TYPES OF SUBSTANCES AND TREATMENT
The classes of mood-altering substances have some similari-ties and differences in terms of intended effect, intoxication effects, and withdrawal symptoms. Treatment approaches after detoxification, however, are quite similar. This section presents a brief overview of seven classes of substances and the effects of intoxication, overdose, withdrawal, and detox-ification, and it highlights important elements of which the nurse should be aware.
Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream. Initially, the effects are relaxation and loss of inhibitions. With intoxication, there is slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judg-ment. Some people become aggressive or display inappro-priate sexual behavior when intoxicated. The person who is intoxicated may experience a blackout.
An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression. This combination can cause aspi-ration pneumonia or pulmonary obstruction. Alcohol-induced hypotension can lead to cardiovascular shock and death. Treatment of an alcohol overdose is similar to that for any central nervous system depressant: gastric lavage or dialysis to remove the drug and support of respi-ratory and cardiovascular functioning in an intensive care unit. The administration of central nervous system stimu-lants is contraindicated (Lehne, 2006).
Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symp-toms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium—called delirium tremens (DTs). Alcohol withdrawal usually peaks on the second day and is over in about 5 days (American Psychiatric Association [APA], 2000). This can vary, how-ever, and withdrawal may take 1 to 2 weeks.
Because alcohol withdrawal can be life-threatening, detoxification needs to be accomplished under medical supervision. If the client’s withdrawal symptoms are mild and he or she can abstain from alcohol, he or she can be treated safely at home. For more severe withdrawal or for clients who cannot abstain during detoxification, a short admission of 3 to 5 days is the most common setting. Some psychiatric units also admit clients for detoxification, but this is less common.
Safe withdrawal is usually accomplished with the administration of benzodiazepines such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium) to suppress the withdrawal symptoms. Withdrawal can be accomplished by fixed-schedule dosing known as tapering or symptom-triggered dosing in which the presence and severity of withdrawal symptoms determine the amount of medication needed and the frequency of administration. Often, the protocol used is based on an assessment tool such as the Clinical Institute Withdrawal Assessment of Alcohol Scale. Total scores less than 8 indicate mild withdrawal; scores from 8 to 15 indicate moderate withdrawal (marked arousal); and scores greater than 15 indicate severe withdrawal. Clients on symptom-triggered dosing receive medication based on scores of this scale alone, whereas clients on fixed-dose tapers also can receive additional doses depending on the level of scores from this scale. Both methods of medicating clients are safe and effective.
This class of drugs includes all central nervous system depressants: barbiturates, nonbarbiturate hypnotics, and anxiolytics, particularly benzodiazepines. Benzodiazepines and barbiturates are the most frequently abused drugs in this category (Ciraulo & Sarid-Segal, 2005). The intensity of the effect depends on the particular drug. The effects of the drugs, symptoms of intoxication, and withdrawal symptoms are similar to those of alcohol. In the usual pre-scribed doses, these drugs cause drowsiness and reduce anxiety, which is the intended purpose. Intoxication symp-toms include slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, and even stupor and coma.
Benzodiazepines alone, when taken orally in overdose, are rarely fatal, but the person is lethargic and confused. Treatment includes gastric lavage followed by ingestion of activated charcoal and a saline cathartic; dialysis can be used if symptoms are severe (Lehne, 2006). The client’s confusion and lethargy improve as the drug is excreted.
Barbiturates, in contrast, can be lethal when taken in overdose. They can cause coma, respiratory arrest, cardiac failure, and death. Treatment in an intensive care unit is required using lavage or dialysis to remove the drug from the system and to support respiratory and cardiovascular function.
The onset of withdrawal symptoms depends on the half-life of the drug . Medications such as lora-zepam, whose actions typically last about 10 hours, pro-duce withdrawal symptoms in 6 to 8 hours; longer-acting medications such as diazepam may not produce with-drawal symptoms for 1 week (APA, 2000). The withdrawal syndrome is characterized by symptoms that are the oppo-site of the acute effects of the drug: that is, autonomic hyperactivity (increased pulse, blood pressure, respira-tions, and temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitation. Seizures and halluci-nations occur only rarely in severe benzodiazepine with-drawal (Ciraulo & Sarid-Segal, 2005).
Detoxification from sedatives, hypnotics, and anxiolyt-ics is often managed medically by tapering the amount of the drug the client receives over a period of days or weeks, depending on the drug and the amount the client had been using. Tapering, or administering decreasing doses of a medication, is essential with barbiturates to prevent coma and death that occur if the drug is stopped abruptly. For example, when tapering the dosage of a benzodiazepine, the client may be given Valium, 10 mg four times a day; the dose is decreased every 3 days, and the number of times a day the dose is given also is decreased until the cli-ent safely withdraws from the drug.
