According to a Chinese medical compendium dated from 2737 BC, the Chinese were the first to use marijuana to achieve euphoria. As early as the year 2000 BC, the Greeks used opium, and the Aztecs incorporated hallucinogens into religious rituals. During the Middle Ages (400 to 1500), witches brewed potent concoctions, and New World merchants transported opium along with slaves and rum. The use and abuse of several substances increased during the Civil War period (1861–1865), when soldiers became addicted to prescription drugs that were used to alleviate pain in the battlefield. Cocaine was introduced as a miracle drug and used in patent medicine. Heroin was also produced and sold by traveling salesmen; however, the addictive potential limited the use of these drugs by society. Marijuana was openly used until the federal government discouraged its use in 1930. The recreational use of illicit drugs resurfaced between 1950 and 1960. Cocaine, which was popular during the 1970s, became available as “crack cocaine” in the 1980s. During the 1990s, the use of heroin and smoking of marijuana regained popularity. Since that time, several forms of illicit drugs (eg, methamphetamine, designer drugs, anabolic steroids) have become more commonplace in society than ever before. Drug use and abuse continues to be a significant public health problem despite public outcry and regulation by the U.S. Drug Enforcement Administration (DEA) (Goulding & Shank, 2005).

There was a time when the sale and consumption of alcoholic beverages was illegal in the United States. Alcohol was first introduced in the U.S. by the Puritans around 1620. The use of alcohol reflected their religious belief that drinking was a natural and normal part of life. Alcohol was also an effective analgesic, and generally enhanced the quality of life. People of both sexes and all ages typically drank beer with their meals. By 1697, distilleries were used to make rum, wine, beer, and cider.

In 1784, Benjamin Rush, a physician, argued that excessive use of alcohol caused injury to physical and psychological health. Followers of Rush formed a temperance movement in 1789 as an organized effort to encourage moderation or complete abstinence in the consumption of intoxicating liquors. Drinking had become an activity associated with masculine aggression and antisocial behavior. In fact, alcohol was blamed for many of society’s problems, among them severe health issues, destitution and crime. The movement’s ranks were mostly filled by women who, with their children, had endured the effects of unbridled drinking by many of the men in their lives. By 1826, the American Temperance Society was organized with a mission to educate individuals about the effects of drinking on religion and morality. Antialcohol education was introduced in the schools between 1901 and 1902. On January 16, 1920, prohibition of the sale and consumption of alcohol became a law. Speakeasies soon flourished across the country and there were underground saloons. Prohibition spawned organized crime, bootlegging, and corruption, and, by the late 1920s, prohibition became a very unpopular reality. Democrats used prohibition as an issue during the 1932 presidential campaign. In February of 1933, Congress passed the 21st amendment to repeal prohibition. Unfortunately, statistics kept by the Center for Disease Control indicate
the use and abuse of alcoholism continues to have an adverse effect on society (eg, motor vehicle accidents, various medical problems, depression, suicide) (Essortment.com, 2006; Hanson, 2006).

According to the 2004 National Survey on Drug Use and Health, an annual survey of the civilian, noninstitutionalized population of the United States age 12 years or older, 22.5 million Americans (or 9.4% of the population) were classified as having past-year substance dependence or abuse, about the same number as in 2002 and 2003. Alcohol- and drug-related use or abuse problems continue to contribute to enormous damage to society, and the magnitude of these costs underscores the need to find better ways to prevent and treat these disorders. The rising costs from substance-related public health issues warrant a major and continuous investment in research on prevention and treatment (Substance Abuse and Mental Health Services Administration [SAMHSA], 2005).

