**TABLE 9-1** Diagnoses Associated with Class of Substances
From American Psychiatric Association: *Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision*, Washington, DC, 2000, American Psychiatric Association. © American Psychiatric Association2000
	Dependence	Abuse	Intoxication	Withdrawal	Intoxication Delirium	Withdrawal Delirium	Dementia	Amnestic Disorder	Psychotic Disorder	Mood Disorders	Anxiety Disorders	Sexual Dysfunctions	Sleep Disorders
N ote: X, I, W, I/W, or P indicates that the category is recognized in DSM-IV-TR. In addition, I indicates that the specifier With Onset During Intoxication may be noted for the category (except for Intoxication Delirium); W indicates that the specifier With Onset During Withdrawal may be noted for the category (except for Withdrawal Delirium); and I/W indicates that either With Onset During Intoxication or With Onset During Withdrawal may be noted for the category. P indicates that the disorder is Persisting.
^*Also hallucinogen persisting perception disorder (flashbacks).
From American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision, Washington, DC, 2000, American Psychiatric Association.
Alcohol	X	X	X	X	I	W	P	P	I/W	I/W	I/W	I	I/W
Amphetamines	X	X	X	X	I				I	I/W	I	I	I/W
Caffeine	X	X	X		I				I		I		I
Cannabis	X	X	X		I				I		I		I
Cocaine	X	X	X	X	I				I	I/W	I/W	I	I/W
Hallucinogens	X	X	X		I				I^*	I	I
Inhalants	X	X	X		I		P		I	I	I
Nicotine	X	X	X	X	I				I	I
Opioids	X	X	X	X	I				I	I		I	I/W
Phencyclidine	X	X	X		I				I	I	I
Sedatives	X	X	X		I				I	I	I
Hypnotics or Anxiolytics	X	X	X	X	I	W	P	P	I/W	I/W	W	I	I/W
Polysubstance	X	X	X	X	I	W	P	P	I/W	I/W	W	I	I/W
Other	X	X	X	X	I	W	P	P	I/W	I/W	I/W	I	I/W

ASSESSMENT AND DIAGNOSTIC CRITERIA

Substance Intoxication

Substance intoxication is a reversible substance-specific syndrome that occurs following intake of or exposure to a substance. Maladaptive symptoms result from drug effects on the central nervous system; mood changes (lability, euphoria, depression), cognitive impairment (insight, judgment, reasoning), and behavior changes (aggression, belligerence, submission).

Substance Abuse

The defining characteristic of substance abuse is at least a 12-month pattern of maladaptive, continuous, or recurrent substance use that results in one or more of the following:

1. Failure to complete obligations in home (neglect family), work (take excess absences), or school (fail to complete assignments/get expelled)

2. Continued use of substances despite danger (driving while intoxicated)

3. Legal problems occur as a result of substance intake (DUI; arrest for threatening neighbor while intoxicated)

4. Recurrent social or interpersonal problems (friends stop inviting person, arguments with spouse about drug use).

Substance Dependence

The defining characteristic of substance dependence is continued use of substance(s) despite substance-related problems, as evidenced by physiologic, cognitive, and behavioral symptoms. The individual uses the substance(s) in a repeated pattern that can result in tolerance, withdrawal, and drug-taking behaviors that become compulsive. The person develops strong physical, psychologic, and behavioral drives to use the substance repeatedly. The presence of three or more of the following characteristics constitutes dependence:

1. Tolerance is the need for greater amounts of the substance to produce the desired effects (e.g., intoxication) or decreased effects when the same amount of substance is used over time.

2. Withdrawal refers to the physiologic, cognitive, and behavioral symptoms (a substance-specific syndrome) that occur when heavy use of substance(s) over a long period is stopped, and blood/tissue levels of the substance decline. In addition, the person usually takes the same or similar substance to relieve the symptoms of withdrawal.

3. Compulsive substance use pattern is characterized by the following:

a. The substance is used for longer than intended, or larger amounts are needed.

b. The person continually wants to stop or decrease use, and the individual tries but fails.

c. More and more time is devoted to obtaining, using, or recovering from the drug.

d. Substance use takes the place of previous activities (recreation, work, family/friends).

e. Use of substances continues despite, physical (cirrhosis, ulcers), legal (DUI, jail), and social/occupational problem (divorce, loss of job).

THE SUBSTANCES OF ABUSE

Alcohol

Alcohol is an orally ingested central nervous system (CNS) depressant that affects every system in the body (see Care Plan: Risk for Injury in this chapter, p. 388).

Physical, psychologic, and interpersonal dysfunction is a by-product of alcohol dependence. Alcoholism is a chronic disease and is the number-one drug problem in the United States that involves a legal substance.

The three major patterns of pathologic alcohol use are as follows:

1. Need for and consumption of large amounts daily

2. Regular and heavy weekend drinking

3. Long intervals of sobriety with intermittent heavy drinking binges that last weeks or months

Reports indicate an intergenerational familial pattern for alcoholism; members of an alcoholic family have a higher inborn tolerance for alcohol. Use and abuse of alcohol are often accompanied by use or abuse of additional psychoactive substances (polysubstance abuse). Nicotine dependence is a common accompaniment; other substances frequently used are cocaine, heroin, amphetamines, cannabis, sedatives, hypnotics, and anxiolytics.

Depression is often a concomitant disorder with alcohol dependence; however, the depression may be secondary to alcohol use, or individuals may drink to “fix” the dysphoria that is already present. Alcoholism and abuse of other substances are often complications in persons with bipolar disorder.

Amphetamines

Amphetamine is a CNS stimulant that is typically taken orally or inhaled but may also be injected. Use often begins for purposes of suppressing appetite or enhancing sexual activity and euphoria. Binges may be followed by a period when the individual is exhausted, depressed, irritable, anergic, and withdrawn (“crash”). Paranoia, sexual dysfunction, memory, and attention disturbances are also common with amphetamine dependence. Tolerance to this drug may occur rapidly, resulting in an inability to experience euphoria and an increase of adverse symptoms.

Caffeine

Caffeine consumption in the United States is a common daily occurrence, as a majority of people begin the day with one or more cups of coffee or tea. Many individuals continue throughout the day, evening, and night to drink caffeine-laden beverages that include sodas and cocoa (Table 9-2). Other frequently used products that contain caffeine are chocolate, over-the-counter cold remedies, stimulants, analgesics, and weight-loss medications.

**TABLE 9-2** Approximate Caffeine Amounts in Common Drinks and Drugs
Drug	Serving	Caffeine
Coffee	1 cup	100-150 mg
Tea	1 cup	50-75 mg
Cola	1 cup	30-50 mg
Over-the-counter substances and caffeine prescriptions	1 cup	⅓-½ strength of coffee
Migraine prescriptions	1 tablet	100 mg

Symptoms of caffeine intoxication include restlessness, anxiety, insomnia, psychomotor excitement, periods of inexhaustibility, speeded thoughts and speech, increased bowel and bladder activity, tachycardia or cardiac dysrhythmia, muscle twitching, and flushed face. To date, caffeine abuse and dependence have not been clearly defined in DSM-IV-TR. However, a caffeine withdrawal syndrome has been described that includes headache and may include fatigue, drowsiness, anxiety, depression, nausea, and vomiting.

Cannabis

The most common drugs in this group are marijuana, hashish, and purified THC (tetrahydrocannabinol), which are usually smoked but may be ingested orally. Cannabis may produce euphoria, calmness, drowsiness, and oneiroid states (dreamlike states while awake) or anxiety, paranoia, and, in very high doses or with long-term use, hallucinations.

Dependence on cannabis can be insidious because (1) many users are able to continue to function socially and occupationally and (2) the physical disorders that may accompany other drugs (cocaine, alcohol, heroin) are relatively lacking. Major problems related to long-term marijuana use are (1) extreme amotivation that renders the individual unable or unwilling to attend to tasks that require persistence; (2) anxiety states; and (3) physical symptoms such as chronic respiratory diseases, impaired immune responses, and hormonal dysfunction.

