Substance-Related Disorders
Chapter 12
Overview of Substance Abuse
• Substance abuse is set apart from other
mental disorders because it is defined by
cause rather than a set of symptoms.
• The symptoms of substance-related
disorder are caused specifically by the use
of a substance, not by a general medical
condition or a mental disorder.
DSM-IV-TR Substance Abuse
Categories (1 of 2)
• Alcohol
• Amphetamines (or similar-acting
sympathomimetics)
• Cocaine
• Caffeine
• Cannabis
• Hallucinogens
DSM-IV-TR Substance Abuse
Categories (2 of 2)
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Inhalants
Nicotine
Opioids
Phencyclidines (PCP)
Sedatives, hypnotics, or anxiolytics
Key Terms and Concepts
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Substance
Craving
Tolerance
Substance abuse
Substance intoxication
Substance withdrawal
Medical Overlap and Substance
Abuse
• Substance-related disorders can lead to
emergency medical situations caused by
the effect of the substance, such as:
– Overdose
– Stimulant-induced cardiac arrhythmias
– Stroke
– Respiratory arrest
Common Routes of
Administration
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Smoking
Snorting
IV
Ingestion
Speed of Onset
• Rapidly acting substances are more likely to
lead to substance abuse than slower acting
substances.
• Relatively shorter acting substances have a
higher potential to lead to substance abuse.
• Longer acting substances (eg, methadone)
will lead to longer withdrawal.
Assessment (1 of 4)
• Assessment will revolve around alleviating
symptoms of the substance-related
disorder.
• Assessment will be more accurate if the
toxic syndrome or toxidrome group is
determined.
Assessment (2 of 4)
• Where was the patient found?
• Are any drug paraphernalia present?
• Was the patient wide awake, anxious,
sleepy, or sedated?
• Are the pupils dilated or constricted?
Assessment (3 of 4)
• Does the patient have vein sclerosis
(tracks) and punctures on their
extremities?
• Are there any symptoms related to septal
erosion, dry mucosa, or postnasal drip?
• Are there any abnormal vital signs related
to a specific toxidrome group?
Assessment (4 of 4)
• Use SAMPLE, OPQRST, and SEA-3
evaluation tools to help gather information
about your patient’s substance-related and
medical conditions.
Alcohol-Related Disorders
• Alcohol is a CNS depressant and is the
most commonly abused substance in the
United States.
• Signs of tolerance and withdrawal are a
mark of alcohol dependence.
• Most alcohol abuse is diagnosed when the
recurrent use of alcohol is established with
no signs of tolerance or withdrawal.
Signs of Alcohol Intoxication
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Slurred speech
Incoordination
Unsteady gait
Nystagmus (rapidly oscillating eye
movements not controllable by the patient)
• Impairment in attention or memory
• Stupor or coma
Signs of Alcohol Withdrawal
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Tachycardia
Insomnia
Hand tremor
Sweating
Nausea
Vomiting
Common Medical Complaints
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Nausea
Vomiting
Abdominal pain
Low-grade hypertension
Signs of Alcohol-Induced
Peripheral Neuropathy
• Tingling
• Numbness
• Muscle weakness
Co-occurrence with Other
Disorders
• Alcohol-related disorder many co-occur
with other medical problems or mental
disorders.
• In some cases patients self-medicate
themselves.
Amphetamine-Related
Disorders
• Amphetamines (or amphetamine-like
substances) are stimulants that may be
illicitly used for their stimulating and
euphoric effect.
• In some forms, they may be legally used
as an appetite suppressant or diet pills.
Routes of Absorption
• Amphetamines may be administered
through different routes:
– Ingested in pill form
– Inhaled intranasally
– Smoked
Common User Characteristics
• Chronic stimulant users (speed freaks or
tweakers) often present with a wild-eyed,
nervous, or jittery appearance.
• The amphetamine user may present with a
thin, emaciated body and picked-open,
raw skin.
• Intense paranoid and psychotic episodes
are common.
