5. Substance-related disorders

The substance-related disorders include abuse of a drug, adverse effects of any medication, and exposure to toxic substances. The DSM-IV lists II types of substances: alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids. phencycltdine (PCP), and the group sedatives, hypnotics, and anxiolytics. Polysubstance dependence and other or unknown substance-related disorders to toxins or prescribed or over-the-counter medications are also included.

Substance Abuse Disorders

DSM-IV CATEGORIES

Alcohol Use Disorders

303.90 Alcohol dependence

305.00 Alcohol abuse

Amphetamine Use Disorders

304.40 Amphetamine dependence

305.70 Amphetamine abuse

Cannabis Use Disorders

304.30 Cannabis dependence

305.20 Cannabis abuse

Cocaine Use Disorders

304.20 Cocaine dependence

305.60 Cocaine abuse

Hallucinogen Use Disorders

304.50 Hallucinogen dependence

305 30 Hallucinogen abuse

Inhalant Use Disorders

304.60 Inhalant dependence

305.90 Inhalant abuse

Nicotine Use Disorder

305.10 Nicotine dependence

Opioid Use Disorders

304.00 Opioid dependence

305.50 Opioid abuse

Phencyclidine Use Disorders

304.90 Phencyclidine dependence

305.90 Phencyclidine abuse

Sedative, Hypnotic, or Anxiolytic Use Disorders

304.10 Sedative, hypnotic, or anxiolytic dependence

305.40 Sedative, hypnotic, or anxiolytic abuse

Polysubstance-Related Disorder

304.80 Polysubstance dependence

Other (or Unknown) Substance Use Disorders

304.90 Other (or unknown) substance dependence

305.90 Other (or unknown) substance abuse

SUBSTANCE DEPENDENCE

With substance dependence, the client experiences cognitive, behavioral, and physiologic symptoms generated from persistent use. The client continues to take the drug despite the health problems that occur. The habit of constant drug use usually follows the pattern of tolerance, withdrawal, and compulsive drug-taking behavior.

Tolerance is defined as either the need for increased amounts of the substance to establish the desired effect, or a decreased effect with continued use of the substance in the same amount. Individuals develop different degrees of tolerance. The amount of drug necessary to cause tolerance in a person who habitually uses the drug could be lethal to a person who doesn't use the drug.

Withdrawal occurs when the tissue and blood levels of the substance decrease in a person who has engaged in prolonged. heavy use of the substance. When the uncomfortable withdrawal symptoms occur, the person usually takes the drug to relieve or decrease the symptoms. A common pattern is to initiate drug use shortly after awakening.

The person experiences withdrawal symptoms specific to the drug used. Major physical signs of withdrawal are seen with alcohol, opioids, sedatives, hypnotics, and anxiolytics. Less obvious physical signs are noted with amphetamines, cocaine, nicotine, and cannabis, but subjective symptoms can be intense if the client is withdrawing from heavy use. Insignificant withdrawal symptoms are seen even with chronic use of hallucinogens and PCP

With compulsive drug use, the substance is taken in significant amounts for a longer period than was originally intended. There is recognition that the use is excessive, and the client has desired or unsuccessfully attempted to decrease or control the use. Even though physical and psychological problems have occurred from use of the substance, the person continues to use the drug despite evidence of the problems it is causing. A great deal of energy continues to be expended in obtaining the substance, taking the substance, and recovering from its effects. The client also sustains intoxication and withdrawal symptoms, often at inappropriate times, such as when expected to fulfill obligations at home, work, or school. Major social, occupational, and recreational activities are sacrificed for the substance use despite the recurrence of negative effects. With continued use, a tolerance to the substance develops, necessitating increased amounts to achieve previous levels of intoxication. This pattern of substance tolerance, withdrawal, and compulsive use has been noted in every category of substances with the exception of caffeine.

