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Aug.13.2020

Elsevier Clinical Skills

Addiction, Chemical Dependency, and Withdrawal - CE

ALERT

Simultaneous consumption of alcohol and sedative-hypnotics increases the risk of death.4

Alcohol withdrawal is a potentially life-threatening health condition requiring medical attention.19 Severe alcohol or sedative-hypnotic withdrawal (e.g., from sedatives or barbiturates) can be fatal; rapid treatment is required for both conditions.

OVERVIEW

Alcohol and substance use are widespread in the United States, and alcohol is commonly abused.15 People who are addicted to drugs have a higher incidence of mood and anxiety disorders than the general population,11 and people with mood and anxiety disorders have a higher risk of developing an addiction to drugs (including prescription medications used for nonmedical purposes) and alcohol.12

The rate of alcohol-related emergency department visits has increased steadily in recent years.14 Alcohol and drug abuse affects adolescents, adults, and older adults.15 Although opioid and cocaine withdrawal produce nonlife-threatening symptoms (opioid withdrawal resembles the flu; cocaine withdrawal leads to restlessness and agitation), alcohol and sedative-hypnotic withdrawal may be fatal.

Nurses working in emergency departments, trauma units, and other medical-surgical settings must be educated about alcohol and drug intoxication and withdrawal so they can treat patients adequately. The nurse’s role in caring for these patients includes conducting a thorough patient assessment and substance abuse history, maintaining safety for the patient and health care team members, and monitoring the patient’s vital signs and electrolyte status.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain to the patient and family that change is difficult.
  • Explain that evidence indicates that the risk of drug and alcohol abuse and addiction is genetic.
  • Explain that the three most common defense mechanisms in addiction are denial, rationalization, and minimization.
  • Provide education about addiction, chemical dependency and withdrawal
  • Recommend a support group, such as Alcoholics Anonymous®, to the patient.
  • Recommend a support group, such as Al-Anon, for the patient’s family members.
  • Allow time for family members to express their concerns.
  • Enlist the support of family members in achieving the patient’s plan of care.
  • Explain the need for consent for opioid treatment using methadone.
  • Instruct the patient regarding the potential adverse effects of the treatment medication.
  • Encourage questions and answer them as they arise.

ASSESSMENT

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.6
  5. Assess the patient’s vital signs.
  6. Assess the need for a psychiatric practitioner consult and seek a consult as appropriate.
  7. Ask which types of drugs the patient has ingested and when the patient last ingested them.
    Rationale: Sedative-hypnotic withdrawal can occur within 20 days of stopping substance use. 8
  8. Ask if the patient drinks alcoholic beverages and when the patient last drank.
    Rationale: Alcohol withdrawal symptoms appear 6 to 72 hours after alcohol use is significantly decreased or discontinued but can appear up to 1 week after discontinuing use. 7
  9. Ask if the patient has used over-the-counter medication, such as cough syrup.
  10. Ask when the patient first used drugs or alcohol.
  11. Ask about the pattern of usage, including frequency, route, and amount typically consumed.
  12. Ask how drugs and alcohol have affected the patient’s life.
  13. Assess the patient’s treatment history.
  14. Ask about the history of withdrawal symptoms, including the severity and treatment.
  15. Ask about attempts to quit using alcohol or drugs and the patient’s motivation to quit.
  16. Assess the patient for signs of intoxication or withdrawal (e.g., body tremors, sweating, agitation, dysphoria, seizures, diarrhea, rapid heart rate, increased appetite).
  17. Use an evidence-based scale to assess the patient for impending delirium tremens and to guide the administration of medications for detoxification.
    1. For alcohol withdrawal: Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar)10
    2. For opioid withdrawal: Clinical Institute Narcotic Assessment (CINA)9 Scale for Withdrawal Symptoms or the Clinical Opiate Withdrawal Scale (COWS)9
  18. Assess the patient’s personal and family psychiatric and substance use history.
  19. Assess the patient’s developmental, social, and legal history.
  20. Assess the patient for specific contraindications to receiving treatment medications and advise the practitioner accordingly.

