Chapter 14 - Substance Use Disorders PDF

# Chapter 14 - Substance Use Disorders ## 14.1 Introduction ### Learning Objectives - Assess clients for intoxication, dependency, withdrawal symptoms, and/or substance use disorders and intervene as appropriate. - Apply the nursing process to clients experiencing withdrawal or toxicity from subs...

# Chapter 14 - Substance Use Disorders ## 14.1 Introduction ### Learning Objectives - Assess clients for intoxication, dependency, withdrawal symptoms, and/or substance use disorders and intervene as appropriate. - Apply the nursing process to clients experiencing withdrawal or toxicity from substances. - Provide care and/or support clients with non-substance-related dependencies (e.g., gambling, sexual addiction). - Describe the neurobiology and risk factors for substance use disorders. - Apply the nursing process to clients with substance use disorders. - Describe protective factors and prevention programs for substance use disorders. - Outline evidence-based treatments for clients with substance use disorders. - Discuss recovery services for clients with substance use disorders. - Evaluate client's response to a treatment plan and revise as needed. - Provide patient education to clients and their family members. ### Key Facts - Misuse of alcohol, drugs, and prescribed medications costs the U.S. over $400 billion annually in health care, law enforcement, criminal justice, lost workplace productivity, and motor vehicle crash losses. - In 2021, the CDC estimated: - 107,622 drug overdose deaths occurred. - 52,000 alcohol-induced deaths occurred. - In 2020, 40.3 million people aged 12+ (14.5%) in the U.S. had a substance use disorder (SUD). - Chronic substance use disorders have widespread impacts on individuals, families, communities, and society. ### Overview of Chapter Topics - Signs of intoxication from various psychoactive substances. - Treatment for overdose and withdrawal symptoms. - Neurobiology and risk factors of substance use disorders. - Evidence-based treatment and prevention interventions (based on the Surgeon General's Report). - Application of the nursing process to hospitalized clients receiving treatment (e.g., alcohol withdrawal). ## 14.2 Substances: Use, Intoxication, and Overdose ### Definition of Substance - A psychoactive compound with the potential to cause health and social problems, including substance use disorder. ### Major Categories of Substances 1. Alcohol 2. Illicit drugs (including nonmedical use of prescription drugs) 3. Over-the-counter drugs 4. Other substances ### Substance Use - Refers to the use of any psychoactive substances, as outlined in Table 14.2a. ### Table 14.2a: Categories and Examples of Substances | Substance Category | Examples | |---|---| | Alcohol | Beer, malt liquor, wine, and distilled spirits | | Illicit drugs (including prescription drugs used nonmedically) | Opioids (e.g., heroin), Cannabis, Sedatives, hypnotics, and anxiolytics, Hallucinogens, Stimulants (e.g., methamphetamine-like substances, cocaine, crack) | | Over-the-counter drugs (used nonmedically) | Dextromethorphan and other cold medications, Pseudoephedrine, and other cold medications | | Other substances | Inhalants (e.g., spray paint, gasoline, cleaning solvents), Delta-8 THC | ### Controlled Substances - The Controlled Substances Act: - Federal law placing controlled substances into five categories (schedules). - Classification is based on: - Medical use. - Potential for abuse or dependency. - Safety concerns. ### Table 14.2b: Examples of Substances by Schedule | Schedule | Definition | Examples | |---|---|---| | I | No currently accepted medical use and high potential for abuse. | Heroin, LSD, MDMA (Ecstasy), cannabis (marijuana) | | II | High potential for abuse, severe psychological or physical dependence. | Hydrocodone, cocaine, methamphetamine, methadone, oxycodone, fentanyl, Adderall, Ritalin, PCP | | III | Considered dangerous. Moderate to low potential for physical and psychological dependence. | Acetaminophen with codeine, ketamine, anabolic steroids, testosterone | | IV | Less abuse potential than I & II. Low potential for abuse and dependence. | Alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), zolpidem (Ambien), tramadol (Ultram) | | V | Lowest potential for abuse, often used for antidiarrheal, antitussive, or analgesic purposes. | Cough medications with codeine, diphenoxylate/atropine (Lomotil), pregabalin (Lyrica) | ### Intoxication and Overdose - **Intoxication:** - Disturbance in behavior or mental function