Happy New Year: Alcohol Withdrawal

Alkoholflasche in PapiertüteIt is New Year’s Eve and the police have just brought a middle aged man into the booking area on an arrest for drinking while driving. The man is in his 50’s, staggering but attempting to follow the booking officer’s directions. This is his first arrest so there is no history or prior information about him. The booking officer asks you to assess the man and decide if he can be accepted at the jail or if the arresting officer should take the man to the hospital for further assessment and possible treatment.

Use of alcohol is widespread among persons brought to jail.  A third of all inmates booked into jail were drinking at the time of arrest. Almost half of all jail inmates report alcohol use that met the definition for dependence or abuse (Karberg & James 2005).  Access to alcohol is disrupted by detention or incarceration and puts individuals who regularly use alcohol at risk of alcohol withdrawal syndrome. Seventy-four percent of deaths from intoxication took place within the first seven days of admission according to the Bureau of Justice Statistics (Noonan 2010). Identifying inmates at risk of alcohol withdrawal and treating these patients proactively is the most important step in preventing alcohol related death in jail. See a post on this topic at http://correctionalnurse.net/2010/03/31/alcohol-withdrawal-jail-nurse-alert/. The decision to accept this man into the jail or send him to the local hospital for further evaluation is going to depend upon two things:

  • An assessment of the patient’s condition and
  • The facility’s capacity to provide ongoing monitoring and treatment.

At the initial medical clearance any person presenting with the following should be referred to the hospital:

  • Inability to ambulate without assistance
  • Fever greater than 1010 F
  • Serious trauma or other injury
  • Profound confusion or altered sensorium
  • Tremors
  • Seizure activity
  • Autonomic dysfunction (dilated pupils, pulse greater than 120, blood pressure greater than 120, severe diaphoresis and/or flushing).

If the person does not have any of the conditions described above use of a standardized alcohol consumption assessment tool is recommended in addition to the health screening questions asked at intake (Laffan 2013, Department of Veterans Affairs 2009).  Two recommended tools are the CAGE Alcohol Abuse Assessment Tool which was discussed in a previous post and the Alcohol Use Disorders Identification Test (AUDIT-C). The AUDIT-C tool identifies individuals who are hazardous drinkers or have active alcohol use disorders.   It consists of only three questions: 1. How often do you have a drink containing alcohol?

  1. Never
  2. Monthly or less
  3. 2-4 times a month
  4. 2-3 times a week
  5. 4 or more times a week

2. How many drinks of alcohol do you have in a typical day?

  • 1 or 2
  • 3 or 4
  • 5 or 6
  • 7 to 9
  • 10 or more

3. How often do you have six or more drinks on one occasion?

  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily

Each answer is scored; an answer of “a” equals zero points and an answer of “e” equals 4 points for a possible total points of 12.  Men who score 4 and women who score 3 or more are considered hazardous drinkers with active alcohol use disorders (Bush et al. 1998, Department of Veterans Affairs 2009). These individuals will likely experience withdrawal symptoms that need to be monitored and treated medically. Inmates who are pregnant, have other chronic medical problems, or give a history of delirium tremens or seizures upon withdrawal are more at risk of morbidity and mortality associated with alcohol withdrawal. A provider should be contacted immediately to initiate and manage the care of these patients during incarceration. The table below describes the symptoms and nursing care required by patients undergoing alcohol withdrawal. Facilities without the capacity to provide 24 hour monitoring and availability of on-call provider consultation should be prepared to refer detainees to the hospital for required monitoring and care. Good clinical oversight, thoughtfully prepared protocols and trained staff are sufficient to manage inmates with minor and moderate withdrawal symptoms.

Condition Symptoms Nursing actions
Minor withdrawal
  •   Nausea
  •   Sleeplessness
  •   Night sweats
  •   Anxiety
  •   Irritability
  •   BP = 140/90
  •   Mild tremor
  •   Disturbance in vision, hearing or sensation.
  •    Symptom monitoring (CIWA –AR) q 4 hours
  •   Encourage fluid intake (8-10 glasses daily)
  •   Medication for anxiety or agitation
  •   Provider ordered medications
Moderate withdrawal
  •   Inability to concentrate
  •   Forgetfulness
  •   Numbness of hands or feet,
  •   Severe agitation or anxiety
  •   Tremors
  •   Disturbance in vision, hearing or sensation
  •  Admit for inpatient care
  •   Vital signs q 4 hours
  •   CIWA-AR q 4 hours
  •   Oral fluids (10-12 glasses daily)
  •   Provider ordered medications
Severe withdrawal
  •   Hallucinations or  delusions
  •   Profound confusion or altered sensorium
  •   Autonomic dysfunction
  •   (dilated pupils, fever, pulse greater than   120, diastolic BP greater than 110, severe diaphoresis or flushing)
  •   Seizure activity
  •  CIWA-AR greater than 15
  •   Emergency transport to the hospital
  •   Notify provider immediately

The Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-AR) is a nationally recognized tool for monitoring alcohol withdrawal (Bayard et al. 2004).  The use of a standardized tool provides a consistent basis for serial evaluations of withdrawal symptom and can serve as the source for protocols that define treatment orders and timeframes for contacting a provider or referring for offsite care (Laffan 2013). On assessment of the inmate in the case example above the nurse found that the patient was at risk of withdrawal symptoms but he did not have any complicating medical conditions and so was cleared for booking. After completing the initial screening exam the nurse put him on the facility’s alcohol withdrawal protocol that included medically supervised housing and a treatment plan concurrent with the suggestions in the table above. What do you do at your facility to recognize and treat alcohol withdrawal? Share your thoughts in the comments section of this post. For more about alcohol withdrawal read Chapter 5 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.  References Bayard, M., McIntyre, J., Hill, K.R., (2004) Alcohol withdrawal Syndrome. American Family Physician, 69 (6) 1443-1450. Bush, K., Kivlahan, D.R., McDonell, M.B., Fihn, F.B., Bradley, K.A. (1998) The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of Internal Medicine 158 (16) 1789-95. Department of Veterans Affairs. (2009) Management of Substance Use Disorder. Accessed 12/230/2013 at http://www.healthquality.va.gov/Substance_Use_Disorder_SUD.asp Karberg, J.C. & James, D.J. (2005) Substance Dependence, Abuse and Treatment of Jail Inmates, 2002. Bureau of Justice Statistics, Special Report (NCJ 209588). US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at http://www.bjs.gov/content/pub/pdf/sdatji02.pdf Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC). Noonan, M. (2010) Mortality in Local Jails, 2000-2007. Bureau of Justice Statistics, Special Report, US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at  http://www.bjs.gov/content/pub/pdf/mlj07.pdf Photo credit: © artenot -Fotolia.com

2 thoughts on “Happy New Year: Alcohol Withdrawal

    • Janet,
      If you click on the underlined words in the post it will take you to the article or tool that is being discussed in the post. All of these references should be available without charge via the internet. If you want to buy our book, the Essentials of Correctional Nursing, go to http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf. If you enter promotional code AF1209 you will get $15 off and free shipping. The book can also be ordered from Amazon at http://www.amazon.com/dp/0826109519. Hope this information helps. Thanks for you inquiry. If you have more questions please post a comment here and we will get back to you ASAP.
      Catherine

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