Substance use is simply the ingestion of a chemically active agent such as OTC medication, a prescribed drug, or illicit drug, alcohol, or nicotine. Addiction has been defined as an illness characterized by “compulsion, loss of control, and continued patterns of abuse despite perceived negative consequences; obsession with a dysfunctional habit” (American Nurses Association [ANA], Drug and Alcohol Nursing Association, & National Nurses Society on Addictions [NNSA], 1987). Addiction is a term used to define a state of chronic or recurrent drug intoxication, characterized by psychological and physical dependence as well as tolerance. Habituation, also referred to as psychological dependence, is a term used to describe a continuous or intermittent craving for a substance to avoid a dysphoric or unpleasant mood state. Habituation implies an emotional dependence on a drug or a desire or compulsion to continue taking a drug. Tolerance refers to the person’s ability to obtain a desired effect from a specific dose of a drug. For example, as a person develops a tolerance for 10 milligrams of diazepam (Valium), she or he increases the dose to 15 or 20 milligrams to achieve the desired effects originally experienced at the 10-milligram dose. Physiologic dependence refers to the physical effects resulting from the multiple episodes of substance use; it is manifested by the appearance of withdrawal symptoms after the person stops taking a specific drug. Behavioral dependence refers to the substance-seeking activities and pathological use patterns of the person using the substance. Behavioral dependence is often associated with social activities. For example, an individual may exhibit the behavioral dependence of smoking marijuana or using other illicit substances while watching television or attending sports activities with one’s peers. Codependency is a term that refers to all the behavioral patterns of family members who have been significantly affected by another family member’s substance use or abuse. Family members may feel the substance-using behavior of the user is voluntary and willful and that the user cares more for the substance than for them. They often experience feelings of anger, rejection, denial, failure, guilt, or depression and shift the blame for the user’s behavior onto other family members. Such behavior by family members actually perpetuates the user’s dependence and is referred to as enabling (Sadock & Sadock, 2003; Shahrokh & Hales, 2003).

In 1964, the World Health Organization (WHO) suggested substituting the term drug dependence for “addiction” to better describe the two concepts of dependence: behavioral dependence and physiologic dependence. In addition, the word “substance” is used in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) because “drug” implies a manufactured chemical, whereas many substances associated with abuse patterns occur naturally (eg, marijuana) or are not meant for human consumption (eg, glue) (Sadock & Sadock, 2003).

According to the WHO, the words “addict” and “addiction” ignore the concept of drug abuse as a medical disorder. However, a recent literature search noted that several disciplines, including nursing and the medical profession, continue to use the word “addiction” interchangeably with “drug dependence” and “abuse.”

Globally, alcohol consumption has increased in recent decades, with all or most of that increase in developing countries. This increase is often occurring in countries with few methods of prevention, control or
treatment. The illicit use of drugs has also taken on global dimensions. There is sufficient reason to believe that unregulated excessive drug supply and consumption trends in some countries may be continuing and new problems may be developing (World Health Organization, 2006a, 2006b).

Substance-related disorders are responsible for dysfunctional marital and family relationships, divorce, desertion, child abuse, displaced children, and impoverished families. Alcohol-related medical problems can be disabling, chronic, or fatal (Figure 25-1). Fetal alcohol syndrome is one of the leading causes of birth defects in the United States. Clients who abuse alcohol or drugs may develop comorbid conditions such as alcohol- or substance-induced mood disorders, anxiety disorders, and dementia. A discussion of the epidemiology of substance-related disorders follows.

In the 1970s and 1980s, the care of clients with substance-related disorders became recognized as a unique nursing practice field. The International Nurses Society on Addictions (IntNSA) is a professional specialty organization founded in 1975 for nurses committed to the prevention, intervention, treatment, and management of addictive disorders including alcohol and other drug dependencies, nicotine dependencies, eating disorders, dual and multiple diagnosis, and process addictions such as gambling. IntNSA’s mission is to advance excellence in addictions nursing practice through advocacy, collaboration, education, research and policy development (IntNSA, 2006).

In 1987, the publication The Care of Clients With Addictions: Dimensions of Addictions Nursing Practice described the dimensions of nursing practice associated with substance-related disorders as including the care of clients with a broad range of abuse and addiction patterns (ANA, Drug and Alcohol Nursing Association, & NNSA, 1987). Addictions nursing was defined as an area of specialty practice concerned with care related to dysfunctional patterns of human response that have one or more of the following key characteristics: some loss of self-control capacity, episodic or continuous maladaptive behavior or abuse of some substance, and development of dependence patterns of a physical and/or psychological nature. The addictions nurse addresses needs at every point on the health–illness continuum, uses skills from a number of nursing specialties, and collaborates with professionals in medicine, psychology, social work, and other disciplines. The recognition of addictions nursing as a distinct practice area led to the development of Standards of Addictions Nursing Practice With Selected Diagnoses and Criteria, published in 1988 (ANA & NNSA).

