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Ch. 19: Addiction

KEY TERMS:
Blackout: an episode during which the person continues to function but has no conscious
awareness of his or her behavior at the time or any waiter memory of the behavior; usually
associated with alcohol consumption
Codependence: a maladaptive coping pattern on the part of family members or others that results
from a prolonged relationship with the person who uses substances
Controlled substance: drug classified under the Controlled Substances Act; it Includes opioids,
stimulants, benzodiazepines, anabolic steroids, cannabis derivatives, psychedelics, and sedatives
Denial: defense mechanism; clients may deny directly having any problems or may minimize the
extent of problems or actual substance use
Designer drugs: synthetic substances made by altering existing medications or formulating new
ones not yet controlled by the FDA; amphetamine-like effects, some also have hallucinogenic
effects; called club drugs
Detoxification: the process of safely withdrawing from a substance
Dual diagnosis: the client with both substance abuse and another psychiatric illness
Flushing: reddening of the face and neck as a result of increased blood flow
Hallucinogen: substances that distort the users perception of reality and produce symptoms
similar to psychosis including hallucinations (usually visual) and depersonalization
Inhalant: a diverse group of drugs including anesthetics, nitrates, and organic solvents that are
inhaled for their effects
Intoxication: use of a substance that results in maladaptive behavior
Opioid: controlled drugs; often abuse because they desensitize the user to both physiologic and
psychological pain and induce a sense of euphoria and well-being; some are prescribed for
analgesic effects but others are illegal in the United States
Polysubstance abuse: abuse of more than one substance

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Spontaneous remission: natural recovery that occurs without treatment of any kind
Stimulants: drugs that stimulate or excite the central nervous system
Substance abuse: can be defined as using a drug in a way that is inconsistent with medical or social
norms and despite negative consequences
Substance dependence: includes problems associated with addiction, such as tolerance,
withdrawal, and unsuccessful attempts to stop using the substance
Tapering: administering decreasing doses of a medication leading to discontinuation of the drug
Tolerance: the need for increased amount of a substance to produce the same effect
Tolerance break: very small amounts of a substance will produce intoxication
12-step program: based on the philosophy that total abstinence is essential and that alcoholics
need the help and support of others to maintain sobriety.
Withdrawal syndrome: refers to the negative psychological and physical reactions that occur when
use of a substance ceases or dramatically decreases

LEARNING OBJECTIVES:

1) Explain the trends in substance abuse and discuss the need for related prevention programs.
a) Forty-three percent of all Americans have been exposed to alcoholism in their families.
Children of alcoholics are four times more likely than the general population to develop
problems with alcohol. Many adult people in treatment programs as adults report having had
their first drink of alcohol as a young child, when they were younger than age 10. With the
increasing rates of use being reported among young people today, this problem could spiral
out of control unless great strides can be made through programs for prevention, early
detection, and effective treatment.
b) Increasing numbers of infants are suffering the physiologic and emotional consequences of
prenatal exposure to alcohol or drugs. Chemical abuse results in increased violence. Drug

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abuse costs business and industry an estimated $102 billion annually. Alcohol abuse is a too
frequent cause of or contributor to death.
c) Approximately 7.5 million children under age 18 (10.5% of this population) live with a parent
with an alcohol use disorder in any given year.
d) 30-60% of elders in treatment programs began drinking abusively after age 60
2) Discuss the characteristics, risk factors, and family dynamics prevalent with substance abuse.
a) Poor outcomes have been associated with an earlier age at onset and longer periods of
substance use. Children who have not yet used substances may be easily influenced because of
their age and the fact that they have not already become addicted.
b) Biologic factors
i) Children of alcoholic parents are at higher risk for developing alcoholism and drug
dependence than are children of nonalcoholic parents
ii) Several studies of twins show a higher rate of concordance among identical than fraternal
twins.
iii) Neurochemical influences on substance use patterns have been studied primarily in animal
research (Jaffe & Anthony, 2005). The ingestion of mood-altering substances stimulates
dopamine pathways in the limbic system, which produces pleasant feelings or a high that
is a reinforcing, or positive, experience.
c) Psychologic factors
i) Children of alcoholics are four times more likely than the general population to develop
problems with alcohol. Some theorists believe that inconsistency in the parents behavior,
poor role modeling, and lack of nurturing pave the way for the child to adopt a similar
lifestyle of maladaptive coping, stormy relationships, and substance abuse. Others
hypothesize that even children who abhorred their family lives are likely to abuse
substances as adults because they lack adaptive coping skills and cannot form successful
relationships.
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ii) Some people use alcohol as a coping mechanism or to relieve stress and tension, increase
feelings of power, and decrease psychologic pain. High doses of alcohol actually increase
muscle tension and nervousness.
d) Social and environmental
i) Urban areas where drugs and alcohol are readily available also have high crime rates, high
unemployment, and substandard school systems that contribute to high rates of cocaine
and opioid use and low rates of recovery.
3) Describe the principles of a 12-step treatment approach for substance abuse.
a) Alcoholics Anonymous (AA) developed the 12-step program model for recovery, which is based
on the philosophy that total abstinence is essential and that alcoholics need the help and
support of others to maintain sobriety. Key slogans reflect the ideas in the 12 steps, such as
one day at a time (approach sobriety one day at a time), easy does it (don't get frenzied
about daily life and problems), and let go and let God (turn your life over to a higher power).
Regular attendance at meetings is emphasized.
4) Apply the nursing process to the care of clients with substance abuse issues.
a) Assessment
i) History: Chaotic family life; some crisis that precipitated entry into treatment, such as
physical problems or withdrawal symptoms while being treated for another condition
ii) General appearance and motor behavior: Appearance and speech may be normal; may
appear anxious, tired, and disheveled; most clients are somewhat apprehensive about
treatment, or feel pressured by others to be there
iii) Mood and affect: wide ranges are possible; some are sad, tearful, express guilt and
remorse; others may be angry and sarcastic or quiet and sullen, unwilling to talk to the
nurse; irritability is common because clients are newly free of substances; clients may be
pleasant and seemingly happy, appearing unaffected especially if they are still in denial

