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The abuse of illegal and prescription drugs in the United States is a rapidly growing epidemic. Even though Americans make up a very small percentage of the world's population, as of 2009 we are reported to consume nearly all of the world's supply of hydrocodone and nearly all of the world's supply of legal and illegal opiates from Percocet to heroin. .
The problem of drug use reaches as far back as the ancient Roman world, when the opium poppy was used for a variety of medicinal, recreational and magical properties (Trancas, Borja-Santos, & Patricio, 2009). Many different addictive substances have been used through the ages, many once portrayed as available to and used only by the very wealthy. In the modern world, the abuse of drugs is less than glamorized.
Because drug abuse issues can be present in nearly all community and healthcare settings, it is exceedingly important that providers in all areas are able to screen patients for drug use, assess the potential health consequences of drug use and treat the consequences of abuse and withdrawal (the abrupt cessation of an addictive substance). In terms of cost, there has been reported an increased health care burden of more than $13,000 per patient between drug users and non-users in terms of both treating health consequences and costs of incarceration for drug-related crimes .
It is hypothesized that because there are so many different types of abusable substances with varying consequences, it can be difficult to assess those consequences in order to intervene appropriately. Additionally, there are different schools of thought regarding the mechanisms of addiction as well as different perspectives of addiction between disciplines such as psychology and medicine, making it challenging to define, assess and treat the problem consistently.
This paper will present a critical review of the literature on drug abuse from different perspectives including how the problem is defined across the disciplines of nursing, medicine, and psychology. The importance and implications of drug abuse will be explored for the discipline of nursing. Assumptions, limitations and biases of each perspective will be discussed. The scope of the problem will be expanded to further define the problem using standardized terminology among each discipline.
Additionally, the critical review of the literature will analyze the problem of drug abuse as well as the health-related consequences of abuse. This critical review will include a historical perspective of drug abuse to further define the origins of the problem. Drug abuse will be defined through the lens of the neurobiochemical theory of addiction and the behavioral theory of addiction. Drug abuse has been discussed in the literature using terminology ranging from "misuse" to "abuse" to "addiction". These concepts, when used to describe dependence to a substance, have been used interchangeably throughout the literature. Concepts such as tolerance, dependence, and addiction will be defined. Finally, based on the analysis of the literature, conclusions will be drawn about research implications for the phenomenon of drug abuse. Two pilot research studies will be proposed at the conclusion of this work about further work to analyze the problem.
This paper will include a review of potentially abusable prescription drugs, opiate drugs and cocaine. It will not include alcohol or tobacco as an addictive substances but it should be recognized that alcohol is the most highly abused substance in the United States, and when alcohol is combined with other drugs can produce especially negative consequences.
Review of the Literature
Drug Abuse from a Historical Perspective
Before discussing the relevant literature from the perspective of different disciplines, it is important to gain an understanding of the roots of drug abuse from a historical perspective and how it became a problem. Using the EBSCO History Reference Center database and searching for the keywords "drug abuse" yields an extensive database of encyclopedia-type literature on the history of drug abuse across the world. Each drug is discussed individually in terms of its origins and patterns of use abuse over time.
The earliest documented record of the use of addictive substances was by the Egyptians in 4000 B.C. Marijuana has been documented to be present in China as early as 2737 B.C. Following this there was an extensive period of time during which new drug discoveries were made- cocaine, morphine and opium were used freely by physicians and nurses to treat ailments from coughs to infection. By the time of the American Civil War, wounded vets were given copious amounts of morphine that was dispensed freely and shared among many. It has been documented that by the early 1900's there were more than 250,000 people addicted to morphine.
Drugs became formally illegal in the United States in 1875 when opium was outlawed in California (San Francisco had many of the country's opium dens). By 1906 it was required by law for all medications containing opium to be properly labeled warning the users of the addictive nature of the drug. In 1914 the Harrison Act made morphine and other opiates available only by physician's prescription, and shortly thereafter banned heroin completely. The use of narcotics and especially cocaine decreased significantly around the time of prohibition in the 1920's. By the time prohibition was repealed in 1933, cocaine abuse was again on the rise. .
Drug addiction and drug abuse. Columbia Electronic Encyclopedia, 6th EditionThe dramatic social change in the 1960's led to a substantial increase in drugs such as marijuana, LSD and amphetamines. By the 1980's, those drugs were on the decline but cocaine and crack cocaine were on the rise. Around this time, the United States military began patrolling US borders for the first time. Since the 1980's, the rise in street gangs and criminalization have given way to an ever-increasing presence of illegal drugs. In most recent years, abuse of prescription drugs has been on a staggering increase across the country. .
