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Substance Use Disorder and Treatment Options

Contact Hours: 2

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Contact Hours: 2

This educational activity is credited for 2 contact hours at completion of the activity.

Course Purpose

The purpose of this course is to provide an overview of substance use disorder, covering the Controlled Substance Act, drug classifications, types of substances used. symptoms of drug overdose, treatment options for opioid use disorder, and essential nursing considerations.

Overview

Substance use disorder (SUD) is an intricate condition that is characterized by an unrestrained use of a substance despite harmful consequences. Until the last few decades, it was assumed that those who struggled with compulsive substance use suffered from nothing more than a lack of willpower. Thus, these individuals were often stigmatized as “addicts” and viewed as having a moral deficiency or character flaw. However, advances in neuroscience have changed this perception. This course discusses substance use disorder, covering the Controlled Substance Act, drug classifications, and types of substances used. It also examines the symptoms of drug overdose, treatment options for opioid use disorder, and essential nursing considerations.

Course Objectives

Upon completion of this course, the learner will be able to:

  • Define substance use disorder (SUD) and Schedule I-V drugs as described by the Controlled Substance Act (CSA).
  • Review the diagnostic criteria for substance use disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
  • Review commonly abused drugs and the National Survey on Drug Use and Health (NSDUH) statistical data associated with each drug.
  • Recognize signs and symptoms of overdose in commonly abused drugs.
  • Identify treatment and recovery options for substance use disorder and overdose.

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This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

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Definitions
AddictionA chronic brain disorder that involves compulsive seeking and using of substances or engaging in activities despite negative consequences.
AlcoholA colorless volatile flammable liquid that is produced by the natural fermentation of sugars and is the intoxicating constituent of wine, beer, spirits, and other drinks.
AnxiolyticMedications that prevent or treat anxiety symptoms or disorders. 
AtaxiaLoss of coordination of voluntary muscle movements.
Attention Deficit Hyperactivity Disorder (ADHD)A mental health condition that affects focus, impulsivity and behavior. 
BenzodiazepinesMedications that slow down the nervous system and treat anxiety, insomnia, seizures and other conditions.
BuprenorphineAn opioid medication used to treat opioid use disorder (OUD), acute pain, and chronic pain. 
CannabisA tall plant with a stiff upright stem, divided serrated leaves, and glandular hairs that is used to produce hemp fiber and as a drug. 
Cardiopulmonary Resuscitation (CPR)A medical procedure involving repeated compression of a patient’s chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest.
CocaineA tropane alkaloid that acts as a central nervous system (CNS) stimulant. 
Cocaine Use DisorderA stimulant addiction where people continue to take cocaine despite its negative effects. 
Controlled SubstanceA drug regulated by the DEA for safety, medical use, and misuse prevention.
Controlled Substance Act (CSA)The statute establishing federal US drug policy under which the manufacture, importation, possession, use, and distribution of certain substances is regulated.
CyanosisA bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
Dextromethorphan (DXM)A cough suppressant that is an ingredient in over the counter (OTC) cold medications. 
Diagnostic And Statistical Manual Of Mental Disorders (DSM-5)A publication by the American Psychiatric Association (APA) for the classification of mental health disorders using a common language and standard criteria. 
DiphenhydramineAn antihistamine used to relieve allergy, cold, and motion sickness symptoms.
DopamineA chemical messenger that helps regulate many functions in the body and brain. 
Drug Enforcement Administration (DEA)A federal agency that combats criminal drug networks and educates the public about the dangers of drugs.
EuphoriaIntense feeling of happiness and pleasure.
FentanylA synthetic opioid that is up to 100 times more potent than morphine and 50 times more potent than heroin.
FlumazenilAn antidote that reverses the effects of benzodiazepine sedatives. 
Gamma Hydroxybutyrate (GHB)A naturally occurring neurotransmitter and a depressant drug.
HallucinogenA group of drugs that alter perception, thoughts and feelings. 
HeroinA highly addictive drug that comes from the opium poppy and can be smoked, snorted, or injected.
HomeostasisThe automatic process that keeps the body steady and balanced in response to changes in the environment. 
HypoxiaA below-normal level of oxygen in the blood, specifically in the arteries.
Illegally Made Fentanyl (IMF)A highly potent synthetic opioid or an analog developed in clandestine laboratories.
InhalantsVolatile substances that produce chemical vapors that can be inhaled to alter the mind.
Meth MouthA colloquial term used to describe severe tooth decay and tooth loss, as well as tooth fracture, acid erosion, and other oral problems that are often symptomatic to extended use of the drug methamphetamine.
MethamphetamineA potent stimulant that can cause euphoria, increased activity, and weight loss.
MiosisA condition where the pupil is smaller than normal, even in bright light. 
Muscarinic ReceptorsAcetylcholine receptors that form G protein-coupled receptor complexes in the cell membranes of certain neurons and other cells. 
NaloxoneA medicine that can reverse an opioid overdose by blocking the effects of other opioids.
NarcolepsyA sleep disorder that causes excessive daytime sleepiness, sudden loss of muscle tone, and other symptoms. 
NicotineA highly addictive substance in tobacco and e-cigarette products that can affect the brain and body.
OpioidsA class of drugs that relieve pain, but can also cause side effects, dependence, and overdose.
OverdoseWhen a person consumes over the recommended or typical dose of a substance. 
Phencyclidine (PCP)A dissociative illicit drug that can cause hallucinations, delirium, and violence.
Premature DeathDeath that occurs before the average age of death in a certain population. 
Schedule I DrugsDrugs with no currently accepted medical use and a high potential for abuse.
Schedule II DrugsDrugs considered to have a high potential for misuse but with acknowledged medical uses under strict regulation.
Schedule III DrugsDrugs that are considered to have a lower potential for abuse compared with Schedule 1 and 2 drugs and have accepted medical uses and a moderate to low potential for physical and psychological dependence.
Schedule IV DrugsSubstances with a lower potential for misuse compared to those in Schedules 1–3 and have currently accepted medical use and a lower risk of physical or psychological dependence than Schedule 3 drugs.
Schedule V DrugsSubstances with a lower potential for misuse compared with those in Schedules 1–4 and have a currently accepted medical use and contain limited quantities of certain narcotics.
SedativesDrugs that slow brain activity and can help with anxiety, insomnia, seizures, and more.
StimulantsMedicines that speed up mental and physical processes, used for conditions such as ADHD, narcolepsy, and obesity. 
Substance Use Disorder (SUD)A mental health condition in which a person has a problematic pattern of substance use that causes distress and/or impairs their life.
Tetrahydrocannabinol (THC)The chemical that is responsible for most of marijuana’s psychological effects. 
TobaccoThe common name of several plants in the genus Nicotiana  of the family Solanaceae and the general term for any product prepared from the cured  leaves of these plants. 
ToleranceA person’s diminished response to a drug, which occurs when the drug is used repeatedly, and the body adapts to the continued presence of the drug.
WithdrawalThe combination of physical and mental symptoms a person experiences after they stop using or reduce their intake of a substance such as alcohol and prescription or recreational drugs.
Introduction

