Substance Abuse Disorders Nursing Care Management

These are chronic, relapsing illnesses, and the patient in front of you will minimize, blame, and rationalize. That is part of the disease, not a character flaw, and your job is to manage the medical picture (intoxication, withdrawal, organ damage) without buying into the denial or fueling the shame. DSM-IV ran two categories, substance abuse and substance dependence. DSM-5 merges them into one diagnosis: substance use disorder.

What is Substance Abuse?

Substance use and related disorders are a national health problem. Substance abuse is the harmful or excessive use of psychoactive substances (drugs, alcohol) that damages physical health, mental well-being, and life functioning. Substance abuse disorders (SAD) are common chronic relapsing illnesses marked by drug-seeking and drug-taking that persist despite negative consequences.

The DSM-IV-TR separated abuse from dependence for diagnosis: abuse meant problems in social, vocational, or legal areas, while dependence added the markers of addiction (tolerance, withdrawal, failed attempts to stop). DSM-5 combines both into substance use disorder and recognizes 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (phencyclidine and similar arylcyclohexylamines, plus others like LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (amphetamine-type substances, cocaine, and others); tobacco; and other or unknown substances.

Criteria

DSM-5 lists 11 criteria for a substance use disorder:

1. Larger amounts/longer time. Using more, or for longer, than intended.
2. Failed efforts to cut down. Wanting to stop or cut back but not succeeding.
3. Time consumed. A lot of time spent getting, using, or recovering from the substance.
4. Craving. Urges and desire to use.
5. Roles neglected. Failing obligations at work, home, or school.
6. Interpersonal problems. Continuing to use despite relationship problems it causes.
7. Activities given up. Dropping social, occupational, or recreational activities.
8. Hazardous use. Using repeatedly even when it puts the person in danger.
9. Continued use despite harm. Using on even as physical or psychological problems arise.
10. Tolerance. Needing more to get the same effect.
11. Withdrawal. Withdrawal symptoms relieved by taking more of the substance.

Diagnosis requires two or more criteria within a 12-month period. Severity tracks the count: mild (2-3 criteria), moderate (4-5 criteria), or severe (6 or more criteria).

Causes

The exact causes are unknown, but several factors contribute. Biologically, children of alcoholic parents carry higher risk for alcoholism and drug dependence than children of nonalcoholic parents. Psychologically, children of alcoholics are 4 times as likely to develop alcoholism as the general population; inconsistent parenting, poor role modeling, and lack of nurturing can set the child up for the same maladaptive coping, stormy relationships, and substance abuse. Socially, cultural factors, attitudes, peer behavior, laws, cost, and availability all shape initial and continued use.

Types and Symptoms

Each substance use disorder stands as its own diagnosis. The most common in the United States:

• Alcohol. A CNS depressant absorbed rapidly into the bloodstream. Early effects are relaxation and loss of inhibition; intoxication brings slurred speech, unsteady gait, poor coordination, and impaired attention, concentration, memory, and judgment.
• Sedatives, hypnotics, and anxiolytics. All CNS depressants: barbiturates, nonbarbiturate hypnotics, and anxiolytics, especially benzodiazepines. Effects, intoxication, and withdrawal resemble alcohol.
• Stimulants (amphetamines, cocaine). Excite the CNS, with intoxication developing rapidly: euphoria, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, repetitive behavior, anger, fighting, and impaired judgment.
• Cannabis (marijuana). The most widely used illicit substance in the United States; short-term effects include lowered intraocular pressure. Intoxication brings impaired motor coordination, inappropriate laughter, impaired judgment and short-term memory, and distorted time and perception.
• Opioids. Desensitize the user to physical and psychological pain and induce euphoria and well-being. Intoxication follows the initial euphoria: apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory.
• Hallucinogens. Distort perception of reality and produce psychosis-like symptoms including hallucinations and depersonalization. Intoxication brings anxiety, depression, paranoid ideation, ideas of reference, fear of losing one's mind, and dangerous behavior such as jumping from a window believing one can fly.
• Inhalants. A diverse group (anesthetics, nitrates, organic solvents) inhaled for effect; the most common are aliphatic and aromatic hydrocarbons in gasoline, glue, paint thinner, and spray paint. Intoxication brings dizziness, nystagmus, poor coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision.

