NURS-316 Exam 2: Lecture 15 (Substance-Related and Addictive Disorders)

Sedative/Hypnotic Use Disorder (continued)

1.) A profile of the substance (again): → The effects of CNS depressants are additive with one another and with the behavioral state of the user. ⤷ For example, when these drugs are used in combination with each other or with alcohol, the depressive effects are compounded. These intense depressive effects are often unpredictable and can even be fatal. Similarly, a person who is mentally depressed or physically fatigued may have an exaggerated response to a dose of the drug that would only slightly affect a person in a normal or excited state. → CNS depressants are capable of producing physiological addiction. ⤷ If large doses of CNS depressants are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs upon withdrawal of the drug. The response can be quite severe, even leading to convulsions and death. → CNS depressants are capable of producing psychological addiction. ⤷ CNS depressants have the potential to generate a psychic drive for periodic or continuous administration of the drug to achieve maximum functioning or feeling of well-being. → Cross-tolerance and cross-dependence may exist between various CNS depressants. ⤷ Cross-tolerance is exhibited when one drug results in a lessened response to another drug. Cross-dependence is a condition in which one drug can prevent withdrawal symptoms associated with physical addiction to a different drug. 2.) Historical aspects: → Cocaine is the most potent stimulant derived from nature. It is extracted from the leaves of the coca plant, which has been cultivated in the Andean highlands of South America since prehistoric times. Natives of the region chew the leaves of the plant for refreshment and relief from fatigue.

Inhalant Use Disorder

1.) A profile of the substance: → Aliphatic and aromatic hydrocarbons found in substances, such as fuels, solvents, adhesives, aerosol propellants, and paint thinners. 2.) Historical aspects: → Use for altered consciousness or for religious rituals dates back to ancient times. → Use of inhalants for altered consciousness or for religious rituals dates back to ancient times. In the early 19th century ether, chloroform, and nitrous oxide were inhaled for recreational purposes. → Methods of use include "huffing"—a procedure in which a rag soaked with the substance is applied to the mouth and nose and the vapors inhaled. Another common method is called "bagging," in which the substance is placed in a paper or plastic bag from which it is inhaled by the user. The substance may also be inhaled directly from the container or sprayed in the mouth or nose. 3.) Patterns of use: → Huffing. → Bagging. → Inhaled through mouth or nose. 1.) Inhalant disorders are induced by substances such as fuels, solvents, adhesives, aerosol propellants, and paint thinners. Common examples include gasoline, varnish remover, lighter fluid, airplane glue, rubber cement, cleaning fluid, spray paint, shoe conditioner, and typewriter correction fluid. Toluene (methylbenzene, toluol, phenylmethane) is a common ingredient in many of the substances that are inhaled and is responsible for the mind altering effects that occur after inhalation. 2.) Inhalant use among children and adolescent is widespread in the United States today. 3.) Inhalant substances are readily available, legal, and inexpensive, three factors that make them attractive to children, teens, and young adults. Highest usage is by youths ages 12 to 17, and this is the only class of drugs used more frequently by younger rather than older teens.

Cannabis Use Disorder

1.) A profile of the substance: → Marijuana. → Hashish. 2.) Historical aspects: → Products of Cannabis sativa have been used therapeutically for nearly 5,000 years. → Cannabis was first employed in China and India as an antiseptic and an analgesic. Its use later spread to the Middle East, Africa, and Eastern Europe. → Many people incorrectly regard cannabis as a substance of low abuse potential. This lack of knowledge has promoted use of the substance by individuals who believe it is harmless. Tolerance, although it tends to decline rapidly, does occur with chronic use. As tolerance develops, physical addiction also occurs, resulting in a withdrawal syndrome upon cessation of drug use. 3.) Patterns of use: → 22.2 million Americans aged 12 years or older are current illicit users of marijuana. → Represents almost 8.4 percent of population ages 12 years and older. 1.) Cannabis is the most commonly used illicit drug in the United States and the fourth most commonly used psychoactive substance after caffeine, alcohol and nicotine. Marijuana, the most prevalent type of cannabis preparation, is composed of the dried leaves, stems, and flowers of the plant. Hashish is a more potent concentrate of the resin derived from the flowering tops of the plant. Hash oil is a very concentrated form of THC made by boiling hashish in a solvent and filtering out the solid matter. 2.) Cannabis products are usually smoked in the form of loosely rolled cigarettes. Cannabis can also be taken orally when it is prepared in food, but about two to three times the amount of cannabis must be ingested orally to equal the potency of that obtained by the inhalation of its smoke. Common cannabis preparations are presented in Table 23-6.

Hallucinogen Use Disorder

1.) A profile of the substance: → Naturally occurring hallucinogens. → Synthetic compounds. → Patterns of use. → Use is usually episodic. 2.) Historical aspects: → Used throughout history in many cultures for religious and mystical experiences, including in Aztec, Mexican Indian, and Hindu ceremonies. 3.) Patterns of use of hallucinogens is usually episodic. 1.) Hallucinogenic substances are capable of distorting an individual's perception of reality and the ability to alter sensory perception and induce hallucinations. Some of the manifestations have been likened to a psychotic break. 2.) Many of the hallucinogenic substances have structural similarities. Some are produced synthetically; others are natural products of plants and fungi. 3.) Because cognitive and perceptual abilities are so affected by these substances, the user must set aside time from normal daily activities for indulging in the consequences. LSD, like other hallucinogens, does not lead to the development of physical addiction or withdrawal symptoms. PCP is usually taken episodically, in binges that can last for several days. However, some chronic users take the substance daily. Psilocybin is an ingredient of the Psilocybe mushroom indigenous to the United States and Mexico. Ingestion of these mushrooms produces an effect similar to that of LSD but of a shorter duration. Mescaline is the only hallucinogenic compound used legally for religious purposes today by members of the Native American Church of the United States. It is the primary active ingredient of the peyote cactus. Salvia is an herb from the mint family that has hallucinogenic effects when dried leaves are chewed, extracted juices are consumed, or smoke from the leaves is inhaled. 4.) Among the very potent hallucinogens of the current drug culture are those that are categorized as derivatives of amphetamines. These include 2,5-dimethoxy-4-methylamphetamine (DOM, STP), MDMA, and MDA. At lower doses, these drugs produce the "high" associated with CNS stimulants. At higher doses, hallucinogenic effects occur. 5.) Many hallucinogenic substances have structural similarities. Some are produced synthetically; others are natural products of plants and fungi. A selected list of hallucinogens is presented in Table 23-5.

Opioid Use Disorder

1.) A profile of the substance: → Opioids of natural origin. → Opioid derivatives. → Synthetic opiate-like drugs. 2.) Historical aspects: → References to the use have been found in the Egyptian, Greek, and Arabian cultures as early as 3000 B.C. → In its crude form, opium is a brownish-black gummy substance obtained from the ripened pods of the opium poppy. → The development of opioid addiction may follow one of two typical behavior patterns. → The first occurs in the individual who has obtained the drug by prescription from a physician for the relief of a medical problem. → The second pattern of behavior occurs among individuals who use the drugs for recreational purposes and obtain them from illegal sources. 3.) Patterns of use: → Obtained by prescription for relief of a medical problem. → Use for recreational purposes and obtain by illegal sources. 1.) The term opioid refers to a group of compounds that includes opium, opium derivatives, and synthetic substitutes. Opioids exert both a sedative and an analgesic effect, and their major medical uses are for the relief of pain, the treatment of diarrhea, and the relief of coughing. 2.) Under close supervision, opioids are indispensable in the practice of medicine. They are the most effective agents known for the relief of intense pain. However, they also induce a pleasurable effect on the CNS that promotes their abuse. 3.) Methods of administration of opioid drugs include oral ingestion, snorting, or smoking, and by subcutaneous, intramuscular, and intravenous injection. A selected list of opioid substances is presented in Table 23-4.

Stimulant Use Disorder

1.) A profile of the substance: → Psychomotor stimulants induce stimulation by augmentation or potentiation of the neurotransmitters norepinephrine, epinephrine, or dopamine. → General cellular stimulants (caffeine and nicotine) exert their action directly on cellular activity. 2.) Historical aspects: → Cocaine is the most potent stimulant derived from nature. It is extracted from the leaves of the coca plant, which has been cultivated in the Andean highlands of South America since prehistoric times. Natives of the region chew the leaves of the plant for refreshment and relief from fatigue. 1.) CNS stimulants are identified by the behavioral stimulation and psychomotor agitation that they induce. 2.) Groups within this category are classified according to similarities in mechanism of action. Psychomotor stimulants induce stimulation by augmentation or potentiation of the neurotransmitters norepinephrine, epinephrine, or dopamine. The general cellular stimulants, such as caffeine and nicotine, exert their action directly on cellular activity. 3.) A selected list of drugs included in these categories is presented in Table 23-2.