after substance consumption. - **Overdose:** - Biological response to excessive substance ingestion. ### Emergency Resources: - **Poison Control:** Call 1-800-222-1222 (24/7 availability). - **Hospital Toxicologists:** Available for bedside consultation in some hospitals. ## Alcohol Use and Intoxication ### Standard Drink Definition - Based on 2015–2020 Dietary Guidelines for Americans: - 1 Standard Drink = 14 grams (0.6 ounces) of pure alcohol. - Examples: - 12 ounces beer - 8-9 ounces malt liquor - 5 ounces wine - 1.5 ounces distilled spirits ### Alcohol Consumption Statistics (2020) - 50% of Americans aged 12+ use alcohol. - 22.2% engage in binge drinking. - 6.4% are heavy alcohol users. ### Definitions - **Heavy Drinking:** - Women: 8+ drinks/week. - Men: 15+ drinks/week. - **Binge Drinking:** - Men: 5+ drinks on one occasion. - Women: 4+ drinks on one occasion. - Either: Binge drinking 5+ days in the past month. ### Alcohol Intoxication Symptoms - Behavioral/psychological changes (e.g., inappropriate sexual/aggressive behavior, mood swings, impaired judgment). - Physical signs: - Slurred speech. - Incoordination. - Unsteady gait. - Nystagmus (uncontrolled eye movements). - Attention/memory impairment. ### What is Alcohol Overdose? - **Definition:** - A condition where excessive alcohol in the bloodstream impairs the brain's control over autonomic nervous system functions, such as breathing, heart rate, and temperature regulation. ### Signs of Alcohol Overdose - **Physical Symptoms:** - Mental confusion or stupor. - Difficulty remaining conscious or inability to wake up. - Vomiting. - Seizures. - Trouble breathing or slow respiratory rate. - Slow heart rate. - Clammy skin. - Extremely low body temperature (hypothermia). - **Reflex Impairment:** - Dulled gag reflex, increasing the risk of choking. - **Increased Risks with Other Substances:** - Combining alcohol with opioids or sedative-hypnotics (e.g., benzodiazepines or sleep medications) amplifies the risk of overdose. ### Key Risk Factors - **Binge Drinking:** - Consuming large amounts of alcohol in a short period significantly increases the risk of overdose. - **Blood Alcohol Concentration (BAC):** - Higher BAC correlates with greater harm: - Mild: Gaps in memory (blackouts). - Severe: Loss of consciousness, inability to wake, and even death. - **BAC Progression:** - BAC can continue to rise even after drinking stops due to ongoing absorption of alcohol from the stomach and intestines. ### Consequences of High BAC - **Cognitive Impairments:** - Blackouts and gaps in memory. - **Life-Threatening Complications:** - Loss of consciousness. - Death from respiratory or cardiovascular failure. ### Important Note: - **Delayed Onset of Symptoms:** - Alcohol levels in the bloodstream may continue to increase even when alcohol consumption has stopped. ### Dangers of "Sleeping It Off" - **Risk of Asphyxiation:** - **Choking on Vomit:** A major danger of alcohol overdose is the inability to protect the airway, as alcohol impairs the gag reflex. This increases the risk of choking on vomit, which results in death from lack of oxygen. - **Airway Obstruction:** Asphyxiation can occur from an obstructed airway or aspiration of stomach contents into the lungs. ### What to Do: Immediate Steps to Prevent Choking - Do Not Leave the Person Alone. - **Positioning to Prevent Choking:** - **Partially Upright:** Keep the person in a partially upright position if possible. - **On Their Side:** Roll them onto one side, with an ear towards the ground. This positioning helps prevent choking if they begin vomiting. ### Critical Signs and Symptoms of Alcohol Overdose - **Mental and Cognitive Effects:** - Mental confusion or stupor. - Difficulty remaining conscious or inability to wake up. - **Physical Symptoms:** - Vomiting. - Seizures. - Slow respiratory rate (fewer than 8 breaths per minute). - Irregular breathing (more than 10 seconds between breaths). - Slow heart rate. - Clammy skin. - No gag reflex. - Extremely low body temperature. - Bluish skin color or paleness. ### What to Do if You Suspect Alcohol Overdose - **Seek Emergency Assistance:** Call 911 immediately. - **Provide Information to Emergency Responders:** - **Alcohol Type & Amount:** Be ready to provide details about the type and amount of alcohol consumed. - **Other Drugs:** Mention any other substances the person may have ingested, including prescription or recreational drugs. - **Medical History:** Provide current medications, allergies, and any relevant medical information. ## Medical Treatment