Substance Use, Addiction/Impulse Control Disorder
Alcohol Use Disorder
Alcohol Use Disorder (AUD) is one of the most prevalent and challenging conditions encountered in psychiatric and primary care practice. For a Psychiatric-Mental Health Nurse Practitioner (PMHNP), understanding the complex interplay between neurobiology, behavior, and environment in alcohol addiction is critical to guiding effective treatment. The chronic and relapsing nature of AUD makes it essential to integrate pharmacologic and non-pharmacologic interventions that address both the physiological dependence and the psychological triggers associated with alcohol use. Naltrexone, an opioid receptor antagonist, has become a cornerstone medication in the treatment of AUD due to its ability to reduce cravings and prevent relapse. This blog provides an evidence-based overview of Alcohol Use Disorder, its diagnostic framework, and comprehensive management strategies with a focus on the clinical use of Naltrexone.
Diagnostic Criteria for Alcohol Use Disorder
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Alcohol Use Disorder is defined by a pattern of alcohol consumption that leads to significant impairment or distress. The diagnosis requires the presence of at least two of eleven criteria within a 12-month period. These criteria include consuming alcohol in larger amounts or over longer periods than intended, unsuccessful efforts to cut down, spending excessive time obtaining or using alcohol, and experiencing cravings or intense urges to drink (MacKillop et al., 2022). Additional indicators include failure to meet responsibilities at work or home, continued drinking despite social or interpersonal problems, and the abandonment of important activities because of alcohol use.
Further criteria involve drinking in hazardous situations such as driving while intoxicated, continuing use despite physical or psychological problems, and developing tolerance or withdrawal symptoms. The severity of AUD is categorized based on the number of symptoms: two to three symptoms indicate a mild disorder, four to five symptoms indicate a moderate disorder, and six or more symptoms signify a severe disorder (McPheeters et al., 2023). As a PMHNP, assessing these criteria involves both clinical interviewing and structured screening tools such as the Alcohol Use Disorders Identification Test (AUDIT) or the CAGE questionnaire. Comprehensive assessment is critical to distinguishing casual alcohol use from problematic dependence that requires intervention.
Street Names of Alcohol
Alcohol, unlike illicit substances, is legal and socially accepted, yet it remains one of the most commonly abused psychoactive substances. It is often referred to by a variety of street or slang names that reflect its widespread cultural presence. Common terms include booze, hooch, sauce, firewater, and juice (McPheeters et al., 2023). While these informal names may seem harmless, they contribute to a cultural normalization of alcohol consumption that minimizes its addictive potential. Recognizing and understanding these terms during clinical assessment can be helpful for building rapport with patients and interpreting self-reported alcohol use in an honest and nonjudgmental way (MacKillop et al., 2022). For many individuals, the transition from social drinking to dependency occurs gradually and is often rationalized or hidden behind social norms.
Methods of Use and Abuse
Alcohol is consumed orally and is available in multiple forms, including beer, wine, and distilled spirits. Abuse occurs when an individual consumes alcohol in excessive quantities or frequency that exceeds safe or recommended limits. Two common patterns of misuse include binge drinking and chronic heavy drinking. Binge drinking refers to the consumption of five or more drinks for men or four or more for women within a two-hour period, leading to intoxication. Chronic heavy drinking involves sustained high levels of consumption over time, resulting in tolerance and physical dependence. Individuals may drink to manage emotional distress, anxiety, depression, or social pressure (McPheeters et al., 2023). Over time, this self-medicating behavior becomes conditioned, reinforcing the cycle of addiction. As dependence develops, individuals often require increasing amounts of alcohol to achieve the desired effect, and withdrawal symptoms may occur when drinking is reduced or stopped.
Symptoms of Alcohol Intoxication
Alcohol intoxication affects multiple organ systems and produces a range of cognitive, behavioral, and physical symptoms. Early signs include euphoria, talkativeness, and lowered inhibitions. As intoxication deepens, individuals may exhibit slurred speech, unsteady gait, impaired coordination, and slowed reaction times. Cognitive impairment manifests as poor judgment, impulsivity, and reduced attention span (McPheeters et al., 2023). Physiologically, alcohol acts as a central nervous system depressant, enhancing the effects of gamma-aminobutyric acid (GABA) while inhibiting excitatory neurotransmitters like glutamate. Severe intoxication may result in vomiting, confusion, hypothermia, respiratory depression, and, in extreme cases, coma or death. Alcohol poisoning is a medical emergency that requires immediate intervention. Chronic intoxication can cause long-term damage to the liver, cardiovascular system, and brain, contributing to conditions such as cirrhosis, cardiomyopathy, and Wernicke-Korsakoff syndrome (MacKillop et al., 2022).