The Chemically Impaired Nurse

1.) Approximately 10 percent of the general population suffers from chemical addiction. 2.) The prevalence of substance abuse among employed nurses is estimated to be 5.1 percent. 3.) Alcohol is the most widely abused drug, followed closely by narcotics. Substance abuse and addiction is a problem that has the potential for impairment in an individual's functioning, and this becomes an especially serious problem when the impaired person is responsible for the lives of others. Approximately 10 percent of the general population suffers from chemical addiction. Nurses who abuse substances have an added vulnerability because they are often handling controlled substances when providing patient care.

Treatment Modalities for Gambling Disorder

1.) Behavior therapy, cognitive behavior therapy, motivational interviewing, 12-step programs. 2.) Psychopharmacology. 3.) SSRIs. 4.) Clomipramine. 5.) Lithium. 6.) Carbamazepine. 7.) Naltrexone. 8.) Gamblers anonymous. 1.) Most pathological gamblers deny that they have a problem, and most gamblers only seek treatment due to legal difficulties, family pressures, or other complaints. Behavior therapy, cognitive therapy, and psychoanalysis have been used with pathological gambling, with various degrees of success. Some medications have been used with effective results in the treatment of pathological gambling. The SSRIs and clomipramine have been used successfully in the treatment of pathological gambling as a form of obsessive-compulsive disorder. Lithium, carbamazepine, and naltrexone have also been shown to be effective. 2.) One of the most effective treatments of pathological gambling is participation by in Gamblers Anonymous (GA). This organization of inspirational group therapy is modeled after Alcoholics Anonymous.

Dual Diagnosis

1.) Clients with a coexisting substance disorder and mental disorder may be assigned to a special program that targets the dual diagnosis. 2.) Program combines special therapies that target both problems. 1.) A client who has a coexisting substance disorder and mental illness may be assigned to a special program that targets both problems. Traditional counseling approaches use more confrontation than that which is considered appropriate for clients with dual diagnoses. Most dual diagnosis programs take a more supportive and less confrontational approach. 2.) Cognitive and behavioral therapies are helpful in training clients to monitor moods and thought patterns that lead to substance abuse. 3.) The individual who abuses or is dependent on substances undoubtedly has many unmet physical and emotional needs. Table 23-9 presents a list of client behaviors and the NANDA nursing diagnoses that correspond to those behaviors, which may be used in planning care for the client with a substance use disorder.

Codependency (continued)

1.) Codependent people sacrifice their own needs for the fulfillment of others to achieve a sense of control. 2.) Derives self-worth from others. 3.) Feels responsible for the happiness of others. 4.) Commonly denies that problems exist. The codependent person is able to achieve a sense of control only through fulfilling the needs of others. Personal identity is relinquished and boundaries with the other person become blurred. The codependent person disowns his or her own needs and wants in order to respond to external demands and the demands of others. Codependence has been called "a dysfunctional relationship with oneself."

Nursing Process: Assessment (continued)

1.) Motivational interviewing: → Used for clients with any disorder. 2.) 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. 1.) Motivational interviewing is an approach that can be used in the assessment and intervention process for clients with any disorder, although it first gained popularity in treatment of clients with substance use disorders. It uses skills like empathy, validation, open-ended questions, and reflection to explore the client's motivation, strengths, and readiness for change. Nurses can use a variety of assessment tools during an admission interview. 2.) The Clinical Institute Withdrawal Assessment of Alcohol Scale is an excellent tool that is used by many hospitals to assess risk and severity of withdrawal from alcohol. It may be used for initial assessment as well as ongoing monitoring of alcohol withdrawal symptoms. 3.) Other screening tools exist for determining whether an individual has a problem with substances. Two such tools include the Michigan Alcoholism Screening Test and the CAGE Questionnaire. Some psychiatric units administer these surveys to all clients who are admitted to help determine if there is a secondary alcoholism problem in addition to the psychiatric problem for which the client is being admitted.

Hallucinogens: Effects on the Body

1.) Physiological: → Nausea/vomiting. → Chills. → Pupil dilation. → Increased blood pressure, pulse. → Loss of appetite. → Insomnia. → Sweating, trembling. → Elevated blood sugar. → Decreased respirations. 2.) Psychological: → Heightened response to color, sounds, body. → Distorted vision. → Sense of slowed time. → Fear of control loss. → Magnified feelings. → Paranoia, panic. → Euphoria, peace. → Depersonalization. → Derealization. → Increased libido. 1.) The effects produced by hallucinogens are highly unpredictable. The variety of effects may be related to dosage, the mental state of the individual, and the environment in which the substance is used. 2.) These effects are not always pleasurable, and toxic reactions—such as intense levels of anxiety, fear, and stimulation—may occur. Flashbacks, or spontaneous repetition of a previous experience may occur in the absence of the substance.

Planning/Implementation

1.) Risk for injury: → Vulnerable to physical damage due to environmental conditions interacting with individual's adaptive and defensive resources, which may compromise health. → Goals and interventions. 2.) Denial: → Conscious or unconscious attempt to disavow knowledge or meaning of an event to reduce anxiety and/or fear, leading to the detriment of health. → Goals and interventions. 1.) Risk for injury is defined as "vulnerable to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources, which may compromise health." Goals should include stabilization of the client and avoiding physical injury. Interventions to achieve these goals include obtaining a drug history, observe the client's behaviors and vital signs, and frequently orient the client to reality and the surroundings. 2.) Denial is defined as a "conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety and/or fear, leading to the detriment of health." Goals should include focusing on behavioral outcomes associated with substance use and helping the client to verbalize acceptance of responsibility for their own behavior. Interventions include conveying an attitude of acceptance to the client, providing information to correct misconceptions, and encouraging participation in group activities. 3.) Table 23-10 presents this nursing diagnosis in care plan format.

Evaluation

1.) The final step of the nursing process involves reassessment. 2.) This determines if the nursing interventions have been effective in achieving the intended goals of care. 3.) Evaluation of the client with a substance-related disorder may be accomplished by using information gathered from the reassessment questions. Evaluation of the client with a substance-related disorder may be accomplished by using information gathered from the following reassessment questions: 1.) Has detoxification occurred without complications? 2.) Is the client still in denial? 3.) Does the client accept responsibility for his or her own behavior? Has he or she acknowledged a personal problem with substances? 4.) Has a correlation been made between personal problems and the use of substances? 5.) Does the client still make excuses or blame others for use of substances? 6.) Has the client remained substance-free during treatment? 7.) Does the client cooperate with treatment? 8.) Does the client refrain from manipulative behavior and violation of limits? 9.) Is the client able to verbalize motivation toward alternative adaptive coping strategies to substitute for substance use? Has the use of these strategies been demonstrated? Does positive reinforcement encourage repetition of these adaptive behaviors? 10.) Has nutritional status been restored? Does the client consume diet adequate for his or her size and level of activity? Is the client able to discuss the importance of adequate nutrition? 11.) Has the client remained free of infection during hospitalization? 12.) Is the client able to verbalize the effects of substance abuse on the body?

Nursing Process: Assessment

1.) The nurse must examine his or her feelings about working with a client who abuses substances. 2.) If behaviors are viewed by the nurse as morally wrong it may be difficult to suppress judgmental feelings. 3.) Nurses must begin relationship development with a substance abuser by examining own attitudes and personal experiences with substances. It is important for a nurse to examine his or her feelings about working with a client who abuses substances. If the nurse views these behaviors as morally wrong, it may be very difficult to suppress judgmental feelings.

Substance Use Disorder

1.) Two groups of substance-related disorders: → Substance-use disorders. → Substance-induced disorders. 2.) Addiction: → A primary chronic disease of brain reward, motivation, memory, and related circuitry where a dysfunction in these circuits is connected to an individual pathologically pursuing reward and or relief by substance use and other behaviors. 1.) Substance-related disorders are composed of two groups: the substance-use disorders (addiction) and the substance-induced disorders (intoxication, withdrawal, delirium, neurocognitive disorder, psychosis, bipolar disorder, depressive disorder, obsessive-compulsive disorder, anxiety disorder, sexual dysfunction, and sleep disorders). 2.) Addiction is a compulsive or chronic requirement. The need is so strong as to generate distress (either physical or psychological) if left unfulfilled. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists diagnostic criteria for addiction to specific substances, including alcohol, cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics, stimulants, and tobacco.

