Substance Use & Violence Lecture – Core Vocabulary

Key Reference Categories & Definitions

• DSM-5 Substance-Related Categories
  • Central Nervous System (CNS) Depressants – alcohol, sedatives/hypnotics/anxiolytics, benzodiazepines, opioids
  • CNS Stimulants – caffeine, nicotine, amphetamine, cocaine, methamphetamine, “bath salts” (synthetic cathinones)
  • Cannabis (its own class; shares some properties with hallucinogens & depressants)
  • Hallucinogens – LSD, PCP, psilocybin, ketamine, mescaline, MDMA (also stimulant)
  • Inhalants – gasoline, glue, propellants, “huffing” hydrocarbons
  • Other / Unknown – laxatives, steroids, over-the-counter or prescription medications misused, novel synthetics

• Substance Use Disorder (SUD)
  • Chronic pattern of craving, tolerance, loss of control, continued use despite harm, legal / social / occupational impairment.
  • Think: addiction → “crave, need more for same effect, need it to feel normal, will break the law to obtain.”

• Substance-Induced Disorders
  • Physiological or psychiatric conditions produced by intoxication, withdrawal, or long-term exposure.
  • Examples: delirium, amnesia, psychosis, mood/anxiety/sleep/sexual dysfunction, physical complications (e.g., liver failure).

• Tolerance
  • Body requires ↑ dose for same effect; overdose can occur when abstinent pts return to previous “usual” dose.

CNS Depressants

Expected Effect (therapeutic / recreational)

• ↓ Respiratory & heart rate, relaxation, sedation, ↓ inhibition (“feel chill”).

Intoxication / Overdose

• Excess CNS depression: slurred speech, ataxia, poor judgment, coma, potential respiratory arrest (esp. opioids, barbiturates).

Withdrawal (usually opposite)

• CNS hyper-excitation: tremors, insomnia, tachycardia, hypertension, seizures (esp. alcohol), anxiety.

Alcohol – Prototype Template

• 3rd leading preventable cause of death (U.S.); contributes to absenteeism, prenatal harm, violence.
• Neurochemistry: potentiates \text{GABA} (inhibitory) & inhibits \text{Glutamate} (excitatory). Chronic use ↓ endogenous GABA & ↑ glutamate activity → abrupt cessation = "neurologic over-drive".

Stages of Alcohol Withdrawal (know!)

1. Stage 1 (6–12 h) – Tremor, diaphoresis, N/V, mild HTN (~140/90), tachycardia, fever, tachypnea.
2. Stage 2 (12–24 h) – Visual/tactile hallucinations, paranoia.
3. Stage 3 (24–48 h) – Abrupt tonic–clonic seizures, minimal post-ictal period.
4. Stage 4 – Delirium Tremens (2–5 d) – Malignant HTN (≈220/160), hyperthermia, wild hallucinations, seizures, coma; ICU emergency.

Management

• Benzodiazepines (diazepam, lorazepam, chlordiazepoxide) guided by CIWA-Ar scale.
• Airway, CV support; possible gastric lavage in OD.
• Thiamine (Vitamin B1) & “banana bag” to prevent Wernicke–Korsakoff, peripheral neuropathy, alcoholic myopathy/rhabdo.
• Long-term: disulfiram (Antabuse) deterrent, rehab (AA/12-step), CBT.

Chronic Complications

• Hepatic (portal HTN, cirrhosis), cardiomyopathy, HTN, pancreatitis, gastritis, cognitive decline.

Sedatives/Hypnotics/Anxiolytics (benzodiazepines, barbiturates, Z-drugs)

• Intoxication: same as EtOH; barbiturate OD → respiratory arrest.
• Withdrawal: anxiety, insomnia, seizures; taper is gold standard.

Opioids (morphine, heroin, codeine, oxycodone, fentanyl)

• 130 U.S. deaths/day; fentanyl ≈ 50× heroin potency; often unknowingly laced.
• Intoxication: euphoria, miosis, apathy, psychomotor retardation → respiratory depression & death.
• Antidote: Naloxone (Narcan) IV/IN; expect agitation & acute withdrawal.
• Withdrawal (not usually life-threatening): yawning, lacrimation, piloerection, GI cramps/diarrhea, myalgias, fever.
• Support: COWS scale; clonidine, symptomatic meds; long-term MAT: methadone (full agonist), buprenorphine ± naloxone (partial agonist/antagonist), CBT & 12-step.

CNS Stimulants

Expected Effect

• ↑ Alertness, energy, euphoria, sympathetic arousal.

Mild Stimulants

• Caffeine – energy drinks/tablets; excessive use → tachyarrhythmia, insomnia; withdrawal HA, irritability.
• Nicotine – highly addictive; withdrawal within hours; numerous limbic cues; bupropion, varenicline, NRT recommended.

Potent Stimulants

• Cocaine/Crack – high 4–8 h; septal perforation (vasoconstriction).
• Amphetamines/Meth – cheaper, 16–20 h high; manufactured with toxic chemicals; users show weight loss, “meth mouth,” formication sores.
• Bath Salts (synthetic cathinones), MDMA (stimulant + hallucinogen).

Intoxication

• Euphoria, hypervigilance, HTN, chest pain, hyperthermia, seizures.
• Hyperthermia & polydipsia → hyponatremia risk.

