Psychoactive Substance Abuse
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abuse(a-bus') [ L. abusus, wasting, misuse]
All health care providers, teachers, and others who work with children are responsible for identifying and reporting abusive situations as early as possible. Risks for abuse may be assessed by identifying predisposing parental, child, and environmental characteristics, but these are not by themselves predictors of actual abuse. A detailed history and thorough physical examination should be carried out. Findings should be assessed not only in comparison to known indicators of maltreatment but also in light of diseases or cultural practices that can simulate abuse. Nurses play an important role in identifying child abuse since they often are the first health care contacts for child and family, e.g., in the emergency department, physician's office, clinic, or school.
Physical neglect may be evidenced by failure to thrive, signs of malnutrition, poor personal hygiene, dental neglect, unclean or inappropriate dress, frequent injuries from lack of supervision, enuresis, and sleep disorders.
Emotional abuse (belittling, rejection) and neglect may be suspected but are difficult to substantiate. Physical abuse is not always obvious and may be difficult to diagnose. Overt evidence of abuse includes bruises and welts, imprint burns (forming the shape of a cigarette tip or other item), immersion burns (socklike on feet and legs or donut-shaped on buttocks or genitalia), spiral fractures and dislocations of limbs, facial and rib fractures, abrasions and lacerations in various stages of healing, human bite marks (with tissue compression and contusion), and chemical poisonings. Behavioral indicators include self-stimulating behaviors; lack of social smile and stranger anxiety during infancy; withdrawal; unusual wariness; antisocial behavior (destructiveness, cruelty, stealing); being indiscriminately friendly or displaying unexpected affection; developing only superficial relationships; acting out to seek attention; being overly compliant, passive, aggressive, or demanding; delays in emotional, language, and intellectual developmental; and suicide attempts.
Symptoms in the older child include begging or stealing food, frequent school absences, vandalism, shoplifting, or substance abuse.
When sexual abuse is suspected, a thorough but gentle physical examination must be conducted. Physical indicators may include any injury to the external genitalia, anus, mouth, and throat; torn, stained, or bloody undergarments; pain on urination or recurrent urinary tract infections; pain, swelling, unusual odor, and itching of the genitalia; vaginal or penile discharge, vaginitis, venereal warts, or sexually transmitted diseases; difficulty with walking or sitting; or pregnancy in the young adolescent. In most cases, the child knows the sexual abuser; in about half the cases the abuser is a caregiver or parent.
Abuse should be suspected in the presence of physical evidence, including old injuries; conflicting stories about an accident or injury from parents or others; injury blamed on siblings or another party; injury inconsistent with the history given; a history inconsistent with the child's developmental age; a chief complaint not associated with physical evidence; inappropriate level of parental concern (absence or an exaggerated response); refusal of parents to sign for needed tests or treatments; excessive delay in seeking treatment; absence of parents for questioning; inappropriate response of the child (little or no response to pain, fear of being touched, excessive or deficient separation anxiety); previous reports of abuse in the family; and/or repeated visits to emergency facilities with injuries (this may require checking with other facilities). Suspicions may be aroused by a feeling that behaviors are “not right.”
The first priority of care for the abused child is prevention of further injury. This usually involves removing the child from the abusive situation by reporting the situation to local authorities. All U.S. states and Canadian provinces have laws for mandatory reporting of such mistreatment. If evidence of abuse is supported, further action is taken. Care consistent with that for a rape victim is provided when sexual abuse is present. All needs of the abused child are considered as they would be for any other child. Caregivers act as role models for parents, helping them to relate positively to their child and fostering a therapeutic environment: there is no accusation or punishment, only concern and treatment to help parents recognize and change abusive behavior. Referral to self-help groups, resources for financial aid, improved housing, and child care are important to help families deal with overwhelming stress.
