Substance-Related Disorders PDF

chapter 28 Substance-Related Disorders http://evolve.elsevier.com/Morrison-Valfre/ Objectives Upon completion of this chapter, the student will be able to: 1. Define five terms relating to substance use and treatment. 2. Explain how chemical dependency affects persons from different age groups. 3. D...

chapter 28 Substance-Related Disorders http://evolve.elsevier.com/Morrison-Valfre/ Objectives Upon completion of this chapter, the student will be able to: 1. Define five terms relating to substance use and treatment. 2. Explain how chemical dependency affects persons from different age groups. 3. Describe four serious consequences of substance abuse. 4. Classify four categories of abused substances, and give an example from each group. 5. Identify three reasons why inhalants are abused by adolescents and young adults. 6. Describe the three stages or phases of becoming addicted. 7. Compare the three criteria for the diagnosis of a substance-related disorder. 8. Explain what is meant by the term relapse. 9. Plan at least four interventions for clients who are diagnosed with substance-related disorders. Key Terms abstinence (ĂB-stĭ-nĕns) (p. 327) abused substances (p. 327) addiction (p. 327) alcohol (p. 329) alcoholism (p. 327) amphetamines (ăm-FĔT-ă-mēnz) (p. 332) caffeine (p. 330) cannabis (KĂN-ă-bĭs) (p. 330) cocaine (p. 333) crack (p. 333) delirium tremens (DTs) (p. 330) designer drugs (p. 334) detoxification (dē-TŎK-sĭ-fĭ-KĀ-shŭn) (p. 338) disulfiram (dī-SŬL-fĭ-răm) (Antabuse) (p. 339) dual diagnosis (p. 329) habituation (h -BĬCH-oo-ā-shun) (p. 327) The practice of using substances to make one feel better is as old as humans themselves. Even animals have been seen eating certain plants that change their behaviors. Alcohol has played a role in many cultures throughout recorded time. Various drugs, potions, solutions, and formulas have been developed as humans attempted to cope with the problems of disease and illness. Drugs have also played a role in political history. For example, the Opium Wars of the 19th century between China and Britain and the drug movement of the 1970s in the United States changed the course of history. Even today, we are struggling with political and social events that relate to drugs and other illicit substances. 326 hallucinogens (hă-LOO-sĭ-nō-jĕnz) (p. 331) heroin (HAIR-ō-ĭn) (p. 332) inhalants (p. 331) intoxication (ĭn- TŎK-sĭ- KĀ-shŭn) (p. 335) methadone (MĚTH-ă-dōn) (p. 338) methamphetamine (p. 334) narcotics (năr-KŎ-ĭkz) (p. 332) nicotine (NĬK-ă-tēn) (p. 334) phencyclidine (fēn-SĬ-klĭ-dēn) (PCP) (p. 331) relapse (p. 339) spice (p. 331) substance (p. 327) substance (drug) abuse (p. 327) substance (chemical) dependency (p. 327) substance use (p. 327) tolerance (p. 336) Cultural Considerations Today, in the drug-producing countries of Central and South America, the growing of cocaine plants is the only means of making a living for many poor farmers. Prices for coca leaves far outstrip the money paid for corn, wheat, or other agricultural products. When officials spray or otherwise destroy their crops, many men, women, and children suffer from hunger and malnutrition as a consequence. What do you think could be done to prevent drug use and prevent the starvation of farmers at the same time? The world of substance use and abuse is always changing. As health care providers become familiar with current chemical fads, new and more potent drugs are introduced. The focus of this chapter is to CHAPTER 28 provide an understanding of substance use, abuse, and addiction; its effects on society; and the current interventions used to treat and educate clients with substance-related problems. VOCABULARY OF TERMS To communicate about substance-related disorders, an understanding of terms is necessary. Several terms describe addictive disorders. A substance is defined as a drug, medication, or a toxin that is used to induce feelings of pleasure. Substances are also called chemicals or drugs. Substance use is the ingesting (eating, drinking, injecting, or inhaling) of any chemical that affects the body. This includes legal, illegal, and medicinal substances. Abused substances are those chemicals that alter the individual’s perception by affecting the central nervous system (CNS). They are often called mind-altering drugs because of their ability to enhance or depress moods or emotions. Substance (drug) abuse is culturally and socially defined. In some cultures, the use of certain drugs is expected to fulfill religious obligations or other culturally defined duties. In other societies, the use of the same substance is considered illegal or immoral. In the United States, Canada, Great Britain, and other industrialized societies, for example, laws define which substances are socially approved and legal and those that are illegal. In other cultures, the use of “illegal” substances is acceptable and even provides economic opportunities. A broad but workable definition of substance (drug) abuse is the “excessive use of a substance that differs from societal norms” (Keltner and Steele, 2014). However, no matter which culture, when the use of a substance falls outside society’s definition of approved use, a drug problem exists. Drug or chemical habituation occurs when an individual depends on a substance to provide pleasure or relief. Substance (chemical) dependency occurs when a user must take his or her usual dose of the drug to prevent the onset of withdrawal signs and symptoms. When the dependence on the substance is physical, the term addiction is used. The term alcoholism describes an addiction to alcohol. Today the term substance or chemical dependency is preferred for describing addictions. Abstinence occurs when an addicted individual is not using an addictive substance. ROLE OF CHEMICALS IN SOCIETY Chemical substances are important in modern socie­ ties. Without them, we would be unable to produce food, fight disease, or develop products that allow us to live comfortably. The use of different chemical substances has increasingly become a part of everyday life. Children are unconsciously taught to solve problems by using substances. The physician prescribes a Substance-Related Disorders 327 medicine to help a family member recover from an illness, and the child learns that drugs can be beneficial. Children observe their parents taking pills or drinking beverages that change their actions and unconsciously register approval of those behaviors. We are constantly bombarded with encouragement to ingest chemicals in advertisements on television, radio, and electronic media. Commercials routinely encourage us to cope with constipation, heartburn, allergies, and depression by taking drugs. Many of society’s athletes and role models freely admit to using body-enhancing chemicals. SUBSTANCE USE AND AGE The use of chemical substances occurs throughout the life cycle, from the fetus to the elderly individual. Even the growing life protected within the mother’s uterus is not safe from the effects of chemicals. It is estimated that 20% of pregnant women still use alcohol during pregnancy despite huge educational efforts about the effects of alcohol on the fetus. There are no safe drugs for pregnant women. Every chemical ingested by a pregnant woman poses a potential danger to her unborn child, especially during the first trimester of pregnancy when the developing fetus is highly sensitive. Chemicals taken during pregnancy can seriously interfere with normal fetal growth and development. They may also alter the placenta itself or interfere with its ability to perform its life-promoting functions. A sad but common example of the effects of maternal drug use can be seen in infants and children with fetal alcohol syndrome (FAS)—the result of excessive alcohol use during pregnancy. FAS affects more than 1 child per 1000 live births. In countries in which the intake of alcohol is high, the incidence of FAS is greater. In the United States and some Western European countries, it is estimated that as many as “20 to 50 out of every 1000 school children (or 2%–5% of the population) is living with the effects of alcohol misuse in pregnancy” (Lifescript, 2014). Children with FAS are smaller at birth, have small heads (microcephaly), and fail to develop normally. Fig. 28.1 illustrates the physical effects on the child of a chronically alcoholic mother. The less obvious effects include CNS deficits, various degrees of mental retardation and hyperactivity, irritability, and poor feeding habits. These children also have slow rates of growth, developmental delays, behavioral problems, intellectual impairment, poor judgment, and certain facial characteristics common to the children of alcoholic mothers. Infants who were exposed to cocaine in utero have sleeping and eating problems, unusual levels of irritability, and high-pitched cries. Other syndromes and developmental problems result from the use of different drugs, but all drugs have one thing in common: pregnancy and substance use do not mix. 328 UNIT V Clients With Psychosocial Problems Small head circumference Low nasal bridge Epicanthic folds Short eyelid tissues Short nose Small midface Indistinct infranal depression Thin upper lip B A FIGURE 28-1 Fetal alcohol syndrome. Milder forms of alcohol-induced