Chapter 11: Substance Use Disorders in Acute Care

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Welcome to the Deep Dive.

We're here to cut through the noise and give you those essential knowledge nuggets.

And today, we're tackling something really significant.

Yeah, a topic you'll definitely encounter.

Absolutely.

It impacts patient outcomes hugely and, well, it's going to challenge both your clinical skills and your compassion.

We're talking about substance use disorder.

We've done a deep dive into Lewis's medical surgical nursing and we're aiming to arm you, our listeners, with the key insights for acute care.

It's so important.

What nurses really need to grasp is just how widespread substance use disorder or SED actually is.

It really isn't confined to certain groups.

Right.

It cuts across all demographics.

Exactly.

You see it everywhere.

So our mission today is really to give you that essential knowledge to help you identify and manage patients with SUD, especially when they hit that really challenging point of withdrawal in the hospital.

Perfect.

Think of this as your go -to guide for understanding SUD from a nursing standpoint.

We're going to cover the path of physiology,

look at risk factors, the signs and symptoms, the manifestations.

And the diagnostics too.

Diagnostics and, crucially, the nursing management.

Everything from, say, nicotine addiction right through to life -threatening alcohol withdrawal.

We want to give you that high -impact info you need to really make a difference.

Sounds good.

Let's jump in.

Okay.

So first things first, let's lay the groundwork.

What exactly is substance use disorder?

It's definitely not just a casual habit, right?

No, not at all.

It's a diagnosed medical condition.

It happens when someone's recurrent use of alcohol or drugs or both causes significant impairment.

And that impairment can look like a lot of different things.

Absolutely.

Health problems are a big one.

Or, you know, failing to meet major responsibilities, work, school, home life, it really impacts our whole life.

And importantly, it exists on a spectrum.

A spectrum, meaning?

Meaning be mild, moderate or severe.

Understanding where someone falls on that spectrum is, well, it's key for tailoring the right treatment.

Think binge drinking versus, say, heroin use very different levels of severity and risk.

Okay, that makes sense.

So how is that severity actually determined?

What are the diagnostic criteria?

Right.

So the source material, Lewis's, breaks it down really clearly into three main categories based on the DSM criteria.

First, there's impaired control.

Impaired control.

Yeah, means things like using more of the substance or for longer than they originally intended.

Or maybe they've tried to cut down or quit multiple times, but just can't.

Spending a lot of time getting the substance, using it or recovering from it.

And really intense cravings, that almost overwhelming urge.

Okay, that's one category.

What else?

Second is social impairment.

This is where the substance use starts messing with their responsibilities,

like missing work or school, or maybe they keep even though it's causing fights with family or friends, or they might give up activities they used to enjoy because of the substance use.

Got it.

And the third?

The third is dependence.

This is where you see physical tolerance needing more and more to get the same effect

and experiencing withdrawal symptoms when they stop or cut back.

Those really unpleasant, sometimes dangerous, physical and mental effects.

And it's crucial to remember, isn't it, that it's not just about the immediate high or the withdrawal?

Oh, absolutely not.

Every single substance linked to SUD over time can cause damage to specific tissues or organs.

You know, we often think of liver damage with alcohol, which is classic.

Or lung cancer with smoking.

Exactly.

Yeah.

But there are also so many indirect problems, like injuries from falls when intoxicated, or maybe infections like hepatitis C from sharing needles.

Malnutrition is common too.

So SUD really creates this ripple effect of health issues.

It really does.

Whole cascade.

And that's where you, as the nurse, come in.

Your role is just vital.

How so?

Specifically in acute care?

Well, in acute care, you're offered the very first person to pick up on the subtle signs that a patient might be using substances.

You're managing withdrawal symptoms when they suddenly stop because they're hospitalized.

Right.

That abrupt cessation.

Yeah.

And you're doing that crucial screening,

but it goes beyond just the physical stuff.

You're in a unique position to actually motivating patients to encourage behavior change and to connect them with treatment programs that could, frankly, save their life.

That's a huge responsibility.

It is a profound one.

Okay.

Let's zoom in on one of the most common SUDs you'll see absolutely everywhere.

Tobacco Use Disorder, or TUD.

Nicotine.

Right.

Nicotine is the addictive culprit here.

And it's not just cigarettes anymore, is it?

