Nursing Continuing Education

Substance Abuse and Addiction

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This is Your Course on Substance Abuse and Addiction

Syllabus

Introduction

Nurses face challenges when planning the of care for clients who suffer from substance use disorders. These may be clients whose primary care needs relates to their substance use or they may be clients who have sought care for another condition but for whom substance use is part of their life style. Therefore, there are a range of areas in which the nurse is likely to be involved in caring for clients with substance use disorders. The nurse needs to be aware of the range of substances that may be used by clients, how disorders may manifest themselves, and how the nurse can plan care for these clients.

Substance use disorders are related to alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants, tobacco, and other (or unknown) substances.

A substance use disorder involves repeated use of chemical substances, leading to clinically significant impairment during a 12‑month period. The term “substance use disorder” refers not only to chemical substances (as are commonly expected) but also applies to particular behaviors or activities that interfere with the client’s ability to function on a daily basis and which may also be associated with a level of social disapproval. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) “Addiction is the term used to describe the repeated involvement with a substance or activity despite the substantial harm it causes because that involvement was, and may continue to be, pleasurable and/or valuable”.  According to the DSM-5 for Substance Use Disorders there are four categories of behavior that characterize the aberrant behaviors related to abuse of a chemical substance. 

1.         Impaired Control - The loss of control over the use of a substance as well as the discontinuation of its use.

2.         Social Impairment – The use of a substance continues even though it is the catalyst for issues with social relationships.

3.         Risky use – The placing of one’s self and others in risky situations such as driving a car or operating machinery when using a substance or continuing use when physical and/or psychological problems develop as a result of its use.

4.         Pharmacological indicators (Tolerance, Withdrawal) –

a.          Tolerance – The need to increase the amount of a substance to achieve the desired effect.

b.         Withdrawal – The untoward and/or fatal complications that occur upon sudden discontinuance of a substance.

There are a variety of possible reasons why a person may become involved in substance use. For example, the prolonged continuation of prescribed medication, or an attempt to self-medicate for a particular physical or emotional problem. Even peer pressure may be a factor in the continued use of substances. Since client involvement in substance use may involve the use of illegal substances, their issues may include involvement with legal agencies or being referred for care. Other substances, such as tobacco, alcohol, and increasingly cannabis, are legal (given certain parameters, such as age and certain states) but carry with them, through continued use/misuse, the possibility of physical, psychological or emotional health consequences.

The client may or may not have insight into the fact that they have a substance use disorder or that they have a problem with substance use. Clients who have problems with substance use commonly use the defense mechanism of denial. For example, a person who has long‑term tobacco use might say, “I can quit whenever I want to, but smoking really doesn’t cause me any problems.” Frequently, denial prevents a client from obtaining help with substance use. This can lead to challenges for the nurse who must care for clients with substance use disorders, because the client may deny that they require the care that the nurse is trying to provide or they may decide not to participate fully in their recovery and may revert to previous addictive type behaviors following completion of the care provided by the nurse. These negative attitudes displayed by the client can be discouraging for providers. However, it must be remembered that these are symptoms of the addictive process and hopefully clients are brought to an understanding of the unhealthy position that they find themselves in and become committed and engaged in the process of recovery.

Data Collection

In order to be able to plan care for the client with substance use disorder the nurse will be required to collect data from a range of sources that may apply to the client. There are a number of theories as to why a person may develop a substance use disorder and there are a number of ways that these may manifest themselves.

Risk Factors

A number of risk factors have been identified in relation to substance use disorders, and these are:

  • Genetics: predisposition to developing a substance use disorder due to family history
  • Chronic stress: socioeconomic factors
  • History of trauma: abuse, combat experience
  • Lowered self‑esteem
  • Lowered tolerance for pain and frustration
  • Few meaningful personal relationships
  • Few life successes
  • Risk‑taking tendencies

Sociocultural Theories

Apart from the risk factors outlined above there are also sociocultural theories that attempt to explain the development of substance use disorders. These are:

  • There may be cultural variables that influence the use of alcohol. For example, it may be acceptable within a cultural group to excessively use alcohol. Also, there may be certain cultural groups where the metabolic tolerance is lower therefore the possibility of addiction is increased.
  • Metabolism of alcohol and cultural views of alcohol use provide possible explanations for the incidence of alcohol use within a cultural group.
  • Peer pressure and other sociological factors can increase the likelihood of substance use.
  • Older adult clients can have a history of alcohol use or can develop a pattern of alcohol/substance use later in life due to life stressors (losing a partner or a friend, retirement, social isolation).

Expected Findings

It is important for the nurse to be able to ascertain if a client has a substance use disorder and also at what stage of their disorder they are currently functioning at. Therefore, assessment of clients by the nurse should include questions relating to possible substance use as the client may hide these or they may be reluctant to admit or discuss these. The nurse should never shy away from relevant questions on substance use, even though these questions may be considered to be somewhat intrusive by the client. The nurse should use open‑ended questions to obtain the following information for the nursing history:

  • Type of substance used
  • Pattern and frequency of substance use
  • Amount of substance used
  • Age at onset of substance use
  • Changes in occupational or school performance
  • Changes in use patterns
  • Periods of abstinence in history
  • Previous withdrawal manifestations
  • Date of last substance use

Review of Systems

An assessment of a client who is suspected of having substance use disorder should include a comprehensive review of the client’s body systems in order t to provide an appropriate plan of care. This should include questions pertaining to:

  • Blackout or loss of consciousness
  • Changes in bowel movements
  • Weight loss or gain
  • Experience of stressful situation
  • Sleep problems
  • Chronic pain
  • Skin changes (track marks, bruising, excessive diaphoresis)
  • Pupillary changes, such as pinpoint or dilated pupils
  • Unexplained sudden change in vital signs

Population-Specific Considerations

When carrying out a client assessment there are a number of sociological and demographic variables in relation to substance use disorder that the nurse should be aware of. These may influence how the assessment is conducted or the interpretation of the actual assessment results. These considerations should therefore be made when assessing clients with substance use disorders:

  • The younger the person is at the time of initial substance use, the higher the incidence of developing a substance use disorder.
  • Cocaine use is decreased among adolescents. However, about half of adolescents report access to marijuana.
  • Older adults who use substances are especially prone to falls and other injuries, memory loss, somatic reports (headaches), and changes in sleep patterns.
    • Indications of alcohol use in older adults can include a decrease in ability for self‑care (functional status), urinary incontinence, and manifestations of dementia.
    • Older adults can show effects of alcohol use at lower doses than younger adults.
    • Depression is a common cause of heavy alcohol use in older adults.
    • Poly-pharmacy (the use of multiple medications), the potential interaction between substances and medications, and age‑related physiological changes raise the likelihood of adverse effects, such as confusion and falls in older adults.

Standardized Screening Tools

The nurse should be aware that a range of screening tools are currently used when assessing a client with suspected substance use disorder. The types of standardized tools that the nurse may encounter within the clinical environment include the following:

  • Michigan Alcohol Screening Test (MAST) – this is an easy to use self-scoring test to help a person to assess if they have a drinking (alcohol) problem.
  • Drug Abuse Screening Test (DAST) – this is a brief 28-item (yes/no answer) tool that can be self-administered or given by a health care provider to determine drug dependency. The DAST‑A is an adolescent version of this test.
  • CAGE Questionnaire – uses four (4) questions to determine how clients perceive their current alcohol use. These are: 1) have they ever Cut down your drinking; 2) have people Annoyed you by criticized your drinking; 3) have you ever felt Guilty about drinking; 4) do you ever need and Eye opener drink in the morning to settle your nerves or a hangover.
  • Alcohol Use Disorders Identification Test (AUDIT) – this is a tool developed by the World Health Organization (WHO) that contains test items. Each question has options that are awarded for points to determine the risk or level of alcohol problems.
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA‑Ar) – this measures the severity of alcohol withdrawal in order that the appropriate therapy can be planned.
  • Clinical Opiate Withdrawal Scale (COWS) – this is an 11-item scale used by clinicians to rate the signs and symptoms of opiate withdrawal and to monitor these.

Commonly Abused Substances

A range of substances are available that are commonly abused by clients. These will be discussed in terms of their reasons for use, the intended effects, the effects of intoxication, and the manifestations of withdrawal that the nurse should be aware of. The commonly abused substances according to the DSM-5:

1.         Central Nervous System Depressants

a.          Opiates

b.         Alcohol

2.         Central Nervous System Stimulants

a.          Cocaine

b.         Methamphetamines/Amphetamines

c.          Caffeine

3.         Anxiolytics/sedatives/hypnotics

4.         Tobacco (nicotine)

5.         Cannabis

6.         Hallucinogens

a.          Lysergic acid diethylamide (LSD)

b.          Inhalants

c.           Mescaline

d.          Psilocybin

e.          Salvia divinorum

f.            Dimethyltryptamine

g.          Dissociative drugs (DMT)

a.          Ketamine (Special K)

b.         Phencyclidine

f.            Dextromethorphan (DXM)

7.         Club drugs

o   Methylenedioxymethamphetamine (MDMA)

o   Flunitrazepam (Rohypnol)

o   Gamma-hydroxybutyrate (GHB)

 

1.         Central Nervous System Depressants

This category of abused substances is perhaps one of the most commonly used and widely misunderstood of the legal substances. The chief central nervous system depressant used is alcohol, but other substances such as sedatives, hypnotics, and cannabis are also used to depress the central nervous system (CNS).

CNS depressants can produce physiological and psychological dependence and can have cross‑tolerance, cross‑dependency, and an additive effect when taken concurrently.

a.         Opioids

These substances remain a focus of attention within society as their widespread use is regarded as an epidemic that is causing harm across the country. Although having widespread and historical use for pain relief, their use has become increasingly illegal. Heroin, morphine, and hydromorphone can be ingested, injected, smoked, and inhaled. Fentanyl is available for transdermal use.

1)         Intended Effects

The uses of opioid substances are associated with immediate relief and pleasure and include:

  • A rush of euphoria
  • Relief from pain

2)         Effects of Intoxication

Although providing pleasure, these substances can have serious and detrimental effects including:

  • Euphoria, slurred speech, impaired memory, pupillary changes (pinpoint pupils)
  • Impaired coordination, hypokinesis, dizziness, and drowsiness, confusion, sedation and nausea
  • Decreased respirations and level of consciousness, which can cause death
  • Bradycardia, hypothermia
  • Maladaptive behavioral or psychological changes, including impaired judgment or social functioning
  • It is important for nurses to identify and understand appropriate management of intoxication.
  • An antidote, naloxone, is available for IV and IM use to relieve effects of overdose.
  • Naloxone is also readily available over the counter in every state, but there are many states where it can be purchased at drug stores.