Signs of Amphetamine
Intoxication (1 of 2)
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Tachycardia or bradycardia
Pupillary dilation
Elevated or lowered blood pressure
Perspiration or chills
Signs of Amphetamine
Intoxication (2 of 2)
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Nausea or vomiting
Evidence of weight loss
Psychomotor agitation or retardation
Muscular weakness
Signs of Withdrawal
• Depression
• Anhedonia (inability to feel pleasure)
• Suicidal thoughts (sometimes)
Cocaine-Related Disorder
• Cocaine is extracted from the leaves of the
coca plant.
• Different preparations of the plant have
different onset times and vary in potency.
• Powdered cocaine is a hydrochloride salt
that can be dissolved and injected or
snorted intranasally.
Crack Cocaine
• Crack cocaine is sold in the form of small
rocks that have not been neutralized by
some form of acid that make it a
hydrochloride salt.
• Crack has a relatively low vaporization
point, and the vapor is inhaled for rapid
onset of effect.
Psychosocial Aspects of
Cocaine Dependence
• The effect of cocaine dependence is short
lived, so individuals have to spend a huge
amount of money in a short amount of
time to maintain a high.
• They may resort to acts of crime or
prostitution in order to obtain funds.
Signs of Intoxication and
Withdrawal
• Similar to the signs of intoxication of
amphetamines.
• Cocaine withdrawal has a faster onset and
shorter duration than amphetamine
withdrawal because of the short half-life of
cocaine.
Caffeine-Related Disorder
• Caffeine is a stimulant commonly found in
coffee, tea, some sodas, anti-drowsiness
pills, and chocolate.
• Potentially fatal co-morbid conditions such
as cardiac conditions or anorexia can lead
to life-threatening reactions.
Signs of Caffeine Intoxication
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Restlessness
Nervousness or excitement
Insomnia
Rambling flow of thoughts and speech
Tachycardia or cardiac arrhythmias
Cannabis-Related Disorder
• Cannabis is the most commonly used illicit
substance in the United States.
• Various part of the cannabis plant can be
prepared as various drugs including
marijuana and hashish. The active
ingredient in cannabis is delta-9tetrahydrocannabinol or THC.
Signs of Cannabis Intoxication
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Euphoric high
Inappropriate laughter
Bloodshot eyes
Increase of appetite (munchies)
Slight tachycardia
Health Problems Associated
with Cannabis Use
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Sinusitis
Pharyngitis
Bronchitis
Persistent cough
Emphysema
Pulmonary dysplasia (change in lung
tissue)
Hallucinogen-Related Disorder
• Substances that induce perceptual
changes (eg, hallucinations or delusions)
in a state of full alertness, including
substances such as:
– LSD
– Methamphetamine (Ecstasy)
– Mescaline (peyote)
– Psilocybin (mushrooms)
Routes of Absorption
• Ingestion
• Inhalation
• Injection
Signs of Intoxication
• Seeing shapes and colors
• Ideation of superhuman abilities and
senses
• Visual hallucinations
Physiologic Signs of
Hallucinogen Intoxication
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Tachycardia
Pupillary dilation with possible blurry vision
Sweating
Tremors
Incoordination
Labile mood
Inhalant-Related Disorder
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Gasoline
Glue
Paint thinner
Spray paint
Spray propellant
Signs of Inhalant Intoxication
(1 of 2)
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Dizziness
Nystagmus
Incoordination
Slurred speech
Unsteady gait
Signs of Inhalant Intoxication
(2 of 2)
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Lethargy
Depressed reflexes
Psychomotor retardation
Tremor
Common Characteristics
of Users
• Inhalants are legal and relatively easy to
obtain.
• They appeal to adolescents, who
commonly use them in group settings.
• The process of breathing in the inhalant is
known as huffing, and may pose a threat
to the airway of the user.
Considerations for Emergency
Care
• Consider you own safety first.
– You might need to call for the Hazmat team.
• Remove the patient from the toxic
environment.
• Administer high concentration oxygen.
Nicotine-Related Disorders
• Nicotine is legal and mostly found in
tobacco products, including:
– Cigarettes
– Chewing tobacco
– Nicotine gums
– Transdermal nicotine patches
Signs of Smokers
• Smell of smoke
• Signs of chronic obstructive pulmonary
disease
• Burned or stained fingers
• Excessive skin wrinkling
Opioid-Related Disorder
• Opioids are a class of substance used for
their analgesic, anesthetic, antidiarrheal,
and cough suppressant qualities.
