Chapter 19- Addiction

24% of adults report binge drinking in past month

30% driving fatalities are alcohol related
chemical abuse also results in increased violence, including domestic abuse, homicide, and child abuse/neglect
children of alcoholics are 4x more likely than general public to develop alcohol problems

intoxication is use of substance that results in maladaptive behavior. Withdrawal refers to neg physiologic and
physical reactions that occurs when use of substance ends or decreases substantially. Detox is withdrawing
safely.

Early course of alcoholism typically begins earlier- btwn 12-14 yr old, first evidence of minor alc related
problems is seen in late teens.
More severe difficulties begin in mid 20s-30s. Breakup of a significant relationship, DWI/DWAI, arrests, alc
withdrawal, significant interference with school/work. Might blackout first time.
Tolerance built, then tolerance break (where very small amounts of alc intoxicate the person)
later course of alcoholism- person functioning definitely affected, might have abstinence or temporary controlled
drinking. May happen after some legal, social, or interpersonal crisis, person might set up drinking rules, ie time,
quantity, only beer, etc. period soon leads to escalation of alcohol intake, more problems, then a subsequent
crisis. Cycle repeats itself.
Nearly half of people relapse in the year after treatment.
Highest rates of successful recovery- highly motivated, abstaining from substances, actively working on relapse
prevention

alcoholism-
biologic- children of alcoholic parents at higher risk for alcoholism/drug dependence than others. Partly due to
environmental factors, genetic factors as well.
Genetic vulnerability influenced by various social and environmental factors
some people have might have an alarm when substances consumed gives off pleasant feelings, and they go no
further. Addicts do not have this swithc

psychologic factors-family dynamics are thought to play a part. Inconsistency in parental behavior, poor role
modeling, lack of nurturing pave way for child to adopt maladaptive coping, stormy relationships, substance
abuse. Some people use alcohol for coping, relieve stress/tension, increase feelings of power, decrease
psychologic pain. High doses of alcohol actually increase tension and nervousness.
Social and environmental factors- cultural, social, peer behaviors, laws, cost, availability. Younger people do
substances with less social disapproval like weed and alcohol, where older people use drugs with higher rates of
disapproval like cocaine and heroine.

Types of substances and treatment

alcohol- CNS depressant, absorbed rapidly. Relaxation and loss of inhibitions. Slurred speech, unsteady gait,
lack of coordination, impaired attention, concentration, memory, judgment. Some become aggressive. May
blackout.
Overdose- can vomit, unconsciousness, resp. depression→ can cause aspiration pneumonia or pulm obstruction.
Alcohol hypotension can lead to CV shock or death…. Treatment- gastric lavage or dialysis, support
respiratory/cardiovasc function
effects of long term alc use- cardiac myopathy, wernickes encephalopathy, korsakoffs psychosis, pancreatitis,
esophagitis, hepatitis, cirrhosis, leukopenia, thrombocytopenia, ascites.

Withdrawal- starts 4-12 hr after cessation. Coarse hand tremors, sweat, elevated pulse/BP, insomnia, anxiety,
nausea, vomit. Severe- may progress to transient hallucinations, seizures, delirium--- Dts delirium tremens.
Usually peaks on 2nd day, over in about 5 days, but can last 1-2 weeks
CAN BE LIFE THREATENING. For more severe withdrawal or those that cant abstain- short admission of 3-5
days is most common setting.
Safe withdrawal – usually w/ benzos like lorazepam, chlordiazepoxide or diazepam to suppress withdrawal
symptoms. Fixed dose scheduling/ tapering, or symptom triggered dosing. Often use the CIWA scale during
dosing- Clinical institute withdrawal assessment. Scores up to 8 are mild withdrawal, 8-15 moderate, 15+ severe.

