Key Takeaways
- Alcohol withdrawal can progress to Delirium Tremens (DTs), a life-threatening emergency characterized by severe hypertension, tachycardia, hallucinations, and seizures
- Alcohol withdrawal symptoms typically begin 6-24 hours after last drink, with DTs occurring 48-72 hours after cessation
- Benzodiazepines (Lorazepam, Diazepam) are first-line treatment for alcohol withdrawal to prevent seizures
- Opioid withdrawal is extremely uncomfortable but rarely life-threatening; symptoms include rhinorrhea, lacrimation, muscle aches, and diarrhea
- Naloxone (Narcan) reverses opioid overdose but has a shorter half-life than most opioids, requiring monitoring for re-sedation
Substance Misuse and Withdrawal
Substance use disorders are common in healthcare settings. Nurses must recognize withdrawal syndromes, understand their timelines, and implement appropriate interventions. The NCLEX tests your knowledge of the most dangerous withdrawal syndromes and their management.
The Danger Hierarchy of Withdrawal
Not all withdrawal syndromes are equally dangerous. Know which ones can kill:
| Substance | Withdrawal Danger Level | Can Be Fatal? |
|---|---|---|
| Alcohol | High | Yes (DTs, seizures) |
| Benzodiazepines | High | Yes (seizures) |
| Barbiturates | High | Yes |
| Opioids | Moderate | Rarely (discomfort extreme) |
| Cocaine/Stimulants | Low | No (depression, fatigue) |
| Cannabis | Low | No |
| Nicotine | Low | No |
Critical point: Alcohol and benzodiazepine withdrawal can cause fatal seizures and require medical management. Opioid withdrawal, while extremely uncomfortable, is rarely life-threatening.
Alcohol Withdrawal
Timeline of Alcohol Withdrawal
| Time After Last Drink | Stage | Symptoms |
|---|---|---|
| 6-24 hours | Minor withdrawal | Tremors, anxiety, nausea, insomnia, tachycardia |
| 12-24 hours | Alcoholic hallucinosis | Visual/auditory/tactile hallucinations (client knows they're not real) |
| 24-48 hours | Withdrawal seizures | Grand mal seizures possible |
| 48-72 hours | Delirium Tremens (DTs) | Life-threatening medical emergency |
Delirium Tremens (DTs)
Delirium Tremens is the most severe form of alcohol withdrawal and is a medical emergency with 5-15% mortality if untreated.
Symptoms:
- Severe confusion and disorientation
- Severe agitation
- Profuse sweating (diaphoresis)
- High fever
- Severe hypertension
- Tachycardia
- Visual/tactile hallucinations (often insects, snakes)
- Tremors
- Seizures
Risk factors for DTs:
- History of DTs
- Heavy, prolonged alcohol use
- Concurrent medical illness
- Previous withdrawal seizures
- Older age
Nursing Assessment: CIWA-Ar
The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is used to monitor withdrawal severity. Scores determine medication dosing.
| CIWA-Ar Score | Severity | Intervention |
|---|---|---|
| 0-8 | Minimal | Monitor closely |
| 9-14 | Mild | May need medication |
| 15-20 | Moderate | Medication indicated |
| >20 | Severe | Aggressive treatment |
Treatment of Alcohol Withdrawal
First-line medications: Benzodiazepines
| Medication | Route | Key Points |
|---|---|---|
| Lorazepam (Ativan) | PO, IM, IV | Preferred in liver disease (no active metabolites) |
| Diazepam (Valium) | PO, IV | Long-acting; self-tapering |
| Chlordiazepoxide (Librium) | PO | Traditional choice; oral only |
Other interventions:
- Thiamine (Vitamin B1) - GIVE BEFORE GLUCOSE to prevent Wernicke's encephalopathy
- IV fluids for dehydration
- Electrolyte replacement
- Seizure precautions
- Quiet, well-lit environment
- Frequent vital signs
- Fall precautions
Exam tip: Always give thiamine BEFORE dextrose (glucose) in alcoholic clients. Glucose metabolism depletes thiamine and can precipitate Wernicke's encephalopathy.