Types of Drugs and Their Effects
Numerous studies have been published in the literature on potentially addictive substances and their immediate and long-term effects. These studies have been conducted with a variety of populations, most notably with adolescents. For example, a 2005 national survey of adolescents that reported 9.3% of the 12 to 17 year old adolescents in the study reported abusing prescription drugs. Of those, nearly 60% abused illegal drugs as well and 75% reported consuming alcohol as well . Aside from adolescents, drug abuse prevalence has been documented in literature on adults, the incarcerated, pregnant women, and even the elderly. Table 1 presents a synthesis of studies describing the prevalence of drug abuse among a variety of populations.
Opiates, otherwise known as narcotics, include the drugs heroin, morphine, codeine, oxycontin, hydrocodone and others. All opiates are considered dispensable only by prescription in the United States with the exception of heroin which is illegal in all circumstances. Opiates exert their effects by activating pleasure centers in the brain. The neurobiochemical model of addiction suggests that over time, the brain's chemistry changes so that it yearns for the substance when it is not there (this model will be discussed at length to follow). Opiates can cause sedation, respiratory depression related consequences, and overdose death. Abrupt cessation of opiates once addicted can cause profound gastrointestinal effects such as diarrhea and vomiting, dehydration, hyperthermia and tachycardia. There are no direct fatal consequences of opiate withdrawal, although symptoms such as dehydration may indirectly lead to fatality as a consequence. .
Prescription drugs may have potentially addictive properties. The problem of prescription drug misuse is a relatively recently discussed phenomenon. The rate of prescription drug use is growing at a faster rate than illegal drug use- over a ten year period between 1992 and 2003, the number of people in America abusing prescription drugs increased by 81%. (Manchikanti, et al., 2008). Central nervous system depressants such as benzodiazepines (Valium, for example) and barbiturates (such as Phenobarbital) are known to have addictive properties because of the sedating effects on the brain. These drugs often cause a feeling of euphoria for the user and when stopped abruptly can cause serious health effects such as seizures (Doweiko, 2009). Over-the-counter drugs such as diet pills, sleep aids and cold medicines have been abused as well.
Cocaine is a neurotoxic substance derived from the coca plant that was found by field workers hundreds of years ago to alleviate symptoms of tiredness and hunger and allowing the workers to work stronger and harder if they chewed on the leaves. Over time, more sophisticated means of using the drug were developed, such as smoking or snorting a powdered formulation of the drug. Cocaine causes permanent damage to the vascular system because of its constrictive effects. Cocaine causes marked vasoconstriction and is attributed to 40-50% of the heart attack deaths and at least some of the increased incidence of asthma deaths in recent years related to illicit drugs . Table 2 presents a review of studies that have explored the health consequences of drugs and the health consequences of abrupt cessation (withdrawal) from drugs across different populations in different settings.
It can be noted from tables 1 and 2 that there is no lack of studies in the literature on the prevalence and consequences of drug use. The assumption can be made that drug abuse is a problem in the United States and that there is no clear end in sight to the problem. Through a historical review of how the problem began to current literature on the prevalence of the problem in modern times, it is clear that the challenge of drug abuse and addiction persists and will continue to persist.
Concepts of Addiction
Drug addiction and drug abuse. Columbia Electronic Encyclopedia, 6th EditionDrug addiction and drug abuse. Columbia Electronic Encyclopedia, 6th EditionBefore beginning to discuss the vast implications of drug abuse, it is important to understand several concepts of addiction. It is important to have a good understanding of the levels of the addiction process in order to critique the literature for appropriateness when defining the problem. According to Doweiko and his book Concepts of Chemical Dependency, the term addiction is more properly described as a dependence, which is defined in the text as "a primary, chronic disease with genetic, psychosocial and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control, preoccupation with the drug, use despite adverse consequences and distortion in thinking" (Doweiko, 2009).
According to Doweiko withdrawal (synonymous with detoxification) refers to a syndrome during abrupt cessation of an addictive substance, and when generally the opposite of the drug's effect occurs (Doweiko, 2009). For example, if a drug were to produce sedative effects during use, its withdrawal is likely to produce agitation, aggression and insomnia.
The neurobiochemical concept of addiction has the premise that one's likelihood to become addicted to a substance is biologically predetermined. It also purports that substances of abuse cause permanent chemical changes in the brain which lead to addiction and the symptoms experienced during use and withdrawal. For example, heroin (which is chemically related to morphine) is transformed into a potent morphine- like substance once taken into the body. However heroin, unlike morphine, is far more lipid-soluble and is able to cross the blood-brain barrier much more rapidly to exert its effects. There, it attaches to the dopamine receptors in the brain causing a rapid spilling of dopamine into the neurons and producing heroin's sense of euphoria. It is for this reason also that withdrawal from heroin, and the lack of activated dopaminergic receptors in the brain, causes one to crave and seek out more of the drug. Consequences of abuse and withdrawal of heroin include respiratory depression, seizures, cardiac arrhythmia, and death with even the first use. .
