Chapter 19:

Addiction
Substance Abuse disorders
• Socially maladaptive behavior characterized by abuse of substance or the regular use
of such substance impairs the functioning of individual
• National health problem
• Actual prevalence of substance abuse difficult to determine
• Detrimental effects
• Alcohol-related death is the third leading preventable cause of death in United States.
• Absenteeism at work
• Prenatal exposure
• Increased violence
Categories of Drugs
• Alcohol
• Sedatives, hypnotics, and anxiolytics
• Stimulants
• Cannabis
• Opioids
• Hallucinogens
• Inhalants
Terminologies:
Substance abuse - Can be defined as using a drug in a way that is inconsistent with medical or social
normal and despite negative consequences.

Intoxication- use of a substance that results In maladaptive behavior

Withdrawal syndrome- refers to the negativepsychological and physical reactions that occur when use
of a substance abuse ceases or dramatically decreases
Detoxification- the process of safely withdrawing from a substance Substance abuse- defined as using a
drug in a way that is inconsistent with medical or social norms and despite negative consequences. It
denotes problems in social, vocational, or legal areas of the person's life.
Substance dependence- includes problems associated with addiction such as tolerance, withdrawal
and unsuccessful attempts to stop using the substance.
Black-out- a episode during which the person continues to function but has no consciousawarenessof his
or her behavior
Tolerance- the patient needs more of the substance (alcohol) to produce same effect.
Spontaneous remission- also known as natural recovery. Some people with alcohol problems can
modify or quit drinking on their own without a treatment program

Substance tolerance - The need for greatly increased amounts of substance to achieve the desired
effects or markedly diminished effect with the continued use of the same amount of substance

Polysubstance abuse - Abuse of two or more drugs

Potentiation - 2 or more substance interact interact in the body to produce an effect greater than the
sum of the effects of each substance taken alone

Withdrawal - Person experience a substance specific syndrome following reduction or cessation of intake
of the substance

Addiction - Characterized by psychological and behavior syndrome in which drug craving, compulsive use
and a strong tendency to relapse after withdrawal is observe
Tolerance break - Very small amount of substance intoxicate a person.

Blackout - The person has no conscious awareness of his or her behavior at the time or at any later memory

