Substance Use Disorders Overview
A pattern of substance use leading to clinically significant impairment or distress.
Substance use disorders (SUDs) involve a problematic pattern of using a substance that causes significant impairment in functioning. Diagnosis is based on behavioral, cognitive, and physiological criteria. The DSM-5 classifies SUDs by severity (mild, moderate, severe) based on the number of criteria met.
Key Diagnostic Criteria (DSM-5)
A problematic pattern of use leading to impairment or distress, with 2 or more of the following in a 12-month period:
- Taking the substance in larger amounts or for longer than intended
- Persistent desire or unsuccessful efforts to cut down
- Spending a great deal of time obtaining, using, or recovering from the substance
- Craving — strong desire to use
- Use results in failure to fulfill obligations at work, school, or home
- Continued use despite social or interpersonal problems
- Important activities given up because of substance use
- Recurrent use in physically hazardous situations
- Continued use despite physical or psychological problems caused by substance
- Tolerance — needing more to get the same effect
- Withdrawal — substance-specific symptoms when stopping
Severity Classification
- Mild: 2-3 criteria
- Moderate: 4-5 criteria
- Severe: 6 or more criteria
Key Terms
- Tolerance
- Needing more of the substance to achieve the same effect, or diminished effect with the same dose
- Physical Dependence
- Physiological adaptation to a substance, resulting in withdrawal when discontinued
- Psychological Dependence
- Compulsive use driven by emotional or psychological factors
- Intoxication
- Reversible substance-specific physiological and behavioral changes
- Withdrawal
- Substance-specific physical and psychological symptoms after stopping or reducing use
- Addiction
- Chronic disease of brain reward, motivation, and memory; characterized by compulsive use despite harm
- Relapse
- Return to substance use after a period of abstinence
- Recidivism
- Tendency to relapse into previous behavior, especially relapse into substance use after treatment
CAGE Screening Tool
A brief 4-question screening tool for problem drinking. Two or more "yes" answers suggest a problem and warrant further evaluation.
- C — Have you ever felt you should Cut down on your drinking?
- A — Have people Annoyed you by criticizing your drinking?
- G — Have you ever felt Guilty about your drinking?
- E — Have you ever needed a drink first thing in the morning to steady your nerves (Eye-opener)?
The nurse should approach substance use assessment with a non-judgmental, matter-of-fact tone. Avoid lectures, expressions of disapproval, or moralizing. Address the client as a person, not a label. Substance use disorders are recognized as a chronic disease, not a moral failing. A trusting nurse-client relationship is essential for honest disclosure.
Every key point in this guide fits on one free printable page. Jump to the free cheatsheet PDF →
Alcohol Use
The most commonly used and tested substance in nursing practice.
Alcohol Intoxication
- CNS depression — slurred speech, ataxia, impaired judgment
- Disinhibition — aggressive or sexual behavior, emotional lability
- Respiratory depression at high blood alcohol levels
- Stupor or coma at very high levels
- Death from respiratory failure at blood alcohol levels above 0.40-0.50
Long-Term Complications of Chronic Alcohol Use
- Neurological
- Wernicke encephalopathy, Korsakoff syndrome, peripheral neuropathy, alcoholic dementia
- GI
- Gastritis, esophageal varices, fatty liver, alcoholic hepatitis, cirrhosis, pancreatitis
- Cardiovascular
- Cardiomyopathy, hypertension, dysrhythmias
- Hematologic
- Anemia, thrombocytopenia, increased bleeding risk
- Nutritional
- Thiamine, folate, and other B-vitamin deficiencies
- Pregnancy
- Fetal alcohol syndrome — growth deficiency, facial abnormalities, intellectual disability
Wernicke Encephalopathy — acute neurological emergency from thiamine (B1) deficiency. Classic triad: Confusion · Ataxia (gait disturbance) · Ophthalmoplegia (eye muscle weakness, nystagmus). Korsakoff Syndrome — chronic neurological condition that often follows untreated Wernicke. Causes severe, often PERMANENT memory impairment with confabulation (making up stories to fill memory gaps). Key Nursing Action: Give thiamine IM or IV BEFORE administering any glucose-containing IV fluids. Glucose without thiamine can precipitate Wernicke encephalopathy.
