Drug Diversion

Substance Misuse and Drug Diversion

• Substance misuse encompasses a range of issues including physical and psychological dependence, habituation, and addiction.
• Commonly misused substances include opioids (heroin, codeine phosphate, hydrocodone, hydromorphone, meperidine hydrochloride, morphine, fentanyl, oxycodone), stimulants (racemic amphetamine, dextroamphetamine, methamphetamine, cocaine), depressants (benzodiazepines, barbiturates, marijuana), alcohol, anabolic steroids, dextromethorphan hydrobromide, LSD, methamphetamine, MDMA (ecstasy), nicotine, and PCP.

Opioids

• Also known as narcotics
• Intended effects: pain relief, cough suppression, diarrhea relief, and anesthesia
• High potential for misuse and psychological dependence; promote relaxation and euphoria
• Common forms of use: injection ("mainlining" or "skin popping"), sniffing ("snorting"), and smoking
• Adverse effects (CNS): drowsiness, diuresis (increased urination), miosis (pupillary constriction), convulsions, nausea, vomiting, respiratory depression
• Adverse effects (Non-CNS): hypotension, constipation, decreased urinary retention, flushing of the face, neck, upper thorax, sweating, urticaria, and pruritus
• Withdrawal: peak period 1-3 days, duration 5-7 days, signs include: drug seeking, mydriasis, diaphoresis, rhinorrhea, lacrimation, vomiting, diarrhea, insomnia, elevated BP and pulse
• Treatment: opioid receptor blockers like naltrexone hydrochloride, methylnaltrexone bromide (Relistor®), and naloxone combined with buprenorphine hydrochloride (Suboxone®) or hydromorphone hydrochloride (Targin®).

Stimulants

• Effects include mood elevation, fatigue reduction, increased alertness, and heightened aggressiveness.
• Common stimulants include amphetamines (methylphenidate hydrochloride, dextroamphetamine sulfate, methamphetamine), cocaine, and bath salts.
• Methamphetamine: stronger effects than other amphetamines, available in pill or powder forms (snorted or injected). Crystallized form (e.g., "ice," "crystal meth") is also smokable.
• MDMA (Ecstasy): usually prepared in secret labs, more calming effects than other amphetamines, generally taken in pill form.
• Cocaine: derived from coca plant leaves, available as powdered form (snorted or injected) or crystallized form (smoked, known as "crack").
• Adverse effects: restlessness, confusion, syncope (fainting), aggression, increased libido, anxiety, delirium, paranoid hallucinations, suicidal or homicidal tendencies. Headaches, chilliness, pallor or flushing, palpitations, tachycardia, cardiac dysrhythmias, anginal pain, hypertension or hypotension, circulatory collapse, gastrointestinal issues (dry mouth, anorexia, nausea, vomiting), diarrhea, abdominal cramps, and fatal hyperthermia.
• Overdose: death results from convulsions, coma, and cerebral hemorrhage during periods of intoxication or withdrawal.
• Withdrawal: peak period 1-3 days, duration 5-7 days, symptoms include social withdrawal, psychomotor retardation, hypersomnia, hyperphagia, depression, suicidal thoughts, and paranoid delusions
• No specific pharmacological treatments

Depressants

• Drugs such as barbiturates, benzodiazepines, marijuana, and flunitrazepam (Rohypnol®).
• Intended use: relieve anxiety, irritability, tension, treat seizure disorders, and induce anesthesia.
• Adverse effects (CNS): drowsiness, sedation, loss of coordination, dizziness, blurred vision, headaches, and paradoxical reactions
• Adverse effects (Gastrointestinal): nausea, vomiting, constipation, dry mouth, and abdominal cramping
• Adverse effects (others): pruritus and skin rash, marijuana ("amotivational" syndrome)
• Withdrawal: peak period 2 to 4 days (short-acting drugs), 4 to 7 days (long-acting drugs); duration 4 to 7 days (short-acting drugs), 7 to 12 days (long-acting drugs). Signs include increased psychomotor activity, agitation, muscular weakness, hyperthermia, diaphoresis, delirium, convulsions, elevated BP, pulse rate, and temperature
• Symptoms: anxiety, depression, euphoria, incoherent thoughts, hostility, grandiosity, disorientation, hallucinations, suicidal thoughts.
• Treatment: tapering over 7-14 days

Alcohol

• More accurately known as ethanol
• Causes CNS depression by dissolving in lipid membranes in the CNS.
• Few legitimate uses; commonly used as a solvent for many drugs.
• Effects: CNS depression (respiration stimulation or depression), vasodilation producing warm flushed skin, increased sweating, and diuretic effects.
• Chronic ingestion: nutritional and vitamin deficiencies (especially B vitamins), Wernicke's encephalopathy, Korsakoff's psychosis, polyneuritis, nicotinic acid deficiency encephalopathy, seizures, alcoholic hepatitis progressing to cirrhosis, and cardiomyopathy.
• Withdrawal: signs and symptoms include elevated blood pressure, pulse rate, and temperature, insomnia, tremors, agitation, classified as mild, moderate, or severe.
• Treatment: benzodiazepines (diazepam, Valium®), dosage and frequency depend on severity, acamprosate calcium. Sever cases may require critical care unit monitoring.

Nicotine

• Found in nature (tobacco plants); no known therapeutic uses.
• Effects: transient stimulation of autonomic ganglia followed by persistent depression, stimulation of CNS and respiration followed by depression, increased heart rate and blood pressure, and increased bowel activity.
• Withdrawal: manifested by craving, irritability, restlessness, decrease heart rate and BP; symptoms resolve in 3-4 weeks but craving may persist for months or years.
• Treatments: nicotine transdermal system (patch), nicotine polacrilex (gum), inhalers, nasal spray, bupropion hydrochloride (Zyban®), and varenicline tartrate (Champix®)

Drug Diversion

• Drug diversion: harm to patients and risks for staff who are diverting medications and others who are not.
• Red flags include careful investigations, non-threatening communication, confidential drug testing, negative results not filed, and watchlist.

Nurses' Health Program (NHP)

• Voluntary and confidential programs that are effective in protecting the public and supporting recovery for clinicians.
• Non-punitive approach to mental or substance use disorders.
• Promotes the recovery of healthcare workers

Nursing Implications

• Assessments should include nonjudgmental and open-ended questions about substance abuse to avoid withdrawal symptoms and establish therapeutic rapport.
• Identify and use assessment tools: CAGE-AID, SASSI, MAST-G, and POSIT.
• Patient safety is crucial, especially during withdrawal. Monitoring, support, and education on the recovery process are vital. Recovery can be ongoing (lifelong).

Question (from slide):

• A patient with a diagnosis of delirium tremens is admitted to the acute care facility. The nurse expects hyperthermia upon assessment.

Test your knowledge on opioids, their effects, and withdrawal symptoms with this quiz. Explore the risks associated with opioid misuse and the options available for treatment. Gain insights into the classification of these substances and the common misconceptions surrounding their use.