Substance Misuse and Alcohol Use Disorders
A. Several factors increase the risks associated with alcohol and drug use for the older individual; continuing drug use patterns that were commonplace earlier in life can be potentially harmful. Constitutional risk factors include changes in body composition such as decreased muscle mass, decreased organ efficiency (especially kidney and liver), and increased vulnerability of the central nervous system (CNS).
B. Alcohol use in combination with other drugs or used excessively may result in falls, impaired cognition, malnourishment, and decreased resistance to disease, as well as interpersonal and legal problems.
C. At-risk drinking (more than one drink per day or more than three drinks on one occasion) by older adults increases the likelihood of negative health consequences.
D. Any smoking is considered drug abuse and places the person at risk for negative health consequences; advancing age increases the likelihood of respiratory and cardiovascular illnesses.
BACKGROUND AND STATEMENT OF THE PROBLEM
A. The use of alcohol, tobacco, illicit drugs, and the misuse of prescription drugs can result in SUDs. These are classified on a continuum of mild, moderate, and severe based on the number of symptoms associated with drug use.
- Symptoms include mental or physical health problems; impairment in the performance of social, family, work, and civil role relationships because of excessive and frequent use of a substance or multiple substances. For 25% of the U.S. population, at-risk drinking—defined as more than one drink per day, 7 days a week, or more than three drinks on any one occasion for persons 65 years and older—is an example of drug use that results in short- and long-term health problems. For older adults, at-risk drinking increases the likelihood of negative health consequences, including depression, falls, impaired motor function, and interactions with prescription drugs.
- The frequency and quantity of the drug used generally determines the extent of a SUD. For example, heavy drinking—five or more drinks (four for women) every day for more than 5 days in the past 30 days—can result in health, safety, and social problems. In addition, some drugs, including alcohol, opioids, nicotine, benzodiazepines, and barbiturates, induce tolerance, defined as
- A need for markedly increased amounts of alcohol to achieve intoxication or desired effect
- A markedly diminished effect with continued use of the same amount of the drug
- Tolerance drives the need to increase amounts of a drug in an effort to achieve the “high” experienced on early use and is indicative of physiological dependence.
- When physiological dependence has developed, sudden cessation of use of the drug precipitates withdrawal, characteristic signs and symptoms derived from the chemical properties of the drug. The continuous use of alcohol, opioids, and sedating drugs results in CNS depression, and withdrawal symptoms can be nausea, agitation (mild) to seizure, and fluid and electrolyte disorder (severe).
- Untreated withdrawal from depressant drugs can be life threatening. Older adults, especially those with comorbid conditions, must be monitored closely and appropriately medicated.
- Decreased metabolic capacity for any drug places older adults at risk for intoxication and interaction or potentiation of other prescription or illicit drugs. Intoxication is evidenced in signs such as drowsiness, slurred speech, and uneven gait following consumption of sedative drugs such as opioids, alcohol, or barbiturates or agitation, anxiety, and mania associated with the use of cocaine or other stimulants. The symptoms derive from the effects of the drug properties. Of note, women develop more pathology from lower levels of alcohol consumption than do men of the same age as a function of their physiological vulnerability. Intoxication will have an earlier onset even with tolerance, and withdrawal can be more severe. An aging metabolism complicates these constitutional traits.
- Drug misuse is a common practice among older adults but is not limited to this population. Drug misuse is defined as taking a drug for purposes other than that for which the drug was prescribed or intended to achieve a desired effect. Because older adults are often prescribed five or more drugs as common practice in the treatment of chronic illness and common health problems, reliance on pharmacotherapy to address pain, sleep disorders, depression, and general malaise is not uncommon. A comprehensive history of drug use (including tobacco and alcohol) is important in identifying this problem as well as polysubstance-related disorder, defined as misuse, abuse, or dependence on three or more drugs that have psychotropic effects. For older adults, this is often a combination of illicit and prescription drugs and often includes nicotine and/or alcohol.
- Older adults, once engaged in treatment for an SUD, have good rates of recovery. Recovery means learning and maintaining a lifestyle of sobriety at various levels of personal health and the capacity to engage productively with society. Early recovery spans a first year, and, beyond 1 year, recovery is referred to as “sustained.” Relapse, or returning to regular use of a substance in a maladaptive pattern, is a lifetime concern, which is why persons often self-refer as “recovering.” SUDs are chronic illnesses that require ongoing monitoring and self-care and may include medication.
