Want to know more

SUBSTANCE ABUSE
Nursing Standard of Practice Protocol: Substance Misuse and Alcohol Use Disorders

Madeline Naegle, APRN-BC, PhD, FAAN

Evidence-Based Content - Updated July 2012

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Goal

Implement best nursing practices to care for older persons with drug, alcohol, tobacco, or other drug misuse, abuse, or dependencies 

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Overview 

A. Several factors increase the risks associated with alcohol and drug use for the older individual, continuing drug use patterns that earlier in life were commonplace, can be potentially harmful. Constitutional risk factors include changes in body composition such as decreased muscle mass, decreased organ efficiency (especially kidney and liver), and increased vulnerability of the central nervous system (CNS).

B. Alcohol use in combination with other drugs or used excessively may result in falls, impaired cognition, malnourishment, and decreased resistance to disease, interpersonal, and legal problems.

C. At-risk drinking (more than one drink per day or more than three drinks on one occasion) by older adults increases the likelihood of negative health consequences.

D. Any smoking is considered drug abuse and places the older person at risk for negative health consequences; advancing age increases the likelihood of respiratory and cardiovascular illnesses. 

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Background/Statement of Problem

A. Definitions (Ref 4)

1. Substance Use Disorders: A broad category of disorders on a continuum of use or misuse of alcohol, tobacco, prescription or illicit drugs, and the abuse or dependence on these drugs.

2. Substance Abuse: A maladaptive pattern of substance use evidenced in recurrent and significant adverse consequences related to the repeated use of substances. It is associated with repeated failure to fulfill role obligations, use in situations where use is physically hazardous, and/or when it results in legal and/or interpersonal problems.

3. Substance Dependence: A maladaptive pattern of self-administering a drug that results in the development of tolerance, withdrawal, and compulsive drug-taking behavior. Dependence is both physiologic and psychological.

4. Drug Misuse: Use of a drug for purposes other than that for which it was intended.

5. Polysubstance-Related Disorder: Misuse, abuse, or dependence on three or more drugs.

6. Tolerance: (a) A need for markedly increased amounts of a substance to achieve intoxication or the desired effects, or (b) a markedly diminished effect with the continued use of the same amount of a substance.

7. Withdrawal: A characteristic group of signs and symptoms that has its onset following the sudden cessation of consumption of a drug (including alcohol and nicotine) that induces physiologic dependence. 

8. At-Risk Drinking: Defined as more than one drink per day, seven days a week, or more than three drinks on any one occasion for persons 65 years and older. For older adults, at-risk drinking increases the likelihood of negative health consequences

9. Relapse: Return to regular use of a substance in a maladaptive pattern.

10. Recovery: A lifestyle voluntarily maintained by an individual that includes sobriety, varying levels of personal health, and citizenship. Recovery is categorized as early (1-11 months), sustained (1-5 years), and beyond.

B. Etiology and/or Epidemiology: Of persons older than 50 years, 16.7% reported drinking two or more drinks a day (risky drinking) and 19.6% reported binge drinking on occasion. Among primary care patients older than 60 years, 15% of men and 12% of women regularly drank in excess of the NIAAA recommended levels (one drink per day and no more than three drinks on any one occasion).

1. The drugs used, abused, and misused most frequently by older adults are nicotine, alcohol, and prescription drugs, particularly analgesics and benzodiazepines.

2. Excessive drinking by individuals of all ethnic groups ages 65 years and older is approximately 7%, down from 12% in persons ages 55-64 years.

3. Five hundred thousand persons ages 55 years and older reported monthly use of illicit drugs in the National Household Survey of Drug Use National Institute of Drug Abuse.

