Nursing Continuing Education

Substance Abuse and Addiction

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This is Your Course on Substance Abuse and Addiction


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. Non‑substance‑related disorders (behavioral/process addictions) include gambling, sexual activity, shopping, social media, and Internet gaming.

Substance use and addictive disorders are characterized by loss of control due to the substance use or behavior, participation that continues despite continuing associated problems, and a tendency to relapse back into the substance use or behavior.

The defense mechanism of denial is commonly used by clients who have problems with a substance use or addictive disorder. 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 or an addictive behavior.


Data Collection

Risk Factors

  • 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

  • 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

The nurse should use open‑ended questions to obtain the following information for the nursing history:

  • Type of substance or addictive behavior
  • 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 or addictive behavior

Review of Systems

  • 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

  • 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.
    • Polypharmacy (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

  • Michigan Alcohol Screening Test (MAST)
  • Drug Abuse Screening Test (DAST) or DAST‑A: Adolescent version
  • CAGE Questionnaire: Asks questions of clients to determine how they perceive their current alcohol use
  • Alcohol Use Disorders Identification Test (AUDIT)
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA‑Ar)
  • Clinical Opiate Withdrawal Scale (COWS)

Commonly Abused Substances

  • Designer or club drugs, such as ecstasy, can be combined with substances from different categories, producing varying effects of intoxication or withdrawal.
  • Improper use of prescription medications—specifically opioids, CNS depressants, and CNS stimulants—can result in substance use disorder and drug‑seeking behavior.

Central Nervous System Depressants

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

Alcohol (ethanol)

  • 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.
Intended Effects
  • Relaxation
  • Decreased social anxiety
  • Stress reduction
Effects of Intoxication 
  • Effects of excess: Slurred speech, nystagmus, memory impairment, altered judgment, decreased motor skills, decreased level of consciousness (can include stupor or coma), respiratory arrest, peripheral collapse, 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
Withdrawal Manifestations 
  • Manifestations include abdominal cramping; vomiting; tremors; restlessness and inability to sleep; 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.

Anxiolytics/sedatives/hypnotics

  • Most anxiolytics can be taken orally or by injection.
  • Barbiturates include amobarbital, pentobarbital, and secobarbital.
  • Benzodiazepines include diazepam, lorazepam, chlordiazepoxide, clorazepate, and oxazepam, and are generally much safer to take than barbiturates.
Intended Effects 
  • Decreased anxiety
  • Sedation
Effects of Intoxication 
  • Increased drowsiness and sedation, agitation, slurred speech, uncoordinated motor activity, nystagmus, disorientation, nausea, vomiting
  • 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 to reverse barbiturate toxicity
Withdrawal Manifestations
  • Anxiety
  • Insomnia
  • Diaphoresis
  • Hypertension
  • Possible psychotic reactions
  • Hand tremors
  • Nausea
  • Vomiting
  • Hallucinations or illusions
  • Psychomotor agitation
  • Possible seizure activity

Cannabis

  • 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
  • Euphoria
  • Sedation
  • Hallucinations
  • Decrease of nausea and vomiting secondary to chemotherapy
  • Management of chronic pain
Effects of Intoxication
  • 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
  • Irritability
  • Aggression
  • Anxiety
  • Insomnia
  • Lack of appetite
  • Restlessness
  • Depressed mood
  • Abdominal pain
  • Tremors
  • Diaphoresis
  • Fever
  • Headache

Central Nervous System Stimulants

The CNS stimulation seen in some CNS stimulants is dependent on the area of the brain and spinal cord affected.

Cocaine

  • Blow, bump, coke, crack, rock, snow
  • Can be injected, smoked, or inhaled (snorted)

Intended Effects

  • Rush of euphoria (extreme well‑being) and pleasure
  • Increased energy
Effects of Intoxication
  • Mild toxicity: dizziness, irritability, tremor, blurred vision
  • Severe effects: hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, cardiovascular collapse, death
  • Nasal damage from inhaled cocaine
Withdrawal Manifestations
  • Depression
  • Fatigue
  • Craving
  • Excess sleeping or insomnia
  • Dramatic unpleasant dreams
  • Psychomotor retardation
  • Agitation
  • Not life‑threatening, but possible occurrence of suicidal ideation