Treatment Modalities for Substance-Related Disorders (continued again and again)

1.) Various support groups patterned after AA but for individuals with problems with other substances. 2.) Counseling. 3.) Group therapy. 1.) AA has been the model for various other self-help groups associated with addiction problems. Some of these groups and the memberships for which they are organized can be found in Table 14-11 in the text. Nurses need to be fully and accurately informed about available self-help groups and their importance as a treatment resource. 2.) Group therapy with substance abusers has long been regarded as a powerful agent of change. In groups, individuals are able to share their experiences with others who are going through similar problems. They are able to "see themselves in others," and confront their defenses about giving up the substance. Therapy groups and self-help groups such as AA are complementary to each other. Whereas the self-help group focus is on achieving and maintaining sobriety, in the therapy group the individual may learn more adaptive ways of coping, how to deal with problems that may have arisen or were exacerbated by the former substance use, and ways to improve quality of life and to function more effectively without substances. 3.) Counseling on a one-to-one basis can also be used to help the client who abuses substances. The relationship should be goal-directed, and the length of the counseling may vary from weeks to years. The focus is on current reality, development of a working treatment relationship, and strengthening ego assets. Counseling often includes the family or specific family members. In family counseling the therapist tries to help each member see how he or she has affected, and been affected by, the substance abuse behavior.

Planning/Implementation (continued)

3.) Ineffective coping: → Establish trust. → Set limits. → Explore options. → Goals and interventions. 4.) Dysfunctional family processes: → Review history. → Provide information. → Involve the family. → Goals and interventions. 5.) Concept care mapping. 6.) Client/family education. 1.) Ineffective coping is defined as the "inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources." Goals should include helping the client express feelings about using substances as a method of coping with stress and the use of adaptive coping mechanisms. Interventions include setting limits on manipulative behavior, explaining the effects of substance abuse, and providing positive reinforcement. 2.) Dysfunctional family processes is defined as "psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized, which leads to conflict, denial of problems, resistance to change, ineffective problem solving, and a series of self-perpetuating crises." Goals should include helping family members participate in programs and support groups and take action to change self-destructive behaviors. Interventions include exploring the roles of family members, determining the extent of enabling behaviors, and involving the family in plans for discharge. 3.) An example of a concept map care plan for a client with a substance use disorder is presented in Figure 23-4. 4.) The role of client teacher is important in the psychiatric area, as it is in all areas of nursing. A list of topics forclient/family education relevant to substance related disorders is presented in Box 23-6.

Sedative/Hypnotic Use Disorder (continued again)

3.) Patterns of use 4.) Effects on the body: → Effects on sleep and dreaming. → Respiratory depression. → Cardiovascular effects. → Renal function. → Hepatic effects. → Body temperature. → Sexual functioning. 1.) Two main patterns of addiction exist. The first is one of an individual whose physician originally prescribed the drug as treatment for anxiety or insomnia. Use of the medication is justified on the basis of treating symptoms, but as tolerance grows, more and more of the medication is required to produce the desired effect. Substance-seeking behavior is evident as the individual seeks prescriptions from several physicians in order to maintain sufficient supplies. 2.) The second pattern involves young people in their teens or early 20s who use substances that were obtained illegally for recreational use. This pattern of intermittent use leads to regular use and extreme levels of tolerance. Combining use with other substances is not uncommon. Physical and psychological addiction leads to intense substance-seeking behaviors, most often through illegal channels. 3.) Sedative/hypnotic/anxiolytic compounds depress the activity of the brain, nerves, muscles, and heart tissue. 4.) Barbiturate use decreases the amount of sleep time spent in dreaming. During drug withdrawal, dreaming becomes vivid and excessive. Rebound insomnia and increased dreaming are not uncommon with abrupt withdrawal. 5.) Barbiturates are capable of inhibiting the reticular activating system, resulting in respiratory depression and can be lethal in overdose. In addition, additive effects can occur with the concurrent use of other CNS depressants, also effecting a life-threatening situation. 6.) Hypotension may be a problem with large doses. Only a slight decrease in blood pressure is noted with normal oral dosage. High dosages of barbiturates may result in decreased cardiac output, decreased cerebral blood flow, and direct impairment of myocardial contractility. 7.) In doses high enough to produce anesthesia, barbiturates may suppress urine function. At the usual sedative/hypnotic dosage, however, there is no evidence that they have any direct action on the kidneys. Barbiturates may produce jaundice with doses large enough to produce acute intoxication. Barbiturates stimulate the production of liver enzymes, resulting in a decrease in the plasma levels of both the barbiturates and other drugs metabolized in the liver. 8.) High doses of barbiturates can greatly decrease body temperature. It is not significantly altered with normal dosage levels. 9.) CNS depressants have a tendency to produce a biphasic response. There is an initial increase in libido, presumably from the primary disinhibitory effects of the drug. In men this initial response is then followed by a decrease in the ability to maintain an erection.

Stimulant Use Disorder (continued)

3.) Patterns of use: → CNS stimulant use is usually characterized by either episodic or chronic daily or near-daily use. 4.) Effects on the body: → CNS effects. → Cardiovascular/pulmonary effects. → Gastrointestinal and renal effects. → Sexual function. 1.) Many individuals who abuse or are addicted to CNS stimulants began using the substance for the appetite-suppressant effect in an attempt at weight control. Chronic users tend to rely on CNS stimulants to feel more powerful, more confident, and more decisive. They often fall into a pattern of taking "uppers" in the morning and "downers," such as alcohol or sleeping pills, at night. The average American consumes two cups of coffee (about 200 mg of caffeine) per day and caffeine is consumed in various amounts by about 90 percent of the population. Next to caffeine, nicotine, an active ingredient in tobacco, is the most widely used psychoactive substance in U.S. society. 2.) Stimulation of the CNS results in tremor, restlessness, anorexia, insomnia, agitation, and increased motor activity. Amphetamines, nonamphetamine stimulants, and cocaine produce increased alertness, decrease in fatigue, elation and euphoria, and subjective feelings of greater mental agility and muscular power. 3.) Amphetamines can induce increased systolic and diastolic blood pressure, increased heart rate, and cardiac arrhythmias. These drugs also relax bronchial smooth muscle. Cocaine intoxication typically produces a rise in myocardial demand for oxygen and an increase in heart rate. Severe vasoconstriction may occur and can result in myocardial infarction, ventricular fibrillation, and sudden death. Inhaled cocaine can cause pulmonary hemorrhage, chronic bronchiolitis, and pneumonia. Caffeine ingestion can result in increased heart rate, palpitations, extrasystoles, and cardiac arrhythmias. Caffeine induces dilation of pulmonary and general systemic blood vessels and constriction of cerebral blood vessels. Nicotine stimulates the sympathetic nervous system, resulting in an increase in heart rate, blood pressure, and cardiac contractility, thereby increasing myocardial oxygen consumption and demand for blood flow. 4.) Gastrointestinal effects of amphetamines are somewhat unpredictable, but a decrease in GI tract motility commonly results in constipation. Contraction of the bladder sphincter makes urination difficult. Caffeine exerts a diuretic effect on the kidneys. Nicotine stimulates the hypothalamus to release antidiuretic hormone, reducing the excretion of urine. 5.) CNS stimulants appear to increase sexual urges in both men and women. Women, more than men, report that stimulants make them feel sexier and have more orgasms. Some men may experience sexual dysfunction with the use of stimulants. 6.) Table 23-3 lists some common sources of caffeine.

Dynamics of Substance-Related Disorders (continued)

3.) Patterns of use: → Phase I. Pre alcoholic 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 → 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. 1.) Alcohol exerts a depressant effect on the CNS, resulting in behavioral and mood changes. The effects of alcohol on the CNS are proportional to the alcoholic concentration in the blood. Alcohol can be harmless and enjoyable if used in moderation, but like any other mind-altering drug, has the potential for abuse. Jellinek outlined four phases through which an alcoholic's pattern of drinking progresses. 2.) Phase I: The Prealcoholic Phase. This phase is when alcohol is used to relieve the everyday stress and tensions of life. As a child, the individual may have observed parents or other adults drinking alcohol and enjoying the effects. Tolerance develops, and the amount required to achieve the desired effect increases steadily. 3.) Phase II: The Early Alcoholic Phase. This phase begins with blackouts, and alcohol stops being a source of pleasure or relief for the individual but rather a drug that is required. Common behaviors include sneaking drinks or secret drinking, preoccupation with drinking and maintaining the supply of alcohol, rapid gulping of drinks, and further blackouts. The individual feels enormous guilt and becomes very defensive about his or her drinking. 4.) Phase III: The Crucial Phase. In this phase, the individual has lost the inability to choose whether or not to drink, and addiction is clearly evident. Binge drinking is common. These episodes are characterized by sickness, loss of consciousness, squalor, and degradation. In this phase, the individual is extremely ill. Anger and aggression are common manifestations. By this phase of the illness, it is not uncommon for the individual to have experienced the loss of job, marriage, family, friends, and most especially, self-respect. 5.) Phase IV: The Chronic Phase. This phase is characterized by emotional and physical disintegration. Emotional disintegration is evidenced by profound helplessness and self-pity. Impairment may result in psychosis. Life-threatening physical manifestations may be evident in virtually every system of the body. Unmanaged withdrawal from alcohol results in a terrifying syndrome of symptoms that include hallucinations, tremors, convulsions, severe agitation, and panic. Depression and ideas of suicide are not uncommon. For long term, heavy drinkers, abrupt withdrawal of alcohol can be fatal.

