Substance Use Disorders: Practice Questions & Explanations

Alcohol withdrawal occurs in people physically dependent on alcohol. Severity ranges from mild discomfort to life-threatening. Timeline: (1) 6-24 hours: minor withdrawal — tremors (especially hands), anxiety, headache, nausea/vomiting, sweating, increased pulse and blood pressure, insomnia, agitation; (2) 12-48 hours: withdrawal seizures (typically tonic-clonic, brief) — at-risk window 12-48 hours; (3) 12-48 hours: alcoholic hallucinations — visual hallucinations more common than auditory (different from psychotic hallucinations which are typically auditory); sensorium intact; (4) 48-96 hours: delirium tremens (DTs) — disorientation, severe agitation, hallucinations (often vivid, fearful), severe autonomic instability (very high BP, tachycardia, hyperthermia), tremors, diaphoresis; mortality 5-15% without treatment, <5% with treatment. CIWA scale (Clinical Institute Withdrawal Assessment) quantifies severity and guides medication. Treatment: (1) Benzodiazepines — gold standard; cross-tolerance with alcohol allows controlled detoxification; lorazepam, diazepam, chlordiazepoxide commonly used; can be scheduled or symptom-triggered (CIWA-based); (2) Thiamine BEFORE glucose — to prevent Wernicke encephalopathy (B1 deficiency in alcoholics; characterized by confusion, ataxia, ophthalmoplegia); (3) Folate, multivitamin; (4) Electrolyte replacement (magnesium especially); (5) Fluids; (6) Quiet, well-lit environment; (7) Seizure precautions; (8) Frequent reorientation. Severe cases need ICU monitoring. Long-term treatment for alcohol use disorder: medications (naltrexone, acamprosate, disulfiram), 12-step programs (AA), therapy (CBT, motivational interviewing), residential treatment.

Opioid withdrawal is uncomfortable but not life-threatening in healthy adults (unlike alcohol/benzodiazepine withdrawal). Symptoms: anxiety, restlessness, dysphoria; pupils dilated (mydriasis — opposite of intoxication which causes pinpoint pupils); muscle aches and bone pain; abdominal cramps, diarrhea, nausea/vomiting; runny nose (rhinorrhea), tearing (lacrimation), yawning, sneezing; sweating, chills, fever; piloerection ('goosebumps'); tachycardia, hypertension; insomnia. Duration: short-acting opioids (heroin, oxycodone, morphine) — onset 6-12 hours, peak 36-72 hours, resolves 5-7 days; long-acting (methadone) — onset 24-48 hours, peak 4-6 days, resolves 14+ days. Severity scale: COWS (Clinical Opiate Withdrawal Scale). Treatment options: (1) Medication-assisted treatment (MAT) — gold standard for opioid use disorder. Methadone: full agonist, long half-life, prevents withdrawal and cravings; only at certified clinics. Buprenorphine: partial agonist, ceiling effect on respiratory depression, available through certified providers; often combined with naloxone (Suboxone) to deter injection. Naltrexone: opioid antagonist, oral or monthly injection, requires being opioid-free before starting; (2) Symptomatic management — clonidine (reduces autonomic symptoms), antiemetics, antidiarrheals, analgesics for muscle aches, hydroxyzine for anxiety, melatonin or trazodone for sleep. While withdrawal is not life-threatening directly, complications include dehydration from vomiting/diarrhea, suicidal ideation from acute depression, return to use after detoxification is leading cause of overdose death (tolerance drops during abstinence). Pregnancy: methadone or buprenorphine — withdrawal can cause fetal distress; opioid-dependent pregnant women should NOT detox abruptly.

Nurses have an ethical and (in most states) legal duty to report suspected impairment of colleagues. The behavior may be substance use, mental health issues, or medical conditions affecting function. Why report: (1) Patient safety — impaired nurses can harm patients through errors, missed observations, poor judgment; (2) Colleague's welfare — early intervention enables recovery; ignoring enables progression of disease; (3) Profession's integrity — nursing's trust depends on accountability; (4) Mandatory in many states — nurse practice acts require reporting; failure to report can result in nurse's own license discipline. Signs of impairment: (1) Behavior changes — mood swings, isolation, irritability; (2) Performance issues — errors, missed assignments, falling asleep; (3) Physical signs — slurred speech, unsteady gait, dilated/constricted pupils, smell of alcohol; (4) Medication discrepancies — missing controlled substances, frequent waste, unusual patient pain complaints (when nurse is involved); (5) Working extra shifts or unusual hours (access to medications). What to do: (1) Document specific observations factually; (2) Report to charge nurse or nursing supervisor — proper chain of command; (3) Do not confront the colleague yourself or accuse publicly; (4) Maintain confidentiality; (5) Cooperate with subsequent investigation. Outcomes: investigation, drug testing if indicated, intervention if confirmed; many states have alternative-to-discipline programs (peer assistance programs) that allow recovery while licenses are maintained under monitoring. Punitive responses harm individuals and discourage future reporting. Nurses in recovery often return to practice successfully with proper support.

The CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL (CIWA-Ar) is a 10-item standardized scale used to assess alcohol withdrawal severity and guide treatment. CIWA-Ar ITEMS (each scored 0-7, except orientation which is 0-4): nausea/vomiting; tremor; paroxysmal sweats; anxiety; agitation; tactile disturbances; auditory disturbances; visual disturbances; headache/fullness in head; orientation and clouding of sensorium. MAXIMUM SCORE: 67. SCORE INTERPRETATION: 0-9: MINIMAL withdrawal — monitor, possible oral benzodiazepines; 10-15: MILD-MODERATE — oral benzodiazepines (chlordiazepoxide, lorazepam, or diazepam per protocol); 15-20+: MODERATE-SEVERE — IV benzodiazepines, intensive monitoring; ≥20: SEVERE — high risk for DTs and seizures, may require ICU admission, IV diazepam or lorazepam, continuous monitoring. MEDICATION-GUIDED TREATMENT ('symptom-triggered'): benzodiazepines are given based on CIWA score rather than on a fixed schedule; has been shown to reduce total benzodiazepine use while maintaining safety. FIXED-DOSE SCHEDULES: some protocols use scheduled doses (q4-8h for 24-48 hours) with additional PRN doses for breakthrough symptoms. NURSING ROLE: assess CIWA-Ar every 1-4 hours during active withdrawal (frequency based on severity); administer benzodiazepines per score and protocol; monitor vital signs (BP, HR — elevated in withdrawal); monitor for progression to DTs; thiamine before glucose; IV fluids; seizure precautions; quiet, low-stimulation environment; one-to-one nursing for severe withdrawal. NEVER ABRUPTLY STOP ASSESSMENT — withdrawal progresses over time.

ALCOHOL WITHDRAWAL PROGRESSION: MILD (6-12 hours): Tremors, anxiety, nausea, diaphoresis, palpitations; MODERATE (12-48 hours): Same plus headache, vomiting, transient hallucinations (often visual/auditory), seizures (peak 24-48 hours); SEVERE — DELIRIUM TREMENS (48-96 hours): Life-threatening; disorientation and confusion; agitation; auditory, visual, tactile hallucinations; severe autonomic instability (fever to 104°F+, HR>120, BP crisis); seizures; WITHOUT TREATMENT: DT mortality is 5-15%; WITH TREATMENT: <1%; TREATMENT: IV benzodiazepines (lorazepam, diazepam) — first-line; thiamine IV before any glucose (prevents Wernicke's encephalopathy); fluid/electrolyte replacement (hypomagnesemia, hypokalemia common); beta-blockers or clonidine for autonomic symptoms; CIWA-Ar scale monitors symptom severity to guide benzodiazepine dosing.

CIWA-Ar SCALE: THE STANDARD: Most commonly used validated tool for alcohol withdrawal monitoring; ITEMS: Nausea/vomiting; tremor; diaphoresis; anxiety; agitation; tactile disturbances (formication); auditory disturbances; visual disturbances; headache; orientation/clouding; SCORING: 0-67 total; INTERPRETATION: <10: Mild — monitoring, no medication unless symptoms progress; 10-15: Moderate — consider benzodiazepine; >15: Severe — benzodiazepine required; >20: Risk for delirium tremens; SYMPTOM-TRIGGERED vs FIXED SCHEDULE: CIWA-Ar allows symptom-triggered dosing — only administer benzodiazepine when score exceeds threshold (reduces total benzodiazepine dose, shortens withdrawal duration, improves safety vs fixed schedule); NURSING ROLE: Assess CIWA-Ar every 1-4 hours per protocol; administer PRN benzodiazepines per orders when threshold reached; monitor vital signs; ensure IV access; COMPARE: CAGE questionnaire = screening tool (Cut-down, Annoyed, Guilty, Eye-opener) for AUD history — not for acute withdrawal monitoring.

CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised): A validated 10-item scale that quantifies alcohol withdrawal severity. ITEMS: Nausea/vomiting, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation; SCORING: Higher score = more severe withdrawal; guides symptom-triggered benzodiazepine dosing; RISING SCORE = worsening — requires more aggressive treatment; WITHDRAWAL PROGRESSION (if untreated): Tremors/anxiety (6-12h) → hallucinations (12-24h) → seizures (24-48h) → delirium tremens (48-96h, life-threatening); TREATMENT: Benzodiazepines (lorazepam, diazepam, chlordiazepoxide) are first-line — symptom-triggered dosing based on CIWA score; thiamine (B1) BEFORE glucose (prevents Wernicke encephalopathy); fluid/electrolyte management; quiet environment; DELIRIUM TREMENS: Medical emergency with high mortality if untreated — confusion, severe autonomic instability, hallucinations; nursing role: assess with CIWA, administer benzodiazepines per protocol, monitor for escalation, ensure safety, give thiamine.