Substance-Related

Disorders
The Dynamics of Substance-
Related Disorders
Discuss causes for substance-related
disorders.
Define intoxication, withdrawal, tolerance,
and dependence.
Identify symptoms related to these
disorders.
Apply the nursing process to treatment
planning, including health teaching.
Describe relevant treatments.

Learning Objectives
Maladaptive pattern of substance use
manifested by recurrent and significant
adverse consequences related to repeated
use of the substance.
Impairment or distress manifested by one
or more of the following, occurring within
a 12-month period:
1. Failure to fulfill major role obligations at
work, school, or home

Substance Use Disorder

2. Recurrent substance use in situations
that are physically hazardous
3. Recurrent substance-related legal
problems
4. Continued use despite persistent
relational problems caused by or
exacerbated by the effects of the substance

Substance Use Disorder

Physical dependence evidenced by cognitive,
behavioral, and physiological symptoms,
with continued use despite problems
Repeated use requires continued use of
substance to prevent unpleasant withdrawal
symptoms
Tolerance: need for increasingly larger or
more frequent doses to obtain desired
effects originally produced by a lower dose

Substance Dependence & Tolerance

Addictive substances activate dopamine
transmission, causing “cue-sensitivity,” or
the overwhelming urge to use the
substance when presented with the
stimulus.
This explains the high rate of first-year
relapse.

Addictive Quality of Substances

Reversible drug-specific syndrome following
excessive use of a substance.
Symptoms are not due to a general medical
condition or another mental disorder.
Symptoms occur during or shortly after the
ingestion of a substance.
There is a direct effect on the central
nervous system, with disruption in physical
and psychological function.

Substance Intoxication
Occurs upon abrupt reduction or
discontinuation of a substance used
regularly over a period of time.
Clinically-significant physical and
psychological s/s present (disturbances in
thinking, feeling, and behavior).
Physiological and mental readjustment
occurs due to stopping an addictive
substance.

Substance Withdrawal
Alcohol
Caffeine
Cannabis
Hallucinogens
Inhalants
Opioids
Sedatives, hypnotics, anxiolytics
Stimulants
Tobacco

Classes of Psychoactive Substances

Genetics: children of alcoholics are 4x more
likely to become alcoholics (Amer. Academy of
Child & Adolescent Psychiatry, 2011).
Twin studies support the genetic hypothesis:
higher rate for identical twins.
Biochemical: alcohol may produce morphine-
like substances in the brain responsible for
alcohol addiction: reaction of dopamine &
serotonin with metabolic products of alcohol
(acetaldehyde).

Biological Factors: Alcohol Use

Disorder
Developmental influences: psychodynamic
theory of punitive superego to diminish
unconscious anxiety and increase feelings
of self-worth (Sadock & Sadock, 2007).
Personality traits: low self-esteem,
depression, passivity, inability to defer
gratification; antisocial personality.

Psychological Factors
Sociallearning: modeling behavior, imitation
from early childhood onward.
Conditioning: pleasurable experience of using
a specific substance (reinforcing properties).
Cultural influences: Native American culture
mortality rate twice that of general population
(Indian Health Service, 2012); Northern
Europeans.
Asian cultures: possible genetic intolerance to
alcohol

Sociocultural Factors
2/3 of U.S. population 12 years and older
consume alcohol (23% binge drink, 6.7%
engage in heavy alcohol use.
Alcohol is 3rd leading cause of preventable
death in the U.S.
Alcohol is a factor in heart disease,
cancer, and stroke; homicides, suicides,
and traffic accidents.

Epidemiology
50% of full-time college students binge
drink or use on a monthly basis.
60% of convicted homicide offenders
drank just before committing the crime.
Strong association between sexual
violence and alcohol (up to 90% of
convicted rapists are drunk at the time of
the offense).

Epidemiology
Classified as a food since it contains
calories.
Natural substance formed by the reaction
of fermenting sugar with yeast spores.
Content differs by type of beverage.
Exerts a depressant effect on the CNS,
causing behavioral and mood changes.
Effects of alcohol on CNS are proportional
to blood concentration levels.

Profile of Alcohol
Measured by blood, urine, saliva, or breath
tests.
Negative: no alcohol detected.
Lower limit of detection: 80mg/dL: positive
for driving under the influence in all states.
>300-400 mg/dL: potentially fatal.
Blood alcohol concentration: convert serum
ethanol level to BAC: move decimal point 3
places to the left.

