SUBSTANCE USE DISORDERS
Substance use disorders may be suspected from the history obtained from the patient or family, or be the recognition of signs of intoxication or withdrawal. A person can have more than one substance use disorder at a time. Substances of abuse include:
- Alcohol
- Caffeine
- Cannabis
- Hallucinogens (PCP and LSD)
- Hypnotics, sedatives, anxiolytics
- Inhalants (nitrites, paint thinners, aerosol sprays, gases)
- Prescription and nonprescription opioids (codeine, oxycodone, heroin)
- Prescription and nonprescription stimulants (Adderall, cocaine, methamphetamine)
- Tobacco/nicotine
Signs and Symptoms of Substance Use Intoxication and Withdrawal
Each substance with the potential for intoxication and withdrawal has signs and symptoms that are unique. If not medically managed, withdrawal from certain substances, such as alcohol and benzodiazepines, can be quite severe and, in some rare cases, lethal.
ALCOHOL
Signs and symptoms of alcohol intoxication include:
- Disinhibition of sexual or aggressive impulses
- Mood lability
- Impaired judgment
- Impaired social or occupational functioning
- Slurred speech
- Incoordination
- Unsteady gait
- Nystagmus (rapid, involuntary movement of the eyes)
- Flushed face
Following reduction or cessation in heavy or prolonged use (several days or longer), these withdrawal symptoms may appear:
- Coarse tremor of hands, tongue, or eyelids
- Nausea or vomiting
- Tachycardia
- Diaphoresis
- Elevated blood pressure
- Anxiety
- Depressed mood or irritability
- Transient hallucinations or illusions (misperceptions or misinterpretations of the environment)
- Headache
- Insomnia
- Seizures
A complicated withdrawal may progress to delirium:
- Difficulty sustaining and shifting attention
- Distractibility
- Disorganized thinking
- Rambling, irrelevant, pressured, or incoherent speech
- Flight of ideas
- Impaired reasoning or goal-directed behavior
- Disorientation to time and place
- Impaired recent memory
- Illusions
- Hallucinations
- Fluctuating psychomotor activity
- Emotional instability
A small number of individuals will have the serious form of withdrawal called delirium tremens (DTs). DTs may appear suddenly and is evidenced by:
- Seizures
- Fever
- Severe confusion
- Agitation
- Hallucinations
DTs can be fatal without swift medical intervention, making alcohol withdrawal safest when monitored around the clock by medical professionals (Townsend, 2018; Sharp, 2022).
OPIOIDS
These drugs desensitize the person to both psychological and physiological pain and induce a sense of euphoria. Following the initial euphoria, signs and symptoms of opioid intoxication include:
- Apathy
- Dysphoria
- Psychomotor agitation or retardation
- Impaired judgment
- Pupillary constriction
- Pupillary dilatation due to anoxia from severe overdose
- Drowsiness
- Slurred speech
- Impaired attention or memory
Severe opioid intoxication can lead to respiratory depression, coma, and death.
Signs and symptoms of withdrawal from opioids include:
- Dysphoric mood
- Nervousness or anxiety
- Nausea or vomiting
- Flu-like symptoms
- Muscle aches and pains
- Abdominal cramping
- Teary eyes
- Rhinorrhea
- Dilated pupils
- Piloerector (goose bumps)
- Diaphoresis
- Diarrhea
- Yawning
- Fever
- Insomnia
(Sharp, 2022)
COCAINE
Signs and symptoms of cocaine intoxication include:
- Excitability
- Dilated pupils
- Rhinorrhea
- Weight loss
- Mood swings
- Epistaxis (nosebleeds)
- Talkative habits
- Changes in sleeping and eating patterns
Signs and symptoms of cocaine withdrawal include:
- Agitation and restless behavior
- Anxiety
- Irritability
- Paranoia
- Depressed mood
- Fatigue
- Problems with concentration
- Increased appetite
- Vivid and unpleasant dreams
- Lethargy or ongoing tiredness
(Sharp, 2022; Borke, 2021)
BENZODIAZEPINES
Signs and symptoms of benzodiazepine intoxication include:
- Diaphoresis
- Shallow respirations
- Slurred speech
- Impaired coordination
- Nausea and vomiting
- Complaints of dizziness
- Weakness
- Poor judgment or thinking
- Blurred vision
- Drowsiness
- Mood changes
Signs and symptoms of benzodiazepine withdrawal include:
- Sleep disturbances
- Increased tension
- Anxiety
- Panic attacks
- Difficulty concentrating
- Diaphoresis
- Heart arrhythmias
- Headache
- Muscle stiffness or discomfort
- Mild to moderate changes in perception
- Cravings
- Hand tremors
Less common and more severe symptoms can occur as well, which include:
- Hallucinations
- Seizures
- Psychosis or psychotic reactions
- Increased risk of suicidal ideation
(AAC, 2022)
SCREENING FOR SUBSTANCE USE DISORDERS
There are several screening tools available for both alcohol and substance use in adults, such as:
- NIDA Drug Use Screening Tool, also known as the NIDA Quick Screen
- DAST-10 (Drug Abuse Screen Test), designed for both adults and older youth
(NIH, 2021)
Treatment Modalities for Substance Use Disorders
Treatments for substance abuse disorders are highly individualized, and one individual may require different types of treatment at different times. Treatment often requires continuing care to be effective, as substance use disorder is a chronic condition with potential for both recovery and relapse. The three main forms of treatment include:
- Detoxification
- Cognitive and behavioral therapies
- Medication-assisted therapies
(Cleveland Clinic, 2022b)
How to Respond to and Care for a Patient with Signs and Symptoms of Substance Use Disorder
Substance use is common among patients in all healthcare settings and is known to have a substantial impact on health. It is a challenge to address drug use disorders and to detect problematic use. Studies have shown that patients tend to deny or underreport substance use, and those with substance use disorders may not report any problems at all. Therefore, it is important to determine the presence of signs and symptoms that may indicate substance use problems in order to identify patients in need of comprehensive screening, intervention, and referral (Krause, 2021).
