Chapter 27 Violence Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. Overview of Violence Violence is a national public health problem.  WHO (2013) defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”  Injuries from violence are referred to as intentional injuries. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2 Factors That Contribute to Violence         Poverty, unemployment, economic dependency Substance abuse Dysfunctional family and/or social environment and lack of emotional support Mental Illness Media influence (e.g., violent video games, television shows, and movies) Access to firearms Political and/or religious ideology Intolerance and ignorance Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3 History of Violence  Long history of human violence. ➢ In the Bible, Cain killed his brother Abel out of jealousy and anger ➢ Audience pleasure (e.g., gladiators in Rome) ➢ Infanticide—if child was female, a twin, sickly, or deformed ➢ Children, especially firstborn, sacrificed for religious reasons Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4 History of Violence (Cont.)  Corporal punishment used to control children ➢ ➢ ➢  Spousal abuse/marital rape ➢ ➢ ➢  “Spare the rod and spoil the child” (Proverbs, 13:24) “Beating some sense into him” First legal protection in the United States in 1874 “Rule of thumb” “Wives be subject to your husband” (Ephesians, 5:22) Assault against women not explored until 1960s Elder abuse ➢ ➢ Often undetected because of lack of awareness of HCP Lack of mandatory reporting Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5 Interpersonal Violence    Crosses all ethnic, racial, socioeconomic, and educational lines Interpersonal Violence (IPV) is about control, not anger. Includes: ➢ Homicide and suicide ➢ Intimate partner violence ➢ Child maltreatment Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6 Interpersonal Violence: Homicide  Homicide ➢ One of the leading causes of death in the United States. • For black males aged 15 to 34, homicide is the leading cause of death. ➢ ➢ Young people, women, and African American and Hispanic males at higher risk than the general population. African Americans were more likely to commit homicide than whites and were more likely to be victims of homicide than whites (2010 data) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7 Interpersonal Violence: Suicide   Suicide is 10th leading cause of death for all Americans in all age groups (2010) More people die from suicide than homicide. ➢ ➢  Men often use firearms. Women use poisoning. In Native Americans and Alaska Natives, suicide is the second leading cause of death in persons 15 to 34 years of age. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8 Interpersonal Violence: Suicide (Cont.)  Risk factors for suicide ➢ Psychiatric disorders such as major depression, bipolar disorder, and/or schizophrenia ➢ Substance abuse ➢ Posttraumatic stress disorder (PTSD) ➢ Bulimia or anorexia nervosa ➢ Past history of attempted suicide ➢ Genetic disposition to suicide ➢ Age, such as elderly, and white males (highest rate) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9 Interpersonal Violence: Partner  Intimate partner violence (IPV) ➢ ➢ ➢ A pattern of coercive behaviors perpetrated by someone who is or was in an intimate relationship with the victim May include battering, resulting in physical injury, psychological abuse, and sexual assault to progressive social isolation and intimidation of the victim Typically repetitive and often escalates in frequency and severity Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10 Interpersonal Violence: Partner (Cont.)  Risk factors for IPV ➢ Low self-esteem ➢ Poverty ➢ Risky sexual behavior ➢ Eating disorders and/or depression ➢ Substance abuse ➢ Trust and relationship issues  Victims often suffer in silence and accept abuse as a transgenerational pattern of normal behavior Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11 Interpersonal Violence: Partner (Cont.)  Pregnancy ➢ ➢ May increase stress within the family All pregnant women should be routinely screened for abuse for commons sign of IPV • Delay in seeking prenatal care • Unexplained bruising or damage to breasts or abdomen • Use of harmful substances (cigarettes, alcohol, drugs) • Recurring psychosomatic illnesses • Lack of participation in prenatal education Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 12 Interpersonal Violence: Dating  Abusive, controlling, or aggressive behavior in an intimate relationship that takes the form of emotional, verbal, physical, or sexual abuse ➢ ➢   May involve the use of date rape drugs Studies have linked alcohol with dating violence Stalking—a pattern of repeated and unwanted attention, contact, harassment, or any type of conduct directed at a person that instills fear Bullying—a repeated oppression, psychological or physical, of a less powerful person by a more powerful person or group of persons Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13 Wheel of Power and Control Figure 27-1 Developed by the Domestic Abuse Intervention Project. 