Prescription Opioids
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Morphine
Codeine
Dilaudid
Methadone
Oxycodone
Demerol (meperidine)
Fentanyl
Heroin
• Heroin is the most commonly used illicit
opioid, and may be:
– Injected
– Smoked
– Snorted
Signs of Opioid Intoxication
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Drowsiness
Hypotension
Respiratory depression
Pinpoint pupils
Nausea
Vomiting
Constipation
Symptoms of Opioid Withdrawal
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Dysphoric mood
Nausea or vomiting
Muscle aches
Lacrimation
Rhinorrhea
Pupil dilation
Prehospital Care for OpioidRelated Disorder
• EMS providers may administer 0.4 to 2.0
mg of naloxone (Narcan) as per local
protocol to arouse the unconscious patient
who is intoxicated from opioids.
• Naloxone can cause the intoxicated
patient to rapidly awaken from their selfinduced euphoria, which may lead to
violence.
Phencyclidine-Related Disorder
• Phencyclidine (PCP) and similar acting
compounds such as ketamine and
cyclohexamine were originally developed
as dissociative anesthetics.
• PCP is commonly called “angel dust” or
simply “dust.”
Signs of PCP Intoxication
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Nystagmus
Tachycardia
Hypertension
Muscle rigidity
Incoordination
Management of PhencyclidineRelated Disorder
• Controlling or restraining this person can
be difficult and dangerous; law
enforcement assistance will be essential.
• Valium, Ativan, or Haldol may be effective
for sedation, treatment, and transportation.
(Prehospital care personnel should follow
local protocols.)
Sedative-, Hypnotic-, or
Anxiolytic-Related Disorder
• CNS depressants include barbiturates,
benzodiazepines, and similar-acting
substances often used as antianxiety,
anticonvulsant, and sleep medications.
Signs of Intoxication
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Slurred speech
Incoordination
Unsteady gait
Nystagmus
Attention or memory impairment
Stupor or coma
Withdrawal from Sedatives,
Hypnotics, or Anxiolytic Agents
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Hand tremor
Insomnia
Hallucinations
Anxiety
Prehospital Care Issues
• The administration of flumazentil via IV
push (0.2 mg/min) may be considered in
cases of benzodiazepine overdose.
• In cases of barbiturate (eg, phenobarbital)
overdose, the administration of 1–2 mEq
of sodium bicarbonate may help.
SAFER-R Model
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Stabilize
Acknowledge
Facilitate
Encourage
Recovery
Referral
Prehospital Care Management
(1 of 4)
• A good physical examination is imperative
in the management of individuals with a
substance-related disorder.
• Individuals may deny using substances
because of their illicit status.
• The SAFER-R Model will provide you with
a guide for these complicated patients.
Prehospital Care Management
(2 of 4)
• Many patients have a risk of respiratory
compromise. The rescuer must ensure a
patent airway and adequate breathing.
• All patients should be give a high
concentration of oxygen.
• In the case of substance-induced coma or
stupor, an advanced airway is needed to
prevent aspiration.
Prehospital Care Management
(3 of 4)
• In opioid intoxication, naloxone can restore
consciousness and respiratory drive.
• IV access should be obtained in cases of
hypotension caused by stimulant use or
substance-related injury.
• ECG, pulse oximetry, and capnometry
should be applied to all patients showing
signs of drug use.
Prehospital Care Management
(4 of 4)
• Normal saline or lactated Ringer’s can be
given as a fluid challenge according to
local protocol or at a rate of 20 mL/kg,
provided the patient is not presenting with
pulmonary edema.
Summary (1 of 2)
• The reality is that many of our patients
experience polysubstance abuse (taking
more than one chemical at a time),
presenting a confusing mixture of
symptoms.
• The polysubstance abuse patient may be
in a severe crisis state both medically and
psychologically.
Summary (2 of 2)
• As an EMS provider, it is extremely
important for you to recognize that patients
presenting with signs of depression and
psychosis may have a potentially lifethreatening medical condition as well.
• Your assessment skills and experience will
be a valuable tool for dealing with a patient
suffering from a substance-related
disorder.