Some people may exhibit a pattern of compulsive drug use without manifesting signs of tolerance or withdrawal. In contrast, others can develop a tolerance and experience withdrawal symptoms without having used the drug compulsively.

SUBSTANCE ABUSE

The major characteristic of substance abuse is the maladaptive behavior pattern that occurs with repeated use of the drug. The person is unable to manage typical role responsibilities at work, home, or school. There is a recurrent pattern of being in situations that are physically hazardous, such as driving while intoxicated, or engaging in high-risk leisure activities, such as rock climbing. Often there are substance-related legal issues, such as driving under the influence of a drug, or disorderly conduct. The person continues to take the substance despite a history of interpersonal, familial, and social problems that are instigated or exaggerated because of the use of the substance.

A substance abuse diagnosis is used when the dysfunctional behaviors recur over a 12-month period. Abuse continues despite knowledge of the problems and dangers it causes. Unlike substance dependence, the diagnosis of substance abuse doesn't include tolerance, withdrawal, or a pattern of compulsive use: rather, it focuses on the detrimental effects of the person's repeated use of the drug.

To help clients understand behaviors associated with substance abuse disorder, it is important to share with them current knowledge of the biological and psychological roots of addiction. Although no specific genes for alcoholism have been identified, alcoholism does run in families. Children of alcoholics have a fourfold greater chance of becoming addicted than children of non-alcoholics. Research has further shown that individuals who are prone to alcoholism have low levels of monoamine oxidase and acetaldehyde dehydrogenase. A certain part of the brain, the medial forebrain bundle, is believed to be associated with positive reinforcement of drug and alcohol use. Many other variables, especially environmental factors and personality traits, play a maior role in determining whether or not a person will become drug-dependent.

In working with clients who have substance-related disorders, it is essential for the nurse to know the routes of administration as well as the main effects of the drugs. (For further information, see Characteristic Effects From Use of Major Substances, pages 87 to 90, and Common Withdrawal Symptoms Associated With Psychoactive Drugs, pages 91 to 93.)