Ethanol Levels
1. Pre-alcoholic phase: used to relieve
everyday stress; tolerance develops.
2. Early alcoholic phase: blackouts;
dependency occurs; denial and rationalization.
3. Crucial phase: physiological addiction is
evident; loss of control; binge drinking; person
becomes ill and drinking is the total focus.
4. Chronic phase: emotional and physical
disintegration; intoxication is prevalent.

Jellinek’s Phases of Alcohol

Addiction
Generalized depression of CNS
Peripheral neuropathy
Alcoholic myopathy
Alcoholic cardiomyopathy
Esophagitis
Gastritis
Pancreatitis
Alcoholic hepatitis
Cirrhosis

Physiological Complications of
Alcohol
Leukopenia: abnormally low WBCs
Thrombocytopenia: impaired platelet
production and survival
Sexual dysfunction
Fetal alcohol spectrum disorders
Small size for gestational age (0.2-1.5 per
1000 live births) (CDC, 2015).

Complications from Alcohol

Most serious form of thiamine
deficiency in alcoholics.
Death will occur without thiamine
replacement.
Characterized by diplopia, ataxia,
somnolence, stupor, paralysis of ocular
muscles.

Wernicke’s Encephalopathy
Syndrome of confusion, loss of recent
memory, and confabulation in alcoholics
(falsification of memory).
Frequently encountered in clients recovering
from Wernicke’s encephalopathy.
Wernicke-Korsakoff syndrome: both
disorders are considered together in the U.S.
Treatment includes parenteral or oral
thiamine replacement.

Korsakoff”s Psychosis
Prenatal exposure can result in a broad
range of disorders to the fetus (FASDs).
Most common is fetal alcohol syndrome
(FAS): physical, mental, behavioral, learning
disabilities with lifelong complications
Problems with memory, attention span,
communication, vision, hearing
No amount of alcohol during pregnancy is
safe (Carmona, 2005).

Alcohol Use During Pregnancy

Neuro-imaging of children with FAS shows
abnormalities in the size and shape of
brain structures.
Frontal lobes and cerebellum are smaller.
Increased incidence of ADHD, mood
disorders, anxiety disorders, drug and
alcohol dependence, eating disorders.
Alcohol consumption should be part of
every nursing assessment.

Alcohol Use During Pregnancy

Peripheral nerve damage results in pain,
burning, tingling, or prickly sensations of
the extremities.
Direct result of vitamin B deficiencies,
particularly thiamine.
Toxic effect of alcohol results in
malabsorption of nutrients.
Permanent muscle wasting and paralysis
can occur with continued use.

Peripheral Neuropathy
Acute or chronic condition.
Sudden onset of muscle pain, swelling,
weakness; reddish tinge in urine
(myoglobin); rapid rise in muscle
enzymes (CPK), (LDH), (AST).
Gradual wasting and weakness in skeletal
muscles.

Alcoholic Myopathy
Caused by an accumulation of lipids in the
myocardial cells, resulting in enlargement.
Weakening of the cardiac muscle.
Clinical findings: congestive heart failure,
arrhythmias.
Decreased exercise tolerance, tachycardia,
dyspnea, edema, palpitations, and non-
productive cough.
Elevation of CPK, AST, ALT, and LDH.
Changes seen on ECG; chest x-ray.

Alcoholic Cardiomyopathy
Mood lability (euphoria, irritability).
Disinhibition of sexual and aggressive
impulses.
Impaired social and occupational
functioning, including poor judgment.
Slurred speech
Ataxia, unsteady gait
Nystagmus
Flushed face

Symptoms of Alcohol Intoxication

Begins within 4-12 hours of cessation of, or
reduction in heavy and prolonged use.
Coarse tremors of hands, tongue, or eyelids
Nausea, vomiting
Malaise, weakness
Tachycardia, sweating
Elevated blood pressure
Anxiety, depressed mood, irritability
Transient hallucinations or illusions
Headache, insomnia

Symptoms of Alcohol Withdrawal

Complicated withdrawal syndrome
Known as delirium tremens (DTs)
Onset on 2nd or 3rd day following cessation
of or reduction in prolonged, heavy
alcohol use.
Ultimate level of CNS irritability
Extreme motor agitation
Grand mal seizures can occur

Alcohol Withdrawal Delirium

ClinicalInstitute Withdrawal Assessment
of Alcohol Scale, revised (CIWA-Ar):
maximum score = 67
Michigan Alcoholism Screening Test
(MAST): 4 points = possible problem; 5
points = problem with alcohol
CAGE Questionnaire: 2 or 3 “yes” answers
suggest a problem with alcohol

Nursing Assessment Tools

10-item rating scale that discriminates
symptoms of gastric distress, tremor,
paroxysmal sweats, anxiety, agitation,
tactile disturbances, visual disturbances,
headache/fullness in head, and
orientation/clouding of sensorium.