Substance use disorder (SUD) is an intricate condition that is characterized by an unrestrained use of a substance despite harmful consequences.1 Until the last few decades, it was assumed that those who struggled with compulsive substance use suffered from nothing more than a lack of willpower. Thus, these individuals were often stigmatized as “addicts” and viewed as having a moral deficiency or character flaw. However, advances in neuroscience have changed this perception.1 It is now understood that SUD involves significant brain changes, establishing them as progressive, treatable disorders. Approximately 48 million cases of SUD are reported yearly, representing 17% of the population aged 12 and above.2 This trend reveals a significant public health challenge.

Not only does SUD contribute to a range of acute and chronic health concerns, including infectious diseases, pulmonary and cardiovascular conditions, metabolic disorders, psychiatric illnesses, and cancers, but it is also a leading cause of premature death.3 Overdose deaths, particularly from stimulants, opioids, and the increasing presence of fentanyl, have surged in recent years.5 The impact of SUD on society is profound and multifaceted. From economic strain to healthcare burdens, the consequence of SUD is extensive and growing. Reports estimate that SUD costs more than $700 billion annually in lost productivity, healthcare expenses, and law enforcement, underscoring the urgent need for comprehensive strategies to address treatment and support those struggling with substance use disorder.6

This course discusses substance use disorder, covering the Controlled Substance Act, drug classifications, and types of substances used. It also examines the symptoms of drug overdose, treatment options for opioid use disorder, and essential nursing considerations.

Controlled Substance Act

The Controlled Substance Act (CSA) stands as the center of the United States drug policy. Enacted in 1970 by President Richard Nixon, its primary purpose is to regulate the manufacturing, importing, possession, distribution, and use of certain substances.7 By creating a framework for drugs that have the potential for abuse, the CSA establishes a system for controlling the use of both legal and illegal substances, reducing and ensuring the availability of drugs for medical and scientific purposes. Healthcare professionals must comply with CSA regulations to legally prescribe, dispense, and administer controlled substances. Violations result in severe penalties, including fines, imprisonment, and loss of professional licenses. Healthcare professionals with prescribing abilities must also register with the Drug Enforcement Administration (DEA) and maintain accurate records of controlled substance transactions, ensuring accountability and traceability.

The CSA classifies drugs into five Schedules (I – V) based on their potential for abuse, accepted medical use, and safety or dependence liability.8 Schedule I drugs have a high threat for abuse. They have no accepted medical use in the United States. Even under medical supervision, they lack any accepted safety. Examples include heroin, marijuana (cannabis), lysergic acid diethylamide (LSD), 3,4-methylenedioxymethamphetamine (MDMA or ecstasy), methaqualone (Quaalude), and peyote.8 Note that despite its legality in some states, federally, marijuana is still classified as Schedule I due to its high potential for abuse. Schedule II drugs also have a high potential for abuse and have a high risk of severe psychological or physical dependence.8 However, they are accepted for medical use under severe restrictions. Examples include pharmacological products with less than 15 mg of hydrocodone per dosage unit (Vicodin), methadone, hydromorphone (Dilaudid), oxycodone (OxyContin), meperidine (Demerol), and fentanyl – all used for moderate to severe pain management – cocaine, methamphetamine, Dexedrine, Adderall, and Ritalin. Cocaine, a powerful stimulant, is sometimes used as a local anesthetic for nasal and eye surgeries. Dexedrine, Adderall, and Ritalin are stimulants commonly prescribed for attention deficit hyperactive disorder (ADHD) and narcolepsy. Methamphetamine may be prescribed for ADHD and obesity in specific cases.