effects on the fetus and the infant are known as fetal alcohol effects. (From Fortinash K, Holoday-Worret P: Psychiatric mental health nursing, ed 5, St Louis, 2012, Mosby.) Children who live with substance-abusing parents are at increased risk for injuries and developing drug problems themselves. Research has demonstrated that most children of parents who use both legal and illegal chemicals do poorly in school, have difficulty controlling their emotions, and exhibit low self-esteem. Many of these children repeat the cycle of substance use and child abuse when they reach adulthood. Some choose alcoholic or drug-abusing spouses. Children abuse substances too, but often the substances are legal and easily available. The 9-year-old who demands cola drinks every day demonstrates the same signs of a caffeine addiction as an adult. The 8-year-old boy who has grown up with beer in the house can become an alcoholic just as quickly as his adult counterpart. The number of admissions of children younger than 12 years old to substance treatment units is increasing. This reminds us that drug abuse problems really do exist among our children. Adolescent substance use, abuse, and dependence are becoming ever-increasing problems. Alcohol is the most frequently abused drug of adolescents. For people in the 15- to 24-year-old age group, alcoholrelated accidents are the leading cause of death. A disturbing trend is the use of prescription drugs by teens. Recent studies indicate that “one in five teens abuses prescription drugs” (Simmons, 2010). Because prescription drugs are easily available and legal, many teens think they are safe. Sadly brain impairment and kidney and liver damage are seen with their use over time. By the time teens are high school seniors many have experimented with alcohol, cigarettes, marijuana, cocaine, hallucinogens, and “designer drugs,” such as ecstasy. Teens are encouraged to explore the adult world because of their developmental levels, but their ability to exercise sound judgment is still limited. Adolescents experiment with a variety of attitudes, behaviors, and lifestyles, and often substance use becomes a part of that experimentation. The younger an individual begins to use substances, the more likely that abuse problems will occur later in life. Adolescents have various patterns of substance abuse. They may experiment by using drugs on a few occasions. They may use substances (usually alcohol, tobacco, or marijuana) in recreational ways, in social settings for the purpose of relaxation or intoxication. Binge drinking, the consumption of large amounts of alcohol in a short period of time, can lead to alcohol poisoning and death. The National Institute on Alcohol Abuse and Alcoholism (2015) defines binge drinking as “4 drinks for women and 5 drinks for men—in about 2 hours.” If actual addiction occurs, teens are likely to become involved in illegal activities, such as drug trafficking, prostitution, or criminal behaviors. In adults, substance abuse is common, with about 10% of the adult population regularly abusing alcohol. This statistic is low because episodes of frequent binge drinking are not documented. Other chemicals may be used on a recreational or even daily basis. Substance use and abuse occur most commonly between 18 and 35 years of age, but significant numbers of older adults abuse alcohol and prescription medications. Older adults are not immune to substance-related problems, but their substance use is often misdiagnosed or treated inappropriately. Older drinkers and many elderly persons are inclined to misuse drugs and prescription medications. Polypharmacy (the use of many drugs at the same time) is common in seniors who visit several medical care providers. Elderly abusers are often isolated within their social groups or families. Although the incidence of substance abuse in older adults is unknown, more than 40% of all drug reactions occur in persons older than 65 years. This fact should alert health care providers to the possibility of substance abuse in every older client. Substances for abuse may vary according to ethnic group. For example, cocaine use is higher among blacks, whereas whites and Hispanics prefer alcohol. CHAPTER 28 Drug use also varies with location. Overall drug use in the United States, for example, is highest in the West and lowest in the North Central region. SCOPE OF THE PROBLEM TODAY The abuse of chemical substances presents many problems for people in today’s society. Alcohol abuse and drug abuse affect every citizen, in both financial terms and human costs. There are more women using street drugs during pregnancy than available drug treatment programs can accommodate. Infants who have been exposed to cocaine and other drugs are filling health and foster care systems as the children of addicted parents are born. Millions of children with alcoholic parents live in the United States today. Children of problem drinkers also have three times the risk for serious injury as children of nondrinking parents. Substance use and dependence cost society dearly. In financial terms, the United States spends more than $51 billion a year on the war on drugs. In human terms, the number of people who died of a drug overdose in 2013 was 43,982 (Drug Policy Alliance, 2015). The use of alcohol and drugs often results in trauma, violence, and mental health problems. Family and social relationships suffer. Alcohol-related motor vehicle accidents are one of the leading causes of death among people younger than 45 years. Many deaths attributed to falls, drowning, and burns are often related to alcohol and drug use. Society’s homeless and mentally ill people often use and abuse chemicals. Homeless persons with alcohol, drug, or mental disorders are one of the most disadvantaged and underserved groups in the United States. People with serious mental illness who also are addicted to or use chemicals are said to have a dual diagnosis. It is estimated as many as 75% of the mentally ill population have a dual diagnosis. CATEGORIES OF ABUSED SUBSTANCES Every chemical, including many substances found in nature, has the potential for abuse. The current concern over the effectiveness of antibiotic drugs, for example, stems from a form of abuse. As people routinely insisted on being treated with antibiotics for illnesses that did not actually require them, the microorganisms the antibiotics were designed to kill grew stronger and increasingly resistant. The repeated abuse of antibiotics has resulted in serious consequences for us all. Box 28.1 lists the most common categories of abused substances. Certain behaviors, such as gambling or shopping to excess, meet the criteria for addictions. Researchers have found that addictive behaviors stimulate the same neurotransmitter pathways as illicit drugs. Not all abused substances are illegal. In this text, however, the discussion of abused substances is limited to those that are currently considered illicit or harmful. Substance-Related Disorders 329 Box 28-1 Categories of Abused Substances Alcohol Caffeine Cannabis Hallucinogens Inhalants Opioids Sedatives, hypnotics, anxiolytics Stimulants Tobacco Unknown/other substances CHEMICALS OF ABUSE The most popular substance of abuse in the United States and most developed countries is alcohol. Other substances increase and decrease in popularity, but, as noted earlier, more than 10% of the adult population in the United States abuses alcohol and that number has remained constant for more than 20 years (Drug Policy Alliance, 2015). Alcohol has been used since the beginning of recorded time. The effects of beverages containing alcohol are caused by the presence of ethanol (ETOH), a chemical that results from the fermentation of yeast and grains, malts, or fruits. “Hard liquor,” such as whiskey, brandy, gin, and vodka, is derived from distilled spirits, whereas beer and wine are not. The process of distillation increases the alcohol content of the beverage. See the Drug Alert for an example. Drug Alert One shot of distilled alcohol (whiskey, vodka, brandy) Five ounces of wine Twelve ounces of beer: All contain 1⁄2 ounce of alcohol. Many people think of alcohol as a stimulant because they feel relaxation, alertness, and pleasure when they drink. Actually, these feelings are caused by the depressant effects of alcohol on the central nervous system (CNS). Once swallowed, alcohol is rapidly diffused to all the body’s organ systems. Because of its high solubility in water, alcohol collects in organs that have a high content of water (brain, heart, liver, gastrointestinal tract). It is then metabolized and detoxified in the liver and excreted by the kidneys and lungs. Alcohol impairs judgment and motor coordination. Each state passes laws defining the legal limits of blood alcohol levels and criteria for Driving Under the Influence (DUI) legal charges. Low doses of alcohol cause a rise in blood pressure and pulse, but large doses can affect the pumping action of the heart, resulting in cardiac dysrhythmias (irregularities). Surface blood vessels dilate, producing flushing of the skin and rapid loss of body heat. Alcohol also causes numbness of the hands and feet, which creates a false sense of warmth. In large doses, alcohol can actually reduce body temperature. The effects of