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Substance Abuse Disorders

Substance use disorders, also identified as substance abuse, develop when a person’s use of alcohol or another substance such as drugs leads to health issues, disability, and or not adhering to responsibilities at home, work, or school. This disorder is also called drug addiction. In the last edition of the DSM, DSM-IV, there were two categories: substance abuse and substance dependence. DSM-5 merges these two categories into one called “substance use disorder.” Learn more about substance use disorders, its nursing care management, interventions, and assessment in this study guide.

What is Substance Abuse?

Substance use/abuse and related disorders are a national health problem.
  • Substance abuse can be defined as using a drug in a way that is inconsistent with medical or social norms and despite negative consequences.
  • Substance abuse disorders (SAD) are common chronic relapsing illness that are characterized by drug-seeking and drug-taking behaviors that persist despite negative consequences.
  • The DSM-IV-TR distinguishes substance abuse from dependence for purposes of medical diagnosis; substance abuse denotes problems in social, vocational, or legal areas of the person’s life, whereas substance dependence also includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance.
  • DSM-5 combines substance abuse and substance dependence into one called “substance use disorder.” It recognizes substance-related disorders resulting from the use of 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, and other hallucinogens, such as LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (including amphetamine-type substances, cocaine, and other stimulants); tobacco; and other or unknown substances.

Criteria

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria. The 11 DSM-5 criteria for a substance use disorder include:
  1. Took more extensive amounts/extended time. Using the substance in larger amounts or for longer than it’s meant to be.
  2. Repeated efforts to control use or quit. Wanting to cut down or stop using the substance but not succeeding.
  3. Full time spent using. Consuming a lot of time getting, using, or recovering from use of the substance.
  4. Craving. Desires and urges to use the substance.
  5. Disregarded major roles. Not accomplishing what is need to be done at work, home, or school because of substance use.
  6. Social or interpersonal dilemmas. Resuming to use even when it causes problems in relationships.
  7. Missed activities. Giving up significant social, occupational, or recreational activities because of substance use.
  8. Hazardous use. Using substances again and again even when it places the person in danger.
  9. Physical or psychological problems. Extending the use even if physical or psychological problems arise.
  10. Tolerance. Requiring more of the substance to get the effect the person desires.
  11. Withdrawal. Development of withdrawal symptoms, which can be alleviated by taking more of the substance.
In order to be diagnosed with a substance use disorder, the person must meet two or more of these criteria within a 12-month period. A person with a mild substance use disorder possesses two or three of the criteria. Four to five is considered moderate, and if the person has six or more criteria, he or she has a severe substance use disorder.

Causes

The exact causes of drug abuse, dependence, and addiction are not known, but various factors are thought to contribute to the development of substance-related disorders.
  • Biologic factors. Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are children of nonalcoholic parents.
  • Psychological factors. Children of alcoholics are four times as likely to develop alcoholism compared with the general population; some theorists believe that inconsistency in the parent’s behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse.
  • Social and environmental factors. Cultural factors, social attitudes, peer behaviors, laws, cost and availability all influence initial and continued use of substances.

Types and Symptoms

Each substance use disorder is classified as its own disorder. Here are the most common substance use disorders in the United States:
  • Alcohol. Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream; initially, the effects are relaxation and loss of inhibition; with intoxication, there is slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judgment.
  • Sedatives, hypnotics, and anxiolytics. This class of drugs includes all central nervous system depressants, barbiturates, nonbarbiturate hypnotics, and anxiolytics, particularly benzodiazepines; the effects of the drugs, symptoms of intoxication, and withdrawal symptoms are similar to those of alcohol.
  • Stimulants (amphetamines, cocaine). Stimulants are drugs that stimulate or excite the central nervous system; intoxication from stimulants develops rapidly; effects include the high or euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic or repetitive behavior, anger, fighting, and impaired judgment.
  • Cannabis (marijuana). Cannabis is the most widely used illicit substance in the United States; research has shown that cannabis has short-term effects of lowering intraocular pressure; symptoms of intoxication include impaired motor coordination, inappropriate laughter, impaired judgment, and short-term memory, and distortions of time and perception.
  • Opioids. Opioids are popular drugs of abuse because they desensitize the user to both physiologic and psychological pain and induce a sense of euphoria and well-being; opioid intoxication develops soon after the initial euphoric feeling; symptoms include apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory.
  • Hallucinogen. Hallucinogens are substances that distort the user’s perception of reality and produce symptoms similar to psychosis, including hallucinations and depersonalization; hallucinogen intoxication is marked by several maladaptive behavioral or psychological changes; anxiety, depression, paranoid ideation, ideas of reference, fear of losing one’s mind, and potentially dangerous behavior such as jumping out the window in the belief that one could fly.
  • Inhalants. Inhalants are a diverse group of drugs that includes anesthetics, nitrates, and organic solvents that are inhaled for their effects; the most common substances in this category are aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint; inhalant intoxication involves dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision.

