The Diagnostic and Statistical Manual of Mental Disorders IV states that substance abuse and dependence (defined in Table 11-1) are specific psychiatric diagnoses.³ Abused substances are discussed in detail in psychiatric and pharmacologic books and resources. Long-term management of patients who abuse substances is most often provided in specialized treatment facilities that provide both drug and behavior therapies.

TABLE 11-1

TERMINOLOGY OF SUBSTANCE ABUSE

Term	Definition
Abstinence	Avoidance of substance use.
Addiction	Compulsive, uncontrollable dependence on a substance, behavior, or practice to such a degree that cessation causes severe emotional, mental, or physiologic reactions.
Addictive behavior	Behavior associated with maintaining an addiction.
Craving	Subjective need for a substance, usually experienced after decreased use or abstinence. Cue-induced craving occurs in the presence of experiences previously associated with drug taking.
Dependence	Reliance on a substance to the degree that its absence will cause impairment in function.
• Physical	Altered physiologic state from prolonged substance use; regular use is necessary to prevent withdrawal.
• Psychologic	Compulsive need to experience pleasurable response from the substance.
Overdose	Ingestion of excessive dose of one drug or a combination of similarly acting drugs. Leads to toxic reactions, including respiratory and circulatory arrest.
Relapse	Return to substance use after a period of abstinence.
Substance	Drug, chemical, or biologic entity that is self-administered. The words “drug,” “substance,” and “chemical” are often used interchangeably.
Substance abuse	Overindulgence in a substance that has a negative impact on an individual’s psychologic, physiologic, and/or social functioning.
Substance misuse	Use of a drug for purposes other than those for which it is intended.
Tolerance	Decreased effect of a substance that results from repeated exposure. It is possible to develop cross-tolerance to other substances in the same category.
Withdrawal	Combination of physiologic and psychologic responses that occur when there is abrupt cessation or reduced intake of a substance on which an individual is dependent.

Individuals who abuse substances use the health care system more than those who do not.⁴ Almost every drug of abuse harms some tissue or organ in addition to the brain. Some health problems are caused by the effects of specific drugs, such as liver damage related to alcohol use or chronic obstructive pulmonary disease (COPD) related to smoking. Other health problems result from behaviors associated with substance abuse, such as injecting drugs or neglecting nutrition and hygiene. Common health complications related to substance abuse are identified in Table 11-2.

TABLE 11-2

COMMON HEALTH PROBLEMS RELATED TO SUBSTANCE ABUSE

Substance	Health Problems*
Nicotine and smoking	• Chronic obstructive pulmonary disease (COPD) • Cancers of lung, mouth, larynx, esophagus, stomach, pancreas, bladder, prostate, cervix • Coronary artery disease, peripheral artery disease • Peptic ulcer disease, GERD
Cocaine	• Nasal sores, septal necrosis or perforation • Chronic sinusitis • Cardiac dysrhythmias, myocardial ischemia and infarction • Stroke • Psychosis
Amphetamines	• Cardiac dysrhythmias, myocardial ischemia and infarction • Death of brain cells • Mood disturbances, violent behavior, psychoses
Caffeine	• Gastrointestinal irritation, peptic ulcer disease, GERD • Anxiety, insomnia
Alcohol	• See Table 11-7 on p. 160
Sedative-hypnotics	• Possible memory impairment • Respiratory depression • Risk for falls and fractures
Opioids	• Sexual dysfunction • Gastric ulcers • Glomerulonephritis
Cannabis	• Bronchitis, chronic sinusitis • Cardiac dysrhythmias, myocardial ischemia and palpitations • Memory impairment • Impaired immune function
Behaviors	Health Problems
Injecting drugs	• Blood clots, phlebitis, skin infections • Hepatitis B and C • HIV/AIDS • Other infections: endocarditis, tuberculosis, pneumonia, meningitis, tetanus, bone and joint infections, lung abscesses
Snorting drugs	• Nasal sores, septal necrosis or perforation • Chronic sinusitis
Risky sexual behavior	• HIV/AIDS • Hepatitis B and C • Other sexually transmitted infections
Personal neglect	• Malnutrition, impaired immunity • Accidental injuries

GERD, Gastroesophageal reflux disease.