alcohol on the CNS are directly related to the amount (dose) consumed (Table 28.1). Episodes of 330 UNIT V Clients With Psychosocial Problems Table 28-1 Effects of Alcohol on the Nervous System BLOOD ALCOHOL CONTENT 0.05% APPROXIMATE NUMBER OF DRINKS* 1 or 2 (1⁄2-1 oz of alcohol) CENTRAL NERVOUS SYSTEM (BEHAVIORAL) RESPONSES Thought, restraint, judgment slowed; more socially at ease; reaction time slowed; unable to do complicated tasks; rise in blood pressure and pulse; close to legal limit for driving (0.08%) 0.10% 3 or 4 (11⁄2 oz of alcohol) Voluntary motor actions clumsy; depth perception altered; reaction time to stimuli slowed; eye movement and focus affected; judgment and control continue to decrease 0.20% 5 or more (21⁄2 oz of alcohol) Entire motor area of brain depressed; may want to lie down; staggers; loses conscious control of reason; easily angered; may weep, shout, fight 0.30% 6 or more (3 oz of alcohol) Acts confused; may be in a stupor; unresponsive to most external stimuli; losing ability to control involuntary responses; decreased heart rate, blood pressure, respiratory rate 0.40%–0.50% 7 or more (31⁄2 oz of alcohol) Comatose; medulla severely depressed; death from respiratory failure; death can occur with 0.40% if blood alcohol rises too rapidly; blood alcohol level of 0.50% is fatal without immediate medical attention *Consumed within a 4-hr period. binge drinking, where large amounts are consumed in a short time, can actually lead to death from acute alcohol intoxication. With continued use, tolerance develops, and individuals become dependent on (addicted to) alcohol. Heavy drinkers of longer than 10 years are prone to developing delirium tremens (DTs), a severe form of alcohol withdrawal that involves sudden and severe physical, mental, behavioral, and nervous system changes. Symptoms begin 48 hours to 10 days after the last drink. They worsen quickly and can include changes in mental function, delirium hallucinations, and seizures. Delirium tremens is a medical emergency. Treatment and close monitoring in the hospital setting are required. If drinking does not stop, death from multiple organ failure (especially the liver) will result, usually after a series of assorted chronic health problems. Although socially accepted, alcohol is not a harmless drug. Caffeine is a CNS stimulant. It is an ingredient in many products found in every supermarket. It is the main active ingredient in coffee, black teas, most cola drinks, other bottled beverages, and energy drinks. However, caffeine is also found in chocolate, diet aids, cold remedies, and over-the-counter pain relievers. Children are increasingly using caffeine on a regular basis. Energy drinks, which contain large amounts of caffeine, are popular with teens and young adults. Overdoses from too many energy drinks have resulted in death due to cardiac problems. Caffeine stimulates the nervous system, relieving fatigue and increasing alertness and the body’s metabolic rate. In large amounts, it can produce tremors, tachycardia, nervousness, and insomnia. The most prominent withdrawal symptom from caffeine is headache. Caffeine intoxication occurs when high doses are consumed within a short time. Symptoms can last from 4 to 6 hours. They include restlessness, nervousness, rambling speech, high energy levels, agitation, muscle twitching, rapid heart rate, increased blood pressure, and disturbances in heart rhythms. Cannabis (marijuana) is a term applied to the hemp plant, Cannabis, which grows wild in many tropical and temperate climates all over the world. The hemp plant has been used for centuries by many cultures in folk remedies and other medicines. Historically, it is used to treat pain, decreased appetite, muscle and gastrointestinal tract spasms, asthma, and depression. It has also been used as an antibiotic and a topical anesthetic. Commercially, rope, clothing, and paper are made from hemp (marijuana). Critical Thinking For years, debate about the legalization of marijuana has taken place. Advocates cite numerous commercial and medicinal properties of the substance. They feel that keeping it illegal prevents many medical advances from being made and commercial products (eg, paper, cloth, oil) from being developed. Those who disagree feel that legalization will lead to increased use. What do you think should be done? What is your rationale for this position? Cannabis is available in several forms. The dried tops and leaves are called marijuana. Hashish (hash) is the dried resin that seeps from the top and leaves, and hash oil is the distilled oil of hashish. All are usually smoked, but they also may be eaten in baked goods and candies. CHAPTER 28 Marijuana and other cannabis products produce a sense of well-being and relaxation. They alter time perception and affect short-term memory and concentration. Motivation, especially for distasteful tasks, may be decreased. Frequently, an increase in hunger occurs. Large doses can result in feelings of anxiety and paranoia. There are no proven withdrawal signs or symptoms, but anxious moods, irritability, and sleep disturbances have been reported. As of 2016 in the United States, cannabis products were legal in four states and the District of Columbia. Many other states have authorized its use for medical purposes. It is important for care providers to be familiar with the laws governing cannabis use in their own state. A new synthetic cannabis, known as spice, is being sold as a synthetic marijuana. It is also known as K2. A variety of unnamed chemicals are sprayed onto plant material and then smoked. Spice is often packaged as incense and sold at convenience stores and head shops. The effects of spice are more intense and quicker than cannabis. Spice is highly addicting. Users have serious side effects due to the unknown chemicals uses. Anxiety, paranoia, aggression, and seizures may occur. Spices users can become violently paranoid and attack others. “Deaths from violent behavior or suicide are some of the unfortunate side effects of Spice use” (NARCONON, 2015). The hallucinogens are natural and synthetic substances that alter one’s perception of reality. The active ingredients of the peyote cactus, mescaline, has been used in the religious ceremonies of certain Native Americans for many years. The introduction of laboratorydesigned hallucinogens in the United States did not occur until the early 1970s. Today they are commonly available. Most doses are taken orally or inhaled, and they are frequently contaminated with toxic chemicals. It is believed that they may temporarily interfere with the actions of neurotransmitters in the brain. These hallucinogens vary in onset, duration of action, and potency, but all produce a sense of altered reality. The four major hallucinogens are LSD, peyote, psilocybin, and PCP. Lysergic acid diethylamide (LSD), an ergot fungus, was discovered by accident in the 1930s while researching ergot, a fungus that grows on certain grains. It is sold in tablet, capsule, and liquid forms. The effects of LSD, called a “trip,” last about 12 hours. Peyote buttons are the disc-shaped crowns of the peyote cactus. The active ingredient in peyote is mescaline. The buttons are usually chewed or soaked in water to produce a tea. The effects last about 12 hours. Peyote has been used in some cultural religious ceremonies for centuries. Psilocybin is found in certain bitter-tasting mushrooms. They are eaten fresh, dried, or seeped into a tea. The hallucinogenic compounds are not inactivated by freezing or cooking. The effects begin within 20 to 30 minutes and last about 6 hours. Substance-Related Disorders 331 Phencyclidine (PCP) was originally developed for use as an animal tranquilizer. It is a white crystal powder that is smoked, snorted, or swallowed. When taken by humans, it produces feelings of being separated from one’s body and environment (dissociation). It also produces mild depression with low doses and a schizophrenic-like reaction with higher doses. It is highly addictive. Long-term abuse results in memory loss, weight loss, depression, and problems with thinking and speech. PCP is a dangerous drug because it causes people to behave in unpredictable, often violent ways (Table 28.2). Users of hallucinogens experience everything from profound mind-expanding experiences to “bad trips” in which dangerous behavioral reactions occur. The mind-altering effects of hallucinogens include a heightened awareness of reality; distortions in time, space, and body image; feelings of depersonalization; and the loss of a sense of reality. Physically, users will have dilated pupils, dizziness, nausea, rapid heart rate, weakness, and an inability to perform tasks such as driving. With severe reactions, convulsions and death have occurred. Flashbacks, which are a return to the psychedelic experience after the drug has worn off, can occur with the use of hallucinogens. The repeated use of hallucinogens can lead to various health problems. The breathing in of volatile substances or chemical gases (inhalants) has become popular with adolescents and young adults for several reasons: they are legal, inexpensive, and easily available, and they have a rapid onset of effects. Unfortunately, the practice is also associated with significant complications, such as sudden