Substance Misuse and Opioids

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

Commonly Misused Substances

• Includes opioids, stimulants, depressants, alcohol, anabolic steroids, dextromethorphan hydrobromide, lysergic acid diethylamide (LSD), methamphetamine, methylenedioxymethamphetamine (ecstasy, molly), nicotine, and phencyclidine (PCP).

Opioids

• Opioids, also known as narcotics such as heroin, are misused for their intended drug effects
• Intended drug effects include pain relief, cough reduction, diarrhea relief, and inducing anesthesia.
• Opioids have a high potential for misuse and psychological dependency, promoting relaxation and euphoria.
• Opioid use has side effects due to affecting areas outside the central nervous system (CNS).
• Methadone is used to treat opioid dependence to reduce the patient's dosage gradually so that patients can eventually live drug-free, but relapse rates are often high
• Heroin (diacetylmorphine) can be injected ("mainlining" or "skin popping"), snorted, or smoked.
• Heroin use causes a brief "rush" followed by a few hours of a relaxed, contented state.
• Large doses of heroin can stop respiration.
• Heroin is consistently among the most misused drugs in Canada each year.

Opioids: Adverse Effects

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

Opioid Drug Withdrawal

• Peak withdrawal period lasts 1 to 3 days with a duration of 5 to 7 days.
• Signs of withdrawal include drug-seeking behavior, mydriasis, diaphoresis, rhinorrhea, lacrimation, vomiting, diarrhea, insomnia, elevated blood pressure (BP), and pulse.
• Symptoms of withdrawal include an intense desire for the drug, muscle cramps, arthralgia, anxiety, nausea, and malaise.

Opioid Drug Withdrawal: Treatment

• Treatment involves blocking opioid receptors to prevent euphoria from opioid use.
• Medications used include naltrexone hydrochloride, methylnaltrexone bromide (Relistor®), and naloxone combined with buprenorphine hydrochloride (Suboxone®) or hydromorphone hydrochloride (Targin®).

Stimulants

• Stimulants elevate mood, reduce fatigue, increase alertness, and invigorate aggressiveness.
• Common stimulants include amphetamines, cocaine, methylphenidate hydrochloride, dextroamphetamine sulphate, methamphetamine, and methylenedioxymethamphetamine (MDA).
• Stimulants work by releasing biogenic amines such as norepinephrine from their storage sites in the nerve terminals.
• The release of biogenic amines results in CNS stimulation, as well as cardiovascular stimulation, leading to increased blood pressure and heart rate and may also incite cardiac dysrhythmias.
• CNS stimulation often results in wakefulness, alertness, and a decreased sense of fatigue, as well as elevation of mood with increased initiative, self-confidence, ability to concentrate, elation, euphoria, and an increase in motor and speech activity

Methamphetamine

• Methamphetamine has stronger effects than other amphetamines and can come in pill or powder form that is snorted or injected.
• Crystallized methamphetamine is also known as "ice", "crystal," or "crystal meth", and is a smokable, 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, also known as "ecstasy" and "E", is prepared in secret home laboratories and has more calming effects than other amphetamine drugs.
• It is usually taken by pill and is a "popular party drug - raves".

Cocaine

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

Stimulants: Adverse Effects

• CNS adverse effects of stimulants include restlessness, syncope (fainting), tremor, hyperactive reflexes, talkativeness, irritability, insomnia, fever, euphoria, confusion, aggression, increased libido, anxiety, delirium, paranoid hallucinations, suicidal or homicidal tendencies.
• Cardiovascular adverse effects include 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 in stimulant overdose results from convulsions, coma, or cerebral hemorrhage.
• Overdose may occur during periods of intoxication or withdrawal and requires sedation.

Stimulant Withdrawal

• Peak withdrawal period lasts 1 to 3 days, with a duration of 5 to 7 days.
• Signs of stimulant withdrawal include social withdrawal, psychomotor retardation, hypersomnia, and hyperphagia.
• Symptoms of stimulant withdrawal include depression, suicidal thoughts and behavior, and paranoid delusions.
• There are no specific pharmacological treatments.

Depressants

• Depressants relieve anxiety, irritability, and tension when used as intended and are also used to treat seizure disorders and induce anesthesia.
• Two main pharmacologic classes of depressants include benzodiazepines and barbiturates.
• Other depressants include marihuana and Flunitrazepam.
• Benzodiazepines and barbiturates increase the action of gamma-aminobutyric acid which is an amino acid in the brain, which inhibits nerve transmission in the CNS
• These results in sedation, muscle relaxation, and relief of anxiety
• Marihuana (δ-9-trans-tetrahydrocannabinol) binds to and stimulates two cannabinoid receptors in the CNS
• This results in mild euphoria, memory lapses, dry mouth, enhanced appetite, motor awkwardness, and a distorted sense of time and space
• Benzodiazepines are used for anxiety, to induce sleep, to sedate, and to prevent seizures.
• Barbiturates are used as sedatives and anticonvulsants and to induce anesthesia.