Common Lab Findings in Chronic Alcohol Use
- Elevated GGT (gamma-glutamyl transferase) — one of the most sensitive markers
- AST > ALT (typically 2:1 ratio — "Scotch and Tonic" mnemonic; AST higher in aLcoholic)
- Elevated MCV (macrocytic anemia from folate deficiency)
- Elevated bilirubin
- Low albumin in advanced liver disease
- Thrombocytopenia
Alcohol Withdrawal & CIWA
Potentially life-threatening — recognize early and treat with benzodiazepines.
Timeline of Alcohol Withdrawal
- 6-12 hours
- Minor withdrawal: tremor, anxiety, nausea, insomnia, sweating, mild tachycardia, headache
- 12-24 hours
- Alcoholic hallucinosis: visual, auditory, or tactile hallucinations with intact reality testing (client knows they are not real)
- 6–48 hours
- Withdrawal seizures: generalized tonic-clonic (grand mal). Can occur 6–48 hours after the last drink, commonly 12–48 hours.
- 48-96 hours
- Delirium Tremens (DTs): severe agitation, disorientation, hallucinations, hyperthermia, severe tachycardia, hypertension, diaphoresis. 5-15% mortality without treatment.
CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised)
A standardized 10-item tool used to assess severity of alcohol withdrawal and guide treatment. Items rated on scales of 0-7 (or 0-4) for a total possible score of 67: nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, orientation/clouding of sensorium.
- CIWA 0-9Mild
- Supportive care, monitor frequently, may not require medication
- CIWA 10-19Moderate
- Benzodiazepines per protocol, frequent reassessment
- CIWA ≥20Severe
- Higher benzodiazepine doses, possible ICU monitoring, watch closely for DTs
Treatment of Alcohol Withdrawal
- Benzodiazepines — first-line treatment. Cross-tolerant with alcohol, suppress withdrawal symptoms, prevent seizures.
- Lorazepam (Ativan) — commonly used; short-acting; safer in liver disease
- Diazepam (Valium) — long-acting; smooth taper
- Chlordiazepoxide (Librium) — long-acting; commonly used
- Thiamine 100 mg IM/IV — given BEFORE glucose to prevent Wernicke
- Folate, multivitamins — correct nutritional deficiencies
- IV fluids — correct dehydration and electrolyte imbalances
- Magnesium — often low in alcohol withdrawal; helps prevent seizures
- Quiet, low-stimulation environment
- Reorient frequently — calendar, clock, frequent verbal cues
- Frequent vital signs — every 1-4 hours depending on severity
- Seizure precautions
- Fall precautions — tremor and ataxia increase fall risk
Unlike opioid withdrawal (which is uncomfortable but rarely deadly), alcohol withdrawal can be life-threatening. Untreated delirium tremens has a 5-15% mortality rate. Clients with a history of heavy daily drinking, prior DTs, or prior withdrawal seizures are at highest risk. Never abruptly discontinue alcohol in a hospitalized chronic user without a withdrawal management plan.
? A chronic alcohol user is admitted after a minor fall. He is alert and oriented. Why should the nurse monitor for alcohol withdrawal even though he shows no symptoms now?
Opioids
High-priority content given the opioid crisis — intoxication is dangerous, withdrawal is uncomfortable but not deadly.
Common Opioids
- Prescription: oxycodone, hydrocodone, morphine, fentanyl, methadone, hydromorphone
- Illicit: heroin, illicitly-manufactured fentanyl
- Mixed: Tramadol (also has serotonergic activity — risk of serotonin syndrome)
Opioid Intoxication vs Withdrawal
- Pupils
- Intoxication: Constricted (pinpoint, miosis). Withdrawal: Dilated (mydriasis).
- Respirations
- Intoxication: Depressed (slow, shallow). Withdrawal: Increased.
- Mental Status
- Intoxication: Sedated, drowsy, "nodding." Withdrawal: Anxious, restless.