death caused by cardiac dysrhythmia or respiratory depression. The use of inhalants can also result in hyperactive motor responses, loss of coordination, and seizures. The most commonly inhaled substances are alcohol solvents, gasoline, glue, paint thinner, hairspray, and spray paints. Chemicals less frequently used as inhalants include cleaning fluids, typewriter correction liquids, and spray can propellants. Table 28-2 Signs and Symptoms of PCP Use PHYSICAL SIGNS AND SYMPTOMS Increased blood pressure Increased temperature Muscle rigidity, ataxia (uncoordinated, staggering) Repeated jerking Agitated movements Vertical and horizontal nystagmus (eye tremors) Weight loss PCP, Phencyclidine. PSYCHOLOGICAL SIGNS AND SYMPTOMS Belligerence (wants to fight) Bizarre behaviors Delusions, hallucinations distorted thinking Impaired (poor) judgment Impulsive behaviors Paranoia, rapid mood swings Unpredictable behaviors 332 UNIT V Clients With Psychosocial Problems Inhalants are most often used by adolescents in group settings. Several methods are used to inhale the vapors, such as soaking a rag and then holding it to the nose and mouth. The substance may be inhaled directly from the container (huffing) or placed in a bag or other closed container and then inhaled. Soon after inhaling, the individual feels a “high” that is associated with feelings of great well-being (euphoria), excitement, sexual aggressiveness, a lessened sense of right and wrong, and loss of judgment. Signs and symptoms of inhalant intoxication include delusions, hallucinations, anxiety, and confusion. Although no withdrawal syndrome has been recognized, the repeated use of inhalants can result in profound physical and psychosocial harm. Opioids have strong pain-relieving actions and are used for medicinal purposes. These substances, called narcotics or opiates, are obtained by milking a flower called Papaver somniferum, the opium poppy. They are commonly prescribed for a variety of painful conditions, coughs, and diarrhea. Narcotics are CNS depressants. They occur naturally, semisynthetically, and synthetically. Some natural narcotics have been altered to make new, artificially produced (synthetic) drugs. Natural narcotics are opium and its principal ingredient, morphine The use of opium was documented 4000 years before Hippocrates, and it continues to be a commonly used substance in many countries today. Opium can be found in several forms. The fluid scraped from the base of the poppy flower and rolled into dark brown chunks is called raw opium (Fig. 28.2). Processed opium can appear as a fine white powder. Before the 1900s opium was readily available in the United States and a common ingredient in many patent medicines. Today there is little opium use in the United States as a result of the restrictive laws governing the drug. The semisynthetic narcotics include heroin, hydromorphone, and thebaine derivatives. The Bayer Company of Germany first marketed heroin in 1898 as a new pain reliever. In the United States heroin was legally available to the public until the passage of the Harrison Narcotic Act of 1914. A Pure heroin is a white, bitter-tasting powder that is usually put into solution and injected. Today potent forms of heroin are available. Some are so strong that they need only to be smoked or inhaled to produce the same effect as injecting. Street heroin is found in colors ranging from white to dark brown depending on the additives. An especially potent form, called black tar heroin, has become available throughout the United States (Fig. 28.3). This crudely processed form of heroin is manufactured in Mexico and may contain as much as 80% impurities. It is most commonly diluted and injected. The signs and symptoms of heroin use, overdose, and withdrawal are listed in Table 28.3. Morphine is one of the most effective painkillers available. It is marketed as a white powder or in solution for injection. It is administered by injection under the direction of a licensed health care practitioner. Hydromorphone and the thebaine derivatives are semisynthetic narcotics made from opium. A common brand name for hydromorphone is Dilaudid. It is used as an analgesic and is produced in liquid or tablet form. It is shorter acting, more sedating, and up to eight times more powerful than morphine. Although available only by prescription, it is highly sought by addicts. Thebaine derivatives, another opium product, are up to 1000 times more potent than morphine. Because of the danger of overdose, these drugs are used by veterinarians for the care of large animals only. Stimulants are another group of commonly abused substances. They include “bath salts,” caffeine, cocaine and crack cocaine, ice, methamphetamines, and certain prescription drugs, such as amphetamines, appetite suppressants, and methylphenidate (Ritalin). Amphetamines were originally pharmaceutically manufactured medicines to treat depression, narcolepsy, hyperactivity in children, and obesity. Amphetamines were initially sold without a prescription in inhalers and diet pills. Today they are available only by prescription, but many are illegally manufactured. They are strong stimulants with addictive properties. Bath salts have nothing to do with bathing. They are made from a variety of chemical stimulants and are B FIGURE 28-2 A, Poppy. B, Opium. (Courtesy U.S. Drug Enforcement Agency.) CHAPTER 28 A Substance-Related Disorders 333 B C FIGURE 28-3 A, Black tar heroin. B, Heroin powder. C, Asian heroin. (Courtesy U.S. Drug Enforcement Agency.) Table 28-3 Signs and Symptoms of Heroin Use, Overdose, and Withdrawal HEROIN USE Constricted pupils Depression Drowsiness Euphoria (feelings of great well-being) Nausea Respiratory depression HEROIN OVERDOSE Shallow respirations Clammy skin Convulsions Coma HEROIN WITHDRAWAL Watery eyes Runny nose Sweating Muscle cramps Loss of appetite, nausea Chills Tremors Panic strongly addictive. The most intense highs come from snorting or injecting. Serious, even fatal, events have resulted from the use of bath salts. Because they act as strong stimulants, bath salts are often used by methamphetamine or cocaine addicts. Users may overheat and remove their clothes. Users’ “paranoia may drive [them] to aggressive, uncontrolled attacks on others, or self-destruction” (NARCONON, 2015). Tasers and pepper spray usually have no effect. Multiple murders and suicides can be attributed to the use of bath salts. Cocaine is a potent natural stimulant. For centuries, the natives of the South American Andes Mountains chewed the weakly psychoactive leaves of the coca plant to relieve fatigue and hunger. Today coca is grown, processed into cocaine, and shipped to many countries throughout the world. Cocaine is available “on the street” as a white, crystalline powder that is commonly contaminated with local anesthetics or sugar. It is either injected or “snorted” by inhaling. Cocaine produces an immediate rush of energy, vigor, and feelings of well-being that last less than 1 hour. The intense pleasurable feelings can lead to a mental dependency that can ultimately destroy one’s life as more and higher doses are used. Common signs of cocaine use include changes in eating and sleeping behaviors, a disregard for hygiene, runny nose, and bloodshot eyes. Repeated use can dissolve the nasal septum, resulting in a collapsed nose. Cocaine overstimulates the nervous system. Overdoses can lead to kidney and liver failure, seizures, heart attack, and stroke. Crack is a type of processed cocaine (Fig. 28.4). Combining cocaine with ammonia or baking soda and FIGURE 28-4 Crack cocaine. (Courtesy U.S. Drug Enforcement Agency.) 334 UNIT V Clients With Psychosocial Problems heating it removes the hydrochloride molecule and produces chips or chunks of highly addicting cocaine, called rocks. These are usually vaporized in a pipe or smoked with tobacco or marijuana. Because of its concentrated form, crack reaches the brain immediately and produces a more intense but shorter-lasting high. Tolerance and addiction develop quickly as users chase the feeling of that first, intense experience. Crack users will ignore family, work, and friends as the drug becomes the priority in life. Designer drugs (also called club drugs) are substances “created by underground chemists who alter the molecular structures of existing drugs” (Hess and DeBoer, 2002). Designer drugs, such as MDMA (ecstasy), STP, and “ice,” are easily available in all areas of the United States. The designer drug called ecstasy is fast becoming the preferred recreational drug of teens and young adults because it allows its users to “party” for long periods of time. Taking this drug, however, can have severe consequences. Because the drug suppresses the need to drink, eat, and sleep, it promotes severe dehydration and physical exhaustion. The leading cause of death among ecstasy users is hyperthermia, a dangerously high body temperature. Kidney or liver failure can result, even after one dose. Methamphetamine (meth) is one of the most addictive and destructive drugs available today. It is available in bags of white to pale brown powder that is smoked, snorted, injected, or swallowed. “Crystal meth” is a more potent form of the drug. Users experience a “rush” of euphoria and well-being that lasts for up to 10 to 12 