Nurses Revision

Psychoactive Substance Use Disorders: Assessment, Withdrawal and Nursing Management

Psychoactive Substance Use Disorders: Assessment, Withdrawal and Nursing Management

Psychoactive substances alter mood, perception, cognition or behaviour. Substance use disorder is a maladaptive pattern causing impaired control, priority given to use, risky use, social/occupational harm, tolerance or withdrawal. Care must be non-judgmental, trauma-informed and integrated with physical and mental healthcare.

Major substance groups

GroupIntoxicationWithdrawal/dangers
AlcoholDisinhibition, slurred speech, ataxia, reduced consciousnessTremor, sweating, anxiety, seizures, hallucinations, delirium tremens
OpioidsEuphoria/sedation, pinpoint pupils, respiratory depressionYawning, rhinorrhoea, pain, vomiting/diarrhoea; relapse overdose risk
CannabisAltered perception, red eyes, impaired coordination; anxiety/paranoiaIrritability, poor sleep, reduced appetite
StimulantsAgitation, dilated pupils, sweating, tachycardia, hypertension, psychosisFatigue, low mood, craving; suicide risk
SedativesDrowsiness, ataxia, respiratory depressionAnxiety, insomnia, seizures/delirium—abrupt cessation can be fatal
Hallucinogens/inhalantsPerceptual disturbance; inhalants may cause arrhythmia/hypoxiaVariable; persistent psychosis or organ toxicity possible

Assessment

  1. ABCDE first for reduced consciousness, respiratory depression, seizure, severe agitation, chest pain or hyperthermia; check glucose and trauma.
  2. Ask substance, local name, quantity, frequency, route, last use, mixing, tolerance, withdrawal, overdose, injecting and previous treatment.
  3. Assess impact on health, HIV/hepatitis/TB risk, pregnancy, relationships, violence, work/education, finances and law.
  4. Screen depression, psychosis, suicide/self-harm, cognition and safeguarding; determine readiness to change.
  5. Use targeted tests: breath alcohol where available, ECG, glucose, electrolytes, liver/renal function, FBC, pregnancy, HIV/hepatitis/STI/TB testing with consent and indication. Toxicology supports but does not replace clinical assessment.

Emergency management

  • Opioid overdose: open airway, ventilate with bag-mask and oxygen, give naloxone per Uganda/local protocol, observe for recurrent depression because naloxone may wear off first.
  • Alcohol/sedative withdrawal: admit severe/high-risk cases, monitor using clinical protocol, administer benzodiazepine regimen and thiamine as prescribed, correct fluids/electrolytes and treat seizures. Do not give glucose before thiamine when hypoglycaemia is life-threatening—treat glucose immediately while giving thiamine promptly.
  • Stimulant toxicity: low-stimulation environment, temperature/ECG monitoring, cooling, fluids and protocol-directed benzodiazepine; avoid prolonged physical struggle.
  • Psychosis/agitation: exclude delirium, hypoxia and glucose disturbance; de-escalate and use least-restrictive care with cardiorespiratory monitoring when sedation is prescribed.

Continuing treatment

Brief intervention and psychosocial care

  • Give personalized feedback, explore goals and ambivalence, agree one achievable step and arrange follow-up.
  • Use motivational interviewing, CBT, relapse-prevention skills, contingency management, peer/family support and rehabilitation according to need.
  • Identify triggers, craving plan, safe housing, livelihood, violence protection and co-occurring mental illness.

Pharmacological approaches

MedicineIndicationSafety and monitoring
Methadone/buprenorphineOpioid agonist treatment within authorized programmeRespiratory depression, sedation and interactions; methadone QT risk. Supervised individualized dosing.
NaltrexoneRelapse prevention for selected alcohol/opioid patients after opioid-free assessmentPrecipitates withdrawal if opioids present; liver caution; blocks opioid analgesia.
AcamprosateAlcohol abstinence support where availableRenal contraindication/dose adjustment; diarrhoea; adherence burden.
ThiaminePrevention/treatment of Wernicke encephalopathy in alcohol dependence/malnutritionRoute/dose follow protocol; give parenterally when high risk or absorption unreliable.

Harm reduction and prevention

  • Overdose education, take-home naloxone where available, avoid using alone or mixing opioids with alcohol/sedatives.
  • Sterile injecting equipment and safe disposal, HIV/hepatitis testing and treatment, vaccination where indicated, wound care and contraception.
  • After abstinence tolerance falls; previous dose may cause fatal overdose. Create a relapse/overdose safety plan.
  • Safe medicine storage, school/community prevention and screening in routine care.

Nursing care plan

No.InterventionRationale/outcome
1Monitor airway, RR, SpO₂, consciousness, vitals, glucose and withdrawal trend.Detects overdose, delirium, seizure and treatment response.
2Maintain hydration/nutrition, falls/aspiration/seizure precautions and calm environment.Prevents common withdrawal and intoxication complications.
3Administer protocol medicines; monitor sedation, interactions and recurrence.Ensures safe detoxification and overdose reversal.
4Use respectful language, assess readiness and create individualized discharge plan.Improves engagement and continuity rather than shame-driven dropout.

Revision questions

  1. Differentiate intoxication, tolerance, dependence and withdrawal.
  2. Outline management of opioid overdose and severe alcohol withdrawal.
  3. Explain four harm-reduction interventions.

References

  • WHO. mhGAP Guideline, 2023.
  • Uganda Ministry of Health. Uganda Clinical Guidelines, 2023.

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