Stimulants are drugs that stimulate or excite the central nervous system. Although the DSM-IV-TR categorizes amphetamines, cocaine, and central nervous system stim-ulants separately, the effects, intoxication, and withdrawal symptoms of these drugs are virtually identical. They are grouped together here for this reason.
Stimulants have limited clinical use (with the exception of stimulants used to treat attention deficit hyperactivity disorder;) and a high potential for abuse. Amphetamines (uppers) were popular in the past; they were used by people who wanted to lose weight or to stay awake. Cocaine, an illegal drug with virtually no clinical use in medicine, is highly addictive and a popular recre-ational drug because of the intense and immediate feeling of euphoria it produces.
Methamphetamine is particularly dangerous. It is highly addictive and causes psychotic behavior. Brain damage related to its use is frequent, primarily as a result of the substances used to make it—that is, liquid agricul-tural fertilizer. The percentage of people admitted to inpatient settings for methamphetamine abuse had increased in 49 of the 50 states in the United States from 2000 to 2005. Use of methamphetamine, however, seems to have peaked and actually declined in the past few years (Substance Abuse and Mental Health Services Adminis-tration, 2009).
Intoxication from stimulants develops rapidly; effects include the high or euphoric feeling, hyperactivity, hyper-vigilance, talkativeness, anxiety, grandiosity, hallucina-tions, stereotypic or repetitive behavior, anger, fighting, and impaired judgment. Physiologic effects include tachy-cardia, elevated blood pressure, dilated pupils, perspira-tion or chills, nausea, chest pain, confusion, and cardiac dysrhythmias. Overdoses of stimulants can result in sei-zures and coma; deaths are rare (Jaffe, Ling, & Rawson, 2005). Treatment with chlorpromazine (Thorazine), an antipsychotic, controls hallucinations, lowers blood pres-sure, and relieves nausea (Lehne, 2006).
Withdrawal from stimulants occurs within a few hours to several days after cessation of the drug and is not life-threatening. Marked dysphoria is the primary symptom and is accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation. Marked withdrawal symptoms are referred to as “crashing”; the person may experience depressive symptoms, including suicidal ide-ation, for several days. Stimulant withdrawal is not treated pharmacologically.
Cannabis sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and for oil from its seeds. It has become widely known for its psychoactive resin (Hall & Degenhardt, 2005). This resin contains more than 60 substances, called cannabinoids, of which d-9-tetrahydrocannabinol is thought to be responsible for most of the psychoactive effects. Marijuana refers to the upper leaves, flowering tops, and stems of the plant; hashish is the dried resinous exudate from the leaves of the female plant. Cannabis is most often smoked in cigarettes (joints), but it can be eaten.
Cannabis is the most widely used illicit substance in the United States. Research has shown that cannabis has short-term effects of lowering intraocular pressure, but it is not approved for the treatment of glaucoma. It also has been studied for its effectiveness in relieving the nausea and vomiting associated with cancer chemotherapy and the anorexia and weight loss of AIDS. Currently, two cannabi-noids, dronabinol (Marinol) and nabilone (Cesamet), have been approved for treating nausea and vomiting from can-cer chemotherapy.
Cannabis begins to act less than 1 minute after inhala-tion. Peak effects usually occur in 20 to 30 minutes and last at least 2 to 3 hours. Users report a high feeling simi-lar to that with alcohol, lowered inhibitions, relaxation, euphoria, and increased appetite. Symptoms of intoxica-tion include impaired motor coordination, inappropriate laughter, impaired judgment and short-term memory, and distortions of time and perception. Anxiety, dyspho-ria, and social withdrawal may occur in some users. Physiologic effects, in addition to increased appetite, include conjunctival injection (bloodshot eyes), dry mouth, hypotension, and tachycardia. Excessive use of cannabis may produce delirium or, rarely, cannabis-in-duced psychotic disorder, both of which are treated symptomatically. Overdoses of cannabis do not occur (Hall & Degenhardt, 2005).
Although some people have reported withdrawal symp-toms of muscle aches, sweating, anxiety, and tremors, no clinically significant withdrawal syndrome is identified (Lehne, 2006).
Opioids are popular drugs of abuse because they desensi-tize the user to both physiologic and psychologic pain and induce a sense of euphoria and well-being. Opioid com-pounds include both potent prescription analgesics such as morphine, meperidine (Demerol), codeine, hydromor-phone, oxycodone, methadone, oxymorphone, hydro-codone, and propoxyphene as well as illegal substances such as heroin and normethadone. People who abuse opi-oids spend a great deal of their time obtaining the drugs; they often engage in illegal activity to get them. Health care professionals who abuse opioids often write prescrip-tions for themselves or divert prescribed pain medication for clients to themselves (APA, 2000).
