Violence and nursing response

Chapter 26 Substance Abuse Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. More deaths, illnesses, and disabilities are attributed to substance abuse than to any other preventable health conditions in the United States. – Substance Abuse and Mental Health Services Administration (SAMSHA) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2 Social Consequences of Substance Abuse      Crimes while under the influence of drugs, alcohol, or both Need for money to buy substances Specific theft of drugs Almost 75% of inmates report prior drug use All aggregates in society are potentially affected by substance abuse problems regardless of age or economic level Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3 Etiology of Substance Abuse  Numerous theories try to explain it ➢ Combination of many factors ➢ Genetics within families ➢ Individual (impulsivity and ease of disinhibition) ➢ Environmental factors ➢ Medical models ➢ Biopsychosocial models Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4 Historical Overview of Alcohol and Illicit Drug Use   Alcohol use has gained more social acceptance than other drug use. Public attitudes and governmental policies have also influenced the history of illicit drug use. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5 Historical Overview of Alcohol and Illicit Drug Use (Cont.)  Consumption and laws affected by: ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ Alcohol-related deaths after lowered drinking age Less tolerant national attitudes toward drinking Increased societal and legal pressures and actions against drinking and driving Increased health concerns among Americans Knowledge of addictive properties Counterculture acceptance of hallucinogens, cannabis, and heroin The “War on Drugs” Renewed interest in prevention/treatment efforts Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6 Laws Impacting Substance Abuse  Anti–Drug Abuse Acts of 1986 and 1988 ➢ ➢ ➢  Increased funding for treatment and rehabilitation Created the Office of National Drug Control Policy (“drug czar”) Worked on a public health approach to drug control National Institute on Drug Abuse (NIDA) ➢ Science on drug abuse and addiction • Prevention • Treatment • Decreasing the spread of HIV/AIDS • Other priority areas Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7 Laws Impacting Substance Abuse (Cont.)  Substance Abuse and Mental Health Services Administration (SAMHSA) ➢ Builds and sustains programs, policies, information and data, contracts, and grants toward helping the nation act on the knowledge that promotes behavioral health treatment through all levels of prevention Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8 Prevalence, Incidence, and Trends  Alcohol use by persons aged 12 or older: ➢ Slightly more than half (52.8%) drink alcohol ➢ Binge drinking at least once in prior 30 days— (22.6%) ➢ Heavy drinking—6.2% ➢ Young adults ages 18-25 had highest prevalence of binge and heavy drinking—39.8% ➢ Drove under the influence of alcohol at least once in past year—11.1% – SAMHSA (2011) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9 Prevalence, Incidence, and Trends (Cont.)  Illicit drug use by persons aged 12 or older: ➢  About 8.7% were current drug users, used an illicit drug during the past month Illicit drugs used ➢ ➢ Marijuana was the most commonly used drug Others included cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) used nonmedically – SAMHSA (2011) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10 Prevalence, Incidence, and Trends (Cont.)  Nonmedical use of prescription-type psychotherapeutics ➢ There is a significant increase in the lifetime nonmedical use of pain relievers—specifically Percocet®, Percodan®, Vicodin®, Lortab®, Darvocet®, Darvon®, Tylenol® with Codeine, Propoxyphene, or Codeine Products, Oxycodone, and Hydrocodone – NIDA (2010) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of

Elsevier Inc. 11 Prevalence, Incidence, and Trends (Cont.)  Hallucinogen, inhalant, and heroin use ➢ LSD (d-lysergic acid diethylamide) ➢ Peyote cactus ➢ Psilocybin ➢ PCP (phencyclidine) ➢ Inhalants of choice are amyl nitrite, “poppers,” followed by glue, shoe polish, or toluene; correction fluid, degreaser, or cleaning fluid; gasoline or lighter fluid; and spray paints and other aerosols. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 12 Prevalence, Incidence, and Trends (Cont.)  Gender difference ➢ ➢  Geographic trends ➢  Males more likely to be current illicit drug users Female illicit drug use (12 and older) increasing Highest in West > Midwest > Northeast > South Racial/ethnic groups ➢ Highest among American Indians or Alaska natives > African Americans> whites > Hispanics > Asians – SAMHSA (2010) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13 Trends in Substance Abuse     May or may not relate to classically or clinically defined dependence or addiction. Many are turning to recovery before they have developed physiological dependence. Need to differentiate between use and misuse/abuse. Use of harmful substances is indirectly and directly related to all of the leading health indicators targeted in Healthy People 2020. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14 Methamphetamine (MA)

    Most widely produced controlled substance in the United States. Illegal street names of the drug (crank, crystal, meth, ice, or glass). Can be injected, inhaled, taken orally, or smoked. Used predominantly by white young persons, with an overrepresentation of females. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15 Methamphetamine (MA) (Cont.)  Pleasurable effects are caused by the release of high levels of dopamine in the brain, leading to increased energy, a sense of euphoria, and increased productivity. ➢ ➢  Short-term effects: increased heart rate, insomnia, excessive talking, excitation, and aggressive behavior Prolonged use results in tolerance and physiological dependence Negative consequences range from anxiety, convulsions, and paranoia, to brain damage. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16 Methamphetamine (MA) (Cont.)