Depressants: Adverse Effects

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

Depressants: Withdrawal

• Peak Period: Typically 2 to 4 days for short-acting drugs, or 4 to 7 days for long-acting drugs.
• Lasts between 4 to 7 days for short-acting drugs and 7 to 12 days for long-acting drugs
• Signs of depressant withdrawal include increased psychomotor activity, agitation, muscular weakness, hyperthermia, diaphoresis, delirium, convulsions, elevated BP, pulse rate, and temperature.
• The symptoms are anxiety, depression, euphoria, incoherent thoughts, hostility, grandiosity, disorientation, hallucinations, and suicidal thoughts.
• Treatment involves tapering the drug over 7 to 10 days or 10 to 14 days and combining depressants with alcohol can have a lethal effect.

Alcohol

• Alcohol is more accurately known as ethanol which causes CNS depression by dissolving in lipid membranes in the CNS causing a GABA effect
• Alcohol has systemic uses such as the treatment of methyl alcohol and ethylene glycol intoxication.

Ethanol: Drug Effects

• Includes CNS depression, respiratory stimulation or depression, vasodilation (producing warm flushed skin), increased sweating, and diuretic effects.

Effects of Chronic Ethanol Ingestion

• Chronic Ethanol Ingestion causes nutritional and vitamin deficiencies, especially B vitamins.
• These deficiencies can cause Wernicke’s encephalopathy, Korsakoff’s psychosis, polyneuritis, and nicotinic acid deficiency encephalopathy
• Other effects include seizures, alcoholic hepatitis progressing to cirrhosis, cardiomyopathy, and fetal alcohol spectrum disorder (FASD).
• Pregnant women should be educated about the effects of alcohol consumption, as FASD is characterized by craniofacial abnormalities, CNS dysfunction, and prenatal and postnatal growth retardation

Ethanol: Withdrawal

• Consists of elevated blood pressure, pulse rate, temperature, insomnia, tremors, and agitation
• It is classified as mild, moderate, or severe
• Benzodiazepines, such as diazepam (Valium®), is a treatment of choice for ethanol withdrawal
• Also Acamprosate calcium is used, and dosage and frequency depend on severity
• For severe withdrawal, monitoring in a critical care unit is highly recommended.

Treatment of Alcoholism

• Disulfiram (Antabuse®), while no longer manufactured in Canada, can be used, but results in acetaldehyde syndrome (more toxic)
• Other medications used are naltrexone, acamprosate calcium, and counselling via individual and Alcoholics Anonymous.

Nicotine

• Many smoke to “calm nerves", but it releases epinephrine, that creates physiological stress rather than relaxation
• Tolerance develops and is physical and psychological dependent
• Two hundred known poisons are present in cigarette smoke

Nicotine: Drug Effects

• Nicotine has no known therapeutic uses and is a a transient stimulation of autonomic ganglia before a more-persistent depression of all autonomic ganglia occurs.
• The release of epinephrine, increases heart rate and blood pressure on top of the increased bowel activity.
• Is medically significant because of its addictive and toxic properties

Nicotine Withdrawal

• It is manifested by cigarette craving, irritability, restlessness, decreased heart rate, and BP
• Cardiac symptoms resolve in 3-4 weeks, and cigarette cravings may persist for months or years.

Nicotine: Withdrawal Treatment

• Treatments provide nicotine without the carcinogens in tobacco, for example: Nicotine transdermal systems (patch), nicotine polacrilex (gum), inhalers & nasal sprays
• First nicotine-free prescription medication to treat nicotine dependence: bupropion hydrochloride(Zyban®)
• Varenicline tartrate stimulates nicotine receptors

Nursing Implications

• Assessments should include nonjudgmental and ended questions about substance abuse and nurses should be observant for clues of substance abuse to avoid withdrawal symptoms
• Other important 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)
  • Problem Oriented Screening Instrument for Teenagers (POSIT)
• The CNS depressants, such as barbituates, BEZs and Ethanol can be very dangerous to withdraw from
• It is very important to establish therapeutic rapport, and use empathy toward the patient to keep them calm
• Patient safety is of the outmost importance at all times during patient care, but especially if the patient is experiencing signs and symptoms of withdrawal
• Provide monitoring and support as needed through the withdrawal process
• Educate the patient and family members or significant others about the recovery process and emphasize that recovery is lifelong.