1. Substance-Related and Addictive Disorders
Chapter 14
Substance-Related and Addictive Disorders

2. Substance use disorders Substance induced disorders
Substance abuse, substance dependence (addiction)
Substance induced disorders
Intoxication, withdrawal
Dementia, amnesia, psychosis, mood and anxiety disorders

3. Substance Use Disorder
Substance dependence (Addiction)
Physical dependence
Need for increasing amounts to produce the desired effects (tolerance)
Syndrome of withdrawal upon cessation
Psychological dependence
Overwhelming desire to repeat the use of a particular drug to produce pleasure or avoid discomfort

4. Substance Use Disorder (cont’d)
Substance Addiction (cont’d)
Use of the substance interferes with ability to fulfill role obligations
Attempts to cut down or control use fail
Intense craving for the substance
Excessive amount of time spent trying to obtain the substance or recover from its use

5. Substance Use Disorder (cont’d)
Substance Addiction (cont’d)
Use of the substance causes the person difficulty with interpersonal relationships or to become socially isolated
Engages in hazardous activities when impaired by the substance
Tolerance develops and the amount required to achieve the desired effect increases
Substance-specific symptoms occur upon discontinuation of use

6. Substance-Induced Disorders
Substance Intoxication
Development of a reversible syndrome of symptoms following excessive use of a substance
Direct effect on the central nervous system
Disruption in physical and psychological functioning
Judgment is disturbed and social and occupational functioning is impaired

7. Substance-Induced Disorders (cont’d)
Substance Withdrawal
Development of symptoms that occurs upon abrupt reduction or discontinuation of a substance that has been used regularly over a prolonged period of time
Symptoms are specific to the substance that has been used
Disruption in physical and psychological functioning, with disturbances in thinking, feeling, and behavior

8. Classes of Psychoactive Substances
Alcohol
Caffeine
Cannabis
Hallucinogens
Inhalants
Opioids
Sedatives/hypnotics
Stimulants
Tobacco

9. Predisposing Factors Biological factors
Genetics: apparent hereditary factor, particularly with alcoholism
Biochemical: alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction

10. Predisposing Factors (cont’d)
Psychological factors
Developmental influences
Punitive superego
Fixation in the oral stage of
psychosexual development
S. Freud

11. Predisposing Factors (cont’d)
Psychological factors (cont’d)
Personality factors: certain personality traits are thought to increase a tendency toward addictive behavior, including
Low self-esteem
Frequent depression
Passivity
Inability to relax or defer gratification
Inability to communicate effectively

12. Predisposing Factors (cont’d)
Sociocultural factors
Social learning: children and adolescents more likely to use substances with parents who provide model for substance use
Use of substances may also be promoted within peer group

13. Predisposing Factors (cont’d)
Sociocultural factors (cont’d)
Conditioning: pleasurable effects from substance use act as a positive reinforcement for continued use of substance
Cultural and ethnic influences: some cultures are more prone to substance abuse than others

14. 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. Feeling guilty but defensive about drinking

15. Alcohol use disorders Patterns of use (cont’d)
Phase III. The crucial phase: person has lost control; physiological dependence is clearly evident. S/S: binge drinking, anger, agression, loss of job, marriage or family
Phase IV. The chronic phase: characterized by emotional and physical disintegration. The person is usually intoxicated more often than sober. Severe withdrawal symptoms, depression, suicidal ideation

16. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body
Reversible depression of the CNS
At low doses, alcohol produces:
Relaxation
Lack of concentration
Drowsiness
Slurred speech
Sleep

17. Dynamics of Substance-Related Disorders (cont’d)
Alcohol intoxication: occurs at blood alcohol levels between 100 and 200 mg/dl
Alcohol withdrawal: occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use

18. Effects of alcohol on the body (chronic use or intoxication)
Peripheral neuropathy, characterized by
Peripheral nerve damage
Pain
Burning
Tingling
Prickly sensations of the extremities

19. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Alcoholic myopathy: thought to result from same B vitamin deficiency that contributes to peripheral neuropathy
Acute: sudden onset of muscle pain, swelling, and weakness; reddish tinge to the urine; rapid rise in muscle enzymes in the blood
Chronic: gradual wasting and weakness in skeletal muscles

20. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Wernicke’s encephalopathy: most serious form of thiamine deficiency in alcoholic patients
S/S: paralysis of ocular muscle, diplopia, ataxia, stupor
Korsakoff’s psychosis: syndrome of confusion, loss of recent memory, and confabulation in alcoholic patients

21. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Alcoholic cardiomyopathy: effect of alcohol on the heart is an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition
Arrhythmias, Congestive heart failure

22. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Esophagitis: inflammation and pain in the esophagus occurs because of the toxic effects of alcohol on the esophageal mucosa and also because of frequent vomiting associated with alcohol use

23. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Gastritis: effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention

24. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Pancreatitis
Acute: usually occurs 1 or 2 days after a binge of excessive alcohol consumption. Symptoms include constant, severe epigastric pain; nausea and vomiting; and abdominal distention

25. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Pancreatitis (cont’d)
Chronic: leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus

26. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Alcoholic hepatitis
Caused by long-term heavy alcohol use
Symptoms: enlarged, tender liver; nausea and vomiting; lethargy; anorexia; elevated white cell count; fever; and jaundice. Also ascites and weight loss in severe cases.

27. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Cirrhosis of the liver
Cirrhosis is the end-stage of alcoholic liver disease and is believed to be caused by chronic heavy alcohol use. There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue.

28. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Cirrhosis of the liver (cont’d)
Portal hypertension: elevation of blood pressure through the portal circulation results from defective blood flow through cirrhotic liver

29. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Cirrhosis of the liver (cont’d)
Ascites: a condition in which an excessive amount of serous fluid accumulates in the abdominal cavity; occurs in response to portal hypertension

30. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Cirrhosis of the liver (cont’d)
Esophageal varices: veins in the esophagus become distended because of excessive pressure from defective blood flow through the cirrhotic liver

31. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Cirrhosis of the liver (cont’d)
Hepatic encephalopathy: occurs in response to the inability of the diseased liver to convert ammonia to urea for excretion. The continued rise in serum ammonia, if allowed to progress, leads to coma and eventual death.

32. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Leukopenia: impaired production, function, and movement of white blood cells
Thrombocytopenia: platelet production and survival are impaired as a result of the toxic effects of alcohol

33. Dynamics of Substance-Related Disorders (cont’d)
Effects of alcohol on the body (cont’d)
Sexual dysfunction
In the short term, enhanced libido and failure of erection are common
Long-term effects include gynecomastia, sterility, impotence, and decreased libido

34. Dynamics of Substance-Related Disorders (cont’d)
2. A client is brought to the ED. The
client is aggressive, has slurred speech, and impaired motor coordination. Blood alcohol level is 347 mg/dl. Among the physician’s orders is thiamine. Which is the rationale for this intervention?
a) To prevent nutritional deficits
b) To prevent pancreatitis
c) To prevent alcoholic hepatitis
d) To prevent Wernicke's encephalopathy

35. Dynamics of Substance-Related Disorders (cont’d)
Correct answer: D
Wernicke’s encephalopathy is the most serious form of thiamine deficiency in clients diagnosed with alcoholism. If thiamine replacement therapy is not undertaken quickly, death will ensue.

36. Dynamics of Substance-Related Disorders (cont’d)
Alcohol use during pregnancy can result in fetal alcohol spectrum disorders (FASDs)
Fetal alcohol syndrome (FAS): problems with learning, memory, attention span, communication, vision, and hearing
Alcohol-related neurodevelopmental disorder
Alcohol-related birth defects

37. Dynamics of Substance-Related Disorders (cont’d)
No amount of alcohol during pregnancy is considered safe
Alcohol can damage a fetus at any stage of pregnancy

38. Dynamics of Substance-Related Disorders (cont’d)
Characteristics of FAS
Abnormal facial features
Small head size
Shorter-than-average height
Low body weight
Poor coordination
Hyperactive behavior
Difficulty paying attention
Poor memory
Difficulty in school
Learning difficulties
Speech and language delays
Intellectual disability
Poor reasoning skills
Sleep and sucking problems as a baby
Vision or hearing problems
Problems with the heart, kidneys, or bones

39. Treatment Modalities for Substance-Related Disorders
Alcoholics Anonymous
A major self-help organization for the treatment of alcoholism
Based on the concept of
Peer support
Acceptance
Understanding from others who have
experienced the same problem

40. Treatment Modalities for Substance-Related Disorders (cont’d)
Alcoholics Anonymous (cont’d)
The 12 steps that embody the philosophy of AA provide specific guidelines on how to attain and maintain sobriety.
Total abstinence is promoted as the only cure; the person can never safely return to social drinking.

