Mental health

Opioid and substance use

NCLEX addictions chapter: opioid overdose and naloxone, opioid withdrawal cues, stimulant and sedative patterns, and recovery safety teaching.

Clesial Editorial TeamReviewed by Clesial Editorial Team, Clinical Content Review

4 minUpdated Aug 6, 2026

Contents7 sections

Non-alcohol substance items ask whether the client is not breathing from opioids, climbing out of their skin from stimulants, or withdrawing in a way that still needs nursing skill. Alcohol withdrawal and delirium tremens live in Substance use and withdrawal — this chapter owns opioids and the broader SUD safety map.

Opioid overdose and naloxone

Opioids blunt the drive to breathe. The classic triad is decreased consciousness, slow shallow respirations, and pinpoint pupils. Your first job is ventilation and oxygenation — open the airway, give breaths or oxygen per protocol, then reverse with naloxone as ordered. Naloxone displaces opioid from receptors; the client may wake agitated and in withdrawal pain, and the opioid can outlast a single naloxone dose, so stay and reassess.

Naloxone nasal spray rescue device on white linen. — Naloxone nasal spray — reverse opioids, then stay and reassess breathing.

Support airway and breathing now — reversal does not replace ventilation.
Give naloxone as ordered; prepare to repeat when RR falls again.
Check for mixed use (alcohol, benzos) that naloxone will not fully fix.

Safety

After naloxone, do not discharge attention early — recurrent respiratory depression is the trap.

Community and discharge teaching includes recognizing overdose, calling emergency services, and using naloxone kits when available. Stigma teaching fails the stem: a calm, factual approach gets more accurate last-use history for safe dosing of pain meds and for MAT planning.

Opioid withdrawal vs alcohol emergencies

Opioid withdrawal looks loud: yawning, runny nose, tearing, goosebumps, abdominal cramps, diarrhea, myalgias, and intense craving. Autonomic signs appear, but the seizure and delirium tremens pathway that defines alcohol withdrawal is not the usual opioid story. Treat symptoms as ordered (comfort meds, hydration), prevent complications, and connect to treatment — do not dismiss the client as “just drug seeking” when they are acutely sick from withdrawal.

	Opioid withdrawal	Alcohol withdrawal (other chapter)
Look	Flu-like + craving + diarrhea	Tremor, HTN, tachy → seizure/DT risk
Airway killer	Usually the overdose, not the withdrawal	Seizure / DT / aspiration
Priority meds (as tested)	Supportive / MAT pathway	Benzodiazepines + thiamine

Other substances on exams

Stimulants (cocaine, amphetamines) push heart rate, blood pressure, and temperature up and can tip into chest pain, arrhythmia, seizure, or rhabdomyolysis. Priority is cardiac monitoring, cooling, hydration as ordered, and a low-stimulus environment. Physical restraints that fight a hyperthermic agitated client worsen muscle breakdown — use least restrictive safety and ordered sedation pathways.

Pattern	Priority angle
Stimulant high	Cardiac / hyperthermia / agitation safety
Benzo or barbiturate OD	Airway and breathing first
Cannabis / hallucinogen panic	Calm milieu; safety; rare medical emergency unless trauma
Inhalants	Sudden sniffing death / arrhythmia risk — oxygen and cardiac watch

Substance use disorder care on the NCLEX is still nursing process: assess last use and route, protect ABCs, treat acute toxicity or withdrawal, then offer brief intervention and referral. Medication-assisted treatment stems expect you to know that methadone and buprenorphine are prescribed pathways — not “trading one addiction” as a nursing judgment to withhold — and that stacking sedatives raises overdose risk.

Ask amount, route, time of last use — it changes monitoring and dosing.
Needle-use stems: infection and HIV/hepatitis counseling without moralizing.
Pain in recovery: multimodal plans as ordered; do not abandon analgesia out of fear alone.

Priority map

Situation	First move
RR 6 + pinpoint pupils	Ventilate; naloxone as ordered; stay and reassess
Opioid withdrawal diarrhea + craving	Supportive care; treatment link — not DT algorithm
Cocaine chest pain + agitation	ABCs; cardiac monitor; cool/calm
Mixed OD unknown	Airway first; naloxone if opioid picture; do not assume one antidote fixes all

Revision

Must know

1Opioid overdose: pinpoint pupils, slow/absent respirations, decreased LOC — airway support and naloxone as ordered; expect repeat doses as naloxone wears off.
2Naloxone reverses opioids, not alcohol or benzos alone — still support breathing for mixed overdoses.
3Opioid withdrawal is miserable (yawning, rhinorrhea, goosebumps, diarrhea, craving) but usually not the same seizure/DT emergency as alcohol — still treat comfort and complications.
4Alcohol withdrawal, thiamine, and DT priorities live in Substance use and withdrawal.
5Stimulant intoxication: tachy, hypertension, hyperthermia, agitation — cool, calm, cardiac watch; avoid restraints that worsen rhabdo when possible.
6Sedative/hypnotic overdose: respiratory depression — airway first; flumazenil is not a casual home antidote on exams.
7Therapeutic communication: nonjudgmental, ask about last use and amounts for dosing safety, offer naloxone teaching to peers/family when ordered.
8MAT teaching (methadone/buprenorphine as tested): take only as prescribed; mixing with other CNS depressants raises overdose risk.

Memory hooks

Slow, small, sleepy = opioid
Bradypnea, miosis, and falling LOC point to opioid toxicity until proven otherwise.
Naloxone is a bridge
It buys breathing time. Effects can fade — monitor and redose as ordered.

How it's tested

Stems ask first action for a client with RR 6 and pinpoint pupils, what naloxone does, how opioid withdrawal differs from alcohol DT, or how to speak with a client who uses. Distractors start with a lecture, give flumazenil for opioid OD, or leave after one naloxone dose.

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