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The following course content

Introduction   

Substance abuse is described as “a pattern of using a substance (drug) that causes significant problems or distress” (1). As of 2020, 37.309 million Americans were currently using illegal drugs (2). Medical professionals are on the front lines of recognizing, treating, and providing support to individuals who suffer from substance abuse. This Delaware Substance Abuse course will walk you through the different types of substances abused, the prevalence of that abuse, the symptoms one experiences while using that substance, overdose symptoms, and how to counteract an overdose. You will also learn about substance abuse in adolescents and nurses and prevention methods currently being used to combat substance abuse in these populations.

Alcohol

Alcohol abuse is the second most common type of substance abuse, after tobacco use as the most common (3). While many individuals in the United States can drink alcohol in moderation and not considered abuse, there are some individuals whose drinking causes harm or distress. In the case of an alcohol use disorder, harm or distress is described as alcohol leading to health problems, or trouble while at home, work, school, or with law enforcement (3).   

This Delaware Substance Abuse course will help you identify several signs and symptoms of alcohol use disorder. As health care providers, it is important to understand the signs and symptoms to properly help and treat those who are experiencing alcohol use disorder. Symptoms can range from mild to severe, depending on the number of symptoms experienced (5), and include: 

1. Unable to limit the amount of alcohol consumed 
2. Wanting to decrease the amount consumed, but being unsuccessful 
3. Spending a large amount of time obtaining alcohol, drinking alcohol, or recovering from alcohol use 
4. Having a strong craving or urge to drink alcohol 
5. Not completing major obligations at work, school, or home due to alcohol use 
6. Continuing to drink alcohol even though you know it is causing problems physically, at work, at home, or in relationships 
7. No participating in social activities or work-related functions to consume alcohol  
8. Developing a tolerance to alcohol so more is needed to elicit the same effect 
9. Experiencing symptoms of withdrawal, such as nausea, sweating, and shaking when you are not drinking
   

While the above signs and symptoms are typically ones that do not have a medical component attached, alcohol use disorder impacts nearly every organ and system in the body. This widespread impact can have a detrimental effect on an individual suffering from alcohol use disorder (4) such as: 

1. Neurologic
   – Ischemic stroke
   – Hemorrhagic stroke
2. Cardiac
   – Cardiomyopathy
   – Arrhythmias
   – Ischemic heart disease
   – Hypertension
3. Lung
   – Acute respiratory distress syndrome
   – Pneumonia
4. Liver
   – Steatosis
   – Steatohepatitis
   – Fibrosis
   – Cirrhosis
   – Alcohol-associated hepatitis
   – Liver cancer
5. Pancreas
   – Acute and chronic pancreatitis
6. Gastrointestinal
   – Gut leakiness
   – Microbial dysbiosis
   – Colorectal cancer

Clear patterns have emerged between alcohol use disorder and increased risk for certain types of cancers (4): 

1. Head and neck cancer
   – Oral cavity
   – Pharynx
   – Larynx
2. Esophageal Cancer
3. Liver Cancer
4. Breast
5. Colorectal Cancer
   

Knowing the effects of chronic alcohol use on the body is important in understanding the treatment methods that will be needed. Treatment options range from spiritual to medical, with many individuals utilizing more than one option (6).  

1. Detox and withdrawal
   – This treatment option is typically done in an inpatient setting. Treatment begins with detoxification, which leads to withdrawal symptoms. These symptoms can be medically managed, and occasionally require sedating medications. Detox and withdrawal generally take 2 to 7 days.
2. Psychological counseling
   – This treatment option will help the individual better understand their problem with alcohol and provide support on the psychological aspects of alcohol use disorder. This type of treatment can be done individually or in a group setting.
3. Oral medications
   – Disulfiram is a medication that helps to curb one’s want for alcohol. While the drug doesn’t remove the urge to drink, it will produce a physical reaction to consuming alcohol in the form of flushing, nausea, vomiting, and headaches.
   – Naltrexone is used to block the good feelings alcohol causes, which can aid in recovery.
   – Acamprosate is used to help curb cravings for alcohol and is generally used in combination with Naltrexone.
4. Injected medication
   – Vivitrol is the injected version of Naltrexone and is injected once a month. Injected medications may be easier, or more consistently used than oral medications.
5. Medical treatment
   – As we’ve learned, alcohol use disorder comes with a large amount of health concerns. These concerns typically require medical treatment in the form of medication, surgery, outpatient care, etc.
6. Spiritual practice
   – It has been shown that individuals involved in some type of spiritual practice find it easier to maintain recovery.

