SUBSTANCE ABUSE

 DEFINITION OF TERMS:
 Substance Abuse – using a drug in a way that is inconsistent with medical or social norms
& despite negative consequences; denotes problems in social, vocational, or legal areas of
a person’s life
 Substance Dependence – associated with addiction such as tolerance, withdrawal, &
unsuccessful attempts to stop using the substance
 Intoxication – use of a substance that results in maladaptive behavior
 Withdrawal Syndrome – refers to the negative psychological & physical reactions that
occur when use of a substance ceases or dramatically decreases
 Detoxification – the process of safely withdrawing from a substance

 ONSET & CLINICAL COURSE:

 Blackout – an episode during 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
behavior
 Tolerance – needs more of the substance to produce the same effect
 Tolerance Break – little amount will intoxicate the person
 Spontaneous Remission – quit the abuse on their own without a treatment program

 SYMPTOMS OF SUBSTANCE ABUSE:

 Denial of problems
 Minimizes use of substance
 Rationalization
 Blaming others for the problem
 Anxiety
 Irritability
 Impulsivity
 Feelings of guilt, sadness or anger & resentment
 Poor judgment
 Limited insight
 Low self-esteem
 Ineffective coping strategies
 Difficulty expressing genuine feelings
 Impaired role performance
 Strained interpersonal relationships
 Physical problems such as sleep disturbance & inadequate nutrition

TYPES OF SUBSTANCES & TREATMENT:

 ALCOHOL
 A CNS depressant that is absorbed rapidly into the bloodstream
 Initial Effects – relaxation & loss of inhibitions
 Intoxication Effects – slurred speech, unsteady gait, lack of coordination, impaired
attention, concentration, memory & judgment; some people become aggressive or
display inappropriate behaviors; may experience a blackout
 Excessive intake for a short period can result in vomiting, unconsciousness &
respiratory depression; may lead to aspiration pneumonia & cardiovascular shock &
death

 Phases:
 PRE-ALCOHOLIC – characterized by drinking to medicate feelings and for relief
from stress.
 EARLY - characterized by sneaking drinks, blackouts, rapidly gulping drinks, and
preoccupation with alcohol.
 CRUCIAL - marked by physical dependence.
 CHRONIC - characterized by emotional and physical deterioration
  Physiologic Effects of Long-Term Use
 Cardiac Myopathy
 B1 or Thiamine Deficiency (associated with Alcoholism)
 Wernicke’s Encephalopathy – an inflammatory, hemorrhagic,
degenerative condition of the brain characterized by lesions in several
parts of the brain including the hypothalamus resulting to double vision;
involuntary & rapid movements of the eyes, lack of muscle coordination &
decrease mental function
 Korsakov Psychosis – a form of amnesia characterized by a loss of short-
term memory & inability to learn new skills
 Pancreatitis
 Esophagitis
 Hepatitis
 Cirrhosis
 Leukopenia
 Thrombocytopenia
 Ascites

 Treatment:
 Gastric lavage or dialysis to remove the drug
 CV & respiratory support in the ICU

 Withdrawal
 Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked
reduction of alcohol intake
 Peaks on the second day & is over in about 5 days
 Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink;
SX/SY: anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile
hallucinations, changes in LOC, agitation, fever, delusions.
 Symptoms:
 Coarse hand tremors
 Sweating
 Elevated pulse & BP
 Insomnia
 Anxiety
 Nausea & vomiting
 Detoxification
 Needs to be accomplished under medical supervision
 If withdrawal symptoms are mild & client can abstain from alcohol, he can be
treated at home
 With severe withdrawal & those who cannot abstain from alcohol, a short
admission of 3 to 5 days is the most common setting.
 Safe withdrawal is accomplished with the administration of anxiolytics
(Lorazepam, Chlordiazepoxide (Librium), Diazepam) to suppress withdrawal
symptoms
 Restraining a Violent Client: Emergency department personnel should use an
organized, team approach when restraining violent clients so that no one is injured in
the process. The leader, located at the client's head, should take charge; four staff
members are required to hold and restrain the limbs. For safety reasons, restraints
should be fastened to the bed frame instead of the side rails. For quick release, loops
should be used instead of knots.

