Substance Misuse and Commonly Misused Substances

• Substance misuse can lead to physical dependence, psychological dependence, habituation, and addiction.

Commonly Misused Substances

• Opioids include heroin, codeine phosphate, hydrocodone, hydromorphone, meperidine hydrochloride, morphine, fentanyl, and oxycodone.
• Racemic amphetamine, dextroamphetamine, methamphetamine, and cocaine are examples of stimulants.
• Benzodiazepines, barbiturates, and marijuana are examples of depressants.
• Other commonly misused substances include alcohol, anabolic steroids, dextromethorphan hydrobromide, lysergic acid diethylamide (LSD), methamphetamine, methylenedioxymethamphetamine (ecstasy, molly), nicotine, and phencyclidine (PCP).

Opioids

• Opioids, also known as narcotics, include heroin and are intended to relieve pain, reduce cough, relieve diarrhea, and induce anesthesia.
• Opioids have a high potential for misuse and psychological dependency, and promote relaxation and euphoria.
• Opioids affects areas outside the central nervous system (CNS), and side effects occur there.
• Methadone is used to treat opioid dependence.
• The goal of methadone treatment is to reduce the patient's dosage gradually so that the patient can live permanently drug-free long term.
• Relapse rates with methadone are often high, and it can be misused
• Heroin (diacetylmorphine) can be injected ("mainlining" or "skin popping"), sniffed ("snorted"), or smoked.
• Heroin causes a brief rush, followed by a few hours of a relaxed, contented state.
• Large doses of heroin can stop respirations.
• Heroin is one of the top 10 most misused drugs in Canada.

Opioids: Adverse Effects

• CNS adverse effects include drowsiness, diuresis, miosis, convulsions, nausea, vomiting, and respiratory depression.
• Non-CNS adverse effects (histamine related) include hypotension, constipation, decreased urinary retention, flushing of the face, neck, and upper thorax, sweating, urticaria, and pruritus.

Opioid Drug Withdrawal

• The peak period for opioid drug withdrawal is 1 to 3 days.
• The duration of opioid drug withdrawal is 5 to 7 days.
• Signs of withdrawal includes drug seeking, mydriasis, diaphoresis, rhinorrhea, lacrimation, vomiting, diarrhea, insomnia, elevated blood pressure (BP), and elevated pulse.
• Symptoms includes intense desire for the dug, muscle cramps, arthralgia, anxiety, nausea, malaise.

Opioid Drug Withdrawal: Treatment

• Opioid drug withdrawal's treatment blocks opioid receptors so that using opioid drugs does not produce euphoria.
• Naltrexone hydrochloride is an opioid antagonist.
• Methylnaltrexone bromide (Relistor) is an injectable form of naltrexone.
• Naloxone can be combined with buprenorphine hydrochloride (Suboxone) or with hydromorphone hydrochloride (Targin).

Stimulants

• Stimulants can cause elevation of mood, reduction of fatigue, increased alertness, and invigorated aggressiveness.
• Examples of Stimulants include Amphetamines, Cocaine, Methylphenidate hydrochloride, Dextroamphetamine sulphate, Methamphetamine, Methylenedioxymethamphetamine (MDA).
• Stimulants work by releasing biogenic amines (norepinephrine) from their storage sites in the nerve terminals.
• The release of biogenic amines results in stimulation of the CNS and cardiovascular stimulation, leading to increased blood pressure and heart rate and possible cardiac dysrhythmias.
• CNS stimulation commonly results in wakefulness, alertness, decreased fatigue, elevation of mood with increased initiative, self-confidence, ability to concentrate, elation, euphoria and an increase in motor and speech activity.

Methamphetamine

• Methamphetamine causes stronger effects than other amphetamines.
• Methamphetamine can be in pill form or powder form, taken by being snorted or injected.
• Methamphetamine can be crystallized, and is known as “ice,” “crystal,” “glass,” “crystal meth.”
• The crystallized form of methamphetamine can be smoked and is a more powerful form.
• Sales of over-the-counter ephedrine, pseudoephedrine, and red phosphorus are now restricted to be behind the counter in pharmacies, as they are used to synthesize methamphetamine in secret drug laboratories.

