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Chapter 17

Substance Abuse
Substance Abuse
• The actual prevalence of substance abuse is
difficult to determine
• Detrimental effects of substance abuse
– Workplace injuries
– Motor vehicle accidents and fatalities
– Domestic abuse, homicide, and child
abuse and neglect
• 14% of adults have an alcohol-related
• 6.2% have a substance-related disorder
(excluding nicotine)
• Adolescent substance abuse is rising
• Increasing numbers of babies are being born
to substance-addicted mothers
• Half of all persons seeking alcohol-related
treatment have at least one alcoholic parent
Types of Substance Abuse
Classes of substances abused:
– Alcohol
– Amphetamines or similarly acting sympathomimetics
– Caffeine
– Cannabis
– Cocaine
– Hallucinogens
– Inhalants
– Nicotine
– Opioids
– Phencyclidine (PCP) or similarly acting drugs
– Sedatives, hypnotics, or anxiolytics
• Intoxication is use of a substance that results in
maladaptive behavior
• Withdrawal syndrome refers to the negative
psychological and physical reactions that occur when
use of a substance ceases or dramatically decreases
• Detoxification is the process of safely withdrawing
from a substance
• Substance abuse is 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
Onset and Clinical Course
• Typically begins with the first episode of intoxication
between 15 and 17 years of age
• More severe difficulties begin in the mid-20s to
– Alcohol-related breakup of a significant
– An arrest for public intoxication or
driving while intoxicated
– Evidence of alcohol withdrawal
– Early alcohol-related health problems
– Significant interference with functioning at work
or school
• Blackout drinking in which the person continues to
function but has no conscious awareness of his or her
behavior at the time nor any later memory of the
• As the person continues to drink, he or she often
develops a tolerance for alcohol; that is, he or she needs
more alcohol to produce the same effect
• After continued heavy drinking, the person experiences a
tolerance break, which means that very small amounts of
alcohol will intoxicate the person
• The later course of alcoholism, when the person’s
functioning definitely is affected, is often characterized
by periods of abstinence or temporarily controlled
• Biologic factors
– Genetic vulnerability
– Neurochemical influences
• Psychological factors
– Familial dynamics
– Coping styles
• Social and environmental factors
Cultural Considerations
• Muslims do not drink alcohol
• Wine is an integral part of Jewish religious rites
• Some Native American tribes use peyote, a hallucinogen, in
religious ceremonies
• The Japanese do not regard alcohol as a drug, and there are no
religious prohibitions against drinking
• Certain ethnic groups have genetic traits that either predispose
them to or protect them from developing alcoholism
• Variations have been found in enzymatic activities among
Asians, African Americans, and whites
• Alcohol abuse plays a part in the five leading causes of death
for Native Americans
• Drinking is a major health problem among some Aboriginal
people and in Russia
• Central nervous system depressant
• Overdose can result in vomiting,
unconsciousness, and respiratory depression
• Symptoms of withdrawal usually begin 4 to
12 hours after cessation or marked reduction
of alcohol intake
• Alcohol withdrawal usually peaks on the
second day and is over in about 5 days
• Withdrawal symptoms include:
– Coarse hand tremors, sweating, elevated pulse and
blood pressure, insomnia, anxiety, and nausea or
– Severe or untreated withdrawal may progress to
transient hallucinations, seizures, or delirium—called
delirium tremens (DTs)
• Withdrawal symptoms are monitored using an
assessment tool such as the Clinical Institute Withdrawal
Assessment of Alcohol Scale, Revised (CIWA-AR)
• Benzodiazepines used for detoxification
– Lorazepam (Ativan), chlordiazepoxide (Librium), or
diazepam (Valium) suppress the withdrawal
Sedatives, Hypnotics, and Anxiolytics
• Central nervous system depressants
• Benzodiazepines alone, when taken orally
