Substance Use Disorders

Substance use disorders and related disorders are a global health problem. 3,000,000 deaths annually occur from the harmful use of alcohol. Alcohol is a causal factor in many diseases and injury conditions. This also affects infants as prenatal exposure to alcohol or drugs e.g. fetal alcohol syndrome, neonatal abstinence syndrome, and “crack babies”. Substance abuse is commonly paired with another psychiatric issue and other substances (polysubstance abuse). Incidence of negative behaviors increase in many substances, and implication with the legal system is comm5on.

• Substance use is more marked the younger the onset. Alcoholism often starts with sips of alcohol eight years or younger, intoxication from twelve to fourteen, and blackouts from 20s to mid 30s.

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Factors Contributing to Substance Use

1. Biologic Factors: the children of alcoholic parents, even after adoption and between identical twins, exhibit higher risk for developing alcoholism and drug dependence, suggesting a genetic link or vulnerability.
   • Substances alter the limbic system (reward center of the brain), changing feelings of pleasure, pain, and reward; producing a “high” that is a reinforcing/positive experience for the user.
   • A proposition hypothesizes that an “internal alarm” for substance levels are present in most individuals, but are missing in those who continue to use substances until complete intoxication.
2. Psychological Factors: parental behaviors, poor role modeling, and lack of nurturing may result in substance use. Alcohol may be used as a coping mechanism, to relieve stress or tension, to increase feelings of power, and to reduce psychological pain.
3. Social and Environmental Factors: cultural factors, social attitudes, peer behaviors, laws (sin taxes), cost, and availability all influence initial and continued use of substances.

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Alcohol

Alcohol is a CNS depressant. Using it produces sedation (relaxation) and loss of inhibitions, at least initially. Intoxication produces slurred speech, unsteady gait, ataxia, and impaired attention, concentration, memory, and judgment. Aggression, inappropriate sexual behavior, and blackouts may occur. Repeated and long-term use results in more physiological effects:

• Cardiac myopathy
• Wernicke-Korsakoff Syndrome: Wernicke Encephalopathy, Korsakoff Psychosis
• Pancreatitis
• Esophagitis
• Hepatitis, Cirrhosis, and Ascites
• Leukopenia and Thrombocytopenia

Withdrawal and Detoxification

• Onset of Withdrawal: 4 to 12 hours since cessation or reduction
  • Coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and N&V
• Severe/Untreated Withdrawal: transient hallucinations, seizures, or delirium (delirium tremens)
  • If withdrawal symptoms are severe, a 3 to 5 day inpatient stay is common.
• Peak and End of Withdrawal: 5 days, as long as 1 to 2 weeks.
• Treatment: safe withdrawal is done with the use of (mn. VAL) Benzodiazepines e.g. Diazepam (Valium), Lorazepam (Ativan), Chlordiazepoxide (Librium) to suppress symptoms.
  • Fixed-schedule dosing for tapering off alcohol can also be used.
  • Symptom-triggered dosing matches severity of withdrawal with medication dosage and frequency.
  • The use of assessment tools like the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (Addiction Research Foundation) can score patients for withdrawal.

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Sedatives, Hypnotics, and Anxiolytics

This class of drugs includes all CNS depressants: barbiturates, nonbarbiturate hypnotics, anxiolytics (particularly benzodiazepines). The most commonly abused forms are barbiturates and benzodiazepines. Symptoms of drug use and its withdrawal are similar to that of alcohol. In intended therapeutic doses, drowsiness and relaxation (reduced anxiety) is the effect of these drugs.

• Intoxication: slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, and even stupor and coma.
• Benzodiazepines when taken by itself is rarely fatal in overdoses, but lethargy and confusion are severe.
  • Treatment: gastric lavage, followed by ingestion of activated charcoal and a saline cathartic. In severe cases, dialysis may be done.
• Barbiturates can be lethal when taken in overdose. Coma, respiratory arrest, cardiac failure, and ultimately death.
  • Treatment is in an ICU setting: lavage or dialysis removes the drug from the system, and to support respiratory and cardiovascular function.

