SUBSTANCE ABUSE SUBSTANCE ABUSE AND AND DEPENDENCE: DEPENDENCE: An OverviewAn Overview RNSG 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 coca leaves, Tribal cultures have e.g. chewed coca leaves,

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

Which legal drug is the Which legal drug is the

most widely used?most widely used?

Illicit Drug UseIllicit Drug Use

Most used illicit drugs world-wide:Most used illicit drugs world-wide: Cannabis (#1) Cannabis (#1) Amphetamines (& synthetic stimulants) Amphetamines (& synthetic stimulants)

*greatest increase*greatest increase

CocaineCocaine OpioidsOpioids World Health Organization 2010World Health Organization 2010

www.who.int_substanceabuse/facts.htmwww.who.int_substanceabuse/facts.htm

Illicit Drugs: Illicit Drugs: A Global IssueA Global Issue

EconomicsEconomics CrimeCrime HealthHealth Effects on young peopleEffects on young people Environmental effectsEnvironmental effects

Illegal Drugs: U.S.A.Illegal Drugs: U.S.A.

CDC CDC www.cdc.govwww.cdc.gov (2010 report): (2010 report):

Persons in U.S. Persons in U.S. >> 12 y/o who in past month: 12 y/o who in past month: used illegal drug(s) used illegal drug(s) 8%8% used Marijuanaused Marijuana 6.1% 6.1% non-medical use of a psychotherapeutic non-medical use of a psychotherapeutic

agentagent 2.5% 2.5%

(CDC Statistics from 2008)(CDC Statistics from 2008)

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

Co-Morbidity with other Co-Morbidity with other Mental Disorders:Mental Disorders: Dual Diagnosis Dual Diagnosis

Shared Risk FactorsShared Risk Factors Genetic factorsGenetic factors Environmental factorsEnvironmental factors

Similar brain regions affectedSimilar brain regions affected Drugs can change the brainDrugs can change the brain Drug use can induce mental illnessDrug use can induce mental illness Mental disorders may lead to drug use Mental disorders may lead to drug use

(“self-medication”)(“self-medication”)

Co-Morbidity With Mental D/O

“Vegetable compound” Alcohol content =18%

The Bayer Co.’s best-seller

Laudanum = 50% opium/50% alcohol

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

1914: Harrison Narcotics Act – Prohibition of 1914: Harrison Narcotics Act – Prohibition of non-doctor-prescribed opiatesnon-doctor-prescribed opiates

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 cocaine/crack amphetamines amphetamines opiates opiates anesthetics anesthetics nicotine (PCP, ketamine)nicotine (PCP, ketamine) alcohol alcohol benzodiazepines benzodiazepines

marijuana marijuana

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 oneself or others. (e.g. interpersonal, legal or safety issues)or safety issues)

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

Definitions MatchingDefinitions Matching1.1. Client 1 states morphine Client 1 states morphine

for cancer pain is not for cancer pain is not working: Dr. writes working: Dr. writes order for increased order for increased dose.dose.

2.2. Client 2 smokes some Client 2 smokes some marijuana and feels marijuana and feels “mellow,” eats junk “mellow,” eats junk food.food.

3.3. Most nights, Client 3 Most nights, Client 3 drinks a 6-pack of beer drinks a 6-pack of beer and falls asleep in front and falls asleep in front of TV. (Spouse is not of TV. (Spouse is not happy.)happy.)

4.4. While waiting for more While waiting for more cocaine to be delivered, cocaine to be delivered, Client 4 feels very Client 4 feels very depressed, anxious and depressed, anxious and is desperate to feel is desperate to feel “good” again.“good” again.

A. Substance abuseA. Substance abuse

B. B. SubstanceSubstance withdrawalwithdrawal

C. C. ToleranceTolerance

D. D. Substance Substance dependencedependence

E. E. Substance Substance intoxicationintoxication

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 problems Substance use continues despite problems

causedcaused

DSM IV CRITERIA FOR DSM IV CRITERIA FOR SUBSTANCE WITHDRAWALSUBSTANCE WITHDRAWAL

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

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

Biological Theory: Biological Theory: Neurotransmitters of Neurotransmitters of AddictionAddiction

Dopamine (DA) –”reward pathway”Dopamine (DA) –”reward 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 Addiction: Etiology of Addiction: Biological TheoryBiological Theory

Repeated use of a drug results in stimulation of Repeated use of a drug results in stimulation of brain’s “reward” pathwaybrain’s “reward” pathway

Biological Theory of Addiction cont’dBiological Theory of Addiction cont’d

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

Biological Theory, cont’dBiological Theory, cont’d

Genetic predisposition Genetic predisposition Examples: -Allergic response to ETOH in Examples: -Allergic response to ETOH in

many Southeast Asiansmany Southeast Asians -Twins born to alcoholic parents -Twins born to alcoholic parents

who are then adopted have 3x rate of who are then adopted have 3x rate of becoming alcoholic than children of non-becoming alcoholic than children of non-alcoholics who are then adopted. alcoholics who are then adopted.

