Drugs Used to Treat Substance Use Disorders

Introduction to Substance Use Disorders and Pharmacotherapeutics\n* This study guide is based on Chapter $17$ of Clayton’s Basic Pharmacology for Nurses, $20^{th}$ edition, authored by Michelle J. Willihnganz, MS, RN, CNE.\n* The curriculum focuses on identifying substance use disorder (SUD) severity, screening methodologies, professional responsibilities, withdrawal symptoms, and specific pharmacologic treatments for alcohol and opioid use disorders.\n\n# Classification and Categorization of Substance Use Disorders\n* The Diagnostic and Statistical Manual of Mental Disorders, $5^{th}$ edition (DSM-5), provides a framework for classifying substance abuse.\n* The DSM-5 redefines \"substance abuse\" under a newer, unified category termed Substance Use Disorders.\n* Dependency and specific disorders are categorized according to the specific chemical substance used by the individual.\n* There are a total of $12$ distinct categories of substances identified under this classification system, including:\n * Alcohol, nicotine, and caffeine.\n * Amphetamines.\n * Cannabis (marijuana).\n * Cocaine.\n * Hallucinogens and Phencyclidine (PCP).\n * Inhalants.\n * Opioids.\n * Sedatives and hypnotics.\n\n# Key Terminology and Epidemiology\n* Substance Abuse: Defined as the periodic, purposeful use of a substance that results in clinically significant impairment.\n* Impairment: Classified as a failure to fulfill major life obligations across the domains of work, school, or the home environment.\n* Dependence/Addiction: Characterized by symptoms of compulsive use, the development of tolerance (needing more for the same effect), and the onset of withdrawal symptoms upon the discontinuation of the substance.\n* Illicit Substances: Refers to any chemical that alters biological function and is not fundamentally required for the maintenance of health.\n* Epidemiological Statistics (2014): Approximately $7.1 \times 10^6$ people, representing $2.7\%$ of the United States population aged $12$ or older, were classified as having an illicit drug disorder.\n\n# Progression and Signs of Impairment\n* Physical and behavioral signs of substance impairment typically manifest in a specific progression:\n 1. Family Life: This is usually the first area to show signs of impairment. Indicators include domestic violence, legal separation, divorce, and significant financial problems.\n 2. Social Life Disintegration: Characterized by public intoxication and social isolation.\n 3. Physical and Mental Changes: Symptoms include chronic fatigue, frequent illness, recurrent injuries or accidents, and emotional crises.\n 4. Occupational Impairment: Flagrant evidence of impairment at the workplace is considered rare and is often the final stage of the progression.\n\n# Screening Instruments for Substance Abuse\n* There are four primary categories of screening instruments used in clinical practice:\n 1. Comprehensive drug abuse screening and assessment tools.\n 2. Brief drug abuse screening tools.\n 3. Alcohol abuse screening tools.\n 4. Drug and alcohol abuse screening tools specifically designed for adolescents.\n* CAGE Assessment: A rapid assessment tool for alcohol use, where each letter represents a question for the patient:\n * C — Cut down: \"Have you ever felt you should cut down on your drinking?\"\n * A — Annoyed: \"Have people annoyed you by criticizing your drinking?\"\n * G — Guilt: \"Have you ever felt bad or guilty about your drinking?\"\n * E — Eye opener: \"Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?\"\n\n# Substance Use in Health Professionals\n* Health professionals face unique risk factors for substance use disorders, including:\n * The extreme stress of intense patient care.\n * Increased patient loads coupled with static or diminishing resources.\n * A professional climate of \"zero tolerance\" for errors.\n * Significant financial debt.\n* Indicators of Abuse in Colleagues:\n * Behavioral changes such as mood swings and a noticeable lack of attention to personal hygiene.\n * Deterioration in professional performance.\n* Reporting Responsibilities:\n * Suspected abuse must be reported confidentially to the appropriate supervisor.\n * An official investigation involves systematic observation and documentation over a period of time.\n * Ethical Rationale: Healthcare practice is a privilege, not a right. Reporting is necessary to protect patient safety. An unreported colleague is at risk of death due to impairment, whereas a reported colleague has a high probability of retaining their professional license through legal protections and treatment programs.