Substance use and withdrawal

Alcohol withdrawal items ask whether you can spot the autonomic climb, prevent seizures with the right class of drug, protect the brain with thiamine, and keep disulfiram clients truly alcohol-free. Opioid and stimulant emergencies live in Opioid and substance use.

Withdrawal: expected vs dangerous

After abrupt cessation in a dependent client, alcohol withdrawal is a timed autonomic climb. Alcohol had been damping the nervous system; when it disappears, glutamate and catecholamines rebound. Early findings — tremor, anxiety, sweating, rising HR and BP, nausea, insomnia — mean the nervous system is overfiring. Those signs are expected withdrawal that still needs protocol treatment and close monitoring. They are not proof the client is safe to leave alone.

Your assessment job is to trend severity, not guess a dose. Use the facility withdrawal tool (often CIWA-style): score symptoms, watch vitals and mentation, and give benzodiazepines as ordered to blunt the climb and prevent seizures. Score cutoffs and drug amounts live in the order set — follow them; do not invent numbers from memory on the exam.

1. Assess CIWA-style severity per facility tool.
2. Give benzodiazepines as ordered to control symptoms and prevent seizures.
3. Keep the environment safe and quiet; stay with escalating clients.
4. Pad rails, suction ready, and low stimulus for high-risk clients.
5. Notify for DT or seizure activity immediately.

Delirium tremens

Delirium tremens is withdrawal’s dangerous peak: global confusion, vivid hallucinations, severe agitation, and dangerous autonomic instability (marked tachycardia, hypertension, fever, diaphoresis). Aspiration, arrhythmia, and injury risk are high. This is escalate-now care: continuous presence, ordered benzos (and adjuncts per protocol), airway readiness, and immediate team notification. Quiet reassurance without escalation is the distractor that fails both the exam and the bedside.

Thiamine, glucose, and electrolytes

Chronic heavy alcohol use depletes thiamine (vitamin B1). Without thiamine, a glucose load can precipitate or worsen Wernicke encephalopathy — confusion, ataxia, and abnormal eye movements. Protocol language on exams is clear: give thiamine before or with glucose in at-risk clients. Do not race dextrose alone into a malnourished drinker and call it helpful.

• Thiamine prevents and treats Wernicke encephalopathy; start it early as ordered.
• Replace electrolytes as ordered; low K+ and Mg++ raise arrhythmia and seizure risk.
• Offer food when the gut allows; malnutrition is part of the disease, not a character flaw.
• Folate and multivitamins often ride along — still do not skip thiamine for a “multi” alone when Wernicke risk is high.

Disulfiram and other AUD meds

Disulfiram creates a severe acetaldehyde reaction with alcohol: flushing, headache, nausea, hypotension, and worse. Teach total avoidance, including unexpected sources the provider lists (mouthwash, cooking wine, some sauces, topical products). If the client cannot commit, this is the wrong drug. Other AUD meds (naltrexone, acamprosate patterns) appear as adherence and contraindication stems — read the stem’s drug, do not swap teaching across classes.

Priority map