Case Study

A 35-year-old male is admitted to the medical surgical unit with acute abdominal pain a temperature of 99.7F. Upon examination and CT Scan findings, the provider diagnosed him with acute pancreatitis. During your assessment of the patient, you notice he appears anxious and is fidgeting a lot in bed. You also notice a strong alcohol odor on his breath.

• What can you ask the patient to further assess his alcohol use?
• Does your facility use a specific alcohol screening tool?
• What treatment plan do you anticipate the doctor will order?
• Will this patient require special monitoring?

One of the most widely used alcohol abuse screening tools is the CAGE screening tool. You can ask your patient the following questions. Each “Yes” answer is 1 point. A score of 2 or higher is significant for alcohol abuse.

1. Have you ever felt you ought to cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

If you suspect a patient may also be abusing illegal substances, there is a modified version of the tool called CAGE-AID. The scoring system is the same.

1. Have you ever felt you ought to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you ever felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

CIWA-AR

The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised or CIWA-AR is a common tool used in hospitalized patients with alcohol abuse like the one we discussed in the case study. The assessment scores obtained using this tool are intended to guide the treatment plan for alcohol withdrawal. The nurse will score the following categories:

• Nausea and Vomiting
• Tactile Disturbances
• Tremor
• Auditory Disturbances
• Paroxysmal Sweats
• Visual Disturbances
• Anxiety
• Headache, fullness in the head

Marijuana

Marijuana, also known as cannabis, weed, or pot, refers to the dried flowers, leaves, stems, and seeds of the cannabis plant. In one cannabis plant, there are over 100 compounds ranging from tetrahydrocannabinol (THC) to cannabidiol (CBD) (7). While THC and CBD have the same molecular structure, the difference in how the atoms are arranged accounts for the different effects on the body. THC is the main psychoactive compound in cannabis, which produces a high sensation, while CBD, although psychoactive, does not produce a high sensation (8). 

Marijuana is the most used federally illegal drug in the United States. In 2019, the CDC reported that 48.2 million, or ~18% of Americans have used marijuana at least once. There are several ways to use marijuana, including smoking in joints, blunts, or bongs, vaping via electronic vaporizing devices, mixing or infusing into foods or drinks, or inhaling oil concentrates (7).  

This Delaware Substance Abuse course will help you identify the health risks associated with using marijuana, in any form. It is estimated that 3 in 10 people who use marijuana have marijuana use disorder (7).  

The risks include: 

Brain Health

Since marijuana is a psychoactive drug, the main effect is on brain function. Marijuana specifically affects the parts of the brain responsible for memory, learning, attention, decision-making, coordination, emotions, and reaction time.  

Heart Health 

Marijuana is known to make the heart beat faster, which can make blood pressure higher immediately after use. This can lead to an increased risk of stroke, heart disease, or vascular disease. 

Lung Health 

Inhaled marijuana can cause damage to lung tissues and small blood vessels, as well as scarring to the lung. More research is being done to understand the effects of secondhand marijuana smoke. 

Mental Health 

While the relationship is not fully understood, marijuana has been linked to social anxiety, depression, and schizophrenia. 

Unintentional Poisoning 

There is a greater risk for unintentional poisoning with edibles (marijuana baked or put into food or drinks) than with inhaled marijuana. This risk is because children can easily mistake food with marijuana in it. In some instances, emergency medical care has been required. 

The CDC reports that 37% of high school students in the United States have reported using marijuana. This use can come with impacts on their developing brains, resulting in (7): 

1. Difficulty thinking and problem-solving 
2. Problems with memory and learning 
3. Reduced coordination 
4. Difficulty maintaining attention 
5. Problems with school and social life 

Prescription Medicines

Prescription drug abuse is classified as the abuse of a prescription medication that is taken in a way not intended by the prescriber. This abuse can be by the person who the drug was initially prescribed for, or by someone taking another person’s prescription medication.

