Psychoactive Substance Abuse

Psychoactive substances are drugs or chemicals that have an effect on the central nervous system (CNS). The National Institute on Drug Abuse (NIDA) defines drug misuse as improper or unhealthy use and implies use that can cause harm to the user or their friends or family. It is roughly equivalent to the term “abuse” but is believed to be a less stigmatizing description. Physical dependence is a condition in which the body adapts to regular use (develops tolerance) and is accompanied by withdrawal symptoms when the substance is taken away. Addiction is a broader term describing a chronic disorder characterized by drug seeking and use that is compulsive, despite negative consequences. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes (and replaces) all of the above terms as varying degrees of a substance use disorder. Harmful drug use impairs one's ability to perform daily activities of living and function in work environments. Relationships with family and friends become impaired and dysfunctional.

Most of the misused drugs fall into two main categories: CNS depressants and CNS stimulants. CNS depressants include narcotics, sedatives, barbiturates, tranquilizers, and inhalants. The desired effect by the user is a sense of increased self-esteem, euphoria, relaxation, and relief from pain and anxiety. CNS stimulants include amphetamines, hallucinogens, and cocaine. The desired effect by the user is a sense of well-being, alertness, excitation, overconfidence, and increased initiative.

In 2019, the U.S. National Survey on Drug Use and Health (NSDUH) estimated that 5.5 million people age 12 years or older were past users of cocaine, including about 778,000 users of crack and 2 million users of methamphetamine in the past year. Approximately 1 million people had a methamphetamine use disorder. Overdose deaths have increased for both cocaine and methamphetamines; methamphetamine overdose deaths quadrupled from 2011 to 2017 and in 2020 during the COVID-19 pandemic, overdose deaths from psychostimulants (like methamphetamine) increased by almost 35%.

NIDA (2020) reported significant increases in vaping among teenagers with as high as 40.6% admitting to use within the past year. Vaping of marijuana among teenagers has doubled in the past 2 years. Reports of serious respiratory illness secondary to vaping have raised additional safety concerns. Inhalant use (such as fuels, solvents, adhesives, aerosol propellants, and paint thinners, many of which contain toluene) has been increasing among teenagers over the last several years with significant increases among eighth graders.

Opioid misuse, overdose, and death continue to be a national epidemic in the United States. The CDC (2020) report that on average 128 Americans die per day from opioid overdose. While prescription misuse and heroin use have been primary sources of opioid addiction in the past, illicitly manufactured synthetic opioids such as fentanyl (30 to 50 times more potent than pure heroin) and carfentanil (100 times more potent than fentanyl) are primary drivers of the current epidemic. Mixtures of fentanyl and heroin are particularly lethal. According to the CDC, opioid overdose deaths increased by over 38% in the 12-month period ending in May 2020.

According to the most recent NSDUH, in 2018, 2% of Americans age 12 years and older reported using hallucinogens in the past year (NIDA, 2020). Lysergic acid diethylamide (LSD), like other hallucinogens, does not lead to the development of physical addiction or withdrawal symptoms. However, tolerance for LSD and other hallucinogens develops quickly and to a high degree. In fact, tolerance is complete after 3 to 4 consecutive days of use. Recovery from the tolerance also occurs very rapidly (in 4 to 7 days), so that the individual is able to achieve the desired effect from the drug repeatedly and often. LSD, psilocybin, and ketamine are all being explored for potential benefits in treatment-resistant depression. Currently, only ketamine has approval from the U.S. Food and Drug Administration for this use, and its administration must be in certified medical clinics with a Risk Evaluation and Mitigation Strategy (REMS). Chronic misuse of psychoactive substances may lead to complications, including pulmonary emboli, respiratory infections, trauma, musculoskeletal dysfunctions, psychosis, malnutrition disturbances, gastrointestinal disturbances, hepatitis, thrombophlebitis, bacterial endocarditis, gangrene, coma, and death.

Causes ⬆ ⬇

The causes of substance misuse are complex and multifactorial, influenced by the type and availability of the drug, personality type, environmental factors, peer pressure, coping abilities of the individual, genetic factors, and sociocultural influences. Cocaine dependence is thought to be associated with a deficiency in dopamine and norepinephrine neurotransmitters. Use of narcotics and opiates may interfere with the biochemical factors related to the body's own production of opiate-like substances.