 The impact of MA abuse on communities, families, and social networks is considerable. ➢ Young children of users are at risk for abuse and neglect. ➢ Prenatal use puts children at risk for developmental problems, aggression, and attention disorders. ➢ Exposure to combustible second-hand fumes. ➢ Associated with increased incidence of violence (e.g., domestic abuse, homicide, and suicide) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17 Steroids  Anabolic steroids are synthetic variants of male sex hormone testosterone ➢ ➢  Build muscle and said to be androgenic Most commonly used in athletes and other individuals willing to risk potential and irreversible health consequences to build muscle Potentially fatal risks ➢ ➢ Blood clots, liver damage, premature cardiovascular changes, increased cholesterol Increased potential for suicide and aggressive and risky behaviors Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18 Inhalants  Contain volatile components with psychoactive properties ➢   Many products found in home or workplace (e.g., spray paints, markers, glues, and cleaning fluids) Produce a rapid high that may resemble alcohol intoxications; may progress to loss of sensation and even unconsciousness Irreversible effects: ➢ Hearing loss, limb spasms, CNS or brain damage, or bone marrow damage; may result in death from heart failure or suffocation Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19 Adolescent Substance Abuse  Highest prevalence of illicit drug use during lifetime between 18 and 25 years ➢ Teen use of cigarettes and smokeless tobacco has declined ➢ Nearly half of teens try marijuana before they graduate—skepticism about drug’s danger  As harmful, illicit substances come in and out of vogue, CHN needs a good understanding of drug culture, terminology, and differing signs and symptoms Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20 Conceptualizations of Substance Abuse

   Conceptualizations have changed over the years, often for political and social reasons rather than for scientific reasons. “Dependence” or “abuse” What substances can be abused? ➢ APA focuses on alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, and hypnotics or anxiolytics Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21 Defining Substance Abuse  Substance abuse: a maladaptive pattern of substance use that is manifested by recurrent and significant adverse consequences related to repeated use of a substance. ➢ Failure to fulfill major role obligations ➢ Repeated use in physically hazardous situations ➢ Multiple legal problems ➢ Recurrent social and interpersonal problems Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 22 Defining Substance Abuse (Cont.)  Dependence: a cluster of cognitive, behavioral, and physiological symptoms that indicate continued use of the substance despite significant substance-related problems ➢ ➢ ➢ ➢ Pattern of repeated, self-administered use Tolerance, withdrawal, and compulsive drug-taking behaviors A craving or strong desire for the substance Preoccupation with supply, money to purchase, and getting through time between periods of use Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 23 Sociocultural and Political Aspects of Substance Abuse    Determined largely by economic, cultural, and political conditions of potential users Cultural conditions create ambiguity in clearly determining when a problem exists. Competing value systems lead to cultural disintegration and a sense of powerlessness and hopelessness. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 24 Course of Substance-Related Problems  Path from initiation to dependency is multidimensional.

➢     Person + substance + context/environment Progression varies—from initiation to continuation, transition to abuse, and finally, addiction and dependency Critical point is transition from use to abuse Addiction/dependency marked by changes in both behavior and cognition Once addiction is established, withdrawal symptoms are strong motivators to continue use Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 25 Legal and Ethical Concerns  U.S. policy based on prohibition and criminal sanctions against use and sale of illicit drugs ➢ ➢ ➢  Criminal activities (violence and drug trafficking) Drinking and driving, working while intoxicated Impact on fetus (FAS) Modes of intervention ➢ ➢ ➢ ➢ Limit access Media campaigns Educational programs National organizations that promote community education, research, and support Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 26 Prevention Strategies Violence and nursing response

 Primary prevention ➢ Needs assessment to identify high-risk situations and potential problems ➢ Decriminalization and legalization of drugs(?) ➢ Community-based programs ➢ Training of health professionals ➢ Faith-based initiatives ➢ Volunteer consumer groups ➢ Organized sports programs ➢ Employer programs  Often overshadowed by “War on Drugs” Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 27 Prevention Strategies (Cont.)  Secondary prevention ➢ ➢ ➢ ➢ Screening and finding resources • CAGE: an alcoholism screening test • Clinical Institute Withdrawal Assessment (CIWA) • Use evidence-based programs Efforts should be specific to aggregates, rather than directed at the “general public” Incorporate culturally sensitive and appropriate interventions and strategies Work toward improving individuals’ general competencies, communication skills, and selfesteem Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 28 Treatment  For individuals, consider: ➢ Cultural and educational background ➢ Resources of the person ➢ Attitudes of significant others ➢ Degree of invasiveness of the effects of the substance use The existence of alternatives ➢ Relapse prevention Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 29 Treatment (Cont.)  Inpatient and outpatient treatment programs Violence and nursing response

