Care of the Patient with an Addictive Personality

FON Ch 36
Addiction

The definition of addiction contains four elements: (1) excessive use or abuse, (2) display of psychological disturbance, (3)
decline of social and economic function, and (4) uncontrollable consumption, indicating dependence. Alcoholism refers to
addiction to alcohol. It is possible to suffer from more than one addiction at the same time. An example is the alcoholic
person who is also a smoker and a compulsive gambler.

Addictive Personality
These traits have often been grouped under the term addictive personality (a person who exhibits a pattern of compulsive
and habitual use of a substance or practice to cope with psychic pain from conflict and anxiety). These personality traits
include low stress tolerance, dependency, negative self-image, feelings of insecurity, and depression. It is not clear whether
these traits are present before the development of dependence or are a result of it.

Stages of Dependence

Early Stages
Increased drug tolerance

Strong denial

Defends drug use to family concerns

More socializing with users

Increased tardiness or call-offs from work/school

Possible legal problems

Good prognosis for recovery, even without a treatment program

Middle Stage
Moderate impairment

Withdrawal signs with abstinence

Uses to feel “normal”

Established pattern of use

Further alienation from family

Drug-related behavior such as lying, stealing, mood swing

Physical health declines

Weight loss noticeable

 Blackouts

Financial/legal problems

Job loss or frequent job changes

Few recover without treatment

Late Stage
Severe impairment in all areas of function

Continuous use but cannot achieve “normal” feeling

Medical problems worsen; organ involvement

Malnutrition worsens

Poor problem solving and judgment

Manipulative, denies problems

Unemployed

Often homeless

Must receive treatment for improvement

Alcohol Abuse and Alcoholism

Alcoholism is a national health problem surpassed only by heart disease and cancer. No one theory explains the cause of
alcoholism.

Etiology and Pathophysiology

Alcohol is a central nervous system (CNS) depressant. The so-called stimulating effect occurs because the first areas
alcohol affects are the higher centers of the brain, including the frontal cortex, which govern self-control. Judgment is
blocked, but memory of pleasure is retained. As a person continues to ingest alcohol, it affects the nucleus accumbens in
the limbic system (the most primitive part of the brain; it regulates hunger, thirst, and sexual desire). Repeated alcohol
consumption affects the basal ganglia of the brain, where it unbalances compulsion controls, leading to obsessive-
compulsive behavior. Unconsciousness from rapid, large-quantity consumption is possible, during which respiration is
sometimes affected. Death from acute alcohol poisoning is possible.

Fetal Alcohol Syndrome

Fetal alcohol syndrome (FAS) is a congenital anomaly resulting from daily maternal ingestion of alcohol equivalent to
3 ounces of absolute alcohol per day. This syndrome is common in newborns whose mothers drank heavily during
pregnancy. Birth defects related to alcohol use include mental retardation, growth disorders, wide-set eyes, malformed
body parts, and spontaneous abortion or stillbirths. As few as two drinks per day have the potential to cause adverse
effects in an infant.

Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome occurs in a person who has developed physiologic dependence and quits drinking for
whatever reason. Alcoholics at risk for having alcohol withdrawal syndrome include older people, people who have
previously suffered delirium tremens, malnourished people, and people suffering with another acute illness. The range
of possible signs and symptoms varies from mild tremor and flulike signs and symptoms to severe agitation and
 hallucinations. Signs and symptoms associated with the cessation of alcohol consumption include diaphoresis,
tachycardia, hypertension, tremors, nausea and/or vomiting, anorexia, restlessness, disorientation, hallucinations, and
seizures.

The tremors from alcohol cessation are seen 6 to 48 hours after the last drink and sometimes last for 3 to 5 days.
Usually tremors occur in the hands but are also possible in the tongue, the chin, the trunk, and the feet. Seizures are
possible 12 to 24 hours after cessation. Usually these are tonic-clonic (grand mal) seizures and often are not preceded
by an aura.