Psychological factors include low self-esteem, feelings of inadequacy, loneliness, shame, guilt, depression, hopelessness, and despair. Sociocultural factors include relationships with individuals and groups where drug use is an accepted practice, isolation, unemployment, and poverty. Teenagers and young adults often begin experimenting as a result of peer pressure and the easy availability of drugs. Risk factors for substance misuse include family history of addiction, mental health disorders, peer pressure, lack of family involvement, exposure to use at an early age, exposure to violence and sexual assault, and posttraumatic stress disorder.

Genetic Considerations ⬆ ⬇

The ways in which genes influence behavior are complex, and definitive studies have proved elusive. Finding genetic causes of susceptibility to substance misuse has been difficult, but twin studies estimate that a susceptibility to substance misuse is highly genetic (heritability of ~60% to 80%). Genes associated with predisposition to dependence and risky behaviors include those encoding the dopamine D4 receptor, phosphodiesterase 1B, the AMPA receptor subunit GluR1, 5HT1B receptor, protein kinase C, and the transcription factor FosB. Variations in monoamine oxidase B (MAOB) influence a behavioral response to novelty. Some evidence has shown that a decreased expression of the gene encoding the 5-HTT transporter may be associated with an increased risk for substance use disorders.

Sex and Life Span Considerations ⬆ ⬇

Drug use and misuse are prevalent across the life span from young adolescents to the oldest of the old. Increasing numbers of older adults are abusing drugs as a way of coping with the stressors of aging. Young teens are vulnerable to experimentation as they attempt to conform to group norms and peer pressure. Club drugs such as MDMA (Ecstasy, Adam, clarity, Eve, lover's speed, etc.), flunitrazepam (Rohypnol, forget-me pill, roofies), and gamma-hydroxybutyrate (GHB, G, Georgia home boy, liquid ecstasy) are used primarily by adolescents and young adults at bars, nightclubs, concerts, and parties.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

Rates of substance misuse vary by race and ethnicity, depending on the substance, geography, and a variety of sociocultural factors. Socioeconomic vulnerability seems to be less important to substance misuse patterns than mental health issues. Transgender is a term used to describe persons whose gender identity is different from their sex assigned at birth. Approximately 1% of the U.S. population identify themselves as transgender. The CDC report that when compared to heterosexual individuals, gay and bisexual men, and lesbian and transgender individuals are more likely to use drugs and have higher rates of substance misuse. They suggest that drug use may be a reaction to homophobia, discrimination, marginalization, and violence they experience. Experts suggest that the exclusion of transgender persons from the substance use literature makes it difficult to determine their substance use prevalence.

Global Health Considerations ⬆ ⬇

According to the 2019 World Drug Report, an estimated 35 million people have drug use disorders requiring treatment. The report estimates that 53 million people worldwide are opioid users (up 56% from previous estimates), and two-thirds of the 585,000 people who died from drug use in 2017 had deaths related to opioid overdose. Fentanyl and its analogues are the primary driver of the synthetic opioid crisis in North America, but West and Central and North Africa are experiencing a crisis of another synthetic opioid, tramadol. Cannabis continues to be the most widely used psychoactive substance with an estimated 188 million users.

Assessment ⬆ ⬇

ASSESSMENT

History

The physiological signs and symptoms of use or intoxication vary, depending on the substance. Consequently, when a person is admitted in an intoxicated state or in withdrawal, it is important to know what drug or drugs have been used, the route used, and if possible, the amount of drug used. Determine if alcohol is also being used because there is a synergistic effect that increases the effect of both drugs.

Some patients may be misusing psychoactive drugs through ignorance. Others may have begun using them as part of a physician-prescribed treatment regimen and then became addicted. If the individual is unable to give a history because of overdose, friends or family members may provide needed information, and clothing can be checked for drug paraphernalia. Elicit a history of previous detoxification treatments, effectiveness, length of recovery, and what influenced a return to drug usage.

Physical Examination

The most common symptoms depend on the illicit drug (see Table 1). If the patient is admitted with intoxication and a drug history cannot be obtained, signs and symptoms can be indicators of the type of drug used (Table 1). Inspect the patient for evidence of how the drug is used, such as needle marks from mainlining, nasal irritation caused by snorting, ulcerations on lips and tongue from chewing, cellulitis from injecting drugs and missing the vein, and infections from sites used for mainlining.

