Chapter 18

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Chapter 18Chapter 18Addictive DisordersAddictive Disorders

2Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Tolerance and WithdrawalTolerance and Withdrawal

ToleranceTolerance

• Person’s physiological reaction to drug Person’s physiological reaction to drug decreases with repeated administration decreases with repeated administration of same dose of same dose

WithdrawalWithdrawal

• Psychological changes occur when Psychological changes occur when blood and tissue concentrations of blood and tissue concentrations of drug decrease after heavy prolonged drug decrease after heavy prolonged use of substanceuse of substance


Synergistic and AntagonisticSynergistic and Antagonistic

• Synergistic effectSynergistic effect – when drugs are – when drugs are taken together, effect of either or both taken together, effect of either or both is intensified or prolongedis intensified or prolonged

• Antagonistic effectsAntagonistic effects –– whenwhen drugs are drugs are taken together, effect of one is taken together, effect of one is inhibited or weakened inhibited or weakened


ComorbidityComorbidity

• Psychiatric comorbidityPsychiatric comorbidity – 6 out of 10 – 6 out of 10 people affected by substance-abuse people affected by substance-abuse disorder also affected by mental health disorder also affected by mental health disorderdisorder

• Medical comorbidityMedical comorbidity – alcohol-related – alcohol-related medical problems are the comorbidities medical problems are the comorbidities most commonly seen in medical most commonly seen in medical settingssettings


EtiologyEtiology• Biological factorsBiological factors

– Specific effects on neurotransmitter systemsSpecific effects on neurotransmitter systems

• Psychological factorsPsychological factors

– Lack of tolerance for frustration and painLack of tolerance for frustration and pain

– Lack of success in lifeLack of success in life

– Lack of affectionate and meaningful relationshipsLack of affectionate and meaningful relationships

– Low self-esteem, lack of self-regardLow self-esteem, lack of self-regard

– Risk-taking propensityRisk-taking propensity

• Sociocultural factorsSociocultural factors

– Social and cultural normsSocial and cultural norms– Socioeconomic stressSocioeconomic stress


General AssessmentGeneral Assessment

• Two questions of importanceTwo questions of importance

1.1. In the last year, have you ever drank or used In the last year, have you ever drank or used drugs more than you meant to? drugs more than you meant to?

2.2. Have you felt you wanted or needed to cut down Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?on your drinking or drug use in the last year?

• Details includeDetails include

– Drugs usedDrugs used

• RouteRoute

• QuantityQuantity

• Time of last useTime of last use

• Usual pattern of useUsual pattern of use


Psychological ChangesPsychological Changes

• DenialDenial

• DepressionDepression

• AnxietyAnxiety

• DependencyDependency

• HopelessnessHopelessness

• Low self-esteemLow self-esteem

• Various psychiatric disorders Various psychiatric disorders


Signs of Intoxication Signs of Intoxication and Withdrawaland Withdrawal

• Alcohol poisoning Alcohol poisoning

– Large amounts of alcohol consumed quickly or Large amounts of alcohol consumed quickly or over timeover time

• Alcohol withdrawalAlcohol withdrawal

– Signs develop within a few hours after cessationSigns develop within a few hours after cessation

– Peaks at 24 to 48 hoursPeaks at 24 to 48 hours

• Alcohol withdrawal deliriumAlcohol withdrawal delirium

– Medical emergencyMedical emergency

– Can result in death, even if treatedCan result in death, even if treated


• A nurse is assigned the care of four A nurse is assigned the care of four patients detoxifying from alcohol. The patients detoxifying from alcohol. The patient with which symptom would be patient with which symptom would be the nurse’s highest priority?the nurse’s highest priority?


a.a. Fine-motor tremorsFine-motor tremors

b.b. DiaphoresisDiaphoresis

c.c. DiarrheaDiarrhea

d.d. Hallucinations and delusionsHallucinations and delusions


Central Nervous System Central Nervous System StimulantsStimulants

Common signs of stimulant abuseCommon signs of stimulant abuse

– Dilation of the pupilsDilation of the pupils

– Dryness of the oronasal cavityDryness of the oronasal cavity

– Excessive motor activityExcessive motor activity

Cocaine and crackCocaine and crack

Caffeine and nicotineCaffeine and nicotine


Cocaine and CrackCocaine and Crack• Extracted from leaf of coca bushExtracted from leaf of coca bush