CAHARACTERISTIC EFFECTS FROM USE OF MAJOR SUBSTANCES
DRUG CLASSIFICATION	ROUTE OF ADMINISTRATION	EFFECTS (In order of increasing sympton severity)
Alcohol	Oral	Relaxation and sedation Decreased inhibition Lack of coordination and unsteady gait Slurred speech Nausea and vomiting Transient visual, tactile, or auditory hallucinations Severe anxiety Psychomotor agitation High potential for permanent damage to liver or brain
Amphetamines (dexedrine, methamphetamine, ice uppers, crank, speed).	Oral or injected	Grandiosity Hypervigilance Hypertension or hypotension Tachycardia or bradycardia speed) Mydriasis (dilated pupils) Euphoria Appetite suppression Personality changes Antisocial behavior Schizophrenic episodes
Cannabis (marijuana, grass, pot, hashish, joint, weed.TCH)	Smoked or injected	Mild intoxication Increased appetite Dry mouth Lack of coordination Impaired judgment and memory Sexual arousal Tachycardia Visual hallucinations
Cocaine (coke, snow, lady, powder, crack)	Oral, injected, or inhaled	Talkativeness Grandiosity Hypervigilance Anxiety Impaired judgment Tachycardia or bradycardia Hypertension or hypotension Mydriasis (dilated pupils) Muscle twitching Respiratory depression Hallucinations, paranoid delusions or paranoia Formication (sensation of insectos crawling on the skin) Personality Changes Antisocial behavior Euphoria followed by depression and feeling let down
Hallucinogens (lysergic acid diethylamide a.k.a. LSD or acid, peyote, Psilocybin, mescaline	Oral or inhaled	Intensified perceptions and feelings Synesthesia ( seeing sound or hearing colour) Visual, auditory, or tactile hallucinations Fear of losing one's mind Mydrtasis(dilated pupils) Tachycardia anci palpitations Blurred vision Dizziness, weakness, and tremors Altered perceptions (flashbacks) Impaired judgment and bizarre behavior Mood swings and psychotic like symptoms
Inhalants (sprayInhaled can propellants, paint products and solvents, glue, gasoline, cleaning fluid)	Inhaled	Euphoria and giddiness Headache Dizziness, fatigue, or drowsiness Nystagmus (involuntary, rapid movement of the eye) Unsteady gait or tremors Slurred speech Blurred vision or diplopia (double vision) Damage to lungs, liver, and kidneys
Opioids (morphine, codeine, methadone, dilaudid, heroin a.k.a. smack or horse	Oral, injected, or inhaled	Immediate euphoria followed by dysphoria Psychomotor retardation or agitation Slurred speech Impaired judgment and memory Sedation and respiratory depression Constricted pupils Decreased sexual and aggressive drives
Phencyclidine (PCP, angel dust, hog)	Oral, injected, or inhaled	Grandiosity and illusions of strength Impulsiveness Psychomotor agitation Assaultive behavior Decreased sensory awareness Hypertension and tachycardia Unsteady gait and lack of coordination Nystagmus (involuntary, rapid movement of the eye) Mood swings and paranoia
Sedatives, hypnotics, or anxiolytics (such as secobarbital sodium [Seconal], pentobarbital sodium [Nembutal], diazepam [Valium], alprazolam [Xanax], chlordiazepoxide [Libriurn])	Oral or injected	Unsteady gait and lack of coordination Slurred speech Nystagmus (involuntary, rapid movement of the eye) Sedation Impaired judgment Inappropriate sexual behavior and aggressive drives Mood swings
Nicotine	Oral or inhaled	Tachycardia Vasoconstriction Irritation of the oral mucosa Persistent cough (smoker's cough) Damaged alveoli and bronchioli Emphysema High potential for oral, laryn-geal, or lung cancer Stimulation of senses Alertness and enhanced performance Anxiety and restlessness
Caffeine	oral	flushed face Talkativeness Tremors or muscle twitching Tachycardia or arrhythmias Insomnia Irritation of the stomach

COMMON WITHDRAWAL SYMPTONS ASSOCIATED WITH PSYCHOACTIVE DRUGS
DRUG CLASSIFICATION	MAJOR WITHDRAWAL SYMPTON
Alcohol	Nausea and vomiting Tremors and weakness Sweating* Tachycardia and hypertension* Delusions* Agitated behavior* Hallucinations and nocturnal illusions* * indicates the symptoms of alcohol withdrawal syndrome
Amphetamines	Dysphoria Disorientation Fatigue and depression with suicidal potential Disturbed sleep and unpleasant dreams Hallucinations or delusions
Caffeine	Irritability and nervousness Inability to concentrate Headache Tremors Lethargy Impaired psychomotor performance
Cannabis	No acute withdrawal symptoms; symptoms appear over varying time periods after withdrawal Amotivational syndrome (inability to concentrate or complete tasks) Chronic respiratory problems Memory and learning difficulty Suppressed prolactin and testosterone levels
Cocaine	Severe craving for drug Severe depression ("postcoke blues") Fatigue Psychomotor agitation or retardation Anxiety Insomnia or hypersomnia Increased appetite
Hallucinogens	Symptoms appear over varying time periods after withdrawal Apprehension, fear, or panic Hyperactivity Sweating Tachycardia Altered perceptions (flashbacks) Perceptual distortions, especially hallucinations
Inhalants	Symptoms appear over varying time periods after withdrawal Central nervous system damage (cerebral atrophy or peripheral neuropathies) Anxiety and tremors Sleep disturbances Acute or chronic renal failure Bone marrow depression Cardiac arrhythmias Respiratory damage (lung or sinus damage, pneumonitis, emphysema, lung changes, or respiratory depression) Liver disease (hepatitis or cirrhosis)
Nicotine	Irritability and nervousness Headache Inability to concentrate Craving for tobacco Increased appetite Fatigue and dizziness Tremors and palpitations
Opioids	Dysphoria Anxiety Insomnia Increased respirations and yawning Sweating Lacrimation and rhinorrhea (nasal discharge) Tremors and muscle twitching Mydriasis (dilated pupils) Piloerectlon ("goosebumps") Nausea, abdominal cramps, and vomiting
Phencyclidine	Symptoms may appear over varying time periods after withdrawal Anxiety Withdrawn, catatonic state Hypertension Seizures Bizarre behavior and speech associated with temporary psychosis
Sedatives, hypnotics, anxiolytlcs	Anxiety and agitation or Sweating Tachycardia Tremors Nausea and vomiting Insomnia and disturbing dreams Transient visual, auditory, or tactile hallucinations Seizures

