CH-19 Substance Use and Addictive Disorders – Varcaroliss Canadian Psychiatric Mental Health Nursing : Chapter Notes

Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 19: Substance Use and Addictive Disorders Instructor’s Manual Thoughts About Teaching the Topic Because most graduates deal with patients who use substances in the community and in the general hospital, and because of the risk within the profession as a whole, it is important to spend time on assessment strategies, including recognizing intoxication and impending withdrawal. The severe and disabling psychiatric and medical co-morbidities associated with substance use and addictions also make this a crucial topic for learners. Role-playing can help the learner gain both skill and empathy, so this teaching–learning strategy can be very helpful, particularly as it relates to assessment and intervention techniques. Discussion of motivational interviewing is useful for students in any setting. Learners should also be assisted to learn about resources available in the community to assist patients and families with substance abuse problems. It is highly advisable to arrange for student experience the stories of those in recovery as well as to observe or hear about the acute phases of treatment and recovery. If, however, only a few students can be given that opportunity, their experiences should be shared with the entire group during a conference or in class. There are many films and DVDs that can be helpful to teach students the process of addiction and recovery, such as 28 Days, Bill’s Story (the story of one of the co-founders of AA), and Ray (the story of Ray Charles) and many others. Having students view these films, or portions of them, concentrating on the rehabilitation methodologies and perspectives, can be valuable discussion topics for a class, clinical postconference, or workshop. Key Terms and Concepts abuse action phase addiction Al-Anon Alateen Alcoholics Anonymous (AA) alcohol poisoning alcohol withdrawal alcohol withdrawal delirium blood alcohol level (BAL) codependence concurrent disorder contemplation phase dependency enabling maintenance phase misuse motivational interviewing precontemplation phase preparation phase relapse substance abuse intervention therapeutic communities tolerance Transtheoretical Model of Change withdrawal Objectives Compare and contrast the terms substance use, abuse, dependence, tolerance, and addiction. Discuss four components of the assessment process, including assessment of readiness for change, to be used with a person who is experiencing substance abuse or other addictions. Describe the difference between the behaviours of a person with alcoholism and a nondrinker in relation to blood alcohol level. Discuss the symptoms of alcohol withdrawal and alcohol delirium and the recommended treatments for each. Describe the signs of alcohol poisoning and the appropriate treatment based on the individual’s presentation. List the appropriate steps to take if a co-worker is impaired. Recognize signs of substance abuse or impaired practice in colleagues. Compare and contrast the signs and symptoms of intoxication, overdose, and withdrawal for cocaine and amphetamines. Distinguish between the symptoms of opioid intoxication and those of opioid withdrawal. Identify two short-term goals for a person who abuses alcohol in terms of (a) withdrawal, (b) active treatment, and (c) health maintenance. Analyze the pros and cons of the following treatments for opioid addictions: methadone, therapeutic communities, and abstinence-oriented self-help programs. Explore the principles and practices of motivational interviewing as an evidence-informed intervention and an approach to communication for recovery. Recognize the phenomenon of relapse as it affects people who abuse substances during different phases of treatment. Evaluate four indications that a person is successfully recovering from substance abuse. Chapter Outline Teaching Strategies Clinical Picture The diagnosis of a substance-related disorder or behavioural addiction requires knowledge of the class of drug use, specific behaviours and patterns of use, and the severity of symptoms (considered mild, moderate, or severe), which may include tolerance and withdrawal. Cox and Leyton (2009) identified that the progression of addiction reflects a continuum, ranging from no use to experiences of dependency, addiction, and recovery. At the dependency stage, the person has lost the ability to choose to use or not to use. Using substances or engaging in behaviour such as gambling, gaming, shopping, or having casual sexual activity has become a way of life. The person may experience physical or psychological withdrawal, cravings for the substance of abuse, and decreased physical, mental, and emotional health. The person now has an addiction—the persistent, compulsive dependence on or use of a substance or behaviour despite its negative consequences and the increasing frequency of those consequences. With regular use of a substance or behaviour, a person develops tolerance. Tolerance is a physiological experience that occurs when a person’s