The discovery that all drugs of abuse have one thing in common—namely, the stimulation of dopamine secretion—occurred in the 1980s. With scientific innovations, studies have identified the neural structures and pathways responsible for pleasure and reinforcement of behavior. For example, researchers have discovered that the brains of addicts have fewer dopamine D2 receptors in several regions of their brains than do the brains of control subjects. Addictive drugs such as cocaine, methamphetamine, heroin, and alcoholism capture these receptor sites and pathways or neural circuits and subvert normal functions (Yasgur, 2004). For instance, cocaine blocks the mechanism by which dopamine is reabsorbed into the cells that release dopamine. Amphetamines provoke the release of dopamine. Nicotine acts on a receptor for the neurotransmitter acetylcholine, possibly preventing the enzyme mono-amine oxidase from breaking up the dopamine molecule. Opiates act at receptor sites for the brain’s own morphine-like substances. Sedative-hypnotics, alcohol, barbiturates, and benzodiazepines act in various parts of the brain on neurons that release γ-aminobutyric acid (GABA), which directs neurons to stop firing. Consequently, alcohol and drugs can change the way individuals feel and cause them to want to take these substances more often (Grinspoon, 1998a; Smith, 1999).

Researchers have also speculated that some individuals have a predisposition to or are at risk for addiction due to a high level of stress hormones, a deficit in dopamine function that is temporarily corrected by their drug of choice, or the presence of electrical phenomena in the brains of people at risk for alcoholism (Grinspoon, 1998b).

Separate studies of twins, adoptees, and siblings indicate that the cause of alcohol abuse has a genetic component. According to Grinspoon, “Individual differences in sensitivity to the addictive powers of drugs are almost certainly strongly influenced by genetics” (1998b, p. 1). Jellinek (1977, 1988) theorized that some individuals have a predisposition to alcoholism as a result of the “loss of control” over alcohol. His theory was supported by comparing data from studies of twins living with their biologic parents to data from studies of twins born to alcoholic parents, but separated after birth and raised by nonalcoholic foster parents. The data indicated that children born to alcoholic parents are particularly susceptible to becoming alcoholic (Goodwin, 1992, 1979). Additional studies with less conclusive data show that other types of substance-related
disorders may be caused by a genetic component (Sadock & Sadock, 2003).

Behavioral theorists believe that addiction results from the positive effect of mood alterations and reduction in feelings of fear and anxiety that one experiences using drugs or alcohol. Additionally, several types of learning are thought to be associated with compulsive self-administration of drugs.

Associative learning is exhibited during relapses experienced among clients addicted to psychostimulants. The brain is specifically designed to absorb and respond in very powerful ways to environmental cues and contexts. Nothing could be more specific, or powerful, than large doses of mind-altering drugs. The brain stores discrete patterns of information related to specific drug usage and produces context-independent sensitization of the organism to the drug or a general lethargy and unresponsiveness to the environment. The response depends on the individual’s choice of substance (Medina, 2000).

The potential for addiction is affected by economic conditions, formal and informal social controls, cultural and ethnic traditions (eg, Asians and conservative Protestants use alcohol less frequently than do liberal Protestants and Catholics), and the companionship and approval of other drug users (Grinspoon, 1998b; Sadock & Sadock, 2003).

Additionally, a drug must be available in sufficient amounts to sustain addiction. For example, college dormitories and military bases are two social settings in which excessive and frequent drinking are often considered normal and socially expected. People risk addiction when they lack other capacities, choices, interest, or sources of attachment to something outside themselves.

