Substance Use Disorders

- Context
- Defining substance use disorders
- Assessing substance use
- Managing substance use disorders
- Commonly used substances
Overview - Intoxication
- Assessment
- Management
- Withdrawal
- Assessment
- Management
Context
Why do people use substances?
What are some common beliefs about
substance use?
Common Myths About Substance Use
• People with substance use disorders lack willpower
• People who use substances don’t want to stop or get help
• People with substance use disorders don’t care about the harm they may
cause
• The best treatment for substance use disorders is abstinence
• People mostly use substances to get high
• People usually use only one substance at a time
• Mental health treatment doesn’t work for substance use disorders
• Taking methadone or suboxone is replacing one addiction for another
• Methadone and suboxone are short-term solutions
Problem: National
• Over 40 million people have a substance use disorder
• Less than 10% get treatment
• Over 100,000 accidental overdose deaths annually
• Increase in substance availability
• Cannabis
• Opioids
• Synthetic substances
• Increase in substance potency
• Cannabis
• Nicotine
• Opioids
• Increase in deaths involving multiple substance (ie: opioids and stimulants)
• Disproportionate impact on already marginalized communities (ie: Black, American
Indian/Alaskan native, low income, rural)
Images from an epidemic
Problem: Local

• In Philadelphia, over 1,400 individuals died

from unintentional overdose in 2022
• Fentanyl is the most commonly detected
substance involved in overdose deaths
(77%) followed by cocaine
• Overdose deaths are highest in non-Hispanic
Black individuals
Problem: Local (continued)
How did we get here?
Stigma
• War on Drugs
• Mass incarceration

• Public perception
• Lack of comprehensive and compassionate treatment
• Decreased access to social services (ie: housing, insurance, employment)
Increased Opioid Access

• Pharmaceutical company marketing

• Increased prescriptions for noncancer
pain
• Disjointed prescription drug monitoring
• Decreased street price of non-
prescription opioids
• Infiltration of fentanyl and other high
potency synthetic opioids
Limited Treatment Access
• Siloed care (physical health, mental health, substance use, criminal
justice)
• High threshold for treatment program entry and continuation
• Prescriber limitations for MOUD
• Gaps in insurance coverage
Public Health Impact
• Frequent use of emergency medical services
• Infectious disease
• HIV, Hep B, Hep C

• Loss of education, housing, employment

• Children
• Risk of accidental ingestion
• Parents lost to death, disability, or prison
Some Good News!
What is a substance use disorder?
DSM Categories

Substance-Induced
Disorders Substance Use Disorders
• Intoxication • Problematic pattern of use
• Withdrawal leading to
distress/impairment
• Other substance/medication-
induced mental disorder
Substance-Induced Disorders
Intoxication
A. Recent ingestion
B. Problematic behavior and psychological effects
C. The specific symptoms for each substance
D. Symptoms are not explained by other condition

Withdrawal
E. Cessation or reduced in heavy / prolonged use
F. The specific symptoms for each substance
G. Causes clinically significant stress or impairment
H. Symptoms are not explained by other condition
Other substance/medication-induced mental disorder

A. Symptoms of a specific mental disorder

B.Evidence of BOTH
A. Onset within 1 month of intoxication or
withdrawal
B. Substance is capable of producing the symptoms.

C.Not explained by other condition

D.Not only during delirium
E. Significant stress or impairment
DSM5 Criteria for SUD
Risks Associated with Substance Use
• Physical
• Medical complications of use
• Neglect of personal health

• Psychiatric
• Exacerbation of comorbidities
• Increased risk of certain disorders

• Social/interpersonal
• Financial
• Occupational
• Legal
Neurobiology of Substance Use

ACUTE EFFECTS CHRONIC EFFECTS

• Substance binds to receptor, • Alterations in cognition and

mimicking a neurotransmitter, memory
or increasing/decreasing • Development of tolerance
neurotransmitter release
• Impulsive  compulsive
• Onset varies by substance and
• Altered reward system
route
• Duration varies by substance
Brain Response
to Substance
Use
a) VTA releases dopamine:
anticipation
b) Nucleus accumbens : motivation
and action
c) Hippocampus: learning and
memory
d) Amygdala: decision making
e) Prefrontal cortex: decision making