reaction to a substance decreases with repeated administrations of the same dose. At this point, if the person attempts to stop using the substance or engaging in the behaviour, he or she may experience symptoms of withdrawal. Withdrawal causes physiological changes as the blood and tissue concentrations of a drug decrease after heavy and prolonged use of a substance. Other phenomena frequently encountered by those who abuse substances are flashbacks, synergistic effects, and antagonistic effects. Tolerance and Withdrawal Tolerance is the need for higher and higher doses of substances to achieve the desired effect. Withdrawal involves physiological and psychological signs and symptoms associated with stopping or reducing use of substances. Flashbacks Flashbacks are the transitory recurrences of perceptual disturbance reminiscent of disturbances experienced in earlier hallucinogenic intoxication. Synergistic Effects Synergistic effects refer to the intensification or prolongation of the effect of two or more drugs occurring when they are taken together (e.g., alcohol and a benzodiazepine). Antagonistic Effects Antagonistic effects refer to weakening or inhibiting the effect of one drug by using another (e.g., using cocaine and heroin together; using naloxone (Narcan), a narcotic antagonist, to treat opiate overdose). Codependence Codependence is a cluster of behaviours that prevents one individual from taking care of his or her own needs because of preoccupation with another who is addicted to a substance. Epidemiology A 2011 study found that 78% of Canadians over 15 years use alcohol regularly. The same study found that 14.4% of Canadians aged 15 years and older report drinking to excess, with 10.1% who exceeded the quantity to be considered an acute health risk (e.g., alcohol poisoning). The rate of drug use by youth 15 to 24 years of age remains much higher than that reported by adults 25 years and older: three times higher for cannabis use (21.6% versus 6.7%), and nearly five times higher for other drugs (4.8% versus 1.1%). Binge drinking among Canadian men is ranked as the highest in the world. Alcohol dependence is highest in men, young people, those selfidentifying as Caucasian, those from Aboriginal communities, those with low incomes, and those who are unmarried. Co-Morbidity Psychiatric CoMorbidity The combination of both substance abuse or behavioural addiction and a mental health condition known as concurrent disorder or, interchangeably, dual diagnosis is considered “so common, dual diagnosis should be expected rather than considered the exception” (Minkoff, 2001, p. 597). Alcohol dependence is associated with abuse of other substances, mood and anxiety disorders, and paranoid, histrionic, and antisocial personality disorders. Antisocial personality disorders are associated with drug use. Other examples of common concurrent disorders include major depression with cocaine abuse, alcoholism with generalized anxiety disorder, alcoholism and polydrug abuse with schizophrenia, and borderline personality disorder with episodic polydrug abuse. Drug dependence is significantly associated with generalized anxiety disorders and mood disorders. While the exact incidence and prevalence of concurrent disorders in Canada are not clear, the poor clinical and social outcomes have been described. Patients with concurrent disorders often experience more severe and chronic medical, social, and emotional problems. Medical Co-Morbidity Alcohol can affect all organ systems, but problems often seen involve the CNS (Wernicke’s encephalopathy and Korsakoff’s psychosis) and the GI system (esophagitis, gastritis, pancreatitis, hepatitis, cirrhosis). Cocaine abusers may experience malnutrition, myocardial infarction, and stroke. IV drug users have a higher incidence of HIV, TB, STDs, abscesses, and bacterial endocarditis. Smoking a substance increases the incidence of respiratory problems, and intranasal use predisposes to sinusitis and perforated nasal septum. Etiology Addiction study incorporates the concepts of loss of control of substance ingestion, using drugs despite associated problems, and a tendency to relapse. Biological Factors Children of alcoholic parents are more likely to develop alcoholism than are children of nonalcoholic parents. Both alcohol use and drug use have recently been demonstrated to affect selected neurotransmitter systems. Alcohol and certain other drugs act on the GABA system; cocaine use is associated with deficiency in dopamine and norepinephrine. Psychological Factors The following are associated psychodynamic factors: intolerance for frustration and pain, lack of success in life, lack of affectionate and meaningful relationships, low self-esteem, and risk-taking propensity. A person uses substances to feel better, and over time this habitual behaviour develops into an addiction. Sociocultural Factors There are differences in the incidence of substance abuse in various groups. In Asian Canadian cultures, the prevalence rate of alcoholism is relatively low, due in part to a common physiological inability in this population to break down acetaldehyde, an