STRATEGIES

  1. Take vital signs as soon as the patient arrives for treatment.
    Rationale: Taking vital signs as soon as possible can assist in detecting the risk of organ damage (e.g., detection of hypertension, hyperventilation, and tachycardia). 5
  2. Administer a screening tool such as the CAGE Questionnaire Adapted to Include Drugs (CAGE-AID) per the organization’s practice.
    Rationale: Nurses should assess all patients with a validated instrument. The CAGE-AID is a questionnaire that helps patients identify drug and alcohol usage trends in their lives. 1
    If the patient has a positive response to the screening tool, perform more in-depth assessment or refer the patient for further assessment.
  3. Consider using the SBIRT method, providing Screening, Brief Intervention, and Referral to Treatment, which has demonstrated effectiveness in improving patient care.10
  4. Monitor the safety of the patient and the health care team members.
    Rationale: Alcohol withdrawal can result in agitation and aggression toward others. Dysphoria is a withdrawal symptom experienced by opioid abusers that may provoke self-harm. Alcohol and sedative-hypnotic withdrawal can also result in seizures and alcohol withdrawal can lead to a potentially life threatening condition called delirium tremens. Taking precautions, such as implementing falls protocols, can prevent injury. 4
  5. Monitor the patient’s fluid and electrolyte status.
    Rationale: Dehydration is common with diaphoresis, nausea, and vomiting related to alcohol and sedative-hypnotic withdrawal. Diarrhea and diaphoresis are related to opioid withdrawal.
  6. Perform hand hygiene and administer medications to the patient as ordered.
  7. Perform hand hygiene.
  8. Document the strategies in the patient’s record.

REASSESSMENT

  1. Reassess the patient’s vital signs.
  2. Reassess the patient’s mood, affect, and behavior.
  3. Reassess the patient for withdrawal symptoms and plan for continued medical intervention if the patient continues to experience them.
  4. Reassess the patient for adverse effects of treatment medications and advise the practitioner accordingly.
  5. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • The patient is free of delirium tremens and seizures.
  • The patient abstains from alcohol, opioids, sedative-hypnotics, and other illicit substances.
  • The patient notifies a health care team member, friends, or family of cravings.
  • The patient attends an outside support group, such as Alcoholics Anonymous.
  • The patient receives follow-up care with an addiction specialist or a mental health professional.

UNEXPECTED OUTCOMES

  • The patient continues to use the substance despite the problems it causes in social and occupational functioning.
  • The patient continues to use drugs or alcohol despite needing more of the substance to achieve the desired effect.
  • The patient experiences withdrawal symptoms.
  • The patient refuses all suggested interventions, such as detoxification and rehabilitation.
  • The patient dies because treatment is not initiated quickly.

DOCUMENTATION

  • Threats of harm to self or others
  • History of legal problems
  • Mood, affect, and behaviors
  • Substances used
  • Quantity of drug or alcohol used
  • Length of time and pattern of substance use
  • Consequences of use
  • Vital signs
  • Previous withdrawal and severity of withdrawal
  • Signs and symptoms of withdrawal
  • Medications used to manage withdrawal symptoms
  • Referral to addiction specialist, treatment center, or mental health professional
  • Education
  • Patient’s response to medication, including any adverse reactions
  • Unexpected outcomes and related interventions

ADOLESCENT CONSIDERATIONS

  • Alcohol is commonly used by people 12 to 20 years old, even though alcohol use is illegal for part of this age group.2
  • Many underage drinkers are treated in emergency departments.2
  • Binge drinking (defined as four or more drinks for women and five or more drinks for men during a single occasion)3 is a common pattern.12
  • The consequences of underage drinking include school, social, and legal problems; unwanted, unplanned pregnancy; unprotected sexual activity; risks of suicide and homicide; risks of car crashes and other unintentional injuries; changes in brain development; and death from alcohol poisoning.2

