Ch. 27: Substance Abuse
Trends in Substance Abuse
- May or may not relate to classically or clinically defined dependence or addiction - Turning to recovery before they have developed physiological dependence - Need to differentiate between use and misuse/abuse
DSM-5 substance use disorders
- Mild, moderate, or severe - Determined by 2 or more of 11 of diagnostic criteria
Course of Substance-Related Problems
Path from initiation to dependency is multidimensional. - Addiction nor dependency is a unitary phenomenon with a single isolated cause. Progression varies—from initiation to continuation, transition to abuse, and finally, addiction and dependency Critical point is transition from use to abuse. Addiction/dependency marked by changes in both behavior and cognition Once addiction is established, withdrawal symptoms are strong motivators to continue use.
Conceptualizations of Substance Abuse
Political & social reasons rather than scientific reasons change conceptualizations. - Focus on addiction DSM-5 revisions included combining abuse and dependence criteria into a single substance use disorder Specific interventions needed for each addictive problem (e.g., overeating and gambling)
Etiology of Substance Abuse
Several theories Some address - Individual Factors - Physiological Factors - Spiritual Factors - Psychological Factors
Nursing Perspective on Substance Abuse
Since 1070s nursing has become more involved in: - Spectrum of compulsive behavior problems - Substance abuse Nurses may reflect negative attitudes and have difficulty providing care to persons with substance abuse clients.
Problems & consequences of substance abuse are in areas like:
Social Psychological Physical Economic Political
Gender Differences: Demographics
Some reginal, racial, and gender differences and changes over past few years - West highest percentage 11.56% - Midwest 8.83% - Northeast 9.61% - South 7.95%
Steroids:
Synthetic variants of male sex hormone testosterone - Proper term anabolic-androgenic steroids - Build muscle and said to be androgenic - Most commonly used in athletes and other individuals willing to risk potential and irreversible health consequences to build muscle
DSM-5 substance use disorders: Criteria for diagnosis dependence include cluster of cognitive, behavioral, and physiological symptoms.
•Pattern of repeated, self-administered use •Tolerance, withdrawal, and compulsive drug-taking behaviors •A craving or strong desire for the substance •Preoccupation with supply, money to purchase, and getting through time between periods of use •Dependence—continued use of the substance despite significant substance-related problems
Mutual Help Groups
* Mutual help groups*: Operate through face-to-face supportive interaction focusing on a mutual goal; AA was first. *Alcoholics anonymous*: oFounded in 1935; stay sober "one day at a time"
Historical Overview of Alcohol andIllicit Drug Use: Laws impacting substance abuse:
*Anti-Drug Abuse Acts of 1986 & 1988* •Increased funding for treatment and rehabilitation •Stiffened penalties for drug offenses •Created the Office of National Drug Control Policy ("drug czar") •Coordinated national drug control policy *The "War on Drugs"*
Harm Reduction: Remain Controversial
*Methadone* substitution of heroin Psychotherapy aims to support process of self-transformation.
Preadolescents and Adolescents: Primary prevention focuses on:
- Advocating for these vulnerable children - Educating teachers on the vital importance of maintaining a validating, nonjudgmental attitude toward these students - Supporting strong families in the community - Improving knowledge through education and media - Early detection of predisposing factors - Providing structured clubs and organizations - Facilitating school success, career skills, family communication skills, and conflict resolution
Treatment Essentials
- Assessment process is of primary importance. - Therapeutic relationship based on trust is essential. - Physical examination is a valuable tool. - Nonjudgmental attitude minimizes defensiveness.
Nonmedical Use of Prescription-Type Psychotherapeutics
- Constitute a serious public health problem - Estimated 52 million people (20% of those aged 12 and older) used prescription drugs for nonmedical reasons at least once in lifetime.
More Nursing Interventions in the Community
- Coordinating health care services for the client to prevent prescription drug abuse and avoid fragmentation of care - Providing consultation to nonmedical professionals and lay personnel - Facilitating care through appropriate referrals and follow-up - Knowing how to use community resources for working with substance abuse, mental health, and other issues
Treatment: Programs usually include:
- Group and individual therapy and counseling - Motivational interviewing - Family counseling - Edu - Socialization into 12-step mutual self-help groups - Integrate psychotherapy with pharmacotherapy - May include other strategies: • Hypnosis, OT, confrontation, assertiveness training, blood alcohol level discrimination training, behavior modification approaches
Prevalence, Incidence, and Trends
- Growing recognition initiated extensive collection of data - U.S. National Survey on Drug Use and Health o Annual survey conducted by SAMHSA that estimates prevalence of illicit drug and alcohol use in United States
Nursing Interventions in the Community ctd.
