3.1 Alcohol Intoxication, Overdose, and Withdrawal

Alcohol as a CNS depressant

Alcohol (ethanol) is a central nervous system (CNS) depressant that enhances inhibitory GABA activity and suppresses excitatory glutamate (NMDA) activity. The CADC exam wants you to link that pharmacology to observable behavior: slowed reaction time, impaired judgment, slurred speech, ataxia (poor coordination), emotional lability, blackouts (anterograde amnesia), and reduced capacity to give reliable informed consent. As intoxication deepens, the safety question outranks the counseling question.

IC&RC places drug classes, intoxication, overdose, and withdrawal inside the foundation knowledge supporting Domain I, Screening, Assessment, and Engagement. The exam is one-best-answer multiple choice, so read each stem for the action that protects life and stays within counselor scope.

Tolerant drinkers may walk and talk at a BAC that would sedate a naive drinker, but tolerance never equals safety — it masks impairment from casual observers while overdose and withdrawal risk still climb.

Overdose (alcohol poisoning) and the dangerous withdrawal cascade

Alcohol poisoning is a true emergency: signs include vomiting, confusion, hypothermia, pale or bluish skin, slow or irregular breathing (fewer than ~8 breaths/min), seizures, and unresponsiveness. The lost gag reflex creates aspiration risk, and respiratory depression can stop breathing. The CADC action is to activate emergency protocol — never let the client "sleep it off" alone.

Alcohol withdrawal is exam-critical because, alongside sedative-hypnotics, it is one of the few withdrawals that can be fatal. The cascade follows a predictable timeline after the last drink:

Delirium tremens carries significant mortality if untreated and is a medical condition requiring hospital-level care with benzodiazepines. A history of prior seizures or DTs predicts severe withdrawal. A counselor may gather history, ask about last use, note symptoms, contact supervision, and follow agency emergency procedures — but must never promise that withdrawal can be handled with rest, hydration, or willpower.

CIWA-Ar and the counselor role

The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is the standard withdrawal-severity tool the exam expects you to recognize. It is a 10-item scale (nausea/vomiting, tremor, sweating, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and orientation/clouding of sensorium) scored 0 to 67.

Medical settings use CIWA-Ar for symptom-triggered benzodiazepine dosing (e.g., lorazepam until the score falls below ~10). The CADC does not score-and-dose; the value of knowing CIWA-Ar is recognizing that a structured tool drives the medical decision and that high scores mean urgent referral.

Applied scenario: a client arrives for intake smelling of alcohol, speaks slowly, and reports stopping after a week-long binge, now with tremor and sweating. The best CADC response is to pause routine intake, assess immediate safety, follow agency policy, and refer for medical evaluation because withdrawal danger is present. Document objectively: observed behavior, client statements, actions taken, and consultation.

Distinguish tolerance from dependence. Tolerance means the body adapted so more alcohol is needed for the same effect. Physical dependence means withdrawal can occur when use stops or drops. Neither proves motivation, morality, or diagnosis by itself, and neither is the same as a substance use disorder, which is a behavioral diagnosis requiring multiple criteria over time.

Wernicke-Korsakoff awareness. Heavy chronic alcohol use depletes thiamine (vitamin B1), which can produce Wernicke encephalopathy — the triad of confusion, ataxia, and eye-movement abnormalities — that, untreated, progresses to the largely irreversible memory loss of Korsakoff syndrome. The CADC does not treat it, but recognizing confusion plus unsteady gait in a chronic drinker as a possible medical emergency, not mere intoxication, is testable. Thiamine before glucose is the medical rule the counselor only needs to recognize as urgent referral.

Common exam traps: (1) choosing motivational interviewing when the stem describes acute danger — MI does not replace emergency response during confusion, breathing problems, or seizure risk; (2) assuming high tolerance protects the client; (3) treating withdrawal as a willpower issue. In one-best-answer items, choose the response that recognizes both impairment and medical risk, then assesses, consults, and refers.

• Alcohol is a depressant with behavioral, cognitive, and physical effects.
• Withdrawal can be lethal — seizures (12-48h) and DTs (48-72h).
• CIWA-Ar (10 items, 0-67; ≥16 = severe) guides medical management.
• CADCs assess, document, consult, and refer; they do not prescribe detox.
• Safety precedes treatment planning when intoxication or withdrawal is active.