We've got smokeless tobacco, chewing tobacco, and of course, vaping or e -cigarettes.

Everywhere now.

So physiologically, what's happening?

Nicotine is a stimulant, right?

Yes.

A central nervous system stimulant.

It gets the brain really fast and triggers this release of adrenaline that gives the user that temporary feeling that high or buzz.

But it doesn't last long.

No, that's the hook.

It fades really quickly, often within just an hour or two.

And as it fades, the withdrawal kicks in.

Irritability, feeling anxious, tired.

Which drives the craving for nicotine.

Precisely.

It creates this powerful cycle of use and withdrawal.

And the long -term complications.

They're just immense, aren't they?

Staggering, really.

When you look at smoking, it damages practically every organ system.

You've got the obvious ones like lung disease, COPD,

emphysema, lung cancer, but also many other cancers,

bladder, throat, stomach.

Heart disease, too, right?

Stroke?

Absolutely.

Major cardiovascular impacts.

Even things like cataracts and periodontitis.

Now, smokeless tobacco avoids the lungs, sure, but it dramatically increases the risk for oral cancers, pharyngeal cancer, and still impacts heart health.

And vaping.

It used to be seen as safer.

Yeah, but we now know it carries significant risks.

There's evil eye, that serious lung injury associated with the vaping.

There are links to cardiovascular problems, potential harm to adolescent brain development, and risks during pregnancy.

So given all these really serious health effects, what's our specific role as nurses when it comes to TT?

That's the key question.

And it's pretty clear.

We have a professional responsibility.

The Joint Commission actually mandates that healthcare providers identify tobacco users and provide cessation information.

Okay, so it's mandated.

How do we do that effectively?

Is there a framework?

There is.

A really useful one, often called the 5As and 5Rs.

It's a brief clinical intervention.

For patients who are willing to try quitting, you use the 5As.

Okay, what are they?

You ask about their tobacco use at every visit.

You advise them clearly and personally to quit.

You assess their willingness to make a quit attempt right now.

You assist them in making that plan.

This might involve counseling, setting a quit date, talking about challenges, and recommending approved medications.

And finally, you arrange for follow -up contact to support them.

Ask, advise, assess, assist, arrange.

Got it.

What about patients who aren't ready to quit?

For them, we use the 5Rs.

It's more about motivational interviewing.

You explore the relevance of quitting for them personally.

Discuss the specific risks of their continued smoking.

Highlight the potential rewards of stopping.

Help them identify the roadblocks or barriers to quitting.

And crucially,

you repeat this motivational intervention at subsequent visits.

The key is persistence and personalization.

That makes sense.

It meets the patient where they are.

Exactly.

And even just brief advice from a nurse significantly increases the chance someone will try to quit.

What about when they're actually admitted to the hospital?

Well, inpatient care has specific interventions.

You need to document their smoking status clearly.

List tobacco use as an active problem in their chart.

Offer counseling and cessation medications like nicotine replacement therapy or NRT to help manage withdrawal and cravings while they're unable to smoke.

And planning for discharge.

Crucial.

Discharge planning should include continued cessation support, prescriptions for medications if needed, and arranging that follow -up.

Let's talk about those cessation aids.

What are the options?

We have several good ones.

There are the nicotine replacement therapies,

NRTs.

These give the patient nicotine without all the other harmful chemicals and tobacco smoke.

They come as patches, gum, lozenges, even nasal sprays and inhalers.

They help manage the physical withdrawal.

Right.

Then there are non -nicotine medications.

Varenicline, brand name Chantix, works by blocking nicotine receptors and reducing cravings.

Bupropion or Zybon is actually an antidepressant that also helps reduce cravings.

Are there important safety points with those non -nicotine meds?

I remember seeing alerts.

Yes, absolutely critical.

Both varenicline and bupropion have a drug alert because they can potentially cause serious neuropsychiatric effects.

Things like behavior changes, hostility, agitation, depressed mood, and even suicidal thoughts or actions.

Wow.

So what's the nursing implication there?

You must educate patients about this risk.

Tell them to stop taking the drug immediately and contact their health care provider if they experience any of those symptoms.

Vigilance is key.

Okay.

So patient education is huge for TUD.

What are the key teaching points for someone trying to quit?