Statistics and Incidences

The full spectrum of SADs represents one of the nation’s leading health problems.
  • In 2007, approximately 22.3 million adults were classified as having substance dependence or abuse disorders.
  • Among this population, an estimated 3.2 million were dependent on or abused both alcohol and illicit drugs, another 3.7 million were dependent on or abused drugs alone, and 15.5 million were dependent on or abused alcohol alone.
  • The rate of abuse and dependence was twice as high for males as it was for females (12.5 vs. 5.7%).
  • Illicit drug use among those aged 50 to 54 increased from 3.4% in 2002 to 5.7% in 2007.
  • The most popular illicit drugs in the 2007 survey were marijuana (3.9 million), pain relievers (1.7 million), and cocaine (1.6 million).

Assessment and Diagnostic Findings

Various diagnostic studies may also demonstrate evidence of SADs-related organ dysfunction.
  • PPD. A positive PPD is a frequent finding among substance abusers living in crowded conditions.
  • Hematology. Additional laboratory clues include mild anemia with macrocytosis, folate deficiency, thrombocytopenia, granulocytopenia, abnormal liver function tests, hyperuricemia, and elevated triglycerides.

Medical Management

Clients being treated for intoxication and withdrawal or detoxification are encountered in a wide variety of medical settings from emergency departments to outpatient clinics.
  • Alcoholics Anonymous (AA). Alcoholics Anonymous was founded in the 1930s by alcoholics; this self-help ground developed the 12-step program model for recovery, which is based on the philosophy that total abstinence is essential and that alcoholics need the help and support of others to maintain sobriety.

Pharmacologic Management

Pharmacologic treatment in substance abuse has two main purposes: to permit safe withdrawal from alcohol, sedative-hypnotics, and benzodiazepines and to prevent relapse.
  • Benzodiazepines. Alcohol withdrawal is usually managed with a benzodiazepine-anxiolytic agent, which is used to suppress the symptoms of abstinence.
  • Disulfiram. Disulfiram (Antabuse) may be prescribed to help deter clients from drinking.
  • Acamprosate. Acamprosate (Campral), may be prescribed for clients recovering from alcohol abuse or dependence to help reduce cravings for alcohol and decrease the physical and emotional discomfort that occurs especially in the first few months of recovery.
  • Methadone. Methadone, a potent synthetic opiate, is used as a substitute for heroin in some maintenance programs.
  • Levomethadyl. Levomethadyl is a narcotic analgesic whose only purpose is the treatment of opiate dependence.
  • Naltrexone. Naltrexone (ReVia) is an opioid antagonist often used to treat an overdose. It can also be used to treat alcohol abuse.

Nursing Management

Nursing care of a client with substance abuse disorder include the following:

Nursing Assessment

Assessment of a client with substance abuse disorder include:
  • History. Client with a parent or other family members with substance abuse problems may report a chaotic family life, although this is not always the case.
  • Thought process and content. During the assessment of thought process and content, clients are likely to minimize their substance abuse, blame others for their problems, and rationalize their behavior.
  • Sensorium and intellectual process. Clients generally are oriented and alert unless they are experiencing lingering effects of withdrawal.
  • General appearance and motor behavior. Assessment of general appearance and behavior usually reveals appearance and speech to be normal.
  • Self-concept. Clients generally have low self-esteem, which they may express directly or cover with grandiose behavior.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnosis for substance abuse are:
  • Risk for injury related to substance intoxication or withdrawal.
  • Ineffective denial related to underlying fears and anxieties.
  • Ineffective coping related to inadequate support system or coping skills.
  • Imbalance nutrition: less than body requirements related to drinking alcohol instead of eating nourishing food.
  • Chronic low self-esteem related to retarded ego development

Nursing Care Planning and Goals

Main Article: Nursing Diagnosis for Substance Abuse: 8 Care Plans

Treatment outcomes for clients with substance use may include the following:
  • The client will abstain from alcohol and drug use.
  • The client will express feelings openly and directly.
  • The client will verbalize acceptance of responsibility for his or her own behavior.
  • The client will practice nonchemical alternatives to deal with stress or difficult situations.
  • The client will establish an effective after-care plan.

Nursing Interventions

Nursing interventions for a client with substance abuse include:
  • Providing health teaching for client and family. Clients and family members need facts about the substance, its effects, and recovery.
  • Addressing family issues. Without support and help to understand and cope, many family members may develop substance abuse problems of their own, thus perpetuating the dysfunctional circle; treatment and support groups are available to address issues of family members.
  • Promoting coping skills. Nurses can encourage clients to identify problem areas in their lives and to explore the ways that substance use may have intensified those problems.