in overdose, are rarely fatal, but the person
will be lethargic and confused
• Barbiturates, in contrast, can be lethal
when taken in overdose. They can cause
coma, respiratory arrest, cardiac failure,
and death
• Withdrawal symptoms in 6 to 8 hours or up to 1
• Withdrawal syndrome is characterized by symptoms
opposite of the acute effects of the drug:
– Autonomic hyperactivity (increased pulse, blood
pressure, respirations, and temperature), hand
tremor, insomnia, anxiety, nausea, and
psychomotor agitation; seizures and
hallucinations occur rarely in severe
benzodiazepine withdrawal
• Detoxification from sedatives, hypnotics, and
anxiolytics is managed by tapering the amount of
the drug
Stimulants (Amphetamines, Cocaine, Others)
• Central nervous system stimulants
• Overdoses can result in seizures and coma
• Withdrawal occurs within hours to several days
• Withdrawal syndrome:
– Dysphoria accompanied by fatigue, vivid and
unpleasant dreams, insomnia or hypersomnia,
increased appetite, and psychomotor retardation or
agitation; withdrawal symptoms are referred to as
“crashing”--the person may experience depressive
symptoms, including suicidal ideation, for several
• Stimulant withdrawal is not treated pharmacologically
Cannabis (Marijuana)
• Used for its psychoactive effects
• Excessive use of cannabis may produce delirium
or cannabis-induced psychotic disorder;
overdoses of cannabis do not occur
• Withdrawal symptoms:
– Insomnia, muscle aches, sweating, anxiety,
and tremors
• Effects are treated symptomatically
• Central nervous system depressants
• Overdose can lead to coma, respiratory depression,
pupillary constriction, unconsciousness, and death
• Withdrawal:
– Short-acting drugs: begins in 6 to 24 hours;
peaks in 2 to 3 days and gradually subside in 5
to 7 days
– Longer-acting drugs: begins in 2 to 4 days,
subsiding in 2 weeks
• Withdrawal symptoms:
– Anxiety, restlessness, aching back and legs,
cravings, nausea, vomiting, dysphoria,
lacrimation, rhinorrhea, sweating, diarrhea,
yawning, fever, and insomnia
• Withdrawal does not require pharmacologic
• Administration of naloxone (Narcan) is the
treatment of choice
• Methadone can be used as a replacement for heroin,
serving to reduce cravings
• Distort reality and produce symptoms similar to
psychosis, including hallucinations (usually visual) and
• Toxic reactions to hallucinogens (except PCP) are
primarily psychological; overdoses as such do not occur.
PCP toxicity can include seizures, hypertension,
hyperthermia, and respiratory depression
• Hallucinogens can produce flashbacks that may persist
for a few months up to 5 years
• Treatment is supportive:
– Isolation from external stimuli; physical restraints;
(for PCP) medications to control seizures and blood
pressure; cooling devices; mechanical ventilation
• Inhaled for their effects
• Overdose:
– Anoxia, respiratory depression, vagal stimulation, and
– Death may occur from bronchospasm, cardiac arrest,
suffocation, or aspiration of the compound or vomitus
– People who abuse inhalants may suffer from persistent
dementia or inhalant-induced disorders such as psychosis,
anxiety, or mood disorders even if the inhalant abuse
• Withdrawal symptoms: none
• Treatment:
– Supporting respiratory and cardiac functioning until the
substance is removed from the body
Substance Abuse Treatment
• Treatment is based on the concept that
alcoholism and drug addiction are medical
illnesses: chronic, progressive, characterized
by remissions and relapses
• Treatment models include:
– The Hazelden Clinic model
– 12-step program of Alcoholics Anonymous
– Individual and group counseling
Treatment Settings and Programs
• Emergency departments
• Medical units
• Extended treatment
• Outpatient treatment
• Clinics offering day and evening programs
• Halfway houses
• Residential settings
• Chemical dependency units in hospitals
Pharmacologic Treatment
Two main purposes:
• To permit safe withdrawal from alcohol,
sedative-hypnotics, and
• To prevent relapse
Pharmacologic Treatment (cont’d)
Safe withdrawal from alcohol involves:
• Benzodiazepines to suppress withdrawal
– Lorazepam, chlordiazepoxide, and diazepam