Opioid intoxication develops soon after the initial euphoric feeling; symptoms include apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory. Severe intoxication or opioid over-dose can lead to coma, respiratory depression, pupillary con-striction, unconsciousness, and death. Administration of naloxone (Narcan), an opioid antagonist, is the treatment of choice because it reverses all signs of opioid toxicity. Nalox-one is given every few hours until the opioid level drops to nontoxic; this process may take days (Lehne, 2006).
Opioid withdrawal develops when drug intake ceases or decreases markedly, or it can be precipitated by the admin-istration of an opioid antagonist. Initial symptoms are anxi-ety, restlessness, aching back and legs, and cravings for more opioids (Jaffe & Strain, 2005). Symptoms that develop as withdrawal progresses include nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia. Symptoms of opioid withdrawal cause sig-nificant distress but do not require pharmacologic interven-tion to support life or bodily functions. Short-acting drugs such as heroin produce withdrawal symptoms in 6 to 24 hours; the symptoms peak in 2 to 3 days and gradually sub-side in 5 to 7 days. Longer-acting substances such as metha-done may not produce significant withdrawal symptoms for 2 to 4 days, and the symptoms may take 2 weeks to subside. Methadone can be used as a replacement for the opioid, and the dosage is then decreased over 2 weeks. Substitution of methadone during detoxification reduces symptoms to no worse than a mild case of flu (Lehne, 2006). Withdrawal symptoms such as anxiety, insomnia, dysphoria, anhedonia, and drug craving may persist for weeks or months.
Hallucinogens are substances that distort the user’s percep-tion of reality and produce symptoms similar to psychosis, including hallucinations (usually visual) and depersonal-ization. Hallucinogens also cause increased pulse, blood pressure, and temperature; dilated pupils; and hyperreflexia. Examples of hallucinogens are mescaline, psilocybin, lyser-gic acid diethylamide, and “designer drugs” such as Ecstasy. PCP, developed as an anesthetic, is included in this section because it acts similarly to hallucinogens.
Hallucinogen intoxication is marked by several maladap-tive behavioral or psychologic changes: anxiety, depression, paranoid ideation, ideas of reference, fear of losing one’s mind, and potentially dangerous behavior such as jumping out a window in the belief that one can fly (Jones, 2005). Physiologic symptoms include sweating, tachycardia, pal-pitations, blurred vision, tremors, and lack of coordination. PCP intoxication often involves belligerence, aggression, impulsivity, and unpredictable behavior.
Toxic reactions to hallucinogens (except PCP) are primar-ily psychologic; overdoses as such do not occur. These drugs are not a direct cause of death, although fatalities have occurred from related accidents, aggression, and suicide. Treatment of toxic reactions is supportive. Psychotic reactions are managed best by isolation from external stimuli; physical restraints may be necessary for the safety of the client and others. PCP toxic-ity can include seizures, hypertension, hyperthermia, and respiratory depression. Medications are used to control sei-zures and blood pressure. Cooling devices such as hyper-thermia blankets are used, and mechanical ventilation is used to support respirations (Lehne, 2006).
No withdrawal syndrome has been identified for halluci-nogens, although some people have reported a craving for the drug. Hallucinogens can produce flashbacks, which are transient recurrences of perceptual disturbances like those experienced with hallucinogen use. These episodes occur even after all traces of the hallucinogen are gone and may persist for a few months up to 5 years.
Inhalants are a diverse group of drugs that include anes-thetics, nitrates, and organic solvents that are inhaled for their effects. The most common substances in this category are aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint. Less frequently used halogenated hydrocarbons include cleaners, correction fluid, spray can propellants, and other compounds contain-ing esters, ketones, and glycols (APA, 2000). Most of the vapors are inhaled from a rag soaked with the compound, from a paper or plastic bag, or directly from the container. Inhalants can cause significant brain damage, peripheral nervous system damage, and liver disease.
Inhalant intoxication involves dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision. Stupor and coma can occur. Significant behavioral symptoms are belliger-ence, aggression, apathy, impaired judgment, and inability to function. Acute toxicity causes anoxia, respiratory depression, vagal stimulation, and dysrhythmias. Death may occur from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomitus (Crowley & Sakai, 2005). Treatment consists of supporting respiratory and cardiac functioning until the substance is removed from the body. There are no antidotes or specific medica-tions to treat inhalant toxicity.
There are no withdrawal symptoms or detoxification pro-cedures for inhalants as such, although frequent users report psychologic cravings. People who abuse inhalants may suffer from persistent dementia or inhalant-induced disorders such as psychosis, anxiety, or mood disorders even if the inhalant abuse ceases. These disorders are all treated symptomatically (Crowley & Sakai, 2005).