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iv) Thought process and content: clients are likely to minimize their substance use, blame
others for their problems, and rationalize their behavior; they may believe that they can
quit on their own if they wanted to, and they continue to deny or minimize the extent of
the problem
v) Sensorium and intellectual processes: are generally orients and alert unless experiencing
lingering effects of withdrawal. Intellectual abilities are intact unless clients have
experienced neurologic deficits from long-term alcohol use or inhalant use.
vi) Judgment and insight: poor judgment especially while under the influence of the substance;
client may behave impulsively such as leaving treatment to obtain the substance of choice;
insight usually is limited regarding substance use
vii) Self-concept: low self-esteem; do not feel adequate to cope with life and stress without the
substance; difficult identifying and expressing true feelings; preferred to escape feelings
and avoid any personal pain or difficulty with the help of the substance
viii) Roles and relationships: absenteeism and poor work performance are common; family
members have told them the substance use was a concern; family relationships are strained
ix) Physiologic considerations: poor nutrition, sleep disturbances; liver damage, hepatitis or
HIV infection from IV drug use, or lung or neurologic damage from using inhalants
b) Data analysis:
i) Nsg dx related to physical health:
(1) Imbalanced nutrition: less than body requirements
(2) Risk for infection
(3) risk for injury
(4) diarrhea
(5) excess fluid volume
(6) activity intolerance
(7) self-care deficits
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ii) Nsg dx related to substance use:


(1) Ineffective denial
(2) Ineffective role performance
(3) Dysfunctional family processes alcoholism
(4) Ineffective coping
c) Outcome identification
i) The client will
(1) Abstain from alcohol and drug use
(2) Express feelings openly and directly
(3) Verbalize acceptance of responsibility for his or her own behavior
(4) Practice nonchemical alternatives to deal with stress or difficult situations
(5) Establish an effective aftercare plan
d) Intervention
i) Providing health teaching for client and family:
(1) Substance abuse is an illness
(2) Dispel myths about substance abuse
(3) Abstinence from substances is not a matter of willpower
(4) Any alcohol, whether beer, wine, or liquor, can be an abused substance
(5) Prescribed medication can be an abused substance
(6) Feedback from family about relapse signs, for example, a return to previous
maladaptive coping mechanisms is vital
(7) Continued participation in an aftercare program is important
ii) Addressing family issues
(1) Characteristics of codependence are poor relationship skills, excessive anxiety and
worry, compulsive behaviors, and resistance to change; family members learn these

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dysfunctional behavior patterns as they try to adjust to the behavior of the substance
user.
(2) Decrease codependent behaviors among family members
iii) Promoting coping skills
(1) Encourage clients to identify problem areas in their lives and to explore ways that
substance use may have intensified those problems
(2) Role-play situations is an opportunity to help clients learn to solve problems or to
discuss situations with others calmly and more effectively
(3) Help clients to find ways to relieve stress or anxiety; relaxing, listening to music,
exercising, or engaging in activities may be effective
(4) Help clients focus on the here-and-now instead of dwelling on past problems and
regrets
(5) Encourage clients to set attainable goals
e) Evaluation: effectiveness of treatment is based heavily on the clients abstinence from
substances; successful treatment should result in more stable role performance, improved
interpersonal relationships, and increased satisfaction with quality of life
5) Provide education to clients, families, and community members to increase knowledge and
understanding of substance use and abuse.
a) Family members and friends should be aware that clients who begin to revert to old behaviors,
return to substance-using acquaintances, or believe they can handle myself now are at high
risk for relapse, and loved ones need to take action. The nurse must dispel myths and
misconceptions such as, It's a matter of will power, I can't be an alcoholic if I only drink beer
or if I only drink on weekends, I can learn to use drugs socially, or I'm okay now; I could
handle using once in a while.
6) Discuss the nurses role in dealing with the chemically impaired professional.
a) Client safety is a priority; the impaired nurse should not be caring for clients. After client safety
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is ensured, the nurse should call the supervisor to handle the situation. It is not the nurse's
responsibility to give out information on the hospital's employee assistance program. It is not
appropriate to ignore the situation.
b) General warning signs of abuse include poor work performance, frequent absenteeism,
unusual behavior, slurred speech, and isolation from peers. Physicians, dentists, and nurses
have far higher rates of dependence on controlled substances, than other professionals of
comparable educational achievement. One reason is thought to be the ease of obtaining
controlled substances. Health-care professionals also have higher rates of alcoholism than the
general population.
7) Evaluate your feelings, attitudes, and responses to clients and families with substance use and
abuse.
a) The nurse must examine his or her beliefs and attitudes about substance abuse. A history of
substance abuse in the nurse's family can strongly influence his or her interaction with clients.
The nurse may be overly harsh and critical. Conversely, the nurse may unknowingly act out old
family roles and engage in enabling behavior. Examining one's own substance use or use by
close friends and family may be difficult and unpleasant but is necessary if the nurse is to have
therapeutic relationships with clients. The nurse also might have different attitudes about
various substances of abuse. Health-care professionals also have higher rates of alcoholism
than the general population. With the pervasive nature of substance abuse nationally, odds are
great that nurses and other health professionals have been affected by substance abuse in
their lives.

UNIT 4: NURSING PRACTICE FOR PSYCHIATRIC DISORDERS