Chapter 18: Substance Use and Addictive Disorders

Chapter 18: Substance Use and Addictive Disorders

Repeated use of chemical substances

Causes clinically significant impairment within 12 months

Non-substance-related (behavioral/process) addictions:

• Gambling

• Sexual activity

• Shopping

• Social media

• Internet gaming

Characteristics

• Loss of control over use/behavior

• Continued use despite problems

• Relapse tendency (returning to use/behavior after attempts to stop)

Defense Mechanism: Denial

• Common in clients with substance use/addictive disorders

• Example: “I can quit whenever I want to, but smoking doesn’t cause me problems.”

• Denial → Prevents clients from seeking or accepting help

Related Substances

Alcohol

Caffeine

Cannabis

Hallucinogens

Inhalants

Opioids

Sedatives/hypnotics/anxiolytics

Stimulants

Tobacco

Other/unknown substances

Substance Use and Addictive Disorders Risk Factors

Genetics: Family history → predisposition to substance use disorder

Adolescents: Ongoing development of decision-making, judgment, and self-control

Chronic stress: Socioeconomic stressors

Trauma history: Abuse, combat exposure

Low self-esteem

Low tolerance for pain/frustration

Few meaningful relationships

Few life successes

Risk-taking tendencies

Substance Use and Addictive Disorders Protective Factors

Positive family support, relationships, and self-esteem

Caregiver involvement in child/adolescent activities

Access to community resources/programs

Employment

Substance Use and Addictive Disorders Expected Findings

Nursing History – Open-ended questions should cover

• Type of substance or addictive behavior

• Pattern and frequency of use

• Amount of substance used

• Age at onset of use

• Changes in occupational/school performance

• Changes in use patterns

• Periods of abstinence in history

• Previous withdrawal symptoms

• Date of last use/behavior

Review of Systems

• Blackout or loss of consciousness

• Bowel changes

• Weight loss or weight gain

• Stressful life situations

• Sleep problems

• Chronic pain

• Concern about substance use

• Attempts to cut down on use/behavior

Substance Use and Addictive Disorders Population-Specific Considerations

Highest risk group: Ages 18–25 → highest rate of substance use

Younger onset = higher risk for substance use disorder

Adolescents:

• Lower cocaine use

• ~50% report access to marijuana

Pregnant clients: Increased risk for infant complications → prematurity, low birth weight, neonatal abstinence syndrome

Healthcare providers: Vulnerable to drug diversion (workplace stress, access to drugs)

• Warning signs: volunteering for extra work, working on off days, poor appearance, mood swings, forgetting, lying

Older adults: Increased risk for falls, injuries, memory loss, headaches, and sleep changes

• Alcohol use in older adults → decreased self-care, incontinence, dementia-like symptoms

• Effects occur at lower doses than in younger adults

• Polypharmacy + age-related physiological changes → higher risk of confusion and falls

Substance Use and Addictive Disorders Standardized Tools

MAST: Michigan Alcohol Screening Test

DAST / DAST-A: Drug Abuse Screening Test (adult/adolescent versions)

CAGE Questionnaire: Identifies perception of current alcohol use

AUDIT: Alcohol Use Disorders Identification Test

CIWA-Ar: Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised

Clinical Opiate Withdrawal Scale

SBIRT: Screening, Brief Intervention, Referral to Treatment

• Included in routine wellness screenings

• Reduces risky drinking/related harms

• Promotes referrals to treatment

• Increases help-seeking for those in need

Substance Use and Addictive Disorders Sociocultural Theories

Alaska Native & Native American groups → higher alcohol use disorder rates

Asian groups → lower alcohol use disorder rates

Metabolism & cultural views: Alcohol metabolism and social norms affect use

Peer pressure & social factors: Increase likelihood of substance use

Older adults: May develop patterns of use related to stressors (e.g., retirement, loss, isolation)

A nurse is planning a staff education program on substance use in older adults. Which of the following information should the nurse to include in the presentation?

a

Older adults require higher doses of a substance to achieve a desired effect.​​​​​​​

b

Older adults commonly use rationalization to cope with a substance use disorder.​​​​​​​

c

Older adults are at an increased risk for substance use following retirement.​​​​​​​

d

Older adults develop substance use to mask manifestations of dementia.

c Older adults are at an increased risk for substance use following retirement.​​​​​​​

---

Requiring higher doses of a substance to achieve a desired effect is a result of the length and severity of substance use rather than age.