41. Treatment Modalities for Substance-Related Disorders (cont’d)
Various support groups patterned after AA but for individuals with problems with other substances
Counseling
Group therapy

42. Treatment Modalities for Substance-Related Disorders (cont’d)
Pharmacotherapy for alcoholism
Disulfiram (Antabuse)
Other medications
Naltrexone (ReVia)
Nalmefene (Revex)
SSRIs
Acamprosate (Campral)

43. Treatment Modalities for Substance-Related Disorders (cont’d)
Psychopharmacology for substance intoxication and substance withdrawal
Alcohol
Benzodiazepines
Anticonvulsants
Multivitamin therapy
Thiamine

44. Dynamics of Substance-Related Disorders (cont’d)
Sedative/Hypnotic Use Disorder
A profile of the substance
Barbiturates
Non-barbiturate hypnotics
Antianxiety agents (diazepam, alprazolam)
Club drugs

45. Sedative/Hypnotic Use Disorder
Patterns of use
Effects on the body
Effects on sleep and dreaming
Respiratory depression
Cardiovascular effects (hypotension, decreased cardiac output)
Renal function

46. Sedative/Hypnotic Use Disorder (cont’d)
Effects on the body (cont’d)
Hepatic effects (jaundice, increase enzymes function)
Body temperature (hypothermia)
Sexual functioning

47. Sedative/Hypnotic-Induced Disorder
Intoxication
With these CNS depressants, effects can range from disinhibition and aggressiveness to coma and death
Impaired judgement, unsteady gait, slurred speech
Withdrawal
Onset of symptoms depends on the half-life of the drug from which the person is withdrawing.
Severe withdrawal from CNS depressants can be life threatening.
Sweating, tachycardia, insomnia, N/V, anxiety, seizures

48. Dynamics of Substance-Related Disorders
Stimulant Use Disorder
A profile of the substance
Amphetamines
Synthetic stimulants
Non-amphetamine stimulants
Cocaine
Caffeine
Nicotine

49. Stimulant Use Disorder
Patterns of use
Effects on the body
CNS effects
Cardiovascular effects
Pulmonary effects
Gastrointestinal and renal effects
Sexual functioning

50. Stimulant-Induced Disorders
Intoxication
Amphetamine and cocaine intoxication produce euphoria, impaired judgment, confusion, changes in vital signs (even coma or death, depending on amount consumed).
Caffeine intoxication usually occurs following consumption in excess of 250 mg. Restlessness and insomnia are the most common symptoms.

51. Stimulant-Induced Disorders (cont’d)
Withdrawal
Amphetamine and cocaine withdrawal may result in dysphoria, fatigue, sleep disturbances, and increased appetite.
Withdrawal from caffeine may include headache, fatigue, drowsiness, irritability, muscle pain and stiffness, and nausea and vomiting.
Withdrawal from nicotine may include dysphoria, anxiety, difficulty concentrating, irritability, restlessness, and increased appetite.

52. Inhalant Use Disorder A profile of the substance
Aliphatic and aromatic hydrocarbons found in substances such as fuels, solvents, adhesives, aerosol propellants, and paint thinners
They act as CNS depressants

53. Inhalant Use Disorder (cont’d)
Patterns of use/abuse
Effects on the body
CNS effects (neuropathy)
Respiratory effects (dyspnea, pulmonary hypertension, ARD)
Gastrointestinal effects (unusual breath odor, mouth rash)
Renal system effects (renal failure)

54. Inhalant-Induced Disorder
Intoxication
Develops during or shortly after use of or exposure to volatile inhalants
Symptoms include
Dizziness, ataxia, muscle weakness
Euphoria, excitation, disinhibition, slurred speech
Nystagmus, blurred or double vision
Psychomotor retardation, hypoactive reflexes
Stupor or coma

55. Dynamics of Substance-Related Disorders
Opioid Use Disorder
A profile of the substance
Opioids of natural origin (morphine, opium)
Opioid derivatives (heroin)
Synthetic opiate-like drugs (oxycodone)

56. Opioid Use Disorder Patterns of use/abuse Effects on the body
CNS effects (euphoria, drowsiness, pupillary constriction, respiratory depression)
Gastrointestinal effects (constipation)
Cardiovascular effects (hypotension)
Sexual functioning (decreased libido)

57. Opioid-Induced Disorders
Intoxication
Symptoms are consistent with the half-life of most opioid drugs and usually last for several hours.
Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment.
Severe opioid intoxication can lead to respiratory depression, coma, and death.