Delirium Tremens
Delirium tremens (DTs) is a complication of alcohol withdrawal. This acute psychotic reaction is a result of excessive
alcohol consumption over a long period. The risk of death from this complication is as high as 15%, even with
treatment. Signs of DTs are tremors, activity increased sometimes to the point of extreme agitation, disorientation, fear
with an appearance of panic, hallucinations, and elevated temperature. DTs most often occur 1 to 4 days after cessation
of alcohol and usually last from 2 days to a week.

Korsakoff’s Phychosis and Wernicke’s Encephalopathy

Korsakoff's psychosis and Wernicke's encephalopathy are two brain disorders that sometimes occur in chronic
alcoholics. Characteristics of Korsakoff's psychosis are short-term memory loss, disorientation, muttering delirium,
insomnia, hallucinations, polyneuritis, and painful extremities with footdrop affecting the gait. Wernicke's
encephalopathy occurs in association with thiamine deficiency, causing brain damage in the temporal lobes of the
brain. It features memory loss, aphasia, involuntary eye movement and double vision, lack of muscle coordination, and
disorientation with confabulation (i.e., the patient fills in memory gaps with inappropriate words).

Because alcohol affects all tissues in the body, chronic alcohol ingestion has potential to cause damage to all parts of
the body. Table 36-3 presents other disorders arising from chronic alcohol use.

Assessment
It is important to collect both subjective and objective data about the patient suffering from substance abuse or
dependence. Collection of subjective data includes the person's normal using or drinking pattern, as well as the date and
time of the last drink or use of a drug. The specific substance and the quantity the person used are important. Other
complaints such as nausea, indigestion, sleep disturbance, or pain sometimes indicate the simultaneous occurrence of
another disease process, not only side effects of substance abuse. Assessment of normal dietary patterns, the presence of
any disease requiring treatment with prescribed medications, and regular use of any over-the-counter drugs help to
complete the picture of the patient's present state of wellness. Obtain this information in as much detail as possible. Do
not forget to ask about drug allergies or unusual responses to anesthesia, sedatives, or preoperative medications.
Maintaining a concerned, nonjudgmental attitude when asking for details helps to reassure the patient, as does the promise
of confidentiality about this very private part of his or her life.

Assess for any history of tremors, hallucinations, delusions, seizures, or DTs. Note any past periods of abstinence. Inquire
about any problems with occupation, family, or legal matters. Assess for any family history of substance dependency.
Remember that denial is very strong in the person with untreated substance abuse or dependence, and patient information
will often not be accurate. It is helpful to validate information with families or significant others if possible. Another
helpful questionnaire that is often useful in affirming alcohol abuse is the CAGE questionnaire, whose title arises from an
acronym formed from among the tool's four questions (Box 36-1).

Collection of objective data includes height, weight, vital signs, and physical assessment. Note the presence of tremor or
skin conditions, especially on the forearms. Needle tracks and small scabs on forearms, backs of hands, and insteps
indicate intravenous use. Acne-like facial rash is possibly related to MDMA (ecstasy) use.

Frequent sniffing, stuffy nose, or harsh nonproductive cough is possibly related to drug use. Assess general behavior and
cognitive abilities for impairment. The presence of tachycardia, hypertension, petechiae, and neuropathies is significant.
The presence of ascites or a urine or blood sample positive for drugs or alcohol will alert you to the need for further
investigation of the history.
CAGE Questions
 Two or more affirmations to these questions indicate probable alcoholism:

1. Have you ever felt you ought to cut down on your drinking?

2. Have people annoyed you by criticizing your drinking?

3. Have you ever felt bad or guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or for your hangover (i.e., eye-
opener)?

Diagnostic Tests
Blood and urine tests help screen for toxins. Some foods will at times cause a false-positive reading in a urine screen. If a
person ate a poppy seed roll and later gave urine for a drug screen, it is possible that it will yield a positive result for
heroin. Abnormalities in routine blood tests are sometimes directly related to alcoholism. Elevated liver enzymes,
hypoglycemia, and abnormal blood protein levels occur with alcoholism. Magnesium levels will be decreased in some
cases. It is not uncommon to find anemia and other evidence of poor nutrition in the addicted patient. Some practitioners
will also order testing for hepatitis and HIV.

