Substance Abuse

By: Cuadra, Romarie BSN3-1

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Substance use/abuse and related disorders are a national health problem. The actual prevalence of substance abuse is difficult to determine precisely because many people meeting the criteria for diagnosis do not seek treatment and surveys conducted to estimate prevalence are based on self-reported data that may be inaccurate.

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TYPES OF SUBSTANCE ABUSE

Many substances can be used and abused; some can be obtained legally while others are illegal. Abuse of more than one substance is termed polysubstance abuse.

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The DSM-IV-TR lists 11 diagnostic classes of substance abuse: Alcohol Amphetamines or similarly acting sympathomimetics Caffeine Cannabis

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Cocaine Hallucinogens Inhalants Nicotine Opioids Phencyclidine (PCP) or similarly acting drugs Sedatives, hypnotics, or anxiolytics

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Intoxication is use of a substance that results in maladaptive behavior. Withdrawal syndrome refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases. Detoxification is the process of safely withdrawing from a substance.

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Substance abuse can be defined as using a drug in a way that is inconsistent with medical or social norms and despite negative consequences.

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Substance abuse denotes problems in social, vocational, or legal areas of the persons life, whereas substance dependence also includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance.

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ONSET AND CLINICAL COURSE A pattern of more severe difficulties for people with alcoholism begins to emerge in the middle 20s to the middle 30s; these difficulties can be the alcohol related breakup of a significant relationship, an arrest for public intoxication or driving while intoxicated, evidence of alcohol withdrawal, early alcohol-related health problems, or significant interference with functioning at work or school.

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Blackout is an episode during which the person continues to function but has no conscious awareness of his or her behavior at the time nor any later memory of the behavior. As the person continues to drink, he or she often develops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect.

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After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol will intoxicate the person. Abstinence may occur after some legal, social, or interpersonal crisis, and the person may then set up rules about drinking such as drinking only at certain times or drinking only beer.

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Evidence shows that some people with alcohol-related problems can modify or quit drinking on their own without a treatment program; this is called spontaneous remission or natural recovery (Cloud & Granfield, 2001). Spontaneous remission can occur in as many as 20% of alcoholics although it is highly unlikely that people in the late stage of alcoholism can recover without treatment (Schuckit, 2000).

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ETIOLOGY

The exact causes of drug use, dependence, and addiction are not known, but various factors are thought to contribute to the development of substancerelated disorders (Jaffe, 2000c).

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Biologic Factors

Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are children of nonalcoholic parents (Jaffe, 2000c). Several studies of twins have shown a higher rate of concordance (when one twin has it, the other twin gets it) among identical than fraternal twins.

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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. Distribution of the substance throughout the brain alters the balance of neurotransmitters that modulate pleasure, pain, and reward responses.

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Psychological Factors Children of alcoholics are four times as likely to develop alcoholism (Schuckit, 2000) compared to the general population. Some people use alcohol as a coping mechanism or to relieve stress and tension, increase feelings of power, and decrease psychological pain. High doses of alcohol, however, actually increase muscle tension and nervousness (Schuckit, 2000).

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Social and Environmental Factors

Cultural factors, social attitudes, peer behaviors, laws, cost, and availability all influence initial and continued use of substances (Jaffe, 2000c). Alcohol consumption increases in areas where availability increases and decreases in areas where costs of alcohol are higher because of increased taxation.

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CULTURAL CONSIDERATIONS

Attitudes toward substance use, patterns of use, and physiologic differences to substances vary in different cultures. It is important to be aware of such beliefs when assessing for a substance abuse problem. Certain ethnic groups have genetic traits that either predispose them to or protect them from developing alcoholism.

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TYPES OF TREATMENT

SUBSTANCES

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Alcohol Intoxication and Overdose Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream. Initially the effects are relaxation and loss of inhibitions.

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An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression. This combination can cause aspiration pneumonia or pulmonary obstruction. Alcoholinduced hypotension can lead to cardiovascular shock and death.

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Withdrawal and Detoxification Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or deliriumcalled delirium tremens (DTs).

Box 17-1 PHYSIOLOGIC EFFECTS OF LONG-TERM ALCOHOL USE Cardiac myopathy Wernickes encephalopathy Korsakoffs psychosis Pancreatitis Esophagitis Hepatitis Cirrhosis Leukopenia Thrombocytopenia Ascites

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Sedatives, Hypnotics, and Anxiolytics Intoxication and Overdose This class of drugs includes all central nervous system depressants: barbiturates, nonbarbiturate hypnotics, and anxiolytics particularly benzodiazepines. The intensity of the effect depends on the particular drug. Intoxication symptoms include slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, and even stupor and coma.

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Withdrawal The withdrawal syndrome is characterized by symptoms that are the opposite of the acute effects of the drug: that is, autonomic hyperactivity (increased pulse, blood pressure, respirations, and temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitation. Seizures and hallucinations occur only rarely in severe benzodiazepine withdrawal (Ciraulo & Sarid-Segal, 2000).

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Detoxification Detoxification from sedatives, hypnotics, and anxiolytics is often managed medically by tapering the amount of the drug the client receives over a period of days or weeks, depending on the drug and the amount the client had been using. Tapering, or administering decreasing doses of a medication, is essential with barbiturates to prevent coma and death that will occur if the drug is stopped abruptly.

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BOX 17.2
At the Psychiatric Book (pg 353-354)

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THE END