Table 1 Signs and Symptoms of Drug Use and Withdrawal

DRUG	OVERDOSE	WITHDRAWAL
Marijuana (cannabis)	Euphoria, fatigue, decreased coordination, paranoia, panic, psychosis	Cravings, appetite loss
Narcotics	Small pupils, shallow respirations, increasing unresponsiveness, seizure activity	Tearing of the eyes, runny nose, anorexia, nausea, abdominal cramping and pain, irritability, shaking chills, diaphoresis
Depressants/barbiturates	Dilated pupils, shallow breathing, diaphoresis, thready and rapid pulse, increasing unresponsiveness	Shakiness, anxiety, sleeplessness, shaking, seizure activity
Stimulants/amphetamines, cocaine	Fever, anxiety, restlessness, hypertension, agitation, hallucinations, seizure activity	Depression, sleepiness, fatigue, apathy, irritability, weight gain
Hallucinogens	Dilated pupils, hypertension and tachycardia, sweating, vomiting, flushing, tremors and seizures, coma, stroke, organ failure, muscle necrosis, death	Flashbacks, anxiety, problems with concentration, confusion, depersonalization, depression, paranoia, delusions

Psychosocial

Obtain information on how patients perceive the effect drugs have on their life, work, and relationship with family and friends. Identify strengths and limitations. Assess the patient's emotional state before admission, especially noting depression and thoughts about suicide. If the patient is involved in a relationship, determine the degree of stability. Ask whether the partner or significant others use drugs and what their attitude is toward the patient's drug use. If the patient is a parent, find out the children's ages and investigate how the children are affected by the patient's drug use.

Elicit an employment history, including the type and length of employment. Determine how the use of drugs has affected the patient's work. Determine how much time off from work has been caused by the drug use. Establish a history of the financial effects of the drug use; ask how much the patient spends on drugs, and if there are other sources of income besides the primary job that were developed to gain income for drugs. Determine how the use of drugs has affected the patient's financial resources.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Serum and urine drug screens	Negative for screened substance	Positive for screened substance	Identify drugs that have been ingested

Other Tests: Gas chromatography–mass spectrometry. For unresponsive patients with suspected drug overdose—serum glucose, complete blood count, blood urea nitrogen, serum electrolytes, arterial blood gases, electrocardiogram, chest x-ray.

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisRisk for injury as evidenced by seizures, difficulty breathing, delirium, or anxiety (potential overdose) or nervousness, trouble sleeping, or flu-like symptoms (potential withdrawal)

Outcomes

OutcomesCoping; Role performance; Mood equilibrium; Risk control: Drug use

Interventions

InterventionsCounseling; Substance use treatment: Withdrawal; Substance use treatment: Overdose; Therapy group; Support group; Emotional support; Mood management

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

The immediate goal after depressant ingestion is to keep the individual safe during a drug overdose or withdrawal. The long-term goal is for the patient to remain drug free. In the acute phase, the immediate effects of narcotics can be reversed with naloxone (Narcan). In the case of barbiturate overdose when the patient is conscious, mild intoxication can be treated by letting the individual “sleep it off.” More severe cases of overdoses need to be handled in an acute or critical care environment where continuous monitoring can occur. Of paramount importance is to make sure the patient has adequate airway, breathing, and circulation (ABCs) during the time period that depressants may lead to severe respiratory depression.

Generally, if the patient is unconscious and the substance is unknown, the following steps are taken in management: (1) Begin supplemental oxygen; (2) insert an IV line with saline infusion or dextrose in water; (3) administer dextrose, thiamine, and naloxone; (4) protect airway with endotracheal intubation; (5) pass orogastric tube, lavage, and administer activated charcoal; and (6) admit the patient for ongoing observation and management. Activated charcoal is produced from the destructive distillation of organic materials. The substance absorbs toxic substances because of large external pores and a large internal surface area that binds with toxic ions. A cathartic such as magnesium citrate is given to help gastrointestinal excretion of the toxic substance bound with activated charcoal. Activated charcoal is also given for overdoses when the substance is known, such as phenobarbital, carbamazepine, cyclic antidepressants, amphetamines, and cocaine. Lipid emulsion therapy may be used to treat drug toxicities from tricyclic antidepressants and cocaine.