You really want to help them build a solid quit plan.

That means setting a specific quit date, identifying triggers and planning coping strategies, building a support system, friends, families, support groups.

And using those NRTs correctly.

Yes.

Teaching proper use is important and reminding them that slips can happen, but they don't mean failure.

The goal is to get back on track and emphasize the benefits.

Quitting improves health almost immediately.

Circulation improves.

Breathing gets easier.

Risk of heart attack drops.

It benefits every single body system, no matter how old they are or how long they've smoked.

It's never too late.

Never.

Think about a patient like CM and the case study from Lewis is 78 years old.

Admitted for a fall, smokes half a pack a day.

Even a brief intervention from you using those five A's could genuinely change the course of her health.

That's powerful.

Okay.

Let's shift gears now to another really common issue you'll see constantly in acute care.

Alcohol use disorder or AUD?

Definitely a major comorbidity.

Statistics show lots of patterns, right?

Absolutely.

Moderate drinking is generally defined as up to one drink per day for women and up to two drinks per day for men.

But binge drinking, which is bringing your blood alcohol concentration or BAC up to 0 .08 % or higher, usually after four drinks for women or five for men in about two hours is very common.

And AUD itself affects millions.

What's alcohol actually doing in the body?

Well, unlike some substances that target specific receptors, alcohol seems to have widespread effects.

It impacts almost every cell, but it has major effects on neurotransmitters in the central nervous system, GABA, glutamate, dopamine.

It influences impulses, mood, coordination, even basic vital functions like breathing and heart rate.

And BAC is key here, right?

Blood alcohol concentration.

Yes.

BAC measures the amount of alcohol in the bloodstream.

Factors like body weight, gender, food intake, and how fast you drink all affect it.

An important concept is tolerance, meaning you need more to get the same effect.

Exactly.

Someone with chronic heavy alcohol use can develop significant tolerance.

They might have very high BAC, but not show the same level of impairment as someone who drinks infrequently.

Also, it's worth noting women generally achieve higher BACs than men for the same amount of alcohol consumed due to differences in body composition and metabolism.

And the long -term health problems from chronic alcohol use, the list is long, isn't it?

Incredibly long and diverse.

As nurses, you have to be aware of this because AUD can complicate almost any other health issue.

Think about the heart hypertension,

cardiomyopathy, atrial fibrillation.

GI system.

Major impacts.

Gastritis, peptic ulcers, esophageal varices.

Those can bleed catastrophically.

Pancreatitis, both acute and chronic.

And increased risk for several cancers like esophageal liver and colorectal.

What about blood liver brain?

Yep.

Hematologic problems like anemia.

Liver damage is huge fatty liver, alcoholic hepatitis, and eventually cirrhosis, which is irreversible scarring.

Neurologically, you can see dementia.

Wernicke -Korsakov syndrome, which we'll talk more about seizures.

Peripheral neuropathy, causing numbness and tingling.

And nutrition.

Often significant nutritional deficiencies because of poor intake and impaired absorption.

Plus, alcohol messes with reproductive function and can cause skin problems.

And a critical point for nurses,

alcohol interacts dangerously with tons of medications.

How so?

It can potentiate other CNS depressants like sedatives or opioids,

increasing the risk of respiratory depression.

It increases the risk of GI bleeding with NSAIDs or aspirin.

It can affect blood sugar control and diabetics.

The list goes on.

You always need to consider potential interactions.

Okay, that covers the chronic picture.

Let's talk acute management.

What happens with acute alcohol toxicity or overdose?

Acute toxicity is basically when someone drinks a large amount of alcohol over a short period, leading to dangerously high BAC levels.

This causes profound CNS depression.

So like passing out?

Passing out, yes.

But it can progress rapidly to respiratory depression, circulatory failure, coma, and even death.

And critically, there is no antidote for alcohol itself.

No antidote.

So care is supportive.

Entirely supportive.

It needs to be immediate.

Your absolute priorities are the ABCs.

Airway, breathing, circulation.

Maintain that airway.

Be ready for intubation if needed.

Monitor vital signs and level of consciousness constantly.

What about 5E fluids and meds?

5E fluids are usually needed for hypotension and dehydration.

Glucose -containing solutions if they're hypoglycemic.

And this is vital.

