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Psychiatric-Mental Health Nursing

19.1 Substance Use Disorders

Psychiatric-Mental Health Nursing19.1 Substance Use Disorders

Learning Objectives

By the end of this section, you will be able to:

  • Define substance use disorder
  • Demonstrate an understanding of substance use disorder
  • Outline the symptoms of substance use disorder
  • Describe the role of the nurse in planning care and approaches to recovery for a client with substance use disorder

Chronic substance use disorders significantly impact individuals, families, communities, and society. Misuse of alcohol, drugs, and prescribed medications is estimated to cost the United States more than $400 billion annually in health-care expenses, law enforcement, criminal justice costs, lost workplace productivity, and losses from motor vehicle crashes (Substance Abuse and Mental Health Services Administration [SAMHSA] & Office of the Surgeon General, 2016). The Centers for Disease Control and Prevention (CDC) National Center for Health Statistics estimates that 107,622 drug overdose deaths and 52,000 alcohol-induced deaths occurred in the United States in 2021 (National Center for Health Statistics, 2022).

Unfolding Case Study

Substance Misuse: Part 1

The nurse is assessing a thirty-year-old female who has been admitted to the hospital psychiatric unit.

PMH Client is a thirty-year-old female who works as a project manager at a construction firm. She has a medical-surgical history of lumbar disc herniation repair, GERD, and ovarian cysts. She is current on all vaccinations and reports a history of tobacco use but quit last year.
Family History: Client reports a family history of depression. Maternal grandmother was a smoker and died of lung cancer four years ago. Mother has a history of depression. Father does not have a mental health diagnosis.
Social History: Client is married and has one child, age three. She has worked as a project manager for the past six years and finds her job to be interesting but stressful at times. She struggles to balance motherhood, family, and her work, and this has resulted in her having a glass of wine to relax after work. Recently, she has started to refill her glass throughout the evening and states that her husband is starting to comment on the amount of wine she is drinking. She has difficulty sleeping and she has been prescribed medication to help her to sleep, which she also takes throughout the day to help with the anxiety since it is for “relaxation.”
Current Medication: Alprazolam 1mg HS and No Known Allergies.
Nursing Notes 1020 Assessment
Physical Examination: Client clean and appropriately dressed, alert and oriented ×4, mild tremors noted.
HEENT: Pupils equal, reactive to light (PERRL), mucus membrane dry, pharynx without lesions, palate intact. No thyroid enlargement. Complains of headache.
Lymphatic: Tonsillar and cervical lymph nodes noted but not enlarged; no enlargement of right axillary or inguinal nodes, no pain or tenderness noted.
Respiratory: Clear to auscultation bilaterally, no stridor, no crackles or murmur.
Cardiovascular: Regular rate and rhythm, no edema, peripheral pulses 2+
Abdomen: Bowel sounds present in all four quadrants, no organomegaly or tenderness.
Musculoskeletal: Within normal limits, full ROM
Skin: Dry and intact. No skin injuries noted.
Mental Assessment: Client appears anxious
Flow Chart 1020 Admission Assessment
Client presents with irritability and anxiety, mild tremors, and headache. She reports that her last drink was the previous evening at 1900, which promoted an argument with her husband leading to her admitting herself to the hospital. She is concerned about her employer finding out she is on a psychiatric unit and is worried about losing her job and her child. She reports anxiety 10/10 and is visibly fidgeting and tense. Her husband reports that the client has increased her drinking over the past several months, and currently consumes at least one bottle to a bottle and a half of wine every night. He also reports that she has been taking her prescribed benzodiazepine and alprazolam throughout the day rather than just before bedtime as it was intended. He states that she has been increasingly more detached from their child and unable to participate in family activities at home, including dinner and bedtime routines that used to be important to her. The client reports symptoms of insomnia, and anxiety, usually related to her guilt over distancing from her family and child. She identifies her faith, spouse, and child as reasons for living.
Blood pressure: 145/92 mmHg
Heart rate: 109 beats/minute
Respiratory rate: 18 breaths/minute
Temperature: 98.5°F (36.9°C)
Oxygen saturation: 99% on room air
Pain: 3/10 (head)
Lab Results Ethanol: 0.13
Urine Drug Screen: negative for all except Benzodiazepine (positive)
Diagnostic Tests/Imaging Results EKG within normal limits
Provider’s Orders Initiate Clinical Institute Withdrawal Assessment (CIWA)
Close observation
Vitamin B12 and Folic Acid daily
1.
Highlight the cues that indicate what the nurse will evaluate further.
2.
After close review of the client’s signs and symptoms, what would the nurse expect to be priority actions in the plan of care?