of Acute Alcohol Intoxication ### Initial Evaluation and Considerations - **Blood Alcohol Concentration (BAC) Evaluation:** The first step in treating acute alcohol intoxication is assessing the client's BAC. - **Other Drug Use:** It is crucial to identify if the individual has ingested other substances (e.g., opioids, benzodiazepines, or street drugs) because this can increase the risk of overdose and may require additional treatments (such as naloxone). ### Routine Lab Work - For clients with moderate to severe intoxication, routine lab work includes: - Serum Glucose: To assess for hypoglycemia. - Electrolyte Panel: To assess for imbalances like: - Hypokalemia (low potassium) - Hypomagnesemia (low magnesium) - Hypocalcemia (low calcium) - Hypophosphatemia (low phosphate) - Hyperlactatemia (high lactate levels) ### Hypoglycemia Treatment - If hypoglycemia is detected, administer a dextrose intravenous infusion. ### Thiamine and Wernicke's Encephalopathy - **Intravenous Thiamine:** Severely intoxicated clients may be given intravenous thiamine along with dextrose to prevent Wernicke's encephalopathy. - **Wernicke's Encephalopathy:** - A life-threatening neurological condition associated with thiamine (B1) deficiency, common in those with alcohol use disorder. - Symptoms include nystagmus (involuntary eye movement), ataxia (lack of coordination), and confusion. - Thiamine is critical for cerebral energy utilization, and its deficiency can lead to neurological damage. - **Korsakoff's Syndrome:** If untreated, Wernicke's encephalopathy may progress to Korsakoff's syndrome, a chronic, irreversible memory disorder.. ### Management of Agitation and Sedation - **Chemical Sedation:** If the client becomes agitated, violent, or uncooperative, benzodiazepines may be required for sedation to prevent harm to themselves or others. - **Caution with Benzodiazepines:** These must be used carefully as they can worsen withdrawal symptoms. ### Critical Care and ICU Admission - Approximately 1% of clients with acute alcohol intoxication require critical care. - **Risk Factors for ICU Admission:** - **Abnormal Vital Signs:** - Hypotension (low blood pressure), tachycardia (fast heart rate), fever, or hypothermia (low body temperature). - Hypoxia (low oxygen levels) or hypoglycemia. - **Need for Parenteral Sedation:** If the client requires sedation beyond what can be managed on the general ward. - **Airway Support and Ventilation:** If the client has inadequate respirations or difficulty maintaining their airway, intubation and mechanical ventilation may be required. ### Ineffectiveness of Certain Treatments - **Activated Charcoal and Gastric Lavage:** These treatments are generally not helpful in alcohol intoxication because alcohol is absorbed rapidly from the gastrointestinal tract. ### Head Trauma Consideration - Clients with acute alcohol intoxication may suffer from head trauma due to injuries sustained while intoxicated. - If the client's mental status does not improve as their BAC decreases, a CT scan of the head may be performed to assess for any head injury ## Opioid Use and Intoxication ### Overview of Opioid Use - **Prevalence of Use:** - In 2020, 9.5 million Americans (3.4% of those aged 12 and older) reported using opioids in the past year. - Of these, 9.3 million misused prescription pain relievers, and 902,000 used heroin. - **Opioid Classification and Medical Use:** - Opioids act on opioid receptors in the central nervous system (CNS). - Medically, opioids are prescribed to relieve moderate to severe pain and for anesthesia. - Common prescription opioids include: - Schedule II Medications: Morphine, oxycodone, hydrocodone, fentanyl, and hydromorphone. - Heroin is an illegal opioid classified as a Schedule I. ### Misuse Effects - When misused, opioids can induce relaxation and euphoria, but they also can lead to dependence and overdose. ### Health Risks Associated with Opioid Misuse - **Increased Risk of Infectious Diseases:** - Injected opioid misuse increases the risk of contracting: - HIV, hepatitis B, hepatitis C, and bacterial endocarditis. - **CDC Report (2016):** People who inject drugs accounted for 9% of new HIV diagnoses in the U.S. in 2016. ### Signs and Symptoms of Opioid Intoxication - Opioid intoxication causes behavioral and psychological changes such as: - **Initial Euphoria:** A sense of intense happiness. - **Subsequent Symptoms:** - Apathy (lack of interest or concern). - Dysphoria (unease or dissatisfaction). - Psychomotor retardation (slowed physical movement). - Agitation (restlessness). - Impaired judgment (difficulty making sound decisions). ### Physical Signs of Opioid Intoxication - **Pupillary Changes:** - Constriction (pinpoint pupils), or, in severe overdose, dilation. - **Drowsiness or Coma:** The individual may become excessively sleepy or unresponsive. - **Slurred Speech:** Difficulty articulating words. - **Impaired Attention or Memory:** Difficulty focusing or remembering. ## Opioid Overdose ### Opioid Overdose Triad (Typical Signs) - **Pinpoint Pupils:** Extremely constricted pupils. - **Respiratory Depression:** Slowed or stopped breathing. - **Decreased Level of Consciousness:** The person may become unresponsive or unconscious. ### Increasing Rates of Opioid Overdose Deaths - From 1999 to 2019, nearly 500,000 people died from overdoses involving prescription or illicit opioids. ### The Three Waves of Opioid Overdose Deaths 1. **First Wave (1990s - 2010):** The rise in opioid overdose deaths started with the increased prescription rates of opioid painkillers. 2. **Second Wave (2010 - 2013):** Beginning in 2010, there was a rapid increase in overdose deaths specifically involving heroin. The availability of heroin became more widespread and its misuse increased. 3. **Third Wave (2013 - Present):** In 2013, significant increases in opioid overdose deaths were seen due to synthetic opioids, particularly illicitly manufactured fentanyl. This form of fentanyl is much stronger than prescription fentanyl. ## Fentanyl and Its Impact on Overdose Deaths ### Types of Fentanyl - **Pharmaceutical fentanyl** is prescribed for severe pain. - **Illicitly manufactured fentanyl** is not prescribed and is often added to street drugs like heroin or counterfeit prescription pills to make them stronger and more addictive. ### Illicit Fentanyl - The majority of recent fentanyl-related overdose deaths are linked to illicitly manufactured fentanyl, which is far more dangerous than prescription versions due to its potency and unregulated nature. ## Carfentanil and Its Role in the Epidemic - Carfentanil is an extremely potent synthetic opioid used to tranquilize large animals like elephants. - It is 10,000 times more potent than morphine and 100 times more potent than fentanyl. - Even a miniscule amount (as little as 2 milligrams) of carfentanil can be lethal. - **Dangers of Carfentanil:** - Carfentanil can be accidentally absorbed through the skin or inhaled, posing a serious risk to first responders, healthcare workers, and anyone who comes into contact with it. - If carfentanil or any fentanyl-related substances are suspected, responders must follow strict safety protocols to avoid lethal exposure. ## Treating Opioid Overdose with Naloxone - Naloxone is a life-saving medication that can reverse the effects of opioid overdose. It is most commonly administered via nasal spray, which is effective and easy for community members and first responders to use. Naloxone can also be administered through an intramuscular injection. ## Five Essential Steps for Responding to an Opioid Overdose 1. **Recognize Signs of Opioid Overdose** - Signs include: - Unconsciousness or inability to awaken. - Pinpoint pupils. - Slow, shallow breathing or breathing difficulty (e.g., choking sounds, gurgling/snoring). - Blue or purple fingernails/lips. - To check, try calling their name or rubbing your knuckles on their sternum to stimulate them. 2. **Obtain Emergency Assistance** - If the person does not respond, immediately call 911 for emergency help. 3. **Provide Rescue Breathing, Chest Compressions, and Oxygen as Needed** - If the person is not breathing, perform rescue breathing: - Clear their airway. - Tilt their head back and pinch their nose. - Give two slow breaths and watch for chest rise. - Continue with one breath every five seconds. - If the person is pulseless, start CPR. - Provide oxygen if available. 4. **Administer the First Dose of Naloxone** - Naloxone should be given to anyone suspected of opioid overdose. - Naloxone can be administered intranasally, intramuscularly, subcutaneously, or intravenously. - The nasal spray is a prefilled, easy-to-use device, delivering a dose into one nostril. - If using an auto-injector, administer it into the outer thigh. - Naloxone can reverse opioid overdoses, including those involving fentanyl. However, additional doses may be needed for overdoses involving potent opioids or large quantities. - Be aware that withdrawal symptoms may occur after naloxone administration, causing confusion, agitation, or aggression. Offer reassurance and explain the situation. 