In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of chemical and other dependencies and substance abuse disorders in order to:

  • Assess the client's reactions to the diagnosis/treatment of substance-related disorder
  • Assess client for drug/alcohol dependencies, withdrawal, or toxicities and intervene as appropriate
  • Plan and provide care to clients experiencing substance-related withdrawal or toxicity (e.g., nicotine, opioid, sedative)
  • Provide information on substance abuse diagnosis and treatment plan to the client
  • Provide care and/or support for a client with non-substance-related dependencies (e.g., gambling, sexual addiction)
  • Provide symptom management for clients experiencing withdrawal or toxicity
  • Encourage client to participate in support groups (e.g., Alcoholics Anonymous, Narcotics Anonymous)
  • Evaluate the client's response to a treatment plan and revise as needed

Some of the commonly used terms and terminology relating to substance abuse will now be defined:

Substance Abuse

Substance abuse, simply defined, is one's overindulgence of an addictive substance which can be alcohol, prescription drugs and/or illicit, illegal drugs. Substance abuse does not include prescribed medications, such as narcotic pain medications, that are being used for medical reasons; however, these same medications when used after there is no longer a medical need to use them is considered substance abuse.

Addiction

Addiction is defined as the unending and constant need for the person to have the chosen substance even when the use of the substance causes the client to have serious physical, psychological, social and/or economic consequences and harm including a loss of control over the substance abuse and use. Contrary to popular opinion, addiction can occur with and without physical dependence.

Physical Dependence

Physical dependence occurs when the cessation of a drug causes adverse physical effects; these ill effects are typically greater and more intense when the cessation of the drug is rapid and abrupt. Some of the drugs that are most often associated with physical dependence include cocaine, opioid drugs, alcohol and benzodiazepines. As previously stated, physical dependence does not necessarily indicate addiction; addiction can be present with or without any physical dependency.

Psychological Dependence

Psychological dependence is defined as the person's need to continue the use of the substance to avoid any unpleasant feelings and experiences that can occur when the substance is not taken. Amphetamines and hallucinogenic drugs like LSD are often associated with psychological dependence.

Chronic Drug Abuse

Chronic drug abuse is defined as the abuse of a substance that causes the person to have physical, psychological, social and/or economic consequences and harm.

Dual Diagnosis

The existence of substance abuse in combination with a psychiatric mental health comorbidity such as clinical depression

Relapse Prevention Therapy

Individual therapy that includes facilitating the client's ability to recognize and avoid triggers, to increase the client's level of self-control, and to have an emergency plan to avoid a relapse

Acceptance and Commitment Therapy

Therapy that fosters the client's ability to self-control their behaviors and poor choices

Drug Seeking Behavior

Drug seeking behavior, which is a signal of possible substance abuse, is client behaviors that aim to get drugs. Some of the signs and symptoms of drug seeking behaviors are using a false form of legal identification, pretending to have a physical or mental disorder such as pain or anxiety to get a prescription medication from a doctor, false client claims that they have lost their prescription medications so that the doctor will order it again, forging prescriptions which is a felony, and coercing, persuading and even threatening their health care providers into giving them a prescription for the client's drug of choice.

Assessing the Client for Drug and Alcohol Dependencies, Withdrawal or Toxicities And Intervening Appropriately

Assessing the Client

Nurses assess clients for drug and alcohol dependencies, withdrawal, toxicities, and related risk factors.

Some of the risk factors associated with substance abuse are decreased levels of self-esteem, genetics, a poor tolerance for pain, the lack of successes in life, a tendency to take risks, a proneness to "self medication", the presence of a psychiatric mental health disorder, a vulnerability to peer pressure and other factors.

Some of the general physical signs and symptoms of substance related abuse include hyperactivity, needle track marks on the extremities, poor hygiene, shakiness, moist and cool hands, and a state of poor health. Some of the general behavioral signs and symptoms of substance related abuse include things like irritability, a low tolerance for frustration, forgetfulness, drug seeking behaviors, poor job performance and possible termination, problems with school, the possession of drugs and drug paraphernalia, drug seeking behaviors, and a poor attention span.