The National Center for Drug Abuse Statistics shows that 6% of Americans over the age of 12 abuse prescriptions in a year, and 12% of prescription drug abusers are addicted. This is perpetuated by 4 out of 5 pharmacy-filled prescriptions being opioids (10).  

This Delaware Substance Abuse course will help you identify the three categories of prescription drugs: opioids, anti-anxiety medications/sedatives/hypnotics, and stimulants. Signs and symptoms of prescription drug abuse vary depending on the type of drug used (9).

Opioids are a type of medication that is used to treat pain. These medications usually contain oxycodone or hydrocodone. Opioids are the leading cause of drug overdose death, with 74.8% of drug overdose death being from Opioids (11).  The signs of symptoms of opioid drug abuse include (9): 

1. Constipation 
2. Nausea 
3. Feeling high 
4. Slowed breathing rate 
5. Drowsiness 
6. Confusion 
7. Poor coordination 
8. Increased dose needed for pain relief 
9. Worsening or increased sensitivity to pain with higher doses
   

Anti-anxiety medication, sedatives, and hypnotics are used to treat anxiety and sleep disorders. Some medications used for these disorders are alprazolam (Xanax), diazepam (Valium), and zolpidem (Ambien).  The signs and symptoms of drug abuse by these types of medications are (9): 

1. Drowsiness 
2. Confusion 
3. Unsteady walking 
4. Slurred speech 
5. Poor concentration 
6. Dizziness 
7. Problems with memory 
8. Slowed breathing
   

Stimulants are a type of medication used to treat attention deficit/hyperactivity disorder (ADHD) and certain sleep disorders. Some medications used to treat these disorders include methylphenidate (Ritalin, Concerta, and others), dextroamphetamine-amphetamine (Adderall XR, Mydayis), and dextroamphetamine (Dexedrine).  Signs and symptoms of drug abuse by these types of medications are (9): 

1. Increased alertness 
2. Feeling high 
3. Irregular heartbeat 
4. High blood pressure 
5. High body temperature 
6. Reduced appetite 
7. Insomnia 
8. Agitation 
9. Anxiety 
10. Paranoia 
    

Medical complications differ depending on the type of medication abused. Opioids can decrease respiratory rate with the potential for breathing to stop altogether. They can also cause a coma, and lead to death. Anti-anxiety/sedatives/hypnotics can cause memory problems, low blood pressure, and slowed breathing. Like opioids, they can also lead to coma or death. Abrupt withdrawal of these medications can lead to an overactive nervous system and seizures. Stimulants can increase the body’s temperature, produce heart problems, high blood pressure, seizures or tremors, hallucinations, aggressiveness, and paranoia (9).  

Opioids can be reversed with a medication called Naloxone. This medication works by binding to the opioid receptors, then reversing and blocking the effects of other opioids. It is used to restore an individual’s breathing and can be given through injection or nasal spray. If Naloxone is given outside of a medical facility, emergency personnel should be contacted immediately (18).

Naloxone Access

Depending on the state you live in, access to naloxone without a prescription may be available to you. It is recommended to have this on hand if you have a loved one that frequently uses opioid medications. When you obtain naloxone for a loved one, this is called Third Party Prescribing. This initiative was started to reduce the risk of death by opioid overdose.

SafeProject.Org offers a comprehensive list of resources and access rules for each state.

What are some ways that providers with prescriptive authority can mitigate the risks associated with opioid use?

• Ensuring that the patient meets the clinical criteria for the prescription.
• Screening for risk using an evidence-based tool before prescribing.
• Using a safe prescription drug monitoring program (PDMP).
• Completing continuing education on safe prescribing practices.
  • As of December 2022, the Drug Enforcement Administration set forth new requirements for all DEA-registered prescribers to complete 8 hours of continuing education on the treatment and management of opioid disorders and other substance use disorders.
• Discussing treatment goals and alternative pain management with the patient and/or caregiver.
• Include information about tapering off the medication if opioid therapy is discontinued.
• Follow up and monitor before refilling any controlled substance prescription.

If you are not an APRN with prescriptive authority but frequently care for patients that use opioid medications, it is important for you to conduct a thorough pain assessment and report to the provider if you feel that the patient is showing signs of addiction, is misusing the medication or appears too impaired while on it.