Methamphetamines/Amphetamines

  • Meth, ice, crank, chalk, crystal, fire, glass; bennies, black beauties, speed, uppers
  • Can be swallowed, snorted, smoked or injected
  • Amphetamines are prescribed therapeutically for ADHD and narcolepsy, but also have a high risk for abuse.
Intended Effects
  • Feeling of exhilaration
  • Increased energy
  • Mental alertness
  • Self-confidence
Effects of Intoxication
  • Increased heart rate, blood pressure, body temperature, cardiac dysrhythmia, stroke, kidney failure
  • Irritability, anxiety, panic, paranoia, psychosis
  • Weight loss
  • Heavy use can cause severe dental problems
  • Prolonged deficits in cognition and memory
Withdrawal Manifestations
  • Craving, depression, fatigue, sleeping
  • Not life‑threatening

Tobacco (nicotine)

  • Cigarettes and cigars are inhaled.
  • Smokeless tobacco is snuffed or chewed.
Intended Effects
  • Relaxation
  • Decreased anxiety
Effects of Intoxication
  • Highly toxic, but acute toxicity seen only in children or when exposure is to nicotine in pesticides
  • Also contains other harmful chemicals that are highly toxic and have long‑term effects
  • Long‑term effects:
    • Cardiovascular disease (hypertension, stroke), respiratory disease (emphysema, lung cancer)
    • With smokeless tobacco (snuff or chew): irritation to oral mucous membranes and cancer
Withdrawal Manifestations
  • Abstinence syndrome evidenced by irritability
  • Craving
  • Nervousness
  • Restlessness
  • Anxiety
  • Insomnia
  • Increased appetite
  • Difficulty concentrating
  • Anger
  • Depressed mood

Opioids

Heroin, morphine, and hydromorphone can be ingested, injected, smoked, and inhaled. Fentanyl is available for transdermal use.

Intended Effects

  • A rush of euphoria
  • Relief from pain
Effects of Intoxication
  • Slurred speech, impaired memory, pupillary changes
  • Decreased respirations and level of consciousness, which can cause death
  • Maladaptive behavioral or psychological changes, including impaired judgment or social functioning
  • An antidote, naloxone, available for IV use to relieve effects of overdose
Withdrawal Manifestations
  • Abstinence syndrome begins with sweating and rhinorrhea progressing to piloerection (gooseflesh), tremors, and irritability followed by severe weakness, diarrhea, fever, insomnia, pupil dilation, nausea and vomiting, pain in the muscles and bones, and muscle spasms.
  • Withdrawal is very unpleasant but not life‑threatening.

Inhalants

Amyl nitrate, nitrous oxide, and solvents are sniffed, huffed, or bagged, often by children or adolescents.

Intended Effects

  • Euphoria
Effects of Intoxication

Depends on the substance, but inhalants generally can cause:

  • Behavioral or psychological changes
  • Dizziness
  • Nystagmus
  • Uncoordinated movements or gait
  • Slurred speech
  • Drowsiness
  • Hyporeflexia
  • Muscle weakness
  • Diplopia
  • Stupor or coma
  • Respiratory depression
  • Possible death

Hallucinogens/psychedelics

Intended Effects
  • 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

Lysergic acid diethylamide

  • LSD, acid, blotter, cubes, yellow sunshine, blue heaven
  • Synthetic
  • Swallowed or absorbed through mouth tissue, injected, or smoked
Effects of Intoxication
  • Anxiety
  • Depression
  • Paranoia
  • Impaired judgment (extreme impairment could cause death)
  • Impaired social functioning
  • Pupil dilation
  • Tachycardia
  • Diaphoresis
  • Palpitations
  • Blurred vision
  • Tremors
  • Incoordination
  • Panic attacks
  • Users never know if they will have a “good” or “bad” trip.
Withdrawal Manifestations

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

Other Hallucinogens

Mescaline
  • Peyote, buttons, cactus
  • Constituent of the peyote cactus found in nature
  • Swallowed or smoked
Psilocybin
  • Magic mushrooms, purple passion, shrooms
  • Compound found in nature
  • Swallowed
Salvia divinorum
  • Magic Mint, Safe of Seers, Sally D
  • Hallucinogenic herb that is part of the mint family

Dimethyltryptamine (DMT)

  • Synthetic compound
  • Less potent than LSD with shorter duration of effect

Caffeine

Includes cola drinks, coffee, tea, chocolate, energy drinks

Intended Effects

  • Increased level of alertness
  • Decreased fatigue
Effects of Intoxication
  • 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
  • Restlessness
  • Diuresis
  • GI disturbances
  • Anxiety
  • Insomnia
Withdrawal Manifestations
  • Can occur within 24 hr of last consumption
  • Headache, nausea, vomiting, muscle pain, irritability, inability to focus, drowsiness

