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Chapter 26

Substance Abuse

More deaths, illnesses, and disabilities are attributed to substance abuse than to any other preventable health conditions in the United States.

– Substance Abuse and Mental Health

Services Administration (SAMSHA)

Social Consequences of Substance Abuse

Crimes while under the influence of drugs, alcohol, or both

Need for money to buy substances

Specific theft of drugs

Almost 75% of inmates report prior drug use

All aggregates in society are potentially affected by substance abuse problems regardless of age or economic level

Etiology of Substance Abuse

Numerous theories try to explain it

Combination of many factors

Genetics within families

Individual (impulsivity and ease of disinhibition)

Environmental factors

Medical models

Biopsychosocial models

Historical Overview of Alcohol and Illicit Drug Use

Alcohol use has gained more social acceptance than other drug use.

Public attitudes and governmental policies have also influenced the history of illicit drug use.

Historical Overview of Alcohol and Illicit Drug Use (Cont.)

Consumption and laws affected by:

Alcohol-related deaths after lowered drinking age

Less tolerant national attitudes toward drinking

Increased societal and legal pressures and actions against drinking and driving

Increased health concerns among Americans

Knowledge of addictive properties

Counterculture acceptance of hallucinogens, cannabis, and heroin

The “War on Drugs”

Renewed interest in prevention/treatment efforts

Laws Impacting Substance Abuse

Anti–Drug Abuse Acts of 1986 and 1988

Increased funding for treatment and rehabilitation

Created the Office of National Drug Control Policy (“drug czar”)

Worked on a public health approach to drug control

National Institute on Drug Abuse (NIDA)

Science on drug abuse and addiction

Prevention

Treatment

Decreasing the spread of HIV/AIDS

Other priority areas

Laws Impacting Substance Abuse (Cont.)

Substance Abuse and Mental Health Services Administration (SAMHSA)

Builds and sustains programs, policies, information and data, contracts, and grants toward helping the nation act on the knowledge that promotes behavioral health treatment through all levels of prevention

Prevalence, Incidence, and Trends

Alcohol use by persons aged 12 or older:

Slightly more than half (52.8%) drink alcohol

Binge drinking at least once in prior 30 days— (22.6%)

Heavy drinking—6.2%

Young adults ages 18-25 had highest prevalence of binge and heavy drinking—39.8%

Drove under the influence of alcohol at least once in past year—11.1%

– SAMHSA (2011)

Prevalence, Incidence, and Trends (Cont.)

Illicit drug use by persons aged 12 or older:

About 8.7% were current drug users, used an illicit drug during the past month

Illicit drugs used

Marijuana was the most commonly used drug

Others included cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) used nonmedically

– SAMHSA (2011)

Prevalence, Incidence, and Trends (Cont.)

Nonmedical use of prescription-type psychotherapeutics

There is a significant increase in the lifetime nonmedical use of pain relievers—specifically Percocet®, Percodan®, Vicodin®, Lortab®, Darvocet®, Darvon®, Tylenol® with Codeine, Propoxyphene, or Codeine Products, Oxycodone, and Hydrocodone

– NIDA (2010)

Prevalence, Incidence, and Trends (Cont.)

Hallucinogen, inhalant, and heroin use

LSD (d-lysergic acid diethylamide)

Peyote cactus

Psilocybin

PCP (phencyclidine)

Inhalants of choice are amyl nitrite, “poppers,” followed by glue, shoe polish, or toluene; correction fluid, degreaser, or cleaning fluid; gasoline or lighter fluid; and spray paints and other aerosols.

Prevalence, Incidence, and Trends (Cont.)

Gender difference

Males more likely to be current illicit drug users

Female illicit drug use (12 and older) increasing

Geographic trends

Highest in West > Midwest > Northeast > South

Racial/ethnic groups

Highest among American Indians or Alaska natives > African Americans> whites > Hispanics > Asians

– SAMHSA (2010)

Trends in Substance Abuse

May or may not relate to classically or clinically defined dependence or addiction.

Many are turning to recovery before they have developed physiological dependence.

Need to differentiate between use and misuse/abuse.

Use of harmful substances is indirectly and directly related to all of the leading health indicators targeted in Healthy People 2020.

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.

Used predominantly by white young persons, with an overrepresentation of females.

Methamphetamine (MA) (Cont.)

Pleasurable effects are caused by the release of high levels of dopamine in the brain, leading to increased energy, a sense of euphoria, and increased productivity.

Short-term effects: increased heart rate, insomnia, excessive talking, excitation, and aggressive behavior

Prolonged use results in tolerance and physiological dependence

Negative consequences range from anxiety, convulsions, and paranoia, to brain damage.

Methamphetamine (MA) (Cont.)

The impact of MA abuse on communities, families, and social networks is considerable.

Young children of users are at risk for abuse and neglect.

Prenatal use puts children at risk for developmental problems, aggression, and attention disorders.

Exposure to combustible second-hand fumes.