hours. Many users become sexually excited and experience a false sense of energy. They become unusually active, nervous, or anxious. Feeling of power and aggressiveness may be present. Delusions, hallucinations, and paranoia are common. Because the nervous system is overstimulated, meth users do not eat or sleep for long periods (several days). When users do come down or “crash,” they may sleep for many hours and be extremely hungry. Weight loss makes users appear thin and gaunt. Once fed and rested, they will begin the cycle again. Some users will pick at their skin, trying to remove the bugs or hairs they feel moving under their skin. Because meth depresses the immune system, skin sores and injection sites often become infected. Chronic respiratory infections are common. Caustic chemicals in the drug, plus the fact that meth decreases the flow of saliva, causes the rotten, brown, and abscessed teeth known as “meth mouth” (Fig. 28.5). The long-term use of meth causes irreversible harm to the brain, nervous system, heart, blood vessels, lung, liver, and kidneys. Death can also be sudden from a stroke, seizure, or irregular heartbeat. Nicotine is present in all forms of tobacco (cigarettes, chewing tobacco, pipe tobacco, cigars, snuff) and certain medications (nicotine patch, nicotine gum). FIGURE 28-5 “Meth mouth” in a chronic user. (Courtesy Dr. Stephen Wagner in Darby ML and Walsh M: Dental Hygiene, ed 4, St. Louis, 2015, Saunders.) It produces relaxation, increases alertness, and helps to relieve feelings of hunger. Nicotine is frequently used as a method to control body weight and is currently a legal inhalant. Although its popularity is declining, tobacco is still a commonly used substance. Tobacco is either smoked or held between the gum and lip and absorbed through the mucous membranes of the mouth. It is never swallowed because of its toxic effects. Tobacco is addictive, and its continued use is associated with many health complications. Recently in the United States, Canada, and other industrialized countries, a movement to restrict the sales and use of tobacco products (especially to children and teens) has arisen. OTHER/MEDICATIONS Many chemicals that were developed to save lives and ease suffering have the potential for being abused. For example, almost all the opium arriving in the United States today is broken down into its most useful alkaloids, morphine and codeine. These substances are then refined into powerful pain-relieving medications (narcotic analgesics). They are available in the United States only with the prescription of a licensed physician, dentist, or nurse practitioner, but they remain a source of abuse. Rohypnol and GHB are central nervous system depressants, developed by drug companies and abused teens and young adults. They are odorless, colorless liquids that combine unnoticed with alcoholic and other drinks. Often referred to as “date rape” drugs, they render the victim sedated and helpless during a sexual attack. Often the victim will suffer from “retroactive amnesia, where the person who took the drug can’t remember events that occurred while under the influence of the drug” (Helmenstine, 2015). As a result of this unfortunate side effect, many sexual assault cases are not reported and go unsolved. Commonly abused stimulants include the amphetamines, diet pills, and the appetite suppressants. Methylphenidate (Ritalin), a medication used to treat attention-deficit/hyperactivity disorders, is another often abused stimulant. The signs and symptoms of CHAPTER 28 stimulant use include changes in personality, anxiety, tension, anger, restlessness, and rapid speech and movement. Laxatives and diuretics are commonly abused by elderly people and people who are trying to lose weight. Individuals with eating disorders or altered body images often use these drugs to keep themselves excessively thin or to atone for an eating binge. Elderly people can develop a dependence on laxatives when they are used too frequently. The sedative, hypnotic, and antianxiety drug classes are commonly used in ways other than therapeutic. During the 1950s, many people were unknowingly addicted to the drug diazepam (Valium) and other sedatives. The individual who is unable to sleep without hypnotic medications may be abusing sleeping pills, and many people reach for their “nerve pills” when they feel anxious or upset. The importance of obtaining a thorough history of every client’s medication use cannot be overemphasized. There are many substances that have the potential for abuse. Some clients may be addicted to more than one substance. Many practice binge drinking, in which short periods of ingestion are followed by periods of abstinence. For these reasons, it is important to obtain an accurate history of every client’s substance use patterns. For a brief review of substances and their main actions, see Table 28.4. CHARACTERISTICS OF SUBSTANCE USE AND ABUSE It is important to remember the differences between substance use and abuse. Some people can use various chemicals to change the way they feel, but the use Substance-Related Disorders 335 does not affect their ability to perform the activities of daily life. This is substance use. Substance abuse, however, occurs when use of the chemical interferes with or becomes more important than the activities of daily living. The causes of substance abuse are unknown, but several theories have attempted to explain why people use mind-altering chemicals. Biological theories state that variations among ethnic groups offer genetic and biochemical explanations for substance abuse. Theories relating to psychological factors explore the roles of personality and emotional problems as causes. Environmental theories concentrate on the individual, the family, and the sociocultural surroundings in which substance abuse takes place. STAGES OF ADDICTION Many individuals use alcohol, tobacco, or other chemicals and function very well. Those who move from use to dependency (addiction) follow a fairly predictable course. During the early stage, individuals are able to use and enjoy their chosen substance. A desire to repeat the first pleasurable experience leads to a frequent pattern of use. One begins to prefer being “high” to other activities. Soon a habit of excessive use develops as the individual begins to ignore responsibilities and obligations. The person may deny that a problem exists, ignore others’ comments, lie to cover up the activity, or conceal the problem by sneaking drinks or doses. During these periods, the individual may also become intoxicated. Intoxication is defined as a state of maladaptive behavioral or psychological changes resulting from exposure to certain chemicals. Intoxicated people are Table 28-4 Abused Substances and Their Main Actions SUBSTANCE Alcohol EXAMPLES Beer, wine, vodka, whiskey MAIN ACTIONS CNS depressants; large dose can lead to death; addictive Narcotics Heroin, opiates, morphine CNS depressants; large dose can lead to death; addictive Stimulants Caffeine, cocaine, certain prescription drugs, amphetamines, appetite suppressants Stimulate CNS; increase alertness, metabolic rate; can overstimulate CNS; highly addictive Hallucinogens LSD (acid), PCP, peyote All produce a sense of altered reality; use can result in flashbacks and mental health problems Cannabis Marijuana, hash, hash oil Produce a sense of well-being; alter time perception, concentration, motivation Designer drugs Ecstasy, STP, Rohypnol, GHB Mild hallucinogen; increased feelings, empathy; confusion; memory loss; decreased consciousness; seizures; coma Medications Pain killers, antidepressants, antianxiety drugs, stimulants, sedatives, laxatives, diuretics, others CNS stimulation or depression, depending on drug; weight loss, metabolic problems with misuse of laxatives, diuretics Inhalants Solvents, aerosol propellants, nitrous oxide, poppers, snappers Varies by chemical; loss of inhibition; slurred speech; loss of coordination, muscle weakness; damage to the CNS; sudden death CNS, Central nervous system. 