5E thiamine, vitamin B1.

You give it before or IV glucose.

Why is the order so important?

Because giving glucose to a thiamine -deficient patient can precipitate for Niki -Korsakov syndrome, that serious neurologic disorder causing confusion, eye muscle paralysis, and ataxia.

It can lead to permanent brain damage.

So thiamine first is a non -negotiable rule.

Okay.

Thiamine first.

What else?

Also often give multivitamins and magnesium as deficiencies are common.

Managing agitation is tricky.

You need keep the patient safe, often requiring restraints or sedation, but carefully, avoiding further CNS depression.

Safety is paramount because their judgment is severely impaired.

Right.

Okay.

So that's toxicity.

What about the flip side withdrawal?

Alcohol withdrawal syndrome or AWS.

This is incredibly common when a patient who is physically dependent on alcohol suddenly stops drinking, often because they're admitted to the hospital for something else.

When does it typically start?

Early signs like anxiety, tremors, insomnia, maybe nausea, can begin within just 6 to 12 hours after their last drink.

Symptoms usually peak around 24 to 48 hours.

Is it always just those milder symptoms?

No, and that's the danger.

AWS can progress to seizures usually within the first 12 to 48 hours.

And the most severe form is alcohol withdrawal delirium or AWDEL, previously called delirium tremens or DTs.

AWDEL.

That sounds serious.

It is.

It's a medical emergency.

AWO typically starts 2 to 3 days after the last drink, sometimes later, and can last for several days.

It involves profound disorientation, terrifying visual or tactile hallucinations, agitation, fever, high blood pressure, and tachycardia.

What causes it?

And why is it so dangerous?

It's thought to be due to severe neurotransmitter imbalance as the brain readjusts to the absence of alcohol's depressant effects.

It's dangerous because the extreme autonomic hyperactivity can lead to complications like fatal dysrhythmias, fluid and electrolyte imbalances, respiratory failure, or aspiration pneumonia.

Mortality can be significant if not managed properly.

So identifying who's at risk for severe withdrawal is critical.

How do we do that?

Assessment is key.

First, you have to ask about alcohol use.

Then we use standardized assessment tools.

The most common is the Clinical Institute Assessment of Alcohol Scale.

Revise the CIWR.

The CIWR, what does that measure?

It systematically scores the severity of common withdrawal symptoms.

Things like nausea, vomiting, tremor, sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and orientation.

You score each category and the total score helps guide treatment, particularly bendylodiazepine dosing.

Okay, so based on the CIWR score and the symptoms, what's the treatment for AWS and AW?

For milder AWS, think agitation, anxiety, maybe mild tremors, increased heart rate, and BP.

The cornerstone of treatment is benzodiazepines.

Benzos.

Like lorazepam or diazepam.

Exactly.

Lorazepam, adivon, or diazepam, Valium are commonly used.

They substitute for alcohol's effects on GABA receptors, reducing CNS hyper -excitability.

This helps control agitation, prevent seizures, and reduce the risk of progressing to ADL.

The dose is often titrated based on the CIWA scores.

What else besides benzos?

That critical 5E thiamine, again before glucose, multivitamins, magnesium replacement if levels are low.

5E fluids, potentially with glucose if needed after thiamine.

Sometimes beta blockers like propranolol or alpha -2 agonists like clonidine might be used cautiously to help manage autonomic symptoms like high BP and heart rate, but they don't prevent seizures or delirium, so benzos remain primary.

What's the core nursing management for a patient in AWS?

Continuous vigilance.

Monitor vital signs and neurologic status frequently, maybe every hour initially.

Use the CIWA R scale regularly and reliably to track severity and guide medication administration.

Implement seizure precautions, padded side rails, suction available.

Right.

Safety first.

Absolutely.

Maintain a quiet, calm, well -lit environment to reduce simuline.

Orient the patient frequently.

Manage fever if present.

Address pain.

Ensure adequate hydration and nutrition once they can tolerate intake, sometimes NPO initially if risk of aspiration is high.

And again, infuse thiamine before any dextrose -containing fluids.

And if it progresses to AWDL with the hallucinations and seizures.

The principles are similar, but often more intensive.

You're continuing benzodiazepines, possibly at higher doses, or via continuous infusion.

Sometimes anticonvulsants like valproic acid or gabapentin might be added.

