Substance Use, Chemical Dependency, and Withdrawal - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Simultaneous consumption of alcohol and sedative-hypnotics increases the risk of death.^{undefined#ref3">3}

Alcohol withdrawal is a potentially life-threatening health condition requiring medical attention.¹¹

OVERVIEW

Substance use disorders (SUDs) involve a cluster of cognitive, behavioral, and physiologic symptoms indicative of the continued use of alcohol, nicotine, and illicit drugs, or the misuse of prescription drugs irrespective of any associated consequences.¹ The diagnosis of an SUD is determined based on the pathologic pattern of behaviors related to the use of a substance (Box 1). Drug classes encompassed by SUD diagnoses include caffeine, alcohol, cannabis, opioids (including prescribed opioids), anxiolytics, hypnotics, sedatives, benzodiazepines, stimulants, hallucinogens, inhalants, and others.¹

Individuals with SUDs often have one or more associated health problems (e.g., lung or heart disease, severe dental problems, cancer, nerve cell damage), which can increase the risk of contracting viral (e.g., hepatitis C, HIV) or bacterial (e.g., endocarditis, cellulitis) infections.⁷ SUDs and mental health conditions also commonly co-exist (known as co-occurring disorders). The mental health condition (e.g., anxiety, depression, or schizophrenia) may have existed prior to substance use or the substance use may have triggered it, particularly in individuals with specific vulnerabilities (e.g., genetic link, history of childhood neglect, physical or sexual abuse).⁷ Individuals may also use substances to alleviate psychiatric symptoms, which may exacerbate the condition.⁷ Concurrent treatment for all conditions is recommended.⁷

Health care team members working in all acute care settings (e.g., emergency departments; trauma, psychiatric, and medical-surgical units) must be educated about alcohol and drug intoxication and withdrawal so that they can treat patients adequately. The nurse’s role in caring for these patients includes conducting a thorough patient assessment and substance use history, maintaining safety for the patient and other health care team members, and monitoring the patient’s vital signs and electrolyte status. Appropriate patient care also involves using non-stigmatizing language, treating all patients with respect and empathy, and avoiding blame and judgmental attitudes and behaviors during all interactions.

SUPPLIES

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EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Give information regarding the patient’s rights and responsibilities in the acute care setting.
• Discuss assessments (e.g., fall risk, skin assessment, drug screening, suicide, violence risk) and measures that may be employed to promote, achieve, and maintain a safe environment in the acute care setting (e.g., seizure precautions, increased frequency of rounding or monitoring).
• Discuss factors (e.g., psychological stressors, psychiatric or medical conditions) that may contribute to the patient demonstrating unsafe behaviors (e.g., unsafe or unhealthy substance use, self-harm behaviors).
• Give education on healthy and unhealthy coping skills and discuss reasons why coping abilities vary.
• Give education about potential risks of substance use (e.g., health, personal, and professional consequences).
• To reduce stigma and promote acceptance and understanding, provide information on the etiology of co-occurring mental health disorders and SUDs (e.g., the result of a combination of multi-factorial gene-environment interactions). Explain that having mental health and substance use concerns should not be viewed as a personal weakness.
• Give information about United States Food and Drug Administration (FDA)-approved, medication-assisted treatment (MAT) options (e.g., for alcohol and opiate use disorders).
• Give information about community support resources (e.g., support groups, emergency contact numbers, suicide hotline numbers).
• Give education to the patient about the benefits and importance of allowing others (e.g., family, partner, sponsor) to be involved in treatment.

