Mental health
Opioid and substance use
NCLEX addictions chapter: opioid overdose and naloxone, opioid withdrawal cues, stimulant intoxication, sedative overdose, and recovery safety teaching.
ClesialReviewed by Sophia Bennett, RN
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. Reversal without ventilation leaves a blue client waiting on a drug to work.
Naloxone displaces opioid from receptors. The client may wake agitated and in withdrawal pain. Many street and prescription opioids outlast a single naloxone dose, so stay, reassess RR and SpO2, and prepare to repeat doses or start a continuous infusion as ordered. Naloxone does not reverse alcohol or benzodiazepines — mixed overdoses still need airway support after the opioid piece is antagonized.
- 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.
- Recover in a monitored setting; early “feels fine” discharges miss renarcotization.
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 (piloerection), 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, clonidine/antiemetics/antidiarrheals per protocol), 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 |
Medication-assisted treatment
Methadone and buprenorphine are prescribed treatment pathways, not “trading one addiction” as a nursing judgment to withhold. Teach take-only-as-prescribed, clinic dosing rules for methadone, and the overdose risk of stacking benzodiazepines, alcohol, or other sedatives. Buprenorphine can precipitate withdrawal if started too soon after full-agonist opioids — timing follows the order set. Pain in recovery still deserves a plan; multimodal analgesia and specialist input beat abandonment.
Stimulants and other substances
Stimulants (cocaine, amphetamines, methamphetamine) push heart rate, blood pressure, and temperature up and can tip into chest pain, arrhythmia, seizure, stroke, or rhabdomyolysis. Priority is ABCs, 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; chest pain = ACS pathway |
| Benzo or barbiturate OD | Airway and breathing first; flumazenil is not casual |
| Cannabis / hallucinogen panic | Calm milieu; safety; rare medical emergency unless trauma |
| Inhalants | Sudden sniffing death / arrhythmia risk — oxygen and cardiac watch |
Sedative-hypnotic overdose looks like opioid overdose without the reliable pinpoint-pupil stamp: falling LOC and respiratory depression. Airway first. Flumazenil for benzodiazepines is a specialist/controlled decision on exams because it can precipitate seizures in chronic users — do not treat it like home naloxone. Substance use disorder care is still nursing process: assess last use and route, protect ABCs, treat acute toxicity or withdrawal, then offer brief intervention and referral.
- 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.
- Family naloxone teaching saves lives when opioids remain in the environment.
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 |
| MAT + new benzo prescription | Overdose-risk teaching; clarify with prescriber |
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.
Stimulant = speed the vitals
High HR, high BP, high temperature, and agitation need cool, calm, cardiac watching.
On the exam
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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