SUBSTANCE ABUSE AND ADDICTION

This module aligns with key elements of APNA’s “Growth & Development” and “Clinical Decision Making” (American Psychiatric Nurses Association Education Council, Undergraduate Branch, 2022).

Module Outline

• Assessment of Substance Abuse and Addiction
• Problems Associated with Substance Abuse and Addiction
• Treatment of Substance Abuse and Addiction

Module Learning Outcomes

• Describe the signs and symptoms of Substance Abuse and Addiction
• Identify the common nursing problems associated with Substance Abuse and Addiction
• Summarize the treatment of Substance Abuse and Addiction

Concepts

• Addiction
• Behavior
• Coping
• Safety

Overview

This chapter cover matters related to substance-related and addictive disorders. Our discussion will include substance intoxication, substance use disorder, and substance withdrawal. Substance abuse, in general, has a high comorbidity rate within itself (meaning abuse of multiple different substances), as well as with other mental health disorders. Individuals diagnosed with a mental health disorder may turn substances for self-medication and coping (Rebar et al., 2020). If a patient has both a mental health disorder and a substance use disorder, this may be referred to as a dual diagnosis (National Alliance on Mental Illness, 2020).

What are substances? Substances are any ingested materials that cause temporary cognitive, behavioral, or physiological symptoms within the individual. Substance intoxication symptoms vary greatly and are dependent on the type of substance ingested. Specific substances and their effects will be discussed later in the module.

Repeated use of these substances or frequent substance intoxication can develop into a long-term problem known as substance abuse. Abuse typically occurs when an individual consumes the substance for an extended period and develops a tolerance to the ingested substance. As tolerance builds, additional physical and psychological symptoms present, often causing significant disturbances in an individual’s personal and professional life. Individuals with substance abuse are often spending a significant amount of time engaging in activities that revolve around their substance use, thus spending less time in recreational activities that once consumed their time. Sometimes, there is a desire to reduce or abstain from substance use. However, cravings and withdrawal symptoms often prohibit this from occurring on one’s own attempts. Detoxification from some substances, including prescription medications, may require tapering. Common withdrawal symptoms include but are not limited to cramps, anxiety attacks, sweating, nausea, tremors, and hallucinations. Depending on the substance and the tolerance level, most withdrawal symptoms last anywhere from a few days to a week. For those with extensive substance abuse or abuse of multiple substances, withdrawal should be closely monitored in a hospital setting to avoid severe consequences such as seizures, stroke, or even death.

Types of Substances Abused

The most commonly abused substances can be divided into three categories based on how they impact one’s physiological state: depressants, stimulants, and hallucinogens/cannabis/combination.

            Depressants

Depressant substances such as alcohol, sedative-hypnotic drugs, and opioids are known to have an inhibiting effect on one’s central nervous system; therefore, they are often used to alleviate tension and stress. Unfortunately, when used in large amounts, they can also impair an individual’s judgment and motor activity.

While alcohol is one of the only legal (over the counter) substances we will discuss, it is also the most commonly consumed substance. The “active” substance of alcohol, ethyl alcohol, is a chemical that is absorbed quickly into the blood via the lining of the stomach and intestine. Once in the bloodstream, ethyl alcohol travels to the central nervous system (i.e., brain and spinal cord) and produces depressive symptoms such as impaired reaction time, disorientation, and slurred speech.

The effect of ethyl alcohol in moderation allows for an individual to relax, engage more readily in conversation, and in general, produce a confident and happy personality. However, when consumption is increased or excessive, the central nervous system is unable to metabolize the ethyl alcohol adequately, and adverse effects begin to present. Symptoms such as blurred vision, difficulty walking, slurred speech, slowed reaction time, and sometimes, aggressive behaviors are observed.

Sedative-Hypnotic drugs, more commonly known as anxiolytic drugs, have a calming and relaxing effect on individuals. When used at a clinically appropriate dosage, they can have a sedative effect, thus making them a suitable drug for treating anxiety-related disorders.

Opioids are naturally occurring, derived from the sap of the opium poppy. Opioids are unique in that they provide both euphoria and drowsiness. Tolerance to these drugs builds quickly, thus resulting in an increased need of the medication to produce desired effects. This rapid tolerance is also likely responsible for opioids’ highly addictive nature. Opioid withdrawal symptoms can range from restlessness, muscle pain, fatigue, anxiety, and insomnia. Unfortunately, these withdrawal symptoms, as well as intense cravings for the drug, can persist for several months, with some reports up to years.

           Stimulants

The two most common types of stimulants abused are cocaine and amphetamines. Unlike depressants that reduce the activity of the central nervous system, stimulants have the opposite effect, increasing the activity in the central nervous system. Physiological changes that occur with stimulants are increased blood pressure, heart rate, pressured thinking/speaking, and rapid, often jerky behaviors. Because of these symptoms, stimulants are commonly used for their feelings of euphoria, to reduce appetite, and prevent sleep.

