Chapter 31: Substance-Related Disorders & Addiction

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Hello and welcome back to the Deep Dive.

Today we're doing something a little different, a very special edition of the show.

We are!

We're calling this the Last Minute Lecture series, and you know, if you're listening to this right now, I'm gonna guess there's a pretty good chance you're a nursing student.

I would bet on it.

Yeah, maybe you're staring down the barrel of a massive exam tomorrow morning,

or perhaps you're about to start a clinical rotation on a psych unit and you're feeling just a little bit unprepared.

Or maybe you're just curious.

I mean, maybe you're someone who is just really fascinated by the medical and psychological reality of addiction.

That too.

But whoever you are, we've got you covered.

That's right.

We are cutting through all the noise today.

We're going to be doing a serious, really deep dive into Chapter 31 of Psychiatric Nursing, Seventh Edition.

The chapter is called Substance -Related Disorders.

And I have to say, you know, I've reviewed a lot of medical texts over the years, and this is a heavy hitter of a chapter.

It is dense.

It really is.

It's massive.

And our goal today, it's pretty simple.

We're going to be your personal guides.

We are going to walk through this chapter sequentially, literally page by page, section by section, from the intro all the way to the nursing interventions at the end.

Right.

We're going to unpack all the clinical concepts.

We're going to break down the medication so they actually make sense.

Yeah, that's a big one.

It is.

And we want to clarify exactly what the nurse's role is in all of this.

Exactly.

We are not just going to, you know, read you definitions from a page.

The goal is to synthesize this information so you can actually walk into that exam or that clinical rotation and use it.

Absolutely.

Because as the text points out in the very first paragraph, this isn't just a chapter in a textbook.

I mean, this is a massive, systemic, societal issue.

Okay, so let's start there.

Let's start with a big picture.

The text throws some numbers at us right away that are honestly hard to wrap your head around.

They really are.

It cites a statistic that substance use costs the United States economy approximately

$559 billion.

Billion.

With a B.

It's an astronomical figure.

And you have to think about what that covers.

It's everything.

It's health problems.

It's lost work productivity, the strain on the legal system, property damage, you know, social welfare.

The huge drain on resources.

Huge.

But the text does something really smart right off the bat.

It gives us that huge number.

But then it immediately quotes Joseph Stalin, which is jarring.

It is, but it's effective.

The quote is a single death is a tragedy.

A million deaths is a statistic.

And that's a chilling quote, but it makes the point perfectly, doesn't it?

It's so easy for our brains to just tune out words like billions and millions.

They become meaningless.

So the chapter grounds us immediately with a specific clinical example.

It talks about a student from the University of Wisconsin, Milwaukee.

This story really anchors the whole chapter in reality for me.

It's just, it's so tragic.

It's a young man, a student who went out to celebrate New Year's Eve, just a normal college night out, right?

He went missing and they didn't find him for nearly three months.

He was eventually found drowned in the Milwaukee river.

And when the toxicology report came back, his blood alcohol level was 0 .2, two, nearly three times the legal limit.

Exactly.

And the real tragedy here is that this wasn't some

criminal or someone on the fringes of society.

This was a student with a future, a family.

It just highlights that behind every single one of those data points in that $559 billion figure, there's a family that's been absolutely destroyed.

So to even begin to prevent these tragedies, we have to understand the mechanism.

We have to answer the why.

And the text is very, very firm on this.

Substance use is a brain disorder.

Yes.

It uses a specific phrase that I think is really sticky.

The hijacked brain.

What does that actually mean biologically?

This is the foundational concept for this entire deep dive.

I mean, if you don't get this part, none of the pharmacology we talk about later is going to make sense.

So the hijacked brain refers to how addicting substances essentially take over the brain's natural reward system.

Specifically, we're talking about the dopamine pathways in the limbic system, which is like the emotional part of the brain.

And the main target is the nucleus accumbens, right?

Spot on.

Yes.

The nucleus accumbens is often called the brain's pleasure center.

In a healthy brain, if you say eat a delicious meal or have sex or accomplish a goal, your brain releases a moderate amount of dopamine there.

It's a signal.

It's a signal that says that was good.

Do it again.

This helps us survive.

It's a survival feedback loop.

Okay, that makes sense.

But drugs, and it doesn't matter if it's alcohol, cocaine, opioids, they all do this.

They cheat the system.

They cause a dopamine spike that is significantly higher and lasts much, much longer than any natural reward.

So it's like a megaphone compared to a whisper.

That's a perfect analogy.

The brain gets flooded with the super reward.

And that's where the hijacking happens.

That is exactly where it happens.

With repeated use, the brain tries to protect itself from this constant flood.

It essentially says, okay, this is way too much noise, and it turns down the volume.

How do they do that?

It reduces the number of dopamine receptors.

It's a process called neuroadaptation.

It's literally changing the wiring to cope with the new normal.

And that leads to the problem where the person can't feel normal pleasure anymore from normal things.

Right.

You've hit the nail on the head.

