Learning Objectives
By the end of this section, you will be able to:
- Outline the approaches used to treat addiction
- Recall the principles used to treat an overdose
- Review management of a client who is in withdrawal
- Plan collaborative care for a client who has an addiction
Substance use disorder treatment is designed to help individuals stop or reduce harmful substance misuse, improve their health and social function, and manage their risk for relapse. For example, mild substance use disorders can be identified quickly in many medical settings and often respond to brief motivational interventions and/or supportive monitoring, referred to as guided self-change. In contrast, severe and chronic substance use disorders often require specialty substance use disorder treatment and continued posttreatment support to achieve full remission and recovery. To address the spectrum of problems associated with substance use disorders, it is necessary to plan and implement a continuum of care based on an individual’s needs, including early intervention, treatment, and recovery support services (SAMHSA & Office of the Surgeon General, 2016).
Approaches to Treating Addiction
The use of substances has a staggering cost of approximately $442 billion in the United States each year in health care costs, lost productivity, and criminal justice costs (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). Research shows that integration of substance use treatment in primary health-care settings can greatly improve outcomes. Many people in the United States with a substance use disorder also have a mental health disorder, further complicating treatment. Traditionally, health-care providers have separated substance use treatment from other health-care practices (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). This separation appears counter to the similar goals of treating substance use disorder and other chronic health conditions, which are reduce symptoms of the substance use, increase overall health, monitor motivation to change, and manage possible relapse.
The U.S. Department of Health and Human Services, Office of the Surgeon General (2016) suggests that screening for substance misuse begin in health-care organizations by training health-care teams, including nurses, to recognize the signs and symptoms of substance misuse. Screening should follow with training and the use of therapeutic communication skills to engage the client in brief interventions for mild substance use problems or referral to more intense therapies and use of medications for more severe cases.
Link to Learning
SAMHSA has developed a short booklet called “Faces of Change. Do I have a Problem with Alcohol or Drugs?” It covers the case studies of five people who have problems with either drugs or alcohol.
Steps for Quitting Addiction
As health-care professionals struggle to support their clients who have substance use disorders, Harvard Medical School (2021) suggests a basic five-step process that can be introduced in any office visit. The first step is the client setting a quit date. Step two is the client agreeing to change their environment, removing any triggers to the addiction. This could mean separating oneself from other people who are involved in the object of the addiction, and removing items from their environment (alcohol, wine glasses). Step three is learning to use distraction as a technique when feeling the urge to use. This could be as simple as going outside for a walk or calling a friend. Step four is to review what worked and what did not work in past attempts to quit. The final step is to create a support network of people who can help to encourage them.
Medication-Assisted Treatment (MAT)
Medication-assisted treatment, or MAT, combines the use of medication and behavioral therapy to prevent opioid overdose and treat substance use disorder (Food and Drug Administration [FDA], 2023). This type of treatment takes a holistic approach that has been shown to improve outcomes for people using substances, help people get jobs and work, increase clients staying in treatment, and increase positive outcomes of babies born to women who were using substances while pregnant (FDA, 2023). Depending upon the substance that the client has used, medications may either help block the cravings and good feelings produced by the substance or decrease withdrawal symptoms.
Medications to Combat Drug Use
Medications that have been approved by the FDA for use during MAT include methadone, buprenorphine, and naltrexone (FDA, 2023). Methadone is taken once a day under the supervision of a nurse at a methadone clinic. It comes in tablet, liquid, and wafer forms. It works by blocking the effects of the opioid and reducing cravings. Buprenorphine gives the same euphoric feelings as the opioids without the side effects. It helps to decrease cravings and withdrawal symptoms. Naltrexone blocks the euphoria associated with opioids. If a person relapses while taking naltrexone, they will not get “high.” One concern is that when a person discontinues naltrexone and relapses, they will have a lower tolerance to opioids and may overdose if they take the same opioid doses previously taken.
Using Medications for Detoxification
The amount of time it takes for the body to get rid of the substances (detoxification) differs based on the substance consumed. Likewise, the medications prescribed to help with detox differ based on the substance consumed. Nurses closely monitor the use of medication during withdrawal/detoxification, including performing withdrawal assessment scales. These scales have symptom items that are scored by the observation of the nurse or provider or through direct questioning of client (Prunty & Prunty, 2016). The data collected on these forms is used to help determine the medication to manage withdrawal symptoms.
Much of the medication that is used is based on the symptoms that the client is experiencing, such as stomach upset, runny nose, headache, diarrhea, anxiety, and increased blood pressure. For example, it is common practice to have orders for acetaminophen (Tylenol) for headache, dyphenhydramine (Benadryl) for runny nose, Maalox for stomach upset, and Imodium for diarrhea. Clonidine (Catapres) is commonly prescribed to reduce the high blood pressure seen during some detoxes. Nursing management is indicated with Catapres, as renal impairment and rapidly dropping blood pressure can result.
Unfolding Case Study
Substance Misuse: Part 3
See Substance Misuse: Part 2 for a review of the client data.
| Nursing Notes | 1445 Ongoing Assessment The client is seen in her bedroom, lying on her bed. She appears to be more relaxed. Currently, you repeat her vitals. She reports feeling less anxious. She denies hallucinations and appears oriented, yet still shifts frequently in the bed as you talk with her. She reports that she would like to try to take a nap. 1445 Intervention You offer her an additional blanket and make sure she has a full water cup at her bedside. You tell her you will return in two hours to repeat her vitals and reassess her withdrawal. |
| Flow Chart | 1445 Ongoing Assessment Blood pressure: 145/90 mmHg Heart rate: 100 beats/minute Respiratory rate: 20 breaths/minute Temperature: 99.1°F (37.2°C) Oxygen saturation: 98% on room air Pain 4/10 (head) |
| Lab Results | No additional laboratory tests results |
| Diagnostic Tests/Imaging Results | No additional diagnostic tests |
| Provider’s Orders | CIWA-Ar with protocol Close observation Seizure precautions |
Hospital and Residential Treatment
Inpatient treatment for substance use disorder at a hospital typically runs overnight to a few weeks. Some programs are short-term three- to five-day inpatient hospital programs that assist the client in the initial detox while supporting them with medications and milieu therapy. During their stay, a case manager/social worker will assist the client with discharge planning that could include admission to a long-term recovery center (SAMHSA, 2014).
Residential treatment entails a client living at a treatment center for a period of time. This allows the client to live in a supportive environment aimed at helping them to stay sober, learn about substance use disorders and healthier coping mechanisms, receive therapy to help them stay motivated, and get life skills training (SAMHSA, 2014). This time depends upon the facility, insurance coverage, and/or the severity of the person’s substance use disorder. This type of treatment may cost the client, so it is important to understand which types of insurances the program takes, if it has a low-cost or free option, and if there are other program alternatives (SAMHSA, 2023a).
Community Treatment
Community treatment takes place through community health centers, mental health facilities, and hospitals. Groups and educational options are often listed on these facilities’ websites or can be obtained by calling them directly. Community treatment gives individuals the option to be supported while continuing to live and work in their communities (SAMHSA, 2014).
An intensive outpatient program (IOP) is a treatment option that involves meeting at a facility for both individual and group therapy, three to five days a week for approximately three hours a day. These types of programs are used to treat depression, dual diagnosis, substance use, and eating disorders (Blanchfield, 2022). IOPs are considered a “step down” type of treatment that helps individuals transition from inpatient care back to their normal lives.
Peer Support Services
Peer support services provide an individual with the option to attend groups at times that are flexible and convenient to them. These groups, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), The National Alliance on Mental Illness (NAMI), and cultural, religious, or social networks (SAMHSA, 2023a), include face-to-face and virtual options. There are also groups such as Nar-Anon, Al-Anon, and NAMI for families of those with substance use or mental health problems. Veterans can reach out to their local VA to find out more information about self-help groups specifically available to them.
Many apps are available for those with smartphones. These apps offer 24/7 support that is easy to take anywhere you want to go. In times of crisis, individuals or family members can call 988 to talk with a trained crisis counselor.
Recognizing and Treating Overdose
Overdoses happen when people misuse their prescription medications, consume illegal drugs, and relapse after abstinence. Symptoms observed in the person who has taken an overdose depend upon the substance taken (Hartney, 2023). In opioid overdoses, the symptoms include clammy skin, slowed breathing, pinpoint pupils, vomiting, and becoming unconscious. Naloxone aids people who have overdosed on opioids. It works by blocking the effects of opioids and it can reverse the overdose.
In stimulant overdoses, the symptoms include rapid breathing, increased heart rate, convulsions, paranoia, and even coma. Medication can be used for symptom management once the person is taken to the hospital. Benzodiazepines are usually the most used medication for cardiovascular symptoms. Nitroglycerin might be used for the client who complains of chest pain. There is no specific medication for stimulant overdoses comparable to the use of naloxone for opioid overdoses (SAMHSA, 2021a).