Schedule III drugs are those with a risk of abuse lower than Schedule I and II drugs. They are generally accepted for medical use, having moderate to low risk for physical and psychological dependence. Examples include products containing less than 90 mg of codeine per dosage unit (Tylenol with codeine), ketamine, anabolic steroids, and testosterone.8 Ketamine is used in anesthesia but has hallucinogenic effects. Anabolic steroids are used medically for hormone deficiencies but can lead to physical dependence. Testosterone is a natural hormone with anabolic effects that may be abused for athletic performance enhancement or bodybuilding purposes. Schedule IV drugs have a low potential for abuse relative to Schedule III substances, are accepted for medical use, and limited risk of dependence. Examples include alprazolam, diazepam, and tramadol.8 Alprazolam is an anxiolytic used to treat anxiety disorders. Diazepam is also prescribed for anxiety as well as muscle spasms. Tramadol is a pain reliever. All these have a low risk of abuse. Schedule V drugs have the least risk of abuse relative to Schedule IV substances. They are accepted for medical use and have a limited risk of dependence. Examples include cough medications with below 200 mg per 100 ml or 200 mg per 100 g of codeine and ezogabine. As these drugs have the lowest potential for abuse and dependence, Schedule V drugs are the least restricted under the CSA.8

Substance Use Disorder Definition

According to DSM-5, SUD encompasses 10 separate classes of drugs that, when taken in surplus, directly activate the brain’s reward system – a pathway involved in behavior reinforcement and memory production.9 These drugs are:

  • Alcohol
  • Caffeine
  • Cannabis
  • Hallucinogens
  • Inhalants
  • Opioids
  • Sedatives, hypnotics, and anxiolytics
  • Stimulants
  • Tobacco
  • Other (or unknown) substances

The excessive use of these substances can trigger the reward system so intensely that daily responsibilities may be neglected. Unlike adaptive behaviors that naturally activate the reward system, drugs directly stimulate these pathways. While the pharmacological mechanisms vary across drug classes, they generally induce pleasure sensations, commonly known as a “high.”

Diagnostic Criteria

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), substance use disorders are diagnosed through a set of eleven cognitive, behavioral, and physiological symptoms that reveal ongoing substance use despite substantial substance-related issues.9 The criteria are organized into four main categories9:

  1. Impaired Control
  2. Social Impairment
  3. Risky Use
  4. Pharmacological

The criteria are applicable to all substance classes except caffeine. The first grouping, Impaired Control, includes Criteria 1 – 4:9.

  • Criterion 1: An individual uses the substance in larger amounts or for a longer duration than originally intended.
  • Criterion 2: There is often an obstinate desire or unsuccessful attempts to reduce or control substance use.
  • Criterion 3: Significant time is spent in activities to acquire, use, or recover from the substance’s effects. In severe cases, this can dominate the individual’s daily activities.
  • Criterion 4: Includes the presence of cravings, which refers to an intense desire or urge for the drug. It can be triggered by environmental cues and is often a precursor to relapse, reflecting activation in specific brain reward areas.

The second grouping, Social Impairment, includes Criteria 5–7:9.

  • Criterion 5: Substance use may interfere with fulfilling major obligations at work, school, or home.
  • Criterion 6: The individual may continue using the substance despite recurrent social or interpersonal problems caused or worsened by its effects.
  • Criterion 7: Important social, occupational, or recreational activities are often reduced or stopped as a result of substance use. This may lead to withdrawal from family and social activities.

The third grouping, Risky Use, includes Criteria 8–9:9

  • Criterion 8: The individual has recurrent substance use in physically hazardous circumstances, such as operating machinery or driving while impaired.
  • Criterion 9: The individual continues using the substance in spite of knowing it causes or exacerbates physical or psychological problems.

The key to evaluating criterion 9 is the individual’s failure to abstain from substance use despite recognizing the problems it causes.

The fourth and final grouping, Pharmacological, includes Criteria 10 and 11:9.

  • Criterion 10: Tolerance, which is characterized by the need for considerably higher quantities of the substance to realize the anticipated effect or a noticeably diminished effect with continued use of the same amount. This varies widely among individuals and substances.
  • Criterion 11: Withdrawal, which refers to a group of symptoms that occur when substance use is reduced or stopped after prolonged use. To relieve the withdrawal symptoms, the individual feels compelled to consume that substance.

Withdrawal varies significantly between different substance classes. For substances like alcohol, opioids, and sedatives, they are common and easily identified. However, they are less apparent for stimulants, tobacco, and cannabis. Withdrawal is not typically associated with substances such as phencyclidine, other hallucinogens, and inhalants, so this criterion is not applied to these substances. It is important to note that tolerance and withdrawal resulting from medically supervised use of medications (prescription opioids for pain management), without the presence of other indications of substance misuse, should not be diagnosed as substance use disorder.

Behavioral and Physical Signs

Behavioral signs of SUD often manifest as significant changes in an individual’s daily habits and interactions.1 The signs may include neglecting responsibilities at work, school, or home, and withdrawing from previously enjoyed social activities. It may also involve exhibiting secretive or suspicious behavior to hide substance use. Individuals with SUD often continue using the substance despite experiencing negative consequences, such as strained relationships, job loss, or legal issues. They may also exhibit a noticeable decline in their performance and reliability in various aspects of life. Physical signs of SUD vary widely as they depend on the specific substance being used.1 In general, signs may include noticeable changes in physical appearance and health. This may include rapid weight loss or gain, poor physical coordination, and bloodshot or glassy eyes. Other physical symptoms may involve unusual body odors indicative of substance use or poor personal hygiene and sudden, unexplained changes in mood or behavior, including increased agitation, irritability, or periods of euphoria followed by depression. Physical signs may also consist of track marks from intravenous drug use, frequent nosebleeds from snorting drugs, or burns on fingers or lips from smoking substances.

