Substance use and misuse. (Substance abuse)

INTRODUCTION

Disorder due to psychoactive substance use refers to conditions arising from the abuse of alcohol, psychoactive drugs and other chemicals such as volatile solvents.

DEFINITION:

Substance: refers to commonly known drugs of abuse like cannabis and opioids, legal substances like alcohol and tobacco, medicinal compounds with abuse liability like tranquilizers and sedatives, and other chemicals like volatile substance that one is dependent on or uses habitually and that is often illegal or subject to government regulation.

Substance use is when someone consumes alcohol or drugs. The very first time that he took a sip of alcohol, he was using. Substance use does not always lead to addiction; many people occasionally use alcohol or certain drugs without being addicted. However, substance use always comes with the risk that it might lead to addiction.

Substance abuse or misuse is defined as the use of a substance for a purpose not consistent with legal or medical guidelines (WHO, 2006). It has a negative impact on health or functioning and may take the form of drug dependence, or be part of a wider spectrum of problematic or harmful behaviour.

SUBSTANCE DEPENDENCE

Dependence: A compulsive or chronic requirement. The need is so strong as to generate distress (either physical or psychological) if left unfulfilled.

1. Physical Dependence

Physical dependence on a substance is evidenced by a cluster of cognitive, behavioural, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems (APA, 2000). As the condition develops, repeated administration of the substance necessitates its continued use to prevent the unpleasant effects characteristic of the withdrawal syndrome associated with that particular drug. The development of physical dependence is promoted by the phenomenon of tolerance. Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

2. Psychological Dependence

An individual is considered to be psychologically dependent on a substance when there is an overwhelming desire to repeat the use of a particular drug in order to produce pleasure or avoid discomfort. It can be extremely powerful, producing the intense craving for a substance as well as its compulsive use.

3. Substance Intoxication

Substance intoxication is defined as the development of a reversible substance-specific syndrome caused by the recent ingestion of (or exposure to) a substance (APA, 2000). The behaviour changes can be attributed to the physiological effects of the substance on the CNS and develop during or shortly after use of the substance. This category does not apply to nicotine. A strong desire to take the substance

4. Tolerance:

Tolerance refers to a physiological state where the effectiveness of a drug has decreased due to chronic administration. This means that more of the drug will be required to achieve the same effect in the future. One of the reasons for why this occurs is that any organism can build up a resistance to the effects of some drugs.

There are said to be two mechanisms involved in tolerance: pharmacokinetic tolerance and pharmacodynamic tolerance. With pharmacokinetic tolerance, there is a decreased quantity of the substance reaching the target area. There are different reasons for why this can occur but a common example is that there has been an increase in enzymes that lead to degradation of the drug. Pharmacodynamic tolerance occurs because there is a decreased response to the drug by the cellular mechanism. A common way that this happens is that there has been a reduction in the number of receptors.

5. Substance Withdrawal

Substance withdrawal is the development of a substance specific maladaptive behavioural change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use (APA, 2000). Withdrawal is usually, but not always, associated with substance dependence.

CLASSIFICATION OF PSYCHOACTIVE SUBSTANCE

The following 11 classes of psychoactive substances are associated with substance use and substance-induced disorders:

1. Alcohol
2. Amphetamines and related substances
3. Caffeine
4. Cannabis
5. Cocaine
6. Hallucinogens
7. Inhalants
8. Nicotine
9. Opioids
10. Phencyclidine (PCP) and related substances
11. Sedatives, hypnotics, or anxiolytics

ETIOLOGICAL FACTORS AND CONTRIBUTING FACTORS

a. Biological factors:

• Genetic vulnerability: family history of substance use disorder, e.g. twin study suggests that genetic mechanism might account for alcohol consumption.
• Biochemical factors: for e.g. role of dopamine and norepinephrine have been implicated in cocaine, ethanol, and opioid dependence. Abnormalities in alcohol dehydrogenase or in the neurotransmitter mechanism are thought to play the role in alcohol dependence.
• Withdrawal and reinforcing effects of drugs (they serves as maintaining factors). 
• Co-morbid medical disorder, (e.g. to control chronic pain).