 SEDATIVES, HYPNOTICS, ANXIOLYTICS

 All CNS depressants particularly barbiturates & anxiolytics
 Symptoms of intoxication & withdrawal are similar to alcohol abuse
 Benzodiazepines when taken orally in overdose are rarely fatal but will cause lethargy
& confusion; treatment includes gastric lavage, followed by ingestion of activated
charcoal & saline cathartic (feces) ; dialysis can be used if symptoms are severe
  Barbiturates are lethal when taken in overdose; they can cause coma, respiratory arrest,
cardiac failure & death; treatment in an ICU is required using lavage & dialysis
 Detoxification
 Managed medically by tapering the amount of the drug the client receives over a
period of days or weeks

 STIMULANTS (AMPHETAMINES, COCAINE, OTHERS)

 Stimulants – drugs that stimulate or excite the CNS
 Amphetamines (“uppers”) are 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
& a popular recreational drug because of the intense & immediate feeling of euphoria it
produces
 Methamphetamine – very dangerous & highly addictive; causes psychotic behavior &
brain damage is frequent as a result of its use
 Intoxication Effects – high or euphoric feeling, hyperactivity, hypervigilance,
talkativeness, anxiety, grandiosity, anger, fighting, & impaired judgment
 Physiologic Effects – tachycardia, ↑ BP, dilated pupils, perspiration or chills, nausea,
chest pain, confusion & cardiac dysrhythmias
 Overdose can result to seizures & coma
 Withdrawal Symptoms – are not life threatening & has a primary symptoms of
marked dysphoria which includes fatigue, vivid & unpleasant dreams, insomnia or
hypersomnia, increased appetite, psychomotor agitation or retardation
 Crashing – marked withdrawal symptoms in which the person may experience
depressive symptoms which includes suicidal ideation for several days
 Treatment: Chlorpromazine (Thorazine) to control hallucination, lower BP & relieves
nausea

 CANNABIS (MARIJUANA)
 Cannabis sativa – a hemp plant cultivated for its fiber & seed; widely known for its
psychoactive resin
 Marijuana – refers to the upper leaves, flowering tops & stems of the plant
 Hashish – the dried resinous exudates from leaves of the female cannabis plant; most
often smoked as cigarette (―joints‖) but could also be eaten

 Medical Use:
 Short-term effects of lowering ↓IOP but it is not approved for treating glaucoma
 Relieves nausea & vomiting association with cancer chemotherapy & anorexia &
weight loss in AIDS
 Dronabinol (Marinol) & Nabilone (Cesamet) have been approved for treating
nausea & vomiting for cancer chemotherapy
 Intoxication effects begin to act less than 1 minute after inhalation; peak effects usually
occur 20-30 minutes & last at least 2 to 3 hours

 Intoxication Effects:
 High feeling similar to alcohol
 Lowered inhibition, relaxation, euphoria & increased appetite
 Impaired motor coordination, inappropriate laughter, impaired judgment & short-
term memory, distortions of time & perception
 Anxiety, dysphoria & social withdrawal may occur in some users

 Physiologic Effects:
 Conjuctival Injection (―bloodshot eyes‖)
 Dry mouth
 Hypotension
 Tachycardia
  May produce delirium

 Withdrawal Symptoms:
 No significant withdrawal symptom is identified although some people have
reported muscle aches, sweating, anxiety & tremors

 OPIOIDS
 Desensitize the user to both physiologic & psychological pain & induce
euphoria & well-being

 Includes:
 Potent Analgesics: Morphine, Meperidine (Demerol), Codeine,
Hydromorphone, Oxycodone, Hydrocodone, Propoxyphene
 Illegal Substances: Heroin & Normethadone

 Abuse is common in healthcare professionals – write prescriptions for themselves;

divert patient’s pain medication to themselves

 Intoxication Effects
apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation,
constricted pupils, drowsiness, slurred speech, impaired attention & memory; severe
intoxication can lead to coma, respiratory depression, pupillary constriction,
unconsciousness & death

 Treatment of Choice – Naloxone (NARCAN) to reverse all signs of opioid

toxicity; given every few hours until level drops to nontoxic; process may take days

 Withdrawal Symptoms:
 Anxiety, restlessness, aching back & legs, cravings for more opioids
 Nausea, vomiting, diarrhea
 Dysphoria, yawning, insomnia
 Lacrimation, rhinorrhea, sweating, fever

 Detoxification:
 Methadone (Dolophine) **BQ**– can be used as a replacement for opioid & the
dosage is then decreased over 2 weeks

 HALLUCINOGENS
 Substances that distort the user’s perception of reality & produce symptoms
similar to psychosis including hallucination (usually visual) & depersonalization
 Includes:
 Lysergic Acid Diethylamide (LSD); Mescaline, Psilocybin
 Designer Drugs – Ecstasy & Phencyclidine (PCP)

 Intoxication Effects
anxiety, paranoid ideation, ideas of reference, fear of losing one’s mind, potentially
dangerous behavior such as jumping out of a window in the belief that one can fly;
PCPs often involves aggression, impulsivity & unpredictable behavior

 Physiologic Effects:
sweating, tachycardia, palpitations, blurred vision, tremors, lack of coordination

 Treatment is mainly supportive:

 Psychotic reactions are managed by isolation from external stimuli
 Physical restraints may be necessary for safety of client & others
 PCP toxicity can include seizures, hypertension, hyperthermia & respiratory
depression so medications are used to control seizures (Dilantin,
 Phenobarbiturates) & ↓BP (Apresolin, Propanolol); cooling devices such as
hypothermic blankets are used & mechanical ventilation is used to support
respirations

