Ppt chapter 09-1

Chapter 9
Lifestyle: Substance Abuse
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
• The use of alcohol, tobacco products, and illicit drugs can
seriously complicate drug therapy.
– A. True
– B. False

Answer
• A. True
• Rationale: The use of alcohol, tobacco, and illicit
drugs affects the pharmacokinetics and
pharmacodynamics of concurrent drug therapy.

Overview
• Lifestyle, diet, and habits are core patient variables that
exert one of the most important effects on a patient’s
response to drug therapy.
• Substance abuse is the inappropriate and usually
excessive self-administration of a drug substance for
nonmedical purposes.
• Drug addiction is a complex process involving
interactions among the drug, the user, and society.

Dopamine Hypothesis
• Scientists are becoming increasingly convinced that a link
exists between the neurotransmitter dopamine and drugs
of abuse.
• Dopamine is associated with feelings of pleasure and
elation.
• Cocaine use stimulates a surge of dopamine in the
addict’s brain.
• Addiction may be a disorder of the brain no different from
other forms of mental illness.
• The major drugs of abuse mimic the structures of
neurotransmitters.

Factors that Affect Substance Abuse

Physiology
• The physiologic effects of drugs with a high potential for
abuse involve the body’s adaptation to the toxic effects of
the drugs at the biochemical and cellular levels.
• Several physiologic changes characterize this process:
tolerance, physical dependence, and psychological
dependence.
• It is important to note that tolerance or physical
dependence alone does not imply addiction.

Physiologic Changes
• Tolerance occurs when the body develops a natural
resistance to the drug’s physical or euphoric effects.
• Physical dependence occurs when actual changes in
body cells cause the body to “need” the drug for
homeostasis.
• Psychological dependence involves the compulsive
use of a drug. It results from the direct influence of drugs
on brain chemistry.

Question
• Cross-tolerance can occur between clonazepam
(Klonopin) and meperidine (Demerol).
– A. True
– B. False

Answer
• B. False
• Rationale: Cross-tolerance may occur within a drug
class, meaning that tolerance to a drug in a
particular class may be transferred to other drugs in
the same class. Clonazepam and meperidine are not
in the same class of drugs.

Factors Influencing Drug Abuse
• Genetic factors: Certain genes may predispose a person
to, or protect the person from, drug abuse.
• Developmental and environmental influences: They
can trigger changes in brain hormones, making a person
more at risk.
• Personality traits: No absolute addictive personality
has been identified.
– Risk traits: low tolerance for frustration, impulsivity,
manipulativeness, fears of failure, feelings of
inadequacy, resentment, hostility, and anger

Factors Influencing Drug Abuse (cont.)
• Mood disorders: They are more likely to cause
substance abuse.
• Availability of drugs: If the substance is more readily
available, abuse can occur.
• Drug diversion: It estimated to cost employers and
insurance companies $25 billion annually.
• Socioeconomic circumstances: People may use or
traffic drugs to escape harsh surroundings of poverty and
illiteracy and change their perceptions of reality.

Substance Abuse and the Central Nervous
System
• Virtually all abused drugs have some effect on the CNS.
• The excessive use, these drugs can have adverse effects
when their use leads to dependence.
• Commonly abused drugs that affect the CNS are
classified into five main categories:
– CNS depressants
– CNS stimulants (psychoactive drugs)
– Hallucinogens (psychedelic drugs)
– Cannabis
– Miscellaneous drugs

Central Nervous System Stimulants
• The most commonly abused CNS stimulants include
cocaine and the amphetamines.
• These CNS stimulants initially increase heart rate and
blood pressure, energize muscles, decrease appetite, and
cause some degree of mental and physical alertness.
• CNS stimulants produce feelings of self-confidence and
induce some degree of euphoria.
• All stimulant drugs pose a risk of both physical and
psychological dependence.
• As a general rule, intoxication with stimulant drugs is
more dangerous than withdrawal.

Central Nervous System Depressants
• CNS depressants decrease heart rate, respiration,
muscular coordination and energy and cause
constipation, depression, nausea, vomiting, physical
dependence.
• Commonly abused CNS depressants include sedative-hypnotics,
alcohol, barbiturates, and benzodiazepines.
• Alcoholism is the number one drug problem in America.
• Abrupt withdrawal from long-term use of sedative-hypnotic
drugs should never be attempted because
withdrawal symptoms are serious and potentially fatal.

