Module 6: Substance Use and Abuse

Learning Objectives:

Key Focus Areas:

Key Terms:

Substance Use and Abuse – Comprehensive Module

Definitions and Diagnostic Criteria (DSM-5)

Substance Use Disorder (SUD): According to DSM-5, a Substance Use Disorder is a pathological pattern of using a substance that leads to significant impairment or distress. It is characterized by a cluster of cognitiv​engage.healthynursehealthynation.orgl, and physiological symptoms indicating the individual continues using the substance despite substantial substance-related problems【24†L41-L49】【24†L55-L63】. DSM-5 defines 11 diagnostic criteria (symptoms) falling in four domains (impaired control, social impairment, risky use, and pharmacologic dependence)【4†L453-L461】【4†L469-L476】. Examples include using larger amounts or over longer time than intended, persistent desire or unsuccessful efforts to cut down, excessive time spent obtaining/using/recovering, cravings, recurrent use despite obligations or interper​engage.healthynursehealthynation.orgs, giving up important activities, use in physically hazardous situations, and continued use despite health problems【4†L459-L467】【4†L469-L476】. Two or more of these within 12 months qualifies as SUD, with severity specifiers: mild (2–3 symptoms), moderate (4–5), or severe (6+ symptoms)【4†L453-L461】【4†L469-L476】. Notably, DSM-5 merged the previous “abuse” and “dependence” into engage.healthynursehealthynation.org​engage.healthynursehealthynation.orgas the older terms were inconsistently used【24†L55-L63】.

Tolerance and Dependence: Tolerance is a physiological phenomenon where increasing amounts of a substance are needed to achieve the same effect, or a markedly diminished effect occurs with continued use of the same amount【4†L459-L467】. Dependence in a physical sense refers to the brain’s adaptation to continuous su​engage.healthynursehealthynation.orgce, leading to tolerance and withdrawal symptoms upon cessation【24†L55-L63】. Importantly, physical dependence can occur with appropriate medical use of certain drugs (e.g. opioids for pain management) without meeting crit​engage.healthynursehealthynation.org​engage.healthynursehealthynation.orges the maladaptive pattern and psychosocial components. DSM-5 avoids using “addiction” or separating “abuse vs. dependence” and instead uses SUD with the criteria above. It also notes that tolerance and withdrawal, while criteria for SUD, can be normal physiological responses in patients taking medications under medical supervision (these alone are not sufficient for SUD diagnosis in that context).

Intoxication and Withdrawal: Intoxication is defined in DSM-5 as the development of a reversible, substance-specific syndrome due to recent ingestion of a substance, producing significant maladaptive behavioral or psychological changes due to effects on the central nervous system【24†L78-L86】. Intoxication symptoms vary by substance (e.g., euphoria and slowed reaction with alcohol, or hyperactivity with stimulants) and can impair judgment, coordination, and perception; severe intoxication can lead to overdose, medical emerg​engage.healthynursehealthynation.org​engage.healthynursehealthynation.org. Withdrawal is a substance-specific syndrome that occurs when blood or tissue concentrations of a substance decline in someone who had prolonged heavy use, leading to a characteristic set of symptoms (usually opposite to the drug’s acute effects)【24†L87-L93】. Withdrawal syndromes (e.g. tremors and anxiety after alcohol cessation) cause significant distress or impairment and can range from mild to life-threatening, depending on the substance【23†L49-L57】【20†L47-L55】. Not all substances produce clear withdrawal syndromes (for example, classic hallucinogens do not cause significant physical withdrawal).

Related definitions: The term addiction is not a clinical DSM-5 term but is commonly used to describe severe SUD, typically involving compulsive use and loss of control. Dual diagnosis (or co-occurring disorder) refers to having a SUD along with another mental health disorder (e.g., depression or PTSD), which is common and can complicate treatment.

Common Substance Categories: Pharmacology, Pathophysiology, and Clinical Presentation

Substances of abuse span several categories with distinct pharmacological effects and healt​engage.healthynursehealthynation.org​engage.healthynursehealthynation.orgtail major substance classes, including their mechanisms of action, acute intoxication effects, chronic use sequelae, and withdrawal manifestations.

Alcohol

Pharmacology & Mechanism: Alcohol (ethanol) is a central nervous system (CNS) depressant. It enhances inhibitory GABA_A receptor activity and inhibits excitatory glutamate (NMDA) receptors in the brain, leading to sedation, anxiolysis, and impaired motor function. It also affects dopamine pathways related to reward, which contributes to its reinforcing properties. Over time, the brain adapts by downregulating GABA receptors and upregulating glutamate function, so chronic heavy drinkers become tolerant and their CNS becomes hyper-excitable without alcohol【23†L47-L55】【23†L49-L57】.

Intoxication: Acute alcohol intoxication causes behavioral disinhibition (euphoria or aggression), impaired judgment, slurred speech, incoordination (ataxia), unsteady gait, and memory impairment. Physical signs include flushed face, nystagmus, and at higher levels stupor or coma. Severe overdose can result in respiratory depression, loss of consciousness, aspiration, and death【23†L47-L55】. In the U.S., a blood alcohol concentration (BAC) ≥0.08% is legally intoxicated for driving. Very high BAC (e.g. >0.3%) can be life-threatening due to CNS depression. Notably, mixing alcohol with other depressants (benzodiazepines, opioids) greatly increases overdose risk due to synergistic respiratory depression.

Chronic Use and Pathophysiology: Long-term alcohol abuse affects virtually every organ. It can cause liver disease (fatty liver, alcoholic hepatitis, cirrhosis), gastrointestinal problems (gastritis, pancreatitis), cardiovascular issues (hypertension, cardiomyopathy), neuropathy, and cognitive impairment. Neuroadaptation leads to tolerance (requiri​engage.healthynursehealthynation.org​engage.healthynursehealthynation.orgeffect) and physical dependence. Many chronic users develop thiamine (vitamin B1) deficiency, risking Wernicke–Korsakoff syndrome (encephalopathy and amnesia). Psychologically, alcohol use often becomes a maladaptive coping mechanism, and users may continue despite social, occupational, or legal problems, hallmarking Alcohol Use Disorder. Approximately 13–14% of adults meet criteria for an alcohol use disorder in any given year【23†L75-L80】.

Withdrawal: Alcohol has one of the most dangerous withdrawal​ncsbn.org​ncsbn.orgion of heavy prolonged use, symptoms begin within 6–24 hours: minor withdrawal includes tremors (“shakes”), anxiety, irritability, insomnia, tachycardia, hypertension, sweating, nausea, and hyperreflexia【16†L29-L37】【16†L31-L39】. Between 12–48 hours, some patients develop alcoholic hallucinosis (primarily visual hallucinations) and/or seizures (generalized tonic-clonic seizures typically peak around 24–48 hours without treatment). The most severe form is *Delirium Tr​cdc.govusually 48–72 hours after the last drink: this is a medical emergency characterized by delirium (confusion, disorientation), severe agitation, hallucinations, profuse sweating, fever, and autonomic instability (e.g., blood pressure spikes)【23†L49-L57】【23†L51-L59】. Untreated DTs carry a significant mortality risk. Thus, medical detoxification is indicated for moderate-to-severe alcohol withdrawal. The CIWA-Ar scale (Clinic​cdc.govithdrawal Assessment for Alcohol, revised) is a 10-​cdc.govcoring tool used by nurses and providers to quantify withdrawal severity and guide treatment【13†L197-L205】【13†L207-L216】. Management usually includes benzodiazepines (see later section) to cross-treat GABA underactivity, plus thiamine and hydration.

Opioids

Pharmacology: Opioids are a class of CNS depressants that include natural opiates (morphine, codeine), semi-synthetics (heroin, oxycodone, hydrocodone), and synthetics (fentanyl, methadone). They primarily agonize mu-opioid receptors in the brain and spinal cord. This produces analgesia and intense euphoria (via dopamine release in reward pathways), but also sedation, miosis (pinpoint pupils), and respiratory depression【20†L47-L55】【20†L49-L57】. Repeated opioid use causes receptor downregulation and cAMP pathway upregulation in neurons, leading to tolerance (needing higher doses for effect) and physical dependence.

**I​nature.com​nature.comtoxication (or overdose) classically presents with miosis (pinpoint pupils), respiratory depression, and CNS depression (drowsiness to coma)【20†L47-L55】. Other signs include slurred speech, impaired attention, and hypotension. The “opioid overdose triad” is depressed mental status, slow shallow breathing, and pinpoint pupils【19†L25-L33】【19†L35-L43】. Skin might be clammy, and severe overdoses can cause cyanosis and death from respiratory arrest. Prompt administration of naloxone (an opioid antagonist) can reverse life-threatening opioid toxicity by displacing opioids from receptors. Given the potency of synthetic opioids like fentanyl, multiple naloxone doses may be needed in overdose scenarios.

Chronic Use: Long-term opioid abuse leads to high tolerance (users may require extremely high doses to stave off withdrawal). Tolerance develops to euphoria and respiratory depression, but partial tolerance to respiratory effects means overdose risk remains high with escalating doses. Chronic injection use (e.g., heroin) carries risks of bloodborne infections (HIV, hepatitis C), endocarditis, and collapsed veins. Opioid Use Disorder is characterized by compulsive use and severe withdrawal avoidance behavior. Psychosocial consequences include unemployment, legal problems, and relationship strain. Among U.S. overdose fatalities, opioids (particularly synthetic fentanyls) are the leading cause, reflecting the danger of misuse.

Withdrawal: Opioid withdrawal, while extremely uncomfortable, is generally not life-threatening (unlike alcohol or sedative withdrawal). Onset depends on the opioid’s half-life – e.g., heroin withdrawal starts 6–12 hours after the last dose, whereas methadone (long-acting) starts ~30+ hours. Early symptoms (within hours) include anxiety, intense drug craving, yawning, sweating, lacrimation (tearing), and rhinorrhea (runny nose)【20†L49-L57】【20†L59-L63】. This progresses to dilated pupils, piloerection (“goosebumps” – origin of the term “cold turkey”), muscle and bone aches, abdominal cramping, nausea, vomiting, diarrhea, tachycardia, hypertension, insomnia, and profound restlessness【20†L47-L55】【20†L49-L57】. Patients often describe it like a severe flu. Although not usually dangerous, complications like dehydration or rarely arrhythmias can occur. Opioid withdrawal can be confirmed with clinical signs and sometimes urine toxicology【20†L51-L59】. It can be treated with opioid agonist medications (e.g., methadone or buprenorphine) to alleviate symptoms, or with supportive medications (antiemetics, loperamide for diarrhea, NSAIDs for aches, clonidine for autonomic symptoms). The intense cravings and dysphoria du​cdc.gov​aafp.orgead to relapse if no treatment is provided, so linking patients to treatment (like Medication-Assisted Treatment, below) is critical.

Stimulants (Cocaine and Amphetamines)

Pharmacology: Stimulants such as cocaine and methamphetamine are CNS activators. Cocaine blocks the reuptake of dopamine, norepinephrine, and serotonin in the brain, leading to an acute buildup of these neurotransmitters in synapses. Amphetamines (including methamphetamine) not only block reuptake but also increase release of dopamine and norepinephrine. The result is heightened sympathetic nervous system activity and intense euphoria and alertness. Both cause a surge of dopamine in reward pathways, reinforcing their use.

Intoxication (Acute Effects): Stimulant intoxication produces feelings of energy, confidence, talkativeness, and euphoria. Users often have increased alertness, decreased need for sleep, and diminished appetite. Physical signs include tachycardia, elevated blood pressure, dilated pupils, and often psychomotor agitation. Sweating or chills and nausea may occur. At high doses, sympathomimetic toxicity is evident: potential for cardiac arrhythmias, chest pain, hyperthermia, and seizures. Cocaine intoxication may cause a fleeting but intense “rush” followed by a shorter-lived high (minutes to 1–2 hours if snorted), whereas methamphetamine has a longer duration of action (several hours). High-dose use of stimulants can induce psychosis – users may have paranoid delusions or tactile hallucina​acog.org​acog.orgawling on skin, known as formication). They can become irritable, aggressive, or experience panic.

Severe acute toxicity from stimulants can be life-threatening. For example, cocaine can precipitate myocardial infarction, stroke, aortic dissection, or seizures even in young individuals【27†L49-L57】【27†L51-L59】. Hyperthermia and hypertension from amphetamine overdose can lead to rhabdomyolysis and multi-organ failure【28†L49-L57】【28†L51-L59】. Management of severe stimulant overdose is largely supportive: benzodiazepines to reduce agitation, blood pressure, and seizure risk; cooling measures for hyperthermia; and rapid evaluation for cardiac or neurologic events【27†L49-L57】【28†L49-L57】. There is no specific antidote.

Chronic Use: Prolonged stimulant abuse can cause significant weight loss, malnutrition, and dental problems (especially “meth mouth” in methamphetamine users, du​acog.org​acog.orgng, and poor oral hygiene). Chronically elevated catecholamines can lead to cardiomyopathy. Many chronic users develop anxiety, insomnia, and paranoid thinking even between use episodes. Repetitive behaviors or psychosis can occur with long-term high-dose methamphetamine. Socially, stimulant addiction often leads to severe financial, legal, and health consequences, and users may go on multi-day binges (“runs”) without sleep, followed by crashes.

Withdrawal: Stimulant withdrawal (sometimes called the “crash”) is characterized by the opposite of intoxication effects. After stopping heavy use, individuals experience fatigue, hypersomnia (sleeping for extended periods), increased appetite (often craving carbohydrates), and psychomotor slowing. Mood symptoms dominate: profound depression, dysphoria, anhedonia, and in some cases suicidal ideation can occur in the days after cessation【27†L53-L63】. Anxiety and irritability are common. Cravings for the drug are intense. Unlike alcohol or opioid withdrawal, there are usually no prominent physical signs like fever or seizures, and stimulant withdrawal is not life-threatening. Symptoms generally peak within a few days and improve over 1–2 weeks, though some lethargy and mood symptoms can persist longer. Because there is no specific pharmacologic treatment for stimulant withdrawal, management is supportive: ensure safe environment, adequate sleep, nutrition, and observe for any suicidal ideation. The depression typically self-resolves, but if severe, short-term use of antidepressants may be considered. Importantly, the dysphoria can drive relapse, so connecting the individual to ongoing therapy and support is key during withdrawal recovery【27†L53-L63】.

Cannabis (Marijuana)

Pharmacology: Cannabis contains delta-9-tetrahydrocannabinol (THC) as the primary psychoactive component. THC is a partial agonist at cannabinoid receptors (CB1 receptors in the brain), which modulate neurotransmitter release. Activation of CB1 causes dopamine release in reward circuitry, but cannabis’s effects are a mix of depressant and mild hallucinogenic qualities. In addition to THC, cannabis contains other cannabinoids like CBD (cannabidiol) that have minimal psychoactivity but can modulate effects.

Acute Effects (Intoxication): Cannabis intoxication typically causes euphoria and relaxation, often with altered sensory perception (e.g. enhanced colors or music appreciation) and a distorted sense of time. Common signs include conjunctival injection (red eyes), increased appetite (the “munchies”), dry mouth, and mild tachycardia【31†L13-L21】. Users may have impaired short-term memory and slowed reaction time and motor coordination (hence an increased risk of accidents while driving). Anxiety or paranoid ideation can occur, especially at high THC doses or in inexperienced users; some experience panic attacks or a sense of depersonalization during a “bad trip.” High-potency marijuana or synthetic cannabinoids can occasionally precipitate acute psychotic symptoms (delusions or hallucinations), though these usually resolve as the drug wears off. Physical effects are generally mild compared to other drugs; lethal overdose from cannabis alone is extremely unlikely, as cannabinoid receptors are not concentrated nida.nih.gov​nida.nih.govng respiration. However, impairment can indirectly lead to injury or risky behaviors.

Chronic Use: Repeated cannabis use can lead to Cannabis Use Disorder in susceptible individuals (roughly 1 in 10 users overall, higher if use begins in adolescence). Chronic heavy use may produce amotivation syndrome – apathy, decreased drive, and social withdrawal (though this is debated). Cognitive effects can persist: attention, memory, and learning may be impaired during heavy use periods, and some deficits could be long-lasting especially if use began in early teens (when the brain is still developing)【62†L108-L115】【62†L115-L123】. Long-term smoking of marijuana may cause chronic bronchitis or lung irritation (si​nida.nih.gov​nida.nih.govough cannabis smoke contains some different components). Also, cannabis use at a young age has been associated with increased risk of psychosis or schizophrenia in genetically predisposed individuals.

Withdrawal: Although many people believe marijuana is non-habit-forming, cannabis withdrawal syndrome is recognized, particularly in daily users. Symptoms usually begin within 24–48 hours of stopping after​nida.nih.govvy use (weeks to months of near-daily use), peak in about 3–7 days, and last up to 1–2 weeks【35†L380-L387】. Common withdrawal symptoms include irritability, anger or aggression, nervousness or anxiety, insomnia (often with strange dreams), decreased appetite or weight loss, restlessness, and depressed mood【35†L358-L366】【35†L368-L376】. Some have physical symptoms like abdominal cramps, tremors, sweating, chills, or headache【35†L368-L376】【35†L378-L386】. While not medically dangerous, these symptoms can be significant enough to cause distress and lead to relapse. Management is typically supportive – reassurance that symptoms will pass, promoting sleep hygiene, and possibly short-term symptomatic medications (e.g., NSAIDs for headaches or melatonin for sleep). Counseling can help the user cope with mood symptoms during withdrawal. Importantly, not all heavy users experience withdrawal; studies suggest a subset manifest significant symptoms, often correlating with level and duration of use【35†L382-L386】.

Sedatives, Hypnotics, and Anxiolytics (Benzodiazepines, Barbiturates, etc.)

Pharmacology: This category includes benzodiazepines (e.g., diazepam, alprazolam, lorazepam), older barbiturates (phenobarbital, secobarbital), and other prescription sleep aids (like zolpidem). They all depress CNS activity, primarily by enhancing the effect of GABA at the GABA_A receptor (benzodiazepines increase frequency of chloride channel opening; barbiturates increase duration of opening). The result is anxiolytic, sedative, muscle relaxant, and anticonvulsant effects. These drugs are medically used for anxiety, insomnia, seizures, anesthesia, etc., but all have misuse potential. Barbiturates, an older class, carry higher overdose risk and largely have been replaced by benzodiazepines which have a wider safety margin – though benzos are also addictive.