Defining Substance Use Disorder

A substance is defined as a psychoactive compound with the potential for dependence and detrimental effects, including substance use disorder. According to Substance Abuse and Mental Health Services Administration (SAMHSA, 2022d), substance use disorders (SUD) happen when the repeated use of alcohol and/or other drugs significantly impairs a person’s health and results in an inability for them to meet major responsibilities at work, school, or home. People who have an SUD may be dually diagnosed with a mental health disorder (National Institute of Mental Health, 2023). Conversely, some people with a mental health disorder may use substances as a coping mechanism and then develop an SUD.

Three regions of the brain play a critical role in the development and persistence of substance use disorders: the basal ganglia, the extended amygdala, and the prefrontal cortex (SAMHSA & Office of the Surgeon General, 2016).

  • The basal ganglia control the rewarding, pleasurable effects of substance use and are responsible for the formation of habitual substance taking. Two subregions of the basal ganglia are particularly important in substance use disorders: the nucleus accumbens, involved in motivation and reward; and the dorsal striatum, involved in forming habits and other routine behaviors.
  • The extended amygdala is involved in the stress response and the feelings of unease, anxiety, and irritability that typically accompany substance withdrawal.
  • The prefrontal cortex is involved in executive function (e.g., the ability to organize thoughts and activities, prioritize tasks, manage time, and make decisions), including exerting control over substance use.

Changes in the brain from substance misuse persist long after substance use stops and are associated with a high incidence of relapse with substance use disorders. More specifically, when a person uses substances, the basal ganglia begin to react to those substances by producing pleasant surges of dopamine, a neurotransmitter, sending messages to the nerve cells in this reward center of the brain (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). If the person continues to use substances, the neurotransmitters adapt, and the person demonstrates a reduced response to the substance and requires more of the substance to feel an effect; this is called tolerance (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). The extended amygdala and the prefrontal cortex play against each other as the person continues to increase the amount of substance used. Just as the basal ganglia react in response to the good feeling that results from the burst of dopamine, pushing the person to use again, the extended amygdala responds to negative stimuli like stress by trying to get away from unpleasant feelings. When a person has a substance use disorder, these two areas no longer balance each other. The reward control center begins to take over and the person begins to feel physical or emotional upset when they are not using a substance; this is called withdrawal. The only way the person can begin to feel better is to use the substance once again. At this point, the person gets stuck in a cycle of a substance use disorder where they neglect other parts of their lives, family, work, and pleasurable activities (Figure 19.2).

Chart describing some serious consequences of substance misuse, including: heart and liver disease, cancer, HIV/AIDS, and developmental or congenital disorders in fetus if occurring during pregnancy.
Figure 19.2 There are serious health consequences related to substance misuse (Office of the Surgeon General, 2023). (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

DSM-5 Diagnosis: Substance Use Disorder

Substance use disorders are diagnosed based on cognitive, behavioral, and psychological symptoms. To be diagnosed, a person meets with a health-care provider for a comprehensive evaluation to review substances used, patterns of use, effects on living, and range of symptom severity. After gathering and reviewing this information, the health-care provider will compare it with the DSM-5 criteria, which includes degrees of substance use disorder but not addictive disorder. The most severe form of substance use disorder is categorized as addiction, and severe substance use disorder can be considered a neurological disorder and a mental illness (Partnership to End Addiction, 2023). Generally, according to the DSM-5, substance use disorder (SUD) is an illness caused by repeated misuse of substances such as alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants (amphetamines, cocaine, and others), and tobacco. These substances taken in excess have a common effect of directly activating the brain reward system and producing such an intense activation of the reward system that individuals may neglect normal life activities.