Predisposing Factors to Gambling Disorder (continued)

3.) 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. Sadock et al, report that the following may be predisposing factors to the development of pathological gambling: "loss of a parent by death, separation, divorce, or desertion before the child is 15 years of age; inappropriate parental discipline (absence, inconsistency, or harshness); exposure to and availability of gambling activities for the adolescent; a family emphasis on material and financial symbols; and a lack of family emphasis on saving, planning, and budgeting.

Substance Use Disorder (continued)

3.) Substance addiction: → 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. → Use of the substance causes the person difficulty with interpersonal relationships or to become socially isolated. → The person 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. 1.) Individuals are considered to have a substance use disorder when use of the substance interferes with their ability to fulfill role obligations, such as at work, school, or home. Often the individual would like to cut down or control use of the substance, but attempts fail, and use of the substance continues to increase. 2.) There is an intense craving for the substance, and an excessive amount of time is spent trying to procure more of the substance or recover from the effects of its use. This causes problems with interpersonal relationships, and the individual may become socially isolated. 3.) Individuals with substance use disorders often participate in hazardous activities when they are impaired by the substance, and continue to use the substance despite knowing that its use is contributing to a physical or psychological problem.

Treatment Modalities for Substance-Related Disorders (continued)

3.) The 12 steps that embody the philosophy of AA provide specific guidelines on how to attain and maintain sobriety. 4.) Total abstinence is promoted as the only cure; the person can never safely return to social drinking. AA provides a Twelve Step process to achieving and maintaining sobriety. These steps include: 1.) Admitting powerlessness over alcohol 2.) Believing that a greater power could restore sanity 3.) Make a decision to turn lives over to the care of God 4.) Making a moral inventory 5.) Admitting wrongs 6.) Become ready to have God remove defects of character 7.) Ask God to remove shortcomings 8.) Make a list of all persons harmed 9.) Made direct amends to such people wherever possible except when to do so would injure them or others 10.) Continued to take personal inventory admit wrongdoing 11.) Seek to improve conscious contact with God 12.) Carry the message to other alcoholics Some of these groups and the memberships for which they are organized are listed in Table 23-11.

The Chemically Impaired Nurse (continued again)

4.) Clues for recognizing substance impairment in nurses (again). → Increase in "wasting" of drugs, higher incidences of incorrect narcotic counts, and a higher record of signing out drugs for other nurses who 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. 1.) As uncomfortable as it may seem to tell a supervisor about suspected impairment in one of your peers, it is in the interest of the nurse's health and critically important to ensuring patient safety. 2.) If suspicious behavior occurs, it is important to keep careful, objective records.

The Chemically Impaired Nurse (continued)

4.) Clues for recognizing substance impairment in nurses. → 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. 1.) Some states require observers to report nurses who have substance-abuse problems to the state board of nursing. 2.) A number of clues for recognizing substance impairment in nurses have been identified. They are not easy to detect and will vary according to the substance being used.

Dynamics of Substance-Related Disorders (continued again and again)

4.) Effects of alcohol on the body (again): → Alcoholic cardiomyopathy: ⤷ Effect of alcohol on the heart is an accumulation of lipids in the myocardial cells. → Esophagitis: ⤷ Inflammation and pain in the esophagus. → Gastritis: ⤷ Effects of alcohol on the stomach include inflammation of the stomach lining. → Pancreatitis: ⤷ Acute: Usually occurs 1 or 2 days after a binge. ⤷ Chronic: Leads to pancreatic insufficiency. → Alcoholic hepatitis: ⤷ Caused by long-term heavy alcohol use. ⤷ Enlarged, tender liver; nausea and vomiting; lethargy; anorexia; elevated white blood cell count; fever; and jaundice; also, ascites and weight loss in severe cases. 1.) Alcoholic cardiomyopathy generally relates to congestive heart failure or arrhythmia. Symptoms include decreased exercise tolerance, tachycardia, dyspnea, edema, palpitations, and nonproductive cough. Changes may be observed by electrocardiogram, and congestive heart failure may be evident on chest x-ray films. 2.) Treatment is total permanent abstinence from alcohol. Treatment of the congestive heart failure may include rest, oxygen, digitalization, sodium restriction, and diuretics. The death rate is high for individuals with advanced symptomatology. 3.) Esophagitis—inflammation and pain in the esophagus—occurs because of the toxic effects of alcohol on the esophageal mucosa. It also occurs because of frequent vomiting associated with alcohol abuse. The effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention. Alcohol breaks down the stomach's protective mucosal barrier, allowing hydrochloric acid to erode the stomach wall. Damage to blood vessels may result in hemorrhage. 4.) Pancreatitis may be categorized as acute or chronic. Acute pancreatitis usually occurs shortly after binge drinking. Symptoms include constant, severe epigastric pain, nausea and vomiting, and abdominal distention. The chronic condition leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus. 5.) Alcoholic hepatitis is inflammation of the liver caused by long-term heavy alcohol use. Symptoms include an enlarged and tender liver, nausea and vomiting, lethargy, anorexia, elevated white blood cell count, fever, and jaundice. Ascites and weight loss may be evident in more severe cases. With treatment—which includes strict abstinence from alcohol, proper nutrition, and rest—the individual can experience complete recovery. Severe cases can lead to cirrhosis or hepatic encephalopathy.

Dynamics of Substance-Related Disorders (continued again and again and again)

4.) Effects of alcohol on the body (again): → 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: ⤷ Portal hypertension: Elevation of blood pressure through the portal circulation results from defective blood flow through the cirrhotic liver. ⤷ Ascites: A condition, in which an excessive amount of serous fluid accumulates in the abdominal cavity, occurs in response to portal hypertension. The increased pressure results in the seepage of fluid from the surface of the liver into the abdominal cavity. ⤷ Esophageal varices: Veins in the esophagus that become distended because of excessive pressure from defective blood flow through the cirrhotic liver. As this pressure increases, these varicosities can rupture, resulting in hemorrhage and sometimes death. ⤷ Hepatic encephalopathy: This serious complication occurs in response to the inability of the diseased liver to convert ammonia to urea for excretion. The continued rise in serum ammonia results in progressively impaired mental functioning, apathy, euphoria or depression, sleep disturbance, increasing confusion, and progression to coma and eventual death. Cirrhosis of the liver may be caused by anything that results in chronic injury to the liver, but it is also the end-stage of alcoholic liver disease and results from long-term chronic alcohol abuse. There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue. Symptoms nausea and vomiting, anorexia, weight loss, abdominal pain, jaundice, edema, anemia, and blood coagulation abnormalities. Treatment includes abstention from alcohol, correction of malnutrition, and supportive care to prevent complications of the disease.

Dynamics of Substance-Related Disorders (continued again and again and again and again)

4.) Effects of alcohol on the body (again): → 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. 1.) Production, function, and movement of the white blood cells are impaired in chronic alcoholics. This condition, called leukopenia, places the individual at high risk for contracting infectious diseases as well as for complicated recovery. 2.) Platelet production and survival is impaired as a result of the toxic effects of alcohol. This places the alcoholic at risk for hemorrhage. Abstinence from alcohol rapidly reverses this deficiency. 3.) Alcohol can interfere with the normal production and maintenance of female and male hormones. For women, this can mean changes in the menstrual cycles and a decreased or loss of ability to become pregnant. For men, the altered hormone levels result in a diminished libido, decreased sexual performance, impaired fertility, and gynecomastia may develop secondary to testicular atrophy.