Denial, rather than rationalization, is a defense mechanism commonly used by substance users of all ages

Substance use in the older adult can result in manifestations of dementia.

Commonly Used Substances

Designer/club drugs (e.g., ecstasy): Combine substances → mixed intoxication/withdrawal effects

Prescription misuse: Opioids, CNS depressants, CNS stimulants → substance use disorder & drug-seeking behavior

Opioid Agonists

Central Nervous System (CNS) Depressants

Sedatives / Hypnotics / Anxiolytics

Cannabis

Central Nervous System (CNS) Stimulants

Amphetamines / Methamphetamines

Inhalants

Hallucinogens

Caffeine

Tobacco (Nicotine)

Tobacco (Nicotine)

Forms:

• Cigarettes/cigars (inhaled)

• Smokeless tobacco (snuffed or chewed)

Intended Effects

• Relaxation

• ↓ Anxiety

Effects of Intoxication

• Acute toxicity: Rare; usually only in children or with pesticide nicotine exposure

• Contains multiple toxic chemicals with long-term effects

• Long-term effects:

  • Cardiovascular disease: hypertension, stroke

  • Respiratory disease: emphysema, lung cancer

  • Smokeless tobacco: irritation of oral mucosa, oral cancer

Withdrawal Manifestations

• Irritability, craving, nervousness, restlessness

• Anxiety, insomnia, ↑ appetite

• Difficulty concentrating, anger, depressed mood

Caffeine

Sources: Cola, coffee, tea, chocolate, energy drinks

Intended Effects

• ↑ Alertness

• ↓ Fatigue

Effects of Intoxication

• Occurs with ingestion > 250 mg (≈ one 2 oz energy drink = 215–240 mg)

• Tachycardia, arrhythmias, flushed face, muscle twitching, restlessness

• Diuresis, GI disturbances, anxiety, insomnia

Withdrawal Manifestations

• Onset: within 24 hrs after last use

• Symptoms: Headache, nausea, vomiting, muscle pain, irritability, inability to focus, drowsiness

Hallucinogens

Examples: LSD, mescaline (peyote), PCP
Route: Usually oral, can be injected or smoked

Intended Effects

• Heightened sense of self

• Altered perceptions (e.g., colors more vivid)

Effects of Intoxication

• Anxiety, depression, paranoia

• Impaired judgment, impaired social functioning

• Pupil dilation, tachycardia, diaphoresis, palpitations

• Blurred vision, tremors, incoordination, panic attacks

Withdrawal Manifestations

• Hallucinogen Persisting Perception Disorder: Visual disturbances or flashbacks, may recur intermittently for years

Inhalants

Examples: Amyl nitrate, nitrous oxide, solvents

Use: Sniffed, huffed, or bagged (often by adolescents)

Intended Effects

• Euphoria

Effects of Intoxication

• Behavioral/psychological changes

• Dizziness, nystagmus, uncoordinated movements/gait, slurred speech

• Drowsiness, hyporeflexia, muscle weakness, diplopia, stupor/coma

• Respiratory depression, possible death

Withdrawal Manifestations

• None

Amphetamines / Methamphetamines

Route: Oral, IV, or smoked

Intended Effects

• ↑ Energy, euphoria (similar to cocaine)

Effects of Intoxication

• Impaired judgment, psychomotor agitation, hypervigilance, irritability

• Acute cardiovascular effects (tachycardia, hypertension) → can cause death

Withdrawal Manifestations

• Craving, depression, fatigue, sleeping

• Not life-threatening

Central Nervous System (CNS) Stimulants

Route: Injected, smoked, or inhaled (snorted)

Intended Effects

• Euphoria, pleasure, ↑ energy

Effects of Intoxication

• Mild: Dizziness, irritability, tremor, blurred vision

• Severe: Hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, cardiovascular collapse, death

Withdrawal Manifestations

• Depression, fatigue, craving

• Excessive sleep/insomnia, unpleasant dreams

• Psychomotor retardation, agitation

• Not life-threatening, but suicidal ideation possible

Cannabis

Forms: Marijuana, hashish (more potent) → smoked or orally ingested

Intended Effects

• Euphoria, sedation, hallucinations

• ↓ Nausea/vomiting (esp. chemotherapy patients)

• Chronic pain management

Effects of Intoxication

• Chronic use: Respiratory risks, impaired performance in daily activities

• High doses → paranoia (delusions, hallucinations)

• Increased appetite, dry mouth, tachycardia

• Impaired motor skills (8–12 hrs) → unsafe driving, machinery use

• Synthetic cannabinoids (K2, Spice) = highly toxic, more potent

Withdrawal Manifestations

• Irritability, aggression, anxiety, insomnia

• Loss of appetite, restlessness, depressed mood

• Abdominal pain, tremors, diaphoresis, fever, headache

Sedatives / Hypnotics / Anxiolytics

Examples: Benzodiazepines (diazepam), barbiturates (pentobarbital), club drugs (flunitrazepam “date rape drug”)

Intended Effects

• ↓ Anxiety, sedation

Effects of Intoxication

• Drowsiness, sedation, agitation

• Slurred speech, uncoordinated motor activity, nystagmus, disorientation

• Nausea, vomiting

• Respiratory depression, ↓ LOC → can be fatal

• Antidote: Flumazenil (for benzodiazepine toxicity)

• No antidote for barbiturate toxicity

Withdrawal Manifestations

• Anxiety, insomnia, diaphoresis, hypertension

• Possible psychotic reactions

• Hand tremors, nausea, vomiting

• Hallucinations/illusions, psychomotor agitation

• Possible seizure activity

Central Nervous System (CNS) Depressants

Cause psychological/physiological dependence

Cross-tolerance, cross-dependency, additive effects when combined

Alcohol (Ethanol)

• Legal intoxication: BAC ≥ 0.08% (80 mg/dL)

• Toxicity risk: BAC > 0.4% (400 mg/dL) → possible death

• BAC influenced by body weight, gender, alcohol concentration, # of drinks, gastric absorption, tolerance

• Fetal alcohol syndrome: Microcephaly, craniofacial malformations, limb/heart defects, developmental problems

Intended Effects

• Relaxation, ↓ social anxiety, stress reduction

Effects of Intoxication

• Acute: Slurred speech, nystagmus, impaired memory/judgment, ↓ motor skills, ↓ LOC (stupor/coma), respiratory arrest, collapse, death (large doses)

• Chronic: Cardiovascular damage, liver damage (fatty liver → cirrhosis), erosive gastritis, GI bleeding, acute pancreatitis, sexual dysfunction

Withdrawal Manifestations

• Symptoms: Abdominal cramping, vomiting, tremors, insomnia, ↑ HR, hallucinations/illusions, anxiety, ↑ BP, ↑ RR, ↑ temp, seizures

• Alcohol withdrawal delirium: 2–3 days after cessation; medical emergency → hallucinations, severe hypertension, dysrhythmias, delirium, can progress to death

Opioid Agonists

Attach to CNS receptors → alter pain perception, cause CNS depression

Classified as Schedule II (Controlled Substances Act)

Examples: Heroin, morphine, hydromorphone (routes: injection, smoking, inhalation, swallowing)

Intended Effects

• Euphoria ("rush"), pain relief

Effects of Intoxication

• Slurred speech, impaired memory, pupillary changes

• Respiratory depression, ↓ LOC → can cause death

• Maladaptive behavior/psychological changes (impaired judgment, poor functioning)

• Antidote: Naloxone (IV)

Withdrawal Manifestations

• Sweating, rhinorrhea → piloerection (gooseflesh), tremors, irritability

• Severe: diarrhea, fever, insomnia, dilated pupils, nausea/vomiting, muscle aches, spasms

• Withdrawal is very unpleasant but not life-threatening

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?

Select all that apply.

a

Bradycardia​​​​​​​

b

Fine tremors of both hands​​​​​​​

c

Decreased blood pressure ​​​​​​​

d

Vomiting​​​​​​​

e

Restlessness

b Fine tremors of both hands​​​​​​​

d Vomiting​​​​​​​

e Restlessness

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority?

a

Orient the client frequently to time, place, and person.​​​​​​​

b

Offer fluids and nourishing diet as tolerated.​​​​​​​

c

Implement seizure precautions.​​​​​​​

d

Encourage participation in group therapy sessions.

c Implement seizure precautions.​​​​​​​

Substance Use and Addictive Disorders Nursing Care

Nurse’s personal views/culture/history can affect care → must self-assess & remain objective, nonjudgmental

Primary focus: Safety during acute intoxication or withdrawal

• Maintain safe environment (fall/seizure precautions)

• Close observation for withdrawal (1:1 if needed; restraints = last resort)

• Orient to time, place, person

• Maintain adequate nutrition & fluids

• Create low-stimulation environment

• Administer prescribed meds (for intoxication/withdrawal; may include substitution therapy)

• Monitor for covert substance use during detox

Additional Nursing Interventions

• Provide emotional support & reassurance to client/family

• Educate about addiction, abstinence goal, and codependent behaviors

• Instruct on safe medication management (remove unused meds, no sharing)

• Promote motivation & commitment for abstinence/recovery (personal growth, self-discovery)

• Encourage self-responsibility

• Help client develop emergency plan (contacts/resources if needed)

• Encourage participation in self-help groups

Substance Use and Addictive Disorders Interprofessional Care

Dual Diagnosis (Comorbidity):

• Client has both a mental health disorder (e.g., depression) and a substance use/addictive disorder

• Both must be treated simultaneously with a team approach

Individual Psychotherapies

• CBT: Relaxation techniques, cognitive reframing → ↓ anxiety, promote behavior change

• ACT (Acceptance & Commitment Therapy): Promotes acceptance of experiences & commitment to positive behavior change

• Relapse Prevention Therapy: Helps client identify relapse potential & promotes self-control

Group Therapy

• Clients with similar diagnoses meet in outpatient or residential settings

Family Therapy

• Identifies codependency → family/significant others enable addictive behavior (e.g., covering for client at work)

• Helps family change enabling patterns

• Families learn about substance effects

• Families educated on coping, problem-solving, relapse signs, support groups

---

Client Education

• Teach relapse indicators & contributing factors

• Teach CBT techniques → maintain sobriety, create pleasure from non-substance activities

• Develop communication skills (family, coworkers, sober relationships)

• Encourage participation in 12-step programs:

  • Alcoholics Anonymous (AA)

  • Narcotics Anonymous

  • Gamblers Anonymous

  • Family groups (Al-Anon, Alateen)

Core Teachings of 12-Step Programs

• Abstinence = necessary for recovery

• Reliance on higher power

• Clients are responsible for recovery, not for their illness

• Others cannot be blamed for client’s disorder; clients must acknowledge their problems

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol?

a

Chlordiazepoxide​​​​​​​

b

Bupropion​​​​​​​

c

Disulfiram​​​​​​​

d

Carbamazepine

c Disulfiram​​​​​​​

---

Chlordiazepoxide is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol.

Bupropion is indicated for nicotine withdrawal rather than to maintain abstinence from alcohol.

Carbamazepine is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol.

A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicates an understanding of the teaching?

Select all that apply.

a

“We need to understand that our sibling is responsible for their disorder.”​​​​​​​

b

“Eliminating codependent behavior will promote recovery.”​​​​​​​

c

“Our sibling should participate in an Al-Anon group to assist with recovery.”​​​​​​​

d

“The primary goal of treatment is abstinence from substance use.”​​​​​​​

e

“Our sibling needs to discuss personal feelings about substance use to help with recovery.”

b “Eliminating codependent behavior will promote recovery.”​​​​​​​

d “The primary goal of treatment is abstinence from substance use.”​​​​​​​

e “Our sibling needs to discuss personal feelings about substance use to help with recovery.”