Addictive Disorders

Addictive disorders that are not substance-related include excessive behaviors that the person cannot control or stop, even if these behaviors pose risks or harm. The neurological aspects of addiction involving motivation and reward drive these behaviors, and stimulate the same addiction centers of the brain as addictive substances. The person’s judgment may be impaired regarding consequences of the behaviors.

Behavioral addictions can include gambling, viewing pornography, compulsive sexual activity, internet gaming, overeating, shopping, overexercising, and overusing mobile phone technologies. Gambling disorder is the only nonsubstance use disorder with diagnostic criteria listed in the DSM-5. Additional research is being performed to determine the criteria for diagnosing other nonsubstance-related disorders (National Institute on Drug Abuse [NIDA] & National Institutes of Health, 2019).

Understanding Substance Use Disorder

Chronic substance use disorders significantly affect individuals, families, communities, and society. According to the 2021 National Survey on Drug Use and Health (NSDUH), 46.3 million people in the United States aged twelve or older (16.5 percent) have a substance use disorder (SAMHSA, 2022c).

Prolonged, repeated misuse of substances can produce changes to the brain that can lead to a substance use disorder. Substance misuse (the term now used by professionals rather than substance abuse) is defined as the use of alcohol or drugs in a manner, situation, amount, or frequency that could cause harm to the user or to those around them (SAMHSA & Office of the Surgeon General, 2016). Misuse can be of low severity and temporary, but it can increase the risk for serious and costly consequences, such as motor vehicle crashes; overdose death; suicide; various types of cancer; heart, liver, and pancreatic diseases; HIV; and unintended pregnancies. Substance use during pregnancy can cause complications for the baby, such as fetal alcohol spectrum disorders (FASDs) or neonatal abstinence syndrome (NAS). Substance misuse is also associated with intimate partner violence, child abuse, and neglect (SAMHSA & Office of the Surgeon General, 2016).

Legal and Illegal Substances That Can Be Misused

There are many types of substances that can be misused and not all of them are illegal or classified as medications. Legally obtained substances include alcohol, tobacco, and caffeine. In the United States, tobacco use disorder is the second most common substance use disorder, following alcohol (Cleveland Clinic, 2023). Even though electronic cigarettes or “e-cigarettes” are advertised as being safer than cigarettes, they also contain nicotine, the addictive ingredient in cigarettes.

Legal substances that are medication and can be misused include inhalants, sedatives, opioids, and stimulants. In 2020, 2.4 million (0.9 percent) of people aged twelve or older in America misused inhalants. Inhalants are various products easily bought or found in the home, such as spray paints, markers, glue, gasoline, and cleaning fluids. Unlike other drugs, the percentage of inhalant use was highest among adolescents aged twelve to seventeen (NIDA & National Institutes of Health, 2020). People who use inhalants breathe in the fumes through their nose or mouth, usually by sniffing, snorting, bagging, or huffing. Although the high that inhalants produce usually lasts just a few minutes, people often try to make it last by continuing to inhale again and again over several hours (NIDA & National Institutes of Health, 2020). Prescription medications can also be misused as inhalants. For example, amyl nitrate is a prescription medication administered via inhalation to relieve chest pain. It can be misused by individuals to cause a high. It is referred to as the street drug, “poppers.” Inhalant intoxication causes problematic behavioral or psychological changes, such as belligerence, being assaultive, apathy, and impaired judgment.

