Substance related & addictive disorders

Psych

Substance Use Disorder

• a condition in which a person’s repeated use of alcohol, drugs, or medications leads
  to significant problems in daily life.

• It is more than just “using” a substance—it involves a pathological
  pattern of behaviors related to the substance

Impaired Control

• Using more than intended, unsuccessful attempts to cut down, craving

Social Impairment

• Problems at school, work, or home; giving up activities; strained relationships

Risky use

• Using in dangerous situations (e.g., driving), continued use
  despite physical or psychological harm

Physical effects

• Tolerance (needing more for the same effect) and withdrawal (physical/psychological symptoms when not using)

Process Addictions

• Does not involve a substance, but rather a compulsive behavior that activates
  the brain’s reward pathways in a similar way as drugs or alcohol.

• Examples:
  — Gambling disorder (the only one formally recognized in DSM-5)
  — Internet gaming disorder (listed for further study)
  — Other compulsive behaviors: shopping, sex, exercise, eating

Process Addictions assessments

• Patients may present with physical health issues (liver disease, infections,
  injuries) and mental health concern (depression, anxiety, suicidality).

• Nurses must assess for:
   Signs and symptoms of intoxication, withdrawal, or compulsive behaviors.
   Readiness to change (Stages of Change model).
   Safety risks (self-harm, impaired judgment, risky behaviors).

• Nurses play a key role in screening, therapeutic communication, education,
  and relapse prevention

Addiction

• A primary, chronic disease of brain reward, motivation, memory, and related circuitry. Without treatment, people with addiction are typically unable to abstain and may not
  recognize the functional problems caused by their substance use. Addiction is progressive and can lead to disability or death

Intoxication

• A reversible set of physical and psychological changes caused by the recent use of a substance.

• What happens:
  — Substances affect the brain and body systems, altering mood, thinking, consciousness, judgment, and behavior.

• Examples:
  — Alcohol intoxication → slurred speech, unsteady gait, impaired judgment.
  — Cocaine intoxication → euphoria, hypervigilance, increased heart rate.

• Nursing focus:
  — Assess for safety risks (falls, aggression, risky behaviors).
  — Monitor vital signs, level of consciousness, and potential for injury.

Alcohol Intoxication

• Legal definition of intoxication in most states: blood concentration of 80 or 100 mg ethanol per deciliter of blood (mg/dL).

• Often expressed as 0.08 to 0.10 g/dL.

Tolerance

• A need for increased amounts of a substance to achieve the desired effect, OR a diminished effect with continued use of the same amount.

• What happens:
  — The brain and body adapt to the substance.
  — The original dose no longer produces the same “high” or relief.

• Examples:
  — A person who once felt relaxed after 1-2 beers now needs 6-8.
  — Someone prescribed opioids for pain needs higher doses for the same pain control.

• Nursing focus:
  — Recognize escalating use as a warning sign of dependence.
  — Assess for risk of overdose when patients increase amounts on their own

Withdrawal

• A set of physiological and psychological symptoms that occur when a person who has developed dependence abruptly reduces or stops using the substance.

• What happens:
  — Symptoms are usually opposite of intoxication effects.
  — Can range from uncomfortable to life-threatening.

• Examples:
  — Alcohol withdrawal → tremors, sweating, anxiety, seizures, delirium tremens.
  — Opioid withdrawal → muscle aches, diarrhea, yawning, runny nose, insomnia.

• Nursing focus:
  — Monitor for life-threatening complications (e.g., seizures, delirium, unstable vital signs).
  — Use withdrawal scales (e.g., CIWA for alcohol, COWS for opioids).
  — Provide safe detoxification and support (fluids, comfort measures, medications like benzodiazepines for alcohol withdrawal or buprenorphine for opioids).

Risk Factors for Susbstance Use Disorders

• Genetic factors play a role, as substance use disorders such as cannabis, cocaine, and opioid use often run in families.

• Neurobiological factors include neurotransmitter systems such as opioid, catecholamine (→ dopamine), and GABA systems.