Anticipation and memory of

pleasurable experience drives this
process
McMaster Brain Research Society (2022)
Common process/behavior disorders

Internet
Shopping Gambling Sex
use

(+/-)
Pornograph Video
Work Disordered
y games
eating
Chronic Disease Model
• Cycle of recovery, relapse, prevention
• Need for ongoing, collaborative care
• Biopsychosocial aspects
• Multimodal treatment
General Assessment and
Management of SUD
Risk Factors
• Biological
• Genetics
• Dysfunction in reward system
• Pain

• Psychological
• Impulsivity
• Psychiatric comorbidity
• Classical conditioning

• Sociological
• Early onset of substance use
• Trauma history
• Early exposure to substance use
• Financial strain
Substance Use Screening Tools
• CAGE (alcohol)
• AUDIT-C (alcohol)
• CRAFFT (adolescent substance use)
• DAST (substance use)
Substance Use Assessment
• Substance(s)
• Route(s)
• Amount (including changes in tolerance)
• Onset
• Duration (including fluctuations, periods of recovery)
• Frequency
• Last use
• Withdrawal symptoms
• Aggravating factors
• Relieving factors
• Treatment (and efficacy)
• Severity (functional impact)
Assessment: Biological Domain
• Toxicology
• Nutrition status
• Cardiovascular
• GI/Liver
• Integumentary
• Reproductive
• Musculoskeletal
• Neurologic
• Immune
Medical Complications of Injecting
Substances
• Injection site infections
• Cellulitis
• Necrosis
• Sepsis
• Osteomyelitis
• Endocarditis
• Valve failure

• Infectious disease
• HIV
• Hepatitis B, C
Medical Complications of Inhaled
Substances
• Oral disease
• Respiratory disease
• Nasal passage injury
Assessment: Psychological Domain
• Suicidality
• Aggression
• Mood (depressed, euphoric, anxious, irritable, labile)
• Psychosis
• Cravings
• Memory
• Concentration
Assessment: Sociological Domain
• Relationships and social support
• Occupational functioning
• Educational functioning
• Risk for harm to others
• Legal involvement
• Access to care
• Cultural norms for substance use
Analysis
• Healthy vs. unhealthy substance use
• Immediate vs. chronic risks
• Physical safety
• Psychological safety
Prioritization
• Safety risks of intoxication
• Safety risks of withdrawal
• Suicide risk
• Basic physical needs (food, shelter)
• Psychiatric comorbidities
• Chronic health risks
Transtheoretical
Stages of
Change Model
Prochaska & DiClemente
General Treatment Principles
• Trauma-informed
• Patient-centered
• Collaborative, shared decision making
• Informed consent
• Interdisciplinary
• Equitable
Non-Pharmacologic Treatment
• SBIRT
• Motivational interviewing
• Individual psychotherapy
• Mutual support/self-help groups
• Peer support
• Contingency management
Alcoholics Anonymous/Narcotics Anonymous
• AKA AA/NA, 12-step groups
• Focus on ”higher power”
• Abstinence-based
• Open or closed meetings
• Able to connect with sponsors
Family Support
• Enabling
• Codependency
• Caregiver role disruption
• Grief
Group Activity
• Identify a mutual support group (other than AA/NA) for substance use or
related disorders and answer the following questions:
• What population(s) does the group target?
• What is the inclusion/exclusion criteria for participation?
• How are groups structured?
• How/where can someone find out more?
Special Populations
Pediatric and Adolescents
• Earlier onset substance use increases risk of SUD
• Increasing access to prescription drugs
• Fewer treatment options
Childbearing Adult
• Increasing rates of SUD in pregnancy
• Impact of substance use on fetus
• Impact of substance withdrawal on fetus
• Impact of substance use on infant if lactating
• Barrier to accessing treatment
• Stigma
• Caregiving duties
Older Adult
• History risk for CNS depression, respiratory depression, falls
• Decreased hepatic function
• More DDI and polypharmacy
LGBTQIA+
• Higher rates of trauma
• Social norms
• Use of substances to enhance sexual performance
• Decreased treatment access
• Insurance
• Gendered treatment
Substance Use Disorders in Nursing
• High stress
• Access to controlled substances
• Knowledge of controlled substances

https://www.ncsbn.org/video/substance-use-disorder-in-nursing
Substance-specific Assessment and
Management
What is the most commonly used substance among
US adults?