Withdrawal and Detoxification

• Onset depends on the halflife of the drug being used. Lorazepam action lasts for about 10 hours, and produces withdrawal symptoms in 6 to 8 hours. Diazepam is longer acting, and may not produce withdrawal symptoms for 1 week.
• Withdrawal symptoms are opposite of acute presentation; autonomic hyperactivity produces increased pulse rate, blood pressure, respirations, and temperature. Hand tremors, insomnia, anxiety, nausea, and psychomotor agitation occur. Seizures and hallucinations occur but rarely in Benzodiazepine withdrawal.
• Detoxification is managed by tapering. This is important especially for barbiturates, which may cause coma and death when abruptly stopped.

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Stimulants

Drugs that stimulate or excite the CNS and have limited use, often only being used for managing ADHD. These have a high potential for abuse, most often being amphetamines (uppers). These were previously used for weight loss and staying awake, and is now mostly used in recreation.

• Cocaine is an illegal drug with virtually no clinical use that produces immediate feelings of euphoria.
• Methamphetamines are particularly dangerous, being highly addictive and producing psychotic behavior. Its use often results in brain damage, primarily due to one of its ingredients during production: liquid agricultural fertilizer.

Intoxication is produced rapidly. Effects include euphoria, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic or repetitive behaviors, anger, fighting, and impaired judgment. Physiological effects include tachycardia, elevated blood pressure, dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmias. Overdosing can result in seizures, comas, and death.

Withdrawal and Detoxification

• Onset begins within a few hours to several days after cessation. Symptoms are often not life-threatening.
• Marked dysphoria is the primary symptom, accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor agitation or retardation.
• Marked withdrawal can be referred to as “crashing”. Depressive symptoms with suicide ideation and risk persist for several days.
• Treatment is not pharmacological.

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Cannabis

Cannabis sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and for oil from its seeds. It has become widely known for its psychoactive resin, containing more than 60 substances called cannabinoids. The cannabinoid $\delta \text{-9-tetrahydrocannabinol}$ is thought to be responsible for most psychoactive effects. Marijuana refers to the leaves, roots, and flowering tops of the plant. Hashish is the dried resinous exudate from the leaves of the female plant. Consumption of cannabis is often through cigarettes (joints), though it may also be eaten.

• Currently, two cannabinoids dronabinol (Marinol) and nabilone (Cesamet) are approved for N&V from cancer chemotherapy. Research suggests it may also provide short-term decreases in intraocular pressure for glaucoma and seizure control in otherwise pharmacologically nonresponsive patients.

Cannabis acts within 1 minute of inhalation. Its effect peaks within 20 to 30 minutes, and lasts for 2 to 3 hours. A euphoric “high” feeling similar to alcohol is reported, with lowered inhibitions, relaxation, and increased appetite. Intoxication results in ataxia, inappropriate laughter, impaired judgment, short-term memory, and alterations of time orientation and perception.

• Physiological effects include conjunctival injection, xerostomia, hypotension, and tachycardia.
• Excessive cannabis use may result in delirium or rarely cannabis-induced psychotic disorder. These are treated symptomatically. Overdosing on cannabis is not possible.

Withdrawal and Detoxification

There are no clinically significant withdrawal syndromes from cannabis, but some report of muscle aches, sweating, anxiety, and tremors.

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Opioids

Opioids desensitize users to physiological and psychological pain, simultaneously producing a sense of euphoria and well-being. Opioids are commonly used as prescribed analgesics e.g. morphine, meperirdine (Demerol), codeine, hydromorphone, oxycodone, methadone, oxymorphone, hydrocodone, and propoxyphene, as well as illegal substances such as heroin, illegal fentanyl, and normethadone.

• Fentanyl (Duragesic, Actiq) is a synthetic opioid used in clinical settings for anesthesia. It is 50 to 100 times more potent than morphine.

Addiction to opioids result in profound drug-seeking behaviors, often becoming implicated with the law aside from the substance use. Medical professionals may also become addicts and write prescriptions for themselves or use their clients’ prescriptions. Intoxication develops soon after an initial euphoric feeling.