3)         Withdrawal Manifestations

Contrary to popular belief concerning opioids, the impact of withdrawal from long-term usage is debilitating rather than life threatening.  Issues relating to withdrawal are:

  • Opioid withdrawal begins with sweating and rhinorrhea progressing to piloerection (gooseflesh), yawning, tremors, and irritability followed by severe weakness, abdominal cramps, diarrhea, fever, anxiety, insomnia, pupil dilation, nausea and vomiting, pain in the muscles and bones, and muscle spasms.
  • Withdrawal is very unpleasant but not life‑threatening.

b.         Alcohol (ethanol)

There are a number of ways to screen for the ingestion of alcohol. The measurement of alcohol is carried out for many purposes, including screening for employment, legal implications for driving, health assessment status, and workplace performance indicators, etc. 

  • A laboratory blood alcohol concentration (BAC) of 0.08% (80 g/dL) is considered legally intoxicated for adults operating automobiles in most U.S. states. Death can occur from acute toxicity in levels greater than 0.4% (400 g/dL).
  • BAC depends on many factors, including body weight, sex, concentration of alcohol in drinks, number of drinks, gastric absorption rate, and individual tolerance level.

1)         Intended Effects

 

Alcohol is widely available and relatively inexpensive. Used in a number of social and recreational contexts, it is also used for self-medication by clients who may have pain issues or emotional challenges. Therefore, although the consequences of regular alcohol use are devastating the intended effects from the client’s perspective are often viewed as positive and can include:

  • Relaxation
  • Euphoria
  • Decreased social anxiety
  • Stress reduction

2)         Effects of Intoxication 

Due to the widespread use of alcohol within society, the effects of alcohol intoxication are usually well known and recognizable. They include:

  • Effects of excess: Slurred speech and speech impairment, nystagmus, memory impairment, altered judgment, decreased motor skills, urinary and bowel incontinence, nausea and vomiting, excessive sleepiness, decreased level of consciousness (can include stupor or coma), memory black outs, amnesia, severe decrease in temperature, blood pressure, pulse and breathing, respiratory arrest, peripheral collapse, and death (with large doses)
  • Chronic use: Direct cardiovascular damage, liver damage (ranging from fatty liver to cirrhosis), erosive gastritis and gastrointestinal bleeding, acute pancreatitis, sexual dysfunction, and fetal damage if used during pregnancy

3)         Withdrawal Manifestations 

The withdrawal manifestations for alcohol are some of the worst that the nurse can face when dealing with substance use disorders. Unlike addition to most other substances, withdrawal from alcohol can result in seizures and may be fatal for the client. Therefore, the nurse must be aware of the potential of these withdrawal effects and the plan of care to implement. The delirium associated with alcohol can take a couple of days to occur. The client may have been regularly ingesting alcohol over a long period of time and this habit is suddenly terminated when they become ill or have a traumatic event requiring hospitalized care. The nurse will therefore come in contact with clients who have had a sudden withdrawal from alcohol and these clients can be of any age and social background. This makes the aforementioned screening and assessment of clients of paramount importance to ensure that the appropriate issues relating to alcohol withdrawal are identified. These issues include:

  • Manifestations include irritability; anorexia; nausea and vomiting; tremors; restlessness and inability to sleep; impaired cognitive functions; sweating; increased heart rate; transient hallucinations or illusions; anxiety; increased blood pressure, respiratory rate, and temperature; and tonic-clonic seizures.
  • Alcohol withdrawal delirium can occur 2 to 3 days after cessation of alcohol. This is considered a medical emergency. Manifestations include severe disorientation, psychotic manifestations (hallucinations), severe hypertension, cardiac dysrhythmias, and delirium. Alcohol withdrawal delirium can progress to death.

2.         Central Nervous System Stimulants

Central Nervous System (CNS) stimulants are usually taken by clients in order to give them some kind of “high” and they are usually addictive. This means that people can build up a physiological and psychological dependency on these drugs. Some stimulants can be obtained legally or over the counter, whereas some are classified as the main enemy in the “war against illegal drug dependency” in this country. The CNS stimulation seen in some CNS stimulants is dependent on the area of the brain and spinal cord affected.

a.         Cocaine

Many years ago cocaine was commonly available and used drug for the over counter treatment of pain and as a stimulant in certain soda (carbonated) beverages. Famous people, such as Sigmund Freud, are known to have used it to treat cancer pain and Queen Victoria is known to have enjoyed its stimulating effects in a soda drink.

  • Cocaine is known in the street as: Blow, bump, coke, crack, rock, snow, lady, flake
  • It can be injected, smoked, or inhaled (snorted)

1) Intended Effects

The intended effect of cocaine helps to explain its popularity in being used as a stimulant. It produces a number of effects that are viewed by users as being very positive. These include:

  • A rush of euphoria (extreme well‑being) and pleasure
  • A feeling of increased energy

2) Effects of Intoxication


Although the intended effects of cocaine for the user may be pleasurable, there are a range of effects emanating from intoxication that can be damaging or dangerous for the user. These include:

  • Mild toxicity: dizziness, irritability, tremor, blurred vision, increased energy, dilated pupils, decreased appetite
  • Severe effects: hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, “Cocaine bugs”, cardiovascular collapse, death
  • Nasal damage from inhaled cocaine

3) Withdrawal Manifestations

 

As with all substances that are used for medicinal or pleasurable effects, which can become addictive, there are manifestations of withdrawal that the nurse should be aware of. These include:

  • Depression
  • Fatigue
  • Craving and increased appetite
  • Excess sleeping or insomnia
  • Anxiety
  • Dramatic unpleasant dreams
  • Psychomotor retardation
  • Agitation and irritability
  • Poor concentration
  • Paranoia
  • Drug craving
  • Not life‑threatening, but possible occurrence of suicidal ideation

b.         Methamphetamines/Amphetamines

These are another category of CNS stimulants that are used widely that had an initial pharmaceutical purpose but have come to be used illegally and widely within certain sectors of society.