Commonly Abused Drugs

In the United States, the most abused drugs are alcohol, tobacco, cannabis, benzodiazepines, methamphetamines, opioids, cocaine, and prescription stimulants.10 Other drugs seeing a surge in misuse and with a high potential for abuse and dependency include illegally made fentanyl, GHB, and non-prescription cold and cough medicines.

Alcohol

According to the 2022 National Survey on Drug Use and Health (NSDUH), an estimated 60% of SUD cases (29 million) among people aged 12 and older were related to alcohol use, making alcohol the most abused substance in the United States.10 The high prevalence is attributed to alcohol’s widespread social acceptance, ease of obtaining, and legal status. Alcohol is a potent depressant, producing feelings of relaxation and euphoria, thus making it appealing for stress relief and socialization.11 However, chronic use causes dependence and significant health issues, including liver disease, cardiovascular problems, and neurological damage. Reasons for abuse often include social pressures, genetic predisposition, and its use as a coping mechanism for psychological issues like anxiety and depression.

Tobacco

Tobacco use, whether through smoking cigarettes or vaping e-cigarettes, is driven by the addictive nature of nicotine. This chemical stimulates the release of dopamine, creating feelings of pleasure and relaxation.12 Despite widespread awareness of its severe health risks, including lung cancer, heart disease, and respiratory problems, tobacco remains highly abused due to its legal status and addictive properties. It is estimated that among people aged 12 or older, 8% struggle with a nicotine addiction.13 Individuals often begin using tobacco in their youth, influenced by peer pressure, social norms, or as a stress-relief mechanism. Over time, nicotine addiction can lead to habitual use, making quitting difficult despite the known health risks. The habitual nature of smoking, along with its physical and psychological dependencies, contributes to its high abuse rates.

Cannabis

Cannabis, or marijuana, is known for its psychoactive effects, primarily driven by the compound tetrahydrocannabinol (THC).14 Users often seek its euphoric and relaxing effects, which help lessen stress, anxiety, and pain. With increasing legalization and social acceptance, cannabis use has become more common. However, the perception of cannabis as a “safe” drug compared to other illicit substances is misguided and contributes to its widespread use and, ultimately, abuse. Excessive use of cannabis can lead to dependency, cognitive impairments, and mental health issues like anxiety and depression.14 The 2022 NSDUH estimated 61 million people aged 12 or older have used cannabis, and 30% were diagnosed with cannabis use disorder.10 People abuse cannabis for various reasons, including recreational enjoyment, self-medication for chronic pain or mental health disorders, and social influences.

Opioids

Opioids, such as heroin, and prescription opioids (narcotics), such as hydrocodone (Vicodin), oxycodone (OxyContin), and morphine, are highly addictive due to their potent pain-relieving and euphoric effects.15 They work by binding to opioid receptors in the brain, reducing the perception of pain and triggering feelings of pleasure. Abuse often starts with legitimate medical use and escalates due to tolerance and dependence. Among those aged 12 or older in 2022, 8 million people misused opioids in the past year.10 Over 95% of these cases were misused prescription pain relievers, while less than 5% were heroin abuse. Psychological factors, such as the desire to escape emotional pain, and social factors, like peer pressure and availability, significantly contribute to opioid misuse.

Benzodiazepines

Benzodiazepines, such as Valium and Xanax, are sedatives that elevate gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits neural activity, resulting in a calming effect.16 Generally prescribed for anxiety and insomnia, benzodiazepines are potent and therefore highly addictive. In cases of misuse, individuals either use the medication without a prescription or take higher doses than prescribed to alleviate stress. Among those aged 12 or older in 2022, 3 million misused prescription benzodiazepines in the past year, with 64% developing a prescription sedative use disorder.10 Factors contributing to benzodiazepine abuse include the need for rapid stress relief, self-medication for unaddressed mental health issues, and the desire for the drugs’ pronounced sedative effects. Chronic abuse can lead to addiction, tolerance, and severe withdrawal symptoms, making it difficult for users to quit.

Methamphetamines

Methamphetamines, commonly known as meth, is a highly addictive stimulant that significantly increases the release of dopamine, resulting in intense euphoria, increased energy, and heightened focus.17 The addictive properties and intense highs make it difficult for users to stop using methamphetamines, leading to a high potential for abuse and dependency. In 2022, 2 million people aged 12 or older in the US reported using methamphetamine in the past year. Among users, approximately 66% developed methamphetamine use disorder.10 Meth abuse causes severe physical and psychological health problems, including dental issues (“meth mouth”), skin sores, paranoia, and aggressive behavior. The reasons for methamphetamine abuse often include the pursuit of its euphoric and stimulating effects, weight loss, and enhanced concentration or performance. It is important to note that while methamphetamine is legally available by prescription (Desoxyn), most used in the United States is produced and distributed illicitly.