What is the most common type of SUD in US adults?

What substance has the highest rate of overdose

deaths?
Commonly Used Substances
• Caffeine
• Nicotine
• Alcohol
• Cannabis
• Opioids*
• Sedative/hypnotics*
• Hallucinogens
• Stimulants*
• Inhalants
• Other* (ie: ketamine, K2)
Nicotine
• Mechanism of action: stimulates nicotinic receptors  dopamine release
• Route: oral (chew, buccal), inhaled (smoke, vape)
• Adverse effects (chronic): respiratory disease (COPD, emphysema),
cancer (lung, GI, oral, throat, pharynx, esophagus), poor dentition,
yellowing of skin and nails
Management of Nicotine Withdrawal
• Nicotine replacement therapy (patch, gum, lozenge, nasal spray)
• Offer candy/gum/mints
• Relaxation techniques
• Distraction
• Pharmacologic treatment
• Bupropion (Wellbutrin)
• Varenicline (Chantix)
 Alcohol
• Mechanism of action: GABA receptors agonist
• Pharmacology: metabolism dependent on hepatic function, GI function,
weight, body water, food intake, other medications/substances taken
concurrently
• Adverse effects (chronic): cirrhosis, malnutrition, anemia, vitamin
deficiency, gastritis, pancreatitis, neuropathy, encephalopathy, psychosis,
dementia, cancer (liver, GI, oral)
Assessment: Alcohol Intoxication
• Moderate
• Disinhibition
• Lack of coordination
• Unsteady gait
• Slurred speech
• Slowed reaction time
• Impaired attention
• Blurred vision
• Nystagmus

• Severe
• Nausea/vomiting
• Respiratory depression
• Coma
Management: Alcohol Intoxication
• Vital signs
• Respiratory support as needed
• Positioning to prevent aspiration
• Fall precautions
• Risk for injury from falls

• Hydration
Assessment: Alcohol Withdrawal
• Typically begins 6-8 hours after last drink, peaking at 24-48 hours
• Early (0-48 hours after last drink)
• Autonomic hyperactivity (tremors, diaphoresis, nausea, vomiting,
headache/fullness, tachycardia, hypertension, piloerection)
• Neuropsychiatric (agitation, anxiety, disorientation, confusion, hallucinations-
visual or tactile)

• Late (48-72 hours after last drink)- Delirium Tremens (DTs)

• Delirium
• Seizures
• Decreased GABA production + increased NMDA activation = lower seizure threshold
• Coma
Management: Alcohol Withdrawal
• Vital signs
• Seizure precautions
• CIWA assessment
• Fall precautions
• Re-orientation as needed
• Decrease environmental stimuli (noise, lights)
• Administer medication
• Benzodiazepines
• Medication to manage BP/HR
• Vitamin infusions
Psychiatric Complications of Chronic
Alcohol Use
• Caused by thiamine deficiency
• Wernicke encephalopathy (acute)
• Oculomotor dysfunction
• Ataxia
• Confusion

• Korsakoff psychosis (chronic)

• Amnesia (anterograde, retrograde)
• Confabulation
Medications for Alcohol Use Disorder
• Naltrexone
• Partial opioid agonist, reduces cravings

• Acamprosate
• Mechanism of action unknown but thought to modulate GABA

• Disulfiram
• Causes severe nausea/vomiting if alcohol is ingested

• Topiramate (off-label)
• Multimodal, exact mechanism of action unknown but thought to increase
GABA activity
Sedative/Hypnotics
• Therapeutic uses: anxiolytic, sedation, insomnia, anti-epileptic
• Benzodiazepines
• Barbiturates
• Intoxication: similar to alcohol
• Withdrawal: similar to alcohol
• Similar protocol for assessment & management
• May require slow taper of prescribed medication
Cannabis Pharmacology
• Routes: oral, inhalation (smoke, vaped)
• Mechanism of action: cannabinoid receptor agonist (increases release of
dopamine and norepinephrine)
• Pharmacology: onset and duration of action varies widely by route &
potency
• Adverse effects (acute): sedation, psychosis, anxiety
• Adverse effects (chronic): cannabis hyperemesis syndrome, respiratory
disease, decreased motivation, possible decrease in learning ability,
decreased sperm count
Cannabis