Dual diagnosis - Both substance abuse and another psychiatric illness

Codependence - Maladaptive coping pattern on the part of family members or others that results from a
prolonged relationship with the person who uses substances
Onset and Clinical Course
• Average age for first episode of intoxication is adolescence.
• Episodes of “sipping” as early as 8 years old
• Pattern of more severe difficulties emerges in mid-20s to mid-30s.
• Blackout
• Tolerance
• Tolerance break
• Periods of abstinence or temporarily controlled drinking
• Leads to escalation of alcohol use and subsequent crisis
• Cycle continues
• For many, substance use is chronic illness.
• Remissions and relapses
• Relapse rates 60% to 90%
• Highest rates for successful recovery—abstinence and high level of motivation
• Spontaneous remission
• Poor outcomes associated with earlier age at onset
Related Disorders
• Gambling disorder
• Caffeine and tobacco additions
• Substances can induce symptoms similar to other mental illness diagnoses.
Etiology
• Biologic factors
Genetic vulnerability- children of alcoholic parents are at higher risk for developing
alcoholism and drug dependence than are children of non-alcoholic parents.
Neurochemical influences- Distribution of the substance throughout the brain alter the
balance of neurotransmitter that modulate pleasure, pain, and reward responses
• Psychological factors
• Family dynamics and Coping styles
- inconsistency in the parent’s behavior, poor role modelling, and lack of nurturing
pave the way for the child to adopt a similar style of maladaptive coping, stormy
relationship, and substance abuse.
• Social and environmental factors
- Cultural factors, social attitudes, peer behaviors, laws, cost, and availability all
influence initial and continued use of substance.
Cultural Considerations
• Attitudes vary in different cultures.
• Muslims do not drink alcohol.
• Wine is an integral part of Jewish religious rites.
• Some Native American tribes use peyote (hallucinogen) in religious ceremonies.
• Genetic traits of certain ethnic groups as predisposing to or protective against
alcoholism
• Variations in enzymatic activities among Asians, African Americans, whites
• Alcohol abuse: a part in the five leading causes of death for Native Americans and Alaska
Natives
• One-eighth of Native Americans identified as needing treatment for alcohol or drugs
• Japan: alcohol not regarded as a drug
• Russia: high rates of alcohol abuse, suicide, and cigarette smoking in male population
Alcohol/ ALCOHOLISM
• Commonly abused substance
• 6 months - 3x a week Excessive (presence in the blood)
• Excessive (presence in the blood) o 10 mL: 1L
• Alcohol Metabolism – 10 mL in 90 mins
• Social Drinker: 6 months + Excessive
• Etiology:
Biologic – genetics
Psychodynamic Lack of adaptive coping
 Denial
 Projection
 Rationalization
 Fixated in oral stage
 Inconsistency, poor role modeling, lack of nurturing, lack of adaptive coping
 Id – strong - Ego – weak (alcohol as coping)
 Alcohol is classified as a central nervous system depressant.
 Metabolism of alcohol lasts for 1.5 hours and gives off acetaldehyde – acetaldehyde dehydrogenase – gives off acetic
acid
• Personality Profile – weak ego, dependent, manipulative
• Behavioral - Learned behavior
• Social - Peer pressure Group therapy – mgt is better in groups
• Give up a drinking friend
• Relapse – go back to alcohol-drinking friends
Family can contribute to drinking behaviors
Enabling behavior – kunsintidor
Codependency – behaviors of relatives of alcoholics; adjust to the alcoholic
Breath analyzer level
Alcohol
• Intoxication and overdose
Clinical manifestations
• CNS depressant: relaxation/loss of inhibitions
• Slurred speech, unsteady gait, lack of coordination, and impaired attention, memory,
judgment
• Aggressive behavior or display of inappropriate sexual behavior; blackout
• Overdose: vomiting, unconsciousness, respiratory depression
• Treatment: gastric lavage or dialysis to remove the drug and support of respiratory and
cardiovascular functioning in an intensive care unit

 The administration of central nervous system stimulants is contraindicated

Alcohol
• Withdrawal (see Box 19.2)
• Onset within 4 to 12 hours after cessation or marked reduction of alcohol intake; usually
peaks on the second day and complete in about 5 days
• Symptoms: coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia,
anxiety
• Severe or untreated withdrawal may progress to transient hallucinations, seizures, or
delirium tremens (DTs).
• Withdrawal can be life-threatening.
• Withdrawal may take 1 to 2 weeks.
Treatment:
• Administration of benzodiazepines such as:
 Lorazepam (Ativan),
 Chlordiazepoxide (Librium)
 Diazepam (Valium).

Detoxification: Disulfiram- Antabuse

Complications of Alcohol Use
GI – stomach absorbs alcohol – does not need to reach intestines
Malnutrition – early satiety
inflammation – esophagitis
CNS – due to deficiency in Vitamin B
Neuritis – tingling sensation
Wernicke’s - Korsakoff’s syndrome (psychosis)
Reproductive System
 Impotence - Testosterone
Cardio Vascular
 Cardiomyopathy, CHF
Fetal Alcohol Syndrome
Others:
• Pancreatitis • Hepatitis • Cirrhosis • Leukopenia • Thrombocytopenia •
Ascites
• Nursing Diagnosis r/t Chemical Dependence
Ineffective denial
Ineffective individual coping
 Altered family process
Anxiety – before and during withdrawal
Altered sensory perception (Hallucination – withdrawal)
 Altered thought processes
 Impaired verbal communication – slurring
 Sleep pattern disturbance
Altered nutrition (Vitamin B supplement)
 Self-esteem disturbance
Alteration in social interaction
 Risk for violence
Management of Alcoholism
• Short-term – Detoxification
Process of safely withdrawing from the substance
Best done in a controlled environment - Institution
Search things and confiscate anything that has alcohol
Disulfiram Therapy