5. **Administer a Second Dose if the Person Does Not Respond** - If there is no response after 2 to 3 minutes, administer a second dose of naloxone. - Long-acting or potent opioids like fentanyl may require additional doses of naloxone. - Naloxone's duration of action is shorter than that of some opioids, meaning additional doses may be necessary. 6. **Monitor the Person's Response** - Most people will begin breathing spontaneously within 2 to 3 minutes after naloxone administration. Continue resuscitation efforts if necessary. - The goal is to restore adequate breathing, not necessarily to fully awaken the person. - Monitor for the return of overdose symptoms for at least four hours after the last naloxone dose. Long-acting opioids (e.g., fentanyl) may require longer monitoring. - Even if the person appears to recover, get them to a medical facility immediately, as overdose symptoms may return once the effects of naloxone wear off ## Preventing Opioid Overdose - Preventing opioid overdoses requires a multifaceted approach, including the identification of key risk factors, early intervention, and the provision of appropriate treatment and education. ### Key Circumstances for Intervention - Certain situations present an opportunity to prevent overdose by linking individuals to care: - **Bystanders Present:** Nearly 40% of opioid and stimulant overdose deaths happen in the presence of a bystander. Immediate action and naloxone administration can save lives. - **Recent Release from an Institution:** About 10% of opioid overdose deaths occur in people who have recently been released from institutions like jails, inpatient rehab, or psychiatric hospitals. These individuals are at higher risk due to decreased drug tolerance from abstinence during their stay. - **Previous Overdose:** 10% of those who die from opioid overdoses had experienced a prior overdose. This population is at increased risk and requires close monitoring and access to care. - **Mental Health Diagnosis:** 25% of those who died from drug overdoses had a documented mental health condition, suggesting that integrated mental health and substance use disorder treatment may be important for reducing risk. - **Substance Use Disorder Treatment:** Nearly 20% of people who died from opioid overdoses had previously received treatment for substance use disorder, indicating that ongoing care and relapse prevention services are critical. ### Preventive Measures - **Treatment for Opioid Use Disorder:** Providing access to effective treatment and recovery services for those with opioid use disorder is crucial. This includes both medication-assisted treatment and behavioral therapies. - **Public Education on Naloxone:** Educating the public and at-risk individuals about naloxone (a medication that can reverse opioid overdoses) is vital. This education can help save lives by enabling people to respond effectively in an emergency. - Opioid overdose deaths are largely preventable with the right strategies. Efforts to provide access to treatment, increase awareness about naloxone, and promote effective prevention strategies, such as universal school programs, are crucial to address this public health crisis. ## Cannabis (Marijuana) Use and Intoxication - Cannabis use is widespread, with significant numbers of individuals experiencing cannabis use disorder. While marijuana has been legalized in many states for both recreational and medicinal purposes, there are important considerations regarding its effects and potential risks. ### Health Effects and Risks - **Psychoactive Effects:** The primary psychoactive component in marijuana, Delta-9-tetrahydrocannabinol (THC), affects brain regions involved in memory, coordination, and decision-making. It impairs cognitive functions, such as memory formation, learning, and the ability to perform complex tasks. - **Impaired Coordination:** THC affects the cerebellum and basal ganglia, regions responsible for balance and coordination. This can make activities like driving or playing sports dangerous after marijuana use. - **Potential for Psychosis:** High doses of marijuana, especially potent varieties, can induce acute psychosis, leading to hallucinations, delusions, and disorientation. - **Delayed Effects from Edibles:** When consumed as food or drink, marijuana's effects are delayed, which can lead individuals to overconsume, unintentionally ingesting more than intended. ### Health Risks of Regular Use - **Cognitive Development in Teens:** Regular use of marijuana, especially in teens, can