6.6 Withdrawal

Clients frequently underreport alcohol and substance use, so nurses must be aware of signs of withdrawal in clients receiving medical care for other issues and notify the health care provider. Nurses working in hospital settings or emergency departments commonly administer treatment for clients experiencing withdrawal from alcohol, opioids, or other substances.1

Alcohol Withdrawal

Assessment

Symptoms of early or mild alcohol withdrawal include anxiety, minor agitation, restlessness, insomnia, tremor, diaphoresis, palpitations, headache, and alcohol craving. Clients often experience loss of appetite, nausea, vomiting, and diarrhea. Physical signs include sinus tachycardia, systolic hypertension, hyperactive reflexes, and tremor. Without treatment, symptoms of mild alcohol withdrawal generally begin within 6 to 36 hours after the last drink and resolve within one to two days.^[1]

Some clients develop moderate to severe withdrawal symptoms that can last up to six days, such as hallucinations, seizures, or delirium tremens^[2]:

• Hallucinations typically occur within 12 to 48 hours after the last drink. They are typically visual and commonly involve seeing insects or animals in the room, although auditory and tactile phenomena may also occur.
• Alcohol withdrawal-related seizures can occur within 6 to 48 hours after the last drink. Risk factors for seizures include concurrent withdrawal from benzodiazepines or other sedative-hypnotic drugs.
• Delirium tremens (DTs) is a rapid-onset, fluctuating disturbance of attention and cognition that is sometimes associated with hallucinations. In its most severe manifestation, DTs are accompanied by agitation and signs of extreme autonomic hyperactivity, including fever, severe tachycardia, hypertension, and drenching sweats. DTs typically begin between 72 and 96 hours after the client’s last drink. Mortality rates from withdrawal delirium have been historically as high as 20 percent, but with appropriate medical management, the mortality rate is between 1 and 4 percent. Death is attributed to cardiovascular complications, hyperthermia, aspiration, and severe fluid and electrolyte disorders.

The Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) is the most widely used scale to determine the need for medically supervised withdrawal management. It is used in a wide variety of settings when there is a clinical concern regarding a client’s alcohol withdrawal. The CIWA-Ar scale is typically utilized in association with a protocol containing medications to guide symptom-triggered treatment.^[3]

The CIWA-Ar contains ten questions related to nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and level of orientation. View the full CIWA-Ar scale in the following box.

Treatment

When the sedating properties of alcohol are not available to a person with physical dependence on alcohol, symptoms of anxiety and psychomotor agitation begin. Benzodiazepines such as diazepam, lorazepam, or chlordiazepoxide are prescribed for psychomotor agitation and to help prevent a client from progressing to severe symptoms of withdrawal such as hallucinations, seizures, or delirium tremens. An alternative protocol uses clonidine and gabapentin to manage withdrawal symptoms rather than benzodiazepines. This reduces the risks that accompany benzodiazepines such as sedation and dependence. Medications are typically dosed based on client’s current CIWA-Ar score.^[5],[6],[7]

Opioid Withdrawal

Clients who take opioids over an extended period of time can develop physical dependence that causes withdrawal symptoms when they abruptly stop taking opioids. Medically supervised opioid withdrawal, also known as detoxification, involves administering medication to reduce the severity of withdrawal symptoms.^[8]

Assessment

Symptoms of opioid withdrawal include drug craving, anxiety, restlessness, gastrointestinal distress, diaphoresis, and tachycardia.

The Clinical Opiate Withdrawal Scale (COWS) is a widely used scale to assess the need for supervised opioid withdrawal. COWS rates the severity of 11 signs and symptoms of opioid withdrawal on a scale from 0 to 5. View the COWS in the following box.

Treatment

The first line of treatment for clients with physical dependence on opioids who are undergoing medically supervised withdrawal is buprenorphine. It can be administered in outpatient settings, but clients must already be experiencing mild to moderate withdrawal symptoms. After withdrawal symptoms have been well-controlled for 24 hours on buprenorphine, the daily dose is gradually tapered. Methadone is also used as treatment but has a risk of lethal overdose and requires monitoring in inpatient and outpatient settings.^[9]

Various medications may also be prescribed to provide targeted relief for the following symptoms of opioid withdrawal^[10]:

• Anxiety, irritability, restlessness: Diphenhydramine, hydroxyzine, lorazepam, clonazepam, and clonidine^[11]
• Abdominal cramping: Dicyclomine
• Diarrhea: Bismuth and loperamide
• Nausea/vomiting: Ondansetron, prochlorperazine, and promethazine
• Insomnia: Trazodone, doxepin, mirtazapine, quetiapine, and zolpidem
• Muscle aches, joint pain, and headache: Ibuprofen, acetaminophen, ketorolac, and naproxen
• Muscle spasms and restless legs: Cyclobenzaprine, baclofen, diazepam, and methocarbamol

Use of benzodiazepines and zolpidem are not recommended for clients receiving methadone or buprenorphine therapy unless they are under close medical supervision due to the risk of oversedation. Warm baths, rehydration, and gentle stretching are also helpful for relieving muscle aches and cramps.^[12]