SUBSTANCE ABUSE AND DEPENDENCE: An Overview

1. SUBSTANCE ABUSE AND DEPENDENCE: An Overview RNSG 2213

2. INTRODUCTION • Substance abuse is not a new problem. • Mood-altering and mind-altering substances have been used throughout human history. • Opium used openly into the 20th century; Freud used Cocaine. • Tribal cultures have e.g. chewed coca leaves, used peyote in religious ceremonies, smoked the “peace pipe.”

3. Which legal drug is the most widely used?

4. Illicit Drug Use • Most used illicit drugs world-wide: • Cannabis (#1) • Amphetamines (& synthetic stimulants) *greatest increase • Cocaine • Opioids World Health Organization 2010 www.who.int_substanceabuse/facts.htm

5. Illicit Drugs: A Global Issue • Economics • Crime • Health • Effects on young people • Environmental effects

6. Illegal Drugs: U.S.A. • CDC www.cdc.gov (2010 report): Persons in U.S. > 12 y/o who in past month: • used illegal drug(s) 8% • used Marijuana6.1% • non-medical use of a psychotherapeutic agent 2.5% (CDC Statistics from 2008)

7. Introduction • No clear transition from therapeutic to abusive substance use • Use is significantly underreported and effects are often misdiagnosed • Much social stigma attaches to abuse and addiction • Implicated in many accidental deaths, crimes • Severe adverse effects on health, work, relationships and quality of life

8. Co-Morbidity with other Mental Disorders: Dual Diagnosis • Shared Risk Factors • Genetic factors • Environmental factors • Similar brain regions affected • Drugs can change the brain • Drug use can induce mental illness • Mental disorders may lead to drug use (“self-medication”)

9. Co-Morbidity With Mental D/O

10. “Vegetable compound” Alcohol content =18% The Bayer Co.’s best-seller Laudanum = 50% opium/50% alcohol

11. Introduction: Drugs and U.S. Law • 1914: Harrison Narcotics Act – Prohibition of non-doctor-prescribed opiates • Alcohol Prohibition in the 1920’s and 1930’s • 1970: Drug Enforcement Agency created; Controlled Substances Act passed • 1987: AMA declared all chemical dependency as disease • 1990: ADA—non discrimination against persons with history of drug/alcohol addiction

12. ADDICTION LIABILITY Highest Lower • cocaine/crack  amphetamines • opiates  anesthetics • nicotine (PCP, ketamine) • alcohol  benzodiazepines  marijuana

13. DEFINITIONS • Intoxication: Substance-specific CNS effects • Substance Abuse: Recurrent use of a drug which results in adverse effects to oneself or others. (e.g. interpersonal, legal or safety issues) • Addiction: (compulsive use of substance = same as substance dependence; term is sometimes considered judgmental )

14. Definitions, cont’d • Chemical/Substance Dependence: Loss of Control over use, which involves: • Tolerance: Must increase the amount of drug to get the needed effect. • Withdrawal: Refers to psychoactive substance-specific syndrome that occurs when person stops using the drug

15. Client 1 states morphine for cancer pain is not working: Dr. writes order for increased dose. Client 2 smokes some marijuana and feels “mellow,” eats junk food. Most nights, Client 3 drinks a 6-pack of beer and falls asleep in front of TV. (Spouse is not happy.) While waiting for more cocaine to be delivered, Client 4 feels very depressed, anxious and is desperate to feel “good” again. A. Substance abuse B. Substancewithdrawal C. Tolerance D. Substance dependence E. Substance intoxication Definitions Matching

16. DSM IV CRITERIA FOR SUBSTANCE DEPENDENCE • Tolerance, Withdrawal • Desires and attempts to cut down • Much time is spent in obtaining drug and recovering from drug • Social and occupational problems result • Substance use continues despite problems caused

17. DSM IV CRITERIA FOR SUBSTANCE WITHDRAWAL • Development of specific symptoms due to cessation of drug • Syndrome causes distress • Symptoms not due to a medical condition

18. Biological Theory: Neurotransmitters of Addiction • Dopamine (DA) –”reward pathway” • Serotonin (SER) • Endorphins (END) • GABA/Glutamate (GLU) Theory: heavy drug use decreases response of “brain calming” neuroreceptors (= tolerance)

19. Etiology of Addiction: Biological Theory • Repeated use of a drug results in stimulation of brain’s “reward” pathway

20. Biological Theory of Addiction cont’d • Repeated use of a drug targets specific brain areas for that drug, with resulting creation of extra receptors and brain’s perception that drug’s stimuli are necessary for survival (cravings)

21. Biological Theory, cont’d • Genetic predisposition • Examples: -Allergic response to ETOH in many Southeast Asians -Twins born to alcoholic parents who are then adopted have 3x rate of becoming alcoholic than children of non-alcoholics who are then adopted.

