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Substance Use &
Withdrawal Care

Recognizing withdrawal syndromes, prioritizing safety, and delivering evidence-based nursing interventions across the continuum of care.

NCLEX-RN

Defining the Key Terms

Tolerance
Needing more of a substance to achieve the same effect over time.
Dependence
Physiological adaptation; the body requires the substance to function normally.
Withdrawal
Predictable physical/psychological symptoms when the substance is reduced or stopped.

Why Withdrawal Care Matters

Withdrawal is not just uncomfortable — for some substances it is life-threatening. The nurse's role is to anticipate, assess, and intervene before complications escalate.

Alcohol Withdrawal Timeline

Hours since last drink 6–12h Minor tremor, anxiety 12–24h Hallucinations visual/tactile 24–48h Seizures peak risk 48–72h DTs medical emergency

The Core Tool: CIWA-Ar

The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) is a standardized 10-item scale used to score withdrawal severity and trigger medication dosing.

Score < 10
Minimal withdrawal — often no medication needed.
Score 10–18
Moderate — treat with benzodiazepines per protocol.
Score > 18
Severe — high risk; aggressive treatment & close monitoring.

Pharmacology Essentials

1
Alcohol/Benzo withdrawal: Treat with benzodiazepines (lorazepam, diazepam) plus thiamine before glucose to prevent Wernicke's.
2
Opioid withdrawal: Use methadone or buprenorphine; clonidine eases autonomic symptoms.
3
Opioid overdose: Naloxone reverses respiratory depression — monitor for re-sedation.
4
Alcohol relapse prevention: disulfiram, naltrexone, acamprosate.

CNS Depressant vs. Opioid Withdrawal

Alcohol / Benzo Opioids
Life-threatening?Yes — seizures, DTsRarely fatal
Hallmark signsTremor, seizures, autonomic stormYawning, rhinorrhea, GI upset
First-line drugBenzodiazepinesMethadone / buprenorphine
AdjunctThiamineClonidine
Reversal agentFlumazenil (benzo)Naloxone

Nursing Approach: Step by Step

1
Assess: Obtain accurate substance history (type, amount, last use) and baseline vitals.
2
Score: Use a validated scale (CIWA-Ar for alcohol, COWS for opioids).
3
Prioritize safety: Seizure precautions, fall precautions, frequent monitoring.
4
Medicate: Administer symptom-triggered medications per protocol.
5
Support & refer: Provide nonjudgmental care, hydration, and connect to recovery resources.

Worked Example: Alcohol Withdrawal

1
Interpret: Score 14 = moderate withdrawal requiring treatment.
2
Intervene: Administer lorazepam per protocol; give thiamine.
3
Monitor: Reassess CIWA-Ar in 1 hour; institute seizure precautions.

Worked Example: Opioid Overdose

1
Priority (ABC): Support the airway and breathing — this is the immediate threat.
2
Reverse: Administer naloxone to reverse respiratory depression.
3
Watch: Naloxone half-life is shorter than opioids — monitor for re-sedation and repeat as needed.

Worked Example: Wernicke Risk

1
Recognize: These are signs of Wernicke encephalopathy (thiamine deficiency).
2
Critical sequence: Give thiamine BEFORE glucose — glucose first can worsen the deficiency.
3
Act: Question the order; advocate for thiamine administration first.

Common Mistakes

✕ Glucose before thiamine
Giving dextrose first in alcohol use can precipitate Wernicke encephalopathy.
✕ Underestimating CNS withdrawal
Treating alcohol/benzo withdrawal casually misses fatal seizure and DT risk.
✕ One naloxone dose only
Failing to monitor for re-sedation as naloxone wears off before the opioid.
✕ Judgmental attitude
Stigma reduces disclosure; nonjudgmental, therapeutic care improves outcomes.

Quick-Reference Summary

Substance Withdrawal Treatment Overdose / Antidote
AlcoholBenzodiazepines + thiamineSupportive care
BenzodiazepinesTaper / benzodiazepinesFlumazenil
OpioidsMethadone, buprenorphine, clonidineNaloxone
StimulantsSupportive, monitor moodSupportive care

Check Your Understanding

The following 5 questions test your ability to apply substance use and withdrawal nursing care. Choose the single best answer for each.

Question 1 of 5

A client with chronic alcohol use is admitted. Before administering IV fluids containing dextrose, the nurse should ensure which medication is given first?

Question 2 of 5

Which type of substance withdrawal is most likely to be life-threatening due to risk of seizures and delirium?

Question 3 of 5

A client is found unresponsive with a respiratory rate of 5 and pinpoint pupils. What is the nurse's priority action?

Question 4 of 5

A client's CIWA-Ar score is 16. How should the nurse interpret and act on this result?

Question 5 of 5

After giving naloxone for an opioid overdose, the client's breathing improves. What must the nurse continue to monitor for?

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