CH14 - Townsend

Chapter 14
Substance-Related and Addictive

Disorders
Copyright ©2017 F.A. Davis Company

Substance Use Disorder
Substance addiction
 Physical dependence
• Need for increasing amounts to produce the desired
effects
 Psychological dependence
• Overwhelming desire to repeat the use of a particular
drug to produce pleasure or avoid discomfort

Substance Use Disorder (cont’d)
Substance addiction (cont’d)

Use of the substance interferes with ability to fulfill
role obligations
Attempts to cut down or control use fail
Intense craving for the substance
Excessive amount of time spent trying to procure
the substance or recover from its use

Substance Use Disorder (cont’d)
Substance addiction (cont’d)

 Use of the substance causes the person difficulty
with interpersonal relationships or to become
socially isolated
 Engages in hazardous activities when impaired by
the substance
 Tolerance develops and the amount required to
achieve the desired effect increases
 Substance-specific symptoms occur upon
discontinuation of use
Substance-Induced Disorders
Substance intoxication
 Development of a reversible syndrome of
symptoms following excessive use of a substance
 Direct effect on the central nervous system
 Disruption in physical and psychological
functioning
 Judgment is disturbed and social and occupational
functioning is impaired.

Substance-Induced Disorders (cont’d)
Substance withdrawal
 Development of symptoms that occurs upon
abrupt reduction or discontinuation of a substance
that has been used
 Symptoms are specific to the substance that has
been used.
 Disruption in physical and psychological
functioning

Classes of Psychoactive Substances
 Alcohol
 Caffeine
 Cannabis
 Hallucinogens
 Inhalants
 Opioids
 Sedatives/hypnotics
 Stimulants
 Tobacco

Predisposing Factors
Biological factors
 Genetics: Apparent hereditary factor, particularly
with alcoholism
 Biochemical: Alcohol may produce morphine-like
substances in the brain that are responsible for
alcohol addiction.

Predisposing Factors (cont’d)
Psychological factors
 Developmental influences
• Punitive superego
• Fixation in the oral stage of
psychosexual development
S. Freud

Psychological factors (cont’d)

 Personality factors: Certain personality traits are
thought to increase a tendency toward addictive
behavior.
 Cognitive factors: Irrational thinking patterns have
long been identified as a problem that is central in
addictions.

Sociocultural factors
 Social learning: Children and adolescents are more
likely to use substances with parents who provide
model for substance use.
 Use of substances may also be promoted within
peer group.

Sociocultural factors (cont’d)

 Conditioning: Pleasurable effects from substance
use act as a positive reinforcement for continued use
of substance.
 Cultural and ethnic influences: Some cultures are
more prone to substance abuse than are others.

1. Which of the following has been implicated in

the predisposition to substance abuse?
a) Hereditary factor
b) Fixation in the adolescent stage of
psychosexual development
c) Punitive ego
d) Narcissistic and dependent personality traits

Correct answer: A
Research has indicated that an apparent

hereditary factor is involved in the development of
substance-use disorders. This is especially evident
with alcoholism.

Dynamics of Substance-Related Disorders
Alcohol use disorder

 Patterns of use
• Phase I. Prealcoholic phase: Characterized by use of
alcohol to relieve everyday stress and tensions of life
• Phase II. Early alcoholic phase: Begins with blackouts—
brief periods of amnesia that occur during or
immediately following a period of drinking; alcohol is
now required by the person.

Dynamics of Substance-Related Disorders (cont’d)
 Patterns of use (cont’d)

• Phase III. The crucial phase: Person has lost control;
physiological dependence is clearly evident.
• Phase IV. The chronic phase: Characterized by emotional
and physical disintegration. The person is usually
intoxicated more often than sober.