• Environmental factors such as poverty, lack of parental supervision, poor educational resources, and impaired support systems increase risk. Negative environmental cycles often begin in disadvantaged neighborhoods, contributing to stress, anxiety, negative social ties leading to depression

Caffeine

• The most widely used psychoactive substance.

• Occurs with high intake (typically >250 mg in a short time; ~2–3 cups strong coffee).

• Intoxication can cause restlessness, nervousness, rapid speech, flushed face, and tachycardia.

• Withdrawal symptoms include headache, drowsiness, and irritability.

Hallucinogens

• LSD and PCP cause profound disturbances in reality.

• Intoxication may involve paranoia, hallucinations, pupillary dilation, and tachycardia.

• PCP intoxication can be a medical emergency due to violent and impulsive behavior.

Cannabis

• The most widely used illicit drug worldwide.

• It is utilized in some states to treat nausea, vomiting, and loss of appetite in cancer patients. It is legal in some states.

• Intoxication heightens sensory perception, slows time perception, and impairs motor skills for ~8 – 12 hours.

• Withdrawal can include irritability, anxiety, sweating, abdominal pain, and headache

Inhalants

• Found in household products such as glue, aerosols, and fuels.

• Intoxication produces euphoria, hallucinations, and disinhibition,can produce auditory and visual hallucinations.

• High doses can cause arrhythmias and sudden death

Sedative-hypnotics/anti-anxiety medications

• Includes benzodiazepines and barbiturates, club drugs, sleep medications.

• Intoxication can cause slurred speech, impaired thinking, and coma.

• Withdrawal can be life-threatening; treatment often involves gradual dose reduction.

• Overdose: gastric lavage

Opioids

• Are central nervous system depressants that relieve pain and produce
  euphoria.

• Opioid Use Disorder (OUD) is a pattern of opioid use leading to clinically significant
  impairment or distress, as defined by the DSM-5.

• Includes prescription opioids (e.g., oxycodone, hydrocodone, morphine), heroin, and
  synthetic opioids (e.g., fentanyl).

• This is a chronic relapsing disorder. Intoxication produces drowsiness, constricted pupils,
  and impaired judgment.

• Withdrawal causes GI distress, muscle aches, lacrimation, rhinorrhea, dilated pupils,
  and insomnia.

• Overdose often results in respiratory depression and requires naloxone.
  
  

Opioid Use Disorder

• Opioid misuse has increased dramatically, contributing to the opioid epidemic.

• Prescription opioids often serve as gateway drugs to heroin or illicit synthetic opioids.

• Overdose deaths are a major public health concern.

• Opioid Use Disorder is a chronic, relapsing disease with high risk of overdose, withdrawal, and social/medical complications.

• Nursing care includes assessment, safe withdrawal management, medication-assisted treatment, education, and supportive interventions.

Medication-Assisted Treatment (MAT) for Opioid Use Disorder

• MAT combines FDA-approved medications with behavioral therapy and counseling to treat OUD.

• Goal: reduce opioid use, prevent relapse, and improve patient functioning.

• Recognized as evidence-based and highly effective.

Medications Used in MAT

Methadone

• Full opioid agonist

• Reduces cravings and withdrawal symptoms- Administered in licensed opioid treatment programs- Risk of respiratory depression if misused

Buprenorphine

• Partial opioid agonist

• Reduces cravings and withdrawal- Can be prescribed in office-based
  settings- Lower risk of overdose than methadone

Naltrexone

• Opioid antagonist

• Blocks opioid effects and prevents relapse- Must be opioid-free for 7–10 days
  before starting- Can be oral or monthly injectable

Stimulants

• Second most frequently used drug. Includes cocaine and amphetamines.

• Intoxication produces euphoria, energy, and hypervigilance, they feel “super-human”. Unfortunately, stimulants can produce anxiety, chest pain, and possible coma.

• Withdrawal leads to fatigue, depression, vivid dreams, and suicidal thoughts.

• Severe Manifestations: Seizures, cardiac arrhythmias, and potential for overdose
  leading to death.

