Psychoactive Substance Use Related Disorders

1. CHAPTER 16 Psychoactive Substance Use Related Disorders

2. Learning Objectives • Define drug abuse, dependence, tolerance and withdrawal • Identify and describe the signs and symptoms of intoxication and withdrawal from various psychoactive drugs • Discuss the management of acute withdrawal as well as long-term maintenance treatment • Discuss the various strategies of relapse prevention • Evaluate the success of treatment programme for a person recovering from substance abuse

3. Introduction • Psychoactive substances are the compounds that can alter a person’s state of mind. • Attitude and tolerance of society to substance use has affected the type of substance abused and the prevalence of substance abuse. • Alcohol is probably the oldest psychoactive substance (drug) abused.

4. Definition of Substance Abuse A maladaptive pattern of substance use leading to significant distress or impairment in personal, social, occupational area and legal and physical danger over a period of one year. World Health Organization (WHO)

5. Definitions • Substance dependence.Characterized by a typical drug-seeking behaviour which takes priority over every other thing in life despite the impairment in various areas and also the person develops tolerance to the drug abused or withdrawal phenomena in the absence of the drug.

6. Definitions (cont.) • Tolerance A state when higher and higher doses are required to achieve the desired effect. • Withdrawal A state when reduction in dose or stopping the drug leads to specific physical and psychological signs and symptoms. This usually occurs after a prolonged period of continued use.

7. Epidemiology 90% of adults drink alcohol, 25% smoke and 30–40% have lifetime use of one illegal drug. Onset of alcohol abuse is relatively later in women than in men. Incidence of alcohol abuse is four times more common in men than in women. Rates of alcoholism are very high in certain countries such as Russia, Australia and France and are low in Islamic countries such as Saudi Arabia.

8. Epidemiology (cont.) • Cannabis is the most commonly abused illegal drug but the use of opioids especially the intravenous use is on increase. • Though not illegal in its strict sense, nicotine is smoked by one thousand million people worldwide.

9. Comorbidity Psychiatric Comorbidity About 50% of people with severe psychiatric illness have a substance use disorder sometime in their lives. Abuse of psychoactive substances leads to worsening of other psychiatric disorders and vice versa.

10. Comorbidity (cont.) • The commonly seen psychiatric disorders in persons with psychoactive substance abuse include: • depressive disorder, schizophrenia, anxiety disorders, cognitive impairment disorders, personality disorders and attention deficit disorder. • The rate of suicide is 3–4 times higher in substance abusers than in the general population.

11. Comorbidity (cont.) Physical Comorbidity of Psychoactive Substance Abuse • Alcohol-related medical problems are most commonly seen: • Gastrointestinal problems • Central nervous system problems • Fetal alcohol syndrome • Drugs predispose users to respiratory problems. • Intravenous drugs have a higher incidence of infections and complications.

12. Aetiology • i. Biological Factors • Genetic: Children born to substance abusing parents show an increased rate of drug abuse and first-degree relatives of alcoholics show higher rates of risk for the disorder than the general population. • b. Neurochemical: The presence of benzodiazepine and opiate receptors in the brain may predispose one to anxiolytic drugs and opiates abuse respectively. An association between dopamine D2 receptor gene and alcoholism has been put forward.

13. Aetiology (cont.) ii. Psychological Factors • Rates of alcohol abuse are quite high in antisocial and borderline personality disorders while cocaine abuse is much higher in persons with narcissistic traits. • Low self-esteem, inflexibility, low frustration tolerance and hostility are some of the traits that predispose to substance abuse.

14. Aetiology (cont.) • Clients with chronic pain, insomnia, anxiety and depressive disorder often use benzodiazepines to get relief and are at high risk of abuse. • Learning theory views drug abuse as a learned behaviour wherein children imitate their parents’ drug abuse behaviour.

15. Aetiology (cont.) • iii. Sociocultural Factors • Easy availability, low restrictions and high tolerance of society for the drugs of abuse increase the prevalence of drug abuse. • Children of parents who smoke, drink or use other drugs are more prone to drug abuse. • Lack of emotional bond with parents, greater reliance on friends and staying away from home can predispose to drug abuse under the influence of peers.

16. Aetiology (cont.) • iv. Drug Factors • Certain properties of the drug itself may contribute to high abuse potential. Relief of anxiety (e.g. by opiates and benzodiazepines), alteration of perception (e.g. hallucinogens), relief of fatigue and heightened mental alertness (e.g. stimulants) are some of the properties that make these drugs favourite for abuse. • Drugs with faster onset and briefer action (e.g. cocaine) are also favoured for abuse.