• When smoked, takes effect in 4 to 6 seconds; a When smoked, takes effect in 4 to 6 seconds; a 5- to 7-minute high follows, then a deep 5- to 7-minute high follows, then a deep depressiondepression

• Two main effects on bodyTwo main effects on body– AnestheticAnesthetic

– StimulantStimulant

• Produces imbalance in neurotransmittersProduces imbalance in neurotransmitters

• Withdrawal symptoms includeWithdrawal symptoms include– Depression, paranoia, lethargy, anxiety, insomnia, Depression, paranoia, lethargy, anxiety, insomnia,

nausea, vomiting, sweating, chillsnausea, vomiting, sweating, chills


OpiatesOpiates

• MorphineMorphine

• HeroinHeroin

• CodeineCodeine

• FentanylFentanyl

• MethadoneMethadone

• MeperidineMeperidine


Marijuana (Marijuana (Cannabis sativaCannabis sativa))

• Indian hemp plantIndian hemp plant

• Tetrahydrocannabinol (THC) is active Tetrahydrocannabinol (THC) is active ingredient ingredient

• Depressant and hallucinogenic propertiesDepressant and hallucinogenic properties

• Usually smoked Usually smoked

• Desired effects – euphoria, detachment, Desired effects – euphoria, detachment, relaxationrelaxation

• Long-term effects – lethargy, anhedonia, Long-term effects – lethargy, anhedonia, difficulty concentrating, loss of memorydifficulty concentrating, loss of memory


HallucinogensHallucinogens

• Lysergic acid diethylamide (LSD or Lysergic acid diethylamide (LSD or acid)acid)

• Mescaline (peyote)Mescaline (peyote)

• Psilocybin (magic mushroom)Psilocybin (magic mushroom)

• Phencyclidine piperidine (PCP, angel Phencyclidine piperidine (PCP, angel dust, horse tranquilizer, peace pill)dust, horse tranquilizer, peace pill)


InhalantsInhalants

• Volatile solventsVolatile solvents

– Spray paintSpray paint

– GlueGlue

– Cigarette lighter fluidCigarette lighter fluid

– Propellant gases used in aerosolsPropellant gases used in aerosols


Club DrugsClub Drugs

• Common drugsCommon drugs

– EcstasyEcstasy - also called MDMA, Adam, yaba, - also called MDMA, Adam, yaba, XTCXTC

– MDAMDA – “love” – “love”

– MDEMDE – “Eve” – “Eve”

• Produce subjective effects resembling Produce subjective effects resembling stimulants and hallucinogensstimulants and hallucinogens


Date Rape DrugsDate Rape Drugs

• Flunitrazepam (Flunitrazepam (RohypnolRohypnol or “or “roofiesroofies”)”)

• GammaGamma hydroxybutyric acid ( hydroxybutyric acid (GHBGHB))

• Rapidly produceRapidly produce

– Disinhibition Disinhibition

– Relaxation of voluntary musclesRelaxation of voluntary muscles

– Anterograde amnesiaAnterograde amnesia


Assessment GuidelinesAssessment Guidelinesfor the Chemically Impairedfor the Chemically Impaired

• Assess for withdrawal syndromeAssess for withdrawal syndrome

• Assess for overdose that warrants medical attentionAssess for overdose that warrants medical attention

• Assess for suicidal thoughts or other self-destructive Assess for suicidal thoughts or other self-destructive behaviorsbehaviors

• Evaluate for physical complications related to drug Evaluate for physical complications related to drug abuseabuse

• Explore interests in doing something about drug or Explore interests in doing something about drug or alcohol problem alcohol problem

• Assess patient and family for knowledge of Assess patient and family for knowledge of community resourcescommunity resources


