Chemically Mediated Responses and Substance-Related Disorders

Chemically Mediated Responses and Substance-Related Disorders

Donald L. Taylor and Gail W. Stuart

Drugs have been used by people in almost all cultures since early times. Psychoactive substances alter the mind, the way reality is perceived, and the way a person feels. People use drugs for relief of negative emotional states such as depression, fear, and anxiety; for relief from fatigue or boredom; and as a break from daily routines because the drugs produce altered states of consciousness.

Moderate use for any of these purposes is not likely to result in major social or individual harm. However, all cultures have recognized the negative effects of alcohol and drug use. Excessive use of these substances has contributed to profound individual and social problems.

Any drug that affects the pleasure centers of the brain and produces pleasurable changes in mental or emotional states has the potential for abuse. Drugs that cause the most marked and immediate desirable effects have the greatest abuse potential. Alcohol and cocaine are very popular because they produce effects in the brain within minutes. Drugs of potential abuse include legal drugs such as alcohol and prescription medications; illegal drugs such as heroin, cocaine, and methamphetamine; and household products such as inhalants.


This case can help you understand some of the issues you will be reading about. Read the case background and then, as you read the chapter, think about your answers to the Case Critical Reasoning Questions. Case outcomes are presented at the end of the chapter.

Case Background

On the phone she said she needed help. Her life was chaotic, and she felt out of control. An aspiring fashion designer, she clearly had talent but could never break out of a moment-to-moment existence. When she came in for treatment, she was thin, athletic, androgynous in appearance, and serious in her demeanor. She looked around the room nervously.

She had grown up in a small rural town, moved to a larger city, and distanced herself from her family because she assumed they would not accept her sexual orientation. She began getting jobs in the food and beverage sector, usually getting off work around midnight. She had developed a pattern of drinking heavily with friends and had experimented with cocaine. Her parents had both an anxiety disorder and depression.

She was surprised to learn that anxiety and depression had a genetic basis and that the amount she was drinking might lead to alcoholism. She thought she just drank like most people because the people she worked and partied with all drank that same amount. Occasionally when drinking, she briefly had thoughts of suicide, but they quickly went away. She said she would think about all of these things but wanted an antidepressant. She thought it would make her feel better and therefore make her life better.

She continued drinking, smoking, and coming to therapy intermittently during crises for 2 years. Then one morning she called saying she was ready to quit drinking. She had awakened at home from a blackout. Her car had been wrecked during the night with bumpers smashed and paint scraped off doors, but she had no recollection of the event. She was terrified.

After coming to the office, she went to her first Alcoholics Anonymous meeting. She took the program seriously and chose a sponsor. Soon she began the 12-step program, and her life started to change.

Continuum of Chemically Mediated Responses

Definition of Terms

A person may achieve a state of relaxation, euphoria, stimulation, or altered awareness in several ways. The range of these chemically mediated responses is shown in Figure 23-1. Although there is a continuum from occasional drug use to frequent drug use to abuse and dependence, not everyone who uses drugs becomes an abuser, nor does every abuser become dependent.

The definitions of the terms use, abuse, and dependence have changed through the years. The nurse needs to understand that what one person or health care professional means by addiction is not necessarily what is meant by another.

• Substance abuse refers to continued use despite related problems.

• Substance dependence indicates a severe condition, usually considered a disease. There may be physical problems and serious disruptions in the person’s work, family, and social life.

• Addiction refers to the psychosocial behaviors related to substance dependence. The terms dependence and addiction are often used interchangeably.

• Dual diagnosis is the co-existence of substance abuse and one or more psychiatric disorders in the same person.

• Withdrawal symptoms result from a biological need that develops when the body becomes adapted to having the drug in the system. Characteristic symptoms occur when the level of the substance in the system decreases.

• Tolerance means that with continued use, more of the substance is needed to produce the same effect.

Many people progress from use to abuse at some time in their lives. However, only about 1 in 10 people progresses from use to abuse to dependence. After use has begun, the risk of becoming dependent is influenced by many biological, psychological, and sociocultural factors.

Attitudes About Substance Abuse

Substance abuse is viewed differently depending on the substance used, the person using it, and the setting in which it is used. Nurses should be aware of these social and cultural attitudes and recognize their impact on individual users and people close to them.

Changing laws related to the consumption, sale, and serving of alcohol and drugs may reflect changing attitudes about their use. Driving while intoxicated (DWI) or driving under the influence (DUI) laws are becoming tougher. When groups of friends go out, it is common for one person to be chosen as the designated driver who will not drink alcohol. Places where alcoholic beverages are served can be held liable if a customer overindulges and then causes an accident. Mandatory sentencing for certain drug offenses is intended to show an unaccepting attitude about drug abuse.

