CHEMICAL CHEMICAL DEPENDENCY: DEPENDENCY: An OverviewAn OverviewRNSG 2213RNSG 2213

INTRODUCTIONINTRODUCTION Substance abuse is not a new problem. Substance abuse is not a new problem. Mood-altering and mind-altering substances Mood-altering and mind-altering substances

have been used throughout human history.have been used throughout human history. Opium used openly into the 20th century; Opium used openly into the 20th century;

Freud used Cocaine. Freud used Cocaine. Tribal cultures have e.g. chewed coco leaves, Tribal cultures have e.g. chewed coco leaves,

used peyote in religious ceremonies, smoked used peyote in religious ceremonies, smoked the “peace pipe.”the “peace pipe.”

Illicit Drug UseIllicit Drug Use Most used illicit drugs world-wide:Most used illicit drugs world-wide:

Cannabis (#1)Cannabis (#1) AmphetaminesAmphetamines CocaineCocaine OpioidsOpioids (WHO 2004)(WHO 2004)

IntroductionIntroduction No clear transition from therapeutic to abusive No clear transition from therapeutic to abusive

substance usesubstance use Use is significantly underreported and effects Use is significantly underreported and effects

are often misdiagnosedare often misdiagnosed Much social stigma attaches to abuse and Much social stigma attaches to abuse and

addictionaddiction Implicated in many accidental deaths, crimesImplicated in many accidental deaths, crimes Severe adverse effects on health, work, Severe adverse effects on health, work,

relationships and quality of liferelationships and quality of life

Introduction: Drugs and Introduction: Drugs and U.S. Law U.S. Law

1914: Harrison Narcotic Act --Opiate prohibition1914: Harrison Narcotic Act --Opiate prohibition Alcohol Prohibition in the 1920’s and 1930’sAlcohol Prohibition in the 1920’s and 1930’s 1970: 1970: DDrug rug EEnforcement nforcement AAgency created; gency created;

Controlled Substances Act passed Controlled Substances Act passed 1987: AMA declared all chemical dependency 1987: AMA declared all chemical dependency

as diseaseas disease 1990: ADA—non discrimination against 1990: ADA—non discrimination against

persons with history of drug/alcohol addictionpersons with history of drug/alcohol addiction

ADDICTION LIABILITYADDICTION LIABILITY

Highest LowerHighest Lower cocaine/crack amphetaminescocaine/crack amphetamines opiates anestheticsopiates anesthetics (PCP, ketamine)(PCP, ketamine) alcohol nicotine alcohol nicotine

benzodiazepinesbenzodiazepines marijuanamarijuana

(Addiction liability, cont’d)(Addiction liability, cont’d)

These are non-addicting:These are non-addicting:

LSD and other hallucinogens LSD and other hallucinogens antidepressant drugs antidepressant drugs antipsychotic drugs antipsychotic drugs naltrexone-Trexannaltrexone-Trexan

DEFINITIONSDEFINITIONS IntoxicationIntoxication:: Substance-specific CNS Substance-specific CNS

effectseffects Substance AbuseSubstance Abuse: Recurrent use of a : Recurrent use of a

drug which results in adverse effects to drug which results in adverse effects to oneself or others. (e.g. interpersonal, legal or oneself or others. (e.g. interpersonal, legal or safety issues)safety issues)

AddictionAddiction:: (compulsive use of substance = (compulsive use of substance = same as substance dependence; term is same as substance dependence; term is now considered judgmental ) now considered judgmental )

Definitions, cont’dDefinitions, cont’d

Chemical/Substance DependenceChemical/Substance Dependence: : Loss of Control over use, which involves:Loss of Control over use, which involves: Tolerance:Tolerance: Must increase the amount of Must increase the amount of

drug to get the needed effect.drug to get the needed effect. WithdrawalWithdrawal:: Refers to psychoactive Refers to psychoactive

substance-specific syndrome that occurs substance-specific syndrome that occurs when person stops using the drug when person stops using the drug

DSM IV CRITERIA FOR DSM IV CRITERIA FOR SUBSTANCE DEPENDENCESUBSTANCE DEPENDENCE

Tolerance, Withdrawal Tolerance, Withdrawal Desires and attempts to cut down Desires and attempts to cut down Much time is spent in obtaining drug and Much time is spent in obtaining drug and

recovering from drug recovering from drug Social and occupational problems resultSocial and occupational problems result Substance use continues despite Substance use continues despite

problems causedproblems caused

DSM IV CRITERIA FOR DSM IV CRITERIA FOR SUBSTANCE WITHDRAWALSUBSTANCE WITHDRAWAL

Development of specific symptoms due Development of specific symptoms due to cessation of drug to cessation of drug