The things that used to make them happy, a sunset, a good grade, hanging out with friends, they don't register anymore because the brain's volume knob is turned down so low.

The only thing that can break through that new baseline and create any feeling of normalcy or even pleasure is the drug.

So the survival mechanism has been rewired.

It's been hijacked to prioritize the substance above everything else.

Food, water, family, it all comes second.

This leads to my absolute favorite analogy in the entire textbook.

I think it's an old alcoholic's anonymous saying, but it explains neuroplasticity so perfectly.

Once a cucumber becomes a pickle, it can never be a cucumber again.

It's brilliant in its simplicity, isn't it?

It explains the permanence of addiction.

When you expose the brain to these substances over time, you physically alter the structure and chemistry of the neurons.

You turn the cucumber into a pickle and you can't unpickle it.

You cannot.

You can stop drinking.

You can be sober for 20, 30, 40 years.

You can be what they call a dry pickle, but you can never go back to being a cucumber.

Meaning you can't go back to being a social drinker.

Never because those neural pathways, those structural changes are still etched into your brain.

They're dormant, maybe, but they aren't gone.

A single drink can reactivate them.

The text also highlights a specific vulnerability when it comes to age.

Why does this pickling process happen faster or maybe more intensely in adolescents?

It all comes down to brain development, specifically something called myelination.

The human brain develops from the back to the front.

The very last part to finish developing is the frontal lobe.

That's the CEO of the brain.

It's where we do our executive functioning or impulse control, our long -term decision making.

And myelination is kind of like the rubber insulation on electrical wires.

It helps the signals move faster.

Exactly.

It makes the signals move fast and efficiently.

In teenagers, the frontal lobe isn't fully insulated yet.

It's still under construction.

The wiring is still being laid down.

So if you introduce these powerful chemicals, you disrupt that construction.

The hijacking is much easier to accomplish, and the damage tends to be more widespread and more permanent.

It explains why the single biggest predictor of lifelong addiction problems is the age of first use.

The earlier you start, the higher the risk.

Okay, so we've got the biology down.

That's a solid foundation.

Now let's put on our scrubs.

We're walking into the clinic.

Section one is all about assessment.

Right.

And the text warns us right away that assessing for substance use is tricky because of one major defense mechanism.

Denial.

Denial is the absolute hallmark of the disease.

And it's not necessarily lying in the way we usually think of it.

It's a deep -seated psychological shield.

Right.

The text suggests that 40 to 60 percent of patients will underreport their use.

They minimize.

They rationalize.

They'll just have a couple of beers to unwind.

What they mean is it's a 12 -pack every single night.

So as a nurse, you can't just take everything the patient says at face value.

You need a high index of suspicion.

What are some of the physical or behavioral tells we should be scanning for?

You're looking for patterns.

The text gives a great list.

Absenteeism from work or school is a big one, especially what they call the Monday flu.

If a patient is constantly calling in sick right after the weekend or a holiday, that's a red flag.

Frequent accidents or unexplained injuries, bruises they can't quite account for, falls.

Or more subtle, right?

Yeah.

Wardrobe choices.

Yes, that's a good one.

Wearing long sleeves in the middle of July, what could that be hiding?

Track marks.

Track marks, needle scars on their arms.

Or you might hear about disappearing prescriptions where the patient is maybe reading the family medicine cabinet or they keep losing their own pain meds to get early refills.

So because the verbal interview is so unreliable, we often have to rely on the hard science.

Biological testing.

The text gives us table 31 -3 on urine detection windows.

This feels like classic exam material.

Oh, this is 100 % going to be on your test, but it's also crucial for triage in the real world.

And there are some massive misconceptions here.

Okay, let's break it down.

Let's look at alcohol first.

If a patient went on a bender Saturday night, can we catch it in a urine screen on say Wednesday?

Probably not.

The text says the window is really short, just one to three days.

Okay.

Alcohol is water soluble and it metabolizes pretty quickly.

Cocaine is similar.

It's usually out of the system in two to three days.

But then we have the big outlier.

Marijuana.

Marijuana.

This is the one that trips people up all the time.

Why is it so different?

Because THC, the active component, is fat soluble.

We call that lipophilic.

It doesn't just stay in the water of your blood.

It tucks itself away into your fat cells.

It hangs out there.

And because of the storage mechanism, it releases very, very slowly back into the system over time.

So the detection window is much longer.

Much longer.

For a heavy, chronic user, THC can be detected in their urine for up to 30 days and sometimes even longer than that.

That's a vital distinction for a nurse to make.

It's critical because a positive pot test doesn't necessarily mean the patient is high right now.

It means they have used in the last month.

A positive alcohol or cocaine test, on the other hand, usually means very recent use.

Okay.

That's a great clinical pearl.

Now, going back to the interview itself, the text gives some really good advice on how to talk to these patients.

It says we need to avoid what they call pejorative labels.

Words matter so much.

If you walk into a room and your first question is,

are you an alcoholic or are you a junkie?