➢ May or may not include detoxification component ➢ Voluntary vs. compulsory ➢ Pharmacologically based vs. drug free ➢ Treatment approaches and models vary     Assessment process is of primary importance. Therapeutic relationship based on trust is essential. Physical examination is a valuable tool. Nonjudgmental attitude minimizes defensiveness. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 30 Treatment (Cont.)  Programs usually include: ➢ Group and individual therapy and counseling ➢ Motivational interviewing ➢ Family counseling ➢ Education ➢ Socialization into 12-step mutual self-help groups ➢ Integrate psychotherapy with pharmacotherapy ➢ May include other strategies: • Hypnosis, occupational therapy, confrontation, assertiveness training, blood alcohol level discrimination training, behavior modification approaches Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 31 Treatment (Cont.)  Pharmacotherapies ➢  Mutual help groups Violence and nursing response

➢  Used in detoxification, stabilization, maintenance, as antagonists, and as treatment for coexisting disorders Operate through face-to-face supportive interaction focusing on a mutual goal; AA was first Harm reduction ➢ Elimination of the more harmful effects of substance use through behavior and policy modifications Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 32 Social Network Involvement Therapy that involves the family has proved to be most effective in aiding recovery.  Family and friends ➢ Highly influential or aid and abet ➢ Codependency and enabling  Effects on the family ➢ ➢  Functional or dysfunctional families Psychological and financial burdens Professional enablers ➢ ➢ Treatment of symptoms by medication Reluctant to bring up this taboo subject Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 33 Vulnerable Aggregates: Preadolescents and Adolescents Violence and nursing response

     Times of experimentation, searching, confusion, rebellion, poor self-image, alienation, and insecurity Use of legal substances (e.g., tobacco, alcohol) almost always precedes use of illegal drugs. Poor school performance and drug use among peers are strongest predictors of subsequent drug involvement, followed by lack of strong family bond. The younger the initiation, the greater the probability of prolonged and accelerated use. Feeling of powerlessness; selling drugs seen as a viable economic solution to poverty. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 34 Vulnerable Aggregates: Preadolescents and Adolescents (Cont.)  Primary prevention focuses on: ➢ ➢ ➢ ➢ ➢ ➢ ➢ Violence and nursing response

Advocating for these vulnerable children Educating teachers on the vital importance of maintaining a validating, nonjudgmental attitude toward these students Supporting strong families in the community Improving knowledge through education and media Early detection of predisposing factors Providing structured clubs and organizations Facilitating school success, career skills, family communication skills, and conflict resolution Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 35 Vulnerable Aggregates: Elderly  Elderly experience ➢ Diminished physiological tolerance ➢ Increased use/misuse of medically prescribed drugs ➢ Cultural and social isolation  Misuse of prescription drugs may be the most common form of drug abuse among the elderly ➢ Use prescription medications approximately three times as frequently as general population Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 36 Vulnerable Aggregates: Women Violence and nursing response

  Alcohol use and abuse affects women much differently than men. Women absorb and metabolize alcohol differently. ➢ ➢ Body composition differences and production of less gastric alcohol dehydrogenase Metabolize alcohol at a different rate Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 37 Vulnerable Aggregates: Women (Cont.)  Increased risk stems from economic, social, and cultural factors. ➢ Marginalization of certain groups ➢ History of child abuse ➢ Physical and medical problems related to reproductive systems ➢ Use during pregnancy has long-term developmental consequences for the newborn Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 38 Vulnerable Aggregates: Ethnocultural Considerations  African Americans, Hispanics, and Native Americans—increased risk for substance abuse. ➢ ➢ ➢ ➢ ➢ ➢  Economically disenfranchised groups Discrimination and racism Socioeconomic, political, and historical realities Myths and stereotypes Social support—positive effect on treatment/outcome Environmental cues and conditioned reinforcement Treatment poses special challenges. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 39 Vulnerable Aggregates: Other Aggregates  Substance abuse is most common psychopathological problem in the general population. ➢ ➢ ➢ ➢ Dual-diagnosis individuals • Psychiatric disorder + substance abuse disorder Risk for multiple vulnerabilities in one individual Impact of substance abuse on STDs Substance abuse among health care professionals Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 40 Nursing Interventions in the Community       Understand own experience Violence and nursing response