Alcohol, Tobacco and Other Drugs

427 Pages·2012·3.17 MB·English

by  Team Power Special

Alcohol, Tobacco and Other Drugs:
Clinical Guidelines for Nurses and Midwives
Version 3, 2012
Endorsed by the South Australian Alcohol and Drug Nursing
and Midwifery Statewide Action Group
This work is copyright. It may be reproduced in whole or in part for educational or training purposes subject to the
inclusion of an acknowledgement of the source. Commercial usage or sale is not permissible without negotiation
with the authors.
Electronic Index: This publication is available as a down-loadable PDF with fully searchable text. To access PDF
copies go to:
www.dassa.sa.gov.au
www.health.adelaide.edu.au/nursing

For further information contact:
The University of Adelaide School of Nursing
Phone [phone]
Email: [email protected]
This work may be cited as:
de Crespigny, C & Talmet, J. 2012. (Eds). Alcohol, Tobacco and Other Drugs: Clinical Guidelines for Nurses and
Midwives. Version 3. The University of Adelaide School of Nursing, Drug and Alcohol Services, South Australia.
Subject Keywords: Alcohol, Tobacco, Other Drugs, Drug and Alcohol, Substances, Clinical Guidelines, Nurses,
Midwives.
For Cataloguing-in-Publication data please contact National Library of Australia: [email protected]
ISBN 978-0-9803130-8-6
First printing Version 1 2003
Second printing Version 2 2003
Third printing Version 3 2012

© University of Adelaide and Drug & Alcohol Services, South Australia 2012
FFoorreewwoorrdd
The use of alcohol, tobacco and other drugs (ATOD) is prevalent in our society. Nurses,
midwives and other health care professionals are faced with a diverse group of consumers
many of whom are affected either temporarily or in the longer term by ATOD related health
challenges. These challenges include intoxication, withdrawal, trauma, medical and mental
health conditions, and social issues. The complexities of providing safe care to consumers
affected by ATOD are unmistakable and challenging. The provision of safe care is at the core
of good nursing and midwifery practice. For nurses and midwives to do this they require
reliable evidence based clinical guidelines that are accessible and easy to use.
These guidelines aim to support and provide a benchmark for quality assessment,
intervention and referral by nurses and midwives in their daily practice. Clinicians should aim
to use these guidelines within the context of their roles and scopes of practice and, to update
their knowledge base by accessing current research and clinical guidelines as they emerge. To
this end I draw your attention to the information, links to key resources and websites listed at
the back of this publication.