Educational programs in the prenatal period, infancy home visits, and outpatient parent groups provide opportunities for health care providers to inform families about normal growth and development and routine health care. Families can also share their concerns, gain support from others, and obtain referrals to appropriate services when needs are identified. Prevention of sexual abuse focuses on teaching children about their bodies, their right to privacy, and their right to say no. Parents and school nurses can discuss such topics with children, using “what if” questions to explore potentially dangerous situations. Everyone ought to know that “nice” people can be sexual abusers and that a change in a child's behavior toward a person requires investigation. The child must always be reassured that whatever happened was not his or her fault. Prevention of false accusations is also important. Caregivers play an important role by carefully documenting all evidence of abuse and recording exactly what they observed on examination and what behaviors occurred without interpreting their meaning.
For further information on abuse or reporting abuse, contact: U.S. Department of Health and Human Services Children’s Bureau: Childhelp USA’s National Child Abuse Hotline at 1-800-4 A CHILD (http://www.acf.dhhs.gov/programs/cb/); Prevent Child Abuse America at 1-800-CHILDREN or 312-663-3520 (http://www.preventchildabuse.org); or National Clearinghouse on Child Abuse and Neglect Information at 1-800-394-3366 or 703-385-7565 (http://nccanch.acf.hhs.gov).
Domestic violence should be considered in any patient who presents with unexplained bruises, lacerations, burns, fractures, or multiple injuries in various stages of healing, esp. in areas normally covered by clothing; delays seeking treatment for an injury; has a partner who is reluctant to leave the patient alone or is uncooperative or domineering; indicates that he or she has a psychiatric history or drug or alcohol problems; presents with injuries inconsistent with the “accident” reported; expresses fear about returning home or for the safety of children in the home; or talks about harming himself or herself. Professional health care providers should screen such patients privately to ensure confidentiality and patient safety. “Do you feel safe at home?” may elicit a history of abuse. A sympathetic and nonjudgmental manner helps victims communicate. Scrupulous documentation of evidence of abuse is critical. Reporting is mandatory in many states.
Health care workers, many of whom have easy access to narcotics, are at high risk of abusing analgesics. Increased awareness of this problem has led hospitals to establish special programs for identifying these individuals, esp. physicians, nurses, and pharmacists, in order to provide support and education in an attempt to control the problem and prevent loss of license.
In the U.S., the abuse or misuse of prescription drugs has been identified by the Centers for Disease Control and Prevention (CDC) as a growing problem. In 2007, for example, the CDC reported that more than 27,500 Americans died of drug overdose, an increase of more than 100% in the preceding ten years. More than five times as many people died from misuse of prescribed opioids as from heroin.
The assessment of older people thought to have been abused includes looking for evidence of impairment in caregiver relationships to the aged and in finding unusual patterns of injuries or illnesses unlikely to occur from disease. When abuse is suspected, questions such as “Do you feel safe and well cared for at home?” or “Has someone hurt you?” or “Did someone do this to you?” may elicit a history of abuse if the patient is mentally competent. Careful documentation of historical and physical findings (including discrepancies between patient and caregiver reports) and notification of legal authorities (such as a local adult protective services agency, long-term-care ombudsman, or the police) are mandated in most jurisdictions. Resources for health care providers include the National Center on Elder Abuse Phone (202-898-2586; www.elderabusecenter.org); Adult Protective Services (www.elderabusecenter.org/default.cfm?p=apsstate.cfm); The National Long Term Care Ombudsman Resource Center (202-332-2275; www.ltcombudsman.org); The U.S. Administration on Aging Elder Care Locator (1-800-677-1116; www.eldercare.gov/Eldercare/Public/Home.asp).
Health care providers can also help the elderly by educating them about the potential for abuse (such as in community education and outreach programs), explaining that abuse can be physical, emotional, or financial, and that even people who appear to be kind can be abusive. Talking points include recommendations that the elderly remain active and engaged with others in the community and that they get help and representation from ombudsmen or family lawyers who can be trusted to represent their interests.
medical child abuse
psychoactive substance abuseSubstance abuse.
solvent abuseSee: glue-sniffing
Psychoactive Substance Abuse
|Mean LOS:||11.7 days|
|Description:||MEDICAL: Alcohol/Drug Abuse Or Dependence With Rehabilitation Therapy|
Psychoactive substances are drugs or chemicals that have an effect on the central nervous system (CNS). The National Institute of Drug Abuse defines drug abuse or drug dependence as a condition in which the use of a legal or illegal drug causes physical, mental, emotional, or social harm. Drug usage impairs one’s ability to perform daily activities of living and function in work environments. Relationships with family and friends become impaired and dysfunctional.