CIWA
C: Have you ever felt you ought to CUT
down on your drinking?
A: Have people ANNOYED you by
criticizing your drinking?
G: Have you ever felt bad or GUILTY
about your drinking?
E: Have you ever had a drink first thing in
the morning to steady your nerves or get
rid of a hangover (EYE-OPENER)?

The CAGE Questionnaire

Disulfiram (Antabuse): acts as a deterrent to
drinking; produces symptoms of extreme discomfort;
interferes with metabolic process of alcohol and stops
production of acetyldehyde into acetic acid; symptoms
of a reaction can occur within 5-10 minutes of
ingestion of alcohol; abstinence from alcohol for a
minimum of 12 hours before taking Antabuse; if
discontinued, sensitivity to alcohol can last for 2
weeks.
Contraindicated for clients with cardiac, renal, hepatic
disease.
Be aware of products containing alcohol.

Pharmacotherapy for Alcoholism

Chest pain
Flushed skin
Severe headaches
Respiratory distress
Dizziness
Nausea and vomiting
Diaphoresis
Hypotension
Blurred vision
Confusion

Symptoms of Alcohol Use with

Antabuse
Naltrexone HCl(ReVia, Duramed):
1. Opioid antagonist: treatment of alcohol and
opioid dependence
2. Does not produce a “narcotic high” and is not
habit forming.
3. Decreases cravings for alcohol; blocks effects
of opioids.
4. Contraindicated in acute hepatitis, liver failure.

Injectable forms: Vivitrex, Vivitrol

Pharmacotherapy for Alcoholism

Acamprosate calcium(Campral):
1. Approved by FDA in 2004.
2. Clients are abstinent at initiation of
treatment.
3. Thought to restore the balance of neuron
excitation and inhibition by interacting
with glutamate and GABA
neurotransmitter systems.

Pharmacotherapy for Alcoholism

Benzodiazepines: Substitution Therapies
Chlordiazepoxide (Librium)
Diazepam (Valium)
Lorazepam (Ativan)
Oxazepam (Serax)
Start with higher doses depending on symptoms and
reduce dosage until withdrawal is complete
Additional doses for breakthrough s/s
Shorter-acting benzos for those with liver disease
Anticonvulsants: Tegretol, Depakote, Neurontin
Thiamine replacement, multivitamins, minerals

Pharmacotherapy for Alcohol

Withdrawal
Follow hospital protocol
Implement safety measures
Continuous vital sign monitoring
Thiamine replacement
CIWA
Neuro checks
Possible bedrest, IV fluids
Fall precautions

Nursing Actions: Withdrawal

CNS depressants:
1. Barbiturates: Nembutal, Seconal,
Amytal, Tuinal, Phenobarbital,
Butabarbital
2. Nonbarbiturate hypnotics: Halcion,
Chloral hydrate, Dalmane, Restoril, Doral
3. Anxiolytics: Valium, Librium, Serax,
Xanax, Ativan, Tranxene, Rohypnol
4. Dependency and tolerance issues

Sedative, Hypnotic, Anxiolytic

Related Disorders
Cause CNS depression from mild sedation
to death
Depress activity of brain, neurons,
muscles, heart tissue, renal function
Reduce rate of metabolism
Barbiturates cause rebound insomnia and
increased dreaming during withdrawal
Respiratory depression, hypotension,
decrease in libido

Physiological Effects of Sedatives,

Hypnotics, and Anxiolytics
Intoxication: sexual or aggressive behavior,
mood lability, impaired judgment, impaired
social and occupational functioning, slurred
speech, inccordination, unsteady gait,
nystagmus, memory impairment, stupor or coma
Withdrawal: onset depends on drug; short-acting
benzo can produce s/s within 6-8 hours of
decreased blood levels; autonomic activity; treat
with long-acting benzos, phenobarb (Luminal)

Sedative, Hypnotic, Anxiolytic

Intoxication and Withdrawal
Amphetamines/stimulants/cocaine (crack)
Caffeine/nicotine
Excite nervous system
Tremors, anorexia, insomnia, agitation,
increased motor activity
Alertness, elation, euphoria
Chronic use causes compulsive behavior,
paranoia, hallucinations, aggression
Hypertension, tachycardia, n/v