Ms Lydia Dennett
Chief Nurse and Midwifery Officer
Nursing and Midwifery Office
Department for Health and Ageing
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CCoonntteennttss
FOREWORD................................................................................................................................................. I
CONTENTS ................................................................................................................................................. II
LIST OF FIGURES ........................................................................................................................................ VII
LIST OF TABLES ......................................................................................................................................... VIII
PURPOSE AND PRINCIPLES ............................................................................................................................IX
Statement of purpose ....................................................................................................................... ix
Principles for practice ....................................................................................................................... ix
ACKNOWLEDGEMENTS ................................................................................................................................. X
GLOSSARY ................................................................................................................................................ XII
USEFUL RESOURCES AND INFORMATION ........................................................................................................ XIX
Blood Borne Viruses ....................................................................................................................... xxii
Useful Websites .............................................................................................................................. xxii
Peer reviewed journals ................................................................................................................... xxii
Professional Resources .................................................................................................................. xxiii
Relevant services and community groups ..................................................................................... xxiv
LIST YOUR OWN CONTACT NUMBERS ........................................................................................................... XXVI
SECTION 1 BASIS FOR PRACTICE ........................................................................................................... 1
1.1 ALCOHOL, TOBACCO AND OTHER DRUG USE ........................................................................................... 2
Introduction ....................................................................................................................................... 2
Poly drug use ..................................................................................................................................... 2
Patterns of ATOD use ........................................................................................................................ 3
Myths ................................................................................................................................................ 4
1.2 HARM MINIMISATION ......................................................................................................................... 5
Introduction ....................................................................................................................................... 5
Harm reduction ................................................................................................................................. 5
Demand reduction ............................................................................................................................. 6
Supply reduction ................................................................................................................................ 7
1.3 NON-JUDGEMENTAL CARE ................................................................................................................... 8
Barriers to people seeking help ......................................................................................................... 8
Engaging people in treatment and care ............................................................................................ 9
1.4 UNDERSTANDING ATOD PROBLEMS ................................................................................................... 10
Theories ........................................................................................................................................... 10
Integrating the models in practice .................................................................................................. 16
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SECTION 2 CLIENT CARE ...................................................................................................................... 17
2.1 COMMUNICATION AND CULTURAL ISSUES ............................................................................................. 18
Introduction ..................................................................................................................................... 18
General principles of communication .............................................................................................. 18
Working effectively with Indigenous People ................................................................................... 21
Working with young people and children ....................................................................................... 28
2.2 ASSESSMENT .................................................................................................................................. 30
Introduction ..................................................................................................................................... 30
Rationale for assessment ................................................................................................................ 30
Using a person-centred approach ................................................................................................... 32
Issues for assessment ...................................................................................................................... 33
Nursing guidelines—general assessment ........................................................................................ 37
Pattern and recent history of ATOD use .......................................................................................... 37
Physical assessment ........................................................................................................................ 41
Planning care ................................................................................................................................... 44
2.3 EARLY AND BRIEF INTERVENTION ......................................................................................................... 48
Introduction ..................................................................................................................................... 48
General principles of early and brief intervention ........................................................................... 49
Motivational interviewing ............................................................................................................... 53
Harm reduction strategies .............................................................................................................. 59
Relapse prevention strategies ......................................................................................................... 60
2.4 MANAGING INTOXICATION ................................................................................................................ 62
Introduction ..................................................................................................................................... 62
Screening for alcohol and other drug use ....................................................................................... 68
Managing intoxication .................................................................................................................... 72
2.5 MANAGING OVERDOSE ..................................................................................................................... 76
Introduction ..................................................................................................................................... 76
Rationale for overdose management .............................................................................................. 76
Nursing management of overdose .................................................................................................. 79
2.6 MANAGING WITHDRAWAL ................................................................................................................ 82
Introduction ..................................................................................................................................... 82
Rationale for withdrawal management .......................................................................................... 82
General principles of withdrawal management .............................................................................. 83
Nursing guidelines—withdrawal management .............................................................................. 84
Nursing care plan—minimising risk of severe withdrawal .............................................................. 84
Decreasing risk of injury or self-destructive behaviour ................................................................... 85
Eliminate risk of dehydration, electrolyte and nutritional imbalance ............................................. 85
Identify presence of concurrent illness that mask or mimic withdrawal ......................................... 86
Provide supportive care ................................................................................................................... 86
Brief intervention and relapse prevention ....................................................................................... 88
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Maternal and neonatal care ........................................................................................................... 89
2.7 ALCOHOL, TOBACCO, OTHER DRUGS & PREGNANCY .............................................................................. 93
Harm and risk for withdrawal from drug use during pregnancy ..................................................... 94
Antenatal Care ................................................................................................................................ 96
Client Education .............................................................................................................................. 97
Screening ......................................................................................................................................... 99
Managing withdrawal during pregnancy ...................................................................................... 100
Categories: .................................................................................................................................... 102
Discharge planning ........................................................................................................................ 103
Neonatal Abstinence Syndrome (NAS) .......................................................................................... 103
Care of neonate with NAS ............................................................................................................. 104
Medical treatment of significant NAS ........................................................................................... 104
2.8 BLOOD BORNE VIRUSES .................................................................................................................. 106
Testing ........................................................................................................................................... 106
Hepatitis B ..................................................................................................................................... 109
Hepatitis C ..................................................................................................................................... 110
Risk Factors ................................................................................................................................... 116