Syndrome causes distress Syndrome causes distress Symptoms not due to a medical Symptoms not due to a medical

conditioncondition

Biological Theory: Biological Theory: Neurotransmitters of Drug Neurotransmitters of Drug DependenceDependence

Dopamine (DA) –”pleasure pathway”Dopamine (DA) –”pleasure pathway” Serotonin (SER) Serotonin (SER) Endorphins (END) Endorphins (END) GABA/Glutamate (GLU) Theory: heavy GABA/Glutamate (GLU) Theory: heavy

drug use decreases response of “brain drug use decreases response of “brain calming” neuroreceptors (= calming” neuroreceptors (= tolerancetolerance))

Etiology of Dependence: Etiology of Dependence: Biological TheoryBiological Theory

Repeated use of a drug results in Repeated use of a drug results in stimulation of brain’s “reward” or “pleasure” stimulation of brain’s “reward” or “pleasure” pathwaypathway in mesolimbic systemin mesolimbic system

Biological Theory of Dependence Biological Theory of Dependence cont’dcont’d

Repeated use of a drug targets Repeated use of a drug targets specific brain areas for that drug, specific brain areas for that drug, with resulting creation of extra with resulting creation of extra receptors and brain’s perception receptors and brain’s perception that drug’s stimuli are necessary for that drug’s stimuli are necessary for survival (survival (cravingscravings))

The Addicted BrainThe Addicted Brain

Bottom LineBottom Line:: Major sites targeted by addicting drugs Major sites targeted by addicting drugs(Within medial forebrain, not cortex) are evidence that (Within medial forebrain, not cortex) are evidence that addictions are not under conscious controladdictions are not under conscious control

Biological Theory, cont’dBiological Theory, cont’d Evidence of genetic predisposition for Evidence of genetic predisposition for

alcoholism.alcoholism. Example: Allergic response to ETOH in many Example: Allergic response to ETOH in many

Southeast AsiansSoutheast Asians Strong concurrence with bipolar disorder Strong concurrence with bipolar disorder Twins born to alcoholic parents who are then Twins born to alcoholic parents who are then

adopted have 3x rate of adopted children of adopted have 3x rate of adopted children of non-alcoholics. non-alcoholics.

Multivariant Theory: Multivariant Theory: Biology + Learning Biology + Learning

Drug dependence results from interaction of Drug dependence results from interaction of the physiological effects of substances on the physiological effects of substances on brain areas associated with motivation and brain areas associated with motivation and emotion, combined with ‘‘learning’’ about the emotion, combined with ‘‘learning’’ about the relationship between substances and relationship between substances and substance-related cues.substance-related cues.

This theory gives support to why relapse This theory gives support to why relapse may occur even after long period of may occur even after long period of abstinence. (e.g.: smell of cigarette can abstinence. (e.g.: smell of cigarette can cause an ex-smoker to light up)cause an ex-smoker to light up)

Etiology: Sociocultural Etiology: Sociocultural FactorsFactors

Advertising: “Relief is just a swallow away” Advertising: “Relief is just a swallow away” Don’t suffer; take action Don’t suffer; take action Sex differences: Males abuse alcohol and Sex differences: Males abuse alcohol and

opiates more. Females abuse prescription opiates more. Females abuse prescription drugs drugs

Catholics: Highest rate of alcohol abuse Catholics: Highest rate of alcohol abuse Observant Jews: lowest Observant Jews: lowest StressStress Availability, costAvailability, cost

Etiology: Etiology: Psychological/Psychodynamic Psychological/Psychodynamic TheoryTheory

Person who abuses drugs seeks to Person who abuses drugs seeks to escape from anxiety or emotional pain. escape from anxiety or emotional pain. Sees self in a fundamentally negative Sees self in a fundamentally negative way.way.

Personality Traits Personality Traits Associated with Chemical Associated with Chemical DependenceDependence

DENIAL/ anger DENIAL/ anger Inability to express emotions Inability to express emotions High anxiety in interpersonal relations High anxiety in interpersonal relations Emotional immaturity; overdependence Emotional immaturity; overdependence Ambivalence towards authority; rule Ambivalence towards authority; rule

breakerbreaker Low frustration tolerance; wants instant Low frustration tolerance; wants instant

gratificationgratification

Personality Traits, continuedPersonality Traits, continued

Low self-esteem Low self-esteem Feelings of isolation Feelings of isolation Perfectionism and compulsiveness Perfectionism and compulsiveness Sex role confusion Sex role confusion

Are these qualities the cause or the result of drug use?