- GI
- Intoxication: Constipation. Withdrawal: Nausea, vomiting, diarrhea, abdominal cramps.
- Skin
- Intoxication: Warm, dry. Withdrawal: Cool, sweating, piloerection (goosebumps).
- Risk
- Intoxication: Respiratory arrest, death. Withdrawal: Uncomfortable but rarely life-threatening.
1. Pinpoint pupils (miosis). 2. Respiratory depression (slow, shallow breathing or apnea). 3. Decreased level of consciousness (sedation to coma). This is a medical emergency. Without intervention, the client can die from respiratory failure.
Treatment of Opioid Overdose — Naloxone (Narcan)
- Naloxone is the antidote for opioid overdose
- Pure opioid antagonist — rapidly reverses respiratory depression, sedation, and miosis
- Routes: IM, IV, or intranasal spray
- Duration: Short-acting (30-90 minutes). Many opioids last longer — client must be monitored for re-sedation.
- Can be repeated every 2-3 minutes if needed
- Precipitates acute withdrawal in opioid-dependent clients — this is expected and acceptable; saving the airway is the priority
- Now widely available in the community for laypeople to use during suspected overdose
Opioid Withdrawal Management
- Supportive care — hydration, antiemetics, antidiarrheals, NSAIDs for muscle aches
- Clonidine — reduces autonomic symptoms (sweating, anxiety, tachycardia)
- Methadone — long-acting full opioid agonist; suppresses withdrawal and craving
- Buprenorphine — partial opioid agonist; suppresses withdrawal with lower overdose risk; ceiling effect on respiratory depression
- Buprenorphine-naloxone (Suboxone) — combination that discourages injection
- Naltrexone — opioid antagonist; used for relapse prevention after detox (not during active use — precipitates withdrawal)
The Clinical Opioid Withdrawal Scale (COWS) is used to assess severity of opioid withdrawal. It evaluates 11 items (resting pulse rate, sweating, restlessness, pupil size, bone/joint aches, runny nose/tearing, GI upset, tremor, yawning, anxiety, gooseflesh). Higher scores indicate more severe withdrawal and guide medication dosing.
Stimulants
Cocaine, methamphetamine, amphetamines, MDMA — intoxication is dangerous; withdrawal is psychological.
Common Stimulants
- Cocaine — powder (insufflated/snorted) or crack (smoked)
- Methamphetamine — smoked, injected, or insufflated
- Amphetamines — prescription stimulants (Adderall) misused
- MDMA (ecstasy) — stimulant and entactogen with serotonergic effects
- Nicotine and caffeine — legal stimulants
Stimulant Intoxication
- Dilated pupils (mydriasis)
- Tachycardia, hypertension
- Hyperthermia — severe with methamphetamine and MDMA
- Diaphoresis
- Euphoria, increased energy, talkativeness
- Decreased appetite, insomnia
- Anxiety, agitation, paranoia
- Psychosis — especially with methamphetamine; hallucinations, paranoid delusions
- Tactile hallucinations (formication — bugs crawling on skin)
- Seizures at high doses
- Cardiac complications — MI, dysrhythmias, stroke (cocaine especially)
- Rhabdomyolysis — from hyperthermia and muscle activity
Stimulant Withdrawal ("The Crash")
- Dysphoria — intense depression
- Fatigue, hypersomnia
- Increased appetite
- Vivid, unpleasant dreams
- Psychomotor retardation or agitation
- Intense craving
- Suicidal ideation — common, especially during the crash phase
Unlike alcohol or opioids, stimulant withdrawal is not physically dangerous. However, the severe dysphoria and crashed mood can lead to acute suicidal ideation. The nurse should assess suicide risk regularly during stimulant withdrawal, even though the client is not at risk from physical withdrawal symptoms.
Treatment
- Supportive care for intoxication — cooling, hydration, benzodiazepines for agitation
- Antipsychotics for stimulant-induced psychosis
- No FDA-approved medications specifically for stimulant use disorder
- Behavioral interventions — CBT, contingency management, motivational interviewing
- Monitor for suicide risk during withdrawal
Sedatives, Hypnotics, & Hallucinogens
Benzodiazepines, barbiturates, GHB, and hallucinogens like LSD and PCP.
