to 60% of the variation in causes of alcoholism was the result of genetics.
Ingestion of mood-altering substances stimulates dopamine pathways in the limbic system.
Psychological factors:
Inconsistency in the parent’s behavior, poor role modeling, and lack of nurturing.
Lack of adaptive coping skills and inability to form successful relationships.
Use alcohol as a coping mechanism to relieve stress, increase feelings of power, and decrease psychological pain.
Social and environmental factors:
Cultural factors, social attitudes, peer behaviors, laws, cost, and availability.
Urban areas with high crime rates, high unemployment, and substandard school systems.
Cultural Considerations:
Attitudes toward substance use, patterns of use, and physiological differences to substances vary in different cultures.
Flushing, a reddening of the face and neck linked to variants of genes for enzymes involved in alcohol metabolism, is highest among people of Asian ancestry.
Alcohol use overall plays a part in the five leading causes of death for Native Americans and Alaska Natives.
Types of Substances and Treatment
Classes of mood-altering substances have some similarities and differences in terms of intended effect, intoxication effects, and withdrawal symptoms.
Alcohol
Intoxication and Overdose:
Central nervous system depressant.
Slurred speech; unsteady gait.
Impaired attention, concentration, memory, and judgment.
Overdose can result in vomiting, unconsciousness, and respiratory depression.
Treatment includes gastric lavage or dialysis and support of respiratory and cardiovascular functioning.
Contraindicated the administration of central nervous system stimulants.
Withdrawal and Detoxification:
Symptoms begin 4 to 12 hours after cessation.
Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting.
Severe withdrawal may progress to transient hallucinations, seizures, or delirium (delirium tremens).
Treatment includes benzodiazepines (lorazepam, chlordiazepoxide, or diazepam) to suppress symptoms.
Medication is based on assessment tools such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised.
Sedatives, Hypnotics, and Anxiolytics
Intoxication and Overdose:
Symptoms similar to alcohol.
Treatment includes gastric lavage, activated charcoal, and saline cathartic.
Barbiturates can be lethal when taken in overdose.
Withdrawal and Detoxification:
Symptoms that are the opposite of the acute effects of the drug.
Autonomic hyperactivity, hand tremor, insomnia, anxiety, nausea, and psychomotor agitation.
Treatment is medically managed by tapering the amount of the drug.
Stimulants
Intoxication and Overdose:
High or euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic behavior, anger, fighting, and impaired judgment.
Physiological effects include tachycardia, elevated blood pressure, dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmias.
Overdoses can result in seizures and coma.
Withdrawal and Detoxification:
Dysphoria is the primary symptom.
Accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation.
Not treated pharmacologically.
Cannabis
Intoxication and Overdose:
High feeling similar to alcohol, lowered inhibitions, relaxation, euphoria, and increased appetite.
Symptoms include impaired motor coordination, inappropriate laughter, impaired judgment and short-term memory, and distortions of time and perception.
Overdoses do not occur.
Withdrawal and Detoxification:
No clinically significant withdrawal syndrome is identified.
Opioids
Intoxication and Overdose:
Apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory.
Severe intoxication can lead to coma, respiratory depression, pupillary constriction, unconsciousness, and death.
Treatment includes naloxone (Narcan), an opioid antagonist.
Withdrawal and Detoxification:
Symptoms include anxiety, restlessness, nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia.
Short-acting drugs produce withdrawal symptoms in 6 to 24 hours.
Longer acting substances may not produce significant withdrawal symptoms for 2 to 4 days.
Methadone can be used as a replacement for opioids.
Hallucinogens
Intoxication and Overdose:
Anxiety, depression, paranoid ideation, ideas of reference, fear of losing one’s mind, and dangerous behaviors.
Physiological symptoms include sweating, tachycardia, palpitations, blurred vision, tremors, and lack of coordination.
PCP intoxication often involves belligerence, aggression, impulsivity, and unpredictable behavior.
Treatment of toxic reactions is supportive.
Withdrawal and Detoxification:
Treatment includes talking down the person.
Haloperidol (Haldol) or a benzodiazepine such as diazepam (Valium) can be used.
No withdrawal syndrome has been identified.
Hallucinogens can produce flashbacks.
Inhalants
Intoxication and Overdose:
Dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision.
Significant behavioral symptoms are belligerence, aggression, apathy, impaired judgment, and inability to function.
Treatment consists of supporting respiratory and cardiac functioning until the substance is removed from the body.
Withdrawal and Detoxification:
No withdrawal symptoms or detoxification procedures.
