Substance Use Disorders

What are the categories of SUD symptoms?

• Impaired Control

  • Using more of a substance or more often than intended

  • Wanting to cut down or stop using but not being able to

• Social Problems

  • Neglecting responsibilities and relationships

  • Giving up activities they used to care about because of their substance use

  • Inability to complete tasks at home, school, or work

• Risky Use

  • Using in risky settings

  • Continued use despite known problems

• Physical Dependence

  • Needing more of the substance to get the same effect (tolerance)

  • Having withdrawal symptoms when a substance isn’t used

What is abuse?

Impaired control over engaging in substance use (or other reward-seeking behavior, such as gambling) despite suffering severe harms caused by such activity.

What is addiction?

Persistent and increased use of a substance or behavior that, when discontinued, causes distress and an urge to resume use despite related adverse consequences; known as psychological dependence

What is dependence?

Repeated use of a substance for physical needs leading to increased tolerance, and when discontinued, results in physical withdrawal symptoms.

What is detoxification?

The process focused on treating the physical effects of withdrawal from substance use and achieving metabolic stabilization (can occur in rehab, at home, in jail, etc.)

What is relapse?

Recurrence of substance use after a person gone through detox or rehab

What is sobriety?

State in which one is not intoxicated or affected by the use of alcohol or drugs (temporary or sustained)

What is tolerance?

A need to increase the dosage of a drug over time to obtain the same original effect obtained at a lower dose

What is use?

Ingestion, smoking, sniffing, or injection of mind-altering substance

What is withdrawal?

Physical, cognitive, and affective symptoms that occur after chronic use of a drug is reduced abruptly or stopped among individuals who have developed tolerance to a drug

What are the risk factors of substance abuse?

• 1^st degree relative with substance use disorder

• Mental health disorders

• Gender (males at higher risk)

• High ACEs

• Social circumstances & susceptibility to peer pressure

• Availability of the substance

• Racial statistics

  • Less common in Asian Americans

  • More common in First Nation Americans & Alaska Natives

What is the neurobiology of substance abuse?

• Substance use increases the dopamine released

• Feedback mechanisms create more dopamine receptors to “catch” the dopamine

• Greater number of dopamine receptors means we need more baseline dopamine -> cravings!

• Things other than substance use don’t meet dopamine threshold

What did rats teach us about addiction?

• Addiction is reversible

• Community, social interaction, and activity may be protective factors against addiction

• Hopelessness, isolation, and boredom may prompt substance use

• Availability of a substance does not guarantee compulsive use, when other activities are available

What are the life-threatening signs of alcohol poisoning?

• Inability to wake up

• Vomiting

• Slow breathing (fever than 8 breaths per minute)

• Irregular breathing (10 seconds or more between breaths)

• Seizures

• Hypothermia (low body temperature), bluish skin color, and paleness

What is the alcohol effect on body systems?

• CV: Cardiomyopathy, CHF, hypertension

• Respiratory: Increased rate, pneumonia, and other respiratory infections

• Hematologic: Anemia, leukemia, hematomas

• Nervous: Withdrawal symptoms, nervousness, irritability, diminished brain size and functioning

• GI/Nutrition deficiency: Liver disease, pancreatitis, esophageal varices, cancer of upper GI tract, alcohol amnestic disorder, scurvy

• Endocrine: Increased risk of diabetes, hyperlipidemia, gout

• Immune: Impaired immune functioning, higher incidence infectious disease, including TB

• Integumentary: Skin lesions, infections, burns

• Musculoskeletal: Increased incidence of traumatic injury, myopathy

• Genitourinary: Hypogonadism, increased secondary female sexual characteristics in men, erectile dysfunction

What are the lab indicators of alcohol dependency?

• Liver enzymes elevated (AST, ALT, GGT)

• MCV elevated; PT elevated

• Hyponatremia and hyperkalemia

• Total cholesterol & triglycerides elevated

• Amylase (pancreatic enzyme) elevated

• Homocysteine elevated.

What to know about detoxification?

• Detox is needed after long-term heavy drinking

• Withdrawal syndrome: symptoms occur within 12 hours of last ETOH.

• Severe symptoms: DT’s or delirium tremens: autonomic hyperarousal, disorientation, hallucinations, tremors, tonic-clonic seizures (seizures occur within first 48 hours of withdrawal)

What are the symptoms of alcohol withdrawal?

• Early Withdrawal:

  • Anxiety; psychomotor; tremors; diaphoresis; restlessness; nausea; vomiting; increased HR, BP, and T; impaired concentration and memory; increased sensitivity to sound and light; insomnia; headache

  • Onset; 6-24 hr; peaks 24-36 hr

  • Usually lasts hours to days

  • Can last 2 weeks

• Seizures:

  • Generally major motor seizures

  • Onset: 8-24 hr; peak 24 hr

  • Usually lasts up to 1 day

  • Can last 2 weeks

• Severe Withdrawal/DTs:

  • Medical emergency; disorientation; delusions (usually paranoid type); visual hallucinations; continuation of early withdrawal symptoms but much more pronounced

  • Onset: 3-5 days

  • Lasts 2-3 days

  • Confusion can last up to 50 days

What are the medications for ETOH withdrawal?

• Benzodiazepines substitute for alcohol.

• Chlordiazepoxide (Librium) and Diazepam (Valium) for smoother tapers (These have longer half lives than other benzo’s)

• Lorazepam (Ativan) better for older adults and those with liver impairment

• Sleep medications to promote regular sleep pattern

• Can use antipsychotics if needed

What is included in the health promotion for alcohol withdrawal?

• Adequate nutrition & hydration

• Need thiamine during detoxification, given to decrease ataxia

• Need folic acid to correct folic acid deficiency

• Magnesium sulfate enhances body’s response to thiamine and reduces seizures

What are the alcohol-induced amnestic disorder?

• Wernicke encephalopathy: thiamine deficiency, vision impairment, ataxia, hypotension, confusion, coma

• Korsakoff’s amnestic syndrome: heart, vascular, nervous systems. Affects ability to acquire new information. Affects ability to retrieve memories.

• Wernicke-Korsakoff syndrome: Wernicke is acute phase, Korsakoff chronic phase

What to know about sustained sobriety and prevention of relapse?

• Psychosocial: self-help groups, psychoeducation, cognitive behavioral therapy

• Biologic: Medications

  • Disulfiram (Antabuse) deters from drinking.

    • Will cause side effects with even small amounts of ETOH, including flushing, headache, copious vomiting.

    • Helps disconnect the dopamine rush from the alcohol use in the amygdala so that the individual doesn’t associate drinking with positive feelings – rewrites the memories and associates alcohol with negative feelings.

  • Naltrexone can reduce craving ETOH, can help maintain abstinence, can interfere with tendency to want to drink more

What to know about cocaine?

• Stimulants

• Biologic Responses:

  • Rapidly absorbed through blood-brain barrier. Readily absorbed through skin and mucous membranes. Rapid intoxication with injection or inhalation. Increases dopamine, serotonin, and norepinephrine availability; blocks neurotransmitter reuptake.

  • Increased dopamine = euphoria and psychosis.

  • Increased serotonin = anorexia and sleep disturbances.

  • Increased norepinephrine = tachycardia, hypertension, dilated pupils, rising temperature.

What is the difference between cocaine and crack?