Commonly used pain assessment scales

• Wong-Baker Faces
• Numeric Rating Scale
• Visual Analog Scale
• FLACC
• Pain Assessment in Advanced Dementia Scale

Although policies may vary depending on your workplace, it is generally best practice to assess a patient’s pain level before administering pain medication and one hour after to assess its effectiveness.

Additionally, you can provide education to your patients on alternatives to opioids or complementary therapeutic options to help reduce the amount of opioid medication they use.

Pain management is a multidisciplinary approach, you can also reach out to other team members such as physical therapists, occupational therapy, etc. for recommendations.

The 2022 CDC Clinical Practice Guidelines recommends the following non-opioid pain management options whenever indicated:

• NSAIDS
• Acetaminophen
• Ice or Heat Therapy
• Elevating affected limb/extremity
• Rest
• Immobilizing affected limb/extremity
• Exercise and/or stretching.

Case Study

You are providing discharge teaching and instructions to a female patient that recently underwent gallbladder removal surgery and her husband. The patient will be going home with a prescription for oxycodone-acetaminophen 5/325 mg for acute pain management. During the teaching, the patient states, “I don’t think I will need to take this for more than 2-3 days” to which the husband replies “I can use whatever you don’t finish for my back pain”.

• What additional information will you need to provide based on this statement by the husband?
• What are some ways to safely dispose of controlled substances?

Case Study

A patient that was recently diagnosed with metastatic prostate cancer has been admitted to your unit due to a sequelae of complications. The doctor has ordered a patient-controlled analgesic or PCA pump for pain management. The patient has been more tired than usual and his family reports they have been pressing the PCA pump button for him.

• What education will you need to provide to the family?
• If the patient is unable to press the button themselves, are they still a good candidate for a PCA?

Methamphetamine

Methamphetamine is a highly addictive, man-made, central nervous system stimulant. This drug increases heart rate, body temperature, respiration, and blood pressure. It also enhances the user’s energy, attention, focus, pleasure, and excitement (12). It has commonly been referred to as meth, ice, speed, and crystal. Research has shown that 2.5 million Americans aged 12 or older reported using methamphetamine within the past year. 53% of those individuals met diagnostic criteria for methamphetamine use disorder, but less than 1 in 3 received substance use treatment within the past year (13).  

This Delaware Substance Abuse course will help you identify the four ways methamphetamine can be used: smoking, swallowing (pill), snorting, or injecting the powder that has been dissolved in water or alcohol. While methamphetamine produces a high quickly, it also fades quickly. This produces what is called a “binge and crash” pattern of use. This type of use is where an individual will take the drug every few hours for several days at a time, resulting in a lack of food and sleep (14). 

There is a substantial amount of long-term health effects from methamphetamine use. Those who inject methamphetamine are at a higher risk of contracting infectious diseases like HIV and hepatitis C.  

Other long-term problems include (14): 

1. Extreme weight loss 
2. Severe dental problems 
3. Intense itching which can lead to skin sores and infection from scratching 
4. Anxiety 
5. Changes in brain structure and function
   – Changes have been noted to the brain’s dopamine system which has resulted in problems with coordination and verbal learning.
   – Severe changes have also been noted to the areas of the brain that deal with emotion and memory 
6. Confusion and memory loss 
7. Sleeping problems 
8. Violent behavior 
9. Paranoia 
10. Hallucinations
    

Due to the effect methamphetamine has on the body, an overdose often leads to a stroke, heart attack, or organ problems. Because of this, it is imperative health care providers restore blood flow to the affected part of the brain for a stroke, restore blood flow to the heart in the event of a heart attack, or treat the organ issues that present (14). Treatment for methamphetamine use disorder focuses on cognitive-behavioral therapy and motivational incentives, such as vouchers or small cash rewards that encourage individuals to remain drug-free. There is currently no FDA-approved medication to treat a methamphetamine addiction (14).

Cocaine

Cocaine is a highly addictive stimulant drug that is derived from the leaves of the coco plant that is native to South America. Dealers of cocaine may add other drugs to the cocaine, such as amphetamine or synthetic opioids, like fentanyl. Adding synthetic opioids can be especially dangerous and lead to overdose and even death (15). Over 5 million Americans reported current cocaine use in 2020, with nearly 1 in 5 overdose deaths reported (13). 