Sedative-Hypnotic Use (Benzodiazepines, Barbiturates)
- Intoxication
- Slurred speech, ataxia, sedation, impaired memory, respiratory depression. Can cause respiratory failure (especially combined with alcohol or opioids).
- Withdrawal
- Anxiety, tremor, insomnia, tachycardia, hypertension, seizures, delirium. SIMILAR TO ALCOHOL WITHDRAWAL — can be LIFE-THREATENING.
- Treatment
- Intoxication: supportive; flumazenil for benzodiazepine overdose (caution: can precipitate seizures). Withdrawal: long taper. Never stop abruptly. Substitute long-acting benzodiazepine and slowly reduce.
Like alcohol, benzodiazepine withdrawal can cause seizures and death. Clients on long-term benzodiazepines should NEVER stop abruptly. A gradual taper over weeks to months is required. This is an important assessment for any hospitalized client — ask about benzodiazepine use to prevent unexpected withdrawal.
Hallucinogens (LSD, PCP, Psilocybin, Ketamine)
- LSD (Lysergic acid diethylamide) — visual hallucinations, distortion of time and space, synesthesia (mixing of senses)
- PCP (Phencyclidine, "angel dust") — dissociation, violent behavior, increased pain tolerance, nystagmus (key sign), can cause severe agitation requiring restraints
- Psilocybin — mushrooms; similar to LSD but shorter duration
- Ketamine — dissociative; medical use as anesthetic and antidepressant
"Bad Trip" Nursing Care
- Calm, quiet, low-stimulation environment
- Talk down — remain calm, reassuring, orient to reality
- Stay with the client
- Benzodiazepines for severe anxiety or agitation
- Antipsychotics may be needed for severe agitation, especially with PCP
- Watch for self-injury — client may not feel pain (especially with PCP) and may injure self
Cannabis
- Most commonly used illicit substance in the U.S. (legal in many states)
- Intoxication: euphoria, relaxation, slowed reflexes, conjunctival injection (red eyes), increased appetite, dry mouth, tachycardia, impaired memory
- Withdrawal: irritability, anxiety, insomnia, decreased appetite, restlessness (mild)
- Risks: psychosis in vulnerable individuals (especially heavy use in adolescence), respiratory effects when smoked, cannabinoid hyperemesis syndrome with chronic heavy use
Antidotes Quick Reference
Memorize these — commonly tested on the NCLEX-PN.
- Opioidsheroin, morphine, fentanyl
- Naloxone (Narcan) — IM, IV, or intranasal. Short-acting — monitor for re-sedation. Precipitates withdrawal in dependent clients.
- Benzodiazepines
- Flumazenil (Romazicon) — IV only. Can precipitate seizures in dependent clients. Use cautiously.
- Acetaminophen (Tylenol)
- N-acetylcysteine (Mucomyst) — most effective if given within 8-10 hours of overdose. Replenishes glutathione. PO has a rotten egg smell.
- Warfarin
- Vitamin K (phytonadione) — for elevated INR or bleeding. Fresh frozen plasma (FFP) for severe bleeding.
- Heparin
- Protamine sulfate — 1 mg neutralizes 100 units of heparin.
- Digoxin
- Digoxin immune Fab (Digibind) — for severe toxicity (level > 2 ng/mL with symptoms, or potassium > 5).
- Iron
- Deferoxamine — chelates iron. Urine may turn reddish ("vin rosé" color).
- Lead
- Dimercaprol (BAL) or EDTA — for lead poisoning. Common in older homes (lead paint, pipes).
- Magnesium sulfate
- Calcium gluconate — for mag toxicity (RR < 12, hyporeflexia). Keep at bedside during mag infusion.
- Methanol/Ethylene glycol
- Fomepizole or ethanol — antifreeze (ethylene glycol) and wood alcohol (methanol) poisoning.
- Anticholinergic toxicity
- Physostigmine — for severe anticholinergic toxicity ("red as a beet, dry as a bone, blind as a bat, mad as a hatter, hot as a hare").