negatively impact brain development and long-term cognitive functions. - **Respiratory Issues:** Smoking marijuana is linked to airway inflammation, increased airway resistance, and chronic bronchitis. Vaping marijuana can lead to serious lung diseases. ### Addiction and Dependency - While many believe marijuana is not addictive, THC stimulates the brain's reward system, which can lead to dependency. People who regularly use marijuana may find it difficult to stop, even when it negatively affects their lives. ### Potential Medicinal Benefits - **FDA-approved Uses:** The FDA has approved THC-based medications such as Dronabinol (Marinol) and Nabilone (Cesamet) for specific medical conditions, such as cancer-related nausea and AIDS-related appetite loss. - **Multiple Sclerosis (MS):** Marijuana is sometimes used to alleviate symptoms of MS, including spasticity and muscle spasms. ### Signs of Cannabis Intoxication - Enlarged conjunctival vessels (red eyes). - Increased appetite and dry mouth. - Tachycardia (increased heart rate). - Impaired motor coordination, euphoria, anxiety, and altered perception. ### Overconsumption and Risks of Street Marijuana - **Unintentional Injury:** Marijuana intoxication can lead to accidents such as falls or car crashes. - **Contamination:** Marijuana purchased from street dealers may be laced with dangerous substances, such as synthetic fentanyl, which can lead to overdose. - While marijuana may offer some therapeutic benefits, it is important to understand its potential health risks, especially when used recreationally or in non-regulated products like Delta-8 THC. Regular education on both its adverse effects and possible medical benefits is essential for public health. ## Sedative, Hypnotic, and Anxiolytic Use and Intoxication - Sedatives, hypnotics, and anxiolytics are a class of medications commonly prescribed to manage anxiety, insomnia, and other conditions. Some of the most common drugs in this category include benzodiazepines (e.g., alprazolam, diazepam, lorazepam, clonazepam, chlordiazepoxide) and hypnotics (e.g., zolpidem). While these medications are intended for medical use, they are often misused, leading to various health concerns, including dependence and overdose. ### Benzodiazepine Use and Tolerance - Chronic use of benzodiazepines can lead to physical changes in the brain, particularly in the gamma-aminobutyric acid (GABA) receptors. GABA is a neurotransmitter that inhibits brain activity, leading to a calming effect. Long-term use results in decreased GABA activity and the development of tolerance, meaning users need higher doses to achieve the same effect. If the drug is suddenly reduced or discontinued, withdrawal symptoms can occur. ### Symptoms of Sedative, Hypnotic, and Anxiolytic Intoxication - Intoxication from sedatives, hypnotics, and anxiolytics typically leads to symptoms similar to alcohol intoxication. These can include: - Slurred speech. - Incoordination (lack of physical coordination). - Unsteady gait (difficulty walking or standing). - Nystagmus (involuntary eye movements). - Impaired attention and memory. - Stupor or coma (extreme sedation or loss of consciousness). - These symptoms are a result of the CNS depression caused by these medications. ### Benzodiazepine Overdose - Benzodiazepine overdose can be dangerous, as these medications depress the central nervous system (CNS), potentially leading to: - Stupor or coma. - Respiratory depression (slowed or stopped breathing), especially when taken with other depressants such as alcohol or opioids. - When overdosing on benzodiazepines, the following interventions may be necessary: - Monitoring of capnography (end-tidal CO2) to assess for hypoventilation (slow breathing). - Endotracheal intubation and mechanical ventilation may be required to ensure proper breathing. ### Flumazenil for Benzodiazepine Overdose - Flumazenil is a medication used to reverse benzodiazepine-induced sedation, particularly in cases following anesthesia or procedural sedation. - However, it is used with caution in cases of benzodiazepine overdose because it can precipitate withdrawal seizures in individuals who have developed a tolerance to benzodiazepines. This makes its use risky in people who are regularly dependent on these medications. ### Detection of Benzodiazepines - Benzodiazepines are not detected in standard urine drug tests, which typically screen for substances like opioids, cocaine, and marijuana. However, specific benzodiazepine urine tests can identify metabolites associated with these