If there's severe agitation or psychosis, antipsychotics like haloperidol might be used cautiously, but they can lower the seizure threshold, so it's a careful balance.

And the nursing focus for AWDL.

Intense monitoring.

Prioritize safety.

Protect them from injury due to confusion or agitation.

Continue frequent orientation.

Address the hallucinations calmly and reassuringly.

Don't argue about them, but gently reinforce reality.

Maintain that calm environment.

It's incredibly demanding nursing care.

Let's connect this back to our patient, CM.

The 78 -year -old who fell had a BAC of 0 .12 % and was confused and restless overnight.

Perfect example.

Her presentation the recent fall suggesting possible intoxication or withdrawal -related instability, the documented BAC, the overnight confusion and restlessness screams potential AWS.

Your nursing assessment, including using the CIWAR, would be absolutely crucial.

Right.

That score would directly guide interventions like initiating seizure precautions, administering prescribed lorazepam, and ensuring she gets thiamine before any glucose.

Precisely.

It shows how these tools and principles apply directly at the bedside.

Okay, we've covered tobacco and alcohol in depth, but nurses see other substances too.

Let's briefly touch on stimulants and depressants.

What are the key things we need to know about stimulants like amphetamines or cocaine?

The core issue with stimulants is sympathetic nervous system overdrive.

They flood the brain with norepinephrine, serotonin, and dopamine.

Users feel euphoric, super alert, energized.

But toxicity is the opposite of euphoria, right?

Exactly.

Toxicity is like a sympathetic storm.

Extreme restlessness, agitation,

paranoia, maybe even full -blown psychosis.

Physically, you see dangerously high blood pressure, tachycardia, often a high fever, and potentially seizures, stroke, or heart attack.

Emergency management is about calming that storm.

Yes.

ABC is first.

Always.

Get IV access.

Monitor the ECG continuously.

You need to aggressively treat the hypertension and tachycardia, often with nitrates, calcium channel blockers, maybe aspirin.

Benzodiazepines, like diazepam or lorazepam, are key for controlling agitation and seizures.

Antipsychotics might be needed for psychosis.

And cooling measures for hyperthermia.

Gastric lavage might be considered for recent large ingestions, but it's risky.

What about stimulant withdrawal?

It's usually not life -threatening like alcohol withdrawal can be.

But it's deeply unpleasant.

It's often called a crash.

Patients feel profound depression, extreme fatigue, maybe anxiety, and intense cravings.

Nursing care is mainly supportive.

Ensure a safe environment.

Monitor for suicide risk if depression is severe.

Offer comfort measures.

Okay, now for depressants.

This key point for both these classes is that tolerance and physical dependence can develop really rapidly, making overdose and withdrawal significant risks.

Let's start with sedative hypnotics like barbiturates and benzodiazepines.

These drugs slow down the CNS.

They're used medically for anxiety or sleep, but abused for sedation or euphoria.

Toxicity is dangerous.

It causes hypotension, severe respiratory depression, coma, and potentially death.

Is there an antidote, like with opioids?

For benzodiazepine overdose specifically, yes, there's flumazenil.

It's a benzoantagonist.

But you have to use it cautiously, because its duration is shorter than most benzos, meaning sedation can return, and it can also precipitate seizures in dependent individuals.

For barbiturates and other non -benzo sedative hypnotics, there's no specific antidote.

Management is supportive of securing the airway.

Respiratory support, possibly with ventilation.

IV fluids, maybe vasopressors for hypotension.

Activated charcoal if ingestion was recent, and sometimes dialysis to remove the drug.

Okay, now opioids.

Morphine, heroin, fentanyl, prescription painkillers.

These act on opioid receptors, causing analgesia, sedation, and euphoria.

Toxicity, or overdose, is a major public health crisis, largely due to fentanyl.

And the primary danger is respiratory depression.

Absolutely.

Opioids suppress the brain's respiratory drive.

So, in an overdose, the patient can simply stop breathing.

Emergency management is again ABC's first.

Secure the airway, provide oxygen, potentially intubate, get IV access, continuous monitoring.

And the critical intervention is administering the opioid antagonist naloxone narcan.

Naloxone reverses the effects.

Yes, it rapidly reverses the respiratory depression and sedation.

