CHAPTER 48
Substance Abuse
Objective Questions
Identify the differences between mild, moderate, and severe substance use disorder, focusing on diagnostic criteria and clinical presentation.
Differentiate between the screening instruments for substance use disorders, including their sensitivity, specificity, and appropriate use cases.
Cite the responsibilities of professionals who suspect substance abuse by a colleague, emphasizing ethical and legal obligations.
Explain the primary long-term goals in the treatment of substance abuse, including harm reduction, relapse prevention, and improved quality of life.
Identify the withdrawal symptoms for major substances that are commonly abused, detailing the timeline, severity, and management strategies for each.
Key Terms
Substance abuse: Periodic purposeful use of a substance that leads to clinically significant impairment. This includes failure to fulfill major obligations at work, school, or home. The prevalence is approximately 8.7% of the U.S. population.
Impairment: Failure to fulfill major obligations at work, school, or home due to substance use.
Dependence/addiction: Symptoms of compulsive use, tolerance (the need for increased amounts of the substance to achieve the desired effect), and withdrawal symptoms upon discontinuation. This is a chronic, relapsing brain disease.
Illicit substances: Any chemical that alters biologic function and is not required for health maintenance. This includes illegal drugs as well as prescription medications used without a prescription or not as prescribed.
Screening
Four categories of instruments:
Comprehensive drug abuse screening and assessment: In-depth evaluations that may include interviews, psychological testing, and biological assays to determine the extent and nature of substance use disorders.
Brief drug abuse screening: Quick, standardized tools used to identify individuals who may have a substance use disorder and warrant further evaluation.
Alcohol abuse screening: Specific tools designed to detect problematic alcohol use.
Drug and alcohol abuse screening for use with adolescents: Instruments tailored to the unique challenges and developmental considerations of adolescents.
(See Table 48-2 for details)
CAGE: A widely used, quick assessment tool for identifying potential alcohol problems:
C—cut down: Have you ever felt you needed to cut down on your drinking?
A—annoyed: Have people annoyed you by criticizing your drinking?
G—guilt: Have you ever felt guilty about your drinking?
E—eye opener: Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover?
Theories
Biologic model: The theory that abuse is caused by a genetic profile, indicating a hereditary condition and predisposing individuals to substance use disorders.
Psychological theories:
Psychoanalytic theories: Focus on underlying psychological issues, such as unresolved conflicts or trauma, that may contribute to substance abuse.
Behavior or learning theories: Suggest that substance use is a learned behavior reinforced by its rewarding effects.
Cognitive theories: Examine the role of thought processes and beliefs in the development and maintenance of substance use disorders.
Sociocultural factors: The attitudes, values, and norms of a person's environment can significantly affect their susceptibility to abuse.
Signs of Impairment
First manifested in family life:
Violence, separation, divorce, and financial problems are common indicators.
Disintegration of social life:
Public intoxication and isolation from social activities.
Physical and mental changes:
Fatigue, multiple illnesses, injuries, accidents, and emotional crises.
Flagrant evidence of impairment at work (rare): This might include decreased productivity, absenteeism, or poor job performance.
Health Professionals and Substance Abuse
Factors leading to substance abuse:
Stress of intense patient care.
Managing more patients with the same resources.
“Zero tolerance” for mistakes.
Financial debt.
Signs of abuse:
Behavioral changes: lack of attention to hygiene, mood swings, and changes in work habits.
Performance deterioration: Errors in judgment, difficulty concentrating, and decreased productivity.
Substance Abuse Reporting
Confidential report to the appropriate supervisor is crucial.
Investigation to ascertain the extent and nature of the issue.
Observation and documentation over time to establish a pattern of behavior.
Clinical practice is a privilege that must be protected.
Need to protect patients from harm.
Unreported colleague may die as a result of impairment, highlighting the urgency of intervention.
Reported colleagues have a good chance of retaining their licenses because legal protections do exist.
Substances of Abuse
Alcohol, nicotine, caffeine.
Amphetamine.
Cannabis (marijuana).
Cocaine.
Hallucinogens.
Inhalants.
Opioids.
Phencyclidine (PCP).
Sedatives and hypnotics.
Long-Term Goals of Treatment
Reduction in or abstinence from the use and effects of substances to improve overall health and well-being.
Reduction in the frequency and severity of relapse through effective coping strategies and support systems.
Improvement in psychological and social functioning to enhance overall quality of life.
Alcohol
Withdrawal symptoms:
Visual and auditory hallucinations.
