Craving to Rave
The agony of Ecstasy abuse

An estimated 22 million Americans suffered from substance dependence or abuse due to drugs, alcohol, or both in the past year, according to the 2002 Household Survey released by the Substance Abuse and Mental Health Services Administration (SAMSHA).¹ There were 19.5 million Americans, 8.3% of the population aged 12 or older, who used illicit drugs.¹ Additionally, the report highlights that 7.7 million people, 3.3% of the total population aged 12 and older, required treatment for a diagnosable drug problem and 18.6 million, 7.9% of the population, needed treatment for a serious alcohol problem. “Club drugs” are a group of psychoactive, illicit, and dangerous substances used mainly by youth and young adults at all-night dance parties called raves and trances. (See the table “Popular Club Drugs.”)

Some of these chemicals are produced in legitimate laboratories for medical use and then diverted for illegal purposes. Others are developed in clandestine laboratories using formulas obtained on the Internet, while some substances are imported from outside the United States. These chemicals are taken to enhance mood and provide intense energy for dancing, social interaction, and sexual engagement. Use and abuse of methylene-dioxymethamphetamine (MDMA), commonly called Ecstasy, is associated with these rising drug abuse statistics. For example, the initial use of MDMA has been rising since 1993, when there were 168,000 new users. There were 1.9 million initiates in 2000 and 1.8 million in 2001 (not a statistically significant decline).² The National Institute on Drug Abuse (NIDA) reports that the use of MDMA has spread beyond the rave and nightclub scene of the late 1990s to a variety of urban, suburban, and rural areas throughout the country, including greater use on college campuses.³

Although the 2003 Monitoring the Future Study sponsored by NIDA reports an 11% reduction in past-month use of any illicit drug by youth between 2001 and 2003, it remains that 2.1% of 8th graders, 3.0% of 10th graders, and 4.5% of 12th graders had used MDMA in the 12 months before the survey.4,5 This is a decrease from 2001 peak rates of 3.5%, 6.2%, and 9.2%, respectively, and supports NIDA’s national education strategy focused on Ecstasy. 6

Cause for concern
Use of Ecstasy among these age groups is of great concern. Some researchers have found that taking only one dose may have long-term or irreversible effects on memory and learning⁷ (This finding remains open to debate in some scientific circles since the recent revelation that some of the research related to MDMA was based on flawed methodologies.⁸) Complicating the abuse of these chemicals is their combination with licit and illicit substances such as alcohol, cocaine, and heroin.

Ecstasy is a synthetically produced psychoactive drug with both amphetamine and hallucinogenic properties. MDMA is similar to methylenedioxyamphetamine (MDA), its parent drug, and methamphetamine, both which are known to result in brain damage.⁹ MDA was first produced in 1910 and MDMA in 1914 to be used as an appetite suppressant, but since that time MDMA has moved rapidly into the illegal drug market in the United States and Europe.¹⁰ The novelty of this and other club drugs has led to a widespread belief that they are harmless recreational substances with only rare or exaggerated adverse effects.

Science now is proving the lethality and long-term damaging consequences of MDMA, as it did with cocaine in the 1980s. Mild to moderate adverse effects associated with Ecstasy fall into two major areas: physiological reactions and cognitive/psychological reactions.

Contributing factors that complicate the severity of symptoms are the amount of drug ingested and environmental factors combined with duration and chronicity of drug use.

Adverse effects
Common mild to moderate adverse physiological reactions are loss of appetite, bruxism (grinding of teeth), nausea, fainting, blurred vision, rapid eye movement, muscle aches or stiffness, ataxia (discoordination), sweating, dehydration, and increased heart rate and blood pressure.³ Psychological symptoms such as confusion, depression, insomnia, drug craving, and severe anxiety may occur during use and sometimes continue for weeks. The progression of these adverse effects to toxic or fatal reactions is complicated by the prevailing environmental factors during use, genetic protective elements prevalent in the drug user, and the dosage and purity of the chemical itself.

MDMA is taken orally, usually in tablet or capsule form, with its effects lasting approximately three to six hours. This stimulant enables users to dance for extended periods of time in crowded and overheated parties, which further complicates the negative physiological effects caused by the drug itself: dehydration, hypertension and hyperthermia.

Toxic and often irreversible fatal reactions can progress quite rapidly in such psychological and environmental conditions. For this reason, drug users should be advised to wear cool, loose clothing; increase fluid intake (not alcohol); and take frequent breaks from physical activity in a well-ventilated place. These recommendations, however, are in conflict with the psychological-perceptual effects that Ecstasy produces: euphoria, aggression, intense energy, and heightened sensory experiences.

Individual responses to MDMA cannot be predicted. Survival after a massive overdose of more than 50 tablets has been reported as well as single-dose fatalities.^11,12

Studies of these drug-sensitivity differences have focused on the enzyme P4502D6 (CYP2D6), which promotes cellular metabolism of MDMA.¹³ A deficiency in this enzyme allows toxic levels of the substance to accumulate in the body.

According to some researchers, 7% to 10% of Caucasians do not have the genetic predisposed ability to produce this enzyme.¹³ Additionally, the user’s response to the drug depends on the purity and amount of MDMA in each tablet or capsule. According to one source, more than 200 derivatives have been recorded in the analysis of MDMA and MDA, with some substances showing deliberate modifications to create a more potent and potentially lethal stimulant.¹⁴

Toxic reactions, which are highly unpredictable, may be fatal or have irreversible negative outcomes for users of MDMA.

Toxic and chronic effects
The acute toxic effects of MDMA and the development of chronic conditions are due to drug-induced damage to serotonin-producing brain cells.⁷ MDMA stimulates a massive release of serotonin from brain neurons, which creates positive psychological effects such as euphoria, intense energy and heightened sensations.

However, this initial release of excessive amounts of serotonin also produces physiological symptoms associated with acute toxicity. These symptoms include malignant hyperthermia (reportedly as high as 42.8 degrees Celsius), locomotor hyperactivity (possibly with seizure), salivation, dilation of the pupils, shivering and “goosebumps.”^11,15

Medical interventions involve immediate environmental and chemical attempts to attenuate the hyperthermia by traditional cooling measures often combined with the use of a central nervous system depressant such as haloperidol (Haldol) to decrease agitation and seizure risk.¹⁶ Gastric lavage, ventilator-respiratory support, and intravenous fluids also are used in the acute, emergency care phase.

If the toxic condition progresses with or without medical care, kidney, heart, and respiratory failure are common. In fact, postmortem examinations in victims of a drug use episode have shown significant damage to hepatic, myocardial, and brain tissue.¹⁶

MDMA is well absorbed in the gastrointestinal tract and reaches peak serum levels in one to three hours.¹¹ Because the substance is highly fat soluble, it passes the blood-brain barrier, with highest concentrations found in the liver and the brain.¹⁶

Some studies indicate that Ecstasy also may damage the brain cells that produce dopamine but to a lesser degree than serotonin-producing neurons.¹⁶ According to researchers, use of the stimulant ultimately produces widespread reduction in the neurotransmitter serotonin, possibly due to irreversible damage to the neurons responsible for producing this brain chemical.¹⁷ Long-term reduction in the density of the neuron structures has been seen in various parts of the brain on human autopsy and in animal studies.¹⁶

Considerable debate continues in the medical literature about the permanent damage caused to brain cells from a single dose of MDMA. This is partially based on clinical assessments indicating significant mental impairment with a single-dose ingestion of the drug. Animal studies, however, seem to indicate that even repeated doses may not permanently damage brain cells that produce serotonin.¹⁸

Of greater concern are the long-term psychiatric and cognitive effects of MDMA. Some clinical case reports indicate a prevalence of chronic psychiatric symptoms that persist long after the use of the drug stops. These symptoms are panic disorder, depersonalization, depression, “flashbacks,” visual distortions and hallucinations, and obsessive-compulsive syndromes.¹⁹

Diagnosing mental illness in association with MDMA requires verification of drug use; this can be difficult because many users abuse other substances such as cannabis (marijuana), cocaine, and LSD, all of which have psychoactive effects. The consensus is that if MDMA does lead to pervasive psychiatric symptoms, these are more likely to develop in people who already are predisposed to mental illness.

