Updated

1. Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Substance-Related Disorders

2. 2Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Substance Use
 Substance abuse is a maladaptive response
to stress affecting relationships at any age
 Leads to failure to meet role obligations at home,
work, school, or in recreational activities
 Creates hazardous situations, legal problems

3. 3Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Alcohol and Drug Use
 Excessive use contributes to profound individual
and social problems
 ANY substance that produces pleasurable brain
changes can be abused
 Legal drugs (alcohol, prescription drugs)
 Illegal drugs (heroin, cocaine, marijuana)
 Household products (inhalants)

4. 4Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Definition of Terms
 Substance use disorder: is used to describe the
wide range of the disorder, from a mild form to a
severe state of chronically relapsing, compulsive drug
taking. There are 10 separate classes of drugs.
Gambling disorder is also included in addition to
these 10.
 Substance-Induced Disorders: includes
intoxication, withdrawal, and other
substance/medication induced mental disorders (eg.
Substance induced psychotic disorder, substance
induced depressive disorder)

5. 5Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Definition of Terms
Intoxication: the essential feature is the development of a
reversible substance-specific syndrome due to the recent ingestion
of a substance. (eg. Belligerence, mood lability, and impaired
judgement.)
Withdrawal symptoms: effects resulting from physiological need
when the body adapts to a drug. Uncomfortable and can be fatal.
Most individuals with withdrawal have an urge to re-administer the
substance to reduce the symptoms.
Tolerance: with continued use, more of the substance is needed
to produce the same effect

6. 6Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Attitudes
 Affected by social and cultural norms
 Laws becoming tougher for driving while intoxicated
(DWI) or driving under the influence (DUI) offenses
 Most people with substance use disorders do not
seek treatment
 Patients may try to hide or minimize substance use
history and are often not diagnosed for substance
use disorder as a result.

7. 7Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Prevalence of Substance Use
Disorders
 U.S. has one of highest levels of problematic substance
use in the world
 Involved in many illnesses, emergency room visits,
hospitalizations, deaths
 Increases motor vehicle accidents, suicide and suicidal
ideation, sexual assault, high-risk sexual behaviors
 Teenagers: from nicotine to alcohol to marijuana, then
more dangerous drugs

8. 8Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Prevalence
 At least half of adults arrested for major crimes
(including homicide, theft, assault) test positive for
drugs at time of their arrest
 Alcohol plays a role in domestic violence, affecting
married and unmarried couples
 Only 11% of people seek treatment

9. 9Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Quality and Safety Alert
 Apart from being illegal, underage drinking poses a
high risk for injury and social consequences, such as
increased motor vehicle accidents, suicide, sexual
assault, and high-risk sexual behavior
 Underage alcohol use is more likely to kill young
people than are all the illegal drugs combined
 From accidents AND poisoning

10. 10Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Quality and Safety Alert
 Alcohol use and intoxication substantially increases
the risk for self- and other-inflicted injury or suicide

11. 11Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Co-Occurring Disorders
 Coexistence of substance use disorder and
psychiatric disorders within same person
 Is substance use to “self-medicate” symptoms of
psychiatric disorder? YES but is not an excuse.
 Does substance use counter side effects of
medication? YES.
 Does substance use cause psychiatric disorder?
YES.
 Genetic predisposition to both? YES

12. 12Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Law Enforcement Implications
 Easy to form negative attitudes towards individuals with
problematic substance use
 Usually see individuals with problematic substance use
only at their worst
 Despite their prevalence, substance-related disorders are
frequently under detected and underdiagnosed

13. 13Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Substance Related Disorder Classes of
Drugs
 Alcohol (Central Nervous System [CNS] Depressant)
 Caffeine
 Cannabis
 Hallucinogens
 Inhalants
 Opioids
 Sedatives, Hypnotics, Anxiolytics (CNS Depressants)
 Stimulants (amphetamine type substances, cocaine,
and other stimulants)
 Tobacco
 Other ( or unknown) substances

14. 14Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
CNS Depressants
 Alcohol, barbiturates, benzodiazepines
 Also called sedative-hypnotics
 Primary effects: reduce anxiety (calming, antianxiety, or
sedative effect), induce sleep (hypnotic effect), or both.
 Usually feel “numb”

15. 15Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
CNS Depressants
 Although alcohol is sedative, it creates initial feeling of
euphoria, probably related to decreased inhibitions
 If cross-tolerance develops, some individuals need an
increased amount of other drugs in this category

16. 16Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
CNS Depressants
 Barbiturates: depressants that cause initial response of
euphoria; popular street drugs
 Once widely prescribed for sedative-hypnotic effects but
have been a major cause of overdose death from
accidental poisonings, suicide
 Produce excessive drowsiness, even at therapeutic
doses
 Tolerance develops rapidly
 DANGEROUS AND LETHAL withdrawal

17. 17Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Quality and Safety Alert
 Combinations of barbiturates and alcohol are
particularly dangerous and can lead to accidental
overdose and death

18. 18Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Benzodiazepines
 Have replaced barbiturates as preferred treatment for
anxiety related disorders in the clinical setting
 Can be addictive, causing physical and psychological
dependence
 Can lead to withdrawal symptoms when discontinued
 Despite drawbacks, commonly prescribed in U.S. with few
resulting problems if used as directed

