2.7 Substance Use, Intoxication, and Withdrawal Assessment
Key Takeaways
- The CIWA-Ar protocol evaluates alcohol withdrawal across 10 items (max score 67); scores >15 indicate severe withdrawal requiring immediate symptom-triggered benzodiazepines.
- The Clinical Opiate Withdrawal Scale (COWS) scores 5-12 (mild), 13-24 (moderate), 25-36 (moderately severe), >36 (severe); buprenorphine induction requires COWS score >=8-12 to prevent precipitated withdrawal.
- The CAGE questionnaire screens for alcohol use disorder; a score >=2 indicates 93% sensitivity and 86% specificity for AUD.
- The AUDIT screening tool score >=8 for men or >=4 for women indicates hazardous/harmful alcohol consumption requiring clinical intervention.
Substance Use, Intoxication, and Withdrawal Assessment
Accurate assessment of substance use, intoxication, and withdrawal is a vital skill for the PMHNP. Failure to identify severe withdrawal can lead to life-threatening complications, such as delirium tremens or status epilepticus in alcohol withdrawal. Standardized screening and assessment tools provide objective measures to guide treatment decisions.
SBIRT Framework
The PMHNP should be familiar with the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model, a comprehensive, integrated approach to identifying and treating substance use disorders:
- Screening: Universal screening with validated tools (CAGE, AUDIT, DAST-10) at every clinical encounter.
- Brief Intervention: A short motivational interviewing conversation (5-15 minutes) to raise awareness and encourage behavioral change.
- Referral to Treatment: Connecting patients with moderate-to-severe SUDs to specialty addiction treatment.
Screening Tools for Substance Use
Several validated screening tools are used to identify potential substance use disorders in primary care and psychiatric settings.
1. CAGE Questionnaire: A classic, brief 4-question screen specifically for alcohol use. A score of 2 or more "Yes" answers indicates a high likelihood of alcohol use disorder.
- C: Have you ever felt you should Cut down on your drinking?
- A: Have people Annoyed you by criticizing your drinking?
- G: Have you ever felt bad or Guilty about your drinking?
- E: Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
2. AUDIT (Alcohol Use Disorders Identification Test): Developed by the WHO, this 10-item questionnaire is more comprehensive than the CAGE and assesses alcohol consumption, drinking behaviors, and alcohol-related problems. A score of 8 or more suggests harmful drinking.
3. DAST-10 (Drug Abuse Screening Test): A 10-item self-report scale focusing on drugs other than alcohol. It provides a quick index of drug-related problems. A score greater than 0 suggests further assessment is warranted.
Assessing Alcohol Withdrawal: The CIWA-Ar
The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) is an objective, 10-item scale used to quantify the severity of alcohol withdrawal syndrome and guide symptom-triggered dosing of benzodiazepines.
Components Evaluated (Scored 0-7, except orientation 0-4):
- Nausea and vomiting
- Tremor (arms extended and fingers spread apart)
- Paroxysmal sweats
- Anxiety
- Agitation
- Tactile disturbances
- Auditory disturbances
- Visual disturbances
- Headache, fullness in head
- Orientation and clouding of sensorium
Scoring Interpretation:
- 0-8: Mild withdrawal. Usually managed with supportive care; medication may not be necessary.
- 9-15: Moderate withdrawal. Often requires medication (e.g., chlordiazepoxide, lorazepam).
- >15: Severe withdrawal. High risk for seizures and delirium tremens (DTs). Requires immediate pharmacological intervention and close monitoring.
Alcohol Withdrawal Timeline and Complications
| Time Since Last Drink | Symptoms | Clinical Concern |
|---|---|---|
| 6-12 hours | Tremor, anxiety, insomnia, nausea | Minor withdrawal |
| 12-24 hours | Alcoholic hallucinosis (clear sensorium) | Hallucinations without delirium |
| 24-48 hours | Generalized tonic-clonic seizures | Withdrawal seizures |
| 48-96 hours | Delirium tremens (DTs) | Hyperthermia, autonomic instability, mortality 5% untreated |
Clinical Pearl: DTs typically peak at 72 hours and require ICU-level monitoring. Benzodiazepines (lorazepam preferred in hepatic impairment) are first-line. Phenobarbital is second-line.
Assessing Opioid Withdrawal: The COWS
The Clinical Opiate Withdrawal Scale (COWS) is an 11-item clinician-administered tool used to assess opioid withdrawal severity. It is crucial for determining the appropriate time to initiate buprenorphine induction (to avoid precipitated withdrawal).