4. Approximately 11% of women older than 59 years misuse psychoactive drugs.

C. Risk Factors 9

1. Family history of dependence on alcohol, tobacco, prescription or illicit drugs

2. Co-occurrence of addiction with dependency or abuse of another substance dependence (i.e., alcohol and tobacco)

3. Lifelong pattern of substance use, including heavy drinking

4. Male gender

5. Social isolation

6. Recent and multiple losses

7. Chronic pain

8. Co-occurrence with depression

9. Unmarried and/or living alone

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Parameters Of Assessment

A. Screening for alcohol, tobacco, and other drug use is recommended for all community-dwelling and hospitalized older adults. It is essential that the nurse:

1. state the purpose of questions about substances used and link them to health and safety

2. be empathic and nonjudgmental

3. ask the questions when the patient is alcohol- and drug-free

4. inquire re: patient's understanding of the question. 10

B. Assessment/Screening Tools

1. The Quantity-Frequency (QF) Index: 11: Review all classes of drugs: alcohol, nicotine, illicit drugs, prescription drugs, OTC drugs and vitamin supplements, for each drug used. Record the Types of drugs, including types of beverages; Frequency: the number of occasions on which the drug is consumed (daily, weekly, monthly); Amount of drug consumed on each occasion during the last 30 days. The psychological function that the substance serves for the individual is also important to identify. The QF Index tool should be part of the intake nursing history. The Brown Bag approach is useful. The patient is asked to bring all drugs and supplements listed herein to the interview with the provider

2. Short Michigan Alcohol Screening Test-Geriatric Version (SMAST-G):
Highly valid and reliable, this is a 10-item tool that can be used in all settings. Three minutes for administration. This instrument is derived from the MAST-G with a sensitivity of 93.6% and positive predictive values of 87.2%. 13

3. Alcohol Use Disorders Identification Test (AUDIT): This 10-item questionnaire has good validity in ethnically mixed groups and scores classify alcohol use as hazardous, harmful, or dependent. Administration: 2 minutes. Sensitivity scores range from 0.74% to 0.84% and specificity around 0.90% in mixed age and ethnic groups. 14 This instrument is highly effective for use with older adults. 15 Its derivative, the Alcohol Use Disorders Identification Test-Condenced (AUDIT-C), is composed of three questions that have proved equally valid in detecting an alcohol-related problem.

4. Fagerstrom Test for Nicotine Dependence: 16
This six-question scale provides an indicator of the severity of nicotine dependence: scores less than 4, (very low); 4-6 (moderate), and 7-10 (very high). The questions inquire about first use early in the day, amount and frequency, inability to refrain, and smoking despite illness. This instrument has good internal consistency and reliability in culturally diverse, mixed-gender samples (Ref 16).

C. Atypical Presentation:
Men and women older than 65 may have substance-use and dependence problems even though the signs and symptoms may not correspond to those listed in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV TR).

D. Signs of CNS Intoxication (i.e., slurred speech, drowsiness, unsteady gait, decreased reaction time, impaired judgment, disinhibition, ataxia):

1. Assess by individual or collateral (speaking with family members) data collection, detail the consumption of amount and type of depressant medications including alcohol, sedatives, hypnotics, and opioid or synthetic opioid analgesics. 

2. Obtain a blood alcohol level. Marked intoxication 5 0.3%-0.4%, toxic effects occur at 0.4%-0.5%, coma and death at 0.5% or higher.

3. Assess vital signs and determine respiratory, cardiac, or neurological depression. 

4. Assess for treatable existing medical conditions, including depression. 

5. Arrange for emergency room/hospitalization treatment as necessary. 

6. Obtain urine for toxicology, if possible.

7. Assess for delirium that can be confused with intoxication and withdrawal in the older adult.

E. At-risk drinking is regular consumption of alcohol in excess of one drink per day for 7 days a week or more than three drinks on any one occasion.

1. Assess for readiness to change behavior using stages of change model. 17

2. Is drinker concerned about amount or consequences of the drinking? Has she/he contemplated cutting down?

3. Does she or he have a plan for cutting down/stopping consumption?

4. Has she or he previously stopped but then resumed risky drinking?

5. Personalized feedback and education and education on "at-risk drinking" results in a reduction in at risk drinking among older primary-care patients.

