Editing Mental Health and Psychosocial Nursing (section)

== Substance-Related and Addictive Disorders ==

=== General Concepts ===
Tolerance is the need for more substance for the same effect. Withdrawal is a substance-specific syndrome on cessation. Substance use disorder is diagnosed by impaired control, social impairment, risky use, and pharmacologic criteria, and graded mild, moderate, or severe.

Screening: CAGE (Cut down, Annoyed, Guilty, Eye-opener), AUDIT, CRAFFT for adolescents. Ask about substance use in a nonjudgmental, matter-of-fact way, including exact substances, amounts, routes, and time of last use. '''Time of last use determines when withdrawal will begin''' and is the most important assessment datum on admission.

=== Alcohol ===
Withdrawal timeline after last drink:
* 6 to 12 hours: tremor, anxiety, nausea, diaphoresis, tachycardia, hypertension
* 12 to 24 hours: alcoholic hallucinosis (usually visual, sensorium otherwise clear)
* 24 to 48 hours: withdrawal seizures (generalized tonic-clonic)
* 48 to 96 hours: '''delirium tremens''' - clouded sensorium, disorientation, severe autonomic hyperactivity, hallucinations, fever. This is a medical emergency with meaningful mortality even when treated.

Management: CIWA-Ar symptom-triggered '''benzodiazepines''' (lorazepam is preferred in hepatic impairment because it does not require oxidative metabolism), quiet well-lit room, frequent orientation, seizure precautions, fluids and electrolytes, and '''thiamine before glucose''' to prevent precipitating Wernicke encephalopathy.

Wernicke encephalopathy is the acute triad of confusion, ataxia, and ophthalmoplegia or nystagmus; it is reversible with thiamine. Korsakoff syndrome is the chronic sequel with anterograde amnesia and confabulation, and it is largely irreversible.

Maintenance pharmacotherapy: '''disulfiram''' causes flushing, throbbing headache, vomiting, and hypotension if alcohol is ingested; teach avoidance of hidden alcohol in mouthwash, cough syrup, sauces, aftershave, and hand sanitizer. '''Naltrexone''' reduces craving and reward but is contraindicated with current opioid use because it precipitates withdrawal. '''Acamprosate''' supports abstinence and is renally cleared.

=== Opioids ===
Intoxication: pinpoint pupils, respiratory depression, sedation, hypotension, decreased bowel sounds. '''Naloxone''' reverses it; monitor for re-sedation because naloxone has a shorter half-life than many opioids, and expect abrupt withdrawal in dependent clients.

Withdrawal (COWS scale): lacrimation, rhinorrhea, yawning, mydriasis, piloerection, myalgia, abdominal cramping, vomiting, diarrhea. It is intensely uncomfortable but '''not usually life-threatening in healthy adults''', unlike alcohol and sedative withdrawal, which can kill. Neonatal opioid withdrawal, by contrast, is dangerous and requires swaddling, low stimulation, small frequent feedings, and scoring-based pharmacologic treatment.

Treatment: methadone (full agonist, clinic-dispensed), buprenorphine or buprenorphine-naloxone (partial agonist), and naltrexone (antagonist, requires 7 to 10 days opioid-free first).

=== Sedative-Hypnotics, Stimulants, and Others ===
* '''Benzodiazepine withdrawal''' mirrors alcohol withdrawal and can produce seizures and death. Never stop abruptly; taper. Flumazenil reverses overdose but can precipitate seizures and is used cautiously.
* '''Stimulants''' (cocaine, methamphetamine): intoxication causes hypertension, tachycardia, hyperthermia, mydriasis, agitation, paranoia, and risk of seizure, stroke, myocardial infarction, and formication. Withdrawal is a "crash" with hypersomnia, hyperphagia, dysphoria, and '''significant suicide risk'''.
* '''Cannabis''': conjunctival injection, increased appetite, impaired time sense; hyperemesis syndrome with chronic heavy use.
* '''Hallucinogens''': perceptual distortion with retained insight in some cases; manage with a quiet environment and "talking down."
* '''Phencyclidine''': violence, nystagmus (including vertical), analgesia, hypertension. Prioritize staff and client safety and minimize stimulation.
* '''Inhalants''': risk of sudden sniffing death from arrhythmia.

Recovery support: 12-step and other mutual-help programs, relapse prevention planning, contingency management, motivational interviewing. Approach relapse as a clinical event to analyze, not a moral failure.