Stimulant-Related Disorders
Amphetamine and cocaine: euphoria, affective
blunting, changes in social behavior, hypervigilance,
anxiety, anger, impaired judgment, tachycardia or
bradycardia, pupillary dilation, high or low B/P,
diaphoresis, chills, n/v, weight loss, psychomotor
agitation or retardation, muscle weakness, respiratory
depression, chest pain, arrhythmias, confusion,
seizures, tremors, coma
Caffeine: excess of 250mg
Treatment includes Librium and Haldol
Occurs during or shortly after use of substance

Stimulant Intoxication
Develops within a few hours to several days
after cessation of, or reduction in, heavy and
prolonged use
Dysphoria, fatigue, vivid unpleasant dreams,
insomnia or hypersomnia, increased appetite,
psychomotor retardation or agitation
Crashing: follows intense, high-dose use:
requires several days of rest
Treatment aimed at reducing craving and
managing depression

CNS Stimulant Withdrawal

Watch for seizures
Nutrition and hydration
Sleep, quiet environment
Benzodiazepines
Antidepressants (desipramine)

Nursing Care for Stimulant

Withdrawal
Inhalation of hydrocarbons found in fuels,
solvents, adhesives, aerosol propellants,
and paint thinners; huffing, bagging
Examples: gasoline, lighter fluid, glue,
cleaning fluids, spray paint, typewriter
correction fluid
Readily available, legal, inexpensive
Highest use ages 12-17
Mild withdrawal syndrome documented

Inhalant Use Disorder

Absorbed through the lungs and reach CNS rapidly
Acts as a depressant
Effects last from several minutes to a few hours
CNS and peripheral nervous system damage: neuro
deficits, cerebral atrophy, cerebellar degeneration
Pulmonary hypertension, acute respiratory distress,
sinus disorders, asphyxia
Abdominal pain, n/v, rash around nose and mouth
Chronic renal failure

Effects of Inhalants on Body

Maladaptive behaviors or psychological changes
(belligerence, assaultiveness, apathy, impaired
judgment, social and occupational impairment
2 or more s/s are present: dizziness, nystagmus,
incoordination, slurred speech, unsteady gait,
lethargy, depressed reflexes, psychomotor
retardation, tremor, muscle weakness, blurred
vision, diplopia, stupor or coma
Intoxication occurs within 5 minutes of inhalation;
s/s last 60-90 minutes
No antidotes

Inhalant Intoxication
Opium, heroin, morphine, codeine,
fentanyl, methadone, dilaudid, percodan,
oxyContin, vicodin, talwin
Sedative and analgesic effects
Pain relief and management
Addictive
Promote pleasurable effects on CNS:
physiological and psychological addiction

Opioid Use Disorder

CNS: euphoria, mood lability, mental
clouding, drowsiness, pain reduction, pupillary
constriction, depression of respiratory centers
and cough center (medulla)
G.I.: increase in stomach and intestinal tone,
diminished peristalsis, decrease in food
movement through G.I. tract, constipation
and fecal impaction
CV: causes hypotension at high doses
Decreased sexual functioning and libido

Effects of Opiates on Body

Initialeuphoria followed by apathy,
dysphoria, psychomotor agitation or
retardation, impaired judgment
Pupillary constriction (or dilation due to
anoxia from severe overdose), drowsiness,
slurred speech, impaired memory and
attention
Can lead to respiratory depression, coma,
and death
Treated with narcotic antagonists

Opioid Intoxication
Dysphoric mood, cravings, n/v
Muscle pain, rhinorrhea, lacrimation,
pupillary dilation
Diaphoresis, abdominal cramping,
diarrhea, yawning, fever, insomnia,
piloerection
Heroin w/d: s/s occur within 6-8 hours
after the last dose, peak within 1-3 days,
subside over 5-10 days

Opioid Withdrawal
Methadone w/d: s/s occur within 1-3 days
after last dose, peak between 4-6
days,and are complete within 14-21 days
Clonidine used for methadone withdrawal
Buprenorphine (Suboxone): used for those
struggling with addiction to narcotics;
does not cause “high”; relieves w/d
symptoms and reduces cravings; contains
naloxone to guard against misuse

Opioid Withdrawal
Vital signs
Fluids
Nutrition
Quiet environment, sleep
IV fluid support as needed
Seizure precautions
Meds to decrease symptoms (Naltrexone,
Clonidine, Buprenorphine)

Nursing Care of Opioid Withdrawal

Naturally-occurring: mescaline,
mushrooms
Synthetics: LSD, PCP, MDMA, MDA
No evidence of physical dependence or
withdrawal, but psychological dependence
occurs
Flashbacks, “bad trips”
Distorts perception of reality
Induces visual hallucinations