Most of the abused drugs fall into two main categories, CNS depressants and CNS stimulants. CNS depressants include narcotics, sedatives, barbiturates, tranquilizers, and inhalants. The desired effect by the user is a sense of increased self-esteem, euphoria, relaxation, and relief from pain and anxiety. CNS stimulants include amphetamines, hallucinogens, and cocaine. The desired effect by the user is a sense of well-being, alertness, excitation, overconfidence, and increased initiative.
Tolerance to the drug results in the need for increasing amounts, and the physiological and psychological dependence on the drug leads to maladaptive behaviors. Attempts to discontinue or control use of the drug lead to withdrawal symptoms, which, if left untreated, can range from flu-like symptoms to coma and possibly death. The withdrawal from a drug produces feelings and sensations opposite of the effects produced by using the drug. Withdrawal can be treated to avoid withdrawal symptoms. Chronic abuse of psychoactive substances may lead to complications, including pulmonary emboli, respiratory infections, trauma, musculoskeletal dysfunctions, psychosis, malnutrition disturbances, gastrointestinal disturbances, hepatitis, thrombophlebitis, bacterial endocarditis, gangrene, and coma.
Nonmedical use of prescription medications is a serious epidemic in the United States. Approximately 7 million (2.8%) persons aged 12 or older use prescription-type psychotherapeutic drugs nonmedically each month. Of these, at least 5 million use pain relievers. The epidemic of nonmedical use of prescription opioids (NUPO) affects teens and adults, but the effect on the life of adolescents is serious. The Office of National Drug Control Policy, in its analysis of the emerging drug threat, noted that (1) teens are turning away from street drugs and using prescription drugs to get high; (2) new users of prescription drugs have caught up with new users of marijuana; (3) next to marijuana, the most common illegal drugs teens are using to get high are prescription medications; and (4) pain relievers such as OxyContin (oxycodone) and Vicodin (hydrocodone/acetaminophen) are the most commonly abused prescription drugs by teens.
The cause of substance abuse is complex and involves many factors, including the type and availability of the drug, personality type, environmental factors, peer pressure, coping abilities of the individual, genetic factors, and sociocultural influences. Cocaine dependence is thought to be associated with a deficiency in dopamine and norepinephrine neurotransmitters. Use of narcotics and opiates may interfere with the biochemical factors related to the body’s own production of opiate-like substances.
A psychological factor that seems common to all forms of substance abuse is low self-esteem. Also found are feelings of inadequacy, loneliness, shame, and guilt that lead to depression and a sense of hopelessness and despair. Sociocultural factors have significant influence. Increasing numbers of individuals experience family breakup and separation, school failure, poverty, unemployment, “living in the fast lane,” and stressors related to highly competitive work environments. Teenagers and young adults often begin experimenting as a result of peer pressure and the easy availability of drugs.
The ways in which genes influence behavior are complex, and definitive studies have proved elusive. Finding genetic causes of susceptibility to substance abuse has been difficult. Genes associated with predisposition to dependence and risky behaviors include those encoding the dopamine D4 receptor, phosphodiesterease 1B, the AMPA receptor subunit GluR1, 5HT1B receptor, protein kinase C, and the transcription factor FosB. Variations in monoamine oxidase B (MAOB) influence a behavioral response to novelty. A decreased expression of the gene encoding the 5-HTT transporter may also be associated with an increased risk for substance use disorders.
