SUBSTANCE RELATED AND

ADDICTIVE DISORDERS
MS.MTAITA
OBJECTIVES
At the end of the session, one should be able to:
• Define addiction, intocxicationn and withdrawal
• Predisposing factors implicated in the etiology of the disorder
• Symptomatology of the clients with the disorder
• Principles of a 12 step treatment approach towardsn substance
abuse
Objectives cont…
• Nursing diagones to clients with substance related and addictive
disorders and appropriate interventions
• Teaching to clients and families of clients that is relevant to
substance related and addictive disorders
• DSM V criteria for diagnosing such clients
• Nurses’s role in dealing with chemically impaired professionals
Objectives cont…
• Define codependency and identify the behavioral characteristics
associated with such clients
• Treatment of co-dependency
• Modalities relevant to the treatment of such individuals
DEFINITION OF TERMS

• What is a drug?
qAny substance other than food that affects our bodies or
minds
qCurrent language uses the term “substance” rather than
“drug” to overtly include alcohol, tobacco, and caffeine
Defn of terms cont…
• ADDICTION- refers to a behavior pattern characterized by
overwhelming(compulsive) involvement with securing and using
a drug and a high tendency of relapse after discontinuation.
• Often refered to as disease of perception in that denial plays a
major role, in that a client refuse to admit that tgey are
powerless to their problem.
• They continue the habit despite the negative consequences,
and justifying the behavior while projecting the cause of
external sources.
Substance addiction forms
• Physical addiction- need for increasing amounts to produce the
desired effects and syndrome of widrawal upon cessation
• Psychological dependence- overwhelming desire to repeat the
use of a particular drug to produce pleasure or avoid discomfort
Substance-Use disorder
Substance addiction
• Use of the substance interferes with ability to fullfil role
obligations
• Attempts to cut down or control use fail
• Intense craving for the substance
• Excessive amount of time is spent trying to procure the
substance or recover from its use
Substance Use disorder
Substance Addiction cont…
• Difficult interpersonal relationships
• Social isolation
• Engages in harzadous activities when impaired by the substance
• Tolerance develops
• Substance- specific symptoms occur upon discontinuation of use
SUBSTANCE RELATED DISORDERS
• Substance-related disorders involve substances that directly
activate the brain's reward system. The activation of the reward
system typically causes feelings of pleasure; the specific
characteristics of the pleasurable feelings evoked vary widely
depending on the drug.
• These drugs are divided into 10 different classes that have
different, although not completely distinct, pharmacologic
mechanisms. The classes of drugs include:
Classes of psychoactive substances

• CNS depressants-relieve anxiety,intoxicate,sedate, decrease

inhibitions e.g alcohol, barbituates, benxodiazepines
• Opioids- reduce pain, sedate, cause euphoria e.g heroin,
morphine, codeine, hydromorphone, fentanyl
• CNS stimulants- cause excitement, euphoria, depress
appetite, decrease need for sleep e.g cocaine,
amphetamines, phenmetrazine, caffeine, nicotine
• Cannabinoids- produce sense of detarchment, euphoria,
altered time perception e.g marijuana, hashish, cannabis
Psychoactive substances cont…
• Hallucinogens- produce hallucinations(usually visual but also
auditory/olfactory) e.g LSD, psilocybin, mescaline, MDMA
• Inhalants- produce euphoria, sedate e.g gasoline, amyl nitrite,
nitrous oxide
• Phenycyclidines – produce intoxication, muscular rigidity,
reduced pain e.g ketamine, PCP
Classes of psychoactive substances (DSMV)
• Alcohol
• Caffeine
• Cannabis
• Hallucinogens
• Inhalants
• Opiods
• Sedatives,hypnotics, Anxiolytic
• Stimulants
• Tobacco and other (unknown) substances
Substance related disorders

• Use and cessation of substances may cause psychologic,

behavioral, and physiologic changes, i.e, intoxication and
withdrawal. Substance misuse can also result in psychiatric
disorders (eg, depression, psychosis, anxiety, neurocognitive
disorders).
There are two catergories of substance related disorders that
is
i. Substance use disorders and
ii. Substance induced disorders.
Substance- Use disorders
• These involve a pathologic pattern of behaviors in which
patients continue to use a substance despite experiencing
significant problems related to its use. There may also be
physiologic manifestations, including changes in brain circuitry.
• The common terms "addiction," "abuse," and "dependence" are
too loosely and variably defined to be very useful in systematic
diagnosis; "substance use disorder" is more comprehensive and
has fewer negative connotations.
Substance use disorders
Drugs in the 10 classes vary in how likely they are to cause a
substance use disorder. The likelihood is termed addiction
liability and depends upon a combination of factors including
• Route of administration
• Rate at which the drug crosses the blood-brain barrier and
stimulates the reward pathway
• Time to onset of effect
• Ability to induce tolerance and/or withdrawal symptoms
Progression to dependence/ addiction

• a person who does not try a drug never gets addicted.