Intoxication: Sedative intoxication presents similarly to alcohol intoxication (since both facilitate GABA). Signs include sedation, drowsiness, slurred speech, incoordination, unsteady gait, and impaired attention or memory. Inappropriate behavior or mood lability may occur (ranging from euphoria to irritability). In high doses, or when combined with other depressants, these drugs can cause stupor or respiratory depression. Benzodiazepines by themselves, in overdose, typically cause deep sedation but not pure respiratory collapse unless doses are very high; however, barbiturate overdose can readily cause life-threatening breathing suppression and hypotension【37†L108-L116】【37†L112-L119】. Mixed overdoses (e.g., benzodiazepines plus alcohol or opioids) frequently result in severe CNS and respiratory depression. Other physical findings can include nystagmus and hypotonia. One hallmark in intoxication is relief of anxiety (anxiolysis) progressing to somnolence. Because tolerance develops to sedatives, chronic users may appear relatively normal even on high doses, but adding any other sedative can precipitate overdose.

Overdose management for benzodiazepines is largely supportive (airway protection, ventilation support). Flumazenil is a benzodiazepine antagonist that can reverse sedation, but it is used cautiously (if at all) because it can trigger seizures especially in patients chronically on benzodiazepines【39†L17-L22】. There is no specific antidote for barbiturate overdose; intensive care support is required. Importantly, sedative intoxication often co-occurs with alcohol or other substances in practice, so evaluation and treatment must consider polysubstance effects.

Chronic Use: Regular use of benzodiazepines leads to tolerance – often first to the sedative and euphoric effects, with anxiolytic effects sometimes retained longer. Dose escalation can occur. Chronic high-dose use impairs cognition (memory, conce​pmc.ncbi.nlm.nih.govcan produce a persistent depressive effect on mood. Patients may doctor-shop for prescriptions or escalate to illicit procurement when dependent. In older adults, even therapeutic use of sedatives markedly raises risk of falls and confusion. Long-term sedative use disorder often coexi​pmc.ncbi.nlm.nih.govther substance problems (e.g., alcohol) or underlying anxiety disorders. Socially, sedative-dependent individuals may become withdrawn, spend significant time obtaining medications, or suffer​pmc.ncbi.nlm.nih.goval impairment due to oversedation or accidents.

Withdrawal: Withdrawal from sedative-hypnotics is potentially life-threatening and shares similar features with alcohol withdrawal (as both affect GABA). Benzodiazepine withdrawal can range from mild anxiety and insomnia to severe symptoms like seizures and delirium. Typical withdrawal begins​pmc.ncbi.nlm.nih.gov​pmc.ncbi.nlm.nih.govstopping short-acting benzos (or 4–7 days for longer-acting like diazepam). Symptoms include rebound anxiety, restlessness, insomnia (often with disturbing dreams), headache, muscle tension, irritability, and sensory hypersensitivity (sensitivity to light/sound). More severe cases progress to autonomic instability (elevated blood pressure, heart rate, sweating), tremors, nausea, and perceptual disturbances. Grand mal seizures can occur, usually 2–5 days after the last dose in severe cases【37†L139-L147】. Withdrawal delirium (similar to DTs) is a risk with barbiturates or very high benzodiazepine dependence – characterized by confusion, hallucinations, and potentially fatal cardiovascular collapse【37†L139-L147】. Given these dangers, sedative withdrawal should be medically supervised. The standard management is to gradually taper the benzodiazepine dose over weeks, or switch the patient to a longer-acting benzodiazepine (like diazepam or clonazepam) then taper. In barbiturate dependence, phenobarbital is often used to taper safely. During withdrawal treatment, vital signs and neurological status are monitored closely. Inpatient detox is recommended for high-dose sedative users, as seizures or severe symptoms may require prompt treatment (IV benzodiazepines, anticonvulsants, or intensive care). Even mild withdrawal symptoms (e.g., jitteriness and sleep difficulty) can persist for weeks – a protracted withdrawal syndrome – and may need symptomatic treatment (such as beta-blockers for tremor or short-term sedatives at a tapering dose).

Hallucinogens (e.g. LSD, PCP)

This group includes substances that profoundly alter perception, mood, and cognition. They can be broadly divided into classic hallucinogens (like LSD and psilocybin) which primarily affect serotonin receptors, and dissociative anesthetics (like PCP and ketamine) which antagonize NMDA receptors. Notably, hallucinogens typically do not cause physical dependence or classic withdrawal syndromes, but they can cause intense psychological experiences.

Lysergic Acid Diethylamide (LSD) and Similar Hallucinogens:
Mechanism: LSD, psilocybin (magic mushrooms), mescaline (peyote) and other “psychedelics” are thought to act as agonists at serotonin 5-HT2A receptors in the brain【41†L84-L92】【41†L86-L94】. This disrupts normal sensory and serotonergic signaling, leading to hallucinations and altered consciousness. Tolerance to these effects builds rapidly; frequent use on consecutive days yields a diminished effect (and cross-tolerance exists among them)【41†L101-L109】【41†L104-L107】. However, tolerance also fades quickly after cessation, and these drugs are not known to produce physical withdrawal symptoms【41†L101-L109】【41†L104-L109】.

Intoxication (Acute Trip): Hallucinogen intoxication causes profound perceptual changes. Users experience sensory distortions and hallucinations – for example, colors may appear more vivid, shapes may blend or move, and they may perceive sounds as visuals (synesthesia, e.g., “seeing sounds”)【41†L109-L117】【41†L111-L119】. There is often altered sense of time and self; depersonalization (feeling unreal) or derealization (feeling the environment is unreal) may occur【41†L109-L117】【41†L113-L120】. Emotions during an LSD “trip” can swing from euphoria to anxiety or even terror, depending on the set (user’s mindset) and setting. Physiological effects of LSD and similar drugs are usually mild: pupils dilate (mydriasis), heart rate and blood pressure may rise slightly, sw​share.upmc.com​share.upmc.coms can occur【41†L117-L125】【41†L118-L125】. Nausea and vomiting are more common with plant-based hallucinogens like peyote (mescaline) or psilocybin mushrooms【41†L117-L125】【41†L118-L125】. Coordination can be impaired. Notably, in contrast to stimulants, users are usuall​navisclinical.comir surroundings (except for visual distortions) and might have periods of lucidity between waves of perceptual chang​share.upmc.com0】【41†L121-L127】. Bad trips refer to acute anxiety, panic, or paranoia triggered by hallucinogen use – the person may have terrifying hallucinations or feel they are losing their mind. Although classic hallucinogens do not cause direct physical toxicity at typical doses, high doses of LSD can exceptionally lead to accidents or risky behaviors due to impaired judgment, and massive overdose could theoretically cause hyperthermia or cardiovascular collapse【41†L123-L131】【41†L127-L134】 (though fatal LSD overdose is exceedingly rare). Psilocybin and mescaline are less potent per weight; psilocybin trips last ~4–6 hours, LSD ~8–12 hours, and mescaline up to 12 hours【41†L92-L100】. There is no antidote; management of acute hallucinogen intoxication focuses on a calm, reassuring environment, “talking down” the patient, and, if needed for severe agitation or panic, giving benzodiazepines. Infrequently, an antipsychotic might be used if severe psychosis persists.

Aftereffects: Some users experience lingering perceptual changes after hallucinogen use. Hallucinogen Persisting Perception Disorder (HPPD), colloquially “flashbacks,” involves spontaneous, transient recurrences of perceptual distortions (like halos around objects or trailing images) long after the drug has left the body. This condition is relatively rare but can be distressing and last for weeks or longer in susceptible individuals.

PCP (Phencyclidine) and Ketamine (Dissociative Hallucinogens):
Mechanism: Phencyclidine (PCP, “angel dust”) and ketamine are NMDA receptor antagonists. Initially developed as anesthetics, they produce a state of “dissociation” – a feeling of detachment from one’s body and environment. They also release dopamine, adding some stimulant and euphoric properties. PCP is more potent and longer-acting than ketamine. These can be smoked, snorted, or taken orally (or injected in medical contexts for ketamine).

Intoxication: Low to moderate doses of PCP/ketamine cause euphoria and feeling “floaty” or disconnected, along with numbness or analgesia (users may be less responsive to pain)【42†L79-L87】. People often present with horizontal or vertical nystagmus (rapid jerky eye movements – vertical nystagmus is classically associated with PCP intoxication). Other signs include ataxia (unsteady gait), dysarthria (slurred or garbled speech), and muscle rigidity or unusually high strength for the individual (due to catatonic like state or reduced pain perception)【42†L79-L87】【42†L81-L89】. Blood pressure, heart rate, and temperature can elevate, particularly with higher doses【42†L81-L89】【42†L83-L90】. With moderate intoxication, individuals may appear confused, impulsive, and agitated, with mood swings from laughing to paranoia. They often have a blank stare and may be unaware of surroundings or exhibit depersonalization. High doses of PCP induce a dissociative anesthesia: a trance-like state with eyes open but unresponsive (“catatonic”), or conversely, extreme agitation and bizarre, violent behavior can occur if the person is responsive but hallucinating. Psychotic symptoms are common – e.g., paranoid delusions or auditory hallucinations – and can be prolonged. Combativeness is a concern: PCP intoxication is notorious for unpredictable aggression or self-harm; because pain is blunted, individuals may injure themselves severely without normal protective reflexes. “Superhuman strength” is a misnomer but reflects how a struggling PCP-intoxicated person may seem unnaturally strong due to high adrenaline and indifference to pain.

Overdose and Complications: Severe PCP overdose can cause seizures, severe hypertension, arrhythmias, hyperthermia, or coma, and though death is uncommon, it can result from trauma or accidents while intoxicated (e.g., jumping from heights due to delusion of invincibility)【42†L79-L87】【42†L83-L90】. Rhabdomyolysis (muscle breakdown) and kidney failure are possible due to extreme agitation and muscle activity. An acute “emergence delirium” or reaction phase can occur as PCP/ketamine wear off, with confusion and hallucin​navisclinical.com​navisclinical.comout of the dissociative state【42†L97-L103】. Management of PCP intoxication prioritizes safety – for patient and staff. Physical restraints may be required briefly for an out-of-control patient to prevent harm. Pharmacologically, benzodiazepines are given to reduce severe agitation, anxiety, muscle rigidity, and to treat/prevent seizures【42†L79-L87】. If psychosis is prominent, a low-stimulation environment and perhaps antipsychotic medication (like haloperidol) may help, though caution is used as some antipsychotics can lower seizure threshold or exacerbate blood pressure issues. Cooling measures treat hyperthermia. There is no specific antidote; support and monitoring continue until the drug’s effects subside (PCP’s effects may last 8+ hours). Ketamine intoxication is usually shorter (1–2 hours of main effects) and typically less likely to cause violent behavior, though a similar dissociative state and hallucinations occur. Ketamine has legitimate medical uses (anesthesia, pain control, depression therapy at low dose), but in recreational use (“Special K”)​share.upmc.com​navisclinical.comimpaired judgment.

Withdrawal: There is generally no defined withdrawal syndrome for classic hallucinogens, PCP, or ketamine, as they do not cause the type of physical dependence seen with alcohol or opioids【41†L101-L109】【41†L104-L109】. After heavy frequent use of PCP or ketamine, some users may feel dysphoric or crave the drug, but not a reliable physiological withdrawal pattern. Most issues are psychological, like flashbacks (for LSD) or mood disturbances. This means these drugs’ potential for addiction tends to be psychological craving or habitual use for the experience, rather than needing the drug to avoid withdrawal. Nonetheless, PCP Use Disorder can occur, characterized by continued use despite life problems and intense craving for the dissociative state.

Inhalants

Pharmacology: “Inhalants” are a broad c​msdmanuals.com​msdmanuals.comemicals that produce mind-altering effects. They include volatile solvents (e.g., toluene in glue,​merckmanuals.com​merckmanuals.coms), aerosols (spray propellants in cans), gases (butane, propane, nitrous oxide), and *nitrites​merckmanuals.com​merckmanuals.comoppers”). These substances are commonly found in household or industrial pro​merckmanuals.com​merckmanuals.comy accessible especially to children and adolescents【44†L55-L63】【44†L47-L54】. When inhaled (often by​merckmanuals.com​merckmanuals.com rag or “bagging” concentrated fumes), these chemicals rapidly absorb through the merckmanuals.com​merckmanuals.comin. Many solvents are CNS depressants that enhance GABA and glycine or disrupt neuronal membranes glo​merckmanuals.com​merckmanuals.cometics. Nitrites act as vasodilators and produce a brief intense head rush.

Intoxication: In​merckmanuals.com​merckmanuals.com within minutes and typically lasts a short time (15–45 minutes for many solvents, though can be longer if repeated). Immediate samhsa.gov​samhsa.govative intoxication: dizziness, euphoria, lightheadedness, slurred speech, ataxia, drowsiness, and disinhibition【4​oasas.ny.gov​oasas.ny.gov3】. Users often feel a brief “high” and may alternate between excitability and CNS depression. Some inhalants (l​ncbi.nlm.nih.gov​ncbi.nlm.nih.govhallucinations or delusions; perception is distorted and users may experience a dreamy or floating sensation【46†L119-L1​aafp.org​aafp.orgusion, delirium, and aggressive behavior can occur with higher doses or prolonged sniffing in a session【46†L119-L124】. Physically, inhalants often c​acog.org​acog.orgation*, and generalized muscle weakness. Many solvents produce a distinct chemical odor on the breath or clothes (e.g., ga​hhs.gov​samhsa.govher signs: glue sniffer’s rash or paint stains around the nose/mouth from chronic use, and conjunctival irritat​ncsbn.org​engage.healthynursehealthynation.orghe heart to catecholamines, which can lead to arrhythmias. Sudden Sniffing Death Syndrome is a engage.healthynursehealthynation.org​engage.healthynursehealthynation.orgealthy young person can suffer fatal cardiac arrest on inhaling certain agents (like butane or aerosol​cdc.gov​cdc.govular fibrillation【46†L132-L139】【46†L133-L136】. Additionally, acute inhalant overdose can cause ​nida.nih.gov​nida.nih.govres, or coma. Some specific inhalants have unique acute dangers (e.g., inhaling toluene-based p​pmc.ncbi.nlm.nih.gov​pmc.ncbi.nlm.nih.gov from oxygen displacement and cardiac arrhythmias; nitrous oxide can cause loss of consciousness navisclinical.com​navisclinical.com oxygen).

Chronic Use and Toxicity: Long-term inhalant abuse is extremely damaging to organs. Solvents like toluene and naphthalene are directly neurotoxic – chronic abuse can cause permanent nerve and brain damage (e.g., polyneuropathy, cognitive impairment, and even spongy degeneration of white matter similar to multiple sclerosis)【46†L138-L146】【46†L140-L147】. Chronic inhalant users may develop tremors, hearing loss, gait disturbances, and memory deficits. Many solvents harm the liver, kidneys, lungs, and heart. For instance, chronic gasoline or glue sniffing can lead to liver toxicity, renal tubular damage, and serious arrhythmias. Inhalants can also damage bone marrow, causing aplastic anemia or leukemia in severe cases【46†L140-L147】【46†L142-L146】. “Huffer’s eczema,” a rash around the mouth/nose, results from irritant chemicals contacting the skin【46†L140-L147】. Additionally, use during pregnancy can cause fetal solvent syndrome (similar to fetal alcohol effects)【46†L139-L146】. Psychologically, inhalant users (often very young or in lower socioeconomic situations) may progress to other substances as they get older, but even inhalant use alone can severely disrupt schooling and social development. It is noted that many inhalant users cease by young adulthood (perhaps due to availability of other drugs or the deterrent of health effects)【46†L173-L179】, but those who continue have among the poorest recovery rates of any substance, partly due to cognitive damage and psychosocial factors【46†L173-L179】.

Withdrawal: Unlike other substances, inhalants generally do not produce a well-defined withdrawal syndrome with prominent physical symptoms【46†L148-L154】【46†L150-L153】. Tolerance does develop with repeated exposure (users need more inhalations to achieve the same high), and psychological dependence can be strong (cravings to re-experience the euphoria or escape reality)【46†L148-L154】【46†L150-L153】. However, physical dependence is minimal – meaning stopping inhalant use usually does not cause severe illness. Some chronic users report irritability, restlessness, insomnia, or headache upon abrupt cessation, but these are relatively mild and short-lived. The main challenge is psychological: users must overcome habits and often underlying social issues. Given the lack of a medical withdrawal, treatment focuses on supportive care and long-term rehabilitation: monitoring for any mood symptoms, providing a structured environment, and addressing any organ damage. Because many inhalant abusers are adolescents, involving family therapy and addressing environmental factors (like access to products, peer influence) is crucial.

Overall, inhalants are unique in that even sporadic use can be fatal (via arrhythmia or asphyxiation), and chronic use can leave lasting neurological impairment. Early intervention and prevention (education about risks in schools, restricting youth access to volatile substances) are key measures.

Assessment and Screening Tools for Substance Use

Early identification of problematic substance use is essential in healthcare. Nurses play a critical role in screening patients for substance misuse and assessing the extent of a Substance Use Disorder. A variety of validated tools and approaches are available:

Comprehensive Assessment: If a screening is positive or suspicion is raised, a nurse proceeds with a full assessment of substance use. This includes a detailed history of all substances used (what substances, quantity, frequency, route, duration), age of first use, last use time, periods of abstinence, prior treatment attempts, and consequences experienced (health, legal, occupational, social). It’s important to ask about withdrawal history (any past seizures or severe withdrawal episodes), as this informs the risk in detox. A psychiatric history (co-occurring depression, anxiety, PTSD, etc.) and medical history (e.g., liver disease, HIV status, chronic pain) are essential to integrate care. Collateral information from family may help, with patient consent. Tools like the Addiction Severity Index (ASI) structure a comprehensive assessment across domains (medical, employment, alcohol, drugs, legal, family/social, psychiatric).

During assessment, the nurse maintains a nonjudgmental tone, building trust so the patient feels safe disclosing sensitive information. Vital signs and physical exam are also part of assessment: noting signs like track marks (IV injection sites), nasal mucosa damage (from snorting drugs), jaundice (alcoholic liver disease), or neurologic abnormalities. Mental status exam assesses for intoxication (e.g., pinhole pupils in a sedated patient might suggest opioid use, or rapid pressured speech might suggest stimulant use) or psychiatric comorbidities (like hallucinations or suicidal ideation).

Screening in Special Settings: Healthcare guidelines recommend routine substance use screening in primary care and hospital settings. For example, the U.S. Preventive Services Task Force recommends that all adults be screened for unhealthy alcohol use in primary care, with brief counseling offered for those who screen positive【16†L57-L65】【16†L67-L73】. Pregnant women should be screened for alcohol and drug use at initial prenatal visits (using tools like AUDIT or 4Ps for pregnancy) because early intervention can improve maternal-fetal outcomes. Adolescents should be confidentially screened during health visits (e.g., using CRAFFT). In emergency departments, nurses often use quick screens for alcohol intoxication or overdose assessment (like the AUDIT-C, a 3-question version of AUDIT). In mental health settings, every intake should include substance use screening, as many psychiatric crises are precipitated or complicated by substance use.

