Substance abuse, as a recognized disorder, involves the misuse of illicit substances or the harmful use of legal substances. Ethanol is the most commonly misused legal substance.

SUBSTANCE ABUSE/CHEMICAL DEPENDENCE IN ADOLESCENTS

The consumption of alcohol and other drugs constitutes a significant danger to the well-being of children and teenagers. Beyond health consequences, substance misuse often correlates with other risky behaviors such as acts of violence, early sexual experiences, skipping school, and poor academic performance.

Physicians who care for children and other primary healthcare providers are ideally positioned to identify substance abuse and offer preventative guidance and education to young people, adolescents, and their families.

Epidemiology

Between the 1990s and recent times, the rates of alcohol and other drug misuse among adolescents have been on the rise. Research indicates that approximately half of all adolescents have experimented with an illegal drug by the time they finish secondary school. The most frequently misused substance is alcohol.

Definitions

Various terms are utilized to define disorders related to substance use, including:

• Substance abuse: Refers to the unauthorized use of a substance resulting in notable difficulties or suffering. These difficulties may manifest as:

  • Absenteeism from educational settings

  • Substance use in hazardous contexts (e.g., operating a vehicle)

  • Legal issues linked to substance use

  • Negative impact on friendships and/or family connections

• Tolerance: Describes the necessity for increasing quantities of a substance to achieve the originally experienced effect.

• Substance dependence: Signifies a compelling and ongoing reliance on a specific substance for both physical and emotional relief, coupled with an inability to cease its use even after significant negative consequences in daily life have arisen. Indicators can include:

  • Elevated tolerance levels

  • Experiencing withdrawal symptoms upon reducing use

  • Repeated failed attempts to cut down

  • Increased time dedicated to obtaining substances

  • Social and recreational withdrawal

  • Persistent substance use despite awareness of physical or mental health problems resulting from its use.

• Alcohol intoxication: This involves a transient disturbance of mental function following significant alcohol consumption, where blood alcohol concentration is sufficiently high to affect behavior, mood, and awareness.

• Alcoholism: Represents a chronic condition where an individual excessively consumes alcohol over an extended period, leading to detrimental physical, mental, social, and psychological repercussions.

• Alcoholic: An individual who has consumed alcohol excessively for a prolonged duration and has experienced significant mental, social, psychological, and physical problems as a result.

Substances commonly abused by adolescents

Substances that are often misused by adolescents encompass, but are not limited to:

• Alcoholic beverages

• Cannabis (Marijuana)

• Tobacco products

• Prescription medications (misused)

• Hallucinogenic drugs

• Cocaine

• Amphetamine-type stimulants

• Opioid drugs

• Anabolic-androgenic steroids

• Inhalants (volatile solvents)

• Methamphetamine

Causes of substance abuse

1. Cultural and societal norms and accepted patterns of substance use: Public statutes dictate the legality of substance use.

2. Genetic predisposition: A tendency for substance abuse can be observed across family lines.

3. Psychological factors such as:

   • Anxiety disorders

   • Stress and frustration

   • Craving sensations

4. Environmental stressors such as:

   • Academic setbacks

   • Anxiety about the future

   • Failure to meet specific objectives

   • Experiences of child maltreatment

   • Inadequate parenting

   • Limited educational opportunities

   • Overly large and unmanaged family units

   • Financial difficulties

   • Traumatic experiences like sexual assault or incest

5. Peer influence and pressure

6. Underlying personality disorders

7. Co-occurring psychiatric conditions such as:

   • Major depressive disorder

   • Suicidal ideation

   • Paranoia

Adolescents at risk of substance abuse

Parental and peer substance use are significant contributing factors to decisions made by young people regarding substance involvement.

Certain adolescents face a heightened risk of developing substance-related disorders, including those with one or more of the following factors:

• Children with parents who have substance use disorders

• Adolescents who have been subjected to physical, sexual, or emotional abuse

• Adolescents experiencing mental health conditions, particularly depression and suicidal thoughts

• Adolescents with physical disabilities

• Children whose parents are involved in substance dealing for income

• Homeless or runaway youth

Symptoms of substance abuse

The following behaviors might suggest that an adolescent is struggling with substance abuse. However, symptom presentation can vary among individuals. These symptoms may include:

• Frequent intoxication from drugs or alcohol

• Dishonesty, particularly concerning substance use

• Withdrawal from social connections with family and friends

• Abandonment of previously enjoyed activities, like sports or time with non-using friends

• Frequent discussion about using drugs or alcohol

• Belief in the necessity of substance use for enjoyment

• Encouraging others to use substances

• Trouble with school authorities or law enforcement

• Engagement in risky behaviors, such as unsafe sexual practices or driving while impaired

• School suspension related to substance use

• Absence from school due to substance use and/or declining academic performance

• Feelings of sadness, hopelessness, or thoughts of self-harm

Diagnosis of substance abuse

A diagnosis of substance abuse in adolescents is typically made by a pediatrician, family physician, psychiatrist, or a qualified mental health professional. However, it is believed by some that adolescent substance abuse is a frequently overlooked pediatric diagnosis. Adolescents who use drugs often present at a doctor’s office without obvious physical signs. Substance abuse issues are more likely to be detected when adolescents are injured in accidents while under the influence, or when they seek medical attention due to self-inflicted harm.

