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Course: Mental Health Nursing

Topic: Substance Related Disorders and Addictive Behavior

The Nurses International Community

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Module Goals

Learners will be able to:

Define substance related disorders and addictive behaviors.
Identify the clinical manifestations of substance related and addictive disorders.
Discuss the pharmacological indications for the substance related disorders and addictive disorders.
Identify the appropriate nursing interventions for substance related and addictive disorders.

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Substance and Substance Misuse:

“Substance” is any psychoactive compound with the potential to cause health and social problems, including addiction.”

These substances may be legal (e.g., alcohol and tobacco); illegal (e.g., heroin and cocaine); or controlled for use by licensed prescribers for medical purposes such as hydrocodone or oxycodone (e.g., Oxycontin, Vicodin, and Lortab)

McLellan , 2017

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Substance and Substance Misuse:

Substance Misuse:

Defined as using any legal, illegal, or controlled substances inappropriately. May cause health or social problems — immediately or over time.

McLellan , 2017

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Substance Use Disorder:

Mental health disorder that leads to inability to control the use of legal or illegal drugs, substance, medications including: Alcohol, nicotine, marijuana, barbiturates, Cocaine etc.

Disorders range from mild and temporary to severe, and chronic.

The frequency and dose of addictive substances increases to maintain the same effect despite its harmful effect.

National Institute of Mental Health, 2021

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Substance Use Disorder

Symptoms may be mild to severe (depending on the severity).
Often present with other mental disorders.
Common co-occurring disorders: Anxiety disorders, depression, bipolar disorders, schizophrenia.
Use may begin at different stages of life.
Risk factors: Genetics, drug action, peer pressure, emotional distress, anxiety, depression, and environmental stress.
Risk of addiction depends on the type of substance.
Craving and withdrawal symptoms associated with dependency.

MedlinePlus, 2020

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What Would a Nurse Do?

A teenager tells a school nurse that he thinks that drinking alcohol is not substance abuse because it is legal and widely used in their community for recreation and relieving the stress of a day.

What responses by the nurse would help to give the teenager a more realistic (evidenced based) perception of alcohol and misuse.

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Substance Use Disorder: Diagnostic Criteria

Individuals who meet two or more of the following criteria within a 12-months period are considered to have substance use disorder:

Inability to control use of the substance
Becomes socially impaired
Use of the substance in physically dangerous situations (while driving)
Physical signs of use and/or dependence

Note: The severity of the substance use disorder is determined by the number of criteria met

Khan, 2020

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Substance Use Disorder: Diagnostic Criteria

Criteria:

Inability to control use
Social Impairments
Risky Use
Physical symptoms: Tolerance, Withdrawal

The severity of the substance use disorder is determined by the number of criteria met.

Khan, 2020

Image by: Wannapik

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According to Khan, 2020 (Merk Manual),

Criteria for diagnosis:

Inability to control use: Takes larger amount for a longer period of time, craves for the substance, spends a lot of time obtaining, using, or recovering from the effects of the substance.

Social impairment: A person with substance use frequently fails to meet the role, responsibility or obligation in the work area, personal life or academics. The person does not hesitates to continue to use despite of social or interpersonal problems. Ultimately the person gives up important works, or reduces the social interactions, occupational or recreational activities.

Risky use: A person with substance use tend to lead a very risky life, has to face physically hazardous situations (eg, when driving or in dangerous social circumstances).

Physical symptoms: A person may develop physical symptoms like

Tolerance towards a specific substance and has to increase amount and frequency to get the desired effect.

Other symptoms could be withdrawal where a person experiences an unpleasant sensation/symptoms if the intake is stopped.

Note: People who have 2 or more of these criteria within a 12-month period are considered to have a substance use disorder. The severity of the substance use disorder is determined by the number of criteria met:

Mild: 2 to 3 criteria
Moderate: 4 to 5 criteria
Severe: ≥ 6 criteria

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Specific Substance and Substance Types:

National Survey on Drug Use and Health (NSDUH) Module

Tobacco
Alcohol
Marijuana
Cocaine
‘Crack’
Heroin

Substance Abuse and Mental Health Services Administration, 2016

Hallucinogens
Inhalants
Prescription pain relievers
Tranquilizers
Stimulants
Sedatives

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Specific Substance Use Disorder Classified by NSDUH

Alcohol Use Disorder
Caffeine Use Disorder
Cannabis Use disorder
Phencyclidine Use Disorder and Other Hallucinogen Use Disorder
Inhalant Use Disorder
Opioid Use Disorder
Sedative, Hypnotic, or Anxiolytic Use Disorder
Stimulant Use Disorder
Tobacco Use Disorder

Substance Abuse and Mental Health Services Administration, 2016

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Classes of Substances Based on the Pharmacological and Behaviour Effects

Nicotine: Cigarettes, vapor-cigarettes, cigars, chewing tobacco, and snuff.
Alcohol: Including all forms of beer, wine, and distilled liquors.
Depressants: Benzodiazepines (e.g., Valium, Librium, and Xanax) and Barbiturates (e.g., Seconal).
Opioids: Heroin, methadone, buprenorphine, Oxycodone, Vicodin, and Lortab.

