Substance Abuse

Concept of Addiction

  • Definition:

    • Addiction is characterized as a brain disease that evolves over time.

    • It occurs primarily due to individuals voluntarily consuming drugs.

    • The repeated use of substances leads to uncontrollable and compulsive drug craving and seeking, ultimately destroying personal functioning.

    • Abuse:

    • Describes the use of a substance outside of its medical necessity, resulting in adverse effects both for the user and others.

    • Dependence (Addiction):

    • Occurs when there is a tolerance developed to the drug, necessitating increased amounts to avoid withdrawal symptoms.

Operational Definition of Addiction: The Three C’s

  • Addiction behaviors are motivated by varying emotional responses.

  • These behaviors can range from the craving to the compulsive spectrum.

  • Continued usage happens despite adverse health, mental, relational, occupational, and financial consequences.

  • Loss of Control: A critical element in identifying addiction.

Substance Use, Abuse & Dependence (Addiction)

  • Examples:

    • Use:

    • Having a drink after work.

    • Abuse:

    • Having several drinks after work every day and frequently on weekends.

    • Dependence/Addiction:

    • Stopping drinking leads to severe withdrawal symptoms such as tremors, elevated blood pressure, and a strong craving for alcohol.

The Most Commonly Abused Substances (Part I)

  • Caffeine:

    • Found in coffee, tea, colas, energy drinks, chocolate, Excedrine, and many over-the-counter “diet” pills.

  • Nicotine

The Most Commonly Abused Substances (Part II)

  • Common abused substances include:

    1. Alcohol

    2. Amphetamines/Meth

    3. Cannabis

    4. Cocaine

    5. Hallucinogens

    6. Inhalants

    7. Opioids

    8. PCP

    9. Sedatives/Hypnotics/Anxiolytics

  • Statistics:

    • Prescription drug overdose is the second leading cause of accidental death in the U.S., with motor vehicle accidents being the first.

Theoretical Approaches to Addiction: Why Some Become Addicts

  • Contributing Factors:

    1. Genetics & Family Influence

    2. Peer Pressure

    3. Environmental Stress Factors

    4. Chronic Physiologic Disease

    5. Personality Characteristics

    6. Codependency, recognized as a family disease

Genetics/Family Influence

  • Statistics:

    • A first-degree relative of an alcoholic has a 50% increased likelihood of abusing alcohol.

  • The combination of genetics and environment is crucial in promoting substance use, abuse, and addiction tendencies.

Peer Pressure

  • Individuals most susceptible to peer pressure include:

    • Those with a family history of substance abuse

    • Individuals with low self-esteem

    • Those suffering from depression who may seek self-medication through substances

Environmental Stress Factors

  • Feeling a lack of control over one’s environment increases susceptibility to substance abuse.

  • Substance use may become a coping mechanism for stressors.

  • The absence of effective coping mechanisms may lead to relapse when attempting to cease substance use.

Chronic Physiologic Disease

  • Abusers undergo physiological changes, particularly in brain chemistry.

  • Continued drug use is necessary to prevent withdrawal, which can induce significant distress and suffering.

Personality Characteristics

  • Certain personality types may be predisposed to substance abuse:

    • Dependent:

    • Often displays low self-esteem and succumbs to peer pressure.

    • Antisocial:

    • Exhibits a disregard for laws, may seek control over others through substance use.

    • Substance abuse can serve as a form of self-medication for many personality types seeking to improve self-feelings.

Codependency

  • Definition:

    • A multi-generational pattern where maladaptive behaviors of others are normalized and excused.

    • Family members may enable negative behavior, mistakenly believing they are helping by controlling the behavior, when they are in fact being controlled, leading to dysfunctional dynamics.

Treatment for Substance Addiction

  • Detoxification:

    • A necessary period for detoxing from substance use.

    • Certain substances like alcohol and benzodiazepines require a gradual weaning to prevent dangerous withdrawal symptoms.

  • Medical Intervention:

    • Proper medications during withdrawal may be necessary to manage symptoms effectively.