Components Evaluated:
- Resting pulse rate
- Sweating
- Restlessness
- Pupil size (dilated in withdrawal)
- Bone or joint aches
- Runny nose or tearing (rhinorrhea/lacrimation)
- GI upset (cramps, nausea, vomiting, diarrhea)
- Tremor
- Yawning
- Anxiety or irritability
- Gooseflesh skin (piloerection)
Scoring Interpretation:
- 5-12: Mild
- 13-24: Moderate (Typically the threshold for initiating buprenorphine)
- 25-36: Moderately severe
- >36: Severe
Buprenorphine Induction Trap: Precipitated Withdrawal
A critical ANCC exam concept: buprenorphine must not be initiated too early. Because buprenorphine is a partial opioid agonist with high receptor affinity, administering it while full agonists (e.g., heroin, oxycodone) still occupy receptors will displace them and precipitate acute withdrawal. The PMHNP must wait until the patient is in moderate withdrawal (COWS >=8-13) before administering the first dose.
Toxicology Screening
Urine Drug Screens (UDS) are a common component of psychiatric assessments, particularly in acute settings or when monitoring adherence to controlled substance prescriptions. However, PMHNPs must understand the limitations and potential for cross-reactivity.
Detection Windows (Approximate):
- Alcohol: 10-12 hours (longer for ethyl glucuronide [EtG] metabolites, up to 3-5 days)
- Amphetamines: 1-3 days
- Benzodiazepines: 1-7 days (longer for long-acting agents like diazepam, up to 30 days)
- Cannabis: 1-3 days for occasional use; up to 30+ days for chronic heavy use
- Cocaine: 1-3 days (metabolite benzoylecgonine)
- Opioids (Heroin/Morphine): 1-3 days
Common False Positives:
- Amphetamines: Bupropion, pseudoephedrine, trazodone, selegiline, labetalol.
- PCP: Venlafaxine, dextromethorphan, diphenhydramine, ketamine.
- Opioids: Poppy seeds, dextromethorphan, fluoroquinolones (rarely).
- Benzodiazepines: Sertraline (rarely).
Clinical Pearl: A standard opiate screen tests for natural opiates (morphine, codeine) and heroin (via metabolite). It often misses semi-synthetic or synthetic opioids like oxycodone, fentanyl, buprenorphine, and methadone. Specific assays must be ordered for these substances.
Differentiating Intoxication vs Withdrawal Across Substance Classes
| Substance | Intoxication Signs | Withdrawal Signs |
|---|---|---|
| Alcohol | Disinhibition, ataxia, slurred speech, blackouts | Tremor, anxiety, seizures, DTs, hallucinosis |
| Opioids | Miosis, respiratory depression, euphoria, constipation | Piloerection, mydriasis, yawning, cramps, rhinorrhea |
| Stimulants (cocaine/meth) | Mydriasis, tachycardia, paranoia, hypertension | Hypersomnia, depression, increased appetite, anhedonia |
| Benzodiazepines | Sedation, ataxia, anxiolysis | Rebound anxiety, seizures, insomnia, autonomic hyperactivity |
| Cannabis | Euphoria, conjunctival injection, increased appetite | Irritability, insomnia, decreased appetite (usually mild) |
ANCC Exam Tip: Stimulant withdrawal is predominantly psychological (depression, anhedonia, hypersomnia) and is NOT life-threatening, unlike alcohol or benzodiazepine withdrawal.
A PMHNP is evaluating a patient in the emergency department who stopped drinking alcohol 24 hours ago. The patient is exhibiting bilateral hand tremors, significant diaphoresis, and complains of feeling extremely anxious and nauseous. The PMHNP administers the CIWA-Ar and calculates a score of 18. What is the most appropriate next step?
A patient undergoing an intake assessment is asked the four CAGE questions. They report that they frequently feel they should cut down on drinking and that they sometimes feel guilty about their drinking, but deny annoyance from others or using alcohol as an eye-opener. How should the PMHNP interpret this screening?
A patient with a history of depression and allergic rhinitis presents for a routine urine drug screen. The screen returns positive for amphetamines, but the patient strongly denies any illicit drug use or prescribed stimulant use. Which of the following medications in the patient's history is most likely responsible for a false-positive amphetamine result?