Opioids
• Opioids are commonly prescribed to relieve pain,
suppress coughing, enhance anesthetic effect for surgery,
and relieve severe diarrhea.
• These narcotic drugs have a high potential for abuse and
are extremely addicting both physically and
psychologically.
• All opioids affect the CNS and cause cerebral changes,
mood changes, confusion, euphoria, and analgesia.
• Regular use of narcotics over several weeks usually
results in tolerance to the drug’s effects.
• Withdrawal effects from narcotics induce muscle pain,
nausea and vomiting, abdominal cramps, and diarrhea.

Tranquilizers
• Certain tranquilizing drugs, known as “date rape” drugs,
have made headlines. They are Rohypnol and gamma-hydroxybutyrate
(GHB).
• Rohypnol is 10 times more potent than diazepam
(Valium).
• Rohypnol induces slowing of psychomotor performance,
muscle relaxation, decreased blood pressure, sleepiness,
and amnesia.

Tranquilizers (cont.)
• Some of the adverse effects associated with use of
Rohypnol are drowsiness, headaches, memory
impairment, dizziness, nightmares, confusion, and
tremors.
• GHB is a powerful, rapidly acting CNS depressant.
• Produced naturally by the body in small amounts, the
physiologic function of GHB is unclear.

Hallucinogens
• Hallucinogenic drugs have pronounced mental and
emotional effects because they distort the way the brain
interprets sensory information.
• Included in this category are marijuana, mescaline,
psilocybin, lysergic acid diethylamide (LSD),
dimethyltryptamine (DMT), and phencyclidine
hydrochloride (PCP).
• These drugs can be inhaled, injected, or swallowed.
• They cause a long-lasting reduction in the brain’s supply
of serotonin and produce powerful psychic changes.

Inhalants
• The term “inhalants” refers to products that can be
abused by inhaling them through the nose or mouth to
achieve an intoxicating effect.
• Because they are easily accessible, inexpensive, and easy
to conceal, inhalants are some of the first substances
abused.
• Effects of inhalant use resemble alcohol inebriation.

Inhalants (cont.)
• The user initially experiences stimulation, a loss of
inhibition, and a distorted perception of reality and
spatial relations.
• After a few minutes, the senses become depressed, and a
sense of lethargy arises as the body attempts to stabilize
blood flow to the brain.
• Users also experience headaches, nausea, vomiting,
slurred speech, loss of coordination, and wheezing.

Designer Drugs
• These drugs are similar in chemical structure to existing
drugs and are developed with relative ease in illegal
laboratories.
• They are extremely potent, and when used
recreationally, they have addictive capabilities greater
than those of existing drugs.
• These drugs can destroys brain cells and much of
voluntary muscular movement.

Anabolic Androgenic Steroids
• Anabolic androgenic steroids are synthetic formulations of
the male hormone testosterone.
• The abuse of these drugs in men and women is
widespread to increase strength and enhance athletic
performance.
• Anabolic androgenic steroids also have a dramatic effect
on emotions and make the user feel more confident and
aggressive.
• Continued use of anabolic androgenic steroids may lead
to emotional instability, rage, depression, or psychosis.
• Serious health effects include sex hormone imbalances,
changes in secondary sexual characteristics, permanent
sterility, hepatic cancer, and myocardial infarction.

Commonly Abused Drugs
• Commonly abused drugs include alcohol, cocaine, heroin,
and marijuana.
• The nurse’s role in substance abuse involves having core
knowledge related to specific drugs and to abuse
prevention.
– Assess for potential or actual abuse.
– Formulate plan of care for the patient who is abusing
drugs or is at risk for abuse.

Pharmacokinetics of Alcohol Abuse
• Alcohol, known clinically as ethanol (ETOH), does not
require digestion before absorption.
• It is completely absorbed by the stomach and small
intestine within 2 hours of ingestion.
• The liver metabolizes alcohol by two different pathways.
• People with chronic alcoholism metabolize alcohol by way
of the MEOS, which causes damage to the liver cells.
• Alcohol is excreted in urine by the kidneys, in the breath
by the respiratory system, and in sweat by the skin.

Question
• Food in the stomach will _______ the effects of alcohol.
– A. Increase
– B. Decrease
– C. Have no effect

Answer
• B. Decrease
• Rationale: Food in the stomach decreases the effects
of alcohol, delays gastric emptying time, and retards
absorption from the small intestine.

Pharmacodynamics of Alcohol Abuse
• Alcohol affects many body systems.
• Alcohol is thought to interfere with the transmission of
nerve impulses.
• Alcohol sequentially depresses the CNS.

Adverse Effects of Alcohol Abuse
• Alcohol depresses the CNS.
• Alcohol impairs muscular coordination.
• It increases the heart rate and dilates the blood vessels.
• In low doses, alcohol lowers the blood pressure.
• Prolonged alcohol use causes hypertension and
cardiovascular damage.
• Alcohol irritates the gastrointestinal (GI) tract.
• Excess alcohol consumption inhibits antidiuretic hormone
and therefore increases urine production.