Prescription Stimulants

Prescription stimulants elevate dopamine and norepinephrine levels in the brain. Thus, they are utilized to treat attention deficit hyperactivity disorder (ADHD) and narcolepsy.18 This in turn enhances focus, attention, and energy levels. They are particularly favored by students and professionals seeking to enhance cognitive performance, stay awake, or boost productivity. Non-medical use can lead to dependency and adverse health effects. The 2022 NSDUH showed that among those 12 or older, 4 million people misused prescription stimulants, and 1 million had a prescription stimulant use disorder.10 The reasons for abuse often include academic pressures, demanding work environments, and the desire for increased alertness and concentration. Some individuals also misuse these drugs recreationally to experience euphoria, which can contribute to the risk of addiction. The availability of prescription stimulants through legitimate medical channels also makes them more accessible, increasing the potential for misuse.

Cocaine

Cocaine is a powerful stimulant drug derived from the leaves of the coca plant.19 Cocaine heightens dopamine in the brain, creating feelings of intensified energy, alertness, and euphoria. However, these effects are short-lived, leading users to frequently take more to maintain the high. Given these properties, cocaine has an extremely high potential for abuse. Of the 1.9 million people aged 12 and above who reported to have used cocaine, up to 74% experience cocaine use disorder.10 Reasons for cocaine abuse include the pursuit of its stimulating effects, social and recreational use, and the desire to enhance performance or self-confidence. Chronic use can lead to severe health issues, including heart problems, respiratory issues, and neurological damage, as well as significant psychological dependence and addiction.

Illegally Made Fentanyl

Illegally made fentanyl (IMF) has become a significant concern due to its role in the increasing number of fatal opioid overdoses. Fentanyl is an extremely intoxicating synthetic opioid, shown to be 50 – 100 times stronger than morphine.20 Fentanyl’s high potency drastically elevates the risk of addiction, overdose, and adverse effects, particularly among individuals unaccustomed to opioids. Illegally made fentanyl is often found in products sold as heroin or in counterfeit prescription drugs, leading many users to unwittingly consume fentanyl. In 2022, approximately 0.4 percent of people aged 12 or older, or approximately 991,000 individuals misused fentanyl.10 The primary reasons for fentanyl misuse include its potent euphoric effects and its unintended presence in other drugs.

Gamma Hydroxybutyrate (GHB)

Gamma hydroxybutyrate (GHB), also known as “Liquid G,” is a central nervous system depressant that induces hallucinations, euphoria, drowsiness, and decreased anxiety.21 Paradoxically, it may also induce excited and aggressive behavior. As regular use of GHB can quickly lead to addiction and severe withdrawal symptoms, its illegally produced form is classified as a Schedule I controlled substance. In 2022, approximately 211,000 individuals aged 12 or older reported using GHB.10 The reasons for GHB misuse often include its psychoactive effects and its reputation as a “party drug.” The high potential for abuse and dependency is driven by its ability to produce strong, desirable effects rapidly.

Non-prescription Cough and Cold Medicines

Non-prescription cough and cold medicines, particularly those containing dextromethorphan (DXM), have seen a surge in misuse.22Dextromethorphan, a common cough suppressant, is available over the counter and is generally safe when used as directed. However, when taken in large doses, it can produce hallucinations and dissociative “out-of-body” experiences, similar to hallucinogens like Phencyclidine (PCP) and ketamine.23 Other ingredients in cough and cold medicines, such as the antihistamine diphenhydramine, can also have psychoactive effects, including sedation and drowsiness. In 2022, 2.2 million people aged 12 or older misused these medications.10 The reasons for abuse include the ease of access, the misconception of safety due to their over-the-counter status, and the pursuit of psychoactive effects.

Signs and Symptoms of Overdose

An overdose is a toxicological condition that occurs when an individual ingests or administers a dose of a substance that exceeds the therapeutic or lethal threshold, overwhelming the body’s homeostatic mechanisms.24 This results in elevated blood concentration of the substance, disrupting normal physiological functions. Clinically, an overdose can induce a range of symptoms depending on the substance involved, including central nervous system depression, cardiovascular instability, respiratory failure, and metabolic derangements. The severity of an overdose is often assessed by monitoring vital signs, neurological status, and laboratory parameters. Prompt medical intervention is essential to mitigate life-threatening complications and restore homeostasis.

Alcohol Poisoning

Alcohol poisoning, also known as acute alcohol intoxication, presents a spectrum of symptoms, reflecting alcohol’s depressant effects on the central nervous system.25 Initially, individuals may exhibit confusion, impaired coordination, and slurred speech as blood alcohol concentration rises. As intoxication progresses, severe vomiting may occur. This leads to dehydration and electrolyte imbalances. Respiratory depression, marked by slow and irregular breathing, is another indication of alcohol poisoning and can culminate in respiratory failure if untreated. Hypothermia, or abnormally low body temperature, may also develop due to alcohol’s vasodilatory effects and impaired thermoregulation. In severe cases, individuals may experience seizures or lose consciousness. This is a life-threatening state and requires immediate medical attention. Treatment involves airway management, intravenous fluids to maintain hydration, and close monitoring of vital signs to prevent complications such as hypoglycemia and aspiration pneumonia.

