11
Substance Use Disorders
in Acute Care
Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Addiction
Cognition
Stress and Coping
LEARNING OUTCOMES
1. Relate the effects of substance use to its resulting major 4. Summarize the nursing and interprofessional management
health complications. of patients with toxicity or withdrawal from stimulants and
2. Discern among the effects of the use of stimulants, depressants.
depressants, and cannabis. 5. Apply the Screening, Brief Intervention, and Referral to
3. Explain your role in promoting the cessation of smoking Treatment approach in clinical situations.
and tobacco use. 6. Describe the incidence and effects of substance use in the
older adult.
KEY TERMS
acute alcohol toxicity Screening, Brief Intervention, and Referral to Treatment
alcohol use disorder (AUD) (SBIRT)
alcohol withdrawal syndrome (AWS) substance use disorder (SUD)
binge drinking tobacco use disorder (TUD)
vaping
Substance use is a serious problem affecting society and the exist in isolation. There are many interrelated problems depend-
health care system. Substance-related disorders involve several ing on the patient’s situation. Every drug associated with SUD
types of substances. These range from widely used and accepted harms some tissue or organ. Substance use causes specific health
tobacco and alcohol to illegal, brain-altering drugs such as her- problems, such as liver damage related to alcohol use or lung
oin and cocaine. Substance use disorder (SUD) occurs when cancer related to smoking. Other problems result from injuries
the use of alcohol and/or drugs causes significant impairment, associated with substance use, such as falls or motor vehicle
including health problems and failure to meet responsibilities accidents. Common health problems related to substance use
(Table 11.1).1 are outlined in Table 11.2.
Some describe SUD as mild, moderate, or severe, depending This chapter focuses on the nurse’s role in identify-
on the pattern of use and its impact on the person’s daily life. ing and managing the patient with SUD in the acute care
Knowing the severity of substance use allows the health care setting. A hospitalized patient who uses substances can
team to tailor treatment to the patient’s needs. For example, a develop withdrawal when substance use abruptly stops. You
person who binge drinks may not have alcohol SUD but is at need to be able to recognize substance use and its effects on
increased risk for SUD. On the other hand, a person who uses health problems and manage withdrawal. The health care
heroin or cocaine is likely to have severe SUD because these setting offers an opportunity for screening and teaching
substances are highly addictive. about substance use. It is your responsibility to motivate
Many patients with substance use problems receive acute the patient to change behavior and refer the patient to treat-
care for problems associated with substance use. SUD does not ment programs.
162
, CHAPTER 11 Substance Use Disorders in Acute Care 163
TABLE 11.1 Diagnostic Criteria TABLE 11.2 Health Problems Related to
Substance Use Disorder Substance Use
Health Problemsa
The following general criteria can be used to identify the presence of SUD:
Substance
Impaired Control Amphetamines • Dysrhythmias, myocardial ischemia, and
• Taking more or for longer than intended infarction
• Not quitting use despite multiple times of trying • Liver, lung, kidney damage
• Spending a great deal of time obtaining, using, or recovering from use • Mood changes, violent behavior, psycho-
• Urge or craving to use the substance ses
Cannabis • Bronchitis, chronic cough
Social Impairment • Depression, anxiety, schizophrenia
• Missing school, work, or other responsibilities due to use • Impaired memory
• Continuing use despite problems caused or worsened by use Cocaine • Dysrhythmias, myocardial ischemia and
• Giving up or reducing important activities because of use infarction
• Use takes precedence over other interests or enjoyments, daily activities, • Psychosis
or health or personal care • Seizures, stroke
• Use takes a central role in the person’s life Inhalants • Acute and chronic kidney injury
• Cognitive and motor impairment
Dependence Opioids • Gastric ulcers
• Physical tolerance to effects of the substance • Glomerulonephritis
• Presence of withdrawal symptoms when not using or using less • Sexual problems
• Repeated use to prevent or alleviate withdrawal symptoms. Sedative-hypnotics • Impaired memory
Source: Saunders JB, Latt NC: Diagnosis and classification of sub- • Personality changes, depression
stance use disorders. In Addiction medicine: Science and practice,
2020, Elsevier. Behaviors
Injecting drugs • Blood clots, phlebitis, skin infections
• Hepatitis B and C
DRUGS ASSOCIATED WITH SUBSTANCE USE • HIV/AIDS
DISORDER • Other infections: endocarditis, tuberculo-
sis, pneumonia, meningitis, tetanus, bone
NICOTINE and joint infections, lung abscesses
You are most likely to encounter people with tobacco use dis- Personal neglect • Accidental injuries
order (TUD). People with TUD are dependent on the drug • Malnutrition
nicotine from using tobacco products. Products that contain Risky sexual behavior • Hepatitis B and C
• HIV/AIDS
nicotine include smoked tobacco (cigarettes, cigars, pipes),
• Sexually transmitted infections
smokeless tobacco (chew, snuff, dip), and some electronic ciga- Snorting drugs • Chronic sinusitis
rettes. Cigarette smoking is the main form of tobacco use in the • Nasal sores, septal necrosis, perforation
United States.
