Alcohol Withdrawal

It is through the nurse-patient relationship that many nurses are able to assist the individual through detoxification.

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Learning Scope #337
1 contact hour
Expires Oct. 4, 2014

You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate; take the test online; grade and certificate are available immediately after taking the test. 2) Mail your completed exam (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the completed exam to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this CE offering is to review the latest evidence about the treatment of individuals in alcohol withdrawal syndrome and the nursing role during controlled detoxification. After reading this article, you will be able to:

1. Explain the nursing role in controlled alcohol detoxification.
2. Recognize the signs and symptoms of alcohol withdrawal syndrome (AWS).
3. Determine the best treatment location of individuals detoxifying from alcohol.
4. Compare and contrast the pharmacological treatments for alcohol detoxification.
5. Discuss non-pharmacological treatments needed by individuals in alcohol detoxification.

The author has completed a disclosure form and reports no relationships relevant to the content of this article.

Alcohol withdrawal syndrome (AWS) is a clinical syndrome that affects people accustomed to regular alcohol intake who either reduce their alcohol consumption significantly or stop drinking completely.1 A controlled, supervised alcohol detoxification is the best way to manage the symptoms of AWS, thus preventing seizures, delirium and death from complications. Controlled alcohol detoxification requires a set of interventions that manage both the symptoms of acute intoxication, as well as the symptoms of withdrawal.2

Symptoms
Sometimes individuals stop drinking alcohol unintentionally -- for example, as a result of an emergency surgery or an acute illness episode. Sometimes individuals with alcohol problems who are admitted to emergency departments are not diagnosed as having problems with alcohol.3 Therefore, nurses need to be aware that all  individuals need a thorough workup including, a drug and alcohol screen, and an assessment  for the signs and symptoms of AWS (see Table 1). Symptoms of AWS appear within hours of stopping or reducing alcohol intake.Risk factors for prolonged or complicated alcohol withdrawal include duration of alcohol consumption, the number of lifetime prior detoxifications, history of prior seizures, history of prior episodes of delirium tremens (DTs) and current intense craving for alcohol.

Treatment Location
Individuals going through controlled alcohol detoxification can be treated as outpatients or inpatients, depending on the severity of their symptoms. Individuals with mild-to-moderate alcohol withdrawal symptoms and no serious psychiatric or medical problems can be safely treated in an outpatient setting.

Advantages of outpatient detoxification include the opportunity for greater social support during treatment, the ability to continue to work and maintain daily activities with fewer disruptions, and a lower cost for the treatment. When assessing a patient for outpatient detoxification, nurses need to ascertain the level of motivation to stay sober, the patient's ability to return for daily physical checks, and whether the patient has a support person at home.

People with moderate-to-severe alcohol withdrawal symptoms or a previous history of DTs or alcohol withdrawal seizures usually need inpatient detoxification. Assessment also includes a blood alcohol level along with a urine drug screen because high levels of alcohol intake and abuse of other substances place individuals at a higher risk for complications.

Others at risk for complications and who might need inpatient alcohol detoxification include those who:

• are pregnant or have a serious medical illness;
• are unable to tolerate oral medication;
• have a serious psychiatric illness, are actively psychotic, have severe cognitive impairment or are at high risk to harm self or others;
• have previous unsuccessful detoxification attempts, multiple past detoxifications or a likelihood of not being able to complete detoxification successfully;
• have regularly consumed large amounts of alcohol; and/or
• lack a reliable support system.

Less than 10 percent of patients need inpatient detoxification. The advantages of inpatient detoxification include the availability of constant medical care, and supervision and treatment of serious complications. The major disadvantage is its higher cost over outpatient detoxification.

Assessing for Detox
When assessing patients for detoxification, the nursing assessment must include a thorough history of any physical and psychiatric conditions, presence of risk factors for complications during withdrawal, and description of the severity of previous withdrawal symptoms. It is particularly important to assess for mood disorders, delirium, psychosis, severe depression and/or suicidal or homicidal ideation.