But, like flumazenol, naloxone has a shorter duration of action than many opioids, especially long -acting ones or fentanyl.

So, repeated doses or continuous IV infusion might be necessary.

You can't just give one dose and assume the patient is fine.

And naloxone is available outside the hospital too, right?

Yes, thankfully.

Increased availability of naloxone kits for laypeople has saved countless lives in community overdose situations.

Nurses play a role in educating patients and families about this.

What about withdrawal from these depressants?

First,

sedative hypnotics.

Sedative hypnotic withdrawal, especially from barbiturates or high -dose benzodiazepines, can be life -threatening.

It's very similar to severe alcohol withdrawal.

Really?

Seizures and delirium?

Yes.

Tremors, anxiety, insomnia can rapidly progress to delirium, seizures, cardiovascular collapse, and respiratory arrest.

It's a medical emergency.

Treatment involves carefully tapering the dose of a long -acting benzodiazepine, like diazepam or chlorazepoxide.

Severe withdrawal might require a 5 -iazepam.

Close monitoring in a controlled setting of an inpatient is essential.

Safety is paramount.

And opioid withdrawal, is it life -threatening too?

Generally, no.

Opioid withdrawal isn't usually life -threatening like sedative, hypnotic, or alcohol withdrawal, but it's extremely uncomfortable and distressing for the patient.

What are the symptoms like?

Intense cravings, nausea, vomiting, diarrhea, muscle aches, lacrimation, tearing, rhinorrhea, runny nose, sweating, anxiety, insomnia.

The timing and intensity vary.

Depending on the specific opioid's half -life heroin withdrawal starts quickly.

Methadone withdrawal is more delayed and prolonged.

How is it managed?

Treatment focuses on symptom relief and managing cradings.

Sometimes long -acting opioids like methadone or buprenorphine are used as part of medication -assisted treatment, MAT, both acutely and long -term.

Alpha -2 agonists like clonidine can help with some autonomic symptoms.

Other medications target specific symptoms, antidiarrheals, antimedics, analgesics for pain, maybe antihistamines for anxiety.

Supportive care is key.

Okay, just a few more substances to touch on briefly.

What about inhalants?

Inhalants are things like solvents, aerosols, gases, hydrocarbon fumes.

They're rapidly absorbed through the lungs, causing CNS depression, a brief euphoria.

Long -term use can cause serious permanent neurologic damage.

Acute toxicity might look like lethargy, slurred speech, tremors.

A rare but fatal risk is sudden sniffing death from acute cardiac dysrhythmias.

Management is supportive care, especially respiratory and cardiac monitoring.

Cannabis?

Marijuana?

The main psychoactive component is THC.

It causes euphoria, relaxation,

but also potential adverse effects like impaired memory and coordination, anxiety, paranoia, even psychosis, especially with high -potency products.

Long -term use has potential cardiopulmonary and mental health effects.

We also need to be aware of synthetic cannabinoids, which can be much more dangerous and unpredictable.

How is cannabis toxicity managed?

Hugely supportive.

For acute psychotic episodes or severe anxiety, ensure a quiet, safe environment.

Benzodiazepines might be used for agitation.

Monitor for tachycardia or hypertension.

Withdrawal is usually mild irritability, insomnia, anorexia, and managed supportively.

And lastly, caffeine.

Seems harmless, but...

It's the most widely used psychoactive substance globally.

Usually find in moderation, but very high doses, often from energy drinks or caffeine pills, can be dangerous.

It can cause cardiac dysrhythmias, hypertension, anxiety, insomnia, and even seizures.

Treatment involves seizure control if needed, cardiac monitoring, and supportive care.

And be aware of caffeine withdrawal in hospitalized patients who suddenly stop headaches, muscle pain, irritability, or common.

Okay, that covers the main substance types.

Let's pull it all together now.

How do we approach nursing management comprehensively for any SUD?

It starts with assessment, right?

Absolutely.

And early detection is everything.

A key framework here is Esperort.

Screening, brief intervention, and referral to treatment.

It's a systematic approach.

Feast, you screen pretty much everyone for substance use using quick, validated questions or tools.

Like asking everyone about alcohol or drug use?

Exactly.

Simple questions first, like how many times in the past year have you used an illegal drug or used a prescription medication for non -medical reasons?