206 West Fourth Street, Duluth, MN 55806. Used with permission. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14 Impact of Interpersonal Violence  Victims often experience… ➢ ➢ ➢   Chronic fatigue and tension Disturbed sleeping and eating patterns Vague gastrointestinal and genitourinary complaints Misdiagnosis often occurs because of the obscurity of symptoms and/or failure to adequately assess Victims stay in abusive relationships because of cultural, religious, and economic factors Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15 Impact of Interpersonal Violence (Cont.)  Victims who are most likely to leave a battering situation: ➢ Have resources and power ➢ No children ➢ No personal history of abuse (themselves or their mother)  Most dangerous time for victim is when he or she leaves or attempts to leave the relationship ➢ More likely to be killed at this time than any other time in the relationship Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16 Interpersonal Violence: Child  Child maltreatment ➢ Most child maltreatment occurs within the family. ➢ More often abused by parents than other relatives or caregivers. ➢ More commonly seen in families in poverty, families in disorganization, or with parents who are younger and who are substance abusers. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17 Interpersonal Violence: Child (Cont.)  Child maltreatment ➢ Risk factors include but are not limited to • Special needs children • Children less than 4 years of age • Family history of violence • Substance abuse • Poverty • Social isolation Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18 Interpersonal Violence: Child (Cont.)  Child maltreatment ➢ Four types of child abuse: 1. Neglect 2. Physical abuse • • Includes beating, burning, biting, and bruising Abusive head trauma/shaken baby syndrome is leading cause of death in the United States from abuse 3. Emotional abuse 4. Sexual abuse Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19 Interpersonal Violence: Elderly  Elder abuse ➢ Society fails to recognize the cruelty many older adults experience. • Elders are an “invisible” segment of the population. ➢ Reasons for underreporting of elder abuse • Shame on part of victim • Social and physical isolation from resources • Failure of health care provider to routinely assess during points of contact • No uniform reporting system Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20 Interpersonal Violence: Elderly (Cont.)  Elder abuse ➢ Types of abuse and neglect • Physical abuse • Psychological-emotional abuse • Sexual abuse • Neglect • Financial exploitation • Health care fraud and abuse Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21 Community Violence   Community violence usually occurs suddenly and without warning and can potentially destroy entire segments of the population Community violence includes ➢ Workplace violence ➢ Youth violence ➢ Gang-related violence ➢ Hate crimes ➢ Terrorism Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 22 Community Violence: Workplace Workplace violence includes physical assaults, muggings, and verbal and written threats Risk factors include: ➢ Increasing number of acute and chronically mentally ill patients ➢ Working alone ➢ Availability of drugs at worksite ➢ Low staffing levels ➢ ➢ ➢ ➢ ➢ Poorly lit parking areas and corridors Long waits for service Inadequate security Increasing number of substance abusers Access to firearms Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 23 Community Violence: Youth  Youth-Related Violence ➢ ➢ ➢ ➢ Concentrated in minority communities and inner cities, causing a disproportionate burden on these communities Adolescents and youth increasingly use violence to settle disputes. Even when taught peaceful ways of resolving differences, learn by what they observe at home, on television, and in movies. Schools have become common sites for violence. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 24 Risk Factors for Youth Violence (from Textbook, Table 27-3) Individual Risk Factors Involvement with drugs, alcohol, or tobacco Antisocial beliefs and attitudes Low IQ History of violent victimization History of early aggressive behavior Community Risk Factors Diminished economic opportunities High concentration of poor residents High level of family disruption Low levels of community participation Socially disorganized neighborhoods Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 25 Risk Factors for Youth Violence (from Textbook, Table 27-3—Cont.) Individual Risk Factors Attention deficits, hyperactivity, or learning disorders Poor behavioral control Deficits in social, cognitive or information-processing abilities Exposure to violence and conflict in the family High emotional distress History of treatment of emotional problems Community Risk Factors High level of