Club Drugs

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

Methylenedioxymethamphetamine (MDMA)

  • Ecstasy, Adam, Eve, lover’s speed, peace, uppers
  • Can be swallowed, inhaled, injected or inserted rectally
Intended Effects
  • Low doses produce mild LSD-like psychedelic effects.
  • Higher doses produce amphetamine-like stimulant effects.
  • Can cause CNS stimulation causing tachycardia, hypertension, cardiac arrhythmia and hyperthermia
  • Associated with teeth clenching, jaw clenching and seizures

Flunitrazepam (Rohypnol)

  • Forget-me-pill, Mexican Valium, R2, roofies, ropes
  • Can be swallowed or inhaled
Intended Effects
  • Sedation, relaxation
  • Can be used to facilitate a sexual assault
  • Effects can occur 10 minutes after ingestion and last up to 12 hours

Gamma-hydroxybutyrate (GHB)

  • Georgia home boy, liquid ecstasy, soap, scoop, goop, liquid X 
Intended Effects
  • Can be used to facilitate a sexual assault
  • Available as a powder to be dissolved in liquids or a pure liquid
Effects of Intoxication
  • Side effects include nausea, vomiting, slowed heart rate, low blood pressure, amnesia and coma.
  • Effects can occur within 5 min after ingestion and last up to 12 hr.

Dissociative Drugs

Intended Effects
  • Distort perception of sight and sound
  • Produce feeling of dissociation (detachment from the environment)

Ketamine (Special K)

  • 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
Intended Effects

Similar to PCP, except action is shorter

Effects of Intoxication

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

Phencyclidine

  • PCP, angel dust, peace pill
  • Swallowed, smoked, snorted, injected
  • Can cause CNS depression, CNS excitation, and analgesia
Intended Effects

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

Effects of Intoxication

  • High doses produce excitation, disorientation, anxiety, disorganized thoughts, altered body image, and reduced perception of tactile and painful stimuli.
  • Physiologic effects can include hypertension, muscle rigidity, coma, seizure, and death.

Dextromethorphan (DXM)

Cough suppressant found in many cough and cold remedies

Effects of Intoxication

High doses cause euphoria, disorientation, paranoia, and altered senses


Patient-Centered Care

Nursing Care

  • Personal views, culture, and history can affect the nurse’s feelings regarding substance use and addictive 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.
    • 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.
  • Provide emotional support and reassurance to the client and family. Reinforce education with the client and family about codependent behaviors.
  • Reinforce education with the client and family about addiction and the initial treatment goal of abstinence.
  • Reinforce education with the client and family regarding removing any prescription medications in the home that are not being used. Encourage the client not to share medication with someone for whom that medication is not prescribed.
  • Help the client begin to develop motivation and commitment for abstinence and recovery (abstinence plus developing a program of personal growth and self‑discovery).
  • Encourage self‑responsibility.
  • Help the client develop an emergency plan: a list of things the client would need to do and people he would need to contact.
  • Encourage attendance at self‑help groups.

Medications

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

  • Monitor vital signs and neurological status.
  • Provide for client safety by implementing seizure precautions.

Client Education

  • Adhere to the treatment plan.
  • Avoid all alcohol and reinforce teaching about substances which contain alcohol, such as cold remedies, after-shave products, and colognes.

Interprofessional Care

Dual diagnosis, or comorbidity, means that an individual has both a mental health disorder, such as depression, and a substance use or addictive 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 or process 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 or addiction disorder. 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.

  • 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.

Client Education

  • Relapse and factors that contribute to relapse.
  • Cognitive‑behavioral techniques to help maintain sobriety and create feelings of pleasure from activities other than using substances or from process addictions.
  • Develop communication skills to communicate with coworkers and family members while sober.
  • 12‑step programs (Alcoholics Anonymous [AA], Narcotics Anonymous, and Gambler’s Anonymous) and family groups (Al‑Anon, Ala‑Teen) 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.

References

  1. PN Mental Health Nursing REVIEW MODULE EDITION 10.0 2017 Assessment Technologies Institute, LLC.
  2. Fundamentals for NursingREVIEW MODULE EDITION 9.0 2017 Assessment Technologies Institute, LLC.


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