Other Substance-Related Disorders

Concepts and principles:
- Three interacting key factors give rise to dependence - psychopathology of the individual; frustrating environment; and availability of powerful, addicting, and temporarily satisfying drug.
- According to conditioning principles, substance abuse and dependence proceed in several phases:
  1. Use of sedatives-hypnotics, CNS stimulants, hallucinogens and narcotics, for relief from daily tensions and discomforts or anticipated withdrawal symptoms.
  2. Habit is reinforced with each relief by drug use.
  3. Development of dependency - drug has less and less efficiency in reducing tensions.
  4. Dependency is further reinforced as addict fails to maintain adequate drug intake - increase in frequency and duration of periods of tension and discomfort.

Assessment:
- Abuse
  1. Hallucinogens (LSD, marijuana, STP, PCP, peyote): euphoria and rapid mood swings, flight of ideas; perceptual impairment, feelings of omnipotence, “bad trip” (panic, loss of control, paranoia), flashbacks, suicide.
  2. CNS stimulants (amphetamines and cocaine abuse): euphoria, hyperactivity, hyperalertness, irritability, persecutory delusions; insomnia, anorexia —> weight loss; tachycardia; tremulousness; hypertension; hyperthermia —> convulsions.
  3. Narcotics (opium and its derivatives, e.g., morphine, heroin, codeine, meperidine HC1 [Demerol]): used by “snorting,” “skin popping,” and “mainlining.” May lead to abscesses and hepatitis. Decreased pain response, respiratory depression; apathy, detachment from reality; impaired judgment; loss of sexual activity; pinpoint pupils.
  4. Sedatives hypnotics (barbiturate abuse): similar to alcohol-induced behavior, e.g., euphoria followed by depression, hostility; decreased inhibitions; impaired judgment; staggering gait; slurred speech; drowsiness; poor concentration; progressive respiratory depression.
- Withdrawal symptoms
  1. Narcotics (e.g., heroin): begins within 12 hours of last dose, peaks in 24-36 hours, subsides in 72 hours, and disappears in 5-6 days.
    - Pupil dilation.
    - Muscle: twitches, tremors, aches, pains.
    - Goose flesh (piloerection).
    - Lacrimation, rhinorrhea, sneezing, yawning
    - Diaphoresis, chills.
    - Potential for fever.
    - Vomiting, abdominal distress.
    - Dehydration.
    - Rapid weight loss.
    - Sleep disturbance.
  2. Barbiturates: maybe gradual or abrupt (“cold turkey”); latter is dangerous or life-threatening; should be hospitalized.
    - Gradual withdrawal reaction from barbiturates:
      1. Postural hypotension.
      2. Tachycardia.
      3. Elevated temperature.
      4. Insomnia.
      5. Tremors.
      6. Agitation, restlessness.
    - Abrupt withdrawal from barbiturates:
      1. Apprehension.
      2. Muscular weakness.
      3. Tremors.
      4. Postural hypotension.
      5. Twitching.
      6. Anorexia.
      7. Grand mal seizures.
      8. Psychosis-delirium.
  3. Amphetamines: depression, lack of energy, somnolence.
- Difference between alcohol and other abused substances (e.g., opioid).
  1. Other abused substances may need to be obtained by illegal means, making it a legal and criminal problem as well as a medical and social problem; not so with alcohol abuse and dependency.
  2. Opium and its derivatives inhibit aggression, whereas alcohol releases aggression.
  3. As long as she or he is on large enough doses to avoid withdrawal symptoms, abuser of narcotics, sedatives, or hypnotics is comfortable and functions well, whereas chronically intoxicated alcoholic cannot function normally.
  4. Direct physiological effects of long-term opioid abuse and dependence on other abused substances are much less critical than those with chronic alcohol dependence.