B. Etiology and/or epidemiology: Of persons older than 50 years, 16.7% reported drinking two or more drinks per day (risky drinking), and 19.6% reported binge drinking on occasion. Among primary care patients older than 60 years, 15% of men and 12% of women regularly drank in excess of the NIAAA-recommended levels (one drink per day and no more than three drinks on any one occasion).
- The drugs used and misused most frequently by older adults are nicotine, alcohol, and prescription drugs, particularly analgesics and benzodiazepines.
- Excessive drinking by individuals of all ethnic groups ages 65 years and older is approximately 7%, down from 12% in persons aged 55 to 64 years.
- Five hundred thousand persons aged 55 years and older reported monthly use of illicit drugs in the National Household Survey on Drug Use, NIDA.
- Approximately 11% of women older than 59 years misuse psychoactive drugs.
C. Risk factors (USDHHS, 2004a)
- Family history of dependence on alcohol, tobacco, prescription, or illicit drugs
- Co-occurring moderate to severe SUD of another substance (i.e., alcohol and tobacco)
- Lifelong pattern of substance use, including heavy drinking
- Male gender
- Social isolation
- Recent and multiple losses
- Chronic pain
- Co-occurrence with depression
- Unpartnered and/or living alone
PARAMETERS OF ASSESSMENT
A. Screening for alcohol, tobacco, and other drug use is recommended for all community-dwelling and hospitalized older adults. It is essential that the nurse:
- State the purpose of questions about substances used and link them to health and safety.
- Be empathic and nonjudgmental; avoid stigmatic terms such as alcoholic.
- Ask the questions when the patient is alcohol and drug free.
- Inquire about the patient’s understanding of the question (Aalto, Pekuri, & Seppä, 2003).
B. Assessment and screening tools
- The QF Index (Khavari & Farber, 1978): Review all classes of drugs, alcohol, nicotine, illicit drugs, prescription drugs, OTC drugs, and vitamin supplements, for each drug used. Record the types of drugs, including the kinds of beverages. Note the frequency: The number of occasions on which the drug is consumed (daily, weekly, and monthly). Record the amount of drug consumed on each occasion over the past 30 days. The psychological function, what the drugs do for the individual, is also important to identify. The QF Index tool should be part of the intake nursing history. The brown bag approach is also useful. Ask the patient to bring all drugs and supplements he or she uses in a brown bag to the interview.
- SMAST-G: Highly valid and reliable, this is a 10-item tool that can be used in all settings. Between 2 and 3 minutes are needed for administration. This instrument is derived from the SMAST-G with a sensitivity of 93.6% and a positive predictive value of 87.2% (Blow et al., 1992).
- The AUDIT: This 10-item questionnaire has good validity in ethnically mixed groups, and scores classify alcohol use as hazardous, harmful, or dependent; administration: 2 minutes. Sensitivity scores range from 0.74% to 0.84% and specificity around 0.90% in groups of mixed age and ethnicity (Allen, Litten, Fertig, & Babor, 1997). This instrument is highly effective for use with older adults (Roberts, Marshall, & Macdonald, 2005). Its derivative, the AUDIT-C, is composed of three questions that have proved equally valid in detecting an alcohol-related problem.
- Fagerström Test for Nicotine Dependence (Pomerleau et al., 1994): This six-question scale provides an indicator of the severity of nicotine dependence: scores of less than 4 (very low), 4 to 6 (moderate), and 7 to 10 (very high). The questions inquire about first use early in the day, amount and frequency, inability to refrain, and smoking despite illness. This instrument has good internal consistency and reliability in culturally diverse, mixed-gender samples (Pomerleau et al., 1994).
C. Atypical presentation
- Men and women older than 65 years may have substance-related disorder problems even though the signs and symptoms may be less numerous than those listed in the DSM-5 (APA, 2013).
D. Signs of CNS intoxication (i.e., slurred speech, drowsiness, unsteady gait, decreased reaction time, impaired judgment, disinhibition, ataxia)
- Assess by individual or collateral (speaking with family members) data collection; detail the consumption of amount and type of depressant medications, including alcohol, sedatives, hypnotics, and opioid or synthetic opioid analgesics.
- Obtain a blood alcohol level. Marked intoxication occurs at 0.3% to 0.4%, toxic effects occur at 0.4% to 0.5%, and coma and death occur at 0.5% or higher.