Alcohol: Drug Interactions
• Alcohol has no nutritional value, and it interferes with the
absorption of vitamins and minerals.
• Alcohol can affect iron absorption, folate activities, and
platelets.

Cocaine Abuse
• Cocaine is derived from the leaves of Erythroxylon coca.
• Cocaine is usually administered orally, intravenously, or
by nasal insufflation.
• Treatment for cocaine addiction is difficult because of the
extreme physical and psychological dependence
associated with its use.

Cocaine Abuse (cont.)
• Pharmacokinetics
– Cocaine is rapidly absorbed into the bloodstream.
– Onset, peak, and duration vary with route of
administration.
– Cocaine is extensively metabolized in the liver and
the blood.

Cocaine Abuse (cont.)
• Pharmacodynamics
– Cocaine has pronounced effects on the central and
peripheral nervous systems.
– It causes hypertension, tachycardia, and
vasoconstriction.
– It interferes with serotonin uptake and dopamine
reuptake.

Adverse Effects of Cocaine Abuse
• Adverse reactions to cocaine include the following:
– CNS: agitation, anxiety, excitement, paranoid
psychosis, and seizures
– Cardiovascular: atrioventricular arrhythmias, severe
hypertension, cardiomyopathy, coronary and peripheral
vasoconstriction
– Pulmonary: pneumothorax, pulmonary edema, and
respiratory arrest
– Metabolic: disseminated intravascular coagulation,
hepatotoxicity, hyperthermia, renal failure, and
rhabdomyolysis
– Complications of nasal inhalation: anosmia, nasal
mucosal atrophy, nasal septal necrosis, and rhinorrhea

Opioid Abuse
• Heroin is the most abused opioid in the United States.
• It is a synthetically manufactured drug that possesses
morphine-like pharmacologic activity.
• It has a poor oral availability; therefore, abusers often
begin by smoking the drug.
• Pure heroin is very expensive and dangerously powerful.

Opioid Abuse (cont.)
– The rate of heroin’s absorption by the bloodstream
depends on the method of administration.
– The effects of injected heroin persist for
approximately 4 to 6 hours.
– Most heroin is converted to morphine and excreted
by the kidneys.

Opioid Abuse (cont.)
– Heroin acts on the body in a manner similar to that
of other opioids.
– The abuser feels relaxed, carefree, and somewhat
dreamy.

Adverse Effects of Opioid Abuse
• The pathophysiologic effects of heroin are similar to
those of other opioids.
• An overdose of heroin may result in severe respiratory
depression, pulmonary edema, coma, and possibly death.
• Some pathophysiologic effects specific to IV heroin use
include infection with human immunodeficiency virus
(HIV) or hepatitis.

Marijuana Abuse
• The most commonly abused psychedelic drug is
marijuana.
• The major ingredient of marijuana is 9-
tetrahydrocannabinol (THC).
• The THC concentration in the average marijuana
cigarette has increased substantially during the past 3
decades.
• A typical marijuana cigarette delivers a dose of THC
ranging from 2.5 mg to 5 mg.

Marijuana Abuse (cont.)
• Pharmacotherapeutics
– An oral form of marijuana is used for anorexia,
nausea, and vomiting.
– The systemic availability is based on the route of
administration.
– THC is metabolized in the liver and excreted by the
kidneys.

Marijuana Abuse (cont.)
– The mechanism of action of THC is unknown, but it
does have antiemetic properties.
– THC produces minor cognitive effects.

Adverse Effects of Marijuana Abuse
• Some of the adverse effects of THC include decreased
myocardial oxygen supply, increased heart rate, and
impaired fertility.
• Cannabinoid receptors are concentrated most heavily in
the cerebellum and hippocampus.
• Although smoking marijuana is often thought to be
relatively safe compared with smoking tobacco, the
smoke is virtually identical in both cases.
• Tolerance to the effects of marijuana develops quite
slowly.

Hallucinogen Abuse
• Although often associated with the 1960s, LSD and PCP
are still used.
• LSD is taken orally, and PCP can be taken orally,
smoked, or injected.
• Tolerance develops with continued use of these drugs.
• No specific withdrawal syndrome is associated with these
drugs.

Hallucinogen Abuse (Cont.)
– Dependent on the route and dosage of the drug
– PCP is rapidly metabolized in the liver and excreted
in the kidneys.
– The mechanism of action is unclear.
– Alterations in sensory perception occur.
– Sensory input is also enhanced.