One study found that 50 percent of MDMA users with chronic psychiatric problems also had a close family member with mental illness and that at least 50 percent of the users had experienced transient psychiatric symptoms following experimentation with other illicit drugs.¹⁹

There has been considerable scientific interest in both the acute and long-term cognitive effects of Ecstasy, particularly on learning and memory. Animal studies have shown that measurable cognitive effects are species-, dose- and dosage-specific, and at least one study indicated that a one-time ingestion of the drug failed to adversely affect human volunteers.²⁰

Other researchers have found that current and previous users of MDMA who consumed at least one tablet a month (with most consuming weekly or twice a week) demonstrated impaired information-processing speed and recent memory, and measured higher on anxiety scales when performing cognitive tasks.²¹ Because human studies remain inconclusive and individual genetic differences prevail, complicated by issues of dosage, drug dosing, potency and purity, it is advisable to consider MDMA potentially damaging to human cognitive functioning.

Risk factors
Adolescents and young adults are known to be at greater risk for developing drug abuse/dependence in general. This is due, in part, to the novelty-seeking and temperamental behavior that is inherent in this group.

Studies indicate that the periadolescence (the period immediately preceding puberty) and adolescence phase of development are accompanied by a high degree of novelty-seeking behaviors that create sensations of pleasure and excitement in these age groups.¹⁷ Researchers are hoping to establish the link between developmental levels, the drive to seek novel experiences, and behaviors such as impulsivity, aggression, and risk taking.²²

Adolescents are reported to be statistically more vulnerable than other age groups are to sensation-seeking and novelty-seeking behaviors that may convey considerable physiological and psychological risk. In fact, novelty-seeking behaviors are known to decline considerably as an individual ages.

Because Ecstasy is promoted and consumed within a peer group context and in a party atmosphere, it is not surprising that this age group is the most rapidly growing among abusers of amphetamine-based drugs like MDMA.

Nursing implications
Nursing implications must take into consideration the high lethality level of the drug and its predicted long-term effects, specific population vulnerability factors, and client/community education issues.

The effects of MDMA are unpredictable and influenced by factors beyond the drug user’s control. Physiological responses to the massive release of serotonin and dopamine, genetic vulnerability and drug potency and purity do not permit accurate risk assessment.

Because adolescents and young adults are experiencing profound changes in their neurobiological and hormonal systems, illicit drug effects can be unpredictable. Clients in these developmental phases are formulating psychological, cognitive and behavioral patterns based on learning and their interaction with the environment. It is likely that even short-term chemically induced alterations in brain function may have lasting effects on perception and personality.

Nurses who are working with clients in this high-risk category or with their families must be knowledgeable about the toxic and chronic effects of the use and abuse of MDMA; be aware of feasible prevention strategies; and be prepared to provide referral for further information and support. (See “Community Drug Abuse Prevention Programs.”)

Research has shown that although many factors affect a young person’s drug use, one’s early development in the family is a critical factor.² Family-based protective factors include strong, nurturing bonds between parent and child; clear rules of conduct within the family; the involvement of parents in the child’s life; successful performance at school; and positive relationships with supportive youth organizations.

All adolescents should be considered at-risk for drug use and abuse in part because of their novelty- and sensation-seeking behaviors and vulnerability to peer pressure. However, some young people in this age range are at even greater risk.

Several studies indicate that economic deprivation, parent/family drug use, poor or inconsistent family management, family conflict, peer rejection, academic failure, learning disabilities, physical disabilities, and low self-esteem are all strong indicators for greater substance abuse risk.²³

Additionally, an involvement in gangs or cults, runaway behaviors, and a history of abuse, violence and drug use within the family all point to an absence of the family protective factors that are seen to be essential to the young person’s successful development and ability to resist destructive influences.

Adolescent development is critical to a person’s future adult functioning and the ability to live a productive life. Drug use and abuse, particularly the use of Ecstasy and other illicit substances, have the potential to create cognitive and psychological effects that may impair an individual for life.

Adolescent Drinking
The sobering facts about teen alcohol use and abuse

Adolescent alcohol use and abuse is a serious public health problem that shows no signs of abating. Alcohol use by teens is defined as at least one drink in the past 30 days; binge use is five or more drinks on the same occasion at least once in the past 30 days, and heavy use is five or more drinks on the same occasion on at least five different days in the past 30 days.¹ Alcohol dependence is characterized by tolerance, withdrawal, and psychological/physical problems.^1,2 Most young people begin drinking at about age 13 with some starting even younger.¹ Among all youth aged 12 to 20, 10.7 million reported drinking alcohol at least once in the past year, and of these, nearly 7.2 million were binge drinkers, and 2.3 million were heavy drinkers.³ By the time teens are finishing high school, 77% have consumed alcohol (more than just a few sips), and nearly half (46%) have done so by 8th grade. In fact, 58% of the 12th graders and 20% of the 8th graders reported having been drunk at least once in their life.³

Of concern to researchers is the sharp increase of alcohol use associated with increasing age. For example, 2.0% of 12-year-olds used compared to 6.5% of 13-year-olds, 13.4% of 14-year-olds, and 29% of 16-year-olds. The rate of binge drinking also rose with age; 7% of the 14-year-olds, 17.9% of the 16-year-olds, and 25% of the 17-year-olds drank heavily in at least one episode.¹

These same studies reveal demographic differences and similarities. Males were more likely than females to report drinking, 57% to 45%, but differences for binge drinking were not as large, with males at 22% and females at 17%.^1,3 Adolescents from rural counties showed only slight differences in alcohol use from their metropolitan counterparts, 46% to 50%, respectively. Higher education of parents was associated with increased rates of adolescent alcohol consumption and being drunk. Among teens whose parents have advanced degrees, 60% use alcohol.⁴

African-American teens had the lowest rates for drinking and being drunk (35%), while Caucasian teens had the highest at 56%. Hispanic adolescents were intermediate in their use, at about 52%.⁴ These findings indicate that alcohol use, and in some cases abuse, has infiltrated all sociodemographic groups in the U.S. and that race, locale, or age group is not a protective factor.

One of the most ominous predictions about youth drinking is that 40% of children who start drinking before age 15 will develop problems with alcohol at some point in their lives.⁵ If the child delays drinking until at least age 20, his or her risk of serious alcohol-related problems is half that of those who use and abuse alcohol before age 20.

Adolescent alcohol use has been associated with self-reported health problems, both physical and emotional. Adolescents who abuse alcohol may have sleep disturbances and mood and anxiety disorders.⁶ As a general health status measure, periodontal disease and dental caries often are an early indicator of alcohol abuse in adolescents, appearing before symptoms that may develop later, such as elevated liver enzymes. The most common mood disorders for adolescents are major depressive and post-traumatic stress disorder.⁶ The diagnosis of major depressive disorder is cause for concern because some studies indicate alcohol-abusing teens are at much greater risk for suicidal ideation.^7,8

Adolescents who engage in alcohol use or sexual activity are more likely to experience suicidal ideation and consider suicidal acts.^7,8 According to a national study, 19.3% of students aged 10 to 18 had considered attempting suicide. Female adolescents were more likely (24.9%) than males (13.7%) to have contemplated suicidal acts.^7,8 Because alcohol is a central nervous system depressant, teens experiencing depressive episodes who drink are at greater risk for self-destructive behaviors.

