Running head: SUBSTANCE ABUSE DISORDERS 1

Substance Abuse Disorders:

Opiates

Joylynne Burgess, Carla Coc, Phelan Coy, Giovanni Garcia,

Briea Gentle, Lizzet Novelo, Bonaventure Nwangwu,

Corine Salam, Timmy Teul & Desiree Wiltshire

University of Belize

Promoting Mental Wellness

NURS 4152

Mrs. Leolin Castillo

March 13, 2017

 SUBSTANCE ABUSE DISORDERS 2

Table of Contents

Introduction --------------------------------------------------------------------------------- 3

Definition of terms -------------------------------------------------------------------------- 5

Etiology -------------------------------------------------------------------------------------- 6

Mechanism of action ------------------------------------------------------------------------ 7

Clinical manifestations -------------------------------------------------------------------- 8

Diagnostic tests ----------------------------------------------------------------------------- 9

Treatment modalities ------------------------------------------------------------------------ 11

Nursing management ------------------------------------------------------------------------ 14

Scenario -------------------------------------------------------------------------------------- 17

Nursing care plan --------------------------------------------------------------------------- 18

Conclusion ---------------------------------------------------------------------------------- 21

References ---------------------------------------------------------------------------------- 22
 SUBSTANCE ABUSE DISORDERS 3

Introduction

Opiates are used as pain killers and cover a huge variety of drugs, ranging from legal

drugs such as fentanyl, codeine, and morphine to illegal drugs such as heroin and opium. The

concept of "opiates" encompasses drugs naturally derived from the active narcotic components

of the opium poppy. Whereas the "opioid" label includes synthetic and semi-synthetic drugs that

are modified versions of these opiate building blocks (Patterson, 2016). The two terms can be

used interchangeably. Opiates have long been used for medicinal and recreational purposes. The

word “opium” comes from the Greek word opos meaning juice.

When the poppy plant reaches maturity the seeds are cut and bled for their opium gum

which leaks from the plant. Opiates suppress the central nervous system, creating pain relief and

a euphoric feeling. There are three types of opiates: natural opiates, synthetic opiates and semi-

synthetic opiates. Natural opiates are extracted from the poppy plant and include opium,

morphine and codeine. Opium is commonly used as a recreational drug for smoking and often

combined with other drugs of abuse like marijuana and methamphetamine.

Synthetic opiates are man-made opiates made in laboratories with similar chemical

structures to the milk extracted from the poppy plant. These drugs are widely used and cause the

same basic effects that natural opiates cause. They include: fentanyl, pethidine, and

dextropropoxyphene. Semi-synthetic opiates are only half-natural, these drugs are a combination

of natural opiates from the milk of the poppy plant and synthetics which are made in

laboratories. These include Oxycodone, Oxymorphone, Hydrocodone, Heroin and

Buprenorphine. Many of the mostly prescribed narcotics are semi-synthetic opiates.

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Opiates can be abused through different routes. These include intravenous, nasal,

intramuscular, oral, and dermal. However, each route has a specific onset of action. The onset of

action is as follows: intravenously takes ten minutes, intramuscular takes ten to fifteen minutes,

oral takes thirty to forty-five, orally takes ninety minutes or hour and a half, and dermal takes

two to four hours. There are a variety of disorders resulting from opiate use and abuse. Some of

these include: opioid use disorder, opioid intoxication, opioid withdrawal, unspecified opioid-

related disorder, and other opioid induced disorder. This paper will focus on opioid intoxication

and withdrawal.
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Definition of Terms

Opiates - drugs derived from the opium poppy; used as pain killers and sometimes abused as

they produce euphoria.

Opium poppy - a Eurasian poppy plant with ornamental white, red, pink, or purple flowers. Its

seed yield a gum from which opium is obtained.

Opioid intoxication - occurs when a person takes too much of an opioid drug.

Opioid addiction - a medical condition that is characterized by the compulsive use of opioids

despite adverse consequences.

Physical dependence - reliance on the drug to prevent withdrawal symptoms.

Opioid withdrawal - refers to the wide range of symptoms that occur after stopping or

dramatically reducing opiate drugs after heavy and prolonged use.

Drug tolerance - over time, more of the drug is needed for the same effect.

Agitation - an unpleasant state of extreme arousal. Person may feel stirred up, excited, tense,

confused, or irritable. This feeling lasts for a few minutes, weeks or even months.

Insomnia - the inability to obtain sufficient sleep, difficulty in falling or staying asleep.

Mydriasis – abnormal dilation of the pupils resulting from drug abuse.