transiency Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 26 Risk Factors for Youth Violence (from Textbook, Table 27-3—Cont.) Family Risk Factors Poor family functioning Low emotional attachment to parents of caregivers Low parental education and income Parental substance abuse or criminality Poor monitoring and supervision of children Harsh, lax, or inconsistent disciplinary practices Authoritarian childrearing practices Peer/Social Risk Factors Association with delinquent peers Involvement in gangs Social rejection by peers Lack of involvement in conventional activities Poor academic performance Low commitment to school and school failure Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 27 Community Violence: Gangs  Reasons that young people join gangs: ➢ Believe that gangs will protect them ➢ Peer pressure ➢ The need for respect ➢ A sense of belonging  Increasingly responsible for crimes and violence throughout the United States ➢ Crimes include illegal alien smuggling, armed robbery, assault, auto theft, drug and weapon trafficking, identity theft, and murder. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 28 Community Violence: Prison  Prison violence ➢ ➢ ➢ ➢ The United States has one of the world’s highest rates of incarceration Inmates are both victims and perpetrators of violence. Includes allegations of physical abuse and reports of rape by corrections officers and inmates Little sympathy for this population for a variety of reasons, including indifference, disbelief, and denial Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 29 Community Violence: Trafficking   Human trafficking is a global problem and a public health issue. Involves: ➢ Prostitution ➢ Sexual exploitation ➢ Forced labor ➢ Slavery ➢ Removal of organs Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 30 Community Violence: Hate Crimes  Crimes in which offender is motivated by An individual’s race*1 ➢ Sexual orientation*3 ➢ Religious beliefs*2 ➢ Ethnic background ➢ National origin ➢ *Rank—most commonly reported  Hate crimes may include ➢ Murder ➢ Rape ➢ Sexual or physical assault ➢ Harassment ➢ Attacks on homes or on places of worship ➢ Vandalism Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 31 Community Violence: Terrorism  “The calculated use of unlawful violence or threat of unlawful violence to inculcate fear; intended to coerce or to intimidate governments or societies in the pursuit of goals that are generally political, religious, or ideological.” (Department of Defense)  All terrorist acts include at least three key elements—violence, fear, and intimidation. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 32 Factors Influencing Violence  Firearms A gun in the home… • …triples the risk for homicide in the home • …increases the risk for suicide 3 to 5 times • …increases risk for accidental deaths by 4 ➢ Firearms are the number one weapon of choice in homicides in the United States. ➢ Direct and indirect costs are staggering. ➢ “Right to bear arms” arguments persist. ➢ Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 33 Factors Influencing Violence (Cont.)  Media violence includes exposure to and participation in … ➢ ➢ ➢  …violent video games …music and music videos that depict date rape or violence …virtual violence that allows subscribers to harm or kill victims Repeated exposure to media violence leads to emotional desensitization to real-life violence Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 34 Factors Influencing Violence (Cont.)  Mental illness is considered by many to be a major factor in violence. ➢  Studies are inconclusive that all violence is committed by mentally unstable persons. Increasing push for legislation to fund public health strategies that identify and treat mental illness across the country ➢ Funding issues have forced states to eliminate or reduce availability of mental health services Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 35 Violence Is a Public Health Epidemic   The public health system is challenged to go beyond its traditional programs to include prevention and management of violence. Efforts being made with ➢ ➢ ➢  Public health strategies Community approaches Local, state, and federal governments Addressed by Healthy People 2020 Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 36 Prevention of Violence: Primary Prevention   Goal: to stop violence, abuse, or neglect before it occurs Education may include life skills training: ➢ ➢ ➢  Parenting and family wellness Anger management Conflict resolution Nurses should: ➢ ➢ ➢ Increase awareness of violence Identify cases Work with the community Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 37 Prevention of Violence: Primary Prevention (Cont.)   