Substance abuse, as a disorder, refers to the abuse of illegal substances or the abusive use of legal substances. Alcohol is the most common legal drug of abuse.
SUBSTANCE ABUSE/CHEMICAL DEPENDENCE IN ADOLESCENTS
Alcohol and other drug use pose a serious threat to health of children and adolescents. In addition to health risks, substance abuse is often linked with other risk behaviors like violence, early sexual activity, truancy and academic failure.
Pediatricians and other PHC providers are in ideal positions to identify substance abuse and to provide preventive guidance and education to children, adolescents and their families.
Between 1990’s and recent, the prevalence rates of alcohol and other drug abuse among adolescents are increasing. Research has found out that one of every two adolescents has tried an illicit drug by the time he completes high school. The most commonly abused drug is alcohol.
There are different terms used to define substance-related disorders, including the following:
Substance abuse; Substance abuse refers to an illegal use of a substance leading to significant problems or distress
Such as problems might include;
- failure to attend school
- substance use in dangerous situations (driving a car)
- substance-related legal problems
- interfering with friendships and/or family relationships
Tolerance; refers to a need for increased amounts of a substance to attain the desired effect.
Substance dependence refers to a compulsive use and continuous relying on a specific substance for both physical and psychological relief with an inability to stop its usage even after significant problems in everyday functioning have developed.
- an increased tolerance
- Withdrawal symptoms with decreased use
- unsuccessful efforts to decrease use
- increased time spent in activities to obtain substances
- withdrawal from social and recreational activities
- continued use of a substance even with awareness of physical or psychological problems encountered by the extent of the substance use
Alcohol intoxication; this is a temporary mental disturbance following heavy drinking so that the level of alcohol in blood is high and sufficient to affect someone’s activity, mood and level of consciousness.
Alcoholism; is a chronic condition where a person takes alcohol excessively and for long period of time thus leading to adverse physical, mental, social and psychological effects
Alcoholic; is a person who have been taking alcohol excessively and for a long period of time in whom it has cause serious mental, social, psychological and physical problems
Substances commonly abused by adolescents
Substances frequently abused by adolescents include, but are not limited to, the following:
- Prescription drugs
- Anabolic steroids
Causes of substance abuse
1. Cultural and societal norms and acceptable standards of substance use. Public laws determine the legality of the use of substances.
2. Genetic vulnerability; it tends to run in families
3. Psychological problems such as;
- -stress and frustrations
- -feelings of desire
4. Environmental stressors such as;
- -failure of exams
- -worry of the future
- -failure to achieve a certain goal
- -child abuse
- -faulty upbringing
- -lack of education
- -large uncontrolled families
- -economic constraints
- -rape, incest and defilement
5. Social pressures from peers
6. Individual personality disorders
7. Psychiatric problems such as;
- -depressive disorder
- -suicidal intentions
Adolescents at risk of substance abuse
Parental and peer substance use are two of the more common factors contributing to youthful decisions regarding substance use.
Some adolescents are more at risk of developing substance-related disorders, including adolescents with one or more of the following conditions present:
- Children of substance abusers
- Adolescents who are victims of physical, sexual, or psychological abuse
- Adolescents with mental health problems, especially depressed and suicidal teens
- Physically disabled adolescents
- Children whose parents deal with substances for financial support
Symptoms of substance abuse
The following behaviors may indicate an adolescent is having a problem with substance abuse. However, each adolescent may experience symptoms differently. Symptoms may include:
- Getting high on drugs or getting intoxicated (drunk) on a regular basis
- Lying, especially about if and how much they are using or drinking
- Avoiding friends and family members
- Giving up activities they used to enjoy such as sports or spending time with nonusing friends
- Talking a lot about using drugs or alcohol
- Believing they need to use or drink in order to have fun
- Pressuring others to use or drink
- Getting in trouble at school or with the law
- Taking risks, such as sexual risks or driving under the influence of a substance
- Suspension from school for a substance-related incident
- Missing school due to substance use and/or declining grades
- Depressed, hopeless, or suicidal feelings
Diagnosis of substance abuse
A pediatrician, family doctor, psychiatrist, or qualified mental health professional usually diagnoses substance abuse in adolescents. However, adolescent substance abuse is believed by some to be the most commonly missed pediatric diagnosis. Adolescents who use drugs are most likely to visit a doctor’s office with no obvious physical findings. Substance abuse problems are more likely to be discovered by doctors when adolescents are injured in accidents occurring while under the influence, or when they are brought for medical services because of intentional efforts to hurt themselves.