Detoxification - the process of removing toxic substances from the body.

Methadone (Dolophine) - is a medication use to relieve withdrawal symptoms and helps with

detox. It is also used as a long-term maintenance medicine for opioid dependence.

Clonidine (Catapres) - is used to help reduce anxiety, agitation, muscle aches, sweating, runny

nose, and cramping. It does not help reduce cravings.

Naloxone (Narcan) - a medication designed to rapidly reverse opioid overdose.

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Etiology

Opioid intoxication or opioid overdose can occur from both a therapeutic use or from

opioid abuse by drug-dependent person. Intoxication can occur from therapeutic use when

doctors make errors in prescribing a high dose to a client and the nurse fails to recognize that the

dose is too high. On the other hand, when a drug-dependent person over use the drug or mix the

drug with other illicit drug it can result in an overdose. In both cases the overdose may result in a

severe respiratory depression which can lead to coma. These drugs usually require a prescription

however many people sell the drug illegally. The most common opioids drugs that are abused are

heroin and methadone.

The body becomes desensitized to the effects of opiate medication when they are taken

for a long time. Over time the body needs more and more of the drug to achieve the same effect.

This can be very dangerous and increases risk of accidental overdose. Prolonged use of these

drugs changes the way nerve receptors work in the brain, and these receptors become dependent

upon the drug to function. When an individual stops taking these opiate medications, they start to

experience withdrawal symptoms, which are the body’s physical response to the absence of the

drug. Many people don’t realize that they have become dependent and often mistake withdrawal

for symptoms of the flu or another condition.

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Mechanism of Action

The body produces its own natural opiates such as endorphins, enkephalins, and

dynorphins. They are formed in the brain, in small quantities and for short periods of time to

help an individual deal with pain. Whenever individuals use opioid drugs, it travels to the brain

through the bloodstream. Once in the brain, opioids target receptors that are densely located in

the limbic system where it is capable of binding to the mu receptors as it mimics the structure of

the naturally occurring opiates produced by the body.

Opiates have both excitatory and inhibitory effects. Opiates reduce the capacity of

adenylate cyclase to produce cAMP closing Ca2+ channels that inhibits the signal to release

norepinephrine or open K+ channels to hyperpolarize cells increasing release of dopamine

(Stolbach & Hoffman, 2017). An increase in dopamine elicits the euphoric feeling and slower

respiration. Whenever opiate use is discontinued, it no longer has its inhibitory effects.

The neurons are able to work efficiently but with enhanced supply of the converting

enzyme that converts adenosine triphosphate (ATP) into cAMP. This causes abnormal high

levels of cAMP to be produced which in turn triggers an increase of norepinephrine. The

increased norepinephrine causes the patient to experience withdrawal symptoms such as muscle

cramps, anxiety, and jittery.

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Clinical Manifestations

Opioid intoxication

 Euphoria- when taking opiates, it give the person a perception of high energy or intense

pleasure but won’t last very long, which is then followed by a few hours of relaxed or

depressed mental state.

 Depressed respiration –opiates affect the respiratory system by depressing actions on the

brain stem that regulates breathing which decrease the frequency and depth of breathing.

When overdosed the person can stop breathing.

 Constipation- opioids can slow or stop peristalsis by sending messages along the nerves

inside the intestine and spine which can cause a decrease in bowel movements.

 Itching- when taking opiates it can release histamines which make most people itchy and

even have flushed skin.

Opioid Withdrawal

 Diaphoresis

 Akathisia

 Anxiety

 Hyperthermia
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Diagnostic Tests

1. Your health care provider will perform a physical exam and inquire about your medical

history and drug use.

2. Urine screening or toxicology to screen for drugs can confirm opiate use.

Diagnostic Test for Opioid Intoxication

DSM 5 criteria:

A. Recent use of an opioid.

B. Clinically significant problematic behavioral or psychological changes (e.g., initial euphoria

followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment) that

developed during, or shortly after, opioid use.

C. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or

more) of the following signs or symptoms developing during, or shortly after, opioid use:

1. Drowsiness or coma.

2. Slurred speech.

3. Impairment in attention or memory.

D. The signs or symptoms are not attributable to another medical condition and are not better

explained by another mental disorder, including intoxication with another substance.

Diagnostic test for Opioid Withdrawal

DSM 5 criteria:

A. Either of the following:

1. Cessation or reduction in opioid use that has been heavy and prolonged (several weeks or

longer).