Sexual activity is associated with alcohol misuse, and regrets over these actions can add to existing depressive states. Sexual intercourse, multiple partners, unprotected sex, and sexual assault (for example, date rape) are related to alcohol-use disorders in teens. Forty-four percent of the sexually active teens reported they were more likely to have sexual intercourse if they had been drinking, and 17% indicated they were least likely to have safe sex after using alcohol.^7,9 Researchers estimate that alcohol use is implicated in one-third to two-thirds of sexual assault cases among teens and college students.^7,9 The relationship between teen violence and alcohol has been demonstrated in states that raised the minimum drinking age, with incidents of violence decreasing.^7,9

Developmental risk factors
Several elements and attributes are developmental risk factors in adolescent alcohol misuse. According to several investigators, the risk elements and attributes fall into following major categories: genetic factors, childhood behavioral and psychiatric disorders, parental influences, peer relationships, and adolescent expectancies.^10-12

Some sources report that children of alcoholics are significantly more likely to start drinking during adolescence and to develop alcohol-use disorders, leading them to conclude that genetics is a risk factor.⁹ Some researchers indicate that the dopamine receptor (DRD2) gene has demonstrated strong implication for vulnerability to substance abuse and that specifically the A1 allele of the DRD2 gene has been associated with alcoholism.¹⁰

Others point out that in children of alcoholics, drinking behavior is more profoundly influenced by parents, siblings, and friends, just as with other adolescents, but once alcohol has been ingested, genetic factors affect the frequency and quantity of use.¹¹ However, the interaction between environmental influences and genetics has not been determined, and individual differences may result in wide variability in youth alcohol use and abuse.⁹

Childhood temperament is associated with alcohol abuse. Children who are restless and impulsive at age 3 are more likely to be diagnosed with alcohol abuse at 21. Aggressiveness in children as young as 5 to 10 is related to alcohol and other drug use in adolescence.^9,11 Associated with these findings are adolescent psychiatric disorders such as conduct disorder—an antisocial mental disorder characterized by aggressive acts that cause or threaten physical harm to other people or animals and nonaggressive conduct that causes property damage, deceitfulness or theft and serious violations of rules.^12,13 These coexisting mental disorders may precipitate alcohol-use disorders or result from them.

Parental and peer/sibling relationships have a far greater influence on adolescent alcohol use than other factors.¹³ Parental drinking is one of the best predictors of alcohol use among preadolescents. Sibling alcohol misuse, especially an older sibling, also influences childhood alcohol use.

Influencing factors
Several prominent social and environmental factors have been examined for their influence on underage drinking: peer groups, media/advertising, and adolescent social behaviors related to novelty-seeking/risk-taking and positive alcohol-use expectations. Peer influence includes modeling alcohol use by friends, friends’ making alcohol or other drugs available, and peers’ creating norms and expectancies that encourage or condone alcohol use.¹⁴ Teens who have friends who use alcohol are much more likely to misuse alcohol, with 58% of the students aged 11 to 16 reporting some lifetime history of use.¹⁴

Complicating peer influence are the media messages that bombard adolescents. According to some sources, 90% of the 200 most popular movie rentals in the last five years depicted alcohol use. In more than 57% of these films, no consequences were associated with alcohol consumption.^8,15 In the music medium, 47% of the top-selling popular songs mention alcohol.⁹ To large corporations, adolescents represent a potential $150 billion market.¹⁴ Teen income from employment totaled $121 billion in 1998, and adolescent spending is expected to exceed $155 billion in the next decade.¹⁶ Through the entertainment industry companies can market their products to teen-agers. Health care providers can counter glamorized messages about alcohol and drugs with accurate and age-appropriate information.

Adolescent development includes a high degree of novelty-seeking behaviors that create excitement, pleasure, and risks in this age group, more so than any other.⁷ Associated with these behaviors are teens’ expectations that alcohol use is positive and that it results in either no consequences or rewarding ones.¹⁶ Even heavy drinking does not equate to identification of negative results. In one study, 13.4% of the adolescents met the criteria for heavy alcohol consumption, but only 15.9% of this group acknowledged having a substance-abuse problem.¹⁵

Risk reduction
Family relationships and parental monitoring, peer associations, health beliefs, and life skills are the most powerful risk-reduction protective factors for adolescents. Family and parental monitoring becomes crucial as teens attempt to identify with and develop the adult role. Adolescence is a high-risk period as the child moves toward independence while struggling to master a unique identity. The family exerts a strong influence in reducing adolescent risk behaviors while helping the child move forward developmentally.^17,18 Families can support adolescent development with communication, boundaries, cohesion, and parental involvement and monitoring.¹⁵

Families that confront their own minimization of teen alcohol abuse and encourage teens to discuss their problems create a protective climate for role socialization through adulthood.¹⁷ Modeling constructive communication patterns is an effective teaching tool for children and adolescents. Behavioral boundaries that reduce risk factors and exert a protective function include parental monitoring of the child’s activities and parental presence at key times during the day (such as in the morning, after school, at dinner, and at bedtime). A family routine provides a sense of predictability important to the adolescent’s sense of security.¹⁷ Family cohesion is expressed through communication, shared activities, and a routine that includes the child. Parental involvement and monitoring also includes consistently enforced limits and rules when behavior needs to be modified.^17,19 Nurses can encourage parent-teen communication and emphasize the importance of the family as a source of support during adolescent development.

Peer associations have been discussed in terms of their negative effects, but positive outcomes result when such relationships are based on shared health values and beliefs. Teens involved in peer sports and social/religious activities that exclude alcohol and other drugs benefit from these relationships. These peer associations exert a protective influence to reduce the migration to peers who abuse alcohol.¹⁴

Life skills such as alcohol-refusal strategies and anger-coping methods are important. Teaching teens ways to refuse alcohol is associated with reduced alcohol misuse when combined with other preventive approaches such as accurate and age-appropriate alcohol/drug information.¹⁹ The effectiveness of those skills differs developmentally, with alcohol-refusal training best provided during junior high rather than later. Refusal techniques can be taught through role play with assertive communication. A clear “No, I do not want any,” a firm tone and consistent body language such as shaking the head and making direct eye contact are important for success.

Adolescents who don’t know how to express anger appropriately show higher rates of alcohol consumption and spend fewer hours a week in health-focused physical activities.²⁰ This shows the importance of encouraging the discussion of problems and concerns in the home and modeling good communication skills by parents and other adults. Health care providers, in numerous roles, are adult models for adolescents and their families.

Nursing implications
Prevention and early intervention are keys to reducing the consequences of teen drinking, and nurses can play a critical role. One intervention is to involve the adolescent in making health decisions by providing accurate information and guidance as he or she moves through developmental phases. Encouraging the appropriate expression of feelings and the identification of problems and concerns reduces the known risk for alcohol abuse and models constructive communication and problem-solving methods.

It is critical to reach the parents, and nurses can take advantage of opportunities to teach them about teen alcohol abuse and the value of parenting skills. The risk-reduction elements previously discussed can become the structure for teaching parenting skills such as presence and monitoring at crucial times during the day.Formal teaching opportunities may be available through the PTA, sports activities, and community events such as health fairs.

Knowing the protective elements inherent to supportive families helps the nurse assess family functioning such as communication methods, boundaries, cohesion, and parental monitoring. School and community affiliations are important to an adolescent’s abstinence from alcohol and other drugs.

School and pediatric nurses have opportunities to promote healthy behaviors by providing early intervention and crisis intervention and incorporating teaching into the care of youth. Community/public health nurses and other nurses can help by establishing a community action plan. (See table.)