What happens?

The wall goes up.

Yeah.

Instantly.

Instantly.

You've triggered their defense mechanism and the conversation is over before it started.

So how do we rephrase it to get an honest answer?

We use factual non -judgmental cause and effect questioning.

Instead of the label, you link the substance to the consequence.

Can you give an example?

Sure.

You could ask, have you had any problems at work because of your drinking?

Or are you finding that you often drink more than you intended to when you go out?

Oh, I see.

You're linking the substance to a real world problem.

Exactly.

It's much harder for a person to deny that they missed a shift at work than it is for them to deny a loaded label like alcoholic.

This whole approach seems to align perfectly with a major theoretical framework that the chapter introduces next, the trans theoretical model of change.

Yes.

That's a mouthful, but it's absolutely essential nursing theory.

It is.

It was developed by Prochaska and DiClemente and it's so brilliant because it recognizes that change isn't a light switch.

You don't just wake up one day and decide to be different.

It's a process with distinct stages.

And as a nurse, you have to know which stage your patient is in.

You have to.

If you don't, your interventions are going to fail.

They'll just bounce right off.

Okay.

Let's walk through the stages.

Let's use a hypothetical patient.

Let's call him Bob.

Stage one is pre -contemplation.

Where is Bob at in his head?

Bob is in the zone of total denial.

He is saying, I don't have a problem.

You have the problem.

My wife has the problem because she won't stop nagging me.

He has absolutely no intention of changing his behavior.

So if you try to force Bob into rehab at this stage, he'll check himself out an hour later.

It's a waste of time.

Your job here is just to gently plant a seed of doubt.

Okay.

So then we move to stage two, contemplation.

Now the gears are starting to turn a little bit.

Bob is fence sitting.

He's ambivalent.

He might acknowledge, okay, maybe my drinking is hurting my liver and maybe that DUI last year was pretty bad, but I really need it to relax after work.

He's weighing the pros and cons.

So there's an opening there.

Small one.

Stage three, preparation.

Now Bob is getting ready to jump.

This is a critical window for us as clinicians.

He might be looking up AA meeting schedules online or buying a self book or maybe he's the one who called your clinic to ask about detox programs.

So he hasn't stopped drinking yet, but he's making a plan to stop.

Exactly.

The intent is there.

Then come stage four, action.

This is the visible change.

This is what most people think of as quitting.

Bob flushes the pills down the toilet.

He walks into that first AA meeting.

He commits to the treatment plan.

This is the stage that requires the most energy and commitment.

Followed by stage five, maintenance.

This is the hardest part for so many people.

This isn't about the first week.

This is about keeping the change going for six months, a year, five years.

It's about total lifestyle remodeling, sometimes changing friends, changing your route home from work so you don't pass your old bar.

It's about preventing relapse, but the model includes a sixth element, which is relapse itself.

This is so, so important for you and for the patient to grasp.

The model views relapse not as a catastrophe or a failure, but as a likely almost expected part of the cycle.

It's not back to square one.

No, it's a recycling.

The person falls back usually to the contemplation or preparation stage.

The goal of the nurse is to reengage them and help them learn from the relapse.

What was the trigger?

What can we do differently next time?

It's part of the process.

Okay.

Moving into section two, let's get a bit more technical with the actual diagnosis.

Right.

We're looking at the DSM -5 criteria for substance use disorders.

Right.

The text lists a whole bunch of criteria, but the key is that to get a diagnosis, the patient needs to meet at least two of them within a 12 -month period.

We can group these criteria into a few different buckets to make them easier to remember for an exam.

Okay, good.

First, you have the physiological buckets, tolerance and withdrawal.

Tolerance goes right back to that hijacked brain concept, right?

Yes, exactly.

It means needing markedly increased amounts of the substance to get the desired effect.

The two beers that used to give you a buzz now do absolutely nothing, so you need to drink six to feel the same way.

And withdrawal is the body protesting when you stop taking the substance.

Precisely.

Then you have the behavioral buckets.

A big one is loss of control.

This is using larger amounts or for a longer period than you intended.

Like the person who says, I'm only going to have one glass of wine at the wedding.

And they wake up three days later with no idea what happened.

Or they express a persistent desire to cut down but find that they fail every single time they try.

Then there's social impairment.

This is when the drug starts to cannibalize the rest of their life.

They start giving up hobbies they used to love.

They fail to pick up their kids from school.

They stop showing up for work.

And finally, the last bucket is risky use.

This is pretty straightforward.

It's using in physically hazardous situations like driving a car or operating heavy machinery while intoxicated.

Or continuing to use despite knowing it's causing or worsening a physical or psychological problem.

Like drinking even though you know you have liver failure and your doctor has explicitly told you it will kill you.

That's a perfect example.

Okay, let's do a deep dive into the specific substances now.

Section three focuses on what the text calls the heavyweight champion of addiction,

alcohol.

It is without a doubt the primary drug problem in North America.