58. Opioid-Induced Disorders (cont’d)
Withdrawal
From short-acting drugs (e.g., heroin)
Symptoms occur within 6 to 8 hours, peak within 1 to 3 days, and gradually subside in 5 to 10 days
From long-acting drugs (e.g., methadone)
Symptoms occur within 1 to 3 days, peak between days 4 and 6, and subside in 14 to 21 days
From ultra-short-acting meperidine
Symptoms begin quickly, peak in 8 to12 hours, and subside in 4 to 5 days

59. Opioid-Induced Disorders (cont’d)
Symptoms of opioid withdrawal
Dysphoria, muscle aches, nausea/vomiting, lacrimation or rhinorrhea, pupillary dilation, sweating, abdominal cramping, diarrhea, yawning, fever, and insomnia

60. Hallucinogen Use Disorder
A profile of the substance
Naturally occurring hallucinogens
Synthetic compounds
Patterns of use
Use is usually episodic

61. Hallucinogen-Induced Disorder
Intoxication
Occurs during or shortly after using the drug
Symptoms include perceptual alteration, depersonalization, derealization, tachycardia, palpitations

62. Hallucinogen-Induced Disorder (cont’d)
Symptoms of PCP intoxication include belligerence and assaultiveness and may proceed to seizures or coma

63. Hallucinogens: Effects on the Body
Physiological
Nausea/vomiting
Chills
Pupil dilation
Increased BP, pulse
Loss of appetite
Insomnia
Elevated blood sugar
Decreased respirations
Psychological
Heightened response to color, sounds
Distorted vision
Sense of slowed time
Magnified feelings
Paranoia, panic
Euphoria, peace
Depersonalization
Derealization
Increased libido

64. Dynamics of Substance-Related Disorders
Cannabis Use Disorder
A profile of the substance
Marijuana
Hashish
Patterns of use

65. Cannabis Use Disorder Effects on the body
Cardiovascular (tachycardia, orthostatic hypotension)
Respiratory (obstruction disorders)
Reproductive (risk for infertility)
Central nervous system (euphoria, depersonalization, disorientation)
Sexual functioning

66. Cannabis-Induced Disorder
Intoxication
Symptoms include impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment
Physical symptoms include conjunctival injection, increased appetite, dry mouth, and tachycardia
Impairment of motor skills lasts for 8 to 12 hours

67. Cannabis-Induced Disorder (cont’d)
Withdrawal
Occurs upon cessation of cannabis use that has been heavy and prolonged
Symptoms occur within a week following cessation of use
Symptoms include irritability, anger, aggression, anxiety, sleep disturbances, decreased appetite, depressed mood, stomach pain, tremors, sweating, fever, chills, or headache

68. Application of the Nursing Process
Nurses must begin relationship development with a substance abuser by examining own attitudes and personal experiences with substances.

69. Nursing Process: Assessment
Various assessment tools are available for determining the extent of the problem a client has with substances.
Drug History and Assessment
Clinical Institute Withdrawal Assessment of Alcohol Scale
Michigan Alcoholism Screening Test (MAST)
CAGE Questionnaire

70. Nursing Process: Assessment (cont’d)
CAGE Questionnaire
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)

71. Dual Diagnosis
Clients with a coexisting substance disorder and mental disorder may be assigned to a special program that targets the dual diagnosis
Program combines special therapies that target both problems

72. Nursing Diagnosis/Outcome Identification
Ineffective Denial related to weak, underdeveloped ego
Outcome: Client will demonstrate acceptance of responsibility for own behavior and acknowledge association between personal problems and use of substance(s)

73. Nursing Diagnosis/Outcome Identification (cont’d)*
07/16/96
Nursing Diagnosis/Outcome Identification (cont’d)
Ineffective Coping related to inadequate coping skills and weak ego
Outcome: Client will be able to demonstrate more adaptive coping mechanisms that can be used in stressful situations (instead of taking substances) *