In summary, using structured screening instruments and thorough assessment techniques allows nurses to identify substance use issues early and accurately, which is the first step toward providing appropriate intervention or referral to treatment. Documenting the findings clearly and communicating them to the interdisciplinary team ensures continuity of care (while respecting patient confidentiality rules).

Nursing Process in Caring for Patients with SUD

Nursing care for individuals with substance use disorders involves applying the nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation) in a holistic, patient-centered manner. The nurse addresses not only the physiological aspects of substance use, but also the psychosocial, safety, educational, and environmental needs of the patient. Below is a breakdown of key considerations at each phase, along with examples of nursing diagnoses, interventions, and outcomes for patients with SUD.

Nursing Assessment

Assessment was discussed above in screening context; once a patient is identified as having a substance issue or is admitted for a related condition (e.g., overdose, withdrawal, or medical illness complicated by SUD), the nurse performs a comprehensive assessment. This includes:

Assessment is ongoing. In an acute setting, the nurse continuously monitors for withdrawal symptoms or medical complications (like checking CIWA or COWS – Clinical Opiate Withdrawal Scale – scores regularly). In a rehab or psychiatric unit, the nurse might assess daily mood, sleep, and any cravings.

Common Nursing Diagnoses

Based on the assessment, the nurse identifies nursing diagnoses (NANDA-I terms) that reflect the patient’s problems. These diagnoses may address direct physiological issues or psychosocial and knowledge deficits. Examples of nursing diagnoses for patients with substance use include【52†L429-L437】:

Nursing diagnoses should be prioritized: physical safety comes first (e.g., Risk for injury/seizures is acute priority). Psychosocial diagnoses can be addressed once the patient is medically stabilized.

Planning and Goals

For each nursing diagnosis, the nurse, in collaboration with the patient, sets goals (outcomes) that are SMART: Specific, Measurable, Achievable, Realistic, and Time-limited. Examples of goals/outcomes:

These goals will feed into the Interventions phase. For instance, if the goal is to have the patient practice non-chemical coping alternatives, the interventions will involve teaching and practicing those skills.

Nursing Interventions and Implementation

Nursing interventions for SUD span acute medical management, therapeutic communication and counseling, education, and coordination of care. Key interventions include:

Evaluation

Continuous evaluation is needed to determine if nursing interventions are effective and if goals are being met. Outcomes to evaluate:

If outcomes are not met, the nurse must reassess and modify the care plan. For example, if a patient continues to deny the problem at discharge (“I think you’re all overreacting, I don’t really need rehab”), the team might refine the approach: maybe involve a peer support specialist to talk with them, or enlist a family meeting to confront the denial with love and concern. If withdrawal signs are not adequately controlled (e.g., patient still very hypertensive and anxious despite the symptom-triggered dosing), perhaps the protocol needs adjusting (increase medication dose or frequency) – the nurse would advocate this to the provider.

Evaluation also covers long-term outcomes: in follow-up, is the patient maintaining sobriety? This might be beyond the immediate care episode, but it’s part of the continuum – e.g., a clinic nurse checking in at 1-month post detox: has the patient engaged in outpatient counseling, remained abstinent (via self-report or urine drug screens)? If not, evaluate what barriers exist (side effects of a med, inability to get to counseling, relapse triggers that were not addressed) and intervene accordingly.

It’s important to celebrate progress to reinforce patient’s efforts. For instance, acknowledging: “You’ve been sober 10 days now – that’s a great start and you should be proud of how you handled withdrawal and sought help.”

In summary, using the nursing process ensures systematic, compassionate, and effective care for individuals with substance use disorders. The nurse’s interventions address immediate medical needs and lay the groundwork for long-term recovery through education, skill-building, and linkage to ongoing support. This comprehensive approach improves both acute outcomes (safe withdrawal, medical stabilization) and long-term outcomes (reduced relapse and improved functioning)【52†L467-L475】【52†L469-L477】.

Management Strategies: Pharmacological and Non-Pharmacological Treatments

Effective treatment of substance use disorders often requires a combination of medication, if appropriate, and psychosocial interventions. This section outlines major pharmacological therapies – including Medication-Assisted Treatment (MAT) – and key non-pharmacological strategies (counseling, behavioral therapies, support groups, etc.). The integration of approaches is critical; for example, medications can help normalize brain chemistry and reduce cravings, while therapy helps patients rebuild life skills and coping mechanisms.

Medication-Assisted Treatment (MAT) and Detoxification Protocols

Medication-Assisted Treatment (MAT) refers to the use of FDA-approved medications in combination with counseling and behavioral therapies to treat SUD. MAT has a strong evidence base, especially for opioid and alcohol use disorders, and is considered a gold standard for those conditions. It helps by relieving withdrawal symptoms, reducing cravings, or blocking drug effects, enabling patients to engage more successfully in recovery activities.

Nurses will often be involved in giving naltrexone injections or ensuring oral med adherence, and monitoring patient outcomes (like asking about any drinking episodes, side effects like injection site reactions, etc.). Also, emphasize that these medications are adjuncts – patients should ideally also engage in counseling or support groups for best results【56†L2219-L2225】.

Key Point: MAT does not “cure” addiction by itself but treats it as a manageable chronic condition. Combining MAT with counseling dramatically improves retention in treatment and outcomes. Nurses should advocate for MAT when indicated – e.g., if an opioid-dependent patient is skeptical (“I want to be totally drug-free, no methadone”), the nurse can educate that craving and relapse rates are extremely high and that using a medication is like using any other medical therapy for a chronic disease, not a crutch or weakness. On the flipside, respect patient preferences – some may decline MAT, in which case maximize non-pharm supports and perhaps suggest naltrexone as an alternative.

Psychosocial and Behavioral Therapies

Multiple evidence-based therapies address the psychological and behavioral aspects of addiction. Often delivered by psychologists, counselors, or social workers, nurses should be familiar with them to reinforce techniques and encourage participation.

Relapse Prevention and Discharge Planning: Because addiction is a chronic relapsing condition, preparing patients for post-treatment life is crucial. Before discharge from any program, the team (including the nurse, patient, counselor, possibly family) should develop a relapse prevention plan. Key elements:

Nurses often coordinate the discharge planning, ensuring all referrals are in place (to counseling, MAT provider, primary care for follow-ups on medical issues). They may also schedule a follow-up call to check in on the patient a week or two after discharge – a brief call to say “How are things going? We care about your progress, any issues getting to your appointments?” – which can improve engagement.

In sum, an integrated approach – combining appropriate pharmacotherapy (to manage withdrawal or support abstinence) with comprehensive psychosocial support – yields the best outcomes in SUD treatment【56†L2201-L2209】【56†L2203-L2211】. Nurses function as care coordinators, educators, and supportive counselors across these interventions. The chronic care model of addiction means the nurse might see the patient across multiple episodes (ED visits, hospitalizations, clinic visits), continually encouraging and guiding them along the path to recovery. Consistent empathy, hope, and firm belief in the patient’s capacity to change can make a profound difference in keeping them engaged in treatment.

Ethical and Legal Considerations in Substance Abuse Care

Caring for patients with substance use disorders presents specific ethical and legal responsibilities for nurses and other healthcare providers. Key issues include confidentiality (privacy rights), mandatory reporting duties, consent and patient rights, and addressing impairment in healthcare workers. Adhering to professional ethics and laws is crucial to protect patient welfare and public safety while respecting patients’ dignity.

Confidentiality and 42 CFR Part 2

Patients with substance use disorders are protected not only by general privacy laws (like HIPAA) but also by special federal regulations. The U.S. law 42 CFR Part 2 (Title 42 of the Code of Federal Regulations, Part 2) provides extra confidentiality protections to records of patients in substance abuse treatment programs【56†L2243-L2251】【56†L2245-L2249】. The intent is to encourage people to seek treatment without fear that their information will be disclosed (for instance, to law enforcement or employers) without their consent.

Under these rules:

A related topic is patient rights in treatment. Patients have the right to informed consent or refusal of treatments (with some exceptions in emergencies or if patient lacks decision-making capacity). For example, you can’t force someone into detox unless they are a danger to themselves/others (or under legal mandate). Treatment should ideally be voluntary; coerced care is ethically tricky, although sometimes leverage (like legal pressure or family ultimatums) does push patients into treatment that ends up helping them. Nurses should uphold autonomy by educating patients on options and respecting their choices, while also considering beneficence (doing good by recommending effective treatment) and nonmaleficence (avoiding harm, e.g., ensuring a patient isn’t discharged to drive drunk).

Mandatory Reporting and Public Safety

Mandated reporting laws require healthcare providers to report certain information to authorities:

Consent for Treatment is another legal aspect. For instance, if initiating disulfiram or naltrexone, ensure the patient consents and understands, especially disulfiram’s reactions. For MAT like methadone, specific consent forms and patient contracts are often used (due to its controlled nature).

Impaired Healthcare Professionals: Ethically, nurses have a duty to report colleagues who may be diverting drugs or working while impaired by substances – this overlaps with legal duty in many states (nurses could face discipline if they fail to report known diversion). This will be detailed in the next section, but from a legal perspective: most states have alternative-to-discipline programs (like peer assistance) where nurses or doctors with SUD can be reported for the purpose of getting them into monitoring/treatment rather than immediately punitive action. Still, if a nurse observes a coworker stealing medications or suspects them of practicing under the influence, it’s both an ethical duty (to protect patients from potential harm and help the colleague) and often a requirement by the state nursing board or employer to report it. The reporting could be to a supervisor or compliance officer who then engages the proper program.

Ethical Principles and Stigma: Nurses should uphold the ethical principles of beneficence, nonmaleficence, autonomy, and justice. For example, treat pain adequately in a person with addiction (justice and beneficence) – don’t under-treat due to stigma or personal bias (that would be nonmaleficence violation causing needless suffering). Use veracity (truth-telling) in education – give honest information about prognosis or what a medication can/can’t do. And maintain fidelity to the patient – which in context means being an advocate even when the patient’s behavior is challenging. An ethical nurse avoids enabling (like giving benzodiazepines on demand to an addicted patient without clear indication, which could worsen their situation) but also avoids punitive attitudes (like withholding comfort measures “to teach a lesson”).

HIPAA in practice: Even aside from Part 2, everyday HIPAA means not disclosing a patient’s health information without permission. With substance issues, be careful with visitors – the patient may not want certain family to know details. Always ask, “Is it okay if we discuss your treatment in front of your sister here?” Also, some patients might use aliases in treatment (allowed in some programs) to protect identity – be aware of how to handle records properly in those cases.

Legal issues specific to SUD patients: Some patients might be on probation or court-mandated to treatment. Nurses may interact with probation officers or drug courts. Generally, patient consent is needed to release information to these officials (or a court order). Often, patients sign such consent as part of the program entry if it’s mandated. If so, provide factual reports on attendance, tox screens, etc., without subjective judgment.

Advocacy: Nurses should also be aware of healthcare laws/policies affecting SUD treatment (

Substance Use Among Healthcare Professionals

Substance use can also affect healthcare providers themselves, including nurses, physicians, etc. It is estimated that approximately 10-15% of nurses (about 1 in 10) may have a substance use problem or be in recovery from one, similar to rates in the general population【60†L81-L89】. Caring for patients in pain and ready access to medications (especially opioids and sedatives) can tempt some healthcare workers into misuse or diversion. This is a serious issue as it jeopardizes both the impaired provider’s health and patient safety.

Warning Signs in Colleagues: Nurses must remain vigilant for signs a coworker might be impaired or diverting drugs. Red flags of a Substance Use Disorder in a healthcare professional include sudden mood swings or personality changes, deteriorating work performance, and unexplained absences or tardiness【60†L97-L105】. The person may have elaborate excuses for behavior or frequently call in sick. Physical signs such as shakiness, slurred speech, or red eyes during a shift can suggest intoxication or withdrawal. Other clues might be wearing long sleeves when not appropriate (to hide injection marks) or a noticeable decline in personal appearance/hygiene and significant weight loss or gain【60†L97-L105】【60†L100-L103】.

Drug Diversion indicators: When a nurse or other provider diverts (steals) controlled substances, there may be telltale patterns: frequent volunteering to administer narcotics or frequently needing to waste excess medication (and insisting on doing it alone), discrepancies in medication count records, or patients reporting inadequate pain relief under that person’s care【60†L105-L113】. The individual may spend a lot of time near medication dispensing areas or show an inappropriate level of interest in patients’ pain meds. They might also refuse drug testing or avoid situations where they might be caught【60†L97-L105】【60†L99-L102】. Coworkers could find syringes or medication vials in odd places (sign the person is self-injecting on the job). In sum, behavioral changes plus drug handling irregularities strongly suggest an impaired provider.

Ethical Duty to Report: Nurses have an ethical and legal obligation to address suspected impairment in colleagues. This follows the principles of nonmaleficence (preventing harm to patients) and fidelity to the nursing profession’s integrity. If a nurse suspects a coworker is diverting drugs or working while impaired, they should not cover up or enable that behavior. Protecting a peer out of misplaced loyalty could result in patient harm (e.g., an impaired nurse might make a life-threatening error or leave patients in pain by diverting their meds). Instead, the nurse should discreetly document objective observations and report concerns to the appropriate supervisor or manager per facility policy【60†L115-L123】【60†L121-L128】. Many institutions have an Employee Assistance Program or a specific process for this. The goal is to ensure the individual is removed from patient care duties until safely evaluated and, if needed, to initiate help for them.

Professional Programs and Recovery: Importantly, the focus should be on treatment, not punishment. Most state boards of nursing and medicine have alternative-to-discipline programs for impaired professionals. These programs (often called Peer Assistance, Diversion Program, or Professional Health Program) allow the nurse or doctor to undergo rehabilitation and monitoring under a contract, rather than immediately lose their license. For example, a nurse may agree to attend a treatment program, submit to random drug screens, practice under certain restrictions, and regularly report to the board. If they comply and stay sober, they can often continue their career. This approach aligns with viewing SUD as a treatable illness. The American Nurses Association and other organizations endorse a non-punitive, supportive approach that encourages colleagues to report and impaired providers to seek help early【60†L115-L123】【60†L121-L128】. In workplaces with a “just culture” and clear policies, coworkers are more likely to step forward, which ultimately protects patients and helps the affected nurse get care before something dire occurs.

Managing the Situation: Once reported, management will typically meet with the nurse in question, possibly require a for-cause drug test, and remove them from duty if impairment is suspected. It’s critical to handle this confidentially and compassionately, as the individual is likely fearful and ashamed. The nurse may be referred to the employee health or occupational assistance program. If substance use is confirmed, they will be guided to detox or rehab. Colleagues should refrain from gossip and support the nurse in recovery upon return, while ensuring all safeguards (like not allowing them access to controlled substances unsupervised, if that’s a stipulation) are in place.

Returning to Work: A healthcare professional in recovery can often return to safe practice with appropriate monitoring. They may have conditions on their license such as no access to narcotic administration for a period, or working daytime shifts only, etc., and will be subject to random drug tests for several years. Many nurses are able to resume productive careers after completing recovery programs. Coworkers should create an environment that reduces stigma – the recovering nurse should not be ostracized but rather encouraged in their sobriety. However, everyone remains watchful for relapse signs, as relapse can happen. If relapse occurs, it should be treated promptly as a medical issue and the person should be removed from duty again to protect patients.

In summary, substance use among healthcare professionals is a serious but addressable problem. Nurses must know the signs of impairment and diversion【60†L97-L105】【60†L105-L113】, and uphold their duty to ensure patient safety by reporting concerns. By doing so within a framework that offers treatment and hope (rather than immediate punishment), the impaired nurse or doctor has the best chance to recover and return to being a safe practitioner. This ultimately exemplifies caring for our own, as well as our patients. Resources like the NCSBN’s “Substance Use Disorder in Nursing” guidelines and state peer assistance programs provide guidance for handling these situations constructively【72†L39-L47】【72†L41-L47】.

Special Populations: Considerations in Substance Use

Certain populations have unique vulnerabilities or needs regarding substance use and its treatment. Adolescents, pregnant women, older adults, veterans, and LGBTQ+ individuals are groups warranting special consideration.

Adolescents (Youth): The teen years are a critical period, as the brain is still developing and risk-taking behavior is high. Most adults with SUD began using in their teens or early twenties【62†L108-L115】, so prevention and early intervention in youth are paramount. Common substances among adolescents include alcohol, cannabis, and vaping nicotine or marijuana concentrates, as well as prescription pill misuse and inhalants (which are often tried by younger teens due to availability). In fact, a CDC survey found about 15% of U.S. high school students have tried illicit or injection drugs (cocaine, heroin, meth, etc.) at least once【62†L113-L121】, and around 14% have misused a prescription opioid【62†L115-L123】. Underage drinking and binge drinking are also prevalent concerns. Adolescents are particularly prone to peer pressure and may use substances to fit in socially, to cope with academic or family stress, or due to curiosity.

Effects on Adolescents: Substance use can derail normal adolescent development. Short-term consequences include accidents (e.g., drunk driving crashes are a leading cause of teen deaths), injuries, violence, risky sexual behaviors (leading to STIs or unplanned pregnancies), and legal issues. It also affects school performance and can lead to dropout. Because the adolescent brain is maturing (especially the prefrontal cortex responsible for judgment), introducing substances can impair cognitive and emotional development. Early heavy use of substances like marijuana is linked to worse memory and learning and a higher chance of developing a SUD in adulthood【61†L10-L18】【61†L12-L14】.

Assessment & Screening: It is vital to screen adolescents in healthcare settings (pediatricians, school clinics) for substance use. Tools like the CRAFFT questionnaire (Car, Relax, Alone, Forget, Friends, Trouble) are designed for ages 12-21 to detect risky use. Ensuring confidentiality encourages honest disclosure (teens need to know their parents won’t automatically be told everything they share, except safety issues). Nurses should also assess for co-occurring issues common in teens with SUD, such as ADHD, depression, trauma, or family dysfunction.

Interventions: Engaging the teen and their family is key. Family-based interventions (like Multisystemic Therapy or Functional Family Therapy) have strong evidence – they work to improve communication, set appropriate limits, and address issues at home that contribute to use. Educating parents on monitoring and on not enabling (for example, locking up medications and alcohol at home) is important. Motivational interviewing can be very effective with adolescents to enhance their own desire to change. Peer interventions (sober recreational activities, teen recovery support groups) can replace the peer network that was using. School-based counseling and academic support help the teen get back on track. If addiction is severe, specialized adolescent rehab programs exist (both outpatient and residential). These should ideally include schooling so the teen doesn’t fall behind.