Similar to opioids, cocaine is extracted from a South American plant—the coca plant—and produces feelings of energy and euphoria. Low doses can produce feelings of excitement, talkativeness, and euphoria; however, as the amount of ingested cocaine increases, physiological changes such as rapid breathing, increased blood pressure, and excessive arousal can be observed.

Crack is a derivative of cocaine that is formed by combining cocaine with water and another substance (commonly baking soda) to create a solid structure that is then broken into smaller pieces. Because of this process, it requires very little cocaine to make crack, thus making it a more affordable drug. Coined for the crackling sound that is produced when it is smoked, it is also highly addictive, likely due to the fast-acting nature of the drug.

Amphetamines are manufactured in a laboratory setting. Currently, the most common amphetamines are prescription medications such as Ritalin, Adderall, and Dexedrine (prescribed for sleep disorders). These medications produce an increase in energy and alertness and reduce appetite when taken at clinical levels. However, when consumed at larger dosages, they can produce intoxication similar to psychosis, including violent behaviors. Methamphetamine, a derivative of amphetamine, is often abused due to its low cost and feelings of euphoria and confidence.

Caffeine is consumed in coffee, energy drinks, soft drinks, chocolate and tea. While caffeine is often consumed in moderate dosages, caffeine intoxication and withdrawal can occur. In fact, an increase in caffeine intoxication and withdrawal have been observed with the simultaneous popularity of energy drinks.

          Hallucinogens/Cannabis/Combination

The final category includes both hallucinogens and cannabis- both of which produce sensory changes after ingestion. While hallucinogens are known for their ability to produce more severe delusions and hallucinations, cannabis also has the capability of producing delusions or hallucinations; however, this typically occurs only when large amounts of cannabis are ingested. More commonly, cannabis has been known to have stimulant and depressive effects, thus classifying itself in a group of its own due to the many different effects of the substance.

Hallucinogens come from natural sources and have been involved in cultural and religious ceremonies for thousands of years. Synthetic forms of hallucinogens have also been created—most common of which are PCP, Ketamine, LSD, and Ecstasy. In general, hallucinogens produce powerful changes in sensory perception. Depending on the type of drug ingested, effects can range from hallucinations, changes in color perception, or distortion of objects.  Interestingly, the effect of hallucinogens can vary both between individuals, as well as within the same individual. This means that the same amount of the same drug may produce a positive experience one time, but a negative experience the next time.

Similar to hallucinogens and a few other substances, cannabis is also derived from a natural plant—the hemp plant. Many external factors impact the potency of cannabis, such as the climate it was grown in, the method of preparation, and the duration of storage. Of the active chemicals within cannabis, tetrahydrocannabinol (THC) appears to be the single component that determines the potent nature of the drug. Various strains of marijuana have varying amounts of THC; hashish contains a high concentration of THC, while marijuana has a small concentration. Cannabidiol (CBD) and THC both are derived from the hemp plant (marijuana). Both THC and CBD act on the body’s cannabinoid receptors, located throughout the central and peripheral nervous systems. However, CBD does not is non-psychotropic and is not associated with the euphoric characteristics of THC (Jahan and Burgess, 2022).

It is not uncommon for substance abusers to consume more than one type of substance at a time. This combination of substance use can have dangerous results depending on the interactions between substances. For example, if multiple depressant drugs (i.e., alcohol, benzodiazepines, and/or opiates) are consumed at one time, an individual is at risk for severe respiratory distress or even death due to the compounding depressive effects on the central nervous system. Additionally, when an individual is under the influence of one substance, judgement may be impaired, and ingestion of a larger amount of another drug may lead to an accidental overdose. Finally, the use of one drug to counteract the effects of another drug—taking a depressant to combat the effects of a stimulant—is equally as dangerous as the body is unable to regulate homeostasis.

Assessment

When gathering data for a thorough assessment, effective communication strategies are imperative. Wu and Baker (2022) present several key communication initiatives to use when communicating with an individual diagnosed with a substance abuse disorder and gathering information specific to the substance abuse. An overview of these communication strategies are presented below.

Overview of Communication Strategies

• Be professional, but avoid medical jargon (e.g., instead of “illicit” drugs, use “street” or “recreational”) to facilitate the patient’s understanding
• Be mindful of non-verbal communication which can affect a patient’s perception of you as their healthcare provider
• Assume a neutral position and refrain from spontaneous judgments, especially in the case of interacting with a patient presenting with irrigation or anger
  • Attempt to identify the cause of their emotion, acknowledge their feelings, and address the situation
• Use a patient-centered approach by communicating with person-first language, involve the patient in their healthcare decisions, and allow an opportunity to ask questions
• Reduce patient anxiety by informing patients that substance use questions are routine questions asked to all patients and provide an explanation as to the pertinence of the information to their healthcare (e.g., to proactively address risk for ETOH withdrawal)

Signs and Symptoms of Substance Abuse and Addiction

Memorable Psychiatry and Neurology. (2022). Addiction and substance use disorder mnemonics (memorable psychiatry lecture) [Video]. YouTube. https://youtube.com/watch?v=IQxVzaRiFPI&si=EnSIkaIECMiOmarE

Problems

Problems associated with a Substance Abuse and Addiction diagnosis include:

• Ineffective Denial
• Ineffective Coping
• Powerlessness

Treatment

Given the large number of the population affected by substance abuse, it might be anticipated that there are many different approaches to treat substance use disorder.