We often overlook it because it's legal and so culturally embedded, but the damage it causes is unparalleled.

The text notes that alcohol misuse alone costs the U .S.

over $223 billion a year.

So let's talk about etiology.

Where does alcoholism come from?

The text brings up the idea of an alcoholic personality.

Is that a real thing?

You know, the text actually steers us away from that idea.

For a long time, psychology was looking for a specific addictive personality type.

Right.

But the current thinking is that many of the traits we associate with addiction like dependency, low self -esteem, passivity are often the consequences of the addiction, not the root cause.

But genetics.

Yeah.

That's a different story.

Oh, that's a huge factor.

The evidence is overwhelming.

Children of alcoholics are four to ten times more likely to become alcoholics themselves even if they're adopted at birth and raised by non -alcoholic parents.

Wow.

If you have that genetic loading, the gun is loaded.

Environment just pulls the trigger.

Now for all the nursing students who need to pass their pharmacology exam,

we need to geek out on the pharmacokinetics for a minute.

How did the body actually process booze?

Okay.

Let's trace the journey.

About 20 % of it is absorbed right through the stomach wall.

That's why you feel it so fast on an empty stomach.

But the other 80 % is absorbed in the small intestine.

From there, it all heads straight to the liver.

And the liver is the main chemical factory.

Can you explain the oxidation process?

Because this is key to understanding how some of the medications work later.

Absolutely.

Okay.

Picture an assembly line in the liver.

Step one.

An enzyme called alcohol

dehydrogenase takes the alcohol molecule and breaks it down into a new chemical called acetaldehyde.

And acetaldehyde is bad news.

Acetaldehyde is the villain of this story.

It's toxic.

It's the chemical that's responsible for the nausea, the flushing, the pounding headache, all the misery of a bad hangover.

So the body needs to get rid of it fast.

Right.

So step two, another enzyme, a different one, comes along and breaks that toxic acetaldehyde down into acetic acid.

And acetic acid is harmless.

It's basically vinegar and the body just flushes it out.

So the flow is alcohol becomes toxic stuff, which then becomes harmless stuff.

Simple as that.

Now here's where it gets interesting.

There is a medication called disulfiram, brand name anti -abuse.

It acts like a roadblock at step two of that assembly line.

It stops the breakdown of the toxic stuff.

Precisely.

It inhibits the enzyme that clears the acetaldehyde.

So if a patient takes their anti -abuse and then drinks even a small amount of alcohol, that toxic chemical accumulates instantly in their body.

And what happens to them?

They get violently ill.

We're talking flushing, a throbbing headache, projectile vomiting, chest pain, palpitations.

It's called the disulfiram alcohol reaction.

It sounds like you're giving them a chemical aversion therapy.

If I drink, I will feel like I'm dying.

That is exactly what it is.

It's for highly motivated patients.

Now, speaking of enzymes, the text explains why women tend to get intoxicated faster than men.

And it's not just about body size.

Right.

There's actual biology at play here.

It's a kind of biological unfairness, really.

Women actually have less of that first

dehydrogenase in their stomach lining.

Oh, interesting.

So when a man drinks, a significant amount of that alcohol is neutralized in the stomach before it ever even enters his bloodstream.

It's called first pass metabolism.

Women don't have that protection to the same degree.

They absorb more of what they drink.

Plus the body water difference.

Exactly.

Women biologically have less body water and more body fat than men.

So the alcohol becomes more concentrated in their system much more quickly.

Let's talk about tolerance again.

The text adds a nuance here.

Pharmacokinetic versus pharmacodynamic tolerance.

What's the difference?

This is a great distinction.

Perfect for an exam question.

Pharmacokinetic tolerance is all about the liver.

If you're a chronic heavy drinker, your liver essentially goes to the gym.

It creates more of those enzymes to handle the constant load.

It gets very, very efficient at scrubbing alcohol from the blood.

And the other one, pharmacodynamic.

Pharmacodynamic tolerance is all about the brain.

The neurons themselves adapt to the constant presence of alcohol.

They become less sensitive to its effects.

They sort of toughen up.

And this explains how a chronic alcoholic can be walking and talking with a blood alcohol level that would put me in a coma.

100%.

You might see a patient in the ER who is walking, talking and demanding cigarettes with a blood alcohol level or BAL of 0 .35%.

A non -drinker would likely be unresponsive or even dead at that level.

That's dangerous for us as nurses because you might underestimate how intoxicated they really are based on their behavior alone.

You have to trust the number, not just what you see.

So let's look at the benchmarks in the text box on blood alcohol levels.

At 0 .05%, we're seeing euphoria, some disinhibition.

At 0 .08 % to 0 .10%, we're legally intoxicated.

Motor skills get sloppy.

But where's the real danger zone?

Once you get up to 0 .40 % to 0 .50%, you're looking at severe respiratory depression, coma and death.

And here's the scary part, because of that tolerance we just talked about.

The gap between the dose that makes them feel drunk and the dose that kills them gets narrower and narrower for chronic alcoholics.

