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 pleasure/reward system producing feelings of pleasure or euphoria. The substance may also produce clinically significant cognitive and motor impairment that diminishes the ability to practice nursing safely with reasonable skill.

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 2014). Eighty percent of states have recognized the necessity of quickly removing affected nurses from duty as well as 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.


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 and/or 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/or committing errors when giving care. The potential for harm to patients is always a possibility.

The Diagnostic and Statistical Manual of Mental Disorders, currently known as the DSM-5, refers to substance abuse as substance use disorders. These disorders can be categorized as mild, moderate or severe. The severity of the disorders is dependent upon the number of criteria with which a person presents during an assessment, the fewer signs and symptoms the milder the disorder. Signs and symptoms of an SUD may include: impaired self-control, social impairment, risky use, tolerance and withdrawal.

Some of the substances commonly involved in SUDs include:

Alcohol Use Disorder (AUD)

Recommended abstinence from alcohol
  • Under the age of 21
  • During pregnancy
  • Driving a motor vehicle or other vehicles
  • Use of medications that interact with alcohol
  • Certain medical conditions such as anemia, cancer, cardiovascular disease, liver disease, dementia, depression, seizures, gout, pancreatitis
  • Recovering from alcoholism or are unable to control the amount they drink.
CDC. Fact Sheets- Alcohol Use and Your Health

The Centers for Disease Control and Prevention (CDC) estimates 88,000 deaths in the U.S. occur each year because of excessive alcohol use. The alcohol related deaths shortened the lives of those who died by 30 years.

Drinking alcohol has been defined as moderate drinking, binge drinking, and heavy drinking. Moderate drinking is characterized as drinking one alcoholic drink a day for women and two for men. There has been some research showing moderate alcohol consumption, particularly red wine, may decrease the risk for heart disease.

Binge drinking is defined as drinking more than 4 drinks in a single occasion for women and 5 drinks for men once in a 30-day period. Heavy drinking is defined as consuming more than 8 drinks a week for women and 15 or more drinks per week for men as well as 5 or more episodes of binge drinking in a 30-day period.

A diagnosis of (AUD) includes:

Genetics of Alcohol Use Disorder (AUD)

Several research studies have found that multiple genes play a role in about 50% of the risk for AUD. Some genes alter the rate of alcohol metabolism leading to flushing, nausea and rapid heartbeat. These effects lead to and increased avoidance of alcohol. Some genes also enable the effectiveness of some medications like naltrexone to help reduce the desire for alcohol but some individuals without the specific gene do not respond positively to the medication. Much more research is needed and being conducted to examine the effects of genetics on the risk of AUD.

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Signs and symptoms of AUD amongst colleagues

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Diagnostic criteria of Alcohol Use Disorder.

Inability to control alcohol intake
Disregard for problems resulting from drinking
Involvement in risky situations because of the drinking
All the above

Cannabis Use Disorder

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Cannabis (marijuana, weed, pot, grass) is the most commonly used inebriant after alcohol and tobacco in America. Cannabis is a combination of dried, shredded leaves and flowers from the marijuana plant. It can be smoked like a cigarette or cigar and in a pipe. It can also be mixed in food and brewed as a tea. Hashish and hash oil are resin extract from the Cannabis plant that can be mixed with tobacco or marijuana and smoked or vaporized over a heat source and inhaled.

Some of the reactions to marijuana can be relaxation, sleepiness, happiness, dizziness, and/or nervousness.

More serious problems are memory problems, learning difficulties, attention deficits, heart problems, increased risk for lung cancer more than cigarettes if smoked (Callaghan, Allebeck & Sidorchuk, 2013), slower reaction time making driving dangerous, and an attitude of disregard for important life issues. It is possible to become addicted to marijuana. Signs of marijuana use includes laughing for no reason, feeling silly, relaxed, sleepy, and happy—or nervous and scared. The drug may change senses of sight, hearing, and touch. Marijuana can make it hard to think clearly and lead to forgetting something that just happened. It is not unusual for marijuana to make people feel very hungry.

Marijuana legal status

The National Survey on Drug Use and Health (NSDUH) refers to marijuana as an illicit drug. However, the classification of this substance as legal or not legal is complicated. Twenty-six states and the District of Columbia have passed laws legalizing marijuana use for medical use and some for recreational use. Three additional states, Arkansas, Florida and North Dakota, have been passed medical marijuana laws waiting to be implemented.

However, the federal government, which regulates drugs through the Controlled Substances Act (CSA), classifies Cannabis as a Schedule 1 drug meaning it is highly addictive with no medical benefit. In recent years the federal prosecution has been reserved for cases of large distribution and cultivation of cannabis. There is concern that federal government is returning to aggressive incarceration for non-violent marijuana offenses even in states with laws approving its use. (Review the applicable laws often, they are changing).