Gender, ethnic/racial, and life span considerations
Drug use and abuse are prevalent across the life span from young adolescents to the elderly. Increasing numbers of the elderly are abusing drugs as a way of coping with the stressors of aging. Young teens are vulnerable to experimentation as they attempt to conform to group norms and peer pressure. The typical users of barbiturates, sedatives, and tranquilizers are middle-class, middle-aged women. NUPO is epidemic among teenagers and college-age students, and opioids are the most commonly abused drugs after alcohol and marijuana by people 14 years of age and older. Cocaine use is often seen in younger adult professionals, entertainers, and business executives. Marijuana usage is seen most frequently in teens and young adults, but there is no propensity for any race or ethnicity. Club drugs such as methylene-dioxymethamphetamine (MDMA, Ecstasy, Adam, clarity, Eve, lover's speed, etc.), flunitrazepam (Rohypnol, forget-me pill, roofies), and gamma-hydroxybutyrate (GHB, G, Georgia home boy, liquid ecstasy) are used primarily by adolescents and young adults at bars, nightclubs, concerts, and parties. Rates of current cocaine use are slightly higher for African Americans and Hispanic/Latinos as compared with other populations. Males have a higher rate of current cocaine and marijuana use than females.
Global health considerations
An estimated 16 million people are injecting drug users globally. Excluding alcohol, the World Health Organization estimates that the total number of illicit drug users overall around the world is more than 300 million people, or up to 6% of the global population ages 15 to 64. Cannabis remains by far the most widely used drug (220 million people), followed by amphetamine-type stimulants (80 million people including amphetamine and ecstasy users). The number of opiate/opioids abusers is approximately 56 million people. About 20 million people use cocaine. NUPO is growing exponentially in developed nations.
The physiological signs and symptoms of use or intoxication vary, depending on the substance. Consequently, when a person is admitted in an intoxicated state or in withdrawal, it is important to know what drug or drugs have been used, the route used, and if possible, the amount of drug used. Determine if alcohol is also being used because there is a synergistic effect that increases the effect of both drugs.
Some patients may be misusing and abusing psychoactive drugs through ignorance. Others may have begun using them as part of a physician-prescribed treatment regimen and then became addicted. If the individual is unable to give a history because of overdose, friends or family members may provide needed information, and clothing can be checked for drug paraphernalia. Elicit a history of previous detoxification treatments, effectiveness, length of recovery, and what influenced a return to drug usage.
The most common symptoms depend on the illicit drug (see Table 1 below). If the patient is admitted with intoxication and a drug history cannot be obtained, signs and symptoms can be indicators of the type of drug used (Table 1). Inspect the patient for evidence of how the drug is used, such as needle marks from mainlining, nasal irritation caused by snorting, ulcerations on lips and tongue from chewing, cellulitis from injecting drugs and missing the vein, and infections from sites used for mainlining.
|Marijuana (cannabis)||Euphoria, fatigue, decreased coordination, paranoia, panic, psychosis||Cravings, appetite loss|
|Narcotics||Small pupils, shallow respirations, increasing unresponsiveness, seizure activity||Tearing of the eyes, runny nose, anorexia, nausea, abdominal cramping and pain, irritability, shaking chills, diaphoresis|
|Depressants/barbiturates||Dilated pupils, shallow breathing, diaphoresis, thready and rapid pulse, increasing unresponsiveness||Shakiness, anxiety, sleeplessness, shaking, seizure activity|
|Stimulants/amphetamines, cocaine||Fever, anxiety, restlessness, hypertension, agitation, hallucinations, seizure activity||Depression, sleepiness, fatigue, apathy, irritability, weight gain|
Obtain information on how the patient perceives the effect drugs have on her or his life, work, and the relationship with family and friends. Identify strengths and limitations. Assess the patient’s emotional state before admission, especially noting depression and thoughts about suicide. If the patient is involved in a relationship, determine the degree of stability. Ask whether the partner uses drugs and what her or his attitude is toward the patient’s drug use. If the patient is a parent, find out the children’s ages and investigate how the children are affected by the patient’s drug use.
Elicit an employment history, including the type and length of employment. Determine how the use of drugs has affected the patient’s work. Determine how much time off from work has been caused by the drug use. Establish a history of the financial effects of the drug use; ask how much the patient spends on drugs and if he or she has developed other sources of income besides his or her job. Determine how the use of drugs has affected the patient’s financial resources.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Serum and urine drug screens||Negative for screened substance||Positive for screened substance||Identify drugs that have been ingested|
Other Tests: Gas chromatography–mass spectrometry. For unresponsive patients with suspected drug overdose—serum glucose, complete blood count, blood urea nitrogen, serum electrolytes, arterial blood gases, electrocardiogram, chest x-ray.