Teenagers are at risk for alcohol abuse because it is the drug of choice among most adults, it is legal, and it is socially acceptable. Parents indirectly sanction the use of alcohol by drinking in front of their children and telling them that alcoholic beverages are acceptable if drunk in moderation.

Teenagers who possess more leisure time and money and experience less parental or community supervision are at risk for substance abuse, especially when they attend weekend or all-night parties. Drugs are available “everywhere,” according to grade-school children. OTC drugs, prescriptions readily obtained for insomnia, and pain-relief medication used by parents all make substance abuse easy for children and teenagers.

Peers and their values are particularly strong influences. Experimentation, curiosity, rebellion, and boredom are just a few reasons cited by adolescents when asked why they use or abuse drugs (National Criminal Justice Reference Service [NCJRS], 2004a).

Although a particular addictive personality has not been identified, many theorists consider individuals who abuse substances to be fixed at an oral or infantile level of development. The abuser searches for immediate gratification of needs, or ways to escape tension, turning to alcohol or drugs to experience euphoria or oblivion. Characteristics frequently seen include low self-esteem, feelings of dependency, low tolerance for frustration and anxiety, antisocial behavior, and fear. Theorists are not certain whether these characteristics were present before the addictive behavior or whether the characteristics are a result of substance or alcohol abuse (Berman, 2001; Sadock & Sadock, 2003).

Other theorists believe that early childhood rejection, overprotection, or undue responsibility can cause an individual to become dependent on alcohol or drugs to cope with increased anxiety, depression, social or sexual inadequacy, increased social pressures, self-destructive behavior, or due to a desire to lower one’s inhibitions (Berman, 2001).

The American Medical Association and the U.S. Public Health Service consider alcoholism to be a disease. Most authorities in the field of alcohol abuse base their beliefs on the pioneering work of Jellinek (1988). He surveyed 2,000 alcoholic men and classified alcoholics into five types. He also identified four progressive phases that the alcoholic experiences.

Alcohol is known to shorten an individual’s life span by 12 to 15 years unless treatment is received. Like other chronic illnesses, it has certain observable symptoms. For example, tolerance occurs as the individual drinks more with less effect. Withdrawal occurs when an individual abruptly stops drinking after alcohol has become a necessity of life to maintain functioning. Finally, alcoholism can be fatal.

The same can be said for substance abuse, because both the alcoholic and the substance or drug abuser
lose control over when they drink or take drugs, how much they take, and where the abuse occurs.

Patterns of alcohol use disorders include alcohol dependence and alcohol abuse. An understanding of these patterns is essential for psychiatric–mental health nursing practice.

Alcohol-induced disorders are the result of the effects of alcohol on the CNS. Clients with alcohol-induced disorders exhibit impairment of neurologic functioning such as delirium or dementia. They also may exhibit behavioral changes.

Substances included in the category of sedatives, hypnotics, and anxiolytics include benzodiazepines, carbamates, barbiturates, barbiturate-like hypnotics, all prescription sleeping medications, and all anxiolytic medications except the nonbenzodiazepine antianxiety agents (eg, buspirone). Ingestion of these drugs in high doses can be lethal, especially when they are mixed with alcohol.

Taken orally or intravenously, these drugs are used to relax the CNS or slow down body processes. They temporarily ease tension and induce sleep. Medically, they may be used in the treatment of hypertension, peptic ulcers, or seizures; as a relaxant before and during surgery; and as a sedative for use in mental and physical illness.

Normal effects of these drugs include a decrease in cardiac and respiratory rate, lowered blood pressure, and a mild depressant action on nerves, skeletal muscles, and the heart. Overdoses or intoxication may result in symptoms such as slurred speech, incoordination, drunken appearance, staggering gait, nystagmus, impaired memory, stupor, or coma. Other symptoms may include poor judgment, mood swings, paranoia, lack of sexual inhibition, and aggressive impulses. Medical symptoms include dry mouth, headaches, dizziness, chills, and diarrhea (American Psychiatric Association [APA], 2000; Sadock & Sadock, 2003). Street names for these drugs include “libs,” “blues,” “rainbows,” “yellow-jackets,” and “downers.” Barbiturates are the leading cause of accidental poisoning, as well as a primary method of committing suicide. Barbiturate dependency is one of the most difficult disorders to cure. Clinical symptoms of sedative, hypnotic, or anxiolytic withdrawal may include diaphoresis, increased pulse rate (greater than 100 beats per minute), hand tremors, nausea and vomiting, insomnia, transient hallucinations or illusions, psychomotor agitation, and anxiety (APA, 2000; Sadock & Sadock, 2003).

