20.2 Substance Use Disorder Assessment

Alcohol Use

The nurse needs to assess the patient’s alcohol use behaviors. Questioning the patient about how much alcohol they consume (e.g., daily, weekly) can help the nurse determine the patient’s risk for alcohol misuse.

A moderate alcohol use in a healthy adult is considered one drink daily for women and two drinks daily for men. An example of one drink includes the following:

• wine: 5 fluid ounces
• beer: 12 fluid ounces
• distilled spirits (80 proof): 1.5 fluid ounces

An alcohol use disorder (AUD) is a medical condition characterized by a person’s inability to control or stop using alcohol, despite the possible adverse events resulting from their drinking. What was previously referred to as alcohol abuse is now called alcohol use disorder. The severity of AUD—mild, moderate, or severe—is based on the number of criteria met (Grant et al., 2015).

Clinicians often gauge a person’s AUD severity by risk, recommended treatment options, and eligibility for various treatment programs (Table 20.5) (National Institute on Alcohol Abuse and Alcoholism, 2021). Having any one of these symptoms could be a reason for concern. The more symptoms present, the more urgently the patient needs treatment.

A destructive pattern of alcohol consumption that causes adverse physical, psychological, or social side effects is harmful drinking. Alcohol consumption that threatens a person’s health, safety, and well-being is considered at-risk drinking. It consists of binge drinking, drinking while pregnant, underage drinking, or any other form of potentially hazardous alcohol use. An excessive or dangerous intake of alcohol that leads to considerable impairment in physical and mental health is considered hazardous drinking. Inebriation caused by alcohol or other psychoactive substances, resulting in behavioral and physiological changes is referred to as intoxication.

When a person begins drinking excessively, they can develop alcohol dependence, a complex condition that results in a compulsive, chronic reliance on alcohol for physiological and psychological gratification. Dependence on alcohol is marked by the inability to stop drinking, even if a person wants to quit due to experiencing the symptoms of withdrawal. Over time, the person can build a tolerance to the alcohol, or the physiological capacity to withstand the effects of a substance with repeated use or exposure. In tolerance, the person needs to drink more to get the same effect. The term addiction refers to the changes in a person’s behavior, such as seeking out alcohol despite experiencing negative consequences from using it, that come from having developed a dependence on the substance.

In a controlled environment, such as a hospital or treatment center, the treatment staff are available to help the patient eliminate those things working against their recovery and maximize their efforts toward remission. A controlled environment is an artificial atmosphere that is carefully regulated and monitored to ensure maximum accuracy and precision. The first milestone in remission is early remission, which is when a patient who previously met all the criteria for alcohol use disorder has been sober for three months but less than twelve months. As the patient continues to work through their program, the next milestone is sustained remission, which means they have maintained sobriety for more than twelve months.

Special Developmental Considerations

A patient’s developmental age and stage of life affect the nursing assessment for use of alcohol. The nurse first needs to establish whether a patient has the capacity to understand alcohol use and its consequences. For example, a young teenaged patient may not be able to fully grasp the risks of their alcohol use, either in the short or long term, due to the limitations of their still-developing brain. The nurse needs to consider the context of the patient’s development when both assessing and discussing alcohol use.

There are also special developmental stage considerations that are not related to comprehension, but rather, to life events at that stage that may be important for the nurse to note. For example, women of reproductive age who could become or are currently pregnant need to be counseled about the risks of alcohol use as it pertains to conception, pregnancy, and breastfeeding. Another common clinical situation would be an older adult patient who is taking multiple medications to manage chronic health conditions who may not be aware of the potential for these drugs to interact with alcohol.

Older Adults

AUD appears different in the older adult, as AUD could have been a lifelong activity or a newly developed coping mechanism. The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) is used to evaluate alcohol use in older adults. The short evaluation allows the practitioner to assess alcohol consumption in a way that is specific to older adults, as it may be affected by variables like changes in metabolism associated with aging, liver function, and interactions with medications.

The following questions are asked during the evaluation:

1. Do you ever underestimate how much you drink when talking with others?
2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn’t feel hungry?
3. Does having a few drinks help decrease your shakiness or tremors?
4. Does alcohol sometimes make it hard for you to remember parts of the day or night?
5. Do you usually take a drink to calm your nerves?
6. Do you drink to take your mind off your problems?
7. Have you ever increased your drinking after experiencing a loss in your life?
8. Has a doctor or nurse ever said they were worried about your drinking?
9. Have you ever made rules to manage your drinking?
10. When you feel lonely, does having a drink help you?

The Patient Who Is Pregnant

The nurse needs to assess alcohol use in patients who are pregnant both for the health of the patient and the fetus. While the nurse can use adult alcohol use screening tools, they should consider the context of the patient’s life stage. For example, pregnancy may introduce new stressors and physical/mental health changes that may influence a patient’s health behaviors.

