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MENTAL HEALTH NURSING

Topic 15:
Substance Abuse

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Substance Abuse

• Depressants
• Cannabis
• Opioids
• Alcohol
• Stimulants: Drugs, Solvents, Nicotine
• Hallucinogens

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DRUGS ABUSE

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Learning Outcome
At the end of the lecture, students will be able to:

1. recognize clients with the characteristics of a

drug dependent.
2. explain the roles of nurses in care management
and prevention of drugs and hallucinogenic
substance abuse.
3. recognize methods of treatment clients with
the characteristics of a drug dependent.
4. explain the role of nurses in handling patient
with withdrawal symptoms.
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Substance Abuse

Definition:

Substance abuse is indicated by a pattern

of pathological use (due to a physical or mental
disease) for at least 1 month, associated with
impairment in social and occupational
functioning.

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Pattern of pathological use:

1. Intoxication throughout the day.

2. Inability to cut down or stop.
3. Repeated efforts to control use through periods
of temporary abstinence / restriction of use to
certain times of the day.
4. Continuation of use despite serious physical
disorder caused the by substance abuse.
5. Episodes of a complication of substance
intoxication.
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Substance dependence
It requires physiological dependence evidenced by
either tolerance  or withdrawal.
• Tolerance:
Markedly increased amounts of the substance are
required to achieve the desired effect
• Withdrawal:
A substance specific syndrome follows reduction in
intake of a substance to induce physiological state
of intoxication
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Substance dependence
• HABITUATION
A desire to take the drug, detrimental to individual only,
without need to increase the dose or frequency and not
followed by physical withdrawal symptoms

• ADDICTION
A state of periodic or chronic intoxication, detrimental
(harmful) 
to the individual & society, produced by repeated
consumption of a
drug (natural or synthetic)

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Predisposing factor

• Individual characteristics
• Drug availability
• Society influence

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Individual characteristics
• Hostility • Low religiosity
• Social non-conformity • Concern with
• Low self-esteem personal autonomy
• Depressive feelings • Lack of interest in
• Sensation seeking conventional
• Curiosity institutions goals
• Antisocial personality
• Low
traits
frustration tolerance
• Presence of
• Need for
various psychiatric
immediate gratification disorders
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Society influence

• Peer pressure
• Unemployment, low income
• Knowledge deficit of drug effects or sources
information
• Abuse of socially acceptable drugs
• Lacking in legal system

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Drug availability

• Pharmacodynamic characteristics (stimulants
are preferred)
• Amount & frequency (drugs needed in less
quantity are preferred)
• Routes of administration (ingestion &
inhalation drugs are preferred)
• Ready availability & cost
• Public acceptance of drug
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Example of addictive drugs
1. Opium derivatives 
(e.g. Morphine, Heroin, Pethidine, Barbiturates)

• Causes strong physical dependence (Compulsion to continue

drug and obtain by any means)

• Development of tolerance - ↑ dose

• Withdrawal symptoms appear few hours after last dose, reaching

peak in 24 – 58 hours and subsides spontaneously in 10 days

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Example of addictive drugs
2. Amphetamines 
(e.g. Adderall, Dexedrine, (treat Attention deficit
hyperactivity disorder (ADHD),  methamphetamine, ecstasy
(recreational use)

• Causes chronic intoxication features such as: anorexia,

nervousness, insomnia, tremors, weight loss, hallucinations

• Sudden withdrawal
 Somnolence - a strong desire for sleep
 apathy
 inertia

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Example of addictive drugs
3. Cocaine – powerful stimulant
(e.g. street name coke, crack, snow)

• Causes euphoria, excitement, pleasurable effect (short

duration)

• After euphoria - ↑ anxiety & fear, sometimes

with hallucinations & paranoid delusions

• Unpleasant effect is more marked if drug is

taken intravenously.
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Example of addictive drugs
4. Cannabis (Marijuana) – intoxicant

• Smoked – effect in a few minutes

• Eaten – effect in ½ - 1 hr. Lasts 5 – 12 hrs.

• Causes: 
 Feeling of power
 Distortion of time & space
 ↑ appetite for food
 ↑ auditory sensitivity

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Opium withdrawal

• Can be categorized as mild, moderate,

moderately severe and severe.

• Evaluating your opioid use history and

symptoms, and by using diagnostic tools like
the Clinical Opiate Withdrawal Scale.