Withdrawal

• “Crash” – dysphoria, fatigue, prolonged sleep, hunger; usually self-limiting; benzos for severe agitation.

Cannabis

• 2nd most-used drug; today’s THC concentrations far exceed 1960s.
• THC – psychoactive, analgesic for chronic neuropathic pain, antiemetic.
• CBD – anxiolytic, anticonvulsant; may modulate THC effects.
• Synthetic (“spice”) unpredictable, often adulterated (e.g., fentanyl).
• Intoxication: euphoria, time distortion, impaired coordination, red eyes, tachycardia.
• Heavy youth use → ↓ motivation, possible ↓ IQ, social drift.
• Withdrawal: irritability, insomnia, tremor, abdominal pain; not medically dangerous.
• Caution in pts/families w/ schizophrenia or bipolar I – risk of precipitating persistent psychosis.
• Medical marijuana: regulated CBD/THC ratios, dronabinol & nabilone oral synthetics; avoid raw plant in immunocompromised.

Hallucinogens

• LSD, psilocybin, PCP, ketamine, mescaline.
• Effects: visual hallucinations, depersonalization, sympathomimetic (↑BP/HR/T°).
• “Flashbacks” up to 5 yrs.
• Manage agitation w/ benzos; antipsychotics if needed; low-stimulus milieu.

Inhalants

• Huffed hydrocarbons; rapid lung absorption.
• Intoxication: euphoria, disinhibition, wheeze, N/V, neurological damage.
• Acute toxicity: respiratory depression, vagal brady-arrhythmia, “sudden sniffing death.”
• Priority: airway, O₂, supportive care; no classic withdrawal syndrome, but cravings possible.

Other / Unknown Substances

• OTC cold meds (dextromethorphan, diphenhydramine), laxatives (weight loss), anabolic steroids, novel synthetics.
• Diagnosis when SUD criteria met but drug unclassified.

Universal Withdrawal Issues & Patient Teaching

• Expect insomnia, nightmares, anxiety, GI distress for several weeks.
• Anticipatory guidance: avoid substituting another substance for sleep; realistic timeline promotes adherence.

Nursing Assessment & Care

• Examine personal biases; offer unconditional positive regard.
• Priority: patient safety (OD, seizures, falls, violence).
• Obtain private history; use drug screens.
• Utilize CIWA-Ar or COWS; administer benzos per protocol.
• Seizure precautions, assist ambulation.
• Address malnutrition (protein, vitamins — esp. \text{B}_1).
• Evaluate sensorium, judgment; confront denial/rationalization gently.
• Involve family; educate on codependency, limit-setting.
• Refer to CBT, 12-step, social services.

Elder Abuse (Mirror of Child / IPV Concepts)

• Mandatory reporting to Adult Protective Services.

Forms & Indicators

• Physical: unexplained bruises, fractures, restraint marks, fear of touch.
• Emotional: withdrawal, rocking, self-soothing.
• Sexual: genital injury, STIs.
• Neglect: malnutrition, dehydration, pressure ulcers, poor hygiene, abandonment.
• Financial: missing funds despite income; unpaid bills.

Perpetrator/Victim Dynamics

• Often caregiver; substance abuse ↑ risk.
• Victim may conceal abuse (dependency, shame, love).
• Self-neglect possible when elder refuses help.

Nursing Role

• Separate elder from others for private interview.
• Ask safety questions: “Do you feel safe?” “Are you threatened?”
• Document discrepancies; follow facility policy; partner with social work, law enforcement; arrange respite services.

Cycle of Intimate Partner Violence (also applies to elder/child scenarios)

1. Tension-Building – criticism, arguments, minor incidents.
2. Acute Violence – physical/sexual assault.
3. Honeymoon/Contrition – apologies, gifts, promises; cycle then repeats.

Barriers to Leaving Violent Situations

• Fear of custody loss, finances, deportation, pet safety, low self-efficacy, inadequate institutional response, cultural norms.
• Restraining orders helpful but shelters + safety planning superior; marriage counseling NOT indicated during active abuse.

Resilience & Adverse Childhood Experiences (ACEs)

• ACEs alter brain development & epigenetics → ↑ risk \uparrow heart disease, asthma, autoimmune, SUD, mental illness, premature death.
• 7 C’s of Resilience: Competence, Confidence, Connection, Character (values/caring), Contribution, Coping, Control (differentiating controllable vs uncontrollable).

Workplace Violence (Nurses)

• Primary risk = history of violence in patient/family.
• Added risks: lone work, understaffing, long waits, bad news, pain, mental health/substance disorders, inadequate security.
• Know Crisis Development Model & Verbal Escalation Continuum (information-seeking vs challenging questions → refusal → release → intimidation).
• CPI principles: remain calm, set limits, maintain safety radius, call assistance early; use physical interventions only as last resort.

Human Trafficking (Preview – Learning Activity)

• Nurses must recognize potential victims in ED/clinic: inconsistent story, controlling “companion,” no ID, signs of abuse, branded tattoos, occupational injuries, STIs, fearful demeanor.
• Follow facility protocol; involve social work, trained advocates; ensure privacy; use non-judgmental approach; do NOT confront trafficker if present; know national hotline.