Effects of alcohol on the body

 Peripheral neuropathy, characterized by:
• Peripheral nerve damage
• Pain
• Burning
• Tingling
• Prickly sensations of the extremities

Effects of alcohol on the body (cont’d)

 Alcoholic myopathy: Thought to result from same
B vitamin deficiency that contributes to
peripheral neuropathy
• Acute: Sudden onset of muscle pain, swelling, and
weakness; reddish tinge to the urine; rapid rise in muscle
enzymes in the blood
• Chronic: Gradual wasting and weakness in skeletal
muscles


 Wernicke’s encephalopathy: Most serious form of
thiamine deficiency in alcoholic patients
 Korsakoff’s psychosis: Syndrome of confusion, loss
of recent memory, and confabulation in alcoholic
patients


 Alcoholic cardiomyopathy: Effect of alcohol on
the heart is an accumulation of lipids in the
myocardial cells, resulting in enlargement and a
weakened condition.


 Esophagitis: Inflammation and pain in the esophagus


 Gastritis: Effects of alcohol on the stomach include
inflammation of the stomach lining characterized by
epigastric distress, nausea, vomiting,
and distention


 Pancreatitis
• Acute: Usually occurs 1 or 2 days after a binge of
excessive alcohol consumption. Symptoms include
constant, severe epigastric pain; nausea and vomiting;
and abdominal distention.
• Chronic: Leads to pancreatic insufficiency resulting
in steatorrhea, malnutrition, weight loss, and
diabetes mellitus


 Alcoholic hepatitis
• Caused by long-term heavy alcohol use
• Symptoms: Enlarged, tender liver; nausea and vomiting;
lethargy; anorexia; elevated white blood cell count; fever;
and jaundice. Also ascites and weight loss in severe cases.


 Cirrhosis of the liver
• Cirrhosis is the end-stage of alcoholic liver disease and is
believed to be caused by chronic heavy alcohol use.
There is widespread destruction of liver cells, which are
replaced by fibrous (scar) tissue.


 Complications of cirrhosis of the liver can include:
• Portal hypertension
• Ascites
• Esophageal varices
• Hepatic encephalopathy


 Leukopenia: Impaired production, function, and
movement of white blood cells
 Thrombocytopenia: Platelet production and
survival are impaired as a result of the toxic effects of
alcohol.


 Sexual dysfunction
• In the short term, enhanced libido and failure of
erection are common.
• Long-term effects include gynecomastia, sterility,
impotence, and decreased libido.

2. A client is brought to the emergency department.

The client is aggressive, has slurred speech, and
impaired motor coordination. Blood alcohol level is
347 mg/dL. Among the physician’s orders is thiamine.
Which is the rationale for this intervention?
a) To prevent nutritional deficits
b) To prevent pancreatitis
c) To prevent alcoholic hepatitis
d) To prevent Wernicke’s encephalopathy

Correct answer: D
Wernicke’s encephalopathy is the most serious

form of thiamine deficiency in clients diagnosed
with alcoholism. If thiamine replacement therapy
is not undertaken quickly, death will ensue.

 Alcohol use during pregnancy can result in fetal

alcohol spectrum disorders (FASDs).
• Fetal alcohol syndrome (FAS): Problems with learning,
memory, attention span, communication, vision,
and hearing
• Alcohol-related neurodevelopmental disorder
• Alcohol-related birth defects

Characteristics of FAS
 Abnormal facial features  Learning difficulties
 Small head size  Speech and language
 Shorter-than-average delays
height  Intellectual disability
 Low body weight  Poor reasoning skills
 Poor coordination  Sleep and sucking
 Hyperactive behavior problems as a baby
 Difficulty paying attention  Vision or hearing problems
 Poor memory  Problems with the heart,
 Difficulty in school kidneys, or bones

 Alcohol intoxication: Occurs at blood alcohol levels

between 100 and 200 mg/dL
 Alcohol withdrawal: Occurs within 4 to 12 hours of
cessation of or reduction in heavy and prolonged
alcohol use

Sedative/Hypnotic Use Disorder
Sedative/hypnotic use disorder

 A profile of the substance
• Barbiturates
• Nonbarbiturate hypnotics
• Antianxiety agents
• Club drugs

Sedative/Hypnotic Use Disorder
Patterns of use
 Effects on the body
• Effects on sleep and dreaming
• Respiratory depression
• Cardiovascular effects
• Renal function

Sedative/Hypnotic Use Disorder (cont’d)
 Effects on the body (cont’d)

• Hepatic effects
• Body temperature
• Sexual functioning

Sedative/Hypnotic-Induced Disorder
 Intoxication
• With these central nervous system (CNS) depressants,
effects can range from disinhibition and aggressiveness to
coma and death (with increasing dosages of the drug).
 Withdrawal
• Onset of symptoms depends on the half-life of the drug
from which the person is withdrawing.
• Severe withdrawal from CNS depressants can be
life threatening.