• Vitamin B1 (thiamine) to prevent or to treat

Wernicke’s syndrome and Korsakoff’s
• Cyanocobalamin (vitamin B12) and folic acid
for nutritional deficiencies
Pharmacologic Treatment (cont’d)
Relapse prevention involves:
• Disulfiram (Antabuse)
• Methadone
• Naltrexone (ReVia)
• Clonidine (Catapres)
• Odansetron (Zofran)
Dual Diagnosis
Client with both substance abuse and another
psychiatric illness
Traditional treatment programs have little
• Impaired abilities to process abstract concepts
• Avoidance of all psychoactive drugs may not be possible
• Substance abuse has no “limited recovery” concept as do
psychiatric illnesses
• Lifelong abstinence may seem impossible to the client with a
chronic mental illness
• The use of alcohol and other drugs can precipitate psychotic
Application of the Nursing Process:
Substance Abuse
The nurse may encounter clients with substance
problems in various settings unrelated to mental
– Seeking treatment of medical problems related
to alcohol use
– Withdrawal symptoms may develop while in the
hospital for surgery or an unrelated condition
Be alert to the possibility of substance use in these
situations and be prepared to recognize their
existence and to make appropriate referrals.
Application of the Nursing Process:
Substance Abuse (cont’d)
• History: chaotic family life, family history,
crisis that precipitated treatment
• General appearance and motor behavior:
depends on physical health; likely to be
fatigued, anxious
• Mood and affect: may be tearful, expressing
guilt and remorse; angry, sullen, quiet,
unwilling to talk
Application of the Nursing Process:
Substance Abuse (cont’d)
Assessment (cont’d)
• Thought processes and content: minimize
substance use, blame others for problems,
rationalize their behavior, say they can quit on
their own
• Sensorium and intellectual processes: alert and
oriented; intellectual abilities intact (unless
neurologic deficits from long-term alcohol or
• Judgment and insight: poor judgment while
intoxicated and due to cravings for substance;
insight limited
Application of the Nursing Process:
Substance Abuse (cont’d)
Assessment (cont’d)
• Self-concept: low self-esteem, feels
inadequate at coping with life
• Roles and relationships: strained
relationships and problems with role
fulfillment due to substance use
• Physiologic considerations: may have trouble
eating and sleeping; HIV risk if IV drug user
Application of the Nursing Process:
Substance Abuse (cont’d)
Data Analysis
Nursing diagnoses common to physical
health needs include:
• Imbalanced Nutrition: Less Than Body Requirements
• Risk for Infection
• Risk for Injury
• Diarrhea
• Excess Fluid Volume
• Activity Intolerance
• Self-Care Deficits
Application of the Nursing Process:
Substance Abuse (cont’d)
Data Analysis (cont’d)
Nursing diagnoses common to
psychosocial health needs include:
• Ineffective Denial
• Ineffective Role Performance
• Interrupted Family Processes: Alcoholism
• Ineffective Coping
Application of the Nursing Process:
Substance Abuse (cont’d)
The client will:
• Abstain from alcohol/drugs
• Express feelings openly and directly
• Accept responsibility for own behavior
• Practice nonchemical alternatives to deal
with stress or difficult situations
• Establish an effective after-care plan
Application of the Nursing Process:
Substance Abuse (cont’d)
• Providing health teaching for client and
• Addressing family issues:
– Codependence
– Changes in roles
• Promoting coping skills
Application of the Nursing Process:
Substance Abuse (cont’d)
Is the client abstaining from substances?
Is the client more stable in his or her
role performance?
Does the client have improved
interpersonal relationships?
Is the client experiencing increased
satisfaction with quality of life?
Elder Considerations
• Estimates are 30% to 60% of elders in
treatment began drinking abusively after age 60
• Risk factors for late-onset substance abuse in
elders include:
– Chronic illness that causes pain; long-term
use of prescription medication (sedative-
hypnotics, anxiolytics); life stress; loss;
social isolation; grief; depression; an
abundance of discretionary time and money
• Elders may experience physical problems
associated with substance abuse more quickly
Community-Based Care
• Outpatient treatment
• Freestanding substance abuse treatment
• Self-help programs such as AA and
Rational Recovery
• Agency-sponsored after-care program
• Individual or family counseling
• Clinic or physician’s office
Mental Health Promotion

• Public awareness and educational

• Early identification of older adults with
• The College Drinking Prevention
Substance Abuse in Health Professionals

• Higher rates of dependence on

controlled substances
• Ethical and legal responsibility to report
suspicious behavior to a supervisor
Substance Abuse in Health Professionals
Warning signs of abuse include:
• Poor work performance, frequent absenteeism, unusual behavior,
slurred speech, isolation from peers
• Incorrect drug counts
• Excessive controlled substances listed as wasted or contaminated
• Reports by clients of ineffective pain relief from medications,
especially if relief had been adequate previously
• Damaged or torn packaging on controlled substances
• Increased reports of “pharmacy error”
• Consistent offers to obtain controlled substances from pharmacy
• Unexplained absences from the unit
• Trips to the bathroom after contact with controlled substances
• Consistent early arrivals at or late departures from work for no
apparent reason
Self-Awareness Issues

• Examine own beliefs and/or family

behavior about alcohol and drugs
• Recognize that substance abuse is a
chronic illness with relapses and
• Be objective and reasonably optimistic