OLDER ADULT CONSIDERATIONS

  • Because of decreased total body fluid in older adults, the blood alcohol level increases more rapidly.8 Ingestion of even small amounts of alcohol affects older adults.
  • Because older adults metabolize alcohol slowly, its effects last longer.
  • Alcohol intake guidelines differ for older adults. Hazardous drinking for men and women in this age group (generally considered to be 65 years old and older) is defined as consuming three or more alcoholic drinks in one sitting or seven or more alcoholic drinks in 1 week.8
  • A preoccupation with or an intense attachment to a psychoactive substance, including concerns about the quantity and timing of the medication, suggests medication misuse.
  • Alcohol use can worsen some health issues commonly seen in older adults, including diabetes, hypertension, congestive heart failure, liver problems, and memory problems.8

SPECIAL CONSIDERATIONS

  • Many cough and cold medications and mouthwash contain alcohol.
  • A patient in an unresponsive state should have his or her blood alcohol level checked and additional laboratory work completed because intoxication can mimic a diabetic coma, head trauma, or drug overdose.
  • Because of the stigma associated with drug and alcohol use and the fear of legal consequences, many patients are dishonest about their substance use.
  • Some patients with untreated or poorly managed pain exaggerate their use of opioids to acquire methadone or buprenorphine (an opioid) to alleviate their discomfort.

REFERENCES

  1. Basu, D. and others. (2016). Use of Family CAGE-AID questionnaire to screen the family members for diagnosis of substance dependence. Indian Journal Of Medical Research, 143(6), 722-730. doi:10.4103/0971-5916.191931 (Level VI)
  2. Centers for Disease Control and Prevention (CDC). (2020). Underage drinking. Retrieved July 2, 2020, from https://www.cdc.gov/alcohol/fact-sheets/underage-drinking.htm (Level VII)
  3. Centers for Disease Control and Prevention (CDC). (2019). Alcohol use and your health. Retrieved July 2, 2020, from https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm (Level VII)
  4. Donroe, J.H., Tetrault, J.M. (2017). Substance use, intoxication, and withdrawal in the critical care setting. Critical Care Clinics, 33(3), 543-558. doi:10.1016/j.ccc.2017.03.003
  5. Eads, V., Maruzzella, G. (2016). The clinical nurse as an agent of change. MEDSURG Nursing, 25(3), 173-175.
  6. Joint Commission, The. (2020). National patient safety goals. Hospital accreditation program. Retrieved July 2, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf (Level VII)
  7. Long, D., Long, B., Koyfman, A. (2017). The emergency medicine management of severe alcohol withdrawal. The American Journal of Emergency Medicine, 35(7), 1005-1011. doi:10.1016/j.ajem.2017.02.002
  8. National Institute on Aging. (2017). Older adults and alcohol: You can get help. Retrieved July 2, 2020, from https://order.nia.nih.gov/sites/default/files/2018-01/older-adults-and-alcohol.pdf (Level VII)
  9. Nuamah, J.K. and others. (2019). The past, present and future of opioid withdrawal assessment: A scoping review of scales and technologies. BMC Medical Informatics and Decision Making, 19(1), 113. doi:10.1186/s12911-019-0834-8 (Level I)
  10. Rosenthal, L.D. (2018). Initiating SBIRT, alcohol, and opioid training for nurses employed on an inpatient medical-surgical unit: A quality improvement project. MEDSURG Nursing, 27(4), 227-230.
  11. Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Behavioral health trends in the United States: Results from the 2014 national survey on drug use and health. Retrieved July 2, 2020, from https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf (Level VII)
  12. Substance Abuse and Mental Health Services Administration (SAMHSA). (2019). Results from the 2018 National Survey on Drug Use and Health: Detailed tables. Retrieved July 2, 2020, from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2018R2/NSDUHDetailedTabs2018.pdf (Level VII)
  13. U.S. National Library of Medicine, MedlinePlus. (2019). Alcohol withdrawal. Retrieved July 2, 2020, from https://medlineplus.gov/ency/article/000764.htm (Level VII)
  14. White, A.M. and others. (2018). Trends in alcohol-related emergency department visits in the United States: Results from the nationwide emergency department sample, 2006 to 2014. Alcoholism, Clinical and Experimental Research, 42(2), 352-359. doi:10.1111/acer.13559 (Level VI)
  15. Wolf, C. and others. (2020). Management of alcohol withdrawal in the emergency department: Current perspectives. Open Access Emergency Medicine: OAEM, 12, 53-65. doi:10.2147/OAEM.S235288
  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports