Substance Use Disorder

CMH Wk 8

Substance Use Disorder Categories

Alcohol

Illicit drugs

Tobacco

Caffeine

Inhalants

Process addictions:  gambling, shopping, internet, gaming

Substance Use Disorder Common Patient Problems

Impaired control over use

Preoccupation with use (priorities become out of order)

Use despite adverse consequences

• Physical health problems

• Psychological functioning

• Interpersonal functioning

• Occupational functioning

• Legal, financial, or spiritual problems

Neurobiological Factors for Substance Abuse

Dopamine is the primary one — drives reward, motivation, and reinforcement. Repeated substance use floods the reward pathway, but over time the brain downregulates dopamine receptors, meaning less pleasure from everyday life and a need for more of the substance to feel the same effect (tolerance).

Serotonin regulates mood, impulse control, and emotional wellbeing. Disruptions contribute to depression, anxiety, and impulsivity — all of which can both drive substance use and result from it.

GABA is the brain's main inhibitory neurotransmitter. Alcohol, benzodiazepines, and opioids enhance GABA activity, producing sedation and anxiety relief. With chronic use the brain compensates by reducing its own GABA activity, which is why withdrawal from these substances can be medically dangerous.

Glutamate is the main excitatory neurotransmitter and is critical in learning, memory, and craving. It plays a major role in the environmental associations and triggers discussed in your slide — essentially encoding the "memories" of drug use.

Norepinephrine drives the stress response. During withdrawal it becomes overactive, contributing to anxiety, agitation, elevated heart rate, and hypertension — particularly significant in opioid and alcohol withdrawal.

Endogenous opioids (endorphins) are the brain's natural pain and pleasure regulators. Opioid drugs mimic these directly, and chronic use suppresses the brain's own production, which underlies much of the emotional pain and dysphoria seen in withdrawal.

Substance Abuse Predisposing Factors

Neurobiological

Genetics - No single gene, but up to 40% of propensity can be attributed to genetics – ex: biological changes in dopamine pathways.

Psychological

• Childhood trauma

• Mental health factors

Environmental factors

Substance Abuse and Psychiatric Comorbidity

50% of people with a serious mental illness have a substance use disorder some time in their lives

Suicide risk is 3-4 times higher with alcohol comorbidity

Relapse can lead to decompensation in the psychiatric problem

Some psychiatric disorders associated with substance abuse:

• Attention deficit disorder

• Borderline and antisocial personality disorder

• Anxiety disorder

• Depression

• Eating disorder

Alcohol Effects on CNS

CNS Depressant:

• SLOWS everything down

• Relaxation

• Less self-conscious

• Loss of coordination

• Increases sleepiness

• Slows breathing

• Lowers body temperature

Binge drinking Definition

5+ drinks on one occasion 5 or more days out of 30

Heavy Drinking Definition

8+ drinks per week for women

15+ drinks per week for men

Alcoholic Intoxication S/S

• Slurred speech

• Uncoordinated

• Unsteady gait

• Nystagmus

• Impaired attention/memory

Blood Alcohol Concentration Complications

DSM-5 Diagnostic Criteria: Substance (e.g., Alcohol) Use Disorder

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by 2 of the following, occurring within a 12-month period:

1.Alcohol is often taken in larger amounts or over a longer period than was intended.

2.There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

3.A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

4.Craving, or a strong desire or urge to use alcohol.

5.Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

6.Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

7.Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

8.Recurrent alcohol use in situations in which it is physically hazardous.

9.Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

10.Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.

11.Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol.
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

DSM-5 Criteria Alcohol Abuse Severity

Mild - 2-3 Symptoms

Moderate - 4-5 Symptoms

Sever - 6 or more Symptoms

Alcohol Acute Complications

Respiratory Depression

Aspiration

Cardiac Arrythmias

Injuries

Alcohol Poisoning

Chronic Complications

• Peripheral Neuropathy

• Alcoholic Cardiomyopathy

• Gastrointestinal Issues

• Neurologic consequences

• Esophagitis

• Pancreatitis

• Fatty Liver

• Cirrhosis of the Liver

• Leukopenia

• CVA

• Cancer

• Malnutrition

• Wernicke’s Encephalopathy

• Korsakoff Syndrome

Wernicke’s Encephalopathy Definition

an acute, life-threatening neurological medical emergency caused by a severe deficiency of vitamin B1 (thiamine).

Wernicke’s Encephalopathy S/S

a medical emergency presenting with confusion, memory loss, poor coordination, and nystagmus

Wernicke’s Encephalopathy Treatment

IV thiamine

Other Supplements - multivitamin, folic acid

Korsakoff Syndrome

Occurs if wernicke’s encephalopathy goes untreated

an irreversible brain disorder characterized by severe memory impairment, confabulation, and disorientation.

Alcohol Withdrawal Pathophysiology

Brain adapts to CNS depression leading to tolerance

Stopping consumption abruptly, depression effect is no longer present and causes profound rebound in excitation of CNS

Other changes in CNS occur in the function neuro transmitters

Alcohol Withdrawal Timing

can start 6-36 hours after last drink

Severe Alcohol Withdrawal Risks

• Seizures

• Hallucinations

• Delirium Tremens (DTs)

Delirium tremens (DTs)

the most severe form of alcohol withdrawal and a medical emergency. It typically occurs 48–72 hours after the last drink and is potentially fatal without treatment.

presents with severe agitation, hallucinations (visual, auditory, or tactile), profound confusion, seizures, and dangerous autonomic instability — fever, rapid heart rate, and hypertension

It is caused by the brain going into a hyperexcitable state after being chronically suppressed by alcohol.

Treatment requires close monitoring, benzodiazepines, and often ICU-level care.

CIWA-Ar Aspects

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised

• Nausea and Vomiting

• Tremors

• Paroxysmal Sweats

• Anxiety

• Tactile Disturbances

• Auditory Disturbances

• Visual Disturbances

• Headache, Fullness in Head

• Agitation

• Orientation and Clouding of Sensorium

Patients often underreport alcohol use, so withdrawal symptoms can be mistaken for other things – medication, hypoxia, lack of sleeps, other mental health disorders

Alcohol Withdrawal Nursing Interventions

Safety

VS

Sleep

Nutrition/supplements

• Multivitamin

• Thiamine

• Folic acid

Supportive Environment

Therapeutic Relationship

Alcohol Withdrawal Pharmacologic Interventions

Benzodiazepines

• diazepam

• lorazepam

• chlordiazepoxide

Anticonvulsants

Alcohol Abuse Therapies

• Psychotherapy

• Rehabilitation

• Halfway Houses

• Partial Hospitalization Programs

• Intensive Outpatient Programs

• Outpatient Therapy

• Support Groups

• Peer support

Disulfiram (Antabuse)

• used as a deterrent to drinking

• ingestion of alcohol while taking causes symptoms such as flushed skin, throbbing in head and neck, respiratory difficulty, NV, palpations, High HR, Dizziness, weakness, Anxiety

• same symptoms occur when using products with alcohol (e.g. mouthwash with alcohol, some cough syrups, hand sanitizer absorbed through skin, and even certain foods and sauces.)

Naltrexone (Revia)

also used for heroin abuse, works on the same receptors as heroin without the high; effective with alcohol also

Acamprosate (Camprel)

used in the maintenance of abstinence, mechanism of action not clearly understood

Topiramate (Topamax)

used to decrease craving for alcohol.