Among the many standardized tests that can be employed for the assessment of substance related addictions and client recovery include:

  • The Drug Abuse Screening Test
  • The Addiction Severity Index
  • The Michigan Alcohol Screening Test
  • The Recovery Attitude and Treatment Evaluation
  • The CAGE-AID Test

The signs and symptoms of various substances when used and abused are described below:

Inhalants Like Gasoline, Aerosol Products, Felt Tip Pen Fluid, Paint Thinner, Glue And "White Out"

  • Nausea and vomiting
  • Slurring of speech
  • Euphoria
  • Decreased coordination and an impaired gait
  • Tremors
  • Stupor
  • An oral and/or nasal rash and soreness

Withdrawal Signs and Symptoms: None

Cocaine

  • Euphoria
  • Increased level of activity
  • Irritability
  • Blurry vision
  • Hallucinations
  • Seizures
  • High fever
  • Hypertension
  • Tachycardia
  • Cardiac standstill

Withdrawal Signs and Symptoms: Excessive sleep or insomnia, depression, agitation or decreased psychomotor movements, nightmares and possible suicidal ideation

Opioids: Heroin, Codeine, Methadone, Morphine, and Oxycodone

  • Pupil constriction
  • Impaired coordination and gait
  • Confusion
  • Euphoria
  • Sedation
  • Slurring of speech
  • Loss of memory
  • Poor attention span
  • Diaphoresis
  • Tremors, muscular pain and spasms
  • Diarrhea
  • Goose bumps (piloerection)

Withdrawal Signs and Symptoms: Piloerection, insomnia, fever, nausea, vomiting, muscular spasms, weakness and dilated pupils

Club Drugs Such as Ecstasy or Molly, Ketamines, Gamma Hydroxybutyric Acid (the Date Rape Drug), and Flunitrazepam

  • Sedation
  • Hallucinations
  • Paranoia
  • Pupil dilation
  • Increased sensory functioning (visual and auditory)
  • The lack of coordination
  • Impaired judgment
  • Memory impairment
  • Altered level of consciousness
  • Diaphoresis
  • Tremors
  • Behavioral changes

Alcohol

  • Decreased level of consciousness
  • Stupor
  • Coma
  • Respiratory arrest
  • Tremors
  • Tachycardia
  • Vomiting
  • Abdominal cramps
  • Hepatic disease
  • Gastritis
  • Pancreatitis
  • Blackouts
  • Gastrointestinal hemorrhage and bleeding
  • Collapse of the peripheral venous system
  • Death

Withdrawal Signs and Symptoms: Tachycardia, hypertension which can be very pronounced, a loss of orientation, tremors, insomnia, hallucinations, anxiety, cardiac arrhythmias, delirium, and psychotic symptoms

Sedatives and Hypnotics

  • Anxiety
  • Nausea and vomiting
  • Seizures
  • Agitation
  • Respiratory depression
  • A loss of coordination
  • The slurring of speech

Withdrawal Signs and Symptoms: Tremors, hallucinations, agitation, seizures, diaphoresis, increased levels of anxiety, and agitation

Cannabis

  • Euphoria
  • Irritability
  • Impaired coordination
  • Tremors
  • Increased sensory functioning (visual and auditory)
  • Aggression
  • Tachycardia
  • Hypertension
  • Reddened eyes
  • Dry mouth
  • Increased appetite
  • Paranoia
  • Decreased mentition

Withdrawal Signs and Symptoms: Increased levels of anxiety, irritability, tremors, fever, emotional depression, a loss of appetite, insomnia, and aggression

Synthetic Cannabinoids: Spice and K2:

  • Decreased mentition
  • Tachycardia
  • Hypertension
  • Euphoria and elation
  • Anxiety
  • Agitation
  • Relaxation
  • Paranoia
  • Hallucinations

Withdrawal Signs and Symptoms: Similar to cannabis

Cathinones, Which Are Referred to as Bath Salts, Are Similar to Amphetamines and Cocaine

  • Intoxication
  • Euphoria
  • Tachycardia
  • Hallucinations
  • Delirium
  • Hypertension
  • Agitation
  • Increased libido
  • Paranoia
  • Panic
  • Psychotic and violent behavior