F. Treatment of acute alcohol withdrawal syndrome (guidelines are modified for other CNS depressant drugs such as barbituates, heroin, sedative hypnotics):

1. Assess for risk factors: (a) previous episodes of detoxification; (b) recent heavy drinking; (c) medical comorbidities including liver disease, pneumonia, and anemia; and (d) previous history of seizures or delirium. 19

2. Assess for extreme CNS stimulation and a minor withdrawal syndrome evidenced in tremors, disorientation, tachycardia, irritability, anxiety, insomnia, and moderate diaphoresis. When these signs are not detected, life-threatening situations for older adults often result. Withdrawal, occurring 24-72 hours after the last drink, can progress to seizures, hallucinosis, withdrawal delirium, extreme hypertension, and profuse diarrhea from 4 to 8 hours and for up to 72 hours following cessation of alcohol intake (delirium tremens [DTs]).

3. Assess neurological signs, using the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar). This CIWA-Ar is a 10-item rating scale that delineates symptoms of gastric distress, perceptual distortions, cognitive impairment, anxiety, agitation, and headache. 20

4. Medicate with a short-acting benzodiazepine (lorazepam or oxazepam) in doses titrated to patient’s score on the CIWA-Ar, patient’s age and weight; use one third to one half recommended dose (Amato, Minozzi, Vecchi, & Davoli, 2010). Continue CIWA-Ar to monitor treatment response.

5. Provide emotional support and frequent reorientation in a cool, low stimulation setting; monitor hydration and nutritional intake. Give therapeutic dose of thiamine and multivitamins.

G. Reported sleep disturbance, anxiety, depression, problems with attention and concentration (acute care):

1. Assess for neuropsychiatric conditions using the mental status exam, Geriatric Depression Scale, or Hamilton Anxiety Scale. (See Dementia and Depression topics). 

2. Obtain sleep history because drugs disrupt already altered sleep patterns in older persons. 

3. Assess intake of all drugs, including alcohol, OTC, prescription, herbal and food supplements, and nicotine. Use Brown Bag strategy.
 
4. If positive for alcohol use, assess for last time of use and amount used. 

5. Assess for alcohol or sedative drug withdrawal as indicated.

H. Smoking cigarettes or using smokeless tobacco:

1. Assess for level of dependence using the Fagerstrom Test (See Screening Tools for Alcohol and Drug Use section).

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Nursing Care Strategies

A. At-risk drinking (consumption of alcohol in excess of one drink per day for seven days a week or more than three drinks on any one occasion) or excess alcohol consumption (more than three or four drinks on frequent occasions):

1. Conduct Screening, Brief Intervention, and as indicated, Referral to Treatment: (SAMHSA, 2008)

a. Screen using the AUDIT-C, AUDIT, or SMAST-G
b. Feedback information to the client about current health problems or potential problems associated with the level of alcohol or other drug consumption.
c. Stress client's responsible choice about actions in response to the information provided.
d. Advice must be clear about reducing his or her amount of drinking or total consumption.
e. Recommend drinking according to NIAAA levels for older adults.

f. Provide a menu of choice to the patient or client regarding future drinking behaviors.

g. Offer information based on scientific evidence, acknowledge the difficulty of change, and avoid confrontation. Empathy is essential to the exchange.

2. Conduct Brief Intervention (FRAMES) 21

a. Feedback information to patients about current health problems or potential problems associated with their level of consumption.
b. Responsible choice about how to respond to the information provided to the patients is their choice.
c. Advice must be clear about drinking their amounts and recommended moderate levels of drinking.
d. Menu of choices is provided by the nurse to the patient/client regarding future drinking behaviors.
e. Empathy is essential to the exchange. Offer information based on scientific evidence, acknowledge the difficulty of change, avoid confrontation.
f. Self-efficacy of the individual is supported and the nurse helps patient explore options for change.

B. Support self-efficacy. Help client explore options for change.

1. Assist client in identifying options to solving the identified problem.

2. Review the pros and cons of behavior change options presented.

3. Help client weigh potential decisions by considering outcomes.

C. Smoking cigarettes or using smokeless tobacco.

1. Apply the 5 A's Intervention (Agency for Healthcare Research and Quality [formerly the Agency for Health Care Policy and Research] Guidelines): 24

a. Ask: Identify and document tobacco use.

b. Advise: Urge the user to quit in a strong personalized manner.

c. Assess: Is the tobacco user willing to make a quit attempt at this time?

d. Assist: If user is willing to attempt, refer for individual or group counseling and pharmacotherapy.