McLellan , 2017

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Nicotine: Nicotine is the chemical found in substances like tobacco, cigarette, vapor-cigarettes that produces pleasing effect in our brain. Though the effects are temporary, it makes hard to quit.
Alcohol: Alcohol is classed as a ‘sedative hypnotic’ drug that can depress the central nervous system at high doses and can act as stimulant at lower dose. It induces the feelings of euphoria and talkativeness, but drinking too much alcohol at one session can lead to drowsiness, respiratory depression, coma or even death. It is found in all forms of beer, wine and distilled liquors (Alcohol, n.d.)
Depressants: Depressants cause drowsiness and reduce anxiety. They include alcohol, barbiturates, benzodiazepines (Valium, Ativan, Xanax), chloral hydrate, and paraldehyde. Using these substances can lead to addiction.(MedlinePlus, 2020)
Opiates and other narcotics: are powerful painkillers that can cause drowsiness, and sometimes intense feelings of well-being, elation, happiness, excitement, and joy. These include heroin, opium, codeine, and narcotic pain medicines that may be prescribed by a doctor or bought illegally.

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Class of Substance Based on the Pharmacological

and Behaviour Effects

Cannabinoids: Marijuana, hashish, hash oil, and edible cannabinoids.
Stimulants: Cocaine, amphetamine, methamphetamine, methylphenidate (e.g., Ritalin), and atomoxetine (e.g., Strattera).
Hallucinogens: LSD, mescaline, and MDMA (e.g., Ecstasy).

McLellan , 2017

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Case Study

Mary, is a 34 year old woman who suffers from anxiety since adolescence. She began drinking alcohol after her husband died two years ago. Her family is concerned that she is drinking more often and is often “drunk” in the mornings. Mary is annoyed at her family and says that she can stop drinking any time she wants. However, her daughter said she tried several times in the past and was unsuccessful.

Identify Mary’s risk factors for addiction.

What symptoms does Mary display that indicate she suffering from addiction?

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Risk Factors of Substance Use Disorders

Environmental risk: Easy access to inexpensive alcohol and other substances, heavy advertisement, low parental monitoring, and high levels of family conflict.
Personal level risk: Family history of substance use or mental disorders, current mental health problem, low performance at the school, history of abuse and neglect, family conflict, violence.
Peer Pressure and curiosity of drugs/substance use among young population.

McLellan ,2017

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Clinical Manifestation of Substance Use Disorder

Behavioral Changes:

Drop in attendance and performance at work or school.
Frequently getting into trouble (fights, accidents, risky behaviour).
Engaging in secretive or suspicious behaviors.
Changes in appetite or sleep patterns.
Unexplained change in personality or attitude.
Sudden mood swings, irritability, or angry outbursts.
Periods of unusual hyperactivity, agitation, or giddiness.
Lack of motivation.
Appearing fearful, anxious, or paranoid, with no reason.

MentalHealth.gov, 2019

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Clinical Manifestation of Substance Use Disorder: General

Physical changes:

Bloodshot eyes and abnormally sized pupils.
Sudden weight loss or weight gain.
Deterioration of physical appearance.
Unusual smells on breath, body, or clothing.
Tremors, slurred speech, or impaired coordination.

MentalHealth.gov, 2019

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Clinical Manifestation of Substance Use Disorder:

General

Social changes:

Sudden change in friends, favorite hangouts, and hobbies.
Legal problems related to substance use.
Unexplained need for money or financial problems.
Using substances even though it causes problems in relationships.

MentalHealth.gov, 2019

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What Would the Nurse Do?

As a school nurse you were asked by a teacher to see Mark, a 16 year old male student who is falling asleep in class and has the smell of alcohol on his breath.

What are some things you would want to know about this student to help determine if he has an addiction problem?