• Long-term
Rehabilitation
Foundation is abstinence
Detoxification
• Assessment
• Withdrawal Symptoms Earliest: Tremors
• Stage 1 – 6 to 8 hours after last drink
Tremors, headache, n/v, anxiety, sweating

• Stage 2 – 8 to 12 hours
Stage 1 + anorexia and insomnia
 May start hallucinations
 Intensifying anxiety = perception
 NOT managed with antipsychotics
Given anxiolytics Side effect: seizure threshold – more prone to seizure
• Stage 3 – 2 to 3 days later
Stage 2 + seizure
 Cannot be managed at home
 Risk for aspiration

• Stage 4 – 2 to 5 days after delirium tremens

CNS Depressants
 Intoxication – depressant
 Withdrawal – stimulant
CNS Stimulant
 Intoxication – stimulant
 Withdrawal - Depressant
• Delirium tremens – excitability, agitated, disoriented and confused, increase VS, seizures, red eyes
 Most extreme withdrawal symptom
Goal and Priority Management of Withdrawal Patients
 Ensure physiologic integrity and safety of patient
 Quiet, non-stimulating environment
 VS q hour or 2 hours
 Safety – put up side rails Restraints (last resort)
 Offer emotional support
 Reorient patient
 Well-lighted room
Illusion – misinterpretation of external stimuli
Hallucination – false perception
 Present reality
 Offer to stay
Antianxiety meds
• Seizure
Anticonvulsants
Dilantin
MgSO4 – enhance absorption of Vit D
• Bloodshot eyes – no management
• Long term - Rehabilitation – foundation is abstinence Remain sober
Goals: To give up alcohol
• Disulfiram or Antabuse Therapy
• If drank alcohol Disulfiram reaction: HA, n/v, hypoBP, DOB, retching
 Meds are for safe withdrawal and to prevent relapse

Live a positive lifestyle; use other coping strategies o

 Things you do everyday in life o Group therapy – Alcoholics anonymous group
 Group - collection of people working together working towards a common goal
 8-10 persons o Brings interpersonal learning; more input and feedback
 Instilling of hope and universality
 Altruism – feeling of helping others o Cohesiveness and unity is important; must give up denial

Therapeutic Goal: Abstinence from the substance

• Nursing Interventions:
 Providing for physical and nutritional needs
 Confrontation
Tough love – accept person
 Group work – alcoholics anonymous; leader is a reformed alcoholic
Education
Sedatives, Hypnotics, and Anxiolytics
• Intoxication and overdose
• CNS depressants
• Intensity depends on drug.
• Intoxication symptoms: slurred speech, lack of coordination, unsteady gait, labile mood, stupor
• Barbiturate overdose possibly lethal; coma, respiratory arrest, cardiac failure, death
• Onset of withdrawal dependent on half-life of drug
• Symptoms opposite of drug’s acute effect
• Clinical manifestations:
 Autonomic hyperactivity (Increased pulse, blood pressure, respirations and
temperature)
 Hand tremors
 Insomnia
 Anxiety
 Nausea
 Psychomotor agitation
 Seizures
 Hallucinations
• Detoxification via drug tapering
This class of drugs includes all central nervous system depressants:
 Barbiturates
 Nonbarbiturate
 Hypnotics
 Anxiolytics
• Benzodiazepines - rarely fatal,lethargic and confused
• Barbiturates- Can be lethal , Coma , Respiratory arrest , Cardiac failure , Death
• Treatment:
Benzodiazepines: Gastric lavage
 Ingestion of activated
 charcoal
 Saline cathartic
 Dialysis.
Barbiturates:
 Intensive care unit
 Lavage or dialysis
 Support respiratory and cardiovascular function
 Stimulants (Amphetamines, Cocaine)
• Stimulants are drugs that stimulate or excite the central nervous system.
Amphetamines ("uppers") were popular in the past;
they were used by people who wanted to lose weight or to stay awake
Cocaine- an illegal drug with virtually no clinical use in medicine, is highly addictive and a
popular recreational drug because of the intense and immediate feeling of euphoria it
produces.
Methamphetamine HCL (shabu)- is particularly dangerous. It is highly addictive and
causes psychotic behavior. Brain damage related to its use is frequent, primarily as a
result of the substances used to make it.
• Intoxication and overdose
• High or euphoric feeling, hyperactivity, hypervigilance, anger; elevated blood
pressure, chest pain, confusion
• Seizures, coma with overdose