Tobacco

• Causes dependence and tolerance.

• Withdrawal can cause irritability, depressed mood, restlessness, and difficulty concentrating

Alcohol

• A sedative that initially produces euphoria and lowered inhibitions.

• Intoxication is measured by blood alcohol level, with higher levels leading to impaired coordination, speech, and judgment.

• Withdrawal can progress from tremors and nausea to seizures and life-threatening delirium tremens. Chronic alcohol use can lead to Wernicke-Korsakoff syndrome, liver disease, cardiovascular problems, neuropathy, and cancer

Alcohol Use Disorder Severity

Severity is based on the number of DSM-V symptoms.

Mild

• 2–3 # of symptoms

• Some impairment in control, social functioning, or risky use; mild physical effects possible

Moderate

• 4–5 # of symptoms

• Greater impairment in daily life, increased risky behavior, physical effects more evident

Severe

• 6 or more symptoms

• Significant impairment, high risk of physical complications, tolerance, and withdrawal present

Types of Problematic Drinking

• BINGE DRINKING – TOO MUCH TOO QUICK.

• HEAVY DRINKING – TOO MUCH TOO OFTEN

Wernicke's Encephalopathy (Acute)

• Cause: Thiamine deficiency (common in chronic alcohol use

• Onset: Sudden/acute

• Main Symptoms: Confusion, ataxia (unsteady gait), ocular abnormalities (nystagmus, diplopia)

• Reversibility: Often reversible with prompt IV thiamine

• Treatment: Immediate thiamine replacement (IV/IM) (banana bag), supportive care, alcohol cessation

Korsakoff's Syndrome (Chronic)

• Cause: Often follows untreated Wernicke’s; chronic thiamine deficiency

• Onset: Gradual, develops after Wernicke's

• Main Symptoms: Severe short-term memory loss, confabulation, difficulty learning new
  information

• Reversibility: Usually permanent; recovery is limited (~20%)

• Treatment: Long-term thiamine supplementation, supportive care, safety measures, cognitive rehabilitation

Fetal Alcohol Syndrome

• FAS is the leading, preventable and mostsevere outcome of fetal alcohol spectrum
  disorders (FASDs), caused by maternal alcohol use during pregnancy.

• Alcohol is a teratogen that crosses the placenta and disrupts normal fetal
  development.

Systemic Effects of Alcohol Abuse

• Peripheral Neuropathy

• Alcohol Myopathy

• Alcohol Cardiomyopathy

• Esophagitis, pancreatic, & gastrits

• Alcohol induced hepatitis

• Cirehosis of the liver

• Leukopenia

• Thromobocytopenia

• Head & neck cancer

Comorbidities in Substance Use Disorder

• Comorbidities occur when a patient with a substance use disorder (SUD) also has one or more additional physical or mental health disorders.

• This is common because substance use can exacerbate or trigger other conditions, and vice versa

Psychiatric Comorbidities

• Depression: Substance use can mask or worsen depressive symptoms.

• Anxiety disorders: Stimulants, alcohol, and sedatives can trigger or worsen
  anxiety.

• Bipolar disorder: High-risk for substance misuse during manic or depressive
  episodes.

• Post-traumatic stress disorder (PTSD): Individuals may use substances to self-
  medicate trauma-related symptoms.

• Psychosis: Hallucinogens or stimulants may induce psychotic symptoms in
  vulnerable individuals.

Comorbidities & Key Points

• High prevalence: approximately 50% of patients with SUD have at least one
  comorbid psychiatric disorder.

• Bidirectional relationship: psychiatric or medical disorders can predispose
  someone to substance use, and substance use can worsen or trigger other conditions.