336 UNIT V Clients With Psychosocial Problems frequently belligerent (looking for a fight or an argument) and have wide emotional swings. They often lack sound judgment, and their critical thinking ability is reduced. They will often stagger or show other signs of impaired motor abilities. The actual picture of an intoxicated individual varies greatly. Psychological effects arise from the person’s expectations of what the chemical will do and the environment in which the substance is taken. During the middle (crucial) stage of addiction, the intoxicating episodes increase as the body attempts to compensate by adapting to the substance. Tolerance develops as increased amounts of the chemical are needed to produce the same effects that one dose once produced. Physical tolerance occurs when the body has adjusted to living and functioning with the substance in its system. Psychological tolerance develops when individuals feel that they cannot function without the use of their chosen chemical. By the time one has progressed to the chronic (late) stage, tolerance for the chemical is usually quite high. The need for the substance now leads to a loss of control over one’s behavior. Without the chemical, life is miserable. Daily living becomes a nightmare, and all waking effort and energy are focused on obtaining and using the now required substance. Case Study Ernie’s father was 15 years old when Ernie was born. His mother, who was 14 years old, gave custody to the father after the first 6 months of Ernie’s life. To keep Ernie quiet during his infant and toddler years, his father would blow marijuana smoke into his face. It worked. Ernie would sleep for hours while his father partied. By the time Ernie was 5 years old, he was drinking beer. At 8 years, he graduated to vodka, gin, and tequila. By 10 years old, Ernie was mixing alcohol with cocaine. School became impossible, so he dropped out at 12 years old. By the time he was 14 years old, Ernie was hustling drugs and trying to sell the sexual favors of three neighborhood girls. Where is Ernie today? Fortunately, he overdosed one evening when he was about 17 years old. The nurse in the emergency department, recognizing the potential in this young man, took the time to tell him that he had choices. He was in charge of his own life. Ernie listened. His detoxification was painful. His recovery was slow and difficult, but he persisted, knowing there was something more in life than a fog of consciousness. Today, despite several setbacks, Ernie has been clean for more than 10 years. He is a college graduate, happily married, and the father of two boys. The strongest thing he drinks now is orange juice. How do you think the nurse influenced Ernie’s life? CRITERIA FOR DIAGNOSIS For a diagnosis of a substance-related disorder, individuals must meet certain criteria. Intellectual, behavioral, and psychological changes that lead the individual to keep using the substance despite problems are key features of abuse. The pattern of substance use must be disabling and lead to significant impaired functioning and distress. A great deal of time is spent in obtaining, using, and recovering from the substance. The individual must demonstrate signs of tolerance, withdrawal, and dependence (American Psychiatric Association, 2013). CLINICAL PRESENTATION Unlike physical illness, there is no classic presentation of a substance abuser. Each person has a unique variety of signs and symptoms, depending on chemical use and individual characteristics. However, because substance abuse affects every body system, there are some common indicators, such as alterations in neurological functioning or appearance, which can help with the assessment and monitoring of clients. Refer to Tables 28.1 through 28.3 for specific signs and symptoms. GUIDELINES FOR INTERVENTION The three most commonly abused types of drugs are alcohol and sedative-alcohol combinations; opiate narcotics, chiefly heroin; and stimulants, chiefly cocaine and amphetamines. The costs and consequences of substance abuse are high. As individuals progress with their drug abuse, their world narrows as they begin to suffer physical deterioration and become isolated from occupational and community relationships. Drug Alert Remember, elderly persons are at a high risk for becoming drug dependent. When an older adult becomes less social and begins to isolate himself or herself, suspect a problem with drugs. The usual drugs of abuse in the elderly population are pain medications and drug combinations. Have your elderly clients bring all their medications to you in a paper bag. These medications should include all over-thecounter and herbal preparations. In this way, an accurate assessment of their medication use can be obtained. Do not forget to ask about alcohol use, especially in combination with their medications. Absenteeism from work, unpaid bills, and job loss frequently result when chemical use is out of control. Involvement with the legal system can occur. Some people deplete their financial resources to obtain their substances. Accidents, trauma, crime, domestic violence, child abuse, prostitution, suicide, disease, and the loss of safe communities are associated with substance abuse. Therefore it is important for all health care providers to be alert to the possibility of substance-related problems in every client. CHAPTER 28 ASSESSMENT The physical examination, client history, and emotional assessment for any client suspected of chemical abuse should focus on the following aspects: Central nervous system: Assess for orientation, level of consciousness, balance, gait, and ability to follow instructions. Head and neck: Examine eyes, and check pupils and sclera (whites) of the eyes. Note ruddy or pale complexion, distended neck veins, or petechiae (small red dots) on the face. Observe for evidence of injections under the tongue, and inspect the area between the gums and lips. Chest: Do not forget to take vital signs. Count pulse and respirations for a full minute. Palpate pedal and radial pulses. Observe for any difficulty in breathing. Auscultate the heart for irregular rates or rhythms. Listen to the breath sounds, and note any abnormal sounds. Abdomen: Inspect the size, shape, and contours of the abdomen. Auscultate all four quadrants, and count the bowel sounds. Check for ascites (water in the abdomen), distention, or enlarged organs. Look for bruising, petechiae, and other signs of bleeding. Have the client describe the color and consistency of stool. Skin: Observe and document the size, location, and characteristics of any skin lesions or marks. Check for needle marks on the client’s arms, fingers, legs, and toes. Note the skin turgor and muscle mass of the arms and legs. Nutritional status: Many chemically dependent persons do not eat regularly and are at risk for malnutrition. Observe the client’s body build and appearance. Ask the client to list everything he or she ate yesterday and tell you how the meals were prepared. Ask if there have been any recent appetite or weight changes. Inspect the client’s skin color, hair, and fingernails. If the client lives alone or is homeless, find out how food is obtained on a daily basis. The psychosocial assessment includes the following: General appearance: Is the client tidy or unkempt? Note the client’s manner and style of dress, jewelry, makeup, hairstyle, and body marks (eg, tattoos, symbolic scars). Behaviors: Note rate of speech, motor activity, and interactions during the interview. Observe for signs of memory loss, difficulty following directions, and problems with communication. When exploring alcohol use, remember that individuals tend to minimize the quantity of alcohol used in a day. Have them describe the size of the container that holds the alcohol. Two 4-ounce drinks and two 12-ounce drinks have very different amounts of the drug. Emotional state: Watch for signs of depression, emotional instability (mood swings), suspiciousness, anger, agitation, self-pity, or jealousy. Ask Substance-Related Disorders 337 clients if they have ever had a hallucination, a blackout (period of time during which the user cannot remember events), any violent impulses, or suicidal ideas. Social support: Have clients identify the most important people in their lives. Are these people willing to become involved in treatment with the client? If possible, observe how clients interact with their family and friends. Remember that family members may also need support and treatment. Motivation: Obtain a description of the chemicals currently being used: how often, how much, when was last dose? When did use begin? How has it progressed? What (if anything) has been tried to decrease or stop using the chemical? Describe clients’ history of treatment for substance-related or emotional problems. Ask what motivated them to seek treatment now. Is the court, the job, or the family insisting on treatment, or are they seeking relief from the problems associated with the chemical use? The motivation level of clients plays an important part in recovery. Diagnostic tests: Diagnostic testing usually includes standard blood and urine examinations. A complete blood count (CBC), urinalysis, and chemistry panel are done to assess for organ damage. Frequently tests for hepatitis, human immunodeficiency virus (HIV), tuberculosis (TB), and other infectious diseases are performed. Clients are also assessed for nutritional or bleeding problems. Other diagnostic tests, such as a computed tomography (CT) scan, magnetic resonance imaging (MRI), x-ray films, or an electroencephalogram (EEG), may also be ordered. TREATMENTS AND THERAPIES The treatment of substance-related disorders continues to change and grow. Consequently a broad range of approaches is available today. Most treatment programs are based on a certain philosophy, although they may offer many different types of therapy. The disease model of treatment states that substance abuse is a disease and should be treated as such. Substance abuse has acute and chronic signs and symptoms, a certain pattern of progression, and physical pathological conditions associated with continued use. Two types of treatment programs based on the disease model are the 12-step programs and residential treatment programs. The first 12-step program was a self-help, groupcentered program developed by two alcoholics in 1935. The 12-step process involves admitting one’s powerlessness to control drug use and then seeking help from a higher power through prayer or meditation, moral inventories, confessing