  • There are a number of street names for these substances, including: Meth, ice, crank, chalk, crystal, fire, glass; bennies, black beauties, speed, uppers, Adam, pep pills
  • Can be swallowed, snorted, smoked or injected
  • Amphetamines are prescribed therapeutically for ADHD and narcolepsy, but also have a high risk for abuse.

1)         Intended Effects

 

The intended effects of these drugs are associated with their properties as stimulants and include:

  • Feeling of exhilaration
  • Increased energy
  • Mental alertness
  • Self-confidence

2)         Effects of Intoxication

Although providing pleasure for their misuse (associated with increased energy and exhilaration) the effects of intoxication can lead to physical and psychological consequences a serious challenge in the provision of nursing care. These include:

  • Increased heart rate, blood pressure, body temperature, cardiac dysrhythmia, stroke, kidney failure
  • Increased energy and feelings of exhilaration
  • Irritability, tremors, anxiety, panic, paranoia, violent behaviors, psychosis
  • Weight loss, insomnia
  • Heavy use can cause severe dental problems
  • Prolonged deficits in cognition and memory

3)         Withdrawal Manifestations

Withdrawal from methamphetamines/amphetamines is not in itself life-threatening. Patients may experience:

  • Craving
  • Depression
  • Fatigue
  • Sleeping

c.         Caffeine

A commonly available, but often-ignored CNS stimulant, when considering substance use disorder, is caffeine. It is included in cola drinks, coffee, tea, chocolate, and energy drinks.

1)         Intended Effects

Users of caffeine take it for its well-known stimulant qualities with the intended effects of:

  • Increased level of alertness
  • Decreased fatigue

2)         Effects of Intoxication

Although often widely available, and often ingested regularly throughout the day, the effects of caffeine intoxication may not be widely known to users. These include:

  • Intoxication commonly occurs with ingestion of greater than 250 mg. (One 2 oz high‑energy drink can contain 215 to 240 mg caffeine)
  • Tachycardia and arrhythmias
  • Flushed face
  • Muscle twitching
  • Excitement
  • Restlessness
  • Nervousness
  • Diuresis
  • GI disturbances
  • Anxiety
  • Insomnia
  • Psychomotor agitation

3)         Withdrawal Manifestations


Because of the wide spread use of caffeine, the nurse must be aware of the withdrawal manifestations as these may impact client care planning and may include:

  • Headache, nausea, vomiting, muscle pain, irritability, inability to focus, drowsiness
  • Manifestations of withdrawal can occur within 24 hr of last consumption.

3.         Anxiolytics/sedatives/hypnotics

These substances may have been introduced to the client through clinical use where they have been prescribed legally. The client may have moved onto the inappropriate or illegal use of these substances.  Common street names for anxiolytics and benzodiazepines include roaches, candy, green and whites, dollies, and dolls. Barbiturates street names are blue angels, yellow birds, red birds, red devils, and bluebirds or blue angels.  They are chiefly:

  • Anxiolytics can be taken orally or by injection.
  • Barbiturates, including amobarbital, pentobarbital, and secobarbital.
  • Benzodiazepines, including diazepam, lorazepam, chlordiazepoxide, clorazepate, and oxazepam, and are generally safer to take than barbiturates.

            Intended Effects 

These substances are used extensively within clinical situations because of their intended effects of:

  • Decreased anxiety
  • Sedation

Effects of Intoxication 

 

Clients move forward in their use of these substances because of the intoxicating effects that they produce. The effects of intoxication are something that the nurse should be aware of and monitor for because of the potential for harm or even death in the client because of the level of misuse of the substance involved. The effects to be aware of include:

  • Increased drowsiness and sedation, agitation, slurred speech, uncoordinated motor activity, unsteady gait, nystagmus, disorientation, nausea, vomiting, and impaired thinking
  • Respiratory depression and decreased level of consciousness, which can be fatal
  • An antidote, flumazenil, is available for IV use for sedative effects of benzodiazepine toxicity.
  • Benzodiazepines taken over time should be tapered to minimize withdrawal symptoms.
  • No antidote is available to reverse barbiturate toxicity

Withdrawal Manifestations

One of the key issues in withdrawing a client from these substances, particularly the benzodiazepines, is the need to taper the intake of the drug over a period of time to lessen the potential for withdrawal symptoms. It should be noted that benzodiazepines are used to replace alcohol when dealing with a client facing alcohol withdrawal. The drug is given because it mimics the impact of alcohol on the body, but as a substitute it can be titrated clinically to ensure that the client does not face the potential of developing delirium. Therefore, there are a number of reasons that the nurse should be aware of the manifestations of withdrawal from anxiolytics/sedatives/hypnotics. These include:

  • Anxiety
  • Hyperactivity
  • Insomnia
  • Diaphoresis
  • Hypertension
  • Possible psychotic reactions
  • Hand tremors
  • Nausea
  • Vomiting
  • Hallucinations or illusions
  • Psychomotor agitation

 Grand mal seizures

4.         Tobacco (nicotine)

Nicotine products available through the legal purchase of tobacco are one of the biggest health challenges faced by the health care system today. Not only in terms of the physical complications that can arise because of ingestion of tobacco products, but also through the use of tobacco in substance use disorders. The most widely available source of nicotine is through the tobacco contained in cigarettes and also available in cigars and pipes. These sources require inhalation. It should also be remembered that nicotine could also be ingested if it is snuffed or chewed although these forms of ingestion are common within certain cultures or regions of the country.