17. Common Substances of Abuse • Alcohol • Illegal drugs (opiates, cannabis, stimulants) • Hallucinogens • Volatile substances • Prescription and OTC drugs • Nicotine • Caffeine

18. Nursing Assessment • Assessment of psychoactive substance abuse is often complicated by: • Polydrug abuse • Presence of comorbid psychiatric and physical illness • Assessment includes history of substance dependence and psychiatric disorders.

19. Nursing Assessment (cont.) • It is important to differentiate between abuse and dependence from the treatment point of view. • Physical examinations may be conducted to assess for the signs of substance abuse. • The nurse should look for signs of intoxication, withdrawal and overdose.

20. Imbalanced nutrition Deficient fluid volume Disturbed sleep pattern Self-care deficit Disturbed thought process Disturbed sensory perception Non-adherence to health care regimen Poor physical health Nursing Diagnoses for Substance Abuse

21. Nursing Diagnoses for Substance Abuse (cont.) Ineffective coping Dysfunctional family processes Impaired parenting Impaired social interactions Sexual dysfunction Risk for suicide Risk for other directed violence Chronic low self-esteem.

22. Stage Outcome Goals Acute withdrawal Consciousness - Is well oriented - Does not develop seizures Sensory perception - Describes the content of illusions and hallucinations - Able to correct misperceptions Fluid and nutrition level - Eats and drinks normally - No diarrhoea/vomiting - BP within normal range Nursing Outcome Criteria for Substance Abuse

23. Stage Outcome Goals Acute detoxification Motivation - Shows willingness to take treatment - Adheres to treatment regimen - Commits to control drug abuse Risk control - Acknowledges the consequences of drug abuse - Abstains from drug abuse - Discusses craving for the drug - Uses skills to control urges Nursing Outcome Criteria for Substance Abuse (cont.)

24. Stage Outcome Goals Maintenance Relapse prevention - Adheres to treatment regimen - Attends self-help groups regularly - Asks for help when needed Effective coping - Uses effective coping skills - Functions adequately in a family setting, society and at work - Maintains his job Nursing Outcome Criteria for Substance Abuse (cont.)

25. Planning and Implementation • Total abstinence is the ultimate aim. Various factors which help a person to remain abstinent include: • good physical health • absence of comorbid psychiatric illness • good interpersonal relationships • being employed • good social support

26. Intervention Strategies • All treatment programmes encourage self-control and self-responsibility. • The choice of inpatient or outpatient care depends upon the level of motivation, severity of withdrawal symptoms and available support system. • Severe withdrawal symptoms, associated malnutrition and medical problems and a possibility of complicated withdrawal would make the hospitalization mandatory.

27. Treatment of Comorbid PsychiatricDisorder (Dual Diagnosis) • Dual diagnosis is a common phenomenon rather than an exception. Comorbid psychiatric disorder should be identified carefully. • Both the substance use disorder and the psychiatric disorder are considered primary and should be treated simultaneously. • Both the disorders follow their own recovery pattern and recovery occurs in stages. So the outcome criteria must be appropriate and according to the diagnosis and individual needs.

28. Counselling • Various therapeutic approaches found effective in the treatment of such clients include: • i.cognitive-behaviour therapy • ii. interpersonal and psychodynamic therapies • iii. family therapy • iv. group therapy • In the initial stages including during detoxification, the client is given supportive psychotherapy to encourage him and to enhance his motivation.

29. Counselling (cont.) • The therapy focuses on abstinence and becoming comfortable with abstinence. • This phase may last for 6 months and the main focus is on the following issues: • Body’s reactions and adaptations to the absence of abused substance • Recognizing external and internal stimuli which promote substance abuse

30. Counselling (cont.) • Learning new coping skills to deal with the cues • ‘Saying no to drugs’ as a step to prevent relapse • Learning to deal with emotions underlying the substance abuse • Dealing with changes in interactions with family, friends and colleagues

31. Relapse Prevention • Substance abuse should be considered a disease and relapses are a common part of recovery process. • The client is helped to learn from each relapse and make more efforts to achieve longer periods of abstinence. Cognitive-behavioural approaches are simple and effective.

32. Self-Help Groups • All clients with substance abuse and their families should be encouraged to join these support groups. • Such groups provide counselling and support to deal with common issues. These groups use educational and operational principles to explain the drug abuse as a disease and various methods used to avoid drug-seeking behaviours.

33. Self-Help Groups (cont.) • Most of these self-help groups are based on the 12-step programme. • Examples of these groups are: • Alcoholics Anonymous (AA) • Narcotics Anonymous (NA)

34. Evaluation • Continuous monitoring and evaluation increases the chances for prolonged recovery. The success of treatment is judged by the following: • increased lengths of time in abstinence • improved occupational functioning • improved family and social relationships, decreased denial

35. Evaluation (cont.) • readiness to use the help of support groups when needed and • attending the self-help group meetings regularly.