• Cocaine

  • An addictive stimulant drug that comes in a powdered form. Individuals who abuse cocaine (coke) typically snort the drug, however, it can be smoked or intravenously injected when an individual alters its form

  • Characteristics

    • More common to be abused by users

    • More expensive compared to crack cocaine

  • Health Effects

    • Fast heart rate

    • Constricted blood vessels

    • Enlarged heart

    • Heart attacks

    • Cardiac arrest

• Crack Cocaine

  • Crack-cocaine, or crack, is a free base form of cocaine that can be smoked. Crack is a derivative of cocaine, as it is created by mixing a few substances together

  • Characteristics

    • Fast-acting drug than cocaine

    • More dangerous and addictive than cocaine

    • Crack is generally inexpensive drug when compared to cocaine due to its potential for impurity

  • Health Effects

    • Stroke

    • Heart Failure

    • Paranoia

    • Seizures

    • Anxiety

    • Coke bugs

    • Death from respiratory failure

    • Stimulant induced psychosis

• Cocaine plus ETOH can be lethal combination: taken together they form cocaethylene, which has longer duration of action in the brain; more toxic than either drug individually.

What is cocaine intoxication?

CNS stimulation, then depression.  Restlessness, tremors, agitation, convulsions, psychosis, euphoria

What is cocaine overdose?

Cardiac arrhythmias/arrest, seizures, respiratory depression, psychosis. (Table 31.1, p. 574) Lethal dose: respiratory failure and death.

What is cocaine withdrawal?

• Severe anxiety, restlessness, psychomotor retardation then agitation.  Severe dysphoria, unpleasant dreams, insomnia. Long-term use depletes norepinephrine,  resulting in crashing , causing user to sleep 12-18 hours.

What to know about amphetamines?

• Act on CNS and peripheral nervous system

• Used in treatment of ADHD, narcolepsy, depression, obesity

• Cause release of newly synthesized norepinephrine. Block reuptake of NE and dopamine (NE and dopamine stay longer in the synapse)

• Examples: Adderall, Vyvanse, Dexedrine (extended release and immediate release formulations)

What to know about methamphetamines?

• CNS stimulant that releases excess dopamine

• Toxic effect: damages nerve terminals, interfering with neurotransmitter release (dopamine and serotonin)

• High doses can cause hyperthermia and seizures

• Highly addictive

• Tolerance occurs within minutes

• Longer duration of action than cocaine

• Long-term can cause  paranoia, hallucinations, mood disturbances, repetitive motor activity, stroke, weight loss, and extensive tooth decay (teeth grinding, drug additives, such as battery acid, antifreeze, drain cleaner, lack of dental hygiene), poor diet, and dry mouth (loss of protective saliva)

What to know about nictotine?

• Biologic Response: CNS stimulant. Highly addictive.

• Nicotine Withdrawal and Smoking Cessation: withdrawal can cause irritability, sleep disturbances, gastric upset, increased appetite.

• Patches and gum have been shown to be effective. However, generally recommend more than one type of intervention.

• Varenicline (Chantix) can be dangerous in mental health disorder. Black Box warning because some develop suicidal thoughts.

• Bupropion (Wellbutrin) has had good efficacy for smoking cessation

What to know caffeine?

• Stimulant

• Sign of intoxication: restlessness, nervousness, palpitations

• Withdrawal: headache, drowsiness, fatigue

• Watch for increased anxiety with increased use

• Ask about coffee, tea, soda, energy drinks, pre-workout supplements

What to know about benzodiazepines?

• Classified as sedatives, anxiolytics, anti-epileptics

  • Prescribed for anxiety, sleep, seizures, short-term use for phobias

  • Used to help during alcohol withdrawal

  • “Jack Daniels in a pill”

• “Benzos” or “Tranks”

  • Xanax – xannies, bricks, school bus

  • Klonipin – K, K-pin, Super valium

  • Valium – Tranqs, Howards, Blue V’s

• Flumazenil for benzo overdose (respiratory depression, oversedation)

• Benzodiazepine withdrawal can be fatal – needs to be medically supervised.

  • Symptoms can start within 24 hours to 2 weeks, depending on half life of benzo being used

  • Disturbed sleep, agitation, seizures, hallucinations, altered mental status, nausea, altered body sensations, aches/pains, muscle spasms, depression

What are the side effects of benzodiazepines?