Nursing Interventions
Care for the addicted patient starts with detoxification, the removal of the poisonous effects of a substance. A controlled
setting where it is possible to closely observe and treat the patient for any complications is important during this acute
phase of recovery.

Safety of the patient is a primary concern. If the patient is intoxicated, maintain a patent airway. Consider the side-lying
position and oral suctioning if you think it will be possible to aspirate oral secretions or vomiting. If swallowing is intact,
elevate the head of the bed at least 30 degrees to encourage better air exchange. Administration of intravenous (IV) fluids
is possible to correct the patient's fluids and electrolyte balance. Monitor the IV site often, especially if the patient is
restless. Institute your facility's seizure precautions, such as padded side rails, floor pads, and moving patient to a room
close to the nurse's station.

The practitioner will usually treat tremors, nervousness, and restlessness with drugs such as chlordiazepoxide (Librium)
or naltrexone (ReVia). Give scheduled doses on time.

Cardiorespiratory distress is a possible result of stimulant abuse. The health care provider will sometimes prescribe beta-
adrenergic agents such as propranolol (Inderal) and calcium blockers such as nifidepine (Procardia) and oxygen.
Continuous cardiac monitoring and frequent checks on vital signs with respiratory assessment will help you detect any
adverse changes early, before they have the chance to become life threatening.

If the patient is extremely restless, the physician will sometimes order magnesium sulfate to raise the seizure threshold or
another anticonvulsant medication such as phenytoin (Dilantin). High doses of chlordiazepoxide have potential to cause
urinary retention. Intake and output measurements will be appropriate in some cases.

Rehabilitation
After detoxification, the acute phase of recovery, it is time to start rehabilitation. The object of treatment is to assist the
patient to abstain from substance abuse. Because there is no cure, abstinence is the practical equivalent to the control of
the disease. Administration of disulfiram (Antabuse) is sometimes a way to encourage abstinence. It causes facial
flushing, nausea, tachycardia, dyspnea, dizziness, and confusion when the patient consumes alcohol. The purpose is to
reduce alcohol consumption by aversion. Treatment programs often include family in part of the treatment plan. These
programs are sometimes inpatient programs, and sometimes outpatient or day-treatment programs.

Group Therapy

Alcoholics Anonymous
 Treatment Centers

Pain Management

Drug Abuse
Although you will see alcohol abuse more frequently in patients fighting addiction or who you are helping to treat for
another health problem, drug abuse is also rearing its ugly head in the health care setting. Many people think only of illegal
drugs when drug abuse is mentioned. However, abuse of prescription and over-the-counter drugs is common. Older adults
sometimes trade or share prescription drugs. Rationalizations such as, “If it worked for me, it will for my friend,” and, “If
one pill works, two pills will work better,” often serve to deny or justify misuse or abuse of many prescription and over-the-
counter drugs.

When a person takes drugs for other than medical reasons or in a higher-than-recommended dosage, we call this drug misuse
or abuse. Club drugs refer to those drugs people frequently take for euphoric effect at parties, concerts, dance clubs, or all-
night raves or “trances.” Club drugs are often street drugs. Street drugs are substances that users buy from illegal drug
dealers. Either they come from illegal manufacturers without strict controls, are illegally obtained prescription drugs, or are
not approved for use in the United States. Chronic abuse has the potential to lead to psychological and/or physical
dependence.

Depressants
CNS depressants include alcohol, sedative-hypnotic medications, and opioid analgesics. The sedativehypnotic
medications most often abused include barbiturates and benzodiazepines (minor tranquilizers). People usually take them
orally in tablet or capsule form. Box 36-6 lists the effects of depressants.