Nurses also need to assess for physical conditions such as gastritis, gastrointestinal bleeding, liver disease, cardiomyopathy, pancreatitis, neurological impairment, electrolyte imbalances and nutritional deficiencies. Other health problems such as arrhythmias, congestive heart failure, hepatic or pancreatic disease, infectious conditions, bleeding and nervous system impairment need to be ruled out.

Nurses need to be aware some individuals may display symptoms that might be confused with AWS. These include thyrotoxicosis, anticholinergic drug poisoning and amphetamine or cocaine use. Be aware central nervous system infection or hemorrhage can cause seizures and mental status changes that mimic AWS. Additionally, withdrawal from other sedative-hypnotic agents can cause symptoms similar to those occurring in AWS.5

Nursing care for those in acute alcohol withdrawal strives to stabilize the individual's vital signs, fluid and electrolyte levels, and any nutritional disturbances. Check for electrolyte deficiencies, as well as deficiencies in thiamine, folate and magnesium. Treatment often includes thiamine, 100 mg orally every day for 5 days; folate, 1 mg orally every day; and vitamins taken orally or by injection.

Thiamine is especially important in malnourished patients to prevent Wernicke's encephalopathy, a condition caused by thiamine deficiency. Some people in withdrawal may require intravenous fluids, especially if they vomit, or have diarrhea, sweating and/or fever.

Assess Withdrawal Severity
Determining the severity of withdrawal helps keep the patient safe and alerts the nurse to the possibility of the individual progressing to DTs. The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is the gold standard assessment tool (find it at www.chce.research.va.gov/apps/PAWS/pdfs/ciwa-ar.pdf).

• CIWA-Ar scores of less than 8 suggest mild withdrawal symptoms.
• CIWA-Ar scores of 15 or greater denote an increased risk for confusion and seizures.

Determine Nursing Care
Individuals in minor withdrawal usually are coherent but may have mild cognitive impairment. Symptoms usually begin within 8 hours of the last drink and include anxiety, restlessness, agitation, mild nausea, decreased appetite, sleep disturbance, facial sweating, mild tremulousness, and fluctuating tachycardia and hypertension.

Individuals in moderate withdrawal often have marked tachycardia and high blood pressure, and may display signs of alcoholic hallucinosis, which consists of auditory or visual hallucinations. The individual may be disoriented and appear confused, but reorientation often is possible. A single grand mal seizure that lasts less than 5 minutes may occur, but some individuals may have two or three seizures.

Individuals in severe withdrawal develop DTs with fever, severe hypertension and tachycardia, delirium, drenching sweats and marked tremulousness. Death can occur and is usually caused by head trauma, cardiovascular complications, infections, aspiration pneumonia and/or fluid and electrolyte imbalances.4


Pharmacological Therapy

There is strong evidence to support pharmacotherapy therapy for individuals in moderate alcohol withdrawal. Nursing's role includes administering medication according to the dosing method chosen, monitoring patient progress, assessing for side effects and/or any untoward effects of the medications used (see Table 2).

Medications used during alcohol detoxification can be administered using one of following three medication dosing regimens:

• Gradual tapering -- Patient receives medication according to a predetermined schedule for several days as the medication is gradually tapered
• Fixed-schedule -- Patient receives a fixed dose of medication every 6 hours for 2-3 days regardless of severity of symptoms
• Symptom-triggered -- Medication is administered according to the individual's CIWA-Ar score

Nurses' Role in Therapy
Nurses play a significant role in supportive therapeutic interventions during controlled alcohol detoxification. These include providing frequent reassurance, reality orientation and other physical and emotional nursing care as needed. Patients seem to do best when they are kept in an evenly lit, quiet room, avoiding dark shadows, bright lights, loud noises and other excessive stimuli. Liberal intake of non-caffeinated fluids can prevent dehydration.4