• Symptoms include apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory.
• Severe intoxication may result in coma, respiratory depression, pupillary constriction, unconsciousness, and death.

Overdosing is treated through opioid antagonists that reverses all signs of opioid toxicity: Naloxone (Narcan) is given every few hours until the opioid levels drop to nontoxic, potentially taking days.

Withdrawal and Detoxification

Opioid withdrawal may result from cessation or from the introduction of opioid antagonists. Onset depends on the opioid being used; short-acting opioids like heroin produces withdrawal symptoms within 6 to 24 hours, peaking in 2 to 3 days, and subsides in 5 to 7 days. Longer acting substances e.g. Methadone can replace other opioids, and is then tapered down for two weeks in order to reduce the severity of withdrawal symptoms.

• Initial symptoms are anxiety, restlessness, back and leg aches, and drug craving.
• Progression produces N&V, dysphoria (sad), lacrimation (crying), rhinorrhea (runny nose), perspiration (sweating), diarrhea (shitting), oscitation (yawning), fever, and insomnia. These may cause significant distress, but does not require pharmacologic intervention.
• Anxiety, insomnia, dysphoria, anhedonia, and drug craving may persist for weeks or months.

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Hallucinogens

Hallucinogens distort the user’s perception of reality and produces psychosis-like symptoms, inducing hallucinations (often visual) and depersonalization. These increase the user’s pulse, blood pressure, and temperature; dilates pupils; and produces hyperreflexia.

• Mescaline, Psilocybin, Lysergic Acid Diethylamide (LSD, “acid”, “lucy”), and “designer drugs” such as ecstasy. Phencyclidine (PCP), an anesthetic, produces similar effects and is included in this category.

Intoxication by hallucinogens is marked by several maladaptive behavioral or psychological changes: anxiety, depression, paranoid ideation, ideas of reference, fear of losing one’s mind, and potentially dangerous behaviors such as defenestration in the belief that one can fly.

• Physiological symptoms feature sweating, tachycardia, palpitations, blurred vision, tremors, and ataxia.
• PCP Intoxication involves belligerence, aggression, impulsivity, and other unpredictable behaviors. PCP toxicity may result in seizures, hyperthermia, hypertension, and respiratory depression.
• Toxic reactions are primarily psychological, and therefore not a direct cause of death. Overdoses on hallucinogens do not occur. Fatalities linked to hallucinogens are from related accidents, aggression, and suicide. Treatment is supportive:
  • Isolation from external stimuli
  • Potential need for physical restraint
  • For PCP toxicty, medications for seizures (from PCP) and blood pressure, mechanical ventilation, and cooling devices (e.g. hyperthermia blankets) may be used.

Withdrawal and Detoxification

Treatment for intoxication is primarily talking down the person i.e. reassuring them that their experiences are temporary, that they are safe, and so forth. In severe cases, haloperidol (Haldol, neuroleptic), or diazepam (Valium, benzodiazepine) can be given for a limited time.

• There are no known withdrawal syndromes from hallucinogens. Some cases report drug craving.
• Flashbacks, transient recurrences of perceptual disturbances, may continue to occur in patients even after cessation of hallucinogen use. These may last from a few months to up to 5 years.

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Inhalants

Inhalants feature a diverse range of drugs including anesthetics, nitrates, and organic solvents. The most common kinds are aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint. Other forms include cleaners, correction fluid, spray can propellants, and other compounds that contain esters, ketones, and glycols. These are inhaled through soaking a rag, spraying into a paper or plastic bag, or inhaling the substance directly.

Intoxication involves dizziness, nystagmus, ataxia, slurred speech, unsteady gait, tremors, muscle weakness, and blurred vision. Stupor and coma can occur.

• Significant behavioral changes include belligerence, aggression, apathy, impaired judgment, and an inability to function.
• Acute toxicity causes anoxia, respiratory depression, vagal stimulation, and dysrhythmias.
• Death may occur from bronchospasms, cardiac arrest, suffocation, or aspiration of the compound or vomitus.
• Treatment consists of supporting respiratory and cardiac functioning until the substance is removed from the body. There are no specific medications or antidotes for inhalant toxicity.