^*The health problems related to substance abuse are discussed in the appropriate chapters throughout the text where they are identified as risk factors for these problems.

Source: National Institute on Drug Abuse: Addiction and health. In NIDA: Drugs, brains, and behavior—the science of addiction, NIH pub no 07-5605, Rockwell, Md, 2008, National Institutes of Health, US Department of Health and Human Services. Retrieved from www.nida.nih.gov/scienceofaddiction/health.html.

This chapter focuses on the role of the medical-surgical nurse in identifying and managing the substance-abusing patient in acute care settings. All nurses care for patients dependent on substances, whether they are identified as dependent or not, simply because of the prevalence of substance abuse and its association with health problems.

eTABLE 11-1

CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT OF ALCOHOL SCALE, REVISED (CIWA-Ar)

Patient ___________________________________________	Date __________________________
Time _______________ (24 hour clock, midnight = 00:00)
Pulse or heart rate, taken for 1 minute _______________	Blood pressure _________________
NAUSEA AND VOMITING	TACTILE DISTURBANCES
Ask “Do you feel sick to your stomach? Have you vomited?” Observation 0 no nausea and no vomiting 1 mild nausea with no vomiting 2 3 4 intermittent nausea with dry heaves 5 6 7 constant nausea, frequent dry heaves and vomiting	Ask “Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?” Observation 0. none 1. very mild itching, pins and needles, burning or numbness 2. mild itching, pins and needles, burning or numbness 3. moderate itching, pins and needles, burning or numbness 4. moderately severe hallucinations 5. severe hallucinations 6. extremely severe hallucinations 7. continuous hallucinations
TREMOR	AUDITORY DISTURBANCES
Arms extended and fingers spread apart. Observation 0 no tremor 1 not visible, but can be felt fingertip to fingertip 2 3 4 moderate, with patient’s arms extended 5 6 7 severe, even with arms not extended	Ask “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?” Observation 0. not present 1. very mild harshness or ability to frighten 2. mild harshness or ability to frighten 3. moderate harshness or ability to frighten 4. moderately severe hallucinations 5. severe hallucinations 6. extremely severe hallucinations 7. continuous hallucinations
PAROXYSMAL SWEATS	VISUAL DISTURBANCES
Observation 0 no sweat visible 1 barely perceptible sweating, palms moist 2 3 4 beads of sweat obvious on forehead 5 6 7 drenching sweats	Ask “Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?” Observation 0. not present 1. very mild sensitivity 2. mild sensitivity 3. moderate sensitivity 4. moderately severe hallucinations 5. severe hallucinations 6. extremely severe hallucinations 7. continuous hallucinations
ANXIETY	HEADACHE, FULLNESS IN HEAD
Ask “Do you feel nervous?” Observation 0 no anxiety, at ease1 mild anxious 2 3 4 moderately anxious, or guarded, so anxiety is inferred 5 6 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions	Ask “Does your head feel different? Does it feel like there is a band around your head?” Do not rate for dizziness or lightheadedness. Otherwise, rate severity. Observation 0. no present 1. very mild 2. mild 3. moderate 4. moderately severe 5. severe 6. very severe 7. extremely severe
AGITATION	ORIENTATION AND CLOUDING OF SENSORIUM
Observation 0 normal activity 1 somewhat more than normal activity 2 3 4 moderately fidgety and restless 5 6 7 paces back and forth during most of the interview, or constantly thrashes about	Ask “What day is this? Where are you? Who am I?” Observation 0. oriented and can do serial additions 1. cannot do serial additions or is uncertain about date 2. disoriented for date by no more than 2 calendar days 3. disoriented for date by more than 2 calendar days 4. disoriented for place/or person
Total CIWA-Ar Score ______
Rater’s Initials ______
The cumulative score provides the basis for treatment of patients:
Score
0-9 Absent or minimal withdrawal
No medication is necessary
10-14 Mild withdrawal
Treatment with medication required
15-20 Moderate withdrawal
Strong risk of delirium tremens
>20 Severe withdrawal

The CIWA-Ar is not copyrighted and may be reproduced freely.

