medications for substance use disorders | NURS212

what is substance use disorder?

patterns of symptoms caused by using a substance that an individual continues taking despite negative effects

true or false: substances of abuse all increase dopamine?

true

what is intoxication?

substance-specific physiology effects that occur after exposure to a psychoactive substance → the effects vary depending on the mechanism of action of the substance, and the level of intoxication can vary based on the amount taken and individual response

what is physical dependence?

a hemostatic adaption that occurs when the body is exposed to certain susbtances over a prolonged period of time of which the body becomes accustomied to the drug’s

what is psychological dependence?

the brain’s emotional and mental reliance on a substance → may include cravings, anxiety, depression, sleep disturbances, irritability, and cognitive effects when the substance is reduced or stopped

what is tolerance?

decreased response to a drug after continuous use → it can lead to dose escalation, substitutions, or changes in route of administration → can occur with many prescribed medications and does not equal substances use disorder (SUD)

what is withdrawal?

the physiologic and psychological effects that occur when a substance that has been used for a sufficient period of time is discontinued or reversed → the severity of withdrawal varies depending on the substance and duration of use

what is the symptoms of opioid overdose?

1. classic triad: respiratory depression, pinpoint pupil, and decreased level of consciousness

2. other common symptoms: low oxygen saturation, bradycardia, hypotension, slurred speech, extreme drowsiness, diaphoresis, cyanosis

wha is the MOA, indications, drug interactions, contraindications, and adverse effects of naloxone (Narcan)?

1. MOA: antagonizes opioid receptors to reverse the depressant effects of opioids

2. indication: opioid overdose

3. drug interactions: opioid agonist

4. contraindications: hypersensitivity

5. adverse effects: flushing, hypotension, tachycardia, diaphoresis, abdominal cramps, diarrhea, agitation, dizziness

what is the MOA, indications, contraindications, interactions, and side effects of naltrexone (vivitrol)?

opioid antagonist

1. MOA: pure opioid antagonist - blocks opioid receptors, especially the mu receptors in the brain → reduce craving and the reinforcing effects of opioids as the euphoric and sedative effects of opioid are prevented

2. indications: prevention of opioid use disorder (OUD) and alcohol use disorder (by reducing craving and the reward system)

3. contraindications: acute opioid withdrawl, concurrent use of opioids

4. interactions: will block the effect of opioid pain medication

5. side effects: nausea, injection, site reactions, liver irritation

what is the MOA, indications, contraindications, interaction, and adverse effects of burenorphine-naloxone?

partial opioid agonist

1. MOA: buprenorphine partially activate opioid receptors in the brain to reduce craving and withdrawal symptoms, while naloxone blocks opioid receptors if the medication is misused (such as by injection), helping prevent abuse (the naloxone will not do anything if the medication is used sublingually as intended)

2. indications: reduce symptoms of opioid withdrawals and craving, OUD maintenance

3. contraindications: severe hepatic impairment, hypersensitivity, CNS depression

4. interactions: CNS depressants, diphenhydramine, ethanol

5. side effects: headache, nausea, diaphoresis, abdominal pain, constipation, vasodilation, hepatocellular injury

what is the nursing consideration for buprenirphine-naloxone?

1. the nurse must wait until the patient is in active opioid withdrawal because buprenorphine will displace the stronger opioid that is attached, and the receptor stimulation suddenly drops (basically, the patient goes into rapid, intense withdrawal)

2. Take with food

3. increase fluid and fiber intake

what is the MOA, indications, contraindications, interactions, and side effects of methadone?

1. MOA: long-acting opioid receptor agonist

2. indications: chronic pain, OUD maintenance

3. contraindications: severe hepatic impairment, asthma, GI obstruction, hypersensitivity, CNS depression

4. interaction: CNS depressant, diphenhydramine, ethanol

5. side effects: QT prolongation, respiratory depression, constipation, sedation

what is the nursing consideration for methadone?

1. must be used as a part of medication-assisted treatment (MAT) to provide counseling and structured monitoring in addition to medication

2. must be taken daily to maintain stable blood levels, prevent withdrawals, and reduce relapse risk

3. a baseline EKG is necessary because methadone can prolong the QT interval, increasing the risk of dangerous cardiac arrythymias

when are naltrexone, buprenorphine-naloxone, and methadone preferred for opioid use disorder, and what is one key nursing consideration for each?

