Substance-Related and Addictive Disorders

Substance Use Disorders

  • Pathological use of a substance that leads to a disorder of use.
  • Symptom groups:
    • Impaired control
    • Social impairment
    • Risky use
    • Physical effects (i.e., intoxication, tolerance, and withdrawal)

Substances That Lead to Use Disorders

  • Alcohol
  • Caffeine
  • Cannabis
  • Hallucinogen
  • Inhalant
  • Opioid
  • Sedative-hypnotic
  • Stimulant
  • Tobacco
  • Other: Process addictions—Gambling, shopping, sex, etc.

Concepts Central to Addictive Use Disorders

  • Addiction
    • Chronic medical condition
  • Intoxication
    • In the process of using a substance to excess
  • Tolerance
    • Takes a higher dose to achieve the initial level of response
  • Withdrawal
    • Symptoms that occur when a person stops using a substance

Epidemiology

  • Alcohol
    • 15 million people addicted
  • Other substances
    • About 8 million people addicted
    • Marijuana: 4.5 million
    • Opioids: 2.0 million

Comorbidity

  • Psychiatric comorbidity
    • Any combination of two or more substance use disorders and mental disorders

Risk Factors

  • Genetic factors
  • Neurobiological factors
  • Environmental factors

Clinical Picture

  • Caffeine
    • Most widely used psychoactive substance in the world
    • Can result in intoxication, overdose, and withdrawal
  • Cannabis (Marijuana)
    • Third most commonly used psychoactive drug in the United States after alcohol, and illicit drugs
  • Hallucinogens
    • Cause a profound disturbance in reality

Clinical Picture (Cont.)

  • Inhalants
    • Solvents for glues and adhesives
    • Propellants
    • Thinners
    • Fuels

Opioid Use Disorder

  • Heroin and prescription drugs
  • Opioid intoxication
    • Cravings result in larger amounts, longer periods of use, increasing tolerance to its effects
    • Results in significant impairment in life roles, interpersonal conflict, and puts a person in physically hazardous situations

Opioid Use Disorder (Cont.)

  • Opioid intoxication
  • Opioid overdose
    • Death usually due to respiratory arrest
    • Treatment: promote breathing; naloxone

Opioid Use Disorder (Cont.)

  • Opioid withdrawal
    • Methadone, clonidine, buprenorphine/naloxone
    • Lofexidine
  • Opioid maintenance
    • Pharmacological
    • Psychotherapies

Sedative, Hypnotic, and Antianxiety Medication Use Disorder

  • Problematic Substances
    • Benzodiazepines
    • Benzodiazepine-like drugs
    • Carbamates
    • Barbiturates
    • Barbiturate-like hypnotics
  • Overdose: gastric lavage
  • Withdrawal: gradual reduction to prevent seizures

Stimulant Use Disorder

  • Clinical Picture
    • Amphetamine-type, cocaine, or other stimulant drugs
    • Second only to cannabis as the most widely used illicit substances in the United States
  • Withdrawal treatment
    • Group and individual therapy
    • Possible diazepam for agitation
    • 1 to 2 weeks’ cocaine withdrawal requires no inpatient care; no drugs reduce symptoms
    • Depression treatment once withdrawal is complete (e.g., bupropion)

Other Disorders

  • Tobacco
    • Withdrawal is distressing
    • Withdrawal treatment: behavioral therapy, hypnosis, nicotine replacement therapies; bupropion or verenicline
  • Gambling disorder
    • Gamblers Anonymous (GA)
    • Possible treatment with SSRIs, bupropion (Wellbutrin), mood stabilizers, and anticonvulsants

Alcohol Use Disorder

  • Sedative with initial euphoria
  • Severity based on number of DSM-V symptoms
    • Mild: 2–3 symptoms
    • Moderate: 4–5 symptoms
    • Severe: 5 or more symptoms
  • Extensive List in DSM-V box

Alcohol Use Disorder (Cont.)

  • Epidemiology
    • Almost twice the prevalence among adult men than adult women
    • American Indians/Alaska Natives (12.1%) have the highest rates; disproportionately affected by alcohol problems
  • Comorbidity
    • Bipolar disorders, schizophrenia, antisocial personality disorder, major depressive disorder

Alcohol Use Disorder (Cont.)

  • Risk Factors
    • Genetics
    • Neurobiological
    • Social
    • Cultural
  • Types of Problematic Drinking
    • Binge Drinking
    • Heavy Drinking

Alcohol Use Disorder (Cont.)

  • Alcohol intoxication
    • Legal definition of intoxication in most states: blood concentration of 80 or 100 mg ethanol per deciliter of blood (mg/dL).
    • Often expressed as 0.08 to 0.10 g/dL.
  • Alcohol withdrawal
  • Cognitive disturbances
    • Wernicke-Korsakoff syndrome
  • Fetal alcohol syndrome

Alcohol Use Disorder (Cont.)

  • Systemic effects
    • Peripheral neuropathy
    • Alcoholic myopathy and cardiomyopathy
    • Esophagitis, gastritis, and pancreatitis
    • Alcoholic hepatitis
    • Cirrhosis of the liver
    • Leukopenia
    • Thrombocytopenia
    • Cancer (especially head and neck)

Application of the Nursing Process

  • Screening Tools
    • SBIRT: Screening, brief intervention, and referral to treatment
    • AUDIT: Alcohol use disorders identification test
    • CAGE: 4 questions to identify alcohol abuse
    • CAGE-AID: Same questions as CAGE but adds drug use to alcohol
    • T-ACE: Tolerance, Annoyance, Cut down, Eye-opener

Nursing Process

  • Assessment
    • Family assessment (codependence)
    • Self-assessment
  • Nursing diagnosis
  • Outcomes identification
  • Planning
    • Identifying problem
    • Setting a goal
    • Determining the interventions that will accomplish the goal

Nursing Process Implementation

  • Promoting safety and sleep: first-line interventions
  • Reintroduce good nutrition and hydration
  • Support for self-care (hygiene)
  • Exploring harmful thoughts and spiritual distress
  • Health teaching and health promotion
    • Prevention against genetic vulnerability
    • Public classes

Nursing Process (Cont.)

  • Evaluation
    • Assessing the effectiveness of the treatment plan
    • Using objective data to check whether nursing actions addressed the patient’s symptoms
    • Measuring the changes in the patient’s behaviors for progress toward meeting stated goals

Treatment Modalities

  • Pharmacotherapy
    • Disulfiram
    • Naltrexone
    • Benzodiazepines
  • Psychotherapy
    • Motivational interviewing

Treatment Modalities (Cont.)

  • Transtheoretical stages of change theory
    • Precontemplation
    • Contemplation
    • Preparation
    • Action
    • Maintenance

Care Continuum for Substance Use Disorders

  • Detoxification (detox)
  • Rehabilitation
  • Halfway houses
  • Other housing
  • Partial hospitalization program
  • Intensive outpatient programs
  • Outpatient treatment
  • Alcoholics Anonymous (AA)
  • Relapse prevention