Other commonly misused prescription medications include those in the sedative, opioid, and stimulant classes. Sedatives include both anxiolytic hypnotics for sleep (like Ambien) and anxiolytic benzodiazepines (like Xanax, Valium, Ativan, and Klonopin). Prescriptions misused in the opioid class (used for pain) include codeine and oxycodone (OxyContin). Frequently misused stimulants include ADHD drugs like amphetamine/dextroamphetamine (Adderal) and methylphenidate (Ritalin).

Chronic use of benzodiazepines causes changes in the gamma-aminobutyric acid (GABA) receptor, resulting in decreased GABA activity and the development of tolerance. A person can go through withdrawal after stopping or lowering the dose of benzodiazepines. Sedatives, hypnotics, and anxiolytic intoxication cause behavioral or psychological changes similar to alcohol intoxication, such as inappropriate sexual or aggressive behavior, mood lability, and impaired judgment. Symptoms of intoxication include slurred speech, lack of coordination, unsteady gait, nystagmus, impaired attention and memory, and stupor or coma (American Psychiatric Association, 2013).

Opioid misuse has been and continues to be a major cause of death in the United States with the number of overdose deaths in 2021 being six times the number in 1999 (CDC, 2023). While most people follow their health-care provider’s directions on how and when to take their medications, others use prescribed medications in nonprescription ways: sharing medications with friends or family members, taking medications more frequently or in higher doses than what has been prescribed, combining medications with alcohol or other drugs, and taking medications in a form other than what is prescribed (snorting or injecting) (Alcohol and Drug Foundation, 2021). In an effort to reduce the number of opioid prescription medications being used, most states have monitoring systems in place to track how many opioid prescriptions individuals are receiving. With the help of the Drug Enforcement Agency (DEA), prescribers can review the registry to see if there is a pattern for abuse (Jahan & Burgess, 2023).

A person may use stimulants for the psychological and physical effects of euphoria, excitement, appetite suppression, and wakefulness. Misuse of stimulants can result in paranoia, hallucinations, and agitation, along with elevated body temperature, cardiac dysrhythmias, altered blood pressure, and seizures (Mayo Clinic, 2022).

Also legal, cold medications containing the cough suppressant dextromethorphan, decongestants, and antihistamines are also misused due to the potential for narcotic effects. Heart rate, body temperature, and blood pressure may be altered to the point of life-threatening (Connecticut Poison Control Center, 2024).

Illegal substances used include hallucinogens (PCP and LSD), stimulants (amphetamines, methamphetamine, cocaine), nonprescription opioids (heroin), and cannabis, where not legalized. See the table for a more descriptive list of both legal and illegal substances Table 19.1.

Substance Category Examples
Alcohol Beer, malt liquor, wine, and distilled spirits
Illicit drugs (including prescription drugs used nonmedically)
  • Opioids, including heroin
  • Cannabis (may be legalized by state laws)
  • Sedatives, hypnotics, and anxiolytics
  • Hallucinogens
  • Stimulants, including methamphetamine-like substances, cocaine, and crack
  • Dextromethorphan and other cold medications
Over-the-counter drugs (used nonmedically) Dextromethorphan, pseudoephedrine, and other cold medications
Other substances Inhalants, such as spray paint, gasoline, and cleaning solvents; Delta-8 THC
Table 19.1 Categories and Examples of Substances

Controlled Substances

The Controlled Substances Act is a federal law that places all substances regulated by the U.S. Drug Enforcement Agency into one of five categories called schedules. This placement is based on the substance’s medical use or lack of, its potential for abuse or dependency, and related safety issues. For example, Schedule I drugs have a high potential for abuse and potentially cause severe psychological and/or physical dependence, whereas Schedule V drugs represent the least potential for abuse (U.S. Drug Enforcement Administration, 2020; Table 19.2).