COMMUNICATION STRATEGIES

• Be firm and consistent with the client.
• Promote independence in interactions.
• Confront manipulative behavior by enforcing limits.
• Inform the client about consequences of unacceptable behavior.
• Don't blame, criticize, or preach to the client.
• Don't let the client play staff members against one another.
• Give both positive and negative feedback for behavior.

NURSING DIAGNOSIS: INEEFCTIVE DENIAL

Probable Causes	Defining Characteristics
Severe, anxiety-provoking situations Threat to role or self-esteem Feelings of guilt and shame Sense of inadequacy as a person Feelings of vulnerability	Misperceptions of reality No comprehension of problem Lack of supportive relatiorships Unnecessary risk taking Refusal to discuss troublesome situations

Long-Term Goal
The client will verbalize accountability for personal actions and recognize the relationship between substance abuse and personal problems.

Short-Term Goal #1:The client will verbalize that a substance abuse problem exists.

Interventions and Rationales

• Assess how the client uses denial as a coping strategy. Understanding the use of denial aids the nurse in dealing with the clients defenses.
• Encourage verbal expression of anger, fear, inadequacy, grief and guilt. The client needs assistance with expressing and handling negative feelings rather than denying the discomfort they generate.
• Help the client develop strategies to deal with negative feelings. Exploring the client's unpleasant feelings facilitates competence in handling them and reduces the need for denial.
• Point out the discrepancies between what the client feels, such as loneliness and personal inadequacy, and what the client does about these feelings, such as self-medicate. The nurse must promote an awareness of the incongru.en.ce between the client's feelings and the client's behaviors.
• Encourage the client to discuss his own substance use and any perceptions about how it impacts on the client's life. Having the client discuss his current history of substance use and current life situation facilitates the client's realization that dysfunctional behavior occurs as a result of substance use.
• Discuss the connection between the use of substances and problematic behaviors and situations that have occurred in the client's personal life. The client needs assistance establishing the relationship between substance use and iifestyie problems.

Short-Term Goal #2: The client will verbalize a decreased need for denial as a coping mechanism to solve personal problems.

Interventions and Rationales

• Help the client discover and examine how the use of other defense mechanisms, such as projection and rationalization, contributes to denial. These defense mechanisms actually contribute to the denial and hinder the work of overcoming denial.
• Discuss with the client how denial of the substance use and the accompanying consequences deter the client from problem solving and serve as a barrier to obtaining treatment. This action assists the client to recognize the impact that denial has en seeking help for personal problems.
• Help the client identify the consequences of deviating from the structured treatment plan. This enables the nurse to assess the degree of denial that may still be present.
• Recognize and reinforce client statements that address the client's personal responsibility for decisions and behaviors. Recognizing appropriate behavior enhances the tendency to repeat it.

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Dysfunctional family Lack of parental role modeling Family history of substance abuse Chronic anxiety Impaired or nonexistent support system	Inability to problem solve Verbalization of feelings of inadequacy Limited or no peer contacts to serve as role models Inability to meet basic needs Inability to delay gratification

Long-Term Goal
The client will develop various problem-solving skills and access to a support system to assist in coping with both long-term and short-term stressors.