- Health teaching regarding addictive illness and addictive effects of different substances - Advocating that EBP treatment works in special populations through problem-solving courts (drug courts), specialized adolescent treatment, and other community case management programs. - Providing direct care for abuse- and dependence-related medical problems - Educating clients and families about problems related to substance abuse - Collaborating with other disciplines to ensure continuity of care
Modes of Intervention
- Limit access - Media campaigns - Educational programs - National organizations that promote community education, research, and support
Women: Increased risk stems from economic, social, and cultural factors.
- Marginalization of certain groups - Hx of child abuse - Physical & medical probs r/t reproductive systems - Use during pregnancy has long-term developmental consequences for the newborn
Prevention Strategies: Primary
- Needs assessment to identify high-risk situations and potential problems - Debate continues on cost-benefit ratio of drug legalization or decriminalization - Community-based programs - Training of health professionals - Faith-based initiatives - Volunteer consumer groups - Organized sports programs - Employer programs Often overshadowed by "War on Drugs"
Definitions: Other Conceptualizations
- Rx meds - Analgesics - Eating disorders such as bulimia - Tobacco
Prevention Strategies: Secondary
- Screening & finding resources • *CAGE*: an alcoholism screening test • Clinical Institute Withdrawal Assessment (CIWA) • Use evidence-based programs Efforts should be specific to aggregates, rather than directed at the "general public." Incorporate culturally sensitive and appropriate interventions and strategies Work toward improving individuals' general competencies, communication skills, and self-esteem
Preadolescents & Adolescents
- Times of experimentation, searching, confusion, rebellion, poor self-image, alienation, and insecurity - Use of legal substances (e.g., tobacco, alcohol) almost always precedes use of illegal drugs. - Poor school performance and drug use among peers are strongest predictors of subsequent drug involvement, followed by lack of strong family bond. - The younger the initiation, the greater the probability of prolonged and accelerated use. - Feeling of powerlessness; selling drugs seen as a viable economic solution to poverty.
Nursing Interventions in the Community
- Understand own experiences and prejudices. - Routinely assess substance use patterns when performing client histories. - Be alert to environmental cues in the home that indicate substance abuse. - Increase the individual's and family's awareness of the problem. - Involve the social network in getting the client into treatment. - Develop a caring nursing relationship.
Healthy People 2020 & Substance Abuse
- Use of harmful substances is indirectly and directly related to all of the leading health indicators targeted in Healthy People 2020. - Healthy People 2020 mission encompasses promoting quality of life, healthy development, healthy behaviors across all life stages.
Nursing Care Standards Related to the Patient with Substance Abuse Problems
- Utilization of nursing process is critical. - Develop therapeutic alliances with patient and family - No single treatment appropriate for all individuals - Ongoing assessment is critical for continual assessment in treatment planning and services. - More success when patient remains in treatment for adequate time periods - Med used in correlation with behavioral therapies
Alcohol
138.3 million Americans aged 12 or older were current drinkers of alcohol in 2015
Historical Overview of Alcohol & Illicit Drug Use
20th Century: fluctuations in alcohol & illicit drug use were influences by shifting in public tolerance & political & economic trends Alcohol consumption thru 1990 & into the 21st century declined as result of increased societal & legal pressures & actions against drinking & driving National Institute on Drug Abuse (NIDA): mission to lead US in research on drug abuse & addiction
Heavy Drinking
5 or more drinks in a row at least once in the prior 2 week period oEighth graders—4% oTenth graders—11% oTwelfth graders—17% oCollege students—32% oYoung adults—32%
Underage Drinking
7.7 million underage (12 to 17) drinkers in 2015, including 5.1 million binge drinkers and 1.3 million heavy drinkers Underage consumption usually at home and usually with friends
Costs of substance abuse in United States =
700 billion annually
Prevention Strategies: Tertiary
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Ethnocultural Considerations
African Americans, Hispanics, & Native Americans—increased risk for substance abuse. - Economically disenfranchised groups - Discrimination and racism - Socioeconomic, political, and historical realities - Myths and stereotypes - Social support—positive effect on treatment/outcome - Environmental cues and conditioned reinforcement Treatment poses special challenges.
Women
Alcohol use/ abuse affects women much differently than men. Women absorb & metabolize alcohol differently. - Body composition diffs and production of less gastric alcohol dehydrogenase - Metabolize alcohol at a different rate
Steroids Potentially Fatal Risks
Blood clots, liver damage, premature cardiovascular changes, increased cholesterol Increased potential for suicide and aggressive and risky behaviors
Sociocultural and Political Aspects of Substance Abuse
Determined largely by economic, cultural, and political conditions of potential users Cultural conditions create ambiguity in clearly determining when a problem exists. Competing value systems lead to cultural disintegration and a sense of powerlessness and hopelessness.