Hallucinogen Use Disorder

Nausea, vomiting, chills, pupil dilation
Increased pulse, blood pressure, respiration,
temperature
Tremors, incoordination
Loss of appetite, elevation in blood sugar
Diaphoresis, insomnia
Heightened response to color, texture, sounds
Distortion of vision
Derealization, depersonalization
Increased libido

Effects of Hallucinogens on Body

Maladaptive responses occur within
minutes to a few hours
Delusional thinking
Marked anxiety, depression
Fear of “losing one’s mind”
Paranoia, impaired judgment
Illusions, hallucinations
Blurring of vision, tremors, ataxia, dilated
pupils

Hallucinogen Intoxication
PCP intoxication: occurs within an hour of
use: psychosis, assaultive behaviors,
hypertensive crisis, cardiac event, muscle
rigidity, ataxia, seizures, respiratory arrest,
hyperthermia, paranoia, severe violence
Delirium can occur within 24 hours after PCP
use or up to a week following recovery
Valium, Haldol

Hallucinogen Intoxication
2nd to alcohol as the most widely used drug in the
U.S.
Major ingredient is THC
Marijuana produces greater amount of tar than its
equivalent weight in tobacco
Causes decrease in serum testosterone levels, failure
to ovulate, abnormalities in sperm count and motility
Mood changes range from euphoria to panic and
paranoia
Amotivational syndrome
Psychological dependence and tolerance can occur

Cannabis Use Disorder

Occurs during or shortly after use
Oral ingestion is more slowly absorbed,
with longer-lasting effects
Anxiety, suspiciousness, sensation of
slowed time, impaired judgment, social
withdrawal, tachycardia, increased
appetite, visual and tactile hallucinations
Impaired motor coordination (8-12 hours)

Cannabis Intoxication
Syndrome of symptoms occurring upon
cessation of heavy and prolonged use.
Irritability, anger, aggression
Nervousness or anxiety
Sleep difficulty
Decreased appetite or weight loss
Restlessness
Depressed mood
Physical symptoms: tremors, sweating, fever,
chills, headache, abdominal pain

Cannabis Withdrawal
Self-assessment of personal feelings re.
substance-related disorders
Assessment: comprehensive drug history,
biopsychosocial assessment, mental
status exam; use assessment tools
Determine presence of co-occurring
mental illness (dual diagnosis)
Identify nursing diagnoses by analyzing
data collected during assessment process

Nursing Process
Outcomes should be realistic, measurable,
and time-limited
Address nursing diagnoses and problem
statements: establish short and long-term
goals
Short-term goals focus on medical and
psychological stabilization
Long-term goals focus on recovery,
prevention of relapse

Nursing Process
May include detox protocol depending on
substance
Assess level of safety: institute appropriate
precautions, including seizure and falls
May need to implement suicide precautions;
remove harmful objects
Monitor vital signs, mental status, physical
symptoms; assist with ambulation; quiet
environment; orientation; nutrition and
hydration support

Planning and Implementation

Develop a therapeutic alliance with client
Convey an attitude of acceptance
Explore alternative coping mechanisms
Provide health teaching: effects of
substance abuse on physical and mental
status
Review family history and enabling
behaviors
Provide positive reinforcement for insight

Planning and Implementation

Has detox occurred without complications?
Is the client still in denial and rationalizing
behavior?
Does the client accept responsibility for behavior?
Has the client remained substance-free during
hospitalization?
Can client verbalize alternative coping strategies?
Has nutritional status been restored?
Does client verbalize plans for the future?

Evaluation
Treatment is an ongoing, lifelong process
Abstinence is the goal
Recovery is a dynamic process that takes
into account the possibility of relapse
Success depends on the client’s
motivation
Participation in 12-Step programs
Client/family education

Recovery Process
An estimated 10-15% of nurses are
chemically-dependent
Alcohol is the most widely abused drug
followed by narcotics
Ethical duty to report
Factual documentation of specific events
Support from supervisor

Chemically Impaired Nurse

High absenteeism
Increase in “wasting” of drugs
High incidence of incorrect narcotic counts
Poor concentration
Problems with relationships
Irritability, mood swings
Tendency to isolate
Inconsistent job performance
Frequent use of restroom

Clues of Impairment
Unkempt appearance
Medicating other nurses’ patients
Patient complaints of inadequate pain
control
Discrepancies in documentation
Impaired motor coordination
Slurred speech
Flushed face

Clues of Impairment
Can deny, suspend, or revoke licensure
Diversionary laws: agreement to seek
treatment
Removed from practice during treatment
May be required to practice under specific
conditions for a prescribed time period
ANA national resolution, 1982: provision
of treatment programs for impaired
nurses (peer assistance programs)

State Board Actions