Nursing 172: Substance Use and Addictive Disorders

nursing care plan: dual diagnosis: nursing interventions

-encourage open expression of feelings -validate patient's anger and frustration in dealing with diagnoses -maintain frequent contact with the patient, even with just brief phone calls -give positive feedback for abstinence on a day-to-day basis -if drinking/substance abuse occurs, discuss the events that led to the incident with the patient in a nonjudgmental manner; discuss ways to avoid this in the future -teach positive coping strategies and stress management skills -encourage patient to log feelings, activities, and thoughts -refer patient to community support services that address mental health and substance related needs

alcohol: treatment for intoxication/overdose

-gastric lavage -dialysis -support of respiratory cardiovascular functioning in ICU

Nursing care plan for alcohol treatment program: nursing interventions

-give the patient and significant others information about alcoholism in a matter-of-fact manner. do not argue, but dispel myths such as "I'm not an alcoholic if I only drink on the weekend" -avoid the patients attempt to only focus on external problems, such as martial or employment problems, without relating them to the problem of alcoholism -encourage the patient to identify behaviors that have caused problems in their life -consistently redirect the patient's focus to their own problems and to what they can do about them -do not allow the patient to rationalize difficulties or blame others or circumstances beyond what they can control -positively reinforce the patient when they identify or express feelings or shows any insight into their behaviors or consequences -encourage other patients in the program to provide feedback for each other

opioids: time until withdrawal symptoms occur

-heroin: 6-24 hours; peak at 2-3 days; subside at 5-7

examples of nursing diagnosis or addiction, alcoholism, and substance abuse:

-imbalanced nutrition: less than body requirements -risk for injury, infection -diarrhea -excess fluid volume -activity intolerance -ineffective denial -ineffective role performance -dysfunctional family process: alcoholism -ineffective coping

Stimulants: intoxication and overdose

-intoxications develops rapidly -overdose: seizures, coma, and death (rare).

Hallucinogens intoxication

-marked by several maladaptive behavioral or psychomotor changes -anxiety -depression -paranoid ideation -ideas of reference, fear, or losing one's mind -potentially dangerous behaviors (jumping out of windows to 'fly') physiological symptoms include sweating,, tachycardia, palpations. blurred vision. tremors, lack of coordination PCP intoxication include belligerence, aggression, impulsivity, and unpredictable behavior ***overdose does not oocur

opioids: medications to help with withdrawals

-methadone up to 120 mg/day for maintenance for opioid use (may cause nausea and vomiting) -levomethadyl 60-90 mg three times a week for maintenance for opioid use (do not take on consecutive days- take home doses are not permitted) -buprenorphine 4/1 mg-24/6 mg daily for opioid cravings and maintenance (may cause orthostatic hypotension, sedation, avoid CNS depressants) -naltrexone 350 mg/week, divided into 3 doses for opiate blocking effect (may cause pt to not respond to opioids, headache, restlessness, irritability) clonidine 0.1 mg every 6 hours prn opioid withdrawal symptoms (check BP before each dose-hold if hypotensive)

Cannabis withdrawal symptoms

-muscle aches -sweating -anxiety -tremors -*no clinically significant withdrawal syndrome is identified

Sedatives, Hypnotics, and Anxiolytics: detoxification

-often managed by tapering off the drug the patient used over days-weeks

Pharmacologic treatment goals for withdrawals

-permit safe withdrawals from alcohol, sedative-hypnotics, and benzodiazepines -prevent relapse -promote safety****

nursing care plan: dual diagnosis: assessment data

-poor impulse control -low self-esteem -lack of social skills -dissatisfaction with life circumstances -lack of purposeful daily activity

Sedatives, Hypnotics, and Anxiolytics: intoxication

-similar to alcohol -in prescribes amounts, can cause drowsiness and reduce anxiety (intended purpose) intoxication: -slurred speech -unsteady gait -lack of coordination -labile mood -impaired attention or memory -stupor or coma

inhalants intoxication treatment

-supporting respiratory and cardiac functioning until the substance is removed -no specific medications to treat toxicity

