cHaP 19 AdDiCtiOn

Question 1

Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction?
a. methadone (Dolophine)
b. bromocriptine (Parlodel)
c. disulfiram (Antabuse)
d. naltrexone (Revia)

Answer 1

ANS: D
Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids; because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving.

Question 2

A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
a. Check the patient every 15 minutes.
b. Rigorously encourage fluid intake.
c. Provide one-on-one supervision.
d. Keep the room dimly lit.

Answer 2

ANS: C
One-on-one supervision is necessary to promote physical safety until sedation reduces the patientÕs feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.

Question 3

A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for:
a. slurred speech, excessive drowsiness, and bradycardia
b. paranoid delusions, tactile hallucinations, and panic
c. runny nose, yawning, insomnia, and chills
d. anxiety, agitation, and aggression

Answer 3

ANS: C
Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illness, minus the temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use.

Question 4

A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is:
a. jaundiced
b. dependent on alcohol
c. healthy but underweight
d. microcephalic and cognitively impaired

Answer 4

ANS: D
Fetal alcohol syndrome is the result of alcoholÕs inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distracters.

Question 5

Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient:
a. rarely drinks alcohol.
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
d. has recently ingested both alcohol and sedative drugs

Answer 5

ANS: B
A non tolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between
blood alcohol level and expected behavior. It strongly suggests that the patientÕs body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs

Question 6

Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?
a. Make physical contact by frequently touching the patient.
b. Offer intellectual activities requiring concentration.
c. Avoid manipulation by denying the patient’s requests.
d. Observe for depression and suicidal ideation.

Answer 6

ANS: D
Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice

Question 7

An adult in the emergency department states, ÒI feel restless. Everything I look at wavers. Sometimes IÕm outside my body looking at myself. I hear colors. I think IÕm losing my mind.Ó Vital signs are slightly elevated. The nurse should suspect a(n):
a. schizophrenic episode
b. cocaine overdose
c. phencyclidine (PCP) intoxicationd. D-lysergic acid diethylamide (LSD) ingestion

Answer 7

ANS: D
The patient who has ingested LSD often experiences synesthesia (visions in sound), depersonalization, and concerns about going Òcrazy.Ó Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. PCP use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements

Question 8

A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe?
a. Monoamine oxidase inhibitor, such as phenelzine (Nardil)
b. Phenothiazine, such as thioridazine (Mellaril)
c. Benzodiazepine, such as lorazepam (Ativan)
d. Narcotic analgesic, such as morphine

Answer 8

ANS: C
Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

Question 9

A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
a. Substance abuse
b. Substance intoxication
c. Substance dependence
d. Recreational use of a social drug

Answer 9

ANS: C
Nicotine meets the criteria for a substance, the criterion for dependence (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug

Question 10

Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed?
a. One-week detoxification program
b. Long-term outpatient therapy
c. Twelve-step self-help program
d. Residential program

Answer 10

ANS: D
Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies.

Question 11

Which documentation indicates that the treatment plan for a patient in an alcohol rehabilitation program was effective?
a. Is abstinent for 10 days and states, ÒI can maintain sobriety 1 day at a time.Ó Spoke with employer, who is willing to allow the patient to return to work in 3 weeks.
b. Is abstinent for 15 days and states, ÒMy problems are under control.Ó Plans to seek a new job where co-workers will not know history.
c. Attends AA daily; states many of the members are ÒrealÓ alcoholics and states, ÒI may be able to help some of them find jobs at my company.Ó
d. Is abstinent for 21 days and says, ÒI know I canÕt handle more than one or two drinks in a social setting.Ó

Answer 11

ANS: A
The answer reflects the AA beliefs. The incorrect options each contain a statement that suggests early relapse.

Question 12

A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, ÒBugs are crawling on my bed. IÕve got to get out of here.Ó What is the most accurate assessment of the situation? The patient:
a. is attempting to obtain attention by manipulating staff.
b. may have sustained a head injury before admission.
c. has symptoms of alcohol withdrawal delirium.
d. is having a recurrence of an acute psychosis.

Answer 12

ANS: C
Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis

Question 13

A patient comes to an outpatient appointment obviously intoxicated. The nurse should:
a. explore the patientÕs reasons for drinking today.
b. arrange admission to an inpatient psychiatric unit.
c. coordinate emergency admission to a detoxification unit.
d. tell the patient, ÒWe cannot see you today because youÕve been drinking.Ó

Answer 13

ANS: D
One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment.