2. Administration of an opioid antagonist after a period of opioid use.

SUBSTANCE ABUSE DISORDERS 10

B. Three or more of the following, developing within minutes to several days after criterion A

1. Dysphoric mood

2. Nausea or vomiting

3. Muscle aches

4. Lacrimation or rhinorrhea

5. Pupillary dilation, piloerection, or sweating

6. Diarrhea

7. Yawning

8. Fever

9. Insomnia

C. The symptoms in Criterion B cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by

another mental disorder.

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Treatment Modalities

Death following opioid intoxication can be prevented if the person receives basic life

support as well as the timely administration of the opioid antidote naloxone. Naloxone (Narcan)

is an effective antidote used to reverse the effects of opioid intoxication such as respiratory

depression and slow heartbeat. The duration of effect of naloxone is 30 to 90 minutes, hence it is

important to observe the patient throughout this period for re-sedation. Patients who have taken

longer-acting opioids may require further intravenous bolus doses or an infusion of naloxone.

There are several treatment modalities identified for opiate withdrawal, detoxification

being the primary treatment. However, detoxification alone, without ongoing treatment, is not

adequate to manage patients. Patients in methadone programs have more benefits when cognitive

behavioral therapy, or supportive, are added to standard drug counseling. So the four main

treatment modalities identified are detoxification, cognitive behavioral therapy, support group

therapy and maintenance therapy.

Detoxification

Methadone, buprenorphine, and alpha-2 agonists (clonidine and lofexidine), are

commonly used pharmacologic methods of detoxification. The use of methadone and

buprenorphine is based on the principle of cross-tolerance in which one opioid is replaced with

another and then slowly withdrawn. Alpha-2 agonists appear to be most effective in suppressing

autonomically mediated signs and symptoms of abstinence, but they are less effective for

subjective symptoms.
SUBSTANCE ABUSE DISORDERS 12

Patients using Methadone and Buprenorphine have experienced decreased side effects.

They also stayed in treatment longer using tapered methadone compared to the alpha-2 agonists

(clonidine or lofexidine) and they are more effective for opioid detoxification. Buprenorphine

also have been associated with a shorter duration of withdrawal symptoms.

Cognitive Behavioral Therapy

CBT for opioid withdrawal focuses on the patient's thoughts and behaviors. The

techniques taught in CBT help patients acquire specific skills for resisting substance use and

teach coping skills to reduce problems related to drug use. Two major cognitive behavior

theories are used: relapse prevention and cognitive therapy. Relapse prevention compromises of

prevention concepts and techniques include identification and avoidance of high-risk situations,

understanding the chain of decisions leading to drug use, and changing one's lifestyle. Cognitive

therapy is based on the concept that drug abusers engage in complex behaviors and thought

processes, such as positive and negative drug-related beliefs and spontaneous flashes related to

drug use before giving in to the actual drug use.

Support Group Therapy

Targets the social stigma attached to having lost the ability to control one's self with

regard to the use of a substance. The presence of other group members who acknowledge having

similar problems can provide support. Likewise, help in developing alternative methods of

maintaining abstinence.
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Maintenance Therapy

Patients with opioid addiction and withdrawal will continue to take maintenance therapy

to prevent a relapse. A form of buprenorphine is now available as an implant under the skin for

preventing relapse of opioid dependence. It provides a constant dose of buprenorphine for six

months. It is mostly used by people who have completed acute detoxification and already

maintained on a stable dose of oral buprenorphine.

Medications which were previously mentioned in detoxification such as methadone or

naloxone are medications sometimes taken for many years to minimize relapse risk. Methadone

blocks opiate receptors and prevents opiates from causing a high. Along with medical therapy it

is recommended that all patients continue some other form of therapy.

SUBSTANCE ABUSE DISORDERS 14

Nursing Management

Motivational Approaches

According to Stuart & Taylor (2013), motivational counseling is based on the idea that

motivation for change is not static but dynamic. The clinician can influence change by

developing a therapeutic relationship that respects and builds on the patient’s own intrinsic

motivation for change. Five basic principles used in this approach have been identified. These

include: expressing empathy through reflective thinking, developing discrepancy between

patients’ goals or values and their current behavior, avoiding argument and direct confrontation,

rolling with resistance and supporting self-efficacy.

Managing Withdrawal Symptoms

Physical dependence upon opiates results in withdrawal symptoms if it is abruptly

stopped or significantly reduced (Clinical Guidelines for Withdrawal Management and Drug

Dependence, n.d.). Considering this, withdrawal symptoms are the body’s physical response to

the absence of the drug. The symptoms that the patient experience will depend on the level of

withdrawal experienced.