Short-Term Goal #1:The client will identify and discuss the major stressors that influence daily functioning.

Interventions and Rationales

• Encourage the client to verbalize negative feelings, such as anxiety, anger, sadness, and frustration. Verbalization can faciliate exploration and insight into anxiety.
• Discuss with the client what constitutes acceptable behavior. The client may need assistance establishing a set of guidelines tc govern appropriate response to stressors because the lack of guidelines for acceptable behavior contributes to the client's stress.
• Set limits on the client's attempts to rationalize inappropriate behaviors as being beyond the client's ability to control them The client needs assistance establishing limits and needs to be confronted about inappropriate behavior.
• Have the client maintain a diary to document troublesome situations, stressors, reactions, and responses. A written log enables the client to identify patterns of coping and areas of difficult-. that require additional work.

Short-Term Goal #2: The client will explore alternative behaviors that can be used to cope with identified stressors.

Interventions and Rationales

• Have the client make a personal inventory of strengths and resources that can be used to cope with stress. Often when clients are struggling with the pain of their addiction, they minimize or overlook their strengths.
• Explore with the client how to assess anxiety-provoking situations and apply problem-solving or stress-management techniques when confronted with stressors. Practice with problem-solving and stress-management techniques improves the clients ability to develop healthy coping strategies rather than revert to substance use.
• Have the client formulate goals for maintenance of a drug-free lifestyle. Planning facilitates avoidance of situations that could cause a return to drug use.
• Write down and review with the client the community resources, such as drug and alcohol or other psychotherapy groups, that are available. The client needs easy access to information and support in times of stress or crisis.
• Encourage the client to use group therapy for feedback on how to best accomplish treatment goals and utilize community resources. Croup feedback can provide valuable information abc^' progress and support the client's efforts to change.
• Instruct the client in coping strategies, such as assertiveness skills, communication skills, conflict resolution, and suitable ways to express negative feelings. Learning these strategies enables the client to cope with stressors in constructive ways.
• Encourage the client to join Alcoholics Anonymous, Narcotics Anonymous, or other support groups, such as Rational Recovery. It is essential that the client acquire long-term support mechanisms, because recovery is a lifelong process.

NURSING DIAGNOSIS: SENSORY/PERCEPTUAL ALTERATIONS, INCLUDING VISUAL AND AUDITORY HALLUCINATIONS

Probable Causes	Defining Characteristics
Severe anxiety Substance withdrawal or use Central nervous system damage Metabolic response to trauma or severe stress Delirium	Preoccupation/lack of awareness of environment Lack of attention to personal hygiene and self-care Verbalization of strong fear Bizarre or impulsive behaviors Rapid mood swings

Long-Term Goal
The client will complete the detoxification period and sustain no physical or emotional injury.

Short-Term Goal #1:The client will work with the nurse to remain safe during the detoxification period.

Interventions and Rationales

Short-Term Goal #2: The client will respond appropriately to stimuli and develop an accurate perception of the environment.

Interventions and Rationales

NURSING DIAGNOSIS: RISK FOR INJURY

Probable Causes	Defining Characteristics
Physiologic problems associated with withdrawal period from a chemical substance Cognitive impairment and impaired judgment due to central nervous system damage	Disorientation and confusion Poor impulse control Inability to problem solve Seizures Tremors, poor muscle coordination, and impaired balance

Long-Term Goal
The client will not injure self or others during the course of treatment.

Short-Term Goal #1:The client will recognize the stressors, such as physical health problems, fatigue, and interpersonal conflicts, that increase the risk of injury.

Interventions and Rationales

Short-Term Goal #2: The client will demonstrate impulse control and appropriate judgment in stressful situations.