• Short-term use

  • Is considered to be safe and effective, but still carries side effects:

  • Aggression, dizziness, drowsiness, sexual dysfunction, depression, blurred vision

• Long-term use

  • Can carry some serious negative effects mentally and psychologically:

  • Cognitive problems, sleep disturbances, mental disorders, immune system suppression, cancer risk, addiction

What to know about cannabis?

• Recreational use is legal in 21 states. Medicinal use is legal in 37 states, including Georgia.

• THC vs CBD – only THC shows up in drug tests

• CV disturbance, ataxia, psychotropic effects with THC

• Associated with impaired ability to form memories, recall events, and shift attention

• Disrupts coordination of movement, balance, and reaction time

• Associated with paranoia or psychosis in high doses

• Early use (adolescents) may trigger schizophrenia if there are genetic markers

• Most deaths involving THC are motor vehicle accidents or polysubstance use

What are the therapeutic uses of THC?

• Pain management, especially for chronic pain

• Anti-epileptic

• Appetite stimulant in chemotherapy

• Antispasmodic in multiple sclerosis, spinal chord injury, and Parkinson’s Disease

• Some uses in Tourette’s and Huntington’s Disease

What prescription and OTC drugs that are misused?

• Pain medications (such as opioids)

• Sleep aids (ambien, Tylenol PM, etc.)

• Benzodiazepines

• Stimulants (amphetamines, methylphenidates)

• Steroids

• Metabolism boosters, diuretics, laxatives

What to know about tolerance to opioid effects?

• With repeated exposure to opioids, tolerance (needing more to produce the same effect) develops

• Tolerance involves changes in receptor numbers and functioning

• Tolerance develops at different rates, and to different extents, for different effects

  • Rapid tolerance

    • Sedation

    • Euphoria

    • Respiratory depression

    • Nausea

  • Little to no tolerance

    • Constipation

    • Pupil constriction

• Tolerance is lost while abstaining from opioids for an extended period, including during treatment with an opioid antagonist (i.e. naltrexone)

What is included in pain management for chronic pain?

• Procedural pain management and pain flares are challenging in someone who regularly uses opioid pain management at home

  • Chronic back pain

  • Arthritis

  • Sickle Cell

  • Cancer

• Avoid the temptation to label patients as “drug-seeking”

• Also challenging in someone who is in sustained sobriety after opioid use disorder – might not want to use any opioids

What is COWS?

• Clinical Opiate Withdrawal Scale

• Used to measure severity of withdrawal symptoms

• Modified Finnegan Scale used for Neonatal Abstinence Syndrome uses similar signs and ratings

What is the treatment for opioid use disorder?

• Medicated treatment options reduce overdose death by up to 59 %

• Methadone

  • Long-acting opioid

  • Half-life of 15-30 hours

• Buprenorphine

  • Long-acting partial agonist for mu-opioid receptors

  • Half-life of 24-60 hours

  • Relieves cravings without producing a high or dangerous side effects

• Suboxone

  • Combination of buprenorphine with naltrexone

  • Protects from overdose if patient uses opioids while undergoing treatment

What to know about hallucinogens and dissociative drugs?

• Hallucinogens: Drugs producing euphoria or dysphoria, altered body image, distorted or sharpened visual or auditory perception

• Classic hallucinogens: LSD, Peyote

• Dissociative drugs: class of hallucinogens known for altering sight/sound perception. Include ketamine, dextromethorphan, PCP  

• Initially: increased heart rate, body temperature, blood pressure.  Possible dry mouth, dizziness, subjective feelings of hot or cold. Eventually, can have perceptual distortions and hallucinations.

• Patients in acute states of intoxication or dissociation may become combative.

• Nursing intervention: reduce stimuli, maintain safe environment, manage behavior, observe patient for medical and psychiatric complications. 

What to know about club drugs?

• Rohypnol (Roofies): depressant, date-rape drug; causes anterograde amnesia

• MDMA (Ecstasy): similar in structure to methamphetamine. Causes excessive serotonin and dopamine release. Can cause hallucinations, confusion, paranoia, severe anxiety.