Nursing Diagnosis and Categories of Care	Time Dimension	Goals/Actions	Time Dimension	Goals/Actions	Time Dimension	Goals/Actions
Risk for injury (varied autonomic and sensory responses)	Day 1	Verbalize understanding of unit policies, procedures, and safety concerns relative to individual Cooperate with therapeutic regimen	Day 3	Vital signs stable I&O balanced Display	Day 7	Discharge: Be free of injury resulting from alcohol withdrawal. Display no objective symptoms of withdrawal.
			Day 4	Display marked decrease in objective symptoms
Referrals	Day 1	RN-NP or MD If indicated: Internist Cardiologist Neurologist
Diagnostic studies	Day 1	Blood alcohol level Drug screen (urine and blood) If indicated: Chest x-ray Pulse oximetry ECG	Day 2	SMA 20: serum Mg, amylase Urinalysis	Day 4	Repeat of selected studies as indicated
Additional assessments	Day 1	VS, temperature, respiratory status/breath sounds q4h	Day 2-3	VS q8h if stable	Day 4-7	VS qd
	Day 1-4	I&O q8h Motor activity, body language, verbalizations, need for/type of restraint			Day 6	Discontinue I&O
	Ongoing	Withdrawal symptoms:		Marked decrease in objective symptoms
	Stage I	Tremors, N/V, hypertension, tachycardia, diaphoresis, sleeplessness
	Stage II	Increased hyperactivity, hallucinations, seizure activity
	Stage III	Extreme autonomic hyperactivity, profound confusion, anxiety,
Medical Allergies:	Day 1	Librium 200 mg PO	Day 3	Librium 120 mg PO	Day 5	Librium 40 mg PO
	Day 1-4	Thiamine 100 mg IM	Day 4	Librium 80 mg PO
	Day 2	Librium 160 mg PO
Patient education	Day 1	Orient to room/ unit, schedule, procedures	Day 5	Need for ongoing therapy Goals/availability of AA program	Day 7	Schedule of followup visits if indicated
Additional nursing actions	Day 1	Bedrest 12 hours if in withdrawal Position change, HOB elevated Cough, deep breathe Exercises if on bed rest	Day 3-7	Activity as tolerated
	Day 1-2	Assist with ambulation, self-care as needed Encourage fluids if free of N/V
	Ongoing	Provide environmental safety measures Seizure precautions as indicated Reorient as needed
Ineffective individual coping R/T personal vulnerability, situational crisis, inadequate coping methods	Day 1-7	Participate in development/evaluation of treatment	Day 3	Verbalize understanding of relationship of alcohol abuse to current situation	Day 7	Plan in place to meet postdischarge needs
	Day 2-7	Interact in group sessions	Day 6	Identify/make contact with potential resources, support groups
Referrals	Day 1	Psychiatrist	Day 5	Community classes: Assertiveness training Stress management
	Day 2-7	Group sessions
Additional assessment	Day 1	Understanding of current situation Drinking pattern, previous withdrawal, other drug use, attitudes toward substance use	Day 2-3	Previous coping strategies/consequences Perception of drug use on life, employment, legal issues
	Day 1-2	History of violence Relationships with others: personal, work/school Readiness for group activities	Day 3-7	Congruency of actions based on insight
Medications			Day 5-7	Naltrexone 50 mg/day if indicated
Patient education	Day 1	Physical effects of alcohol abuse	Day 3-7	Human behavior and interactions with others/ transactional analysis (TA)	Day 7	Medication dose, frequency, side effects Written instructions for therapeutic program
	Day 1-2	Types/use of relaxation techniques
	Day 2	Consequences of alcohol abuse	Day 5-6	Community resources for self/family
Additional nursing actions	Day 1-7	Support patient’s taking responsibility for own recovery Provide consistent approach/ expectations for behavior Set limits/confront inappropriate behaviors	Day 2-5	Identify goals for change Discuss alternative solutions Provide positive feedback for efforts
			Day 2-7	Support during confrontation by peer group Encourage verbalization of feelings, personal reflection
Altered nutrition: less than body requirements R/T poor intake, effects of alcohol on digestive system, and hypermetabolic response to withdrawal	Day 2-7	Select foods appropriately to meet individual dietary	Day 4	Verbalize understandings of effects of alcohol abuse and reduced dietary intake on nutritional status	Day 7	Display stable weight or initial weight gain as appropriate, and laboratory results WNL
Referrals	Day 1 and prn	Dietitian
Diagnostic studies	Day 1	CBC, liver function Serum albumin, transferrin	Day 2-7	Finger-stick glucose prn
Additional assessments	Day 1	Weight, skin turgor, condition of mucous membranes, muscle tone			Day 7	Weight
	Day 1-2	Bowel sounds, characteristics of stools
	Day 1-7	Appetite, dietary intake
Medications	Day 1-7	Antacid ac and hs (Maalox)	Day 2-7	Multivitamin tablet qd
Patient education	Day 1-2	Individual nutritional needs	Day 4	Principles of nutrition, foods for maintenance of wellness
Additional nursing actions	Day 1	Liquid/bland diet as tolerated	Day 2-7	Advance diet as tolerated
	Day 1-7	Encourage small, frequent, nutritious meals/ snacks Encourage good oral hygiene pc and hs

Analysis/nursing diagnosis:
- Risk for altered physical regulation processes (cardiac, circulatory, gastrointestinal, sleep pattern disturbance) related to use of mind-altering drugs.
- Risk for injury due to altered judgment related to misinterpretation of sensory stimuli and low frustration tolerance.
- Altered conduct/impulse processes related to rebellious attitudes toward authority.
- Altered social interaction (manipulation, dependency) related to hostility and personal insecurity.
- Altered feeling states (denial) related to underlying self-doubt and personal insecurity.

Nursing care plan/implementation: generally the same as in treating antisocial personality and alcohol abuse and dependence.
- Maintain safety and optimum level of physical comfort. Supportive physical care: vital signs, nutrition, hydration, seizure precautions.
- Assist with medical treatment and offer support and reality orientation to reduce feelings of panic.
  1. Detoxification (or dechemicalization) - give medications according to detoxification schedule.
  2. Withdrawal - may be gradual (barbiturates, hypnotics, tranquilizers) or abrupt (“cold turkey” for heroin). Observe for symptoms and report immediately.
  3. Methadone (Dolophine) - person must have been dependent on narcotics at least 2 years and have failed at other methods of withdrawal before admission to program of readdiction by methadone.
    - Characteristics:
      1. Synthetic.
      2. Appeases desire for narcotics without producing euphoria of narcotics.
      3. Given by mouth.
      4. Distributed under federal control (Narcotic Addict Rehabilitation Act).
      5. Given with urinary surveillance.
    - Advantages:
      1. Prevents narcotic withdrawal reaction.
      2. Tolerance not built up.
      3. Person remains out of prison.
      4. Lessens perceived need for heroin or morphine.
- Participation in group therapy - goals: peer pressure, support, and identification.
- Rehabilitation phase:
  1. Refer to halfway house and group living (e.g., Day-top).
  2. Support employment as therapy (work training).
  3. Expand client’s range of interests to relieve characteristic boredom and stimulus hunger.
    - Provide structured environment and planned routine.
    - Provide educational therapy (academic and vocational).
    - Arrange activities to include current events discussion groups, lectures, drama, music, and art appreciation.
- Achieve role of stabilizer and supportive authoritative figure; this can be achieved through frequent, regular contacts with the same client.
- Health teaching: how to cope with pain, fatigue, and anxiety without drugs.

Evaluation/outcome criteria: replaces addictive lifestyle with self-reliant behavior and a plan formulated to maintain a substance-free life.