Withdrawal and Detoxification

There are no withdrawal symptoms or detoxification procedures for inhalants. Frequent users report psychological cravings and may suffer from persistent dementia or inhalant-induced disorders such as psychosis, anxiety, or mood disorders even after substance use ends. All of these disorders are treated symptomatically.

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Treatment and Prognosis

Current treatment modalities are based on the concept of alcoholism and other addictions as a medical illness that is progressive, chronic, and characterized by remissions and relapses.

1. Twelve-Step Alcoholic Anonymous (AA): a self-help group utilizing a 12-step program model for recovery based on the philosophy that total abstinence is essential. Key slogans include “one day at a time”, “easy does it”, and “let go and let God”. The twelve-step process is available here.
   • Many treatment programs for contexts besides alcoholism also utilize the twelve step process: Narcotics Anonymous, Al-Anon (for spouses, partners, or friends of alcoholics), Ala-Teen (children of parents with substance problems).
   • Education includes group experiences about substance use, problem-solving techniques, cognitive techniques to identify faulty thinking, and an overall theme of coping with life, stress, and other people without the use of substances.
   • Alternatives for minorities (as they may feel left out in a predominantly white, male, middle-class group) have been developed: Women for Sobriety and Rainbow Recovery for members of LGBTQIA+.
2. Pharmacologic Treatment works for two main purposes: (1) to permit safe withdrawal from substances (alcohol, sedative-hypnotics, benzodiazepines), and (2) prevent relapse.

Disorder	Pharmacology
Alcoholism	Thiamine (B1) for Wernicke-Korsakoff syndrome, Folic acid and Cyanocobalamin (B9, B12) for nutritional deficiencies
Alcohol Withdrawal	Benzodiazepine Anxiolytic Agents (Valium, Ativan, Librium) either fixed-schedule or prn. Barbiturates may be used if patient is nonresponsive to Benzodiazepines.
Alcoholism Relapse	Disulfiram (Antabuse) reduces alcohol craving; if the patient takes alcohol while on antabuse, severe adverse reactions may occur. Unpleasant symptoms still appear after 1 to 2 weeks after cessation of disulfiram. Acamprosate (Campral) may be prescribed for clients recovering from alcohol abuse or dependence to help reduce cravings and decrease the physical and emotional discomfort (sweating, anxiety, sleep disturbances) that occurs in the first few months of recovery. Dosage is two tablets, 333 mg each, taken thrice a day. Contraindicated in renal impairment. Side effects are mild: diarrhea, nausea, flatulence, pru .
Heroin Relapse	Methadone (Dolophine) is a synthetic opiate that substitutes for heroin, substituting their addiction for heroin with an addiction for methadone, which is therapeutic because it does not produce a high, in tablet form, is safer, is legal, and can be tapered off by a physician. This may cause N&V.
Opiate Relapse	Levomethadyl (Orlaam) is a narcotic analgesic whose only purpose is treating opiate dependence, in the same manner as methadone. Buprenorphine/Naloxone (Suboxone) is a combination drug that maintains abstinence and decreases cravings. Buprenorphine is a semisynthetic opioid and naloxone is an opioid inverse agonist. This may cause orthostatic hypotension and sedation. Avoid any other CNS depressants when taking this. It also has risk for abuse and diversion. It should be tapered off after treatment.
Opiate Effects	Naltrexone (ReVia, Trexan) is an opioid receptor antagonist often used to treat overdoses. It also reduces the cravings for alcohol in abstinent clients. It may be a once-monthly injectable (Vivitrol) or a 30-day or 60-day interval extended-release dose.
Opiate Withdrawal	Clonidine (Catapres) is an alpha-2-adrenergic agonist used to treat hypertension, given to clients with opiate dependence to suppress withdrawal symptoms. Most effective against N&V and diarrhea, also helping with muscle aches, anxiety, and restlessness.
Cocaine	Sometimes prescribed as off-label: Disulfiram, Modafinil, Propranolol, and Topiramate.