Adolescents have a great capacity for recovery if intervention is early – the brain can still rebound. Nurses should focus on positive reinforcement of any healthy behaviors and help youth build a sober identity (“you’re strong for choosing not to use, that’s something to be proud of”). Preventive education is also part of nursing care: teaching teens about the real risks of drugs (beyond what they hear from peers) and building refusal skills. Emphasizing hobbies, sports, and interests as alternatives to drug use is beneficial. In summary, working with adolescents involves the teen, family, school, and community resources to redirect the young person’s trajectory away from substance abuse and toward healthy development.

Pregnant Women: Substance use during pregnancy raises concerns for both the mother and the developing fetus. No amount of alcohol or illicit drug use is considered “safe” in pregnancy, as substances can cross the placenta and affect fetal development. For example, heavy alcohol use can cause Fetal Alcohol Spectrum Disorders (FASD), which include a range of permanent birth defects and neurodevelopmental abnormalities (such as facial dysmorphisms, growth restriction, and cognitive impairments)【74†L5-L13】【74†L25-L33】. Even moderate drinking may lead to milder learning or behavioral issues in children. With opioids (heroin, oxycodone, etc.), babies can be born with Neonatal Abstinence Syndrome (NAS) – a withdrawal syndrome in newborns characterized by tremors, high-pitched crying, feeding difficulties, and irritability that requires medication and supportive care for the infant. Stimulants like cocaine or methamphetamine increase risk of miscarriage, placental abruption (where the placenta separates too early, a life-threatening emergency), prematurity, and low birth weight. Cannabis use in pregnancy has been linked to lower birth weights and possible impacts on infant neurobehavior (though data is still emerging). Cigarette smoking is also very harmful – it causes low birth weight, placental problems, and increases risk of Sudden Infant Death Syndrome (SIDS) among other issues.

Care Approach: Pregnant individuals with SUD benefit from specialized care that addresses both obstetric and addiction needs. Compassionate, nonjudgmental care is essential; fear of legal consequences or shame often prevents pregnant women from disclosing substance use or seeking prenatal care. Unfortunately, in some jurisdictions, women have been prosecuted or had child welfare involvement due solely to positive drug tests in pregnancy. The American College of Obstetricians and Gynecologists strongly opposes punitive measures, noting they are ineffective and deter women from seeking prenatal care, ultimately harming mother and fetus【63†L217-L225】【63†L219-L223】. Instead, the recommended approach is to encourage prenatal care attendance, screen for substance use, and provide or refer for treatment. Many states now require creating a “Plan of Safe Care” for infants affected by substance use (per federal CAPTA requirements) – this is not to punish the mother, but to ensure she gets treatment and the baby is safe.

Treatment in Pregnancy: Medication-Assisted Treatment is the standard of care for opioid use disorder in pregnancy: methadone or buprenorphine maintenance is recommended over detoxification. Abruptly stopping opioids in a pregnant dependent woman can precipitate withdrawal in the fetus, leading to miscarriage or stillbirth due to fetal distress. Maintenance therapy stabilizes maternal levels and vastly improves prenatal outcomes by reducing relapse, improving engagement in prenatal care, and reducing risk behaviors【63†L217-L225】【63†L221-L224】. Babies born on MAT may still have NAS, but it’s treatable and these infants generally do as well or better than those whose mothers continued illicit use. For alcohol and other drugs, a pregnant woman can undergo detox with medical supervision (e.g., use phenobarbital for sedative withdrawal if needed), but should then transition into relapse prevention therapy and possibly residential treatment if available. Behavioral interventions like CBT and contingency management have shown good outcomes in pregnant smokers and cocaine users – e.g., voucher programs have helped pregnant women stop smoking (improving birth weights). Nutrition and social support for pregnant patients are also crucial: many have poor nutrition and high stress, so connecting them with social services (WIC, housing, IPV support if needed) is part of comprehensive care.

Nursing Role: Nurses working in OB or prenatal settings should screen every pregnant patient for substance use in a supportive manner (e.g., using the 4Ps: Parents (family history), Partner, Past, and Pregnancy substance use questions). If a patient admits use, respond supportively: “Thank you for telling me – that’s brave and it helps us take better care of you and the baby.” Provide clear education on how the substance can affect the baby’s health. Immediately involve a multidisciplinary team: obstetrician, pediatrician/neonatologist (for when baby is born), and addiction specialist or clinical social worker. If the hospital has a MAT program for pregnancy, facilitate referral – many places have clinics specifically for pregnant women (often called “Prenatal Recovery” clinics) that integrate OB care with addiction treatment. Ensure withdrawal prevention if applicable (start methadone quickly for an opioid-dependent pregnant woman rather than letting her go into withdrawal). Teach the mother what to expect with the baby (e.g., NAS symptoms if opioids, or need for NICU observation). Encourage strategies to reduce harm: for example, if she’s unable to quit a substance, at least to reduce and avoid additional risks (like no alcohol at all, use clean needles if injecting drugs and link with needle exchange, etc. – a harm reduction approach).

Nurses must also be prepared to coordinate with child protective services as required by law. Ideally, involvement of CPS is framed to the mother as part of the Plan of Safe Care, focusing on helping her rather than punishing. Emphasize that keeping mother and baby together is the goal whenever safe – for instance, mothers on methadone are encouraged to breastfeed and bond with baby, which can actually help lessen NAS severity, as long as there are no contraindications (HIV positive with unsafe behavior, etc.). Overall, treating pregnant women with SUD with dignity and as “two patients in one” (mother and fetus) leads to better outcomes: healthier babies and more mothers entering recovery.

Older Adults (Elderly): Substance misuse in older adults is often overlooked but is an increasing concern. The aging Baby Boomer generation has shown higher rates of substance use than previous generations of seniors. Nearly 1 million adults aged 65 and older have a SUD according to 2018 data, and the proportion of older adults in addiction treatment has been rising【65†L216-L224】【65†L218-L224】. Some older adults have long-standing addictions (e.g., an alcoholic who has been drinking for 40 years), while others develop problems later in life – often with prescription medications (opioids for chronic pain, benzodiazepines for anxiety or insomnia).

Challenges in Older Adults: The physiological changes of aging (slower metabolism, changes in body composition, brain sensitivity) make seniors more vulnerable to substances. They often experience a stronger effect from a given dose and are at higher risk for adverse outcomes. For instance, older adults metabolize alcohol more slowly and have less lean body mass, so alcohol stays in their system longer and produces higher BACs than in a younger person【65†L223-L231】【65†L233-L241】. This can lead to falls, injuries (hip fractures are a big danger), or medication interactions (like alcohol with blood pressure meds causing hypotension). Many seniors are on multiple prescriptions – raising the risk of polypharmacy interactions or unintentional misuse (confusion about dosing). A study showed a high rate of mixing medications with alcohol or OTC drugs in adults 57-85, which can be dangerous【65†L239-L246】.

Clinically, symptoms of substance problems (memory loss, confusion, fatigue) may be misattributed to “normal aging” or conditions like dementia. Thus, underdiagnosis is common. Healthcare providers might not ask an older patient about alcohol or drug use, assuming it’s not an issue, or the patient may be ashamed as there is heavy stigma (“a grandmother with a drinking problem”). Additionally, loneliness, bereavement, and depression are common in elders and can precipitate or worsen substance misuse (e.g., a widow starts drinking much more after her spouse dies).

Assessment & Intervention: Nurses should include substance use questions in assessments of older patients, just as with younger. Tools like the AUDIT or simpler screens (or the Short Michigan Alcoholism Screening Test – Geriatric Version, SMAST-G) can be used. Be alert to red flags like frequent falls, new cognitive impairment, or gastrointestinal problems that might suggest alcohol misuse, or excessive drowsiness that could indicate medication overuse. If a problem is identified, interventions need to be tailored:

Outcomes in Older Adults: The good news is older adults who receive treatment often do well – many have stable living situations and lots to lose, so once the issue is recognized and they get help, they can be very compliant with treatment. They may particularly benefit from one-on-one counseling focusing on coping with losses, pain management without over-reliance on meds (maybe integrating physical therapy or yoga for pain), and dealing with life transitions (retirement, etc.). Nurses should also advocate for careful prescribing for seniors: for example, avoid unnecessary benzodiazepines or sleep meds (on the Beers list of potentially inappropriate drugs for older adults) and seek non-pharmacologic alternatives for anxiety and insomnia in this population.

Military Veterans: Veterans have higher rates of certain substance use issues, often intertwined with combat exposure and mental health conditions. Alcohol use has traditionally been common in military culture – heavy episodic drinking is a leading substance issue among vets【67†L251-L259】. Additionally, veterans of recent conflicts (OEF/OIF – Iraq and Afghanistan) have faced significant stress, and many have returned with PTSD, depression, or chronic pain, which contribute to SUD. In one study of OEF/OIF veterans receiving care, 63% of those with SUD also had PTSD【66†L1-L9】. This high comorbidity of PTSD and substance use is a critical consideration: these veterans often use alcohol or drugs to self-medicate intrusive memories, anxiety, or hyperarousal symptoms【66†L5-L13】. Another factor has been the use of opioid pain medications for combat-related injuries – some veterans developed opioid dependence or addiction in the course of treating chronic pain.

Patterns and Consequences: Younger veterans (under 25) show higher rates of illicit drug use compared to older vets and even their civilian peers in that age group【67†L255-L263】【67†L273-L281】. Meanwhile, older veterans may have long-standing alcohol dependence (e.g., Vietnam-era vets with decades of drinking). Substance abuse can lead to homelessness, unemployment, legal problems (like DUI or violence when intoxicated), and relationship breakups in this population. Sadly, it also contributes to the high suicide rate among veterans – substance use can worsen depression and lower inhibitions against suicide.

Veteran-Centric Treatment: The U.S. Department of Veterans Affairs (VA) health system provides specialized SUD treatment integrated with other veteran services. For example, VA medical centers often have PTSD-SUD dual-diagnosis programs, where veterans receive trauma-focused therapy and addiction counseling simultaneously. Approaches like Seeking Safety (teaches coping skills for both PTSD and SUD) are commonly used. Veterans tend to do well in group therapy with other veterans, where a sense of camaraderie and understanding of military culture exists. They might be more comfortable discussing combat experiences among those who have “been there.” The VA also uses MAT: methadone or buprenorphine for OUD among veterans, and naltrexone for either alcohol or opioid use disorder. There’s emphasis on treating pain safely – VA has initiatives to reduce opioid prescribing (in response to high rates of opioid-related issues) and increase alternatives like physical therapy, acupuncture, or non-opioid meds, plus MAT for those already with OUD.

Nursing Considerations: When caring for a veteran, always inquire about military history – it opens the door to discussing unique experiences that may underlie substance use (e.g., “Did you ever have experiences in the service that still bother you?” could lead to identifying PTSD triggers). Build trust by acknowledging their service and using respectful communication (some prefer to be called by rank/title). Be aware of resources: every VA has a Veteran Crisis Line, SUD programs, and social workers who can assist with housing or vocational rehab specifically for vets. If you work outside the VA, you can still coordinate with VA services or veteran community groups (like The Mission Continues, etc.) to wrap supports around the patient. Also, screen for PTSD symptoms if not already diagnosed – tools like the PC-PTSD-5 (a 5-item screen) can be used. Understand that hyper-vigilance or anger outbursts might be PTSD-related rather than pure substance effects.

Encourage veterans to utilize peer support – many recovery groups exist specifically for veterans or even active-duty personnel. There are 12-step meetings geared towards vets, and organizations like Veterans Alcoholic Rehabilitation Program (VARP) or online forums where vets support each other. Having a battle buddy approach in recovery can resonate (one vet mentoring another).

In summary, treating veterans requires an integrated approach addressing PTSD, physical health (like pain or TBI), and substance use concurrently. With appropriate care, even severe cases can improve – numerous veterans have successfully overcome SUD and often become peer mentors themselves, using their military resilience and discipline in the service of recovery.

LGBTQ+ Individuals: People who identify as lesbian, gay, bisexual, transgender, queer or other sexual/gender minorities have disproportionately high rates of substance use and addiction. Studies show that LGB adults are significantly more likely than heterosexual adults to use alcohol and drugs and to develop SUDs【69†L108-L116】【69†L113-L117】. According to a SAMHSA report analyzing 2021-2022 data, about one-third of bisexual men, bisexual women, and gay men had a Substance Use Disorder in the past year – compared to roughly one in ten straight adults – and about one-fourth of lesbian women had an SUD【73†L123-L131】. Those are striking figures. Tobacco use is also higher (roughly 1 in 6 LGBTQ+ people smoke vs 1 in 8 heterosexual)【69†L152-L156】, and LGBTQ+ youth have higher rates of binge drinking and illicit drug use than their straight peers.

Contributing Factors: The concept of minority stress helps explain these disparities. LGBTQ+ individuals often face stigma, discrimination, and social rejection which create chronic stress on top of life’s usual stressors. This can lead to higher rates of depression, anxiety, and trauma in the community. Substance use may be adopted as a coping mechanism to deal with feelings of isolation, shame, or rejection (for example, a teen bullied for being gay might start drinking to numb the pain). Additionally, social venues for LGBTQ+ people traditionally centered around bars and clubs – historically, gay bars were among the few safe spaces to socialize, inadvertently normalizing heavy drinking in these settings. Certain subcultures have drug use tied to social or sexual networks (for instance, the use of stimulants like methamphetamine in some MSM – men who have sex with men – communities for party-and-play or “chemsex”). These patterns can increase risk of HIV and other health issues as well.

Barriers to Care: LGBTQ+ persons may hesitate to seek treatment due to fear of discrimination by healthcare providers. Unfortunately, some have experienced prejudice or lack of understanding from medical professionals in the past. Transgender individuals especially may encounter misunderstanding; if a trans person with addiction enters a treatment program and staff are not educated about trans issues (e.g., misusing pronouns, disallowing hormone therapy during rehab), it can alienate the patient and lead to them leaving treatment. Also, many standard rehab programs historically were geared towards heterosexual, cisgender clients and did not address issues like coming-out stress, homophobic family trauma, or unique relationship dynamics, making it harder for LGBTQ+ clients to relate.

Culturally Competent Treatment: It’s essential for healthcare providers to create an affirming environment. This includes using correct pronouns and chosen names, displaying nondiscrimination statements or a rainbow symbol that signals inclusivity, and educating staff on LGBTQ+ cultural competence. Intake forms should allow patients to self-identify gender and orientation (rather than forcing a binary choice). When taking history, ask in a sensitive way about partner gender(s) and sexual health, as these might interplay with substance use (e.g., “Some people use drugs in sexual contexts; is that something you’ve experienced?”).

Many treatment programs now offer LGBTQ-specific groups or even entire programs specialized for this community. For example, there are rehab groups exclusively for gay men, addressing issues like internalized homophobia, or groups for transgender individuals focusing on body image and minority stress. If such specialized resources are available (some cities have them), offering a referral can improve engagement. If not, ensure the patient is connected to an LGBTQ-friendly counselor or support group. Organizations like Lambda (LGBT) AA/NA meetings are present in many areas, providing peer support in a comfortable atmosphere. Nurses should have a resource list of local LGBTQ+ affirming services (such as The Trevor Project for youth, or local LGBTQ centers that often host recovery meetings).

Specific Health Considerations: Be mindful of health issues that may coincide. Gay and bisexual men with stimulant use disorder might need concurrent HIV prevention or treatment services (since meth use can increase sexual risk; offering PrEP (pre-exposure prophylaxis for HIV) could be lifesaving alongside addiction treatment). Transgender individuals may be using non-prescribed hormones or silicone injections – ensure they get proper medical evaluation and integrate their transition-related healthcare with SUD care so they don’t feel they must choose one over the other.

Mental Health: LGBTQ+ folks have higher rates of mental health conditions due to discrimination stress – nearly half of LGB adults report a history of depression or other mental illness【73†L109-L117】【73†L119-L127】. Thus, dual-diagnosis capability is crucial: therapy should tackle both the SUD and underlying issues like trauma from hate crimes or family rejection. Approaches like trauma-informed care and minority stress theory interventions (helping clients reframe experiences of prejudice and build resilience) are beneficial.

Nursing Advocacy: On a broader level, nurses can advocate for policies that support LGBTQ+ health – for instance, pushing for inclusion of same-sex partner support in family programs, or for insurance coverage of treatment for all regardless of orientation/gender identity. Even small actions, like having a unisex bathroom available in a clinic, signal respect for gender-diverse clients.

In summary, LGBTQ+ individuals with substance use issues should be treated with the same empathy and evidence-based approaches as anyone, but with an awareness of the unique social context. By reducing stigma in healthcare and tailoring services (or at least ensuring openness and respect), providers can greatly improve retention and outcomes for this population【69†L108-L116】【73†L119-L127】. Many LGBTQ+ people do recover and go on to help others – indeed, LGBTQ+ recovery communities are strong and growing, offering hope and role models that one’s identity need not be an obstacle to a healthy, sober life.

Conclusion: Each special population – youth, pregnant women, older adults, veterans, and LGBTQ+ – benefits from a nuanced approach that addresses their specific risks and leverages their strengths. Culturally sensitive, developmentally appropriate, and trauma-informed care increases the effectiveness of substance abuse treatment and helps ensure no group is left behind. Nurses, with their holistic perspective and patient advocacy role, are instrumental in adapting care to meet these diverse needs.