- History taking; this can reveal personal history on substance abuse
- Clinical presentation; this often depend on the substance abused, the frequency of use, and the length of time since last used, and may include:
- Weight loss
- Constant fatigue
- curly hair
- Red eyes
- Little concern for hygiene
- use of the questionnaire of CAGE
Treatment for substance abuse
Specific treatment for substance abuse will be determined based on:
- Adolescent’s age, overall health, and medical history
- Extent of adolescent’s symptoms
- Extent of adolescent’s dependence
- The substance abused
- Adolescent’s tolerance for specific medications or therapies
- Expectations for the course of the condition
- Opinion or preference of the care taker
A variety of treatment programs for substance abuse are available on an inpatient or outpatient basis. Programs considered are usually based on the type of substance abused.
Medical detoxification (if needed, based on the substance abused) and long-term follow-up management are important features of successful treatment.
Long-term, follow-up management usually includes formalized group meetings and age-appropriate psychosocial support systems, as well as continued medical supervision. Individual and family psychotherapy are often recommended to address the developmental, psychosocial, and family issues that may have contributed to and resulted from the development of a substance abuse disorder.
Prevention of substance abuse
There are three major approaches used to prevent adolescent substance use and abuse, including the following:
- School-based prevention programs. School-based prevention programs usually provide drug and alcohol education and interpersonal and behavior skills training.
- Community-based prevention programs. Community-based prevention programs usually involve the media and are aimed for parents and community groups. Programs, such as Mothers Against Drunk Driving (MADD) and Students Against Drunk Driving (SADD), are the most well-known, community-based programs.
- Family-focused prevention programs. Family-focused prevention programs involve parent training, family skills training, adolescent social skills training, and family self-help groups. Research literature available suggests that components of family-focused prevention programs have decreased the use of alcohol and drugs in adolescents and improved effectiveness of parenting skills.
ALCOHOL AND DRUG ADDICTION
Alcohol and drug addiction have been a source of serious problems for thousands of years. Recent studies indicate that there are more psychoactive, psychological and social problems related to alcoholism and drug addiction than anything else which affect the individual and society emotionally.
The following are the commonly abused groups of substances;
Drug (substance); this refers to any chemical agent that once taken in the body is capable of causing physiological and psychological changes.
Alcoholic; this is a person who has been taking alcohol excessively in whom it has produced mental, social, physical and psychological problems
Substance intoxication; this is development of a reversible substance-specific syndrome due to recent ingestion of or exposure to the drug
Alcohol intoxication; a this is a temporally mental disturbance following heavy drinking so that the level of alcohol in blood is high and sufficient to affect somebody’s activity, mood and level of consciousness.
Tolerance; this is a need for more of the drug in order to achieve a similar effect realised before at a lower dose
Dependency; refers to compulsion to take the drug on a continuous basis in order to feel its effects and to further avoid the discomfort of its absence. This can both be physical or psychological. It is a bodily response to a substance e.g. relying on medications to control medical condition.
Addiction; this refers to a psychological and physical inability to stop consuming a drug or substance even though it’s causing psychological and physical harm. it involves using the drugs despite the consequences.
Misuse refers to the incorrect, excessive or non-therapeutic use of and mind-altering substances
Definition; alcoholism is a chronic condition occurring in individuals who have been taking alcohol excessively and for a long period of time that it has caused serious adverse effects physically, socially and mentally i.e. There is increased dependency of alcohol both physically and socially.
Causes of alcohol abuse
- Availability; if alcohol is available and drinking is accepted for example as a norm in social gatherings and functions
- Genetic factors; some excessive drinkers have a family history of excessive drinking
- Poor coping strategies; people who are unable to face stress often resort to alcoholism
- Psychiatric disorders; like depressive disorders, anxiety disorders an phobic disorders
- Social disorders; like isolation, unemployment, loss or bereavement, injustice etc.
- High risk groups e.g. people suffering from chronic physical illness, business executives, travelling salespersons, industrial workers, hostel students, military personnel etc.
- Age; its common between late adolescence and early adulthood
Process of alcoholism
- Experimental; due to peer pressure, influences or curiosity, the person starts to consume alcohol
- Recreational; during weekends, or on holidays, the individual starts to enjoy and continue with it. If consumed in small quantities, alcohol may not cause a problem instead it may work to relieve tension and relax mind or sedate the brain from painful emotions and promote a sense of wellbeing and pleasure.
- Compulsive; once used to drinking, some people who started drinking occasionally start drinking almost daily or drinking heavily for a period of time for pleasure or to avoid the discomfort of withdrawal symptoms.
Alcoholism goes through distinct stages;
Increased tolerance– needing more and more of alcohol to experience the same pleasure as experienced earlier
Blackouts- inability to recollect incidents which happened under the incidence of alcohol
Preoccupation– always thinking about how, when and where to drink
Loss of control over amount, time and occasional drinking, Keeping away from alcohol for sometimes but going back to obsessive drinking after some period
Getting drunk even on small amounts of alcohol, willing to lie, beg, borrow or steal to maintain supply of alcohol. Alcohol takes the priority over family or job.