 Treatment with Chlorpromazine (Thorazine), an antipsychotic,controlshallucinations, lowers

blood pressure, and relieves nausea

• Withdrawal
• Onset within hours to several days
• Primary symptom is marked dysphoria.
• “Crashing”
• Not treated pharmacologically
Cannabis (Marijuana)
• Cannabis sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and
for oil from its seeds.
• Marijuana refers to the upper leaves, flowering tops,and stems of the plant; hashish is the dried
resinous exudate from the leaves of the female plant.
• Cannabis is most often smoked in cigarettes (“joints”), but it can be eaten.
• Used for psychoactive effects
• Medical applications
• RED EYES or conjunctival irritation, loss of motivation, change in decision making/judgement, may lead
to sterility due to testosterone.
• Lowered inhibitions, relaxation, euphoria, increased appetite
• Symptoms of intoxication include impaired motor control, impaired judgment
• Delirium, cannabis-induced psychotic disorder
• No overdose
• No clinically significant withdrawal syndrome
• Possible symptoms of insomnia, muscle aches, sweating, anxiety, tremors
Opioids /Narcotics
• Papaver somniferum – derivatives of opiates
• Opium, heroine, codeine (cough syrup), morphine (Demerol)
• Can only bought w/ prescription
• Popular drugs of abuse because they desensitize the user to both physiologic and psychological pain and
induce a sense of euphoria and well being
• Desensitization to pain, euphoria, well-being
Opioids: • Morphine • Meperidine (Demerol) • Codeine • Hydromorphone Oxycodone • Methadone •
Oxymorphone • Hydrocodone • Propoxyphene • Heroin • Normethadone
• Intoxication: apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation,
constricted pupils, drowsiness, slurred speech, and impaired attention and memory
• Overdose: coma, respiratory depression, pupil constriction, unconsciousness, death
• Naloxone
• Treatment
 Administration of Naloxone (Narcan) - An opioid antagonist ,Is the treatment of choice because it
reverses all signs of opioid intoxication. Naloxone is given every few hours until the opioid level
drops to nontoxic
Opioids
• Withdrawal
• Nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever,
and insomnia
• Symptoms cause significant distress, but do not require pharmacologic intervention to
support life or bodily functions
• Short-acting drugs (e.g., heroin): onset in 6 to 24 hours; peaking in 2 to 3 days and gradually
subsiding in 5 to 7 days
• Longer acting drugs (e.g., methadone): onset in 2 to 4 days, subsiding in 2 weeks

Treatment:
Do not require pharmacologic intervention to support life or bodily functions.
 Methadone can be used as a replacement for the opioid
Heroin - most common
• Tell-tale Sign: Pinpoint pupil non reactive to light
• Severe CNS depression – Narcan (Naloxone)
• Can be passed through the placenta – shrill cry of neonates
• Taken via IV push or main line – w/ needle marks
• Risk for blood-borne infections
• Effects of Heroin:
 Euphoria w/ sleepiness
 Relieve physical and emotional pain
Morphine
 Potent respiratory depressant
 RR < 12 – overdose
 Antidote: Narcan – narcotic agonist
 Pupils constriction
 decreased VS