The behavioral, or psychosocial, concept of addiction conversely believes that there are no biologic or genetic factors that "automatically" make someone prone to addiction. The behavioral model largely contends that all behavior is learned, and that substance abuse behaviors and addiction are learned actions . For example, an adolescent may be exposed to drug and alcohol abuse by seeing their parents or friends use these substances. The fact that others around them are using makes them want to use as well. Likewise, others around them may coerce or convince them to use. The behavioral model of addiction is the underlying premise of anti-drug commercials and campaigns .
Relevance of Drug Abuse to Nursing
Illegal and addictive prescription drugs are widespread across the US and can cause serious implications on health. According to the National Institute on Drug Abuse at the National Institutes of Health, drug abuse can cause negative health outcomes ranging from infection to cardiovascular disease to overdose and death. Because the problem is so widespread and can cause potentially significant negative health outcomes, it is important for nurses in all settings to recognize actual and potential addiction among patients they encounter.
Because of its inclusion of research from nursing and allied health fields, the database CINAHL was used for the review of nursing literature on drug abuse. Searching with the keyword "drug abuse" for articles published within the ten years preceding this paper yielded 2,002 relevant articles. Eliminating periodicals and continuing education related articles diminished the group to 1,801. To make this exhaustive list more manageable, the search was limited to articles will full-text access resulting in 684 articles. Searching using the keywords "drug abuse and nursing" resulted in a yield of 40 articles, all of which were scanned via abstract review for inclusion in this review. Articles published on studies outside of the United States were critiqued for appropriateness and studies on tobacco and alcohol dependence were excluded.
The articles presented in the nursing literature have a strong emphasis on educating nurses to recognize signs and symptoms of drug abuse and addiction as well as how to appropriately assess, treat and monitor drug abusers, often times with concurrent medical problems.
A number of articles in the literature related specifically to nursing and substance abuse discuss the nursing curriculum as a means to educate nurses about substance abuse problems. Table 3 presents nursing curriculum strategies discussed in the literature. A review of the literature on nursing interventions and outcomes was sparse, however and are discussed more in the recommendations for future research.
Perspective of Drug Abuse: Psychology
The phenomenon of drug abuse certainly transcends a variety of disciplines, notable psychology and sociology although drug abuse studies have been found literature on the fields of economics and education as well. Using the keywords "drug abuse AND psychology AND NOT alcohol" yielded over two thousand articles. Limiting the search to those published within the past five years gives 1,910. Simply adding the term "addiction" following drug abuse in the keywords mentioned above limits the number of articles to a manageable 400. Each of these articles was skimmed briefly for title and abstract for inclusion in this review. Studies were chosen that addressed either screening for or treatment of drug abuse and addiction.
From this review it has been found that most literature in the psychology discipline addresses drug abuse assessment and treatment (both counseling and pharmacologic treatment) as well as the neurobiochemical brain changes that occur with abuse and addiction. There is some emphasis on the behavioral aspects of addiction, especially in the literature on counseling as a treatment strategy.
Table 4 shows selected psychology literature as it discusses substance abuse from the perspectives of neurobiochemical and behavioral models.
Research Implications for Drug Abuse: Blending Perspectives
For nursing, research implications on drug abuse and addiction are vast. Once again because of the shear availability of drugs in the United States and the significant prevalence of drug abuse as demonstrated in the prevalence studies in Table 1, drug abuse and its subsequent issues are far-reaching and have the potential to affect a myriad of populations and settings. Whether it is viewed from the perspective of nursing or from the psychology or sociology lens, each perspective lends itself to a different yet equally important aspect of the problem. Most certainly a combination of perspectives is beneficial to understanding the many facets of the phenomenon and undoubtedly the literature reviewed for this paper demonstrates marked overlap in how the problem is defined, assessed and studied.
The phenomenon of drug abuse does not "belong" to a single discipline. It is a global and serious problem with negative consequences on health, economics and public policy alike.
For future research on this phenomenon, an analysis of nursing-specific interventions and outcomes could be explored. There was a notable discussion of this in the literature reviewed for this paper. In addition, more and current prevalence studies are continually important in defining the problem and tracking trends over time.
Proposed Pilot Studies to Address This Phenomenon
To address this question, the following pilot study is proposed. Using the specific population of the jail inmates, the self-reported prevalence of drug use will be analyzed and nursing assessment protocols will be developed.