Disulfiram-Alcohol Drug Interaction

Flushing, throbbing headache, sweating, nausea, and vomiting, (in severe cases) severe hypertension, confusion, coma, and death. Avoid all alcohol-containing products such as cough syrup, lotions, mouthwash, perfume, aftershave, vinegar, and vanilla and other extracts.

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Dual Diagnosis

Substance use disorders, when paired with other psychiatric disorders, is said to have a dual diagnosis, and pose the greatest challenge to health care professionals, with as many as 75% of severe mental illness being paired with substance use disorder.

• Impairment in abstract thinking prevents the effectivity of substance abuse programs.
• Programs often require the avoidance of all psychoactive drugs, which may not be possible in psychiatric patients.
• There is no “limited recovery” concept with substance abuse.
• Lifelong abstinence, which is central to recovery, is nearly impossible in patients with chronic mental illness and who live “day-to-day”.

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Care of Clients with Substance Use Problems

Clients may be in denial about their problem. The nurse should be alert in seeing the signs of substance abuse. The Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD) is useful in detecting hazardous drinking patterns and full-blown substance use disorders. Detoxification is the initial priority, followed by individualized needs such as safety, nutrition, fluids, elimination, and sleep.

Assessment Data

1. History: chaotic family lives are common. Some crisis often precipitates entry into treatment such as the loss of a job, spouse, or partner.
2. General Appearance and Motor Behavior: appearance and speech are often normal. A client may appear anxious, tired, and disheveled after initial detoxification. They may appear physically ill from health problems resulting from substance use.
3. Mood and Affect: wide ranges are possible like remorse, withdrawn, or anger. Irritability is common because of recent cessation of substances, or happy.
4. Thought Process and Content: clients often minimize their substance use, blame others, and rationalize their actions. They may focus on legal, financial, or employment issues instead of their substance use. It is common for the patients to believe they are able to quit when necessary.
5. Sensorium and Intellect: generally oriented and alert unless still in withdrawal. Intellect is maintained except for in long-term alcohol or inhalant use.
6. Judgment and Insight: poor judgment may be affected; impulsivity may cause relapses. Insight is often displayed especially in one’s substance use, where the patient fails to attribute the loss of one’s job or spouse to their substance use.
7. Self-Concept: low self-esteem is common, which may be covered with grandiose behavior. They believe they are unable to cope without substances and are often uncomfortable when not using. True feelings are often hard to self-identify and express. Avoidance and escapism is common.
8. Roles and Relationships: many difficulties with social, family, and occupational roles are noted. Absenteeism and poor work performance are common.
9. Physiological considerations: poor nutrition and poor sleep are common, persisting beyond detoxification.
   • Liver Damage may result from long-term alcoholism.
   • Hepatitis or HIV may result from IV drug use.
   • Lung or Neurologic Damage may result from inhalant use.

Nursing Priorities

• Inadequate nutrition
• Risk of infection
• Risk of injury
• Diarrhea
• Excess fluid volume
• Activity intolerance
• Self-care deficits
• Denial
• Inability to fulfill roles
• Dysfunctional family dynamics
• Ineffective coping

Nursing Outcomes

1. The client will abstain from alcohol and drug use.
2. The client will express feelings openly and directly.
3. The client will verbalize acceptance of responsibility for their own behavior.
4. The client will practice nonchemical alternatives to deal with stress or difficult situations.
5. The client will establish an effective aftercare plan.

Nursing Actions

1. Client and Family Education: dispel common myths such as “It’s a matter of willpower”, “I can’t be an alcoholic if I only drink beer or only on weekends”, “I can learn to use drugs socially”, and “I’m OK now; I could handle using once in a while.”. Educate the patients about relapse and its risk factors.
2. Address Family Issues: Codependence by family members, a subtype of which is Enabling.
3. Promote Coping Skills: encourage clients to identify problem areas in their lives to explore the ways that substance use may have intensified those problems. Emphasize that sobriety will not resolve all issues, but rather will assist them in thinking about problems clearly. The use of coping methods that do not involve substance use is encouraged.