Dynamics of Substance-Related Disorders (continued again)

4.) Effects of alcohol on the body: → Peripheral neuropathy: ⤷ Characterized by nerve damage, results in pain, burning, tingling, or prickly sensations of the extremities. → Alcoholic myopathy: ⤷ May occur as an acute or chronic condition. ⤷ Thought to result from same B vitamin deficiency that contributes to peripheral neuropathy. → 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. 1.) At low doses, alcohol produces relaxation, loss of inhibitions, lack of concentration, drowsiness, slurred speech, and sleep. Chronic abuse results in multisystem physiological impairments. 2.) Peripheral neuropathy results in pain, burning, tingling, or prickly sensations of the extremities. Researchers believe it is the direct result of deficiencies in the B vitamins, particularly thiamine. This is reversible with abstinence from alcohol and restoration of nutritional deficiencies, but permanent muscle wasting and paralysis can occur with continued use. 3.) Alcoholic myopathy can occur as an acute or chronic condition. 4.) In the acute condition, the individual experiences a sudden onset of muscle pain, swelling, and weakness. These symptoms are usually generalized, but pain and swelling may selectively involve the calves or other muscle groups. 5.) Chronic alcoholic myopathy includes a gradual wasting and weakness in skeletal muscles. Neither the pain and tenderness nor the elevated muscle enzymes seen in acute myopathy are evident in the chronic condition. 6.) Wernicke's encephalopathy represents the most serious form of thiamine deficiency in alcoholics. Symptoms include paralysis of the ocular muscles, diplopia, ataxia, somnolence, and stupor. If thiamine replacement therapy is not undertaken quickly, death will ensue. 7.) Korsakoff's psychosis is identified by a syndrome of confusion, loss of recent memory, and confabulation in alcoholics. It is frequently encountered in clients recovering from Wernicke's encephalopathy. In the United States, the two disorders are usually considered together and are called Wernicke-Korsakoff syndrome. Treatment is with parenteral or oral thiamine replacement.

Opioid Use Disorder (continued)

4.) Effects on the body: → CNS effects. → Gastrointestinal effects. → Cardiovascular effects. → Sexual functioning. 1.) Development of opioid addiction may follow one of two typical behavior patterns. The first occurs in the individual who has obtained the drug by prescription from a physician. Abuse and addiction occur when the individual increases the amount and frequency of use, justifying the behavior as symptom treatment. 2.) The second pattern of behavior associated with addiction to opioids occurs among individuals who use the drugs for recreational purposes and obtain them from illegal sources. Tolerance develops and addiction occurs, leading the individual to procure the substance by whatever means is required to support the habit. 3.) Describe the effects of opioids on the body. 4.) All opioids, opioid derivatives, and synthetic opioid-like drugs affect the CNS. Common manifestations include euphoria, mood changes, and mental clouding. Other common CNS effects include drowsiness and pain reduction. The antitussive response is due to suppression of the cough center within the medulla. The nausea and vomiting commonly associated with opiate ingestion is related to the stimulation of the centers within the medulla that trigger this response. 5.) Opioids exert a profound effect on the GI tract. Both stomach and intestinal tone are increased, whereas peristaltic activity of the intestines is diminished. These effects lead to a marked decrease in the movement of food through the GI tract. This is a notable therapeutic effect in the treatment of severe diarrhea. In fact, no drugs have yet been developed that are more effective than the opioids for this purpose. 6.) Morphine is used extensively to relieve pulmonary edema and the pain of myocardial infarction in cardiac clients. At high doses, opioids induce hypotension, which may be caused by direct action on the heart or by opioid-induced histamine release. 7.) With opioid use, there is decreased sexual function and diminished libido. Delayed ejaculation, impotence, and orgasm failure may occur.

Inhalant Use Disorder (continued)

4.) Effects on the body: → CNS effects. → Respiratory effects. → Gastrointestinal effects. → Renal system effects. 1.) Inhalants can cause both central and peripheral nervous system damage. Neurological damage, such as ataxia, peripheral and sensorimotor neuropathy, speech problems, and tremors, can occur. Respiratory effects of inhalant use range from coughing and wheezing to dyspnea, emphysema, and pneumonia. There is increased airway resistance due to inflammation of the passages. 2.) Abdominal pain, nausea, and vomiting may occur. A rash may be present around the individual's nose and mouth. Acute and chronic renal failure and hepatorenal syndrome have occurred. Renal toxicity from toluene exposure has been reported.

Cannabis Use Disorder (continued)

4.) Effects on the body: → Cardiovascular. → Respiratory. → Reproductive. → CNS. → Sexual functioning. 1.) Cannabis ingestion induces tachycardia and orthostatic hypotension. With the decrease in blood pressure, myocardial oxygen supply is decreased. Tachycardia in turn increases oxygen demand. 2.) Marijuana produces a greater amount of "tar" than its equivalent weight in tobacco. Because marijuana is most commonly smoked larger amounts of tar are deposited in the lungs, promoting deleterious effects to the lungs. 3.) Although the initial reaction to the marijuana is bronchodilation, thereby facilitating respiratory function, chronic use results in obstructive airway disorders. Frequent marijuana users often have laryngitis, bronchitis, cough, and hoarseness. Cannabis smoke contains more carcinogens than tobacco smoke. 4.) Some studies have shown that, with heavy marijuana use, men may have a decrease in sperm count, motility, and structure. In women, heavy marijuana use may result in a suppression of ovulation, disruption in menstrual cycles, and alteration of hormone levels. 5.) Many people report a feeling of being "high." Symptoms include feelings of euphoria, relaxed inhibitions, disorientation, depersonalization, and relaxation. At higher doses, sensory alterations may occur, including impairment in judgment of time and distance, recent memory, and learning ability. Physiological symptoms may include tremors, muscle rigidity, and conjunctival redness. Toxic effects are generally characterized by panic reactions. Very heavy usage has been shown to precipitate an acute psychosis that is self-limited and short-lived once the drug is removed from the body. 6.) Heavy long-term cannabis use is also associated with a condition called amotivational syndrome. Amotivationalsyndrome is defined as lack of motivation to persist in or complete a task that requires ongoing attention. 7.) Marijuana is reported to enhance the sexual experience in both men and women. The intensified sensory awareness and the subjective slowness of time perception are thought to increase sexual satisfaction. Marijuana also enhances the sexual functioning by releasing inhibitions for certain activities that would normally be restrained.

Substance Use Disorder (continued again)

4.) 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. 1.) Intoxication is a physical and mental state of exhilaration and emotional frenzy or lethargy and stupor. 2.) Substance intoxication is the development of reversible syndromes following excessive use of a substance. These symptoms are drug-specific and occur shortly after ingesting the substance. Judgment is disturbed, resulting in inappropriate and maladaptive behavior, and social and occupational functioning are impaired.

Dynamics of Substance-Related Disorders (continued again and again and again and again and again)

5.) Alcohol use during pregnancy can result in fetal alcohol spectrum disorders (FASDs): → Fetal alcohol syndrome (FAS) includes problems with learning, memory, attention span, communication, vision, and hearing. → Alcohol-related neuro developmental disorder. → Alcohol-related birth defects. Prenatal exposure to alcohol can result in a broad range of disorders to the fetus, known as fetal alcohol spectrum disorders (FASDs), the most common of which is fetal alcohol syndrome (FAS). Fetal alcohol syndrome includes physical, mental, behavioral, and/or learning disabilities with lifelong implications. Other FASDs include alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD).

Codependency (continued again)

5.) Codependent's home life is fraught with stress. 6.) 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. 7.) May have experienced abuse or emotional neglect as a child. 8.) Outwardly focused on others and know very little about how to direct their lives from their own sense of self. 1.) In a relationship, the codependent person derives self-worth from that of the partner, whose feelings and behaviors determine how the codependent should feel and behave. In order for the codependent to feel good, his or her partner must be happy and behave in appropriate ways. If the partner is not happy, the codependent feels responsible for making him or her happy. 2.) Wesson describes the following behaviors characteristic of codependency. She stated that codependents: → Have a long history of focusing thoughts and behavior on other people. → Are "people pleasers" and will do almost anything to get the approval of others. → Outwardly appear very competent, but actually feel quite needy, helpless, or perhaps nothing at all. → Have experienced abuse or emotional neglect as a child. → Are outwardly focused towards others, and know very little about how to direct their own lives from their own sense of self.

Sedative/Hypnotic Use Disorder (continued again and again)

5.) Sedative, hypnotic, or anxiolytic intoxication. → With these CNS depressants, effects can range from disinhibition and aggressiveness to coma and death. 6.) Sedative, hypnotic, or anxiolytic 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. 1.) The DSM-5 describes sedative, hypnotic, or anxiolytic intoxication as the presence of clinically significant maladaptive behavioral or psychological changes that develop during, or shortly after, use of one of these substances. These changes may include inappropriate sexual or aggressive behavior, mood lability, impaired judgment, or impaired social or occupational functioning. Other symptoms that may develop with excessive use of CNS depressants include slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor or coma. 2.) Taken recreationally, "club drugs" can produce a state of disinhibition, excitement, drunkenness, and amnesia. They have been widely implicated as "date rape" drugs, their presence being easily disguised in drinks. They produce anterograde amnesia, rendering the inability to remember events experienced while under their influence. 3.) Onset of withdrawal symptoms depends on the drug from which the individual is withdrawing. With short-acting sedative/hypnotics, symptoms may begin between 12 and 24 hours after the last dose, reach peak intensity between 24 and 72 hours, and subside in 5 to 10 days. Withdrawal symptoms from substances with longer half-lives may begin within 2 to 7 days, peak on the fifth to eighth day, and subside in 10 to 16. 4.) Severe withdrawal is most likely to occur when a substance has been used at high dosages for prolonged periods. Withdrawal symptoms associated with sedative/hypnotics include autonomic hyperactivity, increased hand tremor, insomnia, nausea or vomiting, hallucinations, illusions, psychomotor agitation, anxiety, or grand mal seizures.