More recently the use of digital cigarettes and vaping technology have increased in popularity as alternatives to taking nicotine, while lowering potential physical side effects and risks, have become a factor in life style choices. The long-term effects of intoxication with these products is currently under investigation, but it is known that the level of toxicity may be varied by the user and the impact of concentrating the dosage is not yet well understood. Despite the uncertainties this is still viewed as a safer alternative to smoking tobacco (nicotine) as there is no ingestion of tar products (Shabab et al, 2017).

a.         Intended Effects


The ingestion of tobacco (nicotine) products is often initiated through peer pressure. The sharing of these products is seen to be socially desirable and the user increasingly feels that they are giving themselves a “treat” or time out through the use of the substance. The intended effects are therefore viewed as being associated with:

  • Relaxation
  • Decreased anxiety
  • Relief of stress

b.         Effects of Intoxication

Tobacco (nicotine) is highly addictive and associated with a range of potential physical problems that may be related to a client’s personal health history. Issues that result through the use of these substances are that they:

  • Are highly toxic, but acute toxicity seen only in children or when exposure is to nicotine in pesticides
  • Contain other harmful chemicals that are highly toxic and have long‑term effects
  • Have long‑term effects:
    • Cardiovascular disease (hypertension, stroke), chronic respiratory disease (emphysema, lung cancer), cancers of the pharynx, larynx, mouth, esophagus, stomach, cervix, kidney, bladder, and pancreas
    • Nicotine can have adverse outcomes if used during pregnancy
    • With smokeless tobacco (snuff or chew): irritation to oral mucous membranes and cancer
    • Long-term use of vaping products and digital cigarettes are not well understood and are currently under investigation.

c.         Withdrawal Manifestations

Tobacco (nicotine) products are notoriously difficult to discontinue and the withdrawal manifestations are often used as an excuse for continuation in using the substance or for the resumption of use. Withdrawal manifestations include:

  • Abstinence syndrome evidenced by irritability
  • Craving
  • Headaches
  • Nervousness
  • Restlessness
  • Tremors
  • Anxiety
  • Insomnia
  • Increased appetite
  • Weight gain
  • Difficulty concentrating
  • Anger
  • Depressed mood

5. Cannabis

Cannabis is a controversial substance at the present time with over half of the US states approving it for medicinal use and several of the US states approving it for recreational usage. It is often viewed as a gateway drug to other substance addictions and remains illegal at a federal level. It has a long history of usage for recreational and medicinal usage across many cultures going back several centuries. Facts to remember about cannabis are that:

  • Marijuana or hashish (which is more potent) can be smoked or orally ingested.
  • Most widely used illegal substance in the U.S.
  • Medical and recreational marijuana are legal in some states

Intended Effects

Although having intended effects, if used medicinally, such as the reduction of pain and stimulation of appetite in clients with cancer, cannabis is perhaps more widely known for its intended effects when used recreationally. Therefore, there are a range of intended effects, some of which may be chiefly recreational, and others which can fall within a clinical (therapeutic) context. A summary of the intended effects includes:

  • Euphoria
  • Sedation
  • Hallucinations
  • Decrease of nausea and vomiting secondary to chemotherapy
  • Management of chronic pain

Effects of Intoxication

The effects of the intoxication remain controversial in that it is reported that use can lead to detrimental effects or ill health, including:

  • Chronic use: lung cancer, chronic bronchitis, other respiratory effects
  • In high doses: occurrence of paranoia, such as delusions and hallucinations
  • Increased appetite, dry mouth, tachycardia

Withdrawal Manifestations

Withdrawal from cannabis can be uncomfortable for the client, particularly if its use has been associated with putting them in a relaxed and desired frame of mind. The manifestations are also challenging for the nurse in that care must be planned around changes in mood, behavior and the physical condition of the client in relation to:

  • Irritability
  • Aggression
  • Anxiety
  • Insomnia
  • Lack of appetite
  • Restlessness
  • Depressed mood
  • Abdominal pain
  • Tremors
  • Diaphoresis
  • Fever
  • Headache

6.         Hallucinogens

These substances are taken in an illegal context and the substances used are synthetic in form, such as lysergic acid diethylamide.

a.         Lysergic acid diethylamide (LSD)

  • Also known as LSD, acid, blotter, cubes, yellow sunshine, blue heaven, microdot
  • Synthetic
  • Swallowed or absorbed through mouth tissue, or smoked

1) Intended Effects

The intended effects are associated with the hallucinogen properties of the substance and are a linked to:

  • Increased awareness of sensory stimuli
  • Heightened sense of self and altered perceptions
  • Ability to cause the types of alterations in thought, perception, and feeling that otherwise only occur in dreams

2) Effects of Intoxication


Although associated with pleasurable stimulation, the effects of the intoxication can have psychological rather than physical complications. Before taking the substance the users never know if they will have a “good” trip (resulting in pleasurable experiences) or a “bad” trip (with frightening perceptual experiences and potential physical complications or safety threats). The intoxication effects can include:

