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
| Group | Intoxication | Withdrawal/dangers |
|---|
| Alcohol | Disinhibition, slurred speech, ataxia, reduced consciousness | Tremor, sweating, anxiety, seizures, hallucinations, delirium tremens |
| Opioids | Euphoria/sedation, pinpoint pupils, respiratory depression | Yawning, rhinorrhoea, pain, vomiting/diarrhoea; relapse overdose risk |
| Cannabis | Altered perception, red eyes, impaired coordination; anxiety/paranoia | Irritability, poor sleep, reduced appetite |
| Stimulants | Agitation, dilated pupils, sweating, tachycardia, hypertension, psychosis | Fatigue, low mood, craving; suicide risk |
| Sedatives | Drowsiness, ataxia, respiratory depression | Anxiety, insomnia, seizures/delirium—abrupt cessation can be fatal |
| Hallucinogens/inhalants | Perceptual disturbance; inhalants may cause arrhythmia/hypoxia | Variable; persistent psychosis or organ toxicity possible |
Assessment
- ABCDE first for reduced consciousness, respiratory depression, seizure, severe agitation, chest pain or hyperthermia; check glucose and trauma.
- Ask substance, local name, quantity, frequency, route, last use, mixing, tolerance, withdrawal, overdose, injecting and previous treatment.
- Assess impact on health, HIV/hepatitis/TB risk, pregnancy, relationships, violence, work/education, finances and law.
- Screen depression, psychosis, suicide/self-harm, cognition and safeguarding; determine readiness to change.
- 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
| Medicine | Indication | Safety and monitoring |
|---|
| Methadone/buprenorphine | Opioid agonist treatment within authorized programme | Respiratory depression, sedation and interactions; methadone QT risk. Supervised individualized dosing. |
| Naltrexone | Relapse prevention for selected alcohol/opioid patients after opioid-free assessment | Precipitates withdrawal if opioids present; liver caution; blocks opioid analgesia. |
| Acamprosate | Alcohol abstinence support where available | Renal contraindication/dose adjustment; diarrhoea; adherence burden. |
| Thiamine | Prevention/treatment of Wernicke encephalopathy in alcohol dependence/malnutrition | Route/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. | Intervention | Rationale/outcome |
|---|
| 1 | Monitor airway, RR, SpO₂, consciousness, vitals, glucose and withdrawal trend. | Detects overdose, delirium, seizure and treatment response. |
| 2 | Maintain hydration/nutrition, falls/aspiration/seizure precautions and calm environment. | Prevents common withdrawal and intoxication complications. |
| 3 | Administer protocol medicines; monitor sedation, interactions and recurrence. | Ensures safe detoxification and overdose reversal. |
| 4 | Use respectful language, assess readiness and create individualized discharge plan. | Improves engagement and continuity rather than shame-driven dropout. |
Revision questions
- Differentiate intoxication, tolerance, dependence and withdrawal.
- Outline management of opioid overdose and severe alcohol withdrawal.
- Explain four harm-reduction interventions.
References
- WHO. mhGAP Guideline, 2023.
- Uganda Ministry of Health. Uganda Clinical Guidelines, 2023.