I N T O X I C AT I O N W I T H D R AWA L

• Tachycardia • Irritability
• Restlessness
• Increased reaction time
• Insomnia
• Conjunctival injection
• Vivid dreams
(bloodshot eyes)
• Headache
• Increased appetite • Stomach pain
• Dry mouth • Sweating
• Chills

66
Opioids
• Therapeutic uses: sedation, analgesia
• Routes: oral, inhalation (snort), intravenous
• Examples: heroin, oxycodone, hydrocodone, morphine, meperidine,
tramadol, hydromorphone, codeine, methadone, fentanyl
• Mechanism of action: CNS depressant (stimulates opioid receptors)
• Pharmacology: onset and duration varies widely
• Adverse effects (acute): respiratory depression, sedation
• Adverse effects (chronic): hyperalgesia, constipation, hepatic impairment
Assessment: Opioid Intoxication
• Vital signs
• Bradypnea
• Bradycardia
• Hypotension
• Decreased oxygen saturation

• Analgesia
• Euphoria
• Constricted pupils
• Sedation
• Psychomotor retardation
• Urinary retention
• Constipation
• Pruritus
• Cyanosis
Management: Opioid Intoxication
• Vital signs
• Respiratory rate
• Oxygen saturation

• Airway management
• Oxygenation
• Aspiration risk

• Administer reversal agent as needed

Naloxone (Narcan)
• Opioid receptor antagonist
• Used to treat overdoses
• IN, IM, IM auto-injector, or IV
• Short half-life
• Prescription or OTC
Nalmefene (Zurnai)
• Opioid receptor antagonist
• Used to treat overdoses
• IN, IM (auto-injector), IV
• Prescription only
Common Opioid Additives
• Fentanyl
• Xylazine*
• Etomidate*
• Metomidate*
Assessment: Opioid Withdrawal
• Vital signs
• Tachycardia
• Elevated blood pressure

• Dilated pupils
• Yawning
• Diaphoresis
• Lacrimation
• Diarrhea
• Stomach cramping, nausea, vomiting
• Myalgia
• Insomnia
• Anxiety
• Psychomotor agitation
Management: Opioid Withdrawal
• Vital signs
• COWS assessment
• Maintain hydration
• Perianal care
• Supportive medications
• Ibuprofen: muscle pain
• Clonidine: diaphoresis, agitation, elevated blood pressure, insomnia
• Ondansetron: nausea
• Dicyclomine: stomach cramping
• Loperamide: diarrhea
Medications for Opioid Use Disorder
(MOUD)
• Methadone
• Full opioid agonist
• Oral liquid
• Only available through OTP (opioid treatment program)

• Buprenorphine (Suboxone, Subutex, Sublocade, Subsolv, Brixadi)

• Partial opioid agonist
• ODT, SL film, IM (7 or 30-day)
• May have naloxone in formulation

• Naltrexone (Vivitrol)
• Partial opioid agonist
• Oral or IM (30-day)
Stimulant Pharmacology
• Therapeutic uses: ADHD,
• Routes: oral, intranasal, inhalation, intravenous
• Examples (therapeutic): amphetamine salts (Adderall, Dexedrine), methylphenidate
(Ritalin, Concerta), modafinil (Provigil)
• Examples (non-therapeutic): methamphetamine (crystal meth), cocaine (coke, crack)
• Mechanism of action: stimulates release of dopamine and norepinephrine
• Pharmacology: onset and duration of action varies by substance and route
• Adverse effects (acute): cardiac arrhythmia, MI, psychosis (paranoia, tactile & visual
hallucinations), seizure
• Adverse effects (chronic): itching  sores from skin picking, tooth and gum decay,
stroke, weight loss, sinus injury
Stimulant Use

I N T O X I C AT I O N W I T H D R AWA L

• Tachycardia, hypertension, tachypnea • Fatigue

• Pupil dilation, blurred vision, nystagmus
• Diaphoresis
• Anxiety
• Insomnia • Impaired cognition
• Psychosis (paranoia, tactile & visual
hallucinations)
• Mood swings
• Mood lability • Confusion
• Aggression
• Insomnia
• Reduced appetite
• Increased energy • Vivid dreams
Management of Stimulant Intoxication
• Cardiovascular monitoring
• Maintain safety of patient and others
• May require restraints (physical, chemical)