• methadone is preferred for patients with severe opioid dependence or long histories of opioid use who need strong withdrawal suppression.
  → Key nursing consideration: Obtain a baseline EKG because methadone can prolong the QT interval and cause arrhythmias.

• buprenorphine-naloxone is preferred for patients who need office-based treatment and have moderate opioid dependence. It reduces cravings and withdrawal with a lower risk of respiratory depression due to its ceiling effect.
  → Key nursing consideration: Start only when the patient is in active withdrawal to avoid precipitated withdrawal.

• naltrexone is preferred for highly motivated patients who have already completed detox and are opioid-free. It blocks opioid effects and helps prevent relapse.
  → Key nursing consideration: The patient must be opioid-free before starting, or severe withdrawal can occur.

David Nguyen (he/him) presents to the health care provider’s office stating that he wishes for help with his prescription opioid use. 

He has a history of OUD and takes prescription oxycodone when he can acquire it, smokes 1ppd of cigarettes for 7 years, major depressive disorder, and chronic back pain after a sports-injury 5 years ago. He currently takes duloxetine 40 mg per day and has a PRN prescription for 20 mg oxycodone for pain

VS: T: 98.4F, BP 126/75, HR 78, RR 18, O2 99% on RA
Height/Weight: 5’8”, 175 lb
Physical exam: WNL

Based on the information on the previous slide, what is a priority question for the nurse to ask Daniel?

1. “Have you ever been arrested?”

2. “Where do you get your opioids from?”

3. “Do you use heroin or fentanyl?”

4. “Have you lost or gained weight recently?”

5. “When was your last opioid use?”

1. “When was your last opioid use?”

David Nguyen (he/him) presents to the health care provider’s office stating that he wishes for help with his prescription opioid use. 

He has a history of OUD and takes prescription oxycodone when he can acquire it, smokes 1ppd of cigarettes for 7 years, major depressive disorder, and chronic back pain after a sports-injury 5 years ago. He currently takes duloxetine 40 mg per day and has a PRN prescription for 20 mg oxycodone for pain

VS: T: 98.4F, BP 126/75, HR 78, RR 18, O2 99% on RA
Height/Weight: 5’8”, 175 lb
Physical exam: WNL

Daniel is interested in starting buprenorphine/naloxone (Suboxone) today. Based on his vital signs and physical examination, why would the nurse advise him that he cannot receive his first dose immediately?

he is currently not in an active withdrawal state

David Nguyen (he/him) presents to the health care provider’s office stating that he wishes for help with his prescription opioid use. 

He has a history of OUD and takes prescription oxycodone when he can acquire it, smokes 1ppd of cigarettes for 7 years, major depressive disorder, and chronic back pain after a sports-injury 5 years ago. He currently takes duloxetine 40 mg per day and has a PRN prescription for 20 mg oxycodone for pain

VS: T: 98.4F, BP 126/75, HR 78, RR 18, O2 99% on RA
Height/Weight: 5’8”, 175 lb
Physical exam: WNL

The healthcare provider plans to transition Daniel from oxycodone to buprenorphine/naloxone (Suboxone). Which assessment finding would indicate to the nurse that Daniel is ready to receive his first dose of this medication?

1. Daniel reports his last dose of oxycodone was 4 hours ago. 

2. Daniel's vital signs are within normal limits. 

3. Daniel displays dilated pupils, tremors, and a heart rate of 110 beats/minute. 

4. Daniel states he is highly motivated and has a “strong craving” for opioids.

1. Daniel displays dilated pupils, tremors, and a heart rate of 110 beats/minute. 

David Nguyen (he/him) presents to the health care provider’s office stating that he wishes for help with his prescription opioid use. 

He has a history of OUD and takes prescription oxycodone when he can acquire it, smokes 1ppd of cigarettes for 7 years, major depressive disorder, and chronic back pain after a sports-injury 5 years ago. He currently takes duloxetine 40 mg per day and has a PRN prescription for 20 mg oxycodone for pain

VS: T: 98.4F, BP 126/75, HR 78, RR 18, O2 99% on RA
Height/Weight: 5’8”, 175 lb
Physical exam: WNL

Daniel asks why his new medication contains naloxone if it meant to be taken daily. Which statements by the nurse are correct? Select all that apply. 

1. “The naloxone is added to help you treat your chronic back pain.”

2. “The naloxone is not absorbed well when taken under the tongue as directed.”

