Substance use disorders

Substance use disorder (SUD), primarily drugs and alcohol, is a progressive yet treatable disease characterized by clinically significant impairment or distress. Use of the substance activates the pleasure/reward system producing feelings of pleasure or euphoria. The substance may also produce clinically substantial cognitive and motor impairment that diminishes the ability to practice nursing safely with reasonable skill. The prevalence of substance abuse among nurses ranges from 5-20% (Luurila et al., 2022)

The Diagnostic and Statistical Manual of Mental Disorders, currently known as the DSM-5, refers to substance abuse as substance use disorders.

The DSM-5 recognizes substance-related disorders resulting from the use of 10 separate classes of drugs:

• Alcohol
  
• Caffeine
  
• Cannabis
  
• Hallucinogens
  
• Inhalants
  
• Opioids
  
• Sedatives
  
• Hypnotics
  
• Stimulants
  
• Tobacco (Hartney, 2020)

These disorders can be categorized as mild, moderate, or severe. The disorder's severity depends on the number of criteria a person presents during an assessment; the fewer signs and symptoms, the milder the disorder. Signs and symptoms of a SUD may include impaired self-control, social impairment, risky use, tolerance, and withdrawal.

Screening Tools for substance use of tobacco, alcohol, prescription medication, and other substance use tool (TAPS)

TAPS consists of TAPS-1, a brief initial screening tool, and TAPS-2, an assessment questionnaire for those who screen positive in TAPS-1.

This tool:

• Combines screening and brief assessment for commonly used substances, eliminating the need for multiple screening and lengthy assessment tools
  
• Provides a two-stage brief assessment adapted from the NIDA quick screen and short assessment (adapted ASSIST-lite)
  
• It may be either self-administered directly by the patient or as an interview by a health professional
  
• Uses an electronic format (available here as an online tool)
  
• Uses a screening component to ask about the frequency of substance use in the past 12 months
  
• Facilitates a brief assessment of the past three months problem use to the patient

Substance use disorders are classified as mild, moderate, or severe, depending on how many diagnostic criteria a person meets.

The severity of Substance Use Disorders

• Mild substance use disorder – two or three symptoms
  
• Moderate substance use disorder – four or five symptoms
  
• Severe substance use disorder – six or more symptoms (McLellan, 2017)

The 11 DSM-5 criteria for a substance use disorder are:

1. Hazardous use: used the substance in dangerous ways to yourself and others, i.e., overdosed, driven while under the influence, or blacked out.
   
2. Social or interpersonal problems related to use: Substance use has caused relationship problems or conflicts with others.
   
3. Neglected major roles to use:  failed to meet your responsibilities at work, school, or home because of substance use.
   
4. Withdrawal: stopping using the substance leads to withdrawal symptoms.
   
5. Tolerance:  built up a tolerance to the substance, so need to use more to get the same effect.
   
6. Used larger amounts/longer:  started to use larger amounts or use the substance for longer amounts of time.
   
7. Repeated attempts to control use or quit:  tried to cut back or quit entirely, but haven't been successful.
   
8. Much time spent using:  spend a lot of time using the substance.
   
9. Physical or psychological problems related to use:  substance use has led to physical health problems, such as liver damage or lung cancer, or psychological issues, such as depression or anxiety.
   
10. Activities given up to use:  skipped activities or stopped doing activities once enjoyed in order to use the substance.
    
11. Craving:  experienced cravings for the substance. (Hartney, 2020; Hasin et al., 2012)

These findings result in alcohol or drugs causing failure to meet primary responsibilities at work, school, and home (APA, 2015). They also indicate the need for help.

There is some discussion about the difference between the DSM-5 inclusions and descriptions of substance use disorder and the ICD 11 classification of diseases. The ICD 11 keeps substance dependence as the master diagnosis. That is in contrast to the DSM-5’s broader description. The ICD 11 also provides empirical evidence for substance abuse for alcohol, cannabis and prescribed opioids (Saunders, 2017).