State Cannabus Policies
Alabama Hawaii (M) Minnesota (M) North Dakota (M) Utah (M)
Alaska (M)+(R) Idaho Mississippi Ohio (M) Vermont (M)+(R)
Arizona (M) Illinois (M) Missouri (M) Oklahoma (M) Virgin Islands(M)
Arkansas (M) Iowa Montana (M) Oregon (M)+(R) Virginia
California (M)+(R) Kansas Nebraska Pennsylvania (M) Washington (M)+(R)
Colorado (M)+(R) Kentucky Nevada (M)+(R) Puerto Rico (M) Washington, D.C. (M)+(R)
Connecticut (M) Louisiana (M) New Hampshire (M) Rhode Island (M) West Virginia (M)
Delaware (M) Maine (M)+(R) New Jersey (M) South Carolina Wisconsin
Florida (M) Massachusetts (M)+(R) New Mexico (M) South Dakota  
Georgia Maryland (M) New York (M) Tennessee  
Guam (M)+(R) Michigan (M)+(R) North Carolina Texas  
Medical Use = (M)        Recreational Use = (R)  As of 7/31/19 -



Stimulant Use Disorders

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Many stimulants like cocaine, amphetamines and methamphetamines increase alertness, attention, and energy. Amphetamine, a synthetic compound, can be used legally for weight loss as an appetite suppressant and occasionally for ADHD. They can also be diverted for illegal use. For more information about see the course, Methamphetamine Use: What You Need to Know .

Cocaine (coke, blow) is derived from a plant. It can be snorted up the nose or mixed with water for injection use. It can also be heated and smoked in a glass pipe. Cocaine can give a person energy but also can make a user restless, scared and/or even angry.

Stimulants can also increase your blood pressure and heart rate. Mood changes from happy and excited to crashing and being sad and/or tired can occur when the drug wears off.

Common signs of stimulant use disorder include:

Pain Medications

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There are a several opioids: Morphine, OxyContin, Percocet, Vicodin, Hydrocodone, Oxycodone, that are often prescribed for pain relief but also are sold illegally, heroin being commonly available on the black market.

Opioids give you a rush of good feelings, make you sleepy. Addiction is common when used for recreational use.

It is estimated 1.9 million people had an opioid use disorder related to prescription pain medications in 2014. Another estimated 586,000 people had an opioid use disorder using heroin.

On March 18, 2016, the CDC published new guidelines for prescribing opioids for chronic pain in the US. Opioid prescriptions should be carried out for cancer pain symptoms and palliative/hospice care patients but limited for use for patients with chronic pain. According to the CDC, there is an alarming increase in the number of prescriptions for opioids for patients with chronic pain (Becker, et al, 2008). While no patients should receive less than adequate pain control, long term use of opioids, considered to be more than 3 months, increases the risk of addiction which carries with it a 1 in 32 death rates from overdoses. Opioids have been also referred to as gate way drugs to heroin use (Dasgupta et al, 2014; Compton, et al, 2016).

CDC Opioid guidelines

Symptoms of opioid use disorders include the following:

Signs of opioid use amongst colleagues
Subjective effects of opioids
 Phase  Description
  rush  initial rapid onset of euphoria (intravenous)
  high  perception of joy and ease (ingestion)
  nod  sedation
  straight  period between craving, pleasant feelings
 irritability, restlessness, dysphoria

Most nurses using opioids may have difficulty admitting they have a problem. Initially they often believe that the use of opioids is temporary, justified and that they have everything under control. Regardless of type of substance, it is helpful to be aware of signs to look for that might suggest a SUD.

Performance issues

Signs of drug diversion



Becker, et al. (2008). Non-medical use, abuse and dependence on prescription opioids among U.S. adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend. 94, 38-47.

Callaghan, R.C., Allebeck, P. & Sidorchuk, A. (2013). Marijuana use and risk of lung cancer: a 40-year cohort study. Cancer Causes & Control. 24(10), 1811-1820.

CDC. Fact Sheets- Alcohol Use and Your Health.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Common elements in guidelines for prescribing opioids for chronic pain (http://www .cdc .gov/ drugoverdose/

Compton, W. M., Jones, C. & Baldwin, G. (2016). Relationship between nonmedical prescription-opioid use and Heroin use. N Engl J Med, 374, 154-163.

Dasgupta, N., Creppage, K., Austin, A., Ringwalt, C., Sanford, C. & Proescholdbell, S.K. (2014). Observed transition from opioid analgesic deaths toward heroin. Drug Alcohol Depend. 145, 238-41.

Kolodny, A., Courtwright, D.T., Hwang, C.S. et al. (2015). The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health. 36, 559-74.

NIH. National Institute on Drug Abuse Easy-to-Read Drug Facts. Marijuana Facts. January 2017.

SAMHSA (Substance Abuse and Mental Health Services Administration). (2013).  Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration.

What You Need to Know About Substance Use Disorder in Nursing (2014). National Council of State Boards of Nursing