3. “The naloxone is there to prevent you from crushing and injecting the medication.”

4. “The naloxone will stay in your system longer than the buprenorphine.”

5. “If you try to inject this tablet, the naloxone will cause immediate withdrawal symptoms.”

1. “The naloxone is not absorbed well when taken under the tongue as directed.”

2. “The naloxone is there to prevent you from crushing and injecting the medication.”

3. “If you try to inject this tablet, the naloxone will cause immediate withdrawal symptoms.”

Daniel returns to the clinic 14 days later. He has been successfully inducted onto buprenorphine/naloxone 8mgl/2mg sublingual daily. He reports that his “cravings are 90% gone” and he hasn’t used oxycodone since his last visit. However, he has some new concerns. 

Current Assessment: 

Subjective: “persistent, dull headache” and “feeling stopped up”. He also mentions that his chronic back pain is “flaring up” now that he isn’t taking the oxycodone.

Vitals: BP 118/74, HR 72 beats/minute, RR 14 bpm

Physical exam: no signs of opioid withdrawal, positive bowel sounds in all four quadrants

Daniel asks the nurse if the headaches and constipation are “normal” while taking his new medication. Which response by the nurse is most appropriate?

1. “These are the signs of a mild allergic reaction; we should stop the medication immediately.”

2. “These are common side effects of buprenorphine that often diminish as your body adjusts.”

3. “Constipation is rare with buprenorphine, so we need to screen you for a bowel obstruction.”

4. “The headache indicates that your dose of naloxone is too high.”

1. “These are common side effects of buprenorphine that often diminish as your body adjusts.”

Daniel returns to the clinic 14 days later. He has been successfully inducted onto buprenorphine/naloxone 8mgl/2mg sublingual daily. He reports that his “cravings are 90% gone” and he hasn’t used oxycodone since his last visit. However, he has some new concerns. 

Current Assessment: 

Subjective: “persistent, dull headache” and “feeling stopped up”. He also mentions that his chronic back pain is “flaring up” now that he isn’t taking the oxycodone.

Vitals: BP 118/74, HR 72 beats/minute, RR 14 bpm

Physical exam: no signs of opioid withdrawal, positive bowel sounds in all four quadrants

Daniel asks, “Now that I can’t take oxycodone for my back pain, what am I supposed to do when the pain flares up?” Which pharmacological recommendation should the nurse anticipate discussing?

1. A short--acting opioid for breakthrough pain

2. An increase in the duloxetine for immediate pain relief

3. Non-opioid adjuncts like ibuprofen or naproxen and physical therapy

4. Nothing; the naloxone in the medication will treat his back pain

1. Non-opioid adjuncts like ibuprofen or naproxen and physical therapy

Daniel returns to the clinic 14 days later. He has been successfully inducted onto buprenorphine/naloxone 8mgl/2mg sublingual daily. He reports that his “cravings are 90% gone” and he hasn’t used oxycodone since his last visit. However, he has some new concerns. 

Current Assessment: 

Subjective: “persistent, dull headache” and “feeling stopped up”. He also mentions that his chronic back pain is “flaring up” now that he isn’t taking the oxycodone.

Vitals: BP 118/74, HR 72 beats/minute, RR 14 bpm

Physical exam: no signs of opioid withdrawal, positive bowel sounds in all four quadrants

Which instruction is the priority for the nurse to include when teaching Daniel about the administration of his buprenorphine/naloxone film?

1. “Rinse your mouth with alcohol-based mouthwash immediately after the film dissolves.”

2. “Drink a large glass of water while the medication is under your tongue to help it dissolve.”

3. “Do not eat, drink, or talk until the medication has completely dissolved under your tongue.”

4. “If you miss a dose, double the next one to ensure your brain receptors stay full.”

1. “Do not eat, drink, or talk until the medication has completely dissolved under your tongue.”

what is the MOA, indications, contraindications, interactions, and side effects of chlordiazepoxide (Librium)?

1. MOA: long-acting benzodiazepine; increases the frequency of chloride channel opening, allowing more chloride ions to enter the neuron to reduce neuronal excitability (during alcohol withdrawal the brain is over excited so chlordiazepoxide increase GABA which calm the brain and prevent seizures)

2. indications: anxiety disorders, alcohol withdrawal, preoperative anxiety

3. contraindications: hypersensitivity, severe liver deficiencies, respiratory depression, acute narrow-angle glaucoma, breastfeeding, pregnancy

4. interactions: CNS depressants

5. side effects: drowsiness, ataxia, confusion, constipation, paradoxical reactions

what is the MOA, indications, contraindications, interactions, and side effects of disulfiram?