All nurses need to be educated about the signs of substance use, ways to screen for them, and brief interventions that they can use regardless of clinical setting (Tran et al, 2009; Mollica et al, 2011). Nurses often see substance abusers at their worst, during a medical or psychiatric crisis. They may see these patients returning repeatedly for alcohol- or drug-related health problems.

Nurses have less contact with people with alcoholism and drug addiction who have recovered from their addiction, because after they have recovered, they are usually ill less often. When they do seek health care, these patients may not reveal their substance abuse history. The best way for nurses to understand these individuals is to attend open meetings of self-help groups, where they will meet people recovering from alcoholism and addiction who have overcome tremendous odds to remain sober and lead healthy, productive lives.


The United States has one of the highest levels of substance use and addiction in the world (Table 23-1). Approximately 30% of people in the United States report having some form of alcohol use disorder at some point in their lives.

TABLE 23-1


Alcohol About 18.7 million people, or about 7% of the U.S. population, are dependent on or abuse alcohol. Only about 10% of them belong to Alcoholics Anonymous. Every day, 12,500 people try alcohol for the first time.
Caffeine The most widely used mood-altering drug in the world, caffeine, is regularly ingested by up to 90% of people in the United States. About 100 mg (one cup of coffee) per day can lead to physical dependence and withdrawal symptoms on quitting. Caffeine can alter behavior and affect sleeping habits.
Drugs It is estimated that 3.6 million people are dependent on drugs, and 700,000 of them are in treatment for their addiction at any one time. Every day, 8000 people try drugs of abuse for the first time. Marijuana, cocaine, and pain relievers are the leading drugs of abuse.
Food addiction Food addiction affects 4 million adults and a quickly growing number of children; binge eating is the most common eating disorder. An estimated 15% of mildly obese people are compulsive eaters.
Gambling About 3% of adults experience a serious problem with gambling that results in significant debt, family disruption, job losses, criminal activity, or suicide.
Internet Between 5% and 10% of the population suffer from Internet addiction, which is defined as any online-related, compulsive behavior that interferes with normal living and causes severe stress on family, friends, loved ones, and the work environment.
Sex Sex addiction affects more than 16 million people in the United States. Addicts become dependent on the neurological changes in the brain that occur during sex. They are consumed by sexual thoughts, making it difficult to work or engage in healthy personal relationships.
Shopping At least 1 in 20 people in the United States is a compulsive shopper, with men and women affected equally. Cultural factors, such as those emphasizing happiness associated with purchasing products, are thought to fuel shopping addictions.
Tobacco In the United States, 69.7 million people use tobacco products. The highest rate of use is among 18 to 25 year olds and among people living in the Midwest. Approximately 25% of men and 21% of women are cigarette smokers.

Data from Department of Health and Human Services, SAMHSA Office of Applied Studies 2009 National Survey on Drug Use and Health,; Center for Translational Neuroimaging,; Illinois Institute for Addiction Recovery,; Center for Internet Addiction Recovery,; and, All accessed October 2011.

Substance use is involved in many medical illnesses, hospitalizations, emergency room visits, and deaths. Substance use is a chronic, relapsing health problem that consumes a significant amount of health care resources. Substance users may be in treatment many times or make repeated attempts to quit before they are successful. Key facts about alcohol use and drug abuse are presented in Box 23-1.


Excessive Alcohol Use

Drug Abuse

• Prescription drug abuse is the fastest growing drug problem in the United States.

• Chronic drug use, crime, and incarceration are closely connected.

• Six million children (9%) live with at least one parent who abuses alcohol or other drugs. These children are more likely to experience abuse (physical, sexual, or emotional) or neglect and are more likely to be placed in foster care.

• Illicit, prescription, or over-the-counter drugs are detected in about 18% of motor vehicle drivers’ deaths.

• Injection drug use accounts for approximately 16% of new human immunodeficiency virus (HIV) infections in the United States. Injection and noninjection drug use is associated with sexual transmission of HIV and other sexually transmitted infections.

• Rates of marijuana use by youth and young adults are on the rise, and fewer youth than adults perceive great risk from smoking marijuana once or twice per week.

Adolescence is the most common period for the first experience with drugs. Although teenagers who use psychoactive substances tend to progress from nicotine to alcohol to marijuana and then to drugs that are perceived to be more dangerous, drug use patterns seem to be most related to availability.

According to the National Institute on Drug Abuse, about 71% of high school seniors in the United States have used alcohol sometime in their lives. Among eighth graders, 36% have had at least one drink of alcohol, 5% report having been drunk, 20% have smoked cigarettes, and 17% have used marijuana. Among twelfth graders, 41% had consumed alcohol in the past 30 days; about 23% reported heavy alcohol consumption, called binge drinking (at least five or more drinks on one occasion within the past 2 weeks); and 3% said they consumed alcohol daily (Johnson et al, 2011; NIAAA, 2011).