Sources:

  1. MSD Manual Professional Edition – Substance Use Disorders: Diagnostic Features. 2022【24†L41-L49】【24†L78-L86】

  2. MSD Manual Professional Edition – Alcohol Toxicity and Withdrawal. O’Malley GF et al. 2022【23†L47-L55】【23†L49-L57】

  3. MSD Manual Professional Edition – Opioid Toxicity and Withdrawal. O’Malley GF et al. 2022【20†L47-L55】【20†L49-L57】

  4. MSD Manual Professional Edition – Cocaine. O’Malley GF et al. 2024【27†L49-L57】【27†L59-L63】

  5. MSD Manual Professional Edition – Amphetamines (Methamphetamine). O’Malley GF et al. 2022【28†L49-L57】【28†L51-L59】

  6. MSD Manual Professional Edition – Hallucinogens. O’Malley GF et al. 2022【41†L109-L117】【41†L118-L125】

  7. MSD Manual Professional Edition – Ketamine and Phencyclidine (PCP). O’Malley GF et al. 2023【42†L79-L87】【42†L81-L89】

  8. Merck Manual Consumer Version – Volatile Solvents (Inhalants). O’Malley GF et al. 2022【46†L113-L121】【46†L134-L142】

  9. Substance Abuse and Mental Health Services Administration (SAMHSA) – Medications for Opioid Use Disorder (TIP 63). 2018【56†L2199-L2207】【56†L2201-L2209】

  10. SAMHSA – SBIRT: Screening, Brief Intervention, and Referral to Treatment – An Evidence-Based Approach. 2020【18†L69-L77】【18†L79-L87】

  11. NCBI (TIP 45) – Appendix C: Screening and Assessment Instruments. SAMHSA, 2006 (CIWA-Ar, CAGE details)【13†L169-L177】【13†L207-L215】

  12. American Academy of Family Physicians – Alcohol Withdrawal Syndrome: Outpatient Management. Muncie et al., 2013【16†L31-L39】【16†L39-L47】

  13. American College of Obstetricians and Gynecologists – Committee Opinion 473: Substance Abuse Reporting and Pregnancy. 2011, reaffirmed 2022【63†L217-L225】【63†L229-L237】

  14. U.S. Dept. of Health & Human Services – 42 CFR Part 2: Confidentiality of SUD Patient Records – Fact Sheet. 2017【57†L1-L8】【56†L2243-L2251】

  15. National Council of State Boards of Nursing (NCSBN) – Substance Use Disorder in Nursing: Guidance. 2014【72†L39-L47】【60†L115-L123】

  16. Healthy Nurse, Healthy Nation (ANA) – Warning Signs of SUD in a Nursing Colleague. 2020【60†L97-L105】【60†L105-L113】

  17. Centers for Disease Control and Prevention – Substance Use Among Youth – CDC YRBS Data. 2024【62†L108-L115】【62†L113-L121】

  18. NIDA DrugFacts – Substance Use in Older Adults. National Institute on Drug Abuse, 2020【65†L216-L224】【65†L223-L231】

  19. Veterans Affairs (VA) – Epidemiology of Veteran Substance Use. (Blodgett et al., 2015)【67†L251-L259】【67†L273-L281】

  20. SAMHSA – Lesbian, Gay, and Bisexual Behavioral Health: Results from NSDUH 2021-2022. 2023【73†L123-L131】【73†L119-L127】

Substance Use and Abuse – Comprehensive Module

Definitions and Diagnostic Criteria (DSM-5)

Substance Use Disorder (SUD): According to DSM-5, a Substance Use Disorder is a pathological pattern of using a substance that leads to significant impairment or distress. It is characterized by a cluster of cognitiv​engage.healthynursehealthynation.orgl, and physiological symptoms indicating the individual continues using the substance despite substantial substance-related problems【24†L41-L49】【24†L55-L63】. DSM-5 defines 11 diagnostic criteria (symptoms) falling in four domains (impaired control, social impairment, risky use, and pharmacologic dependence)【4†L453-L461】【4†L469-L476】. Examples include using larger amounts or over longer time than intended, persistent desire or unsuccessful efforts to cut down, excessive time spent obtaining/using/recovering, cravings, recurrent use despite obligations or interper​engage.healthynursehealthynation.orgs, giving up important activities, use in physically hazardous situations, and continued use despite health problems【4†L459-L467】【4†L469-L476】. Two or more of these within 12 months qualifies as SUD, with severity specifiers: mild (2–3 symptoms), moderate (4–5), or severe (6+ symptoms)【4†L453-L461】【4†L469-L476】. Notably, DSM-5 merged the previous “abuse” and “dependence” into engage.healthynursehealthynation.org​engage.healthynursehealthynation.orgas the older terms were inconsistently used【24†L55-L63】.

Tolerance and Dependence: Tolerance is a physiological phenomenon where increasing amounts of a substance are needed to achieve the same effect, or a markedly diminished effect occurs with continued use of the same amount【4†L459-L467】. Dependence in a physical sense refers to the brain’s adaptation to continuous su​engage.healthynursehealthynation.orgce, leading to tolerance and withdrawal symptoms upon cessation【24†L55-L63】. Importantly, physical dependence can occur with appropriate medical use of certain drugs (e.g. opioids for pain management) without meeting crit​engage.healthynursehealthynation.org​engage.healthynursehealthynation.orges the maladaptive pattern and psychosocial components. DSM-5 avoids using “addiction” or separating “abuse vs. dependence” and instead uses SUD with the criteria above. It also notes that tolerance and withdrawal, while criteria for SUD, can be normal physiological responses in patients taking medications under medical supervision (these alone are not sufficient for SUD diagnosis in that context).

Intoxication and Withdrawal: Intoxication is defined in DSM-5 as the development of a reversible, substance-specific syndrome due to recent ingestion of a substance, producing significant maladaptive behavioral or psychological changes due to effects on the central nervous system【24†L78-L86】. Intoxication symptoms vary by substance (e.g., euphoria and slowed reaction with alcohol, or hyperactivity with stimulants) and can impair judgment, coordination, and perception; severe intoxication can lead to overdose, medical emerg​engage.healthynursehealthynation.org​engage.healthynursehealthynation.org. Withdrawal is a substance-specific syndrome that occurs when blood or tissue concentrations of a substance decline in someone who had prolonged heavy use, leading to a characteristic set of symptoms (usually opposite to the drug’s acute effects)【24†L87-L93】. Withdrawal syndromes (e.g. tremors and anxiety after alcohol cessation) cause significant distress or impairment and can range from mild to life-threatening, depending on the substance【23†L49-L57】【20†L47-L55】. Not all substances produce clear withdrawal syndromes (for example, classic hallucinogens do not cause significant physical withdrawal).

Related definitions: The term addiction is not a clinical DSM-5 term but is commonly used to describe severe SUD, typically involving compulsive use and loss of control. Dual diagnosis (or co-occurring disorder) refers to having a SUD along with another mental health disorder (e.g., depression or PTSD), which is common and can complicate treatment.

Common Substance Categories: Pharmacology, Pathophysiology, and Clinical Presentation

Substances of abuse span several categories with distinct pharmacological effects and healt​engage.healthynursehealthynation.org​engage.healthynursehealthynation.orgtail major substance classes, including their mechanisms of action, acute intoxication effects, chronic use sequelae, and withdrawal manifestations.

Alcohol

Pharmacology & Mechanism: Alcohol (ethanol) is a central nervous system (CNS) depressant. It enhances inhibitory GABA_A receptor activity and inhibits excitatory glutamate (NMDA) receptors in the brain, leading to sedation, anxiolysis, and impaired motor function. It also affects dopamine pathways related to reward, which contributes to its reinforcing properties. Over time, the brain adapts by downregulating GABA receptors and upregulating glutamate function, so chronic heavy drinkers become tolerant and their CNS becomes hyper-excitable without alcohol【23†L47-L55】【23†L49-L57】.

Intoxication: Acute alcohol intoxication causes behavioral disinhibition (euphoria or aggression), impaired judgment, slurred speech, incoordination (ataxia), unsteady gait, and memory impairment. Physical signs include flushed face, nystagmus, and at higher levels stupor or coma. Severe overdose can result in respiratory depression, loss of consciousness, aspiration, and death【23†L47-L55】. In the U.S., a blood alcohol concentration (BAC) ≥0.08% is legally intoxicated for driving. Very high BAC (e.g. >0.3%) can be life-threatening due to CNS depression. Notably, mixing alcohol with other depressants (benzodiazepines, opioids) greatly increases overdose risk due to synergistic respiratory depression.

Chronic Use and Pathophysiology: Long-term alcohol abuse affects virtually every organ. It can cause liver disease (fatty liver, alcoholic hepatitis, cirrhosis), gastrointestinal problems (gastritis, pancreatitis), cardiovascular issues (hypertension, cardiomyopathy), neuropathy, and cognitive impairment. Neuroadaptation leads to tolerance (requiri​engage.healthynursehealthynation.org​engage.healthynursehealthynation.orgeffect) and physical dependence. Many chronic users develop thiamine (vitamin B1) deficiency, risking Wernicke–Korsakoff syndrome (encephalopathy and amnesia). Psychologically, alcohol use often becomes a maladaptive coping mechanism, and users may continue despite social, occupational, or legal problems, hallmarking Alcohol Use Disorder. Approximately 13–14% of adults meet criteria for an alcohol use disorder in any given year【23†L75-L80】.

Withdrawal: Alcohol has one of the most dangerous withdrawal​ncsbn.org​ncsbn.orgion of heavy prolonged use, symptoms begin within 6–24 hours: minor withdrawal includes tremors (“shakes”), anxiety, irritability, insomnia, tachycardia, hypertension, sweating, nausea, and hyperreflexia【16†L29-L37】【16†L31-L39】. Between 12–48 hours, some patients develop alcoholic hallucinosis (primarily visual hallucinations) and/or seizures (generalized tonic-clonic seizures typically peak around 24–48 hours without treatment). The most severe form is *Delirium Tr​cdc.govusually 48–72 hours after the last drink: this is a medical emergency characterized by delirium (confusion, disorientation), severe agitation, hallucinations, profuse sweating, fever, and autonomic instability (e.g., blood pressure spikes)【23†L49-L57】【23†L51-L59】. Untreated DTs carry a significant mortality risk. Thus, medical detoxification is indicated for moderate-to-severe alcohol withdrawal. The CIWA-Ar scale (Clinic​cdc.govithdrawal Assessment for Alcohol, revised) is a 10-​cdc.govcoring tool used by nurses and providers to quantify withdrawal severity and guide treatment【13†L197-L205】【13†L207-L216】. Management usually includes benzodiazepines (see later section) to cross-treat GABA underactivity, plus thiamine and hydration.

Opioids

Pharmacology: Opioids are a class of CNS depressants that include natural opiates (morphine, codeine), semi-synthetics (heroin, oxycodone, hydrocodone), and synthetics (fentanyl, methadone). They primarily agonize mu-opioid receptors in the brain and spinal cord. This produces analgesia and intense euphoria (via dopamine release in reward pathways), but also sedation, miosis (pinpoint pupils), and respiratory depression【20†L47-L55】【20†L49-L57】. Repeated opioid use causes receptor downregulation and cAMP pathway upregulation in neurons, leading to tolerance (needing higher doses for effect) and physical dependence.

**I​nature.com​nature.comtoxication (or overdose) classically presents with miosis (pinpoint pupils), respiratory depression, and CNS depression (drowsiness to coma)【20†L47-L55】. Other signs include slurred speech, impaired attention, and hypotension. The “opioid overdose triad” is depressed mental status, slow shallow breathing, and pinpoint pupils【19†L25-L33】【19†L35-L43】. Skin might be clammy, and severe overdoses can cause cyanosis and death from respiratory arrest. Prompt administration of naloxone (an opioid antagonist) can reverse life-threatening opioid toxicity by displacing opioids from receptors. Given the potency of synthetic opioids like fentanyl, multiple naloxone doses may be needed in overdose scenarios.

Chronic Use: Long-term opioid abuse leads to high tolerance (users may require extremely high doses to stave off withdrawal). Tolerance develops to euphoria and respiratory depression, but partial tolerance to respiratory effects means overdose risk remains high with escalating doses. Chronic injection use (e.g., heroin) carries risks of bloodborne infections (HIV, hepatitis C), endocarditis, and collapsed veins. Opioid Use Disorder is characterized by compulsive use and severe withdrawal avoidance behavior. Psychosocial consequences include unemployment, legal problems, and relationship strain. Among U.S. overdose fatalities, opioids (particularly synthetic fentanyls) are the leading cause, reflecting the danger of misuse.

Withdrawal: Opioid withdrawal, while extremely uncomfortable, is generally not life-threatening (unlike alcohol or sedative withdrawal). Onset depends on the opioid’s half-life – e.g., heroin withdrawal starts 6–12 hours after the last dose, whereas methadone (long-acting) starts ~30+ hours. Early symptoms (within hours) include anxiety, intense drug craving, yawning, sweating, lacrimation (tearing), and rhinorrhea (runny nose)【20†L49-L57】【20†L59-L63】. This progresses to dilated pupils, piloerection (“goosebumps” – origin of the term “cold turkey”), muscle and bone aches, abdominal cramping, nausea, vomiting, diarrhea, tachycardia, hypertension, insomnia, and profound restlessness【20†L47-L55】【20†L49-L57】. Patients often describe it like a severe flu. Although not usually dangerous, complications like dehydration or rarely arrhythmias can occur. Opioid withdrawal can be confirmed with clinical signs and sometimes urine toxicology【20†L51-L59】. It can be treated with opioid agonist medications (e.g., methadone or buprenorphine) to alleviate symptoms, or with supportive medications (antiemetics, loperamide for diarrhea, NSAIDs for aches, clonidine for autonomic symptoms). The intense cravings and dysphoria du​cdc.gov​aafp.orgead to relapse if no treatment is provided, so linking patients to treatment (like Medication-Assisted Treatment, below) is critical.

Stimulants (Cocaine and Amphetamines)

Pharmacology: Stimulants such as cocaine and methamphetamine are CNS activators. Cocaine blocks the reuptake of dopamine, norepinephrine, and serotonin in the brain, leading to an acute buildup of these neurotransmitters in synapses. Amphetamines (including methamphetamine) not only block reuptake but also increase release of dopamine and norepinephrine. The result is heightened sympathetic nervous system activity and intense euphoria and alertness. Both cause a surge of dopamine in reward pathways, reinforcing their use.

Intoxication (Acute Effects): Stimulant intoxication produces feelings of energy, confidence, talkativeness, and euphoria. Users often have increased alertness, decreased need for sleep, and diminished appetite. Physical signs include tachycardia, elevated blood pressure, dilated pupils, and often psychomotor agitation. Sweating or chills and nausea may occur. At high doses, sympathomimetic toxicity is evident: potential for cardiac arrhythmias, chest pain, hyperthermia, and seizures. Cocaine intoxication may cause a fleeting but intense “rush” followed by a shorter-lived high (minutes to 1–2 hours if snorted), whereas methamphetamine has a longer duration of action (several hours). High-dose use of stimulants can induce psychosis – users may have paranoid delusions or tactile hallucina​acog.org​acog.orgawling on skin, known as formication). They can become irritable, aggressive, or experience panic.

Severe acute toxicity from stimulants can be life-threatening. For example, cocaine can precipitate myocardial infarction, stroke, aortic dissection, or seizures even in young individuals【27†L49-L57】【27†L51-L59】. Hyperthermia and hypertension from amphetamine overdose can lead to rhabdomyolysis and multi-organ failure【28†L49-L57】【28†L51-L59】. Management of severe stimulant overdose is largely supportive: benzodiazepines to reduce agitation, blood pressure, and seizure risk; cooling measures for hyperthermia; and rapid evaluation for cardiac or neurologic events【27†L49-L57】【28†L49-L57】. There is no specific antidote.

Chronic Use: Prolonged stimulant abuse can cause significant weight loss, malnutrition, and dental problems (especially “meth mouth” in methamphetamine users, du​acog.org​acog.orgng, and poor oral hygiene). Chronically elevated catecholamines can lead to cardiomyopathy. Many chronic users develop anxiety, insomnia, and paranoid thinking even between use episodes. Repetitive behaviors or psychosis can occur with long-term high-dose methamphetamine. Socially, stimulant addiction often leads to severe financial, legal, and health consequences, and users may go on multi-day binges (“runs”) without sleep, followed by crashes.

Withdrawal: Stimulant withdrawal (sometimes called the “crash”) is characterized by the opposite of intoxication effects. After stopping heavy use, individuals experience fatigue, hypersomnia (sleeping for extended periods), increased appetite (often craving carbohydrates), and psychomotor slowing. Mood symptoms dominate: profound depression, dysphoria, anhedonia, and in some cases suicidal ideation can occur in the days after cessation【27†L53-L63】. Anxiety and irritability are common. Cravings for the drug are intense. Unlike alcohol or opioid withdrawal, there are usually no prominent physical signs like fever or seizures, and stimulant withdrawal is not life-threatening. Symptoms generally peak within a few days and improve over 1–2 weeks, though some lethargy and mood symptoms can persist longer. Because there is no specific pharmacologic treatment for stimulant withdrawal, management is supportive: ensure safe environment, adequate sleep, nutrition, and observe for any suicidal ideation. The depression typically self-resolves, but if severe, short-term use of antidepressants may be considered. Importantly, the dysphoria can drive relapse, so connecting the individual to ongoing therapy and support is key during withdrawal recovery【27†L53-L63】.

Cannabis (Marijuana)

Pharmacology: Cannabis contains delta-9-tetrahydrocannabinol (THC) as the primary psychoactive component. THC is a partial agonist at cannabinoid receptors (CB1 receptors in the brain), which modulate neurotransmitter release. Activation of CB1 causes dopamine release in reward circuitry, but cannabis’s effects are a mix of depressant and mild hallucinogenic qualities. In addition to THC, cannabis contains other cannabinoids like CBD (cannabidiol) that have minimal psychoactivity but can modulate effects.

Acute Effects (Intoxication): Cannabis intoxication typically causes euphoria and relaxation, often with altered sensory perception (e.g. enhanced colors or music appreciation) and a distorted sense of time. Common signs include conjunctival injection (red eyes), increased appetite (the “munchies”), dry mouth, and mild tachycardia【31†L13-L21】. Users may have impaired short-term memory and slowed reaction time and motor coordination (hence an increased risk of accidents while driving). Anxiety or paranoid ideation can occur, especially at high THC doses or in inexperienced users; some experience panic attacks or a sense of depersonalization during a “bad trip.” High-potency marijuana or synthetic cannabinoids can occasionally precipitate acute psychotic symptoms (delusions or hallucinations), though these usually resolve as the drug wears off. Physical effects are generally mild compared to other drugs; lethal overdose from cannabis alone is extremely unlikely, as cannabinoid receptors are not concentrated nida.nih.gov​nida.nih.govng respiration. However, impairment can indirectly lead to injury or risky behaviors.

Chronic Use: Repeated cannabis use can lead to Cannabis Use Disorder in susceptible individuals (roughly 1 in 10 users overall, higher if use begins in adolescence). Chronic heavy use may produce amotivation syndrome – apathy, decreased drive, and social withdrawal (though this is debated). Cognitive effects can persist: attention, memory, and learning may be impaired during heavy use periods, and some deficits could be long-lasting especially if use began in early teens (when the brain is still developing)【62†L108-L115】【62†L115-L123】. Long-term smoking of marijuana may cause chronic bronchitis or lung irritation (si​nida.nih.gov​nida.nih.govough cannabis smoke contains some different components). Also, cannabis use at a young age has been associated with increased risk of psychosis or schizophrenia in genetically predisposed individuals.

Withdrawal: Although many people believe marijuana is non-habit-forming, cannabis withdrawal syndrome is recognized, particularly in daily users. Symptoms usually begin within 24–48 hours of stopping after​nida.nih.govvy use (weeks to months of near-daily use), peak in about 3–7 days, and last up to 1–2 weeks【35†L380-L387】. Common withdrawal symptoms include irritability, anger or aggression, nervousness or anxiety, insomnia (often with strange dreams), decreased appetite or weight loss, restlessness, and depressed mood【35†L358-L366】【35†L368-L376】. Some have physical symptoms like abdominal cramps, tremors, sweating, chills, or headache【35†L368-L376】【35†L378-L386】. While not medically dangerous, these symptoms can be significant enough to cause distress and lead to relapse. Management is typically supportive – reassurance that symptoms will pass, promoting sleep hygiene, and possibly short-term symptomatic medications (e.g., NSAIDs for headaches or melatonin for sleep). Counseling can help the user cope with mood symptoms during withdrawal. Importantly, not all heavy users experience withdrawal; studies suggest a subset manifest significant symptoms, often correlating with level and duration of use【35†L382-L386】.