Statistics and Incidences

SADs are one of the nation's leading health problems. In 2007, about 22.3 million adults were classified with substance dependence or abuse. Of those, an estimated 3.2 million were dependent on or abused both alcohol and illicit drugs, another 3.7 million drugs alone, and 15.5 million alcohol alone. The rate ran twice as high for males as females (12.5 vs. 5.7%). Illicit drug use among those aged 50 to 54 rose from 3.4% in 2002 to 5.7% in 2007. The most popular illicit drugs in the 2007 survey were marijuana (3.9 million), pain relievers (1.7 million), and cocaine (1.6 million).

Assessment and Diagnostic Findings

Diagnostic studies often reveal SAD-related organ dysfunction.

• PPD. A positive PPD is common among substance users living in crowded conditions.
• Hematology. Mild anemia with macrocytosis, folate deficiency, thrombocytopenia, granulocytopenia, abnormal liver function tests, hyperuricemia, and elevated triglycerides.
• Cardiac tests. ECG (EKG) and echocardiogram evaluate heart function; some drugs cause arrhythmias or cardiomyopathy.
• Neurological exams. MRI or CT assess brain health, since long-term use causes structural and functional brain changes.
• Toxicology screens. Detect specific substances in the body to identify what is being abused.
• Pulmonary function tests. Assess lung function when tobacco or other inhaled drugs may have caused respiratory damage.

Medical Management

Patients in intoxication, withdrawal, or detox show up everywhere from the ED to outpatient clinics. Alcoholics Anonymous (AA), founded in the 1930s by alcoholics, built the 12-step recovery model on the philosophy that total abstinence is essential and that recovery requires the help and support of others.

Pharmacologic Management

Pharmacologic treatment has two goals: safe withdrawal from alcohol, sedative-hypnotics, and benzodiazepines, and relapse prevention.

• Benzodiazepines. A benzodiazepine-anxiolytic suppresses the symptoms of alcohol withdrawal.
• Disulfiram (Antabuse). Deters drinking.
• Acamprosate (Campral). Reduces cravings and eases the physical and emotional discomfort of early recovery from alcohol abuse or dependence.
• Methadone. A potent synthetic opiate used as a heroin substitute in some maintenance programs.
• Levomethadyl. A narcotic analgesic used solely to treat opiate dependence.
• Naltrexone (ReVia). An opioid antagonist used for overdose and also for alcohol abuse.

Nursing Management

Nursing Assessment

• History. Patients may report a chaotic family life with a parent or relative who had substance problems, though not always.
• Thought process and content. Expect the patient to minimize their use, blame others, and rationalize.
• Sensorium and intellectual process. Generally oriented and alert unless still in withdrawal.
• General appearance and motor behavior. Usually normal appearance and speech.
• Self-concept. Usually low self-esteem, expressed directly or masked with grandiosity.

Nursing Diagnosis

• Risk for injury related to substance intoxication or withdrawal.
• Ineffective denial related to underlying fears and anxieties.
• Ineffective coping related to inadequate support system or coping skills.
• Imbalanced nutrition: less than body requirements related to drinking alcohol instead of eating.
• Chronic low self-esteem related to arrested ego development.

Nursing Care Planning and Goals

• Patient abstains from alcohol and drug use.
• Patient expresses feelings openly and directly.
• Patient accepts responsibility for their own behavior.
• Patient practices nonchemical alternatives for handling stress or difficult situations.
• Patient establishes an effective aftercare plan.

Nursing Interventions

• Health teaching for patient and family. Give facts about the substance, its effects, and recovery.
• Address family issues. Without support, family members can develop their own substance problems and perpetuate the cycle; treatment and support groups exist to help them.
• Promote coping skills. Help the patient name problem areas and explore how substance use has intensified them.

Evaluation

Goals are met when the patient abstains from alcohol and drugs, expresses feelings openly, accepts responsibility for their behavior, uses nonchemical alternatives for stress, and establishes an effective aftercare plan.

Documentation Guidelines

Document individual findings (contributing factors, interactions, the nature of social exchanges, specific behaviors), cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and progress toward the desired outcome.