22. Etiology: Biology + Learning • Drug dependence results from interaction of the physiological effects of substances on brain areas associated with motivation and emotion, combined with ‘‘learning’’ about the relationship between substances and substance-related cues. • This theory gives support to why relapse may occur even after long period of abstinence. (e.g.: smell of cigarette can cause an ex-smoker to light up)

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

24. Etiology: Sociocultural Factors • Advertising • Cultural and religious values • Sex differences: Males abuse alcohol and opioids more. Females abuse prescription drugs • Availability, cost

25. Etiology: Psychological/Psychodynamic Theory • Fundamentally negative view of self • Substances used to escape from anxiety or emotional pain.

26. Personality Traits Associated with Substance Dependence • DENIAL/ anger • Inability to express emotions • High anxiety in interpersonal relations • Emotional immaturity • Ambivalence towards authority; rule breaker • Low frustration tolerance; wants instant gratification

27. Personality Traits, continued • Low self-esteem • Feelings of isolation • Overdependence/lack of autonomy • Perfectionism and compulsiveness • Sex role confusion Are these qualities the cause or the result of drug use?

28. Effects on Family • All family members affected by the substance-dependent member. • Many characteristic behaviors: • Focus of family life = the addict’s behavior • Co-dependency • Care-taking by children • Perpetuation of these dynamics into adulthood • Family in need of treatment

29. http://www.youtube.com/watch?v=mwq0wxZg87g http://www.youtube.com/watch?v=u0ugTOXv0Y4

30. ASSESSMENT • Denial complicates assessment • Use screening tools, e.g. MAST • Careful history: occupational, legal, behavioral alterations • Physical Assessment: substance specific signs and symptoms • Urine and serum drug screens; breathalyzer (alcohol)

31. Short version of Michigan Alcoholism Screening Test (SMAST) > 3 points indicates problem

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

33. Principles of Detoxification Avoids life-threatening withdrawal signs and symptoms but also avoids intoxication with the withdrawal medications. The goal is not absolute comfort. Objective measures of withdrawal (vital signs, observable findings, withdrawal rating scores)are very useful for monitoring the course of withdrawal and supplementing the subjective data from the client.

34. Nursing and Milieu Interventions • Examine own attitudes about substance use and dependence Provide: • Safe environment for client in withdrawal • Empathy and acceptance • Hope for recovery • Group therapy: to deal with denial and provide support for change • Treatment for co-occurring mental illness

35. Client Behaviors and Nursing Interventions for: • Anger: matter-of-fact approach • Guilt and shame: non-judgmental support; offer positive feedback for help-seeking behaviors • Denial and Avoiding Responsibility: supportive confrontation • Manipulation: set limits and clear rules. • Cravings: provide support, teaching and encourage talking with peers.

36. Client: “You all are a bunch of do-gooders who are getting paid to act like you care but you don’t. “ Client: “I want to talk to the dr. now! This dose he ordered is ridiculous—it won’t do anything for my headache. I know the amount I need.” Client: “I feel like I’ve let my whole family down by drinking again.” Client: “You have never used drugs, so you cannot possibly understand my situation.” Nurse:“Your bad attitude is sabotaging your treatment.” Nurse: “Right now this is what the dr. ordered for your headache.” Nurse: “I feel for you. Alcohol does terrible things to a family.” Nurse: “That may be true. But I can see that you are having a rough time.” Nurse-Client Communication: Effective?/Ineffective?

37. Interventions: Client and Family Teaching • Disease process • Total abstinence is the goal • Relapse is part of recovery • Relapse prevention strategies • Recognize and confront own denial • Recognize triggers • “Change people, places and things.” • Often biggest obstacle to abstinence.

38. Client: “I don’t know why I started using again, I guess I just can’t stay clean.” Client: “Ever since I stopped drinking, my friends say I’m no fun.” Client: “I started drinking again because my boyfriend stressed me out.” Nurse: “Write down everything you remember about that day. Triggers may not always be obvious.” Nurse: “It’s time to consider who your friends really are.” Nurse: ________________ Relapse Prevention/Recovery

39. Interventions: Referrals and Community Resources • Long-term residential rehabilitation is best predictor of abstinence (28 days to 6 months or more) • Halfway House • Outpatient rehabilitation • AA, NA, Rational Recovery • Family counseling • Al-Anon, Nar-Anon, Alateen • Other services: job placement, housing, etc.

40. Legal-Ethical: The Chemically Dependent Nurse • Required to report impaired colleague to Board of Nursing • Nursing resources in TX: • TPAPN (Texas Peer Assistance Program for Nurses) www.tpapn.org

41. Addiction Recovery Awareness