Adverse Effects of Hallucinogen Abuse
• Subjective effects and mood changes are quite variable
with LSD.
• LSD produces adrenergic effects: hypertension,
hyperpnea, tachycardia, hyperthermia, pupillary dilation,
and hyperreflexia.
• Diaphoresis, salivation, lacrimation, nausea, and
vomiting may also occur.
• Dopaminergic and anticholinergic effects on the body
occur with PCP use.
• PCP can cause severe psychoses, seizures, respiratory
depression, intracerebral hemorrhage, hyperpyrexia,
and death.

Inhalant Abuse
• Inhalants are volatile chemicals and gases that produce
behavioral effects.
• Commonly abused inhalants include model glue, spray
paint and hair spray propellants, cleaning solvents,
gasoline, and kerosene.
• Long-term inhalant abuse can cause permanent CNS,
hepatic, renal, and bone marrow damage.

Inhalant Abuse (cont.)
– Inhalants are rapid-acting substances.
– The duration of the effect depends on the substance
used.
– Inhaling volatile chemicals and gases produces a
short-lived, mild intoxication.
– These agents produce a sense of exhilaration and
light-headedness.

Adverse Effects of Inhalant Abuse
• Psychological dependence can develop, but physical
dependence is rare.
• Tolerance to the substance can develop over time.
• Toxicities depend on the properties of the individual
solvents.
• Abuse of inhalants has been implicated in severe brain
damage, cancer, neuropathies, kidney failure, liver
damage, respiratory failure, and cardiac arrest.

Health Status
• When the nurse suspects that a patient may be abusing
substances, a physical, psychological, and functional
health assessment is performed.
• Substance abuse screening may be easily incorporated
into a health habits survey.
• At this time, also ask the patient about any family history
of substance abuse.
• During the physical assessment, convey a nonjudgmental
attitude, which may encourage the patient to
communicate.

Life Span
• Pregnancy
– An estimated 10% of infants are exposed to illicit
drugs during the gestational period.
– Drug use and abuse during pregnancy have been
linked to several maternal and fetal complications.
• Infancy
– Exposure to drugs can cause problems at birth and
for the first 3 to 4 months of life.
• Childhood
– Prenatal alcohol exposure can lead to cognitive
deficits and behavior problems.

Life Span (cont.)
• Adolescence
– The greatest physical and emotional changes occur
during adolescence, which can lead to substance
abuse.
• Older Adulthood
– Changes that occur in older adults may put them at
risk for substance abuse.
– Substance abuse may be difficult to recognize due to
chronic medical conditions.

Environment and Culture
• Environment
– Former substance abusers are at risk for relapse.
– Environmental triggers may produce intense desire
for the drug even after years of recovery.
• Culture
– Some populations exhibit an unusual response after
consuming ethanol.
– These people have a genetic deficiency that leads to
an accumulation of ethanol.

Nursing Diagnoses and Outcomes
• Ineffective Denial related to impaired ability to accept
consequences of behavior
– Desired outcome: The patient will acknowledge an
alcohol or substance abuse problem.
• Risk for Other-Directed Violence related to drug or
alcohol abuse
– Desired outcome: The patient will demonstrate
control of behavior with assistance from others.

Nursing Diagnoses and Outcomes (cont.)
• Ineffective Health Maintenance related to substance
abuse
– Desired outcome: The patient will identify barriers
to health maintenance.
• Self-Concept Disturbance related to self-destructive
behavior (substance abuse)
– Desired outcome: The patient will appraise self-situations
in a realistic manner.

Maximizing Recovery
• Initial nursing interventions in acutely intoxicated
patients are generally directed toward preventing life-threatening
and debilitating effects.
• These nursing interventions evolve from the specific
physiologic and psychological effects of the particular
substance.
• Physical or psychological withdrawal symptoms may
follow abrupt cessation of a substance.
• Physiologic symptoms associated with drug withdrawal
may be treated with various pharmacotherapies.

Minimizing Relapse
• For alcohol, cocaine, or narcotic abusers, treatment is
lifelong, and relapses do occur.
• Psychotherapy, support groups, and administration of
withdrawal and anticraving drugs may help prevent
relapse.

Providing Patient and Family Education
• After identifying a substance abuse problem, intervene
by assisting the patient and family to develop ways to
prevent substance abuse.
• Help family members identify their feelings and
responses to the substance abuse problem and cope with
these feelings.
• This is also an opportune time to teach the family more
about the hazards of substance abuse.

Ongoing Assessment and Evaluation
• Health consequences of substance abuse are usually
manifested by changes in physiologic and behavioral
functioning.
• Nurses and other health care professionals have a
community responsibility to provide information about
substance abuse.
• Recovery is lifelong and requires total abstinence from
the abused substance.

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