The patient needs to be educated on the risks of using alcohol while pregnant, not just for themselves but for their baby as well. A fetus is exposed to alcohol before birth when alcohol in the patient’s bloodstream passes to the fetus via the umbilical cord. It is unsafe for patients who are pregnant to drink any amount of alcohol at any time during pregnancy. All types of alcohol are considered dangerous to an unborn baby, including wine and beer. Fetal alcohol spectrum disorder is preventable if patients who are pregnant or suspect they may be pregnant refrain from alcohol use. People with fetal alcohol spectrum disorder may display any of the following signs (CDC, 2023) (Figure 20.3):

• low birth weight
• poor coordination
• hyperactive behavior
• difficulty paying attention
• poor memory
• difficulty in school, especially math
• learning disabilities
• speech and language delays
• intellectual disability or low IQ
• poor reasoning and judgment
• sleep and sucking problems as a baby
• vision or hearing problems
• problems with heart, kidneys, bones
• shorter than average height
• small head size
• abnormal facial features

Figure 20.3 Fetal alcohol spectrum disorder is a range of effects that can occur in people with prenatal alcohol exposure. (credit: modification of work “Alcohol Use During Pregnancy” by Centers for Disease Control and Prevention, Public Domain)

It is important for nurses to be nonjudgmental but, at the same time, not downplay the urgency of not drinking while pregnant. By being honest with patients, nurses can earn their trust and have a greater chance of the patients being more transparent about their drinking. Nurses also have an opportunity to educate patients when they discover any patient misconceptions about alcohol use and abuse and the effects of alcohol on an unborn baby.

Special Developmental Considerations

As with alcohol use, the nurse also needs to consider the developmental stage of the patient when assessing other substance use. While many risk factors and consequences of drug use are shared by patients across the life span, there are also some specific risks that are unique to patients based on their age.

Types of Illicit Drug Use

There is a range of illicit substances on which the nurse needs to be educated, some of which they may be more familiar with than others. Alcohol, cannabis, and tobacco are among the most commonly used substances that the nurse will discuss with patients (Table 20.8). As a healthcare professional, the nurse may be familiar with over-the-counter and prescription medications, including painkillers, opiates, and benzodiazepines. Some illicit drugs are more well-known as “street drugs,” such as heroin, cocaine, and methamphetamine. Hallucinogens and synthetic drugs are also substances of which the nurse should be aware.

The nurse needs to be aware of not only the types of drugs patients may misuse but also the signs of abuse that can be specific to certain drugs. While there are some general patterns of behavior as well as physical and mental health symptoms that may broadly apply to substance use, each drug may also have its own “telltale” signs. The patient’s physical and emotional presentation during the assessment can provide the nurse with additional data, which will need to be considered in the context of the patient’s scores on screeners for drug use.

The tools used for substance use screening can help the nurse ascertain the patient’s level of awareness and understanding of specific drugs. If the patient is using substances, further questioning can help the nurse determine the patient’s level of insight into their drug use. For example, a patient may or may not think their substance use is a problem and may not be aware of (or in denial of) the risks and consequences associated with SUD.

Drug use can also contribute to health risks by altering a person’s judgment and rational thought. This includes the potential for addiction, driving under the influence, increased chances of catching an infectious disease, and adverse effects on pregnancy.

Illicit Drug Withdrawal

The nurse needs to use their clinical judgment, experience, and available tools to assess whether a patient who reports using substances is addicted to drugs. It’s important for the nurse to recall the differences between drug dependence and addiction and be equipped to recognize the behaviors that can separate these two patterns of substance use.

The nurse also needs to evaluate the patient for drug withdrawal (Table 20.9). While the patient may report symptoms of withdrawal, the nurse also needs to observe the patient for the signs and symptoms of drug withdrawal during the assessment.

Nursing Assessment

When assessing a patient for drug and alcohol misuse, the nurse should begin with a thorough history. The nurse should establish if the patient has any history of substance abuse, a history of withdrawal symptoms they have experienced in previous attempts to quit using, their treatment history, their mental health and social history, and any medical history of new physical symptoms they are experiencing.

In addition to the history, the patient’s lab values can provide much information about their current state of health. When evaluating a patient for substance or alcohol use disorder (AUD), there are certain labs that should be assessed (Table 20.10).

Nursing Diagnosis

A nursing diagnosis is made by gathering and analyzing patient data, then using that data to construct a path forward for managing the patient’s current or potential symptoms. Through assessment, the nurse elicits subjective details from the patient about their substance use and observes objective information to create a full picture of the patient’s present state. In analysis, the nurse identifies risk and protective factors, behaviors, and other influences on the patient’s substance use.