• History taking: Gathering information about the adolescent’s personal history regarding substance use.

• Clinical presentation: The physical presentation can vary depending on the substance used, frequency of use, and time since last use, and may manifest as:

  • Unexplained weight loss

  • Persistent tiredness

  • Unkempt hair

  • Bloodshot eyes

  • Neglect of personal hygiene

• Use of screening tools: Employing questionnaires like the CAGE.

Treatment for substance abuse

The specific treatment approach for substance abuse is determined by:

• The adolescent’s age, overall health status, and past medical conditions

• The severity of the adolescent’s symptoms

• The extent of the adolescent’s dependence

• The substance(s) being misused

• The adolescent’s ability to tolerate specific treatments or medications

• Expectations for the progression of the condition

• The caregiver’s opinions or preferences

A range of treatment programs for substance abuse exists, offered on an inpatient or outpatient basis. The chosen programs typically depend on the specific substance involved.

• Medical detoxification: (If necessary, based on the substance misused) is crucial, along with sustained follow-up care for successful treatment outcomes.

• Long-term follow-up management: Typically includes structured group meetings and age-appropriate psychosocial support systems, in addition to ongoing medical oversight. Individual and family therapy are frequently advised to address the developmental, psychosocial, and family dynamics that might have contributed to or resulted from the substance abuse disorder.

Prevention of substance abuse

Three main strategies are employed to prevent adolescent substance use and abuse:

• School-based prevention programs: These programs commonly provide education about drugs and alcohol, and training in interpersonal and behavioral skills.

• Community-based prevention programs: These initiatives often involve media campaigns and target parents and community groups. Organizations like Mothers Against Drunk Driving (MADD) and Students Against Drunk Driving (SADD) are prominent examples of community-based prevention efforts.

• Family-focused prevention programs: These programs involve parent education, family skills training, adolescent social skills development, and family support groups. Existing research indicates that elements of family-focused prevention programs have reduced alcohol and drug use among adolescents and have improved parenting effectiveness.

ALCOHOL AND DRUG ADDICTION

Alcohol and drug addiction have been significant problems for centuries. Contemporary research suggests that alcoholism and drug addiction contribute to more psychoactive, psychological, and social issues than any other factor impacting individuals and society’s emotional well-being.

The following are commonly misused categories of substances:

• Alcohol

• Cannabis

• Cocaine

• Nicotine

• Opioids

• Sedatives, hypnotics, and anxiolytics

Terms

• Drug (substance): Any chemical agent that, upon entering the body, can induce physiological and psychological changes.

• Alcoholic: An individual who has consumed alcohol excessively, resulting in mental, social, physical, and psychological problems.

• Substance intoxication: The development of a reversible syndrome specific to a substance, occurring after recent ingestion or exposure to the drug.

• Alcohol intoxication: A temporary mental disturbance following substantial alcohol intake, resulting in a blood alcohol level high enough to affect activity, mood, and consciousness.

• Tolerance: The requirement for a higher dose of a drug to achieve an effect previously experienced at a lower dose.

• Dependency: A compulsion to use a drug consistently to experience its effects and avoid the discomfort of its absence. This can be physical or psychological. It is a physiological response to a substance, such as relying on medication for a health condition.

• Addiction: A psychological and physical inability to cease consuming a drug or substance despite causing psychological and physical harm. It involves continued drug use despite the consequences.

• Misuse: The incorrect, excessive, or non-therapeutic use of mind-altering substances.

ALCOHOLISM

Definition: Alcoholism is a chronic condition in individuals who have consumed alcohol excessively and for a long time, leading to significant adverse physical, social, and mental consequences, signifying heightened physical and psychological dependence on alcohol.

Causes of alcohol abuse

• Availability: Easy access to alcohol and social acceptance of drinking, such as at gatherings.

• Genetic factors: A family history of excessive alcohol consumption.

• Poor coping mechanisms: Relying on alcohol to manage stress.

• Psychiatric disorders: Co-occurring conditions like depressive, anxiety, or phobic disorders.

• Social factors: Issues like isolation, unemployment, loss, or perceived injustice.

• High-risk groups: Individuals facing chronic physical illness, business professionals with travel requirements, sales personnel, industrial workers, students in hostels, military personnel, etc.

• Age: More prevalent between late adolescence and early adulthood.

Process of alcoholism

1. Experimental: Initiated by peer influence, curiosity, or other factors.

2. Recreational: Consumption becomes regular during weekends or holidays. In small amounts, alcohol may provide relaxation and stress relief.

3. Compulsive: Regular use progresses to near-daily or heavy consumption for pleasure or to avoid withdrawal discomfort.

Alcoholism progresses through distinct phases:

• Early stage:

  • Increased tolerance – needing more alcohol for the same effect.

  • Blackouts – inability to recall events while intoxicated.

  • Preoccupation – constant thoughts about drinking.