aHealth problems related to SUD are discussed in the appropriate
Effects of Use and Complications chapters throughout the text, where they are identified as risk factors
for these problems.
Nicotine is a central nervous system stimulant. Within sec- Adapted from National Institute on Drug Abuse: Medical consequence
onds of entering the body, nicotine reaches the brain, causing of drug abuse. Retrieved from www.drugabuse.gov/related-topics/
the release of adrenaline and creating feelings of a “high” or a medical-consequences-drug-abuse.
“buzz.” The effects last about 1 to 2 hours before withdrawal
symptoms occur, leaving the person feeling tired, irritable, and
anxious. The need to have the “high” or “buzz” feelings again increasing the risk for high blood pressure, heart attack, and
makes the person crave more nicotine, leading to addiction. stroke.
Smoked tobacco is the most harmful method of nicotine use. Vaping, or the use of electronic cigarettes or e-cigs, contin-
Smoking harms nearly every organ in the body and reduces the ues to increase. E-cigs have a similar look and feel of regular
person’s general health. More than 16 million persons in the cigarettes. These battery-operated devices turn nicotine and
United States have a smoking-related disease.2 Smoking causes other chemicals into an inhaled vapor. Vaping is associated with
lung disease, lung and other cancers, and heart disease and is a health risks. It can cause e-cig vaping-associated lung injury
major factor in many other conditions (Fig. 11.1). (EVALI) and other lung and cardiovascular problems. It can
Although those who use smokeless tobacco have less risk for harm adolescent brain development and negatively influence
lung disease, use can cause serious health problems. Holding pregnancy outcomes.3 Although some believe e-cigs may aid
tobacco in the mouth is associated with periodontal disease and in smoking cessation, they are not FDA-approved as a smoking
cancer of the mouth, cheek, tongue, throat, and esophagus. The cessation aid. Instead, you should encourage those who vape to
nicotine in smokeless tobacco affects the cardiovascular system, stop using the same cessation strategies recommended for TUD.
, 164 SECTION 2 Problems Related to Comfort and Coping
Cancers Chronic diseases
Stroke
Blindness, cataracts
Oropharynx Periodontitis
Larynx Aortic aneurysm
Esophagus
Coronary artery disease
Trachea,
bronchus, Pneumonia
and lung Peripheral
vascular disease
Acute myeloid
leukemia Chronic obstructive
pulmonary disease,
Stomach asthma, and other
respiratory effects
Pancreas
Kidney
and ureter
Hip fractures
Cervix
Reproductive effects
Bladder
in women (including
reduced fertility)
Fig. 11.1 Health effects of smoking. (From Samet JM: Tobacco smoking, Thorac Surg Clin 23[2]:103, 2013.)
NURSING AND INTERPROFESSIONAL TABLE 11.3 5 As and 5 Rs
MANAGEMENT: TOBACCO USE DISORDER Brief TUD Intervention
The 5 As for Users Who The 5 Rs for Users Unwilling
Tobacco Cessation Want to Quit to Quit
As a nurse, you have a professional responsibility to help people 1. Ask: Identify all tobacco users 1. Relevance: Ask the patient
stop smoking or using tobacco. The Joint Commission man- at every contact. to say why quitting is personally
dates that every health professional identify tobacco users and 2. Advise: Strongly urge all relevant (e.g., health).
provide them with information on ways to stop using tobacco. tobacco users to quit. 2. Risks: Ask the patient to identify
3. Assess: Determine willingness their potential risks/consequences
Patients who receive even brief advice and intervention from you
to make a quit attempt. of tobacco use.
are more likely to quit than those who receive no intervention.
