CHAPTER 18

UNIT 3 PSYCHOBIOLOGIC DISORDERS ASSESSMENT

CHAPTER 18 Substance Use and RISK FACTORS
Addictive Disorders ●● Genetics: predisposition to developing a substance use
disorder due to family history
●● Chronic stress: socioeconomic factors
Substance use disorders are related to ●● History of trauma: abuse, combat experience
●● Lowered self‑esteem
alcohol, caffeine, cannabis, hallucinogens, ●● Lowered tolerance for pain and frustration
inhalants, opioids, sedatives/hypnotics/ ●● Few meaningful personal relationships
●● Few life successes
anxiolytics, stimulants, tobacco, and other (or ●● Risk‑taking tendencies
unknown) substances. SOCIOCULTURAL THEORIES
●● Some cultures, such as Alaska natives and Native
A substance use disorder involves repeated American groups, have a high percentage of members
use of chemical substances, leading to clinically who have alcohol use disorder.
◯◯ Other cultures, such as Asian groups, have a low rate

significant impairment during a 12‑month period. of alcohol use disorder.

Non‑substance‑related disorders (behavioral/ ◯◯ Metabolism of alcohol and cultural views of alcohol

use provide possible explanations for the incidence of

process addictions) include gambling, alcohol use within a cultural group.
sexual activity, shopping, social media, and ●● Peer pressure and other sociological factors can increase
the likelihood of substance use.
Internet gaming. ●● Older adult clients can have a history of alcohol use or
can develop a pattern of alcohol/substance use later in
Substance use and addictive disorders are life due to life stressors, such as losing a partner or a
characterized by loss of control due to the friend, retirement, or social isolation.

substance use or behavior, participation that

continues despite continuing associated EXPECTED FINDINGS
The nurse should use open‑ended questions to obtain the
problems, and a tendency to relapse back into following information for the nursing history.
the substance use or behavior. ●● Type of substance or addictive behavior

●● Pattern and frequency of substance use

The defense mechanism of denial is commonly ●● Amount of substance used

●● Age at onset of substance use

used by clients who have problems with a ●● Changes in occupational or school performance

substance use or addictive disorder. For ●● Changes in use patterns

●● Periods of abstinence in history

example, a person who has long‑term tobacco ●● Previous withdrawal manifestations

use might say, “I can quit whenever I want ●● Date of last substance use or addictive behavior

to, but smoking really doesn’t cause me any REVIEW OF SYSTEMS

●● Blackout or loss of consciousness
problems.” Frequently, denial prevents a client ●● Changes in bowel movements
from obtaining help with substance use or an ●● Weight loss or weight gain
●● Experience of stressful situation
addictive behavior. ●● Sleep problems
●● Chronic pain
●● Concern over substance use
●● Cutting down on consumption or behavior