Interventions and Rationales

NURSING DIAGNOSIS: KNOWLEDGE DEFICIT ABOUT THE EFFECTS OF SUBSTANCE ABUSE

Probable Causes	Defining Characteristics
History of learning difficulties Denial of the risks and problems associated with substance use Family history of substance abuse Cognitive impairment Beliefs in myths about substance use	Current or recent use of substances Verbalization of misconceptions and misinformation Verbalization of lack of knowledge Verbalization of confusion Denial of substance dependence use or abuse

Long-Term Goal
The client will verbalize understanding of the reasons for abstaining from the drug.

Short-Term Goal #1:The client will verbalize the effects of substance use on the body and mind and state the reasons a specific drug is harmful.

Interventions and Rationales

Short-Term Goal #2: The client will acknowledge that recovery from substance abuse requires changing prior habits and lifestyle.

Interventions and Rationales

TWELVE STEPS OF ALCOHOLICS ANONYMOUS

We admit we were powerless over alcohol, that our lives had become unmanageable. Came to believe that a Power greater than ourselves could restore us to sanity. Made a decision to turn our wills and lives over to the care of God as we understand Him. Made a searching and fearless moral inventory of ourselves. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. Were entirely ready to have God remove all these defects of character. Humbly asked Him to remove our shortcomings. Made a list of all persons we had harmed, and became willing to make amends to them all. Made direct amends to such people whenever possible, except when to do so would injure them or others. Continued to take personal inventory and when we were wrong promptly admitted it. Sought through prayer and meditation to improve our conscious contact i with God as we understood Him, praying only for knowledge of His will for us and the power to carry it out. Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs. From Alcoholics Anonymous World Services, Inc. Twelve steps and twelve traditions. New York: The A.A. Grapevine and Alcoholics Anonymous Publishing, 1952.

THERAPIES

Detoxification (inpatient or outpatient day treatment programs)

• Under medical supervision, administer a drug similar to the abused drug(s) and then gradually withdraw it.
• Facilitate management of the client's withdrawal syndrome.
• Assess and intervene for the client's physical and emotional needs.
• Assess for signs of toxicity from the substitute medication, especially physiologic or behavioral changes.
• Coordinate all emergency medical treatment, if necessary.
• Provide support during periods of crisis.
• Coordinate additional pharmacologic assistance after initial detoxification period (methadone or clonidine may be used for this purpose).

Rehabilitation (inpatient or outpatient day treatment programs)

• Have the client participate in a treatment program designed to evaluate the client's issues and introduce the 12-step recovery program.
• Teach stress management, including the use of relaxation techniques.
• Confront the client's denial of substance abuse, and encourage personal responsibility.
• Assist the client to evaluate and begin to change antisocial habits and behaviors.
• Initiate individual therapy, family therapy meetings, and occupational counseling.

Aftercare (community or outpatient mental health centers)

• Provide for continued support after the rehabilitation experience
• Focus on relapse prevention.
• Strongly encourage participation in Alcoholics Anonymous or Narcotics Anonymous meetings. (See Twelve Steps of Alcoholics Anonymous)
• Begin teaching social skills.
• Establish an exercise program appropriate for the client's physical health.
• Provide nutritional information and counseling, particularly if the client is underweight or malnourished.

Residential Therapeutic Communities (self-regulating communities that operate on the premise that substance use is a symptom of emotional immaturity or a character disorder)

• Provide support to help the client maintain abstinence from substances.
• Focus on ways to develop personal honesty
• Provide crisis intervention.
• Work to eliminate criminal behaviors.
• Teach or provide the mechanism to obtain skills for employment.

Alcoholics Anonymous/Narcotics Anonymous

• Facilitate the recovery process by supporting the client's efforts toward abstinence.
• Provide social support.
• Promote self-help in handling lifestyle change.
• Enable the sober person, once abstinence is maintained, to become a sponsor or supporter of another person.