Stimulant Use Disorder
Stimulant use disorder

• Amphetamines
• Synthetic stimulants
• Non-amphetamine stimulants
• Cocaine
• Caffeine
• Nicotine

Stimulant Use Disorder
Patterns of use
• CNS effects
• Pulmonary effects
• Gastrointestinal and renal effects

Stimulant-Induced Disorders
Intoxication
 Amphetamine and cocaine intoxication produce
euphoria, impaired judgment, confusion, and
changes in vital signs (even coma or death,
depending on amount consumed).
 Caffeine intoxication usually occurs following
consumption in excess of 250 mg. Restlessness and
insomnia are the most common symptoms.

Stimulant-Induced Disorders (cont’d)
Withdrawal
 Amphetamine and cocaine withdrawal may result
in dysphoria, fatigue, sleep disturbances, and
increased appetite.
 Withdrawal from caffeine may include headache,
fatigue, drowsiness, irritability, muscle pain and
stiffness, and nausea and vomiting.
 Withdrawal from nicotine may include dysphoria,
anxiety, difficulty concentrating, irritability,
restlessness, and increased appetite.

Inhalant Use Disorder

• Aliphatic and aromatic hydrocarbons found in substances
such as fuels, solvents, adhesives, aerosol propellants,
and paint thinners

Inhalant Use Disorder (cont’d)
Patterns of use/abuse
• CNS effects
• Respiratory effects
• Gastrointestinal effects
• Renal system effects

Inhalant-Induced Disorder
 Intoxication
• Develops during or shortly after use of or exposure to
volatile inhalants
• Symptoms include:
‒ Dizziness, ataxia, muscle weakness
‒ Euphoria, excitation, disinhibition, slurred speech
‒ Nystagmus, blurred or double vision
‒ Psychomotor retardation, hypoactive reflexes
‒ Stupor or coma

Opioid Use Disorder
Opioid use disorder

• Opioids of natural origin
• Opioid derivatives
• Synthetic opiate-like drugs

Opioid Use Disorder
Patterns of use/abuse
• CNS effects
• Gastrointestinal effects

Opioid-Induced Disorders
Intoxication
 Symptoms are consistent with the half-life of most
opioid drugs and usually last for several hours.
 Symptoms include initial euphoria followed by
apathy, dysphoria, psychomotor agitation or
retardation, and impaired judgment.
 Severe opioid intoxication can lead to respiratory
depression, coma, and death.

Opioid-Induced Disorders (cont’d)
Withdrawal
 From short-acting drugs (e.g., heroin)
• Symptoms occur within 6 to 8 hours, peak within 1 to 3
days, and gradually subside in 5 to 10 days.
 From long-acting drugs (e.g., methadone)
• Symptoms occur within 1 to 3 days, peak between days 4
and 6, and subside in 14 to 21 days.
 From ultra-short-acting meperidine
• Symptoms begin quickly, peak in 8 to 12 hours, and
subside in 4 to 5 days.

Opioid-Induced Disorders (cont’d)
 Symptoms of opioid withdrawal

• Dysphoria, muscle aches, nausea/vomiting, lacrimation
or rhinorrhea, pupillary dilation, piloerection, sweating,
abdominal cramping, diarrhea, yawning, fever, and
insomnia

Hallucinogen Use Disorder
A profile of the substance

 Naturally occurring hallucinogens
 Synthetic compounds
Patterns of use
 Use is usually episodic

Hallucinogens: Effects on the Body
 Physiological  Psychological
• Nausea/vomiting • Heightened response
• Chills to color, sounds
• Distorted vision
• Pupil dilation
• Sense of slowed time
• Increased blood
• Magnified feelings
pressure, pulse
• Paranoia, panic
• Loss of appetite
• Euphoria, peace
• Insomnia • Depersonalization
• Elevated blood sugar • Derealization
• Decreased respirations • Increased libido

Hallucinogen-Induced Disorder
Intoxication
 Occurs during or shortly after using the drug
 Symptoms include perceptual alteration,
depersonalization, derealization, tachycardia, and
palpitations.