Common presentations of disorders due to substance use may include:
- Appearing affected by alcohol or other substances (e.g., odor of alcohol, slurred speech, sedated or erratic behavior
- Signs of recent drug use (recent injection marks, skin infections)
- Deterioration of social functioning (e.g., difficulties at home or work, unkempt appearance)
- Signs of chronic liver disease (jaundiced skin and eyes, palpable and tender liver edge, ascites, spider-like blood vessels on the surface of the skin, and altered mental status)
- Problems with balance, walking, coordinating movements, and nystagmus
- Dilated pupils, disordered thinking, aggression, and elevated blood pressure in patients who may be using a stimulant
- Patients who make repeated requests for psychoactive medications, including analgesics
- Presence of infections associated with intravenous drug use (HIV/AIDS, hepatitis C)
When a patient presents with signs and symptoms of substance use withdrawal, a calm and supportive environment should be provided. Nurses should monitor the patient’s status and administer needed therapy as ordered. Following withdrawal:
- Ask: Ask one or more questions related to drug use. When a patient answers no to drug use, probe gently, perhaps by asking, “Not even when you were in high school or college?”
- Advise: Provide medical advice about the patient’s drug use. Recommend quitting before problems (or more problems) develop. Medically supervised detoxification may be advised for discontinuing the use of some drugs. If patients appear ashamed or embarrassed, state that this is a health-related medical recommendation and is not meant to judge or stigmatize them.
- Assess: Assess how willing a patient is to change their behavior after hearing the clinician’s advice. Acknowledge ambivalence about changing behavior. State concerns about specific ways that the drug of choice may affect the person’s health or personal life. If the patient becomes upset or argumentative, do not argue. Give the patient time unless the condition is life-threatening.
- Arrange: Arrange for a referral for further assessment and treatment if appropriate. If the patient resists referral, explore the concerns.
(NIDA, n.d.)
CASE
A Patient Withdrawing from Substance Use
Patrick, an accountant, had been admitted to the surgical unit following a laparoscopic appendectomy. During the evening he was stable and had good pain relief. Later, Yin, the night nurse, made rounds and found him to be sleeping soundly. A short while later she ran to his room because he was yelling. When Yin arrived at the bedside, Patrick was awake and told her he had had a terrible nightmare. He was sweating profusely and was quite shaken and jittery. She reassured him that he was safe. He then stated that he was very hungry.
Yin took the patient’s vital signs. His pulse rate was 65, despite his bad dream, and everything else was within normal limits. She did a brief physical examination and found no abnormalities. Yin told him she would get him something to eat from the unit kitchen. On her way back to his room, Yin checked his history and physical and nursing assessment for comorbid medical or mental conditions and found no mention of alcohol or drugs.
Yin sat down next to the bed while the patient ate. He began to speak with her.
Patrick: “Geez, I never have nightmares. Not like that anyhow.”
Yin: “Tell me how you’re feeling right now, Patrick.”
Patrick: “I've got a slight headache, and I'm really feeling down in the dumps.”
Yin: “You’re feeling depressed?”
Patrick: “Yeah, and I don't have a clue why I should be.”
Yin: “Is anything else bothering you?”
Patrick: “Well, yeah, as a matter of fact, I feel totally worn out.”
Yin: “You feel fatigued.”
Patrick: “Yeah, I do.”
Yin began to wonder if these could be signs of a stimulant withdrawal, and so she began a short screening conversation:
Yin: “Patrick, I need to ask you an important question. Do you use any recreational drugs?”
Patrick: “No! Never!”
Yin: “Have you ever used any drugs?”
Patrick (hesitatingly): “No.”
Yin (smiling): “Not even when you were younger?”
Patrick: “Well, yeah. I’ve done that.”
Yin: “What type of drug have you used?”
Patrick: “Oh, a little coke now and then.”
Yin: “When did you last use this drug?”
Patrick: “Gee … I don’t remember.”
Yin: “Have you by any chance used this recently?”
Patrick: “Yeah, I guess so.”
Yin: “When was the last time you used cocaine?”
Patrick (looking ashamed): “Well … yesterday after work.”
Yin nods encouragingly.
Patrick: “I suppose you think that’s awful.”
Yin: “No, Patrick, I don’t think that’s awful. I’m only concerned about your well-being.”
Patrick: “Okay. Thanks.”
Yin: “Can you tell me how often you use cocaine?”
Patrick: “Oh, not too often.”
Yin: “Tell me what you mean by ‘not too often.’”
Patrick (pausing): “Actually, I use it every day.”
Yin: “Patrick, I’m concerned that you may be experiencing some withdrawal symptoms, and I want to call your doctor to find out what he wants me to do to help you out. I’ll be right back to talk with you.”
Yin then contacts the physician on call and informs him that Patrick may be going through withdrawal from cocaine.
Discussion
Yin suspected that the signs and symptoms Patrick was experiencing may be indications of withdrawal from a stimulant. These included his jitteriness, an unpleasant dream, slowed heart rate despite his bad dream, increased appetite, and feeling depressed and fatigued. She found that his record did not show any indication of substance use, and so she gently eased into the topic in a nonjudgmental manner, recognizing that people often diminish or deny their use of drugs and alcohol. Her nonthreatening approach allowed Patrick to overcome his concern about her judging him, and he eventually acknowledged his use of cocaine. Following this acknowledgment, Yin reassured him that she was concerned only with his well-being and would be there to help him.