e. Arrange: Referrals to providers, agencies, and self-help groups. Monitor pharmacotherapy once quit date is established. The U.S. Food and Drug Administration (FDA)-approved pharmacotherapies for smoking cessation are the following:

i. Bupropion SR (Zyban) and nicotine replacement products such as nicotine gum, nicotine inhalers, nicotine nasal spray, and nicotine patch. Psychoeducation about these medications is essential.

ii. Zyban, for example, should not be combined with alcohol. Nurses working with in-patients in a case-management model were found to produce outcomes in smoking cessation. 22

iii. Caring, Concern, and provide ongoing support

2. Communicate caring and concern:

a. Encourage moderate intensity exercise as a means of reducing cravings for nicotine because 5 minutes of such exercises is associated with short-term reduction in the desire to smoke and tobacco withdrawal symptoms. 23

b. Arrange: Schedule follow-up contact in person or by telephone within 1 week after planned quit date. Continue telephone counseling especially those using medications and nicotine patches. 25,26

D. Alcohol Dependence

1. Assess patient for psychological dependence.

2. Assess patient for (a) physiological dependence and (b) "tolerance." Psychological dependence also occurs with both abuse and dependence and is more difficult to resolve.

3. Assess for need for medical detoxification (see alcohol withdrawal in Inpatient Hospitalization section)

4. Refer patient and family to addictions or mental health nurse practitioner or physician

5. Evaluate patient and family capacity to implement referral

6. On successful detoxification, monitor use of medications, interpersonal therapies, and participation in self-help groups.

E. Marijuana Dependence: Little research on effective intervention for psychological dependence on marijuana is available. Some guidance can be found in smoking cessation and self-help approaches.

1. Refer to steps for smoking cessation (see section C of Nursing Care Strategies).

2. Refer patient to addiction specialist for counseling for psychological dependence and/or cognitive-behavioral therapy.

3. Refer to community-based self-help groups such as Narcotics Anonymous, Alcoholics Anonymous, and Al-Anon.

4. Encourage development or expansion of patient’s social support system.

F. Heroin or Opioid Dependence

1. Older long-term opioid users may relapse and require treatment. Methadone or Buprenorphine are current pharmacological treatment options, effective in conjunction with self-help programs and/or psychosocial interventions.

2. Treatment with methadone, a synthetic narcotic agonist, suppresses withdrawal symptoms and drug cravings associated with opioid dependence but requires daily dosing of 60 mg, minimum. It is dispensed only in specially licensed clinics.

3. Buprenorphine (Subutex or Suboxone), recently approved for use in office practice by trained physicians, is an opioid partial agonist-antagonist. Alone and in combination with Naloxone (Suboxone), it can prevent withdrawal when someone ceases use of an opioid drug and can be used for long-term treatment. Naloxone is an opioid antagonist used to reverse depressant symptoms in opiate overdose and at different dosages to treat dependence (CSAT, 2010).

a. Close collaboration with the prescriber is required because these drugs should not be abruptly terminated, used with antidepressants, and interact negatively with many prescription medications.

4. Naltrexone, a long-acting opioid antagonist, blocks opioid effects and is most effective with those who are no longer opioid-dependent but are at high risk for relapse. 28

5. Treatment of the older patient who has become addicted to Oxycontin or other opioids should be done in consultation with an addictions specialist nurse or physician (Ref 28).

a. It is recommended that prescribers avoid opioids and the synthetic opioids (Demerol, Dilaudid, and Oxycontin). Opioids have high potential for addiction and Demerol has been associated with delirium in elders (CSAT, 2010).

b. Barbiturates should be avoided for use as hypnotics and the use of benzodiazepines for anxiety should be limited to 4 months. 9

G. Treatment and Relapse Prevention

1. Monitor pharmacologic treatment such as naltrexone as short-term treatment for alcohol dependence. The benefits of this treatment are dependent on adherence, and psychosocial treatment should accompany its use. 30 Methadone or buprenorphine should be used for long-term treatment of opioid dependence.

2. Group psychotherapy in limited studies using a cognitive behavioral approach has produced good outcomes with older adults (Payne & Marcus, 2008).