Hallucinogen-Induced Disorder (cont’d)
 Symptoms of phencyclidine intoxication include

belligerence and assaultiveness, and may proceed
to seizures or coma.

Cannabis Use Disorder
Cannabis use disorder

• Marijuana
• Hashish
 Patterns of use

Cannabis Use Disorder

• Cardiovascular
• Respiratory
• Reproductive
• CNS

Cannabis-Induced Disorder
Intoxication
 Symptoms include impaired motor coordination,
euphoria, anxiety, sensation of slowed time, and
impaired judgment.
 Physical symptoms include conjunctival injection,
increased appetite, dry mouth, and tachycardia.
 Impairment of motor skills lasts for 8 to 12 hours.

Cannabis-Induced Disorder (cont’d)
Withdrawal
 Occurs upon cessation of cannabis use that has
been heavy and prolonged
 Symptoms occur within a week following cessation
of use.
 Symptoms include irritability, anger, aggression,
anxiety, sleep disturbances, decreased appetite,
depressed mood, stomach pain, tremors, sweating,
fever, chills, or headache.

Application of the Nursing Process
 Nurses must begin relationship development with

a substance abuser by examining own attitudes
and personal experiences with substances.

Nursing Process: Assessment
 Various assessment tools are available for

determining the extent of the problem a client has
with substances.
• Drug history and assessment
• Clinical Institute Withdrawal Assessment of Alcohol Scale
• Michigan Alcoholism Screening Test (MAST)
• CAGE Questionnaire

Nursing Process: Assessment (cont’d)
• CAGE Questionnaire
‒ Have you ever felt you should Cut down on your drinking?
‒ Have people Annoyed you by criticizing your drinking?
‒ Have you ever felt bad or Guilty about your drinking?
‒ Have you ever had a drink first thing in the morning to steady
your nerves (Eye-opener)?

Dual Diagnosis
 Clients with a coexisting substance disorder and

mental disorder may be assigned to a special
program that targets the dual diagnosis.
 Program combines special therapies that target
both problems.

Nursing Diagnosis/Outcome Identification
 Ineffective Denial related to weak,

underdeveloped ego
 Outcome: Client will demonstrate acceptance of
responsibility for own behavior and acknowledge
association between personal problems and use
of substance(s).

Nursing Diagnosis/Outcome Identification (cont’d)
 Ineffective Coping related to inadequate coping

skills and weak ego
 Outcome: Client will be able to demonstrate more
adaptive coping mechanisms that can be used in
stressful situations (instead of taking substances).

 Imbalanced Nutrition less than body

requirements/Fluid volume deficit related to
drinking or taking drugs instead of eating
 Outcome: Client will be free from signs or
symptoms of malnutrition/dehydration.

 Risk for Infection related to malnutrition and altered

immune condition
 Outcome: Shows no signs or symptoms of infection.

 Chronic Low Self-Esteem related to weak ego, lack

of positive feedback
 Outcome: Exhibits evidence of increased self-worth
by attempting new projects without fear of failure
and by demonstrating less defensive behavior
toward others.

 Deficient Knowledge (effects of substance abuse on

the body) related to denial of problems with
substances evidenced by abuse of substances
 Outcome: Verbalizes importance of abstaining from
use of substances to maintain optimal wellness.

 For the client withdrawing from CNS depressants

• Risk for Injury related to CNS agitation
 For the client withdrawing from CNS stimulants
• Risk for Suicide related to intense feelings of lassitude
and depression, “crashing,” suicidal ideation

Planning/Implementation
 Risk for injury

• Provide safe and supportive environment.
• Administer substitution therapy.

Planning/Implementation (cont’d)
 Denial
• Develop trust.
• Identify maladaptive behaviors or situations.