Seizures, which can be life-threatening.
Treatment:
Assess hydration, electrolytes, and nutritional status to address any imbalances.
Thiamine and multiple vitamins to prevent or treat nutritional deficiencies.
Benzodiazepines for detoxification to manage withdrawal symptoms efficiently:
Fixed dose schedule.
Symptom-triggered medication regimen.
Alcohol Relapse Prevention
Social support and lifelong effort required for sustained recovery.
Medications used:
Disulfiram (Antabuse): Helps reduce the desire for alcohol by causing nausea and vomiting with the ingestion of alcohol. Must educate patients to avoid hidden alcohol in products like mouthwash, cold medicine, etc.
Naltrexone (Revia): Blocks the effects of the high associated with alcohol consumption, reducing cravings.
Acamprosate (Campral): Promotes abstinence by reducing the physical and emotional discomfort associated with alcohol withdrawal.
Slightly higher success rate of preventing relapse when naltrexone and acamprosate are used together.
Opioids and Cocaine
Withdrawal symptoms:
Mood swings, impaired memory, slurred speech.
Anxiety, restlessness, increased blood pressure and pulse, sweating, nausea, vomiting, sometimes aches and fever.
Opioid Treatment:
May substitute another opioid, such as methadone or buprenorphine, to reduce the severity of withdrawal symptoms and stabilize the patient.
Cocaine relapse prevention:
The rate of relapse is high for cocaine; therefore, comprehensive treatment strategies, including counseling and support groups, are essential.
Amphetamine-Type Stimulants
Uses:
Historically used to treat schizophrenia, depression, radiation sickness, attention deficit hyperactivity disorder (ADHD), opiate and nicotine addiction, although many of these uses are now outdated.
Intoxication:
Produce a sense of heightened alertness, attentiveness, self-confidence, powerfulness, and energy; frequently leads to an additional dose, and may stay awake for 7-10 days.
Often little water or food is taken when high, leading to dehydration and malnutrition.
“Meth mouth” occurs from poor oral hygiene and grinding of teeth, resulting in severe dental problems.
Amphetamine Treatment
No antidotes for methamphetamine, making management primarily supportive.
Psychiatric evaluation is essential due to damaged dopaminergic and serotonergic neurons.
Cognitive behavior therapy to address underlying psychological issues and develop coping strategies.
Contingency management programs to provide incentives for abstinence.
Support group involvement in 12-step programs and/or SMART Recovery.
Drug: Acamprosate (Campral)
Action: NDMA receptor antagonist.
Uses: Chronic alcoholism; with other therapies, enhances abstinence and reduces drinking rates.
Common adverse effect: Diarrhea.
Serious adverse effects: Suicidal actions.
Contraindicated in patients with severe renal failure.
Drug: Disulfiram (Antabuse)
Action: When alcohol is ingested, produces nausea, severe vomiting, sweating, throbbing, dizziness, blurred vision, and other unpleasant effects.
Use: Chronic alcoholism, with other therapies.
Common adverse effects: Drowsiness, fatigue, headache, impotence, metallic taste.
Serious adverse effects: Hepatotoxicity, hypersensitivity.
Should not be administered to an acutely intoxicated patient; the patient should carry an identification card and must not apply or drink alcohol, including OTC meds, mouthwash, etc.
Question 1
What percentage of the U.S. population aged 12 or older was classified as dependent upon or abusers of either alcohol or illicit drugs in 2010?
8.7%
Question 2
What action should the health professional take if he or she suspects that a colleague may be a substance abuser?
Report it confidentially to an appropriate supervisor to initiate investigation and support.
Question 3
A patient who had an emergency appendectomy 24 hours earlier is currently restless, anxious, nauseated, and has an elevated heart rate and blood pressure. The nurse recalls that the patient has no allergies and no significant health history but mentioned drinking a 6-pack of beer nightly. What does the nurse suspect is the probable cause of these symptoms?
Acute alcohol withdrawal, given the patient's history of regular alcohol consumption and the timing of the symptoms.
Question 4
A patient is to be observed for symptoms of opiate withdrawal. Which symptoms are associated with withdrawal?
Anxiety, restlessness, increased blood pressure and pulse, sweating, nausea, vomiting, sometimes aches and fever.
Question 5
What is the use of the prescription drug disulfiram (Antabuse)?
Deterring alcohol consumption by producing unpleasant effects when alcohol is ingested, reinforcing abstinence.