  • Anxiety
  • Depression
  • Loss of appetite
  • Euphoria
  • Paranoid delusions
  • Visual hallucinations
  • Impaired judgment (extreme impairment could cause death)
  • Impaired social functioning
  • Impulsive behavior
  • Pupil dilation
  • Sleeplessness
  • Weakness and numbness
  • Tachycardia
  • Hyperthermia
  • Hypertension
  • Diaphoresis
  • Palpitations
  • Blurred vision
  • Tremors
  • Lack of coordination
  • Panic attacks
  • Overdose can lead to extreme hyperactivity, hallucinations, psychosis, violence, seizures, and possible death

3) Withdrawal Manifestations

There is not a wide range of withdrawal manifestations from using this substance, however two issues are worth noting for the nurse:

 

·             Sometimes the “trip” may be prolonged, causing fear and panic in the client.

·             Hallucinogen persisting perception disorder: Visual disturbances or flashback hallucinations can occur intermittently for years.

 

b.         Inhalants

Inhalants are another group of substances that are widely used for medicinal purposes and are available over the counter and in forms that can be misused. Amyl nitrate, nitrous oxide, and solvents are sniffed, huffed, or bagged, often by children or adolescents. Clients can have irritation around the nose, eyes, and throat.

1) Intended Effects

When used inappropriately the intended effect of using inhalants is for:

  • Euphoria
  • Hallucinations

2) Effects of Intoxication

 

Because of the wide range of inhalant options available there is a corresponding range of the intended effects of intoxication. Depending on the substance, inhalants generally can cause:

  • Behavioral or psychological changes
  • Impaired judgment
  • Apathy
  • Assaultiveness and belligerence
  • Dizziness
  • Nystagmus
  • Uncoordinated movements or gait
  • Slurred speech
  • Drowsiness
  • Lethargy
  • Hyporeflexia
  • Tremors
  • Muscle weakness
  • Diplopia and blurred vision
  • Euphoria
  • Stupor or coma
  • Respiratory depression
  • Possible death

Other hallucinogens commonly in use are natural rather than synthetic products, and are available through a range of sources including:

c.         Mescaline

This most commonly used natural hallucinogen is derived from peyote cactus plants.

·              It is also known as: Peyote, buttons, cactus

  • Constituent of the peyote cactus found in nature
  • Swallowed or smoked

d.         Psilocybin

Psilocybin is derived from mushroom products.

·              It is also known as: Magic mushrooms, purple passion, shrooms

  • Compound found in nature
  • Swallowed

e.         Salvia divinorum


This is an herb from Mexico that is associated with spiritual experiences and used by native healers.

  • It is also known as: Magic Mint, Safe of Seers, Sally D
  • Hallucinogenic herb that is part of the mint family

f.            Dimethyltryptamine (DMT)

Although naturally occurring in many plants or animals this substance is normally misused in its synthetic form. It has a history of being used in many cultures for traditional healing and spiritual rituals. This issues associated with use of this substance are:

  • It is usually taken as a synthetic compound
  • It is a powerful psychedelic drug
  • It’s street name is known as: Businessman’s trip
  • It is less potent than LSD with shorter duration of effect

g.         Dextromethorphan (DXM)

DXM is a cough suppressant found in many cough and cold remedies. It is misused, mostly in teenagers, through its ready availability and its hallucinogenic properties if taken in high doses. It is also known as: Robo, Triple C, and Robotripping.  High doses cause:

·              euphoria

·              disorientation

·              paranoia

·              impaired motor function

·              distorted visual perceptions

·              slurred speech, and altered senses

h.         Dissociative Drugs

These are a class of hallucinogenic drugs that distort perception and create feelings of detachment and disassociation not only from the environment but also from self.

Intended Effects

The intended effects are related to the hallucinogenic properties of the substance and include:

  • Distortion of perception of sight and sound
  • Producing feelings of dissociation (detachment from the environment)

1)         Ketamine (Special K)

This is a drug used mainly for anesthesia, especially in veterinary circles. Issues relating to this substance are:

  • Formulated as a liquid in which liquid is evaporated, leaving a powder
  • Injected, snorted, smoked, or orally used as a sexual assault drug when added to a beverage
  • May have been diverted from veterinary offices where it is used as an anesthetic
  • The street names for ketamine include cat Valium, K, vitamin K, and Special K

a)           Intended Effects

 

Similar to PCP, except action is shorter

b)         Effects of Intoxication

The user can experience a state known as K-hole, which is a feeling similar to near-death experience where there is a sense of rising above one’s own body.

2)         Phencyclidine

This is also primarily used as an anesthetic but when used inappropriately its hallucinogenic side effects are sought.

  • It is also known as: PCP, angel dust, peace pill.
  • It can be swallowed, smoked, snorted, injected
  • Can cause CNS depression, CNS excitation, and analgesia

a)         Intended Effects

At low doses produces effects similar to alcohol (euphoria, reduced inhibition, slurred speech, motor uncoordination)

b)         Effects of Intoxication

Although the intended effects are viewed as pleasant, intoxication can produce negative and potentially serious complications that can include:

  • High doses produce excitation, disorientation, anxiety, disorganized thoughts, altered body image, and reduced perception of tactile and painful stimuli.
  • Delirium can occur within 24 hours after injection of the drug or can occur up to a week following recovery from a drug overdose.
  • Physiologic effects can include hypertension, muscle rigidity, coma, seizure, and death.