intermediate in alcohol metabolism, which produces unpleasant symptoms. Gender differences regarding substance use and addiction are notable. Internationally, women, in general, are diagnosed with substance use at lower rates than men. Another theory correlates substance use with the degree of socioeconomic stress experienced by individuals. Application of the Nursing Process Assessment Assessment is complex because of polydrug use, dual diagnosis, and co-morbid physical illness. General Assessment The nurse should ask questions about what is being taken (prescribed; over-the-counter; social drugs—caffeine, nicotine, alcohol, other drugs), amount, length of use, route, and drug preference. Questions should be asked in a matter-of-fact and nonjudgemental way: What drugs did you take before coming to the hospital? How did you take the drugs (route)? How much did you take? (For ethanol, ask about beer, wine, and liquor individually.) When was the last dose(s) taken? How long have you been using substances? When did this episode start? How often and how many do you use? What problems has substance use caused for you? Your family? Friends? Job? Health? Finances? The law? How a person responds is significant for assessment purposes: rationalizations merit further assessment. Some will answer guardedly, being careful of what is said. Some will answer with hopelessness about being able to attain a drug-free state. Physical indicators of substance abuse should be assessed, including dilated or constricted pupils, abnormal vital signs, needle marks, tremors, and alcohol on the breath. The nurse should also take a history from family and friends and check belongings for drug paraphernalia. There is a significant link between ethanol consumption and injury. Check neurological signs, especially with comatose patients. Urine toxicology and bronchoalveolar lavage (BAL) are useful. Be alert for co-morbid psychiatric impairment. Psychological Changes Psychological characteristics associated with substance abuse include denial, depression, anxiety, dependency, hopelessness, low self-esteem, and various psychiatric disorders. Some people with psychiatric disorders self-medicate; for these people, the symptoms remain even after sobriety is achieved. On the other hand, psychological changes that occurred as a result of drinking resolve quickly. Substance-abusing people are concerned about being rejected by nurses; they may be anxious about recovering because to do so, they must give up the substance they think they need to survive, and because they are concerned about failing at recovery. These concerns prompt the addict to establish a predictable defensive style using denial, projection, and rationalization, and characteristic thought processes such as all-or-none thinking and selective attention, as well as behaviours that include conflict minimization, avoidance, passivity, and manipulation. Assessment of Acute Intoxication and Withdrawal Central Nervous System Depressants These include alcohol, benzodiazepines, barbiturates, and sedatives. Intoxication signs and symptoms include slurred speech; incoordination; ataxia; drowsiness; disinhibition of sexual and aggressive impulses; and impaired judgement, social and occupational functioning, attention, and memory. Withdrawal from alcohol and CNS depressants is associated with severe morbidity and mortality, unlike withdrawal from other drugs. Multiple drug and alcohol dependencies can result in simultaneous withdrawal syndromes that present a bizarre clinical picture and may pose problems for safe withdrawal. Alcohol Withdrawal Early signs (anxiety, anorexia, insomnia, and tremor) develop within a few hours after cessation or reduction of alcohol intake, peak after 24 to 48 hours, and then disappear unless the withdrawal progresses to alcohol withdrawal delirium. Other signs and symptoms include startling easily, “shaking inside,” vivid nightmares, illusions, confusion, fright, elevated pulse and BP, and grand mal seizures. The patient requires a kind, warm, supportive manner from the nurse; consistent and frequent orientation to time and place; and clarification of illusions. Alcohol Withdrawal Delirium This is a medical emergency with up to a 10% mortality rate. Delirium usually peaks after 2 to 3 days (48 to 72 hours) after cessation or reduction of intake and lasts 2 to 3 days. Features of withdrawal delirium include anxiety, insomnia, anorexia, delirium, autonomic hyperactivity (elevated pulse and BP, diaphoresis), disturbed sensorium (clouded consciousness, disorientation), perceptual disturbances (visual and tactile hallucinations), fluctuating levels of consciousness, paranoid delusions, agitation, and fever. Central Nervous System Stimulants These include amphetamines, cocaine, crack, caffeine, and nicotine. These stimulants accelerate normal body functioning. Common signs of abuse include pupil dilation, dryness of oronasal cavity, excessive motor activity, tachycardia, elevated BP, twitching, insomnia, anorexia, grandiosity, impaired judgement, paranoid thinking, hallucinations, hyperpyrexia, convulsions, and death. Dependence develops