Sedatives, Hypnotics, and Anxiolytics: withdrawals

-symptom onset depends on half-life of drug (6 hours-1 week) -symptoms are the opposite of the acute effects of the drug: autonomic hypersensitivity (increased BP, pulse, respirations, and temp), hand tremor, insomnia, anxiety, nausea, psychomotor agitation; seizures and hallucinations can occur but are rare

inhalants withdrawal and detoxication

-there are no withdrawal or detox symptoms -frequent users report psychological cravings -long term users may experience persistent dementia, or inhalants-induced disorders such as psychosis, anxiety, and mood disorders -disorders are treated symptomatically

Alcohol Withdrawal and detoxification

-typically begin 4-12 hours reduced alcohol intake, usually peaks on the 2nd day and is over on about day 5; may take 1-2 weeks -can be life threatening; detoxification should be medically supervised symptoms include: -tremors -sweating -elevated pulse and BP -insomnia -nausea and vomiting

Hallucinogens withdrawal and detoxification

-withdrawal syndromes do not occur -some people have reported cravings of the drug -hallucinogens can produce flashbacks

The nurse should anticipate which behaviors in a client experiencing alcohol withdrawal? Select all that apply: 1. Hypertension 2. Tinnitus 3. Pupil constriction 4. Tachycardia 5. Sedation 6. Startles easily

1, 4, 6 An increased blood pressure and an increased pulse, dilated pupils, are the most prevalent and first clinical manifestations experienced by the client in alcohol withdrawal. Other clinical manifestations include irritability, a sense of being hyperactive, startling easily, anxiety, insomnia, and tremors.

The priority nursing intervention in caring for a client experiencing flashbacks from hallucinogenic intoxication include: 1. assisting the client with anxiety reduction. 2. exploring relapse triggers. 3. providing intrapersonal skills training. 4. teaching the client the medical consequences.

1. assisting the client with anxiety reduction.

Which would the nurse identify as a realistic short-term goal to be accomplished in 2-3 days for a client with substance induced delirium? The client A. Explains the experience of having the delirium. B. Regain a normal sleep-wake cycle. C. Becomes oriented to time place and person. D.Establishes normal bowel and bladder function

C. Becomes oriented to time place and person.

The nurse is preparing to teach a class to a group of new graduate nurses on substance use disorders. Which should the nurse include in the class? 1. A client with a substance dependence must take the same drug to relieve withdrawal symptoms 2. A substance abuse disorder is both a physical and psychological disorder. 3. A client who is motivated and has a substance dependence can overcome the addiction by stopping the substance. 4. A substance must be abused over a long period of time before an addiction develops.

Answer 2-A substance use disorder is both physical and psychological. A client with a substance dependence will take a similar substance to relieve withdrawal clinical manifestations. A client cannot overcome a substance use disorder simply by being motivated and stopping the substance. Management of substance use disorders must include professional intervention. Generally, the most effective treatments are in mental health clinics that can provide both physical and psychological assistance.

Which would the nurse eliminate from the diet of a client who abuses alcohol? A. Milk. B. Caffeine. C Orange Juice. D. Eggs.

B. Caffeine is another means of addiction for an addictive personality.

Clinical Presentation for addiction

**Signs & symptoms will vary with individuals/depending on substances used, but often include: •Sudden weight loss/gain •Periods of excessive sleep or inability to sleep •Periods of excessive energy •Chronic nosebleeds- snorting drugs •Chronic cough or bronchitis- inhalants •Pancreatitis •Ascites •Increased periods of agitation, irritability, or anger •Depressed mood •Temporary psychosis •Inability to perform tasks at work, school, or home •Slurred speech •Stupor or coma (overdose of a CNS depressant) •Pupil changes- constriction vs dilation depending on drug •Poor psychomotor coordination •Nystagmus (rolling back of eyeballs) •Impairment in attention and concentration

Nursing Interventions/Treatment

**•Treatment is substance specific!!!!! •Pharmacologic management (according to substance addicted to, abused, or ingested as an overdose/withdrawal) •Physiological consequences (according to substance addicted to, abused, or ingested as an overdose/withdrawal) •Self-help groups: alcoholics anonymous &narcotics anonymous (most-popular) •Treatment of co-morbid conditions •Medications for relapse prevention •Maintenance medication management ex. Disulfiram & Methadone •Focus on the here and now •Dispel myths surrounding substance abuse •Decrease co-dependent behaviors among family members •Role-play potentially difficult situations •Set realistic goals •Vitamin supplements •Fluids in an emergency •Ventilation •Treatment of hypertension (stimulant overdose) •Cooling blankets for hyperthermia •Seizure precautions