- Assess vital signs and determine respiratory, cardiac, or neurological depression.
- Assess for existing medical conditions, including depression.
- Arrange for emergency department or hospitalization treatment as necessary.
- Obtain urine for toxicology, if possible.
- Assess for delirium, which can be confused with intoxication and withdrawal in the older adult.
E. At-risk drinking is regular consumption of alcohol in excess of one drink per day for 7 days a week or more than three drinks on any one occasion.
- Assess for readiness to change behavior using SBIRT.
- Is the drinker concerned about the amount or consequences of the drinking? Has he or she contemplated cutting down?
- Does he or she have a plan for cutting down or stopping consumption?
- Has he or she previously stopped but then resumed risky drinking?
- Personalized feedback and education on “at-risk drinking” results in a reduction in at-risk drinking among older primary care patients.
F. Treatment of acute AWS (guidelines are modified for other CNS-depressant drugs such as barbiturates, heroin, sedative hypnotics)
- Assess for risk factors: (a) previous episodes of detoxification; (b) recent heavy drinking; (c) medical comorbidities, including liver disease, pneumonia, and anemia; and (d) previous history of seizures or delirium (Wetterling, Weber, Depfenhart, Schneider, & Junghanns, 2006).
- Assess for extreme CNS stimulation and a minor withdrawal syndrome evidenced in tremors, disorientation, tachycardia, irritability, anxiety, insomnia, and moderate diaphoresis. When these signs are not detected, life-threatening situations for older adults often result. Withdrawal, occurring 24 to 72 hours after the last drink, can progress to seizures, hallucinosis, withdrawal delirium, extreme hypertension, and profuse diarrhea from 4 to 8 hours and for up to 72 hours following cessation of alcohol intake (DTs).
- Assess neurological signs, using the CIWA-Ar. The CIWA-Ar is a 10-item rating scale that delineates symptoms of gastric distress, perceptual distortions, cognitive impairment, anxiety, agitation, and headache (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989).
- Medicate with a short-acting benzodiazepine (lorazepam or oxazepam) in doses titrated to the patient’s score on the CIWA-Ar, patient’s age, and weight; use one third to one half the recommended dose (Amato, Minozzi, Vecchi, & Davoli, 2010). Continue CIWA-Ar to monitor treatment response.
- Provide emotional support and frequent reorientation in a cool, low-stimulation setting; monitor hydration and nutritional intake. Give therapeutic dose of thiamine and multivitamins.
G. Report sleep disturbance, anxiety, depression, and problems with attention and concentration (acute care)
- Assess for neuropsychiatric conditions using the mental status exam, Geriatric Depression Scale, or Hamilton Anxiety Scale.
- Obtain sleep history because drugs disrupt sleep patterns in older persons.
- Assess intake of all drugs, including alcohol, OTC, prescription, herbal and food supplements, and nicotine. Use the “brown bag” strategy.
- If positive for alcohol use, assess for last time of use and amount used.
- Assess for alcohol or sedative drug withdrawal as indicated.
H. Smoking cigarettes, e-cigarettes, hookah, or using smokeless tobacco
- Assess for level of dependence using the Fagerström Test (see “Screening Tools for Alcohol and Drug Use” section).
NURSING CARE STRATEGIES
A. At-risk drinking (consumption of alcohol in excess of one drink per day for 7 days a week or more than three drinks on any one occasion) or excess alcohol consumption (more than three to four drinks on frequent occasions):
- Conduct screening, brief intervention, and, as indicated, referral to treatment: (SAMHSA, 2018)
- Screen using the AUDIT-C, AUDIT, or SMAST-G.
- Provide feedback information to the client about current health problems or potential problems associated with the level of alcohol or other drug consumption.
- Stress client’s responsible choice about actions in response to the information provided.
- Advice must be clear about reducing his or her amount of drinking or total consumption.
- Recommend drinking according to NIAAA levels for older adults.
- Provide a menu of choices to the patient or client regarding future drinking behaviors.
- Offer information based on scientific evidence, acknowledge the difficulty of change, and avoid confrontation. Empathy is essential to the exchange.
B. Support self-efficacy. Help client explore options for change.
- Assist client in identifying options to solve the identified problem.
- Review the pros and cons of behavior change options presented.
- Help client weigh potential decisions by considering outcomes.