wrongs, asking for forgiveness, and carrying the message to others. The first 12-step program was Alcoholics Anonymous (AA). Many other 12-step programs are based on this 338 UNIT V Clients With Psychosocial Problems model and revised to fit the beliefs of the population they serve. Box 28.2 offers a general listing of self-help groups available in many countries throughout the world. Self-help groups can be very effective when the individual wants them to be. The medical model considers addictions from a public health, chronic, and acute infectious disease perspective. The biopsychosocial framework for treating clients is a medical model that attempts to explain substance abuse. New understanding of neurotransmitters and other biochemical activities of the brain is leading to the development of medications that may someday help people cope with their chemical dependencies. Psychiatric models view substance abuse as an expression of an underlying emotional conflict or mental Box 28-2 Self-Help Groups for Recovering Abusers Alcoholics Anonymous—For individuals recovering from alcoholism; founded in 1935 Al-Anon—For families of alcoholics Alateen—For 12- to 20-year-olds who are affected by someone else’s drinking problem Association of Recovering Motorcyclists—Support group for motorcyclists recovering from alcohol or drug addiction Calix Society—Catholic alcoholics who maintain sobriety through participation in AA Christian Addiction Rehabilitation Association— Provides support and ministry to individuals with addictions Cocaine Anonymous—For those recovering from cocaine addiction; a 12-step program Drug-Anon Focus—For families and friends of persons addicted to mind-altering drugs; a 12-step program Drugs Anonymous—For individuals addicted to drugs; a 12-step program Dual Disorders Anonymous—For people with both alcohol or drug addiction and mental or emotional disorders; a 12-step program Families Anonymous—For parents, relatives, and friends of drug addicts Gay AA—Provides support for gay and lesbian alcoholics Impaired Physician Program—Provides assistance to physicians and their spouses who have problems with alcohol, drugs, or codependence International Nurses Anonymous—For nurses, nursing students, and former nurses who are involved in a 12-step recovery program Narconon—Provides assistance to drug-dependent individuals and their families Narcotics Anonymous—For individuals recovering from drug abuse; a 12-step program Rational Recovery Systems—Uses rational emotive therapy (vs. a spiritual approach) to assist people in their recovery from substance abuse Data from Keltner NL, Steele D: Psychiatric nursing, ed 7, St Louis, 2014, Mosby. disorder. Several therapies are based on this framework. Sociocultural models state that substance abuse can be treated by changing an individual’s environment and teaching people how to develop new responses to their current environments. This view has led to the establishment of long-term residential treatment programs and therapeutic communities. Regardless of the type of substance used, the goals of care remain the same. The first step in treatment is for the individual to recognize the need for help. Denial is a strong part of most substance-related disorders. For any treatment to be effective, the client must be truly willing to work toward living without his or her addiction. Before treatment of the addiction can actually begin, many persons must first go through detoxification, the process of withdrawing from a substance under medical supervision. Clients who are addicted to opium, narcotics, alcohol, or sedatives are often hospitalized because of potentially fatal complications, such as seizures and respiratory and cardiac problems. Sometimes medications, such as phenobarbital, Dilantin, and Valium, are given to ease physical discomforts and prevent complications. Methadone (a drug used to treat heroin addiction) has been administered to ease the effects of withdrawing from heroin, but methadone itself is addicting, and it is difficult to “detox” from methadone. Once clients are physically free from their addictions (practicing abstinence), the focus turns to uncovering and treating existing emotional or mental health problems. The incidence of psychiatric disorders is very high in substance users. Anxiety and depression are commonly found in clients with substance-abuse problems. These disorders must also be treated if the individual is to remain drug free. The last, and perhaps the most difficult, goal of treatment is to assist individuals in changing their behaviors. Individual psychotherapy is very effective for clients with certain dependencies (cocaine addictions), but it is expensive and unavailable to many people. Group therapy can offer peer support from individuals “who have been there.” It also offers people the opportunity to experiment with and explore their new, drug-free behaviors. Medications are prescribed with extreme care. Two specific medications used in the care of substance-addicted clients are methadone and disulfiram (Antabuse). Methadone is a chemical relative of heroin. Taken orally once each day, it prevents the symptoms of withdrawal and helps to stabilize the lives of these substance abusers. Another form of methadone, called levo-alpha-acetyl-methadol (LAAM), has been developed. It requires that a dose be taken only once every 72 hours. CHAPTER 28 Disulfiram (Antabuse) is a medication taken daily by nonpracticing (dry) alcoholics. It is prescribed as a preventive measure to help reduce the desire for alcohol. Clients taking Antabuse must be warned to avoid any product containing alcohol. Common items, such as aftershave, mouthwash, cough syrups, and lotions can contain alcohol and cause unpleasant reactions. When alcohol is combined with Antabuse it causes intense headaches, flushing, nausea, vomiting, low blood pressure, and blurred vision. It is important to thoroughly research each of these medications and routinely monitor your clients for therapeutic and adverse reactions to these chemicals. RELAPSE Long-term recovery is often marked by periods of relapse. Relapse is the recurrence of substanceabusing behaviors after a significant period of abstinence. In other words, the client returns to “using” after being “dry” for a period of time. Not only do people return to the chemical-abusing behaviors, but also they readopt the psychological and emotional mind-set that brought about the abuse in the first place. Many treatment therapies and programs concentrate on preventing and treating relapses. Remember that clients who have relapsed feel many distressing emotions. True therapeutic care is given when these clients are accepted and respected, even when they are the least accepting and respecting of themselves. Remember, you are a therapeutic agent. Case Study Rex had been in treatment so many times that he stopped counting. It seemed that he would relapse about 2 weeks after each discharge from the inpatient treatment program. One evening after an especially tough detox, he was chatting with the nurse on duty. Knowing that Rex was an intelligent man when sober, the nurse acted on an idea: she pulled the medical record and showed Rex his laboratory work. She discussed the meaning of each liver function test and the damage his alcohol and drug use was doing to his body. But she emphasized that the liver had remarkable healing abilities and could repair itself even when 50% of it was damaged. It was all there, in black and white, and the decision was his. There was still time if he acted, but soon his liver would be beyond repair. Rex left the conversation deep in thought. The next day the nurse made sure to discuss all the support that was available to Rex. More pondering followed. Soon thereafter Rex was discharged. Weeks elapsed and no Rex. The holiday season was in full swing, and the staff prepared for Rex’s admission. Instead they received a Christmas card telling them that he was still clean—and they have received a card with the same message each year since 1998. Substance-Related Disorders 339 NURSING/THERAPEUTIC PROCESS An important intervention for clients with substancerelated problems is to act as a therapeutic agent. Practice effective listening skills to gain an understanding of who the client really is. Use your knowledge of the therapeutic relationship to establish trust and cooperation. Learn to act as a role model, quietly demonstrating problem-solving and other effective coping skills. Be willing to look beyond the addiction to see the person. Nursing diagnoses/problem statements that relate to clients with substance abuse problems are based on the individual’s identified problems and goals. Box 28.3 lists several statements. The Sample Client Care Plan 28.1 presents the diagnosis of ineffective coping. Although the actual care for each client is individually planned, certain key therapeutic actions are common to all substance-dependent clients (Box 28.4). Caring for clients with substance-related problems is challenging and frustrating. Nurses and other care providers are in valuable positions to influence their clients’ well-being. Demonstrations of respect, acceptance, and concern can offer many clients the connection that encourages them to work toward freedom from their