There are a few common clinical scenarios the nurse may encounter when formulating a nursing diagnosis for a patient who is abusing substances. One example would be impaired coping, which is both a factor that contributes to the development of and a barrier to overcoming substance use. By identifying the patient’s need for more effective coping skills in the nursing diagnosis, the nurse starts putting together an action plan with interventions that will support the patient in developing healthy coping skills, reducing their reliance on substances, and preventing relapse. For example, the nurse may discuss coping skills and stress-management techniques with the patient, encourage them to take part in community resources such as support groups, and connect them with other healthcare providers such as therapists.

Outcome Identification

The nurse then considers the intended end result for the patient, or their future goal. An appropriately written goal is specific, measurable, attainable, realistic, and has a time/deadline (SMART). An example of a broad goal related to withdrawal would be that the patient will stabilize and remain free from injury. There are also some additional goals that the nurse may consider for the patient:

• The patient’s vital signs will remain within normal ranges during treatment. The nurse regularly assesses the patient’s vitals to determine the response to treatment and quickly identify any signs of possible complications, such as hemodynamic instability.
• The patient’s electrolyte levels will remain within normal ranges during treatment. As there can be electrolyte disturbances from various factors during withdrawal, such as dehydration, the nurse needs to monitor the patient carefully for signs of electrolyte abnormalities.
• The patient will participate in planning a post-withdrawal treatment program before discharge. By actively engaging the patient in developing a post-hospital plan, the nurse is able to continue to assess the patient’s insight into substance use and their ability and willingness to comply with treatment. Involving the patient also gives them some agency in the decision-making process, which can help motivate them to meet their long-term goals (e.g., maintaining sobriety).

Nursing Interventions

When planning interventions for SUD, the nurse needs to approach it from a patient-centered view. Each patient will need an individualized plan, and there will be specific factors, barriers, and goals for each patient. Key considerations during the planning stage are the severity of the patient’s substance use, any other medical or mental health conditions they have, their level of support (social, financial), and how ready and able they are to commit to change.

The approach that the nurse takes to planning, as well as the interventions they select, will depend on these patient factors, as well as available resources. For example, a patient who demonstrates willingness to try to make changes but is hesitant may benefit from a more phased approach that “meets them where they are” in their current stage and gradually guides them to their long-term goal. The order in which the nurse plans interventions will, to some degree, be dictated by the acuity of the patient’s condition. In some circumstances, such as managing a patient who has more urgent needs related to drug overdose or self-harm, the nurse needs a more immediate action plan to ensure the patient’s safety.

The nurse needs to take an interdisciplinary and collaborative approach to planning that involves the patient’s support system, other healthcare providers, and community resources. This could include referrals for psychotherapy, connecting with local support groups, and following up with their primary care physician.

The specific interventions that the nurse includes will also depend on how feasible they are for a particular patient. For example, even if a patient is willing, there might be practical (such as transportation) or financial (such as healthcare) barriers to participating in community-based therapy that the nurse will need to consider. Another patient may have multiple medical conditions that need to be managed at the same time as they are working toward their goal of sobriety. Some patients may not have support from their family and friends, which presents challenges to their long-term goal of abstaining from substances. If a patient has loved ones who are still using substances, this can present a risk factor for relapse that the nurse needs to proactively plan to prevent.

Nursing interventions provide a supportive environment while the patient undergoes withdrawal treatment. Vital signs are monitored closely because increases in temperature, pulse, and blood pressure are signs of withdrawal. After ensuring that an individual’s physiological needs of airway, breathing, and circulation are met, safety measures receive top priority. Safety measures during withdrawal treatment may include interventions such as fall precautions, seizure precautions, or implementing restraints as needed to maintain the safety of the individual or those around them.

Evaluation

Evaluation involves assessing the individualized outcomes related to the effectiveness of symptom management and the withdrawal treatment plan. In the evaluation stage, the nurse looks at the patient’s goal and uses the details and timeline to assess whether the goal has been met. The nurse needs to ask questions such as, “Did the patient do the activity or meet the specific guidelines? Were they able to do them within the timeline?”

For example, if the goal was for the patient to have vital signs within normal limits while in the hospital, the nurse investigates whether the patient’s vital signs every day that they were in the hospital had been within normal range. If the measurements were all normal, then the goal was met. If the measurements were abnormal, then the goal was not met. If the goal was met, no further action is needed. If the goal was not met, the nurse must revise the interventions and make a new goal for the patient.

Patient Education

Patient education is a vital step in the nursing process that involves providing patients with the information they need to make informed decisions about their health. The goal of patient education is to assist patients in understanding their medical conditions, treatment options, and important self-care measures they can employ to promote better health outcomes. Throughout this process, patients are empowered to take an active role in managing their health (Paterick et al., 2017).