---

Al-Anon is a recovery group for the family of a client, rather than the client who has a substance use disorder.

Abstinence Syndrome

Occurs when a client abruptly withdraws from a substance on which they are physically dependent

Tolerance: Client requires ↑ amounts of substance for desired effect

Withdrawal: Substance concentration ↓ in bloodstream → adverse physiological effects

Certain substances can cause life-threatening withdrawal symptoms

ETOH Withdrawal Manifestations

Onset: 4–12 hrs after last drink; lasts 5–7 days

Common symptoms:

• Nausea, vomiting, tremors, restlessness, insomnia

• Depressed mood, irritability

• ↑ HR, BP, RR, temp

• Diaphoresis

• Tonic-clonic seizures, illusions

Delirium (2–3 days post-cessation) = medical emergency

• Severe disorientation

• Hallucinations, psychosis

• Severe hypertension

• Cardiac dysrhythmias

• Can progress to death

Alcohol Withdrawal Delirium

(2–3 days post-cessation) = medical emergency

• Severe disorientation

• Hallucinations, psychosis

• Severe hypertension

• Cardiac dysrhythmias

• Can progress to death

Opioid Withdrawal Manifestations

Onset: Within hours to several days post-cessation

Symptoms: Agitation, insomnia, flu-like symptoms, rhinorrhea, yawning, sweating, diarrhea

Not life-threatening, but suicidal ideation can occur

Tobacco (Nicotine) Withdrawal Manifestations

Irritability, nervousness, restlessness, anxiety, insomnia, ↓ concentration, anger, depressed mood

EOTH Withdrawal Medications

Benzodiazepines

Examples: Chlordiazepoxide, Diazepam, Lorazepam, Oxazepam

Intended Effects

• Maintain vital signs within expected range

• ↓ Seizure risk

• ↓ Intensity of withdrawal symptoms

• Used for substitution therapy during withdrawal

Nursing Actions

• Administer scheduled or PRN

• Obtain baseline vital signs

• Ongoing monitoring of vitals & neurologic status

• Provide seizure precautions

Adjunct Medications

Examples: Carbamazepine (Mood Stabilizer Antiepileptic), Clonidine, Propranolol, Atenolol (Beta Blockers)

Intended Effects

• ↓ Seizures: Carbamazepine

• ↓ Autonomic hyperactivity (BP, HR): Clonidine, Propranolol, Atenolol

• ↓ Cravings: Propranolol, Atenolol

Nursing Actions

• Implement seizure precautions

• Obtain & monitor baseline vital signs

• Check HR prior to propranolol (withhold if < 60 bpm)

Abstinence Maintenance (Following Withdrawal) Medications (DNA)

DNA requires abstaining alcohol and maintaining water

Disulfiram

Intended Effects

• Daily oral aversion therapy

• When taken with alcohol → causes acetaldehyde syndrome:

  • Nausea, vomiting, weakness, sweating, palpitations, hypotension

  • Can progress to: respiratory depression, cardiovascular collapse, seizures, death

Nursing Actions

• Monitor liver function (risk: hepatotoxicity)

Client Education

• Drinking alcohol = dangerous

• Avoid alcohol-containing products (cough syrup, aftershave, mouthwash, hand sanitizer)

• Wear medical alert bracelet

• Participate in self-help program

• Effects persist 2 weeks after discontinuation

Naltrexone

Intended Effects

• Pure opioid antagonist → suppresses craving & pleasurable effects of alcohol

• Also used for opioid withdrawal

Nursing Actions

• Assess history for concurrent opioid use (↑ toxicity risk)

• Consider monthly IM depot injections for adherence

Client Education

• Take with meals (↓ GI distress)

Acamprosate

Intended Effects

• Taken orally 3x daily → reduces unpleasant abstinence symptoms (dysphoria, anxiety, restlessness)

Client Education

• May cause diarrhea → encourage fluid intake

• Avoid in pregnancy

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should expect prescriptions for which of the following medications to promote long-term abstinence from alcohol?