Both organizations have recently included gambling as a component of substance and addictive use disorder (Darvesh et al., 2020).

Definition

American Nurses Association (ANA) definition of impaired: Is unable to meet the requirements of the code of ethics and standards of practice of the profession.  Has cognitive, interpersonal, or psychomotor skills affected by psychiatric illness, drug or alcohol abuse, or addiction. Impaired nurses can jeopardize patient safety by diverting pain relief medication from patients, neglecting patients and their treatments, and committing errors when giving care. The potential for harm to patients is always a possibility.

Some of the substances commonly involved in SUDs include:

• Alcohol
  
• Cannabis
  
• Opioids
  
• Stimulants

According to the NCSBN (2018), some of the changes that can occur from substance abuse that nurses can see as red flags in their colleagues indicate substance abuse.

Behavioral changes

• Subtle changes in appearance that may escalate over time
  
• Increasing isolation from colleagues
  
• Inappropriate verbal or emotional responses
  
• Diminished alertness
  
• Confusion or memory lapses.

Narcotic discrepancies

• Incorrect narcotic counts
• Large amounts of narcotic wastage
  
• Numerous corrections of medication records
  
• Frequent reports of ineffective pain relief from patients
  
• Offers to medicate co-workers’ patients for pain
  
• Altered verbal or phone medication orders
  
• Variations in controlled substance discrepancies among shifts or days of the week.

The earlier an affected nurse enters treatment for SUD, "the sooner patients are protected, and the better the chances are that the nurse can return to work"(NCSBN 2016). Eighty percent of states have recognized the necessity of quickly removing affected nurses from duty and the value of offering an Alternative to Discipline Program as a pathway back to work. All these states include substance use disorders in their definition of impairments.

The National Council of State Boards of Nursing (NCSBN) has developed educational material that is free to download about substance abuse in nursing. The educational material includes(1) a general description of drug abuse in nursing, (2) information for nurse managers, and (3) two posters.

https://www.ncsbn.org/nursing-regulation/practice/substance-use-disorder/sud-educational-materials.page

References

Darvesh, N., Radhakrishnan, A., Lachance, C. C., Nincic, V., Sharpe, J. P., Ghassemi, M.& Tricco, A. C. (2020). Exploring the prevalence of gaming disorder and Internet gaming disorder: a rapid scoping review. Systematic reviews, 9, 1-10.Hartney, E. (2020).The 11 official criteria for Addiction/substance use disorder. Very well Mind.

Hasin, D. S., Fenton, M. C., Beseler, C., Park, J. Y., & Wall, M. M. (2012). Analyses related to the development of DSM-5 criteria for substance use-related disorders: 2. Proposed DSM-5 criteria for alcohol, cannabis, cocaine, and heroin disorders in 663 substance abuse patients. Drug and alcohol dependence, 122(1-2), 28–37. https://doi.org/10.1016/j.drugalcdep.2011.09.005

Luurila, K., Kangasniemi, M. & Häggman-Laitila, A. (2022). An Integrative Review of Programs for Managing Nurses' Substance Use Disorder in the Workplace. J Addict Nurs. 33(4), 280-298.

McLellan, A.T. (2017). Substance misuse and substance use disorders: Why do they matter in healthcare?. Trans Am Clin Climatol Assoc. 128,112-130. 

National Council of State Boards of Nursing (NCSBN). (2016). A Nurse Manager’s Guide to Substance Use Disorder in Nursing. Accessed 8/12/2017 https://www.ncsbn.org/Mgr_SUDiN_Brochure_2014.pdf

National Council of State Boards of Nursing (NCSBN). (2018). A Nurse’s guide to substance use disorder in nursing. Accessed 6/12/2021 at https://www.ncsbn.org/SUD_Brochure_2014.pdf.

Saunders, J.B. (2017). Substance use and addictive disorders in DSM-5 and ICD 10 and the draft ICD 11. Curr Opin Psychiatry. 30(4), 227-237.