Their brain is tolerant, but their brain stem, the part that controls breathing, is not.

They can literally drink themselves to death just trying to get that buzz they used to get.

That moves us right into section four, alcohol's effects on the CNS and, crucially, withdrawal.

Alcohol is a depressant, but withdrawal is the complete opposite.

It's a state of hyper excitability.

Think of alcohol as a heavy weight that's constantly sitting on a spring.

That spring is your central nervous system.

Alcohol weighs it down, sedates it, keeps it compressed.

And when you quit drinking.

You suddenly remove that weight.

The spring doesn't just go back to normal.

It snaps back wildly.

It overshoots its resting state.

This violent rebound is withdrawal.

So everything speeds up.

Pulse, blood pressure, anxiety.

Yes, psychomotor agitation.

But before we get to the withdrawal timeline, the text mentions some of the damage alcohol does while you're actively using it.

Specifically, blackouts.

And a blackout is not the same as passing out, right?

Correct.

That's a common misconception.

Passing out is losing consciousness.

A blackout is a form of anterograde amnesia, meaning the person is awake, they're walking, talking, driving, maybe even having arguments.

But the alcohol has chemically shut down their hippocampus, the brain's video recorder.

They are living in the moment, but the record button is off.

They wake up the next day with a blank tape.

No memory of what they did.

And then there's Wernicke -Korsakov syndrome.

This is a classic need to know for nurses.

Absolutely.

This is a big one.

Alcoholics often have terrible diets, and alcohol itself blocks the absorption of key vitamins.

This leads to a severe deficiency in thiamine, which is vitamin B1.

And the brain needs thiamine to function.

Desperately.

Without it, the brain starts to die.

Wernicke's encephalopathy is the acute phase.

You see confusion, ataxia, which is a classic wobbly, unsteady walk, and strange eye movement abnormalities.

But this part is reversible.

It is reversible if you catch it early and flood the body with thiamine.

If you don't, it progresses and becomes Korsakov's psychosis.

And that's permanent brain damage.

Yes.

It involves a chronic inability to learn new information and something called confabulation.

The brain has all these holes in its memory, so the patient subconsciously invents plausible stories to fill in the gaps.

They aren't lying on purpose.

Their brain is just trying to make sense of a fragmented reality.

This is why, when an alcoholic comes into the ER, they almost always get a banana bag.

The famous yellow phy bag.

It's full of thiamine and other vitamins.

We are trying to save their brain before it's too late.

Now let's look at that withdrawal timeline.

The text is very clear.

Alcohol withdrawal is unique because it can kill you.

That's right.

Opioid withdrawal will make you wish you were dead.

But alcohol withdrawal can actually stop your heart or cause a fatal stroke.

It's a true medical emergency.

What happens and when?

What's the progression?

It happens in stages.

Minor withdrawal usually starts about six to eight hours after the last drink.

You see tremors, the shakes,

anxiety, sweating, maybe some nausea.

Okay.

Then you can get alcoholic hallucinosis around the 24 to 48 hour mark.

These are usually auditory hallucinations.

They might hear voices, but what's key here is that they usually have a clear sensorium.

They know it's not real.

And then comes the big bad wolf.

Delirium tremens or the DTs.

This is the one we're trying to prevent.

It usually happens around day two or three after the last drink.

This is a full -blown medical emergency.

The patient becomes completely delirious, confused, disoriented.

And the hallucinations change.

They do.

They become terrifying visual hallucinations.

The text mentions pink elephants, which is a bit of a cliche, but they see terrifying things like snakes or bugs crawling on them or the room being on fire.

And their vitals go haywire.

Completely haywire.

Super high blood pressure, racing heart, high fever.

They can seize and those seizures can be fatal.

So how do we stop that spring from snapping back so hard?

The text mentions using the CIWA protocol.

The CIWA scale helps us score the severity of the withdrawal symptoms.

And based on that score, we administer benzodiazepines drugs like chlorodiazepopoxide, which is Librium, Diazepam, Valium, or Lorazepam, Ativan.

So you're treating a depressant withdrawal with another depressant.

Exactly.

Here's the logic.

Benzos and alcohol work on the same receptor in the brain, the GABA receptor.

So we give the benzo to substitute for the alcohol, which calms the brain down and prevents that hyper excitable state.

And then you just taper them off the benzo.

Right.

Over a few days, we slowly, slowly lower the dose of the benzo.

It lets that spring return to its normal position gently instead of snapping back violently.

Okay, that makes perfect sense.

Moving to section five, other CNS depressants.

We touched on benzos, but let's quickly mention barbiturates.

These are older drugs like phenobarbital.

They're really dangerous because the difference between a therapeutic dose and a lethal dose is tiny.

It's a very narrow window.

And their withdrawal is just as deadly as alcohol withdrawal.

And there's one specific drug the text calls out, Flynnitrazapam.

Better known by its street name, Rohypnol, or Rufies.

The text identifies this as the classic date rape drug.

Why is it so dangerous in that context?

It causes rapid, profound sedation and crucially amnesia.

The victim has no memory of what happened.

It used to be colorless, odorless, and tasteless, which made it a terrifying weapon.

Okay, then we have inhalants.

This seems to be a very different demographic.

It is.

The users are often much younger adolescents, 12 to 17 years old.

And the reason is accessibility.

It's cheap.

We're talking glue, gasoline, paint thinner, aerosol cans from the garage.

The text calls it huffing or bagging.

Right.

The high is quick, but the risk is just terrifying.

The text mentioned something called sudden sniffing death.

That is a real medical term.

Inhalants make the heart muscle incredibly sensitive to adrenaline.

So a kid takes a huff, gets startled by a parent coming home or a police officer.

Their body releases a surge of adrenaline.

And the heart just stops.

It goes into a fatal arrhythmia, instant cardiac arrest.

It can happen the very first time they ever use.

And what about the long -term damage for those who survive?

It's devastating.

Long -term, these chemicals are solvents.

They dissolve fat.

And since the brain is mostly fat, specifically that myelin sheath,

chronic inhalant use literally melts the brain's insulation.

It causes severe irreversible dementia and loss of coordination.

That is horrifying.

Let's move to section six, opioids.

We're talking heroin, morphine, oxycodone, fentanyl.

Right.

These drugs act by mimicking our body's own natural painkillers, the endorphins.

They bind to opioid receptors in the brain and produce this rush of euphoria that users often a sexual orgasm followed by a profound heavy calm or the nod.

Physically, though, they are depressants.

So what is the absolute telltale physical sign of an opioid user?

You look at their eyes.

Pinpoint pupils.

The medical term is meiosis.

That is the classic sign, along with drowsiness and slurred speech.

Is that always the case?

Almost always.

There's an exception alert for your exam.

The opioid meparidine or demoral usually doesn't cause pinpoint pupils.

But for pretty much everything else, heroin, morphine, fentanyl, you look at the eyes.

Okay.

Now, the overdose crisis.

This is something every single nurse listening will see in their career.

What is the opioid overdose triad?

This is critical.

If you find someone unresponsive, you check for three things.

One, coma or unconsciousness.

Two, respiratory depression.

Their breathing is dangerously slow and shallow, often less than 12 breaths a minute.

And three, pinpoint pupils.

Coma, respiratory depression, pinpoint pupils.

If you see those three things together, you have to assume it's an opioid overdose until proven otherwise.

And the rescue drug is naloxone, brand name Narcan.

Narcan is an opioid antagonist.

Think of it like a bouncer.

It rushes in, kicks the heroin off the brain's receptors, and then stands guard so the opioid can't get back on.

It reverses the overdose almost instantly.

It's miraculous.

But UT, and this is probably the most critical nursing point of this entire deep dive,

Narcan has a shorter half -life than most of the opioids it's reversing.

Can you explain what that means for the nurse on the floor?

It means the Narcan wears off in about 30 to 90 minutes, but the heroin or methadone in the person's system might last for four to eight hours.

So you give the Narcan, the patient wakes up, they're talking to you, you think, great, job done.

You walk away to care for another patient.

And 45 minutes later.

45 minutes later, the Narcan fades, the opioid reattaches to those unprotected receptors, and the patient stops breathing again.

They slip right back into a coma.

You cannot just give Narcan and release them.

You have to monitor them for several hours.

And how does the patient feel when you wake them up with Narcan?

They feel terrible.

You have just ripped all the soothing, pain -killing chemicals off their brain receptors all at once.

They wake up in immediate precipitous withdrawal.

They'll be agitated in severe pain, vomiting, and often very angry at you for ruining their high.

Safety is key.

Speaking of withdrawal, how does opioid withdrawal compare to alcohol withdrawal?

Like we said, alcohol withdrawal is dangerous.

Opioid withdrawal is miserable.

It is rarely fatal, but it feels like the worst flu of your life times 10.

The text lists the symptoms under the term dope sick.

Yeah, you see yawning, a constantly runny nose, a rhinorrhea, tearing eyes, a deep, aching bone pain that feels like it's in the marrow, and horrible diarrhea.

And there are two famous phrases that come from the physical symptoms, right?

Yes.

The phrase cold turkey comes from the goose flush, or paloerection that covers the skin, making it look like a plucked turkey.

And the phrase kicking the habit comes from the severe involuntary leg spasms and kicking movements they experience.

Moving to section seven.

Stimulants, cocaine, amphetamines, meth.

A total reversal from opioids.

These are the uppers.

They don't just mimic dopamine.

They block its reuptake.

Imagine a little vacuum cleaner in your synapse that sucks up used dopamine.

Stimulants unplug that vacuum.

So the brain gets flooded.

Completely flooded with its own dopamine.

Let's talk cocaine first.

It's a short but very intense high.

The physical signs are the opposite of opioids.

You see dilated pupils.

The term is madriasis, tachycardia, or a racing heart.

High blood pressure.

