1 of 44

Course: Medical Surgical Nursing

Topic: Substance Use Disorder in Various Client Population Part I

The Nurses International Community

Contact info: info@nursesinternational.org

2 of 44

COPYRIGHT

NI Privacy Policy and Terms of Use.

Contact info: info@nursesinternational.org

3 of 44

Module Goals

Learners will be able to:

Describe the types of substance use disorders.
Identify the criteria for the diagnosis of substance use disorders.
Recognize the risk factors for substance misuse.
Describe nursing interventions for individuals experiencing intoxication or overdose from substances.

Contact info: info@nursesinternational.org

4 of 44

Definition of Substance

“Any psychoactive compound with the potential to cause health and social problems including substance use disorders” (p.741).

Four categories

Alcohol
Illicit drugs, including non-medical use of prescription drugs
Over-counter drugs
Other substances - inhalants

Ernstmeyer & Christman, 2022

Contact info: info@nursesinternational.org

5 of 44

Substance Use Disorders

Involves drugs that activate the reward centers of the brain
Involves abnormal pattern of behaviors as the individual continues to use a substance despite problems related to continued use
May have negative health consequences and put a financial burden on individuals, families, and society.

*Terms such as addiction, abuse and dependence have negative connotations. Therefore, “substance use disorder” may be used as it is more comprehensive.

MedlinePlus, 2022

McLellan, 2017

Khan, 2020

World Health Organization, n.d.

Contact info: info@nursesinternational.org

6 of 44

Substance Use and Substance-Induced Disorders

It occurs when an individual continues to use substances despite experiencing negative consequences.

Intoxication, withdrawal, and mental disorders are the effects of the substances.

McLellan, 2017

Contact info: info@nursesinternational.org

7 of 44

Substance Misuse Impact

Use of alcohol or drugs in a manner, situation, or frequency resulting in harm to self or others.

Increased risk of motor vehicle crashes; overdose death; suicide; various cancers, heart, liver, and pancreatic disease, HIV.

Can cause fetal alcohol spectrum disorders or neonatal abstinence syndrome when taken during pregnancy

Associated with intimate partner violence, abuse, neglect.

Ernstmeyer & Christman, 2022

Contact info: info@nursesinternational.org

8 of 44

Worldwide Alcohol Use

Contributes to 3 million deaths each year.
Responsible for 5.1% of the global burden of disease.
Leading risk factor for premature mortality and disability among those aged 15-49.
Disadvantaged populations have higher risks of alcohol-related death and hospitalization.

WHO, 2022

Contact info: info@nursesinternational.org

9 of 44

Worldwide Drug Use

Drug Use, Abuse & Addiction Statistics, Trends & Data (2022 Update) - CFAH

Contact info: info@nursesinternational.org

10 of 44

Substance Use Worldwide

WDR 2021_Booklet 2 (unodc.org)

Contact info: info@nursesinternational.org

11 of 44

Criteria for Substance Use Disorder

Repeated misuse activates the brain reward system.
Persistent desire to stop using or cut back on.
Presence of craving and a strong urge to use the substance.
Continued misuse results in failure to meet home, work school responsibilities.
Uses substance despite resulting social /interpersonal problems.
Gives up or limits activities due to the need to use the substance.
Takes physical risks to obtain and use the substance.

Contact info: info@nursesinternational.org

12 of 44

Tolerance and Withdrawal

Tolerance occurs when:

Increased amounts of the substance are needed to achieve the desired effect.
A decreased effect occurs with continued use of the same amount of substance.

Withdrawal symptoms occur when substance use is cut back or stopped after prolonged use.

Contact info: info@nursesinternational.org

13 of 44

Addiction, Relapse and Recovery

Addiction occurs with the compulsive and uncontrolled use of one or more substances.

Relapse occurs when a person repeats the use of substances after a period of abstinence.

Recovery is the process of change through substance use abstinence and improved lifestyle by achieving optimal health and well-being.

Ernstmeyer & Christman, 2022

Contact info: info@nursesinternational.org

14 of 44

Case Study

Mary is a 34-year-old woman who has suffered from anxiety since adolescence. She began drinking alcohol after her husband died two years ago. Her family is concerned that she is drinking more frequently and is often “drunk” in the mornings. Mary is annoyed at her family and says she can stop drinking whenever she wants. However, her daughter said she tried several times to stop in the past and was unsuccessful.

Identify Mary’s risk factors for alcohol overuse.

What symptoms does Mary display that indicates she is suffering from a substance use disorder?