This Delaware Substance Abuse course will help you identify the several ways in which cocaine can be used. In powder form, it can be snorted or rubbed into an individual’s gums. The powder can be dissolved and injected into the bloodstream. Injecting cocaine produces a faster and more intense high but is short-lasting. If the cocaine is in crystal form, it can be heated and smoked. Cocaine affects the brain by increasing the amount of dopamine produced. This increase in dopamine floods the brain’s reward circuit, which reinforces drug-taking behavior. Repeated cocaine use can lead to the brain’s reward circuit becoming less sensitive, which leads to individuals taking stronger and more frequent doses to achieve the same high as before (15).  

The effects of cocaine are felt almost immediately and can disappear within a few minutes to an hour. There are several health effects of using cocaine (15): 

1. Extreme happiness and energy 
2. Mental alertness 
3. Hypersensitivity to sight, sound, and touch 
4. Irritability 
5. Paranoia 
6. Constricted blood vessels 
7. Dilated pupils 
8. Nausea 
9. Increase in body temperature and blood pressure 
10. Increased or irregular heartbeat 
11. Tremors/muscle twitches 
12. Restlessness 
    

There are several long-term effects of cocaine use. These effects can range from common, to being dependent on the method of use (15) 

1. Malnourished due to a decreased appetite 
2. Movement disorders 
3. Irritability 
4. Restlessness 
5. Auditory hallucinations 
6. Snorting cocaine
   – Loss of smell
   – Nosebleeds
   – Frequent runny nose
   – Problems with swallowing 
7. Smoking cocaine
   – Cough
   – Asthma
   – Respiratory distress
   – Higher risk for infections like pneumonia 
8. Consuming cocaine by mouth
   – Severe bowel decay due to reduced blood flow 
9. Injecting cocaine
   – Increased risk of contracting HIV, hepatitis B and C, and other blood-borne diseases
   – Skin or soft tissue infections
   – Scarring or collapsed veins
   

A cocaine overdose is similar to that of a methamphetamine overdose, with the inclusion of seizures. Like methamphetamine, it is critical that healthcare providers restore blood flow to the heart and brain in the event of a heart attack or stroke. If an individual presents with a seizure due to a cocaine overdose, the first action to be taken is to stop the seizure. Cocaine mirrors that of methamphetamine use in terms of increased dopamine in the brain. This leads to an addictive nature, as well as needing more drugs over time to produce the same high (15).  

Unfortunately, there is no FDA medication approved to treat cocaine use disorder.  

There are several behavioral therapy options available (15): 

1. Cognitive-behavioral therapy 
2. Contingency management or motivational incentives 
3. Therapeutic communities
   – These are residences in which people can recover from substance use disorders with other individuals who understand their addiction, all while being drug-free 
4. Community-based recovery groups 

Heroin

Heroin is a type of drug made from morphine, which is derived from the seed pod of opium poppy plants (16). According to the CDC, over 19% of all opioid overdose deaths in 2020 involved the use of heroin (17). Heroin can be found as a white or brown powder or a black tar-like substance. Like cocaine and methamphetamine, heroin can be injected into the bloodstream, snorted, or heated and smoked. Some individuals mix heroin with cocaine or alcohol, which creates an even higher risk for an overdose and potentially death (16).  

The effects of heroin on the body are like those of prescribed opioids. When heroin reaches the brain, it is turned into morphine, which binds to opioid receptors. This causes the user to feel what is described as a rush, or a pleasurable sensation. How intense the rush is, is determined by how much drug has been taken and how quickly it attaches itself to the opioid receptor (16).   

This Delaware Substance Abuse course will help you identify the several short-term effects that people may experience when using heroin (16): 

1. Dry mouth 
2. Warm, flushing of the skin 
3. Heaving feeling in their arms and legs 
4. Nausea 
5. Vomiting 
6. Severe itching 
7. Clouded mental functioning 
8. Being in a back-and-forth state of consciousness and semi-consciousness
   

Individuals with heroin use disorder may experience some of the following long-term health effects (16): 