 Biological

          Detoxification. Detoxification refers to the medical supervision of withdrawal from a specified drug. While most detoxification programs are inpatient for increased monitoring, some programs allow for outpatient detoxification, particularly if the addiction is not as severe. Unfortunately, relapse rates are high for those engaging in detoxification programs, particularly if they lack any follow-up psychological treatment. Specific to alcohol detoxification, the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is used to monitor alcohol withdrawal symptoms (Jahan and Burgess, 2022).

            Agonist drugs. As researchers continue to learn more about both the mechanisms of substances commonly abused, as well as the mechanisms in which the body processes these substances, alternative medications are created to essentially replace the drug in which the individual is dependent on. These agonist drugs provide the individual with a “safe” drug that has a similar chemical make-up to the addicted drug.

          Antagonist drugs. Unlike agonist drugs, antagonist drugs block or change the effects of the addictive drug. The most commonly prescribed antagonist drugs are Disulfiram and Naloxone. Disulfiram is often given to individuals trying to abstain from alcohol as it produces significant negative effects (i.e., nausea, vomiting, increased heart rate, and dizziness) when coupled with alcohol consumption. Similar to Disulfiram, Naloxone is used for individuals with opioid abuse. Naloxone acts by binding to endorphin receptors, thus preventing the opioids from having the intended euphoric effect. This type of treatment requires appropriate medical supervision to ensure the safety of the patient. Complete the activity below to familiarize yourself with medications used for substance abuse treatment.

            Relapse prevention training. Relapse prevention training is essentially what it sounds like—identifying potentially high-risk situations for relapse and then learning behavioral skills and cognitive interventions to prevent the occurrence of a relapse. Early in treatment, the clinician guides the patient to identify any interpersonal, intrapersonal, environmental, and physiological risks for relapse. Once these triggers are identified, the clinician works with the patient on cognitive and behavioral strategies such as learning effective coping strategies, enhancing self-efficacy, and encouraging mastery of outcomes. Additionally, psychoeducation about how substance abuse is maintained, as well as identifying maladaptive thoughts and learning cognitive restructuring techniques, helps the patient make informed choices during high-risk situations. Finally, role-playing these high-risk situations in session allows patients to become comfortable engaging in these effective coping strategies that enhance their self-efficacy and ultimately reducing the chances of a relapse.

  Sociocultural

          Alcoholics Anonymous (AA). AA and Twelve Step Traditions as a way to help guide members in spiritual and character development. Due to the popularity of the treatment program, other programs such as Narcotics Anonymous and Cocaine Anonymous adopted and adapted the Twelve Steps for their respective substance abuse. Similarly, Al-Anon and Alateen are two support groups that offer support for families and teenagers of individuals struggling with alcohol abuse.

The overarching goal of AA is abstinence from alcohol. In order to achieve this, the participants are encouraged to “take one day at a time.” In using the 12 steps, participants are emboldened to admit that they have a disease, that they are powerless over this disease, and that their disease is more powerful than any person. Therefore, participants turn their addiction over to God and ask Him to help right their wrongs and remove their negative character defects and shortcomings. The final steps include identifying and making amends to those who they have wronged during their alcohol abuse.

      Residential treatment centers. Another type of treatment similar to self-help is residential treatment programs. In this placement, individuals are completely removed from their environment and live, work, and socialize within a drug-free community while also attending regular individual, group, and family therapy. The types of treatment used within a residential program varies from program to program, with most focusing on cognitive-behavioral and behavioral techniques. Several also incorporate 12-step programs into treatment, as many patients transition from a residential treatment center to a 12-step program post discharge. As one would expect, the residential treatment goal is abstinence, and any evidence of substance abuse during the program is grounds for immediate termination.

Additional Resource

Check out the website below to learn more about substance abuse in connection with mental health disorders.

Substance Abuse and Mental Health Services Administration (SAMSHA)

Meeting Guide is a free meeting finder app on Google Play and the App Stores (General Service Office of Alcoholics Anonymous, 2022).

Adapted from Fundamentals of Psychological Disorders 2nd Edition- Module 11 by Alexis Bridley, Ph.D. and Lee W. Daffin Jr., Ph.D. licensed under a Creative Commons Attribution 4.0 International License. Modifications: revised for clarity and flow .