Contact info: info@nursesinternational.org

15 of 44

Categories and Examples of Substances

Ernstmeyer & Christman, 2022

Contact info: info@nursesinternational.org

Alcohol: Alcohol is classed as a "sedative-hypnotic" drug that can depress the central nervous system at high doses and act as a stimulant at a lower dose. It induces feelings of euphoria and talkativeness, but drinking too much alcohol in one session can lead to drowsiness, respiratory depression, coma or even death. It is found in all beer, wine, and distilled liquors (Alcohol, n.d.)
Depressants: Depressants cause drowsiness and reduce anxiety. They include alcohol, barbiturates, benzodiazepines (Valium, Ativan, Xanax), chloral hydrate, and paraldehyde. Using these substances can lead to addiction (MedlinePlus, 2020).
Opiates and other narcotics: are powerful painkillers that can cause drowsiness and sometimes intense feelings of well-being, elation, happiness, excitement, and joy. These include heroin, opium, codeine, and narcotic pain medicines that may be prescribed by a doctor or bought illegally.
Cannabinoids: products derived from the plant Cannabis sativa contain substantial amounts of tetrahydrocannabinol (THC). THC is the substance that's primarily responsible for the effects of marijuana on a person's mental state. (National Centre for Complementary and Integrative Health, 2019)
Stimulants: These are drugs that stimulate the brain and nervous system. They include cocaine and amphetamines, such as drugs used to treat ADHD (methylphenidate or Ritalin). A person can start needing higher amounts of these drugs over time to feel the same effect. (MedlinePlus, 2020)
Hallucinogens: LSD, mescaline, psilocybin ("mushrooms"), and phencyclidine (PCP, or "angel dust") can cause a person to see things that are not there and can lead to psychological addiction. (MedlinePlus, 2020)

16 of 44

Risk Factors

Biology: The genes, gender, ethnicity, and the presence of other mental disorders may also influence the risk for drug use and addiction.

Development: Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction risk.

National Institute on Drug Abuse, 2018

Contact info: info@nursesinternational.org

No one factor can predict if a person will become addicted to drugs. A combination of factors influences the risk for addiction. The more risk factors a person has, the greater the chance that taking drugs can lead to addiction. For example:

Biology: Includes genetics, gender and mental illness. Gender, ethnicity, and the presence of other mental disorders may also influence the risk for drug use and addiction. The genes that people are born with account for about half of a person's risk for addiction. Scientists estimate that genes, including the effects environmental factors have on a person's gene expression, called epigenetics, account for between 40 and 60 percent of a person's risk of addiction. Also, teens and people with mental disorders are at greater risk of drug use and addiction than others.

Environment: A person's environment includes many influences, from family and friends to economic status and general quality of life. Factors such as peer pressure, physical and sexual abuse, early exposure to drugs, stress, and parental guidance can greatly affect a person's likelihood of drug use and addiction.

Development: Genetic and environmental factors interact with critical developmental stages in a person's life to affect addiction risk. Although taking drugs at any age can lead to addiction, the earlier drug use begins, the more likely it will progress to addiction. This is particularly problematic for teens. Because areas in their brains that control decision-making, judgment, and self-control are still developing, teens may be especially prone to risky behaviors, including trying drugs.

17 of 44

Risk Factors (Continued)

Environmental factors:

Economic status
General quality of life
Peer pressure
Physical and sexual abuse
Early exposure to drugs
Stress
Minimal parental guidance
Pain management

National Institute on Drug Abuse, 2018

Contact info: info@nursesinternational.org

18 of 44

Critical Thinking Question

An 18-year-old male lives in a low socioeconomic area of the city with his mother. His father died from a drug overdose when he was a young child. His mother has a history of depression and obesity. He started experimenting with alcohol at 14 and now smokes marijuana a couple of times a week with his friends. What are the risk factors for substance use disorders?

Contact info: info@nursesinternational.org

19 of 44

Alcohol Use

Standard drink 12 ounce (.35 liter) beer, 8-9 ounces (.23-.29 liter) malt liquor, 5 ounces (.147 liter) wine or 1.5 ounces (.044 liter) distilled spirits

https://www.unlv.edu/studentwellness/wellnesszone/alcohol-other-drugs

Contact info: info@nursesinternational.org

20 of 44

Signs and Symptoms of Alcohol Intoxication

Psychological and behavior changes such as:

Aggression
Moodiness
Impaired judgment

Slurred speech
Incoordination
Unsteady gait
Nystagmus

Contact info: info@nursesinternational.org

21 of 44

Alcohol Intoxication/Overdose

Caused by too much alcohol in the bloodstream; depresses autonomic nervous system functions (breathing, heart rate, and temperature control).
Signs of intoxication include:

Mental confusion
Difficulty remaining conscious
Vomiting
Seizures
Trouble breathing
Slow heart rate
Clammy skin
Dulled gag reflex
Low body temperature