C. Smoking cigars, cigarettes, e-cigarettes, or using smokeless tobacco
- Apply the five A’s intervention (Agency for Healthcare Research and Quality [formerly the Agency for Healthcare Policy and Research] Guidelines)
- Ask: Identify and document all tobacco use.
- Advise: Urge the user to quit in a strong personalized manner.
- Assess: Is the tobacco user willing to make a quit attempt at this time?
- Assist: If user is willing to attempt, refer for individual or group counseling and pharmacotherapy. Refer to telephone “quit lines” in region or state.
- Arrange referrals to providers, agencies, and self-help groups. Monitor pharmacotherapy once quit date is established. The U.S. FDA-approved pharmacotherapies for smoking cessation are the following:
- Bupropion SR (Zyban) and nicotine replacement products, such as nicotine gum, nicotine inhalers, nicotine nasal spray, and nicotine patch. Nurse-initiated education about these medications is essential.
- Zyban, for example, should not be combined with alcohol. Nurses working with inpatients in a case management model were found to produce outcomes in smoking cessation (Smith, Reilly, Houston Miller, DeBusk, & Taylor, 2002).
- Show caring, concern, and provide ongoing support.
- Communicate care and concern
- Encourage moderate-intensity exercise to reduce cravings for nicotine because 5 minutes of such exercise is associated with short-term reduction in the desire to smoke and in tobacco withdrawal symptoms (Daniel, Cropley, Ussher, & West, 2004).
- Schedule follow-up contact in person or by telephone within 1 week after planned quit date. Continue telephone counseling, especially with those using medications and nicotine patches (R. G. Boyle et al., 2005; Cooper et al., 2004).
D. Alcohol dependence
- Assess the patient for psychological dependence.
- Assess the patient for (a) physiological dependence and (b) “tolerance.” Psychological dependence occurs with both abuse and dependence and is more difficult to resolve.
- Assess need for medical detoxification (see alcohol withdrawal in “Inpatient Hospitalization” section).
- Refer patient and family to addictions or mental health nurse practitioner or physician.
- Evaluate patient and family capacity to implement referral.
- On successful detoxification, monitor use of medications, interpersonal therapies, and participation in self-help groups.
E. Marijuana dependence: Little research on effective intervention for psychological dependence on marijuana is available. Some guidance can be found for smoking cessation and self-help approaches.
- Refer to steps for smoking cessation (see section C of Nursing Care Strategies).
- Refer patient to addiction specialist for counseling for psychological dependence and/or treatment with cognitive behavioral therapy.
- Refer to community-based self-help groups such as Narcotics Anonymous, Alcoholics Anonymous, or Al-Anon.
- Encourage development or expansion of patient’s social support system.
F. Heroin or opioid dependence
- Older long-term opioid users may continue use, relapse, and seek treatment. Methadone or buprenorphine are current pharmacological treatment options that are effective in conjunction with self-help programs and/or psychosocial interventions.
- Treatment with methadone, a synthetic narcotic agonist, suppresses withdrawal symptoms and drug cravings associated with opioid dependence but requires daily dosing of 60 mg, minimum. It is dispensed only in state-licensed clinics.
- Treatment with buprenorphine (Subutex or Suboxone): Treatment occurs in office practice by trained physicians, with this opioid partial agonist–antagonist. Alone and in combination with naloxone (Suboxone), it can prevent withdrawal when someone ceases use of an opioid drug and then be used for long-term treatment. Naloxone is an opioid antagonist used to reverse depressant symptoms in opiate overdose and at different dosages to treat dependence (Center for Substance Abuse Treatment [CSAT], 2010).
- Close collaboration with the prescriber is required because these drugs should not be abruptly terminated or used with antidepressants, and they interact negatively with many prescription medications.
- Naltrexone, a long-acting opioid antagonist, blocks opioid effects and is most effective with those who are no longer opioid dependent but are at high risk for relapse (Srisurapanont & Jarusuraisin, 2005).
- Treatment of the older patient who has become addicted to Oxycontin or other opioids should be done in consultation with an addictions specialist nurse or physician.
- It is recommended that prescribers avoid opioids and synthetic opioids (Demerol, Dilaudid, and Oxycontin). Opioids have high potential for addiction, and Demerol has been associated with delirium in older adults (CSAT, 2010).
- Barbiturates should be avoided as hypnotics, and the use of benzodiazepines for anxiety should be limited to 4 months (USDHHS, 2004a).