Sedatives, Hypnotics, and Anxiolytics (Benzodiazepines, Barbiturates, etc.)

Pharmacology: This category includes benzodiazepines (e.g., diazepam, alprazolam, lorazepam), older barbiturates (phenobarbital, secobarbital), and other prescription sleep aids (like zolpidem). They all depress CNS activity, primarily by enhancing the effect of GABA at the GABA_A receptor (benzodiazepines increase frequency of chloride channel opening; barbiturates increase duration of opening). The result is anxiolytic, sedative, muscle relaxant, and anticonvulsant effects. These drugs are medically used for anxiety, insomnia, seizures, anesthesia, etc., but all have misuse potential. Barbiturates, an older class, carry higher overdose risk and largely have been replaced by benzodiazepines which have a wider safety margin – though benzos are also addictive.

Intoxication: Sedative intoxication presents similarly to alcohol intoxication (since both facilitate GABA). Signs include sedation, drowsiness, slurred speech, incoordination, unsteady gait, and impaired attention or memory. Inappropriate behavior or mood lability may occur (ranging from euphoria to irritability). In high doses, or when combined with other depressants, these drugs can cause stupor or respiratory depression. Benzodiazepines by themselves, in overdose, typically cause deep sedation but not pure respiratory collapse unless doses are very high; however, barbiturate overdose can readily cause life-threatening breathing suppression and hypotension【37†L108-L116】【37†L112-L119】. Mixed overdoses (e.g., benzodiazepines plus alcohol or opioids) frequently result in severe CNS and respiratory depression. Other physical findings can include nystagmus and hypotonia. One hallmark in intoxication is relief of anxiety (anxiolysis) progressing to somnolence. Because tolerance develops to sedatives, chronic users may appear relatively normal even on high doses, but adding any other sedative can precipitate overdose.

Overdose management for benzodiazepines is largely supportive (airway protection, ventilation support). Flumazenil is a benzodiazepine antagonist that can reverse sedation, but it is used cautiously (if at all) because it can trigger seizures especially in patients chronically on benzodiazepines【39†L17-L22】. There is no specific antidote for barbiturate overdose; intensive care support is required. Importantly, sedative intoxication often co-occurs with alcohol or other substances in practice, so evaluation and treatment must consider polysubstance effects.

Chronic Use: Regular use of benzodiazepines leads to tolerance – often first to the sedative and euphoric effects, with anxiolytic effects sometimes retained longer. Dose escalation can occur. Chronic high-dose use impairs cognition (memory, conce​pmc.ncbi.nlm.nih.govcan produce a persistent depressive effect on mood. Patients may doctor-shop for prescriptions or escalate to illicit procurement when dependent. In older adults, even therapeutic use of sedatives markedly raises risk of falls and confusion. Long-term sedative use disorder often coexi​pmc.ncbi.nlm.nih.govther substance problems (e.g., alcohol) or underlying anxiety disorders. Socially, sedative-dependent individuals may become withdrawn, spend significant time obtaining medications, or suffer​pmc.ncbi.nlm.nih.goval impairment due to oversedation or accidents.

Withdrawal: Withdrawal from sedative-hypnotics is potentially life-threatening and shares similar features with alcohol withdrawal (as both affect GABA). Benzodiazepine withdrawal can range from mild anxiety and insomnia to severe symptoms like seizures and delirium. Typical withdrawal begins​pmc.ncbi.nlm.nih.gov​pmc.ncbi.nlm.nih.govstopping short-acting benzos (or 4–7 days for longer-acting like diazepam). Symptoms include rebound anxiety, restlessness, insomnia (often with disturbing dreams), headache, muscle tension, irritability, and sensory hypersensitivity (sensitivity to light/sound). More severe cases progress to autonomic instability (elevated blood pressure, heart rate, sweating), tremors, nausea, and perceptual disturbances. Grand mal seizures can occur, usually 2–5 days after the last dose in severe cases【37†L139-L147】. Withdrawal delirium (similar to DTs) is a risk with barbiturates or very high benzodiazepine dependence – characterized by confusion, hallucinations, and potentially fatal cardiovascular collapse【37†L139-L147】. Given these dangers, sedative withdrawal should be medically supervised. The standard management is to gradually taper the benzodiazepine dose over weeks, or switch the patient to a longer-acting benzodiazepine (like diazepam or clonazepam) then taper. In barbiturate dependence, phenobarbital is often used to taper safely. During withdrawal treatment, vital signs and neurological status are monitored closely. Inpatient detox is recommended for high-dose sedative users, as seizures or severe symptoms may require prompt treatment (IV benzodiazepines, anticonvulsants, or intensive care). Even mild withdrawal symptoms (e.g., jitteriness and sleep difficulty) can persist for weeks – a protracted withdrawal syndrome – and may need symptomatic treatment (such as beta-blockers for tremor or short-term sedatives at a tapering dose).

Hallucinogens (e.g. LSD, PCP)

This group includes substances that profoundly alter perception, mood, and cognition. They can be broadly divided into classic hallucinogens (like LSD and psilocybin) which primarily affect serotonin receptors, and dissociative anesthetics (like PCP and ketamine) which antagonize NMDA receptors. Notably, hallucinogens typically do not cause physical dependence or classic withdrawal syndromes, but they can cause intense psychological experiences.

Lysergic Acid Diethylamide (LSD) and Similar Hallucinogens:
Mechanism: LSD, psilocybin (magic mushrooms), mescaline (peyote) and other “psychedelics” are thought to act as agonists at serotonin 5-HT2A receptors in the brain【41†L84-L92】【41†L86-L94】. This disrupts normal sensory and serotonergic signaling, leading to hallucinations and altered consciousness. Tolerance to these effects builds rapidly; frequent use on consecutive days yields a diminished effect (and cross-tolerance exists among them)【41†L101-L109】【41†L104-L107】. However, tolerance also fades quickly after cessation, and these drugs are not known to produce physical withdrawal symptoms【41†L101-L109】【41†L104-L109】.

Intoxication (Acute Trip): Hallucinogen intoxication causes profound perceptual changes. Users experience sensory distortions and hallucinations – for example, colors may appear more vivid, shapes may blend or move, and they may perceive sounds as visuals (synesthesia, e.g., “seeing sounds”)【41†L109-L117】【41†L111-L119】. There is often altered sense of time and self; depersonalization (feeling unreal) or derealization (feeling the environment is unreal) may occur【41†L109-L117】【41†L113-L120】. Emotions during an LSD “trip” can swing from euphoria to anxiety or even terror, depending on the set (user’s mindset) and setting. Physiological effects of LSD and similar drugs are usually mild: pupils dilate (mydriasis), heart rate and blood pressure may rise slightly, sw​share.upmc.com​share.upmc.coms can occur【41†L117-L125】【41†L118-L125】. Nausea and vomiting are more common with plant-based hallucinogens like peyote (mescaline) or psilocybin mushrooms【41†L117-L125】【41†L118-L125】. Coordination can be impaired. Notably, in contrast to stimulants, users are usuall​navisclinical.comir surroundings (except for visual distortions) and might have periods of lucidity between waves of perceptual chang​share.upmc.com0】【41†L121-L127】. Bad trips refer to acute anxiety, panic, or paranoia triggered by hallucinogen use – the person may have terrifying hallucinations or feel they are losing their mind. Although classic hallucinogens do not cause direct physical toxicity at typical doses, high doses of LSD can exceptionally lead to accidents or risky behaviors due to impaired judgment, and massive overdose could theoretically cause hyperthermia or cardiovascular collapse【41†L123-L131】【41†L127-L134】 (though fatal LSD overdose is exceedingly rare). Psilocybin and mescaline are less potent per weight; psilocybin trips last ~4–6 hours, LSD ~8–12 hours, and mescaline up to 12 hours【41†L92-L100】. There is no antidote; management of acute hallucinogen intoxication focuses on a calm, reassuring environment, “talking down” the patient, and, if needed for severe agitation or panic, giving benzodiazepines. Infrequently, an antipsychotic might be used if severe psychosis persists.

Aftereffects: Some users experience lingering perceptual changes after hallucinogen use. Hallucinogen Persisting Perception Disorder (HPPD), colloquially “flashbacks,” involves spontaneous, transient recurrences of perceptual distortions (like halos around objects or trailing images) long after the drug has left the body. This condition is relatively rare but can be distressing and last for weeks or longer in susceptible individuals.

PCP (Phencyclidine) and Ketamine (Dissociative Hallucinogens):
Mechanism: Phencyclidine (PCP, “angel dust”) and ketamine are NMDA receptor antagonists. Initially developed as anesthetics, they produce a state of “dissociation” – a feeling of detachment from one’s body and environment. They also release dopamine, adding some stimulant and euphoric properties. PCP is more potent and longer-acting than ketamine. These can be smoked, snorted, or taken orally (or injected in medical contexts for ketamine).

Intoxication: Low to moderate doses of PCP/ketamine cause euphoria and feeling “floaty” or disconnected, along with numbness or analgesia (users may be less responsive to pain)【42†L79-L87】. People often present with horizontal or vertical nystagmus (rapid jerky eye movements – vertical nystagmus is classically associated with PCP intoxication). Other signs include ataxia (unsteady gait), dysarthria (slurred or garbled speech), and muscle rigidity or unusually high strength for the individual (due to catatonic like state or reduced pain perception)【42†L79-L87】【42†L81-L89】. Blood pressure, heart rate, and temperature can elevate, particularly with higher doses【42†L81-L89】【42†L83-L90】. With moderate intoxication, individuals may appear confused, impulsive, and agitated, with mood swings from laughing to paranoia. They often have a blank stare and may be unaware of surroundings or exhibit depersonalization. High doses of PCP induce a dissociative anesthesia: a trance-like state with eyes open but unresponsive (“catatonic”), or conversely, extreme agitation and bizarre, violent behavior can occur if the person is responsive but hallucinating. Psychotic symptoms are common – e.g., paranoid delusions or auditory hallucinations – and can be prolonged. Combativeness is a concern: PCP intoxication is notorious for unpredictable aggression or self-harm; because pain is blunted, individuals may injure themselves severely without normal protective reflexes. “Superhuman strength” is a misnomer but reflects how a struggling PCP-intoxicated person may seem unnaturally strong due to high adrenaline and indifference to pain.

Overdose and Complications: Severe PCP overdose can cause seizures, severe hypertension, arrhythmias, hyperthermia, or coma, and though death is uncommon, it can result from trauma or accidents while intoxicated (e.g., jumping from heights due to delusion of invincibility)【42†L79-L87】【42†L83-L90】. Rhabdomyolysis (muscle breakdown) and kidney failure are possible due to extreme agitation and muscle activity. An acute “emergence delirium” or reaction phase can occur as PCP/ketamine wear off, with confusion and hallucin​navisclinical.com​navisclinical.comout of the dissociative state【42†L97-L103】. Management of PCP intoxication prioritizes safety – for patient and staff. Physical restraints may be required briefly for an out-of-control patient to prevent harm. Pharmacologically, benzodiazepines are given to reduce severe agitation, anxiety, muscle rigidity, and to treat/prevent seizures【42†L79-L87】. If psychosis is prominent, a low-stimulation environment and perhaps antipsychotic medication (like haloperidol) may help, though caution is used as some antipsychotics can lower seizure threshold or exacerbate blood pressure issues. Cooling measures treat hyperthermia. There is no specific antidote; support and monitoring continue until the drug’s effects subside (PCP’s effects may last 8+ hours). Ketamine intoxication is usually shorter (1–2 hours of main effects) and typically less likely to cause violent behavior, though a similar dissociative state and hallucinations occur. Ketamine has legitimate medical uses (anesthesia, pain control, depression therapy at low dose), but in recreational use (“Special K”)​share.upmc.com​navisclinical.comimpaired judgment.

Withdrawal: There is generally no defined withdrawal syndrome for classic hallucinogens, PCP, or ketamine, as they do not cause the type of physical dependence seen with alcohol or opioids【41†L101-L109】【41†L104-L109】. After heavy frequent use of PCP or ketamine, some users may feel dysphoric or crave the drug, but not a reliable physiological withdrawal pattern. Most issues are psychological, like flashbacks (for LSD) or mood disturbances. This means these drugs’ potential for addiction tends to be psychological craving or habitual use for the experience, rather than needing the drug to avoid withdrawal. Nonetheless, PCP Use Disorder can occur, characterized by continued use despite life problems and intense craving for the dissociative state.

Inhalants

Pharmacology: “Inhalants” are a broad c​msdmanuals.com​msdmanuals.comemicals that produce mind-altering effects. They include volatile solvents (e.g., toluene in glue,​merckmanuals.com​merckmanuals.coms), aerosols (spray propellants in cans), gases (butane, propane, nitrous oxide), and *nitrites​merckmanuals.com​merckmanuals.comoppers”). These substances are commonly found in household or industrial pro​merckmanuals.com​merckmanuals.comy accessible especially to children and adolescents【44†L55-L63】【44†L47-L54】. When inhaled (often by​merckmanuals.com​merckmanuals.com rag or “bagging” concentrated fumes), these chemicals rapidly absorb through the merckmanuals.com​merckmanuals.comin. Many solvents are CNS depressants that enhance GABA and glycine or disrupt neuronal membranes glo​merckmanuals.com​merckmanuals.cometics. Nitrites act as vasodilators and produce a brief intense head rush.

Intoxication: In​merckmanuals.com​merckmanuals.com within minutes and typically lasts a short time (15–45 minutes for many solvents, though can be longer if repeated). Immediate samhsa.gov​samhsa.govative intoxication: dizziness, euphoria, lightheadedness, slurred speech, ataxia, drowsiness, and disinhibition【4​oasas.ny.gov​oasas.ny.gov3】. Users often feel a brief “high” and may alternate between excitability and CNS depression. Some inhalants (l​ncbi.nlm.nih.gov​ncbi.nlm.nih.govhallucinations or delusions; perception is distorted and users may experience a dreamy or floating sensation【46†L119-L1​aafp.org​aafp.orgusion, delirium, and aggressive behavior can occur with higher doses or prolonged sniffing in a session【46†L119-L124】. Physically, inhalants often c​acog.org​acog.orgation*, and generalized muscle weakness. Many solvents produce a distinct chemical odor on the breath or clothes (e.g., ga​hhs.gov​samhsa.govher signs: glue sniffer’s rash or paint stains around the nose/mouth from chronic use, and conjunctival irritat​ncsbn.org​engage.healthynursehealthynation.orghe heart to catecholamines, which can lead to arrhythmias. Sudden Sniffing Death Syndrome is a engage.healthynursehealthynation.org​engage.healthynursehealthynation.orgealthy young person can suffer fatal cardiac arrest on inhaling certain agents (like butane or aerosol​cdc.gov​cdc.govular fibrillation【46†L132-L139】【46†L133-L136】. Additionally, acute inhalant overdose can cause ​nida.nih.gov​nida.nih.govres, or coma. Some specific inhalants have unique acute dangers (e.g., inhaling toluene-based p​pmc.ncbi.nlm.nih.gov​pmc.ncbi.nlm.nih.gov from oxygen displacement and cardiac arrhythmias; nitrous oxide can cause loss of consciousness navisclinical.com​navisclinical.com oxygen).

Chronic Use and Toxicity: Long-term inhalant abuse is extremely damaging to organs. Solvents like toluene and naphthalene are directly neurotoxic – chronic abuse can cause permanent nerve and brain damage (e.g., polyneuropathy, cognitive impairment, and even spongy degeneration of white matter similar to multiple sclerosis)【46†L138-L146】【46†L140-L147】. Chronic inhalant users may develop tremors, hearing loss, gait disturbances, and memory deficits. Many solvents harm the liver, kidneys, lungs, and heart. For instance, chronic gasoline or glue sniffing can lead to liver toxicity, renal tubular damage, and serious arrhythmias. Inhalants can also damage bone marrow, causing aplastic anemia or leukemia in severe cases【46†L140-L147】【46†L142-L146】. “Huffer’s eczema,” a rash around the mouth/nose, results from irritant chemicals contacting the skin【46†L140-L147】. Additionally, use during pregnancy can cause fetal solvent syndrome (similar to fetal alcohol effects)【46†L139-L146】. Psychologically, inhalant users (often very young or in lower socioeconomic situations) may progress to other substances as they get older, but even inhalant use alone can severely disrupt schooling and social development. It is noted that many inhalant users cease by young adulthood (perhaps due to availability of other drugs or the deterrent of health effects)【46†L173-L179】, but those who continue have among the poorest recovery rates of any substance, partly due to cognitive damage and psychosocial factors【46†L173-L179】.

Withdrawal: Unlike other substances, inhalants generally do not produce a well-defined withdrawal syndrome with prominent physical symptoms【46†L148-L154】【46†L150-L153】. Tolerance does develop with repeated exposure (users need more inhalations to achieve the same high), and psychological dependence can be strong (cravings to re-experience the euphoria or escape reality)【46†L148-L154】【46†L150-L153】. However, physical dependence is minimal – meaning stopping inhalant use usually does not cause severe illness. Some chronic users report irritability, restlessness, insomnia, or headache upon abrupt cessation, but these are relatively mild and short-lived. The main challenge is psychological: users must overcome habits and often underlying social issues. Given the lack of a medical withdrawal, treatment focuses on supportive care and long-term rehabilitation: monitoring for any mood symptoms, providing a structured environment, and addressing any organ damage. Because many inhalant abusers are adolescents, involving family therapy and addressing environmental factors (like access to products, peer influence) is crucial.

Overall, inhalants are unique in that even sporadic use can be fatal (via arrhythmia or asphyxiation), and chronic use can leave lasting neurological impairment. Early intervention and prevention (education about risks in schools, restricting youth access to volatile substances) are key measures.

Assessment and Screening Tools for Substance Use

Early identification of problematic substance use is essential in healthcare. Nurses play a critical role in screening patients for substance misuse and assessing the extent of a Substance Use Disorder. A variety of validated tools and approaches are available:

Comprehensive Assessment: If a screening is positive or suspicion is raised, a nurse proceeds with a full assessment of substance use. This includes a detailed history of all substances used (what substances, quantity, frequency, route, duration), age of first use, last use time, periods of abstinence, prior treatment attempts, and consequences experienced (health, legal, occupational, social). It’s important to ask about withdrawal history (any past seizures or severe withdrawal episodes), as this informs the risk in detox. A psychiatric history (co-occurring depression, anxiety, PTSD, etc.) and medical history (e.g., liver disease, HIV status, chronic pain) are essential to integrate care. Collateral information from family may help, with patient consent. Tools like the Addiction Severity Index (ASI) structure a comprehensive assessment across domains (medical, employment, alcohol, drugs, legal, family/social, psychiatric).