Effects on FamilyEffects on Family All family members affected by the All family members affected by the

substance-dependent member.substance-dependent member. Many characteristic behaviors:Many characteristic behaviors:

Focus becomes on the addict’s behaviorFocus becomes on the addict’s behavior Co-dependencyCo-dependency Care-taking by childrenCare-taking by children

Perpetuation of these dynamics into Perpetuation of these dynamics into adulthoodadulthood

3 Options: ignore, banish, adapt3 Options: ignore, banish, adapt Family in need of treatmentFamily in need of treatment

AssessmentAssessment Denial complicates assessmentDenial complicates assessment Use screening tools, e.g. MASTUse screening tools, e.g. MAST Careful history: occupational, legal, Careful history: occupational, legal,

behavioral alterationsbehavioral alterations Physical Assessment: substance specific Physical Assessment: substance specific

signs and symptomssigns and symptoms Urine and serum drug screens; Urine and serum drug screens;

breathalyzer (alcohol)breathalyzer (alcohol)

Short version of Michigan Alcoholism Screening Test (SMAST)

> 3 points indicates problem

GOALS FOR GOALS FOR DETOXIFICATIONDETOXIFICATION

American Society of Addiction American Society of Addiction MedicineMedicine lists three immediate goals for lists three immediate goals for detoxification of alcohol and other detoxification of alcohol and other substances: (1) “to provide a safe substances: (1) “to provide a safe withdrawal from the drug(s) of withdrawal from the drug(s) of dependence and enable the patient to dependence and enable the patient to become drug-free”; (2) “to provide a become drug-free”; (2) “to provide a withdrawal that is humane and thus withdrawal that is humane and thus protects the patient’s dignity”protects the patient’s dignity”

Principles of Principles of DetoxificationDetoxification

Ideal detoxification avoids life-threatening Ideal detoxification avoids life-threatening withdrawal signs and symptoms but also avoids withdrawal signs and symptoms but also avoids intoxication with the withdrawal medications. intoxication with the withdrawal medications. The goal is not absolute comfort.The goal is not absolute comfort.

Objective measures of withdrawal (vital signs, Objective measures of withdrawal (vital signs, observable findings, withdrawal rating scores)observable findings, withdrawal rating scores) are very useful for monitoring the course of are very useful for monitoring the course of withdrawal and supplementing the subjective withdrawal and supplementing the subjective data from the client.data from the client.

Nursing InterventionsNursing Interventions Examine own attitudes about substance Examine own attitudes about substance

use and dependenceuse and dependenceProvide:Provide: Safe environment for client in withdrawalSafe environment for client in withdrawal Empathy and acceptanceEmpathy and acceptance Hope for recovery Hope for recovery Group therapy: to deal with denial and provide Group therapy: to deal with denial and provide

support for changesupport for change Medications to treat co-occurring mental illnessMedications to treat co-occurring mental illness

Client Behaviors Client Behaviors and and Nursing Nursing InterventionsInterventions

Anger: Anger: matter-of-fact approach matter-of-fact approach Guilt and shameGuilt and shame: non-judgmental support; : non-judgmental support;

offer positive feedback for help-seeking offer positive feedback for help-seeking behaviorsbehaviors

Denial and Avoiding ResponsibilityDenial and Avoiding Responsibility: : supportive confrontation supportive confrontation

Manipulation: Manipulation: Set limits and clear rules.Set limits and clear rules. CravingsCravings: provide support, teaching and : provide support, teaching and

encourage talking with peers encourage talking with peers

Interventions: Interventions: Client TeachingClient Teaching

Disease process Disease process Total abstinence is the goalTotal abstinence is the goal Relapse prevention strategiesRelapse prevention strategies

Recognize and confront own denialRecognize and confront own denial Recognize triggersRecognize triggers ““Change people, places and things.” Change people, places and things.”

Often biggest obstacle to abstinence.Often biggest obstacle to abstinence.

InterventionsInterventions

Referrals and Community ResourcesReferrals and Community Resources Long-term residential rehabilitation is best predictor Long-term residential rehabilitation is best predictor

of abstinence (28 days to 6 months or more)of abstinence (28 days to 6 months or more) Halfway House Halfway House Outpatient rehabilitationOutpatient rehabilitation AA, NA, Rational RecoveryAA, NA, Rational Recovery Family counselingFamily counseling Al-Anon, Nar-Anon, AlateenAl-Anon, Nar-Anon, Alateen Other services: job placement, housing, etc.Other services: job placement, housing, etc.