Chapter 73 Substance-Related Disorders
PATHOPHYSIOLOGY
Substance-related disorders are a major public health problem affecting young people in the United States. They are the leading cause of preventable death in 15- to 24-year-olds. Substances used can be any of a number of drugs taken for toxic or side effects. Such substances include alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, anxiolytics, and phencyclidine (PCP). The effects of substance intoxication vary widely depending on the individual and the substance used. Generally, intoxication causes physiologic, cognitive, and psychosocial effects. A diagnosis of substance abuse is made when drug use causes adverse consequences such as physically hazardous behaviors, legal problems, and interference with school functioning.
A more serious problem is substance dependence. Prolonged, heavy use of a substance results in dependence. Over time, increasing amounts of the substance are needed to achieve intoxication; this is referred to as tolerance. When blood concentrations of the substance diminish, unpleasant withdrawal symptoms are experienced. Once dependence develops, the individual uses the substance primarily to relieve withdrawal symptoms. Withdrawal from certain drugs such as alcohol and benzodiazepines (e.g., Valium) is potentially life threatening. Hospitalization to manage detoxification may be indicated.
Alcohol, tobacco, and marijuana are the substances most frequently abused by children and adults. Inhalant use, which is often perceived as harmless by adolescents, accounts for a large number of deaths of teenagers. Both inhalant and heroin use are on the rise in the United States. Steroids are also one of the drugs being used with increased frequency by adolescents. Steroids became popular in athletics to improve performance by increasing muscularity. Because steroids do not increase endurance, they are mostly used by athletes who participate in football, wrestling, weight lifting, powerlifting, and bodybuilding.
The use of steroids by adolescents may or may not be for sports performance. Some abusers of steroids have muscle dysmorphia or “bigorexia,” which is when an individual is obsessed with being unreasonably muscular and with low body fat. Some see muscle dysmorphia as an antithesis to anorexia nervosa. The connection is strengthened by the fact that many male and female steroid abusers have been victims of sexual and physical abuse.
Most steroid abusers are considered to be psychologically normal when they start using steroids. Gym dosing is typically 10 to 100 times the dosage for medical use. As with other illicit drugs, the problem with steroids is cessation. One of the major consequences of cessation of administration is depression. Use has decreased, possibly because of the press given to negative consequences suffered by professional athletes. Programs that have failed to reduce steroid use are drug testing–only programs, physical training or nutrition education, and education-only programs that do not focus on changing the perception of risk.
A number of psychosocial, developmental, cultural, attitudinal, and personality factors put a youth at risk for drug experimentation. The most significant predictor for substance use is drug use by peers. Other risk factors include poor self-image, problems with school performance, difficult temperament, hyperactivity, and genetic predisposition. Risk factors include problems associated with family dysfunction, including abuse and neglect, overly rigid or permissive parents, parental rejection, and divorce. The following are factors associated with resistance to illicit substance use: nurturing parents, positive school experience, negative attitudes toward drugs, committed religious attitudes, positive self-esteem, and social competence.
Generally, the younger the age of initial drug use, the higher the risk for serious long-term health consequences and adult abuse. Cigarette, alcohol, and marijuana use has been associated with ready access to these substances in the child’s home.
Gateway phenomenon is a term denoting the pattern of using an increasing variety of substances, ultimately leading to polysubstance abuse. Evidence for this phenomenon is that youth who smoke tobacco and drink alcohol are more likely to use marijuana, and those who use marijuana are more likely to use cocaine. An adolescent may initially begin using to achieve a false sense of maturity, but eventually he or she is likely to develop drug dependence. Substance abuse is associated with depression, low self-esteem, risk for school underachievement, teenage pregnancy, and delinquency. Illicit drug use creates a greater risk of contracting human immunodeficiency virus (HIV) infection and hepatitis C.
Box 73-1 presents the criteria from the American Psychiatric Association’s Diagnostic and statistical manual of mental disorders (DSM IV-TR) for substance abuse, substance dependence, substance intoxication, and substance withdrawal.
Box 73-1 Substance Abuse
The DSM-IV-TR defines substance abuse as a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to repeated use of the substance. Criteria include the following:
1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
2. Recurrent substance use in situations in which it is physically hazardous
3. Recurrent substance-related legal problems
4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
Substance Dependence
The DSM-IV-TR defines substance dependence by the following criteria:
1. Evidence of tolerance, as identified by either of the following:
2. Evidence of withdrawal symptoms, as manifested by either of the following:
3. The substance is often taken in larger amounts or over a longer period than was intended.
4. There is a persistent desire or unsuccessful effort to decrease or control substance use.
5. A great deal of time is spent in activities necessary to obtain or use the substance or to recover from the effects of the substance.