Stimulant Use Disorder (continued again)

5.) Stimulant 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. 1.) Amphetamine and cocaine intoxication typically produces euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; or impaired judgment. In severe amphetamine intoxication, symptoms may include memory loss, psychosis, and violent aggression. 2.) Intoxication from caffeine usually occurs following consumption in excess of 250 mg. Symptoms include restlessness, nervousness, excitement, insomnia, flushed face, diuresis, GI disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, and psychomotor agitation

Substance Use Disorder (continued again and again)

5.) Substance withdrawal: → Occurs upon abrupt reduction or discontinuation of a substance used regularly over a prolonged period of time. → Substance-specific syndrome includes: ⤷ Clinically significant physical signs and symptoms. ⤷ Psychological changes, such as disturbances in thinking, feeling, and behavior. 1.) Withdrawal is the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. 2.) Substance withdrawal occurs upon abrupt reduction or discontinuation of a substance that has been used regularly over a prolonged period of time. The substance-specific syndrome includes clinically significant physical signs and symptoms as well as psychological changes such as disturbances in thinking, feeling, and behavior. 3.) Classes of psychoactive substances are defined in Box 23-1.

Dynamics of Substance-Related Disorders (continued again and again and again and again and again and again and again)

6.) Alcohol intoxication: → Occurs at blood alcohol levels between 100 and 200 mg/dL. 7.) Alcohol withdrawal: → Occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use. 1.) Symptoms of alcohol intoxication include disinhibition of sexual or aggressive impulses, mood lability, impaired judgment, impaired social or occupational functioning, slurred speech, incoordination, unsteady gait, nystagmus, and flushed face. 2.) The following withdrawal symptoms may occur: coarse tremor of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood or irritability; transient hallucinations or illusions; headache; and insomnia. In about 1% of alcoholic patients complicated withdrawal syndrome may progress to alcohol withdrawal deliriumand concomitant medical problems may increase the risk.

Stimulant Use Disorder (continued again and again)

6.) Stimulant 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. 1.) Stimulant withdrawal is often referred to as "crashing." Symptoms include fatigue, cramps, depression, headaches, and nightmares. The dysphoria can be intense enough to result in increased risk for suicide. Peak withdrawal symptoms usually occur within 2-4 days of abstinence. 2.) The DSM-5 states that a withdrawal syndrome can occur with abrupt cessation of caffeine intake after a prolonged daily use of the substance. The symptoms begin within 24 hours after last consumption and may include the following symptoms: headache, fatigue, drowsiness, dysphoric mood, irritability, difficulty concentrating, flu-like symptoms, nausea, vomiting, and/or muscle pain and stiffness. 3.) Withdrawal from nicotine results in dysphoric or depressed mood; insomnia; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; and increased appetite or weight gain.

#3 Sample Question

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).

#2 Sample Question

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.

Sedative/Hypnotic Use Disorder

A profile of the substance: 1.) Barbiturates 2.) Non barbiturate hypnotics 3.) Antianxietyagents 1.) Sedative/hypnotic/anxiolytic compounds are drugs of diverse chemical structures that are all capable of inducing varying degrees of CNS depression, from tranquilizing relief of anxiety to anesthesia, coma, and even death. They are generally categorized as barbiturates, nonbarbiturate hypnotics, and antianxiety agents. 2.) Table 23-1 presents a selected list of drugs included in these categories. Generic names are followed in parentheses by the trade names. Common street names for each category are also included.

Dynamics of Substance-Related Disorders

Alcohol Use Disorder: 1.) A Profile of the Substance: → Alcohol is a natural substance formed by the reaction of fermenting sugar with yeast spores. 2.) Historical Aspects: → Use of alcohol can be traced back to the Neolithic age, with consumption of beer and wine around 6400 B.C. → Introduction of distillation by Arabs in the Middle Ages. → Alchemists believed alcohol was the answer to all ailments. → Word whiskey, meaning "water of life," was widely known. 1.) Although there are many types of alcohol, the kind in alcoholic beverages is known scientifically as ethyl alcohol and chemically as C2H5OH. Its abbreviation, ETOH, is sometimes seen in medical records and other documents and publications. 2.) The alcohol content varies by type of beverage. For example, most American beers contain 3 to 6 percent alcohol, wines average 10 to 20 percent, and distilled beverages range from 40 to 50 percent alcohol. The average-sized drink, regardless of beverage, contains a similar amount of alcohol: 12 ounces of beer, 3 to 5 ounces of wine, and a cocktail with 1 ounce of whiskey all measure approximately 0.5 ounces. If consumed at the same rate, all would have an equal effect on the body.

Treatment Modalities for Substance-Related Disorders

Alcoholics Anonymous (AA): 1.) A major self-help organization for the treatment of alcoholism. 2.) Based on the concept of: → Peer support. → Acceptance. → Understanding from others who have experienced the same problem. 1.) Alcoholics Anonymous (AA) was founded in 1935 by two alcoholics—a stockbroker, Bill Wilson, and a physician, Dr. Bob Smith—who discovered that they could remain sober through mutual support. 2.) AA groups are based on the concept of peer support—acceptance and understanding from others who have experienced the same problems in their lives. Requirement for membership is a desire on the part of the alcoholic person to stop drinking. Each new member is assigned a support person from whom he or she may seek assistance when the temptation to drink occurs.

Predisposing Factors

Biological factors: 1.) Genetics: → Apparent hereditary factor, particularly with alcoholism. 2.) Biochemistry: → Although evidence shows that changes in brain structure and brain neurochemistry occur in the process of developing addiction, whether these changes wholly explain etiology remains controversial. 1.) A number of factors have been implicated in the predisposition to abuse of substances. 2.) Genetics appear to be involved in the development of substance use disorders, especially alcoholism. Children of alcoholics are four times more likely than other children to become alcoholics. Studies with monozygotic and dizygotic twins have demonstrated that monozygotic twins have a higher rate for concordance of alcoholism than dizygotic twins. 3.) Evidence supports the idea that changes in brain structure and brain neurochemistry occur in the process of developing addiction. Neuronal pathways that are responsible for sensing pleasure and reward, once activated, are believed to be responsible for pleasurable sensations associated with these drugs as well creating a "memory" that triggers desire for repeated use of the drug. These pathways are referred to as the brain-reward circuitry.

Predisposing Factors to Gambling Disorder

Biological influences: 1.) Genetic: → Increased incidence among family members. 2.) Physiological: → Abnormalities in neurotransmitter systems. 1.) Familial and twin studies show an increased prevalence of pathological gambling in family members of individuals diagnosed with the disorder. 2.) Hodgins, Stea, and Grant suggest a correlation between pathological gambling and abnormalities in the serotonergic, noradrenergic, and dopaminergic neurotransmitter systems. Biochemical theories suggest that both winning and losing may stimulate the reward and pleasure centers of the brain which could contribute to persistent and repeated desire to gamble even though one is not winning.

Nursing Process: Assessment (continued again)

CAGE Questionnaire: 1.) Have you ever felt you should Cut down on your drinking? 2.) Have people Annoyed you by criticizing your drinking? 3.) Have you ever felt bad or Guilty about your drinking? 4.) Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)?

Dynamics of Substance-Related Disorders (continued again and again and again and again and again and again)

Characteristics of FAS: 1.) Abnormal facial features. 2.) Small head size. 3.) Shorter-than-average height. 4.) Low body weight. 5.) Poor coordination. 6.) Hyperactive behavior. 7.) Difficulty paying attention. 8.) Poor memory. 9.) Difficulty in school. 10.) Learning difficulties. 11.) Speech and language delays. 12.) Intellectual disability. 13.) Poor reasoning skills. 14.) Sleep and sucking problems as a baby. 15.) Vision or hearing problems. 16.) Problems with the heart, kidneys, or bones. 1.) No amount of alcohol during pregnancy is considered safe, and alcohol can damage a fetus at any stage of pregnancy. 2.) Women with alcohol-related disorders have a 35% risk of having a child with defects. Children with FAS may have the following characteristics or exhibit these characteristic behaviors.