Cannabis: how it reacts to the body

- can be smoked or eaten -can be used to help reduce intraocular pressure for glaucoma, anorexia, weight loss of AIDS, vomiting and nausea for chemo patients, and seizures

alcohol overdose: symptoms

- caused from excessive alcohol intake in a short amount of time can result in: -vomiting -unconsciousness -respiratory depression

Hallucinogens: how it effects the body

- increased temp, pulse, BP -dilated pupils -hyperreflexia

opioids intoxication

- intoxication develops shortly after initial euphoric feeling -apathy -lethargy -listlessness -impaired judgement -psychomotor retardation or agitation -*constricted pupils -drowsiness -slurred speech -impaired attention and memory

Alcohol: intoxication

-*CNS depressant -absorbs rapidly into the blood stream -Initially: relaxation, less of inhibitions with intoxication: -slurred speech -unsteady gait -lack of coordination -impaired attention, concentration, memory, and judgement - may show aggressiveness -may show inappropriate sexual behavior -may experience black out

Wernicke encephalopathy

-Confusion and loss of mental activity that can progress to coma and death -Loss of muscle coordination (ataxia) that can cause leg tremor -Vision changes such as abnormal eye movements (back and forth movements called nystagmus), double vision, eyelid drooping -CNS stimulation

Sedatives, Hypnotics, and Anxiolytics

-Eleventh most commonly used substances by college students -Decreases CNS activity -*Benzodiazepines, barbiturates, nonbarbiturate hypnotics, and anxiolytics are in this category -Called downers, ludes

Symptoms of Korsakoff Syndrome:

-Inability to form new memories -Loss of memory, can be severe -Making up stories (confabulation) -Seeing or hearing things that are not really there (hallucinations)

Inhalants

-anesthetics, nitrates, and organic solvents that are sniffed or inhaled to give effects -most common: aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint -vapors are inhaled from rags soaked in compound, paper or plastic bags or directly from the containers

Inhalants acute toxicity symptoms

-anoxia -respiratory depression -vagal stimulation -dysrhythmias - death may occur from bronchospasms, cardiac arrest, suffocation, or aspiration of the compounds or vomitus

alcohol overdose patient's are at risk of:

-aspiration pneumonia -pulmonary obstruction -alcohol-induced hypotension: can lead to cardiovascular shock and death

Alcohol withdrawal and detoxication medications

-benzodiazepines: (nursing considerations: monitor vital signs, and global assessments for effectiveness; may cause drowsiness and dizziness) -lorazepam 2-4 mg q2-4 hrs prn withdrawlas -chlordiazepoxide 50-100 mg for withdrawals repeat in 2-4 hours if needed; do not exceed 300 mg/day -diazepam to suppress withdrawals -accomplished with fixed schedule dosing (tapering) or symptoms triggers dosing

Barbiturates: overdose and treatment

-can be fatal -can cause coma, respiratory arrest, and cardiac failure treatment: -in ICU (required) -gastric lavage or dialysis -supportive (assist respiration, cardiac function and maintain BP)

Inhalants effects on the body

-can cause significant brain damage, peripheral nervous system damage, and liver disease

Cannabis intoxication symptoms

-cannabis begins within 1 minute of inhalation and peaks around 20-30 minutes - lowered inhibitions -relaxation -euphoria -increased appetite -impaired motor coordination -inappropriate laughter -impaired judgment and short-term memory -distortions of time and perception -anxiety, dysphoria, and social withdrawal may occur physiological effects: -dry mouth -tachycardia -hypotension -increased appetite -conjunctional injection (red eyes) ***overdose does not occur!