Barbiturates entered into medical use in the beginning of the twentieth century; they are useful in the clinical context for
their sedative, hypnotic, anesthetic, and anticonvulsant effects. Problematic side effects include respiratory depression,
rapid tolerance, and dependency, with untoward effects (e.g., seizures or status epilepticus) accompanying sudden
withdrawal. In the 1960s, benzodiazepines became popular as a safer alternative to barbiturates. Flurazepam (Dalmane)
and chlordiazepoxide (Librium) were the first in this group, and diazepam (Valium) quickly followed them.

Valium soon became the most frequently prescribed antianxiety agent. The effects of addiction and overdose with
benzodiazepines were not apparent at first, but by 1981, Valium dropped to the sixth most prescribed drug in the United
States. In the 1990s, alprazolam (Xanax) was the most frequently prescribed benzodiazepine for treatment of acute
anxiety (ASAM, 2009).

Another benzodiazepine that gained notoriety in the 1990s was flunitrazepam (Rohypnol). Perpetrators of sexual assault
have frequently misused this drug, and people thus sometimes refer to it as a “date-rape drug.” It is easy to mix it
stealthily into an alcoholic drink, and then the victim consumes it unknowingly. Its effects include muscle relaxation and
amnesia. Alcohol increases these effects; the two together are sometimes a lethal combination. Rohypnol is not legal for
use in the United States.

Some people in the United States have abused GHB (gamma-hydroxybutyrate) for its euphoric, sedative, and
bodybuilding (anabolic) effects. Its abuse as a synthetic steroid is common at fitness centers and gyms. As with Rohypnol,
GHB has been associated with club drug use and sexual assault. Both Rohypnol and GHB are odorless, tasteless, and
colorless. They are easy to mix with drinks and quickly cause unconsciousness. These drugs also rapidly cause relaxation
of voluntary muscles and also potentially cause the victim to have long-term amnesia for events occurring while under the
effect of the drug.
Signs and Symptoms of Central Nervous System Depressants

• Decreased respirations

• Passiveness, listlessness

• Heaviness in extremities

• Pinpoint pupils (opioid effect)

 • Reduced hunger or thirst

• Reduced sexual drive

• Memory loss

• Slurred speech

• Nausea and vomiting

• Ataxic gait (staggering)

• “Nod state”

Opioid Analgesics
Opioid analgesics are those drugs made from the opium poppy.

Three general types of opioid abusers are (1) street abusers who get opioids illegally, (2) abusers of opioids from medical
sources (prescription opioids), and (3) methadone abusers. Nurses often deal with people in the second group, who are
predominantly middle-class older adults, health care professionals, women, and those with chronic pain syndrome.

Symptoms of acute opioid overdose include severe respiratory depression, pinpoint pupils, and stupor or coma. Aspiration
is possible. Treatment involves supporting ventilation and administering naloxone (Narcan) as prescribed. The health care
provider will sometimes prescribe clonidine (Catapres) to help reduce withdrawal symptoms. It is important to continue
monitoring for recurrent toxic symptoms when naloxone is discontinued.

Morphine and heroin addicts who consume huge amounts typically begin with predictable withdrawal signs and
symptoms approximately 6 hours after the last dose. Withdrawal symptoms include flulike signs and symptoms and body
aches, watery eyes and runny nose, dilated pupils, vomiting, cramps and diarrhea, diaphoresis, tachycardia, hypertension,
and chills and fever. The term “cold turkey” comes from the gooseflesh that is common during withdrawal. Intensity of
signs and symptoms usually peaks in 2 to 3 days. Signs and symptoms subside within 5 to 10 days.

Methadone (Dolophine) is a synthetic opioid that helps suppress withdrawal symptoms in the morphine or heroin addict.
Once the patient's condition stabilizes, the methadone dosage decreases daily until the addict is methadone free. Levo-
alpha-acetylmethadol or LAAM (Orlaam) is a long-acting compound of methadone; it has been associated with better
outcomes than has methadone. Methadone itself is sometimes a drug of abuse for former heroin addicts. Success of any
cessation program depends on the motivation of the user.