In 2009 an estimated 21.8 million, or 8.7%, of people in the United States age 12 years or older used an illicit drug, compared with 8.0% in 2008. The largest increase in regular drug use was for “psychotherapeutics”—inappropriately used prescription drugs—most of which were pain relievers.

When examined by age groups, in 2009, 10.0% of youths ages 12 to 17 years were current drug users, compared with 9.3% in 2008. Among adults between the ages of 18 and 25 years, current drug use increased from 19.6%in 2008 to 21.2% in 2009. The rate of drug use among adults age 26 years or older increased from 5.9% in 2008 to 6.3% in 2009 (Substance Abuse and Mental Health Services Administration, 2010).

Overall use of alcohol and illicit drugs increases with age until the mid-20s, levels off, and then decreases. However at-risk and binge drinking are frequently reported by middle-aged and elderly adults (Blazer and Wu, 2009). If regular use begins before age 17 years, the individual is more likely to have alcohol and illicit drug abuse and dependence problems as an adult. The lifetime prevalence and the intensity of alcohol use are greater among males.

At least one half of adults arrested for major crimes, including homicide, theft, and assault, test positive for drugs at the time of their arrest. Among those convicted of violent crimes, approximately 50% of state prison inmates and 40% of federal prisoners had been drinking or taking drugs at the time of their offense.

One of the most troubling effects of alcohol is its effect on marriage, which is reflected in the relationship between heavy drinking and marital violence. Illicit drugs and alcohol play a role in domestic violence, affecting married and unmarried couples. Another consequence of alcohol is self-injury.

Most people with alcohol use disorders do not seek treatment (Substance Abuse and Mental Health Services Administration, 2010). It is estimated that only 11% of people in the United States who need alcohol treatment receive it. The most frequently cited reasons for not seeking alcohol treatment are cost, not wanting to stop using the substance, and not seeing the need for treatment (Edlund et al, 2009; Oleski et al, 2010). Unmet need for treatment is highest among the elderly, persons from racial-ethnic minority groups, those with low income, those without insurance, and those living in rural areas (Grella et al, 2009).

Substance abuse receives relatively little medical and public health attention compared with other medical conditions. Reasons include stigma, tolerance of personal choices, acceptance of youthful experimentation, pessimism about treatment efficacy, powerful tobacco and alcohol industries, and patient resistance.

Dual Diagnosis

In the addicted population, prevalence of psychiatric illness is no greater than in the general population. However, up to 50% of individuals with a serious mental illness are also dependent on or addicted to alcohol or illicit drugs. They are referred to as having a dual diagnosis.

For example, people with schizophrenia are more than four times as likely to have a substance use disorder during their lifetimes, and those with bipolar disorder are more than five times as likely to have such a diagnosis as people in the general population. Many individuals who have experienced trauma and are diagnosed with posttraumatic stress disorder (PTSD) also have a substance use disorder. Almost 60% of male and 70% of female alcohol abusers are thought to have at least one other psychiatric disorder. This is challenging for clinicians because these patients can be more difficult to diagnose and are often treatment resistant with high relapse rates.

Failure to detect substance abuse disorders results in misdiagnosis of the psychiatric disorder and failure to provide appropriate treatment and referral. Underdetection can be caused by the following:

Studies show that despite the high rate of dual disorders in various populations, such as those with severe and persistent mental illness, the chronically homeless, and those incarcerated in prison, the facilities and programs designed to treat both disorders are underused (Brunette et al, 2008).

Substance-Related Disorders in Nurses

Disciplinary records from state boards of nursing provide information about impaired nurses. Unfortunately, it is still a common practice to deal with a nurse who has a drug problem by ignoring the problem, firing the nurse, or asking for the nurse’s resignation rather than reporting it to the state licensing board and facilitating treatment for the nurse. Data reported by each state board may reflect only a small segment of the problem.

As it is in the general population, alcohol is the drug of choice for nurses, and nurses’ choice of substance is influenced by availability and exposure. Of all health care professionals, physicians and nurses use parenteral narcotics the most in their practices, and they are more likely to choose these drugs for their own use.

Among narcotics, the drug of choice for nurses is meperidine (Demerol). Anesthesiologists and nurse anesthetists who abuse substances tend to favor fentanyl, a potent, short-acting narcotic. Health care professionals tend to abuse prescription drugs rather than “street drugs,” whether they acquire them by prescription or diversion.


Accurate assessment of a patient’s pattern of drug and alcohol use is essential, but it is sometimes difficult to accomplish. People with alcohol and drug addictions may use many defense mechanisms when discussing their chemical use. They may deny how much they use and its relationship to problems in their lives. They often rationalize their substance use. Patients should not be criticized for these unconscious mechanisms. They are often not aware of the extent or effects of their use.