1. Insomnia 
2. Collapsed or damaged veins from injecting the drug 
3. Damaged tissues on the inside of the nose due to snorting the drug 
4. Infection in the lining of the heart and the valves 
5. Abscesses 
6. Constipation and stomach cramping 
7. Liver and kidney disease 
8. Lung complications, like pneumonia 
9. Mental disorders like depression and antisocial personality disorder 
10. Sexual dysfunction in men 
11. Irregular menstrual cycle in women 
12. Increased risk for blood-borne diseases such as HIV and hepatitis C 

Heroin overdoses, along with opioid overdoses, have been increasing in the United States. A heroin overdose depresses the user’s heart rate as well as breathing, leading to hypoxia. Those who suffer from heroin use disorder have a wider variety of treatments at their disposal. Behavioral therapies include cognitive-behavioral therapy as well as contingency management. It has been shown that these behavioral therapies work best when used in conjunction with medications.  

Naloxone is a medication that can reverse opioid overdoses if given the correct way. Naloxone can be injected or snorted and has recently been approved for over-the-counter dispense in several states (18).  

There are three other types of medications available to those with heroin use disorder (16):

Methadone

This is an opioid receptor full agonist, which means it attaches itself to and actives an opioid receptor to help ease withdrawal symptoms of heroin cravings.

Buprenorphine

This is an opioid receptor partial agonist, which means it attaches itself to and partially activates opioid receptors to help ease withdrawal symptoms and heroin cravings. 

Naltrexone

This is an opioid receptor antagonist, which means it prevents heroin from binding to opioid receptors, blocking the effects. 

Hallucinogens

Hallucinogenic drugs are described as a group of drugs that alter a person’s awareness of their surroundings, thoughts, and feelings (19). In 2019 it was estimated that 5.5 million people in the United States used hallucinogens within that past year (20).

This Delaware Substance Abuse course will help you identify the two categories of hallucinogenic drugs: classic hallucinogens and dissociative drugs. As the name suggests, both types of hallucinogens can cause the user to experience hallucinations, but dissociative drugs can also cause the user to feel out of control or disconnected from their body (19).  Common classic hallucinogens include (19):

D-lysergic acid diethylamide (LSD)

Considered one of the most powerful mind-altering chemicals. This drug is a clear or white odorless material, made from lysergic acid. Lysergic acid is found in fungi that will grow on rye and other grains.

4-phosphoryloxy-N, N-dimethyltryptamine (Psilocybin)

This hallucinogenic is also referred to as “magic mushrooms” or “shrooms” since it is found on certain types of mushrooms in South America, Mexico, and the United States.

Mescaline (Peyote)

Peyote comes from a small, spineless cactus, but may also be synthetic. While it is illegal in the United States, it can be used in religious ceremonies in the Native American Church.

N, N-dimethyltryptamine (DMT)

A chemical found in some Amazonian plants. It can be made into a tea called Ayahuasca or smoked if synthetically made.

251-NBOMe

This is a synthetic hallucinogen that is like LSD and MDMA but is more potent. It was originally developed for use in brain research. It has also been referred to as “N-Bomb” or “251”.

Common dissociative drugs include (19):

Phencyclidine (PCP)

This drug was initially developed for surgery in the 1950s, but due to its serious side effects, it is no longer used. It can be found in several forms, such as tablets, liquid, and white crystal powder.

Ketamine

This drug is used as an anesthetic for both humans and animals and is typically stolen or sold illegally from veterinary offices. Ketamine comes in powder, pills, or liquid form.

DXM (Dextromethorphan)

This drug is used as a cough suppressant and mucus-clearing ingredient in over-the-counter cold and cough medicines. It can be found in syrup, tablet, or gel capsule form.

Saliva divinorum (Salvia)

This is a plant that is common in southern Mexico and Central and South America. Its leaves are typically chewed, or the juice that is extracted from them is ingested. Saliva can also be inhaled.

The short and long-term side effects of hallucinogens are different depending on the type and category of hallucinogenic used. Short-term side effects for classic hallucinogens are (19):

1. Hallucinations 
2. Increased heart rate 
3. Nausea 
4. Intensified feelings and sensory experiences 
5. Changes in the user’s sense of time 
6. Increased blood pressure, breathing, and body temperature 
7. Loss of appetite 
8. Dry mouth 
9. Sleep problems 
10. Uncoordinated movements 
11. Excessive sweating 
12. Panic  
13. Paranoia 
14. Psychosis
    

There are two specific long-term side effects of classic hallucinogens. These side effects are typically seen in individuals with a history of mental illness but can happen to anyone (19).

