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Everyone, personally or indirectly, is affected and invariably distressed by the multiple problems caused by substance abuse. The excessive consumption of drugs is a progressive disease and when continued and accelerated leads to a deadly, predictable end.
The healthy average person's brain produces enough natural endorphins to give them a sense of well-being and stability. When the brain is getting the wrong chemical signal, and transmission is being interfered with, the production of endorphins is decreased and a feeling of need or craving is the result.
When a person is depressed, fatigued or troubled, the feeling is more intense. No matter what the age of the person or circumstances of life, the urge to escape from the pain and stress to the feelings of pleasure and relaxation the drug provides is overwhelming.
Alcohol is a drug. Most people drink moderately and control their intake. It is a pleasant indulgence that eases tensions, releases inhibitions and creates an atmosphere of congeniality at social functions.
It is the addict or substance abuser who has the trouble. There is much research that verifies that this disease is biogenetic and can be aggravated by psychological stress and influenced by society. It is passed down from generation to generation. The addict's liver and brain begin to function differently from the very first drink or experience with a drug.
When alcohol is ingested orally, it goes through the stomach into the small intestine where it is absorbed into the bloodstream. The bloodstream carries it to the liver where toxic agents in the alcohol are removed by a series of enzymes. The enzyme responsible for this breakdown is alcohol dehydrogenase (ADH).
Evolution provided all of us with the enzyme alcohol dehydrogenase in our liver. Its task is to remove the small amounts of alcohol generated in the gastrointestinal tract by fermentation processes of normal bacterial flora. If nature had not given us this system, we would have many adverse effects due to the accumulation of this toxin.
Through the action of alcohol dehydrogenase in the liver, alcohol is metabolized to acetaldehyde, and finally to carbon dioxide and water. Acetaldehyde is a poison.
Alcohol absorbs faster when the stomach is empty. Food dilutes the alcohol and slows the rate of absorption. The type of alcoholic beverage also has an effect. A carbonated drink enhances the rate of absorption by hastening gastric emptying. The higher the concentration of alcohol, the more quickly it is absorbed.
It takes an hour for a man of average height, weighing 160 pounds to metabolize one drink. Two drinks will take two-and-a-half hours to metabolize, and five drinks in an hour will take five hours to metabolize. A man and a woman of the same body weight drinking the same amount of alcohol will have different blood levels. Hers will be higher. A woman's menstrual cycle can also influence her rate of absorption. The changing hormones make absorption quicker, and result in higher blood levels. The same is true of a woman taking birth control pills.
What does the accumulation of acetaldehyde do to the brain? It flows through the blood brain barrier and inhibits the enzymes which metabolize various brain amines. In other words, it interferes with the normal chemical actions of the brain.
Each person has his own individual chemical balance which provides the basis for his personality, intelligence and capability. The main neurotransmitter in the brain is dopamine. It controls our energy, mood and feelings of pleasure. There are fifteen chemical messengers in the brain cell called neurotransmitters.
The acetaldehyde invades the nerve cells and bonds to dopamine and norepinephrine, two of the many chemicals that are part of the neurotransmitter system. This action results in the substance TIQ (tetrahydroisquinoline).
TIQ is a highly addictive, heroinlike substance. Alcoholics produce more TIQ from alcohol than do nonalcoholics. The percentage of TIQ produced by an alcoholic seems to be genetically set. Because TIQ is similar to endorphins, the brain adjusts its production and soon there are not enough endorphins to relieve the normal everyday pain. The receptors crave the drug to fill the receptors.
The acetaldehyde also combines with the neurotransmitter GABA (gamma amino butyric acid) and floods the cells of the brain with chloride, creating a further sedative-like effect. This is the pleasant euphoric feeling that the substance abuser seeks and so the addiction prevails.
A healthy cell's membrane has a specific dimension and permeability which controls the proper flow of potassium, sodium and chloride in and out of the cell.
When this balance is disrupted by substance abuse, the cell wall thickens in an attempt to reestablish the correct chemical balance within. These thickened membranes require constant supplies of the drug to function "normally" and the addiction is on a one-way road to destruction. Because of the actions of the chemicals and the increased flow of chloride, the neurotransmission system is "out of sync." The ability to think, to remember and to react is impaired. The brain cells are unbalanced when a mood-altering drug enters the brain. The drug causes a release of the neurotransmitters in an abnormal way. This results in a change in the neurotransmitters and a change in the person who has taken the drug.