Must begin at community level to change attitudes Focuses on stopping transgenerational aspect of abuse ➢ ➢   Start with young children Continue across the lifespan Mentoring and peer programs to promote healthy relationships and decrease conflict Work with high-risk individuals Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 38 Prevention of Violence: Secondary Prevention  Goal: assess, diagnose, and treat victims and perpetrators of violence. ➢   Consideration of safety of potential victim is critical Begins with assessment Once identified, victims must be offered… ➢ ➢ Resources to increase their safety Legal options and how to access them Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 39 Prevention of Violence: Secondary Prevention (Cont.)  Nurses must screen for abuse. Ask questions ➢ ➢ ➢   Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Since you’ve been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Within the last year, has anyone forced you to have sexual activities? Intervene when essential Interdisciplinary approach leads to optimal outcomes. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 40 Prevention of Violence: Tertiary Prevention    Goal: Aimed at rehabilitation of individuals, families, groups, or communities and includes both victims and perpetrators of violence May take months or even years Nurses must work in conjunction with a variety of mental health professionals and social service agencies to provide coordinated care ➢ Self-care and recognition of own limitations and needs Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 41 Chapter 26 Substance Abuse Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. More deaths, illnesses, and disabilities are attributed to substance abuse than to any other preventable health conditions in the United States. – Substance Abuse and Mental Health Services Administration (SAMSHA) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2 Social Consequences of Substance Abuse      Crimes while under the influence of drugs, alcohol, or both Need for money to buy substances Specific theft of drugs Almost 75% of inmates report prior drug use All aggregates in society are potentially affected by substance abuse problems regardless of age or economic level Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3 Etiology of Substance Abuse  Numerous theories try to explain it ➢ Combination of many factors ➢ Genetics within families ➢ Individual (impulsivity and ease of disinhibition) ➢ Environmental factors ➢ Medical models ➢ Biopsychosocial models Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4 Historical Overview of Alcohol and Illicit Drug Use   Alcohol use has gained more social acceptance than other drug use. Public attitudes and governmental policies have also influenced the history of illicit drug use. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5 Historical Overview of Alcohol and Illicit Drug Use (Cont.)  Consumption and laws affected by: ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ Alcohol-related deaths after lowered drinking age Less tolerant national attitudes toward drinking Increased societal and legal pressures and actions against drinking and driving Increased health concerns among Americans Knowledge of addictive properties Counterculture acceptance of hallucinogens, cannabis, and heroin The “War on Drugs” Renewed interest in prevention/treatment efforts Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6 Laws Impacting Substance Abuse  Anti–Drug Abuse Acts of 1986 and 1988 ➢ ➢ ➢  Increased funding for treatment and rehabilitation Created the Office of National Drug Control Policy (“drug czar”) Worked on a public health approach to drug control National Institute on Drug Abuse (NIDA) ➢ Science on drug abuse and addiction • Prevention • Treatment • Decreasing the spread of HIV/AIDS • Other priority areas Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7 Laws Impacting Substance Abuse (Cont.)  Substance Abuse and Mental Health Services Administration (SAMHSA) ➢ Builds and sustains programs, policies, information and data, contracts, and grants toward helping the nation act on the knowledge that promotes behavioral health treatment through all levels of prevention Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8 Prevalence, Incidence, and Trends  Alcohol use by persons aged 12 or older: ➢ Slightly more than half (52.8%) drink alcohol ➢ Binge drinking at least once in prior 30 days— (22.6%) ➢ Heavy drinking—6.2% ➢ Young adults ages 18-25 had highest prevalence of binge and heavy drinking—39.8% ➢ Drove under the influence of alcohol at least once in past year—11.1% – SAMHSA (2011) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9 Prevalence, Incidence, and Trends (Cont.)  Illicit drug use by persons aged 12 or older: ➢  About 8.7% were current drug users, used an illicit drug during the past month Illicit drugs used ➢ ➢ Marijuana was the most commonly used drug Others included cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) used nonmedically – SAMHSA (2011) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10 Prevalence, Incidence, and Trends (Cont.)  