An opioid is a drug or naturally occurring substance that resembles opium or one or more of its alkaloid derivatives. Opiates are powerful drugs derived from the poppy plant that have been used for centuries to relieve pain. The opioid classification includes natural opioids such as morphine, semi-synthetics such as heroin, and synthetics with morphine-like action such as codeine or methadone. Medications such as pentazocine, which has both opiate agonist and antagonist effects, are also included in this classification.

Opioids are narcotic drugs that induce sleep, suppress coughing, and alleviate pain. People abuse opiates by taking them orally, inhaling them (eg, snorting or smoking), or injecting them into their veins in an attempt to help relieve withdrawal symptoms, for “kicks,” or to “feel good.” The user becomes passive and listless as the opioids depress the respiratory center of the brain, causing shallow respirations. The person also experiences reduced feelings of hunger, thirst, pain, and sexual desire. As the effects of the drug wear off, the user, who becomes physically and emotionally addicted by requiring increasingly larger dosages, suffers withdrawal symptoms unless another dose of the drug is taken.

Opioids, also referred to as “white stuff,” “hard stuff,” and “junk,” are considered to be the most addictive drugs. Acute overdose or intoxication is identified by symptoms of drowsiness; slurred speech; decreased, slow respirations; constricted pupils; and a rapid, weak pulse. The client also may exhibit mood swings, psychomotor agitation or retardation, impaired judgment, or impaired social or occupational functioning (APA, 2000; Sadock & Sadock, 2003).

Opioid withdrawal symptoms begin 12 to 16 hours after the last dose and are characterized by watery eyes, rhinitis, yawning, sneezing, and diaphoresis. Other symptoms include dilated pupils, restlessness and tremors, goose bumps, irritability, loss of appetite, muscle cramps, nausea and vomiting, fever, and diarrhea. Symptoms subside in 5 to 10 days if no treatment occurs (APA, 2000; Sadock & Sadock, 2003).

Amphetamines or amphetamine-like substances are medically indicated for the treatment of attention-deficit–hyperactivity disorder, narcolepsy, weight reduction, and treatment-resistant depression. Amphetamines (“pep pills”) are drugs that directly stimulate
the CNS and create a feeling of alertness and self-confidence in the user. They are also referred to by drug abusers as “wake-ups,” “speed,” “eye-openers,” “co-pilots,” “truck drivers,” “uppers,” or “bennies.”

These drugs are often abused by oral ingestion, injection into veins, smoking, or inhalation of large doses to obtain an exaggerated effect of the stimulating action. People also take these drugs for kicks, for thrills, or to combat boredom; to stay awake or to allow greater physical effort; or to counteract the effects of alcohol and barbiturates. Amphetamines are considered to be dangerous because they can drive a user to do things beyond his or her physical limits; they can cause mental fatigue, dizziness, and feelings of fear and confusion; and sudden withdrawal can lead to depression and suicide. The heart and circulatory system also may be damaged from the adverse effects of adrenaline overproduction due to drug abuse.

Clinical symptoms of intoxication include tachycardia or bradycardia, alterations in blood pressure, cardiac arrhythmias, respiratory depression, pupillary dilation, excitability, tremors of the hands, increased talkativeness, profuse diaphoresis, dry mouth, nausea and vomiting, weight loss, headaches, pallor, diarrhea, and unclear speech (APA, 2000; Sadock & Sadock, 2003). The abuser can develop a psychological dependence on stimulants and may experience delusions, auditory and visual hallucinations, or a drug psychosis that resembles schizophrenia. Clinical symptoms of withdrawal include dysphoria, fatigue, altered sleep patterns, increased appetite, dreams, and psychomotor agitation or retardation (APA, 2000; Sadock & Sadock, 2003).