It is also true that some patients purposely distort the truth about drug use to avoid feared consequences. The nurse should be aware of these behaviors and take them into account. The nurse also should be aware that only about 1 in 10 people who drink develops substance dependence at some point in their lifetime, and should not jump to the conclusion that a person is in denial if he or she claims to have no alcohol-related problems.

Screening for Substance Abuse

Screening for substance use problems is essential in the primary care setting where most people seek health care (Neushotz and Fitzpatrick, 2008; Savage, 2008; Baird, 2009; Oleski et al, 2010).

To screen effectively, the nurse must ask the right questions in the right way. People who drink, take drugs, or do both tend to be around others who drink and use drugs as they do. They do not have a good idea of what normal use patterns are. However, even people who deny drug and drinking problems are likely to answer certain questions truthfully. These questions are included in screening tools, which are the first level of assessment for alcohol and drug dependence.

Simple screening tools are available that are useful in identifying people who may have problems with substance use. Because screening tools are only suggestive, findings from them should be followed by a full diagnostic assessment.


The Alcohol Use Disorders Identification Test-C (AUDIT-C) is a 3-item screening tool used to identify individuals who are hazardous drinkers or have active alcohol use disorders (Box 23-2).


The Brief Drug Abuse Screening Test (B-DAST) is the quickest drug abuse screening tool (Box 23-3). Each item has a 1-point value. Scores of 6 or more suggest significant drug abuse problems. Patients who score above established cutoff scores are considered to be addicted.


Instructions: The following questions concern information about your involvement and abuse of drugs. Drug abuse refers to (1) the use of prescribed or over-the-counter drugs in excess of the directions and (2) any nonmedical use of drugs. Carefully read each statement and decide whether your answer is yes or no. Then circle the appropriate response.

YESNO1. Have you used drugs other than those required for medical reasons?

YESNO2. Have you abused prescription drugs?

YESNO3. Do you abuse more than one drug at a time?

YESNO4. Can you get through the week without using drugs (other than those required for medical reasons)?

YESNO5. Are you always able to stop using drugs when you want to?

YESNO6. Have you had blackouts or flashbacks as a result of drug use?

YESNO7. Do you ever feel bad about your drug abuse?

YESNO8. Does your spouse (or parents) ever complain about your involvement with drugs?

YESNO9. Has drug abuse ever created problems between you and your spouse?

YESNO10. Have you ever lost friends because of your use of drugs?

YESNO11. Have you ever neglected your family or missed work because of your use of drugs?

YESNO12. Have you ever been in trouble at work because of drug abuse?

YESNO13. Have you ever lost a job because of drug abuse?

YESNO14. Have you gotten into fights when under the influence of drugs?

YESNO15. Have you engaged in illegal activities in order to obtain drugs?

YESNO16. Have you ever been arrested for possession of illegal drugs?

YESNO17. Have you ever experienced withdrawal symptoms as a result of heavy drug intake?

YESNO18. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)?

YESNO19. Have you ever gone to anyone for help for a drug problem?

YESNO20. Have you ever been involved in a treatment program specifically related to drug use?

Items 4 and 5 are scored in the NO, or false, direction. Each item is 1 point. A score of 6 or more points suggests significant problems.

From Skinner HA: Addict Behav, 7:363, 1982; Center for Substance Abuse Treatment: Substance abuse treatment for persons with co-occurring disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3992, Rockville, Md, 2005, Substance Abuse and Mental Health Services Administration.


Screen, Brief Intervention, Refer to Treatment (SBIRT) is a public health approach to delivering early intervention to anyone who uses alcohol or drugs in unhealthy ways (Madras et al, 2009; Robinson, 2010; Kazemi et al, 2011). The goal of SBIRT is to improve early identification of people who are overusing, abusing, or dependent on alcohol or other substances (Table 23-2). Initial screening is completed for all patients annually. When indicated by the initial screening, further evaluation using a standardized instrument such as AUDIT-C or B-DAST is done followed by a brief intervention.

Motivational interviewing skills (Chapter 2) are used as the intervention to increase insight about substance use and motivation to change. Referral to an addiction specialist or treatment facility is indicated for patients who are identified as being at risk for dependency or when use places them or others at risk for harm. SBIRT should be an essential practice skill of all nurses.


The simplest biological measure to obtain is blood alcohol content (BAC) by use of a Breathalyzer. Alcohol in any amount has an effect on the central nervous system (CNS). The behaviors that can be expected from a nontolerant person at different concentrations of alcohol in the blood are shown in Table 23-3. In the United States, the legal limit as of 2011 is 0.08% blood alcohol content as measured by a breath device, urinalysis, or blood test.

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Chemically Mediated Responses and Substance-Related Disorders

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