Sullivan JT, Sykora K, Schneiderman J, et al: Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict 84:1353, 1989.

Common Drugs of Abuse

Nicotine

The addictive behavior that you are most likely to encounter is tobacco use. Nicotine is a stimulant substance in tobacco and is the most rapidly addictive of commonly abused drugs. Cigarette smoking is the predominant form of tobacco abuse in the United States. Tobacco use is the leading cause of preventable illness and death in the United States, claiming 443,000 lives a year.⁵

Effects of Use and Complications

The effects of nicotine are identical to those of other highly addictive stimulant drugs, including cocaine. Although users report that nicotine causes a depressant effect with relaxation and relief of anxiety, these effects are thought to occur when withdrawal is relieved with more nicotine.

Smoking is the most harmful method of nicotine use and can injure nearly every organ in the body. Smoking causes chronic lung disease, cardiovascular disease, and many cancers, and it is associated with cataracts, pneumonia, periodontitis, and abdominal aortic aneurysm ⁶ (see Table 11-2). The chronic respiratory irritation caused by exposure to cigarette smoke is a key risk factor in the development of COPD and lung cancer (carcinogens in tobacco are also involved). The toxic gases inhaled in cigarette smoke constrict the bronchi, paralyze the cilia, thicken the mucus-secreting membranes, dilate the distal airways, and destroy the alveolar walls.

Carbon monoxide is a component of cigarette smoke. Its effects, combined with those of nicotine, increase the risk for coronary artery disease. Carbon monoxide has a high affinity for hemoglobin and combines with it more readily than oxygen, reducing the oxygen-carrying capacity of the blood. Smokers inhale less oxygen when smoking, further decreasing the available oxygen. Together with the increased myocardial oxygen consumption that nicotine causes, carbon monoxide significantly decreases the oxygen available to the myocardium. The result is a cycle of increases in heart rate and myocardial oxygen consumption that can lead to myocardial ischemia.

Children whose parents smoke have a higher rate of respiratory illnesses and sudden infant death syndrome. In adults, secondhand smoking is associated with decreased pulmonary function, increased risk for lung cancer, and increased mortality rates from coronary artery disease.

Women appear to be at greater risk than men for smoking-related diseases. Smoking in women is associated with increased menstrual bleeding and dysmenorrhea, early menopause, and infertility. Lung cancer related to smoking has surpassed breast cancer as the leading cause of cancer deaths among women.⁷

Although those who use smokeless tobacco (snuff, plug, and leaf) have less risk of lung disease than smokers, the use of smokeless tobacco is not without complications. Holding tobacco in the mouth increases the risk of cancer of the mouth, the cheek, the tongue, and gingiva nearly 50-fold. Smokeless tobacco users also experience the systemic effects of nicotine on the cardiovascular system, thus increasing the risk for cardiovascular disease.⁶

All users of nicotine in any form may develop complications directly related to the effects of nicotine itself, including an increased risk for peripheral artery disease, delayed wound healing, peptic ulcer disease, and gastroesophageal reflux disease (GERD).⁶

Nursing and Collaborative Care Tobacco Use

Tobacco Cessation

As a nurse, you have a professional responsibility to help individuals stop smoking or using tobacco. The Joint Commission mandates that every health professional is responsible for identifying tobacco users and providing them with information on ways to stop the use of tobacco. Hospitalization offers an ideal opportunity to provide cessation assistance because hospitals are tobacco-free environments, and patients may be more motivated to quit because of their illness. Patients who receive even brief advice and intervention from you are more likely to quit than those who receive no intervention.

Because many health care facilities are tobacco-free environments, an admitted patient who is addicted to nicotine may experience withdrawal symptoms since they are unable to smoke. These symptoms are the same as for the person who stops using tobacco “cold turkey.” Ask each patient about his or her tobacco status. Unless contraindicated, offer nicotine replacement therapy to those who desire it to control withdrawal symptoms during their hospitalization. These symptoms include craving, restlessness, depression, headache, hyperirritability, drowsiness or insomnia, decreased BP and heart rate, and increased appetite.