• Integrated treatment approach is most effective, combining medical, psychiatric, and psychosocial interventions

Risk factors for Substance Use Disorders 2

• Biological / Genetic: Family history of SUD; genetic predisposition; neurobiological vulnerability (dopamine, GABA, opioid systems)

• Psychological: Co-occurring mental health disorders (depression, anxiety, bipolar, PTSD, ADHD); personality traits like impulsivity, low self-esteem, poor coping skills; history of trauma or abuse

• Social / Environmental: Poor parental supervision; family conflict; peer pressure; poverty; lack of education; high availability of substances; cultural acceptance of substance use

• Developmental: Early age of first use; adolescence or young adulthood with immature prefrontal cortex leading to risk-taking

Nursing Process for Substance Use Disorder

• Assessment involves screening tools, family assessment, and recognition of codependence behaviors. Nurses should also perform self-assessment
  to recognize biases, since substance use disorders are not simply matters of choice.

• Outcomes and Planning include safe detoxification, stabilization, abstinence, and relapse prevention.

• Implementation focuses on safety, nutrition, self-care, sleep, and addressing harmful thoughts or spiritual distress.

• Health teaching and promotion should include education on genetic risks, relapse prevention, coping skills, and resources such as 12-step programs.

• Evaluation should assess the effectiveness of interventions and monitor for sustained abstinence

Screening Tools

• SBIRT: Screening, brief intervention, and referral to treatment

• AUDIT: Alcohol use disorders identification test

• CAGE: 4 questions to identify alcohol abuse

• CAGE-AID: Same questions as CAGE but adds drug use to alcohol

• T-ACE: Tolerance, Annoyance, Cut down, Eye-opener

Codependence (family assessment)

• A pattern of dysfunctional coping where family members enable the substance use
  while trying to maintain control and stability.

• Nursing Considerations: Families often need education and support, not just
  the patient

What nurses can do for patients who abuse alcohol.

• Patients with alcohol use disorder may be resistant, manipulative, or in denial.

• These behaviors can trigger frustration, judgment, or avoidance in nurses.

• Without self-awareness, nurses risk becoming ineffective or punitive.

• Maintain therapeutic neutrality: show empathy without enabling.

• Recognize that addiction is a disease, not a moral failing.

• Use nonjudgmental communication to build trust.

• Seek peer support, supervision, or debriefing if personal reactions become
  overwhelming

Treatments Modalities

• Medications:
  — Alcohol → disulfiram (Antabuse), naltrexone
  — Opioids → methadone, buprenorphine, naltrexone

• Motivational Interviewing: Builds motivation to change

• Continuum of Care: Detox → rehab → halfway house → outpatient → peer support

• Relapse Prevention: Traditional (12-step programs) + tech-based supports (apps, text
  programs)

Alcoholics Anonymous

• AA is a peer-led, community-based support group for individuals seeking recovery from alcohol use disorder.

• Based on the belief that alcoholism is a chronic disease that requires ongoing support and lifestyle change.

• Provides a nonjudgmental, supportive environment where people share experiences and encourage sobriety.

• AA may also help reduce stigma and build sober social networks.

Transtheoretical Model

• Describes how people progress through behavior change over time

• Especially useful for substance use disoders, but appicable to ant health related behavior changes

• Recognize that relaspe is common

Stages of Transtheoretical Model

1. Precontemplation

• The individual is not considering change and may deny a problem.

• Build rapport and trust- Provide education about risks- Avoid confrontation

2. Contemplation

• The person acknowledges a problem but is ambivalent about change.

• Use motivational interviewing- Explore pros and cons of current behavior vs. change

3. Preparation

• The person intends to take action soon and may make small changes.

• Help set realistic goals- Develop a stepwise plan- Provide support and resources

4. Action

• The individual actively modifies behavior and environment.

• Reinforce positive change- Provide encouragement and coping strategies- Monitor progress

5. Maintenance

• The person sustains behavior change over time and works to prevent relapse.

• Offer ongoing support- Identify triggers and coping strategies- Encourage participation in
  support groups

6. Relaspe

• The person returns to previous behavior, which is common.

• Normalize relapse as part of change- Reassess motivation- Encourage re-entry into the cycle at the appropriate stag

Evaluation for Substance Use Disorder

• Is continuous, multidimensional, and outcome-focused.

• Nurses measure behavioral, physical, and psychosocial progress, adjust interventions
  as needed, and document results to support ongoing recovery and safe care