Alcohol overdose is a medical emergency that can result in death. A person who overdoses on alcohol should be taken to a hospital, monitored closely, and medicated to prevent further physical decline. One potential danger of alcohol overdose is choking on one’s vomit and dying from lack of oxygen because high levels of alcohol intake hinder the gag reflex, resulting in the inability to protect the airway. Asphyxiation can occur due to an obstructed airway or from aspiration of gastric contents into the lungs. For this reason, do not leave a person alone who has passed out due to alcohol misuse. Keep them in a partially upright position or roll them onto one side with an ear toward the ground to prevent choking if they begin vomiting (NIAAA & National Institutes of Health, 2021).
Critical signs and symptoms of an alcohol overdose include mental confusion or stupor, difficulty remaining conscious or inability to wake up, vomiting, seizures, slow respiratory rate (fewer than eight breaths per minute), irregular breathing (ten seconds or more between breaths), slow heart rate, clammy skin, no gag reflex, extremely low body temperature, and bluish skin color or paleness (NIAAA & National Institutes of Health, 2021). If you suspect someone has overdosed on alcohol, seek emergency assistance or call 911. While waiting for help to arrive, be prepared to provide information to the responders, such as the type and amount of alcohol the person drank and any other drugs they ingested, current medications, allergies to medications, and any existing health conditions (NIAAA & National Institutes of Health, 2021).
Overdoses of certain medications, such as Tylenol, require medical intervention, including the use of activated charcoal to leech the medication out of the system. Many people do not realize that Tylenol overdose can result in permanent liver damage.
Issues in Withdrawal Management
Nurses working in medical-surgical hospital settings or emergency departments commonly provide care for clients receiving withdrawal treatment for alcohol, opioids, or other substances. Withdrawal symptoms vary among substances, length, and frequency of use. Clients frequently underreport alcohol and substance use, so nurses must be aware of signs of withdrawal in clients receiving medical care for other issues and notify the health-care provider (Sellers, n.d.). Withdrawal management, also considered detoxification, is highly effective in preventing immediate and serious medical consequences associated with discontinuing substance use, although alone it is not an effective treatment for any substance use disorder. It is considered stabilization, which is assisting a client through a period of acute detoxification and withdrawal so that they are medically stable and substance-free. Stabilization often prepares the individual for treatment. During stabilization, the client has become medically stable and is prepared for the recovery process and treatment plan. It is considered a first step toward recovery, similar to the acute management of a diabetic coma as a first step toward managing the underlying illness of diabetes. Similarly, acute stabilization and withdrawal management work best when followed by evidence-based treatments and recovery services (SAMHSA & Offices of the Surgeon General, 2016).
Unfortunately, many individuals who receive withdrawal management do not become engaged in treatment. Studies have found that, among individuals with substance use disorders who receive withdrawal management services, up to three-quarters of them do not enter treatment (Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General, 2016). The client needs to be ready to make the necessary changes in order to enter into recovery long-term. This is often the most difficult step.
Nurses can use the Motivation to Change Model to assess clients and educate them about the resources available to help them stay sober. This model is a therapeutic process wherein the professional supports positive behavior change. Support includes identifying the client’s existing motivation, empowering the client to choose, recognizing that resistance is part of the change process, and matching helping strategies to the client’s readiness to change. Stages of readiness include precontemplation, contemplation, preparation, action, and maintenance of the change.
One of the most serious consequences when individuals do not continue care after withdrawal management is overdose. Because withdrawal management reduces acquired tolerance, those who attempt to reuse their former substance in the same amount or frequency may overdose, especially those with opioid use disorders (SAMHSA & Offices of the Surgeon General, 2016).
Clinical Safety and Procedures (QSEN)
QSEN Competency: Teamwork and Collaboration
One part of working with clients who are withdrawing from substance use is teaching them about relapse prevention. During this interaction, the nurse will:
- treat clients holistically with no judgment toward their substance use
- discuss the danger of using again at the same amount used prior to withdrawal
- encourage the client to share their feelings about withdrawal, working with them to devise a plan if craving is pushing them toward relapse
(QSEN Institute, n.d.)
Alcohol Withdrawal
The prevalence of alcohol use disorder is estimated to be as high as 40 percent among hospitalized U.S. clients. Approximately half of clients with alcohol use disorder experience alcohol withdrawal when they reduce or stop drinking, with as many as 20 percent experiencing serious manifestations, such as hallucinations, seizures, and delirium tremens (Pace, 2022). Severe alcohol withdrawal is considered a medical emergency that is best managed in an intensive care unit.
