Substance Use and Dependencies: Practice Questions & Explanations

OPIOID WITHDRAWAL is highly uncomfortable but generally NOT life-threatening (contrast with alcohol or benzodiazepine withdrawal, which CAN be life-threatening). TIMELINE for heroin withdrawal: onset 6-24 hours after last use; peak 36-72 hours; resolution 5-7 days for most symptoms (some protracted symptoms persist weeks). SIGNS AND SYMPTOMS — remember with the mnemonic 'WASHOUT': WATERY EYES AND NOSE (lacrimation, rhinorrhea); AGITATION AND ANXIETY; SWEATING AND SHIVERING; HYPERTENSION AND TACHYCARDIA; OUTRAGEOUS GI SYMPTOMS (nausea, vomiting, diarrhea, abdominal cramps); URGE TO USE; TERRIBLE MUSCLE ACHES (myalgia); PILOERECTION (gooseflesh — where the term 'cold turkey' comes from). Also: YAWNING, INSOMNIA, DILATED PUPILS (mydriasis — opposite of the pinpoint pupils seen with opioid intoxication). CLINICAL OPIATE WITHDRAWAL SCALE (COWS): standardized tool to assess withdrawal severity; scored 0-48; used to guide medication-assisted treatment. MEDICATION-ASSISTED TREATMENT (MAT) for opioid use disorder and withdrawal: METHADONE (full agonist, controlled, dispensed at clinics); BUPRENORPHINE/NALOXONE (Suboxone — partial agonist, outpatient prescription, reduces misuse potential); CLONIDINE (alpha-2 agonist, helps with autonomic symptoms but not a controlled substance; used for comfort); LOPERAMIDE for diarrhea; NSAIDS for muscle pain; ANTI-NAUSEA medications.

Nursing care: vital signs monitoring (BP, HR — elevated in withdrawal); administer medications as ordered; comfort measures; non-judgmental attitude; harm reduction counseling; connect to MAT program for long-term management; do not abandon client due to substance use disorder — it is a medical condition.

ALCOHOL POISONING (severe acute alcohol intoxication) is a medical emergency. A blood alcohol level of 0.40% with unconsciousness and respiratory rate of 8 breaths/min indicates LIFE-THREATENING CNS and RESPIRATORY DEPRESSION. Blood alcohol reference points: 0.02-0.05% — mild euphoria, relaxation; 0.05-0.10% — impaired judgment, coordination; 0.10-0.20% — obvious intoxication, slurred speech, unsteady gait; 0.20-0.30% — marked impairment, possible blackout, vomiting with risk of aspiration; 0.30-0.40% — stupor, loss of consciousness; ≥0.40% — potentially FATAL — respiratory depression, coma, death. MANAGEMENT of severe intoxication: ensure AIRWAY patency (aspiration risk if vomiting while unconscious); support BREATHING (supplemental oxygen, possible intubation); IV ACCESS;

Monitor: vital signs, blood alcohol level, glucose (alcohol causes hypoglycemia), electrolytes; THIAMINE (vitamin B1) before any glucose to prevent Wernicke's encephalopathy; position LATERAL RECOVERY POSITION if unconscious to reduce aspiration risk; DO NOT induce vomiting; observe for HYPOGLYCEMIA, HYPOTHERMIA (alcohol dilates vessels, increases heat loss); admit to ICU if severe. There is NO antidote for alcohol — treatment is SUPPORTIVE. NALOXONE (Narcan) reverses OPIOID overdose, NOT alcohol — a common misconception. LESSER SIGNS (options A, C, D) represent mild to moderate intoxication — concerning but not immediately life-threatening; still requires monitoring, especially for aspiration and injury.

ALCOHOL WITHDRAWAL SYNDROME is one of the FEW substance withdrawals that can be FATAL without treatment. Unlike opioid withdrawal (unpleasant but not life-threatening for most), alcohol and benzodiazepine withdrawal carry risk of life-threatening seizures and delirium.

Timeline of alcohol withdrawal: 6-24 HOURS: tremulousness, anxiety, diaphoresis, nausea, tachycardia, hypertension; 24-48 HOURS: WITHDRAWAL SEIZURES ('rum fits') — generalized tonic-clonic seizures; can occur without warning; 48-72 HOURS: DELIRIUM TREMENS (DTs) — severe confusion/delirium, hallucinations (often visual — seeing insects or animals), severe autonomic instability (hyperthermia, hypertension, tachycardia, diaphoresis), agitation; mortality rate of untreated DTs is 5-15%; treated mortality <1%.

Assessment tool: Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) — standard tool to quantify withdrawal severity and guide treatment; score 10-19 = moderate, score ≥20 = severe.

Treatment: BENZODIAZEPINES are first-line — lorazepam (Ativan), chlordiazepoxide (Librium), diazepam (Valium) per CIWA score or scheduled; THIAMINE (Vitamin B1) — must be given BEFORE glucose to prevent Wernicke's encephalopathy; IV FLUIDS — hydration; SEIZURE PRECAUTIONS; close monitoring.