3. Refer to community-based groups such as Alcoholics Anonymous, Narcotics Anonymous, Al-Anon groups, and encourage attendance.

4. Educate family and patient regarding signs of risky use or relapse to heavy or alcohol-dependent behavior.

5. Counsel patient to reduce drug use (Harm Reduction) and engage in relationship healing/building, community or intellectually rewarding activities, spiritual growth, and so on that increase valued nondrinking rewards.

6. Counsel in the development of coping skills:

a. Anticipate and avoid temptation.

b. Learn cognitive strategies to avoid negative moods.

c. Make lifestyle changes to reduce stress, improve the quality of life, and increase pleasure.

d. Learn cognitive and behavioral activities to cope with cravings and urges to use.

e. Encourage development or expansion of patient's social support system.

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Evaluation/Expected Outcomes

A. Patient will have:

1) Improved physical health and function.
2) Improved quality of life, sense of well-being and mental health.
3) More satisfying interpersonal relationships.
4) Enhanced productivity and mental alertness.
5) Decreased likelihood of falls and other accidents.

B. Nurses will demonstrate:

1) Increased accuracy in detecting patient problems related to use/misuse of substances.
2) More evidence-based resulting in better outcomes.

C. Institution will have:

1) Increased number of referrals to ambulatory substance-abuse/mental-health treatment programs.
2) Improved links with community-based organizations engaged in prevention, education, and treatment of elders with substance-related disorders.

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Follow-up Monitoring

A. Evaluate for increase in substance use/misuse associated with growing numbers of aging adults.

B. Increase outreach to targeted vulnerable populations.

C. Document chronic care needs of elders diagnosed with substance-related disorders.

D. Monitor alcohol use among older adults with chronic pain. 31

E. Communicate findings to all members of the caregiver team.

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Guidelines

A. The National Quality Forum has published "Evidence-based Practices to treat Substance Use Disorders." These guidelines are inclusive of primary care, the settings in which most older adults seek treatment (National Quality Forum [NQF], 2007).

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For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Naegle, M. (2008). Substance abuse in older adults. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-based geriatric nursing protocols for best practice. (3rd ed.) (pp. 649-672). New York: Springer Publishing Company, Inc.

 

References

1. 

2. 

3. 

4.  American Psychiatric Association (APA) (2000). Diagnostic and statistical manual of mental disorders-IV-TR (4th ed.). Washington, DC: American Psychiatric Association: Author.

5.

6. 

7. 

8. 

9.  U.S. Department of Health and Human Services (2004a). Substance abuse among older adults: A guide for physicians (DHHS Publication No. SMA 00-3394). Rockville, MD: USDHHS, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Evidence Level VI.

10. Aalto, M., Pekuri, P., & Seppa, K. (2003). Primary health care professionals' activity in intervening in patients' alcohol drinking during a 3-year brief intervention implementation project. Drug and Alcohol Dependence, 69(1), 9–14. Evidence Level III: Quasi-experimental Study.

11. Khavari, K. A., & Farber, P. D. (1978). A profile instrument for the quantification and assessment of alcohol consumption: The Khavari Alcohol Test. Journal of Studies on Alcohol Abuse, 39, 1525. Evidence Level VI: Expert Opinion.

12.

13. Blow, F. C., Brower, K. J., Schulenberg, J. E., Demo-Danenberg, L. M., Young, J. P., & Beresford, T. P. (1992). Michigan Alcoholism Screening Test-Geriatric Version: A new elderly specific screening instrument. Alcoholism, Clinical and Experimental Research, 16(2), 372. Evidence Level III: Quasi-experimental Study.

14. Allen, J. P., Litten, R. Z., Fertig, J. B., & Babor, T. (1997). A review of research on the Alcohol Use Disorders Identification Test (AUDIT). Alcohol, Clinical and Experimental Research, 21(4), 613–619. Evidence Level III: Quasi-experimental Study.

15. Roberts, A. M., Marshall, E. J., & MacDonald, A. J. (2005). Which screening test for alcohol consumption is best associated with "at risk" drinking in older primary care attenders? Primary Care Mental Health, 3(2), 131–138. Evidence Level III: Quasi-experimental Study.