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Diagnosis and Treatment

Accurate diagnosis may be challenging due to overlapping symptoms.
Has to be treated along with co-occuring mental disorders.
Treatment may include behavioral therapies and medications.
Healthcare providers decide the best alternative and method of treatment.

National Institute of Mental Health, 2021

�Image by: Pixabay

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Treatment: Behavioural Therapies

Cognitive Behavioral Therapy (CBT)
Dialectical Behavior Therapy (DBT)
Assertive Community Treatment (ACT)
Therapeutic Communities (TC)
Contingency Management (CM)

National Institute of Mental Health, 2021

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Behavioral Therapies

Research has found several behavioral therapies that have promise for treating individuals with co-occurring substance use and mental disorders. Health care providers may recommend behavioral therapies alone or in combination with medications.

Some examples of effective behavioral therapies for adults with SUDs and different co-occurring mental disorders include the following:

Cognitive Behavioral Therapy (CBT): CBT is a type of talk therapy aimed at helping people learn how to cope with difficult situations by challenging irrational thoughts and changing behaviors.
Dialectical Behavior Therapy (DBT): DBT uses concepts of mindfulness and acceptance or being aware of and attentive to the current situation and emotional state. DBT also teaches skills that can help control intense emotions, reduce self-destructive behaviors (e.g., suicide attempts, thoughts, or urges; self-harm; and drug use), and improve relationships.
Assertive Community Treatment (ACT): This is a form of community-based mental health care that emphasizes outreach to the community and an individualized treatment approach.
Therapeutic Communities (TC): TCs are a common form of long-term residential treatment that focuses on helping people develop new and healthier values, attitudes, and behaviors.
Contingency Management (CM): CM principles encourage healthy behaviors by offering vouchers or rewards for desired behaviors.

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Behavioural Therapies for Children and Adolescents

Brief Strategic Family Therapy (BSFT): Targets family interactions thought to maintain or worsen adolescent SUDs and other co-occurring problem behaviors.
Multidimensional Family Therapy (MDFT): Works with the whole family to address multiple adolescent problem/ behaviors, such as substance use, mental disorders, school problems, delinquency, and others.
Multisystemic Therapy (MST): Targets key factors associated with serious antisocial behavior in children and adolescents with SUDs.

National Institute of Mental Health, 2021

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Medication:

The use of medications play a major role in preventing relapse and facilitating longer periods of abstinence.
Medications are mostly used as adjuncts to psychosocial treatments
Pharmacological agents have three broad objectives:

Management of acute withdrawal syndromes through detoxification
Attenuation of cravings and urges to use illicit drugs (initial recovery), and
Prevention of relapse to compulsive drug use

Douaihy et al., 2013

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Medication:

For Withdrawal Syndromes, Recovery and Relapse Prevention

Nicotine: Transdermal nicotine patch, nicotine gum, nicotine lozenge, nicotine vapor inhaler, and nicotine nasal spray.
Alcohol: Benzodiazepines, Disulfiram, Naltrexone, Acamprosate, Topiramate.
Opioids: Methadone, buprenorphine, Suboxone.
Cannabis: Anti Anxiety medications.
Combination therapy.

Douaihy et al., 2013

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Nicotine: Approved formulations include the transdermal nicotine patch, nicotine gum, nicotine lozenge, nicotine vapor inhaler, and nicotine nasal spray. Behavioral therapies used in conjunction with an nicotine replacement therapy increase quit rates.

Alcohol: Medications for alcohol withdrawal syndromes include benzodiazepines that act on gamma-aminobutyric acid (GABA) at the GABA (A) receptors in the brain to stimulate release of GABA. GABA is a neurotransmitter that is responsible for decreasing activity throughout the nervous system and acts to gradually detoxify the client from alcohol by reducing heart rate, blood pressure, sweating, and anxiety associated with alcohol withdrawal.

Disulfiram (Antabuse) is the first FDA-approved medication for alcohol dependence and has been available for over 50 years.
Naltrexone (Revia) is a good example of an anti-craving medication for the long-term treatment of alcohol dependence.
Acamprosate (Campral) was approved in 2004 by the FDA as a relapse-prevention medication for alcohol dependence.
Topiramate was found to be more effective than placebo for reducing heavy drinking, drinks per drinking day, and increasing percent of abstinent days

Opioids:

In the case of opioids, methadone and buprenorphine are the most commonly used medications.