• Ketamine: used to increase effects of Ecstasy. Anesthetic. Can cause out-of-body experience. Used as date-rape drug. Also used therapeutically for treatment-resistant depression.

What to know about inhalants?

• Organic solvents, CNS depressants

• Inhalation causes euphoria, sedation, emotional lability, impaired judgment – may appear drunk

• Include paint thinner, aerosols, gases, and nitrites

• Abused by children (12-15 years old): glue, shoe polish, gasoline, spray paint, lighter fluid

• Abused by adolescents (16-17 years old): nitrous oxide

• Abused by adults: amyl nitrites (used to enhance sexual pleasure)

• Inhalants other than nitrites act similarly to ETOH on CNS

• Sudden Sniffing Death: inhaled fumes replace oxygen in the lungs and CNS, causing suffocation

What to know about emerging drugs?

• Bath salts contain cathinone, a stimulant. Produce euphoria, increased sociability and sex drive, paranoia, and agitation

• Krokodil: (from the Russian кpoкoдил) synthetic desomorphine Causes scaly, gray-green skin at injection site from necrosis and gangrene

• Synthetic hallucinogen (N-bomb): more powerful than LSD: act on serotonin receptors, considered more powerful than LSD

What is included in evidence-based nursing care for people with substance-related disorders?

• Assess for all substances – ask specifically about drugs by name and get a thorough history (first used, amount, frequency, last use)

• Denial: patient’s inability to accept his or her loss of control over substance use

• Motivation for Change: key predictor of whether individuals will change their substance use behavior

• Countertransference: Therapist or nurse’s reactions to patient that are based on interpersonal experiences, feelings, and attitudes. Can interfere with nurse-patient relationship.

What is included in a therapeutic relationship?

• Encourage expression of feelings

• Listen

• Express caring

• Hold individual responsible for behavior

• Provide fair and consistent consequences for negative behavior

• Confrontation: should only occur within trusting relationship. Point out inconsistences in thoughts, feelings, and actions.

What are the mental health nursing interventions?

• 12-step program

• Cognitive behavioral therapy

• Group therapy

• Individual and family therapy

What to know about brief interventions?

• Conversation focused on harm reduction

• Probing questions on reducing drug/alcohol use

• Reducing frequency

• Reducing amount

• Cover harm reduction strategies R/T overdose, violence, DUI, safe practices

What are harm-reduction strategies?

• designated driver and/or Uber, Lyft

• needle exchanges

• Narcan availability

• fentanyl strip distribution

• safety in numbers

• date rape drug test kits

• Overdose prevention hotline

What are the 12-step programs?

• Alcoholics Anonymous is the first 12-step, self-help program. Exists worldwide.

• AA does not solicit members. It does not provide mental health, legal, or vocational counseling.

• Narcotics Anonymous, Gamblers Anonymous, Marijuana Anonymous, Crystal Meth Anonymous, etc.

• Steps

  1. We admitted we were powerless over alcohol—that our lives had become unmanageable.

  2. Came to believe that a Power greater than ourselves could restore us to sanity.

  3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

  4. Made a searching and fearless moral inventory of ourselves.

  5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

  6. Were entirely ready to have God remove all these defects of character.

  7. Humbly asked Him to remove our shortcomings.

  8. Made a list of all persons we had harmed, and became willing to make amends to them all.

  9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

  10. Continued to take personal inventory and, when we were wrong, promptly admitted it.

  11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

  12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs

What is included in evaluation and treatment outcomes?

• RECOVERY involves lifestyle change, new relationships

• Short-term outcomes can be evaluated in treatment setting.

• Long-term outcomes established and evaluated by the patient who continues to use professional and nonprofessional support.

What to know about chemical dependency and the professional nurse?

• ANA estimates 6% - 8% of nurses have a problem with drugs or alcohol that impairs their practice.

• Nurses can be reluctant to seek help, since license is at stake

• Since 1982, Peer Assistance Programs for early intervention, reducing hazards to patients, and increasing possibility of nurse’s recovery.