Stimulants
CNS stimulants include a wide variety of substances. The category ranges from caffeine (the most widely consumed
substance in the world) to cocaine and amphetamines. Box 36-7 lists the effects of stimulants.
Signs and Symptoms of Central Nervous System Stimulants

• Mental alertness

• Insomnia

• Increased concentration

• Delirium and hallucinations

• Drug-induced psychosis
 • Euphoria

• Elation

• Anxiety and paranoia

• Hostility and anger

• Anorexia

• Dilated pupils

• Bruxism (grinding of teeth)

• Tachycardia

• Peripheral vasoconstriction

• Hypertension

• Bronchodilation

• Hyperreflexia

• Twitching and tremors

• Nausea

• Diarrhea

Caffeine
Caffeine is present in foods and over-the-counter medications such as cold and sinus medications and appetite
suppressants. It is chemically related to theophylline, which is useful in the treatment of chronic obstructive pulmonary
disease (COPD). Stimulant effects of caffeine are usually mild and typically last 5 to 7 hours after consumption.
Habitual use of five to seven cups of caffeinated beverages per day has the capacity to cause withdrawal symptoms of
headache, fatigue, and irritability. Coffee, tea, chocolate, and soft drinks are commonly consumed foods that contain
moderate to large concentrations of caffeine. Caffeine will potentially aggravate anxiety disorders and schizophrenia as
well as heart conditions.

Nicotine
Nicotine is a drug present in tobacco. Tobacco use is a legally sanctioned form of substance abuse. The number of
Americans who smoke is declining, but the number of women smokers and underage smokers is rising. The effects of
nicotine include increased alertness and concentration, appetite suppression, and vasoconstriction. Heavy or persistent
smokers quickly develop tolerance and dependence. Smokers sometimes switch to smokeless, oral forms of tobacco
(snuff or chew) to reduce hazards from smoke. If heavy users stop suddenly, withdrawal symptoms occur that include
craving, irritability, restlessness, impatience, hostility, anxiety, confusion, difficulty in concentration, disturbed sleep,
increased appetite, and decreased heart rate. Treatment for nicotine dependence includes use of agents that deliver
decreasing doses of nicotine. These agents include nicotine gum, transdermal patches, or nasal spray; agents that block
the reinforcing effect of smoking; an antidepressant, bupropion (Zyban); and combinations thereof. Behavioral therapy
is also often beneficial in remaining smoke free. As many as 70% of people who quit smoking relapse within 1 year.

Cocaine
 Cocaine is a white powder that is used as a topical, local, and regional anesthetic and as a vasoconstrictor for some
types of surgery of the eye, the ear, the nose, and the throat. Crack cocaine is an inexpensive form of cocaine mixed
with baking soda. Freebasing is a method of extracting cocaine. Drug abusers often smoke crack cocaine and freebase
cocaine. To take powder cocaine, they make it into lines and snort it. Cocaine is possible to take intravenously. The
rush is within 30 seconds but the effect is very short lived. The crash following the rush brings on intense craving,
agitation, and moderate to severe depression. Crack cocaine addiction occurs rapidly. The cravings have the potential to
persist months into abstinence, making treatment difficult. The use of powder and crack cocaine became epidemic in
the 1980s and 1990s.

Cocaine is a strong CNS stimulant. Chronic abuse erodes the nasal septum and often causes sinusitis and rhinitis.
Smoking freebase cocaine poses the risk of bodily injury from burns, and the caustic chemicals that people use to make
it sometimes cause hemoptysis and pneumonitis. Overdose potentially produces cardiorespiratory distress and seizures.
It is best to hospitalize the user to stabilize heart abnormalities and protect from suicide if profound depression occurs.
Health care providers have used dopaminergic drugs such as amantadine (Symmetrel) and bromocriptine (Parlodel),
which serve in the treatment of Parkinson's disease, to reduce the craving. If psychotic symptoms do not resolve in 3
days, it is appropriate to start conventional treatment. Neonates of addicted mothers (“crack babies”) need close
monitoring for complications. Swaddling or wrapping the baby snugly is often comforting; keep stimuli such as bright
lights, loud noises, and excessive handling to a minimum.