  • Therapy:

    • Prognosis is poor if therapy (including AA, NA, etc.) is omitted from the treatment plan, which often benefits the family as well.

Various Medical Treatments

  • For Alcohol:

    • Use of Librium (chlordiazepoxide) for step-down (weaning) process to control symptoms such as elevated vital signs, agitation, and tremors.

    • Treatment might extend for up to a week or longer, as necessary.

  • For Benzodiazepines and Some Narcotics:

    • Gradual weaning off of drugs is required.

    • Increased seizure risks exist for patients withdrawing from benzodiazepines for up to two weeks post last dose due to the long half-life of these drugs.

Detox off Other Substances

  • For Amphetamines, Cocaine, and Crack:

    • Management focuses on symptomatic relief for abdominal cramps, diarrhea, nausea/vomiting, and elevated vital signs.

    • Expect prolonged periods of sleep ("crash") for several days amidst focus on rest, rehydration, and nutrition.

  • For Caffeine and Nicotine:

    • Withdrawal symptoms may include headaches and agitation and may require a gradual weaning or even "cold turkey" approach.

Other Detox Considerations

  • Alcoholics and amphetamine users often present poor nutritional statuses, necessitating vitamin B injections, oral vitamins, and encouragement for meals.

  • Expect emotional distress indicators such as severe depression and anger as they lose their primary coping methods.

Some Pharmacological Agents for Alcohol (ETOH) Withdrawal

  • Benzodiazepines:

    • Chlordiazepoxide (Librium), oxazepam (Serax), and diazepam (Valium) employed in a step-down regimen and as needed for breakthrough withdrawal symptoms.

  • Additional medications:

    • Thiamine (vitamin B1), potentially via IM, and other vitamins should be administered.

    • PRN medications for nausea/vomiting and blood pressure.

    • Severe symptoms (DTs) will require hospitalization and may necessitate IV medication.

Pharmacological Agents for ETOH Abstinence Maintenance - Post-Withdrawal

  • Acamprosate (Campral):

    • Aids in re-regulating neurotransmitters; not metabolized in the liver; renal function must be adequate; may be paired with naltrexone if liver function is good.

  • Naltrexone (ReVia):

    • Blocks opioid receptors, reducing alcohol "high" and cravings; also applicable for opioid dependence; liver function tests must be adequate.

  • Disulfiram (Antabuse):

    • Acts as aversion therapy by inducing nausea/vomiting; requires adequate liver function before administration.

Pharmacological Agents for Narcotic Abstinence Maintenance

  • Naltrexone (ReVia):

    • Similar application as in alcohol dependence.

  • Buprenorphine-naloxone (Suboxone):

    • A combined drug in 4:1 ratio used as a sublingual tablet or film; acts as a weak, partial agonist/modulator with an opioid antagonist to deter IV use; contraindicated in severe liver problems, respiratory issues, or acute alcoholism.

  • Methadone (Dolophine):

    • A synthetic addictive opioid substitute also used as a pain medication.

Nursing Process: Assessment Guidelines

  • Primary Considerations:

    • Patient’s substance use history:

    • Document number of drugs taken, patterns, and dosages.

    • Include previous treatment instances.

    • Evaluate for blackouts, delirium, seizures, and withdrawal symptoms.

    • Review for comorbid illnesses, including psychiatric conditions.

    • Assess psychosocial problems affecting functioning.

Initial Assessment Tools

  • Two Questions Screening:

    • "In the past year, have you ever drunk or used drugs more than you meant to?"

    • "Have you felt the need to cut back on drinking or drug use within the past year?"

  • CAGE-AID Screening Tool:

    • C: Have you ever felt the need to cut down?

    • A: Have people annoyed you by criticizing your use?

    • G: Have you ever felt guilty about your use?

    • E: Have you ever needed an eye opener in the morning?

Further Initial Assessment Considerations

  • Neurological Changes:

    • Assess potential brain injuries.

  • Urine Toxicology Screen:

    • Perform blood alcohol level (BAL) tests to determine substance types and amounts.

  • Psychological Changes:

    • Monitor for use of defense mechanisms such as denial, projection, and rationalization.