Once stabilized on methadone individuals who are addicted to opiates who use short-acting opioids such as heroin will no longer experience peaks of euphoria or the aversive effects of withdrawal such as anxiety, agitation, diarrhea, and insomnia. As a result, the client is no longer preoccupied with drug-seeking behaviors. Maintaining the client on methadone reduces criminal activity substantially and transferring the client from intravenous heroin use to an oral medication

The combination of buprenorphine with naloxone thereby reduces the risk of it being abused. Suboxone has become the treatment of choice for detoxification from opioids

The action of naltrexone to block dopamine makes it a potential alternative to opiate replacement treatment for opioid dependence.

Cannabis: Anti Anxiety medication buspirone has been found to be helpful for reducing cannabis dependence in one clinical trial

A dopamine agonist medication modafinil that is a weak stimulant has been found to be effective against cocaine cravings and has little potential for abuse

Dronabinol has shown some effectiveness for reducing cravings for cannabis and, therefore, may be of benefit against cannabis dependence.

Combination therapy:

Given the nonspecific pharmacodynamics properties of alcohol and other drugs, and their effects involving multiple neurotransmitters, it would make sense that a combination of medications might be necessary and helpful to optimize treatment outcomes. Moreover, within a particular setting, medications could theoretically be combined to target multiple processes that drive the addiction cycle. For example, relapse prevention medications that reduce cravings for alcohol (i.e., naltrexone) could be combined with those that reduce withdrawal symptoms (i.e., acamprosate). Another combination is disulfiram and naltrexone that might be used during the stabilization phase of recovery, after detoxification. For tobacco addiction, nicotine withdrawal could be addressed using a nicotine patch and acute exacerbations of cravings and urges by nicotine gums or lozenges. Some of these strategies could be sequenced depending on the drug’s mechanisms of action, client preference, insurance coverage issues, and costs. Most important is to discuss treatment options with the clients and tailor them to the clients’ needs.

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Critical Thinking Question

The student Mark, shares with the school nurse that he can’t seem to make friends since he moved to this new school a year ago. He has become friends with a few boys recently who like to drink beer and have encouraged Mark to drink with them. Mark says he really doesn't like them very much and thinks that he would like to change things in his life to feel better but doesn’t know what to do.

The nurse requests a meeting with Mark and his family and the school counselor. What type of behavioral therapy would the nurse expect that would be most helpful for Mark?

Explain your answer.

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Nurse’s Role in Substance Related

and Addictive Behavior

Ensure intoxication is diagnosed accurately.
Develop a professional relationship.
Provide safe environment.
Ensure safety of self, client, and others.
Promote healthy lifestyles.
Promote social networking and support system.
Support.

State of Queensland, 2010

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Ensure intoxication is the accurate diagnosis for the person’s condition establishing the type and quantity of the substance(s) consumed and when they last consumed these substances. Assess for potential withdrawal symptoms and manage these withdrawal symptoms (if applicable) following established local and state protocols.
Develop a relationship with the person based on empathy and trust.
Provide a safe environment for the person and ensure they remain free from injury.
Ensure the safety of one’s self, other staff and other people.
Once the person is no longer intoxicated, promote healthy lifestyle behaviours and establish interest in addressing any issues, thoughts or situations that may cause drug and/or alcohol use.
Ensure the goals for addressing substance use are included on care plans and other relevant service providers are involved.
Promote the person’s engagement with their social and support network.
Ensure effective collaboration with other relevant service providers, through development of effective working relationships and communication.
Support and promote access to relevant information, support and self-care activities for families and carers of the person who is intoxicated.

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Guidelines for Responding to a Person Who is Intoxicated

Be accepting and non judgemental.
Treat the client with respect.
Speak slowly and give information clearly.
Provide a safe environment.
Watch for suicidal behaviour.
Prevent risk of falls, confusion and delirium in older clients.
Treat the clinical symptoms as per protocol.

State of Queensland, 2010

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Guidelines for responding to a person who is intoxicated

Be accepting and non-judgmental. This will provide the first step to engage with the person.
Treat intoxicated people with respect.
Speak slowly and simply and give information clearly.
Move them to a quiet place if possible.
Observe for suicidal behaviour both while the person is intoxicated and if withdrawing. Increased impulsivity, the physical symptoms of withdrawal and the disinhibition produced by intoxication can heighten the risk of self-harm.
Be aware that for older people with medications (including sedatives such as benzodiazepines) there is an increased risk of falls, confusion and delirium.
The person may have clinical symptoms of overdose, intoxication or withdrawal and may be responding to hallucinations or delusions that place the person and the carers at risk of injury. The person may also be experiencing delirium or dementia.