Amphetamines
Amphetamines and their analogs (e.g., methylphenidate [Ritalin]) gained popularity as club drugs in the 1990s.
Amphetamine is a powder that is possible to snort, smoke, or inject. People often mix it with other drugs such as heroin
or marijuana. Methamphetamine is a potent, addictive amphetamine that causes powerful release of the
neurotransmitter dopamine. Over time, dopamine depletion in the brain has the capacity to cause parkinsonian-like
symptoms. Brain cell damage is sometimes permanent. CNS stimulation is so strong that hallucinations and paranoia
are possible. Weight loss and malnutrition from the anorexia effect are sometimes severe. Overstimulation of the heart
will sometimes raise blood pressure, which potentially causes damage to blood vessels, leading to heart attack or
stroke. Brain damage at the cellular level and sudden death have occurred with amphetamine use. Treatment for
withdrawal corresponds to the severity of the symptoms. Chronic abusers typically exhibit flat affect, forgetfulness, and
difficulty in concentration due to irreversible brain damage after completing detoxification .

Hallucinogens
Hallucinogens, which are either natural or synthetic, affect several areas of the brain. These drugs alter perception and
thinking, and some of their effects sometimes last 6 to 12 hours. Deaths have occurred due to altered perceptions that have
potential to trigger the fight-or-flight response, which then leads to possible cardiac arrest or dangerously altered thinking,
such as having the ability to fly from the roof into the clouds.

Drugs in this group are phencyclidine (PCP); lysergic acid diethylamide (LSD); 3,4-methylenedioxymethamphetamine
(MDMA), known as Ecstasy, and its parent drug, methylenedioxyamphetamine (MDA); ketamine; mescaline; and
psilocybin.

PCP
PCP came onto the street scene in the 1960s and quickly gained a reputation of causing bad drug reactions. Experts
consider it addictive with regular use. In low to moderate doses, symptoms of generalized numbness and poor
coordination occur. Flushing and sweating occur with a rise in blood pressure and pulse. Some users report feelings of
increased strength and power. Overdoses of PCP sometimes become apparent through symptoms of schizophrenia-like
psychosis with extreme violence or attempted suicide. Seizures and coma are possible. At high doses, a drop in
respirations, pulse, and blood pressure accompanies loss of balance, blurred vision, nausea, and vomiting. PCP is a
powder that easily dissolves in water or alcohol; users often sprinkle it in other drugs such as marijuana. Some people
take it without knowing, unaware that PCP is mixed into another street drug.

LSD
LSD also came onto the street scene in the 1960s. It is one of the most potent of the hallucinogens. Because its effects
potentially last more than 12 hours, an LSD experience is referred to as a “trip.” Dilation of pupils, sweating, loss of
appetite, dry mouth, sleeplessness, and tremors occur. Crossover of sensory perception such as “hearing colors” and
 “seeing sounds” occurs. Altered perceptions such as melting walls and fear of insanity and death sometimes trigger
panic attacks. Flashback of symptoms is possible, suddenly within a few days or more than a year after LSD use. These
flashbacks usually occur in chronic users. Risks of LSD use include flashbacks, bad “trips,” lingering mental disorders
such as severe depression and schizophrenia, and general impairment of mental function. LSD does not produce
compulsive drug-seeking behavior, and experts consider it nonaddictive.

MDMA (Extasy)
MDMA, also known as Ecstasy, has been a very popular club drug since the 1980s, with a reported increase in use
from 40.1% in 1999 to 51.4% in 2000 (ASAM, 2009). It is considered a hallucinogenic stimulant that is neurotoxic,
causing release of the neurotransmitter serotonin until it is depleted in the brain cells (Figure 36-2). Because serotonin
is involved with regulating mood, aggression, sex drive, sleep, and pain perception, there are many risks of lingering
problems. Normal growth and development are altered in adolescents.