Cocaine

Cocaine, legally classified as a narcotic, produces extreme euphoria, so psychologic dependence may occur after the first use. Cocaine can be inhaled, injected, or smoked (“crack” or “freebase”), and in some cultures it is chewed as coca leaves. The clinical effects of cocaine are similar to the effects of amphetamines, and in addition to euphoria the individual may experience increased task performance, both mental and physical, and increased self-esteem. Intoxication occurs rapidly and is followed by a “crash” caused by dramatic depletion of serotonin. Withdrawal brings symptoms of dysphoria, fatigue, irritability, and anxiety; resultant depression is often accompanied by suicidal ideation.

“Crack” or “rock” cocaine has been labeled one of the most addictive drugs and is even more insidious, addictive, and toxic than cocaine. Cardiac dysrhythmias, which are caused by cocaine use in all forms, may lead to death. The number of babies born to mothers who use crack is significant, and they are likely to be born prematurely and have low birth weight and numerous neurologic problems. They are also subject to abuse and neglect, a problem that is currently considered to be of major proportions.

Long-term use of cocaine may produce the following:

▪ Inhaled: stuffy, runny nose; ulcerated or perforated septum

▪ Smoked: damaged lungs; increased susceptibility to infection

▪ Injected: HIV or other blood-related diseases; infections; embolism

Hallucinogens

Naturally occurring hallucinogens (psychedelics) are found in some species of mushrooms (psilocybin), in cactus (peyote), and in synthetic form (LSD [lysergic acid diethylamide]). Currently, young people are using MDMA (Ecstasy). Animal research has shown that MDMA can damage neurons that contain serotonin.

Hallucinogens are ingested orally and produce physical symptoms of tremors, heart palpitations, tachycardia, blurred vision, and diaphoresis. Psychologic symptoms include euphoria or dysphoria, (extreme perceptual disturbances). The person may experience perceived separation of self from the environment (depersonalization) or heightened sensual stimulation. Colors become brilliant; sounds, smells, and tastes are intense; and synesthesia (seeing sounds, hearing visions) may occur. Other symptoms include fear of going crazy, labile mood, experiencing two feelings at the same time, or an excessive sense of attachment toward or detachment from others.

Flashbacks and “bad trips” are often associated with the use of psychedelics. Flashbacks are a reexperiencing of the drug-induced state that occurs in the absence of recent ingestion of the drug—a reliving of the event. Bad trips refer to a frightening panic reaction to hallucinogen intake. Psychoactive substances may trigger latent psychotic disorders.

Inhalants

Inhalants are volatile substances such as hydrocarbons, esters, ketones, and glycols that are found in paints, glue, gasoline, cleaners, spray-can propellants, and typewriter correction fluids, among other substances. When breathed in through the mouth or nose, these substances act on the CNS, producing dizziness, ataxia, excitement, and euphoria that may lead to aggressiveness and impulsivity. Permanent kidney, liver, and brain damage can result, or death may occur because of depressed respiratory centers.

Nicotine

Nicotine is used most frequently by smoking cigarettes, but nicotine may also be taken by smoking pipes or cigars, chewing tobacco, and inhaling snuff. Cigarette smoking is the most difficult of these habits to break, and in 1989 the U.S. Surgeon General declared nicotine to be one of the most addictive drugs in the world. The difficulty in stopping nicotine use hinges on several factors, including the reinforcers of repeating the process so many times per day (one pack per day is approximately 7300 cigarettes per year multiplied by number of puffs per cigarette), the availability of cigarettes and the omnipresence of smokers, and the adverse symptoms that occur on withdrawal from cigarettes. Withdrawal symptoms include anxiety, irritability, nicotine craving, restlessness, increased appetite, and weight gain.

The number of smokers has decreased in the general public but has increased among women, adolescents, and African Americans. Cigarette smoking is associated with several diseases, including cancer, cardiovascular disease, and emphysema.