Physiological effects of long term alcohol use

-cardiac myopathy -Wernicke encephalopathy -Korsakoff psychosis -pancreatitis -esophagitis -hepatitis -cirrhosis -leukopenia -thrombocytopenia -ascites

medications given for stimulant intoxication/ overdose

-chlorpromazine (Thorazine): an antipsychotic drug used to control hallucinations, lower blood pressure, and relieves nausea

opioids overdose symptoms and treatment

-coma -respiratory depression -pupillary contriction -unconsciousness death treatment: -naloxone (Narcan)- opioid antagonist that reverses all signs of opioid toxicity- given every few hours until opioid level drops to nontoxic

Nursing care plan for alcohol treatment program: assessment data

-denial or minimization of alcohol use or dependence -blaming others for problems -reluctance to discuss self or problems -lack of insight -failure to accept responsibility for behavior -viewing self as different from others -rationalization of problems -intellectuaization

Opiods

-desensitize the user to both physiological and psychological pain -induce feelings of euphoria and well-being

alcohol medications other than for withdrawals

-disulfiram: 500mg/ day for 1-2 weeks; then 250mg/ day (teach pt to read labels and avoid alcohol) -Naltrexone: 50 mg/ day for up to 12 for alcohol cravings (pt may not respond to narcotics; may cause headache, restlessness, or irritability) -Acamprosate: 666mg 3 times daily to suppress alcohol cravings ( monitor for diarrhea, vomiting, flatulence, and pruritis) Thiamine B: 100mg/day to help prevent Wernicke-Korsakoff syndrome in alcoholism ( teach pt about proper nutrition) Folic acid (1-2 mg daily) (urine may be dark yellow) and cyanocobalamin (25-250 ug/ day) (for both, teach pt about proper nutrition)

inhalants intoxication

-dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness , and blurred vision -stupor and coma can occur -significant behavioral symptoms are belligerence, aggression, apathy, impaired judgement, and inability to function

___ the three most common defense mechanisms used-their use must be confronted so accountability for the client's own behavior can be developed.

Denial, rationalization & projection

Stimulants: types and how the body is effected

Drugs (such as caffeine, nicotine, and the more powerful amphetamines, methamphetamines, cocaine, and Ecstasy) that excite neural activity and speed up body functions and excite the CNS.

Denial:

Escaping unpleasant realities by ignoring their existence. Example: "I'm sick of everyone thinking I drink too much. I can control my drinking whenever I want...and stop whenever I want."

What type of is effective as well as support groups such as Alcoholics Anonymous, Narcotics Anonymous, etc.

Group therapy -Can relate to the experience; has lived the experience. More respected by the addict.

What medications can the nurse expect to administer to a patient in alcohol withdrawal?

Librium/Ativan/Haldol or other antianxiety agents or antipsychotic agents(antipsychotic agents help with agitation and psychosis) -Most commonly used medications along with Ativan and possibly an anti-psychotic for delusions, illusions, and or hallucinations.

examples of hallucinogens

Mescaline, LSD, PCP, psilocybin, ecstasy

Communicating -Substance-Abusing Client in Rehabilitation: Client: "I don't need to spend a lot of time talking to you about this stuff. I'm not going to take coke again, and you can bet on that."

Nurse: "I hear that you have no intentions of using cocaine again. I would like to help to make certain that you have the support available to you when you feel like you are could go back to drugs." Rationale: this interaction provides direction around the eventual difficulties that face everyone dependent on a substance-temptation and relapse.

Communicating with a Substance- client in Withdrawal: Client: "I feel so terrible. My muscles are twitching, I feel like "I'm going to throw up, I'm dizzy and weak, and my heart is pounding.

Nurse: "I'm going to take your vital signs now. We will take care of you're physical symptoms and take steps to ensure that you are more comfortable." Rationale: This interaction treats the event as an illness in which there are physical consequences to one's behavior. It also reassures the client that the staff has the client's safety and comfort needs in mind.

Fentanyl

Opioid Analgesic: 50-100x more potent than morphine

What basic needs have priority when working with chemically dependent clients?

Physiological: Psychological needs are priority. (Maslow) -Alcohol & drug intake has superseded the intake of food for these clients.

Wernicke-Korsakoff syndrome

a brain disorder due to thiamine (vitamin B1) deficiency

A blackout

a phenomenon caused by the intake of alcohol in which long term memory creation is impaired. blackouts are classified by the inability to later recall any memories from the intoxicated period, even when prompted. These blackouts are characterized also by the ability to easily recall things that have occurred within the last 2 minutes, yet inability to recall anything prior to this period.

