University of Baghdad/ College of Nursing

Psychiatric and Mental Health Nursing Department

Mental health nursing/13th Lecture

Substance abuse
Overview:
Substance use/abuse and related disorders are a national health problem.
More than 15 million Americans are dependent on alcohol, and 500,000
are between the ages of 9 and 12 years. Almost 7 million persons are
binge drinkers between the ages of 12 and 20 years—under the legal age
limit for drinking in most states. Five thousand deaths occur each
year—motor vehicle accidents, homicide, suicide, injuries—due to
alcohol in persons under age 21. The actual prevalence of substance
abuse is difficult to determine precisely because many people meeting the
criteria for diagnosis do not seek treatment and surveys conducted to
estimate prevalence are based on self reported data that may be
inaccurate.
TYPES OF SUBSTANCE ABUSE
Many substances can be used and abused; some can be obtained legally,
whereas others are illegal. This discussion includes alcohol and
prescription medications as substances that can be abused. Abuse of more
than one substance is termed polysubstance abuse.
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition,
Text Revision (DSM-IV-TR) lists 10 diagnostic classes of substance abuse:
1. Alcohol
2. Amphetamines or Similarly Acting Sympathomimetics
3. Caffeine
4. Cannabis
5. Cocaine 6. Hallucinogens 7. Inhalants
8. Nicotine 9. Opioids 10. Sedatives, Hypnotics, or Anxiolytics

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It also categorizes substance-related disorders into two groups: (1) those
that include disorders of abuse and dependence and (2) substance-induced
disorders such as intoxication, withdrawal, delirium, dementia, psychosis,
mood disorder, anxiety, sexual dysfunction, and sleep disorder.
This lecture describes the specific symptoms of intoxication, overdose,
withdrawal, and detoxification for each substance.
Intoxication is use of a substance that results in maladaptive behavior.
Withdrawal syndrome refers to the negative psychologic and physical
reactions that occur when use of a substance ceases. Detoxification is the
process of safely withdrawing from a substance.
Substance abuse can be defined as using a drug in a way that is
inconsistent with medical or social norms and despite negative
consequences. Substance abuse denotes problems in social, vocational, or
legal areas of the person’s life, whereas Substance dependence also
includes problems associated with addiction such as tolerance,
withdrawal, and unsuccessful attempts to stop using the substance.
DSM-IV-TR DIAGNOSTIC CRITERIA:
Symptoms of substance abuse
• Denial of problems
• Anxiety
• Irritability
• Impulsivity
• Feelings of guilt and sadness or anger and resentment
• Poor judgment
• Limited insight
• Low self-esteem
• Impaired role performance
• Physical problems such as sleep disturbances and inadequate nutrition

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ETIOLOGY
The exact causes of drug use, dependence, and addiction are not known,
but various factors are thought to contribute to the development of
substance-related disorders. Much of the research on biologic and genetic
factors has been done on alcohol abuse, but psychologic, social, and
environmental studies have examined other drugs as well.
Biologic Factors
Children of alcoholic parents are at higher risk for developing alcoholism
and drug dependence than are children of nonalcoholic parents. Adoption
studies have shown higher rates of alcoholism in sons of biologic fathers
with alcoholism than in those of nonalcoholic biologic fathers.
Neurochemical influences on substance use patterns have been studied
primarily in animal research. The ingestion of mood-altering substances
stimulates dopamine pathways in the limbic system, which produces
pleasant feelings or a “high” that is a reinforcing, or positive, experience.
Distribution of the substance throughout the brain alters the balance of
neurotransmitters that modulate pleasure, pain, and reward responses.
Psychologic Factors
In addition to the genetic links to alcoholism, family dynamics are
thought to play a part. Some theorists believe that inconsistency in the
parent’s behavior, poor role modeling. Some people use alcohol as a
coping mechanism or to relieve stress and tension, increase feelings of
power, and decrease psychologic pain. High doses of alcohol, however,
actually increase muscle tension and nervousness.

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Social and Environmental Factors
Cultural factors, social attitudes, peer behaviors, laws, cost, and
availability all influence initial and continued use of substances. Alcohol
consumption increases in areas where availability increases and decreases
in areas where costs of alcohol are higher because of increased taxation.
Many people view the social use of cannabis, although illegal, as not very
harmful; some even advocate legalizing the use of marijuana for social
purposes. Urban areas where cocaine and opioids are readily available
also have high crime rates, high unemployment, and substandard school
systems that contribute to high rates of cocaine and opioid use and low
rates of recovery. Thus, environment and social customs can influence a
person’s use of substances.
TYPES OF SUBSTANCES AND TREATMENT
The classes of mood-altering substances have some similarities and
differences in terms of intended effect, intoxication effects, and
withdrawal symptoms. Treatment approaches after detoxification,
however, are quite similar. This lecture presents a brief overview of seven
classes of substances and the effects of intoxication, overdose, and it
highlights important elements of which the nurse should be aware.
Alcohol
Intoxication and Overdose
Alcohol is a central nervous system depressant that is absorbed rapidly
into the bloodstream. With intoxication, there is slurred speech, unsteady
gait, lack of coordination, and impaired attention, concentration, memory,
and judgment. Some people become aggressive or display inappropriate
sexual behavior when intoxicated. The person who is intoxicated may
experience a blackout.