Treatment and Prognosis
Treatment modalities:
Based on the concept of alcoholism as a medical illness that is progressive, chronic, and characterized by remissions and relapses.
Alcoholics Anonymous (AA) founded in the 1930s, utilizes a 12-step program model for recovery.
Self-help groups.
Individual counseling.
Group experiences.
Treatment programs have been developed to meet these needs and include Women for Sobriety and Rainbow Recovery.
Treatment Settings and Programs:
Emergency departments to outpatient clinics.
Medical units in the hospital setting.
Clinics or centers offering day and evening programs, halfway houses, residential settings, or special chemical dependency units in hospitals.
Plan of Care:
Problem: Denial of problem.
Assessment data: Denial or minimization of alcohol use, blaming others, reluctance to discuss problems, lack of insight, failure to accept responsibility, rationalization.
Expected outcomes: Participate in treatment, identify negative effects, abstain from drug and alcohol use, verbalize acceptance of responsibility.
Implementation: Give information about alcoholism, encourage the client to identify behaviors, redirect the client’s focus, and reinforce the client when they identify or express feelings.
Pharmacologic Treatment
Permit safe withdrawal from alcohol and benzodiazepines and to prevent relapse.
Alcohol withdrawal is usually managed with a benzodiazepine anxiolytic agent.
Disulfiram (Antabuse) may be prescribed to help deter clients from drinking.
Acamprosate (Campral) may be prescribed to help reduce cravings for alcohol.
Methadone, a potent synthetic opiate, is used as a substitute for heroin in some maintenance programs.
Buprenorphine/naloxone (Suboxone) is a combination drug used for opiate maintenance and to decrease opiate cravings.
Naltrexone (ReVia) is an opioid receptor antagonist often used to treat overdose.
Clonidine (Catapres) is an alpha-2-adrenergic agonist used to treat hypertension.
Dual Diagnosis
The client with both substance abuse and another psychiatric illness is said to have a dual diagnosis.
Traditional methods for treatment of major psychiatric illness or primary substance abuse often have limited success.
Plan of Care: Dual Diagnosis
Problem: Ineffective coping.
Assessment data: Poor impulse control, low self-esteem, lack of social skills, dissatisfaction with life circumstances.
Expected outcomes: Take only prescribed medication, interact appropriately, express feelings openly, develop plans to manage unstructured time.
Implementation: Encourage open expression of feelings, validate the client’s frustration, maintain frequent contact, and give positive feedback for abstinence.
Care of Clients with Substance Use Problems
Identifying people with substance use problems can be difficult.
The Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD) is a useful screening device.
Assessment Data
History of chaotic family life.
Anxious, tired, and disheveled appearance.
Wide ranges of mood and affect.
Thought Process and Content may minimize their substance use, blame others for their problems, and rationalize their behavior.
Clients generally are oriented and alert unless they are experiencing lingering effects of withdrawal.
Low self-esteem.
Difficulties with social, family, and occupational roles.
Problems commonly identified: Denial, inability to fulfill roles, dysfunctional family dynamics, and ineffective coping.
Outcome Identification: Abstain from alcohol and drug use, express feelings openly and directly, verbalize acceptance of responsibility.
Actions:
Providing Health Teaching for the Client and Family: Dispel myths and misconceptions.
Addressing Family Issues: all those who have a close relationship with a person who abuses substances suffer emotional, social, and sometimes physical anguish.
Promoting Coping Skills: Encourage clients to identify problem areas and relieve stress.
Evaluation: The effectiveness of substance abuse treatment is based heavily on the client’s abstinence from substances.
Age-Related Considerations
Fifteen percent of children who drink underage began using alcohol before they were 13 years old.
College student drinking is a major problem.
Onset of initial drinking problems after the age of 50 years is not uncommon.
Community-Based Care: Many people receiving treatment for substance abuse do so in community-based settings (outpatient treatment, freestanding substance abuse treatment facilities, and recovery programs such as AA and Rational Recovery).
Mental Health Promotion: Increasing public awareness and educational advertising have not made any significant change in the rates of substance abuse in the United States.
Substance Use in Health Professionals: Physicians, dentists, and nurses have far higher rates of dependence on controlled substances.
Nurses have an ethical responsibility to report suspicious behavior to a supervisor.
Evidence-Based Practice: effective alcohol and substance disorders treatments exist but are not commonly and consistently practiced.
Self-Awareness Issues: The nurse must examine their beliefs and attitudes about substance abuse.