Cannabis Effects

Depressant and hallucinogenic properties

• Desired effect: euphoria, detachment, relaxation

• Other effects: talkativeness, slowed perception of time, inappropriate hilarity, heightened sensitivity to external stimuli, anxiety, and paranoia

• Long-term effects: lethargy, anhedonia, difficulty concentrating, loss of memory

Tolerance and physical addiction can occur

Cannabis Withdrawal Symptoms

irritability, anger, aggression, anxiety, sleep problems, restlessness, depression, abdominal pain

Cannabis Withdrawal Treatment

May use benzodiazepines to treat anxiety during withdrawal

Common Sedative, Hypnotic, or Anxiolytics

•Benzodiazepines

Club drugs included in this category

•GHB and flunitrazepam (Rohypnol)

Sedative, Hypnotic, or Anxiolytics Symptoms of Intoxication

Sedation, drowsiness, slurred speech, confusion, impaired coordination, respiratory depression

Sedative, Hypnotic, or Anxiolytics Withdrawal Symptoms

sweating, increased pulse, hand tremors, insomnia, nausea, vomiting, psychomotor agitation, anxiety or grand mal seizure

Common Stimulants

Amphetamines

cocaine

More potent stimulants “bath salts”, illegal substance with reports of violent behaviors associated with use

Stimulant Effects

• Used to relieve fatigue and increase alertness

• high abuse potential, capable of exciting entire nervous system

• Produce tremors, restlessness, anorexia, insomnia, agitation, increased motor activity

Stimulants Intoxication S/S

• euphoria or affective blunting

• changes in sociability

• anxiety, anger, impaired judgment

• cardiac arrhythmias

• confusion, insomnia

Stimulant Withdrawal

fatigue and depression, dysphoric mood, irritability, difficulty concentrating, restlessness, anxiety, anger

Treatment should focus on maintaining a quiet setting providing time for sleep and nutrition

Common Opioids

Morphine, codeine, opium, heroin, oxycodone, meperidine , fentanyl

Opioid Effects

euphoria, mood changes, mental cloudiness, drowsiness, and pain reduction

Opioid Intoxication Symptoms

apathy, dysphoria, impaired judgment, slurred speech, respiratory depression, coma, death

Opioid Withdrawal

Begins 6-8 hours after last dose, most intense day 2-3

Early: anxiety, muscle aches, tearing or runny nose, sweating, insomnia, yawning

Later: dilated pupils, N/V/D, muscle twitching or jerking (hyperreflexia), abdominal cramps

Also: irritability, agitation, cravings

Naloxone (Narcan)

Treat Opioid Intoxication

Methadone and buprenorphine

treat opioid use disorder (OUD)

Binds to the brains mu-opioid receptors to reduce cravings and withdrawal symptoms without producing a "high." 

Methadone is a full agonist providing consistent, long-acting receptor activation

Buprenorphine is a partial agonist with a "ceiling effect" for safer,, more flexible dosing

Clonidine

used to treat withdrawal symptoms of Opioids along with rest and nutrition

Hallucinogens Effects

Altered mental status within short period of time, induce hallucinations

No evidence of physical addiction, but psychological addiction; use is generally episodic, and tolerance develops quickly

N/V, chills, increased P, BP, T, dizziness, trembling, loss of appetite, insomnia; heightened response to color and sounds, body awareness, distortion of vision, slowing of time, feeling magnified, fear of losing control, paranoia, depersonalization, derealization,

Hallucinogens Intoxication S/S

anxiety, depression, ideas of reference, fear of losing one's mind, paranoid ideas, impaired judgment, impulsiveness

Common Inhalants

Spray paints

Glue

cigarette lighter fluid

Aerosols

typewriter correction fluid

Inhalants Effects

Quick high; drug choice of poor people, children and young adults

Initial excitability followed by drowsiness; “huffing” or “bagging”

Lightheadedness, loss of inhibition, hallucinations

Watch for: unusual breath odor, slurred speech, dazed, paint on the person, red and runny eyes, mouth sores, pen or marker on mouth, coughing

Inhalants Intoxication Symptoms

dizziness, ataxia, excitation disinhibition, blurred vision, slurred speech, lethargy, generalized muscle weakness, stupor, coma