The study will involve newly incarcerated inmates at a large, urban jail in Milwaukee County and will explore the self-reported abuse of substances among inmates during the booking process. The current protocol in the facility is to ask for a self-report of drug abuse with a simple "yes/no" format. Specific questions about the type of drug used and last use are asked, but no additional information is obtained. All inmates who report drug use are placed on a nurse-driven withdrawal monitor for 72 hours, but not all inmates will withdraw or exhibit symptoms of withdrawal creating an inefficient process for the nursing staff and wasteful use of nursing time in some circumstances. The proposed study would investigate the prevalence of not only the type of drug used, but the amount, frequency, duration of use and withdrawal history. This information would be used to promote the development of a standardized nursing assessment which would target only those inmates at risk for withdrawal.
The theoretical framework for this study is Neuman's Systems Model. Neuman's Systems model describes an open system where the person and environment exist in a reciprocal relationship where the goal is for the person to maintain stability. External forces that Neuman calls "stressors" may act either negatively or positively on the person. Psychobiologic theories of addiction often discuss these external stressors in relation to drug abuse .
All inmates entering the jail will be considered for eligibility for this study. Inmates with serious mental illness (actively suicidal or psychotic) will be excluded since these syndromes may complicate the course of drug withdrawal and their ability to answer the study questions. Inmates will not be excluded on the basis of serious medical problems, learning impairments or mental illness such as depression and anxiety.
The data collector will request a list of all eligible inmates daily from the booking nurses and nursing supervisors. This convenience sample of inmates will be called out from their living area once housed from booking to a secure and confidential interview area, and be asked to participate. This will be done within 48 hours of their incarceration in order to screen for withdrawal symptoms as well. Those who are released before their interview will be given an informational packet upon release with information on drug treatment programs in the community. Those who are present at 48 hours will be offered information on the study and asked for their consent to participate. It will be made clear in the informed consent that all information shared is voluntary, and no special treatment/rewards will be given to participate. The participants will be informed that all information collected about drug use is kept strictly confidential and will only be used for purposes of this study.
Because using inmates as research subjects can be tricky, several ethical and procedural issues will be considered. Research involving inmates most certainly has an extensive list of ethical considerations. In his book Public Health Behind Bars (2010), Robert Griefinger discusses this important list of challenges with correctional health research.
First, steps must be taken to ensure that inmates who are asked to participate in research studies are given informed consent in a language they understand, the ability to ask questions about the research, and the assurance that they may remove themselves from the study at any time with no negative consequences. According to Griefinger, inmates should feel that they have as much of a right to participate (or not participate) in research as much as the general population. Secondly, inmates need to be assured that their information will not be shared with any other parties and that their health and criminal information is kept strictly confidential and used only for the purposes of the study. Lastly, it must be clear that there is no level of coercion involved whatsoever when involving inmates in research. What may not be perceived as coercion in the general population may differ among the incarcerated. For example, asking inmates to come out of their cells/living areas to participate in the study may be perceived by some to be "special treatment". Very careful considerations must be taken to ensure that the meeting place for interviews is both secure enough to ensure confidentiality, but also a common area (such as the nursing sick call rooms) so that there is little room for perception of special treatment. .
Descriptive statistics will be run on the data collected to determine if any outliers exist. Frequencies will be run on the items to explore prevalence. Finally, logistic regression will be used to determine whether or not the type of drug used, the amount, frequency, duration and past withdrawal predicts the outcome of withdrawal. If statistically significant, the data may be used to develop a targeted screening tool for use in booking that may better predict those who may experience negative health effects of drug use and withdrawal.
Alternatively, an additional interesting study would be to explore the historical trends of substance abuse over time compared to the nation's "war on drugs" effort and how government policy has correlated with drug abuse prevalence. This study would use a historical perspective to analyze trends in drug abuse prevalence using a large national database of reported drug use (such as the National Health Interview Survey, the largest health status database that has been collecting data on health since 1960) and compare it to trends in governmental initiatives to combat the "war on drugs", including public service announcements, policy changes and laws.
The problem of drug abuse certainly does not exist in a silo belonging only to a single discipline, single population or single setting. It is important not only for nurses but for psychologists, policy makers and the public to understand the problem of drug use, its historical roots and its consequences. Drug abuse has a long and interesting history that is important to recognize when discussing any type of modern research on the subject. The introduction of the phenomenon to school curriculum, possibly as early as the elementary school level, is crucial to increasing awareness of the problem. In addition, teaching substance abuse issues in nursing curricula is crucial for nurses who enter all practice settings, since the problem is so widespread and with no clear end in sight.
Drug abuse can have serious negative health consequences and the ability to recognize those who may be affected is critical in protecting their health and safety. No matter how it is described- abuse, misuse, dependence and addiction are all defined as an unhealthy use of a substance. There can certainly be no lack of opportunity for research on the subject of drug abuse.