Opiates

Opiates are powerful pain relievers. Opium, the basic substance in this group, occurs naturally in the opium poppy. Several psychoactive substances are derived from opium, including morphine, heroin, and codeine. Many synthetic opiates are used in the United States, including propoxyphene (Darvon), meperidine (Demerol), and methadone (used in treatment programs to assist in withdrawal from natural opioids, especially heroin).

Opioids may be ingested, smoked, or nasally inhaled. Clinical effects include drowsiness, analgesia, decreased consciousness, mood changes, euphoria, and pleasurable feelings. Heroin, used medically in other countries because of its excellent analgesic properties, is illegal in the United States. Opiates are respiratory depressants and can lead to death through their direct effect on the respiratory centers of the brain. Deaths caused by heroin continue at an alarming rate in the United States because of increased use and unknown purity (potency) of the illegal drugs.

Heroin is the most commonly abused opiate; it is estimated that there are more than 600,000 heroin addicts in the United States alone. In countries where opiates originate (mainly the Middle and Far East), the incidence per capita is much higher. Once established, opiate dependence dominates the individual’s entire life and is very difficult to stop.

Narcotic analgesics (OxyContin, Vicodin, Percocet) continue to be abused in increasing numbers. Drug use normally begins with a physician’s prescription for pain relief and frequently evolves into abuse and dependence. As a result, clients may “doctor shop” to maintain the drug habit or seek the medications illegally.

Phencyclidine

Phencyclidine (PCP) and similarly acting arylcyclohexyl-amines such as ketamine or thienylcycloexylpiperidine (TCP) can be taken orally, taken intravenously, smoked, or inhaled. PCP and ketamine were originally used as general anesthetics but are now used only by veterinarians because of the severe symptoms that clients may experience when emerging from anesthesia.

Users of these drugs find the effects unpredictable, but many experience feelings of euphoria, warmth, floating sensations, and vivid fantasy in the form of hallucinations and oblivion. Users may also experience depersonalization, estrangement, and isolation. Psychosis can occur and may be more prevalent than currently recognized because of the unreliability of commonly used drug detection tests. Intoxication can lead to convulsions, coma, and death. Several deaths occur each year because of increased use of ketamine with other drugs during rave parties and other recreational settings.

Sedatives, Hypnotics, and Anxiolytics

A pattern of use relating to each substance in this category and leading to dependence usually begins through either (1) a prescription given by a physician that eventually fosters prominent drug-seeking behaviors in which the client may subsequently seek several physicians to obtain an adequate supply of the substance or (2) illegal sources obtained for the purposes of “getting high” with peers or for use with other illicit drugs to enhance, potentiate, or counteract effects. All sedatives, hypnotics, and anxiolytics are cross-tolerant with each other and with alcohol.

Benzodiazepines are among the most widely prescribed and abused legal drugs in the United States. Tolerance for remarkably high doses can occur, and, as is true for most other substances in this category, these drugs are capable of producing physical and psychologic dependence. Withdrawal from these substances by addicted individuals can cause death.

Polysubstance Dependence

Frequently, individuals who use psychoactive substances take several kinds either simultaneously or sequentially. For example, abusers of cocaine may also use alcohol or anxiolytics to contend with anxiety, or marijuana and opiate users may counteract the effects of those drugs by taking amphetamines, anxiolytics, or sympathomimetics.

Repeated use of at least three psychoactive substances (not including caffeine or nicotine) for 12 months or more, without the predominant use of one substance, fulfills the criteria for polysubstance dependence when dependence criteria are met.

INTERVENTIONS

Treatment Settings

Multiple levels of intervention are considered when treating clients who abuse or who are dependent on substances. Clients may voluntarily appear for treatment because of their personal needs and decisions for life changes. A client may arrive for treatment as a result of family or employer ultimatums. Clients may also be admitted involuntarily to an acute care facility because of results of drug use; the client may be dangerous to self, aggressive or dangerous toward others, or unable to meet basic living needs because of drug abuse. Whether the arrival is voluntary or involuntary, a thorough assessment of the client is imperative.