4. Assist: Develop a plan with the 3. Rewards: Ask the patient to
With each patient encounter, encourage the patient to quit patient to help the patient quit relate potential benefits of stopping
and offer specific smoking cessation interventions. There are sev- (e.g., counseling, medication). tobacco use.
eral tools we can use to encourage users to quit (Tables 11.3 and 5. Arrange: Schedule follow-up 4. Roadblocks: Ask patient to
11.4).4 Use the brief clinical intervention the “5 As and 5 Rs” with contact. identify barriers or impediments to
each patient encounter. It will help you identify tobacco users, quitting.
encourage them to quit, determine their willingness to quit, assist 5. Repetition: Repeat process
them in quitting, and arrange for follow-up. A patient teaching every clinic visit.
guide (Table 11.5) expands on the fourth strategy, Assist, to help Source: Agency for Healthcare Research and Quality: AHCPR sup-
you when the user is willing to quit. If a tobacco user is not willing ported clinical practice guideline: Treating tobacco use and depen-
to quit, using the “5 Rs” may encourage them to quit in the future. dence—2008 update, Washington, DC, 2008, U.S. Public Health
A variety of smoking cessation products are available to help Service.
support users in quitting. These include prescription medicines
and over-the-counter (OTC) products such as skin patches, Because most health care agencies are tobacco-free,
lozenges, and gum. Nicotine replacement products are a com- admitted patients addicted to nicotine may have withdrawal
mon smoking cessation product. They reduce the craving and symptoms since they are unable to smoke. These symptoms
withdrawal symptoms of cessation by supplying the body with are the same as for the person who stops using tobacco “cold
smaller amounts of nicotine (Table 11.6). turkey.” Offering nicotine replacement therapy to every
Substance Use Disorders
in Acute Care
Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Addiction
Cognition
Stress and Coping
LEARNING OUTCOMES
1. Relate the effects of substance use to its resulting major 4. Summarize the nursing and interprofessional management
health complications. of patients with toxicity or withdrawal from stimulants and
2. Discern among the effects of the use of stimulants, depressants.
depressants, and cannabis. 5. Apply the Screening, Brief Intervention, and Referral to
3. Explain your role in promoting the cessation of smoking Treatment approach in clinical situations.
and tobacco use. 6. Describe the incidence and effects of substance use in the
older adult.
KEY TERMS
acute alcohol toxicity Screening, Brief Intervention, and Referral to Treatment
alcohol use disorder (AUD) (SBIRT)
alcohol withdrawal syndrome (AWS) substance use disorder (SUD)
binge drinking tobacco use disorder (TUD)
vaping
Substance use is a serious problem affecting society and the exist in isolation. There are many interrelated problems depend-
health care system. Substance-related disorders involve several ing on the patient’s situation. Every drug associated with SUD
types of substances. These range from widely used and accepted harms some tissue or organ. Substance use causes specific health
tobacco and alcohol to illegal, brain-altering drugs such as her- problems, such as liver damage related to alcohol use or lung
oin and cocaine. Substance use disorder (SUD) occurs when cancer related to smoking. Other problems result from injuries
the use of alcohol and/or drugs causes significant impairment, associated with substance use, such as falls or motor vehicle
including health problems and failure to meet responsibilities accidents. Common health problems related to substance use
(Table 11.1).1 are outlined in Table 11.2.
Some describe SUD as mild, moderate, or severe, depending This chapter focuses on the nurse’s role in identify-
on the pattern of use and its impact on the person’s daily life. ing and managing the patient with SUD in the acute care
Knowing the severity of substance use allows the health care setting. A hospitalized patient who uses substances can
team to tailor treatment to the patient’s needs. For example, a develop withdrawal when substance use abruptly stops. You
person who binge drinks may not have alcohol SUD but is at need to be able to recognize substance use and its effects on
increased risk for SUD. On the other hand, a person who uses health problems and manage withdrawal. The health care
heroin or cocaine is likely to have severe SUD because these setting offers an opportunity for screening and teaching
substances are highly addictive. about substance use. It is your responsibility to motivate
Many patients with substance use problems receive acute the patient to change behavior and refer the patient to treat-
care for problems associated with substance use. SUD does not ment programs.