With each patient encounter, encourage the patient to quit and offer specific smoking cessation interventions. The Agency for Healthcare Research and Quality has issued clinical practice guidelines for clinicians, including nurses, to use to motivate users to quit ⁸ (Tables 11-3 and 11-4 and Fig. 11-1). Use these brief clinical interventions, called the “five As,” with each patient encounter. These interventions are designed to identify tobacco users, encourage them to quit, determine their willingness to quit, assist them in quitting, and arrange for follow-up to prevent relapse.

TABLE 11-3

CLINICAL PRACTICE GUIDELINE
Treating Tobacco Use and Dependence

The Five As for Individuals Who Desire to Quit	The Five Rs for Individuals Unwilling to Quit
1. Ask: Identify all tobacco users at every contact. 2. Advise: Strongly urge all tobacco users to quit. 3. Assess: Determine willingness to make a quit attempt. 4. Assist: Aid the patient in developing a plan to quit. 5. Arrange: Schedule follow-up contact.	1. Relevance: Ask the patient to indicate why quitting is personally relevant (e.g., family, health). 2. Risks: Ask the patient to identify negative consequences of tobacco use (e.g., cough, shortness of breath). 3. Rewards: Ask the patient to identify potential benefits of stopping tobacco use (e.g., saving money, feeling better). 4. Roadblocks: Ask patient to identify barriers or impediments to quitting (e.g., weight gain, partner smokes). 5. Repetition: Repeat process every clinic visit.

The Five As for Individuals Who Desire to Quit

The Five Rs for Individuals Unwilling to Quit

1. Ask: Identify all tobacco users at every contact.

2. Advise: Strongly urge all tobacco users to quit.

3. Assess: Determine willingness to make a quit attempt.

4. Assist: Aid the patient in developing a plan to quit.

5. Arrange: Schedule follow-up contact.

1. Relevance: Ask the patient to indicate why quitting is personally relevant (e.g., family, health).

2. Risks: Ask the patient to identify negative consequences of tobacco use (e.g., cough, shortness of breath).

3. Rewards: Ask the patient to identify potential benefits of stopping tobacco use (e.g., saving money, feeling better).

4. Roadblocks: Ask patient to identify barriers or impediments to quitting (e.g., weight gain, partner smokes).

5. Repetition: Repeat process every clinic visit.

Source: Agency for Healthcare Research and Quality: AHCPR supported clinical practice guideline: treating tobacco use and dependence: 2008 update, Washington, DC, 2008, US Public Health Service.

TABLE 11-4

INPATIENT TOBACCO CESSATION INTERVENTIONS

Take the following steps for every hospitalized patient.

• Ask each patient on admission if he or she uses tobacco and document tobacco use status.

• For current tobacco users, list tobacco use status on the admission problem list and as a discharge diagnosis.

• Use counseling and medication to help all tobacco users maintain abstinence and to treat withdrawal symptoms.

• Provide advice and assistance on how to quit during hospitalization and remain abstinent after discharge.

• Arrange for follow-up regarding smoking status. Supportive contact should be provided for at least a month after discharge.

Source: Agency for Healthcare Research and Quality: AHCPR supported clinical practice guideline: treating tobacco use and dependence: 2008 update, Washington, DC, 2008, US Public Health Service.

If a tobacco user is unwilling to quit, motivational interventions based on the principles of motivational interviewing have been shown to increase future quit attempts. The content areas that should be addressed in a motivational counseling intervention can be captured by the “five Rs”: relevance, risks, rewards, roadblocks, and repetition. A patient teaching guide (Table 11-5) expands on the fourth “A” strategy, “Assist: aid the patient in quitting.”

TABLE 11-5

PATIENT TEACHING GUIDE
Smoking and Tobacco Use Cessation

The following interventions are methods that work for quitting tobacco use. Tobacco users have the best chance of quitting if they use more than one method.