Withdrawal from Heroine

Early – can be likened to beginning respiratory infection
 o Runny nose
 o Teary eyes
 o Sneezing
 o Abdominal cramps
 o Muscle cramps
Treatment
Methadone
 A potent synthetic opiate is used as a substitute for heroin in some maintenance programs
 Meets the physical need for opiates but does not produce cravings for more
Levomethadyl
 Is a narcotic analgesic whose only purpose is the treatment of opiate dependence
Naltrexone (ReVia)
 It is an opioid antagonist often used to treat overdose.
 It blocks the effects of any opioids that might be ingested Ø Negating the effects of using more opioids used in
the same manner as methadone.
Clonidine (Catapres)
 Is analpha-2-adrenergic agonist used to treat hypertension.
 It is given to clients with opiate dependence to suppress some effects of withdrawal or abstinence Ø It is most
effective against nausea, vomiting, and diarrhea but produces modest relief from muscle aches, anxiety, and
restlessness
Ondansetron (Zofran)
 A 5-HT3 antagonist that blocks the vagal stimulation effects of serotonin inthe small intestine
 It is used as an antiemetic.
Hallucinogens
• Mind altering drugs/ psychomimetics
• Distortion in time and space Colorful surroundings: psychedelic
• Synethesia – “blending of senses”, see odor, frightening hallucination (bad trip) Effect of substance can
last
• Reality distortion; symptoms similar to psychosis including hallucinations (usually visual),
depersonalization
• Cause increased pulse, blood pressure, and temperature; dilated pupils; and hyperreflexia
• Intoxication: maladaptive behavioral/psychological changes, anxiety, depression, paranoid ideation
• No overdose; toxic reactions are primarily psychological
• PCP toxicity: seizures, hypertension, hyperthermia, respiratory depression
• Medications to control seizures and blood pressure
• Cooling devices
• Mechanical ventilation

Lysergic acid diethylamide (LSD)- Bloodshot eyes , bad trip – conjunctival irritation
Hallucinogens
PCP – Phencyclidine/ Ketamine
 Veterinary anesthesia
 Heightened sexuality and closeness
Distortion in memory, dissociation, near death experience o K-hole experience – do not remember
anything that happened

• No withdrawal syndrome
• Some report a craving for the drug
• Flashbacks possible for few months up to 5 years

• Treatment:
 These drugs are not a direct cause of death although fatalities have occurred from related accidents, aggression
and suicide ü Treatment is supportive.
 Psychotic reactions are managed best by isolation from external stimuli
 Physical restraints
 Cooling devices such as a hyperthermia blanket are used and mechanical ventilation is used to support respirations
Inhalants
• Diverse group of drugs including anesthetics, nitrates, and organic solvents that are inhaled for their
effects.
• Inhalants can cause significant brain damage, peripheral nervous system damage, and liver disease.
• Gasoline, glue, solvents, thinner, nail polish remover, spray paint, rugby (used by street boys)
• Headache, LOC, dizziness, lack of coordination, mirthfulness, mouth ulcers, slurred speech, unsteady
gait, tremors, muscle weakness, blurred vision, GI upset, nausea and vomiting
• Rugby – decreased hunger
• DEATH – severe CNS depression

• Intoxication: neurologic, behavioral symptoms

• Acute toxicity
• Anoxia, respiratory depression, vagal stimulation, dysrhythmias
• Death possible from bronchospasm, cardiac arrest, suffocation, or aspiration
• No withdrawal or detoxification
• Frequent users report cravings
• Symptomatic treatment of related disorders
• Treatment
• Supporting respiratory and cardiac functioning until the substance is removed
from the body
• There are no antidotes or specific medications to treat inhalants toxicity.

• Withdrawal and detoxification

• There are no withdrawal symptoms or detoxification procedures foe inhalants
• Persistent dementia
• Inhalant-including disorders- psychosis, anxiety, or mood disorder
Club drugs
1. Ecstasy 3,4 methylenedioxymethamphetamine (MDMA)
2. GHB (gamma-hydroxybutyric acid) -euphoric,sedative anabolic and sleep inducing drug
3. Rohypnol (date rape)