During assessment, the nurse maintains a nonjudgmental tone, building trust so the patient feels safe disclosing sensitive information. Vital signs and physical exam are also part of assessment: noting signs like track marks (IV injection sites), nasal mucosa damage (from snorting drugs), jaundice (alcoholic liver disease), or neurologic abnormalities. Mental status exam assesses for intoxication (e.g., pinhole pupils in a sedated patient might suggest opioid use, or rapid pressured speech might suggest stimulant use) or psychiatric comorbidities (like hallucinations or suicidal ideation).

Screening in Special Settings: Healthcare guidelines recommend routine substance use screening in primary care and hospital settings. For example, the U.S. Preventive Services Task Force recommends that all adults be screened for unhealthy alcohol use in primary care, with brief counseling offered for those who screen positive【16†L57-L65】【16†L67-L73】. Pregnant women should be screened for alcohol and drug use at initial prenatal visits (using tools like AUDIT or 4Ps for pregnancy) because early intervention can improve maternal-fetal outcomes. Adolescents should be confidentially screened during health visits (e.g., using CRAFFT). In emergency departments, nurses often use quick screens for alcohol intoxication or overdose assessment (like the AUDIT-C, a 3-question version of AUDIT). In mental health settings, every intake should include substance use screening, as many psychiatric crises are precipitated or complicated by substance use.

In summary, using structured screening instruments and thorough assessment techniques allows nurses to identify substance use issues early and accurately, which is the first step toward providing appropriate intervention or referral to treatment. Documenting the findings clearly and communicating them to the interdisciplinary team ensures continuity of care (while respecting patient confidentiality rules).

Nursing Process in Caring for Patients with SUD

Nursing care for individuals with substance use disorders involves applying the nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation) in a holistic, patient-centered manner. The nurse addresses not only the physiological aspects of substance use, but also the psychosocial, safety, educational, and environmental needs of the patient. Below is a breakdown of key considerations at each phase, along with examples of nursing diagnoses, interventions, and outcomes for patients with SUD.

Nursing Assessment

Assessment was discussed above in screening context; once a patient is identified as having a substance issue or is admitted for a related condition (e.g., overdose, withdrawal, or medical illness complicated by SUD), the nurse performs a comprehensive assessment. This includes:

Assessment is ongoing. In an acute setting, the nurse continuously monitors for withdrawal symptoms or medical complications (like checking CIWA or COWS – Clinical Opiate Withdrawal Scale – scores regularly). In a rehab or psychiatric unit, the nurse might assess daily mood, sleep, and any cravings.

Common Nursing Diagnoses

Based on the assessment, the nurse identifies nursing diagnoses (NANDA-I terms) that reflect the patient’s problems. These diagnoses may address direct physiological issues or psychosocial and knowledge deficits. Examples of nursing diagnoses for patients with substance use include【52†L429-L437】:

Nursing diagnoses should be prioritized: physical safety comes first (e.g., Risk for injury/seizures is acute priority). Psychosocial diagnoses can be addressed once the patient is medically stabilized.

Planning and Goals

For each nursing diagnosis, the nurse, in collaboration with the patient, sets goals (outcomes) that are SMART: Specific, Measurable, Achievable, Realistic, and Time-limited. Examples of goals/outcomes:

These goals will feed into the Interventions phase. For instance, if the goal is to have the patient practice non-chemical coping alternatives, the interventions will involve teaching and practicing those skills.

Nursing Interventions and Implementation

Nursing interventions for SUD span acute medical management, therapeutic communication and counseling, education, and coordination of care. Key interventions include:

Evaluation

Continuous evaluation is needed to determine if nursing interventions are effective and if goals are being met. Outcomes to evaluate:

If outcomes are not met, the nurse must reassess and modify the care plan. For example, if a patient continues to deny the problem at discharge (“I think you’re all overreacting, I don’t really need rehab”), the team might refine the approach: maybe involve a peer support specialist to talk with them, or enlist a family meeting to confront the denial with love and concern. If withdrawal signs are not adequately controlled (e.g., patient still very hypertensive and anxious despite the symptom-triggered dosing), perhaps the protocol needs adjusting (increase medication dose or frequency) – the nurse would advocate this to the provider.

Evaluation also covers long-term outcomes: in follow-up, is the patient maintaining sobriety? This might be beyond the immediate care episode, but it’s part of the continuum – e.g., a clinic nurse checking in at 1-month post detox: has the patient engaged in outpatient counseling, remained abstinent (via self-report or urine drug screens)? If not, evaluate what barriers exist (side effects of a med, inability to get to counseling, relapse triggers that were not addressed) and intervene accordingly.

It’s important to celebrate progress to reinforce patient’s efforts. For instance, acknowledging: “You’ve been sober 10 days now – that’s a great start and you should be proud of how you handled withdrawal and sought help.”

In summary, using the nursing process ensures systematic, compassionate, and effective care for individuals with substance use disorders. The nurse’s interventions address immediate medical needs and lay the groundwork for long-term recovery through education, skill-building, and linkage to ongoing support. This comprehensive approach improves both acute outcomes (safe withdrawal, medical stabilization) and long-term outcomes (reduced relapse and improved functioning)【52†L467-L475】【52†L469-L477】.

Management Strategies: Pharmacological and Non-Pharmacological Treatments

Effective treatment of substance use disorders often requires a combination of medication, if appropriate, and psychosocial interventions. This section outlines major pharmacological therapies – including Medication-Assisted Treatment (MAT) – and key non-pharmacological strategies (counseling, behavioral therapies, support groups, etc.). The integration of approaches is critical; for example, medications can help normalize brain chemistry and reduce cravings, while therapy helps patients rebuild life skills and coping mechanisms.

Medication-Assisted Treatment (MAT) and Detoxification Protocols

Medication-Assisted Treatment (MAT) refers to the use of FDA-approved medications in combination with counseling and behavioral therapies to treat SUD. MAT has a strong evidence base, especially for opioid and alcohol use disorders, and is considered a gold standard for those conditions. It helps by relieving withdrawal symptoms, reducing cravings, or blocking drug effects, enabling patients to engage more successfully in recovery activities.

Nurses will often be involved in giving naltrexone injections or ensuring oral med adherence, and monitoring patient outcomes (like asking about any drinking episodes, side effects like injection site reactions, etc.). Also, emphasize that these medications are adjuncts – patients should ideally also engage in counseling or support groups for best results【56†L2219-L2225】.

Key Point: MAT does not “cure” addiction by itself but treats it as a manageable chronic condition. Combining MAT with counseling dramatically improves retention in treatment and outcomes. Nurses should advocate for MAT when indicated – e.g., if an opioid-dependent patient is skeptical (“I want to be totally drug-free, no methadone”), the nurse can educate that craving and relapse rates are extremely high and that using a medication is like using any other medical therapy for a chronic disease, not a crutch or weakness. On the flipside, respect patient preferences – some may decline MAT, in which case maximize non-pharm supports and perhaps suggest naltrexone as an alternative.

Psychosocial and Behavioral Therapies

Multiple evidence-based therapies address the psychological and behavioral aspects of addiction. Often delivered by psychologists, counselors, or social workers, nurses should be familiar with them to reinforce techniques and encourage participation.

Relapse Prevention and Discharge Planning: Because addiction is a chronic relapsing condition, preparing patients for post-treatment life is crucial. Before discharge from any program, the team (including the nurse, patient, counselor, possibly family) should develop a relapse prevention plan. Key elements:

Nurses often coordinate the discharge planning, ensuring all referrals are in place (to counseling, MAT provider, primary care for follow-ups on medical issues). They may also schedule a follow-up call to check in on the patient a week or two after discharge – a brief call to say “How are things going? We care about your progress, any issues getting to your appointments?” – which can improve engagement.

In sum, an integrated approach – combining appropriate pharmacotherapy (to manage withdrawal or support abstinence) with comprehensive psychosocial support – yields the best outcomes in SUD treatment【56†L2201-L2209】【56†L2203-L2211】. Nurses function as care coordinators, educators, and supportive counselors across these interventions. The chronic care model of addiction means the nurse might see the patient across multiple episodes (ED visits, hospitalizations, clinic visits), continually encouraging and guiding them along the path to recovery. Consistent empathy, hope, and firm belief in the patient’s capacity to change can make a profound difference in keeping them engaged in treatment.

Ethical and Legal Considerations in Substance Abuse Care

Caring for patients with substance use disorders presents specific ethical and legal responsibilities for nurses and other healthcare providers. Key issues include confidentiality (privacy rights), mandatory reporting duties, consent and patient rights, and addressing impairment in healthcare workers. Adhering to professional ethics and laws is crucial to protect patient welfare and public safety while respecting patients’ dignity.

Confidentiality and 42 CFR Part 2

Patients with substance use disorders are protected not only by general privacy laws (like HIPAA) but also by special federal regulations. The U.S. law 42 CFR Part 2 (Title 42 of the Code of Federal Regulations, Part 2) provides extra confidentiality protections to records of patients in substance abuse treatment programs【56†L2243-L2251】【56†L2245-L2249】. The intent is to encourage people to seek treatment without fear that their information will be disclosed (for instance, to law enforcement or employers) without their consent.

Under these rules:

A related topic is patient rights in treatment. Patients have the right to informed consent or refusal of treatments (with some exceptions in emergencies or if patient lacks decision-making capacity). For example, you can’t force someone into detox unless they are a danger to themselves/others (or under legal mandate). Treatment should ideally be voluntary; coerced care is ethically tricky, although sometimes leverage (like legal pressure or family ultimatums) does push patients into treatment that ends up helping them. Nurses should uphold autonomy by educating patients on options and respecting their choices, while also considering beneficence (doing good by recommending effective treatment) and nonmaleficence (avoiding harm, e.g., ensuring a patient isn’t discharged to drive drunk).

Mandatory Reporting and Public Safety

Mandated reporting laws require healthcare providers to report certain information to authorities:

Consent for Treatment is another legal aspect. For instance, if initiating disulfiram or naltrexone, ensure the patient consents and understands, especially disulfiram’s reactions. For MAT like methadone, specific consent forms and patient contracts are often used (due to its controlled nature).

Impaired Healthcare Professionals: Ethically, nurses have a duty to report colleagues who may be diverting drugs or working while impaired by substances – this overlaps with legal duty in many states (nurses could face discipline if they fail to report known diversion). This will be detailed in the next section, but from a legal perspective: most states have alternative-to-discipline programs (like peer assistance) where nurses or doctors with SUD can be reported for the purpose of getting them into monitoring/treatment rather than immediately punitive action. Still, if a nurse observes a coworker stealing medications or suspects them of practicing under the influence, it’s both an ethical duty (to protect patients from potential harm and help the colleague) and often a requirement by the state nursing board or employer to report it. The reporting could be to a supervisor or compliance officer who then engages the proper program.

Ethical Principles and Stigma: Nurses should uphold the ethical principles of beneficence, nonmaleficence, autonomy, and justice. For example, treat pain adequately in a person with addiction (justice and beneficence) – don’t under-treat due to stigma or personal bias (that would be nonmaleficence violation causing needless suffering). Use veracity (truth-telling) in education – give honest information about prognosis or what a medication can/can’t do. And maintain fidelity to the patient – which in context means being an advocate even when the patient’s behavior is challenging. An ethical nurse avoids enabling (like giving benzodiazepines on demand to an addicted patient without clear indication, which could worsen their situation) but also avoids punitive attitudes (like withholding comfort measures “to teach a lesson”).

HIPAA in practice: Even aside from Part 2, everyday HIPAA means not disclosing a patient’s health information without permission. With substance issues, be careful with visitors – the patient may not want certain family to know details. Always ask, “Is it okay if we discuss your treatment in front of your sister here?” Also, some patients might use aliases in treatment (allowed in some programs) to protect identity – be aware of how to handle records properly in those cases.

Legal issues specific to SUD patients: Some patients might be on probation or court-mandated to treatment. Nurses may interact with probation officers or drug courts. Generally, patient consent is needed to release information to these officials (or a court order). Often, patients sign such consent as part of the program entry if it’s mandated. If so, provide factual reports on attendance, tox screens, etc., without subjective judgment.

Advocacy: Nurses should also be aware of healthcare laws/policies affecting SUD treatment (

Substance Use Among Healthcare Professionals

Substance use can also affect healthcare providers themselves, including nurses, physicians, etc. It is estimated that approximately 10-15% of nurses (about 1 in 10) may have a substance use problem or be in recovery from one, similar to rates in the general population【60†L81-L89】. Caring for patients in pain and ready access to medications (especially opioids and sedatives) can tempt some healthcare workers into misuse or diversion. This is a serious issue as it jeopardizes both the impaired provider’s health and patient safety.

Warning Signs in Colleagues: Nurses must remain vigilant for signs a coworker might be impaired or diverting drugs. Red flags of a Substance Use Disorder in a healthcare professional include sudden mood swings or personality changes, deteriorating work performance, and unexplained absences or tardiness【60†L97-L105】. The person may have elaborate excuses for behavior or frequently call in sick. Physical signs such as shakiness, slurred speech, or red eyes during a shift can suggest intoxication or withdrawal. Other clues might be wearing long sleeves when not appropriate (to hide injection marks) or a noticeable decline in personal appearance/hygiene and significant weight loss or gain【60†L97-L105】【60†L100-L103】.

Drug Diversion indicators: When a nurse or other provider diverts (steals) controlled substances, there may be telltale patterns: frequent volunteering to administer narcotics or frequently needing to waste excess medication (and insisting on doing it alone), discrepancies in medication count records, or patients reporting inadequate pain relief under that person’s care【60†L105-L113】. The individual may spend a lot of time near medication dispensing areas or show an inappropriate level of interest in patients’ pain meds. They might also refuse drug testing or avoid situations where they might be caught【60†L97-L105】【60†L99-L102】. Coworkers could find syringes or medication vials in odd places (sign the person is self-injecting on the job). In sum, behavioral changes plus drug handling irregularities strongly suggest an impaired provider.

Ethical Duty to Report: Nurses have an ethical and legal obligation to address suspected impairment in colleagues. This follows the principles of nonmaleficence (preventing harm to patients) and fidelity to the nursing profession’s integrity. If a nurse suspects a coworker is diverting drugs or working while impaired, they should not cover up or enable that behavior. Protecting a peer out of misplaced loyalty could result in patient harm (e.g., an impaired nurse might make a life-threatening error or leave patients in pain by diverting their meds). Instead, the nurse should discreetly document objective observations and report concerns to the appropriate supervisor or manager per facility policy【60†L115-L123】【60†L121-L128】. Many institutions have an Employee Assistance Program or a specific process for this. The goal is to ensure the individual is removed from patient care duties until safely evaluated and, if needed, to initiate help for them.

Professional Programs and Recovery: Importantly, the focus should be on treatment, not punishment. Most state boards of nursing and medicine have alternative-to-discipline programs for impaired professionals. These programs (often called Peer Assistance, Diversion Program, or Professional Health Program) allow the nurse or doctor to undergo rehabilitation and monitoring under a contract, rather than immediately lose their license. For example, a nurse may agree to attend a treatment program, submit to random drug screens, practice under certain restrictions, and regularly report to the board. If they comply and stay sober, they can often continue their career. This approach aligns with viewing SUD as a treatable illness. The American Nurses Association and other organizations endorse a non-punitive, supportive approach that encourages colleagues to report and impaired providers to seek help early【60†L115-L123】【60†L121-L128】. In workplaces with a “just culture” and clear policies, coworkers are more likely to step forward, which ultimately protects patients and helps the affected nurse get care before something dire occurs.

Managing the Situation: Once reported, management will typically meet with the nurse in question, possibly require a for-cause drug test, and remove them from duty if impairment is suspected. It’s critical to handle this confidentially and compassionately, as the individual is likely fearful and ashamed. The nurse may be referred to the employee health or occupational assistance program. If substance use is confirmed, they will be guided to detox or rehab. Colleagues should refrain from gossip and support the nurse in recovery upon return, while ensuring all safeguards (like not allowing them access to controlled substances unsupervised, if that’s a stipulation) are in place.

Returning to Work: A healthcare professional in recovery can often return to safe practice with appropriate monitoring. They may have conditions on their license such as no access to narcotic administration for a period, or working daytime shifts only, etc., and will be subject to random drug tests for several years. Many nurses are able to resume productive careers after completing recovery programs. Coworkers should create an environment that reduces stigma – the recovering nurse should not be ostracized but rather encouraged in their sobriety. However, everyone remains watchful for relapse signs, as relapse can happen. If relapse occurs, it should be treated promptly as a medical issue and the person should be removed from duty again to protect patients.

In summary, substance use among healthcare professionals is a serious but addressable problem. Nurses must know the signs of impairment and diversion【60†L97-L105】【60†L105-L113】, and uphold their duty to ensure patient safety by reporting concerns. By doing so within a framework that offers treatment and hope (rather than immediate punishment), the impaired nurse or doctor has the best chance to recover and return to being a safe practitioner. This ultimately exemplifies caring for our own, as well as our patients. Resources like the NCSBN’s “Substance Use Disorder in Nursing” guidelines and state peer assistance programs provide guidance for handling these situations constructively【72†L39-L47】【72†L41-L47】.

Special Populations: Considerations in Substance Use

Certain populations have unique vulnerabilities or needs regarding substance use and its treatment. Adolescents, pregnant women, older adults, veterans, and LGBTQ+ individuals are groups warranting special consideration.

Adolescents (Youth): The teen years are a critical period, as the brain is still developing and risk-taking behavior is high. Most adults with SUD began using in their teens or early twenties【62†L108-L115】, so prevention and early intervention in youth are paramount. Common substances among adolescents include alcohol, cannabis, and vaping nicotine or marijuana concentrates, as well as prescription pill misuse and inhalants (which are often tried by younger teens due to availability). In fact, a CDC survey found about 15% of U.S. high school students have tried illicit or injection drugs (cocaine, heroin, meth, etc.) at least once【62†L113-L121】, and around 14% have misused a prescription opioid【62†L115-L123】. Underage drinking and binge drinking are also prevalent concerns. Adolescents are particularly prone to peer pressure and may use substances to fit in socially, to cope with academic or family stress, or due to curiosity.