Question 14

A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurseÕs first action?
a. Test reflexes
b. Check pupils
c. Initiate vomiting
d. Establish a patent airway

Answer 14

ANS: D
Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration.

Question 15

A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, ÒOften my friend drinks, along with taking more of the drug than is ordered.Ó What is the effect of the use of alcohol with this drug?
a. The drugÕs metabolism is stimulated.
b. The drugÕs effect is diminished.
c. A synergistic effect occurs.
d. There is no effect.

Answer 15

ANS: C
Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

Question 16

A new patient in an alcoholism rehabilitation program says, ÒIÕm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening.Ó Which response by the nurse will help the patient view the drinking more honestly?
a. ÒI see,Ó and use interested silence.
b. ÒI think you may be drinking more than you report.Ó
c. ÒBeing a social drinker involves having a drink or two once or twice a week.Ó
d. ÒYou describe drinking steadily throughout the day and evening. Am I correct?

Answer 16

ANS: D
The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment.

Question 17

A nurse with a history of narcotic dependence is found unconscious in the hospital locker room after overdosing. The nurse is transferred to the inpatient chemical dependence unit for care. Which attitudes or behaviors by nursing staff may be enabling?
a. Conveying understanding that pressures associated with nursing practice underlie substance use.
b. Pointing out that work problems are the result, but not the cause, of substance dependence.
c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing.
d. Providing health teaching about stress management

Answer 17

ANS: A
Enabling denies the seriousness of the patientÕs problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.

Question 18

When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect:
a. acrophobia
b. hypothermia
c. hallucinations
d. anterograde amnesia

Answer 18

ANS: D
Flunitrazepam is also known as the date rape drug; it produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug.

Question 19

Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in 1 year. Before discharge, the patient will
a. use rationalization in healthy ways.
b. state, ÒI see the need for ongoing treatment.Ó
c. identify constructive outlets for expression of anger.
d. develop a trusting relationship with one staff member.

Answer 19

ANS: B
The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety.

Question 20

A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck traction and screams, ÒSomebody tied me up with ropes.Ó The patient is experiencing:
a. illusion
b. delusion
c. hallucinations
d. hypnagogic phenomenon

Answer 20

ANS: A
The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.

Question 21

Which assessment findings will the nurse expect in an individual who has just injected heroin?
a. Anxiety, restlessness, paranoid delusions
b. Heightened sexuality, insomnia, euphoria
c. Muscle aching, dilated pupils, tachycardia
d. Drowsiness, constricted pupils, slurred speech

Answer 21

ANS: D
Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.

Question 22

Which assessment findings best correlate to the withdrawal from central nervous system depressants?a. Dilated pupils, tachycardia, elevated blood pressure, elation
b. Labile mood, lack of coordination, fever, drowsiness
c. Nausea, vomiting, diaphoresis, anxiety, tremors
d. Excessive eating, constipation, headache

Answer 22

ANS: C
The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible

Question 23

A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, ÒI feel terrible.Ó Which analysis is correct?
a. The patient is exhibiting a prodromal symptom of seizures.
b. An idiosyncratic reaction to naloxone is occurring.
c. Symptoms of opiate withdrawal are present.
d. The patient is experiencing a relapse.

Answer 23

ANS: C
The symptoms given in the question are consistent with narcotic withdrawal. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.

Question 24

A patient admitted to an alcoholism rehabilitation program says, ÒIÕm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening.Ó Which defense mechanism is evident?
a. Rationalization
b. Introjection
c. Projection
d. Denial

Answer 24

ANS: D
Minimizing oneÕs drinking is a form of denial of alcoholism. The patientÕs own description indicates that Òsocial drinkingÓ is not an accurate name for the behavior. Projection involves blaming another for oneÕs faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into oneÕs own system.

Question 25

When working with a patient beginning treatment for alcohol dependence, what is the nurseÕs most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distan

Answer 25

ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

Question 26

When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. The alcohol is less potent. b. Tolerance develops. c. Antagonistic effects occur. d. Hypomagnesemia develops.