19. 19Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Stimulants
 Stimulates CNS at many levels
 Most common: amphetamines, cocaine
 Feelings of euphoria, relief from fatigue
 Amphetamines: methamphetamine, benzphetamine,
dextroamphetamine
 Methamphetamine use is a growing problem in the
U.S.; changes brain chemistry, destroying “wiring” in
brain’s pleasure centers

20. 20Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Stimulants
 Methamphetamine use changes physical appearance
 Tolerance develops to euphoria and pleasant effects
of these drugs but not to wakefulness
 Prolonged or excessive use of amphetamines can
lead to psychosis almost identical to schizophrenia
with paranoid features

21. 21Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Stimulants
 Legal use of amphetamines limited to 3 types of
conditions: narcolepsy, ADHD in children and adults,
short-term weight reduction programs
 Legal stimulants
 Amphetamine
 Methylphenidate
 phentermine

22. 22Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Cocaine
 Can be inhaled as powder, injected intravenously, or
smoked
 Cocaine euphoria is short acting, starting with a 10- to 20-
second rush, then 15-20 minutes of a less intense
euphoria
 Produces physical dependence and withdrawal symptoms
with a very high relapse rate; can cause sudden death

23. 23Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Quality and Safety Alert
 Cocaine use can result in sudden death

24. 24Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Drug Use
 As tolerance develops individuals spend more money and
time seeking the substance
 Narcotic overdose can rapidly lead to coma, respiratory
depression, and death
 Accidental overdoses among narcotic addicts is possible
with the uncertainty of the drug’s strength
 Drugs are usually cut with other chemicals (sometimes
toxic) before sale, resulting in varied strengths available on
the streets
 Narcotic withdrawal is rarely life threatening but is very
uncomfortable

25. 25Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Marijuana
 One of most common illicit drugs
 May serve as a “gateway” drug
 Prolonged use may lead to apathy, lack of energy, loss of
desire to work or be productive, diminished concentration,
poor personal hygiene, preoccupation with marijuana; a
cluster of symptoms known as amotivational syndrome
 Tolerance develops in heavy users but have no clear
withdrawal patterns documented thus far

26. 26Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Hallucinogens
 Create experiences very similar to those of psychosis
with perceptual distortions, not true hallucinations;
have been called psychedelic or mind-revealing drugs
 Commonly used hallucinogens: LSD, peyote,
mescaline, psilocybin
 Tolerance develops if used regularly
 Self-destructive behavior possible with “bad trips,”
resulting in very frightening psychotic episodes,
flashbacks

27. 27Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Phencyclidine (PCP)
 May be ingested or smoked when mixed with another
substance, e.g., marijuana
 At low doses may cause euphoric, floating feeling;
heightened emotionality; incoordination; distorted
perception
 High doses may cause intensely psychotic experiences
with extreme agitation, violence
 Because drug is an anesthetic, PCP-intoxicated people
feel little or no pain

28. 28Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Quality and Safety Alert
 PCP users may become violent toward themselves or
others

29. 29Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Inhalants
 Children and adolescents may use inhalants for euphoric
effects because of low cost and easy availability
 Be alert to physical indicators of inhalant abuse
 Residue from paint, glue, or substances noted on
clothes, hands, or face
 Cold symptoms, e.g., runny nose
 Pimples or sores around mouth caused by abrasive
effect of chemicals on skin

30. 30Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Consequences of Problematic
Substance Use
 Accidents
 Violence
 Self-neglect
 Fetal abnormalities and fetal substance
dependence in pregnant women
 Infection with blood-borne pathogens
 Hepatitis
 AIDS

31. 31Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Withdrawal Symptoms
 Tremors
 Agitation
 Anxiety
 Diaphoresis
 Increased pulse/blood
pressure
 Sleep disturbance
 Hallucinations
 Delusions
 Delirium tremens
 Nausea
 Vomiting
 Headache
 Disorientation
 Impaired concentration

32. 32Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Withdrawal Symptoms
 Irritability
 Insomnia
 Mood instability
 Drug cravings
 Anorexia
 Weakness
 Flushing
 Seizures
 Hypersensitivity to
stimuli
 Paresthesias
 Perceptual distortion
 Muscle pains/spasms
 Tension
 Abdominal pain

33. 33Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Quality and Safety Alert
 For patients who are experiencing drug
withdrawal, the highest priority is given to patient
safety
 This involves stabilizing the patient’s physiological
status until the crisis of withdrawal has subsided
 Individuals need to be taken to the ER if they are
suspected to be in withdrawal
 Once safety needs are met, abstinence and support
system issues must be addressed

34. 34Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Quality and Safety Alert
 Substances with potentially life-threatening courses
of withdrawal include alcohol, benzodiazepines, and
barbiturates
 The possibility of seizures should always be
anticipated

35. 35Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Environment
 Need quiet, calm environment to decrease nervous
system irritability, promote relaxation
 Provide reassurance in calm, quiet voice
 Place clock within sight of patient to provide reality
orientation
 Do not leave patient alone
 Treat patient with dignity, respect

36. 36Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Motivational Approaches
 Express empathy through reflective listening
 Discuss discrepancy between individual’s goals or
values and current behavior
 Avoid argument; roll with resistance (arguing,
interrupting, denying, ignoring)

37. 37Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.
Recovery and Relapse
 Rare for an individual with a severe substance related
disorder to suddenly stop substance use forever
 Most typically try to quit at least once or several times,
or attempt to use the drug in a controlled way
 Will need to return to treatment promptly after relapses