Nursing actions: notify RN immediately; obtain CIWA score; vital signs frequently (Q1-4h per severity); initiate seizure precautions (padded side rails, suction at bedside, O2 available); administer ordered medications; document assessment; quiet, low-stimulation environment.

COCAINE INTOXICATION produces classic CNS STIMULANT effects because cocaine blocks the reuptake of dopamine, norepinephrine, and serotonin — flooding the reward pathway and activating the sympathetic nervous system.

Clinical presentation:

Neurological/behavioral: Euphoria (intense but brief — 15-30 minutes for intranasal; seconds to minutes for smoked 'crack'); agitation, grandiosity, talkativeness; impaired judgment; potential paranoia or psychosis with heavy use; CARDIOVASCULAR (most dangerous): Tachycardia; hypertension; cardiac dysrhythmias; coronary artery vasospasm (can cause MI even in young people with no underlying heart disease); cocaine-induced chest pain must be evaluated seriously.

Sympathomimetic: Mydriasis (dilated pupils); diaphoresis; hyperthermia; tremors; APPETITE SUPPRESSION.

Respiratory: Nasal septum damage with intranasal use; pulmonary edema with 'crack lung'; CRASH (post-intoxication): As cocaine wears off: profound fatigue, depression, hypersomnia, intense drug craving.

Nursing care: Cardiac monitoring (MI risk); vital signs; benzodiazepines for agitation, hypertension, seizures (NOT beta-blockers — unopposed alpha stimulation can worsen hypertension); cool environment for hyperthermia; watch for cocaine-associated chest pain; CONTRAST WITH OPIOID INTOXICATION (often confused on tests): Opioids produce sedation, respiratory depression, MIOSIS (pinpoint pupils) — opposite of cocaine.

BENZODIAZEPINE TOXICITY vs INTOXICATION: BENZODIAZEPINE CNS DEPRESSANT effects are dose-dependent: Therapeutic dose: anxiolysis, sedation; Toxic dose: respiratory depression, hypotension, excessive sedation → stupor → coma; RESPIRATORY DEPRESSION is the primary life threat — CNS depression suppresses the respiratory drive;

Vital sign pattern: Low RR (may be <8); shallow breaths; SpO2 declining; hypotension; bradycardia or tachycardia.

Key finding: MIOSIS (pinpoint pupils) is associated with OPIOID overdose; Benzodiazepines typically cause NORMAL to SLIGHTLY CONSTRICTED pupils.

Treatment: Supportive (airway management, oxygen, positioning); FLUMAZENIL (romazicon) is the SPECIFIC ANTIDOTE for benzodiazepine overdose; however, flumazenil use is controversial and not always recommended (can precipitate seizures in benzodiazepine-dependent patients).

Distinguish from: Opioid overdose (also respiratory depression + miosis) vs. stimulant overdose (tachycardia, hyperthermia, dilated pupils) vs. alcohol withdrawal (agitation, tremors, seizures).

Opioid withdrawal timeline: Depends on the opioid type: SHORT-ACTING (heroin, oxycodone, hydrocodone): Onset 6-24 hours; Peak 36-72 hours; Resolution 5-7 days; LONG-ACTING (methadone): Onset 36-48 hours; Peak 72-96 hours; Resolution 2-3 weeks.

Symptoms: Early: yawning, lacrimation, rhinorrhea, diaphoresis; Peak: severe myalgias, nausea, vomiting, diarrhoea, abdominal cramps, gooseflesh (piloerection), anxiety, insomnia, severe drug craving.

Medical significance: Opioid withdrawal is RARELY life-threatening in healthy adults (unlike alcohol withdrawal which can cause fatal seizures); however, dehydration from vomiting/diarrhoea can be dangerous.

Treatment: Methadone or buprenorphine (opioid agonist therapy); clonidine (autonomic symptoms); antiemetics; antidiarrhoeal; comfort measures.

An appropriate general approach is to treat the client with respect and without judgment, recognizing substance use disorder as a health condition rather than a moral failing. A non-judgmental, therapeutic attitude supports trust and engagement in care. Lecturing, refusing care, or telling the client they 'just need willpower' are stigmatizing, non-therapeutic, and can drive the client away from help. Understanding the therapeutic, non-judgmental stance toward substance use disorder is a standard psychosocial concept. (This reflects general principles; clinical management and specific interventions should be verified against current NCLEX prep materials.)

It is important for the nurse to recognize that withdrawal from certain substances can produce physical symptoms that may require medical monitoring and supervision. The general nursing principle is to observe for and report signs of withdrawal and to follow the established plan of care and provider orders, rather than ignoring symptoms or assuming withdrawal is harmless or purely psychological. The nurse works within their scope and the care team to ensure client safety during withdrawal. Understanding that withdrawal can be a medical concern requiring monitoring is a standard concept. (This is a general principle; specific clinical protocols must be verified against current NCLEX prep and provider orders.)