Answer 26

ANS: B Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects would account for this change

Question 27

Which assessment findings support a nurseÕs suspicion that a patient has been using inhalants? a. Perforated nasal septum and hypertension b. Drowsiness, euphoria, and constipation c. Pinpoint pupils and respiratory rate of 12 breaths per minute d. Confusion, mouth ulcers, and ataxia

Answer 27

ANS: D Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant. The incorrect options relate to cocaine snorting and opioid use.

Question 28

A patient in an alcohol rehabilitation program says, ÒI have been a loser all my life. IÕm so ashamed of what I have put my family through. Now, IÕm not even sure I can succeed at staying sober.Ó Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance

Answer 28

ANS: A Low self-esteem is present when a patient sees him- or herself as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options

Question 29

Which statement most accurately describes substance dependence? a. It is a lack of control over use. Tolerance and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the work of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves taking a combination of substances to weaken or inhibit the effect of another drug

Answer 29

ANS: A Psychoactive substance dependence involves a lack of control over use, as well as tolerance and withdrawal symptoms when intake is reduced or stopped.

Question 30

A patient asks for information about Alcoholics Anonymous (AA). Which is the nurseÕs best response? a. ÒIt is a self-help group with the goal of sobriety.Ó b. ÒIt is a form of group therapy led by a psychiatrist.Ó c. ÒIt is a group that learns about drinking from a group leader.Ó d. ÒIt is a network that advocates strong punishment for drunk drivers.Ó

Answer 30

ANS: A AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed

Question 31

An alcohol-dependent individual says, ÒDrinking helps me cope with being a single parent.Ó Which response by the nurse would help the individual conceptualize the drinking more objectively? a. ÒSooner or later, alcohol will kill you. Then what will happen to your children?Ó b. ÒI hear a lot of defensiveness in your voice. Do you really believe this?Ó c. ÒIf you were coping so well, why were d. ÒTell me what happened the last time you drank.Ó

Answer 31

ANS: D The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurseÕs frustration with the patient.

Question 32

Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. ÒHave you ever had blackouts?Ó b. ÒWhen did you have your last drink?Ó c. ÒHas drinking caused you any problems?Ó d. ÒWhen did you decide to seek treatment?Ó

Answer 32

ANS: B Learning when the patient had the last drink is essential to knowing when to begin to observe for symptoms of withdrawal. The other questions are relevant but of lower priority

Question 33

During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, ÒAfter discharge, IÕm sure everything will be just fine.Ó Which remark by the nurse will be most helpful to the spouse? a. ÒIt is good that youÕre supportive of your spouseÕs sobriety and want to help maintain it.Ó b. ÒAlthough sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol.Ó c. ÒIt will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection.Ó d. ÒRemember that alcoholism is a disease of self-destruction. You will need to observe your spouseÕs behavior carefully.Ó

Answer 33

ANS: B During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information.

Question 34

Which nursing diagnosis would likely apply to both patients with paranoid schizophrenia and patients with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane

Answer 34

ANS: B Both types of patients commonly experience paranoid delusions; thus the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.

Question 35

In the emergency department, a patientÕs vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.

Answer 35

ANS: A Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patientÕs physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distracters are desired outcomes later in the plan of care.

Question 36

In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.

Answer 36

ANS: A Patients who have ingested LSD respond well to being Òtalked downÓ by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs.

Question 37

A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurseÕs drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as the medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers

Answer 37

ANS: B The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers and seeks access to medications. Usually, the personÕs appearance will deteriorate, and he or she will blame errors on others

Question 38

A patient admitted yesterday for injuries sustained in a fall while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Ineffective airway clearance b. Ineffective coping c. Ineffective denial d. Risk for injury

Answer 38

ANS: D The clouded sensorium, sensory perceptual distortions, and poor judgment increase the risk for injury. Safety is the nurseÕs priority. The scenario does not provide data to support the other diagnoses.

Question 39

An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)

Answer 39

ANS: B Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium

Question 41

Select the nursing intervention necessary after administering naloxone (Narcan) to a patient with an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.

Answer 41

ANS: A Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer span of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use.

Question 42

The treatment team plans care for a person diagnosed with paranoid schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each diagnosis primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the symptoms of schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.

Answer 42

ANS: A Dual diagnoses clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.