Cannabis has been classified as a Schedule 1 drug since the 1970 Controlled Substances Act. However, more than half of the states in the nation have decriminalized the substance, with some permitting medical usage and others both medical and recreational usage. As of May 2024, the Drug Enforcement Agency has recommended that cannabis be reclassified as a Schedule III drug, which would support wider medical usage and scientific research but not permit recreational usage on a national level. Formal reclassification will require additional steps.

Schedule Definition Examples
Schedule I No currently accepted medical use and a high potential for abuse. Heroin, LSD, MDMA (Ecstasy), and cannabis (marijuana)
Schedule II High potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. They can be used for treating pain, anxiety, insomnia, and ADHD. Hydrocodone, cocaine, methamphetamine, methadone, hydromorphone, meperidine, oxycodone, fentanyl, amphetamine/dextroamphetamine salts (Adderall), methylphenidate (Ritalin), and phencyclidine (PCP)
Schedule III Moderate to low potential for physical and psychological dependence. Abuse potential is less than Schedule I and Schedule II drugs but more than Schedule IV. Acetaminophen with codeine, ketamine, anabolic steroids, and testosterone
Schedule IV Low potential for abuse and low risk of dependence. Alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), zolpidem (Ambien), and tramadol (Ultram)
Schedule V Lower potential for abuse than Schedule IV and consists of preparations containing limited quantities of certain narcotics. Generally used for antidiarrheal, antitussive, and analgesic purposes. Cough medications with codeine, diphenoxylate/atropine (Lomotil), and pregabalin (Lyrica)
Table 19.2 DEA Controlled Substances by Schedule (U.S. Drug Enforcement Administration, 2020)

Symptoms of Substance Use Disorder

Substance use disorder can be mild, moderate, or severe, with severe being considered addiction (Cleveland Clinic, 2023). Examples of symptoms seen in someone who is developing a substance use disorder include the following: using a prescribed substance for longer than intended and in amounts beyond its prescribed directions; being unable to stop using a substance; problems with relationships, work, and school; and development of a tolerance so that more of the substance needs to be used to get the same effects. There are over twenty million people in the United States who have an SUD that involves one substance, and 12 percent of those people have an SUD that includes using a drug and alcohol (Cleveland Clinic, 2023).

Intoxication

The term intoxication refers to a disturbance in behavior or mental function during or after the consumption of a substance. Generally, it is understood that saying someone is intoxicated is the same as saying they are drunk or high. A person using alcohol may experience a feeling of euphoria or excitement, which can become confusion, stupor, coma, or death (LaHood & Kok, 2023). As the level of intoxication increases so does the severity of the symptoms. Signs of intoxication may differ slightly depending on the substance being used. A person using heroin will also have a sense of euphoria along with drowsiness and nodding. A person using cocaine will experience more energy, but also experience paranoia, fatigue, and decreased appetite. A person using cannabis will experience a state of relaxation, increased appetite, and sensory enhancement, which can progress to impaired perception (National Academies Press, 2017).

Tolerance versus Habituation

A person develops a tolerance the more they use a substance because the neurotransmitters adapt to the substance and no longer produce the same pleasurable feelings that occurred when the person first began to use the substance. When this occurs, the person may need to increase the amount used to reach the same “high.”

Very simply, habituation is the process of getting used to doing something—such as using a substance—and then not wanting to stop. Habituation is a cycle that is difficult to break. Physical dependence often follows habituation.

Dependence

A person has a dependence on a substance when the lack of the substance causes physical symptoms. When a person suddenly stops using a substance, if they have developed a dependence, their body goes through withdrawal, a group of physical and mental symptoms that can range from mild to life-threatening. Dependence can be further broken down into psychological dependence and physical dependence although, according to American Addiction Centers (2021), psychological and physical dependence are intertwined.

Psychological Dependence

Psychological dependence stands for the emotional developments and changes that accompany substance misuse (American Addiction Centers, 2021). When most people think of psychological dependence, they think of cravings, the anxiety and/or depression that can occur when a person does not use the substance, denial that there is even a substance use problem, obsessing over the substance, and cognitive decline (American Addiction Centers, 2021). Substances that are associated with stronger psychological dependence are stimulants, cannabis, inhalants, psychotropic medications, and hallucinogens.