Cocaine is a short-acting CNS stimulant substance that is extracted from the leaves of the South American coca plant (Erythroxylon coca). Historically, the leaves of the plant were chewed for refreshment, and were used by peasant laborers to relieve fatigue and fight off pain or hunger. Cocaine also produces feelings of happiness, alertness, sensory awareness, and enhances one’s self-esteem.

Cocaine is available as a white crystalline powder or in larger pieces referred to as “rocks.” Powdered cocaine is usually sniffed, snorted, smoked in a pipe (freebasing), or injected into a vein or subcutaneous tissue.

Physical effects of cocaine intoxication include immediate dilation of the pupils and an increase or decrease in blood pressure, pulse, respirations, and body temperature. Users may also experience a loss of appetite, nausea and vomiting, weight loss, insomnia, impaired thinking, agitation, seizures, chest pain, or coma (APA, 2000; Sadock & Sadock, 2003). Long-term effects include chronic nose bleed, runny nose, chronic sore throat, exhaustion, respiratory ailments, vitamin deficiencies, dangerous weight loss, and miscarriage/birth defects.

Clients who experience cocaine withdrawal may exhibit fatigue, an increased appetite, altered sleep patterns, and behavioral changes such as agitation or psychomotor retardation. Panic attacks or cocaine psychosis may occur. Individuals with a history of cardiac disease may experience chest pain, heart attack, or heart failure. Cocaine also can cause sudden heart attack in healthy young people (APA, 2000; Sadock & Sadock, 2003).

Marijuana is a common plant with the biologic name of Cannabis sativa. With the ability to act as a stimulant or depressant, it is often considered to be a mild hallucinogen with some sedative properties. As of February 2005, 12 states have legalized the use of marijuana to alleviate the symptoms of nausea and vomiting during chemotherapy, stimulate appetite in clients with HIV/AIDS, and lower ocular pressure in clients with glaucoma: Alaska, Arizona, California, Colorado, Hawaii, Maine, Montana, Nevada, Oregon, Rhode Island, Vermont, and Washington (DEA, 2006). With written certification from a physician, clients or their caregivers are able to register with a state to grow and use marijuana. The physician, client, and caregiver are all protected from arrest and prosecution.

When used illegally, marijuana is often combined with other addictive substances such as alcohol or nicotine. Most users in the 18- to 25-year-old age range are male. Many people who try marijuana go on to use it extensively, and many of these people use it in combination with other substances such as opioids, PCP, or hallucinogens (APA, 2000; Pfizer, Inc., 1996).

Persons who use marijuana usually smoke it in a pipe or as a rolled cigarette (“joint”). Individuals also may take it orally as capsules or tablets, on sugar cubes, or in food. Holders (“roach clips”) are used to get the last puffs from marijuana cigarette butts when they become too short to handle with fingers. Slang names for marijuana include “pot,” “herb,” “grass,” “weed,” “smoke,” and “Mary Jane.”

Marijuana acts quickly, in approximately 15 minutes, after it enters the bloodstream, and its effects last
approximately 2 to 4 hours. It affects a person’s mood, thinking, behavior, and judgment in different ways, and in large doses it can cause hallucinations.

General physiologic symptoms of intoxication include increased appetite, lowered body temperature, depression, drowsiness, unsteady gait, inability to think clearly, excitement, reduced coordination and reflexes, and impaired judgment. Users of large amounts may experience suicidal ideation or have delusions of invulnerability, causing them to take risks.

Although marijuana is not considered to be physically addicting and no withdrawal criteria have been established, it may lead to psychological dependence, thereby retarding personality growth and adjustment to adulthood. Its use also can expose the user to those using and pushing stronger drugs (APA, 2000).

Hallucinogens and PCP are associated only with abuse because physiologic dependence has not been demonstrated. They are referred to as “mind benders” or psychedelic drugs, affecting the mind and causing changes in perception and consciousness.