Signs of overdose - memory gaps, unconsciousness and death

Contact info: info@nursesinternational.org

22 of 44

Danger Signs of Alcohol Overdose

Mental confusion or stupor
Difficulty or inability to wake up
Vomiting
Seizures
Slow respiratory rate (fewer than 8 per min)
Irregular breathing (10 seconds or more between breaths)
Slow heart rate
No gag reflex
Extremely low body temperature
Clammy skin, bluish skin color or pale

National Institute of Alcohol Abuse and Alcoholism, 2021

Contact info: info@nursesinternational.org

23 of 44

Medical Treatment - Alcohol Overdose

Can cause hypotension and tachycardia due to peripheral vasodilation or fluid loss.
Evaluate for vital signs.
Assess if other drugs were taken with alcohol.
Routine lab - serum glucose and electrolytes to assess for:

Hypoglycemia
Hypokalemia
Hyperlactatemia

Contact info: info@nursesinternational.org

24 of 44

Medical Treatment - Alcohol Overdose (Continued)

IV thiamine with dextrose for intoxication to prevent Wernicke’s encephalopathy.
Protect client from self-harm or harming others.
May require ICU for ventilation.

Contact info: info@nursesinternational.org

25 of 44

Case Study/ Critical Thinking Question/ What Would the Nurse Do?

A young man was drinking alcohol at a local bar with his friends. Afterward, he walked to his car and passed out.

His friend found him and could not wake him up. What are the signs of alcohol overdose? What should the nurse be alerted to in this situation that requires emergency attention?

Contact info: info@nursesinternational.org

26 of 44

Opioid Intoxication/Overdose

Opioids - used for moderate to severe pain relief and anesthesia
Misuse results in feelings of relaxation and euphoria
Intoxication causes:

Euphoria and subsequent apathy
Dysphoria
Psychomotor problems
Impaired judgment

Contact info: info@nursesinternational.org

27 of 44

Opioid Intoxication/Overdose (Continued)

Intoxication signs include:

Pupillary constriction (or dilation from severe overdose)
Drowsiness or coma
Slurred speech
Impaired attention

Overdose signs include:

Pinpoint pupils
Respiratory depression
Decreased level of consciousness

Contact info: info@nursesinternational.org

28 of 44

Opioid Intoxication/Overdose (Continued)

Recognize signs of overdose:

Decreased consciousness
Pinpoint pupils
Slow, shallow breathing or difficult breathing
Cyanosis

If suspected - stimulate the person by calling their name or vigorously grinding one’s knuckles into the sternum.
Call for emergency assistance
Provide CPR if needed
Administer the first dose of Naloxone if available

If no response after 2-3 minutes, administer the second dose

Contact info: info@nursesinternational.org

All naloxone products are effective in reversing opioid overdose, including fentanyl-involved opioid overdoses, although overdoses involving potent or large quantities of opioids may require additional doses of naloxone.
Withdrawal triggered by naloxone can feel unpleasant; some people may awaken confused, agitated, or aggressive. Provide safety and reassurance, and explain what is happening.
If the person overdosing does not respond within 2 to 3 minutes after administering a dose of naloxone, administer a second dose of naloxone.
People who have taken long-acting or potent opioids (like fentanyl) may require additional intravenous bolus doses or an infusion of naloxone. The duration of the effect of naloxone depends on the dose, route of administration, and overdose symptoms. It is shorter than the effects of some opioids, so a second dose may be required.

29 of 44

Cannabis (Marijuana) and Intoxication

Psychoactive chemical - delta-9-tetrahydrocannabinol (THC).
Alters functioning of the hippocampus and other brain areas involved in learning and performing complex tasks.
Impairs driving safely and other physical activities.
Causes relaxation and euphoria, heightened sensory perception, laughter, altered perception of time and increased appetite.
In large amounts, user may experience acute psychosis.
Overdose is unlikely unless laced with other drugs (fentanyl).