Hallucinogen, Inhalant, & Heroin Use
Disrupts the interaction of nerve cells and neurotransmitter serotonin - LSD (d-lysergic acid diethylamide) - Peyote cactus - Psilocybin - PCP (phencyclidine) - Inhalants; spray paints, markers, glues, and cleaning fluids contain volatile substances that have psychoactive properties
Other Aggregates: Substance abuse is most common psychopathological problem in the general population.
Dual-dx individuals •Psychiatric disorder + substance abuse disorder Risk for multiple vulnerabilities in one individual Impact of substance abuse on STDs Substance abuse among hcps
Elderly
Elderly men and women vulnerable to substance abuse because of: - Increased medically prescribed drugs - Cultural and social isolation Misuse of prescription drugs: most common form of drug abuse among the elderly - VA Hospital system suggests elderly prescribed inappropriately high doses of benzodiazepines
Adolescent Substance Abuse
Highest drug among individuals in late teens and 20s: in 2013 22.6% ages 18 to 20 reported to using illicit drugs during past month Cigarettes have highest level of daily use by adolescents. - Highly available to young ppl Marijuana -Fairly easy or very easy to obtain
Illicit Drug Use
Illicit drug use by persons aged 12 or older: - 27.1 million Americans
Harm Reduction: Individuals and collective approaches to the treatment of substance use not primarily aimed at complete abstinence from all substances
Incremental change involves elimination of more harmful effects of substance use. oBehavior and policy modifications oProcess rather than static approach or an end in itself
Gender Differences
Males more likely to be current illicit drug users Female illicit drug use (12+ yrs) increasing
Illicit Drugs Include:
Marijuana included cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) used nonmedically.
National Institute on Drug Abuse (NIDA):
Mission to lead United States in research on drug abuse and addiction Science on drug abuse & addiction •Prevention •Treatment •Decreasing the spread of HIV/AIDS •Other priority areas 4 strategic goals to identify causes and consequences of drug abuse •Biological •Environmental •Behavioral •Social
Methamphetamine (MA)
Most widely produced controlled substance in the United States Illegal street names of the drug (crank, crystal, meth, ice, or glass) Can be injected, inhaled, taken orally, or smoked Highest use among 20 to 29-year-olds
Social Network Involvement
Therapy that involves the family has proved to be most effective in aiding recovery. - Family and friends: Highly influential or aid and abet. Codependency and enabling - Effects on the family: Functional or dysfunctional families. Psychological and financial burdens - Professional enablers: Tx of symptoms by med. Reluctant to bring up this taboo subject
Definitions & Conceptualizations
Traditional conceptualizations of substance use solely on alcohol and illicit street drugs.
Legal and Ethical Concerns Related to Substance Abuse
U.S. policy based on prohibition and criminal sanctions against use and sale of illicit drugs Nearly 50% of sentenced federal prisoners on September 30, 2015 serving time for drug offences - Criminal activities (violence and drug trafficking) - Drinking and driving, working while intoxicated - Impact on fetus (FAS) Military veterans are an aggregate entitled to substance abuse treatment.
Treatment: Pharmacotherapies
Used in detoxification, stabilization, maintenance, as antagonists, and as treatment for coexisting disorders
Treatment for individuals, Consider:
o Cultural & edu background o Resources of the person o Attitudes of significant others o Degree of invasiveness of the effects of the substance use o The existence of alternatives o Relapse prevention Scientists & hcps advocate abstinence as cornerstone of recovery.
Historical Overview of Alcohol and Illicit Drug Use: Alcohol and illicit drug consumption and policy affected by:
oAlcohol-related deaths after lowered drinking age oLess tolerant national attitudes toward drinking oIncreased societal and legal pressures and actions against drinking and driving oIncreased health concerns oKnowledge of addictive properties oCounterculture acceptance of hallucinogens, cannabis, and heroin oRenewed interest in prevention/treatment efforts
Etiology: Other theories address social influences
oFamily oEthnicity oRace oAccess to drugs oEnvironmental stressors oEconomics oPolitical status oCulture oSex roles
Treatment: Inpatient and outpatient treatment programs
oMay or may not include detoxification component oVoluntary vs. compulsory oPharmacologically based vs. drug free oTreatment approaches and models vary
Substance Abuse and Mental Health Services Administration (SAMHSA) builds and sustains:
oPrograms oPolicies oInformation and data oContracts oAnd grants with intent to helping nation act on knowledge to promote behavioral health treatments