Physical Dependence

Physical dependence is related to the symptoms that a person experiences with tolerance and withdrawal (American Addiction Centers, 2021). Examples of these symptoms include nausea, vomiting, stomach upset, hallucinations, tremors, and headaches. Examples of certain substances that have stronger physical dependence are alcohol, opioids, benzodiazepines, and barbiturates. A person who is experiencing physical dependence will also have psychological symptoms as they go through withdrawal from the substance. Thinking holistically, the mind and body are inextricably connected, so it makes sense that these two types of dependence often accompany one another.

Addiction

Compulsive or uncontrolled use of one or more substances, addiction is a chronic condition that has the potential for both relapse and recovery. The addiction process involves a three-stage cycle of symptoms that become more severe as a person continues to misuse substances, causing neuroadaptations in brain function that reduce a person’s ability to control their substance use. Each stage is associated with one of the brain regions previously described (i.e., basal ganglia, extended amygdala, and prefrontal cortex). This three-stage model provides a useful way to understand the symptoms of addiction, the ways it can be prevented and treated, and the steps for recovery.

  1. Binge/intoxication: The stage at which an individual consumes an intoxicating substance and experiences its rewarding or pleasurable effects.
  2. Withdrawal/negative affect: The stage at which an individual experiences a negative state in the absence of the substance.
  3. Preoccupation/anticipation: The stage at which one seeks substances again after a period of abstinence (SAMHSA & Offices of the Surgeon General, 2016).

Life-Stage Context

The Cycle of Addiction

Research has shown that a person who first tries drugs in their teens is more apt to develop an SUD than a person who first tries drugs as an adult (NIDA, 2022). Conduct problems and delinquent behaviors, such as vandalism and violence, are usually precursors to the initiation of substance use in teenagers. Substance use is also higher in teens who have drug-using friends. Important to consider are the psychosocial factors of education, employment, relationships, and involvement with the legal system. A study by Arria et al. (2020), which evaluated continuous abstinence over a two-year period, found that teens with long-term SUD treatment program completion had greater improvements in relationships with significant others and in relapse avoidance. The authors acknowledged the value of supportive resources after treatment to improve education and employment outcomes.

Overdose

The biological response of the human body when it has ingested lethal or toxic amount of a substance is overdose. Signs of intoxication and overdose differ for categories of psychoactive substances.

Poison control centers are available 24/7, every day of the year to consult about toxic ingestion of substances and overdoses; just call 1-800-222-1222. Some hospitals also have toxicologists available for bedside consultation for overdoses (Rosenbaum & Boyer, 2021).

Approaches to Recovery from Substance Use Disorder

The first step is admitting there is a problem. In addition to medications and behavioral therapies, effective treatment of SUD includes recovery support services (RSS). Recovery support services provided by substance use disorder treatment programs and community organizations provide support to individuals receiving treatment for SUD, as well as ongoing support after treatment. These supportive services are typically delivered by trained case managers, recovery coaches, and/or peers. Specific RSS include assistance in navigating systems of care, removing barriers to recovery, staying engaged in the recovery process, and providing a social context for individuals to engage in community living without substance use. RSS can be effective in promoting healthy lifestyle techniques to increase resilience skills, reduce the risk of relapse, and help achieve and maintain recovery. Individuals who participate in RSS typically have better long-term recovery outcomes (SAMHSA & Office of the Surgeon General, 2016).