Potential Nursing DiagnosesPotential Nursing Diagnoses• Imbalanced nutrition: less than body Imbalanced nutrition: less than body

requirements requirements

• Disturbed thought processesDisturbed thought processes

• Disturbed sleep patternsDisturbed sleep patterns

• Ineffective health maintenanceIneffective health maintenance

• HopelessnessHopelessness

• Risk for suicideRisk for suicide

• Risk for other-directed violenceRisk for other-directed violence

• Ineffective airway clearanceIneffective airway clearance

• Ineffective breathing patternIneffective breathing pattern


Outcomes IdentificationOutcomes Identification• WithdrawalWithdrawal– Fluid balanceFluid balance

– Neurological status: consciousnessNeurological status: consciousness

– Distorted thought self-controlDistorted thought self-control

• Initial and active drug treatmentInitial and active drug treatment– Risk control – alcohol useRisk control – alcohol use

– Risk control – drug useRisk control – drug use

– Substance addiction consequences Substance addiction consequences

• Health maintenanceHealth maintenance

– Knowledge: substance abuse controlKnowledge: substance abuse control

– Family coping Family coping


ImplementationImplementation

• Aim of treatment – self-responsibilityAim of treatment – self-responsibility

• Challenge – matching patients with Challenge – matching patients with types of treatment related to various types of treatment related to various needsneeds

– PhysiologicalPhysiological

– PsychologicalPsychological

– Sociocultural processesSociocultural processes


Health Teaching and Health Teaching and Health PromotionHealth Promotion

• Primary prevention – health teachingPrimary prevention – health teaching

FRAMES FRAMES

– FFeedback of personal riskeedback of personal risk

– RResponsibility of the patientesponsibility of the patient

– AAdvice to changedvice to change

– MMenu of ways to reduce substance useenu of ways to reduce substance use

– EEmpathetic counselingmpathetic counseling

– SSelf-efficacy or optimism of the patientelf-efficacy or optimism of the patient


Intervention Strategies Intervention Strategies ContinuedContinued

• Relapse preventionRelapse prevention

• Self-help groups for patient and familySelf-help groups for patient and family

• 12-Step programs12-Step programs

• Residential programsResidential programs

• Intensive outpatient programsIntensive outpatient programs

• Outpatient drug-free programs and Outpatient drug-free programs and employee assistance programsemployee assistance programs


Pharmacological Interventions Pharmacological Interventions Treatment of AlcoholismTreatment of Alcoholism

• Naltrexone (ReVia)Naltrexone (ReVia)

– Reduces or eliminates alcohol cravingReduces or eliminates alcohol craving

• Acamprosate (Campral)Acamprosate (Campral)

– Helps client abstain from alcoholHelps client abstain from alcohol

• Topiramate (Topamax) Topiramate (Topamax)

– Works to decrease alcohol cravingsWorks to decrease alcohol cravings

• Disulfiram (Antabuse)Disulfiram (Antabuse)

– Alcohol-disulfiram reaction causes unpleasant Alcohol-disulfiram reaction causes unpleasant physical effects physical effects


Pharmacological Interventions Pharmacological Interventions Treatment of Opioid AddictionTreatment of Opioid Addiction

• Methadone (Dolophine)Methadone (Dolophine)– Synthetic opiate blocks craving for and effects of heroinSynthetic opiate blocks craving for and effects of heroin

• LAAM (LAAM (ll--αα-acetylmethadol)-acetylmethadol)– An alternative to methadoneAn alternative to methadone

• Naltrexone (ReVia)Naltrexone (ReVia)– Antagonist that blocks euphoric effects of opioidsAntagonist that blocks euphoric effects of opioids

• Clonidine (Catapres)Clonidine (Catapres)– Effective somatic treatment when combined with Effective somatic treatment when combined with

naltrexonenaltrexone

• Buprenorphine (Subutex)Buprenorphine (Subutex)– Blocks signs and symptoms of opioid withdrawalBlocks signs and symptoms of opioid withdrawal


EvaluationEvaluation

• Increased time in abstinenceIncreased time in abstinence

• Decreased denialDecreased denial

• Acceptable occupational functioningAcceptable occupational functioning

• Improved family relationshipsImproved family relationships

• Ability to relate comfortably to other Ability to relate comfortably to other individualsindividuals

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Chapter 18