ASSESSMENTS AND INTERVENTIONS

1. Perform a comprehensive patient assessment.
   1. Check and assess vital signs.

      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).⁴

   2. Evaluate for underlying etiologies other than those related to withdrawal from a substance (e.g., hypoglycemia, head trauma).
   3. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.⁶
   4. Assess the patient’s personal and family psychiatric and substance use history.
   5. Assess the patient’s developmental, social, and legal history.
2. Administer a screening tool such as the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) Questionnaire Adapted to Include Drugs (CAGE-AID) per the organization’s practice.
3. Consider using the Screening, Brief Intervention, and Referral to Treatment (SBIRT) method, which has demonstrated effectiveness in improving patient care.¹⁰
   1. Ask how drugs and alcohol have affected the patient’s life.
   2. Assess the patient’s treatment history related to substance use.
   3. Ask about the patient’s attempts and motivation to quit using alcohol or drugs.
4. Ask what types of substances the patient has used (recently or historically), the pattern of usage (including frequency, route, and amount of each substance typically consumed), and when each substance was last taken or ingested, including over-the-counter medications such as cough syrup.
5. Ask about a history of withdrawal symptoms, including the severity and treatment.
6. Assess the patient for signs of intoxication or withdrawal, including:¹
   1. Alcohol withdrawal (Table 1)
   2. Sedative, hypnotic, or anxiolytic withdrawal (e.g., symptoms similar to alcohol withdrawal, including hand tremor, insomnia, nausea or vomiting, transient visual, tactile, or auditory hallucinations or illusions, psychomotor agitation, and grand mal seizure)
   3. Stimulant withdrawal (e.g., vivid, unpleasant dreams, insomnia or hypersomnia, increased appetite, psychomotor retardation or agitation)
   4. Opioid withdrawal (e.g., dysphoric mood, muscle aches, sweating, fever, dilated pupils, piloerection [i.e., goose bumps], lacrimation, rhinorrhea, yawning, insomnia, nausea, vomiting, and diarrhea)
7. 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 for Alcohol Scale, revised (CIWA-Ar)¹¹
   2. For opioid withdrawal: Clinical Institute Narcotic Assessment (CINA) Scale or the Clinical Opiate Withdrawal Scale (COWS)⁹
8. Assess the patient for specific contraindications to receiving treatment medications and advise the practitioner accordingly.
9. Monitor the patient’s fluid and electrolyte status.

   Rationale: Common withdrawal symptoms (e.g., diaphoresis, diarrhea, nausea, and vomiting) can contribute to dehydration.

10. Monitor the safety of the patient and the health care team members.

    Rationale: Alcohol withdrawal can result in agitation and aggression toward others and lead to a potentially life-threatening condition called delirium tremens.¹¹ Dysphoric mood experienced with opioid withdrawal may increase the potential for self-harm.

11. Implement appropriate safety precautions (e.g., suicide, self-harm, falls).
12. Administer medications to the patient as ordered.
13. Make referrals for additional consults (e.g., psychiatric practitioner, social worker) as appropriate.

MONITORING AND CARE

1. Monitor withdrawal-related signs and symptoms by performing ongoing cycles of assessment, including using validated screening and assessment tools to evaluate the patient’s withdrawal symptoms and utilizing withdrawal protocols per the organization’s practice.
2. Closely monitor for medical emergencies, particularly if the patient is experiencing withdrawal from alcohol and opiates.
3. Continue to reevaluate the patient for suicidal ideation, thoughts of self-harm, and thoughts of harming others.
4. Monitor for self-directed violence (e.g., self-cutting, ingestion of non-food objects, threats of self-injury or harm).
5. Evaluate the patient’s health care needs based on the patient’s reports and concerns.
6. Monitor laboratory and other diagnostic study results as they become available to promote the successful and appropriate treatment of current or potential medical conditions.
7. Watch the patient for adverse and allergic reactions to the medication. If a reaction occurs, follow the organization’s practice for emergency response.
8. Be prepared to use alternative approaches with a patient who reacts adversely to interventions (e.g., if a patient becomes agitated when a request for an item cannot be met because of safety issues). Consult with other health care team members to determine the best course of action.
9. Perform ongoing monitoring for signs and symptoms of drug seeking and diversion and any associated behavior concerns.

EXPECTED OUTCOMES

• Health care team members employ therapeutic communication and a trauma-informed care (TIC) approach consistently and appropriately.
• The patient undergoes an appropriate level and frequency of monitoring and assessment, along with timely implementation of interventions as indicated per the organization’s practice or licensed practitioner (LP)’s orders.
• The patient does not experience complications related to withdrawal resulting from improper monitoring, assessment, or intervention implementation.
• Health care team members respond safely and in a timely manner to concerning behaviors or behavioral issues.
• Based on the patient’s desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state:
  • Patient verbalizes a clear understanding of patient rights and responsibilities in the acute care setting.
  • Patient is able to recognize potential risks related to substance use.
  • Patient is able to recognize factors that can contribute to demonstrating unsafe behaviors as well as interventions that can be used to mitigate the behaviors.
  • Patient is able to recognize healthy and unhealthy coping skills and reasons for variation in coping abilities.
  • Patient is able to identify that mental health and substance use concerns or conditions are the result of a combination of multi-factor, gene-environment interactions and should not be viewed as weaknesses.
• Based on the patient’s desire and readiness for substance use treatment and the patient’s overall neurologic and psychosocial state:
  • Patient is able to identify the benefits of receiving treatment for substance use and co-occurring mental health issues, as appropriate.
  • Patient and health care team members are able to collaborate to develop a comprehensive treatment plan, including outpatient treatment.