Symptoms of early or mild alcohol withdrawal include anxiety, minor agitation, restlessness, insomnia, tremor, diaphoresis, palpitations, headache, and alcohol craving. Clients often experience loss of appetite, nausea, vomiting, and diarrhea. Their risk for falls often increases when they try to go unassisted to the bathroom with these gastrointestinal symptoms. Physical signs include sinus tachycardia, systolic hypertension, hyperactive reflexes, and tremor. Without treatment, symptoms of mild alcohol withdrawal generally begin within six to thirty-six hours after the last drink and resolve within one to two days (Pace, 2022).
Some clients develop moderate to severe withdrawal symptoms that can last up to six days. Hallucinations, for example, mostly occur within twelve to forty-eight hours after the last drink. They are typically visual and commonly involve seeing insects or animals in the room, although auditory and tactile phenomena may also occur (Pace, 2022). Moreover, alcohol withdrawal-related seizures can occur within six to forty-eight hours after the last drink. Risk factors for seizures include concurrent withdrawal from benzodiazepines or other sedative-hypnotic drugs (Pace, 2022). Importantly, delirium tremens (DT) is a rapid-onset, fluctuating disturbance of attention and cognition that is sometimes associated with hallucinations. In its most severe manifestation, DTs are accompanied by agitation and signs of extreme autonomic hyperactivity, including fever, severe tachycardia, hypertension, and drenching sweats. DTs typically begin between forty-eight and ninety-six hours after the client’s last drink. Mortality rates from withdrawal delirium have been historically as high as 20 percent, but with appropriate medical management, the mortality rate is between 1 and 4 percent. Death is attributed to cardiovascular complications, hyperthermia, aspiration, and severe fluid and electrolyte disorders (Pace, 2022).
Benzodiazepine Withdrawal
Rapid recognition and treatment of benzodiazepine withdrawal is critical because it can be life-threatening. Signs and symptoms of benzodiazepine withdrawal include tremors, anxiety, general malaise, perceptual disturbances, psychosis, seizures, and autonomic instability. Withdrawal is treated with a long-acting benzodiazepine (such as diazepam) and titrated to prevent withdrawal symptoms without causing excessive sedation or respiratory depression. The dose is then tapered gradually over a period of months (SAMHSA, 2022a).
Opioid Withdrawal
Medically supervised opioid withdrawal, also known as detoxification, involves administering medication to reduce the severity of withdrawal symptoms that occur when an opioid-dependent client stops using opioids. Supervised withdrawal alone does not generally result in sustained abstinence from opioids, nor does it address reasons the client became dependent on opioids (Sevarino, 2022). Clients may undergo detoxification for several reasons (Sevarino, 2022):
- Initiating the process to “get clean and stay clean” from opioids. Some clients may follow up with inpatient or outpatient treatment after completing the detoxification process.
- Treating withdrawal symptoms when a client dependent on opioids or heroin becomes hospitalized and lacks access to the misused substance.
- Beginning the first step in treating opioid use disorder and transitioning to medication-assisted treatment like methadone or suboxone treatment.
- Establishing an abstinent state without withdrawal symptoms as required for the client’s setting or status (e.g., incarceration, probation, or a drug-free residential program).
Withdrawal symptoms commonly encountered after prolonged use of opioids include runny nose, watering eyes, yawning, extremely high body temperature, muscle pain, nausea/vomiting, and anxiety (Cleveland Clinic, 2022a).
Stimulant Withdrawal
As soon as a person stops using a stimulant, the symptoms of withdrawal begin. These include feeling depressed, having a lack of energy, and feeling lethargic (American Addiction Centers, 2023). While this withdrawal is not typically life-threatening, the depression can cause suicidal ideation.
There are three phases to this withdrawal (American Addiction Centers, 2023). The first is the emotional feelings of sadness, anxiety, and intense craving. During the second phase, the person begins to feel physically and mentally exhausted as well as experience insomnia and depression. The third phase begins about twelve hours after the initial withdrawal symptoms and the person may notice much stronger symptoms and cravings that can last for ninety-six hours to several weeks.
Collaborative Care for a Client with an Addiction
The care of an individual with an addiction is collaborative in nature. It includes the client, family members, treatment team members such as the provider, nurse, social worker, case manager, and addiction/mental health counselors. Individual treatment plans are developed based on the individual needs and concerns of the client.