Caring For Patients With Substance Use Disorders

You will care for patients with substance use disorders no matter your specialty, so you need to know how to recognize addiction, manage withdrawal, and build enough trust that patients tell you the truth. Nurses are often the first providers these patients meet, which makes them central to whether treatment succeeds.

Substance Use and Addiction: An Overview

The American Society of Addiction Medicine defines addiction as a "treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences."

Substance use disorder is the diagnosis for recurring use of substances. The DSM-5 criteria do not hinge on pharmaceutical dependence alone but on a pattern of behavior marked by social impairment, impaired control, and risky use. Behavioral addictions, like gambling disorder, share many of the same environmental and biological roots and fall under the non-substance-related disorders in the DSM-5.

Prevalence and the Opioid Epidemic

Drug overdose deaths rose roughly 30% from 2019 to 2020, according to the CDC, and nearly 75% of the 2020 overdose deaths involved opioids, including prescription opioids. SAMHSA's 2021 National Survey on Drug Use and Health found that 46.3 million people, or 16.5% of the population aged 12 and older, met DSM-5 criteria for a substance use disorder. The highest rate fell among people aged 18 to 25.

The first wave of opioid overdose deaths hit in the 1990s and involved prescription opioids. After 2013, synthetic opioids drove a sharp rise, led by fentanyl, which is now manufactured into counterfeit pills, heroin, and cocaine.

Joyce McMahon, RN, CARN, manages withdrawal at the Center for Addiction Medicine at the University of Maryland Medical Center Midtown Campus in Baltimore. "In this practice, we see a lot of people who are trying to stop using opioids. When we check their urine toxicology, most of these patients will be fentanyl positive, which is sometimes a surprise to them. Maybe they think they are taking unprescribed Percocet, but their pills are really made of fentanyl. It's a huge risk of fatal overdose," she said.

The Nurse's Role

Only about 6% of the 46.3 million people with a diagnosable substance use disorder receive treatment, which means you will meet these patients far outside rehab and treatment clinics. Nurses in orthopedics, cardiac care, and mother-baby units all encounter patients whose substance use affects their health and their families.

Treat addiction the way you treat any other disease. The National Institute on Drug Abuse notes that addiction, like other chronic diseases, disrupts normal functioning, carries serious long-term effects, and is often preventable and treatable.

Addictions nursing is a distinct specialty covering therapeutic treatment and recovery for substance use and behavioral addictions. Because patients turn up in every setting, the practice is defined as knowledge specific, not setting specific. The epidemic was fueled in part by ineffective pain management, and nurses are well positioned to help patients weigh the risks and benefits of chronic pain treatment, spot potential substance use disorders, and support recovery.

Addiction Nursing Duties

Many nursing programs have not kept pace with the opioid crisis, so nurses who want to specialize must build their own competencies. The Addictions Nursing Certification Board offers the certified addiction registered nurse (CARN) exam for RNs and advanced practice providers; in the last half of 2022, 88 RN candidates and 63 AP candidates sat for it.

"Getting a nationally recognized certification in your nursing specialty is a sign you really know your stuff, which is why I became a CARN," McMahon said.

A CARN nurse's responsibilities include:

• Assessing patients and identifying care requirements
• Keeping current on new drugs
• Administering medications and treatments to relieve withdrawal
• Educating patients and families on healthy lifestyle choices
• Supporting patients through the psychological and emotional toll of substance use
• Recognizing trauma and assessing for its sequelae
• Educating communities and advocating for better practices

Five Practical Tips

1. Keep an open mind about what recovery looks like

Recovery is a process of learning, growth, and healing, and it looks different for every patient. Beyond abstinence, people in recovery take up healthy, meaningful activities, change their thought patterns, and build new routines.

McMahon points out that the National Institute on Drug Abuse's definition of recovery does not turn on whether a patient uses medication to get there. "There are certain traits I see in patients who are living in active recovery, regardless of which supports they use to get there, things like being able to enjoy life without drinking or using illicit substances, being the kind of person that people can count on, and being able to show up when they say they will. Even when they go through challenging experiences like losing a family member or having financial setbacks, if they remain stable in their recovery, that helps the whole situation," she said.

2. Educate patients on programs and resources

Connect patients to programs and local resources that structure the recovery process. McMahon assesses each patient's needs, lays out the options, and hands over a referral list. She rebuilt that list after the COVID-19 shutdown closed or changed many local programs; it now covers mental health providers, crisis hotlines, pain management practices, and inpatient treatment.

"Other nurses I work with serve on hospital-wide committees, provide Narcan training talks to new hospital staff, help train new staff, and act as a team resource. Basically, we notice things that need doing and do them in an effort to improve overall patient wellness," she said.

3. Address special populations and co-occurring mental illness

Pregnant patients, adolescents, and older adults have distinct medical and nursing needs. McMahon's adult practice helps pregnant patients safely withdraw from alcohol and drugs like benzodiazepines and unprescribed opioids, then moves them to a maintenance medication such as methadone or buprenorphine, both approved for use during pregnancy.

"We see a lot of successful pregnancies and moms who take great care of themselves and their babies on either methadone or buprenorphine. We support and educate the patient to make their own best choices. In addition, we have a protocol of additional appointments to see the woman throughout her pregnancy and for six months beyond," she said.

4. Recognize the signs of withdrawal

Patients with unidentified substance use disorders land in every unit, so learn to spot and manage withdrawal. Symptoms depend on the drug, length of use, and the patient's age and underlying conditions, and people who use recreationally without dependence may have none. Watch for:

• Anxiety
• Irritability and mood swings
• Exhaustion or fatigue
• Nausea, vomiting, and diarrhea
• Sweating and shaking
• Runny nose
• Seizures
• Confusion
• Disorientation
• Paranoia

Withdrawal management is only the first step. Inpatient acute care rarely leads to abstinence on its own; many patients need long stretches of psychological care and rehabilitation on maintenance doses of methadone to reach active recovery.

5. Lead with kindness and a non-judgmental attitude

Patients with substance use disorders face judgment across society and the healthcare system. Kindness and a non-judgmental stance help them open up, which builds the trust treatment depends on. Strategies that build rapport include:

• Active listening
• Minimal jargon
• Eye contact
• Mirroring behavior
• Frequent communication
• Empathy
• Respect and support
• Keeping your word

"Kindness makes it possible for people to tell you about their substance use. Kindness makes them believe they can change. Being non-judgmental helps both nurse and patient to look in the direction of harm reduction, and to move towards it," McMahon said.

Working as a CARN Nurse

CARN is a nationally recognized credential from the Addictions Nursing Certification Board. It requires a current, unrestricted RN license, 2,000 hours of addiction nursing experience, and 30 hours of related continuing education within three years of application. CARN nurses work in clinical, administrative, teaching, private practice, consulting, and research roles.

McMahon describes a typical day: "As a nurse, I assess patients, educate them on their choices, including medications, and provide resources. I present the patient to the provider for medication orders, describing the patient's urine toxicology, prescribed medications, substances used, frequency and route of use, last use, withdrawal symptoms (using the COWS or CIWA scales), history of treatment, and their plan for aftercare if we are seeing them for withdrawal management," she said.

No matter your specialty, you will care for patients with substance use disorders. You will not always know the right thing to say, but you can recognize withdrawal, offer real support, and help patients address addictions that are damaging their lives.

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This article covers addiction and recovery in a clinical, educational context. If you or someone you know is struggling with substance use, SAMHSA's National Helpline (1-800-662-4357) offers free, confidential support and treatment referrals.