chemicals. Personalized approaches allow for discussions about diet, health, problem solving, and other health concerns. Drug therapists work with clients to develop long-term strategies for coping with their dependency. Clients are offered opportunities for learning, changing, and developing new and more effective skills for living. Work to become familiar with the subject of substance abuse. Learn as much as you can because you will be caring for clients whose problems are related to the use of chemical substances. Box 28-3 Problem Statements/Nursing Diagnoses Related to Substance Abuse PHYSICAL REALM Noncompliance Imbalanced Nutrition Risk of Injury Ineffective, risky Sexuality patterns Risk of Trauma Risk of self/other directed Violence PSYCHOSOCIAL REALM Anxiety Impaired Communications Ineffective Coping Ineffective Denial Dysfunctional Family processes Hopelessness Risk of Loneliness Powerlessness Social isolation Spiritual distress 340 UNIT V Clients With Psychosocial Problems Sample Client Care Plan 28-1 Ineffective Coping ASSESSMENT History Mary is a 34-year-old housewife with three children and a husband who works long hours. Two years ago, she complained of feeling jittery and tense to her physician. He prescribed a mild sedative, which Mary took religiously every evening before bed. Lately, she has begun to take her “nerve pill” during the day and uses alcohol to help “stabilize” her. She is being admitted for evaluation and treatment after her husband found her unconscious on the sofa yesterday. Current Findings A well-groomed woman with a flattened speech. Mary answers questions when asked but volunteers no information. She states that she does not belong here because she is not really addicted to anything and resents “being treated like a drugger.” Multidisciplinary Diagnosis Planning/Goals Ineffective coping related to increasing use of sedatives and alcohol Mary will abstain from using all mood-altering chemicals for 6 weeks. Mary will identify and seek help for at least three problems by May 1. THERAPEUTIC INTERVENTIONS Interventions Rationale Team Member 1. Confront Mary with her substance-abusing actions and their consequences and assist her with identifying the problem. 2. Encourage Mary to agree to participate in the treatment program. 3. Work with Mary to develop a written contract for behavioral changes. 4. Assist Mary in identifying and adopting more effective coping behaviors. 5. Assess the social support systems available for Mary. 6. Educate Mary and her family about chemical abuse and resources for help. 7. Refer Mary to a treatment center and provide support until Mary is involved in the program. Denial is common with persons who have a substance-related problem; identifying problems is the first step toward change Therapeutic interventions are not effective unless the client wants to cooperate A personal commitment enhances the likelihood of success Encourages problem solving and the use of more effective behaviors Supportive significant others are often unavailable for substance abusers Knowledge helps Mary and her family cope more successfully with problems Specialized drug treatment programs are likely to be more effective if clients are willing to participate Psy, Nsg All Psy, Nsg Nsg, Psy Nsg, Soc Svc Nsg, Soc Svc Soc Svc Evaluation During her entire stay, Mary remained chemical free but expressed many discomforts. Mary was able to identify her drug-using behaviors during her stay but refused to participate in an outpatient treatment program. CRITICAL THINKING QUESTIONS 1. How would the staff confront Mary without making her defensive? 2. What can be done to improve Mary’s willingness to participate in treatment? A complete client care plan includes several other diagnoses and interventions. Nsg, Nursing staff; Psy, psychologist; Soc Svc, social services. Box 28-4 Key Interventions for Abuse and Dependence Problems Meet physical needs during detoxification; this intervention is very important. Address the physiological problems resulting from substance abuse. Monitor the effects of the therapies prescribed to control the substance use. Teach clients about the disease and its progression. Focus on clients’ strengths, and help clients build on them. Help clients learn to problem solve the dilemmas they fear. Encourage focus on the present and the future, not on the past. Behave toward clients in a consistent manner, confronting them in a nonjudgmental, nonpunitive manner if they break the rules of the treatment setting. Assist clients’ families by encouraging them to become involved in group counseling. CHAPTER 28 Substance-Related Disorders 341 Get Ready for the NCLEX® Examination! Key Points Substance use is the ingesting of any chemical that affects the body. Abused substances alter the individual’s perception by affecting the central nervous system. They are often called mind-altering drugs because of their ability to enhance or depress mood and emotions. Every chemical ingested by a pregnant woman poses a potential danger to her unborn child. Children who live with substance-abusing parents are at high risk for injuries and for developing drug problems themselves. Adolescent substance use, abuse, and dependence are becoming an ever-increasing problem. In adults, substance abuse is common. Substance abuse occurs most commonly between 18 and 35 years of age. A significant number of older adults use alcohol and prescription medications. Children of problem drinkers have three times the risk for serious injury. Cocaine-exposed and other drug-exposed infants are filling health and foster care. Alcohol-related motor vehicle accidents are one of the leading causes of death among people under 45 years of age. Deaths from falls, drowning, and burns may all be related to substance use. Many homeless and mentally ill people use and abuse chemicals. Abused substances include alcohol, diet pills, coffee, tea, marijuana, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine (PCP), prescription drugs such as sedatives, hypnotics, and antianxiety drugs. Many medications have the potential for being abused. The use of inhalants has become popular with adolescents and young adults because they are legal, inexpensive, and easily available and have a rapid onset. Significant complications include cardiac dysrhythmia or respiratory depression. Substance abuse occurs when the use of the chemical becomes more important in the individual’s life than the activities of daily living. The movement from use to dependency (addiction) follows a predictable course. In the early stage, use progresses to excessive use. During the middle stage, intoxication progresses to tolerance. In the chronic (late) stage, tolerance progresses to loss of control, dependence, and addiction. For a substance-related disorder to be diagnosed, the pattern of substance use must be disabling and lead to significant impaired functioning and distress, and the individual must demonstrate the signs of tolerance, withdrawal, and dependence. The assessment of clients with substance-related problems should include a thorough history and physical examination. Detoxification is the process of withdrawing a substance under medical supervision. Relapse is the recurrence of the substance-abusing behaviors after a significant period of abstinence. The most important intervention for clients with substance-related problems is to act as a therapeutic agent. Other interventions are designed to meet physical needs, especially during detoxification; monitor effects of therapies; teach about the disease and its progression; help clients problem solve; and encourage the client’s family and significant others to become involved. Additional Learning Resources SG Go to your Study Guide for additional learning activities to help you master this chapter content. Go to your Evolve website (http://evolve.elsevier. com/Morrison-Valfre/) for additional online resources. Review Questions for the NCLEX® Examination 1. The client drinks at least 12 colas every day. Today he is unable to obtain his cola and is becoming more irritated and physically uncomfortable with each hour. The client is experiencing signs of: 1. Relapse 2. Addiction 3. Crankiness 4. Intoxication 2. Every chemical ingested by a pregnant woman poses a potential danger to her unborn child. This is especially true during the: 1. Labor and delivery 2. First trimester of pregnancy 3. Third trimester of pregnancy 4. Second trimester of pregnancy 3. Roxie had been sober for 6 months. Last week, her best friend came to visit and they celebrated with five gin and tonics. Roxie has experienced: 1. Repose 2. Relapse 3. Withdrawal 4. Detoxification 4. The first step in treatment for substance abuse requires that the person recognize: 1. The need for help 2. That he or she is in denial of the problem 3. How ill the substance is making him or her 4. The need for continued use of the substance 5. Key interventions for clients with substance-related problems include: 1. Focusing on the client’s past problems 2. Implementing problem-solving measures for the client 3. Informing the client of punishment measures should he or she break rules in the treatment setting 4. Assisting the client’s family by encouraging them to become involved in the treatment process and in group counseling