 Ineffective coping
• Establish trust.
• Set limits.
• Explore options.

 Dysfunctional family processes

• Review history.
• Provide information.
• Involve the family.

Client/Family Education
Nature of the illness

 Effects of (substance) on the body
• Alcohol
• Other CNS depressants
• Hallucinogens
• Inhalants
• Opioids
• Cannabinols
 Ways in which use of substance affects life

Client/Family Education (cont’d)
Management of the illness

1. Activities to substitute for (substance) in times
of stress
2. Relaxation techniques
• Progressive relaxation
• Tense and relax
• Deep breathing
• Autogenics

Management of the illness (cont’d)

3. Problem-solving skills
4. Essentials of good nutrition

Support services
 Financial assistance
 Legal assistance
 Alcoholics Anonymous (or other support group
specific to another substance)
 One-to-one support person

Nursing Process: Evaluation
 Evaluation involves reassessment to determine

whether the nursing interventions have been
effective in achieving the intended goals of care.

The Chemically Impaired Nurse
 It is estimated that 10 to 15 percent of nurses

suffer from the disease of chemical dependency.
 Alcohol is the most widely abused drug, followed
closely by narcotics.

The Chemically Impaired Nurse (cont’d)
 High absenteeism may be present if the person’s

source is outside the work area.
 Or, the person may rarely miss work if the
substance source is at work.

 Increase in “wasting” of drugs, higher incidences of

incorrect narcotic counts, and a higher record of
signing out drugs for other nurses may be present.
 Poor concentration, difficulty meeting deadlines,
inappropriate responses, and poor memory
or recall
 Problems with relationships
 Irritability, tendency to isolate, elaborate excuses
for behavior

 Unkempt appearance, impaired motor

coordination, slurred speech, flushed face
 Patient complaints of inadequate pain control,
discrepancies in documentation

State board response

 May deny, suspend, or revoke a license based on a
report of chemical abuse by a nurse
 Diversionary laws allow impaired nurses to avoid
disciplinary action by agreeing to seek treatment.

During the suspension period

 Successful completion of an inpatient, outpatient,
group, or individual counseling treatment program
 Evidence of regular attendance at nurse support
groups or 12-step program
 Random negative drug screens
 Employment or volunteer activities

 Peer assistance programs serve to assist impaired

nurses to:
• Recognize their impairment
• Obtain necessary treatment
• Regain accountability within profession

Codependency
 Defined by dysfunctional behaviors that are

evident among members of the family of a
chemically dependent person, or among family
members who harbor secrets of physical or
emotional abuse, other cruelties, or pathological
conditions

Codependency (cont’d)
 Codependent people sacrifice their own needs

for the fulfillment of others to achieve a sense
of control.
 Derives self-worth from others
 Feels responsible for the happiness of others
 Commonly denies that problems exist

 Keeps feelings in control, and often releases

anxiety in the form of stress-related illnesses, or
compulsive behaviors such as eating, spending,
working, or use of substances

 May have experienced abuse or emotional neglect

as a child
 Outwardly focused on others and
know very little about how to direct
their lives from their own sense
of self

The Codependent Nurse
 Classic characteristics
• Caretaking
• Perfectionism
• Denial
• Poor communication

Treating Codependence
 Recovery process
• Survival stage
• Re-identification stage
• Core issues stage
• Reintegration stage

Treatment Modalities for Substance-Related
Disorders
 Alcoholics Anonymous (AA)
• A major self-help organization for the treatment
of alcoholism
• Based on the concept of:
‒ Peer support
‒ Acceptance
‒ Understanding from others who have experienced the same
problem

Disorders (cont’d)
 Alcoholics Anonymous (cont’d)
• The 12 steps that embody the philosophy of AA provide
specific guidelines on how to attain and maintain
sobriety.
• Total abstinence is promoted as the only cure; the person
can never safely return to social drinking.