Or for alcohol, how often have you had a drink containing alcohol?

And how many standard drinks containing alcohol do you have on a typical day?

And if those initial questions raise a flag?

Then you move to more detailed screening tools.

For alcohol, the Auditate, the Alcohol Use Disorders Identification Test is excellent.

It's a 10 -question tool that assesses consumption, dependent symptoms, and alcohol -related problems.

For drugs, the DAS10, the drug abuse screening test is commonly used.

These tools give you a score that indicates the level of risk and helps guide the next steps.

So screening is step one.

What's next in Esperort?

Step two is the brief intervention.

If the screening suggests risky use or a potential disorder, you have a short, non -judgmental conversation with the patient.

You provide feedback on their screening results, express concern, link their substance use to any health issues they have, advise them to cut down or quit, and discuss their readiness to change.

And step three.

Referral to treatment.

For patients who screen positive from moderate to severe SUD, or who are ready to engage in more intensive treatment, you facilitate a referral to specialized care counseling, therapy, MAT programs, support groups.

So Esperort is a really practical framework.

Beyond screening tools, what else is key in the assessment?

You absolutely need to get specifics.

What substances?

When was the last use?

How much?

What route oral baby inhaled?

How long have they been using?

This information is critical for anticipating withdrawal timing and severity and potential drug interactions.

And always suspect polysubstance use.

Always.

It's the norm, not the exception.

Using multiple substances complicates withdrawal and overdose management significantly.

Then there's the physical assessment.

Looking for those telltale signs.

Right.

Your head -to -toe assessment might reveal clues.

General appearance.

Are they malnourished?

Neglecting hygiene?

Look at the abdomen for signs of liver enlargement or tenderness.

Skin for track marks, abscesses, jaundice.

Cardiovascular for murmurous dysrhythmias.

Respiratory for crackles, wheezing.

Neurologic for tremors, confusion, neuropathy.

And mental health is linked too.

Very strongly.

Coexisting mental health disorders like depression, anxiety, bipolar disorder, or PTSD are extremely common in patients with SUD.

You need to assess for both.

Diagnostic tests also play a role.

Serum, or urine drug screens, confirm recent use, though they have limitations.

CBC might show anemia.

Electrolytes can be off.

BUN, creatinine, and especially liver function tests are vital.

What about behavioral cues?

Patients aren't always forthcoming, are they?

No.

Denial.

Minimizing.

I only drink a little.

Rationalizing.

Avoidance.

These are common coping mechanisms or symptoms of the disorder itself.

You need to recognize these behaviors, but maintain a therapeutic non -judgmental stance while still gathering necessary information.

Okay, so after that thorough assessment, what are the main planning goals?

Key nursing diagnoses often revolve around risk for injury due to withdrawal, intoxication, impaired judgment, and impaired cognition.

Overarching goals include maintaining normal physiologic functioning during withdrawal, preventing complications, helping the patient acknowledge the problem and its impact, achieving abstinence, and motivating them to cooperate with long -term treatment.

In implementation,

how do nurses put this plan into action?

It spans the care continuum.

In health promotion, it's about prevention education, early detection through screening, teaching about negative consequences, and using ESPR to motivate change even before acute problems arise.

And in the acute setting, when someone is actively intoxicated or withdrawing.

Acute intervention priorities are always ABCs first.

Then, supportive care.

Frequent assessment of vital signs and neuro status, IV fluids if needed, managing symptoms like pain or nausea, ensuring safety with seizure precautions or fall prevention, orienting the confused patient.

What if you don't know exactly what substance they took?

That's common in overdose situations.

You manage based on symptoms, support ABCs, and consider antagonists.

For instance, if someone presents with CNS depression and respiratory depression, giving naloxone is reasonable.

If it's opioids, it's life -saving.

If it's not, it generally won't cause harm.

And once the acute crisis is managed… Your role shifts towards motivational interviewing.

This isn't about lecturing, it's about empowering the patient.

You explore their ambivalence about changing, help them see the discrepancy between their goals and their substance use, express empathy, support their self -efficacy, and roll with resistance.

It's about facilitating their own motivation to change and connecting them with resources.

Now, a really critical population, older adults, you mention this is often overlooked.

It really is.

