Substance Use/Abuse, Overdose, Withdrawal, Intoxication
Also Consider: Behavioral Disturbance, Delirium, Mental Status Change, Mood Change
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Symptoms & Signs
Suspect with history of substance abuse; previous overdose, withdrawal, legal issues
Possession of substances in the facility
Desire to leave the facility for temporary excursions or for premature discharge; odors, new needle marks, behavior or mood changes (particularly when returning from an excursion or after visitation)
Overdose/Withdrawal: Varies by substance used and are often nonspecific, such as drowsiness, slurred speech, lack of coordination, anxiety,nausea, sweats. Synthetic opioids can cause an overdose with minimal contact. Opioid overdose is more likely in patients also receiving other sedatives, such as benzodiazepines (lorazepam, alprazolam, etc), hypnotics (zolpidem, etc) or alcohol.
Opioid overdose: unresponsive, apneic or with diminished respirations, lack of response to sternal rub, bluish lips or nail beds
(consider immediate treatment of Opioid overdose with naloxone per protocol or standing order)
Goals are to treat the substance abuse disorder, minimize risks to the patient, and identify and treat drug overdose or withdrawal promptly. Both overdose and withdrawal are possible even when medications are used as prescribed.
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Do not enter an overdose scene where drug residues are visible and staff exposure could occur. Activate EMS (911) system. Don N95 respirator, gown, gloves, and eye protection. Wash hands with soap and water (not hand sanitizer) afterwards.
Acute mental status change, unresponsiveness, response to sternal rub
Not eating or drinking as much as usual
Fainting, dizziness or lightheadedness when standing up
Acute decline in ADL abilities
Diaphoresis: Cold, clammy, pale skin
Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress, diminished respirations
Cardiovascular: Chest pain, new irregular pulse, cyanosis, mottling, edema
GI: Nausea, vomiting, diarrhea, constipation, bowel sounds
Neurologic changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)
Skin: sweats (diaphoresis), cold/clammy/pale skin; bluish lips or nail beds, needle marks
Blood glucose (patients with diabetes)
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
Overdose, severe behavioral disturbance endangering the patient or others, or severe withdrawal symptoms
Notify medical staff & resident representative within the next 16 hours.
New suspicion of substance use/abuse
Notify medical staff on the next business day
Change in chronic pattern of substance use/abuse, request for treatment for substance use disorder
Notify medical staff at the next regular rounds
History of substance use/abuse, no longer active
SBAR Report
Situation: "Substance use associated with:" (overdose) (acute symptoms) (withdrawal)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the problems started, how severe they are, getting worse or staying the same, what treatments have been used.
Abnormal vital signs or changes with lying and standing
History of substance use or abuse
MOLST / Advance Directives
General observation of patient condition
Current orders for controlled substances, psychoactive medications
Abnormal findings on eye, lung, cardiovascular, abdomen, neurologic or skin observations.
Signs or symptoms of overdose or withdrawal
Assessment: I am concerned about: __________
Recommendations/Requests:
Labs: CBC, Lactic Acid, CMP/Chem14, Drug levels, Ethanol level, Urine drug screen
INR if patient is on warfarin
EKG
Stop an interacting medication
Start medication assisted treatment
Refer for treatment of substance use disorder or behavioral health services
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
If naloxone is used and the patient is not hospitalized, monitor the patient every 15 minutes for 8 hours (naloxone may wear off before the opioid is out of the patient’s system).
Neuro checks per facility policy/procedure
Monitor vital signs and symptoms every 4-8 hrs for 1-2 days
Place on 24-hour report for 2-3 days
Obtain lab results (if ordered), and notify medical as needed of:
Significantly abnormal values in lab tests (refer to appropriate Situation)
Positive urine drug screen
Ethanol level >50mg/dl or >0.05%
EKG report abnormal
Update care plan regarding risk for substance use in the facility, elopement risk, monitoring for overdose or withdrawal, supervision for safety (particular after visitation or excursion from the facility)
Review status and plan of care with resident representative daily or with any changes
Educate the resident and the resident’s representative: risks of leaving the facility to seek out substances, unplanned discharge, treatment options, support group meetings.
Notify administration for potential referral to law enforcement for illicit substances. Facility staff do not act as an arm of law enforcement.
Update advance directives if appropriate
2025-04-27
Page updated
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