Evaluation

Goals are met as evidenced by:
  • The client was able to abstain from alcohol and drug use.
  • The client was able to express feelings openly and directly.
  • The client was able to verbalize acceptance of responsibility for his or her own behavior.
  • The client was able to practice nonchemical alternatives to deal with stress or difficult situations.
  • The client was able to establish an effective after-care plan.

Documentation Guidelines

Documentation in a client with substance abuse disorders include:
  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward the desired outcome.

Practice Quiz: Substance Abuse Disorders

Nursing practice questions for Substance Abuse Disorders. For more practice questions, visit our NCLEX practice questions page.

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1. Nurse James has observed a co-worker arriving to work drunk at least three times in the past month. Which action by Nurse James would best ensure client safety and obtain necessary assistance for the co-worker? A. Warn the co-worker that this practice is unsafe B. Report the coworker’s behavior to the appropriate supervisor C. Make general statements about safety issues at the next staff meeting D. Ignore the co worker’s behavior, and frequently assess the clients assigned to the co-worker 1. Answer: B. Report the coworker’s behavior to the appropriate supervisor.
  • Option B: The nurse is obligated by ethical considerations of client safety, as well as by nurse practice acts in many states, to report substance abuse in health care workers. Most healthcare facilities have an employee assistance program to help workers with substance abuse problems.
  • Option A: Warning the co-worker is inadequate; it does not ensure client safety or helps him receive necessary aid.
  • Option C: Making general statements about safety in a staff meeting avoids dealing with the problem.
  • Option D: Ignoring the co worker’s behavior would be a form of enabling behavior (codependency) on the staff nurse’s part.
2. Rachel is being treated in a chemical dependency unit. She tells the nurse that she only uses drugs when under stress and therefore does not have a substance problem. Which defense mechanism is the client using? A. Undoing B. Compensation C. Denial D. Suppression 2. Answer: C. Denial.
  • Option C: Individuals who have substance problems often use denial.
  • Options A, B, and D: Undoing, compensation, and suppression are incorrect and do not fit the situation described.
3. Nurse Chelsey is teaching a community group about substance abuse. She explains that a genetic component has been implicated in which of the following commonly abused substances? A. Heroin B. Alcohol C. Marijuana D. Barbiturates 3. Answer: B. Alcohol.
  • Option B: Several chromosomes (1, 3, and 7) have been implicated in increased vulnerability to alcohol abuse. Statistics have shown that risk for alcohol abuse in first-degree relatives of alcohol abusers is as high as 40% to 60%. Most of the genetic research has been done related to alcohol.
  • Options A, C, and D: Definitive data regarding genetic transmission is not available at this time for barbiturates, heroin, and marijuana.
4. Nurse Michael recommends that the family of a client with substance-related disorder attend a support group, such as Al-Anon and Alateen. The purpose of these groups is to help family members understand the problem and to: A. Maintain focus on changing their own behaviors B. Learn how to assist the abuser in getting help C. Prevent substance problems in vulnerable family members D. Change the problem behaviors of the abuser 4. Answer: A. Maintain focus on changing their own behaviors.
  • Option A: Family support groups, such as Al-Anon and Alateen, emphasize the importance of changing one’s own behavior rather than trying to change the behavior of the individual with a substance abuse problem.
  • Options B and D: Trying to change the abuser’s behavior or learning ways to find help for the abuser would be viewed as codependent behaviors, and thus would not be advocated by family support groups.
  • Option C: Learning about substance abuse may help a vulnerable family member to avoid this problem; however, that is not the purpose of these groups.
5. Nurse Christine is teaching a client about disulfiram (Antabuse), which the client is taking to deter his use of alcohol. She explains that using alcohol when taking this medication can result in: A. Increased pulse and blood pressure B. Abdominal cramps and diarrhea C. Drowsiness and decreased respiration D. Flushing, vomiting, and dizziness 5. Answer: D. Flushing, vomiting, and dizziness.
  • Option D: Disulfiram (Antabuse) prevents complete alcohol metabolism in the body. Therefore when alcohol is consumed, the client has a hypersensitivity reaction. Flushing, vomiting, and dizziness are associated with the incomplete breakdown of alcohol metabolites.
  • Options A, B, and C: Other choices are not associated with the use of disulfiram along with alcohol.

References and Sources

Sources and references for this study guide for substance abuse:
  • Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,.
  • Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins.
  • Sullivan, E. J. (2008). Nursing care of clients with substance abuse. Substance978, 0801678813.
  • Hoffman, A. L., & Heinemann, M. E. (1987). Substance abuse education in schools of nursing: A national survey. Journal of Nursing Education26(7), 282-287.

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