MDMA produces physical symptoms of muscle tension, bruxism (grinding of the teeth), nausea, blurred vision,
chilling or sweating, and faintness. In high doses, it has the potential to trigger malignant hyperthermia, which leads to
kidney and heart failure. MDMA gives the user a feeling of euphoria, like being in love. Many people use baby
pacifiers to ease the teeth-grinding effect. Heat exhaustion occurs due to physical exertion (movement eases muscle
tension) and excess fluid loss. Drug effects potentially last 6 hours or longer. Users report drug craving as well as
lasting psychological difficulties such as confusion, sleep disturbance, poor concentration, and anxiety.

MDMA's parent drug, MDA, has properties similar to those of MDMA and is related to the amphetamine group.
Lingering parkinsonian-like tremor has been reported with regular use of this drug.

Cannabis
People have used cannabis or marijuana for thousands of years. Its first descriptions are in Chinese writings of 2700 BC.
No other drug has evoked so much controversy over the appropriateness of legalizing and using it for medical purposes.
Marijuana remains a schedule I drug because of its high abuse and addiction potential in the absence of proven medical
use. Evaluation for therapeutic use as an analgesic, antiemetic for chemotherapy, tranquilizer, glaucoma medication, and
antispasmodic for multiple sclerosis victims shows only fair results. Some county governments in Western states are
challenging the federal law by allowing county law to regulate medical use.

Effects of marijuana include distorted perception; difficulty in problem solving, memory, and learning; euphoria;
uncontrolled laughter; dreamy or sleepy affect, an effect that has earned the nickname being “stoned”; anxiety and panic
attacks; dry mouth and dry eyes; increased sexual interest; loss of coordination; and increased heart rate.

Characteristics of amotivational cannabis syndrome are decreased goal-directed activities, abrupt mood swings,
abnormal irritability and hostility, apathy, and decline of personal grooming. Depression, paranoia, and suicidal thoughts
or attempts are possible. Abstinence reverses this syndrome.

Inhalants
Usually short-acting effects, euphoria, intoxication

Usually chronic use impairs cardiopulmonary function as well as hepatic and renal failure.

Provide teaching concerning health risks (e.g., plastic bags lead to possible suffocation death).

No withdrawal symptoms; drug craving by chronic users noted

Chemically Impaired Nurses

 Warning Signs of Nurse Impairment

The Texas Peer Assistance Program for Nurses lists the following behavior patterns as warning signs that a nurse is
possibly impaired by chemical dependence or a mental health disorder.
ALCOHOLISM

• Irritability, mood swings

• Elaborate excuses for behavior; unkempt appearance

• Blackouts (periods of temporary amnesia)

• Impaired motor coordination, slurred speech, flushed face, bloodshot eyes

• Numerous injuries, burns, bruises, and so on, with vague explanations for same

• Smell of alcohol on breath, or excessive use of mouthwash, mints, and so forth

• Increased isolation from others

DRUG ADDICTION

• Rapid changes in mood and/or performance

• Frequent absence from unit; frequent use of restroom

• Possibly works a lot of overtime; usually arriving early and staying late

• Increased somatic complaints necessitating prescriptions of pain medications

• Consistently signs out more or larger amounts of controlled drugs than anyone else; excessive wasting of
drugs

• Often volunteers to medicate other nurses' patients; sometimes wears long sleeves all the time

• Increased isolation from others

• Patient reports that pain medication is not effective or that did not receive medication

• Excessive discrepancies in signing and documentation procedures of controlled substances

MENTAL HEALTH DISORDER

• Depressed, lethargic, unable to focus or concentrate, apathetic

• Makes many mistakes at work

• Erratic behavior or mood swings

• Inappropriate or bizarre behavior or speech

• Will sometimes also exhibit some of the same or similar characteristics as chemically dependent nurses