162
, CHAPTER 11 Substance Use Disorders in Acute Care 163
TABLE 11.1 Diagnostic Criteria TABLE 11.2 Health Problems Related to
Substance Use Disorder Substance Use
Health Problemsa
The following general criteria can be used to identify the presence of SUD:
Substance
Impaired Control Amphetamines • Dysrhythmias, myocardial ischemia, and
• Taking more or for longer than intended infarction
• Not quitting use despite multiple times of trying • Liver, lung, kidney damage
• Spending a great deal of time obtaining, using, or recovering from use • Mood changes, violent behavior, psycho-
• Urge or craving to use the substance ses
Cannabis • Bronchitis, chronic cough
Social Impairment • Depression, anxiety, schizophrenia
• Missing school, work, or other responsibilities due to use • Impaired memory
• Continuing use despite problems caused or worsened by use Cocaine • Dysrhythmias, myocardial ischemia and
• Giving up or reducing important activities because of use infarction
• Use takes precedence over other interests or enjoyments, daily activities, • Psychosis
or health or personal care • Seizures, stroke
• Use takes a central role in the person’s life Inhalants • Acute and chronic kidney injury
• Cognitive and motor impairment
Dependence Opioids • Gastric ulcers
• Physical tolerance to effects of the substance • Glomerulonephritis
• Presence of withdrawal symptoms when not using or using less • Sexual problems
• Repeated use to prevent or alleviate withdrawal symptoms. Sedative-hypnotics • Impaired memory
Source: Saunders JB, Latt NC: Diagnosis and classification of sub- • Personality changes, depression
stance use disorders. In Addiction medicine: Science and practice,
2020, Elsevier. Behaviors
Injecting drugs • Blood clots, phlebitis, skin infections
• Hepatitis B and C
DRUGS ASSOCIATED WITH SUBSTANCE USE • HIV/AIDS
DISORDER • Other infections: endocarditis, tuberculo-
sis, pneumonia, meningitis, tetanus, bone
NICOTINE and joint infections, lung abscesses
You are most likely to encounter people with tobacco use dis- Personal neglect • Accidental injuries
order (TUD). People with TUD are dependent on the drug • Malnutrition
nicotine from using tobacco products. Products that contain Risky sexual behavior • Hepatitis B and C
• HIV/AIDS
nicotine include smoked tobacco (cigarettes, cigars, pipes),
• Sexually transmitted infections
smokeless tobacco (chew, snuff, dip), and some electronic ciga- Snorting drugs • Chronic sinusitis
rettes. Cigarette smoking is the main form of tobacco use in the • Nasal sores, septal necrosis, perforation
United States.
aHealth problems related to SUD are discussed in the appropriate
Effects of Use and Complications chapters throughout the text, where they are identified as risk factors
for these problems.
Nicotine is a central nervous system stimulant. Within sec- Adapted from National Institute on Drug Abuse: Medical consequence
onds of entering the body, nicotine reaches the brain, causing of drug abuse. Retrieved from www.drugabuse.gov/related-topics/
the release of adrenaline and creating feelings of a “high” or a medical-consequences-drug-abuse.
“buzz.” The effects last about 1 to 2 hours before withdrawal
symptoms occur, leaving the person feeling tired, irritable, and
anxious. The need to have the “high” or “buzz” feelings again increasing the risk for high blood pressure, heart attack, and
makes the person crave more nicotine, leading to addiction. stroke.