\n\n# Alcohol Use Disorder: Withdrawal and Treatment\n* Alcohol Withdrawal Symptoms: Can include visual and auditory hallucinations as well as physical seizures.\n* Acute Treatment Approach:\n * Comprehensive assessment of hydration, electrolyte levels, and overall nutritional status.\n * Administration of Thiamine and multiple vitamins to address deficiencies.\n * Benzodiazepines: Used for detoxification according to two possible protocols:\n 1. A fixed-dose schedule.\n 2. A symptom-triggered medication regimen based on clinical assessment.\n* Relapse Prevention for Alcoholism:\n * Requires lifelong effort and extensive social support.\n * Disulfiram (Antabuse): An aversion therapy drug. If alcohol is consumed while taking this, it produces severe nausea, vomiting, throbbing, dizziness, blurred vision, and sweating. It should never be given to an intoxicated patient.\n * Naltrexone (Revia): Functions by blocking the pharmacological \"high\" or euphoria associated with alcohol.\n * Acamprosate (Campral): A NDMA receptor antagonist used to promote abstinence in chronic alcoholism. Adverse effects include diarrhea (common) and suicidal actions (serious). It is contraindicated in patients with severe renal failure.\n * Multimodal Therapy: Studies show a slightly higher success rate in preventing relapse when Naltrexone and Acamprosate are utilized together.\n\n# Opioid and Stimulant Use Disorders\n* Opioid Withdrawal: Symptoms include mood swings, slurred speech, impaired memory, anxiety, restlessness, sweating, nausea, vomiting, aches, fever, and elevated blood pressure and pulse.\n * Opioid Treatment: May involve substituting another opioid (substitution therapy) to mitigate the severity of withdrawal.\n * Relapse Prevention: Requires lifelong psychosocial, community, and social support alongside pharmacologic treatment.\n* Amphetamine-Type Stimulants: Used clinically for ADHD, schizophrenia, depression, radiation sickness, and addictions, but frequently abused.\n * Intoxication: Induces heightened alertness, self-confidence, and energy. Users may remain awake for $7$ to $10$ days without adequate food or water intake.\n * Meth Mouth: A condition resulting from grinding of teeth and poor oral hygiene during use.\n * Treatment: There is no pharmacological antidote for methamphetamine. Treatment entails psychiatric evaluation (due to damage to dopaminergic and serotonergic neurons), Cognitive Behavioral Therapy (CBT), and contingency management programs.\n* Cocaine: Withdrawal begins within hours of reduced dosage, causing fatigue, vivid/disturbing dreams, insomnia, and extreme depression. There are currently no FDA-approved medications for cocaine addiction; relapse rates are extremely high.\n\n# Nursing Process and Clinical Implementation\n* Nursing Assessment Checklist:\n * Event history, vital signs, and mental status (Basic Mental Status).\n * Physical Appearance and comprehensive Neurological assessment.\n * Targeted assessments: Heart, Eyes, Ears, Oral Cavity, Nose, Throat, and Skin.\n * Musculoskeletal assessment.\n * History: Meds, coexisting diseases, STIs, and pregnancy status.\n * Diagnostic: Laboratory tests.\n* Nursing Implementation:\n * In emergency settings, the immediate stabilization of the individual is the priority.\n * Nurses must be familiar with specific detoxification protocols and healthcare provider orders.\n * Patients require a quiet, safe environment during the withdrawal phase.\n * Support patient autonomy by encouraging them to make choices and take responsibility for their clinical decisions.\n* Patient Education Focus:\n * Nutritional status improvement.\n * Stress management techniques.\n * Health maintenance fostering.\n * Patient self-assessment tools.\n\n# Questions & Discussion\n* Question 1: In 2014, what percentage of the U.S. population aged $12$ or older was classified as having an illicit drug disorder?\n * Answer: $2.7\%$.\n* Question 2: What action should the health professional take if he or she suspects that a colleague may be a substance abuser?\n * Answer: Report it confidentially to an appropriate supervisor.\n* Question 3: A patient who had an emergency appendectomy $24$ hours ago is currently restless, anxious, nauseated, and has an elevated heart rate and blood pressure. The nurse recalls that the patient mentioned drinking a $6$-pack of beer nightly. What does the nurse suspect?\n * Answer: Acute alcohol withdrawal.\n* Question 4: A patient is to be observed for symptoms of opiate withdrawal. Which symptoms are associated with withdrawal?\n * Answer: Anxiety and restlessness.\n* Question 5: What is the use of the prescription drug disulfiram (Antabuse)?\n * Answer: Deterring alcohol consumption (aversion therapy).", "title": "Drugs Used to Treat Substance Use Disorders"}