Management of stimulants can be similar to that of depressants, with the administration of activated charcoal. Seizures are a possibility in the case of an overdose with stimulants, but note that amphetamines and cocaine have a short duration time of 2 to 4 hours. Phenytoin (Dilantin) can be ordered to prevent seizure activity, and benzodiazepines are also used to treat agitation or seizures. External cooling may be used to reduce hyperthermia, and IV fluids may be used to replace fluid loss and to prevent myoglobin damage in the kidneys. All patients with substance misuse and overdoses need counseling and therapy to manage their substance use patterns.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Naloxone	2 mg IV; use smaller doses for patients who are not apneic to avoid withdrawal; 4 mg nasal spray and may repeat using new nasal spray in alternating nostrils, every 2 to 3 min if the patient does not respond, or responds and then relapses into respiratory depression	Opioid antagonist	Blocks the action of opioids that can lead to respiratory depression and apnea
Dextrose	100 mL IV 50% solution	Sugar	Rules out hypoglycemia as a cause for coma; given to patients who are known not to be hyperglycemic
Benzodiazepines	Varies with drug	Chlordiazepoxide, clorazepate, diazepam, lorazepam, oxazepam	Controls seizures and anxiety
Haloperidol	2–5 mg IV or IM	Antipsychotic	Controls combative or agitated behavior during withdrawal or treatment
Clonidine	0.1–0.3 mg every 4–6 hr	Antihypertensive	Opioid withdrawal; treats hypertension and tachycardia
Pentobarbital	100–200 initially PO and then in decreasing doses over 10 days	Barbiturate	Protects the patient from seizure activity
Phenytoin	300–400 mg daily in divided doses PO or IV	Anticonvulsant	Prevents and limits seizures related to drug withdrawal

Other Drugs: Desipramine hydrochloride (Norpramin), bromocriptine mesylate (Parlodel), amantadine hydrochloride (Symmetrel), and melphalan (phenylalanine mustard) have been prescribed to decrease the craving for cocaine during withdrawal. Naltrexone (ReVia [oral] or Vivitrol [injectable]) and methadone (an opioid partial agonist) are medications used to prevent relapse in opioid use disorders. Phenothiazines in low doses may be ordered to control the flashbacks that can occur after the last dose of a hallucinogen. Because the patient has built up a tolerance for drugs, the amount of medication needed to keep the patient safe may be more than what is considered a safe dosage.

Independent

During the acute phase, keep the patient safe. Use strategies for continuous monitoring of ABCs and implement emergency measures as needed to support life. Monitor for seizure activity and place the patient on the seizure precautions regimen. Examine the environment for safety risks such as falls from the bed or self-discontinuation of tubes. Assess the potential for a suicide attempt and, if necessary, initiate suicide precautions and never leave the patient unattended.

Meet the self-care deficits related to hygiene, nutrition, and elimination. Promote a sense of security: Approach the patient in a calm, nonthreatening, and nonjudgmental way. Building a trusting relationship with the patient provides a foundation for addressing the more long-term goals associated with becoming drug free.

Following the acute phase, initiate the process of rehabilitation and implement a treatment plan to maintain abstinence. The first goal is to work toward getting the individual to break through the denial of drug misuse and take responsibility to begin the recovery process. Motivational interviewing is an evidence-based strategy for promoting patient engagement in the change process. Provide educational materials and arrange a consultation with an addictions counselor to begin the process before discharge from an acute care setting. Often, individuals are admitted from an acute care setting to an inpatient or outpatient treatment facility where nursing staff and other healthcare providers can begin specialized treatment programs. These programs include peer group programs in which confrontation, support, and hope are part of the treatment process. Treatment goals for the individual include development of a healthy self-concept, self-discipline, adaptive coping strategies, strategies to improve interpersonal relationships, and ways of filling leisure time without the use of drugs.

Evidence-Based Practice and Health Policy

Wang, Q., Kaelber, D., Xu, R., & Volkow, N. (2021). COVID-19 risk and outcomes in patients with substance use disorders: Analyses from electronic health records in the United States. Molecular Psychiatry, 26, 130–139.

This retrospective case-control study of 73,099,850 electronic health records, 12,030 of whom had COVID-19, sheds light on the following risks and outcomes for patients with substance use disorders. The findings support that screening for and treating substance use disorders has implications as one of the strategies for controlling the COVID-19 pandemic. Patients with a recent (within the past year) diagnosis of substance use disorders were at significantly increased risk for COVID-19, especially those with opioid use disorder (followed by those with tobacco use disorder).
Compared to patients without substance use disorder, patients with substance use disorder had significantly higher prevalence of chronic kidney, liver, and lung diseases; cardiovascular diseases; type 2 diabetes; obesity; and cancer. Among patients with recent diagnosis of substance use disorder, Black persons had significantly higher risk of COVID-19 and worse outcomes than White persons. COVID-19 patients with substance use disorder had significantly worse outcomes (death: 9.6%, hospitalization: 41.0%) than general COVID-19 patients (death: 6.6%, hospitalization: 30.1%).

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DRG Information ⬇

Introduction ⬆ ⬇