Delirium tremens (colloquially, the DTs, "the horrors", "the shakes" literally, "shaking delirium" or "trembling madness" in Latin)

an acute episode of delirium that is usually caused by withdrawal or abstinence, from alcohol following habitual excessive drinking Caused by alcohol, it only occurs in individuals with a history of constant, long-term alcohol consumption .

A nurse is monitoring a client for signs of delirium tremens (alcohol withdrawal delirium). Which assessment data is diagnostic of this condition? a. Slurred speech, lethargy, and confusion. b. Depression, hypotension, and nausea. c. Dizziness, vomiting, and unsteady gait. d. Tachycardia, hallucinations, and seizures.

d. Tachycardia, hallucinations, and seizures.

Antabuse is often used as a deterrent to

drinking alcohol

stimulants: effects shown on patient's behavior

euphoria, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, repetitive behavior, anger, fighting, and impaired judgement. physiological effects: tachycardia, elevated blood pressure, dilated pupils, perspiration, chills, nauseas, and chest pain, confusion, and cardia dysrhythmias,

CIWA most popular-Clinical Institute Withdrawal Assessment for Alcohol

everything is based on a 0-7 scale (0 being none and 7 being very severe) -nausea and vomiting -tremor -paroxysmal sweats -anxiety -agitation -tactile disturbances -auditory disturbances -visual disturbances -headache, fullness in head -orientation and clouding of senses

Rationalization:

falsifying experiences by contrived, socially acceptable, and logical explanations: Example: "Sure I got a little angry with my boss. Everyone comes in late to work, so why does he have to pick on me all the time?"

Nursing care plan for alcohol treatment program: expected outcomes

immediate: patient will... -participate in a treatment program within 24-48 hours -identify negative effects of his or her behavior on others within 24-48 hours -abstain from drug and alcohol use throughout treatment program -verbalize acceptance of responsibility for own behavior, including alcohol dependence and problems related to alcohol use within 24-48 hours stabilization: the patient will... -express acceptance of alcoholism as an illness -maintain abstinence from alcohol -demonstrate acceptance of responsibility for own behavior -verbalize knowledge of illness and treatment plan community: the patient will.. -follow through with discharge plans regarding employment , support groups, etc

nursing care plan: dual diagnosis: expected outcomes

immediate: the patient will... -take only one prescribed medicine throughout the hospital stay -interact appropriately with staff and others patients within 24-48 hours -express feelings openly within 24-48 hours -develop plans to manage unstructured time; example- walking and doing errands, within 2-3 days stabilization: the patient will... -demonstrate appropriate or adequate social skills; example- initiate interaction with others -identify social activities in drug- and alcohol-free environments -assess own strengths ad weaknesses realistically community: the patient will.. -maintain contact or relationship with a professional in the community -verbalize plans to join a community support group that meets the needs of the patient with dual diagnosis, if available -participate in drug- and alcohol-free programs and activities

Detox, short for detoxification

in general is the removal of toxic substances from the body.

nursing care plan: dual diagnosis: nursing diagnosis example

ineffective coping: inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources

Nursing care plan for alcohol treatment program: Nursing diagnosis example

ineffective denial: unsuccessful attempt to ignore or minimize reality of events or situations that are unpleasant to comfort

Opioid withdrawal symptoms

initial symtoms: -anxiety -achy back and legs -cravings for more opioids progressed symptoms: -nausea, vomiting -dysphoria -lacrimation -rhinorrhea -Increased SNS activity (sweating, tremor, tachycardia) -Increased secretions -Yawning -Muscle cramps, spasms -fever -insomnia -CNS-originating pain

sobriety

living without alcohol or substance abuse

dual diagnosis

often used interchangeably with the terms co-morbidity, co-occurring illnesses, concurrent disorders, comorbid disorders, co-occurring disorder, dual disorder, and, double trouble.

Methadone frequently used to treat addiction to

opioid's! It helps withdrawal symptoms caused by stopping other opioids!

Codependence (or codependency)

popular psychology concept popularized by Twelve-Step program advocates. A "codependent" is loosely defined as someone who exhibits too much, and often inappropriate, caring for persons who depend on him or her. A "codependent" is one side of a relationship between mutually needy people. The dependent, or obviously needy party(s) may have emotional, physical, financial difficulties, or addictions they seemingly are unable to surmount. The "codependent" party exhibits behavior which controls, makes excuses for, pities, and takes other actions to perpetuate the obviously needy party's condition, because of their desire to be needed and fear of doing anything that would change the relationship.