Select all that apply.

a

Lorazepam

b

Diazepam

c

Disulfiram

d

Naltrexone

e

Acamprosate

c Disulfiram

d Naltrexone

e Acamprosate

---

Diazepam is prescribed for short-term use during withdrawa

Lorazepam is prescribed for short-term use during withdrawal.

Opioid Withdrawal Medications (MCB)

Do not use opioids for MCBurney’s point pain (appendicitis) or risk a misdiagnosis

Methadone Substitution

Intended Effects

• Oral opioid agonist that replaces illicit opioid dependence

• Prevents abstinence syndrome & reduces need for illegal opioid use

• Used for withdrawal and long-term maintenance

• Transfers dependence from illegal opioid → methadone

Nursing Actions

• Encourage participation in a 12-step program

• Methadone must be tapered slowly for detoxification

• Must be administered from an approved treatment center

Clonidine

Intended Effects

• Reduces autonomic withdrawal symptoms: diarrhea, nausea, vomiting

• Does not reduce opioid cravings

Nursing Actions

• Obtain baseline vital signs

Client Education

• Avoid activities requiring alertness until drowsiness subsides

• Use sugarless gum/hard candy & small amounts of water for dry mouth

Buprenorphine

Intended Effects

• Agonist-antagonist opioid used for withdrawal & maintenance

• ↓ Cravings, ↑ treatment compliance

• FDA-approved in several forms (some with naloxone):

  • Sublingual tablets, buccal film, surgical skin implant

Nursing Actions

• Can be prescribed by a primary care provider (unlike methadone)

• Administer sublingually

Antidotes

Naloxone

• Specific opioid antagonist

• Routes: IM, SQ, IV, inhalation

• Reverses: respiratory depression, coma, other effects of opioid toxicity

Flumazenil

• Competitive benzodiazepine receptor antagonist

• Reverses sedative effects & toxicity

• Administered IV

Non-NRT Nicotine Withdrawal Medications

Bupropion

Intended Effects

• ↓ Nicotine craving

• ↓ Withdrawal manifestations

Client Education

• Dry mouth: treat with sugarless gum, ice chips, hard candy, sips of water

• Avoid caffeine & CNS stimulants (prevent insomnia)

Varenicline

Intended Effects

• Nicotinic receptor agonist → releases dopamine

• ↓ Cravings & withdrawal severity

• ↓ Relapse (blocks pleasurable nicotine effects)

Nursing Actions

• Monitor BP, glycemic control (esp. in diabetics)

• Titrate carefully to reduce adverse effects

• Risk: neuropsychiatric effects (mood swings, suicidal ideation)

• Contraindicated: truck/bus drivers, pilots, air traffic controllers (safety risk)

Client Education

• Take after meals

• Report nausea, insomnia, depression, or suicidal thoughts

Nicotine Replacement Therapy (NRT)

Forms: Gum, patch, nasal spray, lozenges, inhaler

Intended Effects

• Provides controlled nicotine substitution

• Nearly doubles quit rate

• Inhaler simulates smoking behavior

Nursing Actions

• Nasal spray = rapid nicotine rise → similar to smoking

• Avoid spray if sinus/allergy/asthma problems

• Gradually taper inhaler use over 2–3 months

• Contains menthol → throat sensation like smoking

---

Client Education

Nicotine Gum

• Chew slowly/intermittently for 30 min

• Avoid eating/drinking 15 min before & during

• Not recommended > 6 months

Nicotine Patch

• Apply to clean/dry skin daily

• Remove at bedtime (applied AM, removed ~16 hrs later)

• Nightmares/sleep disturbance possible

• Avoid nicotine while using patch

• Remove patch before MRI

Nicotine Spray

• 1 spray/nostril ≈ nicotine of 1 cigarette

• Follow dosage instructions

Nicotine Lozenges

• Avoid food/drink 15 min prior/during use

• Dissolve slowly (20–30 min)

• Max: 5 lozenges/6 hrs or 20/day

Electronic Cigarettes (E-Cigs)

Not recommended: nicotine dose unpredictable, safety/efficacy lacking

Nursing Evaluation of Withdrawal Medication Effectiveness

No injury

Ongoing abstinence from substance

Regular attendance at 12-step program

Decreased cravings

Improved coping skills