Ecstasy
• Rush then crash if next dose is not taken
• Takes next dose even if the first one does not lose its effect yet If they fail, they feel painful depression -
Crash
• Fatigability, painful depression w/c may cause them to commit suicide
• Methylenedioxymethamphetamine (MDMA)
• Snorting, sniffing red nose w/ lesion
• Heightened sexuality and increases feeling of closeness and empathy, “club drug” Symptomatic
management
• May be diagnosed w/ urine test – w/in 1 to 2 days to trace substances Urine should not be diluted
Substance Abuse Treatment
• Concept: medical illness that is progressive and chronic, characterized by remissions and
relapses
• Treatment models:
• Hazelden Clinic model
• 12-step program of Alcoholics Anonymous (AA; see Box 19.3)
• Individual, group counseling
• Treatment settings
• Pharmacologic treatment: safe withdrawal; prevent relapse (see Table 19.1)
• Medications help manage withdrawal or cravings, but is not a specific treatment for
substance abuse.
NURSING INTERVENTIONS FOR CLIENTS WITH SUBSTANCE ABUSE
Health teaching for the client and family
Dispel myths surrounding substance abuse
Decrease codependent behaviors among family members
Make appropriate referrals for family members
Promote coping skills
Role-play potentially difficult situations
Focus on the here-and-now with clients
Set realistic goals such as staying sober today
Dual Diagnosis
• Substance abuse + another psychiatric illness
• Estimated 50% of people with a substance abuse disorder also have mental health
diagnoses
• Successful treatment, relapse prevention strategies (see Nursing Care Plan)
• Healthy, nurturing, supportive living environments
• Help with fundamental life changes, such as finding job, abstinent friends
• Connections with other recovering people
• Treatment of comorbid conditions
Substance Abuse and Nursing Process Application
• Assessment
• History: chaotic family life, family history, crisis that precipitated treatment
• General appearance and motor behavior
• Mood and affect: tearful; expressing guilt, remorse; angry; sullen; quiet;
unwilling to talk
• Thought process and content: minimize substance use; blaming others;
rationalization
• Sensorium and intellectual processes: intact
• Judgment and insight: poor judgment; impulsivity; may still believe he or she can
control substance use
• Self-concept: low self-esteem; problems identifying and expressing feelings
• Roles and relationships: often strained
• Physiological considerations: poor nutrition; sleep disturbances; liver damage;
HIV infection; lung damage
Substance Abuse and Nursing Process
Application
• Assessment—(cont.)
• Sensorium and intellectual processes: intact
• Judgment and insight: poor judgment; impulsivity; may still believe he or she
can control substance use
• Self-concept: low self-esteem; problems identifying and expressing feelings
• Roles and relationships: often strained
• Physiological considerations: poor nutrition; sleep disturbances; liver damage;
HIV infection; lung damage

• Data analysis/nursing diagnoses

• Related to physical health status
• Related to substance use
Substance Abuse and Nursing Process Application
Outcome identification
• Abstain from alcohol and drug use
• Express feelings openly and directly
• Accept responsibility for own behavior
• Practice nonchemical coping alternatives
• Establish an effective aftercare plan

• Interventions
• Health teaching for client, family (see Client and Family Education box)
• Addressing family issues (codependence, shifting roles)
• Promoting coping skills
• Evaluation
Elder Considerations
• Approximately 30% to 60% of elders in treatment began drinking abusively after age 60.
• Risk factors for late-onset substance include chronic illness that causes pain, long-term use
of prescription medication (sedative–hypnotics, anxiolytics), life stress, loss, social isolation,
grief, depression, and an abundance of discretionary time and money.
• Physical problems associated with substance abuse develop rather quickly.
Community-Based Care
• Outpatient treatment
• Freestanding substance abuse treatment facilities
• Recovery programs (AA, Rational Recovery)
• Agency-sponsored aftercare program
• Individual or family counseling
• Clinic or physician’s office
Mental Health Promotion
• Public awareness, educational advertising
• Early identification of older adults with alcoholism
• The College Drinking Prevention Program
Substance Abuse in Health Professionals
• Ethical and legal responsibility to report suspicious behavior to supervisor
• General warning signs
• Poor work performance/frequent absenteeism
• Unusual behavior/slurred speech
• Isolation from peers
• Specific behaviors
Self-Awareness Issues
• Examine own beliefs about alcohol and drugs.
• History of substance use
• Recognize that substance abuse is chronic illness with relapses and
remissions.
• Remain open and objective.