drugs. ### Key Points for Nurses and Healthcare Providers - Monitoring is essential for patients using benzodiazepines to avoid misuse and prevent overdose. - Educating patients about dependency, tolerance, and withdrawal can help prevent long-term misuse. - Benzodiazepines should be prescribed carefully, especially for individuals with a history of substance use disorders or those at risk of polydrug use. - Co-ingestion of benzodiazepines with other CNS depressants (alcohol, opioids) greatly increases the risk of life-threatening overdose and respiratory depression. ## Hallucinogen Use and Intoxication - Hallucinogens are a diverse group of drugs that significantly alter an individual's awareness of their surroundings and self-perception. They are typically divided into classic hallucinogens (e.g., LSD, peyote) and dissociative drugs (e.g., phencyclidine [PCP], ketamine). Hallucinogens can be misused for their ability to induce hallucinations and altered perceptions. ### Prevalence and Misuse - In 2020, 7.1 million people in the United States (2.6% of those aged 12 or older) used hallucinogens. - Dextromethorphan, a cough suppressant available over-the-counter, is also commonly misused for its hallucinogenic and dissociative properties at high doses. ### Hallucinogenic and Dissociative Effects - **Hallucinogens** cause hallucinations, where users perceive images or sensations that are not actually present. - **Dissociative drugs** can induce feelings of being disconnected from the body or reality, causing users to experience an altered state of consciousness. - Some cultures have historically used substances like peyote in religious or healing rituals, which adds a cultural and ritualistic context to hallucinogen use. ### Dangers of Hallucinogen Use - Hallucinogen users often face an increased risk of harm due to altered perceptions and moods. - For example, they may engage in dangerous behaviors, such as jumping off a roof or acting on suicidal thoughts, which they wouldn't typically consider when sober. - **PCP (phencyclidine)**, a hallucinogen, is often abused on the street. It is typically found as a white powder that can be inhaled, injected, smoked, or ingested. - PCP intoxication leads to: - Belligerence - Aggression - Impulsivity - Unpredictability - Psychomotor agitation - Impaired judgment - These behavioral changes increase the risk of violence, including self-injury and violent criminal behavior (assaults, intimate partner violence, homicide). ### Symptoms of PCP Intoxication - Intoxication from PCP often presents within an hour of ingestion with two or more of the following symptoms: - Vertical or horizontal nystagmus (involuntary eye movements). - Hypertension (high blood pressure). - Tachycardia (increased heart rate). - Numbness or diminished pain response. - Ataxia (impaired coordination or balance). - Slurred speech. - Muscle rigidity. - Seizures or coma. - Hyperacusis (increased sensitivity to noise). ### Management of PCP Intoxication - In cases of PCP intoxication, physical restraints may be necessary to control the patient's agitation, followed by chemical sedation with intravenous benzodiazepines to manage psychomotor agitation. ### Hallucinogen and Dissociative Drug Overdose - PCP overdose can result in life-threatening complications such as seizures, coma, or even death, particularly if taken with other CNS depressants like alcohol or benzodiazepines. - Dextromethorphan overdose can also occur when the cough suppressant is misused. The nonmedical use of dextromethorphan leads to around 6,000 emergency department visits annually in the United States, often in combination with alcohol. - Signs of overdose include: - **Neurobehavioral changes:** hallucinations, inappropriate laughing, psychosis with dissociative features, agitation, and coma. - **Tachycardia (increased heart rate).** - **Dilated pupils.** - **Diaphoresis (excessive sweating).** - **A "zombie-like" ataxic gait (impaired walking).