Nonmedical use of prescription-type psychotherapeutics ➢ There is a significant increase in the lifetime nonmedical use of pain relievers—specifically Percocet®, Percodan®, Vicodin®, Lortab®, Darvocet®, Darvon®, Tylenol® with Codeine, Propoxyphene, or Codeine Products, Oxycodone, and Hydrocodone – NIDA (2010) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11 Prevalence, Incidence, and Trends (Cont.)  Hallucinogen, inhalant, and heroin use ➢ LSD (d-lysergic acid diethylamide) ➢ Peyote cactus ➢ Psilocybin ➢ PCP (phencyclidine) ➢ Inhalants of choice are amyl nitrite, “poppers,” followed by glue, shoe polish, or toluene; correction fluid, degreaser, or cleaning fluid; gasoline or lighter fluid; and spray paints and other aerosols. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 12 Prevalence, Incidence, and Trends (Cont.)  Gender difference ➢ ➢  Geographic trends ➢  Males more likely to be current illicit drug users Female illicit drug use (12 and older) increasing Highest in West > Midwest > Northeast > South Racial/ethnic groups ➢ Highest among American Indians or Alaska natives > African Americans> whites > Hispanics > Asians – SAMHSA (2010) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13 Trends in Substance Abuse     May or may not relate to classically or clinically defined dependence or addiction. Many are turning to recovery before they have developed physiological dependence. Need to differentiate between use and misuse/abuse. Use of harmful substances is indirectly and directly related to all of the leading health indicators targeted in Healthy People 2020. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14 Methamphetamine (MA)     Most widely produced controlled substance in the United States. Illegal street names of the drug (crank, crystal, meth, ice, or glass). Can be injected, inhaled, taken orally, or smoked. Used predominantly by white young persons, with an overrepresentation of females. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15 Methamphetamine (MA) (Cont.)  Pleasurable effects are caused by the release of high levels of dopamine in the brain, leading to increased energy, a sense of euphoria, and increased productivity. ➢ ➢  Short-term effects: increased heart rate, insomnia, excessive talking, excitation, and aggressive behavior Prolonged use results in tolerance and physiological dependence Negative consequences range from anxiety, convulsions, and paranoia, to brain damage. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16 Methamphetamine (MA) (Cont.)  The impact of MA abuse on communities, families, and social networks is considerable. ➢ Young children of users are at risk for abuse and neglect. ➢ Prenatal use puts children at risk for developmental problems, aggression, and attention disorders. ➢ Exposure to combustible second-hand fumes. ➢ Associated with increased incidence of violence (e.g., domestic abuse, homicide, and suicide) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17 Steroids  Anabolic steroids are synthetic variants of male sex hormone testosterone ➢ ➢  Build muscle and said to be androgenic Most commonly used in athletes and other individuals willing to risk potential and irreversible health consequences to build muscle Potentially fatal risks ➢ ➢ Blood clots, liver damage, premature cardiovascular changes, increased cholesterol Increased potential for suicide and aggressive and risky behaviors Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18 Inhalants  Contain volatile components with psychoactive properties ➢   Many products found in home or workplace (e.g., spray paints, markers, glues, and cleaning fluids) Produce a rapid high that may resemble alcohol intoxications; may progress to loss of sensation and even unconsciousness Irreversible effects: ➢ Hearing loss, limb spasms, CNS or brain damage, or bone marrow damage; may result in death from heart failure or suffocation Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19 Adolescent Substance Abuse  Highest prevalence of illicit drug use during lifetime between 18 and 25 years ➢ Teen use of cigarettes and smokeless tobacco has declined ➢ Nearly half of teens try marijuana before they graduate—skepticism about drug’s danger  As harmful, illicit substances come in and out of vogue, CHN needs a good understanding of drug culture, terminology, and differing signs and symptoms Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20 Conceptualizations of Substance Abuse    Conceptualizations have changed over the years, often for political and social reasons rather than for scientific reasons. “Dependence” or “abuse” What substances can be abused? ➢ APA focuses on alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, and hypnotics or anxiolytics Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21 Defining Substance Abuse  Substance abuse: a maladaptive pattern of substance use that is manifested by recurrent and significant adverse consequences related to repeated use of a substance. ➢ ➢ ➢ ➢ Failure to fulfill major role obligations Repeated use in physically hazardous situations Multiple legal problems Recurrent social and interpersonal problems Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 22 Defining Substance Abuse (Cont.)  