And if they snort it?

The vasoconstriction is so severe that it can actually kill the tissue inside the nose.

Over time, you can get a perforated nasal septum, a literal hole between the nostrils.

And methamphetamine.

Meth is like cocaine's evil twin.

It's longer acting and much more destructive to the body and brain.

We see things like meth mouth, severe tooth decay from a combination of dry mouth, teeth grinding, and poor hygiene.

And the skin picking.

Yes, that's called formication.

It's a tactile hallucination that bugs are crawling under their skin, which leads to constant frantic skin picking and open sores.

Let's touch on ecstasy or MDMA, the club drug.

Right.

It works by increasing both serotonin and dopamine.

It creates a feeling of empathy and emotional closeness.

But physically, the big danger is hyperthermia.

Overheating.

Exactly.

Kids at raves will dance for hours in a hot club.

They get severely dehydrated, their body temperature skyrockets, and their organs shut down.

It can be fatal.

It also causes severe teeth grinding, which is called bruxism.

That's why you sometimes see kids at raves with pacifiers in their mouths.

It's to save their teeth from cracking.

So what's the number one nursing priority with a patient on stimulants?

Their heart.

You have to think cardiac.

These drugs put a massive strain on the cardiovascular system.

You need to have them on a cardiac monitor, watching for arrhythmias or even a heart attack.

And then there's the crash.

The crash is just as dangerous.

When the drugs wear off, the brain is completely depleted of all its happy neurotransmitters.

The depression that follows is bottomless.

The suicide risk during the crash phase is extremely high.

Section eight covers hallucinogens and marijuana.

Right.

So LSD and PCP.

These drugs cause profound sensory distortions.

One interesting one is synesthesia, where you might hear colors or see sounds, but the real risk is the bad trip.

Panic and paranoia.

Panic, paranoia, and totally unpredictable, sometimes violent behavior, especially with PCP.

A person on PCP can be impervious to pain and have incredible strength due to the adrenaline release, making them very dangerous to themselves and to staff.

And then there's marijuana.

The text notes it's the most widely used illegal drug, though that legal landscape is obviously changing fast.

It is.

The active ingredient is THC.

We already discussed how it's fat soluble and stores in the body.

The effects people seek are euphoria, relaxation, and increased appetite.

Munchies.

Which can be therapeutic.

It can be.

It's used for chemotherapy patients with nausea or AIDS patients with wasting syndrome who need to eat.

But the text really pushes back on the idea that it's a totally harmless drug.

It does.

It points to a motivational syndrome in heavy chronic users, a state of apathy, lack of drive, and general lethargy.

And regarding cognitive impairment, the text poses a fantastic critical thinking question.

I remember this one.

It says,

if you think marijuana is benign, would you want your neurosurgeon to smoke a joint before operating on your mother?

That really puts it in perspective.

It does.

It impairs motor coordination and judgment for hours after use.

OK.

We have covered the drugs.

Now, section nine.

Nursing interventions.

How do we actually treat the patient on the unit?

It all starts with the milieu, the environment itself.

And priority number one is always safety.

We have to check for contraband when they're admitted.

We have to ensure a drug -free environment so that one patient's use doesn't trigger another.

And we have to implement suicide precautions, especially for patients coming down from stimulants or in withdrawal.

And the text talks a lot about limit setting.

This is so essential.

Addictive behavior often involves a lot of manipulation, demanding behavior, or splitting staff against each other.

Like, the day nurse said I could, why are you saying no?

Exactly.

Mom said yes, so dad will too.

The nursing staff has to be a united front.

The rules must be consistent and firm.

No, you cannot have extra meds.

No, you cannot use the phone right now because it's group time.

The text also talks about the nurse -patient relationship.

It mentions the need for confrontation.

That sounds kind of aggressive.

It's not about aggression.

It's about holding up a mirror of reality.

It's about breaking through that denial we talked about at the very beginning.

So what does that sound like?

A patient might say, I really don't drink that much.

The nurse's confrontation would be, you were admitted last night with a blood alcohol level of 0 .30 and a broken leg from falling down the stairs.

You're presenting the objective facts, gently but firmly.

And tough love.

What does that mean in a nursing context?

It means not enabling the addiction.

If you make excuses for the patient or call their boss for them or shield them from the natural consequences of their use, you are helping the addiction, not the person.

You have to let them feel the weight of their choices.

There's a great little acronym in the text for relapse triggers,

HALT.

Yes,

this is a great simple tool to teach patients.

Don't let yourself get too hungry, angry, lonely, or tired.

Because when our basic needs aren't met, our willpower crumbles, our defenses are down.

It's a simple checklist for self -care that can prevent a lot of relapses.

Okay, let's do a rapid -fire review of the meds to know for maintenance.

We already did Desulfuram or Antabuse, the punishment drug.

What else is in our toolbox?

Okay, next up is Nultrexone, brand name Revia.

This is an opioid blocker, but surprisingly, it also works really well for alcohol.