RN MENTAL HEALTH NURSING CHAPTER 18 Substance Use and Addictive Disorders 95

 POPULATION‑SPECIFIC CONSIDERATIONS Alcohol (ethanol)
●● The rate of substance use is highest in clients age ●● A laboratory blood alcohol concentration (BAC) of 0.08%
20 to 29. (80 g/dL) is considered legally intoxicated for adults
●● The younger the person is at the time of initial operating automobiles in most U.S. states. Death could
substance use, the higher the incidence of developing a occur from acute toxicity in levels greater than about
substance use disorder. 0.4% (400 g/dL).
●● Cocaine use is decreased among adolescents. However, ●● BAC depends on many factors, including body weight,
about half of adolescents report access to marijuana. gender, concentration of alcohol in drinks, number of
●● According to 2013 data from the National Institute of drinks, gastric absorption rate, and the individual’s
Alcohol Abuse and Alcoholism, 86.8% of people over the tolerance level.
age of 18 reported alcohol consumption at some point in
INTENDED EFFECTS: Relaxation, decreased social anxiety,
their life with 56.4% reporting alcohol consumption in
stress reduction
the past month.
●● OLDER ADULTS who use substances are especially prone EFFECTS OF INTOXICATION
to falls and other injuries, memory loss, somatic reports ●● Effects of excess: Slurred speech, nystagmus, memory
(headaches), and changes in sleep patterns. impairment, altered judgment, decreased motor skills,
◯◯ Indications of alcohol use in older adults can include decreased level of consciousness (which can include
a decrease in ability for self‑care (functional status), stupor or coma), respiratory arrest, peripheral collapse,
urinary incontinence, and manifestations of dementia. and death (with large doses)
◯◯ Older adults can show effects of alcohol use at lower ●● Chronic use: Direct cardiovascular damage, liver
doses than younger adults. damage (ranging from fatty liver to cirrhosis),
◯◯ Polypharmacy (the use of multiple medications), the erosive gastritis and gastrointestinal bleeding, acute
potential interaction between substances and pancreatitis, sexual dysfunction
medications, and age‑related physiological changes
WITHDRAWAL MANIFESTATIONS
raise the likelihood of adverse effects, such as ●● Manifestations include abdominal cramping; vomiting;
confusion and falls in older adult clients.
tremors; restlessness and inability to sleep; increased
heart rate; transient hallucinations or illusions;
STANDARDIZED SCREENING TOOLS anxiety; increased blood pressure, respiratory rate, and
temperature; and tonic‑clonic seizures.
●● Michigan Alcohol Screening Test (MAST) ●● Alcohol withdrawal delirium can occur 2 to 3 days
●● Drug Abuse Screening Test (DAST) or DAST‑A:
after cessation of alcohol. This is considered a medical
Adolescent version
emergency. Manifestations include severe disorientation,
●● CAGE Questionnaire: Asks questions of clients to
psychotic manifestations (hallucinations), severe
determine how they perceive their current alcohol use
hypertension, cardiac dysrhythmias, and delirium.
●● Alcohol Use Disorders Identification Test (AUDIT)
Alcohol withdrawal delirium can progress to death.
●● Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA‑Ar)
Sedatives/hypnotics/anxiolytics
●● Clinical Opiate Withdrawal Scale
Benzodiazepines like diazepam, barbiturates like
pentobarbital, or club drugs like flunitrazepam (“date
COMMONLY USED SUBSTANCES rape drug”) can be taken orally or injected.
●● Designer or club drugs, such as ecstasy, can combine INTENDED EFFECTS: Decreased anxiety, sedation
substances from different categories, producing varying
EFFECTS OF INTOXICATION
effects of intoxication or withdrawal. ●● Increased drowsiness and sedation, agitation, slurred
●● Improper use of prescription medications, specifically
speech, uncoordinated motor activity, nystagmus,
opioids, CNS depressants, and CNS stimulants, can result
disorientation, nausea, vomiting
in substance use disorder and drug‑seeking behavior. ●● Respiratory depression and decreased level of
consciousness, which can be fatal
CENTRAL NERVOUS SYSTEM DEPRESSANTS ●● An antidote, flumazenil, available for IV use for
benzodiazepine toxicity
CNS depressants can produce physiological and ●● No antidote to reverse barbiturate toxicity
psychological dependence and can have cross‑tolerance,
cross‑dependency, and an additive effect when WITHDRAWAL MANIFESTATIONS: Anxiety, insomnia,
take concurrently. diaphoresis, hypertension, possible psychotic reactions,
hand tremors, nausea, vomiting, hallucinations
or illusions, psychomotor agitation, and possible
seizure activity

96 CHAPTER 18 Substance Use and Addictive Disorders CONTENT MASTERY SERIES

 Cannabis Tobacco (nicotine)
Marijuana or hashish (which is more potent) can be ●● Cigarettes and cigars are inhaled.
smoked or orally ingested. ●● Smokeless tobacco is snuffed or chewed.