Treatment is started based on client assessment and history of drug use, including how long the client has been using before admission and the type and amount of drug. The nurse in an acute care setting is prepared to intervene with the client’s physical needs and problems in addition to one or more psychiatric disorders. Clients who have been using large doses of drugs over an extended period usually have neglected their physical health and nutrition.

Levels of Treatment

Three levels of intervention are usual for a person who has been using drugs heavily before admission. The first level of treatment focuses on acute care for detoxification and withdrawal. Biologic interventions include medications to prevent seizures, alleviate withdrawal symptoms (Box 9-3), and manage other psychiatric and medical symptoms. Replenishing fluids for adequate hydration, attention to nutrition that includes vitamin B supplements, and rest are provided.

BOX 9-3

Stages of Withdrawal from Alcohol

Stage 1 (8 hours or more after abstinence from alcohol): Mild tremors, nausea, anxiety, rapid heart rate, increased blood pressure, diaphoresis

Stage 2: Gross tremors, anxiety, hyperactivity, insomnia, anorexia, generalized weakness, disorientation, illusions, nightmares, hallucinations (mostly visual)

Stage 3 (12 to 48 hours after abstinence): All symptoms described in stages 1 and 2 plus severe hallucinations and grand mal seizures; stages 2 and 3 are known as delirium tremens

Stage 4 (3 to 5 days after abstinence): Initial and continuing delirium tremens manifested by confusion, severe psychomotor activity, agitation, sleeplessness, hallucinations, and uncontrolled and unexplained tachycardia

The nurse interacts with the client using principles for substance disorders and comorbid psychiatric diagnoses. Clients who abuse drugs may suffer from withdrawal effects soon after admission, so nurses need good physical nursing skills, clear boundaries, and kind but firm limit-setting skills to contend with the client’s unique personality, physical/psychologic craving for the substance, and drug-seeking behaviors.

The second level of treatment focuses on chronic health problems, both physical and psychologic, that result from excessive or long-term use of drugs. This treatment includes necessary medical support, psychoeducation groups that assist the client toward insight, self-help groups such as Alcoholics Anonymous (AA), individual therapy, support therapy, and family therapy.

The third level focuses on assisting the client to rebuild a life without drugs. The nurse helps the client develop plans for substituting healthy behaviors for drug-taking activities; replacing drug-using acquaintances with those who support sober living; building relationships; expanding the social support network; ensuring housing; securing finances; setting appointments and keeping a calendar; resolving to stay associated with a healthy therapeutic environment; and continuing to take responsibility for conducting own life without drugs.

Hospitalization

Overdoses of psychoactive substances can result in medical emergencies or death if intervention is not available. When available, intervention is usually focused on dysfunction or failure of the cardiorespiratory system. The person may be hospitalized after emergency treatment if indicated by the drug user’s physical or psychologic dysfunction (Box 9-4).

BOX 9-4

Levels of Consciousness in Substance-Related Emergencies

Full consciousness: Alert, responsive; oriented to person, time, place; intact recent memory; verbalizes spontaneously, coherently; articulates clearly

Impaired consciousness: Drowsy, lethargic, loss of recent memory, slowed thought processes with appropriate responses

Confusion/delirium: Transient periods of disorientation, restlessness; dazed, uncooperative, easily agitated, irritable, fearful, noisy; responsive to verbal stimuli and light tactile stimuli

Stupor: Responds only to repeated verbal stimuli and continuous, painful tactile stimuli

Coma: Response to intense stimuli either reflexive or absent

Physical conditions other than an overdose that warrant medical attention include drug toxicity, withdrawal syndrome, infections, and physical debilities such as dehydration, malnutrition, and allergic reactions. Psychologic impairment for which clients may be hospitalized can manifest in one or more psychiatric syndromes (aggressive behaviors that cause danger to self or others, or behaviors causing grave disability of the client). Examples include suicidal or homicidal threats, gestures, and attempts and the inability of the client to meet personal needs because of compromised mental state.