Prescription Drug Abuse
Knowing the danger signs

The nonmedical use of prescription drugs (using medication for purposes other than those prescribed) has been increasing rapidly in recent years. In 2001, 36 million Americans (16% of people 12 or older) had used prescription-type drugs nonmedically at least once in their lifetime.¹ Most alarming is that the number of people using prescription pain relievers nonmedically for the first time increased from 600,000 in 1990 to more than 2 million in 2001.² The National Household Survey on Drug Abuse (NHSDA) data show that the initiation of nonmedical prescription drug use occurs mostly among those aged 12 to 25 and that new use has been increasing.¹ The annual number of new users of pain relievers has been increasing annually since the 1980s, from 400,000 to 2 million in 2000.¹ New users of stimulants increased from more than 200,000 in 1991 to almost 700,000 in 2000. New users of tranquilizers have been increasing since the 1980s, as well, but the largest increase has been more recent, from more than 700,00 new users in 1999 to almost 1 million in 2000.¹

Most people take prescribed medications properly, but many obtain drugs fraudulently, use more than prescribed, or take them for reasons other than medically indicated. According to the National Institute on Drug Abuse (NIDA), the misuse of prescription drugs refers to taking medication in a manner other than prescribed. Prescription drug abuse is intentional misuse of a medication outside of the normally accepted standards for its use; prescription drug dependence is characterized by compulsive use and development of tolerance and withdrawal symptoms.³

High-risk groups, drug misuse
In 2001, more than 3 million youths 12 to 17 and almost 7 million young adults aged 18 to 25 had used prescription drugs nonmedically at least once in their lifetime.¹ The most common category of prescription drugs used nonmedically by youths and young adults in the past year was pain relievers, with youths, 6%, and young adults at 10%. Pain relievers include codeine, methadone, meperidine (Demerol), Percocet, hydrocodone (Vicodin), and oxycodone (Oxycontin).¹ Additionally, young people comprise the majority of first-time nonmedical users of the prescription opioids such as hydrocodone (Vicodin, Lortab, Lorcet) and oxycodone (OxyContin), with 46% of those 12-17, 34% of those 18-25, and 20% of those 26 and older using the drug nonmedically.⁴

Among youths, females were more likely to have used prescription drugs non-medically in the past year than males (9% to 7% respectively).¹ However, among young adults, males were more likely to have used in the past year, at 14% compared to 10% for females.¹ Among those people aged 12 to 25, whites were more likely to have used prescription drugs nonmedically in the past year compared to Hispanics, blacks, or Asians (whites, 12%; Hispanics, 8%; blacks, 6%, and Asians, 5%).¹

Geographical differences are associated with prescription drug misuse. Youths in nonmetropolitan or small metropolitan areas were more likely to have used prescription drugs nonmedically in the past year (9%) than youths in large metropolitan areas (7%).¹ However, among young adults, the rate of past year nonmedical use of prescription drugs was similar among metropolitan and nonmetropolitan areas.¹ Additionally, treatment admission rates for narcotic pain reliever misuse increased by 135% in nonmetropolitan areas without cities.⁵

The route of administration among narcotic pain reliever abusers entering treatment has changed between the years 1992 and 2000. In 1992, 66% of admissions for narcotic pain reliever abuse took the drugs orally, and 25% injected them.⁵ By 2000, however, the proportion taking the drugs orally had increased to 80%, and the proportion injecting had fallen to 12%.⁵

Women, adolescents, and older adults are at greater risk for prescription misuse, according to the National Household Survey and other studies.^6-8 One researcher indicated that being female is a significant predictor of anxiolytic (anti-anxiety drugs such as diazepam and alprazolam) and narcotic analgesic use, but this association did not occur with sedative-hypnotic drugs (sleeping pills) or stimulants.⁷ The rate of prescription drug use is higher among women, reportedly because of gender differences in coping with and expressing anxiety, a willingness to seek medical care, perception of illness and physician-prescribing bias.^7,8 Women are two to three times more likely to be diagnosed with depression and anxiety, and among 12- to 17-year-olds, girls use psychotherapeutic drugs nonmedically more often than boys.^3,7 When possible, 12- to 17-year-olds should be treated with non-benzodiazepine drugs for anxiety disorders, such as buspirone (Buspar), and SSRIs, such as sertraline (Zoloft) or fluoxetine (Prozac), for depression or anxiety, in combination with psychotherapy.⁹

Older people are prescribed medications about three times more often than the general population and demonstrate lower levels of compliance with directions for use.⁶ This greater exposure combined with age-related physiological changes such as decreased liver metabolism and renal excretion and alterations in brain neurotransmitters place the older person at greater risk for adverse drug effects.¹⁰ Of particular concern are oversedation, falls, motor vehicle accidents, cognitive impairment, and memory loss. The elderly often abuse tranquilizers (benzodiazepines) and sleeping pills as a result of insomnia and chronic health conditions.^9,10 Elderly patients who have symptoms of anxiety and insomnia may respond to buspirone, thereby avoiding the negative effects and addictive potential of benzodiazepines.¹¹ RNs should assess the medications elderly patients are taking, as multiple prescriptions increase the likelihood of adverse effects.

Factors associated with misuse
Several researchers have identified physician, patient, and regulatory factors associated with prescription drug misuse.^12-15 Physician factors encompass misprescribing, inappropriate prescribing in response to patient demands, and uninformed prescribing by physicians who are not fully aware of a patient’s substance abuse history.^9,12 The number of physicians charged with dishonestly prescribing drugs is small, about 1%.^13,14 Actually, physicians may underprescribe pain medication for fear of criminal or civil charges.^14,15 NIDA reports many physicians have difficulty discussing substance abuse, including prescription drug abuse, with patients, and proposes that physicians and pharmacists collaborate on patient education strategies.¹⁶

Patient factors associated with prescription drug misuse include a constellation of drug-seeking behaviors. Examples include patients’ implying that the only possible solution to a medical problem is a prescription for a controlled substance, insisting on a particular medication, reporting high tolerance levels, and describing symptoms that markedly deviate from the objective evidence or the physical examination findings. Patients also may claim that nonaddictive medications do not work; resist nonpharmacological interventions such as relaxation training or therapy; manipulate by threats, bribes, or challenging one physician’s opinion with that of another physician; and doctor-pharmacy “shop” for prescriptions (that is, going from doctor to doctor or pharmacy to pharmacy until the desired prescription is obtained).¹⁷ Patients also may use excuses for needing more medication. They may tell the physician that the bottle spilled, the prescription was lost—or even that their dog ate the medication.⁹ They may also alter or falsify prescriptions.

The federal Drug Enforcement Agency regulates record-keeping on prescription drugs.¹⁸ However, most of the actual power to control and monitor the prescribing and dispensing of prescription drugs resides with the states. Recommendations to improve regulatory processes include increasing surveillance of drugs (such as evaluating their propensity for abuse), limiting prescriptive authority, creating a peer review system to evaluate MD prescribing practices, increasing premarketing tests on drugs prescribed to the elderly, and requiring patient education inserts in drug packaging.¹²

Assessing drug misuse
Assessment of patient drug misuse involves evaluating drug-seeking behaviors and assessing the extent of drug abuse and the symptoms of withdrawal. Addicts refer to drug-seeking behaviors as “working” or “making a doctor,”¹⁷ and patients can be adept at feigning symptoms. Disorders that patients invent or exaggerate to manipulate health care providers include migraine headaches, tic douloureux (trigeminal nerve pain causing jaw and facial pain), back pain, colitis and narcolepsy.¹⁷ Patients also may use a concern about obesity to obtain the desired drugs.¹⁷

The extent of drug use usually is revealed through a patient or family report and assessment of symptoms common to psychoactive drug use or intoxication. Patients who have developed dependence on these drugs may minimize use. Deliberate minimization is related to craving and the need to maintain the physiological and psychological effects of the drug. Unintentional minimization may result from the medication’s depressant effects on the central nervous system, which may reduce memory and recall. Psychoactive effects and withdrawal symptoms of commonly abused prescription drugs are shown in the table.