6. Important social, occupational, or recreational activities are given up or reduced because of substance use.
7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychologic problem that is likely to have been caused or exacerbated by the substance.
Substance Intoxication
The DSM-IV-TR defines substance intoxication by the following criteria:
1. The development of a reversible substance-specific syndrome caused by recent ingestion of or exposure to a substance.
2. Clinically significant maladaptive behavior or psychologic changes that are caused by the effect of the substance on the central nervous system (CNS) and that develop during or shortly after use of the substance.
3. The symptoms are not caused by a general medical condition and are not better accounted for by another mental disorder.
Substance Withdrawal
The DSM-IV-TR defines substance withdrawal by the following criteria:
1. The development of a substance-specific syndrome caused by the cessation of or reduction in heavy and prolonged substance use.
2. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. The symptoms are not caused by a general medical condition and are not better accounted for by another mental disorder.
From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, ed 4, text revision (DSM-IV-TR), Washington, DC, 2000, The Association.
INCIDENCE
1. Half the children in America (36 million) live in a home where a parent or other adult drinks heavily, uses illicit drugs, or smokes tobacco.
2. Children whose parents are alcoholics or drink heavily are 4 times more likely to use alcohol or develop alcohol-related problems compared to peers whose parents are not alcoholics.
3. The prevalence rate depends on the substance; substance use among adolescents has declined, but the use of steroids, opiates, LSD, and inhalants have shown periodic increases.
4. Of high school seniors, 64% have experimented with illicit drugs.
5. Nearly 50% of teenage suicides and accidental deaths have been associated with illegal substance use.
6. Of high school seniors, 6% report using illicit drugs on a regular basis.
7. Nearly 90% of adolescents ages 18 years and younger report having used alcohol.
8. During the past decade, the use of inhalant drugs (glue, aerosols) has increased threefold in the 12- to 17-year-old age group.
9. During the past decade, marijuana and inhalants have become the two most commonly used illicit drugs by the 12- to 17-year-old age group.
10. The age at which experimentation begins has been declining, especially for inhalants.
11. Depression is a comorbidity in 33% to 50% of those with opioid dependence or abuse, and in 40% of those with alcohol dependence.
12. Drug use disorders are strongly associated with anxiety, mood, and personality disorders.
13. Substance abusers are 20 times more likely to commit suicide than the general population; substance abuse is a major precipitating factor for suicide.
14. Substance abuse is generally higher in males than in females.
15. The earlier the onset of drug use and the faster the progression to stronger drugs, the higher the risk of substance abuse disorder.
CLINICAL MANIFESTATIONS
1. Most adolescents experiment with cigarettes and alcohol, some will advance to marijuana, and a smaller portion will advance to other drugs.
4. Changes in cognition: impaired concentration, disturbance of thinking, and changes in attention span and perception.
5. Signs of trauma that result from needle use, violent behaviors, injuries due to intoxication, and high-risk behavior.
6. Behavioral changes that include lethargy, agitation, disinhibition, hyperactivity, hypervigilance, and somnolence.
7. Impairment in psychosocial and academic functioning is the hallmark of substance abuse disorder.
8. Isolation of self from family members and friends.
9. All of the substances used are illegal for adolescents; some of the negative consequences are from the illegal nature of the substance rather than from use of the substance.
10. The course varies, but abuse is often discontinued in early adulthood, whereas dependence is more likely to continue.
COMPLICATIONS
Alcohol
2. Integumentary: diaphoresis, alopecia, spider nevi, telangiectases, angioma, palmar erythema, rosacea, superficial infection
3. Head, eyes, ears, nose, and throat (HEENT): rhinorrhea, sneezing, lacrimation
4. Cardiopulmonary: myocardial infarction, tachycardia, respiratory depression, cardiomyopathy, arrhythmias, hypertension, subacute bacterial endocarditis, chronic upper respiratory infection (URI), aspiration pneumonia
5. Gastrointestinal (GI): inadequate or poor nutritional status, abdominal tenderness, splenomegaly, hepatomegaly, GI bleeding, weight loss, diarrhea, esophagitis, gastritis, gastric ulcers, pancreatitis, pancreatic cancer
6. Musculoskeletal: muscle aches or cramps
7. Endocrine: testicular atrophy, gynecomastia, sexual dysfunction, amenorrhea
8. Neuropsychiatric: cerebrovascular accident, depression, anxiety, nystagmus, emotional lability, irritability, peripheral neuropathy, hallucinations (especially tactile), insomnia, headache, seizure, coma, convulsions, delirium, unsteady gait, difficulty standing, impaired judgment, Wernicke-Korsakoff syndrome (alcoholic encephalopathy)