Opioid Overdose

Opioid overdose presents distinct signs and symptoms as the drug influences the central nervous and respiratory systems.26 A hallmark symptom is miosis. Also known as pinpoint pupils, miosis is characterized by significant narrowing of the pupils. Opioids stimulate the muscarinic receptors on the sphincter muscle of the iris, leading to its contraction. In an overdose, the reduction in pupil size is extreme, making them appear much smaller than normal. Individuals also exhibit extreme drowsiness with the possible loss of consciousness. This is often in conjunction with slow or shallow breathing (respiratory depression). As oxygen levels drop in the bloodstream, cyanosis, a bluish discoloration of the skin and lips, becomes apparent. Other signs include clammy skin, decreased responsiveness to stimuli, and a weak pulse. Left untreated, opioid overdose can progress rapidly to respiratory arrest and death. Immediate treatment involves naloxone, an opioid antagonist, which displaces opioids from their receptors in the brain. This reverses the effects of opioid overdose and restores normal breathing. Timely medical intervention also prevents long-term neurological damage associated with opioid toxicity.

Benzodiazepine Overdose

Symptoms of benzodiazepine overdose reflect its depressant effects on the central nervous system. Early signs include pronounced dizziness, severe drowsiness, and confusion as the drug inhibits cognitive and motor functions.27 Individuals may also exhibit impaired coordination and ataxia, leading to difficulty walking or performing simple tasks. Other potential signs include slurred speech, hypotension, and bradycardia. As the overdose progresses, symptoms can escalate to respiratory depression, which poses a significant risk of hypoxia and subsequent organ damage. In severe cases, benzodiazepine overdose can result in coma. Immediate medical intervention is essential to manage symptoms. Symptom management typically involves airway management, monitoring of vital signs, and administration of flumazenil, a benzodiazepine antagonist, to reverse the effects of the overdose. Supportive care, including intravenous fluids and oxygen therapy, may also be necessary to stabilize the patient and prevent long-term complications.

Stimulant Overdose

Signs of stimulant overdose, which involves substances such as cocaine, methamphetamine, and prescription amphetamines, are a product of heightened CNS and cardiovascular activity.28 The overstimulation of the brain’s neurotransmitter systems leads to severe agitation, anxiety, and paranoia. This is often accompanied by hallucinations or delusional behavior. Stimulant overdose also leads to significant cardiovascular strain, resulting in high blood pressure (hypertension), rapid heart rate (tachycardia), and chest pain. These symptoms increase the risk of severe complications such as heart attack, stroke, or arrhythmias. Hyperthermia, or elevated body temperature, is also common and can lead to further complications if not managed promptly. During overdose, muscle tremors, seizures, and extreme restlessness are also common. Immediate medical intervention is crucial. Interventions include sedation to control agitation, intravenous fluids to manage hydration and electrolyte imbalance, and continuous cardiac monitoring to address any cardiovascular irregularities.

Treatment Options for Opioid Use Disorder

There are several treatment options available for opioid use disorder (OUD). The treatment options involve the use of medications combined with behavioral therapy. Currently, three medications are approved for OUD: 29  

  • Methadone
  • Buprenorphine
  • Naltrexone

Methadone is a full opioid agonist that activates the same opioid receptors in the brain as other opioids, such as heroin or prescription painkillers, without the intense euphoria. This reduces cravings and withdrawal symptoms. Methadone’s duration of action is approximately 24-36 hours, which allows patients to function normally without the constant cycle of highs and lows associated with short-acting opioids. As methadone is a Schedule II drug, it is only available at specialized centers under strict supervision. The treatment protocol involves a single daily dose, with an initial dose typically between 10-20 mg.30 However, a higher initial dose may be needed in cases of high opioid tolerance. Subsequent doses are adjusted based on the patient’s response. If significant opioid withdrawal symptoms occur 2-3 hours after the initial dose, an additional 5-10 mg of methadone may be administered.

If the patient shows signs of sedation after their dose, the next daily dose should be reduced. Methadone is available as a pill, oral suspension, and liquid form – all taken orally.31 Once patients are stabilized and no longer experiencing intoxication or significant withdrawal symptoms, the goal is to titrate methadone to its most effective level. Common side effects of methadone include constipation, sweating, and drowsiness.29 More serious side effects can include respiratory depression, particularly if taken in higher doses or combined with other depressants. To manage these side effects, healthcare providers should closely monitor patients, especially during the initial stages of treatment when the risk of overdose is higher. Interventions are administered as needed to ensure patient safety and treatment efficacy.

Buprenorphine is a partial opioid agonist that brings relief to patients experiencing opioid withdrawal. It has a ceiling effect, meaning that beyond a certain dose, increasing the amount will not produce additional euphoria or respiratory depression. This characteristic reduces the risk of misuse, overdose, and side effects, making it a safer option compared to methadone. However, because it is a partial agonist, buprenorphine does not fully substitute for other opioids, so it is often prescribed as a long-term maintenance treatment. Buprenorphine can be taken sublingually, buccally, or as a subdermal, with effects lasting 24 – 60 hours.31 A typical regimen increases the dose over the first few days, typically to 8 to 12 mg per day, to relieve withdrawal symptoms, and then tapered by 2 mg to 4 mg per day until discontinued.32 Potential side effects can include headaches, nausea, and constipation. Management strategies involve monitoring patients closely, especially during the initiation phase, and when adjusting dosages.