Persistent Psychosis

• This refers to a series of continuing mental problems that include:
• Visual disturbances
• Disorganized thinking
• Paranoia
• Mood changes

Hallucinogen Persisting Perception Disorder (HPPD)

This is a recurrence of certain drug experiences like hallucinations or visual disturbances. These typically happen without warning and can occur any time after drug use.

Antidepressants and antipsychotic medicals have been used to improve an individual’s mood, as well as treat psychosis. Behavioral therapies have been used to help individuals cope with fear or confusion associated with visual disturbances.

Short-term side effects for dissociative drugs have been known to appear within a few minutes of taking the drug and can last hours or days. If the dosage is low, dissociative drugs can cause the following effects (19):

1. Numbness
2. Disorientation and loss of coordination
3. Hallucinations
4. Increase in the user’s blood pressure, heart rate, and body temperature

If higher doses of dissociative drugs are taken the following side effects may occur (19):

1. Memory loss
2. Panic and anxiety attacks
3. Seizures
4. Psychotic symptoms
5. Amnesia
6. Inability to move
7. Mood swings
8. Trouble breathing

The long-term side effects of dissociative drugs are still being researched. However, repeated and prolonged use of PCP has been known to result in addiction. The following long-term effects may continue for a year or more after the drug use stops (19): 

1. Speech problems
2. Memory Loss
3. Weight Loss
4. Anxiety
5. Depression and suicidal thoughts

Most hallucinogens will not typically result in an overdose but do tend to have extremely unpleasant side effects when taken in higher doses. There have been some serious medical emergencies and fatalities that have been reported by 251-NBOMe. Overdose becomes more likely with dissociative drugs. High doses of PCP have been known to cause seizures, coma, and death (19).  

Due to the nature of hallucinogens, there is a high risk of bodily harm due to the alteration of the user’s perception and mood (19):

1. Users could attempt things they wouldn’t normally do when not under the influence, such as jumping out of a window or off a building. 
2. Users could experience a profound sadness or feeling of hopelessness leading to suicidal feelings and/or suicidal actions. 
3. Psilocybin users could accidentally consume a poisonous mushroom that looks like psilocybin, which can result in severe illness or death. 

Substance Abuse in Adolescents

Substance abuse and opioid overdose deaths are beginning to affect school systems. In 2017, 2.2 million adolescents between the ages of 12-17 stated they were currently using illicit substances (21).

Brain growth and development, particularly during one’s adolescent years, has been highly studied and reviewed. One area of the brain that is still developing during adolescents is the prefrontal cortex. This area of the brain is responsible for allowing one to assess situations, make decisions, and keep emotions and desires under control (21). Because this area of the brain is still developing, it places adolescents at an increased risk of trying drugs and continuing them (21).

Substance use during one’s adolescent years has the potential to create several long-term negative effects. It is estimated that 90% of individuals with addictions began using substances during their adolescent years (22). There are several factors that can lead to substance use. These risk factors include a family history of addiction, mental health concerns, behavioral or impulse control problems, exposure to trauma, and environmental factors (22).

Multiple studies have shown that the science of prevention may affect the probability of later problems (23). The main goal in adolescent substance abuse prevention is to reduce risk factors and overall enhance/reinforce protective factors (23). Depending on the addiction, medication may be used in combination with a form of behavioral therapy or counseling. This Delaware Substance Abuse course will help you identify the types of behavioral therapies:

Cognitive-Behavioral Therapy

Helps individuals recognize, avoid and cope with situations in which they may use drugs.

Contingency Management

Uses positive reinforcement for attending counseling sessions, remaining drug-free, or taking prescribed medications.

Motivational Enhancement Therapy

Focuses on strategies that make the most of an individual’s readiness to change their current behavior and enter treatment.

Family Therapy

Focuses on utilizing the family to address influences on drug patterns and improve overall family function.

Twelve-Step Facilitation

Delivered in 12-week sessions. There are no medical treatments but allow the individual social and complementary support.