G. Treatment and relapse prevention
- Monitor pharmacological treatment. The benefits of this treatment are dependent on adherence, and psychosocial treatment should accompany its use (World Health Organization, 2000). Methadone or buprenorphine should be used for long-term treatment of opioid dependence.
- In limited studies using a cognitive behavioral approach, group psychotherapy has produced good outcomes with older adults (Payne & Marcus, 2008).
- Refer to community-based groups, such as Alcoholics Anonymous, Narcotics Anonymous, Al-Anon groups, and encourage attendance.
- Educate family and patient regarding signs of risky use or relapse to heavy drinking or alcohol-dependent behavior.
- Counsel patient to reduce drug use (harm reduction), and engage in relationship healing or building, to engage in community or intellectually rewarding activities, spiritual growth, and so on, that increase valued nondrinking rewards.
- Counsel in the development of coping skills.
- Anticipate and avoid temptation.
- Learn cognitive strategies to avoid negative moods.
- Make lifestyle changes to reduce stress, improve the quality of life, and increase pleasure.
- Learn cognitive and behavioral activities to cope with cravings and urges to use.
- Encourage development or expansion of patient’s social support system.
EVALUATION AND EXPECTED OUTCOMES
A. Patient will have:
- Improved physical health and function
- Improved quality of life, sense of well-being, and mental health
- More satisfying interpersonal relationships
- Enhanced productivity and mental alertness
- Decreased likelihood of falls and other accidents
B. Nurses will demonstrate:
- Increased accuracy in detecting patient problems related to use or misuse of substances
- More evidence-based interventions resulting in better outcomes
C. Institution will have:
- Increased number of referrals to ambulatory substance abuse and mental health treatment programs
- Improved links with community-based organizations engaged in prevention, education, and treatment of older adults with substance-related disorders
FOLLOW-UP MONITORING OF CONDITION
A. Evaluate for increase in substance use or misuse associated with growing numbers of aging adults.
B. Increase outreach to targeted vulnerable populations.
C. Document chronic care needs of older adults diagnosed with substance-related disorders.
D. Monitor alcohol use among older adults with chronic pain.
E. Communicate findings to all members of the caregiver team.
The National Quality Forum has published Evidence-Based Practices to Treat Substance Use Disorders. These guidelines are inclusive of primary care, the settings in which older adults seek treatment (National Quality Forum, 2007).
APA American Psychiatric Association
AUDIT Alcohol Use Disorders Identification Test
AUDIT-C Alcohol Use Disorders Identification Test-Condensed
AWS Alcohol withdrawal syndrome
CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol, Revised
CNS Central nervous system
CSAT Center for Substance Abuse Treatment
DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
DTs Delirium tremens
FDA Food and Drug Administration
NIAAA National Institute on Alcohol Abuse and Alcoholism
NIDA National Institute on Drug Abuse
NQF National Quality Forum
OTC Over the counter
QF Quantity frequency
SAMHSA Substance Abuse and Mental Health Services Administration
SBIRT Screening, brief intervention, and referral to treatment
SMAST-G Short Michigan Alcohol Screening Test-Geriatric version
USDHHS U.S. Department of Health and Human Services
Updated: November 2020
Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description
Chapter 34: McCabe D., Knapp, M., & Naegle, M. (2021) Substance Misuse and Alcohol Use Disorder in the Older Adult. In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 609-632). New York: Springer.
Aalto, M., Pekuri, P., & Seppä, K. (2003). Primary health care professionals’ activity in intervening in patients’ alcohol drinking during a 3-year brief intervention implementation project. Drug and Alcohol Dependence, 69(1), 9–14. doi:10.1016/S0376-8716(02)00228-4. Evidence Level III.
Allen, J. P., Litten, R. Z., Fertig, J. B., & Babor, T. (1997). A review of research on the Alcohol Use Disorders Identification Test (AUDIT). Alcoholism, Clinical and Experimental Research, 21(4), 613–619. doi:10.1111/j.1530-0277.1997.tb03811.x. Evidence Level III.
Amato, L., Minozzi, S., Vecchi, S., & Davoli, M. (2010). Benzodiazepines for alcohol withdrawal. Cochrane Database of Systematic Reviews, (3), CD005063. doi:10.1002/14651858.CD005063.pub3. Evidence Level I.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Evidence Level VI.