** - Additionally, many cough and cold medications contain acetaminophen, which, at toxic doses, can cause severe hepatotoxicity (liver damage), liver failure, and death. When treating dextromethorphan overdose, serum acetaminophen levels should be monitored. ### Key Points for Healthcare Providers: - Hallucinogen use, especially PCP and dextromethorphan, presents with dangerous behaviors and can lead to serious medical emergencies. - Overdose management may require sedation, restraints, and supportive care (including monitoring for seizures, coma, and respiratory support). - Be aware of the psychological and behavioral risks associated with dissociative drugs, which include aggression, violence, and impaired judgment. - Co-ingestion with other substances (such as alcohol or benzodiazepines) increases the likelihood of overdose and fatal outcomes. ## Stimulant Use and Intoxication - Stimulants, including amphetamine-type substances, cocaine, and crack, are drugs that enhance the release of dopamine in the brain, creating intense feelings of euphoria and reinforcement of drug-taking behaviors. As users continue to take these substances, their brain's reward circuit becomes less sensitive, leading them to take larger or more frequent doses in an attempt to experience the same effects and relieve withdrawal symptoms. - Stimulants, due to their rapid onset and quick fade of effects, often lead to patterns of binging, where users take repeated doses, sometimes for several days, while neglecting basic needs like food and sleep. Both amphetamine use and withdrawal can lead to severe physical symptoms. ### Methamphetamine Use - In 2019, 2 million Americans used methamphetamine within the past year. The overdose death rate involving methamphetamine quadrupled from 2011 to 2017. - Methamphetamine is highly addictive and comes in several forms, including powder, which can be smoked, snorted, swallowed, or injected. - Methamphetamine can be illicitly produced in clandestine laboratories using inexpensive ingredients like pseudoephedrine from cold medications. These labs are dangerous, producing harmful chemicals that linger in the environment and can cause health issues long after production ends. ### Negative Consequences of Long-Term Use - Severe dental problems (often called "meth mouth") - Extreme weight loss - Intense itching, leading to skin sores - Involuntary movements (dyskinesia) - Memory loss - Violent behavior ### Cocaine Use - Cocaine, derived from the coca plant, is another highly addictive stimulant, with about 5.5 million people aged 12 or older reporting use, including 778,000 users of crack. - Cocaine is typically snorted, rubbed into gums, or injected. When processed into a rock crystal, it is referred to as crack, which is smoked and rapidly absorbed through the lungs. ### Short-Term and Long-Term Effects of Cocaine Use - **Short-term:** Increased blood pressure, restlessness, and irritability. - **Long-term:** Severe heart attacks, seizures, and other medical complications. ### Stimulant Intoxication - Intoxication from stimulants causes a range of behavioral and psychological changes, including: - Euphoria or blunted affect. - Changes in sociability. - Hypervigilance. - Interpersonal sensitivity. - Anxiety, tension, or anger. - Impaired judgment. - Some common physical symptoms of stimulant intoxication include: - Tachycardia (increased heart rate). - Hypertension (high blood pressure). - Pupillary dilation (enlarged pupils). - Perspiration or chills. - Nausea or vomiting. - Weight loss. - Psychomotor agitation or retardation. - Muscular weakness. - Respiratory depression. - Chest pain or cardiac dysrhythmias. - Confusion, seizures, or coma - Psychosis or hallucinations. - Dyskinesia (involuntary, erratic movements). - Dystonia (slow, repetitive muscle contractions). ### Management of Acute Methamphetamine Intoxication - Severe methamphetamine intoxication may lead to extreme agitation and violence, posing risks to the individual, medical staff, and others. The following interventions are crucial for managing the condition: - **Intravenous benzodiazepines should be administered for chemical sedation to manage agitation.** - **Physical restraints should be avoided, as struggling against them can lead to muscle contractions, lactic acidosis, hyperthermia, cardiac collapse, or death.** - **Airway management may involve endotracheal intubation and mechanical ventilation.** - **Aggressive cooling techniques (e.g., fluid resuscitation, external cooling blankets, evaporative cooling) should be used to manage hyperthermia (body temperature above 41°C).** - **Antipyretics (fever-reducing drugs) should be avoided, as the increased body temperature is caused by muscular activity, not by a change in the hypothalamic temperature set point.** ### Key Points for Healthcare Providers - Stimulant use is associated with severe cardiovascular and neurological risks, including heart attacks, seizures, psychosis, and cardiac dysrhythmias. - Methamphetamine intoxication requires immediate attention for agitation, hyperthermia, and respiratory support. - Benzodiazepines are