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Opium withdrawal 
• Early symptoms typically begin in the first 24
hours after stop using the drug:

 muscle aches
 restlessness
 anxiety
 lacrimation (eyes tearing up)
 runny nose
 excessive sweating
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Opium withdrawal 
• Later symptoms, which can be more intense, begin
after the first day or so:

 diarrhoea
 abdominal cramping
 goose bumps on the skin
 nausea and vomiting
 dilated pupils and possibly blurry vision
 rapid heartbeat
 high blood pressure
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Opium withdrawal 
• Babies born to mothers who are addicted to or
have used opioids while pregnant often
experience withdrawal symptoms as well. 

 digestive issues
 poor feeding
 dehydration
 vomiting
 seizures
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What causes opium withdrawal? 

• Take opioid medication for a long time, body

becomes desensitized to the effects. 

• Over time, your body needs more and more of

the drug to achieve the same effect. 

• very dangerous and increases risk of accidental

overdose.
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What causes opium withdrawal? 
• Prolonged use of these drugs changes the way nerve
receptors work in your brain, and these receptors
become dependent upon the drug to function.

•  If become physically sick after stop taking an opioid

medication, an indication of  physically dependent on
the substance. 

• Withdrawal symptoms are the body’s physical response

to the absence of the drug.
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What causes opium withdrawal? 
• Many people become dependent on these
drugs in order to avoid pain or withdrawal
symptoms. 

• In some cases, people don’t even realize that

they’ve become dependent. They may mistake
withdrawal for symptoms of flu or other
conditions (feeling sick)

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Management 
Treating the drug addict:

• Hospitalization
• Withdrawal of drugs
• Detoxification
• Administration of Vitamins & Painkillers
• Supportive psychotherapy
• Family therapy
• Rehabilitation
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MANAGEMENT OF OPIOIDS USE
DISORDER
• A synthetic analgesic drug with potency equal to that of morphine,
but narcotic action is weaker than morphine. 

• It is a habit-forming agent, and its use should be carefully

supervised. 

• Used experimentally in treatment of drug dependence due to use

of opium derivatives. 

• Trade names are Dolophine HCl or Methadone HCl (Hydrochloride)

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MANAGEMENT OF OPIOIDS USE
DISORDER
1. Substitution or Maintenance Therapy 

Methadone hydrochloride 
 Dosage: 
 20 – 40mg on first day with gradual increase
up to 120mg/day
 Then gradually decrease 10% per week until
10 – 20mg range
 Then decrease 3% per week
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MANAGEMENT OF OPIOIDS USE
DISORDER
2. Opioid detoxification & abstinence:
After patient stabilized on Methadone (20mg/day)

a) Shifted to Clonidine 
• 0.1 – 0.3mg twice daily for 2 days
• then 0.2 – 0.7mg daily on for 8 – 14 days 
• then discontinue slowly

b) Naltrexone 
• 25 – 50mg daily for 5 – 10 days
• then 100 –150mg 3X a week
• then decrease gradually

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Detoxification

• The primary objective of detoxification is

to remove accumulated toxins in the body,
which is deposited after the drug use. 

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PROGNOSIS DEPENDS ON:

• Good pre-morbid personality

• No identifiable stresses
• No psychiatric problems
• Newly & highly motivated addict
• Intake of one drug & in lesser doses
• Good family support

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INDICATIONS OF HOSPITALIZATION

• Chronic IV use.
• Concurrent dependency on other addictive
drugs or alcohol.
• Serious medical or psychiatric problems.
• Severe impairment of psychosocial functioning.
• Insufficient motivation or failure of outpatient
treatment.
• Lack of family supports.
• Free access to drug.

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ALCOHOL ABUSE

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Learning Outcome
At the end of this lecture the students should be able to:
1. list the types of alcohol abuse
2. explain the phases in alcohol dependence
3. explain the risk factors for alcohol abuse
4. recognize clients with the characteristics
of a alcohol related disorders
5. Explain the complications of alcohol abuse
6. explain the roles of nurses in care management and
prevention of alcohol abuse

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Type of alcohol

• Wine (from grapes)

• Beer (from grain & hops)
• Whisky (from grain & corn)
• Rum (from sugarcane)
• Vodka (from potatoes & grain)
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PHASES IN ALCOHOL DEPENDENCE
a. Pre-alcoholic symptomatic phase:

• Start out drinking in conventional social

situations & experiences rewarding relief from
tension.

• Gradually tolerance to tension decreases to

extent that he resorts to alcohol almost daily.

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PHASES IN ALCOHOL DEPENDENCE
b. Prodromal phase:

Sudden onset of blackouts, signs of intoxication

& no memory of events.