Primary nursing diagnosis
DiagnosisSelf-esteem disturbance related to immaturity, personal vulnerability
OutcomesSelf-esteem; Body image; Hope; Mood equilibrium; Role performance; Social interaction skills
InterventionsCounseling; Substance use treatment: Withdrawal and/or overdose; Therapy group; Support group; Emotional support; Mood management; Substance use treatment and prevention
Planning and implementation
The immediate goal after depressant ingestion is to keep the individual safe during a drug overdose or withdrawal. The long-term goal is for the patient to remain drug-free. In the acute phase, the immediate effects of narcotics can be reversed with naloxone (Narcan). In the case of barbiturate overdose when the patient is conscious, mild intoxication can be treated by letting the individual “sleep it off.” More severe cases of overdoses need to be handled in an acute or critical care environment where continuous monitoring can occur. Of paramount importance is to make sure the patient has adequate airway, breathing, and circulation (ABCs) during the time period that depressants may lead to severe respiratory depression.
Generally, if the patient is unconscious and the substance is unknown, the following steps are taken in management: (1) Begin supplemental oxygen; (2) insert an intravenous line with saline infusion or dextrose in water; (3) administer dextrose, thiamine, and naloxone; (4) protect airway with endotracheal intubation; (5) pass orogastric tube, lavage, and administer activated charcoal; and (6) admit the patient for ongoing observation and management. Activated charcoal is produced from the destructive distillation of organic materials. The substance absorbs toxic substances because of large external pores and a large internal surface area that binds with toxic ions. A cathartic such as magnesium citrate is given to help gastrointestinal excretion of the toxic substance bound with activated charcoal. Activated charcoal is also given for overdoses when the substance is known, such as phenobarbital, carbamazepine, cyclic antidepressants, amphetamines, and cocaine.
Management of stimulants can be similar to that of depressants, with the administration of activated charcoal. Seizures are a possibility in the case of an overdose with stimulants, but note that amphetamines and cocaine have a short duration time of 2 to 4 hours. Phenytoin (Dilantin) can be ordered to prevent seizure activity, and benzodiazepines are also used to treat agitation or seizures. External cooling may be used to reduce hyperthermia, and intravenous fluids may be used to replace fluid loss and to prevent myoglobin damage in the kidneys. All patients with substance abuse and overdoses need counseling and therapy to manage their substance use patterns.
|Medication or Drug Class||Dosage||Description||Rationale|
|Naloxone||2 mg IV; use smaller doses for patients who are not apneic to avoid withdrawal||Opioid antagonist||Blocks the action of opioids that can lead to respiratory depression and apnea|
|Dextrose||100 mL IV 50% solution||Sugar||Rules out hypoglycemia as a cause for coma; given to patients who are known not to be hyperglycemic|
|Benzodiazepines||Varies with drug||Chlordiazepoxide, clorazepate, diazepam, lorazepam, oxazepam||Controls seizures and anxiety|
|Haloperidol||2–5 mg IV or IM||Antipsychotic||Controls combative or agitated behavior during withdrawal or treatment|
|Pentobarbital||100–200 initially PO and then in decreasing doses over 10 days||Barbiturate||Protects the patient from seizure activity|
|Phenytoin||300–400 mg daily in divided doses PO or IV||Anticonvulsant||Prevents and limits seizures related to drug withdrawal|
Other Drugs: Desipramine hydrochloride (Norpramin), bromocriptine mesylate (Parlodel), amantadine hydrochloride (Symmetrel), and melphalan (phenylalanine mustard) have been prescribed to decrease the craving for cocaine during withdrawal. Phenothiazines in low doses may be ordered to control the flashbacks that can occur after the last dose of a hallucinogen. Because the patient has built up a tolerance for drugs, the amount of medication needed to keep the patient safe may be more than what is considered a safe dosage. Methadone is used to stabilize individuals during withdrawal from narcotics, which is then followed by withdrawal of the methadone over a period of a week.