Methylenedioxymethamphetamine

• Methylenedioxymethamphetamine is also known as "ecstasy” and “E”.
• Methylenedioxymethamphetamine is usually prepared in secret home laboratories.
• Methylenedioxymethamphetamine's effects are more calming than other amphetamine drugs.
• Methylenedioxymethamphetamine is usually taken by a pill.
• Methylenedioxymethamphetamine is a popular party drug that is taken at raves.

Cocaine

• Cocaine originates from the leaves of the coca plant
• Cocaine snorted or injected intravenously
• Cocaine is highly addictive, physical and psychological dependence
• Powdered form of cocaine is also called “dust,” “coke", "snow," "flake,” “blow,” "girl"
• Crystallized form (smoked) of cocaine is also called “crack,” "freebase rocks,” “rock", "candy"

Stimulants: Adverse Effects

• CNS adverse effects includes restlessness, syncope (fainting), tremor, hyperactive reflexes, talkativeness, irritability, insomnia, fever, and euphoria.
• Others adverse effects include confusion, aggression, increased libido, anxiety, delirium, paranoid hallucinations, suicidal or homicidal tendencies.
• Cardiovascular adverse effects includes dry mouth, metallic taste, anorexia, nausea, vomiting, diarrhea, and abdominal cramps.
• Gastrointestinal adverse effects include headache, chilliness, pallor or flushing, palpitations, tachycardia, cardiac dysrhythmias, anginal pain, hypertension or hypotension and circulatory collapse.

Stimulant Overdose

• Death results from convulsions, coma, or cerebral hemorrhage.
• Overdose can occur during periods of intoxication or withdrawal.
• Sedation may be needed.

Stimulant Withdrawal

• Peak period for stimulant withdrawal is 1 to 3 days with a duration 5 to 7 days
• Signs and symptoms include social withdrawal, psychomotor retardation, hypersomnia, and hyperphagia
• Depression, suicidal thoughts and behaviour, and paranoid delusions.
• No specific pharmacological treatments exist.

Depressants

• Depressants are drugs that relieve anxiety, irritability, and tension when used as intended.
• Depressants can be used to treat seizure disorders and induce anesthesia.
• The two main pharmacologic classes of depressants are benzodiazepines and barbiturates.
• Marihuana (“pot,” “grass,” “weed") is also a depressant
• Flunitrazepam (Rohypnol) is not legally available in Canada, as it is known as “roofies” and used for insomnia.
• Benzodiazepines and barbiturates increase the action of gamma-aminobutyric acid, an amino acid in the brain, which inhibits nerve transmission in the CNS.
• These agents results in sedation, muscle relaxation, and relief of anxiety
• The active ingredient in Marihuana is 6-9-trans-tetrahydrocannabinol, which binds to and stimulating two cannabinoid receptors in the CNS and can have effects of mild euphoria, memory lapses, dry mouth, enhanced appetite, motor awkwardness, along with a distorted sense of time and space.
• Benzodiazepines are used for anxiety, to induce sleep, to sedate, and to prevent seizures
• Barbiturates are sedatives and anticonvulsants that induce anaesthesia

Depressants: Adverse Effects

• CNS effects include drowsiness, sedation, loss of coordination, dizziness, blurred vision, headaches, and paradoxical reactions.
• Gastrointestinal effects includes nausea, vomiting, constipation, dry mouth, and abdominal cramping.
• Additional effects include pruritus and skin rash.
• Marihuana can have an chronic depressive “amotivational” syndrome

Depressants: Withdrawal

• Peak period can be 2 to 4 days for short-acting drugs, and 4 to 7 days for long-acting drugs.
• Duration can be 4 to 7 days for short-acting drugs or 7 to 12 days for long-acting drugs.
• Signs includes increased psychomotor activity, agitation, muscular weakness, hyperthermia, diaphoresis, delirium, convulsions, elevated BP, pulse rate, and temperature, in addition to possible others.
• Symptoms include anxiety, depression, euphoria, incoherent thoughts, hostility, grandiosity, disorientation, hallucinations, and suicidal thoughts.
• Treatment involves tapering of the drug over a course of 7 to 10 days or 10 to 14 days.
• Combined with alcohol, depressants may have a lethal effect

Alcohol

• Alcohol is more accurately known as ethanol
• Ethanol causes CNS depression by dissolving in lipid membranes in the CNS and enhancement of GABA effect
• Ethanol has has few legitimate uses, but is used as a solvent for many drugs
• Systemic uses of ethanol: treatment of methyl alcohol and ethylene glycol intoxication
• Ethanol can cause CNS Depression along with respiratory stimulation or depression.
• Ethanol causes vasodilation, producing warm flushed skin, increased sweating, and diuretic effects