  • Behavioral Traits:

    • Characteristic thought patterns include all-or-none thinking and selective attention, alongside behaviors like conflict minimization, avoidance, passivity, and manipulation.

Nursing Process: Problems and Outcomes Identification

  • Common Nursing Diagnoses:

    • Imbalanced Nutrition: less than body requirements.

    • Deficient Fluid Volume.

    • Disturbed Thought Processes.

    • Acute or Chronic Confusion.

    • Hopelessness.

    • Situational Low Self-Esteem.

    • Ineffective Coping.

Outcomes Identification Targets

  • Maintain injury-free status during withdrawal.

  • Attend treatment programs effectively.

  • Establish a stable social network of friends.

  • Demonstrate coping mechanisms independent of substances.

Nursing Problems

  • Diverse nursing diagnoses encompass:

    • Safety/Risk for Injury

    • Thought Processes

    • Imbalanced Nutritional Needs

    • Ineffective Coping

    • Dysfunctional Family Coping

Nursing Process: Planning and Implementation

  • Care Planning Parameters:

    • Tailor care based on social status, income, ethnic background, gender, age, substance use history, and current condition.

  • Goals:

    • The goal is attaining abstinence from abusive substances.

  • Implementation Strategy:

    • Direct implementation towards fostering self-responsibility, coupled with referrals to specific addiction programs available in either inpatient or outpatient settings.

Nursing Communication Guidelines for Patients with Substance Abuse

  • An accepting, non-judgmental approach is essential for building a therapeutic relationship with patients.

  • Interventional strategies for resistant addicts may be utilized, including engaging significant others in presenting specific evidence regarding the patient’s substance use.

Health Teaching and Promotion for Substance Abusers

  • Focus:

    • key strategies aimed at relapse prevention:

    • Simplifying programs and encouraging documentation/journaling of progress.

    • Employing cognitive-behavioral principles to enhance coping skills.

    • Motivation to join relapse prevention groups.

    • Encourage personal insight improvements through therapeutic measures.

Treatment Modalities: Psychotherapy and Alternatives

  • Psychotherapy:

    • Assists patients in identifying alternative coping mechanisms as replacements for substance reliance.

  • Self-Help Groups:

    • Crucial for both the patient and family members, with 12-step programs being identified as particularly effective.

    • Alcoholics Anonymous (AA): For the patient.

    • Al-Anon and Alateen: For family members.

Nursing Process: Evaluation

  • Outcomes Assessment:

    • Enhanced duration of abstinence from substances.

    • Reduction of denial among patients.

    • Achievement of acceptable levels in occupational and social functioning.

    • Proficiency in employing adaptive coping strategies.

    • Commitment to attending 12-step support groups.

Substance Abuse by Health Professionals

  • It is probable that professionals will encounter impaired colleagues during their careers.

  • Nurses possess easy access to a wide range of medications, heightening the risk of abuse.

  • Mandatory reporting laws require reporting founded suspicions of nurse impairment, despite personal difficulties in doing so.

Addressing Relapse in Patients with Addictions

  • People with addictions may require multiple detox treatments, therapy sessions, or ongoing group support—often throughout their lives.

  • Relapse rates for numerous addictions tend to be quite high, necessitating acceptance of this reality in providing care for those struggling with substance addictions.

Dual Diagnosis Grid

  • Mental health workers frequently encounter clients presenting with both mental illnesses and substance use/abuse/addiction complications.

Additional Important Concepts:

  • Delirium Tremens (DTs)

  • Wernicke-Korsakoff Syndrome

  • Pupil Assessment: For narcotics vs. amphetamines

  • Tremor Assessments: Differentiating between fine motor tremors vs. gross motor tremors

  • Overdose Treatments: Charcoal and gastric lavage methods.

  • Narcotic (opiate) Antagonist: Narcan (naloxone)

  • Benzodiazepine Antagonist: Flumazenil

  • Methadone Utilization: Applications and considerations.

  • Retrograde and Anterograde Amnesia

  • Medical THC Use: Marinol applications.