Dependence: a cluster of cognitive, behavioral, and physiological symptoms that indicate continued use of the substance despite significant substance-related problems ➢ ➢ ➢ ➢ Pattern of repeated, self-administered use Tolerance, withdrawal, and compulsive drug-taking behaviors A craving or strong desire for the substance Preoccupation with supply, money to purchase, and getting through time between periods of use Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 23 Sociocultural and Political Aspects of Substance Abuse    Determined largely by economic, cultural, and political conditions of potential users Cultural conditions create ambiguity in clearly determining when a problem exists. Competing value systems lead to cultural disintegration and a sense of powerlessness and hopelessness. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 24 Course of Substance-Related Problems  Path from initiation to dependency is multidimensional. ➢     Person + substance + context/environment Progression varies—from initiation to continuation, transition to abuse, and finally, addiction and dependency Critical point is transition from use to abuse Addiction/dependency marked by changes in both behavior and cognition Once addiction is established, withdrawal symptoms are strong motivators to continue use Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 25 Legal and Ethical Concerns  U.S. policy based on prohibition and criminal sanctions against use and sale of illicit drugs ➢ ➢ ➢  Criminal activities (violence and drug trafficking) Drinking and driving, working while intoxicated Impact on fetus (FAS) Modes of intervention ➢ ➢ ➢ ➢ Limit access Media campaigns Educational programs National organizations that promote community education, research, and support Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 26 Prevention Strategies  Primary prevention ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢  Needs assessment to identify high-risk situations and potential problems Decriminalization and legalization of drugs(?) Community-based programs Training of health professionals Faith-based initiatives Volunteer consumer groups Organized sports programs Employer programs Often overshadowed by “War on Drugs” Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 27 Prevention Strategies (Cont.)  Secondary prevention ➢ ➢ ➢ ➢ Screening and finding resources • CAGE: an alcoholism screening test • Clinical Institute Withdrawal Assessment (CIWA) • Use evidence-based programs Efforts should be specific to aggregates, rather than directed at the “general public” Incorporate culturally sensitive and appropriate interventions and strategies Work toward improving individuals’ general competencies, communication skills, and selfesteem Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 28 Treatment  For individuals, consider: ➢ Cultural and educational background ➢ Resources of the person ➢ Attitudes of significant others ➢ Degree of invasiveness of the effects of the substance use The existence of alternatives ➢ Relapse prevention Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 29 Treatment (Cont.)  Inpatient and outpatient treatment programs ➢ May or may not include detoxification component ➢ Voluntary vs. compulsory ➢ Pharmacologically based vs. drug free ➢ Treatment approaches and models vary     Assessment process is of primary importance. Therapeutic relationship based on trust is essential. Physical examination is a valuable tool. Nonjudgmental attitude minimizes defensiveness. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 30 Treatment (Cont.)  Programs usually include: ➢ Group and individual therapy and counseling ➢ Motivational interviewing ➢ Family counseling ➢ Education ➢ Socialization into 12-step mutual self-help groups ➢ Integrate psychotherapy with pharmacotherapy ➢ May include other strategies: • Hypnosis, occupational therapy, confrontation, assertiveness training, blood alcohol level discrimination training, behavior modification approaches Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 31 Treatment (Cont.)  Pharmacotherapies ➢  Mutual help groups ➢  Used in detoxification, stabilization, maintenance, as antagonists, and as treatment for coexisting disorders Operate through face-to-face supportive interaction focusing on a mutual goal; AA was first Harm reduction ➢ Elimination of the more harmful effects of substance use through behavior and policy modifications Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 32 Social Network Involvement Therapy that involves the family has proved to be most effective in aiding recovery.  