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Nurse’s Interventions in Substance

Related and Addictive Behavior

Be consistent.
Be realistic and examine own expectations.
Be empathetic about the individual’s view of life without substances.
Set limits on needy or demanding behaviors.
Provide information about intoxication and recovery.
Understand the client’s cultural background.

State of Queensland, 2010

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Ensure a consistent approach based on the above principle. If you repeatedly dismiss or fail to respond to the person’s requests, you may contribute to high levels of frustration that result in arguments, threatening behaviours and seeking of drugs from other sources.
Examine your own expectations. This can clarify your own feelings, beliefs, attitudes and responses to people who are intoxicated.
Be realistic about your expectations. Accept that the person will need repeated intervention over a long period. Substance use disorders are often chronic relapsing conditions.
Try to empathise with the person’s view of life without substances. The factors maintaining substance use in those with mental disorders are complex. People may self-medicate for lots of reasons, including past abuse or trauma and major mental disorders (such as psychosis or depression). Substance abuse should be considered a comorbid issue for some people with a mental illness and appropriate assessment and integrated treatment for both problems should be obtained.
Be prepared to set limits on needy or demanding behaviour. Encourage honesty and challenge manipulative behaviour. Do not ‘give in’ to unreasonable demands or behaviour, as this can promote denial.
Ensure referral to an appropriate drug and alcohol or mental health service is made and ensure the consumer is linked into the appropriate service. Consider child protection issues and report or refer these as indicated.
Provide family members and carers with information about intoxication, substance use problems and dual diagnosis, if appropriate, as well as reassure and validate their experiences with the person. Encourage family members and carers to look after themselves and seek support if required.
A person’s cultural background is important in understanding the context of their drug or alcohol use. It is essential to take this into account when formulating diagnosis and care plans.

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Red Flags

Behaviors noted by the nurse in the clinic or school or by family and friends.
Loss of interests, activities, friends.
Financial problems: may ask to borrow money.
Impulsiveness.
Violence.
Presence of physical, behavioural and emotional symptoms of substance use.
Behavior problems at school.

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Cultural Considerations

Sociocultural beliefs can shape behavior regarding substance use and abuse.

There are certain communities in Nepal where alcohol is worshipped and considered a blessings from the ancestors.
Canada has legalized the recreational use of Cannabis in October, 2018 (Government of Canada, 2021).
Ireland passed sweeping legislation to curb use of alcohol in its country (HRB National Drug Library, 2018).
Oregon became the first state to decriminalize small amounts of cocaine, heroin, methamphetamine and other drugs (New York Times, 2020).

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References:

Alcohol. (n.d.). Alcohol and its effects: What is alcohol. https://www.alcohol.org.nz/alcohol-its-effects/about-alcohol/what-is-alcohol

American Psychiatrist Association. (n.d). FAQs: What is DSM and why it is important. https://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questions

Douaihy, A. B., Kelly, T. M., & Sullivan, C. (2013). Medications for substance use disorders. Social work in public health, 28(3-4), 264–278. https://doi.org/10.1080/19371918.2013.759031

Government of Canada. (2021). Cannabis Law and Regulations: Cannabis Legalization and Regulation. https://www.justice.gc.ca/eng/cj-jp/cannabis/

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References:

Health Research Board National drug library.(2018). Public Health (Alcohol) Act 2018. https://www.drugsandalcohol.ie/31446/

Khan, M. (2020). Mental health disorders: Substance Use Disorders. https://www.msdmanuals.com/home/mental-health-disorders/substance-related-disorders/substance-use-disorders

McLellan A. T. (2017). Substance Misuse and Substance use Disorders: Why do they Matter in Healthcare?. Transactions of the American Clinical and Climatological Association, 128, 112–130.

MedlinePlus. (October 5, 2020). Substance Use Disorder. https://medlineplus.gov/ency/article/001522.htm

MentalHealth.gov. (2019). Mental Health and Substance Use Disorders. https://www.mentalhealth.gov/what-to-look-for/mental-health-substance-use-disorders

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References:

National Institute of Mental Health. (March, 2021). Mental Health Information: Substance Use and Co-Occurring Mental Disorders. https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health

National centre for Complementary and Integrative Health. (2019). Cannabis (Marijuana) and Cannabinoids: What You Need To Know. https://www.nccih.nih.gov/health/cannabis-marijuana-and-cannabinoids-what-you-need-to-know

State of Queensland (Queensland Health). (2010). Queensland Mind Essentials: Mental Illness Nursing Documents. https://www.health.qld.gov.au/__data/assets/pdf_file/0029/444773/mindessentialsfinal.pdf

Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. 2, Substance Use Disorders. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519702/

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