Treatment approaches
The level of treatment is determined by the patient’s presenting physical and psychological status, the drug abused, the extent of drug abuse, and the severity of withdrawal symptoms. Treatment may range from outpatient (for low-intensity symptoms) to intensive inpatient hospitalization (for high-intensity symptoms). Although all psychoactive drugs of abuse create some form of withdrawal symptoms, generally it is accepted that patients who have misused barbiturates (such as secobarbital) and benzodiazepines (tranquilizers such as diazepam and alprazolam) require careful medical monitoring during the withdrawal process.^9,19

Public initiatives
Because of the increase in nonmedical use of prescription drugs, NIDA has proposed a new and more comprehensive public initiative on prescription drug abuse, misuse and addiction.² As part of this effort, NIDA formed partnerships with the American Association of Retired Persons, the American Academy of Family Physicians, the American Pharmaceutical Association, the National Association of Chain Drug Stores, the National Community Pharmacists Association, the National Council on Patient Information and Education, and the Pharmaceutical Research and Manufacturers of America. The goal is to inform the public and health care providers about the dangers of prescription drug abuse and to promote research in this area.²⁰

The NIDA initiative is not the first prescription drug abuse awareness campaign. In 1980, the American Medical Association sponsored a White House conference on prescription drug abuse, and in 1988, the AMA’s Department of Substance Abuse called a second national conference on the abuse of these drugs.¹⁹

The American Nurses Association announced its position on the abuse of prescription drugs in 1991, stating that it “recognizes and acknowledges the abuse and misuse of prescribed drugs” and registering its concern about “over-prescription misuse of certain categories of prescribed drugs for women and teenagers and the role of the health care provider.²¹” The ANA called for education for nurses “to ensure safe measures of the prescription and monitoring of drugs.²¹”

Nursing implications
Nurses are pivotal in detecting prescription drug misuse by identifying patients’ drug-seeking behaviors such as magnifying symptoms, relating multiple somatic complaints, and insisting that other (less addictive or over-the-counter) medications do not work.

RNs should be familiar with the general indicators of drug abuse, which include sudden, unexplained mood changes; irritability or aggression; abnormal fluctuation in concentration or energy; becoming confused; impairment of short-term memory; and loss of interest in work or usual activities.¹⁷

Specific attention to women, adolescents, and the elderly is crucial to early intervention. The RN who provides medication education should evaluate a patient’s reliability in taking a medication. Adolescents may lack the maturity to understand the consequences of drug misuse, and elderly patients may inadvertently misuse medications because of vision or memory deficits.

RNs should assess susceptibility for all patients in these at-risk populations. A prior history of substance abuse or a family history of such abuse may put patients in these categories at even greater risk.

Nurses need to take a careful prescription drug history from patients and also ask about present and past alcohol and drug use, including the use of OTC and herbal products. Studies indicate that as many as half of all patients sampled for appropriate prescription drug use deviate from prescription directions by not taking the drug, taking the medication improperly (taking the incorrect quantity per dose or the incorrect total daily dose), omitting or doubling doses, or discontinuing the medication abruptly or prematurely.⁶

Contracting with patients who are at high risk for abuse often is effective and involves entering into an agreement with patients that specifies that the provider will refuse to order refills without an office visit or will recommend patients go to the emergency room when requesting early refills.

To instruct patients, nurses should write out the times of day the medication should be taken, suggest the use of drug boxes that allow patients to organize their prescription for each day of the week, and provide clearly written drug information. Patient information should emphasize the importance of correct use, reporting adverse reactions and the abuse potential of specific drugs. In addition, nurses should advise patients to obtain the following information for a new medication:

• The name of the medication and what it is supposed to do.
• How and when to take it and for how long.
• What foods, drinks, and other medicine or activities to avoid while taking the medication.
• Any side effects and what should be done if they occur.
• Whether the prescription will work safely with other prescription or nonprescription drugs such as vitamins, herbal remedies, or OTC medications.
• Written information on the medication.

Substance Abuse
Helping women and their children

An estimated 200,000 women die every year in the United States as the result of substance abuse-related illnesses.¹ Smoking, alcohol, and drug abuse and misuse of prescription drugs are seriously affecting the health of women and their families.^1,2 One group of particular concern is women of childbearing age (15 to 44) because their substance abuse affects the children they give birth to and care for.

Substance abuse is defined as a maladaptive pattern of use that leads to impairment or distress. Substance dependence is a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behaviors.³

In the past, substance abuse was seen as affecting mostly men, with treatment models designed to fit their needs.⁴ A lack of gender-specific research has resulted in little information about what women need in treatment and the number and type of treatment programs needed such as inpatient, outpatient and partial hospitalization.

The federal Substance Abuse and Mental Health Services Administration (SAMHSA) allocated $7.5 million in 2000 to support and expand the treatment of women suffering from substance abuse and the related disorders of physical/sexual trauma and mental illness.⁵ This in part was in response to the 1995 National Household Survey on Drug Abuse, which revealed that 4.3 million women aged 15 to 44 had used an illicit drug in the previous month. Of this group, 1.6 million had children living with them, and 390,000 had at least one child younger than 2.⁶

According to the 2002 National Survey on Drug Use & Health, 10.3% of women between the ages of 15 to 44 reported illicit drug use, and among pregnant women in this age group 3.3% were using illicit drugs. This is cause for concern since this age span represents the peak reproductive period for women. Additionally, among pregnant women aged 15 to 44 in 2002, 9.1% used alcohol and 3.1% reported binge drinking in the month before the survey. Alcohol use for nonpregnant women in this same age group was 53.4%, and binge drinking was 23.4%.⁵

Associated disorders
Substance abuse and dependence is often complicated for women by co-occurring factors such as alcohol/tobacco and illicit/prescription drug abuse, past victimization (sexual or physical assault), and stress and psychiatric disorders. In addition, generally it is believed that women who abuse illicit drugs proceed much more rapidly to drug dependence than do men and that the use of tobacco (in cigarette form) has a significant role in female illicit drug use and abuse.⁷
Women substance abusers typically demonstrate disruptions of individual, familial, and environmental protective factors. Individual protective factors include coping and stress-reduction strategies. Familial and environmental protective factors include stable, attentive, and supportive adult/family relationships, success in school and growing up in a supportive home, neighborhood, and school environment. Women substance abusers with disruptions of these protective factors often also had a high level of fear in childhood, anxieties, phobias, and failed relationships. In women, the start of substance abuse more often is related to predisposing psychiatric disorders than is the case with men.⁷

According to one author, the use of tobacco is the most common substance dependence, followed by alcohol and then illicit drugs.8 Research indicates that women differ from men in their tobacco use and that smoking cigarettes for women has a higher correlation with progression to illicit drug abuse.⁹The number of smokers overall declined in the United States between 1970 and 1980, but has remained relatively stable since then. The decline in cigarette use was greater in men, and the prevalence of use is only slightly higher in men than in women today.⁷ For young women aged 18 to 19, early predictors of daily smoking were lower parental education, a one-parent family, drinking alcohol at ages 11 and 12, and a higher drive for thinness at ages 11 and 12.⁸

Large-scale smoking cessation trials have shown that women are less likely to quit and are more likely to relapse. Withdrawal symptoms are more intense for women, and women are more likely to gain weight than are men.⁷ Women smokers have a one-in-three chance of developing dependency, the highest rate for any substance used by females.⁸ For women who smoke and use alcohol, alcohol dependence is most prevalent among women aged 21 to 25.⁶ Nurses working with female patients and their families in all settings must be informed about present-day issues related to female smoking, illicit drug use, alcohol dependence, and associated risk factors. Accurate, comprehensive health education with a focus on both prevention and intervention can make a difference in women’s lives.
Common psychiatric disorders associated with female substance abuse are anxiety and depression, prior victimization (sexual/physical assault), stress, and eating disorders. Women with a lifetime history of substance dependence have higher co-occurring rates of anxiety, depression and obsessions. Women internalize their response to stress in the form of these intrapsychic states (anxiety, depression) more so than men, who tend to use acting-out behaviors such as aggression, rebelliousness, and delinquency.¹⁰ Stress and stress-related psychiatric disorders are strongly associated with substance abuse and dependence. For example, major depression has been the most common associated disorder among alcoholic women, and anxiety and depressive disorders precede substance abuse by as much as five years in some cases.¹¹

Women constitute the largest group diagnosed with depression and anxiety, and although information is limited, more recent findings indicate that women experience post-traumatic stress disorder at a much higher rate than previously believed.¹² PTSD is a stress disorder associated with a past trauma or assault; it often becomes chronic and can be disabling.2 PTSD and eating disorders such as bulimia nervosa and anorexia nervosa are psychiatric diagnoses that complicate the treatment of substance abuse in women.2 One study found that women with PTSD were more than 2.48 times as likely as women without PTSD to abuse alcohol or be dependent and were 4.46 times as likely to evidence drug abuse and dependence.¹² Women seeking substance abuse treatment report high rates of violent assault. Many of these assaults occurred early in their lives: 29% before the age of 11 and 32% between the ages of 11 and 17.¹³ With more funding for health services designed to meet the needs of women, issues such as PTSD, depression, anxiety, and coping strategies will be an integral part of substance abuse treatment for women.