74. Nursing Diagnosis/Outcome Identification (cont’d)
Imbalanced Nutrition less than body requirements/Fluid volume deficit
related to drinking or taking drugs
instead of eating
Outcome: Client will be free from signs or symptoms of malnutrition/dehydration

75. Nursing Diagnosis/Outcome Identification (cont’d)
Risk for Infection related to malnutrition and altered immune condition
Outcome: Shows no signs or symptoms of infection

76. Nursing Diagnosis/Outcome Identification (cont’d)
Chronic Low Self-Esteem related to weak ego, lack of positive feedback
Outcome: Exhibits evidence of increased self-worth by attempting new projects without fear of failure and by demonstrating less defensive behavior toward others

77. Nursing Diagnosis/Outcome Identification (cont’d)
Deficient Knowledge (effects of substance abuse on the body) related to denial of problems with substances evidenced by abuse of substances
Outcome: Verbalizes importance of abstaining from use of substances to maintain optimal wellness

78. Nursing Diagnosis/Outcome Identification (cont’d)
For the client withdrawing from CNS depressants
Risk for Injury related to CNS agitation
For the client withdrawing from CNS stimulants
Risk for Suicide related to intense feelings of lassitude and depression, “crashing,” suicidal ideation

79. Planning/Implementation
Detoxification
Provide safe and supportive environment
Administer substitution therapy

80. Planning/Implementation (cont’d)
Intermediate care
Provide explanations of physical symptoms
Promote understanding and identify causes of substance dependency
Help client accept use of substance as a problem
Provide education and assistance to client and family

81. Planning/Implementation (cont’d)
Rehabilitation
Encourage continued participation
in long-term treatment
Promote participation in outpatient support system
Assist client to identify alternative sources of satisfaction
Provide support for health promotion and maintenance
Alcoholics Anonymous

82. Client/Family Education
Nature of the illness
Effects of (substance) on the body
Alcohol
Other CNS depressants
Hallucinogens
Inhalants
Opioids
Cannabinols
Ways in which use of substance affects life

83. Client/Family Education (cont’d)
Management of the illness
Activities to substitute for (substance) in times of stress
Relaxation techniques
Progressive relaxation
Tense and relax
Deep breathing
Autogenics

84. Client/Family Education (cont’d)
Management of the illness (cont’d)
3. Problem-solving skills
4. Essentials of good nutrition

85. Client/Family Education (cont’d)
Support services
Financial assistance
Legal assistance
Alcoholics Anonymous (or other support group specific to another substance)
One-to-one support person

86. Nursing Process: Evaluation
Evaluation involves reassessment to determine whether the nursing interventions have been effective in achieving the intended goals of care.

87. Treatment Modalities for Substance-Related Disorders (cont’d)
Psychopharmacology for substance intoxication and substance withdrawal (cont’d)
Opioids
Narcotic antagonists
Naloxone (Narcan)
Naltrexone (ReVia)
Nalmefene (Revex)
Methadone
Buprenorphine
Clonidine

88. Treatment Modalities for Substance-Related Disorders (cont’d)
Psychopharmacology for substance intoxication and substance withdrawal (cont’d)
Depressants
Phenobarbital (Luminal)
Long-acting benzodiazepines

89. Treatment Modalities for Substance-Related Disorders (cont’d)
Psychopharmacology for substance intoxication and substance withdrawal (cont’d)
Stimulants
Minor tranquilizers
Major tranquilizers
Anticonvulsants
Antidepressants

90. Treatment Modalities for Substance-Related Disorders (cont’d)
Psychopharmacology for substance intoxication and substance withdrawal (cont’d)
Hallucinogens and cannabinols
Benzodiazepines
Antipsychotics

91. Treatment Modalities for Substance-Related Disorders (cont’d)
3. A client diagnosed with chronic alcoholism says to the nurse, “I’m tired of using and I want to stop. Is there a medication that can help me maintain sobriety?” About which medication would the nurse provide information?
a) Carbamazepine (Tegretol)
b) Clonidine (Catapres)
c) Disulfiram (Antabuse)
d) Folic acid (Folvite)

92. Treatment Modalities for Substance-Related Disorders (cont’d)
Correct answer: C
Disulfiram is used as a deterrent to drinking. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can cause varying degrees of discomfort. It can even result in death if blood alcohol levels are high. It is important that the client understands that all alcohol, oral or topical, and medications that contain alcohol, are strictly prohibited when taking this drug.