1. MOA: aldehyde dehydrogenase inhibitor, leading to acetaldehyde syndrome (block enzyme that breaks down alcohol, causing buildup of acetaldehyde, which make a person feel very sick if they drink alcohol)

2. indications: AUD management, sobriety maintenance

3. contraindications: alcohol use, CV disease, psychosis, pregnancy, liver disease

4. interactions: alcohol, ethanol, warfarin

5. side effects: metallic or garlic-like taste, drowsiness, fatigue, headache, skin ras

what is the patient education for disulfiram?

avoid ALL alcohol as any form of alcohol can cause the patient to feel really sick

why is haloperidol (Haldol) used in alcohol withdrawal?

it helps manage agitation and hallucinations during alcohol withdrawal, but it does not treat the withdrawal itself

why is dexmedetomidine (Precedex) used in severe alcohol withdrawal?

this medication provides continuous IV sedation without requiring airway support → it is used in the ICU and can cause severe bradycardia

what is the role of lorazepam (Ativan) in alcohol withdrawal?

it is a short-acting benzodiazepine used to prevent seizures and reduce agitation during alcohol withdrawal

why is thiamine given to patients with alcohol use disorders?

thiamine (vitamin B1) prevents or treats deficiency that can lead to berberi and wernicke-korsakoff syndrome

which is more dangerous: opioid withdrawal or alcohol withdrawal?

alcohol withdrawal is more dangerous and can be life-threatening due to risk of seizures, delirium tremens (DTs), and severe autonomic instability → opioid withdrawal is extremely uncomfortable but is typically not life-threatening

• Alcohol withdrawal = can kill

• Opioid withdrawal = feels like you’re dying, but usually won’t

what is the mechanism of nicotine?

an acetylcholine agonist that stimulates dopamine release in the brain’s reward center

waht are common symptoms of nicotine withdrawal?

1. anxiety

2. difficulty concentrating

3. irritability

4. severe cravings

when does nicotine withdrawal typically begin and how long does it last?

withdrawal usually begins about 24 hours after discontinuation and can last from days to weeks

when is chlordiazepoxide preferred over disulfiram in alcohol use disorder, and what is one key nursing consideration?

chlordiazepoxide is preferred during acute alcohol withdrawal to prevent seizures and delirium tremens. A key nursing consideration is monitoring for respiratory depression and oversedation.

when is disulfiram preferred over chlordiazepoxide in alcohol use disorder, and what is one key nursing consideration?

disulfiram is preferred for long-term relapse prevention in motivated patients after detox. A key nursing consideration is ensuring the patient has not consumed alcohol for at least 12 hours before starting to avoid a severe reaction.

what is the MOA, indications, contraindications, interactions, and adverse effects of bupropion (Wellbutrin, Zyban)?

1. MOA: inhibits the reuptake of norepinephrine and dopamine, which results in the decreased level reduces nicotine cravings, decreasing withdrawal symptoms, improving mood regulation during cessation, and helping counteract decreased concentration and energy

2. indications: smoking cessation (for someone who is currently smoking and wants to quit: usually started before the quit date), major depressive disorder, SAD, ADHD

3. contraindications: hypersensitivity, seizures, CNS infection, CNS tumor, head injury, anorexia or bulimia nervosa, hepatic/renal impairment (cautious)

4. interactions: ethanol, clopidogrel, haloperidol, MAOIs, digoxin

5. adverse effects: anxiety, insomnia, tinnitus, tachycardia, diaphoresis, weight loss, constipation, N, V, xerostomia, agitation, tremor, blurred vision, and seizures as burpropion cna lower the seizure threshold

what is the MOA, indications, contraindications, interactions, and adverse effecs of Nicotine (NicoDerm/Nicorette)?

MOA: stimulates nicotine (acetylcholine) receptors in the CNS to provide controlled nicotine levels, which reduces cravings and withdrawal symptoms while avoiding the harmful chemicals found in tobacco.

indications: smoking cessation, reduction of nicotine withdrawal symptoms.

contraindications: hypersensitivity to nicotine, recent MI, severe arrhythmias, unstable angina (cautious use), pregnancy (cautious).

interactions: continued tobacco or vaping use (risk of nicotine toxicity), other stimulants that increase heart rate or blood pressure.

adverse effects: tachycardia, increased BP, nausea, insomnia; patch—skin irritation; gum/lozenge—jaw pain, hiccups, dyspepsia; nasal spray—in throat/nasal irritation.