Effects on Adolescents: Substance use can derail normal adolescent development. Short-term consequences include accidents (e.g., drunk driving crashes are a leading cause of teen deaths), injuries, violence, risky sexual behaviors (leading to STIs or unplanned pregnancies), and legal issues. It also affects school performance and can lead to dropout. Because the adolescent brain is maturing (especially the prefrontal cortex responsible for judgment), introducing substances can impair cognitive and emotional development. Early heavy use of substances like marijuana is linked to worse memory and learning and a higher chance of developing a SUD in adulthood【61†L10-L18】【61†L12-L14】.

Assessment & Screening: It is vital to screen adolescents in healthcare settings (pediatricians, school clinics) for substance use. Tools like the CRAFFT questionnaire (Car, Relax, Alone, Forget, Friends, Trouble) are designed for ages 12-21 to detect risky use. Ensuring confidentiality encourages honest disclosure (teens need to know their parents won’t automatically be told everything they share, except safety issues). Nurses should also assess for co-occurring issues common in teens with SUD, such as ADHD, depression, trauma, or family dysfunction.

Interventions: Engaging the teen and their family is key. Family-based interventions (like Multisystemic Therapy or Functional Family Therapy) have strong evidence – they work to improve communication, set appropriate limits, and address issues at home that contribute to use. Educating parents on monitoring and on not enabling (for example, locking up medications and alcohol at home) is important. Motivational interviewing can be very effective with adolescents to enhance their own desire to change. Peer interventions (sober recreational activities, teen recovery support groups) can replace the peer network that was using. School-based counseling and academic support help the teen get back on track. If addiction is severe, specialized adolescent rehab programs exist (both outpatient and residential). These should ideally include schooling so the teen doesn’t fall behind.

Adolescents have a great capacity for recovery if intervention is early – the brain can still rebound. Nurses should focus on positive reinforcement of any healthy behaviors and help youth build a sober identity (“you’re strong for choosing not to use, that’s something to be proud of”). Preventive education is also part of nursing care: teaching teens about the real risks of drugs (beyond what they hear from peers) and building refusal skills. Emphasizing hobbies, sports, and interests as alternatives to drug use is beneficial. In summary, working with adolescents involves the teen, family, school, and community resources to redirect the young person’s trajectory away from substance abuse and toward healthy development.

Pregnant Women: Substance use during pregnancy raises concerns for both the mother and the developing fetus. No amount of alcohol or illicit drug use is considered “safe” in pregnancy, as substances can cross the placenta and affect fetal development. For example, heavy alcohol use can cause Fetal Alcohol Spectrum Disorders (FASD), which include a range of permanent birth defects and neurodevelopmental abnormalities (such as facial dysmorphisms, growth restriction, and cognitive impairments)【74†L5-L13】【74†L25-L33】. Even moderate drinking may lead to milder learning or behavioral issues in children. With opioids (heroin, oxycodone, etc.), babies can be born with Neonatal Abstinence Syndrome (NAS) – a withdrawal syndrome in newborns characterized by tremors, high-pitched crying, feeding difficulties, and irritability that requires medication and supportive care for the infant. Stimulants like cocaine or methamphetamine increase risk of miscarriage, placental abruption (where the placenta separates too early, a life-threatening emergency), prematurity, and low birth weight. Cannabis use in pregnancy has been linked to lower birth weights and possible impacts on infant neurobehavior (though data is still emerging). Cigarette smoking is also very harmful – it causes low birth weight, placental problems, and increases risk of Sudden Infant Death Syndrome (SIDS) among other issues.

Care Approach: Pregnant individuals with SUD benefit from specialized care that addresses both obstetric and addiction needs. Compassionate, nonjudgmental care is essential; fear of legal consequences or shame often prevents pregnant women from disclosing substance use or seeking prenatal care. Unfortunately, in some jurisdictions, women have been prosecuted or had child welfare involvement due solely to positive drug tests in pregnancy. The American College of Obstetricians and Gynecologists strongly opposes punitive measures, noting they are ineffective and deter women from seeking prenatal care, ultimately harming mother and fetus【63†L217-L225】【63†L219-L223】. Instead, the recommended approach is to encourage prenatal care attendance, screen for substance use, and provide or refer for treatment. Many states now require creating a “Plan of Safe Care” for infants affected by substance use (per federal CAPTA requirements) – this is not to punish the mother, but to ensure she gets treatment and the baby is safe.

Treatment in Pregnancy: Medication-Assisted Treatment is the standard of care for opioid use disorder in pregnancy: methadone or buprenorphine maintenance is recommended over detoxification. Abruptly stopping opioids in a pregnant dependent woman can precipitate withdrawal in the fetus, leading to miscarriage or stillbirth due to fetal distress. Maintenance therapy stabilizes maternal levels and vastly improves prenatal outcomes by reducing relapse, improving engagement in prenatal care, and reducing risk behaviors【63†L217-L225】【63†L221-L224】. Babies born on MAT may still have NAS, but it’s treatable and these infants generally do as well or better than those whose mothers continued illicit use. For alcohol and other drugs, a pregnant woman can undergo detox with medical supervision (e.g., use phenobarbital for sedative withdrawal if needed), but should then transition into relapse prevention therapy and possibly residential treatment if available. Behavioral interventions like CBT and contingency management have shown good outcomes in pregnant smokers and cocaine users – e.g., voucher programs have helped pregnant women stop smoking (improving birth weights). Nutrition and social support for pregnant patients are also crucial: many have poor nutrition and high stress, so connecting them with social services (WIC, housing, IPV support if needed) is part of comprehensive care.

Nursing Role: Nurses working in OB or prenatal settings should screen every pregnant patient for substance use in a supportive manner (e.g., using the 4Ps: Parents (family history), Partner, Past, and Pregnancy substance use questions). If a patient admits use, respond supportively: “Thank you for telling me – that’s brave and it helps us take better care of you and the baby.” Provide clear education on how the substance can affect the baby’s health. Immediately involve a multidisciplinary team: obstetrician, pediatrician/neonatologist (for when baby is born), and addiction specialist or clinical social worker. If the hospital has a MAT program for pregnancy, facilitate referral – many places have clinics specifically for pregnant women (often called “Prenatal Recovery” clinics) that integrate OB care with addiction treatment. Ensure withdrawal prevention if applicable (start methadone quickly for an opioid-dependent pregnant woman rather than letting her go into withdrawal). Teach the mother what to expect with the baby (e.g., NAS symptoms if opioids, or need for NICU observation). Encourage strategies to reduce harm: for example, if she’s unable to quit a substance, at least to reduce and avoid additional risks (like no alcohol at all, use clean needles if injecting drugs and link with needle exchange, etc. – a harm reduction approach).

Nurses must also be prepared to coordinate with child protective services as required by law. Ideally, involvement of CPS is framed to the mother as part of the Plan of Safe Care, focusing on helping her rather than punishing. Emphasize that keeping mother and baby together is the goal whenever safe – for instance, mothers on methadone are encouraged to breastfeed and bond with baby, which can actually help lessen NAS severity, as long as there are no contraindications (HIV positive with unsafe behavior, etc.). Overall, treating pregnant women with SUD with dignity and as “two patients in one” (mother and fetus) leads to better outcomes: healthier babies and more mothers entering recovery.

Older Adults (Elderly): Substance misuse in older adults is often overlooked but is an increasing concern. The aging Baby Boomer generation has shown higher rates of substance use than previous generations of seniors. Nearly 1 million adults aged 65 and older have a SUD according to 2018 data, and the proportion of older adults in addiction treatment has been rising【65†L216-L224】【65†L218-L224】. Some older adults have long-standing addictions (e.g., an alcoholic who has been drinking for 40 years), while others develop problems later in life – often with prescription medications (opioids for chronic pain, benzodiazepines for anxiety or insomnia).

Challenges in Older Adults: The physiological changes of aging (slower metabolism, changes in body composition, brain sensitivity) make seniors more vulnerable to substances. They often experience a stronger effect from a given dose and are at higher risk for adverse outcomes. For instance, older adults metabolize alcohol more slowly and have less lean body mass, so alcohol stays in their system longer and produces higher BACs than in a younger person【65†L223-L231】【65†L233-L241】. This can lead to falls, injuries (hip fractures are a big danger), or medication interactions (like alcohol with blood pressure meds causing hypotension). Many seniors are on multiple prescriptions – raising the risk of polypharmacy interactions or unintentional misuse (confusion about dosing). A study showed a high rate of mixing medications with alcohol or OTC drugs in adults 57-85, which can be dangerous【65†L239-L246】.

Clinically, symptoms of substance problems (memory loss, confusion, fatigue) may be misattributed to “normal aging” or conditions like dementia. Thus, underdiagnosis is common. Healthcare providers might not ask an older patient about alcohol or drug use, assuming it’s not an issue, or the patient may be ashamed as there is heavy stigma (“a grandmother with a drinking problem”). Additionally, loneliness, bereavement, and depression are common in elders and can precipitate or worsen substance misuse (e.g., a widow starts drinking much more after her spouse dies).

Assessment & Intervention: Nurses should include substance use questions in assessments of older patients, just as with younger. Tools like the AUDIT or simpler screens (or the Short Michigan Alcoholism Screening Test – Geriatric Version, SMAST-G) can be used. Be alert to red flags like frequent falls, new cognitive impairment, or gastrointestinal problems that might suggest alcohol misuse, or excessive drowsiness that could indicate medication overuse. If a problem is identified, interventions need to be tailored:

Outcomes in Older Adults: The good news is older adults who receive treatment often do well – many have stable living situations and lots to lose, so once the issue is recognized and they get help, they can be very compliant with treatment. They may particularly benefit from one-on-one counseling focusing on coping with losses, pain management without over-reliance on meds (maybe integrating physical therapy or yoga for pain), and dealing with life transitions (retirement, etc.). Nurses should also advocate for careful prescribing for seniors: for example, avoid unnecessary benzodiazepines or sleep meds (on the Beers list of potentially inappropriate drugs for older adults) and seek non-pharmacologic alternatives for anxiety and insomnia in this population.

Military Veterans: Veterans have higher rates of certain substance use issues, often intertwined with combat exposure and mental health conditions. Alcohol use has traditionally been common in military culture – heavy episodic drinking is a leading substance issue among vets【67†L251-L259】. Additionally, veterans of recent conflicts (OEF/OIF – Iraq and Afghanistan) have faced significant stress, and many have returned with PTSD, depression, or chronic pain, which contribute to SUD. In one study of OEF/OIF veterans receiving care, 63% of those with SUD also had PTSD【66†L1-L9】. This high comorbidity of PTSD and substance use is a critical consideration: these veterans often use alcohol or drugs to self-medicate intrusive memories, anxiety, or hyperarousal symptoms【66†L5-L13】. Another factor has been the use of opioid pain medications for combat-related injuries – some veterans developed opioid dependence or addiction in the course of treating chronic pain.

Patterns and Consequences: Younger veterans (under 25) show higher rates of illicit drug use compared to older vets and even their civilian peers in that age group【67†L255-L263】【67†L273-L281】. Meanwhile, older veterans may have long-standing alcohol dependence (e.g., Vietnam-era vets with decades of drinking). Substance abuse can lead to homelessness, unemployment, legal problems (like DUI or violence when intoxicated), and relationship breakups in this population. Sadly, it also contributes to the high suicide rate among veterans – substance use can worsen depression and lower inhibitions against suicide.

Veteran-Centric Treatment: The U.S. Department of Veterans Affairs (VA) health system provides specialized SUD treatment integrated with other veteran services. For example, VA medical centers often have PTSD-SUD dual-diagnosis programs, where veterans receive trauma-focused therapy and addiction counseling simultaneously. Approaches like Seeking Safety (teaches coping skills for both PTSD and SUD) are commonly used. Veterans tend to do well in group therapy with other veterans, where a sense of camaraderie and understanding of military culture exists. They might be more comfortable discussing combat experiences among those who have “been there.” The VA also uses MAT: methadone or buprenorphine for OUD among veterans, and naltrexone for either alcohol or opioid use disorder. There’s emphasis on treating pain safely – VA has initiatives to reduce opioid prescribing (in response to high rates of opioid-related issues) and increase alternatives like physical therapy, acupuncture, or non-opioid meds, plus MAT for those already with OUD.

Nursing Considerations: When caring for a veteran, always inquire about military history – it opens the door to discussing unique experiences that may underlie substance use (e.g., “Did you ever have experiences in the service that still bother you?” could lead to identifying PTSD triggers). Build trust by acknowledging their service and using respectful communication (some prefer to be called by rank/title). Be aware of resources: every VA has a Veteran Crisis Line, SUD programs, and social workers who can assist with housing or vocational rehab specifically for vets. If you work outside the VA, you can still coordinate with VA services or veteran community groups (like The Mission Continues, etc.) to wrap supports around the patient. Also, screen for PTSD symptoms if not already diagnosed – tools like the PC-PTSD-5 (a 5-item screen) can be used. Understand that hyper-vigilance or anger outbursts might be PTSD-related rather than pure substance effects.

Encourage veterans to utilize peer support – many recovery groups exist specifically for veterans or even active-duty personnel. There are 12-step meetings geared towards vets, and organizations like Veterans Alcoholic Rehabilitation Program (VARP) or online forums where vets support each other. Having a battle buddy approach in recovery can resonate (one vet mentoring another).

In summary, treating veterans requires an integrated approach addressing PTSD, physical health (like pain or TBI), and substance use concurrently. With appropriate care, even severe cases can improve – numerous veterans have successfully overcome SUD and often become peer mentors themselves, using their military resilience and discipline in the service of recovery.

LGBTQ+ Individuals: People who identify as lesbian, gay, bisexual, transgender, queer or other sexual/gender minorities have disproportionately high rates of substance use and addiction. Studies show that LGB adults are significantly more likely than heterosexual adults to use alcohol and drugs and to develop SUDs【69†L108-L116】【69†L113-L117】. According to a SAMHSA report analyzing 2021-2022 data, about one-third of bisexual men, bisexual women, and gay men had a Substance Use Disorder in the past year – compared to roughly one in ten straight adults – and about one-fourth of lesbian women had an SUD【73†L123-L131】. Those are striking figures. Tobacco use is also higher (roughly 1 in 6 LGBTQ+ people smoke vs 1 in 8 heterosexual)【69†L152-L156】, and LGBTQ+ youth have higher rates of binge drinking and illicit drug use than their straight peers.

Contributing Factors: The concept of minority stress helps explain these disparities. LGBTQ+ individuals often face stigma, discrimination, and social rejection which create chronic stress on top of life’s usual stressors. This can lead to higher rates of depression, anxiety, and trauma in the community. Substance use may be adopted as a coping mechanism to deal with feelings of isolation, shame, or rejection (for example, a teen bullied for being gay might start drinking to numb the pain). Additionally, social venues for LGBTQ+ people traditionally centered around bars and clubs – historically, gay bars were among the few safe spaces to socialize, inadvertently normalizing heavy drinking in these settings. Certain subcultures have drug use tied to social or sexual networks (for instance, the use of stimulants like methamphetamine in some MSM – men who have sex with men – communities for party-and-play or “chemsex”). These patterns can increase risk of HIV and other health issues as well.

Barriers to Care: LGBTQ+ persons may hesitate to seek treatment due to fear of discrimination by healthcare providers. Unfortunately, some have experienced prejudice or lack of understanding from medical professionals in the past. Transgender individuals especially may encounter misunderstanding; if a trans person with addiction enters a treatment program and staff are not educated about trans issues (e.g., misusing pronouns, disallowing hormone therapy during rehab), it can alienate the patient and lead to them leaving treatment. Also, many standard rehab programs historically were geared towards heterosexual, cisgender clients and did not address issues like coming-out stress, homophobic family trauma, or unique relationship dynamics, making it harder for LGBTQ+ clients to relate.

Culturally Competent Treatment: It’s essential for healthcare providers to create an affirming environment. This includes using correct pronouns and chosen names, displaying nondiscrimination statements or a rainbow symbol that signals inclusivity, and educating staff on LGBTQ+ cultural competence. Intake forms should allow patients to self-identify gender and orientation (rather than forcing a binary choice). When taking history, ask in a sensitive way about partner gender(s) and sexual health, as these might interplay with substance use (e.g., “Some people use drugs in sexual contexts; is that something you’ve experienced?”).

Many treatment programs now offer LGBTQ-specific groups or even entire programs specialized for this community. For example, there are rehab groups exclusively for gay men, addressing issues like internalized homophobia, or groups for transgender individuals focusing on body image and minority stress. If such specialized resources are available (some cities have them), offering a referral can improve engagement. If not, ensure the patient is connected to an LGBTQ-friendly counselor or support group. Organizations like Lambda (LGBT) AA/NA meetings are present in many areas, providing peer support in a comfortable atmosphere. Nurses should have a resource list of local LGBTQ+ affirming services (such as The Trevor Project for youth, or local LGBTQ centers that often host recovery meetings).

Specific Health Considerations: Be mindful of health issues that may coincide. Gay and bisexual men with stimulant use disorder might need concurrent HIV prevention or treatment services (since meth use can increase sexual risk; offering PrEP (pre-exposure prophylaxis for HIV) could be lifesaving alongside addiction treatment). Transgender individuals may be using non-prescribed hormones or silicone injections – ensure they get proper medical evaluation and integrate their transition-related healthcare with SUD care so they don’t feel they must choose one over the other.

Mental Health: LGBTQ+ folks have higher rates of mental health conditions due to discrimination stress – nearly half of LGB adults report a history of depression or other mental illness【73†L109-L117】【73†L119-L127】. Thus, dual-diagnosis capability is crucial: therapy should tackle both the SUD and underlying issues like trauma from hate crimes or family rejection. Approaches like trauma-informed care and minority stress theory interventions (helping clients reframe experiences of prejudice and build resilience) are beneficial.

Nursing Advocacy: On a broader level, nurses can advocate for policies that support LGBTQ+ health – for instance, pushing for inclusion of same-sex partner support in family programs, or for insurance coverage of treatment for all regardless of orientation/gender identity. Even small actions, like having a unisex bathroom available in a clinic, signal respect for gender-diverse clients.

In summary, LGBTQ+ individuals with substance use issues should be treated with the same empathy and evidence-based approaches as anyone, but with an awareness of the unique social context. By reducing stigma in healthcare and tailoring services (or at least ensuring openness and respect), providers can greatly improve retention and outcomes for this population【69†L108-L116】【73†L119-L127】. Many LGBTQ+ people do recover and go on to help others – indeed, LGBTQ+ recovery communities are strong and growing, offering hope and role models that one’s identity need not be an obstacle to a healthy, sober life.

Conclusion: Each special population – youth, pregnant women, older adults, veterans, and LGBTQ+ – benefits from a nuanced approach that addresses their specific risks and leverages their strengths. Culturally sensitive, developmentally appropriate, and trauma-informed care increases the effectiveness of substance abuse treatment and helps ensure no group is left behind. Nurses, with their holistic perspective and patient advocacy role, are instrumental in adapting care to meet these diverse needs.

Sources:

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