- Organophosphate poisoning
- Atropine + Pralidoxime — pesticides. SLUDGE (salivation, lacrimation, urination, defecation, GI upset, emesis).
The most frequently tested antidotes on the NCLEX-PN are: Naloxone (opioids), Flumazenil (benzodiazepines), N-acetylcysteine (acetaminophen), Vitamin K (warfarin), Protamine sulfate (heparin), and Calcium gluconate (magnesium toxicity). If you know these six well, you'll handle most antidote questions.
Treatment & Recovery Support
Medications and behavioral approaches for long-term recovery.
Medications for Alcohol Use Disorder
- Disulfiram (Antabuse)
- Blocks alcohol metabolism — causes severe reaction (nausea, vomiting, flushing, palpitations) if alcohol is consumed. Client must AVOID all alcohol, including in mouthwash, cough syrup, hand sanitizer, cooking wine, vinegar. Reaction can occur up to 2 weeks after last dose.
- Naltrexone
- Opioid antagonist — reduces craving and pleasurable effects of alcohol. Oral daily or monthly IM (Vivitrol). Do NOT use in clients currently using opioids — will precipitate withdrawal.
- Acamprosate (Campral)
- Reduces protracted withdrawal symptoms (anxiety, insomnia, dysphoria). Started after detoxification is complete. Renal dosing required.
Medications for Opioid Use Disorder
- Methadone
- Long-acting full opioid agonist. Dispensed only at federally licensed clinics. Reduces craving and withdrawal. Daily observed dosing.
- Buprenorphine (Subutex)
- Partial opioid agonist. Can be prescribed in office settings. Lower overdose risk due to ceiling effect on respiratory depression.
- Buprenorphine-naloxone (Suboxone)
- Combination — naloxone is inactive PO but causes withdrawal if injected. Discourages diversion and injection.
- Naltrexone (Vivitrol)
- Opioid antagonist — blocks effects. Used after detoxification. Monthly IM. Client must be OPIOID-FREE for 7-10 days before starting or will precipitate severe withdrawal.
Behavioral and Support Approaches
- 12-Step Programs — AA (Alcoholics Anonymous), NA (Narcotics Anonymous), CA (Cocaine Anonymous). Free, peer-based, available worldwide.
- SMART Recovery — alternative to 12-step using cognitive-behavioral approaches
- Cognitive Behavioral Therapy (CBT) — identifying triggers and developing coping strategies
- Motivational Interviewing — client-centered approach to building motivation for change
- Contingency Management — rewards for negative drug screens or attendance
- Inpatient and Outpatient Rehabilitation
- Therapeutic Community — long-term residential treatment
- Halfway Houses and Sober Living — transitional housing after primary treatment
Stages of Change (Prochaska & DiClemente)
Substance use disorder is a chronic disease, much like diabetes or hypertension. Relapse is common and does not mean treatment has failed. The nurse should respond with compassion, identify what triggered the relapse, and help the client re-engage in treatment. Shame and punishment increase relapse risk; support and continued engagement reduce it.
Nursing Approach to Recovery
- Non-judgmental, empathetic approach throughout
- Use person-first language (e.g., "person with substance use disorder" not "addict" or "abuser")
- Assess motivation for change and meet the client where they are
- Provide education about the disease, treatment options, and recovery resources
- Build trust — many clients have experienced stigma from healthcare providers
- Support family — Al-Anon and Nar-Anon for family members of those affected
- Address co-occurring mental health conditions — depression, anxiety, PTSD are common
- Connect to community resources at discharge
Frequently Asked Questions
Common student questions on this topic.
What is the CIWA scale and how is it used?
What are the signs of alcohol withdrawal and DTs?
What is the antidote for opioid overdose and how does it work?
Why is thiamine given before glucose in chronic alcoholics?
What is the difference between tolerance, dependence, and addiction?
What are the key features of Korsakoff syndrome?
Quick-Reference Cheatsheet
Every key point from this guide on a single printable page.
Substance Use Disorders Cheatsheet
One-page PDF — free download.