• Fews people,who use them do not like being under their
influence and stop using them after few times.
• Others find that they love the feelings they get from the
drug, and continue to use them for years without becoming
addicted. Unfortunately, others develop the disease of
chemical dependance.
• The course from drug use to drug dependance is a smooth
progression over a period of time, usually from months to
years.
Progression cont…

• This process can be catergorized into three discrete stages,

Use-Abuse-Dependance.

USE ABUSE DEPENDANCE

WALL

USE- mostly starts during the adolescent stage, mostly begin

with nicotine generally from cigarettes, alcohol and marijuana
use or both then follows.
Progression cont…

• Users learn that the drugs provides a certain feeling they

desire. Feeling drug. In this stage drug is taken with
friends and the user can take or leave it.
• ABUSE- frequency of drug use escalates. User maintains a
supply of the drug and may use it when alone, drug used
only at night or weekends.
• Users never show up intoxicated in official places and can
control the time, amount and outcome of the drug use.
Develop a degree of tolerance and increase quantity of drug
taken.
Progression cont…
• May develop some guilt and occasionally some
blackouts,medical problems( alcoholic gastritis or hangover)
• DEPENDANCE- drug is used almost everyday if not daily. High
level of tolerance developed in a way very large quantity of
drugs needed for user to obtain desired feeling.
• Blackouts more frequent, user prefer taking drugs alone than
with friends, the drug becomes the center of the users life that
is getting, keeping and using.
Progression cont…
• Almost all activities involve drugs and drug using friends, when
confronted by family/friends they tend to deny the problem.
Family relationships, jobs, school and health are destroyed.
• Withdrawal is normal at this stage, user needs to take the drug
to feel normal (severe craving). Loose control of their drug use,
have an overwhelming compulsion to take the drug.
Progression cont…
• Users abnormal behavior is masked by denial system, and have
significant impairment psychologically, physiologically or even
social dysfunction.
• Drug use continues despite the adverse consequences faced by
the user.
Progression cont…
• This progression from use to dependance is referred to as
crossing the wall because in the use and abuse one can cut
back or stop but when one develops depoendance it is no
longer the matter of choice
• Trying to quit at the stage of dependance is almost like beating
one’s head to a wall and very difficult to achieve without help.
Denial of the problem
• Not recognizing or admitting the existence of the problem (
dependence) even in the face of adverse consenquences and
fact that the problem is evident to others.
• Users get addicted to feelings that the drugs bring about rather
than the drug itself, dependence then is a repeated effort to
obtain the specific feeling.
• Feelings originate in the limbic system which also controls
emotions and motivations.
Denial cont…
• The limbic system consists of the hypothalamus, amygdala, and
the septum.
• The hypothalamus is the one containing the body’s pleasure
center, where many drugs exert their psychoactive effects.
• Most addicts know they are hurting themselves and others but
once they develop dependence, driven by impulses from the
limbic system, they continue to use the drug.
The dependence cascade

drug craving
• Drug use Limbic Cerebral Addictive behaviors
system cortex

Guilt
denial
Denial to users
• The addicts use atleast 8 tools in achieving denial
1. Rationalization
2. Projection
3. Minimization
4. Repression
5. Supression
6. Isolation
7. Regression
8. Conversion
Substance- induced disorders
Substance Intoxication
• Development of a reversible syndrome of symptoms following
excessive use of a substance
• Direct effect on CNS
• Disruption in physical and psychological functioning
• Judgement is disrupted and social and occupational functioning
is impaired.
Substance- Induced disorders
Substance- withdrawal
• Symptoms that occur upon abrupt reduction or discontinuation
of a substance that has been used regularly over a prolonged
period of time
• The symptoms-substance specific
• Physical and psychological disruption, with disturbances in
thinking, feeling and behavior
Predisposing factors
Biological factors
• Genetics: apparent hereditary factor, particularly with
alcoholism
• Biochemical: alcohol amy produce morphine-like substances in
the brain that are responsible for alcohol addiction
Predisposing factors cont…
Psychological factors
• Developmental influences
üPunitive superego
üFixation in the oral stage of psychosexual development
Predisposing factors cont…
Personality factors- certain personality traits are thought to
increase a tendency toward addictive behavior. They include:
• Low self-esteem
• Frequent depression
• Passivity
• Inability to relax or defer gratification
• Inability to communicative effectively
Predisposing factors cont…