Symptoms of Alcohol Withdrawal
Withdrawal from alcohol occurs when a person who has developed physical dependence abruptly stops or reduces consumption. The onset of symptoms typically begins within six to twelve hours after the last drink and can range from mild to life-threatening. Early symptoms include tremors, sweating, anxiety, nausea, and insomnia. As withdrawal progresses, symptoms may escalate to hallucinations, agitation, and elevated heart rate or blood pressure. In severe cases, individuals may develop seizures or delirium tremens (DTs), characterized by confusion, fever, severe autonomic instability, and visual or tactile hallucinations. DTs usually occur within 48 to 72 hours of cessation and can be fatal without medical treatment. The severity of withdrawal depends on the duration and quantity of alcohol use, overall health, and previous withdrawal history (MacKillop et al., 2022).
First-Line Treatment Options
Effective treatment for Alcohol Use Disorder involves both pharmacologic and psychosocial interventions. The first-line approach includes the use of evidence-based medications combined with behavioral therapies that target the psychological and social dimensions of addiction. Naltrexone, Acamprosate, and Disulfiram are the three FDA-approved pharmacologic options for AUD (MacKillop et al., 2022). Among these, Naltrexone is often the preferred first-line agent due to its ability to reduce cravings and the rewarding effects of alcohol. For optimal outcomes, medication therapy should be accompanied by counseling, cognitive behavioral therapy (CBT), motivational enhancement therapy, and peer support programs such as Alcoholics Anonymous (AA). Behavioral interventions help patients identify triggers, manage stress, and develop healthier coping strategies. As a PMHNP, adopting a patient-centered approach that combines medication with counseling enhances adherence and promotes long-term recovery.
FDA-Approved Medications for Alcohol Use Disorder
Three medications are approved by the U.S. Food and Drug Administration (FDA) to treat Alcohol Use Disorder: Naltrexone, Acamprosate, and Disulfiram. Among these, Naltrexone is preferred because it decreases the pleasurable effects of alcohol and reduces cravings even if the patient is not fully abstinent. Acamprosate supports long-term abstinence by normalizing brain neurotransmitter activity, while Disulfiram discourages drinking by causing unpleasant reactions when alcohol is consumed (McPheeters et al., 2023). Naltrexone is available as a 50 mg oral tablet taken daily or as an extended-release intramuscular injection administered monthly.
Mechanism of Action of Naltrexone
Naltrexone exerts its therapeutic effect by blocking opioid receptors in the brain, particularly the mu-opioid receptor. Alcohol consumption stimulates the release of endogenous opioids such as endorphins, which activate the brain’s reward pathway by increasing dopamine levels in the nucleus accumbens. This neurochemical activity reinforces drinking behavior and contributes to craving. By antagonizing opioid receptors, Naltrexone prevents alcohol-induced endorphin release, reducing dopamine surge and the pleasurable sensations associated with drinking (Murphy et al., 2022). This mechanism weakens the brain’s conditioned response to alcohol-related cues, helping individuals resist urges and maintain abstinence or controlled drinking. Unlike Disulfiram, which causes aversive symptoms, Naltrexone acts on the reward pathway, making it more tolerable for long-term use.
Common Side Effects of Naltrexone
Naltrexone is generally well-tolerated, but patients may experience mild to moderate side effects. The most commonly reported include nausea, headache, dizziness, fatigue, and sleep disturbances. Some individuals may develop anxiety, irritability, or abdominal pain. In the extended-release injectable form, local site reactions such as redness, swelling, or pain can occur. Serious but rare side effects include hepatotoxicity, particularly at higher doses. Because Naltrexone is metabolized in the liver, it is contraindicated in patients with acute hepatitis or severe liver disease (Murphy et al., 2022). PMHNPs should educate patients to report any symptoms of liver dysfunction, such as jaundice, dark urine, or persistent fatigue. Monitoring liver function throughout treatment is critical to ensure safety and prevent complications.