Sedatives, hypnotics, anxiolytics

CNS depressants- barbituates, nonbarbituate hypnotics, anxiolytics-→ benzos. Benzos and barbituates most
common abused. Similiar to effects of alcohol. Normal doses- drowsiness and reduced anxiety. Intoxication-
slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention, stupor, coma.
Benzos are rarely fatal- lethargic and confused. Gastric lavage, activated charcoal and saline cathartic, dialysis if
severe.
Barbituates can be lethal. Coma, resp arrest, cardiac failure, death. Treatment in ICU, lavage, dialysis. Support
resp and CV

withdrawal- short acting produce withdrawal symptoms sooner. Lorazepam in 6-8 hr, diazepam may take a
week. Opposite of the normal effect of med- autonomic hyperactivity- increased pulse, BP, resp, temperature,
hand tremor, insomnia, anxiety, nausea, psychomotor agitation. Seizures and hallucinations rarely in severe
benzo withdrawal. Detox- usually reduce the dose of the benzo every 3 days until the patient comes off it.

Stimulants- excite CNS, limited clinical use. Amphetamines, cocaine, methamphetamines

intox- rapidly. High/euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity,
hallucinations, repeated behavior, anger, fight, impaired judgment. Physiologic- tachycardia, increased BP,
dilated pupils, perspiration or chills, nausea, chest pain, confusion, cardiac disrhythmias. Can result in seizures,
coma, death. Treatment with chlorpromazine controls hallucination, lowers BP, relieves nausea.
Withdrawal- occurs w/in a few hours to several days. Non fatal. Dysphoria, fatigue, vivid and unpleasant
dreams, insomnia or hypersomnia, increased appetite, psychomotor retardation or agitation. Crashing.
Depressive symptoms. Suicidal ideation.

Cannabis-peak 20-30 mins and last 2-3 hrs+. High feeling, similar to alc, lower inhibition, relaxation, euphoria,
increased appetite. Short term mem, impaired motor coordination. Anxiety, dysphoria, social withdrawal. –
conjunctival injection (bloodshot eyes), dry mouth, hypotension, tachycardia.
No clinically significant withdrawal

OPIOIDS- desensitize to pain.morphine, meperidine, codeine, hydromorphone, oxycodone, methadone,

oxymorphone, vics, propoxyphene, heroine, normethadone.
Intox- soon after initial euphoric feeling. Apathy, lethargy, listlessness, impaired judgment, psychomotor
retardation/agitation, slurred speech, constricted pupils, drowsiness. Can lead to coma, resp depression, pupillary
constriction, unconsciousness, death
Narcan/naloxone- reverses signs of opioid toxicity. Given every few hours until opioid levels drop to nontoxic.
May take days.
Withdrawal- initial symptoms anxiety, restlessness, aching, cravings. Then nausea, vomit, dysphoria,
lacrimation, rhinorrhea, sweat, diarrhea, yawn, fever, insomnia. SIGNIFICANT DISTRESS, but do not require
pharmacologic intervention to support function.
Heroine first in 6-24 hr, peak 2-3 days, subside 5-7 days. Longer acting methadone may take 2-4 days, can take 2
weeks to subside. Methadone can be used as replacement, then decreased over 2 weeks. Symptoms no worse
than case of mild flu.

HALLUCINATIONS- distort perception of reality. Similar to psychosis- mescaline, psilocybin, LSD, ecstacy.
increased pulse, BP, temp, dilated pupils, hyperreflexia.
Intox- anxiety, depression, paranoid ideation, ideas of reference, fear of losing ones mind, potentially dangerous
behavior.--- physiologic-- sweat, tachycardia, palpitations, blurred vision, tremor, lack coordination.
Overdoses do not occur, but deaths can happen as a result- accidents, suicide, etc.
managed best by isolation from stimuli, physical restraints for physical safety of self and others.
PCP toxicity- seizures, HTN, hyperthermia, resp depression. Meds used for seizure and BP. Cooling devices
Withdrawal- none, but can crave the drugs. Also, possible flashbacks. May persist a few months up to 5 years

inhalants- dizziness, nystagmus, lack of coordination, slurred speech, tremor, unsteady gait. Stupor, coma,.
Belligerence, aggression, apathy,
acute toxicity- anoxia, resp depression, vagal stimulation, dysrhythmias. Death from bronchospasm, cardiac
arrest, suffocation, aspiration. Treatment- support resp and cardiac functioning.
Withdrawal- none. People may suffer from persistent dementia or inhalant induced psychosis, anxiety, etc