Substance Abuse in Nurses

It is estimated that the prevalence of substance abuse among nurses is equal to the larger population. It’s a subject that a lot of nurses want to avoid, but it is nonetheless necessary to discuss. A nurse suffering from a substance use disorder may feel a lot of shame and guilt. Because nursing is frequently cited as the most trusted profession, the pressure to uphold those standards and maintain that image to the public can make a nurse with a substance use disorder feel like they are failing morally and professionally.

Fear of losing their job or their nursing license prevents many nurses from self-reporting substance abuse, and it can go unnoticed for a long time, potentially impacting patient safety. Physiological symptoms in nurses will be the same as with anyone else with a substance abuse disorder, so it is important to look for patterns in behavior.

Signs of Substance Use in Nurses

• Controlled substance discrepancy
• Wasting controlled substances without a witness
• Frequent mistakes
• Customer service issues
• Frequent absences
• Errors in documentation
• Paranoia

Contributing Risk Factors

• Being a new graduate nurse
• Identifying as a woman
• Identifying as part of the LGBTQ community
• High nurse-to-patient ratios
• Working night shift
• Working frequent overtime
• Floating to other specialty areas/unfamiliar units
• Working in Med-Surg, Long-term care, or Outpatient Services.
• Unsupportive Work Environment

Contrary to popular belief that most nurses with substance use disorders get drugs from their workplace, only an estimated 25% of nurses do this (31). The act of misappropriating controlled substances from the workplace is known as drug diversion.

Drug Diversion

According to the Department of Health and Human Services (2016), nurses and other healthcare professionals that engage in drug diversion do this mainly to feed their addiction or for recreation. But in some cases, drug theft occurs for monetary gain, with nurses stealing drugs to illegally sell them.

Drug diversion is a criminal offense, which is why most medication dispensing systems in healthcare facilities require permission to be accessed, secure fingerprinting, and are even monitored via camera. Even so, some nurses find their way around these precautions. Depending on which state you live in, the repercussions for engaging in drug diversion will vary. It is important to become familiar with your state’s regulations regarding drug diversion and your Board of Nursing’s disciplinary actions.

What are some ways you can help reduce drug diversion in the workplace?

• Witnessing a controlled substance waste in person – instead of just signing for it without verification.
• Wasting controlled substances in a timely manner and with a witness present.
• Ensuring access to the medication dispensing system is restricted to only those with permission.
• Avoiding distractions when counting controlled substances.
• Notify your supervisor immediately if you find a drug discrepancy, make an error during your count, or witness someone diverting drugs.

It is important to become familiar with your facility’s policy regarding suspected drug diversion reporting, as well as your board of nursing stance on it. Recently many boards have initiated programs to support nurses with a substance abuse disorder by helping them find treatment, keep the matter confidential and have an opportunity to practice nursing again when sober.

Once we recognize and accept that substance abuse is a disease that needs to be treated, not judged, we can take the necessary steps to help lead our community of nurses on a path towards healing and recovery.

Case Study

You are working a regular 7:00 am-7:00 pm shift in a busy medical-surgical unit. Because of recent callouts and staffing issues, the nurse-to-patient ratios have increased from 5 to 6. Everyone is stressed out and trying to get through the shift.

One of your coworkers appears frazzled and asks you if you can witness her controlled substance waste later, she explains she must give the drug now because the patient has been asking for pain medication all morning and to just “trust her” and sign off on the waste when you both have time. You agree to do this.

Unfortunately, the day continues to keep getting busier, and you both forget to document the waste. Days later you are called into your manager’s office, there is a drug discrepancy, and they want your statement because your coworker explained that you witnessed her waste the medication in person.

• What are possible repercussions in your facility for failing to witness a controlled substance waste in person?
• How does your unit or facility handle drug discrepancies?
• How could you have avoided this situation from escalating to management?
• What can you do to avoid being placed in this situation again?

Resources for Nurses and the Public

• NCSBN Substance Use Resources
• Substance Abuse and Mental Health Services Administration 
• National Institute on Drug Abuse
• National Institute on Alcohol Abuse and Alcoholism

Conclusion

Substance abuse in the United States is on the rise, with many hospitals and healthcare centers seeing an increase in patients. Understanding the different types of substances used, their short- and long-term symptoms, overdose symptoms, and medication options will help prepare you to care for these individuals. It is equally important to understand the behavioral therapy options for those with substance use disorders and advocate for them while they are in your care.

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