Types of drinkers
These rarely and occasionally drink alcohol in small amounts or in large amounts but once in a while and it rarely causes problems
These moderately consume not in excess nor large amounts and it doesn’t cause much health problems
These consume large amounts of alcohol daily and usually with high concentrations. As a result, the individual health will be impaired, affects peace of mind, disrupts family, loss of reputation, dignity, poor performance etc.
Effects and complications of alcohol
Physical or medical effects
- Hepatitis and liver cirrhosis
- Peptic ulcers and gastritis
- Cardiomyopathies and heart failure
- Epileptic-like fits (RUM fits)
- Weight loss
- Alcoholic dementia
- Lowered immunity
- Pathological intoxication such as maladaptive behavioural effects such as fighting, impaired judgement, slurred speech, mood changes, irritability and impaired attention
- Delirium tremens
- Alcoholic hallucinosis which are vivid hallucinations developing shortly after cessation or reduction of alcohol
- Alcoholic psychosis this occurs after a person drinking alcohol for a long periods of time and in large quantities and thus develops psychotic disorder which resemble paranoid schizophrenia presenting with delusions, hallucinations and impairment of primary mental functions.
- Alcohol amnestic disorder; there is impairment in short and long term memory with disorientation and confabulation
- Alcoholic dementia; a chronic organic mental disorder that results into irreversible impairment in memory, orientation etc.
- Paranoia- persecutory and feelings of self-hate
- Morbid or pathological jealousy e.g. a drunkard coming back at home and finds a ranch of a bicycle and begins quarrelling who has been at home
- Wernicke’s encephalopathy that occurs as a result of acute deficiency of vitamin B1 (Thiamine) in alcoholics
- Korsakoff syndrome that occurs as a result of gradual depletion of thiamine from the body.
- Decreased work performance hence decreased productivity due to chronic absenteeism
- Family problems like divorce
- Increased accidents due to drunken driving
- Legal effects like rape, theft etc.
- Violence and aggression
Diagnosis of alcoholism
- History taking i.e. upbringing, family background, period taken while bussing etc.
- Clinical presentation like curly hair, swollen cheeks, red lips, poor hygiene etc.
- Using the questionnaire of CAGE
E- Eye opener
The questionnaire looks as below;
Have you ever felt that you should cut down your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt guilty about your drinking?
Have you ever had a drink as a first thing in the morning as eye opener to get rid of hangover or calm your nerves?
Affirmative answers or any yes to two or more of the above is a suggestive to an alcoholic
Concentration of alcohol in blood with their effects
- 80-150mg of alcohol per 100mls of blood leads to intoxication
- 150-300mg of alcohol per 100mls of blood is fatal
- 300-500mg of alcohol per 100mls of blood is very fatal
- 500mg of alcohol per 100mls of blood and above leads to death
Note; all the above symptoms can change according to tolerance
Management of alcoholism
The following are the major goals in the management of alcoholism;
- To detoxify the patient (only in acute stages)
- To improve social relationships and support
- Developing confidence and ability to change
- Identifying reasons to change
- Developing alternative activities
- Learning to prevent relapse
Admission is very essential to ensure that the patient doesn’t have access to alcohol. The patient has to be hospitalised and not allowed home for about 6-8 weeks since they have tremendous for alcohol and can soon start drinking if allowed home.
- Admit the patient in a psychiatric hospital in an open quiet room which is well lit to reduce fears and illusions
- Establish a good nurse patient relationship
- Keep potentially harmful objects away from the room since there is chance of deliberate self-harm
- Keep the bed dry, clean and warm since the patient might be incontinent
- Monitor vital signs every 15 minutes initially including physical and mental behaviour
- Investigations such as
- Urine for sugar
- Blood for haemoglobin level and sugars
- Alcohol level in blood have to be carried out
- Administration of minor tranquilizers like anti-anxiety drugs such as Librium and diazepam are given parenterally if necessary to control anxiety, insomnia, agitation and tremors
- Administer ant-convulsants if there is withdrawal seizure (rum fits)
- Plenty of vitamins especially injection vitamin B1,B6 and B12 (100-300mg twice daily for seven days) and tablets of vitamin B complex and vitamin c
- Antacids to relieve gastritis
- Correct fluid and electrolyte imbalance by intravenous infusion and maintain a fluid balance chart
- Drug Disulfiram (ant abuse therapy) which produces nausea and vomiting, intense headache, palpitation, blurred vision, hypotension and dyspnoea if alcohol is taken. It can be administered but under close patient supervision it is given 1g for one week then o.8g-0.6g-0.4g-0.2g and the patient is maintained on 0.1g for one year
- Aversion therapy (Apo morphine) this is given in injectable form. It is a powerful emetic and the patient vomits whenever he smells alcohol. It is therefore discouraged for that
- Yeast tablets are given two twice a day to induce appetite
- Stamatil (avomine) is given 5-10mg to control vomiting
- Sedation of the patient may be required
- Avoid barbiturate drugs because alcoholics easily become addicted to them
General nursing care
- Physical and psychological conditions or mental conditions associated with advanced alcoholism should be treated like malnutrition, vitamin deficiencies, hallucinations, delirium, gastritis or liver diseases
- Nutrition; Ensure that the patient takes small frequent feeding rather than large meals and the diet should be nutritious and appetising to enable the patient ask for more
- Hygiene; oral care, general body and bed hygiene has to be addressed
- During the recovery and rehabilitation period, acceptance of the patient by the nurse is essential. The nurse’s acceptance and may encourage the patient to socialise and participate in planned activities. This will also reduce the patient’s feelings of inferiority and low self-esteem.