Sociocultural factors
Social learning:
• Parental modeling
• Peer group
Operant conditioning: pleasurable effects act as positive
reinforcement for continued use of substance
Cultural and ethnic influences: some cultures are more prone
to substance abuse than others.
DEPRESSANTS

• Depressants slow activity of the central nervous system

(CNS)
ØReduce tension and inhibitions
ØMay interfere with judgment, motor activity and
concentration.
oThree most widely used depressant
ØAlcohol
ØSedative-hypnotic drugs
Øopioids
Alcohol Use Disorder
— Patterns of Use
◦ Phase I. Prealcoholic phase: Characterized by use of
alcohol to relieve everyday stress and tensions of life.
◦ Phase II. Early alcoholic phase: Begins with blackouts—
brief periods of amnesia that occur during or immediately
following a period of drinking; alcohol is now required by the
person.
Alcohol use disorder
• The individual begins sneaky drinking behaviors , preoccupied
with drinkinb and maintaining the supply of it. Individual has
enormous guilt on ti but very defensive of it- excessive use of
rationalization and denial.
• Phase III. The crucial phase: Loss of control and physiological
addcition evident-drinkimg is the total focus (willing to risk
loosing everything just to maintain the addiction) anger anf
agression common with sickness,LOC, squalor and degradation.
Alcohol use disorder
• Phase IV. The chronic phase: characterized by emotional and
physical disintegration. Individual more intoxicated more often
than sober, unamanaged withdrawal ewsults in terrifying
syndrome of symptoms including hallucinations, tremors,
convulsions, severe agitation and panic, depression and suicidal
ideation are not uncommon.
• Life threatening physical manifestations may be evident in
virtually every system of the body.
SYMPTOMATOLOGY AND DX CRITERIAs

ALCOHOL
Alcohol use disorder
1. A problematic pattern of alcohol use leading to clinically
significant impairment as manifested by at least two of the
following, occurring within a 12-month period:
a) Alcohol taken in larger amounts/ over longer periods than
intended
b) Persistent desire/ unsuccessful efforts to cut down/control
use
Dx criteria
c) Great deal of time in activities of obtaining,use n
recovering from effects of its use
d) Craving/strong urge to use alcohol
e) Recurrent use of alcohol resulting in failure in fulfill major
role obligations
f) Continued alcohol use despite the persistent/recurrent
problems caused by/ exacerbated with use
g) Important activities are given up/ reduced due to use
h) Recurrent use of alcohol in areas that is physically
harzadous
Dx criteria
g) Continued alcohol use despite knowledge of persistent
physical or psychological problems caused/exacerbated by use
h) Tolerance that is either increased amounts to achieve desired
effect/ marked diminished effect with continued use of same
amount
i) Withdrawal that is with characteristic alcohol withdrawal
symptoms/ alcohol taken to avoid or relieve the withdrawal
symptoms.
Dx criteria

Alcohol intoxication
1. Recent ingestion of alcohol
2. Clinically significant problematic behavioral and
psychological changes developed during/shortly after
ingestion
3. One/more symptoms that developed during or shortly after
alcohol ingestion- slurred speech, unsteady gait,
nystagmus, incoordination, stupor/coma, impairment in
attention/memory
Dx criteria

• Alcohol withdrawal
1. Cessation/reduction in alcohol use that has been heavy and
prolonged
2. 2 or more of symptoms that develop few hours to days
after ceasation or reduction in alcohol use- autonomic
hyperactivity, increased hand tremors, insomnia, nausea
and vomiting, transient hallucinations/ illusions,
psychomotor agitation, anxiety, generalized tonic-clinoc
seizures
3. These cause significant impairment in important functional
areas of life.