Nurses and health care providers should be available 24 hours a day with the patient.

Patients in withdrawal may be feeling anxious or scared. Nurses should provide accurate and

realistic information about the drug and withdrawal symptoms to help alleviate anxiety and fears.

Some symptoms of short opioid withdrawal include perspiration, diarrhea, nausea and vomiting.

Nurses should encourage patients with mild opioid withdrawal symptoms to consume at least 2-3

liters of water per day to replace fluids lost through perspiration, diarrhea and vomiting.
SUBSTANCE ABUSE DISORDERS 15

Managing Side and Adverse Effects of Treatment Medications

Clonidine is an opioid medication used to provide relief to many of the physical

symptoms of opioid withdrawal. It can also cause drowsiness, dizziness and hypotension. Nurses

should monitor the patient’s blood pressure and heart rate before administering clonidine.

Clonidine should also be stopped if blood pressure drops below 90/50mm hg.

Clinical Guidelines for Withdrawal Management and Drug Dependence (n.d.) stated that

buprenorphine is the best opioid medication for management of moderate to severe opioid

withdrawal. It alleviates withdrawal symptoms and reduces cravings. Buprenorphine should be

used with caution in patients with respiratory deficiency, urethral obstruction and diabetes. The

dose of buprenorphine given must be reviewed by the nurse daily and adjusted based on the

symptoms and the presence of side effects.

Counseling/Therapy (individual, family and group)

Patients should also be engaged in psychosocial interventions such as counseling and

therapy. The purpose is to find the root of the addiction. Depending on the underlying cause of

the addiction discovered, the counselor develops an individual treatment plan for each patient.

Group therapy can also be used to bring patients together on a regular basis to discuss any drug

use and efforts towards maintaining abstinence.

According to McMacken (2016), counseling for the family and partners of patients being

treated for substance abuse can be very useful under the proper circumstances. A spouse or

partner can provide key support to help the patient achieve or maintain abstinence. Counseling

can aid in relapse prevention and in facilitating adherence to treatment.

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Facilitating Access to Social, Medical, Mental Health and Other Needed Services

It is important for the nurse to know local resources for treatment of substance abusers.

This is because substance abusers often come into contact with the health care system because of

a physiological crisis. It may be related to overdose, withdrawal, allergy or toxicity. The nurse

may notice physical deterioration caused by the damaging effects of opiates including conditions

such as malnutrition, dehydration and infections e.g., HIV. The nurse should facilitate patients’

access to other facilities as needed.

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Scenario

MJ is a 26 year old heroin addict. He comes to the emergency department dressed with a

long sleeved-shirt and long pants with the following symptoms. He has a runny nose, stomach

cramps, dilated pupils, muscle spasms, chills despite the warm weather, elevated heart rate and

blood pressure, and a temperature of 100.9 ̊ F. Aside from these symptoms, there is redness and

scarring from needles at the antecubital area.. He has no other adverse medical problem.

At first he is polite and even charming to you and the staff. He’s hoping you can just give

him some “meds” to tide him over until he can see his regular doctor. However, he becomes

angry and threatening to you and the staff when you tell him you may not be able to comply with

his wishes. He complains about the poor service he’s been given because he’s an addict.

He wants a bed and “meds” and if you don’t provide one for him you are forcing him

to go. He says that is possible he’ll go out and steal and possibly hurt someone or, he will

probably just kill himself “because he can’t go on any more in his present misery.” He also tells

you that he is truly ready to give up his addiction and turn his life around if he’s just given a

chance, some medication, and a bed for tonight.

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Nursing Care Plan

Assessment Diagnosis Plan Implementation Rationale Evaluation

Subjective data: Hyperthermia r/t By the end of the Evaporative cooling: To help with the At the end of the 8

He’ll go out and opiate 8 hour shift the cool with a tepid bath. cooling of the body. hour shift the

steal and possibly withdrawal AEB patient will patient was able to

hurt someone or he temperature of maintain body Eliminate excess Exposing skin to room maintain a

will probably just 100.9 ̊ F. temperature clothing and covers. air decreases warmth temperature of

kill himself within normal and increases 98.1 ̊ F.

“because he range. evaporative cooling.

can’t go on any

more in his present Encourage ample fluid Replaces fluids loss by

misery.” intake by mouth. diaphoresis.