- Psychiatric social workers should be involved in the social problems of the patient
- Religious commitment has to be encouraged
- Familial therapy; these should be encouraged to help the patient to stay away from alcohol
- Patient should be encouraged to change friends and associates may be necessary to remove patient from those situations where drinking is very easy
- Prepare the patient for alcoholic anonymous a self-group of ex-addicts who confront, instruct and support fellow drinkers in their efforts to stay sober one day at a time, through fellowships and acceptance.
- Plan for discharge and resettlement of the patient into the community
STEPS OF ALCOHOLIC ANONYMUS
- We admitted we were powerless over alcohol – that our lives had become unmanageable. AA firmly believes that individuals cannot overcome alcoholism on their own. They are unable to exercise willpower or personal strength that could prevent them from drinking
- Came to believe that a Power greater than ourselves could restore us to sanity. Alcoholics Anonymous is based on the belief in a higher power. For some, this higher power may be God; for others, it may be a belief in the universe itself. The point is that recovery begins, in part, by looking to an entity greater than yourself.
- Made a decision to turn our will and our lives over to the care of God as we understood Him.
- Made a searching and fearless moral inventory of ourselves. During this step, many participants make a list of poor decisions or character flaws. They outline hurt they caused to others, as well as feelings, like fear and guilt, that motivated some of their past actions. Once the individual has acknowledged these issues, the issues are less likely to serve as triggers to future alcohol abuse.
- Admitted to God, to ourselves and to another human being the exact nature of our wrongs. As AA members work this step, they sit down with someone – often their sponsor – and confess everything they identified in Step 4. This step requires the recovering individual to put aside their ego and pride to acknowledge shameful past behavior. The step is also empowering, as the alcoholic no longer has to hide behind guilt and lies.
- Were entirely ready to have God remove all these defects of character. In this step, the recovering alcoholic acknowledges that he or she is ready to have a higher power – again, whatever that may be – take away the moral shortcomings identified in
- Humbly asked Him to remove our shortcomings. This step requires the person to focus on the positive aspects of his or her character – humility, kindness, compassion and a desire for change – as well as step away from the negative defects that have been identified.
- Made a list of all persons we had harmed, and became willing to make amends to them all. During this step, recovering alcoholics write down a list of all the people they have hurt. Often, this list includes people they hurt during their active alcoholism; however, it may go back further to include anyone they have hurt throughout their entire lives
- Made direct amends to such people wherever possible, except when to do so would injure them or others. Paired with Step 8, Step 9 gives recovering alcoholics the opportunity to make things right with those they have hurt. One’s sponsor can be a big source of help during this process, helping the recovering alcoholic to determine the best way to go about making amends.
- Continued to take personal inventory and when we were wrong promptly admitted it. Linked to Step 4, this step involves a commitment to continue to keep an eye out for any defects of character. It also involves a commitment to readily admit when one is wrong, reinforcing humility and honesty.
- Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Step 11 commits the recovering alcoholic to continued spiritual progress. For some, this may mean reading scripture every morning. For others, it may mean a daily meditation practice. Alcoholics Anonymous doesn’t have stringent rules on what form spiritual growth takes. It simply involves a commitment to take time to reassess one’s spiritual and mental state.
- Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs practice these principles in all our affairs. The final step involves helping others and serves as motivation for many to become sponsors themselves. By going through the 12 steps, individuals have a major internal shift and part of that shift is a desire to help others.
Nurses role in the prevention of alcohol abuse
Aim to avoid the appearance of new cases of alcohol abuse by reducing alcohol consumption through health promotion especially health education
Attempt to detect cases early and to treat them before serious complications cause disability
Aim to avoid further disabilities and to reintegrate individuals into the society who have been harmed by severe alcohol related problems
The nurse will be involved in all of these levels