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• Intoxication involves substance use resulting in maladaptive behavior.
• Withdrawal refers to negative reactions when substance use ceases or dramatically decreases.

CNS Depressants

• Types include alcohol, sedatives, hypnotics, and anxiolytics.

Alcohol

• Intoxication signs include relaxation, loss of inhibitions, slurred speech, unsteady gait, lack of coordination, impaired attention/memory/judgment, aggression, inappropriate sexual behavior, and blackouts.
• Overdose signs include unconsciousness, vomiting, respiratory depression, aspiration pneumonia, pulmonary obstruction, and alcohol-induced hypotension, potentially leading to cardiovascular shock and death.
• Chronic effects on the body involve cardiac myopathy (heart disease that inhibits perfusion), Wernicke encephalopathy (neurologic emergency from thiamine (B1) deficiency), and Korsakoff psychosis (confusion, memory loss, confabulation, often a complication of Wernicke encephalopathy).
• Pancreatitis can occur, indicated by elevated amylase and lipase levels.
• Additional effects: esophagitis, hepatitis (liver inflammation), cirrhosis (scarring of the liver tissue with elevated AST/ALT labs), leukopenia (low WBCs), thrombocytopenia (low platelets), and ascites (fluid build-up in the abdomen).
• Wernicke encephalopathy and Korsakoff's psychosis are considered the most dangerous adverse effects.

Withdrawal and Detoxification

• Symptoms include hand tremors, sweating, elevated heart rate and blood pressure, insomnia, anxiety, nausea, and vomiting.
• Severe symptoms involve hallucinations, delirium, and seizures, requiring seizure precautions.
• Withdrawal symptoms typically onset within 4-12 hours after the last alcohol intake, peak on the second day, and usually resolve within 5 days.
• Treatment includes benzodiazepines to suppress withdrawal symptoms like lorazepam, chlordiazepoxide, or diazepam.
• Disulfiram (Antabuse) is administered to deter drinking .
• Educate patients about avoiding contact with any alcohol (mouthwash, lotion, vanilla, vinegar, perfume, cough syrup, etc).
• Ingesting alcohol while on Disulfiram will cause flushing, throbbing headache, diaphoresis, nausea, and vomiting.

Sedative/Hypnotics/Anxiolytics

• Main examples are barbiturates and benzodiazepines.
• Intoxication and withdrawal symptoms resemble those of alcohol.
• Benzodiazepine overdose is rarely fatal when taken orally, but can cause lethargy and confusion.
• Treatment for overdose includes gastric lavage, activated charcoal, saline, and dialysis for severe cases.
• Barbiturate overdose can lead to coma, respiratory depression, cardiac failure, and death.
• Barbiturate overdose treatment includes ICU admission, dialysis, or mechanical ventilation.
• Signs of intoxication include slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention/memory, stupor (unconsciousness), and coma.
• Continuous assessment of vital signs and respiratory status is vital if intoxication is suspected.
• Withdrawal and detoxification: taper off barbiturates and NEVER stop abruptly.
• Detoxification depends on the medication's half-life; Determine the medication and time taken.
• Short-acting drugs like Lorazepam cause withdrawal symptoms within 6-8 hours.
• Long-acting drugs like Diazepam may take up to a week for withdrawal symptoms to appear.
• Symptoms of withdrawal include increased heart rate, hypertension, increased respirations and temperature, hand tremor, insomnia, and anxiety.
• severe symptoms of withdraw includes nausea, psychomotor agitation, seizures and hallucination

Stimulants

• Examples of stimulants include cocaine and methamphetamine.
• Methamphetamine abuse can cause psychotic behavior and brain damage.

Signs of Intoxication:

• Typical effects include a high or euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic behavior, anger, fighting, and impaired judgment.
• Physiological effects: tachycardia, hypertension, dilated pupils, perspiration, chills, nausea, chest pain, confusion, and cardiac dysrhythmias.
• Stimulant overdose can result in seizures, coma, or death.
• Withdrawal and detoxification: dysphoria, fatigue, and vivid, unpleasant dreams.

Cannabis

• Intoxication signs include impaired motor coordination, inappropriate laughter, impaired judgment, short-term memory loss, distortions of time and perception, anxiety, dysphoria, and social withdrawal.
• Physiological effects: increased appetite, conjunctival injection (bloodshot eyes), dry mouth, hypotension, and tachycardia.
• Excessive use of cannabis may produce delirium or cannabis-induced psychotic disorder.
• Both conditions are treated symptomatically as cannabis overdoses do not occur.
• Effects begin soon after inhalation, peak around 20-30 minutes, and last for 2-3 hours.
• Withdrawal and detoxification: muscle aches, sweating, anxiety, and tremors.

Opioids

• Used to relieve physical and mental pain and includes morphine, demerol, oxycodone, methadone, etc.
• Synthetic fentanyl is more potent.
• If intoxication or withdrawal symptoms are present, obtain a drug screen immediately and gather a drug history, including the time and amount of last use.
• Intoxication starts when the euphoria hits.