INTENDED EFFECTS: Euphoria, sedation, hallucinations, INTENDED EFFECTS: Relaxation, decreased anxiety
decrease of nausea and vomiting secondary to
EFFECTS OF INTOXICATION
chemotherapy, management of chronic pain ●● Highly toxic, but acute toxicity seen only in children or
EFFECTS OF INTOXICATION when exposure is to nicotine in pesticides
●● Chronic use: lung cancer, chronic bronchitis, and other ●● Also contains other harmful chemicals that are highly
respiratory effects toxic and have long‑term effects
●● In high doses: occurrence of paranoia, such as delusions ●● Long‑term effects
and hallucinations ◯◯ Cardiovascular disease (hypertension, stroke),

●● Increased appetite, dry mouth, tachycardia respiratory disease (emphysema, lung cancer)
◯◯ With smokeless tobacco (snuff or “chew”): irritation

WITHDRAWAL MANIFESTATIONS: Irritability, aggression,

to oral mucous membranes and cancer
anxiety, insomnia, lack of appetite, restlessness,
depressed mood, abdominal pain, tremors, diaphoresis, WITHDRAWAL MANIFESTATIONS: Abstinence syndrome
fever, headache evidenced by irritability, craving, nervousness,
restlessness, anxiety, insomnia, increased appetite,
difficulty concentrating, anger, and depressed mood
CENTRAL NERVOUS SYSTEM STIMULANTS
The CNS stimulation seen in some CNS stimulants Opioids
is dependent on the area of the brain and spinal
Heroin, morphine, and hydromorphone can be injected,
cord affected.
smoked, and inhaled.

Cocaine INTENDED EFFECTS: A rush of euphoria, relief from pain

Can be injected, smoked, or inhaled (snorted) EFFECTS OF INTOXICATION
●● Slurred speech, impaired memory, pupillary changes.
INTENDED EFFECTS: Rush of euphoria (extreme ●● Decreased respirations and level of consciousness,
well‑being) and pleasure, increased energy
which can cause death
EFFECTS OF INTOXICATION ●● Maladaptive behavioral or psychological changes,
●● Mild toxicity: dizziness, irritability, tremor, including impaired judgment or social functioning
blurred vision ●● An antidote, naloxone, available for IV use to relieve
●● Severe effects: hallucinations, seizures, extreme effects of overdose
fever, tachycardia, hypertension, chest pain, possible
WITHDRAWAL MANIFESTATIONS
cardiovascular collapse and death ●● Abstinence syndrome begins with sweating and
WITHDRAWAL MANIFESTATIONS rhinorrhea progressing to piloerection (gooseflesh),
●● Depression, fatigue, craving, excess sleeping or tremors, and irritability followed by severe weakness,
insomnia, dramatic unpleasant dreams, psychomotor diarrhea, fever, insomnia, pupil dilation, nausea
retardation, agitation and vomiting, pain in the muscles and bones, and
●● Not life‑threatening, but possible occurrence of muscle spasms.
suicidal ideation ●● Withdrawal is very unpleasant but not life‑threatening.

Amphetamines Inhalants
Can be taken orally, injected intravenously, or smoked Amyl nitrate, nitrous oxide, and solvents are sniffed,
huffed, or bagged, often by children or adolescents.
INTENDED EFFECTS: Increased energy, euphoria similar
to cocaine INTENDED EFFECTS: Euphoria
EFFECTS OF INTOXICATION EFFECTS OF INTOXICATION: Depend on the substance, but
●● Impaired judgment, psychomotor agitation, generally can cause behavioral or psychological changes,
hypervigilance, extreme irritability dizziness, nystagmus, uncoordinated movements or
●● Acute cardiovascular effects (tachycardia, elevated blood gait, slurred speech, drowsiness, hyporeflexia, muscle
pressure), which could cause death weakness, diplopia, stupor or coma, respiratory depression,
and possible death
WITHDRAWAL MANIFESTATIONS
●● Craving, depression, fatigue, sleeping WITHDRAWAL MANIFESTATIONS: None
●● Not life‑threatening