Recovery goes beyond abstinence and the remission of substance use disorder to include a positive change in the whole person. There are many paths to recovery. People choose their individual pathway based on their cultural values, socioeconomic status, psychological and behavioral needs, and the nature of their substance use disorder (SAMHSA & Office of the Surgeon General, 2016). In a study by Kaskutas et al. (2014) of over 9,000 individuals with previous substance use disorders, three themes emerged when asked how they defined recovery:

  • Abstinence: 86 percent viewed abstinence as part of their recovery, but the remainder did not think abstinence was required. Abstinence was considered “essential,” however, by those affiliated with twelve-step mutual aid groups.
  • Personal growth: “Being honest with myself” was endorsed as part of recovery by 98 percent of participants. Other almost universally endorsed elements included “handling negative feelings without using alcohol or drugs” and “being able to enjoy life without alcohol or drugs.” Almost all study participants viewed their recovery as a process of growth and development, and about two-thirds saw it as having a spiritual dimension.
  • Service to others: Engaging in service to others was another prominent component of how study participants defined recovery. This is perhaps because during periods of heavy substance misuse, individuals may damage interpersonal relationships, which they later regret doing and attempt to resolve during recovery. Evidence exists that providing service to others helps individuals maintain their own recovery (SAMHSA & Office of the Surgeon General, 2016).

Overlap Between SUD and Mental Health Disorders Causes Treatment Challenges

In 2020, seventeen million adults (6.7 percent) had both a substance use disorder (SUD) and a mental health illness (SAMHSA, 2021b). The relationship between SUDs and mental disorders is known to be bidirectional, meaning the presence of a mental health disorder may contribute to the development or exacerbation of an SUD, or an SUD may contribute to the development or exacerbation of a mental health disorder. The combined presence of SUDs and mental health disorders results in greater functional impairment; worse treatment outcomes; higher morbidity and mortality; increased treatment costs; and higher risk for homelessness, incarceration, and suicide.

The reasons why substance use disorders and mental health disorders often occur together are not definitive, but there are three possible explanations. One reason may be that certain substances may temporarily mask the symptoms of mental health disorders (such as anxiety or depression). A second reason may be that certain substances trigger a mental health disorder that otherwise would not have developed. For example, research suggests that alcohol use increases risk for post-traumatic stress disorder (PTSD) by altering the brain’s ability to recover from traumatic experiences. A third possible reason is that both substance use disorders and mental health disorders are caused by overlapping factors, such as particular genes, neurobiology, or exposure to traumatic or stressful life experiences (SAMHSA & Office of the Surgeon General, 2016).

Mental health disorders and substance use disorders have overlapping symptoms, making diagnosis and treatment planning challenging. For example, people who use methamphetamine for a long period of time may experience paranoia, hallucinations, and delusions that can be mistaken for symptoms of schizophrenia (SAMHSA & Office of the Surgeon General, 2016).

Planning Nursing Care for a Client with Substance Use Disorder

Initial treatment begins with the health-care provider ordering laboratory testing, such as urine and blood tests. A urine drug screen and blood alcohol level can determine what substance the person has been using. Complete blood count (CBC), basic metabolic panel (BMP), liver function test (LTF), hepatitis panel, and pancreatic enzymes can determine the health of the client (Jahan & Burgess, 2023). Female clients may receive a urine pregnancy test (HCG). The CBC will show anemia or infection that may be occurring due to substance use. The BMP will identify any comorbidities and electrolyte imbalances. A liver function test (LFT), hepatitis panel, and, possibly a screen for human immunodeficiency virus (HIV), will check for any problems with the liver due to alcohol/substance consumption or HIV infection due to IV drug use. Lastly, a pancreatic enzyme serum level will show if there is any damage to the pancreas. The results of these tests form the basis for the medical part of the treatment plan (Jahan & Burgess, 2023).

The health-care provider may also look at data from the prescription drug monitoring program (PDMP) to see if the person is obtaining medications from multiple sources (NIDA, 2020a). A PDMP is an electronic database capable of tracking prescriptions for controlled substance. This monitoring can alert providers to clients at risk for overdose or other concerns about inappropriate medication use (Centers for Disease Control and Prevention [CDC], 2022).