 Various support groups patterned after AA
but for individuals with problems with
other substances
 Counseling
 Group therapy

 Pharmacotherapy for alcoholism
• Disulfiram (Antabuse)
• Other medications
‒ Naltrexone (ReVia)
‒ Nalmefene (Revex)
‒ Selective serotonin reuptake inhibitors (SSRIs)
‒ Acamprosate (Campral)

 Psychopharmacology for substance intoxication
and substance withdrawal
• Alcohol
‒ Benzodiazepines
‒ Anticonvulsants
‒ Multivitamin therapy
‒ Thiamine

and substance withdrawal (cont’d)
• Opioids
‒ Narcotic antagonists
 Naloxone (Narcan)
 Naltrexone (ReVia)
 Nalmefene (Revex)
‒ Methadone
‒ Buprenorphine
‒ Clonidine

• Depressants
− Phenobarbital (Luminal)
− Long-acting benzodiazepines

• Stimulants
− Minor tranquilizers
− Major tranquilizers
− Anticonvulsants
− Antidepressants

• Hallucinogens and cannabinols
‒ Benzodiazepines
‒ Antipsychotics

3. A client diagnosed with chronic alcoholism
says to the nurse, “I’m tired of using and I want
to stop. Is there a medication that can help me
maintain sobriety?” About which medication
would the nurse provide information?
a) Carbamazepine (Tegretol)
b) Clonidine (Catapres)
c) Disulfiram (Antabuse)
d) Folic acid (Folvite)

Correct answer: C
Disulfiram is used as a deterrent to drinking. Ingestion of

alcohol while disulfiram is in the body results in a
syndrome of symptoms that can cause varying degrees of
discomfort. It can even result in death if blood alcohol
levels are high. It is important that the client understands
that all alcohol, oral or topical, and medications that
contain alcohol, are strictly prohibited when taking this
drug.

Non-Substance Addictions
Gambling disorder
 Persistent and recurrent problematic gambling
behavior that intensifies when the individual is
under stress.
 As the need to gamble increases, the individual
may use any means required to obtain money
to continue the addiction.

Non-Substance Addictions (cont'd)
Gambling disorder (cont’d)

Gambling behavior usually begins in adolescence,
although compulsive behaviors rarely occur before
young adulthood.
The disorder usually runs a chronic course, with
periods of waxing and waning.
The disorder interferes with
interpersonal relationships,
social, academic, or
occupational functioning.

Predisposing Factors to Gambling Disorder
 Biological influences
• Genetic
− Increased incidence among family members
• Physiological
− Abnormalities in neurotransmitter systems

Predisposing Factors to Gambling Disorder (cont’d)
 Psychosocial influences
• Loss of a parent before age 15
• Inappropriate parental discipline
• Exposure to gambling activities as an adolescent
• Family emphasis on material and financial symbols
• Lack of family emphasis on saving, planning,
and budgeting

Predisposing Factors to Gambling Disorder (cont’d)
 Psychosocial influences (cont’d)

• The psychoanalytical view suggests
that gambling is used to release a
build-up of tension.
S. Freud

Treatment Modalities for Gambling Disorder
 Behavior therapy
 Cognitive therapy
 Psychoanalysis
 Psychopharmacology
• SSRIs
• Clomipramine
• Lithium
• Carbamazepine
• Naltrexone

Treatment Modalities for Gambling Disorder (cont’d)
 Gamblers Anonymous
• Organization modeled after AA
• Only requirement for membership is an expressed desire
to stop gambling
• Reformed gamblers help others resist the urge to gamble.

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Chapter 14

Substance-Related and Addictive

Copyright ©2017 F.A. Davis Company

Copyright ©2017 F.A. Davis Company

Substance addiction (cont’d)

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Substance addiction (cont’d)

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Psychological factors (cont’d)

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Sociocultural factors (cont’d)

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1. Which of the following has been implicated in

Copyright ©2017 F.A. Davis Company

Research has indicated that an apparent

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Alcohol use disorder

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 Patterns of use (cont’d)

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Effects of alcohol on the body

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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Effects of alcohol on the body (cont’d)

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2. A client is brought to the emergency department.

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Wernicke’s encephalopathy is the most serious

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 Alcohol use during pregnancy can result in fetal

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 Alcohol intoxication: Occurs at blood alcohol levels

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Sedative/hypnotic use disorder

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 Effects on the body (cont’d)

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