RN MENTAL HEALTH NURSING CHAPTER 18 Substance Use and Addictive Disorders 97

 Hallucinogens ●● Provide emotional support and reassurance to the
client and family. Educate the client and family about
Lysergic acid diethylamide (LSD), mescaline (peyote), and
codependent behaviors.
phencyclidine piperidine (PCP) are usually ingested orally, ●● Begin to educate the client and family about addiction
but can be injected or smoked.
and the initial treatment goal of abstinence.
INTENDED EFFECTS: Heightened sense of self and ●● Educate the client and family regarding removing any
altered perceptions (colors being more vivid while under prescription medications in the home that are not being
the influence) used. Encourage the client not to share medication with
someone for whom that medication is not prescribed.
EFFECTS OF INTOXICATION: Anxiety, depression, paranoia, ●● Begin to develop motivation and commitment for
impaired judgment, impaired social functioning, pupil
abstinence and recovery (abstinence plus developing a
dilation, tachycardia, diaphoresis, palpitations, blurred
program of personal growth and self‑discovery).
vision, tremors, incoordination, and panic attacks ●● Encourage self‑responsibility.
WITHDRAWAL MANIFESTATIONS: Hallucinogen persisting ●● Help the client develop an emergency plan: a list of
perception disorder: Visual disturbances or flashback things the client would need to do and people he would
hallucinations can occur intermittently for years. need to contact.
●● Encourage attendance at self‑help groups.
Caffeine
Includes cola drinks, coffee, tea, chocolate, energy drinks MEDICATIONS
INTENDED EFFECTS: Increased level of alertness and Alcohol withdrawal: Diazepam, carbamazepine, clonidine,
decreased fatigue chlordiazepoxide, phenobarbital, naltrexone

EFFECTS OF INTOXICATION: Intoxication commonly Alcohol abstinence: Disulfiram, naltrexone, acamprosate

occurs with ingestion of greater than 250 mg. (One 2 oz
Opioid withdrawal: Methadone substitution, clonidine,
high‑energy drink can contain 215 to 240 mg caffeine.)
buprenorphine, naltrexone, levo‑alpha‑acetylmethadol
Tachycardia and arrhythmias, flushed face, muscle
twitching, restlessness, diuresis, GI disturbances, Nicotine withdrawal from tobacco use: Bupropion,
anxiety, insomnia. nicotine replacement therapy (nicotine gum and nicotine
patch), varenicline, bupropion
WITHDRAWAL MANIFESTATIONS
●● Can occur within 24 hr of last consumption Nicotine abstinence: Varenicline, rimonabant
●● Headache, nausea, vomiting, muscle pain, irritability,
NURSING CONSIDERATIONS
inability to focus, drowsiness ●● Monitor vital signs and neurological status.
●● Provide for client safety by implementing seizure
precautions.
PATIENT‑CENTERED CARE
CLIENT EDUCATION
Encourage the client to adhere to the treatment plan.
NURSING CARE
●●

●● Advise clients taking disulfiram to avoid all alcohol.

●● Personal views, culture, and history can affect the
nurse’s feelings regarding substance use and addictive
disorders. Nurse must self‑assess their own feelings
INTERPROFESSIONAL CARE
because those feelings can be transferred to clients Dual diagnosis, or comorbidity, means that an individual
through body language and the terminology nurses can has both a mental health disorder, such as depression, and
use in assessing clients. An objective, nonjudgmental a substance use or addictive disorder. Both disorders need
nurse approach is imperative. to be treated simultaneously and require a team approach.
●● Safety is the primary focus of nursing care during acute
INDIVIDUAL PSYCHOTHERAPIES
intoxication or withdrawal. ●● Cognitive behavioral therapies, such as relaxation
◯◯ Maintain a safe environment to prevent falls;

techniques or cognitive reframing, can be used to

implement seizure precautions as necessary.
decrease anxiety and change behavior.
◯◯ Provide close observation for withdrawal
●● Acceptance and commitment therapy (ACT) promotes
manifestations, possibly one‑on‑one supervision.
acceptance of the client’s experiences and promotes
Physical restraint should be a last resort.
client commitment to positive behavior changes.
◯◯ Orient the client to time, place, and person.
●● Relapse prevention therapy assists clients in identifying
◯◯ Maintain adequate nutrition and fluid balance.

the potential for relapse and promotes behavioral

◯◯ Create a low‑stimulation environment.

self‑control.
◯◯ Administer medications as prescribed to treat the

effects of intoxication or to prevent or manage GROUP THERAPY: Groups of clients who have similar
withdrawal. This can include substitution therapy. diagnoses can meet in an outpatient setting or within
◯◯ Monitor for covert substance use during the mental health residential facilities.
detoxification period.