Complications Related to Stimulant or Opioid Abuse
2. HEENT: Erosion of nasal septum (from cocaine use), dilated pupils, mydriasis
3. Cardiopulmonary: cardiac arrhythmias, myocardial infarction, tachycardia, chest pain, respiratory depression, hypertension, cardiac arrest (from overdose), subacute bacterial endocarditis, bradycardia, hypotension
4. Gastrointestinal: inadequate or poor nutritional status, abdominal tenderness, splenomegaly, hepatomegaly, GI bleeding, weight loss, nausea, vomiting
6. Musculoskeletal: psychomotor retardation, muscle cramps, fatigue
7. Endocrine/immunologic: hypothermia, human immunodeficiency virus (HIV), hepatitis from intravenous use
8. Neuropsychiatric: cerebrovascular accident, depression, anxiety, emotional lability, irritability, hallucinations, insomnia, panic episodes, restlessness, agitation, elated mood, grandiosity, mood swings, headache, seizure, dystonia, dyskinesia, nightmares
Complications Related to Hallucinogens*
1. General: deterioration of health status; sudden death
2. Integumentary: diaphoresis, alopecia, spider nevi, telangiectases, angioma, palmar erythema, rosacea, superficial infection
3. HEENT: dilated pupils, blurred vision
4. Cardiopulmonary: tachycardia, palpitations
5. Neuropsychiatric: tremors, ataxia, nystagmus, mood swings, panic episodes, flashbacks, aggression, hallucination, paranoia, impaired concentration, impaired memory, inability to make decisions, incoordination
Complications Related to Inhalants
1. General: accident or injury while intoxicated
2. Integumentary: residue of inhalant on skin, face, hands, and clothes; diaphoresis
3. HEENT: irritation of the eyes and nose, rash around nose and mouth, unusual breath odor
4. Mouth and throat: irritation of throat and lungs
5. Cardiopulmonary: cardiac arrhythmias, respiratory depression, tachycardia, hypertension, asphyxiation, cardiac arrest
6. GI: nausea and vomiting, anorexia, weight loss, hepatic damage
7. Genitourinary: kidney damage
8. Musculoskeletal: permanent muscle damage associated with rhabdomyolysis
9. Neuropsychiatric: ataxia, anxiety, agitation, confusion, stupor, delusions, hallucinations, irritability, psychosis, delirium, dementia, brain atrophy, decreased intelligence quotient (IQ), temporal lobe epilepsy, nystagmus
Complications Related to Steroids
3. Cardiopulmonary: tachycardia, cerebrovascular disease, hypertension
4. Genitourinary: kidney tumor, gynecomastia, sexual dysfunction, testicular atrophy, prostate cancer, reduced sperm count or infertility (females), amenorrhea, alopecia, facial hair, enlarged clitoris, deepened voice
5. Endocrine: liver cancer, jaundice, HIV infection, hepatitis, tetanus (from use of contaminated needle), increased low-density lipoprotein (LDL), decreased high-density lipoprotein (HDL), stunted growth or premature skeletal maturation
6. Neuropsychiatric: tremor, depression, aggression, delusions, paranoia, manic symptoms, irritability, jealousy, mood swings, impaired judgment
LABORATORY AND DIAGNOSTIC TESTS
Refer to Appendix D for normal values and ranges of laboratory and diagnostic tests.
1. Toxicologic analysis—used for identification of substance, differential diagnosis
2. Urine drug screen (UDS)—indicates type of substance used and time of use (limitations include civil liberties issues, short “window” of detection of metabolites, and intermittent pattern of abuse; also, tests vary in sensitivity, expense, and time)
3. Blood alcohol level—to detect level of alcohol in the blood
4. Complete blood count—low white blood cell (WBC) count, increased prothrombin time (PT), anemia
5. Liver enzymes—increased in alcohol dependence
6. Breathalyzer—measures the level of blood alcohol concentration (BAC) using a breath sample
7. Psychologic evaluations—screening tests for assessment of substance abuse
MEDICAL MANAGEMENT
Treatment for substance abuse is typically done on an outpatient basis. Inpatient hospitalization is indicated if the client is suicidal or requires detoxification. Controlling drug use should never be the end target of treatment. Harm reduction is effective in reducing the use and the adverse effects of substances, increasing level of functioning, and reducing frequency and severity of relapse, while client learns skills to deal with substance abuse. Improved self-confidence may increase the chances of abstinence.
Comprehensive treatment programs include individual and group psychotherapy, family therapy, recreational therapy, and social skills training. Intensive initial treatment, whether provided on an inpatient or outpatient basis, is associated with positive outcomes. Concurrent attention to interpersonal deficits, coexisting psychiatric symptomatology, family functioning, and educational or vocational functioning improves treatment outcomes. It is important that the youth be connected to community resources that can support achievement of long-term outcomes. Linkages to education, training, rehabilitation, and job development programs can be of assistance.