| Normal Function | Neurotransmitter | After Drug Ingestion |
|---|---|---|
| controls muscle coordination/memory nerve cells | Acetylcholine | loss of memory |
| influences energy pleasure | Dopamine | results in depression |
|
controls flight/fight responses/sense of security/hunger/thirst |
Epinephrine | results in paranoia loss of appetite |
| relieve pain/anxiety | Endorphins Enkephalins | causes pain/anxiety craving |
| controls seizures/ depression | GABA | causes pain/anxiety craving |
| controls brain metabolism | Glycine/Glutamate Aspartate | causes imbalance of brain chemicals |
| regulates reactions | Histamine | causes allergic reaction |
| regulates growth reproduction | Neurohormones | results in abnormal growth/reproduction |
| involved with immune system | Neuropeptides | causes changes in immunity/stress |
| regulates heart/ respiration/body temperature/blood pressure | Norepinephrine | causes classic withdrawal symptoms hallucinations |
| regulates the five senses/sleep aggression/hunger | Serotonin | causes depression changes behavior/ alters appetite/sleef patterns |
| influences stress/ pain | Substance P | causes changes stress/pain |
Is the body chemistry of the substance abuser different? Yes. As the alcoholic increases his consumption, the cells in the liver adjust to the presence of large quantities of alcohol and create an alternate system (or backup) known as MEOS (microsomal ethanol oxidizing system). This system works very slowly. Enzymes are increased and new liver cells are made in order to help with the converting of alcohol dehydrogenase to acetaldehyde. The flaw in this system is that it does not allow elimination of the acetaldehyde as quickly as it is produced, and so there can be a buildup of toxic acetaldehyde levels.
Because of the differences in body chemistry, the progression of symptoms is different in everyone. Sometimes it takes years until obvious and variable symptoms are apparent, and by then the person is on the downward spiral.
High acetaldehyde levels are poisonous to the body and are responsible for the withdrawal symptoms that occur on cessation of the drug. These symptoms—agitation, tremors, increased heart rate and headache—cause the addict to indulge in the drug "one more time." It is a catch-22. The hangover that many people experience after a night of excessive drinking is a mild symptom of withdrawal.
Each person has a distinct chemical balance and drugs affect each brain differently, so each withdrawal is different. Stimulant drugs cause certain types of withdrawal symptoms and depressants cause another kind. Each drug has its own rate of recovery, and when drugs are mixed, the recovery is more complicated. The primary drug will be detoxified first.
Withdrawal is the brain's attempt to return to its original chemical balance. The addiction is progressive, and the brain adjusts to the amount of drugs as they are ingested. When the drug is no longer entering the system, it says, "something is wrong here," and it strives to return to normal.
Withdrawal may occur eight to ten days after the ingestion of the last drug. The intensity of the withdrawal symptoms depends on the drug that was used and the length of time it was used. The emotional and physical state of the person will determine whether the symptoms will be mild or severe.
The goal of treating withdrawal symptoms is to prevent serious complications. The patient is usually medicated with drugs that have a longer duration but are similar to the drug that was taken.
Seizures require immediate attention. Valium or phenobarbital may be given intravenously, because quick action is necessary. The nurse should monitor vital signs. An elevated temperature could indicate a dysfunction of the hypothalamus which controls the body temperature.
Addicts withdrawing from opiates may have the feeling that "something is crawling under my skin." Others complain of abdominal pain, severe cramps in the arms and legs and pericardial pain. Their body is clammy to touch, they have a rapid pulse, pupils are dilated and they react sluggishly to light. Insomnia is always present. Delusions and hallucinations are present in many cases.
Those addicted to cocaine do not show withdrawal symptoms. They experience loss of weight, exhaustion, mental fogging, forgetfulness, insomnia and spasmodic contractions of the muscles of the extremities. The withdrawal from cocaine is not as severe as the withdrawal from morphine.
The withdrawal from barbiturates is more dangerous than from narcotics. Those who take barbiturates usually have a cross-addiction to alcohol, which compounds the danger.
Patients in withdrawal need TLC (tender loving care) and though they can be difficult at times, the nurse needs constant vigilance and much patience. Keep the physician informed of any changes. Inform the patient of the importance of his medication and explain all procedures. Keep a discharge plan up-to-date and after he is detoxified, he can return to his home better informed.
The occurrence of withdrawal symptoms upon cessation of taking the drug is evidence of physiological dependence. The most serious form of withdrawal is delirium tremors.
This is a complication that requires hospitalization. It is characterized by confusion, disorientation, agitation, hallucinations and maybe even seizures. These symptoms may occur six to seven days after the last drug and last two or three days or longer.
The person with delirium tremors can exhibit violent behavior as well as paranoia. Persons who are most likely to develop delirium tremors usually combine drugs and have been substance abusers for over ten years. There also may be a previous history of the occurrence of seizures.
The nurse's assessment and reporting to the physician all symptoms is pertinent to the patient's safe recovery. Proper care will include monitoring of fluid and electrolyte imbalance. Document all signs of anxiety, psychomotor agitation and check all stools for possible gastrointestinal bleeding. Be aware of any nutritional deficits.
Drugs affect the brain as long as they remain in the bloodstream. Excretion rate is proportionate to the concentration in the bloodstream. Ninety-five percent of alcohol ingested is metabolized by the liver, and the remaining five percent is excreted through breath, urine and perspiration.
Approximately two percent of alcohol ingested is excreted through the breath. Because this ratio is so constant, the amount of alcohol present in the bloodstream can be inferred by measuring the amount of alcohol present in a sample of expired air from the lungs. This is done with the breathalyzer device and is used by police to substantiate suspicion of driving under the influence of alcohol.