Administer methadone To combat the

as prescribed by symptoms of

physician. withdrawal.
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Objective data: Impaired skin Patient will Monitor site of Systematic inspection Patient understood

Runny nose, integrity r/t demonstrate impaired tissue integrity can identify impending plan and exhibited

stomach cramps, chemical understanding of at least once daily for problems early. and improvement

dilated pupils, irritants and plan to heal tissue color changes, redness, in tissue integrity.

muscle spasms, recurrent trauma and prevent swelling, warmth, pain,

chills, elevated heart AEB redness injury. or other signs of

rate and blood and scarring. infection.

pressure, and a

temperature of Provide tissue care as Each type of wound is

100.9 ̊ F. Redness needed. best treated based on its

and scarring from etiology. Skin wounds

needles on may be covered with

antecubital area. wet or dry dressings

Instruct patient to avoid To avoid further injury

rubbing and scratching, and foster healing.

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Risk for suicide Patient will Monitor patient on a To protect and preserve Patient had no

r/t substance refrain from one to one basis during the client’s life. suicidal attempt

abuse attempting suicide observation. during

suicide. hospitalization.

Follow unit protocol for Provide safe

suicide regarding environment during

creating a safe time client is actively

environment. suicidal and impulsive.

Encourage the patient Gives client other ways

to talk freely about of dealing with strong

feelings and help plan emotions and gaining a

alternative ways of sense of control over

handling their lives.

disappointment, anger

and frustration.
SUBSTANCE ABUSE DISORDERS 21

Conclusion

Opiates are drugs used as pain killers that fall under three categories: natural opiates,

synthetic opiates and semi-synthetic opiates. Opioid intoxication can occur as a result of both

therapeutic use and opioid abuse. With extended use of these drugs the brain receptors change

and become dependent upon the drug to function. When an individual stops taking these opiates

they start to experience withdrawal symptoms.

Opiates can be abused through different routes. These include intravenous, nasal,

intramuscular, oral, and dermal; each with different onset time. Naloxone is used to reverse the

effects of opioid intoxication such as respiratory depression and slow heartbeat. Methadone is

used to treat symptoms of withdrawal. Nursing management for patients with opiates abused

disorders focus around motivational approaches, managing withdrawal symptoms, managing

side effects of treatment medications, counseling and facilitating access to social, medical,

mental health and other needed services.

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References

Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence. (n.d.).

Retrieved March 03, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26269862

DSM 5 Criteria for Opioid Withdrawal. (n.d.). Retrieved March 09, 2017, from

http://www.buppractice.com/node/2645

Goldberg, J. (2016). Counselling. Retrieved from http://www.webmd.com/mental-

health/addiction/counseling-and-addiction-how-therapy-can-help#3

Lakeview, H. (2015). Recovery connection: Opiate withdrawal. Retrieved from

https://www.recoveryconnection.com/substance-abuse/drug-classes/opiate-addiction-

treatment-withdrawal/

McMacken, M. (2016, July 07). The johns hopkins centre for substance abuse treatment and

research. Retrieved March 03, 2017, from

http://www.hopkinsmedicine.org/substance_abuse_center/

Moore, K. (2015). Opioid intoxication. Retrieved on March 10, 2017 from http://www.healthlin

e.com/health/opioid-intoxication#Overview1

Opiate. (2016, August 10). Retrieved March 09, 2017, from

https://www.opiate.com/opiates/list-of-opiates/

Opium. (2016, July 11). Retrieved March 09, 2017, from

http://www.opium.org/natural-opiates.html
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Opiate Abuse. (2016, August 13). Retrieved March 04, 2017, from

http://drugabuse.com/library/opiate-abuse/#signs-and-symptoms

Opioid Abuse & Addiction Signs, Effects & Symptoms. (n.d.). Retrieved March 04, 2017, from

http://www.acadianaaddiction.com/addiction/opioids/symptoms-signs-effects#Effects-of-

Opioid-Use

Opioid Withdrawal Symptoms and DSM-V Diagnosis. (n.d.). Retrieved March 09, 2017, from

http://www.psychtreatment.com/mental_health_opioid_withdrawal.htm

Patterson, E. (2016). Opiate abuse. Retrieved 9 2017, March, from www.drugabuse.com:

http://drugabuse.com/library/opiate-abuse/Stuart, G. W. (2013). Principles and practice of

psychiatric nursing, 10th Ed. Elsevier: Mosby pgs. 557-564

Stolbach, A., & Hoffman, R. S. (2017, February 28). Acute opioid intoxication in adults.

Retrieved March 10, 2017, from www.uptodate.com:

http://www.uptodate.com/contents/acute-opioid-intoxication-in-adults

The Different Types of Opiates. (2016). Retrieved March 10, 2017, from

http://www.recovery.org/forums/discussion/1086/the-different-types-of-opiates