Transmission during pregnancy .................................................................................................... 117
Clinical assessment and investigation of chronic hepatitis C ........................................................ 118
Clinical evidence of cirrhosis .......................................................................................................... 120
Human Immuno-deficiency Virus (HIV) ......................................................................................... 122
Post Exposure Prophylaxis (PEP) ................................................................................................... 122
2.9 COMORBIDITY: CO-EXISTING ATOD AND MENTAL HEALTH PROBLEMS .................................................... 126
Role of early identification and intervention ................................................................................. 127
Principles for intervention in an Acute setting .............................................................................. 131
Comorbidity Assessment in Acute Emergency Setting .................................................................. 133
Principles of care ........................................................................................................................... 136
Nursing Management in the Acute Emergency Setting ................................................................ 137
General Care .................................................................................................................................. 138
Other Nursing Management ......................................................................................................... 143
SECTION 3 DRUG-SPECIFIC NURSING CARE ....................................................................................... 149
3.1 DEPRESSANTS ............................................................................................................................... 151
3.1.1 ALCOHOL ..................................................................................................................................... 152
Introduction ................................................................................................................................... 152
Critical situations ........................................................................................................................... 156
Indicators of harmful alcohol use and risk of withdrawal ............................................................. 159
Alcohol withdrawal regimes .......................................................................................................... 159
Nursing management of alcohol withdrawal ................................................................................ 165
3.1.2 OPIOIDS (OPIATES) ........................................................................................................................ 176
Introduction ................................................................................................................................... 176
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Opioid withdrawal ......................................................................................................................... 184
Clinical management..................................................................................................................... 185
Special considerations ................................................................................................................... 188
Using buprenorphine in opioid withdrawal—suggested dosing protocol ..................................... 194
Pharmacotherapy treatment for opioid dependence .................................................................... 196
Nursing guidelines—maintenance pharmacotherapy in the acute hospital setting ..................... 206
Methadone .................................................................................................................................... 206
Opioid Withdrawal in Pregnancy .................................................................................................. 212
Neonatal Abstinence Syndrome NAS ............................................................................................. 220
3.1.3 PAIN AND ANALGESIA ..................................................................................................................... 224
Pain management for people receiving opioid pharmacotherapy ................................................ 224
Effective pain management .......................................................................................................... 225
3.1.4 BENZODIAZEPINES ......................................................................................................................... 234
Introduction ................................................................................................................................... 234
Neonates ....................................................................................................................................... 240
3.1.5 GAMMA HYDROXYBUTYRATE (GHB) ................................................................................................. 242
Introduction ................................................................................................................................... 242
3.2 CANNABIS .................................................................................................................................... 246
Introduction ................................................................................................................................... 246
Cannabis intoxication .................................................................................................................... 246
Maternal and neonatal care ......................................................................................................... 250
3.3 PSYCHO-STIMULANTS ..................................................................................................................... 252
3.3.1 NICOTINE ..................................................................................................................................... 253
Introduction ................................................................................................................................... 253
Pharmacological management ..................................................................................................... 257
3.3.2 AMPHETAMINES ............................................................................................................................ 262
Introduction ................................................................................................................................... 262
Amphetamine intoxication ............................................................................................................ 263
Amphetamine withdrawal ............................................................................................................ 269
Maternal and neonatal care ......................................................................................................... 273
3.3.3 COCAINE ...................................................................................................................................... 275
Introduction ................................................................................................................................... 275
Nursing Management ................................................................................................................... 282
Maternal and Neonatal Care ........................................................................................................ 290
3.4. OTHER DRUGS ................................................................................................................................. 292
3.4.1 HALLUCINOGENS ........................................................................................................................... 293
Introduction ................................................................................................................................... 293
3.4.2 LSD ............................................................................................................................................. 295
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LSD Intoxication ............................................................................................................................. 295
3.4.3 PSILOCYBIN (MAGIC MUSHROOMS) .................................................................................................... 296
Psilocybin Intoxication ................................................................................................................... 296
3.4.4 PHENCYCLIDINE (PCP) .................................................................................................................... 297
3.4.5 METHYLENE DIOXY-METHAMPHETAMINE (ECSTASY) AND OTHER AMPHETAMINE TYPES ................................ 299
3.5 OTHER DRUGS .............................................................................................................................. 302
3.5.1 KETAMINE .................................................................................................................................... 303
Introduction ................................................................................................................................... 303
Ketamine intoxication ................................................................................................................... 303
Ketamine overdose ........................................................................................................................ 305
3.5.2 INHALANTS (SOLVENTS) .................................................................................................................. 306
Introduction ................................................................................................................................... 306
Health effects ................................................................................................................................ 307
Assessment and quantification ..................................................................................................... 310
Inhalant intoxication ..................................................................................................................... 313
Safety issues during acute intoxication ......................................................................................... 314
Inhalant overdose .......................................................................................................................... 315
Inhalant withdrawal ...................................................................................................................... 315
Screening and medical investigations ........................................................................................... 316
Other interventions ....................................................................................................................... 316
Maternal and Neonatal Care ........................................................................................................ 317
3.5.3 ANABOLIC ANDROGENIC STEROIDS (AAS) ........................................................................................... 318
Introduction ................................................................................................................................... 318
Effects of AAS use .......................................................................................................................... 321
Myths and misinformation ............................................................................................................ 324
Harm reduction information AAS use ............................................................................................ 326
SECTION 4 APPENDICES & REFERENCES ............................................................................................ 330
Screening Tools ............................................................................................................................. 331
Assessment Tools .......................................................................................................................... 331
Overdose Monitoring Tool............................................................................................................. 331
Withdrawal Monitoring Tools ....................................................................................................... 331
REFERENCES ........................................................................................................................................... 381