Stages, consequences
Women pass through three stages in progression to substance dependence, generally lasting through age 35.9 The use of alcohol/cigarettes (legal substances) is the first stage. The next stage is marijuana use. The third and final stage is the use of illicit drugs other than cocaine or marijuana, such as heroin and amphetamines.⁹ Women also are more likely to misuse prescribed psychotropic drugs (that is, take the drug in a manner other than prescribed). But the misuse of prescribed drugs usually happens later in a woman’s life. Early onset of illicit drug use is associated with earlier use of cigarettes in women.⁹

The consequences of substance abuse for women are profound in role functioning and the ability to contribute to society and the well-being of their children and family. The intergenerational effects of substance use/smoking are seen during pregnancy and in criminal acts, risky sexual behaviors, and truncated educational pursuits and vocational functioning. The negative effects for the fetus from maternal drug use are well documented. Despite this, among pregnant women aged 15 to 44, 3.3% reported using illicit drugs. For pregnant young women between 15 and 17, the rate of use was 12.9%, nearly equal to the rate of nonpregnant women in that same age group (13.5%).⁷ Of great concern is the association between cigarettes and the use of alcohol and illegal drugs.⁹ These findings indicate a need for treatment programs specifically for women of childbearing age, pregnant women, and women with children.

Criminal acts and risky sexual behavior often are associated in substance-abusing women who may steal to obtain drugs or trade sex for drugs. The most devastating effect for women and their children is HIV/AIDS.7 AIDS is now the fourth-leading cause of death among women aged 15 to 44, with about two-thirds of AIDS cases among women related to injection drug use.⁷ Among pediatric AIDS cases in the United States, 54% are related to maternal drug use or maternal sex with an injecting drug user.⁷

All of these factors damage the woman’s ability to perform her social roles of mother, wife, productive employee, or student. Interrupted or terminated education has many negative outcomes for women: They may not know how to obtain adequate health care for themselves and their children and may experience poverty, with its effects on physical health due to poor nutrition and substandard living conditions that correlate with other disorders such as anxiety and depression in women.

Components of treatment
Short-term (14-day) and long-term (28-day) treatment for women has been shown to reduce illicit drug use, HIV risk behaviors, and illegal activities.⁷ For example, in one study, 84% of the women in long-term treatment admitted illicit drug use daily or weekly. Twelve months after treatment, only 28% continued to abuse drugs. For women in short-term treatment, 86% admitted drug use at intake while one year later, 32% reported use.⁷

Elements of successful treatment for women include intake screening and comprehensive health assessment, infant and child care services, early intervention for children, and an individualized treatment plan that includes a plan for relapse prevention and counseling. (See “Substance Abuse Treatment for Women.”)¹¹ Treatment for associated factors such as co-occurring anxiety, depression, stress and PTSD is also crucial. The relationship of smoking to alcohol and drug use is also critical to a relapse-prevention plan for women, either through smoking cessation support or education about the risk relationship.

Nursing implications
Nurses in a variety of roles and settings are uniquely positioned to provide assessment, early intervention, education, and referral for women with known risk factors for substance abuse. Assessment involves incorporating the attributes of high-risk groups into the standard nursing assessment instrument. For instance, women aged 12 to 44 should be directly questioned about their smoking, alcohol, and other substance use, including the use of prescription drugs. A particular focus for the assessment should be smoking and age of onset because smoking has a positive relationship with progression to drug use. If a woman reports a past history of anxiety, depression, or childhood victimization, the nurse should question her about previous treatment for the condition, present status and coping strategies used to manage symptoms.

The TWEAK, an alcohol assessment scale for women, may be used with women indicating risk factors.15 (T = Tolerance; W = Worried, meaning close friends or relatives worried about the drinking; E = Eye opener, taking a drink in the morning; A = Amnesia, meaning a friend or family member told you about things you said or did while you were drinking that you could not remember; K(C) = Do you sometimes feel the need to cut down on your drinking?) The questions in sequence are:

1. How many drinks can you hold?
2. Have close friends or relatives worried or complained about your drinking in the past year?
3. Do you sometimes take a drink in the morning or when you first get up?
4. Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
5. Do you sometimes feel the need to cut down on your drinking?

Question 1 receives two points if a woman reports that she needs three or more drinks to feel the effects of alcohol. Two points are given for question 2 for a “yes” answer. The remaining three questions receive one point each when positive.¹⁴ A woman with a total score of 2 or more is likely to be an at-risk drinker, with further assessment warranted.
Early intervention involves discussing a woman’s risk factors with her and providing education about substance abuse treatment such as the options available and the positive outcomes possible. Referral to resources focusing on the needs of women along with continued follow-up by the RN when possible are crucial elements of intervention. The National Women’s Health Information Center (www.4woman.gov and www.4girls.gov) provides comprehensive health information, and SAMHSA (www.samhsa.gov) provides information about prevention and treatment for women with substance abuse and mental disorders.

Substance Abuse
Complementary therapies offer new hope

Alternative therapies have become increasingly popular for treating chronic illnesses, with 425 million consumers using various methods to treat these conditions, according to a national study conducted in 1998.¹ A more recent study, examining the long-term trends of alternative therapies used in the U.S., revealed that 67.6% of respondents had used at least one complementary therapy in their lifetime and that lifetime use steadily increased with age. ² Additionally, use remained stable, with nearly half continuing to use these therapies many years later.² Among the conditions for which alternative therapies are used is chemical dependency, with many clients using specific complementary strategies affecting the brain’s neurochemistry to prevent relapses. In support of this trend, the relationship between alterations in brain neurochemistry and the abuse of licit and illicit chemicals has been substantiated by biochemical research.^3-6

Amino acid neurotransmitters such as glutamate, gamma-aminobutyric acid (GABA) and tryptophan have all been implicated in craving and withdrawal syndromes associated with substance abuse.^6-9 Neurotransmitters, in general, are responsible for the communication that occurs between neurons in the brain and are known to have an important effect on the nervous system. Communication between neurons occurs when these neurotransmitters move through the cellular body of the neuron, passing through to synaptic vesicles that wait to receive them. When released from the vesicles, the transmitters move across the synaptic gap, making contact with the receiving neuron possessing the right shape and electrical charge. When this occurs, the transmitter molecule fits into the receiving neuron like a key in a lock.¹⁰ Studies of specific neurotransmitters have led to the development of pharmaceutically manufactured and physician-prescribed drugs designed to affect the neurochemical system, such as Acomprosate (calcium-acetyl homotaurinate).¹¹ This chemical has been shown to significantly reduce alcohol consumption, thus increasing abstinence rates, by affecting the GABA and glutamate transmitter systems related to craving and withdrawal.¹¹

Research on synthetically manufactured drugs has been accompanied by investigations into the effectiveness of alternative or complementary modalities and their ability to affect brain neurochemistry and behavior. The most promising of these identified in the addictions treatment literature to date are amino acid supplementation, usually referred to as neuro-nutrient therapy or amino acid loading, and acupuncture/acupressure.^12-17 This article describes the physiological basis for and clinical application of these modalities. This growing area of treatment is important to the nurse since neurochemical interventions are being proposed for the addictions along with traditional psychotherapeutic modalities.^12-17