UNEXPECTED OUTCOMES

• Therapeutic communication and a TIC approach are used inconsistently or incorrectly.
• The patient does not undergo an appropriate level and frequency of monitoring and assessments.
• Indicated interventions are not implemented in a timely manner or per the organization’s practice or LP’s orders.
• The patient experiences complications related to withdrawal resulting from improper monitoring, assessment, or intervention implementation.
• Health care team members do not respond safely or in a timely manner to a patient displaying concerning behaviors or behavioral issues.
• Based on the patient’s desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state:
  • Patient is unable to verbalize a clear understanding of patient rights and responsibilities in the acute care setting.
  • Patient is unable to recognize potential risks related to substance use.
  • Patient is unable to recognize factors that can contribute to demonstrating unsafe behaviors and interventions that could be used to mitigate the behaviors.
  • Patient cannot recognize healthy and unhealthy coping skills and reasons why coping abilities vary.
  • Patient cannot identify that mental health and substance use concerns or conditions are the result of a combination of multi-factor, gene-environment interactions and should not be viewed as weaknesses.
• Based on the patient’s desire and readiness for substance use treatment and the patient’s overall neurologic and psychosocial state:
  • Patient is unable to identify the benefits of receiving treatment for substance use and co-occurring mental health issues, as appropriate.
  • Patient and health care team members do not collaborate to develop a comprehensive treatment plan, including outpatient treatment.

DOCUMENTATION

• Data from screenings and assessments (e.g., neurologic, mental, physical), including observations, findings, and frequency of reassessments
• Strategies and interventions used, both pharmacologic and nonpharmacologic, and their associated effectiveness
• Results of completed laboratory or other diagnostic tests, as applicable
• Information obtained from collateral informants relevant to the patient’s care
• Any notification of the LP or the patient’s guardians and the reason for the notification, per the organization’s practice
• Education
• Initiation of the patient’s care plan based on current presentation
• Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

• Alcohol is commonly used by individuals 12 to 20 years old, even though alcohol use is illegal for part of this age group.²
• Many individuals who drink underage are treated in emergency departments.²
• 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

• Unhealthy alcohol use affects people of all ages, including older adults.⁸
• High prescription medication use (i.e., polypharmacy) puts older adults at a greater risk than the general population for harmful side effects and drug-drug interactions.⁸
• The unique physical, emotional, and cognitive challenges facing older adults tend to mask SUD symptoms, making it more difficult for practitioners to identify and address SUDs.⁸
• As the body ages, the process of the absorption and breakdown of substances changes, which often causes older adults to have greater susceptibility to the effects of substances.⁸

SPECIAL CONSIDERATIONS

• Many cough and cold medications and mouthwashes contain alcohol.
• A patient in an unresponsive state should have 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.
• If a patient has a prescription for opioids, the patient’s history of controlled substance prescriptions should be reviewed using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.⁵
• Some patients may exaggerate their use of opioids to acquire methadone or buprenorphine (an opioid) to alleviate untreated or poorly managed pain.

REFERENCES

1. American Psychiatric Association (APA). (2013, revised 2022). Substance-related and addictive disorders. In DSM-5-TR: Diagnostic and statistical manual of mental disorders (5th ed., text rev., pp. 543-666). Washington, DC: Author.
2. Centers for Disease Control and Prevention (CDC). (2024). About underage drinking. Retrieved June 14, 2024, from https://www.cdc.gov/alcohol/underage-drinking
3. Centers for Disease Control and Prevention (CDC). (2024). Drinking alcohol while using other drugs can be deadly. Retrieved June 14, 2024, from https://www.cdc.gov/alcohol/about-alcohol-use/other-drug-use.html
4. Cirilli, A., Wiener, B. (2020). Evaluation and treatment of altered mental status in the emergency department. Emergency Medicine Reports, 41(10). Retrieved June 14, 2024, from https://www.reliasmedia.com/articles/146212-evaluation-and-treatment-of-altered-mental-status-in-the-emergency-department
5. Dowell, D. and others. (2022). CDC Clinical practice guideline for prescribing opioids for pain—United States, 2022. Morbidity and Mortality Weekly Report (MMWR), 71(3), 1-95. doi:10.15585/mmwr.rr7103a1
6. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program. Retrieved June 14, 2024, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
7. National Institute on Drug Abuse (NIDA). (2020). Drugs, brains, and behavior: The science of addiction: Addiction and health. Retrieved June 14, 2024, from https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/addiction-health
8. National Institute on Drug Abuse (NIDA). (2020). Substance use in older adults drugfacts. Retrieved June 14, 2024, from https://nida.nih.gov/publications/drugfacts/substance-use-in-older-adults-drugfacts
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
10. Rosenthal, L.D. and others. (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. 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

Clinical Review: Kristin Bursey, MSN, PMHNP-BC, PMH-BC, PHN, RDH

Published: August 2024