Contact info: info@nursesinternational.org

30 of 44

Stimulant Use and Intoxication

Includes:

Amphetamine-type substances
Cocaine
Crack

Releases dopamine in the brain - highly addictive
Cocaine causes:

Increased blood pressure
Restlessness
Irritability

Long-term use can cause:

Heart attacks
Seizures

Contact info: info@nursesinternational.org

31 of 44

Stimulant Use and Intoxication (Continued)

Methamphetamine use and withdrawal causes:

Psychosis
Hallucinations
Euphoria

Stimulant intoxication causes:

Problematic behavior or psychological changes
Hypervigilance
Anxiety
Tension
Anger
Impaired judgment

Contact info: info@nursesinternational.org

32 of 44

Medical Care for Stimulant Intoxication

Symptoms:

Tachycardia
Hypertension
Dilated pupils
Perspiration/chills
Nausea/vomiting
Weight loss
Agitation
Muscular weakness

Respiratory depression
Chest pain
Confusion
Seizures or coma
Psychosis
Dyskinesia
Dystonia

Contact info: info@nursesinternational.org

33 of 44

Medical Care for Stimulant Intoxication (Continued)

The nurse should be aware of severe agitation with extreme violence putting others at risk of major injury.
IV benzodiazepines are administered to sedate severely agitated clients.
Physical restraints are avoided.
IV fluids, sedation, and external cooling methods are used.
Airway management may be needed.

Contact info: info@nursesinternational.org

34 of 44

Inhalant Use and Intoxication

Use highest among adolescents
Found in spray paints, markers, glue, gasoline, cleaning fluids
Nitrites for chest pain (prescription)
Causes behavior changes such as:

Belligerence
Assaultiveness
Apathy
Impaired judgment

Contact info: info@nursesinternational.org

35 of 44

Inhalant Use and Intoxication (Continued)

Intoxication symptoms:

Dizziness
Nystagmus
Incoordination
Slurred speech
Unsteady gait
Lethargy
Depressed reflexes

Psychomotor problems
Slurred speech
Depressed reflexes
Lethargy
Muscle weakness
Vision changes
Stupor or coma

Contact info: info@nursesinternational.org

36 of 44

Medical Care for Inhalant Intoxication

Long-term use causes:

Liver and kidney damage
Hearing loss
Bone marrow damage
Nerve damage
Delayed behavior development
Brain damage

Overdose is possible in high concentrations.
Acute intoxication may cause seizures, coma and death.
Cardiopulmonary resuscitation may be needed.
Oxygen support and possibly mechanical ventilation.

Contact info: info@nursesinternational.org

37 of 44

Case Study/ Critical Thinking Question/ What Would the Nurse Do?

The emergency room nurse is caring for a patient who has methamphetamine intoxication.

What should be the concerns of the nurse?

Contact info: info@nursesinternational.org

38 of 44

Red Flags

Behaviors noted by the nurse in the clinic or school or by family and friends.
Loss of interests, activities, and friends.
Financial problems: may ask to borrow money.
Impulsiveness.
Violence.
Presence of physical, behavioral and emotional symptoms of substance use.
Behavior problems at school.

Contact info: info@nursesinternational.org

39 of 44

Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in healthcare decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting and following treatment recommendations.

AHRQ, 2020

Contact info: info@nursesinternational.org

40 of 44

Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health-seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be acceptable in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

41 of 44

References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Ashton, L. (2022, January 19). Drug Use, Abuse & Addiction Statistics, Trends & Data (2022 Update). https://cfah.org/drug-use-addiction-statistics/

Ernstmeyer, K., & Christman, E. (Eds.). (2022). Open RN Nursing Mental Health and Community Concepts by Chippewa Valley Technical College is licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingmhcc/front-matter/introduction/

Khan, M. (2020). Overview of Substance-Related Disorders - Psychiatric Disorders - Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/psychiatric-disorders/substance-related-disorders/overview-of-substance-related-disorders#

Contact info: info@nursesinternational.org

42 of 44

References

McLellan, A. T. (2017). Substance Misuse and Substance use Disorders: Why do they Matter in Healthcare?. Transactions of the American Clinical and Climatological Association, 128, 112–130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5525418/

MedlinePlus. (2022, May 10). Substance use disorder. https://medlineplus.gov/ency/article/001522.htm

National Institute of Alcohol Abuse and Alcoholism (2021, May). Understanding the Dangers of Alcohol Use. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-dangers-of-alcohol-overdose

National Institute on Drug Abuse. (2018, June 6). Understanding Drug Use and Addiction Drug Facts. https://nida.nih.gov/publications/drugfacts/understanding-drug-use-addiction

Contact info: info@nursesinternational.org

43 of 44

References

United Nations Office on Drug and Crime. (2021). Booklet 2 - Global overview of drug demand and drug supply. https://www.unodc.org/unodc/en/data-and-analysis/wdr-2021_booklet-2.html

World Health Organization.(n.d.). Substance Abuse. https://www.afro.who.int/health-topics/substance-abuse

World Health Organization. (2022). Alcohol: Overview. https://www.who.int/health-topics/alcohol#tab=tab_1

Contact info: info@nursesinternational.org

44 of 44

Please go to

My Learning Experience

to provide feedback on your experience.

Thank you, and come back soon!

Contact info: info@nursesinternational.org