 

7.         Club Drugs

Designer or club drugs, such as ecstasy, can be combined with substances from different categories, producing varying effects of intoxication or withdrawal. These substances are often associated with current youth culture, reflecting fashions in music, dance and life style. These drugs can be swallowed, snorted and injected.  Improper use of prescription medications—specifically opioids, CNS depressants, and CNS stimulants—can result in substance use disorder and drug‑seeking behavior.

Intended Effects

The intended effects are related to the sociability related to club culture and the need to fit in with the “good times” that are being experienced with the peer group. These include:

  • Elevated mood
  • Increased sensory awareness
  • Reduced anxiety
  • Increased sociability

a.         Methylenedioxymethamphetamine (MDMA)

This is a psychoactive drug used recreationally and is associated with attending clubs and raves where prolonged dancing takes place. It is known as: Ecstasy, Adam, Eve, lover’s speed, peace, clarity, uppers and can be swallowed, inhaled, or injected.

There is a range of intended effects depending upon the situation in which the user wants to use the substance. These are:

  • Low doses produce mild LSD-like psychedelic effects.
  • Higher doses produce amphetamine-like stimulant effects.

There are also unintended effects that can be threatening or uncomfortable for the user.   These are:

  • CNS stimulation causing tachycardia, hypertension, cardiac arrhythmia and hyperthermia
  • Anxiety, teeth clenching, jaw clenching, muscle cramping and seizures

b.         Flunitrazepam (Rohypnol)

This is a benzodiazepine used for its tranquilizing effects. Is has developed an unfortunate reputation as a “date rape” drug. Therefore, the nurse must know of its usage. It is also known as: Forget-me-pill, Mexican Valium, R2, roofies, roach, ropes and can be swallowed or inhaled.  If used negatively as a facilitator for sexual assault the intended effects are:

  • Sedation, muscle relaxation, memory loss, confusion, dizziness, and impaired coordination
  • Can be used to facilitate a sexual assault
  • Effects can occur 10 minutes after ingestion and last up to 12 hours

c.         Gamma-hydroxybutyrate (GHB)

This is a CNS depressant that is often used by young persons as a replacement for alcoholic beverages at clubs and rave dance parties.  It is associated with euphoria and increased sex drive. It is available as a powder to be dissolved in liquids or a pure liquid.  It is also known as: Georgia home boy, liquid ecstasy, soap, scoop, goop, liquid X. There is a range of effects either with sexual activity or sociability at a party.  If used negatively it can be a facilitator for sexual assault.

There is a range of physical effects of intoxication that can become serious for the user. These include:

·              Side effects include drowsiness, disorientation, nausea, vomiting, headache, slowed heart rate, low blood pressure, amnesia, loss of coordination, unconsciousness, coma, and death

·              Effects can occur within 5 min after ingestion and last up to 12 hr.

Patient-Centered Care and Nursing Care Priorities

Clients who have a substance who disorder require a continuum of care that begins with detoxification, rehabilitation, partial hospitalization programs, halfway houses, intensive outpatient programs, and support groups such as Alcoholics Anonymous (AA).  Personal views, culture, and history can affect the nurse’s feelings regarding substance use disorders. Nurses must self‑assess feelings, because those feelings can be transferred to clients through body language and the terminology used in collecting data. An objective, nonjudgmental approach is imperative.

Safety is the primary focus of nursing care during acute intoxication or withdrawal/detoxification

·              Maintain a safe environment to prevent falls.

·              Implement seizure precautions as necessary.

·              Provide close observation for withdrawal manifestations, possibly one‑on‑one supervision.

·              Physical restraint should be a last resort.

·              Orient the client to time, place, and person.

·              Maintain adequate nutrition and fluid balance.

·              Create a low‑stimulation environment.

·              Administer medications as prescribed to treat the effects of intoxication or to prevent or manage withdrawal. This can include substitution therapy.

·              Monitor for covert substance use during the detoxification period.

The nurse needs to provide emotional support and reassurance to the client and family. Also, reinforce education with the client and family about codependent behaviors and the initial treatment goal of abstinence. The family should also be reminded to remove any prescription medications in the home that are not being used.

The patient needs to be encouraged not to share medication(s) with someone for whom that medication is not prescribed. The client should be encouraged to begin to develop the motivation and commitment for abstinence and recovery (abstinence plus developing a program of personal growth and self‑discovery) and taking responsibility for one’s self.

The client should be encouraged to attend self-help groups, with clients having the same substance use disorder(s) as themselves. Care planning with the client should also involve the development of an emergency plan with a list of things the client should need to  do and people the client should need to contact.

Medications

There are lists of medication options that are available to clients who have particular substance use disorders. These include:

·             Acute alcohol withdrawal: Chlordiazepoxide, clorazepate, diazepam, lorazepam, oxazepam

·             Alcohol abstinence: Disulfiram, naltrexone, acamprosate

·             Opioid withdrawal: Methadone, clonidine, buprenorphine, naltrexone

·             Nicotine withdrawal from tobacco use: Bupropion, nicotine replacement therapy (nicotine gum and nicotine patch), varenicline

·             Nicotine abstinence: Varenicline

Nursing Actions

Nursing care should be planned in a holistic fashion, but the focus of nursing actions often concentrates upon the physical dangers that the client may face. Many of these are in relation to withdrawal from the use of a substance and include:

  • Monitoring vital signs and neurological status.
  • Providing for client safety by implementing seizure precautions.