b. Psychological factors; 

• General rebelliousness
• Sense of inferiority 
• Poor impulse control 
• Low self-esteem 
• Inability to cope with the pressures of living and society (poor stress management skill).
• Loneliness, unmet needs 
• Desire to escape from reality 
• Desire to experiment, a sense of adventure 
• Pleasure-seeking 
• Machoism
• Sexual immaturity

c. Social factors

• Religious reasons 
• Peer pressure 
• Urbanization 
• Extended periods of education 
• Unemployment 
• Overcrowding 
• Poor social support 
• Effects of television and other mass media 
• Occupation; substance use is more common in chefs, barmen, executives, salesmen, journalists, medical personnel, etc.

d. Socio-cultural factors

• Social Learning: The effects of modelling, imitation, and identification of behaviour can be observed from early childhood onward. In relation to drug consumption, the family appears to be an important influence.
• Conditioning: Many substances create a pleasurable experience that encourages the user to repeat it. Thus, it is the intrinsically reinforcing properties of addictive drugs that “condition” the individual to seek out their use again and again.
• Cultural and Ethnic Influences: Factors within an individual’s culture help to establish patterns of substance use by molding attitudes, influencing patterns of consumption based on cultural acceptance, and determining the availability of the substance.

NURSING RESPONSIBILITIES

• An informed Consent should be taken before Starting treatment.
• Ensure that at least 12hours have elapsed since the last ingestion of Alcohol before Administering the Drug.
• Patient should be warned against Ingestion of any alcohol- containing preparations such as Cough Syrups, Sauces, Aftershave Lotions, Etc.,
• Caution patient against taking CNS Depressants & Over-the- Counter(OTC) Medications during disulfiram therapy.
• Instruct The Patient to avoid driving or other activities requiring alertness.  
• Patients should be warned that the Disulfiram-alcohol Reaction may continue for as long as or 2 weeks after the last dose of disulfiram.
• Patients should carry identification cards describing Disulfiram- alcohol reaction & listing the name & phone number of the physician to be called. 
• Emphasize the Importance of Follow-Up visits to the physician to monitor progress in long-term therapy.

NURSING MANAGEMENT

Nursing Assessment: Recognition of Alcohol Abuse using CAGE Questionnaire 

• —C – Have you ever felt you ought to CUT down on your drinking ? 
• —A – Have People ANNOYED you by criticizing your drinking ? 
• —G – have you ever felt GUILTY about your drinking ? 
• —E – Have you ever had a drink first thing in the morning (An EYE – OPENER) to steady your nerves or get rid of a Hangover ?

CONCLUSION:

Substance-related disorders have become matters of global concerns because of impact on individual health, familial and social consequences, criminal and legal problems, and the effect on the national productivity and economy. All the problems along the two spectra, that is from use to dependence and from the most harmless substance like tea and coffee to the hardest substances contribute to the cost that the human society or a particular nation has to bear.

REFERENCE

• Mary C. Townsend, Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice, Sixth Edition (pp 441-445,444-445), Philadelphia: F. A. Davis Company.
• Vyas JN, Ahuja Niraj, Textbook of Postgraduate Psychiatry(pp 76-139), Second Edition, Delhi: Jaypee Medical Publishers.
• Sreevani R, A Guide to Mental Health and Psychiatric Nursing(pp 129-143), Second Edition, Delhi: Jaypee Medical Publishers
• Neeraja KP, Essentials of Mental Health and Psychiatric Nursing(pp 593-616), Volume 2, Delhi: Jaypee Medical Publishers
• Namboodiri VMD, Concise Textbook of Psychiatry 3^rd Edition, Gurgaon: Reed Elsevier India Pvt. Ltd 2009