Chapter 25 SubstanceRelated Disorders Copyright 2012 Wolters Kluwer

Substance abuse and addiction can negatively impact health, relationships, finances, school, and employment. Some people hit bottom and seek treatment in an effort to recover. Treatment involves helping the individuals become and remain free from substances, ideally for the rest of their lives. London, 2009 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Learning Objectives After studying this chapter, you should be able to • Explain the disease concept of alcoholism and the following theories of addiction: biologic, genetic, behavioral and learning, sociocultural, psychodynamic, and the disease concept of alcoholism • Differentiate the following terms: substance use, addiction, psychological dependence, tolerance, and physiologic dependence • Discuss the dynamics of enabling and codependency • Articulate the difference between alcohol dependence and alcohol abuse • Recognize the more common physiologic effects of alcoholism • Identify the common medical problems associated with illicit abuse of substances (drugs) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Learning Objectives (cont. ) • Describe the rationale for the use of substance abuse screening tools during the initial assessment of a client with a substance-related disorder • Articulate the rationale for the use of the Stages of Change Model when planning interventions for a client with a substance-related disorder • Evaluate the treatment measures, including nursing interventions, for a client with a substance-related disorder • Formulate a list of nursing interventions for a client with clinical symptoms of acute substance intoxication • Develop a list of services available to clients who abuse substances Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Substance-related disorders refer to the use and abuse of alcohol, illicit drugs, or substances such as over-the-counter or prescription drugs. When substance use creates difficulties for the user or ceases to be entirely volitional, it becomes the concern of all the helping professions, including nursing. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Epidemiology of Substance-Related Disorders • Alcohol use and abuse – World Health Organization • Approximately 76. 3 million individuals have been diagnosed with alcohol use disorder. – National Institute on Drug Abuse • Approximately 20 million individuals commonly abuse drugs. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Specialty Practice: Addictions Nursing Practice • Addictions nursing was defined as an area of specialty practice concerned with care related to dysfunctional patterns of human response that have one or more of the following key characteristics: some loss of self-control capacity, episodic or continuous maladaptive behavior or abuse of some substance, and development of dependence patterns of a physical and/or psychological nature. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Etiology of Substance-Related Disorders • Biologic theories • Genetic theories • Behavioral and learning theories • Sociocultural theories • Psychodynamic theories • Disease concept of alcoholism Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Clinical Symptoms and Diagnostic Characteristics of Alcohol-Related Disorders • Alcohol use disorders – Alcohol dependence – Alcohol abuse disorder • Alcohol-induced disorders – Alcohol intoxication – Alcohol withdrawal delirium – Alcoholic-induced persisting dementia – Alcoholic-induced persisting amnestic disorder – Other alcohol-induced disorders Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Clinical Symptoms and Diagnostic Characteristics of Other Substance. Related Disorders • Sedative-, hypnotic-, or anxiolytic-related disorders • Opioid-related disorders • Amphetamine-related disorders • Cocaine-related disorders • Cannabis-related disorders • Hallucinogen- and phencyclidine-related disorders • Inhalant-related disorders • Caffeine- and nicotine-related disorders Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Clinical Symptoms and Diagnostic Characteristics of Other Substance. Related Disorders: Designer Drugs, Club Drugs, and Anabolic Steroids • Designer drugs • Club drugs • Anabolic steroids • Prescription drug abuse • Internet addiction disorder Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Nursing Process • Assessment • Nursing diagnoses • Outcome identification • Planning interventions • Implementation • Evaluation Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Assessment • Assessment of the client who abuses alcohol: – General description – Behavior – Screening tools for alcohol use or abuse – Diagnostic tests Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Assessment (cont. ) • Assessment of the client who abuses substances other than alcohol: – General description – Behavior – Screening tools – Diagnostic tests • Transcultural considerations Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Diagnoses • Anxiety • Ineffective denial • Ineffective health maintenance • Ineffective coping • Imbalanced nutrition: less than body requirements • Hopelessness • Impaired verbal communication • Impaired social interaction • Deficient knowledge regarding illness • Risk for injury • Risk for other-directed violence • Disturbed sleep pattern • Spiritual distress Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Outcome Identification Outcomes focus on the following: • Providing a safe environment to prevent injury • Stabilizing existing medical complications secondary to substance use or abuse • Improving impaired cognition and communication • Establishing nutritious eating patterns • Establishing a balance of rest, sleep, and activity • Establishing alternative coping skills • Resolving any personal or family issues related to the client’s disorder Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Planning Interventions Planning focuses on the following: • Psychobiological, social, and pharmacological aspects of the client’s substance abuse • Involves the client and family • Includes a multidisciplinary approach – Stages of Change Model Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Implementation • Provision of a safe environment • Assistance in meeting basic needs • Stabilization of medical condition • Stabilization of behavior • Medication management Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Implementation (cont. ) • Detoxification • Disulfiram and naltrexone therapy (alcohol aversion therapy) • Harm avoidance • Pain management of clients with substance-related disorders Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Implementation (cont. ) • Intervention strategy • Interactive therapies • Individual and cognitive–behavioral psychotherapy • Group therapy • Family therapy • CRAFT reinforcement and family training program • Client education • Smoking-cessation program • Support and self-help groups Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evaluation • The ultimate outcome is complete freedom from drug use and abuse. However, the potential for relapse is ever present. • Services available to clients who relapse are the following: – “ 28 -day” inpatient program – Short-term residential rehabilitation for 3 months – Long-term therapeutic community programs for 6 to 18 months – Day-treatment centers – Reentry programs – Outpatient or aftercare programs Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Possible Signs of an Impaired Nurse • Volunteers to work overtime frequently especially on weekends when staffing ratios are less than during the weekdays • Leaves the floor or unit frequently or spends a considerable amount of time in the bathroom • Is frequently involved in incidents in which clients report they haven’t received relief for pain (narcotic analgesics), insomnia (sedative hypnotics), or anxiety (benzodiazepines) although documentation indicates that they have received prescribed medication • Exhibits lapses in memory, changes in personal appearance, and appears preoccupied • Is on duty when the inaccurate drug counts occur • Gives questionable explanations regarding drug wastage and discrepancies in documentation Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Key Terms • Addiction • Enabling • Addictions nursing • Habituation • Addictive personality • Harm avoidance or reduction • Alcohol intoxication • Impaired nurse • Alcohol withdrawal • Intervention • Aversion therapy • Korsakoff’s psychosis • Behavioral dependence • Physiological dependence • Codependency • Psychological dependence • Delirium tremens • Stages of Change Model • Detoxification • Substance use • Drug dependence • Tolerance • Wernicke’s encephalopathy Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Reflection Reflect on the chapter-opening quote. • Compare and contrast the serious medical and social consequences of alcohol abuse and drug abuse. Which abuse do you think is more detrimental to a client’s quality of life? Why? Which abuse do you think is more detrimental to a client’s family? • Explain your answers. ? Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins