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Substance Related Disorders & Dual Diagnosis. Phyllis M. Connolly, PhD, RN, CS NURS 127A. Questions to Consider Today 4/20/01. What behaviors indicate that a nurse may be abusing substances? What is the ego/self theory related to substance abuse? When is denial a problem?

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substance related disorders dual diagnosis

Substance Related Disorders & Dual Diagnosis

Phyllis M. Connolly, PhD, RN, CS


questions to consider today 4 20 01
Questions to Consider Today 4/20/01
  • What behaviors indicate that a nurse may be abusing substances?
  • What is the ego/self theory related to substance abuse?
  • When is denial a problem?
  • What is the relationship between childhood sexual abuse and addiction?
substance disorders facts
Substance Disorders Facts
  • Cost: $144 billion/year in health care and job loss
  • Alcohol most commonly used
  • Marijuana most commonly used illegal drug
  • 50% auto accidents & homicides involve alcohol
  • Involved in crime & violence
  • 500,000 deaths from Tobacco-related disorders
  • One in 10 deaths related to alcohol
  • More die from misuse of legal prescriptions
impaired nurses
Impaired Nurses
  • 5% of 2 million nurses in 1984 (ANA) abused substances
  • 8-10% chemically dependent
  • Narcotic addiction 30 X higher than general population (1987 study)
  • 67% of cases handled by 44 state BRN (1988)
signs of impaired nursing practice
Job Performance Changes, Controlled drug handling

Drug counts incorrect

Excessive errors

Excessive wastage, often not countersigned

Medicine signed out to pt. not in pain

Two strengths of drugs signed out to same pt. Same time

Packaging appears to be tampered

Patient complaints of ineffective pain control

Volunteers to give controlled drugs

General Performance

Medication errors

Poor judgment

Euphoric recall for involvement in unpleasant situations

iIlogical or sloppy charting

Absenteeism, esp. days off

Requesting leave time just before assigned shift

Lateness--elaborate excuses

Job shrinkage

missed deadlines

Signs of Impaired Nursing Practice
signs impaired nurse cont
Behavioral/Personality changes

Sudden changes in mood

Periods of irritability


Wears long sleeves (hot weather)

Socially isolates

Inappropriate behavior

Chronic pain condition

Hx pain treatment with controlled substances

Signs of Use

Alcohol on breath

Constant use of perfumes, mouthwash, breath mints

flushed face, reddened eyes, unsteady gait, slurred speech, hyperactivity

accelerated speech

Increasing family problems interfere with work

Signs Impaired Nurse Cont.
interventions impaired colleagues
Interventions: Impaired Colleagues
  • Reporting required ethical & legal obligation to supervisor
  • Document in writing; time, date, place description, & names of those present
  • An advisor with (state nurse rehabilitation team)
  • Team approach,co-workers, supervisor, nurse administrator, family member
prevalence of substance related disorders
Alcohol abuse




Other drug dependency






Prevalence of Substance-Related Disorders



Dahme, 1998

classes of substances with potential for abuse and dependence









Phencyclidines (PCP)

Sedative, hypnotic,or antianxiety agents

Classes of Substances with Potential for Abuse and Dependence
5 general categories of substances
5 General Categories of Substances
  • CNS depressants,(alcohol, sedative-hypnotics, antianxiety agents,and volatile inhalants
  • Stimulants (cocaine, amphetamine,caffeine, nicotine**, & related substances)
  • Opioids including analgesics
  • Hallucinogens including PCP
  • Cannabis

 Caffeine not considered to cause either dependence or abuse

** Nicotine is currently classified as causing dependence but not abuse

psychoactive substances
Psychoactive Substances
  • Drugs or chemicals which alter one or several of:
    • Perception
    • Awareness
    • Consciousness
    • Thinking
    • Judgment
    • Decision making
    • Insight
    • Mood
    • Behavior
etiological theories substance abuse
Etiological Theories: Substance Abuse


  • Addictive substances activate neurotransmitters in mesolimbic dopaminergic reward pathway
    • chronic use  blood flow to brain
  • Genetic predisposition
  • Behavioral--conditioning & homeostasis
    • drug craving triggers; self-medicating
  • Psychodynamic
    • Unconscious oral needs
    • Dependency
    • Low self-esteem
    • child abuse, physical, sexual
    • family conflict (Trauma model, Walker et al. 1998)
dsm iv criteria substance related disorders
Substance Dependence

A. Maladaptive pattern3 or more:



need for more

inability to stop using

time spent acquiring or recovering from effects

problems, social, occupational, or recreational

Continues use despite knowledge

Substance Abuse

A. Maladaptive pattern leads to significant impairment or distress as manifested by one or more of:

Failure to fulfill major role obligations at work, school, or home

Recurrent use in hazardous situations

Recurrent substance related legal problems

Continued use despite problems

DSM-IV Criteria Substance Related Disorders
dsm iv criteria substance related disorders cont
Substance Intoxication

Development of a substance- specific syndrome due to a recent ingestion of a substance

Clinically significant maladaptive behavioral or psychological changes due to the effect of the substance on the CNS

Not due to general medical condition and not better accounted for by another mental disorder

Substance Withdrawal

Development of a substance-specific maladaptive behavioral or psychological changes due to the effect of the substance on the CNS

The substance-specific syndrome causes clinically significant distress or impairment

Not due to a general medical condition and not better accounted for by another mental disorder

DSM-IV Criteria Substance Related Disorders Cont.
substance dependence
Substance Dependence

Lack of control over drug use and its increasing importance. At least 3 symptoms in 12 month period.