Develop a Quit Plan

• Set a quit date, ideally within 2 weeks.

• Talk to your health care provider about getting help to quit.

• Tell family, friends, and co-workers about quitting and request understanding and support.

• Anticipate withdrawal symptoms and challenges when quitting.

• Before quitting, avoid smoking in places where you spend a lot of time (work, car, home).

• Throw away all tobacco products from your home, car, and work.

• Do not take even a single puff or dip after the quit date. Total abstinence is essential.

Use Approved Nicotine Replacement Systems

• Use a nicotine replacement agent unless you are a pregnant or nursing woman (see Table 11-6).

• Do not use other forms of tobacco when using nicotine replacement systems.

Dealing With Urges to Use Tobacco

• Identify situations that may cause you to want to smoke or use other tobacco, such as being around other smokers, being under time pressure, getting into an argument, feeling sad or frustrated, and drinking alcohol.

• Avoid difficult situations while you are trying to quit. Try to lower your stress level.

• Exercise can help, such as walking, jogging, or bicycling.

• Distract yourself from thoughts of smoking and the urge to use tobacco by talking to someone, getting busy with a task, or reading a book.

• Drink a lot of water.

• Take a shower or soak in the tub.

Support and Encouragement

• If you have tried to stop using tobacco before, identify what helped and what hurt in previous quit attempts.

• Joining a quit-tobacco support group will increase your chances of stopping permanently.

• If you get the urge for tobacco, call someone to help talk you out of it—preferably an ex-user.

• Do not be afraid to talk about how you feel while quitting, especially fears of not being able to quit for good. Ask your spouse or partner, friends, and co-workers to support you. Self-help materials and hot lines are also available:

• American Lung Association: 800-586-4872; www.lungusa.org

• American Cancer Society: 800-227-2345; www.cancer.org

• National Cancer Institute: 877-448-7848 or 800-784-8669; www.smokefree.gov

• Make Smoking History, Massachusetts Department of Public Health: 800-784-8669; http://makesmokinghistory.org

Avoiding Relapse

Most relapses occur within the first 3 months after quitting. Do not be discouraged if you start using tobacco again. Remember, most people try several times before they finally quit. Explore different ways to break habits. You may have to deal with some of the following triggers that cause relapse.

• Change your environment. Get rid of cigarettes, tobacco (in any form), and ashtrays in your home, car, and place of work. Get rid of the smell of cigarettes in your car and home.

• Alcohol. Consider limiting or stopping alcohol use while you are quitting tobacco.

• Other smokers at home. Encourage housemates to quit with you. Work out a plan to cope with others who smoke, and avoid being around them.

• Weight gain. Tackle one problem at a time. Work on quitting tobacco first. You will not necessarily gain weight, and increased appetite is often temporary.

• Negative mood or depression. If these symptoms persist, talk to your health care provider. You may need treatment for depression.

• Withdrawal symptoms. Your body will go through many changes when you quit tobacco. You may have a dry mouth, cough, or scratchy throat, and you may feel irritable. The nicotine patch or gum may help with cravings (see Table 11-6).

• Thoughts. Get your mind off tobacco. Exercise and do things you enjoy.

• Keep a list. Keep a list of “slips” and near-slips, what caused them, and what you can learn from them.

• Focus on the benefits of quitting:

1. At 20 minutes after you quit, blood pressure decreases, pulse rate drops, and the body temperature of your hands and feet increases.

2. At 12 hours, the carbon monoxide level in your blood drops to normal, and the oxygen level in your blood increases to normal.

3. At 24 hours, your chance of a heart attack decreases.

4. At 48 hours, nerve endings start regrowing, and the ability to smell and taste is enhanced.

5. At 2 weeks to 3 months, your circulation improves; walking becomes easier; lung function increases; and coughing, sinus congestion, fatigue, and shortness of breath decrease.

6. At 1 year, your risk of heart disease decreases to half that of a smoker.

7. By 10 to 15 years, your risk of stroke, lung and other cancers, and early death returns to nearly the level of people who have never smoked.