Individual Substance Abuse Counseling/Therapy

• Focus on the here and now.
• Assess the denial of substance abuse.
• Identify the need to change current lifestyle.
• Develop short-term goals that can produce positive results.
• Develop strategies to stop substance abuse.
• Have the client work on establishing healthy interpersonal relationships.
• Explore ways to handle daily stressors and express feelings without the use of a substance.

Group Therapy

• Discuss personal struggles and feelings.
• Promote a positive view of self as a recovering person.
• Provide opportunities to learn, communicate, and support others.
• Provide a vehicle to develop appropriate peer relationships.

Family Therapy

• Acknowledge how substance use by the client affects all family members.
• Assist the family to give up the enabling behavior patterns that abetted the client's substance dependence.
• Acknowledge the pain of family members.
• Discuss family interaction patterns that revolve around denying the problem, avoiding conflict, rationalizing abuse, and protecting the abuser.
• Instruct the family on effective ways to communicate, express feelings, problem solve, and set limits.
• Teach the family how to intervene about issues that could escalate into a crisis.
• Address the needs of all family members, especially children who struggle with guilt, low self-esteem, fear, distorted perceptions, double messages, identity confusion, all-or-none thinking, and rules of don't think and don't feel.
• Assist the family to reformulate roles and responsibilities.

MEDICATIONS

• Disulfiram (Antabuse) interferes with the metabolism of alcohol. Before administering this drug, the client must not have ingested alcohol for at least 12 hours. The ingestion of Antabuse and alcohol causes a toxic reaction and constitutes a medical emergency. Signs of a toxic reaction include nausea, flushing. syncope, dyspnea, coughing, hypertension and, in extreme cases, heart failure.
• Naltrexone (Re Via and Trexan), a narcotic antagonist used to treat heroin abuse, works by binding to opiate receptors. It is also used to treat alcoholism because it reduces the clients craving for alcohol.
• Methadone maintenance therapy is used in the treatment of opioid addiction. Given daily, it subdues the craving for heroin without causing the client to experience euphoria or a "high”. Methadone can be used with pregnant women who are opioid addicts.
• Antidepressants are used to treat depression after the withdrawal phase is complete.
• Selective serotonin reuptake inhibitors are used to reduce alcohol and opioid craving.
• The opioid antagonist naloxone (Narcan) is an I.V drug used to reverse the symptoms of opioid overdose. Sometimes it is given to initiate opioid withdrawal before beginning intensive therapy
• Transdermal patches, nicotine gum, nasal sprays, and inhalers are used to assist the client through the period of nicotine withdrawal by decreasing the client's craving. The transdermal nicotine patch (Habitrol, Nicoderm, ProStep) is the preferred method for nicotine replacement therapy because it promotes long-term abstinence.
• Anxiolytics are used to reduce anxiety after the withdrawal period. They have dependency-producing effects and must be carefully monitored. (See Appendix D for medication information.)

FAMILY CARE

• Discuss the impact that substance abuse has had on the family
• Acquaint families with resources such as family therapy, Alcoholics Anonymous, AI-Anon, Ala-Teen, Adult Children of Alcoholics, Narcotics Anonymous, Nar-Anon, and Families Anonymous.
• Educate the family about substance abuse.
• Encourage family members to communicate their concerns about what is happening.
• Assist family members to understand how they play a role in the addiction process.
• Assess how the family is structured, who assumes what role who has the power, and how family members function.
• Inform family members that the client's recovery process will affect family roles and responsibilities.

A Therapeutic Intervention

• The family believes that a member requires drug and alcohol treatment and requests assistance from the nurse therapist.
• An intervention plan is developed by the family and the nurse. All participants list their personal knowledge about the client 5 drug- and alcohol-related situations and behaviors.
• The family and friends meet with the addict face to face and express their concerns, observations, and compassion. This confrontation strategy is designed to break down the addicted person's denial and defenses.
• A plan for obtaining drug and alcohol treatment is presented the addicted person.
• Consequences are stated if the person refuses to obtain treatment.