Family and friends ➢ Highly influential or aid and abet ➢ Codependency and enabling  Effects on the family ➢ ➢  Functional or dysfunctional families Psychological and financial burdens Professional enablers ➢ ➢ Treatment of symptoms by medication Reluctant to bring up this taboo subject Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 33 Vulnerable Aggregates: Preadolescents and Adolescents      Times of experimentation, searching, confusion, rebellion, poor self-image, alienation, and insecurity Use of legal substances (e.g., tobacco, alcohol) almost always precedes use of illegal drugs. Poor school performance and drug use among peers are strongest predictors of subsequent drug involvement, followed by lack of strong family bond. The younger the initiation, the greater the probability of prolonged and accelerated use. Feeling of powerlessness; selling drugs seen as a viable economic solution to poverty. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 34 Vulnerable Aggregates: Preadolescents and Adolescents (Cont.)  Primary prevention focuses on: ➢ ➢ ➢ ➢ ➢ ➢ ➢ Advocating for these vulnerable children Educating teachers on the vital importance of maintaining a validating, nonjudgmental attitude toward these students Supporting strong families in the community Improving knowledge through education and media Early detection of predisposing factors Providing structured clubs and organizations Facilitating school success, career skills, family communication skills, and conflict resolution Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 35 Vulnerable Aggregates: Elderly  Elderly experience ➢ Diminished physiological tolerance ➢ Increased use/misuse of medically prescribed drugs ➢ Cultural and social isolation  Misuse of prescription drugs may be the most common form of drug abuse among the elderly ➢ Use prescription medications approximately three times as frequently as general population Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 36 Vulnerable Aggregates: Women   Alcohol use and abuse affects women much differently than men. Women absorb and metabolize alcohol differently. ➢ ➢ Body composition differences and production of less gastric alcohol dehydrogenase Metabolize alcohol at a different rate Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 37 Vulnerable Aggregates: Women (Cont.)  Increased risk stems from economic, social, and cultural factors. ➢ Marginalization of certain groups ➢ History of child abuse ➢ Physical and medical problems related to reproductive systems ➢ Use during pregnancy has long-term developmental consequences for the newborn Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 38 Vulnerable Aggregates: Ethnocultural Considerations  African Americans, Hispanics, and Native Americans—increased risk for substance abuse. ➢ ➢ ➢ ➢ ➢ ➢  Economically disenfranchised groups Discrimination and racism Socioeconomic, political, and historical realities Myths and stereotypes Social support—positive effect on treatment/outcome Environmental cues and conditioned reinforcement Treatment poses special challenges. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 39 Vulnerable Aggregates: Other Aggregates  Substance abuse is most common psychopathological problem in the general population. ➢ ➢ ➢ ➢ Dual-diagnosis individuals • Psychiatric disorder + substance abuse disorder Risk for multiple vulnerabilities in one individual Impact of substance abuse on STDs Substance abuse among health care professionals Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 40 Nursing Interventions in the Community       Understand own experiences and prejudices. Routinely assess substance use patterns when performing client histories. Be alert to environmental cues in the home that indicate substance abuse. Increase the individual’s and family’s awareness of the problem. Involve the social network in getting the client into treatment. Develop a caring nursing relationship. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 41 Other Traditional Nursing Roles and Interventions      Health teaching regarding addictive illness and addictive effects of different substances Advocating that EBP treatment works in special populations through problem-solving courts (drug courts), specialized adolescent treatment, and other community case management programs. Providing direct care for abuse- and dependencerelated medical problems Educating clients and families about problems related to substance abuse Collaborating with other disciplines to ensure continuity of care Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 42 Other Traditional Nursing Roles and Interventions (Cont.)     Coordinating health care services for the client to prevent prescription drug abuse and avoid fragmentation of care Providing consultation to nonmedical professionals and lay personnel Facilitating care through appropriate referrals and follow-up Knowing how to use community resources for working with substance abuse, mental health, and other issues Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 43
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