Substance Use Disorders and Withdrawal

• Substance Use Disorder:

  • DSM V diagnosis
• Physical and Psychological Dependence:

  • Substance dependence affects the brains reward system, which impacts psychological dependence
• Tolerance:

  • Physical- body is dependent on the substance
• Cross-tolerance:

  • Drug interaction, increasing effect of the substance
• Withdrawal:

  • Important in alcohol and benzodiazepines due to potential death
• Relapse:

  • Expected part of recovery from substance use disorders
• Tolerance- Nursing Role:

  • Use judgment in using PRN medications
• Withdrawal- Nursing Role:

  • Use withdrawal protocol within the healthcare system
• Relapse- Nursing Role:

  • Common during recovery
  • Develop relapse prevention plan
  • Identify triggers
  • Maintain positive approach with patient
• DSM V Substance Use Disorders:

  • Continued use of a substance despite cognitive, behavioral, and physiological symptoms
• DSM V Substance-Induced Disorders:

  • An underlying change in brain circuitry that may persist after detoxification (intoxication and withdrawal)
• Categories in Substance Use Disorder:

  • Alcohol
  • Stimulants
  • Depressants
  • Club Drugs
  • Hallucinogens
  • Steroids
  • Inhalants
  • Many prescription medications are in these categories
• Nursing Role-Substance Use:

  • Screen ALL patients: Be specific and direct
  • Identify RISK and problem
  • Determine SEVERITY
  • Educate
  • Treat (overdose/withdrawal)
  • Refer
• SBIRT-Screening, Brief Intervention and Referral to Treatment:

  • Evidence-based: large cohort SAMHSA shows effectiveness
  • Screening for risk of a disorder
  • Improve outcomes for those who use substances
  • Used during routine medical and nursing care
• Education Resources- Women:

  • No more than 4 drinks a day
  • No more than 7 drinks a week
• Education Resources- Men:

  • No more than 7 drinks a day
  • No more than 14 drinks per week
• Older Adult Assessment:

  • May be difficult to detect
  • Might believe the effects are a medical disease instead (dementia)
  • Grief/loss may contribute to substance use
  • Toxicity may occur at lower doses of substance
• Alcohol Withdrawal- Information Needed:

  • When alcohol withdrawal is suspected, ask the family/friends:
  • When was the last drink
  • How much was consumed
  • What type of alcohol
  • How long that patient has been drinking heavily
  • Other substances
  • Substance abuse treatment history
• Signs of Alcohol Withdrawal:

  • Autonomic hyperactivity- increased dopamine
  • Hand tremor
  • Insomnia
  • N/V
  • Transient visual, tactile, or auditory hallucinations or illusions
  • Psychomotor agitation
  • Anxiety
  • Generalized tonic-clonic seizures
• Delirium Tremens (DTs)- A medical emergency:

  • Severe autonomic hyperactivity
  • Cardiovascular collapse is a possibility
  • May need ICU admission
  • Symptoms may abruptly worsen
  • We need to prevent this, so following the withdrawal protocol of the institution is important
  • At various levels of the protocol, nurses administer medications (benzodiazepines)
  • Typically begins 72-96 hours after the last drink
• Nursing Treatment of Withdrawal Includes:

  • Supportive (emotional reassurance, and respectful interactions)
  • Fluid and electrolyte replacement
  • Nutritional support
  • Thiamine supplement and multivitamins; glucose
  • Encourage rest - decrease environmental stimuli
  • Fall and seizure precautions; skin assessment; I and O; IV
  • Vital signs hourly
  • Review labs
  • Mental status, suicide risk, sleep patterns
  • Withdrawal assessment hourly
• Treatment/Resources for Persons with Alcohol Use Disorder:

  • One-on-one therapy with health professional
  • Support groups for recovery
  • AA and Narcotics Anonymous
  • SMART
  • Medication support
  • Inpatient, outpatient, group home
• Wernicke Korsakoff:

  • Long Term effects from alcohol use disorder
  • We want to prevent this, using thiamine and nutritional support
• Wernicke's Encephalopathy:

  • Degenerative brain disorder
  • Caused by thiamine deficiency: vision impairment, ataxia, hypotension, confusion and coma
• Korsakoff's Amnestic Syndrome:

  • Involves the heart, vascular, and nervous systems, but the primary issue is in acquiring new information/retrieving memories
  • Confabulation occurs (telling a plausible but imagined story to compensate for the loss of memory)
  • Other symptoms: easily distracted, disorientated, vision impairment
• Opioid Use Disorder- Medications:

  • Naloxone (Narcan):
  • Reverses the effects of opioid medication, including drowsiness, slow breathing and LOC
  • Suboxone decreases craving:
  • Combination of buprenorphine and naloxone
  • Buprenorphine:
  • Treats opioid addiction- is physiologically "addictive" but without the "high" or need for increasing dosage
• Harm Reduction Programs:

  • Nurses working in the community may have roles within methadone clinics and needle exchange programs
  • Needle exchange programs
  • Methadone clinics
  • Designated driver
  • Naloxone (Narcan)- reverse opioid overdose
• Summary Nursing Roles:

  • Nursing Roles in substance use are significant, expected and relevant to all settings
  • Screening and brief intervention (including education and referral)
  • Assessment of mental status and physiological status
  • Management of alcohol or other substance withdrawal in acute care
• Alcohol Use Disorder:

  • A problematic pattern of alcohol use leading to clinically significant impairment or distress
• Alcohol Use Disorder- Manifestations:

  • Large amounts/longer period
  • Unsuccessful attempts to control
  • Excessive time spent in alcohol activities
  • Craving
  • Failure to fulfill major obligations
  • Reduced usual activities
  • Use in physically hazardous situations
• Alcohol Withdrawal Syndrome:

  • Begins within 6-24 hours of the last drink or a sudden reduction in alcohol drinking
  • Abrupt cessation unmasks the adaptive responses to chronic ethanol use, resulting in overactivity of the CNS
• Mild Alcohol Withdrawal Symptoms:

  • Anxiety and agitation
  • Restlessness and insomnia
  • Tremor, diaphoresis, palpitations
  • Headache and alcohol craving
  • Loss of appetite
  • N/V
• Opioid Use Disorder:

  • Previously known as opioid addiction is defined as a problematic pattern of opioid use that leads to serious impairment or distress
  • Can be described as the use of opioids in a manner other than as prescribed, such as in higher doses, or frequent doses or longer than indicated
• Opioid Use Disorder- Symptoms:

  • An overpowering desire to use opioids
  • Increased opioid tolerance
  • Withdrawal syndrome when opioids are no longer in use
  • Can range from dependence on opioids to addication
• Spontaneous Opioid Withdrawal:

  • Occurs when a patient who is physiologically dependent upon opioids reduces or stops opioid use abruptly
• Precipitated Opioid Withdrawal:

  • Occurs when a patient who is physiologically dependent upon opioids and who has or recently had opioids in their system is administered an opioid antagonist (naloxone) or an opioid partial agonist (buprenorphine)
• Opioid Withdrawal- Symptoms:

  • GI Distress- cramps, diarrhea, N/V
  • Flu-like Symptoms
  • SNS Arousal- hypertension, tachycardia, anxiety, insomnia, tremor, restlessness
  • Dizziness, leg cramps, dysthymia, etc
• Harm Reduction Interventions:

  • Aimed at reducing the negative effects related to substance use or other potentially harmful health behaviors
  • Harm reduction does NOT condone or condemn substance use