98 CHAPTER 18 Substance Use and Addictive Disorders CONTENT MASTERY SERIES

 FAMILY THERAPY ●● Encourage the client and family to attend a 12‑step
●● This therapy identifies codependency, which is a program, such as Alcoholics Anonymous (AA), Narcotics
common behavior demonstrated by the significant Anonymous, and Gambler’s Anonymous, and family
other/family/friends of an individual with substance groups like Al‑Anon or Ala‑Teen.
or process dependency, and assists the family to ◯◯ These programs will teach clients the following.

change that behavior. The codependent person reacts ■■ Abstinence is necessary for recovery.

in over‑responsible ways that allow the dependent ■■ A higher power is needed to assist in recovery.

individual to continue the substance use or addiction ■■ Clients are not responsible for their disease but are

disorder. For example, a partner can act as an enabler by responsible for their recovery.
calling the client’s employer with an excuse of illness ■■ Other people cannot be blamed for the client’s

when the client is intoxicated. addictions, and they must acknowledge their
●● Families learn about use of specific substances. feelings and problems.
●● The client and family are educated regarding issues such
as family coping, problem‑solving, indications of
relapse, and availability of support groups.
PRACTICE Active Learning Scenario
CLIENT EDUCATION A nurse is caring for a client who has cocaine use
disorder and is experiencing severe effects of
●● Teach the client to recognize indications of relapse and intoxication. Use the ATI Active Learning Template:
factors that contribute to relapse. System Disorder to complete this item.
●● Teach cognitive‑behavioral techniques to help maintain ALTERATION IN HEALTH (DIAGNOSIS)
sobriety and create feelings of pleasure from activities EXPECTED FINDINGS: Identify three expected findings.
other than using substances or from process addictions.
NURSING CARE: Describe two nursing interventions.
●● Assist the client to develop communication skills to
communicate with coworkers and family members INTERPROFESSIONAL CARE: Describe two
forms of nonpharmacological therapy.
while sober.
CLIENT EDUCATION: Identify two client outcomes.

Application Exercises
1. A nurse is planning a staff education 3. A nurse is planning care for a client 5. A nurse is providing teaching to the
program on substance use in older who is experiencing benzodiazepine family of a client who has a substance
adults. Which of the following withdrawal. Which of the following use disorder. Which of the following
is appropriate for the nurse to interventions should the nurse statements by a family member
include in the presentation? identify as the priority? indicate an understanding of the
A. Older adults require higher A. Orient the client frequently teaching? (Select all that apply.)
doses of a substance to to time, place, and person. A. “We need to understand
achieve a desired effect. B. Offer fluids and nourishing that she is responsible
B. Older adults commonly use diet as tolerated. for her disorder.”
rationalization to cope with C. Implement seizure precautions. B. “Eliminating any codependent
a substance use disorder. behavior will promote
D. Encourage participation in
C. Older adults are at an her recovery.”
group therapy sessions.
increased risk for substance C. “She should participate
use following retirement. 4. A nurse is caring for a client who in an Al‑Anon group to
D. Older adults develop has alcohol use disorder. The help her recover.”
substance use to mask client is no longer experiencing D. “The primary goal of her
manifestations of dementia. withdrawal manifestations. Which treatment is abstinence
of the following medications should from substance use.”
2. A nurse is assessing a client who the nurse anticipate administering E. “She needs to discuss her
has alcohol use disorder and is to assist the client with maintaining feelings about substance
experiencing withdrawal. Which of abstinence from alcohol? use to help her recover.”
the following findings should the A. Chlordiazepoxide
nurse expect? (Select all that apply.)
B. Bupropion
A. Bradycardia
C. Disulfiram
B. Fine tremors of both hands
D. Carbamazepine
C. Hypotension
D. Vomiting
E. Restlessness