Substance use in gerontologic populations is one of the fastest growing health problems, yet it's often missed or misdiagnosed.

Why is it missed?

Symptoms might be attributed to normal aging, dementia, depression, or just seen as a way of coping with loss or isolation.

Older adults might not fit the stereotype, and they might be more likely to hide their use due to stigma.

And the risks are higher for them.

Yes, significantly.

Due to physiological changes, decreased liver and kidney function, changes in body composition,

older adults experience higher BACs from the same amount of alcohol,

metabolize drugs more slowly, and are far more susceptible to toxicity and adverse effects at lower doses.

They're also more likely to have multiple chronic conditions and beyond multiple medications,

increasing the risk of dangerous interactions.

Withdrawal can also be more severe and complicated.

So screening older adults specifically is vital.

Absolutely crucial.

Don't assume they don't use substances.

Ask directly, non -judgmentally.

Involving family or caregivers with permission can be helpful.

There are specific screening tools adapted for older adults, like the SMA -SD,

the Short Michigan Alcoholism Screening Test Geriatric version.

And is quitting still beneficial for older adults, like smoking?

Definitely.

Smoking cessation provides health benefits at any age.

Reducing or stopping alcohol use can improve cognition, reduce fall risk, and help manage chronic conditions.

It's never too late to address SUD.

Let's bring back CM one last time, the 78 -year -old smoker with the Fall and High BAC.

Her case perfectly highlights this intersection.

Her age increases her risk for complications from both alcohol and tobacco.

Her confusion could be withdrawal, toxicity, or underlying dementia exacerbated by substances.

Her fall could be related to intoxication, withdrawal, or other geriatric issues.

It underscores the need for that meticulous assessment tailored to her age, recognizing how her body processes these substances differently.

Okay, one last, very serious area.

Ethical and legal dilemmas for nurses.

What about substance use among colleagues?

This is a tough but critical issue.

What if you suspect a coworker is diverting narcotics or coming to work impaired?

The source material highlights this with a scenario about nursing disciplinary action.

What is our obligation?

As licensed professionals, nurses have a clear legal and ethical obligation to protect patients.

This means you must report suspected impairment or illegal behavior by a colleague to your nurse manager or supervisor.

Even if you're not 100 % sure?

Yes.

Report your objective observations and concerns.

Let the administration investigate.

You also have an obligation to keep reporting up to chain of command if you don't see appropriate action being taken.

What happens if you don't report?

Failing to report can have serious consequences for you, including potential disciplinary action against your own license, possibly even being charged with aiding and abetting.

Patient safety is the priority.

And for the nurse who is impaired?

State boards of nursing have disciplinary processes that can range from monitoring and mandatory rehabilitation programs, often called peer assistance programs, to suspension or even revocation of their license, depending on the circumstances and patient safety risks.

That's a heavy responsibility, but essential for protecting patients and the profession.

Absolutely.

Wow.

We've covered a huge amount of ground today.

What a really crucial deep dive this has been.

It really has.

From understanding the basic science of addiction and SUD, to navigating these really complex withdrawal syndromes, and even touching on the ethical tightropes, it's clear your role as a nurse is just fundamental when caring for patients with SUD.

It demands sharp clinical skills, no doubt, but also, as you said earlier, a huge amount of compassion.

So what are the absolute key takeaways for our nursing student listeners?

I'd say first,

master those screening tools and assessment skills.

Early identification is everything.

Second, be vigilant about monitoring for toxicity and especially withdrawal.

Know the signs, use tools like CIWAR consistently.

Third, remember the importance of patient -centered education and supportive communication.

And finally, recognize the power of motivational interviewing to help patients find their own path to recovery.

Excellent summary.

Understanding this material isn't just about passing exams, though it's definitely key for NCLEX -style thinking.

It's about real -world patient safety and providing competent, compassionate care in the acute setting.

Absolutely.

And that brings us to our final thought for you to consider.

Given everything we've discussed today, the profound impact of SUD on health, the complexities of treatment, and the unique position you hold as nurses,

how might you in your future practice think about integrating more proactive interventions, maybe even beyond the hospital walls at a community level, to really start shifting the narrative around SUD and building healthier communities?

That's a great question to ponder.

Something to think about as you continue on your nursing journey.

Thanks for joining us for this deep dive.