Smoked tobacco is the most harmful method of nicotine use. Vaping, or the use of electronic cigarettes or e-cigs, contin-
Smoking harms nearly every organ in the body and reduces the ues to increase. E-cigs have a similar look and feel of regular
person’s general health. More than 16 million persons in the cigarettes. These battery-operated devices turn nicotine and
United States have a smoking-related disease.2 Smoking causes other chemicals into an inhaled vapor. Vaping is associated with
lung disease, lung and other cancers, and heart disease and is a health risks. It can cause e-cig vaping-associated lung injury
major factor in many other conditions (Fig. 11.1). (EVALI) and other lung and cardiovascular problems. It can
Although those who use smokeless tobacco have less risk for harm adolescent brain development and negatively influence
lung disease, use can cause serious health problems. Holding pregnancy outcomes.3 Although some believe e-cigs may aid
tobacco in the mouth is associated with periodontal disease and in smoking cessation, they are not FDA-approved as a smoking
cancer of the mouth, cheek, tongue, throat, and esophagus. The cessation aid. Instead, you should encourage those who vape to
nicotine in smokeless tobacco affects the cardiovascular system, stop using the same cessation strategies recommended for TUD.
, 164 SECTION 2 Problems Related to Comfort and Coping
Cancers Chronic diseases
Stroke
Blindness, cataracts
Oropharynx Periodontitis
Larynx Aortic aneurysm
Esophagus
Coronary artery disease
Trachea,
bronchus, Pneumonia
and lung Peripheral
vascular disease
Acute myeloid
leukemia Chronic obstructive
pulmonary disease,
Stomach asthma, and other
respiratory effects
Pancreas
Kidney
and ureter
Hip fractures
Cervix
Reproductive effects
Bladder
in women (including
reduced fertility)
Fig. 11.1 Health effects of smoking. (From Samet JM: Tobacco smoking, Thorac Surg Clin 23[2]:103, 2013.)
NURSING AND INTERPROFESSIONAL TABLE 11.3 5 As and 5 Rs
MANAGEMENT: TOBACCO USE DISORDER Brief TUD Intervention
The 5 As for Users Who The 5 Rs for Users Unwilling
Tobacco Cessation Want to Quit to Quit
As a nurse, you have a professional responsibility to help people 1. Ask: Identify all tobacco users 1. Relevance: Ask the patient
stop smoking or using tobacco. The Joint Commission man- at every contact. to say why quitting is personally
dates that every health professional identify tobacco users and 2. Advise: Strongly urge all relevant (e.g., health).
provide them with information on ways to stop using tobacco. tobacco users to quit. 2. Risks: Ask the patient to identify
3. Assess: Determine willingness their potential risks/consequences
Patients who receive even brief advice and intervention from you
to make a quit attempt. of tobacco use.
are more likely to quit than those who receive no intervention.
4. Assist: Develop a plan with the 3. Rewards: Ask the patient to
With each patient encounter, encourage the patient to quit patient to help the patient quit relate potential benefits of stopping
and offer specific smoking cessation interventions. There are sev- (e.g., counseling, medication). tobacco use.
eral tools we can use to encourage users to quit (Tables 11.3 and 5. Arrange: Schedule follow-up 4. Roadblocks: Ask patient to
11.4).4 Use the brief clinical intervention the “5 As and 5 Rs” with contact. identify barriers or impediments to
each patient encounter. It will help you identify tobacco users, quitting.
encourage them to quit, determine their willingness to quit, assist 5. Repetition: Repeat process
them in quitting, and arrange for follow-up. A patient teaching every clinic visit.
guide (Table 11.5) expands on the fourth strategy, Assist, to help Source: Agency for Healthcare Research and Quality: AHCPR sup-
you when the user is willing to quit. If a tobacco user is not willing ported clinical practice guideline: Treating tobacco use and depen-
to quit, using the “5 Rs” may encourage them to quit in the future. dence—2008 update, Washington, DC, 2008, U.S. Public Health
A variety of smoking cessation products are available to help Service.
support users in quitting. These include prescription medicines
and over-the-counter (OTC) products such as skin patches, Because most health care agencies are tobacco-free,
lozenges, and gum. Nicotine replacement products are a com- admitted patients addicted to nicotine may have withdrawal
mon smoking cessation product. They reduce the craving and symptoms since they are unable to smoke. These symptoms
withdrawal symptoms of cessation by supplying the body with are the same as for the person who stops using tobacco “cold
smaller amounts of nicotine (Table 11.6). turkey.” Offering nicotine replacement therapy to every