During the acute phase, keep the patient safe. Use strategies for continuous monitoring of ABCs and implement emergency measures as needed to support life. Monitor for seizure activity and place the patient on the seizure precautions regimen. Examine the environment for safety risks such as falls from the bed or self-discontinuation of tubes. Assess the potential for a suicide attempt and, if necessary, initiate suicide precautions and never leave the patient unattended.
Meet the self-care deficits related to hygiene, nutrition, and elimination. Promote a sense of security: Approach the patient in a calm, nonthreatening, and nonjudgmental way. Building a trusting relationship with the patient provides a foundation for addressing the more long-term goals associated with becoming drug-free.
Following the acute phase, initiate the process of rehabilitation and implement a treatment plan to maintain abstinence. The first goal is to work toward getting the individual to break through the denial of drug abuse and take responsibility to begin the recovery process. Provide educational materials and arrange a consultation with a chemical abuse counselor to begin the process before discharge from an acute care setting. Often, individuals are admitted from an acute care setting to an inpatient or outpatient treatment facility where nursing staff and other healthcare providers can begin specialized treatment programs. These programs include peer group programs in which confrontation, support, and hope are part of the treatment process. Treatment goals for the individual include development of a healthy self-concept, self-discipline, adaptive coping strategies, strategies to improve interpersonal relationships, and ways of filling leisure time without the use of drugs.
Evidence-Based Practice and Health Policy
Morgan, C.J., Noronha, L.A., Muetzelfeldt, M., Fielding, A., & Curran, H.V. (2013). Harms and benefits associated with psychoactive drugs: Findings of an international survey of active drug users. Journal of Psychopharmacology, 27(6), 497–506.
- An Internet-based study including 5,691 participants revealed that 56% of participants reported regular use of mild stimulants, 53% reported regular use of cannabis, 41% reported regular use of alcohol, 37% reported regular use of tobacco, and 18.6% reported regular use of hallucinogens. Between 3.5% and 11.1% reported regular use of amphetamines, benzodiazepines, MDMA (ecstasy), opiates, or prescription analgesics, and between 0.75% and 2.2% reported regular use of Viagra, nitrous oxide, ketamine, or cocaine.
- Participants rated the substances based on perceived harms, which included short- and long-term physical risks, risk of dependence, risk of bingeing, and risk to society. Participants also rated the substances based on perceived benefits, which included sociability, enjoyment, state of mind, pain, anxiety/depression relief, relaxation, influence on body appearance, energy, insomnia, and cognitive improvements.
- Cannabis was identified by participants as the substance with the highest benefit and lowest harm, followed by MDMA. Opiates were rated as the most harmful substance, but perceived to be highly beneficial. Cocaine was also identified as having high benefits, but also high harms, including risk of bingeing, dependence, and long-term physical risks. Tobacco was considered to be the substance with the lowest benefits and high harms, yet it also had the highest proportion of reported dependency. Viagra, hallucinogens, nitrous oxide, and mild stimulants were considered by participants to have low benefits as well as low risk of harm.
- Physical findings: Vital signs; adequacy of ABCs; response to medication protocols for overdose or withdrawal, nutrition, intake and output, elimination patterns
- Mental/neurological findings: Anxiety levels, depression, delusions, hallucinations, presence or absence of seizures
- Understanding of the need for consultation with drug abuse counselor
- Understanding of the need for continued treatment for self and family
Discharge and home healthcare guidelines
The patient should be discharged to an inpatient or outpatient treatment program to address the long-term effects of substance abuse. After discharge from a treatment program, the individual may continue with groups such as Narcotics Anonymous, Cocaine Anonymous, or Alcoholics Anonymous. Family dynamics often play a role in the use of drugs. It is important for the family to be involved in the treatment plan through individual and family therapy and support groups that address issues dealing with family members who abuse drugs. The National Institute of Drug Abuse provides excellent information on drug use for teachers and families at http://www.nida.nih.gov.