Reward pathways and addiction
Neuroscientists now believe that the portion of the brain in which most addictive drugs create their effects is the mesolimbic system, the area where instinctual drives and the ability to experience pleasurable emotions exist. Residing within the mesolimbic system is the medial forebrain bundle (MFB), often referred to as the reward or pleasure pathway. The MFB runs from the center of the brain in an area called the ventral tegmental area (VTA), through the region above the pituitary gland (lateral hypothalamus), continuing on to the central communication station known as the nucleus accumbens (NAc), and up to and through the fore-brain, the frontal cortex.⁷

Drugs such as heroin, alcohol and nicotine are known to act, at least partially, on the VTA, producing the euphoric emotions that are addictive to some users. Chemicals acting on the NAc include cocaine, heroin, nicotine, phencyclidine (PCP, “angel dust”), and tetrahydrocannabinol (marijuana). All of these substances produce euphoria and craving, yet this action alone is not sufficient to produce the loss of control seen in people who become addicted (dependent). Though it is estimated that there are over 80 neurotransmitters affecting brain function in complex ways, research has indicated a strong association between several major neurochemicals and specific drugs of abuse.^18,19 For example, cocaine and amphetamines affect dopamine and serotonin neurotransmitters while alcohol affects dopamine, serotonin, GABA, and glutamate transmitters.

One neurotransmitter, dopamine, present in the mesolimbic system, appears to be a common factor in craving for all drugs of abuse. Dopamine is used by neurons in several brain regions that involve motivation and reinforcement of behaviors, and this chemical affects the sensitivity of target neurons producing other neurotransmitters such as glutamate. From neuroimaging studies such as positron emission tomography (PET scans), it is known that even a small amount of alcohol can increase dopamine release in the NAc, and cessation of alcohol and drug abuse has been associated with decreases of dopamine in the brain.^18-20 The major excitatory and inhibitory neurotransmitters in the brain are closely related to the amino acid receptors GABA and glutamate.¹⁹ The significance of these amino acid neurochemicals has prompted intensive investigations into the role of amino acids in the treatment of addictive illnesses.

Amino acid therapy
Researchers have referred to amino acids as mood foods²¹ and selective amino acid therapy as feeding the addicted brain.²² Amino acids are the building blocks of protein and help to create body tissues and cells, promote growth and repair body parts, produce the enzymes required for digestion and the manufacturing of hormones, support proper functioning of the circulatory system, create energy as they are converted to glucose and glycogen, and promote the communication system within the brain and the rest of the nervous system.²¹

In the last decade, the focus of addictions treatment has shifted from being solely psychoeducational to include nutritional supplementation. In fact, one program offered through the Health Recovery Center in Minneapolis claims a 74% remission/recovery rate using vitamins, minerals and large doses of amino acids.²³ It is believed that people at risk for substance abuse may have genetic deficiencies in neurotransmitters that respond to amino acid therapy or that prolonged stress, regular drug/alcohol use and inadequate nutrition all contribute to amino acid depletion.²³ Though exact dosing has not been established due to individual differences, specific amino acids and their purported neurotransmitter relationship and biological effects are demonstrating promise for addicts. The table above displays amino acids associated with specific neurotransmitters and drugs of abuse along with known contraindications for certain amino acids.
One researcher, based on numerous clinical studies, has packaged specific amino acids by type and dosage into trademarked products for recovering substance abusers.¹³

Acupuncture
Acupuncture was introduced into this country in the 1970s and was received by the Western medical establishment with caution and sometimes disdain. It has been rediscovered more recently because of a positive and growing body of physiological research indicating its effectiveness for many conditions and because of consumer interest in alternative modalities.^24-28 Early biochemical studies indicated an increase in brain neurochemicals such as beta endorphins, associated with analgesia and reduction of anxiety, measured in cerebral spinal fluid and peripheral blood assays.²⁷ More recent studies have substantiated the efficacy of acupuncture for pain relief.²⁶

The effectiveness of acupuncture for the addictions was first discovered in China when subjects were being treated with auricular (ear) acupuncture for another condition and reported a decrease in their desire to smoke or use alcohol. Since the 1980s, the ear has been the primary acupuncture treatment site for alcohol and drug addiction in the United States. The insertion of needles into the Shenmen, Sympathetic and Lung points in both ears has reduced anxiety, craving and relapse to chemical use, purportedly as the result of the stimulation of brain neurochemicals that inhibit these conditions.^14,16,24,28

Treatment consists of a licensed acupuncturist inserting needles into the three points bilaterally for at least 30 minutes three times per week for up to four weeks. Follow-up treatments may be given if clients indicate an increase in craving or anxiety. After treatment with needles, clients can be taught to apply acu-patch pellets on the ear points themselves. These pellets are stainless steel or titanium imbedded in a transparent or flesh-colored adherent round tape that can be pressed against the ear points, remaining in place for up to two weeks. The client can apply the acu-patch pellets as needed.
Implications for nursing care

Nurses are in a unique position to affect the development and progression of substance abuse across a wide span of care settings. One author points out that nurses not only often assess, diagnose, and treat chemical dependency, but also are in a position to provide information to clients that supports the use of good health practices.²⁹ With the rapid growth of research on brain neurochemistry and consumer use of alternative/complementary care modalities, nurses must stay up-to-date on current research and treatments. Since nurses function in a wide variety of settings—from ambulatory to acute care—the caring-healer role of the nurse can have a profound effect on the prevention of and intervention in the progression of substance abuse. It is through this broad-based direct client contact that nurses can implement the latest information about addictive illnesses with a focus on prevention and early intervention.

Some researchers have found that an organized, hospital-based intervention team can have a significant health impact on substance abusers identified in an acute care setting.³⁰ Clients assessed as substance dependent and those who were determined to be at-risk due to heavy drinking were given either full or less intensive interventions by the team. Those who were given the full intervention received personal health assessment data, substance abuse education, and referral to formal addiction treatment while those receiving the less intensive were given personal health assessment data and education only. The full intervention group, on follow-up, demonstrated more numerous periods of abstinence, reduced heavy drinking days and acceptance of referral to treatment. Those receiving the at-risk intervention solely also demonstrated fewer drinking days, less average alcohol consumption, and fewer negative consequences due to substance use.

Given the tremendous strides in neuroscience over the last decade, nurses have much more information at their disposal to use in treating substance abusers. In fact, the relationships between mood, behavior and neurochemistry may actually result in a redefinition of mental/addictive illnesses in the future. One day the psychiatric labels currently used may be replaced with biochemical terms used to identify the neurotransmitter deficiency or impairment involved. For example, depression, which is currently treated pharmacologically with serotonin re-uptake inhibitors (SSRIs such as Prozac), might be referred to as a serotonin deficiency condition or disease.

In order to teach clients about substance abuse, nurses must first possess and understand the information and its significance for treatment and recovery. With close and continuous client contact, nurses are in a better position than any other professionals to provide education to the client, family, and other caregivers. One nurse author has identified the use of analogy in teaching clients and family members about the action of neurotransmitters.³¹ Clients seeking treatment with amino acid supplementation or auricular acupuncture need to have a basic understanding of the neurochemical effects created by these interventions. Using the fingers of both hands, she demonstrates the flow and interlocking nature of neurotransmitters when they leave one neuron and engage with the receptor sites of the receiving neuron. The fingers on one hand are used to demonstrate the movement of the neurotransmitter as it leaves one neuron and the corresponding fingers of the other hand represents the receptor sites receiving the neurotransmitter. The action, through the interlacing of the fingers of both hands, demonstrates the way the neurotransmitter locks into the receiving neuron.³¹ Clients need accurate and current information but most of all they need compassionate and sensitive caregivers who accept the complexity of their illness and who can communicate hope for their future.

Case Studies
Critical issues in substance abuse and its treatment

Case Study 1
Thomas, an emergency room nurse, plans to provide an educational program for 8th, 9th and 10th graders about Ecstasy (MDMA).