The nurse must assess for past or current history of mental health disorders, because SUD and mental health disorders can overlap and affect treatment. The nurse should ask the client what substance they have been using, how much/how often, last use, and the form (pills, snorting, injection). The nurse should check with the client about any current legal problems, their support systems and living situation, and any cultural or religious needs for care. The nurse may administer Clinical Institute Narcotic Assessment (CINA), Clinical Institute Withdrawal Assessment for Alcohol (CIWA), or Clinical Opiate Withdrawal Scale (COWS) scales to determine if the client is experiencing any withdrawal symptoms. All the information from the initial assessment is combined to form the foundation of the nursing plan of care.

Nurses’ Attitudes toward Addiction

According to Tierney (2017), nurses can hold stigmatizing views toward people with substance use disorders and the behaviors caused by substance use. The author continues by saying that nurses sometimes experience feelings of anger, anxiety, powerlessness, and frustration when caring for these clients. Nurses report that many of these feelings come from not having enough training or education about substance use disorders.

Nurse as Client with Substance Use Disorder

Health-care professionals are not immune to developing SUD. SUD is a chronic illness that can affect anyone regardless of age, occupation, economic circumstances, ethnic background, or gender. The National Council of State Boards of Nursing (NCSBN) created a brochure called A Nurse’s Guide to Substance Use Disorder in Nursing. This brochure states that many nurses with SUD are unidentified, untreated, and may continue to practice when their impairment may endanger the lives of their clients. Because of the potential safety hazards to clients, it is a nurse’s legal and ethical responsibility to report a colleague’s suspected SUD to their manager or supervisor. It can be hard to differentiate between the subtle signs of SUD and stress-related behaviors, but three significant signs include behavioral changes, physical indicators, and drug diversion (NCSBN, 2018). Nurses are in an excellent position to notice drug diversion, which occurs when medication is redirected from its intended destination for personal use, sale, or distribution to others. It includes drug theft, use, or tampering (adulteration or substitution). Drug diversion is a felony that can result in criminal charges.

Behavioral changes include less satisfactory job performance, absences from the unit for extended periods, frequent trips to the bathroom, arriving late or leaving early, and making an excessive number of mistakes, including medication errors (NCSBN, 2018). Other evidence includes increasing isolation from colleagues; inappropriate verbal or emotional responses; and diminished alertness, confusion, or memory lapses. Physical signs include subtle changes in appearance that may escalate over time. Signs of diversion look like frequent discrepancies in opioid counts, unusual amounts of opioid wastage, numerous corrections to medication records, frequent reports of ineffective pain relief from clients, offers to medicate coworkers’ clients for pain, and altered verbal or phone medication orders (NCSBN, 2018).

All fifty states have boards of nursing (BON) that promulgate, regulate, and enforce their own rules and guidelines. These BON provide disciplinary action to nurses who practice while impaired (Boehning & Haddad, 2022). The National Council of State Boards of Nursing (NCSBN) website provides alternatives to discipline programs in their “Find a Program” page in which programs are listed by state (NCSBN, n.d.). An individual can click on the link, choose their state, and receive a list of available programs in that state.

The earlier a nurse is diagnosed with SUD and receives treatment, the sooner client safety improves, and the better the chances for the nurse to recover and return to work. In most states, a nurse diagnosed with an SUD enters a nondisciplinary program designed by the board of nursing for treatment and recovery services. When a colleague treated for an SUD returns to work, nurses should create a supportive environment that encourages their continued recovery (NCSBN, 2018).

An example of one such BON program is the Texas Peer Assistance Program for Nurses (TPAPN). This program is funded by the fees paid for nursing licenses (TPAPN, n.d.). According to the Texas Nurse Practice Act, employers are required to report nurses who are suspected of being impaired at work. A recovery plan is set up for nurses who participate in TPAPN. Peer supports meet with participants to provide guidance, support, and mentorship so that they can eventually return to work.

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