Boyle, R. G., Solberg, L. I., Asche, S. E., Boucher, J. L., Pronk, N. P., & Jensen, C. J. (2005). Offering telephone counseling to smokers using pharmacotherapy. Nicotine & Tobacco Research, 7(Suppl. 1), S19–S27. doi:10.1080/14622200500078048. Evidence Level III.
Center for Substance Abuse Treatment. (2010). Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: A treatment improvement protocol, series 40 (DHHS Publication [SMA] 04–3939). Rockville, MD: Substance Abuse and Mental Health Services Administration. Evidence Level VI.
Cooper, T. V., DeBon, M. W., Stockton, M., Klesges, R. C., Steenbergh, T. A., Sherrill-Mittleman, D., & Johnson, K. C. (2004). Correlates of adherence with transdermal nicotine. Addictive Behaviors, 29(8), 1565–1578. doi:10.1016/j.addbeh.2004.02.033. Evidence Level III002E
Daniel, J., Cropley, M., Ussher, M., & West, R. (2004). Acute effects of a short bout of moderate versus light intensity exercise versus inactivity on tobacco withdrawal symptoms in sedentary smokers. Psychopharmacology, 174(3), 320–326. doi:10.1007/s00213-003-1762-x. Evidence Level II.
Khavari, K. A., & Farber, P. D. (1978). A profile instrument for the quantification and assessment of alcohol consumption. The Khavari Alcohol Test. Journal of Studies on Alcohol, 39(9), 1525–1539. doi:10.15288/jsa.1978.39.1525. Evidence Level VI.
National Quality Forum. (2007). Evidence-based treatment practices for substance use disorders: A workshop. Washington, DC: Author. Retrieved from http://www.qualityforum.org. Evidence Level VI.
Payne, K. T., & Marcus, D. K. (2008). The efficacy of group psychotherapy for older adult clients: A meta-analysis. Group Dynamics: Theory, Research, and Practice, 12(4), 268–278. doi:10.1037/a0013519. Evidence Level III.
Pomerleau, C. S., Carton, S. M., Lutzke, M. L., Flessland, K. A., & Pomerleau, O. F. (1994). Reliability of the Fagerstrom Tolerance Questionnaire and the Fagerstrom Test for nicotine dependence. Addictive Behaviors, 19(1), 33–39. doi:10.1016/0306-4603(94)90049-3. Evidence Level V.
Roberts, A. M., Marshall, E. J., & Macdonald, A. J. (2005). Which screening test for alcohol consumption is best associated with “at risk” drinking in older primary care attenders? Primary Care Mental Health, 3(2), 131–138. Retrieved from https://auditscreen.org/cmsb/uploads/2005-which-screening-test-for-alcohol-consumption-is-best-associated-with-at-risk-drinking-in-older-primary-care-attenders.pdf. Evidence Level III.
Smith, P. M., Reilly, K. R., Houston Miller, N., DeBusk, R. F., & Taylor, C. B. (2002). Application of a nurse-managed inpatient smoking cessation program. Nicotine & Tobacco Research, 4(2), 211–222. doi:10.1080/14622200210123590. Evidence Level III.
Srisurapanont, M., & Jarusuraisin, N. (2005). Naltrexone for the treatment of alcoholism: A meta-analysis of randomized controlled trials. International Journal of Neuropsychopharmacology, 8(2), 267–280. doi:10.1017/S1461145704004997. Evidence Level III.
Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, -NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.htm. Evidence Level IV.
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353–1357. doi:10.1111/j.1360-0443.1989.tb00737.x. Evidence Level III.
U.S. Department of Health and Human Services. (2004a). Substance abuse among older adults: A guide for physicians. (DHHS Publication No. SMA 00–3394). Rockville, MD: Author. Retrived from http://lib.adai.washington.edu/clearinghouse/downloads/TIP-26-Substance-Abuse-Among-Older-Adults-67.pdf. Evidence Level VI.
Wetterling, T., Weber, B., Depfenhart, M., Schneider, B., & -Junghanns, K. (2006). Development of a rating scale to predict the severity of alcohol withdrawal syndrome. Alcohol and Alcoholism, 41(6), 611–615. doi:10.1093/alcalc/agl068. Evidence Level III.
World Health Organization. (2000). A systematic review of opioid antagonists for alcohol dependence. Management of substance dependence review series. Retrieved from https://www.who.int/substance_abuse/publications/en/opioid.pdf. Evidence Level I.