The document provides statistics on substance use and abuse in the United States, noting that 28 million Americans over 12 years old use drugs or alcohol, with the highest rates among white males aged 18-25 with a high school education. Reasons for substance use include social and cultural factors, mental health issues, and genetics. The document also discusses signs of substance abuse and dependence based on DSM-IV criteria.

1. Renee Franquiz MSN, RN

2.  28 million Americans
over the age of 12 years
used drugs or etoh (13%)
 17 million Americans
over the age of 12 years
abused (7%) – based on
DSM-IV criteria
 Highest prevalence was
among white males, age
18-25, high school only
education
 Most highly abused
substance was alcohol
Source: http://www.oas.samhsa.gov/nsduh.htm
(US Dept of Health and Human Services)

3. In class we touched on some of the reasons illustrated below,
and we spoke of social acceptance/indifference, peer pressure,
role modeling, taboo makes it tempting, cultural norms,
changes in family (supervision of children), access to
information (internet), result of Rx treatment

4.  Within the US 14% of adults have had an
alcohol dependence or abuse problem at
some time in their lives.
 3% of individuals older that 12 years need
treatment for drug use disorders.

5.  Definition  DSM-IV Criteria (1 of the
 Touse in a following in the past 12
wrong or months)
harmful way  Failure to fulfill role
obligations
 Physical hazard/Injury
 Legal Issue(s)
 Behavior continues despite
an awareness that there is
a problem

6.  Definition  DSM-IV Criteria (3 of
 Compulsive chronic the following in the
requirement where the past 12 months)
need creates distress if  Tolerance
unfulfilled
 Withdraw Symptoms
 A desire to Decrease
 Often involves
 Unsuccessful attempt to
tolerance – which is an
habituation – the decrease
increasing need for  Increase time spent in
greater amount or more pursuit
frequency  Sacrifice personal
Involvements
 Behavior continues
despite an awareness
that there is a problem

7.  Physiological
Biochemical– Substance combines with
neurotransmitters to produce
endogenous morphine, which becomes
addictive
Biologic – Gene of predisposition
 Familial tendency, especially for etoh
 Supported by Twin Studies and Adoption
studies

8.  Psychological
Developmental – Stalled development
at one of the stages (Freud, Erikson,
Kholberg etc) predisposes to use/abuse
Personality – Individual traits
predispose to use/abuse, such as low
self-esteem, impulsiveness, inability to
delay gratification, antisocial,
depressive personality

9.  Social
 Learned– Bandura’s Social Learning Theory.
Modeling in the environment (family and peers)
results in use/abuse
 Operant Conditioning – Skinner, Pavlov Positive
reinforcement from the pleasure aspect of use
leads to repeat behavior
 Cultural– Can fall under “Learned” and relates
to etoh – reflected as Values, Norms, Customs
and Beliefs of a particular culture

10.  Reasons for use –  PLEASE REVIEW
previously covered  ATI pages 154-157
 Intended and Toxic
effects
 Significance  This is material that
¼ all ER admits are will be tested on the
substance related exam
 1/3 of all suicides are
substance related
 ½ of all Homicides are
substance related

11.  First examine and explore yourself
 How do you feel about drugs, alcohol, and addiction?
 This may include reflecting on your own use, or that of
family and friends
 Negative attitudes about use may lead to disapproval,
intolerance, condemnation
 Positive attitudes about use may lead to enabling and boundary
issue
 Maintain Professionalism – your attitude either way should not
factor into the nurse-client relationship
 Empathy is a must
 Anticipate the possibility of manipulation
 addiction creates a powerful need that if unfulfilled,
lead to significant client distress
 Pursuit of the substance may trump all conventional
thought

12.  Assessment
 Review the general mental health history and
physical on pages 142 – 147 in Townsend
 History should include
 Type, Route, Frequency, Amount of Substance used
 Patterns of use and have they changed (Shift from Use
to Dependence)
 Date/Time of last use, abstinence hx (rehab),
withdraw sx
 Be sure to include
 Have you ever used more than you wanted to?
 Have you wanted to change your use? Cut
down/stop?