Etiology: Etiology: 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)

Multivariant Theory Multivariant Theory ScenarioScenario

JJ. was in recovery x 4 months from dependence on alcohol. . was in recovery x 4 months from dependence on alcohol. This week at work had been stressful, then on Thursday his This week at work had been stressful, then on Thursday his dog got hit by a car and had to be euthanized. On Friday, he dog got hit by a car and had to be euthanized. On Friday, he started drinking again at a downtown bar near his office. started drinking again at a downtown bar near his office. After 3 days of inebriation he called his AA sponsor. After 3 days of inebriation he called his AA sponsor. Together they discussed the events leading up to his Together they discussed the events leading up to his relapse. He recalled his usual pattern was binge drinking on relapse. He recalled his usual pattern was binge drinking on weekends, with a stop at the liquor store on Friday after weekends, with a stop at the liquor store on Friday after work. He had been passing by the bar on his way home on work. He had been passing by the bar on his way home on Friday. The combination of the sound of people having “fun,” Friday. The combination of the sound of people having “fun,” and it being Friday after work, triggered his relapse. J. and it being Friday after work, triggered his relapse. J. recognized that, since drinking was the way he relaxed and recognized that, since drinking was the way he relaxed and dealt with stress, this time he put himself in “the wrong place dealt with stress, this time he put himself in “the wrong place at the wrong time.”at the wrong time.”

Etiology: Etiology: Sociocultural Sociocultural FactorsFactors

AdvertisingAdvertising Cultural and religious values Cultural and religious values Sex differences: Males abuse alcohol Sex differences: Males abuse alcohol

and opioids more. Females abuse and opioids more. Females abuse prescription drugs prescription drugs

Availability, costAvailability, cost

Etiology: Etiology: Psychological/Psychodynamic Psychological/Psychodynamic TheoryTheory

Fundamentally negative view of selfFundamentally negative view of self Substances used to escape from anxiety Substances used to escape from anxiety

or emotional pain. or emotional pain.

Personality Traits Personality Traits Associated with Substance Associated with Substance DependenceDependence

DENIAL/ anger DENIAL/ anger Inability to express emotions Inability to express emotions High anxiety in interpersonal relations High anxiety in interpersonal relations Emotional immaturityEmotional immaturity 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 isolationFeelings of isolation Overdependence/lack of autonomyOverdependence/lack of autonomy 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 of family life = the addict’s behaviorFocus of family life = 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

Family in need of treatmentFamily in need of treatment

http://www.youtube.com/watch?v=u0ugTOXv0Y4

http://www.youtube.com/watch?v=mwq0wxZg87g

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

INTERVENTIONS: INTERVENTIONS: 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

Avoids life-threatening withdrawal signs and Avoids life-threatening withdrawal signs and symptoms but also avoids intoxication with the symptoms but also avoids intoxication with the withdrawal medications. 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 and Milieu Nursing and Milieu InterventionsInterventions

Examine own attitudes about substance Examine own attitudes about substance use and dependenceuse and dependence

Provide: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 Treatment for co-occurring mental illnessTreatment for co-occurring mental illness

Client Behaviors Client Behaviors and and Nursing Nursing Interventions for:Interventions for:

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.

Nurse-Client Nurse-Client Communication: Communication: Effective?/Ineffective?Effective?/Ineffective?

1.1. Client: “You all are a bunch Client: “You all are a bunch of do-gooders who are of do-gooders who are getting paid to act like you getting paid to act like you care but you don’t. “care but you don’t. “

2.2. Client: “I want to talk to the Client: “I want to talk to the dr. now! This dose he dr. now! This dose he ordered is ridiculous—it ordered is ridiculous—it won’t do anything for my won’t do anything for my headache. I know the headache. I know the amount I need.”amount I need.”

3.3. Client: “I feel like I’ve let my Client: “I feel like I’ve let my whole family down by whole family down by drinking again.”drinking again.”

4.4. Client: “You have never Client: “You have never used drugs, so you cannot used drugs, so you cannot possibly understand my possibly understand my situation.”situation.”

1.1. NurseNurse:: “Your bad attitude “Your bad attitude is sabotaging your is sabotaging your treatment.” treatment.”

2.2. Nurse: “Right now this is Nurse: “Right now this is what the dr. ordered for what the dr. ordered for your headache.”your headache.”

3.3. Nurse: “I feel for you. Nurse: “I feel for you. Alcohol does terrible Alcohol does terrible things to a family.”things to a family.”

4.4. Nurse: “That may be true. Nurse: “That may be true. But I can see that you are But I can see that you are having a rough time.”having a rough time.”

Interventions: Interventions: Client and Family TeachingClient and Family Teaching

Disease process Disease process Total abstinence is the goalTotal abstinence is the goal Relapse is part of recoveryRelapse is part of recovery 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.

Relapse Relapse Prevention/RecoveryPrevention/Recovery

1.1. Client: “I don’t know why I Client: “I don’t know why I started using again, I guess I started using again, I guess I just can’t stay clean.”just can’t stay clean.”

2.2. Client: “Ever since I stopped Client: “Ever since I stopped drinking, my friends say I’m drinking, my friends say I’m no fun.”no fun.”

3.3. Client: “I started drinking Client: “I started drinking again because my boyfriend again because my boyfriend stressed me out.”stressed me out.”

1.1. Nurse: “Write down Nurse: “Write down everything you remember everything you remember about that day. Triggers may about that day. Triggers may not always be obvious.”not always be obvious.”

2.2. Nurse: “It’s time to consider Nurse: “It’s time to consider who your friends really are.”who your friends really are.”

3.3. Nurse: ________________ Nurse: ________________

Interventions: Referrals and Interventions: Referrals and Community ResourcesCommunity 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.

Legal-Ethical: The Legal-Ethical: The Chemically Dependent Chemically Dependent NurseNurse

Required to report impaired colleague to Required to report impaired colleague to Board of NursingBoard of Nursing

Nursing resources in TX:Nursing resources in TX: TPAPNTPAPN (Texas Peer Assistance Program for (Texas Peer Assistance Program for

Nurses) Nurses) www.tpapn.orgwww.tpapn.org

Addiction Recovery Awareness