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LLiisstt ooff FFiigguurreess
List of Figures
Figure 1: Spectrum of problems and examples of types of associated problems .................................... 12
Figure 2: The interactive model of the ATOD use experience .................................................................. 16
Figure 3: Flow Chart .................................................................................................................................. 51
Figure 4: Assessment and intervention .................................................................................................... 61
Figure 5: Shared (integrated) Care according to Comorbidity Severity .................................................. 129
Figure 6: Progress of alcohol withdrawal from time of last drink .......................................................... 155
Figure 7: Progress of the acute phase of opioid withdrawal last dose ................................................... 188
Figure 8: Severity of signs and symptoms .............................................................................................. 238

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LLiisstt ooff TTaabblleess
List of Tables
Table 1: Summary of common theories of ATOD use ............................................................................... 11
Table 2: Drug use questions & their purposes .......................................................................................... 40
Table 3: Factors assisting decisions about appropriate venue for care/treatment .................................. 47
Table 4: Matching stages of change to intervention strategy .................................................................. 57
Table 5: Symptoms & effects of drugs ...................................................................................................... 65
Table 6: Duration of detectable drugs in urine ......................................................................................... 69
Table 7: Summary of harm and withdrawal potential from drug use during pregnancy ......................... 94
Table 8: Initial Testing for Hepatitis C ..................................................................................................... 118
Table 9: Further Testing for Hepatitis C .................................................................................................. 119
Table 10: Priorities for Comorbidity assessment in the acute setting .................................................... 135
Table 11: Time taken for alcohol to be cleared from breast milk (hours: minutes) ............................... 173
Table 12: Times of onset of withdrawal syndrome in dependent opioid users ..................................... 187
Table 13: Daily buprenorphine dose ....................................................................................................... 194
Table 14: Use with symptomatic medications ........................................................................................ 195
Table 15: Drug interactions with buprenorphine .................................................................................. 200
Table 16: Drug interaction with opioids ................................................................................................. 208
Table 17: Absorption rates, half-life, and equivalent daily doses of common benzodiazepines............ 235
Table 18: Fagerstrom Test Score - level of NRT according to level of dependence ................................ 254
Table 19: Commonly prescribed medications to manage complications ............................................... 284
Table 20: Various inhalants and their affects in the body ...................................................................... 309
Table 21: Key domains of clinical assessment of inhalant use ............................................................... 312

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