Client teaching for Antabuse.

should include the effects of consuming any alcohol while on Antabuse. Encourage the client to read all labels of over-the-counter medications that may contain even small amounts of alcohol. Also, mouthwash, perfume, body wash, etc. -The patient will have a severe reaction: (flushing, nausea, vomiting, sweating, palpitations, shortness of breath etc).

Hallucinogens

substances that create distorted perceptions of reality, similar to psychoses ranging from mild to extreme including hallucinogens and depolarization

Alcohol: severe or untreated withdrawals

symptoms may progress to: -transient hallucinations -seizures -delirium (delirium tremens)

Benzodiazepines: overdose and treatment

when taken orally: -rarely fatal -lethargy -confused treatment: -gastric lavage and activated charcoal and saline cathartic -dialysis (when severe)

Projection

üA defense mechanism in which the individual attributes to other people impulses and traits that he himself has but cannot accept. It is especially likely to occur when the person lacks insight into his own impulses and traits." example: An aggressive man accuses other's of being aggressive.

DSM-IV/V Classes of Psychoactive Substances

•Alcohol •Caffeine •Cannabis •Hallucinogens •Inhalants •Opioids •Sedatives-hypnotics •Stimulants •Tobacco *Commonly tested on NCLEX

Etiology for addiction: Theoretical causes:

•Biologic •Neurochemical •Psychologic •Social & Environment

Diagnostic Work-Up for patients with addiction disorders

•Diagnosis of substance abuse/dependence is typically made by detailed subjective history. •Blood or urine screening for substance (s) and assessment skills.

Application of the Nursing Process for substance abuse and alcoholism

•History •General Appearance & Motor Behavior •Mood & Affect •Thought Process & Content •Sensorium & Intellectual Processes •Judgment & Insight •Self-Concept •Roles & Relationships •Physiologic Considerations

Definition of Disorder

•It is a maladaptive pattern of substance use. •Remissions and exacerbations. •The substance used poses a hazard to health. •Commonly known as addiction. •Tolerance to the substance is examined. •Withdrawal when the substance is eliminated or significantly reduced is common. •An altered physical or mental state due to use of the substance

Demographics for addiction

•Males are twice as likely to be affected than females. •The use of illegal drugs is most common in young adults (aged 10-80). •More than 100 million Americans, aged 10 years or older, report illicit drug use at least once in their lives. •Fifty to seventy-five percent of those with a mental health disorder struggle with substance addiction. •Approximately 1 in 10 Americans has an alcohol problem.

Initial Assessment for addiction patients

•Medical history & examination •Psychiatric history and examination •Family & social history •Detailed history of past and present substance use, tolerance, and withdrawal •How did the substance affect patient mentally and physically? •How does the substance use affecting patient's occupational, family, or social life? •Reliable and Valid Screening Tools (CIWA most popular-Clinical Institute Withdrawal Assessment for Alcohol)-in textbook

Medical/Legal Pitfalls

•Rates of suicide are three to four times more prevalent in people who abuse alcohol or drugs as compared to the general population. •Individuals withdrawing from substances are at great risk for depression. When not properly treated, depression can lead to suicide. •Individuals being treated for addiction may have a history of seeing multiple healthcare professionals obtain medications (doctor shopping). •Such practice may lead to accidental and/or intentional overdose.

Differential Diagnosis for addiction

•Rule out medical problems that may mimic signs & symptoms of substance intoxication and/or withdrawal: •Hypoglycemia •Electrolyte (sodium, potassium, chloride, & sodium bicarbonate) imbalance •Head injury/trauma •Stroke •Drug induced psychosis •Neurological (Traumatic Brain Injury)

Outcomes for alcoholism

•The client will: •Abstain from alcohol and drug use. •Will express feelings openly and directly. •Verbalize acceptance of responsibility for his/her own behavior. •Practice nonchemical alternatives to deal with stress or difficult situations. •Will establish an effective after-care plan.

Risk Factors for addiction

•Unemployment •Poor social coping skills •History of emotional, physical, or sexual abuse •Chaotic home environment •History of mental illness •Untreated physical pain •Family history of addiction •Peer pressure •Recent incarceration