Administration and Dosing Instructions
Naltrexone is available in two formulations: an oral tablet and an extended-release intramuscular injection. The oral form is typically prescribed at 50 milligrams once daily. Taking the medication with food can minimize gastrointestinal discomfort. Consistency is key; patients should take the dose at the same time each day. If a dose is missed, it should be taken as soon as remembered, but double doses should be avoided. The extended-release injectable form, administered as a 380-milligram intramuscular injection once every four weeks, is ideal for patients who struggle with daily adherence or prefer a long-acting option (Murphy et al., 2022). This form must be given by a healthcare professional, typically into the gluteal muscle. Before initiating Naltrexone, patients must be opioid-free for at least seven to ten days to prevent precipitated withdrawal, although this primarily applies to those with coexisting opioid use. For alcohol-only patients, treatment may begin after withdrawal resolution.
Baseline and Ongoing Assessments
Before prescribing Naltrexone, baseline evaluations are essential to determine safety and appropriateness. PMHNPs should order liver function tests, including ALT, AST, and bilirubin levels, as well as assess renal function. A pregnancy test should be conducted in women of childbearing potential (Murphy et al., 2022). Screening for opioid use through history and urine drug testing is necessary to avoid precipitated withdrawal. Ongoing assessments should include repeated liver function tests every three to six months, as well as monitoring for adherence, side effects, and reduction in drinking frequency. Behavioral assessments using standardized tools such as the Alcohol Timeline Followback (TLFB) or the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) can help track progress (Murphy et al., 2022).
Non-Pharmacologic Interventions
Medication alone rarely achieves long-term recovery in Alcohol Use Disorder. Non-pharmacologic interventions are crucial for addressing the psychological and social factors underlying addiction. Cognitive Behavioral Therapy (CBT) helps patients identify triggers, modify thought patterns, and develop coping mechanisms to manage stress and cravings. Motivational interviewing enhances readiness for change and strengthens commitment to sobriety. Participation in peer support programs such as Alcoholics Anonymous (AA) or SMART Recovery provides community reinforcement and accountability. Family or couples therapy can improve communication, rebuild trust, and address enabling behaviors. Lifestyle modifications, including exercise, balanced nutrition, and adequate sleep, improve physical health and mood stability. Stress management techniques such as mindfulness, meditation, and relaxation exercises can further reduce relapse risk.
Conclusion
Alcohol Use Disorder is a complex and multifaceted condition that requires an integrated approach to treatment. For PMHNPs, combining pharmacologic therapy such as Naltrexone with behavioral and psychosocial interventions provides the most effective strategy for long-term recovery. Understanding the diagnostic criteria, mechanisms of action, and necessary monitoring ensures safe and effective use of the medication. Naltrexone addresses the neurobiological reinforcement of alcohol consumption by blocking opioid receptors, thereby reducing the craving and pleasure associated with drinking. When supported by ongoing therapy, patient education, and lifestyle modification, it significantly improves recovery outcomes. As frontline mental health providers, PMHNPs have the responsibility and opportunity to guide patients toward sustainable sobriety and improved quality of life through compassionate, evidence-based care.
References
MacKillop, J., Agabio, R., Feldstein Ewing, S. W., Heilig, M., Kelly, J. F., Leggio, L., & Rehm, J. (2022). Hazardous drinking and alcohol use disorders. Nature Reviews Disease Primers, 8(1), 80. https://doi.org/10.1038/s41572-022-00406-1
McPheeters, M., O’Connor, E. A., Riley, S., Kennedy, S. M., Voisin, C., Kuznacic, K., & Jonas, D. E. (2023). Pharmacotherapy for alcohol use disorder: A systematic review and meta-analysis. JAMA, 330(17), 1653-1665. https://doi.org/10.1001/jama.2023.19761
Murphy, C. E., Wang, R. C., Montoy, J. C., Whittaker, E., & Raven, M. (2022). Effect of extended‐release naltrexone on alcohol consumption: A systematic review and meta‐analysis. Addiction, 117(2), 271–281. https://doi.org/10.1111/add.15572
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Prescription 1
Patient Name: Jane Doe
Date of Birth: 01/01/2001
Date: October 30, 2025
Medication: Sertraline 100 mg tablet
Sig: Take one tablet by mouth once daily.
Indication: Depression
Dispense: 30 tablets
Refills: 2
Duration: 3 months
Prescriber:
[Your Name], PMHNP
NPI: 1765942308
License #: FL-APN-202512
Address: Overlook Behavioral Health Clinic, 520 E Central Blvd, Orlando, FL 32801
Phone: (407) 555-1842
Fax: (407) 555-1843
Signature: ___________________________
[Your Name], PMHNP
Prescription 1
Patient Name: Jane Doe
Date of Birth: 01/01/2001
Date: October 30, 2025
Medication: Lorazepam 1 mg tablet
Sig: Take one tablet by mouth twice daily if needed for panic attacks.
