Alcohol related disorders and Clinical Institute Withdrawal for Alcohol (CIWA-AR) Scale
Alcohol related disorders and Clinical Institute Withdrawal for Alcohol (CIWA-AR) Scale
Alcohol is the only drug for which exact objective measures of intoxication (BAL) currently exist.
Alcohol content varies from product to product; nevertheless, a drink is a drink is a drink, with 1.5 ounces of liquor (40% alcohol), a 12-ounce bottle of beer (5% alcohol), and a five-ounce glass of table wine (12% alcohol) all containing the same amount of ethanol. Thus all affect human physiology in a consistent manner as measured by blood alcohol content (BAC), although there are distinct differences between men and women (Table 18-5). Differences in effects from person to person produced by beverage alcohol do not generally result from the type of drink consumed, but rather from the person’s size, previous drinking experiences, and rate of consumption. A person’s feelings and activities and the presence of other people also play a role in the way the alcohol affects behaviour.
Assessing the patient’s behaviour can assist the nurse in (1) ascertaining whether the person accurately reported recent drinking and (2) determining level of intoxication and possible tolerance, as patient behaviours may indicate greater or lesser levels of tolerance. As tolerance develops, a discrepancy is seen between the BAL and expected behaviour: a person with tolerance to alcohol may have a high BAL but minimal signs of impairment. Alternatively, a person who is highly sensitive to alcohol or compromised medically may have a low BAL but demonstrate a high level of intoxication.
Alcohol poisoning
Is a state of toxicity that can result when an individual has consumed large amounts of alcohol either quickly or over time. It can produce death from aspiration of emesis or a shutdown of body systems due to severe CNS depression. Signs of alcohol poisoning include an inability to rouse the individual, severe dehydration, cool or clammy skin, respirations less than 10 per minute, cyanosis of the gums or under the fingernails, and emesis while semiconscious or unconscious. Refer to Table 18-2 for important assessment and treatment information regarding alcohol intoxication and poisoning.
Alcohol Withdrawal
The early signs of alcohol withdrawal, a physical reaction to the cessation or reduction of alcohol (ethanol) intake, can develop within a few hours of the last intake. Symptoms peak after 24 to 48 hours and then rapidly and dramatically disappear unless the withdrawal progresses to alcohol withdrawal delirium.
Severity of withdrawal tends to be dose related, with heavier drinkers experiencing more severe symptoms. Withdrawal severity is also related to age, with those over 65 years of age experiencing more severe symptoms. During withdrawal, the patient may appear hyperalert, manifest jerky movements and irritability, startle easily, and experience subjective distress often described as “shaking inside.”
Grand mal seizures may appear 7 to 48 hours after cessation of alcohol intake, particularly in people with a history of seizures. Careful assessment, including this history and any other risk factors, followed by appropriate medical and nursing interventions can prevent the more serious withdrawal reaction of delirium.
The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) provides an efficient, objective means of assessing alcohol withdrawal to prevent under- or overtreating patients with benzodiazepines.
Alcohol withdrawal delirium
Also referred to as delirium tremens (DTs), is a medical emergency that can result in death in 20% of untreated patients. It is an altered level of consciousness that presents with seizures following acute alcohol withdrawal. Death is usually due to cardiopathy, cirrhosis, or other comorbidities requiring mechanical ventilation.
The state of delirium usually peaks 48 to 72 hours after cessation or reduction of intake, although it can peak later, and lasts 2 to 3 days. Features of alcohol withdrawal delirium include the following:
• Autonomic hyperactivity (tachycardia, diaphoresis, elevated blood pressure)
• Severe disturbance in sensorium (disorientation, clouding of consciousness)
• Perceptual disturbances (visual or tactile hallucinations)
• Fluctuating levels of consciousness (ranging from hyperexcitability to lethargy)
• Delusions
• Anxiety and agitated behaviours
• Fever (38°C to 39°C)
• Insomnia
• Anorexia
Detoxification or Alcohol Withdrawal Treatment
Acamprosate (Campral) was approved by Health Canada in 2008 to treat people who had been alcohol dependent, had stopped drinking, and wished to remain abstinent. In randomized, double-blind, placebo-controlled trials, though without active comparators, acamprosate in conjunction with psychosocial therapy was generally significantly better than placebo plus psychosocial interventions in improving various key outcomes, including the proportion of patients who maintained complete abstinence from alcohol, the average duration of abstinence duration, and the total number of nondrinking days. Acamprosate is believed to effect a reduction in one’s intake of alcohol through suppression of excitatory neurotransmission and enhanced inhibitory transmission (Lehne, 2014; Plosker, 2015).
Naltrexone (ReVia), an agent used in reversing the effects of opioid addiction, is sometimes used in the treatment of alcohol dependency, especially for those with intense cravings and somatic symptoms. Naltrexone works by blocking opioid receptors, thereby interfering with the mechanism of reinforcement and reducing or eliminating the alcohol craving (Vuoristo-Myllys, Lipsanen, Lahti, et al., 2014). Long-acting injectable forms with the brand names Vivitrex or Vivitrol, Naltrel, and Depotrex are being tested and show promise as having relatively stable plasma levels, allowing for more sustained effects ( Gordon, Kinlock, Vocci, et al., 2015 ; Knopf, 2016 ).
Topiramate
Similar to acamprosate, topiramate (Topamax) is purported to decrease alcohol cravings by inhibiting the release of mesocorticolimbic dopamine, which has been associated with alcohol craving. Currently topiramate is still not approved for use with alcohol-dependent persons, although preliminary findings indicate that it has a beneficial effect in individuals with a typology of craving characterized by drinking obsessions and automaticity of drinking (Guglielmo, Martinotti, Quatrale, et al., 2015).
