Substance Misuse: Opioids, Stimulants, and Depressants

Substance Misuse Overview

• Physical dependence, psychological dependence, habituation, and addiction can all result from substance misuse.

Commonly Misused Substances

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

Opioids

• Also known as narcotics, examples include heroin.
• They are intended to relieve pain, reduce cough, relieve diarrhea, and induce anaesthesia.
• They carry a high potential for misuse and psychological dependency, and produce relaxation and euphoria.
• These affect areas outside the central nervous system (CNS), thus side effects show there.
• Methadone can treat opioid dependence by gradually reducing the patient's dosage, which can help them live permanently drug-free.
• Relapse rates are often high, and the drug 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 10 most misused drugs in Canada.

Opioids: Adverse Effects

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

Opioid Drug Withdrawal

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

Opioid Drug Withdrawal: Treatments

• Block opioid receptors so that the use of opioid drugs does not produce euphoria.
• Naltrexone hydrochloride is an opioid antagonist used in treatments.
• Methylnaltrexone bromide (Relistor®), an injectable form of naltrexone, is used in treatments.
• Naloxone is combined with buprenorphine hydrochloride (Suboxone®) or with hydromorphone hydrochloride (Targin®).

Stimulants

• Cause elevation of mood, reduction of fatigue, increased alertness, and invigorated aggressiveness.
• Amphetamines are often misused.
• Other stimulants are cocaine, methylphenidate hydrochloride, dextroamphetamine sulphate, methamphetamine (crystal, meth), and methylenedioxymethamphetamine (MDA).
• Release biogenic amines such as norepinephrine from storage sites in the nerve terminals.
• The effects result in stimulation of the CNS and cardiovascular system, leading to increased blood pressure and heart rate, and possible cardiac dysrhythmias.
• CNS stimulation commonly results in wakefulness, alertness, and a decreased sense of fatigue.
• Also elevation of mood with increased initiative, self-confidence, and ability to concentrate, elation, and euphoria, and an increase in motor and speech activity.

Methamphetamine

• Has stronger effects than other amphetamines.
• It is available in pill or powder form. Powder form is snorted or injected.
• It comes in crystalized form, also known as “ice,” “crystal,” “glass,” “crystal meth"
• Crystalized 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 and are used to synthesize methamphetamine in secret drug laboratories.

Methylenedioxymethamphetamine

• Also known as “ecstasy” and “E.”
• Usually prepared in secret home laboratories.
• It has more calming effects compared to other amphetamine drugs.
• Usually taken by pill as a Popular party drug.

Cocaine

• Comes from the leaves of the coca plant.
• Can be snorted or injected intravenously.
• It is highly addictive and causes physical and psychological dependence.
• Powdered form is called “dust,” “coke," "snow," "flake,” “blow,” girl”.
• Crystalized smoked form is called “crack".

Stimulants: Adverse Effects

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

Stimulant Overdose

• Death can result from convulsions, coma, or cerebral haemorrhage.
• Overdose may occur during periods of intoxication or withdrawal.
• Sedation might be required.

Stimulant Withdrawal

• Peak period lasts from 1 to 3 days.
• Duration lasts from 5 to 7 days.
• Signs include social withdrawal, psychomotor retardation, hypersomnia, and hyperphagia.
• Symptoms are depression, suicidal thoughts and behaviour, and paranoid delusions.
• There are no specific pharmacological treatments.

Depressants

• Relieve anxiety, irritability, and tension when used as intended.
• Also used to treat seizure disorders and induce anaesthesia.
• Two main pharmacologic classes: benzodiazepines and barbiturates.
• Include Marihuana (“pot,” “grass,” “weed”).
• Flunitrazepam (Rohypnol®): not legally available in Canada; known as “roofies” and used for insomnia
• Affect nerve transmission in the CNS.
• Increases the action of gamma-aminobutyric acid, an amino acid in the brain.
• The effects are sedation, muscle relaxation, and relief of anxiety.
• Marihuana (δ-9-trans-tetrahydrocannabinol) binds to and stimulates two receptors in the CNS, causing mild euphoria, memory lapses, dry mouth, enhanced appetite, motor awkwardness, and a distorted sense of time and space.
• Benzodiazepines treat anxiety, induce sleep, to sedate, and to prevent seizures.
• Barbiturates: sedatives and anticonvulsants and to induce anaesthesia.

Depressants: Adverse Effects

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

Depressants: Withdrawal

• Peak period
  • 2 to 4 days for short-acting drugs
  • 4 to 7 days for long-acting drugs
• Duration
  • 4 to 7 days for short-acting drugs
  • 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, and suicidal thoughts
• Treatment involves tapering of the drug over the course of 7 to 10 days or 10 to 14 days.
• Combining with alcohol may have lethal effect

Alcohol

• Known as ethanol.
• Causes CNS depression by dissolving in lipid membranes in the CNS and through the GABA effect.
• Has few legitimate uses other than as a solvent for many drugs.
• Systemic uses of ethanol includes treatment of methyl alcohol and ethylene glycol intoxication.
• Ethanol causes CNS depression, respiratory stimulation or depression, vasodilation producing warm flushed skin, increased sweating, and diuretic effects.
• Chronic use causes nutritional and vitamin deficiencies, especially of B vitamins such as Wernicke’s encephalopathy, Korsakoff’s psychosis, polyneuritis, and nicotinic acid deficiency encephalopathy.
• Chronic use can lead to seizures, alcoholic hepatitis progressing to cirrhosis, and cardiomyopathy.
• Chronic use can cause fetal alcohol spectrum disorder (FASD).
• Pregnant women should be educated about the effects of alcohol consumption.
• FASD is characterized by craniofacial abnormalities, CNS dysfunction, prenatal and postnatal growth retardation.

Ethanol Withdrawal

• Signs and symptoms include elevated blood pressure, pulse rate, and temperature, insomnia, tremors, and agitation.
• Classified as mild, moderate, or severe.
• Benzodiazepines (diazepam/Valium®) is the treatment of choice, with dosage and frequency depending on severity.
• Acamprosate calcium can be used.
• For severe withdrawal, monitoring in a Critical Care Unit is recommended.
• Disulfiram (Antabuse®) used to be a treatment of choice but is no longer manufactured in Canada.
• Naltrexone and acamprosate calcium can be used.
• Counselling can be used, either individual or through Alcoholics Anonymous.

Nicotine

• Many smoke to “calm nerves.”
• Releases epinephrine, which creates physiological stress rather than relaxation.
• Tolerance develops, as well as physical and psychological dependency.
• Withdrawal symptoms occur if stopped.
• There are no therapeutic uses.
• Two hundred known poisons are present in cigarette smoke.
• Causes transient stimulation of autonomic ganglia, followed by more-persistent depression of all autonomic ganglia.
• Results in CNS and respiratory stimulation followed by CNS depression.
• Increases heart rate and BP, as well as bowel activity.
• Nicotine in nature (i.e., tobacco plants) has is medically significant because of its addictive and toxic properties

Nicotine Withdrawal

• Manifested by cigarette craving, 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: Withdrawal Treatment

• Treatments provide nicotine without the carcinogens in tobacco i.e. nicotine transdermal system (patch), nicotine polacrilex (gum), inhalers, nasal spray.
• Bupropion hydrochloride (Zyban®) - may be prescribed to aid in smoking cessation (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 are 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 is of utmost importance at all times during patient care but especially 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, emphasizing that recovery is lifelong.

Learn about substance misuse, including physical and psychological dependence. Explore commonly misused substances like opioids, stimulants, and depressants, and their effects. Discover the high potential for misuse and psychological dependency associated with these substances.