The Codependent Nurse

Classic characteristics: 1.) Caretaking. 2.) Perfectionism. 3.) Denial. 4.) Poor communication. Certain characteristics of codependence have been associated with the profession of nursing. A shortage of nurses combined with the increasing ranks of seriously ill clients may result in nurses providing care and fulfilling everyone's needs but their own. Many health-care workers who are reared in homes with a chemically addicted person or otherwise dysfunctional family are at risk for having any unresolved codependent tendencies activated. They are attracted to a profession in which they are needed, but they nurture feelings of resentment for receiving so little in return. Their emotional needs go unmet; however, they continue to deny that these needs exist.

#1 Sample Question (answer)

Correct answer: A 1.) Research has indicated that an apparent hereditary factor is involved in the development of substance-use disorders. 2.) This is especially evident with alcoholism.

#3 Sample Question (answer)

Correct answer: C 1.) Disulfiram is used as a deterrent to drinking. 2.) Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can cause varying degrees of discomfort. 3.) It can even result in death if blood alcohol levels are high. 4.) 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.

#2 Sample Question (answer)

Correct answer: D 1.) Wernicke's encephalopathy is the most serious form of thiamine deficiency in clients diagnosed with alcoholism. 2.) If thiamine replacement therapy is not undertaken quickly, death will ensue.

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. The concept of codependency arose out of a need to define the dysfunctional behaviors that are evident among members of the family of a chemically addicted person. The term has been expanded to include all individuals from families that harbor secrets of physical or emotional abuse, other cruelties, or pathological conditions.

The Chemically Impaired Nurse (continued again and again and again)

During the suspension period: 1.) Successful completion of an inpatient, outpatient, group, or individual counseling treatment program. 2.) Evidence of regular attendance at nurse support groups or 12-step program. 3.) Random negative drug screens. 4.) Employment or volunteer activities. Suspension may require successful completion of inpatient, outpatient, group, or individual counseling treatment program(s); evidence of regular attendance at nurse support groups or 12-step program; random negative drug screens; and employment or volunteer activities during the suspension period. When a nurse is deemed safe to return to practice, he or she may be closely monitored for several years and required to undergo random drug screenings.

Treating Codependence

Four stages in the recovery process for individuals with codependent personality: 1.) Stage I Survival stage: In this stage, codependent persons must begin to let go of the denial that problems exist. This initiation of abstinence from blanket denial may be a very emotional and painful period. 2.) Stage II Reidentification stage: Reidentification occurs when the individuals are able to glimpse their true selves through a break in the denial system. They accept the label of codependent and take responsibility for their own dysfunctional behavior. They accept their limitations and are ready to face the issues of codependence. 3.) Stage III Core issues stage: In this stage, the recovering codependent must face the fact that relationships cannot be managed by force of will. Each partner must be independent and autonomous. The goal of this stage is to detach from the struggles of life that exist because of prideful and willful efforts to control those things that are beyond the individual's power to control. 4.) Stage IV Reintegration stage: This is a stage of self-acceptance and willingness to change when codependents relinquish the power over others that was not rightfully theirs but reclaim the personal power that they do possess.

Non-Substance Addictions

Gambling disorder: 1.) Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress. 2.) As the need to gamble increases, the individual may use any means required to obtain money to continue the addiction. 3.) Gambling behavior usually begins in adolescence, although compulsive behaviors rarely occur before young adulthood. 4.) The disorder usually runs a chronic course, with periods of waxing and waning. 5.) The disorder interferes with interpersonal relationships, social, academic, or occupational functioning. 1.) This disorder is defined by the DSM-5 as persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress. The impulse to gamble often intensifies when the individual is under stress, and many describe a physical sensation of restlessness and anticipation that can only be relieved by placing a bet. 2.) The DSM-5 diagnostic criteria for pathological gambling are presented in Box 23-8. 3.) The disorder generally runs a chronic course, with periods of waxing and waning, largely dependent on periods of stress. Prevalence estimates for problem gambling range from 3 to 5 percent, and about 1 percent meet the criteria for a gambling disorder. It is more common among men than women. 4.) Various personality traits have been attributed to pathological gamblers.

Inhalant-Induced Disorder

Inhalant intoxication: 1.) Develops during or shortly after use of or exposure to volatile inhalants. 2.) Symptoms are similar to alcohol intoxication and may include the following: → Dizziness, ataxia, muscle weakness. → Euphoria, excitation, disinhibition. → Nystagmus, blurred or double vision. → Slurred speech, lethargy. → Psychomotor retardation, hypoactive reflexes. → Stupor or coma (at higher doses). A mild withdrawal syndrome has been documented but does not appear to be clinically significant.

Hallucinogen-Induced Disorder

Intoxication: 1.) Intoxication occurs during or shortly after using the drug. 2.) Symptoms include perceptual alteration, depersonalization, derealization, tachycardia, and palpitations. 3.) Symptoms of phencyclidine intoxication include belligerence and assaultiveness, and may proceed to seizures or coma. 4.) General effects of MDMA (Ecstasy) include increased heart rate, blood pressure, and body temperature; dehydration; confusion; insomnia; and paranoia. 1.) Maladaptive behavioral or psychological changes include marked anxiety or depression, ideas of reference, fear of losing one's mind, paranoid ideation, and impaired judgment. Perceptual changes occur while the individual is fully awake and alert and include intensification of perceptions, depersonalization, derealization, illusions, hallucinations, and synesthesias. Because hallucinogens are sympathomimetics, they can cause tachycardia, hypertension, sweating, blurred vision, papillary dilation, and tremors. 2.) Symptoms of PCP intoxication are unpredictable and are dose related. They may include impulsiveness, impaired judgment, assaultiveness, and belligerence, or the individual may appear calm, stuporous, or comatose. Physical symptoms include vertical or horizontal nystagmus, hypertension, tachycardia, ataxia, diminished pain sensation, muscle rigidity, and seizures. Symptoms of ketamine intoxication appear similar to those of PCP.

Cannabis-Induced Disorder

Intoxication: 1.) Symptoms include impaired motor coordination, euphoria, anxiety, sensation of slowed time, and impaired judgment. 2.) Physical symptoms include conjunctival injection, increased appetite, dry mouth, and tachycardia. 3.) Impairment of motor skills lasts for 8 to 12 hours. Symptoms include impaired motor coordination, euphoria, anxiety, a sensation of slowed time, impaired judgment and memory, and social withdrawal. Physical symptoms include conjunctival injection (red eyes), increased appetite, dry mouth, and tachycardia. The impairment of motor skills lasts for 8 to 12 hours and interferes with the operation of motor vehicles. Cannabis intoxication delirium is marked by significant cognitive impairment and difficulty performing tasks.

Opioid-Induced Disorders

Opioid intoxication: 1.) Symptoms are consistent with the half-life of most opioid drugs and usually last for several hours. 2.) Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment. 3.) Severe opioid intoxication can lead to respiratory depression, coma, and death. Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment. Physical symptoms include pupillary constriction, drowsiness, slurred speech, and impairment in attention or memory.

Opioid-Induced Disorders (continued)

Opioid withdrawal: 1.) 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. 2.) 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. 3.) Ultra-short-acting meperidine: → Symptoms begin quickly, peak in 8 to 12 hours, and subside in 4 to 5 days. 4.) Symptoms of opioid withdrawal: → Dysphoria, muscle aches, nausea/vomiting, lacrimation or rhinorrhea, pupillary dilation, pilo erection, sweating, abdominal cramping, diarrhea, yawning, fever, and insomnia. 1.) With short-acting drugs such as heroin, withdrawal symptoms occur within 6 to 8 hours after the last dose, peak within 1 to 3 days, and gradually subside over a period of 5 to 10 days. With longer-acting drugs such as methadone, withdrawal symptoms begin within 1 to 3 days after the last dose, peak between days 4 and 6, and are complete in 14 to 21 days. Withdrawal from the ultra-short-acting meperidine begins quickly, reaches a peak in 8 to 12 hours, and is complete in 4 to 5 days. 2.) Opioid withdrawal produces a syndrome of symptoms that develops after cessation of, or reduction in, heavy and prolonged use of an opiate or related substance. Symptoms include dysphoric mood, nausea or vomiting, muscle aches, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, and insomnia.

The Chemically Impaired Nurse (continued again and again and again and again)

Peer assistance programs: 1.) Recognize their impairment. 2.) Obtain necessary treatment. 3.) Regain accountability within profession. In 1982, the American Nurses Association (ANA) House of Delegates adopted a national resolution to provide assistance to impaired nurses. Since that time, the majority of state nurses' associations have developed (or are developing) programs for nurses who are impaired by substances or psychiatric illness. The individuals who administer these efforts are nurse members of the state associations, as well as nurses who are in recovery themselves. For this reason, they are called peer assistance programs.