 Withdrawal Effects
can produce flashbacks which are transient recurrences or perceptual disturbances; may
persist for a few months up to 5 years

 INHALANTS
 Diverse group of drugs including anesthetics, nitrates & organic solvents that are
inhaled for their effects
 Most common substances are alipathic & aromatic hydrocarbons found in gasoline,
glue, paint thinner & spray paint
 Inhalants can cause significant brain damage, peripheral nervous
system damage & liver disease
 Intoxication Effects:
 Dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor,
muscle weakness, blurred vision
 Stupor & coma can occur
 Behavioral symptoms such as aggression, apathy, impaired judgment & inability to
function
 Acute toxicity includes anoxia, respiratory depression, vagal stimulation &
dysrhythmias
 Death may occur from bronchospasm, cardiac arrest, suffocation or aspiration of the
compound or vomitus
 Treatment consists of supporting respiratory & cardiac functioning until the substance
is removed from the body; no antidotes to treat inhalant toxicity
 Withdrawal Effects & Detoxification:
 No withdrawal symptoms or detoxification procedures
 May suffer persistent dementia or inhalant-induced disorders such as psychosis,
anxiety or mood disorders even if inhalant abuse ceases; these are all treated
symptomatically

 MEDICATIONS USED FOR SUBSTANCE ABUSE TREATMET:

Drug Use Dosage Nursing Considerations

Disulfiram Maintain abstinence from 500mg/day for 1-2 weeks; Teach clients to read labels
(Antabuse) alcohol then 250mg/day to avoid products with
alcohol (OTC cough
syrup, mouthwash,
aftershave lotion, vinegar)
bec alcohol+antabuse =
hypotension & vomiting;
To be given 8-12 hours
after the last ingestion of
alcohol
Lorazepam (Ativan) Alcohol withdrawal 2-4mg q2hrs prn Monitor VS; may cause
dizziness or drowsiness
Chlordiazepoxide Alcohol withdrawal 50-100mg; repeat in 2-4 Monitor VS, may cause
(Librium) hrs if necessary; not to dizziness or drowsiness
exceed 300mg/day
Methadone Maintain abstinence from Up to 120mg/day for May cause nausea &
(Dolophine) heroin maintenance vomiting
Levomethadyl Maintain abstinence from 60-90mg 3x a week for Do not take drug on
(ORLAAM) opiates maintenance consecutive days; take
home doses are not
allowed
Naltrexone (ReVia, Blocks the effects of 350mg/wk; divided into 3 Client may not respond to
Trexan) opiates; reduces alcohol doses for opiate-blocking narcotics used to treat
cravings effect; 50mg/day for up to cough, diarrhea, or pain;
12 weeks for alcohol take with food or milk;
cravings may cause headache,
restlessness or irritability
Clonidine (Catapres) Suppresses opiate 0.1mg q6hrs. prn Take BP before each dose;
 withdrawal symptoms withhold if client is
hypotensive
Thiamine (Vit B1) Prevent or treat Wernicke- 100 mg/day Teach client about proper
Korsakoff syndrome in nutrition
alchoholism
Folic Acid Treat nutritional Teach client about proper
deficiencies1-2mg/day nutrition; urine may be
dark yellow
Cyanocobalamine Treat nutritional 25-250mcg/day Teach client about proper
(Vit B12) deficiencies nutrition

 NURSING INTERVENTIONS:
 Dispel myths surrounding substance abuse
 ―It’s a matter of willpower.‖
 ―I can’t be an alcoholic if I only drink beer or on weekends.‖
 ―I can learn to use drugs socially.‖
 ―I’m okay now; I could handle using once in a while.‖
 Decrease co-dependent behaviors among family members
 Co-dependence ***BQ*** – is a maladaptive coping pattern on the part of family
members or others that results from a prolonged relationship with the person who uses
substances
 Characteristics of Co-dependence: poor relationship skills, excessive anxiety & worry,
compulsive behavior, resistance to change
 Family members learn these dysfunctional behavior patters as they try to adjust to the
behavior of substance abuser
 Also called ―enabling behaviors‖ because they seem to be helpful on the surface but
actually perpetuates the substance abuse
 Examples of co-dependent behaviors: making excuses for client’s behavior, do things
for clients that clients can do for themselves
 Make appropriate referrals for family members
 Promote coping skills (problem-solving skills, relaxation, exercise, listening to music,
engaging in activities such as socializing, leisure pursuits)
 Role-play potentially difficult situations
 Focus on the here-and-now with clients
 Set realistic goals such as staying sober today
 Health teachings for the client & family
 Substance abuse is an illness
 Dispel myths about substance abuse
 Abstinence from substances is not a matter of willpower
 Any alcohol, whether beer, wine or liquor can be an abused substance
 Prescribed medication can be an abused substance
 Feedback from family about a return to previous maladaptive coping mechanisms is
vital
 Continue participation in an aftercare program is important