Client Education

Client education relates to stopping use of the substance and continued abstinence. Therefore, the education should reinforce client behaviors in relation to:

  • Adherence to the treatment plan.
  • Avoidance of all products that may contain the substances that the client was addicted to. For example, with alcohol reinforce teaching about substances that contain alcohol, such as cold remedies, after-shave products, and colognes.
  • Identification of relapse and factors that contribute to relapse.
  • The development of cognitive‑behavioral techniques to help maintain sobriety and create feelings of pleasure from activities other than using substances. The reinforcement of communication skills to communicate with coworkers and family members while sober.
  • Participation in 12‑step programs (Alcoholics Anonymous (AA), and Narcotics Anonymous) and family groups (Al‑Anon, Ala‑Teen) are available for the client and family. These programs will teach clients the following:
    • Abstinence is necessary for recovery.
    • A higher power is needed to assist in recovery.
    • Clients are not responsible for their disease but are responsible for their recovery.
    • Other people cannot be blamed for clients’ addictions, and they must acknowledge their feelings and problems.

Interprofessional Care

Dual diagnosis, or comorbidity, means that an individual has both a mental health disorder, such as depression, and a substance use disorder. Both disorders need to be treated simultaneously and require a team approach.

Individual Psychotherapies

  • Cognitive behavioral therapies, such as relaxation techniques or cognitive reframing, can be used to decrease anxiety and change behavior.
  • Acceptance and commitment therapy (ACT) promotes acceptance of the client’s experiences and promotes client commitment to positive behavior changes.
  • Relapse prevention therapy assists clients in identifying the potential for relapse and promotes behavioral self‑control.

Group Therapy

Groups of clients who have similar diagnoses can meet in an outpatient setting or within mental health residential facilities.

Family Therapy

This therapy identifies codependency, which is a common behavior demonstrated by the significant other/family/friends of an individual who has substance dependency, and assists the family to change that behavior. The codependent person reacts in over‑responsible ways that allow the dependent individual to continue the substance use r. For example, a partner can act as an enabler by calling the client’s employer with an excuse of illness when the client is intoxicated. The benefits of family therapy are:

  • Families learn about use of specific substances.
  • The client and family are educated regarding issues such as family coping, problem‑solving, indications of relapse, and availability of support groups.

Case Study #1

Please answer the following questions related to the case study. Use the material in the CE to construct your answers. The following activity and questions are for your own benefit and reference. They will not be graded and do not count towards earning your CEs.

A nurse is receiving change of shift report on an orthopedic unit. The nurse reports that the client in room 6304 who is 77 years-old and was admitted two days ago with a broken femur has started behaving strangely. The nurse states that the client reported “drinking a few glasses of wine each evening”, and has ceased since the hospital admission.

1.         What signs and symptoms would lead you to believe that the client is suffering from alcohol withdrawal?

2.         What are the potential threats to the clients health and safety?

3.         What are the measures the nurse should implement to assist the client with alcohol withdrawals?

4.         When the client is ready for discharge, what information should the nurse include in the teaching?

Impaired Health Care Workers and Drug Diversion 

The incidence of drug abuse among health care workers is similar to that of the general population.  However, access to drugs through diversion is a serious problem.  It not only affects the performance of the health care worker endangering patients, but can also harm colleagues and employers.  Read the following article, “The Painful Problem of Drug Diversion and What You Can Do” at https://www.americannursetoday.com/painful-problem-drug-diversion-can/ and the NCSBN Brochure “What you Need to Know About Substance Use Disorder in Nursing” at https://www.ncsbn.org/SUD_Brochure_2014.pdf .  Use the information from these resource articles and material in the continuing education module to construct your answers to complete the following activity.  

Develop a policy that addresses issues in regard to impaired health care workers as well as workers who may be diverting drugs. 

·             Purpose of policy

·             Background information on

o   incidence of impaired workers

o   environmental factors that contribute to use of controlled substances

·             Signs to look for when suspecting a health care worker is using drugs. 

·             Signs to look for when suspecting a health care worker is diverting drugs. 

·             Possible profession-related consequences

·             Staff development that espouses the risk of becoming drug dependent and diverting drugs.

·             Potential consequences of using controlled substances in the workplace and/or diverting drugs.

·             Integrate into this policy treatment options found on your state’s board of nursing website. 


References

  1. American Nurses Association. (2014) The Painful Problem of Drug Diversion and What You Can Do, retrieved from https://www.americannursetoday.com/painful-problem-drug-diversion-can/
  2. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders. (5th ed.) Patparganj, New Delhi: CBS Publishers and Distributors.
  3. Halter, M. J. (2014). Varcarolis’ foundations of psychiatric mental health nursing: A clinical approach (7th ed.). St. Louis, MO: Saunders.
  4. NCSBN. (2014) What you Need to Know About Substance Use Disorder in Nursing, retrieved from https://www.ncsbn.org/SUD_Brochure_2014.pdf
  5. Shabab, L., Goniewicz, M.L., Blout, B.C., et al (2017) Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users: A Cross-Sectional Study. Annals of Internal Medicine. Published online February 7, 2017. Available at http://annals.org/aim/article-abstract/2599869/nicotine-carcinogen-toxin-exposure-long-term-e-cigare...T
  6. Townsend, M., Morgan, K., (2017). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidenced-Based Practice (7th ed.) Philadelphia, PA: F.A. Davis Company.



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