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PHASES IN ALCOHOL DEPENDENCE
c. Crucial phase:

Loss of control over drinking, increase isolation

& to further centering of his behavior around
alcohol.

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PHASES IN ALCOHOL DEPENDENCE
d. Chronic phase:

• Intoxicated during anytime on weekday & marked

impairment in thinking process.

• Alcoholic psychoses e.g delirium tremens.

• Fail of rationalizations & vague religious desires.

• Become amenable (open to suggestion) to treatment.

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RISK FACTORS
1. Biological factors:
• Family history of alcoholism
• Develops at early age & is severe after
requiring treatment
2. Biochemical factors:
• Genetically determined deficiency of brain
neurotransmitter (Endorphins)

3. Psychological & interpersonal factors:

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Characteristics of an alcohol related disorder

Early warnings of alcohol dependence:

1. Increase consumption of alcohol.

2. Frequent desire to take alcohol.
3. Extreme behaviour (performing acts under the
influence of alcohol which leave him guilty &
embarrassed the next day).
4. Blankness about episodes.
5. Morning drinking.
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Characteristics of an alcohol related disorder

Other characteristics:

1. Red palms.
2. Cigarette burns between index & middle finger.
3. Weakness in feet & legs.
4. Upper abdominal pain.
5. Tremulousness – shaking.
6. Forgetfulness.
7. Loss of appetite & sleep on stopping alcohol.
8. Hematemesis.

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Complications (Acute or short term effects):

1. Nervous system depression.

2. Decrease efficiency of heart & pancreatitis.
3. Gastric ulcer.
4. Cirrhosis of liver.
5. Decrease body immunity.

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Complications (Long term effects):
1. Korsakoff’s psychosis - amnestic disorder.
2. Dementia.
3. Hepatitis & Liver failure.
4. Polyneuritis.
5. Hemiparesis Marchiafava’s Syndrome (demyelination of
corpus callosum & optic tract).
6. Cardiomyopathies.
7. Silvestrini Corda Syndrome (cirrhosis, testicular atrophy,
breast enlargement/gynecomastia).
8. Skin diseases (eczema, dermatitis,
Acne rosacea, furunculosis or hair infection).
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Complications (Psychological effects):

• Anxiety, depression, paranoia, morbid jealousy

(delusional jealousy).

• Organic mental disorders.

• Individualized symptoms (intoxication,

withdrawal, seizures, chronic
alcoholic hallucinosis).
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Complications (Social effects):

• Increase accident cases, job troubles, marital

separation & financial problems.

• Increase crimes.

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Complications (Pregnancy effects):

• Fetal Alcohol Syndrome.

• Growth retardation before & after birth.

• Abnormal features of face & head (small head

or flat facial).

• Central Nervous System abnormalities.

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Fetal alcohol syndrome

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Fetal alcohol syndrome

• Fetal alcohol syndrome is a condition in a child

that results from alcohol exposure during the
mother's pregnancy. Fetal alcohol syndrome
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causes brain damage and growth problems.

• The severity of fetal alcohol syndrome symptoms

varies, with some children experiencing them to
a far greater degree than others.

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Physical defects
• Distinctive facial features, including small eyes, an
exceptionally thin upper lip, a short, upturned nose,
and a smooth skin surface between the nose and
upper lip.
• Deformities of joints, limbs and fingers.
• Slow physical growth before and after birth.
• Vision difficulties or hearing problems.
• Small head circumference and brain size.
• Heart defects and problems with kidneys and bones.

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Brain and central nervous system problems

• Poor coordination or balance

• Intellectual disability, learning disorders and delayed
development
• Poor memory
• Trouble with attention and with processing information
• Difficulty with reasoning and problem-solving
• Difficulty identifying consequences of choices
• Poor judgment skills
• Jitteriness or hyperactivity
• Rapidly changing moods

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Social and behavioral issues
• Problems in functioning, coping and interacting with others may
include:
• Difficulty in school
• Trouble getting along with others
• Poor social skills
• Trouble adapting to change or switching from one task to
another
• Problems with behavior and impulse control
• Poor concept of time
• Problems staying on task
• Difficulty planning or working toward a goal

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Management of alcohol dependence
i. Acute Detoxification
a) Supportive management with intravenous fluids
and vitamins for complicated withdrawal symptoms
b) Benzodiazepines
• e.g. diazepam and lorazepam: relieve withdrawal
symptoms and reduce risk of seizure
• e.g. Chlormethiazole and Buspirone: acute withdrawal
symptoms
c) If not succesfully controlled - antipsychotic drug
e.g. Haloperidol 5-10mg in divided doses.
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Management of alcohol dependence
ii. Maintenance therapy

1. Disulfiram: inhibits aldehyde dehydrogenase (ALDH) which

converts alcohol to carbon dioxide and water, causing build-up
of acethyldehyde in the blood that causes unpleasent symptoms
such as nausea, vomiting headache and tachycardia.