Medications

Clients admitted to treatment facilities may receive medications to alleviate acute symptoms of withdrawal from psychoactive substances. Most frequently prescribed medications are anxiolytics for excessive anxiety, antihypertensives to control blood pressure, and anticonvulsants to prevent seizures. After discharge, Antabuse (disulfiram) is a deterrent drug that causes a violent toxic reaction when alcohol is also ingested. It works by inhibiting the enzyme that prevents accumulation of acetaldehyde in the blood. Clients become nauseated, hypotensive, flushed, hot, dizzy, and numb and experience malaise.

**TABLE 9-3** Methadone Dosing Schedule for Opiate-Dependent Clients
Grade	Signs and Symptoms	Initial Methadone Dose^* (mg)
N ote: Hospitals and treatment centers that are not specifically licensed for detoxification of opiate dependence with methadone must limit the use of methadone for detoxication to 72 hours (Code of Federal Regulations, 1983).
h, Hours; IM, intramuscular; q, every.
^*Initial methadone dose is determined by the presenting signs and symptoms. This initial methadone dose is repeated in 12 hours. Supplementary doses of methadone (5 to 10 mg) are provided if withdrawal signs are either not suppressed or reappear during the first 24 hours. Once the initial 24-hour dose is established, the dose is tapered at a rate of 20% per day or every other day for a short-acting or long-acting opiate, respectively. Methadone is given on a q12h or q8h dosage schedule (q8–12h), with vital signs taken before each dose. It is unusual for a client to require more than 40 mg during the initial 24 hours of withdrawal. If the client is initially unable to tolerate oral medications, IM methadone (10 mg) should be given as soon as possible, followed with the initial oral dose of methadone, as calculated from the presenting grade of withdrawal.

1	Lacrimation, rhinorrhea, diaphoresis, yawning, restlessness, insomnia	5
2	Dilated pupils, piloerection, muscle twitching, myalgia, arthralgia, abdominal pain	10
3	Tachycardia, hypertension, tachypnea, fever, anorexia, nausea, extreme restlessness	15
4	Diarrhea, vomiting, dehydration, hyperglycemia, hypotension	20

▪ Clonidine (Both patches or tablets can be used. The patch is placed for up to 7 days.)

▪ Combination of naltrexone and clonidine

Acute Withdrawal Symptoms.

The following regimens are designed to manage the acute medical withdrawal symptoms of opiates such as heroin and morphine. Methadone is a synthetic opioid similar to morphine but tolerated orally.

Methadone and levomethadyl (hydrochloride) acetate (levo-alpha-acetylmethadol[LAMM]) maintenance are appropriate for clients with a long history (more than 1 year) of opiate abuse.

Naltrexone (ReVia), a nonaddictive substance, is an alternative pharmacologic treatment, and its effectiveness is limited by noncompliance and low treatment retention.

Naloxone (Narcan), a narcotic antagonist and synthetic cogener of oxymorphone, is indicated for the following:

▪ Complete or partial reversal of narcotic depression, including respiratory depression induced by opioids, as well as natural and synthetic narcotics

▪ Diagnosis of suspected or acute opioid overdose

There is no clinical experience with naloxone overdose in humans (DuPont Merck Pharmaceutical Company, 1990).

Anxiolytic/Hypnotic Withdrawal

A typical low-dose benzodiazepine withdrawal schedule is as follows:

▪ If the client is using long-acting benzodiazepines such as Librium, the current drug should be used and is tapered 20% per week. The tapering schedule is slowed toward the end if necessary.

▪ If the client is using short-acting benzodiazepines such as Serax, a long-acting benzodiazepine should be considered, and the tapering schedule described previously is used.

▪ Alprazolam (Xanax) is tapered slowly, and a dose reduction should not exceed 0.5 mg every 3 days.

High-dose withdrawal involves the following; tolerance testing is used before a withdrawal procedure is initiated:

▪ Diazepam is commonly used with tolerance testing, and if the tolerance test is positive, the client can be started with diazepam at 40% of the test dose, gradually tapering by 10% every week. Daily dosages should be divided.

▪ If the client is using long-acting benzodiazepines, begin with 40% of the current dose, and taper 10% every week.

