NCLIP

Substance Use Disorders

3 min read

Substance Use Disorders

Key Points

  • Substance use disorders involve repeated use of alcohol or drugs that impairs health and role function at home, work, or school.
  • Neuroadaptation in the basal-ganglia, extended-amygdala, and prefrontal-cortex drives tolerance, withdrawal, and compulsive use.
  • Clinical progression often moves from intoxication and misuse to dependence, addiction, and overdose risk.
  • Nursing priorities include withdrawal screening, safety planning, stigma-free communication, and linkage to ongoing treatment.

Pathophysiology

Substance use disorders are chronic brain-based disorders involving reward, stress, and executive-control systems. Repeated substance exposure increases dopamine-driven reinforcement in the reward pathway, then produces neuroadaptation that blunts normal reward response. As tolerance develops, larger or more frequent doses are required for similar effect.

When use decreases, withdrawal symptoms emerge and are often relieved only by further use, reinforcing compulsive patterns. This cycle contributes to neglect of relationships, work, and self-care, while raising risk of medical and psychiatric complications.

Classification

  • Misuse: Harmful pattern of use by amount, frequency, or context.
  • Dependence: Physiologic and psychological withdrawal when use stops.
  • Addiction: Compulsive, uncontrolled use with relapse risk despite consequences.

Nursing Assessment

NCLEX Focus

Differentiate intoxication, withdrawal, and overdose first; immediate priorities are airway, breathing, circulation, and safety.

  • Assess substance type, route, amount, frequency, and last use.
  • Assess withdrawal symptoms and trend severity with tools such as ciwa-ar, cows, or CINA when indicated.
  • Assess co-occurring psychiatric symptoms, trauma history, suicidality, and social risk factors.
  • Assess functional impact (employment, parenting, legal exposure, housing instability).
  • Assess overdose risk factors, including reduced tolerance after abstinence.

Nursing Interventions

  • Use nonjudgmental, therapeutic communication to reduce stigma and improve engagement.
  • Initiate symptom-triggered withdrawal care protocols and frequent reassessment.
  • Provide hydration, nutrition support, sleep support, and fall/seizure precautions as needed.
  • Coordinate referrals to detox, residential, outpatient, and peer-support services.
  • Teach relapse and overdose prevention, including emergency response resources.

Post-Detox Overdose Risk

Tolerance drops after detox; return to prior dose can be fatal, especially with opioids.

Pharmacology

Pharmacologic management is substance-specific and often symptom-triggered during withdrawal. Core nursing responsibilities include protocol adherence, reassessment after each dose, adverse-effect monitoring, and discharge medication teaching.

Common supportive medications in detox settings may include agents for nausea, diarrhea, headache, insomnia, anxiety, and autonomic symptoms. Medication plans should be integrated with behavioral treatment and recovery support, not used in isolation.

Clinical Judgment Application

Clinical Scenario

A client reports escalating nightly alcohol use and daytime sedative misuse with tremor, anxiety, and insomnia.

Recognize Cues: Escalating intake, role impairment, withdrawal signs, and dual-substance pattern. Analyze Cues: Findings support probable SUD with active withdrawal risk. Prioritize Hypotheses: Priority is safe withdrawal management and prevention of deterioration. Generate Solutions: Start protocol-based monitoring, symptom treatment, and psychosocial engagement. Take Action: Implement close observation, withdrawal scoring, and interprofessional referral planning. Evaluate Outcomes: Monitor symptom reduction, improved participation, and linkage to continuing care.

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