Symptoms:

• Euphoria, apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory.
• Severe symptoms include coma, respiratory depression, pupillary constriction, unconsciousness, and death. Withdrawal and Detoxification:
• Anxiety, aching back and legs, nausea, vomiting, lacrimation, sweating, yawning, insomnia, restlessness, cravings for more opioids, dysphoria, rhinorrhea, diarrhea, and fever.
• Short-acting opioid withdrawals happen within 6-24 hours, peak in 2-3 days, and subside over 5-7 days.
• Long-acting opioid withdrawals start within 2-4 days and take up to 2 weeks to subside.
• Opioid cravings can last for 2-3 months.
• Opioid Intoxication Treatment: Naloxone (Narcan) is an opioid antagonist, and reverses all signs of opioid toxicity.
• Naloxone is given every few hours until opioid levels drop to non-toxic.
• This process may take days, depending on dosage; stronger opioids may require extra doses.
• Synthetic opioids may require higher doses of Naloxone.

Methadone:

• Can be used to reduce withdrawal symptoms or as a replacement for opioids.
• Dosage can be decreased to taper patients off of opioids.
• Helps patients abstain from opioids (heroin).
• Naltrexone combats side effects of withdrawal, reduces opioid cravings
• Usually gives monthly injection

Hallucinogens

• Examples include PCP and ecstasy.

Intoxication and Overdose

• Behavioral/Psychological Changes: anxiety, depression, paranoid ideation, ideas of reference, fear of losing one's mind, and potentially dangerous behaviors.
• Physiological Symptoms: sweating, tachycardia, palpitations, blurred vision, tremors, and lack of coordination.
• PCP intoxication includes belligerence, aggression, impulsivity, and unpredictable behavior.
• PCP toxicity includes seizures (require medications to treat), hypertension (require medications to treat), hyperthermia (use cooling blankets to treat), and respiratory depression (may require mechanical ventilation).
• Death occurs from the actions caused by hallucinations.
• Toxic reactions (except PCP) are psychological; overdose does not occur.
• Drugs are not a direct cause of death.
• Isolate patients from external stimuli.
• Use restraints if required for safety. Withdrawal and Detoxification:
• Talk to patients and reassure them that they are safe.
• There are no known withdrawal symptoms other than drug cravings.
• Hallucinogens can cause flashbacks that may last up to 5 years.

Inhalants

• Examples: spray paint, gas, duster.
• Can cause brain damage and liver disease.

Intoxication and Overdose:

• Intoxication Symptoms: dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, blurred vision, stupor, and coma.
• Behavioral Symptoms; belligerence, aggression, apathy, impaired judgment, and inability to function.
• Acute Toxicity: anoxia, respiratory depression, vagal stimulation, dysrhythmias.
• Death related to bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomit.
• There are no medications for inhalant abuse.
• To treat overdose: support respiratory and cardiac systems.
• No known withdrawal symptoms, but some report psychological cravings.
• No detoxification procedures.
• May experience inhalant-induced disorders.
• Treatments of inhalent-induced disorder is symptomatically

Overall Substance Abuse Treatments:#### 12-Step Programs:

• The only requirement for membership is a desire to stop drinking/using.
• Remind patients of this, and that it does not always have to be god-centered.
• Treatment Settings: Intoxication and withdrawal/detoxification can take place in the ER, outpatient clinics, or inpatient.

Pharmacologic Treatments:

• Alcohol: Vitamin B1 (Thiamine) for Wernicke Encephalopathy, Benzodiazepines for withdrawal treatment, Barbiturates
• Disulfiram (Antabuse), to prohibit alcohol abuse in alcoholics.
• Educate patients about not using alcohol while taking this medication.
• Opioids: methadone
• Used to taper patients off of heroin
• Naloxone: reversal agent for overdose
• Buprenorphine: is given with naloxone, sublingual
• Clonidine (Catapres)

Dual Diagnosis

• Patients with a psychiatric illness who abuse substances.
• There's limited treatment success.
• Key elements to address include healthy environments, assistance with fundamental life changes, connections with others in recovery, and treatment of comorbid conditions.
• Goal is to help the patient with support groups for relapse prevention.

Caring for Patients with Substance Use Problems:

• Denial & Rationalization is usually the first response; respond with therapeutic communication.

Priority Steps:

• First: detox.
• Second: address physical needs (safety, nutrition, fluids, elimination, and sleep).
• Always show therapeutic communication.
• Build rapport to build working relationships with our patients. CAGE Questionnaire Screening Tool:
• Used to assess patients' addiction and knowledge of their addiction
• C: Have you ever felt you should Cut down on your drinking?
• A: Have people Annoyed you by criticizing your drinking?
• G: Have you ever felt bad or Guilty about your drinking?
• E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye opener).

Assessment Data:

• History (trauma, treatment, etc)
• General appearance & motor behavior (tremors, cleanliness, etc)
• Mood & affect (restlessness, posture, etc)
• Thought process & content (what stage are they in in this process?)
• Sensorium & intellectual processes
• Judgement & insight
• Self-concept
• roles & relationships
• Physiological considerations

Data Analysis & Priorities:

• The Goal is to Identify what makes one patient different and what puts the patient at risk.

Outcome Identification

• Verbalizing addiction
• Coping skills
• Aftercare treatments.

Actions

• Promote healthcare teaching for the patient and family
• Address any family issues
• Promote coping skills
• Evaluate if they achieved abstinence

Substance Abuse in Health Professionals

• The nurses responsibility to report these signs regardless of relationship with professional
• General Warning signs are include:
• Incorrect drug counts
• Excessive wastes
• Document break through medications
• Medication errors
• Patient reporting pain, especially after documented medications