13.  Assessment
 Labs (Acute Evaluation)
 Complete Blood Count (CBC) – Concerns for infection,
anemia, thrombocytopenia
 Complete Metabolic Panel (CMP) – Concerns for
Electrolyte Imbalance, Liver Function, Nutritional
Deficits
 Urine Analysis (U/A) – Concerns for infection, Renal
Impairment
 Toxicology Screen – Can do as U/A or Blood
 Blood Alcohol Level (BAL) – Legal Limit 0.08% (80g/dl)
 Unable to discharge client until BAL < 100g/dl,
unless they are being transported by someone else
 Life Threatening BAL > 350 g/dl – 400g g/dl - All
depends on the individuals tolerance

14.  Assessment Tools
 Please familiarize yourself with these tools
 Textbook
 MAST (Michigan Alcohol Screening Test)
 CIWA (Clinical Institute Withdraw Assessment)
 ATI
 MAST (As Above)..MAST.pdf
 Addiction Severity Index
..Addiction Severity Index.pdf
 Recovery Attitude and Treatment Evaluator (unable
to provide d/t copyright – for purchase only)
 Drug Abuse Screen Test (DAST)..DAST.pdf
 CAGE-AID..CAGE-AID.pdf

15.  Analysis and Diagnosis
 Consider any Nursing Dx you have data to support
 Due to the breath of impact that substance abuse has,
the list of nursing dx could be quite exhaustive
(physical, psychological, social, cognitive)
 Key Dx associated with Substance Abuse
 Ineffective Coping
 Denial
 Impaired Nutrition
 Risk for Injury
 Disturbed Thought Process
 Suicide
 You likely could add at least 10 more!

16.  Analysis
 Consider that 50% of people with a serious mental illness
have a substance use disorder some time on their lives.
 Disorders associated with substance abuse include:
 Acute and chronic cognitive impairment
 Attention deficit disorder
 Anxiety
 Borderline personalities
 Depression
 Eating disorders/compulsivity
 Therefore, carefully consider Dual-Diagnosis when
assessing a client with Substance Aubse

17.  Plan
 Physiologic health and safety first – Prioritize
ABCs if applicable. Then move on to Psych/Soc
 Aim of psycho-social treatment is self
responsibility
 Match the types of treatment with client needs:
 “Fit” between client and resource
 Type/Severity of addiction
 Age
 Physiologic Health
 Neuropsychological Health
 Location/ length of program and ability of client to
attend
 Finances

18.  Implementation
 Safety During the Acute Phase of Detoxification
 Close Observation – 1:1, usually with a UAP (High risk
for seizures, delirium (psychosis), falls,
vomit/aspiration)
 +/- Restraints - review restraint video in ATI online
 Frequent VS assessment – rapidly changing condition
 Safe Environment – Bed low, No objects in the room
that patient could harm themselves with or throw
 Seizure Precautions – Padded side rails, tongue blade,
Oxygen, Suction, IV access, PRN orders for
antiepileptic drugs (usually Benzodiazepines)
 Low Sensory Stimulation (Visual, Auditory, Tactile)
 Provide for foods, fluids, elimination

19.  Self Help
 Step programs (AA, NA, GA, Al-Anon)
 Peer Driven, Faith Based
 Emphasize Self Responsibility
 Counseling
 Individual
 Educate – About addictions, treatment goals
 Cognitive behavioral therapy
 Emphasize Self-Responsibility
 Family
 Educate – About addictions, codependency, relapse
 Support groups
 Groups
 Clientswith similar diagnosis meet under the
supervision of a professional to discuss issues
 Inpatient or Outpatient

20.  Psychopharmacology
 Alcohol Withdraw
 Benzodiazepines – controls agitation and seizures
 Antiepileptics – Controls seizures
 Thiamine – Nutritional replacement
 Ensure IV access at all times
 Alcohol Abstinence
 Antabuse – Inhibits ETOH metabolism, Acetaldehyde
accumulates and causes serious illness
 Opioid
 Reversal Agent – Narcan (Action is immediate); No
concern if given and no narcotic on board
 Withdraw – Methadone, Buprenorphine (less side effects
than Methadone

21.  Increased time in abstinence
 Decreased denial
 Acceptable occupational functioning
 Improved family relationships
 Ability to relate to other individuals

22.  10-20% of practicing nurses are chemically dependent in
their personal lives
 Access to Controlled Substances presents
opportunity/temptation
 RN license is in jeopardy of suspension or revocation by
the Board of Nursing
 Signs
 Physical/Behavioral signs of impairment
 Work Absenteeism; Frequent breaks from the unit
 Missing Controlled Substances from the unit
 Abusers patients report poor pain control (abuser taking the
meds instead of administering)
 Abuser frequently offers to help other nurses and medicate
their patients (abuser takes the meds instead of administering)
 Co-worker’s Responsibilities:
 Document
 Report facts to immediate supervisor
 Confront your co-worker – that’s a good discussion