Sources: Agency for Healthcare Research and Quality: Help for smokers and other tobacco users: consumer guide, Washington, DC, May 2008, US Public Health Service. Retrieved from www.ahrq.gov/consumer/tobacco/helpsmokers.htm; and American Lung Association: Freedom from smoking online. Retrieved from www.lungusa.org.

The patient is most likely to achieve long-term tobacco cessation with a combination of nicotine replacement products, medications, behavioral approaches, and support.⁹ Support the patient by providing the resources needed to continue or start a quit attempt.

A variety of nicotine replacement products can be used to reduce the craving and withdrawal symptoms associated with tobacco cessation (Table 11-6). These agents enable a smoker to reduce nicotine previously obtained from cigarettes with a system that delivers the drug more slowly and eliminates the carcinogens and gases associated with tobacco smoke. Nicotine replacement therapy is generally not recommended for pregnant women and people who have experienced an acute myocardial infarction within 2 weeks, have unstable angina, or have life-threatening dysrhythmias.

TABLE 11-6

DRUG THERAPY
Smoking Cessation *

Agents	Common Side Effects	Considerations
Nicotine Replacement Agents
Nicotine Gum (OTC) Nicorette 2 mg, 4 mg • Use 12 wk or more • Use 9-12 pieces/day • Maximum dose: 30 pieces of 2 mg, 20 pieces of 4 mg	Hiccups, mouth ulcers, indigestion, jaw pain	Specific 30-min chewing regimen with periods of holding the gum between cheek and teeth. Avoid food and drink 15 min before and during use.
Nicotine Lozenge (OTC) Commit 2 mg, 4 mg • Use 8-12 wk or more • Use 1 lozenge q1-2hr tapering to 1 lozenge q4-8hr in 12 wk	Nausea and indigestion, hiccups, headache, cough, mouth soreness, flatulence	Dissolves in the mouth in 20-30 min. Chewing and swallowing the lozenge increases GI side effects. Avoid food and drink during use.
Nicotine Patch (OTC) NicoDerm CQ, Habitrol, Nicotine transdermal system • 18- or 24-hr doses • Use ≥8 wk	Transient itching, burning, and redness at patch site. Sleep disturbances with 24-hr patch	Provides steady level of nicotine and is easy to use. Cannot be used by those with adhesive allergies.
Nicotine Nasal Spray Nicotrol NS • Use up to 6 mo	Nose and throat irritation, sneezing, rhinitis, watery eyes, cough	Requires a prescription. Provides fastest nicotine delivery and highest nicotine levels. Most irritating product.
Nicotine Inhaler Nicotrol nicotine inhalation system • Delivers 4 mg • Use up to 6 mo	Cough. Nose, mouth, and throat irritation. Heartburn and nausea	Requires a prescription. Simulates smoking with mouthpiece and nicotine cartridge. May not be advisable for those with asthma or pulmonary disease.
Non-Nicotine Agents
Bupropion (Zyban) • 150 mg/day for 3 days, then 150 mg bid • Use 12 wk; can use up to 6 mo or longer	Insomnia, dry mouth, irritability, anorexia	Contraindicated with history of seizures or eating disorders. Promotes weight loss. First choice for smokers with depression.
Varenicline (Chantix)† • 0.5 mg/day for 3 days, 0.5 mg bid for 4 days, then 1 mg bid • Use 12 wk; additional 12 wk recommended for those who stop smoking to increase chance of long-term abstinence	Nausea, sleep disturbances, constipation, flatulence, vomiting, headache	If taken concurrently with nicotine replacement therapy, incidence of nausea, headache, vomiting, dizziness, dyspepsia, and fatigue is increased, but nicotine pharmacokinetics not affected.
Nortriptyline (Aventyl)‡ • 25-75 mg/day • Use 12 wk, longer if depressed	Dry mouth, drowsiness, dizziness	Must have stable ECG. Do not use immediately after MI.
Clonidine (Catapres)‡ • 0.1 mg q6hr PRN for craving	Dry mouth, drowsiness, constipation, hypotension	Used to control craving. Change position slowly to prevent postural hypotension.