• Maintain hydration and nutrition

• Reduce environmental stimuli
• Encourage rest
PCP Pharmacology
• Routes: inhaled (smoke, snort)
• Examples: phencyclidine (PCP, angel dust, wet)
• Mechanism of action: NMDA receptor antagonist  increases glutamate
release
• Pharmacology: onset and duration of action varies by route
• Adverse effects (acute/intoxication): cardiac arrhythmia, insomnia,
psychosis, mood lability, seizure, coma
• Adverse effects (chronic): memory and cognitive impairment
PCP

I N T O X I C AT I O N W I T H D R AWA L

• Tachycardia, hypertension
• No clinical manifestations
• Pupil dilation, nystagmus
• Insomnia, psychosis (paranoia, tactile & visual
hallucinations)
• Mood lability
• Aggression
• Increased energy
• Analgesia
• Impulsivity
• Muscle rigidity
Management of PCP Intoxication
• Monitor cardiovascular status
• Maintain safety of patient and others
• Often requires mechanical and/or chemical restraint

• Monitor for rhabdomyolysis

• Muscle rigidity +/- IM injections

• Monitor hydration and nutrition

• Reduce environmental stimuli
• Encourage rest
Hallucinogen Pharmacology
• Routes: oral
• Examples: MDMA (ecstasy, molly), LSD (acid), psylocibin (mushrooms),
ayahuasca
• Mechanism of action: NMDA receptor antagonist  increases glutamate
release, increased serotonin release
• Pharmacology: duration of several hours
• Adverse effects (acute/intoxication): dehydration, serotonin syndrome
• Adverse effects (chronic): HPPS (hallucinogen persistent perception
disorder), depression
Hallucinogens: Other

I N T O X I C AT I O N W I T H D R AWA L

• Tachycardia • Depression
• Pupil dilation, blurred vision
• Diaphoresis
• Tremors
• Illusions
Harm Reduction
Debates

PROS CONS

• Saves lives • Condones substance use

• Reduction in overdose deaths • Attracts people who use
• Reduction in infectious disease
substances to community
• Increase interface with health
systems
General Harm Reduction Recommendations
• Narcan
• Test strips
• Use only one substance at a time
• Never use alone
• Start with a small amount and go slow
• Use less after period of abstinence or reduced tolerance
• Supervised consumption sites
• Co-prescribe Narcan with opiates
How to get Narcan
• Prescription from provider
• Standing prescription
• OTC at pharmacy
• Local health center, library
• Vending machine
• Department of Public Health
• Next Distro/Sol Collective
Harm Reduction: Injection
• Clean injection site before use
• Rotate injection site
• Use sterile water and filter
• Don’t inject over a wound
• Do not share syringes
• Safe needle disposal
• Needle exchange programs
• Wound care kits
Harm Reduction: Inhalation
• Smoking
• Use mouthpiece and filter with pipe
• Don’t share mouthpiece or pipe
• Avoid use of homemade pipes

• Snorting
• Rotate nostrils
• Use sterile straw
• Grind substance
• Use water or nasal spray
References
• Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health
Statistics. 2024.
• Mee-Lee, D. (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring
conditions. The Change Companies.
• Scher, C., Meador, L., Van Cleave, J. H., & Reid, M. C. (2018). Moving Beyond Pain as the Fifth Vital Sign and
Patient Satisfaction Scores to Improve Pain Care in the 21st Century. Pain management nursing : official journal
of the American Society of Pain Management Nurses, 19(2), 125–129. https://doi.org/10.1016/j.pmn.2017.10.010
• Schuler, M. S., Rice, C. E., Evans-Polce, R. J., & Collins, R. L. (2018). Disparities in substance use behaviors and
disorders among adult sexual minorities by age, gender, and sexual identity. Drug and alcohol dependence, 189,
139-146
• https://nida.nih.gov/sites/default/files/ClinicalOpiateWithdrawalScale.pdf
• https://www.cdc.gov/hepatitis/policy/npr/2024/NationalProgressReport-HepC-ReduceInfectionsPWID.htm
• https://www.shatterproof.org/node/39911
• https://nida.nih.gov/sites/default/files/2024-nida-cj-final-print.pdf