• Middle stage:

  • Loss of control over quantity and timing, with occasional attempts at abstinence followed by relapse into heavy drinking.

• Chronic stage:

  • Intoxication with minimal alcohol, resorting to dishonest means to maintain supply. Alcohol becomes the primary focus, overshadowing family and work.

Types of drinkers

• Mild drinkers: Infrequent, small amounts, rarely causing problems.

• Moderate drinkers: Consume moderately, without significant health issues.

• Problem drinkers: Consume large quantities daily, often high concentrations, leading to impaired health, disrupted family life, and loss of reputation.

Effects and complications of alcohol

• Physical or medical effects:

  • Hepatitis and cirrhosis of the liver

  • Pancreatitis

  • Peptic ulcers and gastritis

  • Cardiomyopathy and heart failure

  • Alcohol-related seizures

  • Tuberculosis

  • Weight loss

  • Alcohol-related dementia

  • Anemia

  • Malnutrition

  • Compromised immune system

• Psychiatric effects:

  • Depression

  • Pathological intoxication characterized by aggression and impaired judgment

  • Delirium tremens

  • Alcoholic hallucinosis

  • Alcoholic psychosis resembling paranoid schizophrenia

  • Alcohol-related amnestic disorder

  • Alcoholic dementia

  • Suicide risk

  • Anxiety disorders

  • Paranoia

  • Morbid jealousy

  • Hallucinations

  • Wernicke’s encephalopathy

  • Korsakoff syndrome

• Social problems:

  • Decreased work performance and productivity due to absenteeism

  • Family problems including divorce

  • Increased accident risk due to impaired driving

  • Legal issues like theft

  • Violence and aggression

• Legal effects:

  • Offenses like sexual assault or theft.

Diagnosis of alcoholism

1. History taking: Gathering information about upbringing and drinking history.

2. Clinical presentation: Observing physical signs like facial features and hygiene.

3. Using the CAGE questionnaire:

   • C – Have you ever felt you should 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 (Eye-opener) to steady your nerves or get rid of a hangover?

   Two or more affirmative responses suggest potential alcoholism.

Concentration of alcohol in blood with their effects

• 80-150mg/100ml blood: Intoxication

• 150-300mg/100ml blood: Potentially fatal

• 300-500mg/100ml blood: Highly fatal

• 500mg/100ml blood and above: Usually results in death

Note: Tolerance can influence these effects.

Management of alcoholism

Aims:

• Detoxification (in acute cases)

• Improving social connections and support

• Building self-confidence and capacity for change

• Identifying motivations for change

• Developing alternative activities

• Learning relapse prevention strategies

Admission:

Hospital admission is crucial to prevent access to alcohol, typically for 6-8 weeks in a psychiatric setting, in an open, well-lit room to minimize fear and illusions.

• Establish a positive nurse-patient relationship.

• Remove potentially dangerous items.

• Ensure a clean, dry, and warm bed due to potential incontinence.

• Monitor vital signs and behavior every 15 minutes initially.

Investigations:

• Urine glucose test

• Blood tests for hemoglobin and glucose levels

• Blood alcohol level assessment

Medication:

• Minor tranquilizers (e.g., diazepam) to manage anxiety and tremors.

• Anticonvulsants for withdrawal seizures.

• High-dose vitamin B complex and C.

• Antacids for gastritis.

• Intravenous fluids to correct electrolyte imbalances.

• Disulfiram (under supervision) as an aversion therapy.

• Yeast tablets to stimulate appetite.

• Antiemetics for vomiting.

• Sedation if necessary.

• Avoid barbiturates due to addiction risk.

General nursing care:

• Address physical and mental health issues related to advanced alcoholism (malnutrition, vitamin deficiencies, hallucinations, liver disease).

• Provide frequent, nutritious meals.

• Maintain hygiene.

• Offer acceptance and encourage socialization.

• Involve psychiatric social workers.

• Encourage religious engagement.

• Promote family therapy.

• Advise changing social circles.

• Introduce Alcoholics Anonymous.

• Plan for discharge and community reintegration.

STEPS OF ALCOHOLICS ANONYMOUS

1. Acknowledging powerlessness over alcohol and unmanageability of life.

2. Believing in a power greater than oneself for restoration.

3. Deciding to surrender will and life to a higher power.

4. Conducting a thorough moral self-assessment.

5. Confessing the nature of wrongs to oneself, a higher power, and another person.

6. Becoming ready for the higher power to remove character defects.

7. Humbly requesting the removal of shortcomings.

8. Listing those harmed and becoming willing to make amends.

9. Making direct amends wherever possible without causing further harm.

10. Continuously taking personal inventory and promptly admitting wrongdoings.

11. Seeking to improve connection with the higher power through prayer and meditation.

12. Carrying the message to other alcoholics and practicing these principles in all aspects of life.

Nurses role in the prevention of alcohol abuse

• Primary prevention: Aiming to prevent new cases through health promotion and education.

• Secondary prevention: Early detection and treatment to prevent complications.

• Tertiary prevention: Preventing further disability and reintegrating individuals into society.

The nurse plays a role in all these levels of prevention.