Ultimately, the purpose of alcohol detoxification is to prepare the person for entry into a rehabilitation program, with the hope of long-term abstinence. Most patients choose long-term involvement with self-help programs such as Alcoholics Anonymous (AA). Others do better with the addition of cognitive-behavior therapy, and family therapy. Research supports family involvement during detox and afterward. Patients whose families were involved in their care were significantly more likely to enter a continuing care program after detoxification.10

It also is important to treat other conditions that may occur after successful detoxification. Many individuals in the early stages of recovery experience depression, which generally can be treated with counseling. Some patients benefit from the addition of antidepressants, especially those who have a history of depression prior to their alcohol dependence, and those who experience symptoms of depression that continue despite ongoing counseling.

Comprehensive nursing care also includes educating the patient about precautions to take after sobriety is achieved. Remind patients to tell any care provider of their status. Teach patients to use caution when using some commonly prescribed medications such as mood-altering drugs, controlled substances, benzodiazepine and antidepressants.

Through the nurse-patient relationship, many nurses are able to assist the individual through the controlled alcohol detoxification process, as well as encourage them to continue in treatment and maintain sobriety.

References
1. Asplund, C.A., Aaronson, J.W., & Aaronson, H.E. (2004). Three regimens for alcohol withdrawal and detoxification. Journal of Family Practice, 53(7). Retrieved July 12, 2010 from the World Wide Web: http://www.jfponline.com/Pages.asp?AID=1730.

2. Miller, N.S. (2006). Detoxification and substance abuse treatment: settings, levels of care, and patient placement. Retrieved July 12, 2010 from the World Wide Web: http://www.guideline.gov/summary/summary.aspx?doc_id=9116.

3. Indig, D, et al (2008). Why are alcohol-related emergency department presentations under-detected? An exploratory study using nursing triage. Drug and Alcohol Review, (27)6,584-590.

4. Blondell, R.D. (2005). Ambulatory detoxification of patients with alcohol dependence. American Family Physician, 71(3), 495-502.

5. Bayard, M., Mcintyre, J., Hill, K.R., et al. (2004). Alcohol withdrawal syndrome. American Family Physician, 69(6), 1443-1450.

6. Malcolm, R., Herron, J.E., Anton, R.F., et al. (2000). Recurrent detoxification may elevate alcohol craving as measured by the Obsessive Compulsive Drinking scale. Alcohol, 20(2), 181-185.

7. Stuppaeck, C.H., Deisenhammer, E.A., Kurz, M., et al. (1996). The irreversible gamma-aminobutyrate transaminase inhibitorvigabatrin in the treatment of the alcohol withdrawal syndrome. Alcohol and Alcoholism, 31(1), 109-111.

8. Myrick, H., Malcolm, R., Randall, P.K., et al. (2009). A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcoholism, Clinical and Experimental Research, 33(9), 1582-1588.

9. Addolorato, G., Caputo, F., Capristo, E., et al. (2002). Baclofen efficacy in reducing alcohol craving and intake: A preliminary double-blind randomized controlled study. Alcohol and Alcoholism, 37(5), 504-508.

10. O'Farrell, T.J., Murphy, N., Alter. J., Fals-Stewart, W. (2008). Brief family treatment intervention to promote continuing care among alcohol-dependent patients in inpatient detoxification: A randomized pilot study. Journal of Substance Abuse Treatment, (34)3, 363-369.

Resources
McKinley, M.G. (2005). Alcohol withdrawal syndrome overlooked and mismanaged? Critical Care Nurse, 25(3), 40-48.

Sullivan, J., Sykora, K., Schneiderman, J., et al. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84(11), 1353-1357.

Joan Monchak Lorenz, RN, MSN, PMHCNS-BC, is  founder and president of Clearly Stated, Gainesville, FL. She provides consultation on a variety of professional nursing issues and writes and edits healthcare materials for both healthcare professionals as well as for the general public.




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