Indication: Panic attacks
Dispense: 60 tablets
Refills: 2
Duration: 3 months
Prescriber:
[Your Name], PMHNP
NPI: 1765942308
License #: FL-APN-202512
Address: Overlook Behavioral Health Clinic, 520 E Central Blvd, Orlando, FL 32801
Phone: (407) 555-1842
Fax: (407) 555-1843
Signature: ___________________________
[Your Name], PMHNP
Schedule IV Controlled Substance
Prescription 3
Patient Name: Jane Doe
Date of Birth: 01/01/2001
Date: October 30, 2025
Medication: Aripiprazole 2 mg tablet
Sig: Take one tablet by mouth at bedtime.
Indication: Depression
Dispense: 30 tablets
Refills: 2
Duration: 3 months
Prescriber:
[Your Name], PMHNP
NPI: 1765942308
License #: FL-APN-202512
Address: Overlook Behavioral Health Clinic, 520 E Central Blvd, Orlando, FL 32801
Phone: (407) 555-1842
Fax: (407) 555-1843
Signature: ___________________________
[Your Name], PMHNP
Prescription 4
Patient Name: Jane Doe
Date of Birth: 01/01/2001
Date: October 30, 2025
Medication: Methylphenidate ER 54 mg tablet
Sig: Take one tablet by mouth every morning before school.
Indication: ADHD
Dispense: 30 tablets
Refills: 2
Duration: 3 months
Prescriber:
[Your Name], PMHNP
NPI: 1765942308
License #: FL-APN-202512
Address: Overlook Behavioral Health Clinic, 520 E Central Blvd, Orlando, FL 32801
Phone: (407) 555-1842
Fax: (407) 555-1843
Signature: ___________________________
[Your Name], PMHNP
Schedule II Controlled Substance
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In this Blog, you will have the opportunity to teach your peers about a specific substance use and/or addiction/impulse control disorder. A Blog is a conversational, informal written piece on a topic. Your faculty will assign you a particular illness and the approved treatment for the illness to create a presentation to share with your peers.
Construct a Blog post, not to exceed 1,500–2,000 words, written for a PMHNP provider audience to post in the Discussion area.
Although you are not required to respond to colleagues, collegial discussion is welcome. Also, it will be important for you to read your peers’ Blog posts in order to learn about all of the medications on the assigned list.
You will be assigned from the following list:
- Opioid Use Disorder
- Vivitrol
- Suboxone
- Methadone
- Lofexidine
- Alcohol Use Disorder
- Acamprosate
- Naltrexone
- Disulfiram
- Phenobarbital (seizure control due to alcohol withdrawal)
- Chlordiazepoxide
- Cannabis Use Disorder
- Nefazodone*
- Fluoxetine*
- Gabapentin*
- Buspirone*
- Stimulant Use Disorder (cocaine, methamphetamine)
- Antipsychotic Medications*
- Combination Injectable Naltrexone*
- Bupropion*
- Gabapentin*
- Tobacco Use Disorder
- Nicotine replacement patch
- Nicotine replacement gum
- Nicotine replacement inhaler
- Zyban
- Sedative/Hypnotic Anxiolytic Use Disorder
- Gabapentin*
- Buspirone*
- Flumazenil*
- Trazodone*
- Binge Eating Disorder (BED)
- Lisdexamphetamine
*Indicates not FDA approved.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
By Day 5 of Week 9
Post your Blog response by doing the following:
- Identify the substance or addiction with discussion on pertinent diagnostic criteria for the use disorder.
- Identify the street names of the substance for the use disorder.
- Describe how someone can use or abuse the substance (oral, smoke, IV, etc.).
- Describe the symptoms of someone under the influence of this substance.
- Describe the symptoms of someone under the withdrawal of this substance.
After describing the substance, discuss the treatment recommendations by doing the following:
- Identify the first-line treatment options.
- Identify the FDA-approved medications for the substance.
Note: If there are no FDA-approved medications, describe any evidenced-based, clinically acceptable off-label medications to treat the illness.
- Identify the proposed mechanisms of action for the medication to treat the illness.
- Describe the common side effects of the medication.
- Describe how the patient should take the medication.
- Identify any baseline and/or ongoing tests and assessment(s) needed when taking the medication.
- Describe the non-pharmacologic intervention recommendations.
This Assignment requires a minimum of three (3) peer-reviewed, evidence-based scholarly references outside of course Learning Resources.
Note: You will need to include the APA formatting citation of all references used with a Reference list.