RN MENTAL HEALTH NURSING CHAPTER 18 Substance Use and Addictive Disorders 99

 Application Exercises Key
1. A. Requiring higher doses of a substance to achieve a desired effect is 4. A. Chlordiazepoxide is indicated for acute alcohol withdrawal
a result of the length and severity of substance use rather than age. rather than to maintain abstinence from alcohol.
B. Denial, rather than rationalization, is a defense mechanism B. Bupropion is indicated for nicotine withdrawal
commonly used by substance users of all ages. rather than to maintain abstinence from alcohol.
C. CORRECT: Retirement and other life change stressors C. CORRECT: The nurse should expect to administer disulfiram
increase the risk for substance use in older adults, especially to help the client maintain abstinence from alcohol.
if there is a prior history of substance use. D. Carbamazepine is indicated for acute alcohol withdrawal
D. Substance use in the older adult can result rather than to maintain abstinence from alcohol.
in manifestations of dementia.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
NCLEX® Connection: Psychosocial Integrity, Expected Actions/Outcomes
Chemical and Other Dependencies/Substance Use Disorder
5. A. Clients are not responsible for their disease
2. A. An expected finding of alcohol withdrawal is but are responsible for their recovery.
tachycardia rather than bradycardia. B. CORRECT: Families should be aware of codependent behavior, such
B. CORRECT: Fine tremors of both hands is an as enabling, that can promote substance use rather than recovery.
expected finding of alcohol withdrawal. C. Al‑Anon is a recovery group for the family of a client, rather
C. An expected finding of alcohol withdrawal is than the client who has a substance use disorder.
hypertension rather than hypotension. D. CORRECT: Abstinence is the primary treatment goal
D. CORRECT: Vomiting is an expected finding of alcohol withdrawal. for a client who has a substance use disorder.
E. CORRECT: Restlessness is an expected finding of alcohol withdrawal. E. CORRECT: Clients must acknowledge their feelings about
substance use as part of a substance use recovery program.
NCLEX Connection: Psychosocial Integrity,
®

Chemical and Other Dependencies/Substance Use Disorder NCLEX® Connection: Psychosocial Integrity,
Chemical and Other Dependencies/Substance Use Disorder
3. A. Reorienting the client is an appropriate
intervention. However, it is not the priority.
B. Providing hydration and nourishment is an appropriate
intervention. However, it is not the priority.
C. CORRECT: The greatest risk to the client is injury.
Implementing seizure precautions is the priority intervention.
D. Encouraging participation in therapy is an appropriate
intervention. However, it is not the priority.

NCLEX® Connection: Safety and Infection Control,

Accident/Error/Injury Prevention

PRACTICE Answer
Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): INTERPROFESSIONAL CARE CLIENT EDUCATION: Client outcomes

Cocaine use disorder involves the repeated ●●
Cognitive behavioral therapies decrease The client will verbalize coping
●●

use of cocaine, leading to clinically significant anxiety and promote a change in behavior. strategies to use in times of stress.
impairment over a 12‑month period. ●●
Acceptance and commitment therapy The client will remain substance‑free.
●●

EXPECTED FINDINGS promotes acceptance of the client and The client will remain free from injury.
●●

promotes a commitment to change. The client will attend a 12‑step

Objective: Seizures, extreme fever, ●●
●●

tachycardia, hypertension
●●
Relapse prevention therapy assists clients in program regularly.
identifying relapse and promotes self‑control.
Subjective: Hallucinations, chest pain
●●

●●
Group therapy allows clients who have similar
NURSING CARE diagnoses to work together toward recovery.
Perform a nursing self‑assessment.
●● ●●
Family therapy allows the client and family
Maintain a safe environment.
●● members to work together toward recovery.
Implement seizure precautions.
●● ●●
Narcotics Anonymous provides a 12‑step
Orient the client to time, place, and person.
●● program to promote recovery and
Create a low‑stimulation environment.
●●
abstinence from future substance use.
Monitor the client’s vital signs
●●

and neurological status.

NCLEX® Connection: Psychosocial Integrity, Chemical and Other Dependencies/Substance Use Disorder

100 CHAPTER 18 Substance Use and Addictive Disorders CONTENT MASTERY SERIES