TREATMENT AND PROGNOSIS

Alcoholics anonymous, 12 step program. One day at a time, easy does it. Early members encouraged to get
sponsor. Regular attendance emphasized. May be closed or open. Also encourage individual counseling and
variety of groups. Some dislike emphasis on god, confrontational, “Im an alcoholic”, women and minorities have
reported feeling ignored. Also have NA, an Al-Anon (for family, friends etc of alcoholics), Alateen (for children
of parents with alcoholism). Same for eating disorders, gambling, etc.

health providers provide extended or outpatient treatment in variety of settings. Clinics, halfway houses,
residential settings, day and evening programs, etc.

PHARMACOLOGIC TREATMENT
permits safe withdrawal from alc, sedatives, benzos and it prevents relapse
thiamine often prescribed for alc to prevent or treat wernicke korsakoff syndrome= neurologic condition from
heavy alcohol
alcohol withdrawal- lorazepam, chlordiazepoxide, diazepam. Fixed schedule around the clock. Works well on as
needed basis as well. Disulfiram may be prescribed to deter. When you take this med and drink alcohol, become
violently ill, vomit, nausea, sweat, flushing, headache. Severe cases- severe hypotension, coma, even death.
Acamprosate to reduce cravings of alcohol and decrease discomfort, especially in first few months. Sweating,
anxiety, sleep disturbances- 2 tablets (666mg) TID. Not for renal impairment patients. Can cause mild diarrhea,
nausea, fatulence, pruritis.
Methadone substitute for heroine in some maintenance programs. One daily dose. Substituting addictions, but
this is safer- DR controlled, avoids risk of IV use, high costs,
buprenorphine/naloxone (suboxone) combo- 1 SL dose- can be tapered after treatment and psychosocial support.
May stay on maintenance for extended time.
Naltrexone blocks opioids, can reduce cravings for alcohol as well.
Also, vivitrol, a once monthly injection.
Clonidine is a med for hypertension- given to opioid dependents to suppress some effects of withdrawal. Most
effective for nausea, vomit, diarrhea, but reduces aches, anxiety, restlessness.

DUAL DIAGNOSIS- have substance abuse and another psychiatric illness. Those w/ schizophrenia/affective or
bipolar disorder are greatest challenge.
Some might have impaired abilities to process abstract concepts. Major barrier.
Treatments emphasize avoidance of all psychoactive drugs. Might not be possible.
Substance abuse has no limited recovery, which might be part of psychiatric recovery
alc and drugs can precipitate psychotic behavior, which makes ID-ing which symptoms are from the substance or
illness.
“lifelong abstinence” might be overwhelming for psych patient living day to day.

NEED HEALTHY, SUPPORTIVE, nurturing living environment, assistance with fundamental life changes,
connections with other recovering people, treatment of comorbid conditions. Stable housing, social support.
Participating in meaningful activity. Eating regularly. Sufficient sleep, looking presentable are important
components in relapse prevention.
Those with substance use typically includes defense mechanisms- especially denial. May deny or minimize the
extent of problems. May be in a variety of settings in the hospital. May come for alcohol withdrawal, or be
treated for alcohol withdrawal while on medsurg for an unrelated condition. Must be alert to the possibility of
substance use in these situations, be prepared to recognize existence and make referrals. Simple screening
instrument for alcohol and other drugs SSI- AOD for detecting hazardous drinking patterns and full blown
substance use disorders. Early detection and treatment are associated with more positive outcomes.
Detox is initial priority. Based on physical needs- safety, nutrition, elimination, fluids, sleep.

AFTER DETOX
Assessment – usually get treatment for someone else, not on their own. Might describe a story of physical
problems, someone threatening to fire them, loss of a relationship

appearance and behavior usually appear normal . May appear anxious, disheveled, tired if they just completed a
vigorous detox. Depending on overall health and substance used, can appear physically ill. Most resent being in
treatment or feel pressured. Might be first time having to deal with any difficulty without the substance

Mood and affect- can vary greatly. Might be sad or tearful, others might be angry or sarcastic. Irritability is
common. Though process- likely to minimize substance use. Blame others for problems, rationalize. May feel
they cant survive without substance. May focus on financial problems legal issues, employment problems as
main issues.