  • Tolerance
  • Withdrawal
  • Taking larger amounts
  • Inability to reduce use
  • Excess time spent on obtaining drugs
  • Impairment in functioning
  • Continued use despite negative consequences

Dahme, 1998

key terms
Key Terms
  • Dependence: A drug abuser must take a usual or increasing dose of a drug in order to prevent the onset of abstinence symptoms/withdrawal
  • Tolerance: The need for increasing amounts of a substance to achieve the same effects
  • Withdrawal: Physical signs and symptoms that occur when the addictive substance is reduced or withheld (abstinence syndrome)
key terms cont
Key Terms cont.
  • Abuse--Excessive use of a substance that differs from societal norms
  • Codependency--stress-related preoccupation with an addicted person’s life, leading to extreme dependence on that person
  • Blackouts--period of time in which the drinker functions socially but for which there is no memory
  • Pharmacodynamic tolerance--occurs when higher blood levels are required to produce a given effect
coping styles contributing to substance abuse maintenance
Coping Styles Contributing to Substance Abuse Maintenance
  • Rationalization
    • Falsifying an experience by giving a contrived, socially acceptable and logical explanation to justify an unpleasant experience or questionable behavior
  • Projection
    • Attributing an unconscious impulse, attitude,or behavior to someone else (blaming or scapegoating)
  • Denial
    • escaping unpleasant realities by ignoring their existence
cognitive framework assessing denial
Cognitive Framework: Assessing Denial

Is it denial?




Is it a problem?



Do nothing

How is it a problem?

What cognitions are in conflict?

What are alternative means of reducing dissonance?

Forchuk & Westwell, 1987

alcohol abuse and culture
Alcohol Abuse and Culture
  • Norms important role
  • Cultures with rate of alcohol abuse may condone drunkenness (Irish)
  • Cultures with  rates appropriate use of small amts. Celebrations (Jewish & Mediterranean)
  • Condemn altogether (Muslim, Jehovah’s Witness, and Mormons)
  • China and Japan lower prevalence-negative physiological response
  • Native Americans & Eskimos  rates
  • US rates similar to northern European countries
  • Behaviors of individuals in family or social system who inadvertently promote continued alcohol or drug use. By protecting them from consequences of their actions. Examples: ignoring or making excuses for person’s behavior, finishing the work of a colleague who is unable to function.
cage screening test alcoholism
CAGE Screening Test Alcoholism

1. Have you ever felt you ought to Cut down on your drinking?

2. Have people Annoyed you by criticizing your drinking?

3. Have you ever felt bad or Guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eyeopener)

Keltner, p. 530

alcohol withdrawal symptoms first 24 hours
Alcohol Withdrawal Symptoms: First 24 hours

Within a few hours, peaks within 24 hrs.

  • Anxiety
  • Insomnia
  • Irritability
  • “Internal shaking”  BP, P, diaphoresis
alcohol withdrawal symptoms sudden to 2 3 days
Alcohol Withdrawal Symptoms: Sudden to 2-3 days
  • Grandmal convulsive seizures--48 hrs.
  • Delerium tremens (DTS)--72 hrs.
    •  Medical Emergency Acute pathological state of consciousness results from interference with brain metabolism
wernicke s syndrome korsakoff s disease
Wernicke’s Syndrome & Korsakoff’s Disease
  • Nutritional disorders related to alcoholism
  • Thiamine deficiency
  • Both treated with withdrawal from alcohol and vitamin supplements.
  • Improvement can occur in Wernicke’s syndrome, some degree of intellectual and emotional impairment remains.
  • Memory impairment is residual in Korsakoff’s even when slight improvement occurs
wernicke s syndrome
Wernicke’s Syndrome
  • Neuronal and capillary lesions in gray matter of brain stem
  • Characterized by delirium, memory loss, confabulation, apathy, apprehension, ataxia, clouding of consciousness, sometimes coma
  • If not treated early with large doses of thiamine, Korsakoff’s Disease may develop
korsakoff s disease
Korsakoff’s Disease
  • Niacin deficiency in addition to thiamine
  • Degeneration of cerebrum and peripheral nerves
  • Characterized by amnesia, confabulation, disorientation, and peripheral neuropathy
  • Commonly observed in chronic brain syndrome
  • Person cannot recall specific aspects of an event
  • Fills in with relevant imaginary information
  • Face-saving device, protects self-esteem
  • Compensates for memory loss
  • Due to lack of access to stored information and lack of new input
  • Inability to form new associations
  • Loss of capacity for introspection and judgment of truth
  • Frequently observed in Korsakoff-Wenicke’s Syndrome
potential nursing diagnoses substance abuse
Potential Nursing Diagnoses: Substance Abuse
  • Altered nutrition
  • Risk for fluid volume deficit
  • Altered thought processes
  • Sensory/perceptual alterations: auditory-visual
  • Sleep pattern disturbance
  • Altered health maintenance
  • Self-care deficit
  • Noncompliance
  • Hopelessness
  • Helplessness
  • Self-esteem disturbance
  •  risk violence to self and others
  • Anxiety
  • Ineffective individual coping
self care deficit
Self-Care Deficit