Associated with increased incidence of violence (e.g., domestic abuse, homicide, and suicide)

Steroids

Anabolic steroids are synthetic variants of male sex hormone testosterone

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

Potentially fatal risks

Blood clots, liver damage, premature cardiovascular changes, increased cholesterol

Increased potential for suicide and aggressive and risky behaviors

Inhalants

Contain volatile components with psychoactive properties

Many products found in home or workplace (e.g., spray paints, markers, glues, and cleaning fluids)

Produce a rapid high that may resemble alcohol intoxications; may progress to loss of sensation and even unconsciousness

Irreversible effects:

Hearing loss, limb spasms, CNS or brain damage, or bone marrow damage; may result in death from heart failure or suffocation

Adolescent Substance Abuse

Highest prevalence of illicit drug use during lifetime between 18 and 25 years

Teen use of cigarettes and smokeless tobacco has declined

Nearly half of teens try marijuana before they graduate—skepticism about drug’s danger

As harmful, illicit substances come in and out of vogue, CHN needs a good understanding of drug culture, terminology, and differing signs and symptoms

Conceptualizations of Substance Abuse

Conceptualizations have changed over the years, often for political and social reasons rather than for scientific reasons.

“Dependence” or “abuse”

What substances can be abused?

APA focuses on alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, and hypnotics or anxiolytics

Defining Substance Abuse

Substance abuse: a maladaptive pattern of substance use that is manifested by recurrent and significant adverse consequences related to repeated use of a substance.

Failure to fulfill major role obligations

Repeated use in physically hazardous situations

Multiple legal problems

Recurrent social and interpersonal problems

Defining Substance Abuse (Cont.)

Dependence: a cluster of cognitive, behavioral, and physiological symptoms that indicate continued use of the substance despite significant substance-related problems

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

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.

Course of Substance-Related Problems

Path from initiation to dependency is multidimensional.

Person + substance + context/environment

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

Legal and Ethical Concerns

U.S. policy based on prohibition and criminal sanctions against use and sale of illicit drugs

Criminal activities (violence and drug trafficking)

Drinking and driving, working while intoxicated

Impact on fetus (FAS)

Modes of intervention

Limit access

Media campaigns

Educational programs

National organizations that promote community education, research, and support

Prevention Strategies

Primary prevention

Needs assessment to identify high-risk situations and potential problems

Decriminalization and legalization of drugs(?)

Community-based programs

Training of health professionals

Faith-based initiatives

Volunteer consumer groups

Organized sports programs

Employer programs

Often overshadowed by “War on Drugs”

Prevention Strategies (Cont.)

Secondary prevention

Screening and 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

Treatment

For individuals, consider:

Cultural and educational background

Resources of the person

Attitudes of significant others

Degree of invasiveness of the effects of the substance use The existence of alternatives

Relapse prevention

Treatment (Cont.)

Inpatient and outpatient treatment programs

May or may not include detoxification component

Voluntary vs. compulsory

Pharmacologically based vs. drug free

Treatment approaches and models vary

Assessment process is of primary importance.

Therapeutic relationship based on trust is essential.

Physical examination is a valuable tool.

Nonjudgmental attitude minimizes defensiveness.

Treatment (Cont.)

Programs usually include:

Group and individual therapy and counseling

Motivational interviewing

Family counseling

Education

Socialization into 12-step mutual self-help groups

Integrate psychotherapy with pharmacotherapy

May include other strategies:

Hypnosis, occupational therapy, confrontation, assertiveness training, blood alcohol level discrimination training, behavior modification approaches

Treatment (Cont.)

Pharmacotherapies

Used in detoxification, stabilization, maintenance, as antagonists, and as treatment for coexisting disorders

Mutual help groups

Operate through face-to-face supportive interaction focusing on a mutual goal; AA was first

Harm reduction

Elimination of the more harmful effects of substance use through behavior and policy modifications

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

Treatment of symptoms by medication

Reluctant to bring up this taboo subject

Vulnerable Aggregates: Preadolescents and 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.

Vulnerable Aggregates: Preadolescents and Adolescents (Cont.)

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

Vulnerable Aggregates: Elderly

Elderly experience

Diminished physiological tolerance

Increased use/misuse of medically prescribed drugs

Cultural and social isolation

Misuse of prescription drugs may be the most common form of drug abuse among the elderly

Use prescription medications approximately three times as frequently as general population

Vulnerable Aggregates: Women

Alcohol use and abuse affects women much differently than men.

Women absorb and metabolize alcohol differently.

Body composition differences and production of less gastric alcohol dehydrogenase

Metabolize alcohol at a different rate

Vulnerable Aggregates: Women (Cont.)

Increased risk stems from economic, social, and cultural factors.

Marginalization of certain groups

History of child abuse

Physical and medical problems related to reproductive systems

Use during pregnancy has long-term developmental consequences for the newborn

Vulnerable Aggregates: Ethnocultural Considerations

African Americans, Hispanics, and 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.

Vulnerable Aggregates: Other Aggregates

Substance abuse is most common psychopathological problem in the general population.

Dual-diagnosis individuals

Psychiatric disorder + substance abuse disorder

Risk for multiple vulnerabilities in one individual

Impact of substance abuse on STDs

Substance abuse among health care professionals

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.

Other Traditional Nursing Roles and Interventions

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

Other Traditional Nursing Roles and Interventions (Cont.)

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