Treating comorbid conditions is a major part of substance abuse disorder. Care must be given to using psychotropic medications with adolescents who have substance problems because of the increased potential for unintentional or intentional overdose, either with these medications or in combination with some substance of abuse. Cognitive behavioral therapy (CBT) is effective in treating conduct disorder, which is the most common comorbid disorder, and can be used to focus on substance abuse issues.
Prevention efforts that emphasize development or enhancement of protective factors (strengthening self-esteem, and problem solving, coping, and communication skills) are most effective. These programs emphasize resistance to peer pressure and highlight that most children and youth do not use drugs. Interactive learning models such as role playing and small-group learning sessions are more effective than educational programs. Prevention programs, referred to as universal, selective, or indicated, should be targeted to specific audiences. Universal programs address the needs of the general public, selective programs provide outreach to at-risk populations such as children of abusing parents, and indicated programs are directed to youths who use illicit substances.
NURSING ASSESSMENT
1. Obtain thorough history of illegal and illicit drugs of choice, time of last use, amount used, frequency and duration of use, and routes of administration (intravenous, oral, and inhalant forms provide more rapid effect).
2. Conduct physical assessment with emphasis on respiratory, cardiovascular, and neurologic systems (see Appendix A).
3. Note any signs of trauma or injury (e.g., needle puncture marks).
4. Assess for depression and suicide potential (refer to Chapter 75). Refer for further evaluation if the answer is yes to two or more of the following questions:
5. Assess for youth and family drug- and alcohol-related problems.
6. Obtain information about school performance.
7. Assess level, type, and frequency of social activities, after-school activities, and peer relationships.
NURSING INTERVENTIONS
1. Assess specific safety requirements by obtaining history of type of substance used and level of toxication (urine toxicology screen may be more accurate than client report), amount and time last consumed, amount consumed on a daily basis, when client started using and frequency of use, signs and severity of withdrawal symptoms.
2. Institute necessary safety precautions.
3. Use caring confrontation regarding rationalizing and fantasizing about drug lifestyle, and provide information to correct misperceptions about substance abuse.
4. Encourage sharing of feelings, anxieties, and fears while encouraging and reinforcing independent positive decision making.
5. Assess client’s readiness to learn and preferred learning method to teach psychologic and physiologic effects of drug dependence, starting with simple and moving on to more complex concepts.
6. Teach assertiveness techniques and effective communication utilizing client’s strengths and accomplishments.
7. Assess family communication, coping, and support; provide support and information about enabling; and involve family in discharge referral plans.
8. Encourage linkages to community-based resources and services.
Discharge Planning and Home Care
1. Provide realistic and credible information about risks and consequences associated with drug use.
2. Provide parental anticipatory guidance on need to create clearly delineated expectations for their youth’s behavior and their responsibility to serve as appropriate role models.
3. Provide parental anticipatory guidance regarding use of home drug test kits—that they have limitations and can generate false-positive results, and that their use does not substitute for open communication or parental supervision.
4. Provide information to parents about relationship between their use of tobacco and alcohol, child and adolescent, and adolescent substance use and abuse.
5. Advise parents that treatment programs must include comprehensive interdisciplinary approach that involves juvenile justice, social services, mental health services, and primary care
CLIENT OUTCOMES
1. Adolescent will stop or decrease illicit drug use.
2. Adolescent will verbally take responsibility for own behavior and acknowledge association between personal problems and substance use.
3. Adolescent will develop more positive coping skills.
4. Family members will learn to communicate and interact with each other more effectively.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with substance use disorder. J Am Acad Child Adolesc Psychiatr. 2005;44(6):609.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, ed 4. Washington, DC: The Association, 2000. text revision (DSM-IV-TR)
Colliver J, et al. Development in the epidemiology of drug use and drug use disorders. Am J Psychiat. 2005;162(8):1494.
Jonnson L, et al. Teen drug use down but progress halts among youngest teens. University of Michigan News and Information Services: Ann Arbor, MI, Monitor the Future. Accessed April 26, 2007 http://monitorthefuture.org (serial online):
National Institute on Drug Abuse [(website):] .NIDA infofacts: Steroids (anabolic androgenic), 2006. www.drugabuse.gov/infofacts/steroids.html. Accessed February 28, 2006
Simkin D. Adolescent substance abuse. Sadock B, Sadock V. Kaplan & Sadock’s comprehensive textbook of psychiatry, ed 8, Philadelphia: Lippincott, Williams & Wilkins, 2005.
Townsend MC. Unit Two—Alterations in psychiatric adaptation. Chapter 4. Substance-related disorders. Townsend M, ed. Nursing diagnosis in psychiatric nursing: Care plans and psychotropic medications, ed 6, Philadelphia: FA Davis, 2004.