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Sedatives, Hypnotics, and Anxiolytics
Intoxication and Overdose
This class of drugs includes all central nervous system depressants:
barbiturates, nonbarbiturate hypnotics, and anxiolytics, particularly
benzodiazepines. Benzodiazepines and barbiturates are the most
frequently abused drugs in this category. The effects of the drugs,
symptoms of intoxication, and withdrawal symptoms are similar to those
of alcohol. In the usual prescribed doses, these drugs cause drowsiness
and reduce anxiety, which is the intended purpose. Intoxication symptoms
include slurred speech, lack of coordination, unsteady gait, labile mood,
impaired attention or memory, and even stupor and coma.
Stimulants (Amphetamines, Cocaine)
Stimulants are drugs that stimulate or excite the central nervous system.
Although the DSM-IV-TR categorizes amphetamines, cocaine, and central
nervous system stimulants separately, the effects, intoxication, and
withdrawal symptoms of these drugs are virtually identical. They are
grouped together here for this reason. Stimulants have limited clinical use
with the exception of stimulants used to treat attention deficit
hyperactivity disorder.
Amphetamines were popular in the past; they were used by people who
wanted to lose weight or to stay awake. Cocaine, an illegal drug with
virtually no clinical use in medicine, is highly addictive and a popular
recreational drug because of the intense and immediate feeling of
euphoria it produces.

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Opioids
Opioids are popular drugs of abuse because they desensitize the user to
both physiologic and psychologic pain and induce a sense of euphoria
and well-being. Opioid compounds include both potent prescription
analgesics such as morphine, codeine and methadone as well as illegal
substances such as heroin and normethadone. People who abuse opioids
spend a great deal of their time obtaining the drugs; they often engage in
illegal activity to get them. Health care professionals who abuse opioids
often write prescriptions for themselves or divert prescribed pain
medication for clients to themselves.
Hallucinogens
Hallucinogens are substances that distort the user’s perception of reality
and produce symptoms similar to psychosis, including hallucinations
(usually visual) and depersonalization.
Hallucinogens also cause increased pulse, blood pressure, and
temperature; dilated pupils. Examples of hallucinogens are mescaline and
psilocybin.
Inhalants
Inhalants are a diverse group of drugs that include anesthetics, nitrates,
and organic solvents that are inhaled for their effects. The most common
substances in this category are aliphatic and aromatic hydrocarbons found
in gasoline, glue, paint thinner, and spray paint. Inhalants can cause
significant brain damage, peripheral nervous system damage, and liver
disease.

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Pharmacologic Treatment
Pharmacologic treatment in substance abuse has two main purposes: (1)
to permit safe withdrawal from alcohol, sedative-hypnotics, and
benzodiazepines and (2) to prevent relapse. For clients whose primary
substance is alcohol, vitamin B1 (thiamine) often is prescribed to prevent
or to treat Wernicke–Korsakoff syndrome, which are neurologic
conditions that can result from heavy alcohol use. Vitamin B12 and folic
acid often are prescribed for clients with nutritional deficiencies.
Alcohol withdrawal usually is managed with a benzodiazepine anxiolytic
agent, which is used to suppress the symptoms of abstinence. The most
commonly used benzodiazepines are lorazepam, and diazepam. These
medications can be administered on a fixed schedule around the clock
during withdrawal.
Disulfiram (Antabuse) may be prescribed to help deter clients from
drinking. If a client taking disulfiram drinks alcohol, a severe adverse
reaction occurs with flushing, sweating, nausea, and vomiting. In severe
cases, severe hypotension, confusion, coma, and even death may result.
Methadone, a potent synthetic opiate, is used as a substitute for heroin in
some maintenance programs. The client takes one daily dose of
methadone, which meets the physical need for opiates but does not
produce cravings for more. The client has essentially substituted his or
her addiction to heroin for an addiction to methadone; however,
methadone is safer because it is legal, controlled by a physician, and
available in tablet form.

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Nursing intervention for Substance Abuse
• Health teaching for the client and family.
• Dispel myths surrounding substance abuse.
• Decrease codependent behaviors among family members.
• Promote coping skills.
• Focus on the here-and-now with clients.
• Set realistic goals such as staying sober today.

Client /family education

• Substance abuse is an illness.
• Dispel myths about substance abuse.
• Any alcohol, whether beer, wine, or liquor, can be an abused substance.
• Prescribed medication can be an abused substance.
• Feedback from family about relapse signs e.g., a return to previous
maladaptive coping mechanism.
• Continued participation in an after-care program is important.

Assistant Prof. Dr. kareem rashq

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