Substance Misuse & Commonly Misused Substances

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

Commonly Misused Substances

• Opioids: heroin, codeine phosphate, hydrocodone, hydromorphone, meperidine hydrochloride, morphine, fentanyl, oxycodone
• Stimulants: racemic amphetamine, dextroamphetamine, methamphetamine, cocaine
• Depressants: Benzodiazepines, Barbiturates, Marihuana
• Other commonly misused substances include alcohol, anabolic steroids, dextromethorphan hydrobromide, lysergic acid diethylamide (LSD), methamphetamine, methylenedioxymethamphetamine (ecstasy, molly), nicotine, and phencyclidine (PCP).

Opioids

• Opioids are also known as narcotics like heroin.
• Intended effects of opioids are to relieve pain, reduce cough, relieve diarrhea, and induce anaesthesia
• Opioids have a high potential for misuse and produce psychological dependency, relaxation, and euphoria.
• Opioids affect areas outside the central nervous system CNS, thus side effects manifest there.
• Methadone is used to treat opioid dependence, reducing the patient's dosage gradually for the patient to eventually live permanently drug free after a long period.
• Relapse rates for opioid users are often high.
• Heroin (also known as diacetylmorphine) can be injected ("mainlining" or "skin popping"), sniffed/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 respirations.
• Heroin is one of the 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

• Peak withdrawal period: 1 to 3 days
• Duration of withdrawal: 5 to 7 days
• Signs of withdrawal: Drug seeking, mydriasis, diaphoresis, rhinorrhea, lacrimation, vomiting, diarrhea, insomnia, elevated blood pressure BP and pulse
• Symptoms of withdrawal: Intense desire for drug, muscle cramps, arthralgia, anxiety, nausea, malaise
• Treatments of opioid withdrawal: Block opioid receptors using naltrexone hydrochloride (an opioid antagonist) so that use of opioid drugs does not produce euphoria, methylnaltrexone bromide (Relistor®), naloxone combined with buprenorphine hydrochloride (Suboxone®) or with hydromorphone hydrochloride (Targin®).

Stimulants

• Stimulant effects include: Elevation of mood, Reduction of fatigue, Increased alertness, Invigorated aggressiveness
• Examples of Stimulants include: Amphetamines which are often misused, Cocaine, Methylphenidate hydrochloride, Dextroamphetamine sulphate, Methamphetamine (crystal, meth), Methylenedioxymethamphetamine (MDA)
• Stimulants work by releasing biogenic amines, specifically norepinephrine, from their storage sites in the nerve terminals.
• This results in stimulation of the CNS and cardiovascular system, leading to increased blood pressure and heart rate, and the possibility of cardiac dysrhythmias.
• CNS stimulation commonly results in wakefulness, alertness, and a decreased sense of fatigue; elevation of mood with increased initiative, self-confidence, and ability to concentrate; also elation and euphoria; and an increase in motor and speech activity

Methamphetamine

• Has stronger effects than other amphetamines
• it is available in pill form or powder form (snorted or injected) and also in Crystallized form (also known as “ice,” “crystal,” “glass,” “crystal meth”)
• Crystallized form is smokable and more powerful.
• Sales of over-the-counter ephedrine, pseudoephedrine, and red phosphorus are now restricted to be kept behind the counter in pharmacies as they are used to synthesize methamphetamine in secret drug laboratories

Methylenedioxymethamphetamine

• Also known as “ecstasy” and “E”
• Usually prepared in secret home laboratories, and has More calming effects than other amphetamine drugs
• Can be taken in pill form and is a popular party drug, often used in raves.

Cocaine

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

Stimulants: Adverse Effects

• CNS: Restlessness, Syncope (fainting), Tremor, Hyperactive reflexes, Talkativeness, Irritability, Insomnia, Fever, Euphoria
• Confusion
• Aggression
• Increased libido
• Anxiety
• Delirium
• Paranoid hallucinations
• Suicidal or homicidal tendencies
• Cardiovascular: Dry mouth, Metallic taste, Anorexia, Nausea, Vomiting, Diarrhea, Abdominal cramps
• Gastrointestinal: Headache, Chilliness, Pallor or flushing, Palpitations, Tachycardia, Cardiac dysrhythmias, Anginal pain, Hypertension or hypotension, Circulatory collapse
• Stimulant Overdose is indicated by: Death resulting from Convulsions, Coma, Cerebral hemorrhage.
• May occur during periods of intoxication or withdrawal, Sedation might be required

Stimulant Withdrawal

• Peak period: 1 to 3 days
• Duration: 5 to 7 days
• Signs: Social withdrawal, psychomotor retardation, hypersomnia, hyperphagia.
• Symptoms: Depression, suicidal thoughts and behaviour, paranoid delusions
• There are no specific pharmacological treatments for stimulant withdrawal