rapidly. Periods of “high” are followed by deep depression as the body tries to rebalance neurotransmitters. Cocaine and Crack Cocaine is a naturally occurring drug extracted from leaves of the coca bush. Crack is an alkalinized form of cocaine. Dependence develops rapidly. Cocaine is a schedule II substance. People who sniff cocaine develop deterioration of the nasal passages. Those who smoke the drug can incur lung damage, upper GI problems, and throat infections. IV users may experience endocarditis, heart attacks, angina, and needle-related infections such as hepatitis and HIV. Cocaine has both anesthetic and stimulant effects. As an anesthetic, it blocks conduction of electrical impulses within nerve cells that transmit pain impulses. As a stimulant, it produces sexual arousal and violent behaviour. It produces an imbalance of dopamine and norepinephrine that may be responsible for many of the physical withdrawal symptoms: depression, paranoia, lethargy, anxiety, insomnia, nausea and vomiting, sweating, and chills. Nicotine and Caffeine Nicotine can act as a stimulant, depressant, or tranquilizer. It is addicting. Bupropion (Wellbutrin, Zyban) has been a successful treatment for nicotine withdrawal. Caffeine is a stimulant ingested daily by many in coffee, tea, and cola drinks. Opiates Opiates include opium, morphine, heroin, codeine, and fentanyl (Abstral) and its analogs, methadone (Metadol) and meperidine (Demerol). Signs of intoxication include constricted pupils, decreased respiration and BP, drowsiness, slurred speech, psychomotor retardation, euphoria or dysphoria, and impaired attention, memory, and judgement. Overdose causes respiratory depression, coma, convulsions, and death. Marijuana The active ingredient in marijuana is tetrahydrocannabinol (THC), which has mixed depressant and hallucinogenic properties. Effects include detachment, relaxation, euphoria, apathy, intensification of perceptions, impaired judgement, slowed perception of time, impaired memory, and heightened sensitivity to stimuli. Overdose may cause panic reactions. Dependence is associated with lethargy, anhedonia, difficulty concentrating, and memory impairment. Hallucinogens Hallucinogens alter mental state within a very short period of time. Lysergic Acid Diethylamide (LSD) and LSD-Like Drugs LSD, mescaline, and psilocybin produce a “trip” characterized by slowing of time, lightheadedness, images in intense colours, and visions in sound (synesthesia). A “bad trip” may produce severe anxiety, paranoia, and terror, compounded by distortions in time and distance. The best treatment for a bad trip is reassurance in a pleasant environment. Flashbacks—transitory recurrence of the drug experience—occur when a person is drug-free. Phencyclidine Piperidine (PCP) The route of administration of PCP plays a significant role in the severity of intoxication: symptoms appear within 1 hour of oral ingestion and within 5 minutes of IV use, sniffing, or smoking. PCP produces a blank stare, ataxia, muscle rigidity, vertical and horizontal nystagmus, and a tendency toward violence. High doses may lead to hyperthermia, chronic jerking of the extremities, hypertension, and kidney failure. Suicidal ideation should always be assessed, especially in cases of toxicity or coma. Long-term use can result in dulled thinking, lethargy, loss of impulse control, poor memory, and depression. Inhalants Inhalants are substances (paint, glue, cigarette lighter fluid, and propellant gases used in aerosols) that when sniffed result in intoxication. Club Drugs/Date Rape Drugs Drugs included in this category are ecstasy (3, 4- methylenedioxymethamphetamine [MDMA]) and ketamine. Ecstasy (“Adam,” “yabba,” “XTC,” “love,” or “Eve”) is a substitute amphetamine representing one of a distinct category of drugs labeled entactogens. These drugs produce euphoria, increased energy, increased self-confidence, increased sociability, and some psychedelic effects. Adverse effects include hyperthermia, rhabdomyolysis, acute renal failure, hepatotoxicity, cardiovascular collapse, depression, panic attacks, and psychosis. The drugs most frequently used to facilitate sexual assault are flunitrazepam (Rohypnol, or “roofies,” a fast-acting benzodiazepine) and GHB, because they produce rapid disinhibition and relaxation as well as retrograde amnesia. Alcohol potentiates the effects of these drugs. Assessment Guidelines: Chemically Impaired The assessment guidelines for chemically impaired patients include assessment of medical needs, psychological needs, family support Patients and education, and recovery motivation. Assessment of Readiness for Change Various scales and tools have been developed to assist in the assessment process. The Rhode Island Change Assessment Scale (URICA), one such tool, is designed to measure the stages of change across diverse problem behaviours. Some interventions, such as motivational interviewing—an approach that can assist clinicians in helping patients through the fluctuations between the various phases toward change (Miller & Rollnick, 2002)—have evolved from the Transtheoretical Model of Change, which was originally