1. How can Thomas tell students about the toxic effects of Ecstasy?

2. What will Thomas say about the chronic effects of Ecstasy?

Case Study 2
James, an addictions nurse, is planning to present a program for the PTA at the local junior high school on the risks associated with Ecstasy.

1. What can James say to parents and teachers about the risk factors related to adolescent Ecstasy use?

2. What can James say about the protective factors that function to prohibit use of Ecstasy?

Case Study 3
Carol, a recovering alcoholic, has been in treatment twice—the second time due to a relapse to alcohol use that ended in a motor vehicle accident and DUI (driving under the influence) charges. She is determined to maintain her sobriety this time. She tells the clinic nurse on her routine visit for a physical that she has heard “something about foods or amino acids that may help in the recovery process.” She wonders if the nurse has any information about this.

1. The nurse provides the patient with the most complete and accurate information on this subject by saying:

2. The patient tells the nurse she does not understand why she has these cravings for alcohol since it has caused so much destruction in her life. The nurse will respond by telling the patient:

Case Study 4
John is being admitted to an inpatient alcohol treatment program that uses auricular acupuncture as an adjunct treatment to standard substance abuse therapy.

1. John asks the admitting nurse to explain how this treatment is effective for alcohol addiction. The nurse will say:

2. John asks the nurse to tell him how the procedure will be done. The nurse tells John the following:

Case Study 5
Janice is providing an inservice educational program for nurses who work in the pediatric clinic. She wants the nurses to be alert to the physical and psychological indicators of teen-age alcohol abuse.

1. What will Janice alert the nurses to in their assessment of adolescents who are at risk for alcohol abuse?

2. What will Janice tell the nurses about early childhood behaviors and their relationship to alcohol abuse in later years?

Case Study 6

Two nurses working with substance-abusing adolescents are developing an education program for the adolescents’ parents. The nurses want to provide the parents with information about the influencing and risk-reduction factors important to the recovery of their children.

1. What will the nurses emphasize about the influencing factors to these parents?

2. What will the nurses say to the parents about the risk-reduction strategies related to adolescent substance abuse?

Case Study 7
Alice is preparing a continuing education course and wants to identify the constellation of drug-seeking behaviors that prescription drug abusers often use.

1. What drug-seeking behaviors will Alice identify in this course?

2. What will Alice advise the nurses to tell the patient when receiving a prescription for a new medication?

Case Study 8
Jane works in a women's clinic and is planning an educational program for the women related to substance abuse and associated disorders.

1. What co-occurring factors will Jane address in her discussion about substance abuse?

2. What will Jane say about the association of cigarette smoking to later illicit drug use by females?

Case Study 9
Joan is talking to a group of women about the developmental stages of substance dependence in women.

1. How will Joan describe the stages to these women?

2. What will Joan say about the association between cigarettes and the use of illicit drugs?

Case Study 1 Answers
1. He will say that Ecstasy has a negative effect on brain cells, causing damage to some of them. Thomas will emphasize that the recommendation is to avoid even a one-time use.

2. He will tell the students that some of the people who have used the drug show problems in the ability to understand and retain information, thereby affecting their ability to learn. These problems cause the person frustration. It is unknown at this time if these changes are permanent.

Case Study 2 Answers
1. James will tell the parents that adolescents are at risk in general because of their novelty-seeking and excitement-seeking behaviors. Other risk factors that interact with these traits are parental/family drug use, inconsistent family management (rules/expectations), family conflict, peer group rejection, academic failure, learning disabilities and low self-esteem. He will emphasize that it is important for parents and teachers to be aware of these factors and take steps to intervene immediately when they occur.

2. James will inform the parents and teachers that strong, nurturing relationships with family members and other adults are critical to adolescent development. Other important factors are clear family rules for conduct, active involvement of parents and other adults in the child's life, successful performance in school and involvement in youth organizations.

Case Study 3 Answers
1. Protein foods are composed of amino acids, which are necessary for the functioning of all body cells and tissues. Certain amino acids are important in the production of brain cells and the brain chemicals produced by these cells. Research indicates that, in some cases, taking amino acid supplements nourishes these brain cells, helps in the production of brain chemicals and reduces the craving for substances such as alcohol and sugar. Amino acids that have been shown to be helpful to people who crave alcohol are L-glutamine and L-tryptophan.

2. Scientists now believe that there is a portion of the brain called the reward or pleasure pathway. Drugs such as heroin, alcohol and nicotine are known to affect this pathway and cause intense sensations of pleasure and, ultimately, craving. Genetic deficiencies, prolonged stress or regular drug/alcohol use and inadequate nutrition may contribute to amino acid deficiencies, thereby affecting the functioning of the brain cells and brain chemicals.

Case Study 4 Answers
1. Research on acupuncture since the 1980s has shown that it increases the production of some brain chemicals that are deficient in the alcoholic. These chemicals create relaxation and may reduce craving for alcohol in some patients.

2. Treatment consists of a licensed acupuncturist inserting needles into three points in both ears known to stimulate these chemicals. The needles will be left in for 30 minutes, and the treatment will be given three times a week for up to four weeks. After the treatment with needles is completed, you will be taught to apply acu-patch pellets to the ear points. These pellets are stainless steel or titanium and adhere to the points with adhesive, round tape.

Case Study 5 Answers
1. She will tell the nurses to assess for sleep disturbances, periodontal disease and dental caries and mood disorders such as depression and suicidal ideation.

2. Janice will inform the nurses that childhood temperament is associated with alcohol abuse in the teen years. Specifically, children who are restless and impulsive at age 3 are more likely to be diagnosed with alcohol abuse at 21. Aggressiveness in children as young as 5 to 10 is related to alcohol and other drug use in adolescence.

Case Study 6 Answers
1. The nurses will inform the parents about the factors that influence underage drinking: peer groups, media/advertising, adolescent novelty-seeking/risk-taking behaviors and positive expectations about alcohol use. Specifically, they will emphasize that teens with friends who use alcohol are much more likely to misuse alcohol and that alcohol use and abuse is glamorized by the entertainment industry and this can be countered by parents who focus on the negative consequences of alcohol use. Additionally, the nurses will address the developmental issues related to novelty-seeking and risk-taking behaviors so parents can teach their children alternative ways to manage these developmental needs.

2. The nurses will emphasize the importance of strong family relationships and parental monitoring. Families can support adolescents with clear communication, reasonable boundaries on behavior and active parental involvement in the child's life. Parents can encourage peer relationships that involve shared healthy activities that are consistent with the family's values and beliefs. Life skills that parents can teach and support in the adolescent include alcohol-refusal methods and anger-coping strategies such as talking about problems and concerns.

Case Study 7 Answers
1. Alice will explain that patients can be adept at feigning symptoms through inventing or exaggerating them. Disorders patients often feign to obtain prescription drugs are migraine headaches, tic douloureux, back pain, colitis and narcolepsy.

2. Alice will tell the patient the name of the medication and what it is supposed to do; how and when to take it and for how long; what foods, drinks and other medications or activities to avoid while taking the medication; any side effects and what should be done if they occur and whether the medication will work safely with other prescription or nonprescription drugs such as vitamins, herbal remedies or over-the-counter medications. Additionally, the nurse should provide the patient with written information on the medication.

Case Study 8 Answers
1. Jane will discuss the co-occurring factors of alcohol/tobacco and illicit/prescription drug abuse, past victimization (sexual/physical assault), stress and psychiatric disorders such as anxiety, depression and eating disorders.

2. Jane will explain that smoking cigarettes has a significant role in the later development of illicit drug use in women. Additionally, she will say that women have a 1 in 3 chance for developing dependency on cigarettes and that withdrawal symptoms are more intense and relapse more common in women.

Case Study 9 Answers
1. Joan will say there are three stages of substance dependence in women: Stage 1 is the use of alcohol/cigarettes; Stage 2 is marijuana use and Stage 3 is the use of illicit drugs other than cocaine or marijuana.

2. Jane will tell the women that early onset of illicit drug use is associated.