Depressants

• Drugs used to relieve anxiety, irritability, and tension when used as intended are also used to treat seizure disorders and induce anaesthesia
• Two types: Benzodiazepines and Barbiturates Marihuana (“pot,” “grass,” “weed")
• Flunitrazepam (Rohypnol®): not legally available in Canada; known as “roofies” – 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
• Results in sedation, muscle relaxation, and relief of anxiety
• Marihuana (δ-9-trans-tetrahydrocannabinol) - binding to and stimulating two cannabinoid receptors in the CNS - mild euphoria, memory lapses, dry mouth, enhanced appetite, motor awkwardness, and distorted sense of time and space
• Benzodiazepines used for anxiety, to induce sleep, to sedate, and to prevent seizures
• Barbiturates: sedatives and anticonvulsants and to induce anaesthesia

Depressants: Adverse Effects

• CNS: Drowsiness, sedation, loss of coordination, dizziness, blurred vision, headaches, and paradoxical reactions
• Gastrointestinal: Nausea, vomiting, constipation, dry mouth, and abdominal cramping
• Pruritus and skin rash
• Marihuana: chronic depressive “amotivational” syndrome
• Withdrawal: Peak period 2 to 4 days for short-acting drugs, or 4 to 7 days for long-acting drugs
• Duration: 4 to 7 days for short-acting drugs, or 7 to 12 days for long-acting drugs
• Signs: Increased psychomotor activity; agitation; muscular weakness; hyperthermia; diaphoresis; delirium; convulsions; elevated BP, pulse rate, and temperature; others
• Symptoms: Anxiety, depression, euphoria, incoherent thoughts, hostility, grandiosity, disorientation, hallucinations, suicidal thoughts.
• Treatment involves tapering of the drug over the course of 7 to 10 days or 10 to 14 days; When combined with alcohol, may have lethal effect

Alcohol

• More accurately known as ethanol which causes CNS depression by dissolving in lipid membranes in the CNS + GABA effect
• Few legitimate uses of ethanol and alcoholic beverages but is used as a solvent for many drugs and for systemic uses include treatment of methyl alcohol and ethylene glycol intoxication
• Ethanol: Drug Effects: CNS depression, Respiratory stimulation or depression, Vasodilation producing warm flushed skin, Increased sweating, Diuretic effects
• Effects of Chronic Ethanol 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, Cardiomyopathy, Fetal alcohol spectrum disorder (FASD)
• 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 indicated Elevated blood pressure, pulse rate, and temperature, Insomnia, Tremors Agitation which can be classified as mild, moderate, or severe
• Ethanol: treatment of choice is Benzodiazepines: diazepam (Valium®), with dosage and frequency depend on severity.
• acamprosate calcium is also used
• For severe withdrawal, monitoring in a Critical Care Unit is recommended.
• Treatment of Alcoholism: disulfiram (Antabuse®) (no longer manufactured in Canada) which causes Acetaldehyde syndrome (more toxic)
• naltrexone and acamprosate calcium (Newest treatment)
• Counselling may also be used, either individual or Alcoholics Anonymous

Nicotine

• Many smoke to “calm nerves.”
• Releases epinephrine, which creates physiological stress rather than relaxation; with tolerance developing and leading to a physical and psychological dependency
• Withdrawal symptoms occur if stopped
• No therapeutic uses exist whilst Two hundred known poisons are present in cigarette smoke.
• Nicotine: Drug Effects: Transient stimulation of autonomic ganglia follows with more-persistent depression of all autonomic ganglia, as well as CNS and respiratory stimulation which is then followed by CNS depression
• Nicotine causes Increased heart rate and BP as well as Increased bowel activity
• Nicotine is medically significant because of its addictive and toxic properties
• Nicotine Withdrawal is Manifested by cigarette craving, Irritability, restlessness, decreased heart rate and BP
• Cardiac symptoms resolve in 3 to 4 weeks, but cigarette craving may persist for months or years.
• Nicotine: Withdrawal treatments provide nicotine without the carcinogens in tobacco via Nicotine transdermal system (patch), nicotine polacrilex (gum), Inhalers,Nasal spray
• 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.
• Be observant for clues to substance misuse so as 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.
• Assessment tools for substance misuse: 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)
• Patient safety is of utmost importance at all times during patient care, but especially when the patient is experiencing the signs and symptoms of withdrawal, along with providing monitoring and support as needed throughout the withdrawal process.
• Educate the patient and family members or significant others about the recovery process and Emphasize that recovery is lifelong.