Judgment may still be affected, but likely had poor judgment

low self esteem typically. May cover with grandiose behavior. Do not feel adequate to cope.
May have experienced difficulties with social, family, and occupational roles. Absenteeism and poor work
performance are common.
Physiologic- may have HX of poor nutrition, sleep disturbances, HIV, liver damage.

Nursing DX- imbalanced nutrition, risk for infection, risk for injury, diarrhea, excess fluid volume, activity
intolerance, self care deficits.

Nurse must dispel the following myths-

“its a matter of willpower”, “I cant be an alcoholic, I only drink XYZ on VVV”, “I can learn to use drugs
socially”, “Im okay now, I can handle using once in a while”

education about relapse is important. Family and friends should be aware that clients reverting to old behavior
are at high risk for relapse. A specific plan for continued support and involvement after treatment increases
chances of recovery.

Codependence- results from prolonged relationship with person who uses substances. Poor relationship skills,
excessive anxiety/worry, compulsive behaviors, resistance to change.
ENABLING. Behavior seems helpful on surface, actually perpetuates substance use.
Roles may shift when a child looks out for parent. Child of alcoholics are at risk, but also develop inability to
trust, excessive sense of responsibility, denial of feelings. May begin to have problems with relationships, low
self esteem, excessive fears of abandonment.
Treatment and support groups are available to address issues of family members

promoting coping skills- encourage clients to see how substance use might have intensified problems in their
life. Sobriety should assist you in thinking about these problems clearly- it wont fix the problems. Might need to
redirect client to their behavior, not fixate on external events.
In group setting, encourage clients to give and receive feedback about how others perceive their interaction or
ability to listen.
Help them find ways to relax and reduce anxiety/stress without substance. May need to develop new social
activities if most of their friends use the substances.
Help client focus on present, not the past. Focus on what they can do now about the behavior or relationships.
Take it one day at a time. “What can I do today to stay sober” rather than “how to abstain for the rest of my life”.
Clients need to believe they can succeed.
Evaluation based heavily on client’s abstinence from substances.

Some start excessive drinking after 60 years old. Might be due to pain, long term use of RX meds, stress, loss,
social isolation, grief, depression. Free time. May experience physical problems much faster.

Most treatment in community based settings as outpatient. AA, rational recovery. Freestanding substance abuse
facilities, group help. Follow up or aftercare based on preferences or available programs. Family care, aftercare
sponsored by treatment facility, group sessions, possibly in physician offices. Etc.

College drinking prevention program designed to help students avoid predictable or expected binge drinking
commonly found. Raise student awareness about extensive drinking.

Physicians, dentists, nurses have far higher rate of dependence on controlled substance- ease of obtaining
controlled substances. Higher rate of alcoholism than general public. Difficult to report peers for abuse, but its
important. Hard to believe a colleague would abuse. May feel guilty or fear accusing someone. VERY
SERIOUS, IT CAN ENDANGER CLIENTS. Ethical responsibility to report suspicious behavior. Do not handle
situations alone.
-poor work performance, frequent absenteeism, unusual behavior, slurred speech, isolation.
-incorrect drug counts, excessive controlled substances listed as wasted or contaminated. Reports of ineffective
pain relief by patients. Damaged or torn packaging. Increased reports of “pharmacy error”, consistence offers to
get controlled substances from pharmacy, unexplained absences, trips to bathroom after contact with patient with
meds.
Nurses with abuse problems deserve opportunity for treatment and recovery as well. Reporting the person might
be first step he or she needs.

Nurse must examine beliefs of substance abuse. Might have HX in your family. May unknowingly act out old
family roles and engage in enabling behavior like sympathizing.
Might have feelings towards different substances- but its important to remember that the treatment process and
underlying issues of substance abuse, remission, and relapse are quite similar regardless of substance.

Substance abuse is chronic, recurring disease for many people. Easily cannot control without assistance and
understanding.
Examine abuse in your own family. Recognize your own background, beliefs, attitudes.
Approach each experience with an open and objective attitude. Client may be successful abstaining after 2 nd or
3rd treatment experience.