Opioid Withdrawal
Timeline of Opioid Withdrawal
| Opioid Type | Onset of Withdrawal | Peak | Duration |
|---|---|---|---|
| Short-acting (heroin, oxycodone) | 6-12 hours | 36-72 hours | 5-7 days |
| Long-acting (methadone) | 24-48 hours | 72-96 hours | 2-3 weeks |
Symptoms of Opioid Withdrawal
Mnemonic: Think "Flu-Like" symptoms
| System | Symptoms |
|---|---|
| Eyes/Nose | Lacrimation (tearing), rhinorrhea (runny nose) |
| GI | Nausea, vomiting, diarrhea, abdominal cramps |
| Musculoskeletal | Muscle aches, joint pain |
| Autonomic | Piloerection (goosebumps), sweating, yawning |
| Other | Dilated pupils, restlessness, insomnia, anxiety |
Nursing Care for Opioid Withdrawal
- Comfort measures (blankets for chills, fluids for dehydration)
- Antiemetics for nausea/vomiting
- Antidiarrheals (loperamide)
- Clonidine to reduce autonomic symptoms
- Medication-assisted treatment (MAT):
- Methadone (full agonist)
- Buprenorphine (partial agonist)
- Naltrexone (antagonist - for maintenance, not acute withdrawal)
Opioid Overdose
Signs of Opioid Overdose
The classic triad:
- Respiratory depression (slow, shallow breathing)
- Pinpoint pupils (miosis)
- Decreased level of consciousness
Emergency Response
Naloxone (Narcan) is the antidote for opioid overdose.
| Route | Onset | Duration |
|---|---|---|
| IV | 2 minutes | 30-90 minutes |
| IM | 5 minutes | 30-90 minutes |
| Intranasal | 5 minutes | 30-90 minutes |
Critical nursing considerations:
- Naloxone has a SHORTER half-life than most opioids
- Client may need repeated doses
- Monitor closely for re-sedation after initial reversal
- Naloxone will precipitate immediate withdrawal in dependent individuals
- Be prepared for agitation when client wakes up
Benzodiazepine Withdrawal
Similar to alcohol withdrawal (both affect GABA receptors).
Symptoms:
- Anxiety, irritability
- Tremors
- Sweating
- Seizures (can be fatal)
- Rebound insomnia
Treatment:
- Gradual taper (never stop abruptly)
- Long-acting benzodiazepine for substitution
- Seizure precautions
Stimulant Withdrawal (Cocaine, Amphetamines)
Symptoms ("Crash"):
- Severe depression
- Fatigue, increased sleep
- Increased appetite
- Irritability
- Suicidal ideation
Nursing care:
- Monitor for depression and suicide risk
- Supportive care
- Ensure sleep and nutrition
- No pharmacological treatment typically needed
Quick Reference: Withdrawal Comparison
| Substance | Life-Threatening? | Key Symptoms | Treatment |
|---|---|---|---|
| Alcohol | Yes | Tremors, seizures, DTs | Benzodiazepines, thiamine |
| Opioids | Rarely | "Flu-like" symptoms | Clonidine, MAT |
| Benzodiazepines | Yes | Anxiety, seizures | Gradual taper |
| Cocaine | No | Depression, fatigue | Supportive care |
On the Exam
NCLEX priorities:
- Alcohol withdrawal can kill - seizures, DTs
- DTs = 48-72 hours after last drink
- Benzodiazepines treat alcohol withdrawal
- Thiamine before glucose in alcoholics
- Opioid withdrawal = uncomfortable, not deadly
- Naloxone = short half-life = watch for re-sedation
A client admitted for alcohol detoxification is confused, diaphoretic, and reports seeing bugs crawling on the walls. Vital signs: T 102.4F, HR 128, BP 180/100. The nurse recognizes this as:
A client with alcohol use disorder is admitted. Before administering IV dextrose, the nurse should ensure the client receives:
A client was given naloxone (Narcan) for suspected opioid overdose and regained consciousness. What is the most important nursing action during the next 2 hours?