Effects of Chronic Ethanol Ingestion

• Chronic Ethanol Ingestion can caused nutritional and vitamin deficiencies (especially B vitamins).
• Nutritional and vitamin deficiencies (especially B vitamins) can lead to Wernicke's encephalopathy, Korsakoff's psychosis, polyneuritis and Nicotinic acid deficiency encephalopathy.
• Seizures, alcoholic hepatitis, progressing to cirrhosis, and cardiomyopathy may also occur
• Fetal alcohol spectrum disorder (FASD) can occur.
• Pregnant women should be educated about the effects of alcohol consumption.
• FASD is characterized by craniofacial abnormalities, CNS dysfunction, and prenatal and postnatal growth retardation

Ethanol: Withdrawal

• Signs and symptoms include elevated blood pressure, pulse rate, and temperature, insomnia, tremors, and agitation.
• Ethanol withdrawal is classified as mild, moderate, or severe.
• Ethanol withdrawal's treatment of choice is benzodiazepines.
• Diazepam (valium) can be used
• Dosage and frequency depends on severity.
• Monitoring in a Critical Care Unit is recommend for severe withdrawal.
• Pharmaceutical treatment for alcoholism includes disulfiram (Antabuse), naltrexone, and acamprosate calcium.
• Disulfiram is no longer manufactured in Canada and has Acetaldehyde syndrome side effects
• Acamprosate is the newest option.
• Counselling includes individual therapy and alcoholics anonymous.

Nicotine

• Many smoke to “calm nerves."
• Nicotine releases epinephrine, which creates physiological stress rather than relaxation.
• Tolerance develops with Nicotine
• Nicotine use results in physical and psychological dependency.
• Withdrawal symptoms occur if use is stopped.
• Nicotine has no therapeutic uses.
• More than two hundred known poisons are present in cigarette smoke.
• Nicotine temporarily stimulates autonomic ganglia, followed by more persistent depression of all autonomic ganglia
• Nicotine stimulates the CNS and respiratory system followed by CNS depression
• Nicotine increases heart rate and BP
• Nicotine increases bowel activity.
• There are no known therapeutic uses of its components but it's addictive and toxic properties are medically significant

Nicotine Withdrawal

• Manifested by cigarette craving along with irritability, restlessness, and decreased heart rate and BP.
• Cardiac symptoms resolve in 3 to 4 weeks, but cigarette craving may persist for months or years.
• Nicotine transdermal system (patch), nicotine polacrilex (gum), inhalers, and nasal sprays may be used to treat nicotine dependence.

Nicotine Withdrawal Treatment

• Treatments provide nicotine without the carcinogens in tobacco
• Bupropion hydrochloride (Zyban) may be prescribed to aid in smoking cessation as a first nicotine-free prescription medication to treat nicotine dependence.
• Varenicline tartrate (Champix) stimulates nicotine receptors

Nursing Implications

• Assessments should include nonjudgemental and open-ended questions about substance abuse.
• Nurses should be observant for clues to substance misuse to avoid withdrawal symptoms.
• The most dangerous substances in terms of withdrawal are CNS depressants such as barbiturates, benzodiazepines, and alcohol.
• Establish therapeutic rapport, and use empathy toward the patient to encourage openness,.
• Utilize assessment tools for substance misuse, include: CAGE Alcoholism Screening Test Adapted to Include Drugs (CAGE-AID), Substance Abuse Subtle Screening Inventory (SASSI), Michigan Alcoholism Screening Test Geriatric version (MAST-G), and Problem Oriented Screening Instrument for Teenagers (POSIT).
• Patient safety takes utmost importance at all times, especially during patient care when the patient is experiencing the signs and symptoms of withdrawal.
• Provide monitoring and support as needed throughout the withdrawal process.
• Educate the patient and family members or significant others about the recovery process.
• Emphasize that recovery is a lifelong endeavor.

This lesson explores substance misuse, differentiating between physical dependence, psychological dependence, habituation, and addiction. It identifies commonly misused substances such as opioids, stimulants, and depressants. The lesson highlights the effects and dependency potential of opioids, including their impact on the central nervous system.