▪ Dosages should be adjusted upward if withdrawal symptoms occur and should be reduced if the client is intoxicated.

Therapies

Individual Therapy

Problems often seen in clients with substance abuse and dependence include denial, low self-concept and self-esteem, anger, manipulation, and dependency needs. Interventions for these problems are located in care plans throughout the text. Denial is a major defense mechanism in drug abuse, and the client must admit and face the drug problem before recovery is possible. Another priority includes support of the client in his or her journey to wellness. This support is best provided within a trusting relationship.

The nurse provides a mature, nonjudgmental role model and firm, kind limit setting for manipulative behaviors. Realistic encouragement and support are also given as the client learns new ways to tolerate life’s inevitable anxieties without drugs and to expand his or her social support network to include healthy, sober significant others.

Group Therapy

Substance dependence group meetings are an integral part of treatment and provide the individual with support, education, necessary confrontation, coping strategies, and a social network.

Self-Help Groups.

The 12-step program of AA is the model for other self-help groups that provide support for the client as he or she attains and maintains abstinence. Al-Anon is a group that provides education and support for spouses or significant others, and Alateen provides support for children of the recovering client.

Confrontation Interventions

Constructive confrontation is often necessary to affect behavioral change. On that premise the family, boss, friends (all significantly involved individuals) meet with the client in this intervention. Each member, openly and honestly states how the client’s drug use has impacted his or her life, for example:

Child: Dad, you missed all my games in school because you were drunk.

You really hurt me when you didn’t make it to my graduation.

Wife: We haven’t had a romantic or intimate evening in 3 years because you are always intoxicated.

You think you’re a good lover, but you never think of me any more.

Boss: Your performance has deteriorated to the point that I’m going to have to let you go.

Then each person tells the client what must change (treatment plan) or suffer consequences.

Behavior Modification

Modification of behavior is a necessary step to recovery from substance dependence, and learning new strategies and techniques provides a method for mastering the environment. Behavior therapy can supply the individual with skills through relaxation training, thought and behavior substitution for self-control, and assertiveness training, to name a few (see Appendix G).

Behavioral aversion programs in the form of electric shocks or medications that produce vomiting upon drug intake have lost popularity.

Halfway Houses

Transitional living arrangements provide recovering substance abusers interim homes and programs between detoxification and the eventual permanent home. They allow a slow adjustment to the community and ease the client’s return home, which may have been a source of difficulty before becoming sober. Family therapy seems to be an essential component of successful recovery.

Employee Assistance Programs

Many employers have established employee assistance programs (EAPs) to help employees recover from drug or alcohol dependence while retaining their positions; some make participation mandatory if the individual desires continued employment. Statistics for loss of dollars from lost productivity related to substance dependence have risen dramatically in the past decade, and EAPs have proved profitable alternatives to firing trained and skilled personnel.

Family Therapy

Family therapy is a critical component in the ongoing recovery of the person who uses alcohol or drugs, as members attempt to eliminate enabling and codependent behaviors that perpetuate the problem. Therapy is directed toward helping the family gain awareness of the negative effects of enabling and codependent behaviors and developing strategies based on confrontational approaches and appropriate support (refer to Care Plan: Disabled Family Coping, p. 383). Support and encouragement of the client/family unit are emphasized.

PROGNOSIS AND DISCHARGE CRITERIA

Prognosis for substance-related disorders is guarded and depends on many factors, including:

▪ Length of time drugs were abused

▪ Type of drugs abused

▪ Familial history

▪ Unique biology

▪ Current stressors

▪ Past experience and success at managing own life responsibly

▪ Desire (and commitment) to be sober

▪ Degree of self-honesty

▪ Motivation for life change

▪ Support network

▪ Access to therapeutic contacts

▪ Involvement with self-help groups

Some clients with drug problems complete treatment the first time and remain sober, while other clients have to repeat treatment several times (recidivism). Some clients do not succeed in staying sober. Nurses remain hopeful and appropriately supportive but realistic when treating clients. Avoidance of enabling is crucial, in conjunction with encouragement and healthy support.