Six months after the last encounter, Daniel presents to his PCP and reports that he is doing well after starting therapy with buprenorphine-naloxone and reports no other opioid use. He states that he now wishes to stop his cigarette-smoking habit. 

History: opioid use disorder being treated with buprenorphine-naloxone, 1 ppd smoker for 7 years, MDD

Current medications: 16mg/4mg Suboxone daily, 40 mg duloxetine daily

Assessment and VS WNL

Based on the intake information, the nurse should anticipate orders for which of the following medications?

1. Bupropion

2. Lorazepam

3. Naltrexone

4. methadone

1. Bupropion

Daniel:

• Stable on buprenorphine-naloxone for OUD

• Wants to quit smoking

• Has MDD

• VS normal

We’re choosing the medication that helps with smoking cessation and is safe with his current regimen.

Now look at the options:

• ❌ Lorazepam → benzodiazepine; used for anxiety or alcohol withdrawal, not smoking cessation.

• ❌ Naltrexone → used for opioid or alcohol use disorder, not nicotine.

• ❌ Methadone → opioid agonist for OUD, not smoking.

• ✅ Bupropion → approved for smoking cessation and also treats depression.

Bupropion:

• Increases dopamine and norepinephrine

• Reduces nicotine cravings

• Helps with withdrawal

• Also treats MDD (which he already has)

This makes it a very logical choice.

---

✅ Correct answer: Bupropion

It addresses:

• Smoking cessation

• Depression

• Dopamine support (helpful since he’s in recovery)

Six months after the last encounter, Daniel presents to his PCP and reports that he is doing well after starting therapy with buprenorphine-naloxone and reports no other opioid use. He states that he now wishes to stop his cigarette-smoking habit. 

History: opioid use disorder being treated with buprenorphine-naloxone, 1 ppd smoker for 7 years, MDD

Current medications: 16mg/4mg Suboxone daily, 40 mg duloxetine daily

Assessment and VS WNL

Why should the provider exercise caution when adding bupropion to Daniel’s current medication regimen?

1. Bupropion will decrease the effectiveness of the Suboxone

2. Combining bupropion with an SNRI can lower the seizure threshold

3. Buproprion causes severe sedation when taken with opioids

4. The combination leads to hypotension

Combining bupropion with an SNRI can lower the seizure threshold

Six months after the last encounter, Daniel presents to his PCP and reports that he is doing well after starting therapy with buprenorphine-naloxone and reports no other opioid use. He states that he now wishes to stop his cigarette-smoking habit. 

History: opioid use disorder being treated with buprenorphine-naloxone, 1 ppd smoker for 7 years, MDD

Current medications: 16mg/4mg Suboxone daily, 40 mg duloxetine daily

Assessment and VS WNL

Daniel decides to use nicotine gum as part of his cessation plan. Which instruction should the nurse include to ensure the medication is absorbed effectively?

1. “Chew the gum vigorously for 30 minutes to release all the nicotine at once.”

2. “Drink a cup of coffee or orange juice right before using the gum to help absorption.”

3. “Use the chew and park method: chew until you feel a tingle, then tuck the gum between your cheek and gum.”

4. “Swallow your saliva frequently to ensure the nicotine reaches your stomach quickly.”

“Use the chew and park method: chew until you feel a tingle, then tuck the gum between your cheek and gum.”

Six months after the last encounter, Daniel presents to his PCP and reports that he is doing well after starting therapy with buprenorphine-naloxone and reports no other opioid use. He states that he now wishes to stop his cigarette-smoking habit. 

History: opioid use disorder being treated with buprenorphine-naloxone, 1 ppd smoker for 7 years, MDD

Current medications: 16mg/4mg Suboxone daily, 40 mg duloxetine daily

Assessment and VS WNL

Before Daniel starts any NRT, which part of his physical assessment is most important for the nurse to re-evaluate?

1. Current weight and BMI

2. Bowel sounds and last bowel movements

3. His CV status, specifically any history of chest pain or arrhythmias

4. Pupillary reaction to light

1. His CV status, specifically any history of chest pain or arrhythmias