Naltrexone is an opioid antagonist that effectively blocks the euphoric effects of opioids, thereby helping to prevent relapse. It is available in two forms: as an oral tablet or as a monthly intramuscular injection. The action of the oral tablet typically lasts 24-48 hours, while the injectable form provides extended coverage for one month. The dosing regimen for naltrexone can vary depending on the formulation. Initially, it may be started at a lower dose of 25 mg once daily for a few days. Subsequently, the dosage can be adjusted to 50 mg once daily, 100 mg every other day, 150 mg every third day, or in the form of a 380 mg injection for monthly administration.32 It is important to note that naltrexone is unsuitable for individuals actively using opioids because of its strong receptor affinity. When administered, naltrexone competes with opioids in the system, resulting in the rapid removal of the opioid’s effects. This can abruptly induce severe withdrawal symptoms, known as precipitated withdrawal. Symptoms can be so extreme that patients may discontinue treatment and seek relief through illicit opioid use. Therefore, initiating naltrexone treatment requires that individuals have completely abstained from opioids for a period long enough to avoid the risk of precipitated withdrawal. Common side effects include injection site reactions, elevated liver enzymes, and gastrointestinal issues. Patients on naltrexone should undergo regular liver function tests, and any gastrointestinal discomfort can often be managed with over-the-counter medications. Behavioral therapies play a pivotal role in the comprehensive OUD treatment plan.33 The therapies address the intricate psychological and behavioral aspects of addiction that medications alone may not fully resolve. By focusing on changing thought patterns, emotional responses, and coping strategies, behavioral therapies help individuals understand and modify the underlying behaviors that contribute to substance use. Practical skills such as stress management, problem-solving, and relapse prevention are taught, empowering individuals to navigate challenges without turning to opioids. Behavioral therapies are instrumental in treating mental health disorders commonly associated with OUD, such as depression or anxiety. By addressing these conditions concurrently, therapies reduce the risk of relapse.

Recovery Options

Recovery options for SUD include inpatient programs, outpatient plans, and behavioral health interventions. Inpatient treatment programs provide intensive, round-the-clock care in a structured environment.34 These programs are for those who need a higher level of supervision, support, and medical attention due to the relentlessness of their addiction or the existence of co-occurring mental health issues. Typically, inpatient facilities offer a range of services, including detoxification, medical stabilization, individual and group therapy sessions, educational programs, and sometimes alternative therapies like art or music therapy. The primary advantage of inpatient treatment is its controlled setting, which removes patients from environments where substances are available. This isolation also removes triggers and stressors, facilitating a more focused and intensive therapeutic experience. Inpatient programs also offer a higher level of medical supervision, ensuring that any withdrawal symptoms or medical complications during detoxification are managed safely. However, inpatient treatment limits personal freedom and causes the disruption of daily routines, which can be difficult for some individuals to adjust to. It also requires a significant time commitment, typically ranging from several weeks to several months, which may not be feasible for everyone due to work, family obligations, or financial constraints. The cost of inpatient treatment is often higher than other recovery options, which can be a strain.

Outpatient treatment plans typically involve regular visits to a treatment center where individuals participate in therapy sessions, counseling, and medication management under the guidance of healthcare professionals.34 As the individual is still living at home, they are able to maintain their personal responsibilities and work commitments. One of the key benefits of outpatient treatment is its cost-effectiveness compared to inpatient care. This makes it more accessible to a broader range of individuals. Outpatient treatment also provides opportunities for patients to practice coping skills and apply what they learn in therapy directly to their everyday lives and environments. However, outpatient programs may present challenges, such as the potential for increased exposure to triggers and substance-use cues in the community. Triggers can test the individual’s resolve and commitment to recovery. The level of supervision and support is also lower compared to inpatient settings. Succeeding in an outpatient program requires a strong motivation and support system from family and peers to maintain progress and prevent relapse during treatment.

Behavioral health interventions for SUD include various therapeutic approaches that aim at modifying behaviors related to substance abuse and promoting long-term recovery. Behavioral interventions typically include techniques such as: 33

  • Cognitive-behavioral therapy (CBT)
  • Motivational interviewing (MI)
  • Contingency management (CM)
  • Dialectical behavior therapy (DBT)

Therapies help individuals understand the motivations behind their substance use, develop coping skills to manage triggers and cravings, and modify problematic behaviors. Behavioral interventions alone may be effective for some individuals with mild to moderate substance use disorders, particularly when they are highly motivated to change and have a supportive environment. However, for many people with more severe or long-standing SUD, behavioral interventions alone may not be sufficient. As addiction often involves a complex interaction between biological, psychological, and social factors, pharmacological interventions are generally needed to reduce withdrawal symptoms and stabilize cravings. Integrated treatment approaches that combine both behavioral and pharmacological interventions tend to yield better outcomes for individuals with moderate to severe substance use disorders.

What to Do When an Overdose Occurs

In the event of an overdose, swift and decisive action is crucial to saving lives. Promptly assess the patient’s vital signs and level of consciousness, ensuring an open airway and initiating basic life support measures, as necessary. Administer antidotes specific to the substance if available and indicated while closely monitoring cardiovascular and respiratory function. For example, in the case of opioid overdose, administer naloxone.26 After naloxone is administered, continuous patient monitoring is essential to detect any recurrence of symptoms, as naloxone’s duration of action is shorter than some opioids. Following initial stabilization, vigilant patient monitoring is essential to detect any complications. Continuous observation of changes in mental status, respiratory distress, or cardiovascular instability helps anticipate and manage potential deterioration. Utilizing appropriate diagnostic tests such as blood toxicology screens aids in assessing the extent of substance exposure and guiding subsequent medical interventions. Long-term care involves a comprehensive assessment of the underlying causes and risk factors contributing to the overdose. If indicated, this may include substance use disorder evaluation and psychiatric assessment.26 Collaborative multidisciplinary care involving addiction specialists, psychologists, and social workers facilitates comprehensive treatment planning aimed at preventing future occurrences.