2. Acamprosate and naltrexone:  anti-craving drugs

3. Drugs to produce aversion of alcoholism e.g.

Emetine, Apomorphine

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Management of alcohol dependence
Psychological treatment: 

1. Group therapy & Family therapy

2. Individualized Behaviour therapy
3. Social therapy

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Nursing management
1. Managing intoxication: During emergency, close
observation, vital signs, I/O, nutrition
2. Managing withdrawal syndrome: Vital signs, safety
3. Dealing with violence: Observe, prevent injury
or suicide
4. Promoting coping skills: Identify and discuss
feelings and teach problem solving skills
5. Overcoming denial: Identify situation
6. Enhancing motivation: Use stages of change model

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Nursing management
7. Preventing relapse: Identify early warning signals of
impending relapse
8. Decreasing isolation: group therapy, family 
9. Supporting spirituality: Discuss with client meaning
in life. Facilitate clients use of meditation & prayers
10. Enhancing physical activities: design exercise
program
11. Providing couple therapy 
12. Educating the family system
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Relapse prevention.
• Identify main causes of relapse: -

 Presence of overt or latent psychiatric illness

 Poor follow up
 Poor rehabilitation services
 Easy availability of drug
 Continuous peer pressure
 Outdoor method of treatment (not hospitalized)

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Primary Prevention
• Reduction of prescription by doctors (e.g.
anxiolytics esp benzodiazepines
• Identification and treatment of family
members who may contribute to the drug
abuse
• Introduction of social changes by;
• Price of alcohol 
• Control of advertising 
• Control or ban of sales
• Restrict availability and less social deprivation
• Strengthen the individual personal and social
skills to increase self-esteem and resistance to
peer pressure
• Health education to college students and
youth
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Secondary Prevention
• Early detection and counselling
• Brief intervention in primary care (simple
advice from healthcare professional and
educational leaflet)
• Motivational interviewing
• Full assessment (include current medical,
psychological and social problems)
• Detoxification with benzodiazepines
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Tertiary Prevention
• Alcohol Deterrent Therapy
• Other therapies e.g. assertive training, teaching coping skills,
behaviour counselling, supportive and individual psychotherapy
• Agencies concerned with alcohol-related problems (e.g.
Alcoholic anonymous AA)
• Motivation enhancement include educatgion about health
consequences of alcohol use
• Identifying high risk situations and developing strategies to feal
with them 9.e.g craving management)
• Drink refusal skills (assertive training)
• Dealing with faulty cognitions

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Tertiary Prevention
• Handling negative mood
• Time management
• Anger management
• Financial management
• Developing the work habit
• Stress management
• Sleep hygiene
• Recreation and spirituality
• Family counselling to reduce interpersonal conflicts
• AVOID RELAPSE
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Rehabilitation
Aim:
1.  to de-addicted form the effects of alcohol/drugs
2. To enable to leave the substance culture
3. To develop new social contacts: engage in work
and social activities in sheltered surroundings and
then take more responsibilities for themselves in
daily life activities
4. Continuation of social support required when
making transition to normal work and living
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Psychoeducation for patient and family
• Teach about the physical, psychological and social
complication of substance use
• Inform the concern that the psychoactive substance may
alter a person's mood, perception, consciousness or
behaviour
• Explain to the family that the patient may use lies, denial or
manipulation to continue substance use and avoid treatment
• Teach the patient and family on drug overdose or withdrawal
can result in medical emergency or death – provide resouces
• Caution the patient about sharing needles can result blodo
bourne disease e.g. AIDS and Hep B
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THANK YOU

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 REFERENCE

• Dr. Ramli Hassan, (1990). Penghantar Psikiatri.
Dewan Bahasa dan
• Pustaka
• Lofstedt, C.R. (1990). Essential of Psychiatric
Nursing: Learning and
• Activity Guide. Mosby
• Stuart & Sundeen. (1995). Principles and
Practice of Psychiatric
• Nursing (5th Ed. Mosby
• Wilson & Kneisl. (1996) Psychiatric Nursing
(5th Ed.) Addison-Wesley)

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