Another method to assess alcohol level is by taking a blood sample and measuring the alcohol concentration. When the alcohol content of the bloodstream reaches 0.1 percent, the person is considered to be legally intoxicated. Many states have adopted a standard that's even more stringent. At this point, coordination, speech and vision are impaired.
The experienced drinker knows "how to drink" to avoid feeling intoxicated. He will not gulp his drink down or drink on an empty stomach. But if his intake is a large quantity, his blood level is climbing and he is impaired. Impairment is greater on the ascending climb or absorption phase.
Even before a person reaches the 0.1 percent, judgment is hindered to such an extent that he misjudges his condition. Drivers are certain of their ability to drive safely long after their driving has, in fact, become quite unsafe.
Newspapers are filled daily with articles about drunken drivers responsible for accidents. There was an article in the paper today about a successful surgeon in our town. He was driving home after attending a social function, and he rammed into a parked police car. The officers were standing on the right side of their car, and he pinned them against the guardrail. Both officers were taken to the hospital in serious condition. The surgeon's blood alcohol was three times the legal limit.
Imagine the pain and havoc in all three of these men's lives. One of the officers lost his leg. The other officer suffered a fractured pelvis. The surgeon's career is in peril. All this misery because he drank beyond a safe limit and misjudged his ability to drive safely.
It is a misconception that beer is less intoxicating than bourbon. I knew a man who regularly drank eight cans of beer in an hour and didn't realize the alcohol content. A twelve-ounce can of beer, six ounces of wine and one mixed drink containing one-and-a-half ounces of eighty-six proof distilled spirits all have the same alcohol content. The six cans of beer are the equivalent of a nine-ounce glass of bourbon in an hour. When too much alcohol is consumed quickly, the high concentration of alcohol in the empty stomach will cause the pyloric valve to spasm and the result is vomiting. This is a protective device of the stomach to prevent toxic substances from entering the bloodstream via the small intestine.
Excessive alcoholic ingestion can lead to death, as has been the case in some college fraternity hazing parties. There have also been cases documented about men in the service who have overdosed on alcohol. Young men in the navy are susceptible to the introduction of drugs when they visit foreign ports. The services warn the young men about the dangers of drugs, but that wasn't always the case. A large number of ex-service men are experiencing health problems today because of substance abuse when they were younger.
Some people experience blackouts from the beginning of their drinking, but it usually characterizes the middle stage of alcoholism. A blackout is a chemically induced period of amnesia. It is not fully understood, but years of high concentrations of alcohol may eventually cause this phenomenon. Some substance abusers never have blackouts.
A person who blacks out will not know how he got home or who he talked to on the phone. He may appear normal and function normally but has no memory of what happened.
"I never drink in the morning," Carol told me. She didn't take into account the large quantities of wine she drinks in the evening. Carol also has blackouts. "Doesn't everyone who drinks have them?" she asked. She thought it was a normal part of drinking. She drank until she passed out. Just because you have no blackouts and don't drink until after five o'clock in the evening doesn't mean you are not a substance abuser.
A common defense mechanism for the substance abuser is repression. This is psychologically induced forgetfulness. It is too painful to look at his behavior, and so the substance abuser represses most of it. This is true of "the life of the party" or the woman who neglects her family.
The most devastating symptom is euphoric recall because the person distorts the memory and loses touch with reality. John has fights with his wife and trouble with the law, but he says, "my wife and I have a great relationship...." He hasn't been able to hold a job because, "bosses are too hard to get along with, they don't give you decent material to do a good job."
Possible nursing diagnosis for the chemically dependent patient might include:
injury potential related to confusion, disorientation
violence potential related to high anxiety, impulsiveness
self-concept disturbance related to shame, guilt
fluid volume deficit potential related to loss of fluid, result of
diarrhea and vomiting sleep pattern disturbance related to anxiety, nightmares
One of the nursing problems you may encounter with the chemically dependent person is inappropriate coping behavior. Show empathy and support, but be clear in declaring set limits. Encourage the patient to express his feelings and inform him about all the options available to him.
Because of their poor nutrition and health, substance abusers are poor surgical risks. Close observation is a must. Notify the physician immediately at the sign of restlessness. You will find the substance abuser a challenging patient, and the reward is great when you discover that you can help someone make positive changes in his life.
The metabolism of the alcoholic differs from that of a normal individual after the ingestion of alcohol in three ways:
Absorption of alcohol is faster on an empty stomach. The higher the concentration of alcohol, the quicker it is absorbed.
A twelve-ounce can of beer, six-ounce glass of wine and one-and-a-half ounce glass of distilled spirits all have the same alcoholic content.
A blackout is a chemically induced period of amnesia. Repression is psychologically induced forgetfulness. Euphoric recall is a memory distortion and loss of touch with reality.
Symptoms of withdrawal are:
| anxiety | confusion | seizures | hallucinations |
| tremors | insomnia | exhaustion | irritability |
Symptoms of delirium tremors are:
| agitation | disorientation | tachycardia | elevated |
| confusion | hallucinations | fever | blood pressure |
A person is considered to be legally intoxicated when his blood alcohol reaches 0.1 percent. Some states have imposed lower limits.