Ego functioning which does not handle painful affects or maximize protective activity

  • Interventions
    • Provide alternative ways to handle or tolerate painful emotions--stress management
    • Furnish structured supportive environment
    • Increase awareness of unsatisfactory protective behaviors
    • Teach skills to recognize & respond to health-threatening situations

Compton, 1989

pharmacological interventions alcohol abuse
Pharmacological Interventions: Alcohol Abuse
  • Disulfiram (Antabuse)--negative aversive
    • inhibits breakdown of acetaldehyde--toxic to body: if alcohol is ingested causes sweating,flushing,  pulse,  BP, headache, nausea, vomiting, palpitations, dyspnea, tremor, and/or weakness. May cause arrhythmias, MI, cardiac failure, seizures, coma, and death
elements of detoxification process
Elements of Detoxification Process
  • Secure environment
  • Sedation
  • Supplements
pharmacological interventions alcohol abuse cont
Pharmacological Interventions: Alcohol Abuse Cont.
  • Naltrexone hydrochloride (ReVia)--opiod receptor antagonist
    • Increases abstinence and reduces alcohol craving in combination with comprehensive treatment plan
    • May cause liver toxicity at high doses
    • Contraindicated for patients who abused narcotics within 7-10 days
interventions alcohol abuse
Interventions Alcohol Abuse
  • AA Self-Help
  • Brief Interventions
    • Feedback
    • Responsibility
    • Advice
    • Menu
    • Empathy
    • Self-efficacy
  • Moderation-Online Self-Help
  • Motivational interviewing
opioid abuse signs symptoms
CNS Effects



mood changes

mental clouding

pain reduction

pinpoint pupils

decreased respiratory rate

GI Effects

chronic constipation

Cardio Vascular


Sexual Functioning

Decreased libido

retarded ejaculation


orgasm failure


Clonidine (Catapress)

Opioid Abuse: Signs & Symptoms

Townsend, 1996, p. 374

antecedents to relapse
Antecedents to Relapse

Keltner, p. 538

stages of change addictive behaviors
Stages of Change: Addictive Behaviors


Permanent Exit






Prochaska & DiClemente, 1992

treatment of substance related disorders
Trusting therapeutic relationship, nurse

Detox & residential treatment

Behavioral model & disease model





Alcohol-Librium, Valium, Ativan



Family education

Treatment of comorbid medical & psychiatric disorders

Group treatment


Personal responsibility

Conscience development


Life-style issues

Treatment of Substance-Related Disorders
percent of population 15 54 1991 with substance abuse disorder mental or both in lifetime
Percent of Population (15 -54) 1991 With Substance Abuse Disorder, Mental, or Both in Lifetime

Substance Abuse Dependence 12%

Both Disorders 13.7%

Only Mental Disorder 21.4%

Dahme, 1998, p. 288

etiology dual diagnosis
Etiology: Dual Diagnosis
  • Generally mental illness first
    • Heredity
    • Biological factors
  • Self-medicating
  • Substance abuse first
    • Brain chemistry altered
    • Guilt, depression, altered self-esteem
  • Personality disorders
examples of dual diagnoses
Examples of Dual Diagnoses
  • Axis I Schizophrenia

Alcohol abuse

  • Axis I Major depression

Anxiolytic dependency

  • Axis I Major Depression

Marijuana abuse

treatment dual diagnosis
Treatment: Dual Diagnosis
  • Multidisciplinary
  • Case management
  • Individual therapy
  • Group therapy
  • Skills training
  • Education groups
  • Vocational counseling
  • Referrals to community resources
  • Self-help groups
  • Five-step model
therapeutic tasks dual diagnosis
Therapeutic Tasks: Dual Diagnosis
  • Establish therapeutic alliance
  • Help patient evaluate costs and benefits of continued substance abuse
  • Individualize goals for change; include harm reduction as alternative to abstinence
  • Help build an environment and lifestyle supportive of abstinence
  • Acknowledge recovery long-term process

Jefferson, 1998, p. 517

outcomes treatment major depression and alcohol abuse
Outcomes Treatment: Major Depression and Alcohol Abuse
  • Short Term
    • Verbalizes plans for future
    • Sleeps 6-8 hrs/night
    • Eats 3 balanced meals/day
    • Recognizes and describes problems with alcohol and depression
    • Plans to live with non substance user friend
  • Long Term
    • Practices abstinence from alcohol
    • Attends self-help groups
    • Attends outpatient treatment
    • Medication compliant
    • Lives in halfway house or non substance user friend