Treatment Modalities for Substance-Related Disorders (continued again)

Pharmacotherapy for alcoholism: 1.) Disulfiram (Antabuse). 2.) Other medications. → Naltrexone (ReVia). → Nalmefene (Revex). → Selective serotonin reuptake inhibitors (SSRIs). → Acamprosate (Campral). 1.) Disulfiram (Antabuse) is a drug that can be administered as a deterrent to drinking to individuals who abuse alcohol. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a great deal of discomfort for the individual. Disulfiram therapy is not a cure for alcoholism, but rather a measure of control to avoid impulse drinking. Clients receiving disulfiram therapy are encouraged to seek other assistance with their problem, such as AA or other support group, to aid in the recovery process. 2.) The narcotic antagonist naltrexone (ReVia) was approved by the Food and Drug Administration (FDA) in 1994 for the treatment of alcohol addiction. Naltrexone, which was approved in 1984 for the treatment of heroin abuse, works on the same receptors in the brain that produce the feelings of pleasure when heroin or other opiates bind to them. The efficacy of selective serotonin reuptake inhibitors (SSRIs) in the decrease of alcohol craving among alcohol dependent individuals has yielded mixed results. In August, 2004, the FDA approved acamprosate (Campral), which is indicated for the maintenance of abstinence from alcohol in patients with alcohol addiction who are abstinent at treatment initiation.

Predisposing Factors (continued)

Psychological factors: 1.) Developmental influences: → Punitive superego. → Fixation in oral stage of psychosexual development. 2.) Personality factors: → Certain personality traits are thought to increase a tendency toward addictive behavior. 3.) Cognitive factors: → Irrational thinking patterns have long been identified as a problem that is central in addictions. 1.) The psychodynamic approach to the etiology of substance abuse focuses on a punitive superego and fixation at the oral stage of psychosexual development. Individuals with punitive superegos turn to drugs to diminish unconscious anxiety and increase feelings of power and self-worth. 2.) Certain personality traits have been associated with an increased tendency toward addictive behavior. Some clinicians believe a low self-esteem, frequent depression, passivity, antisocial personality traits, the inability to relax or to defer gratification, and the inability to communicate effectively are common in individuals who abuse substances. 3.) Irrational thinking patterns are a problem that is central in additions. When these thought patterns are unchallenged they may culminate in additional addictions, even when a person stops using the drug to which they first became addicted. Some examples include denial, projection, and rationalization.

Treatment Modalities for Substance-Related Disorders (continued again and again and again and again)

Psychopharmacology for substance intoxication and substance withdrawal (continued): 5.) Stimulants: → Minor tranquilizers. → Major tranquilizers. → Anticonvulsants. → Antidepressants. 6.) Hallucinogens and cannabinols: → Benzodiazepines. → Antipsychotics. 1.) Treatment of stimulant intoxication usually begins with minor tranquilizers such as chlordiazepoxide and progresses to major tranquilizers, such as haloperidol (Haldol). Antipsychotics should be administered with caution because of their propensity to lower seizure threshold. 2.) Withdrawal from CNS stimulants is not the medical emergency observed with CNS depressants. Treatment is usually aimed at reducing drug craving and managing severe depression. The client is placed in a quiet atmosphere and allowed to sleep and eat as much as is needed or desired. Suicide precautions may need to be instituted. Antidepressant therapy may be helpful in treating symptoms of depression. 3.) Substitution therapy is not required with these drugs, but when adverse reactions, such as anxiety or panic, occur, benzodiazepines (e.g., diazepam or chlordiazepoxide) may be prescribed to prevent harm to the client or others. Psychotic reactions may be treated with antipsychotic medications.

Treatment Modalities for Substance-Related Disorders (continued again and again and again)

Psychopharmacology for substance intoxication and substance withdrawal: 1.) Substitution therapy may be required to reduce the life-threatening effects. 2.) Alcohol: → Benzodiazepines. → Anticonvulsants. → Multivitamin therapy. → Thiamine. 3.) Opioids: → Narcotic antagonists. ⤷ Naloxone (Narcan). ⤷ Naltrexone (ReVia). ⤷ Nalmefene (Revex). → Methadone. → Buprenorphine. → Clonidine. 4.) Depressants: → Phenobarbital (Luminal). → Long-acting benzodiazepines. 1.) Substitution therapy may be required to reduce the life-threatening effects of intoxication or withdrawal from some substances. The severity of the withdrawal syndrome depends on the particular drug used, how long it has been used, the dose used, and the rate at which the drug is eliminated from the body. 2.) Benzodiazepines comprise the most widely used group of drugs for substitution therapy in alcohol withdrawal. Chlordiazepoxide (Librium), oxazepam (Serax), lorazepam (Ativan), and diazepam (Valium) are the most commonly usedagents. Some physicians may order anticonvulsant medication for management of withdrawal seizures. Multivitamin therapy, in combination with daily injections or oral administration of thiamine, is common protocol. Thiamine is commonly deficient in chronic alcoholics. 3.) Opioid intoxication is treated with narcotic antagonists, such as naloxone (Narcan), naltrexone (ReVia), or nalmefene(Revex). In 2015 the FDA approved an intranasal form of naloxone hydrochloride under a fast track approval process in response to the continued increase in deaths associated with drug overdose, particularly from respiratory depression and arrest. Methadone, if ordered, is given on the first day in a dose sufficient to suppress withdrawal symptoms. The dose is then gradually tapered over a specified time. In October 2002, the FDA approved two forms of the drug buprenorphine for treating opiate addiction. Buprenorphine is less powerful than methadone but is considered to be somewhat safer and causes fewer side effects. Clonidine (Catapres) also has been used to suppress opiate withdrawal symptoms. As monotherapy, it is not as effective as substitution with methadone, but it is nonaddicting. 4.) Substitution therapy for CNS depressant withdrawal is most commonly with the long-acting barbiturate phenobarbital (Luminal). The dosage required to suppress withdrawal symptoms is administered. When stabilization has been achieved, the dose is gradually decreased by 30 mg/day until withdrawal is complete. Long-acting benzodiazepines are commonly used for substitution therapy when the abused substance is a nonbarbiturate CNS depressant.

Predisposing Factors (continued again)

Sociocultural factors: 1.) 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. 2.) Conditioning: → Pleasurable effects from substance use act as a positive reinforcement for continued use of substance. 3.) Cultural and ethnic influences: → Some cultures are more prone to substance abuse than are others. 1.) The family appears to be an important influence in substance use. Various studies have shown that children and adolescents are more likely to use substances if they have parents who provide a model for substance use. Peers also often exert a great deal of influence in the life of the child or adolescent. 2.) Conditioning is a term used to describe a learned response that occurs after repeated exposure to a stimulus. Substance abuse can become a learned response from the substance itself as well as the environment where use occurs. 3.) An individual's culture can also establish patterns of substance use. For example, a high incidence of alcohol addiction has existed within the Native American culture, whereas the incidence of alcohol addiction among Asians is relatively low.

The Chemically Impaired Nurse (continued again and again)

State board response: 1.) May deny, suspend, or revoke a license based on a report of chemical abuse by a nurse. 2.) Diversionary laws allow impaired nurses to avoid disciplinary action by agreeing to seek treatment. If a report is made to the state board of nursing, the board may deny, suspend, or revoke a license. Several state boards of nursing have passed diversionary laws that allow impaired nurses to avoid disciplinary action by agreeing to seek treatment. Some of these state boards administer the treatment programs themselves, and others refer the nurse to community resources or state nurses' association assistance programs.

Cannabis-Induced Disorder (continued)

Symptoms occur within a week following cessation of use and may include: 1.) Irritability, anger, or aggression. 2.) Nervousness, restlessness, or anxiety. 3.) Sleep difficulty (e.g., insomnia, disturbing dreams). 4.) Decreased appetite or weight loss. 5.) Depressed mood. 6.) Physical symptoms, such as abdominal pain, tremors, sweating, fever, chills, or headache. Tables 23-7 and 23-8 include summaries of the psychoactive substances, including symptoms of intoxication, withdrawal, use, overdose, possible therapeutic uses, and trade and common names by which they may be referred.

Outcome Criteria

To identify appropriate nursing diagnoses by analyzing the data collected during the assessment phase. The following criteria may be used for measurement of outcomes in the care of the client with substance-related disorders. The Client: 1.) Has not experienced physical injury. 2.) Has not caused harm to self or others. 3.) Accepts responsibility for own behavior. 4.) Acknowledges association between personal problems and use of substance(s). 5.) Demonstrates more adaptive coping mechanisms that can be used in stressful situations (instead of taking substances). 6.) Shows no signs or symptoms of infection or malnutrition. 7.) Exhibits evidence of increased self-worth. by attempting new projects without fear of failure and by demonstrating less defensive behavior toward others. 8.) Verbalizes importance of abstaining from use of substances in order to maintain optimal wellness.

#1 Sample Question

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.