It works by reducing the craving, and it takes the fun out of the substance.

If a patient on Nultrexone slips and has a drink, they don't get that same euphoric high, which helps to break the positive reinforcement loop.

Okay, then there's a Campersate or Camprol.

This one is all about brain chemistry.

It helps to rebalance the GABA and glutamate systems that have been completely wrecked by long -term drinking.

It reduces the physical distress of early sobriety, the anxiety, the insomnia that often drives people to relapse.

It helps you stay quit.

And for opioids, we have methadone.

Methadone is a synthetic opioid.

It is an agonist, meaning it activates the same receptors, but it has a very long half -life.

The patient takes it once a day.

It stops the withdrawal symptoms and the cravings, but if it's dosed correctly, it doesn't provide the high.

So it allows them to stabilize their life.

Yes, it allows them to function, hold a job, be a parent.

It's a philosophy known as harm reduction.

And then there's buprenorphine, like subutex or suboxone.

Similar idea, but buprenorphine is a partial agonist.

This means it has a sealing effect.

It's much, much harder to overdose on it than on methadone, which makes it a safer option for many patients.

Finally, let's talk support groups.

AA and NA are the big ones.

The 12 -step model.

It's the most famous and widespread approach.

It's based on a philosophy of total abstinence.

The core idea is admitting you are powerless over the addiction and surrendering to a higher power.

And the text notes that this spiritual component can be a barrier for some people.

It can be, but the real power of these programs is often in the community aspect, one addict helping another.

That peer support is incredibly powerful.

And what about the families?

Because they suffer immensely too.

Yes, and for them, there is Al -Anon.

That is a group specifically for the spouses, parents, and children of alcoholics.

They learn the three Cs.

They didn't cause it, they can't control it, and they can't cure it.

They learn to detach with love and focus on their own recovery from the effects of the disease.

The final section of the chapter, section 10, brings us to a topic that's uncomfortable but so necessary.

The impaired professional.

Yes, nurses.

We have a rate of substance abuse that's similar to the general population, but we have higher stakes.

We have incredibly high stress.

We often have physical pain from lifting patients.

And most importantly,

we have access.

We have the keys to the candy store.

So what are the signs that a colleague might be devoting drugs for their own use?

You have to watch for patterns.

Be suspicious of the nurse who always volunteers to give all the pain meds on the unit, or the one who volunteers for extra shifts or overtime constantly just to be near the source.

And what about from the patient's perspective?

A huge red flag is when patients start complaining of ineffective pain relief, but only after that specific nurse cared for them.

That could mean the nurse took the morphine for themselves and injected the patient with saline instead.

If a nurse is caught, is their career just over?

Not necessarily.

And that's the good news.

Most state boards of nursing now prefer treatment over punishment.

They have what are called peer assistance programs.

So what does that look like?

The nurse usually signs a contract.

They go to rehab.

They are then monitored with random urine screens for years.

They can often return to work, but usually with restrictions like no working night shifts and no access to the narcotic keys for a set period.

The goal is to save the nurse, not just fire them and push them further into their disease.

We have covered a massive amount of ground today.

I mean, this chapter is huge.

Let's try to summarize the absolute key takeaway.

One, substance use is a brain disease.

The hijacked brain.

Not a moral failure.

Remember the pickle?

The pickle.

Two, assessment requires skepticism because of denial, but also empathy.

And watch those urine detection windows.

They're different for different drugs.

Three, alcohol withdrawal is the most dangerous one physically.

You have to watch for seizures and the DTs.

Four, opioid overdoses that triad.

Coma, respiratory depression, and pinpoint pupils.

And for the love of God, watch out for Narcan wearing off for the opioid does.

And five, nurses are crucial for creating a safe milieu, setting firm limits, and identifying and helping our own impaired colleagues.

The text leaves us with one final thought to ponder.

It circles back to the sheer tragedy of it all.

It mentions another clinical example, a mother named Maggie Jean Wirtman.

This is a heavy one to end on.

She was a methamphetamine user.

She breastfed her six -week -old son.

Oh, no.

The meth passed through the breast milk.

The baby died of a methamphetamine overdose.

She was convicted of manslaughter.

That's just horrific.

It is.

It's an unimaginable tragedy.

But the text asks us to look a little deeper.

Maggie Jean had a profound history of abuse,

domestic violence, and a multi -generational family history of addiction.

It doesn't excuse what happened.

It doesn't excuse the crime at all.

But it forces us to ask the harder question, how would we interrupt this cycle?

If we only punish the crime and we don't treat the underlying disease, we are just waiting for the next tragedy to happen.

And I suppose that's the challenge for the next generation of nurses, to see the person behind the pickle.

That's it, exactly.

Well, that wraps up our last -minute lecture on Chapter 31.

We really hope this helps you ace that exam and, more importantly, be a safer, more compassionate, and better nurse.

Definitely.

Now, go review those tables in the book one more time.

You've got this.

Thanks for listening to The Deep Dive.

We'll see you next time.