Withdrawal Signs and Symptoms: Similar to cocaine and amphetamines

Barbiturates and Benzodiazepines

  • Hypotension
  • Dizziness
  • Depression
  • Respiratory depression
  • Impaired coordination
  • Drowsiness
  • The slurring of speech
  • Euphoria
  • Impaired mentition
  • An inability to concentrate
  • Poor memory
  • Nystagmus

Withdrawal Signs and Symptoms: Sometimes life threatening high temperature, seizures, hallucinations, agitation, tremors and insomnia

Amphetamines

  • Hypervigilance
  • Irritability
  • Hypertension
  • Cravings
  • Depression
  • Increased energy and possible aggression
  • Increased level of alertness
  • Dilated pupils
  • Irritability
  • Weight loss
  • Impaired judgment and mentition
  • Insomnia
  • Paranoia
  • Excessive speech
  • Pupil dilation
  • Hallucinations
  • Delusions
  • Rapid or rambling speech
  • Depression with withdrawal

Withdrawal Signs and Symptoms: Similar to cocaine withdrawal with signs and symptoms such as depression, sleepiness and fatigue

Hallucinogenic Drugs Like Lysergic Acid Diethylamide (LSD) and Phencyclidine (PCP)

  • Anxiety
  • Tachycardia
  • Depression
  • Hallucinations
  • Poor impulse control
  • Emotional mood swings
  • Flashbacks which can occur over the long term
  • Tachycardia
  • Hypertension
  • Rapid shifts in emotions
  • Tremors
  • Pupil dilation
  • Panic
  • A lack of pain sensation
  • Impaired memory and mentation
  • Seizures and even coma
  • Problems with thinking and memory
  • Problems speaking
  • Impaired judgment
  • Intolerance to loud noise
  • Sometimes seizures or coma

Withdrawal Signs and Symptoms: Flash back hallucinations and other visual disturbances that can persist for years and which is often referred to Hallucinogenic Drug Persisting Perception Disorder

Nicotine

  • Hypertension
  • Cerebrovascular accidents
  • Lung cancer
  • COPD

Withdrawal Signs and Symptoms: Irritability, restlessness, increased anxiety, depression, cravings, poor ability to concentrate, increased appetite and anger.

Planning and Providing Care to Clients Experiencing Substance Related Withdrawal or Toxicity

Some of the general interventions for clients who are experiencing substance related toxicity and withdrawal include:

  • Client safety
  • Seizure precautions when indicated
  • Reorientation to reality, time, person and place
  • Falls prevention
  • Close client monitoring and assessments
  • The provision of a calm and quite environment with low levels of stimulation
  • Medications as indicated
  • Patient and family education
  • Information about self-help groups like Alcoholics Anonymous, Al-Anon, Narcotics Anonymous and Nicotine Anonymous
  • Symptom management
  • Information about codependencies for family members and other significant others
  • The prevention of relapse

Individual, family, and group therapies are also provided to the client. For example, cognitive reframing, acceptance and commitment, and relapse prevention therapy are individual therapies that are appropriate for most clients. Family therapies to correct enabling and codependency behaviors within the family unit and group therapies for the client are examples of some of the therapies for clients with a substance abuse health problem.

In addition to these general interventions that should be included in the plan of care for clients who are experiencing substance related toxicity and withdrawal, additional interventions according to the substance abusers needs are detailed below.

Nicotine

  • Nicotine replacement medications such as nicotine gum, lozenges or patches, bupropion, and varenicline (Chantix)

Opioids

  • Medications like methadone, clonidine and buprenorphine
  • Naloxone (Narcan) 0.4 to 2 mg I.V. or by endotracheal tube for toxicity and overdose
  • Maintaining an open airway
  • Protect the patient from harm; the client may be combative and aggressive after recovery from an over dosage

Sedatives

  • Maintaining an open airway
  • Flumazenil (Romazicon) as an antidote to reverse or diminish effects of benzodiazepines
  • Administering activated charcoal
  • Administering vasopressor drugs and/or Ringer's lactate for hypotension

Alcohol

  • Alcohol deterrent and abstinence drugs like acamprosate, disulfiram and naltrexone
  • Alcohol withdrawal medications such as carbamazepine, diazepam, cholordiazepoxide, and clonidine
  • Maintaining and protecting the airway
  • Close monitoring for central nervous system depression and alterations of the client's respiratory status which can be further complicated with a respiratory arrest
  • Administer I.V. fluids such as magnesium sulfate to reduce the risk of seizures, thiamine to prevent Wernicke-Korsakoff syndrome, and glucose to treat any hypoglycemia, as indicated

Amphetamines

  • Monitoring and maintaining the airway, breathing and cardiovascular functioning
  • Monitoring the client's cardiac rhythms
  • Supplemental oxygen as indicated
  • Sedation as necessary.
  • Administering antiarrhythmic, sedating and seizure prevention medications such as diazepam
  • Intravenous fluid hydration when indicated by the client's hemodynamic status

Hallucinogenics

  • Sedating drugs for the prevention and reduction of hyperactivity
  • An environment without sensory stimulation and overload
  • Monitoring the client for a hypertensive crisis

Providing Information on the Substance Abuse Diagnosis and the Treatment Plan to the Client

Nurses, and other health care professionals, provide the client with education and information relating to their substance abuse diagnosis as well as their treatment plan, including follow up care and the prevention of a relapse.

Some of the elements of this teaching and information about the client's substance abuse diagnosis include information that can facilitate the client's abilities to:

  • View and perceive substance abuse as an illness rather than a sign of weakness
  • Overcome society's stigma relating to substance related abuse
  • Recognize and avoid the risk factors associated with substance related abuse

Some of the elements of this teaching and information about the client's substance abuse treatment plan include information that can facilitate the client's abilities to:

  • Understand the medications that will be used
  • Understand the medical and psychological therapies that will be used for their treatment
  • Recognize and act in response to any relapse threats
  • Participate in follow up care
  • Participate in self-help groups to meet the client's ongoing needs
  • Develop and employ better coping skills
  • Seek out and employ stress management and relaxation techniques
  • Utilize social support systems that meet the client's needs

Despite the fact that there are multiple support groups in the community to support the needs of clients who are affected by alcoholism and/or substance abuse, Alcoholics Anonymous and Narcotics Anonymous are perhaps the most popular support groups that are participated in among those patients with a substance related abuse disorder.

Alcoholics Anonymous was founded in 1935 by two men, Bob Smith and Bill Wilson. Alcoholics Anonymous is a spiritual program that is not religious and it is one that supports and helps alcoholics to achieve and sustain their sobriety. This peer support group has group meetings for members in all international communities, in health care facilities, in jails and in other places, at various times during the daytime and night time, and they all consistently follow the twelve steps of this nonreligious but spiritual group. Meetings can also be attended online using a home computer.

Alcoholics Anonymous members choose and maintain a close one-to-one relationship with a sponsor who gives the member ongoing individual support and guidance in respect to the member's recovery and complete abstinence, with the additional help and guidance of the member's higher power. All members maintain the confidentiality of all other members and they follow the Twelve Steps.

"The Twelve Steps of Alcoholics Anonymous are:

  1. We admitted we were powerless over alcohol that our lives had become unmanageable.
  2. Came to believe that a Power greater than ourselves could restore us to sanity.
  3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
  4. Made a searching and fearless moral inventory of ourselves.
  5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
  6. Were entirely ready to have God remove all these defects of character.
  7. Humbly asked Him to remove our shortcomings.
  8. Made a list of all persons we had harmed, and became willing to make amends to them all.
  9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
  10. Continued to take personal inventory and when we were wrong promptly admitted it.
  11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
  12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs."

Narcotics Anonymous is highly similar to Alcoholics Anonymous in terms of its confidentiality, meetings, 12 Steps and sponsorships. Narcotics Anonymous, founded in 1953, has members that also belong to Alcoholics Anonymous.