Nursing Considerations

Nurses are pivotal in the comprehensive management of substance use disorders through their multifaceted roles in patient care.35 Central to their responsibilities is the administration of pharmacological interventions and clinical monitoring. When administering pharmacological treatments, nurses should ensure that patients receive medications according to prescribed protocols. This involves accurate dosage calculations, safe medication administration practices, and adherence to established guidelines to minimize risks and optimize therapeutic outcomes. Nurses should regularly assess patients for signs of withdrawal symptoms, potential overdose, or adverse reactions to prescribed medications. Based on the results of the assessments, nurses must collaborate with healthcare teams to adjust treatment plans and interventions to ensure the welfare and effectiveness of care.36 Nurses should also advocate for patients, ensuring that individualized care plans are developed and implemented effectively. Exhibiting an initiative-taking approach not only enhances patient outcomes, but also contributes meaningfully to the overall success of SUD treatment programs. In cases of overdose, nurses must act swiftly and methodically to ensure patient safety and provide effective care. Nurses should immediately assess the patient’s condition and any visible symptoms of overdose. They should prioritize stabilizing the patient by ensuring a patent airway while administering interventions such as oxygen and cardiopulmonary resuscitation (CPR) as needed. If the overdose involves opioids, nurses should administer naloxone (Narcan) promptly.

In addition, nurses play a critical role in patient education and support.37 They should provide comprehensive education to patients and their families about substance use disorders, treatment options, and strategies for relapse prevention. Education empowers patients with knowledge about the nature of SUD, the effects of substances on their health, and the importance of treatment adherence. Nurses also offer empathetic support throughout the recovery process. By fostering a therapeutic alliance built on trust and understanding, nurses encourage patients to actively engage in their treatment and recovery journey. They provide emotional support, listening attentively to patients’ concerns and addressing their needs with compassion and respect.

Nurses must adhere to ethical standards that prioritize patient welfare, autonomy, and justice.38 This involves upholding professional integrity, maintaining competence in their practice, and treating all patients with dignity and respect. Nurses should also be aware of legal obligations related to their practice, including licensure requirements, scope of practice regulations, and adherence to institutional policies. Nurses are accountable for their actions and decisions, ensuring they are in line with ethical codes and legal standards governing healthcare practice. Nurses must safeguard patient confidentiality at all times, maintaining the privacy of health information in accordance with legal requirements. They should obtain patient consent before disclosing any confidential information, except when required by law or in emergencies where patient safety is at risk. Respecting patient rights includes promoting autonomy, informed decision-making, and the right to participate in their own care planning.38 Nurses should educate patients about their rights, ensure they understand their treatment options, and support their choices within the boundaries of ethical practice. Accurate and timely documentation is essential for maintaining continuity of care, ensuring patient safety, and meeting legal standards. Nurses should document all assessments, interventions, and patient responses comprehensively and objectively. They must adhere to institutional protocols and legal requirements for reporting incidents, adverse events, and suspected cases of abuse or neglect. Reporting obligations extend to collaborating with multidisciplinary teams, healthcare providers, and authorities as necessary to protect patient welfare and promote public health. Nurses should prioritize clarity, completeness, and confidentiality in their documentation practices, adhering to professional standards and regulatory guidelines. It is also important for nurses to stay updated on substances as new drugs and patterns of use are emerging regularly. These trends can significantly impact patient care, as nurses must be aware of the signs, symptoms, and potential complications associated with these substances. By staying informed about current drug trends, nurses can enhance their ability to recognize and respond to substance use disorders effectively. This includes understanding the pharmacological effects of different substances, potential drug interactions, and appropriate interventions for overdose or withdrawal management. For example, the rise of synthetic opioids like fentanyl has dramatically increased overdose risks, necessitating rapid and informed responses from healthcare providers.

Conclusion

Substance use disorders (SUD) are multifaceted conditions that are now recognized as progressive yet treatable. The prevalence of widely abused substances such as alcohol, tobacco, cannabis, opioids, benzodiazepines, methamphetamines, and prescription stimulants highlight the diverse array contributing to SUD. Each substance carries distinct risks and motivations for misuse, from societal acceptance of alcohol and cannabis to the potent addictive properties of opioids and stimulants. The growing misuse of substances like illicitly manufactured fentanyl and non-prescription medications continuously complicates the landscape of SUD further, posing significant health risks and challenging public health interventions. As our understanding of SUD advances, our approach to managing overdoses, treating disorders, and providing support must evolve in tandem. Managing substance overdose demands a swift and coordinated response to mitigate life-threatening complications and ensure patient safety. Regardless of the substance, the primary objective remains stabilizing vital signs, restoring physiological function, and preventing long-term harm. Effective treatment of SUD and promotion of long-term sobriety necessitates comprehensive strategies incorporating thorough assessment, behavioral therapies, and, where appropriate, pharmacological interventions. Whether implemented through inpatient or outpatient programs, integrating evidence-based treatments with tailored care plans is crucial for supporting recovery and preventing relapse. Nurses play a pivotal role in this process by ensuring safe medication administration, monitoring for adverse reactions, educating patients, and advocating for personalized care plans. By integrating medical expertise with compassionate support, healthcare teams can effectively manage overdoses, foster recovery, and mitigate the societal impact of substance use disorders.

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