16. Pomerleau, C. S., Carton, S. M., Lutzke, M. L., Flessland, K. A., & Pomerleau, O. F. (1994). Reliability of the Fagerstrom Tolerance Questionnaire and Fagerstrom Test for Nicotine Dependence. Addictive Behavior, 19(1), 33–39. Evidence Level V: Program Evaluation.

17. Prochaska, J. O., & Di Clemente, C. C. (1992). Stages of change in the modification of problem behaviors. Progress in Behavior Modification, 28, 183–218. Evidence Level II: Individual Experimental Study. 

18.

19. Wetterling, T., Weber, B., Depfenhart, M., Schneider, B., & Junghanns, K. (2006). Development of a rating scale to predict the severity of alcohol withdrawal syndrome. Alcohol and Alcoholism, 41(6), 611–615. Evidence Level III: Quasi-experimental Study.

20. Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-AR). British Journal of Addictions, 84, 1353–1357. Evidence Level III: Quasi-experimental Study.

21.

22. Smith, P. M., Reilly, K. R., Houston-Miller, N., DeBusk, R. F., & Taylor, C. B. (2002). Application of a nurse-managed inpatient smoking cessation program. Nicotine and Tobacco Research, 4(2), 211–222. 

23. Daniel, J., Cropley, M., Usher, M., & West, R. (2004). Acute effects of a short bout of moderate versus light intensity exercise versus inactivity on tobacco withdrawal symptoms in sedentary smokers. Psychopharmacology, 174(3), 320–326. Evidence Level II: Individual Experimental Study.

24. AHRQ Clinical Practice Guidelines: Smoking Cessation Guidelines, 2002, are available to download. Retrieved on January 25, 2007 from http://www.guideline.gov/summary/summary.aspx?
ss=15&doc_id=3307&nbr=2533


25. Cooper, T. V., DeBon, M. W., Stockton, M., Kleges, R. C., Steenbergh, T. A., & Sherrill-Mittleman, D., et al. (2004). Correlates of adherence to transdermal nicotine. Addictive Behaviors, 29(8), 1565–1578.

26. Boyle, R. G., Solberg, L. I., Asche, S. E., Boucher, J. L., Pronk, N. P., & Jensen, D. J. (2005). Offering telephone counseling to smokers using pharmacotherapy. Nicotine & Tobacco Research, 7(Suppl. 1), S19–S27. Evidence Level III: Quasi-experimental Study.

27.

28. Srisurapanont, M., & Jarusuraisin, N. (2005). Naltrexone for the treatment of alcoholism: A meta-analysis of randomized controlled trials. The International Journal of Neuropsychopharmacology, 8, 267–280. Evidence Level III: Quasi-experimental Study.

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30. World Health Organization (WHO) (2000). A systematic review of opioid antagonists for alcohol dependence. Management of Substance Dependence Review Series. Downloaded  from www.who.int.org. Evidence Level I: Systematic Review.

31.

Amato, L., Minozzi, S., Vecchi, S., & Davoli, M. (2010). Benzodiazepines for alcohol withdrawal. Cochrane Database of Systematic Reviews, (3), CD005063. Evidence Level I.

Substance Abuse and Mental Health Services Administration. (2008). Screening, brief intervention, and referral to treatment (SBIRT): Resource manual. Retrieved from http://www.sbirt.samhsa.gov/core_comp/index.htm2.

Centers for Substance Abuse Treatment. (2010). Annual smoking-attributable mortality, years of potential life lost, and productivity losses--United States, 1997-2001. Morbidity and Mortality Weekly Post, 54(25), 625-628. Evidence Level V.

Payne, K.T., & Marcus, D.K. (2008). The efficacy of group psychotherapy for older adult clients: A meta-analysis. Group Dynamics: Theory, Research, and Practice, 12(4), 268-278. Evidence Level III.

National Quality Forum. (2007). National voluntary consensus standards for the treatment of substance use conditions: Evidence-based treatment practices. Washington, DC: Author. Retrieved from http://www.qualityforum.org. Evidence Level VI.

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Last updated - July 2012