Providing Care and/or Support for a Client with a Non Substance Related Dependency

Impulse control disorders, such as sexual addiction, compulsive gambling, internet addiction, exercise addiction, pyromania, shopping addictions which has significantly increased in the recent past as the result of television shopping networks, an addiction to pornography, kleptomania which is uncontrollable shoplifting, an addiction to food and eating, trichotillomania which is compulsive pulling out of one's hair, and even addictions to work are non substance related dependencies which are frequently and often referred to as process addictions or compulsive behavioral disorders. Like other addictions, these addictions are a form of a chronic brain disorder.

According to the American Psychiatric Association's DSM-5, gambling process addiction affects about 2% of the population, eating addiction affects about 2% of the American population, internet addiction impacts on about 2% of the population, an addiction to exercise impacts about 2% of the population, and sexual addiction impacts on approximately 3% of our population.

Some clients can be affected with more than one addiction which can even include one or more process addictions in addition to one or more substance related addictions. When this occurs, all of the addictions should be treated at the same time because it appears that each of these multiple addictions interact with and augment the other addictions and the treatments of two or more addictions are highly similar to the others' recommended treatments. For example, impulse control counseling and therapy are used for virtually all addictions including process addictions and substance related addictions.

The most frequently encountered risk factors that are associated with compulsive behavioral disorders or process addictions include the client's environment, genetics, a history of prior or current physical, emotional and/or sexual abuse or neglect, a recent loss of a significant other like a spouse or a child, inadequate socialization skills, poor coping skills, decreased levels of self-esteem, genetics, the environment, and an abnormal need to achieve perfection.

Some of the environmental risk factors include growing up in and/or living in an environment that is affected with aggression, violence, neglect, abuse and/or substance related use.

These process addictions or compulsive behavioral disorder activities decrease the client's level of stress and anxiety, they enable the client to escape their reality, they provide the client with a rush and they also lead to elation; however, these addictions can cause serious and significant financial, social and personal harm.

Some of the signs and symptoms of process addictions or compulsive behavioral disorders include:

  • Aggression
  • Substance abuse
  • Abusive behaviors towards others
  • Self harm
  • The loss of relationships
  • Poor job performance
  • Financial ruination
  • Destructive behaviors
  • Depression
  • Suicidal ideations and suicide
  • Legal consequences associated with sexual abuse, including child sexual abuse, and rape among those with a sexual addiction
  • Legal consequences for clients who are kleptomaniacs

Typically, a combination of cognitive behavioral therapy and drug therapy is used for the treatment of these disorders. Some of the drugs that can be used to treat compulsive behavioral disorders selective serotonin reuptake inhibitors and antidepressants. Self-help groups in the community, such as Gamblers Anonymous or similar groups for other process addictions, and gambling addiction hot lines are some other treatments that can be indicated for the client.

Providing Symptom Management for Clients Experiencing Withdrawal or Toxicity

Symptom management interventions for specific substances were discussed above under the topic "Planning and Providing Care to Clients Experiencing Substance Related Withdrawal or Toxicity". For example, alcohol toxicity and withdrawal can be treated with magnesium sulfate to reduce the risk of possible seizures, thiamine to prevent potential Wernicke-Korsakoff syndrome, the administration of glucose to treat hypoglycemia; and, flumazenil as the antidote to reverse or diminish effects of benzodiazepines.

Encouraging the Client to Participate in Support Groups

Information about Alcoholics Anonymous and Narcotics Anonymous and the need to encourage the substance related addicted client was previously discussed under the topic "Providing Information on the Substance Abuse Diagnosis and the Treatment Plan to the Client"; and information about process disorders was discussed immediately above.

Evaluating the Client's Responses to Their Treatment Plan and Revising it as Needed

As with all other aspects of nursing care, nurses evaluate the client's responses to their treatment plan and they also revise and update it according to the client's needs. For example:

  • Has the client achieved sobriety?
  • Is the client participating in their individual, family and/or group therapies?
  • Is the client compliant with and adhering to their medication regimen?
  • Is the client therapeutically responding to their medications?
  • Are the family members attending peer support groups to address their codependency and enabling behaviors?
  • Is the client consistently attending community based peer support groups, such as Gamblers Anonymous and Narcotics Anonymous?
  • Is the client knowledgeable about relapses and how to prevent them?

RELATED CONTENT:

SEE - Psychosocial Integrity Practice Test Questions