explained by Prochaska and DiClemente (1984). The Transtheoretical Model of Change theorizes that people pass through a series of stages toward making changes: (1) precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance. Self-Assessment Nurses’ responses to patients who use illicit substances sometimes include disapproval, intolerance, condemnation, and belief that the patient is morally weak. The manipulative behaviours sometimes used by these patients may lead the nurse to feel angry and exploited. In some areas, recreational use of drugs is so common that nurses may accept intoxication and overdose as normal phenomena. This causes the nurse to underestimate the amount of support and education the patient needs. Enabling (i.e., supporting or denying the patient’s physical or psychological substance dependence) is highly detrimental. Enabling behaviours include encouraging denial by agreeing that the patient drinks or takes drugs only socially, ignoring clues to possible dependency, demonstrating sympathy for a patient’s reasons for abusing substances, and preaching. Nurses must attend to personal feelings that arise when they work with drug abusers if they are to be therapeutic. Nurses and Addiction in the Workplace “Current estimates place rates of substance misuse, abuse, and addiction as high as 20% among practicing nurses” (Monroe & Kenaga, 2011, p. 504). The CNA Code of Ethics requires nurses to recognize when their own personal problems might interfere with their effectiveness and take action. The code requires nurses to recognize signs of substance abuse or impaired practice in colleagues and to report such behaviour to the nurse manager. Intervention is the responsibility of the nurse manager and other nursing administrators. Clear documentation by co-workers (specific dates, times, events, consequences) is crucial. The nurse manager’s major concerns are with job performance and patient safety. If the nurse experiencing an addiction remains in the situation, and no action is taken by the nurse manager, then co-workers must take the information to the next level in the management structure or look to the provincial or territorial regulatory body for consultation and guidance. Diagnosis The list of potential diagnoses includes, but is not limited to: Anxiety, Ineffective coping, Ineffective health maintenance, Risk for injury, Impaired verbal communication, Disturbed sensory perception, Hopelessness, Risk for infection, Impaired parenting, Ineffective breathing pattern, Sexual dysfunction, Disturbed sleep pattern, Impaired social interaction, Disturbed thought processes, Risk for self-directed violence, Risk for other-directed violence, Interrupted family processes, Self-care deficit, Imbalanced nutrition: less than body requirements, Powerlessness, Chronic low selfesteem, Spiritual distress, Impaired skin integrity. Table 19-8 Outcomes Identification Withdrawal Example: Remains free from injury while withdrawing; evidence of stable condition within 72 hours. Initial and Active Drug Treatment Examples: Maintains abstinence from chemical substances, demonstrates acceptance for own behaviour at end of 3 months, continues attendance for treatment and maintenance of sobriety, attends a relapse prevention program during active course of treatment, states he or she has a stable group of drug-free friends with whom to socialize at least three times weekly, and similar goals. Health Maintenance Example: Demonstrates responsibility for taking care of health care needs, as evidenced by keeping appointments and adhering to medication and treatment schedules; patient medical tests will demonstrate after 6 months a reduced incidence of medical complications related to substance abuse. Planning Abstinence is the safest treatment goal for all addicts. Planning must address major psychological, social, and medical problems in addition to the substance-abusing behaviour. Lack of interpersonal and social supports and even lack of ability to meet basic needs for shelter, food, and clothing may complicate planning. Implementation Aim of treatment is toward self-responsibility, not compliance. Choice of program is often influenced by cost and health insurance coverage. Outpatient programs work best for employed substance abusers who have an involved support system. People without support and structure do better in inpatient programs. Substance Abuse Interventions Commonly referred to as an intervention. In an intervention, significant others arrange to meet with the person experiencing an addiction to point out current problems and offer treatment alternatives. The concept behind this approach is that addiction is a progressive illness and rarely goes into remission without outside help. The steps or elements of an intervention are outlined in Box 19-3. Motivational Interviewing Miller and Rollnick (2002) established eight steps to the motivational interviewing process: establishing rapport, setting the agenda, assessing readiness to change, sharpening focus, identifying ambivalence, eliciting self-motivating statements, handling resistance, and shifting focus and transition (see Box 19-4). Psychopharmacological Interventions The predominant therapies are intended to support detoxification or to alter drug use. Alcohol Withdrawal Treatment Not all people who stop drinking require management of withdrawal. Medication should not be given until symptoms of withdrawal are seen. Early symptoms are tremors, diaphoresis, rapid pulse, elevated BP, and occasional tactile or visual hallucinations. Interventions include medication as needed for management of withdrawal symptoms (using cross-dependent sedatives), monitoring vital signs, administration of thiamine to prevent Wernicke’s syndrome, correction of hypomagnesemia, and maintaining fluid and electrolyte balance while avoiding overhydration. Anticonvulsants such as diazepam (Valium) or phenobarbital may be used on a short-term basis to control seizures. Phenytoin is used only if the person has a history of primary seizure disorder. Treatment of Alcoholism Naltrexone (Trexan, ReVia) This agent, used for opioid addiction, is sometimes used in the treatment of alcoholism, especially for those with intense cravings and somatic symptoms. Topiramate (Topamax) This works to decrease alcohol cravings by inhibiting the release of mesocorticolimbic dopamine, which has been associated with alcohol craving (Wellbery, 2008). Treatment of Opioid Addiction Methadone (Metadol) This drug is a synthetic opiate. In a sufficient dosage taken daily, it blocks craving for and effects of heroin. Methadone maintenance helps keep the patient out of the illegal drug culture while counselling is undertaken. Methadone is highly addicting and, when stopped, produces withdrawal. Because it is an oral drug, it reduces risk of HIV infection from needles. Methadone is the only medication currently approved for the treatment of pregnant women with an opioid addiction but is not a first line of treatment for adolescents. Naltrexone (Trexan, ReVia) This blocks the euphoric effects of opioids. It has few adverse effects and low toxicity. Clonidine (Catapres) This drug is a nonopioid suppressor of opioid withdrawal symptoms and when combined with naltrexone is an effective nonaddicting treatment for opioid addiction. Buprenorphine (Suboxone) This drug is a partial opioid agonist. At low doses, it blocks signs and symptoms of opioid withdrawal. Early studies suggest it suppresses heroin use. Treatment of Nicotine Addiction A nicotine patch provides transdermal doses of nicotine and has been shown to double long-term abstinence rates. Anti-nicotine vaccines are being developed and tested and show promise in the treatment of nicotine addiction. Primary Prevention In terms of substance use and addiction prevention, primary approaches are those efforts focused on reducing the demand for a substance or behaviour, as well as stopping the occurrence of alcohol or drug use or abuse and addictive behaviours (Rassool, 2010). Examples include implementing healthy public policy; offering health education related to addiction; taxing and labelling products (e.g., cigarettes, alcohol); and promoting educational campaigns (e.g., addiction and mental health in the workplace). Secondary Prevention Secondary prevention seeks to limit further health deterioration and social harm from the use, abuse, dependence, and addiction to substances and behaviours. Examples include programs of early recognition, awareness campaigns, relapse prevention, community support, harm reduction approaches, and strategies for safe prescribing guidelines (Rassool, 2010). Tertiary Prevention Tertiary prevention is concerned with limiting and reducing complications and dysfunction related to the experience of substance or behavioural abuse and addiction. Effective care, treatment, and rehabilitation programs and services are characteristic of tertiary prevention approaches (Rassool, 2010). Specialized addiction detoxification programs, recovery programs, and concurrent disorder programs are examples of tertiary-level services. Advanced-Practice Interventions Psychotherapy Evidence-informed practice indicates that cognitive-behavioural therapy, psychodynamic and interpersonal therapies, group and family therapies, and participation in self-help groups are all effective treatment modalities. Critical issues that arise within the first 6 months of therapy include physical changes as the body adapts to functioning without the substance, needing to learn new responses to former cues to drink or use drugs, experiencing fullstrength emotions instead of drug-mediated emotions, need to address family and co-worker responses to a patient’s new behaviour, and need to develop coping skills to prevent relapse and ensure prolonged sobriety. Evaluation Effectiveness of treatment is judged by increasing lengths of time of abstinence, decreased denial, acceptable occupational functioning, improved family relationships, the patient’s ability to relate normally and comfortably with others without using drugs or alcohol, and the ability to use existing supports and skills used in treatment. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. 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