Alcohol Withdrawal: Jail Nurse Alert
If you work in a jail, it is in your best interest to become an expert at assessing and intervening in alcohol withdrawal syndrome (AWS). It is the most dangerous type of substance withdrawal and the most prevalent. The recently published Behind Bars II: Substance Abuse and America’s Prison Population identifies 85% of all inmates have substance involvement. Over half of American inmates are incarcerated due in some way to alcohol. Once behind bars, withdrawal begins with potential dangers.
Withdrawal from alcohol causes increased excitability in the nervous system leading to nausea, vomiting, sweating, shakiness, agitation and anxiety. A medical emergency can develop when withdrawal leads to delirium tremens (DTs) involving hallucinations, confusion, disorientation, and generalized seizures. Autonomic hyperreactivity can progress to hypertension, tachycardia, hyperthermia, tachypnea and tremors.
Tag, You’re It
A thorough history and assessment at intake can identify inmates who need close watching during the first few days of incarceration. Be sure your intake questioning gathers information about alcohol history and timing of last drink. Ask about any previous withdrawal episodes and if they resulted in hallucinations or hospital visits. Although the mild to moderate withdrawal symptoms will peak and wane in the first 2 days, DT’s occur around 48-72 hours after the last drink. Untreated DT’s can lead to cardiovascular collapse.
The most tested assessment tool for the identification of persons at risk for alcohol withdrawal is the CIWA-AR Scale. It uses a numbering system to objectively determine severity of withdrawal and can be used over time to document the course of AWS for an individual inmate. Experts recommend twice daily CIWA-AR assessment for those determined to be vulnerable.
Hydrate Pronto
High on the list of non-pharmacologic interventions for AWS is hydration. Alcoholics are often dehydrated, which increases nervous system excitability. Encourage withdrawing inmates to increased fluids by mouth. Some facilities provide electrolyte replacement fluids, such as Gatorade or other sports drink to withdrawing inmates, as alcohol-dependent individuals are often electrolyte depleted.
Food for Thought
The chronic drinker is likely to be glycogen-depleted and malnourished. These conditions enhance AWS symptoms. Get these folks into the meal system pronto. Encourage nutritious eating to replace stores. Good choices to have available are milk, sandwiches and peanut butter crackers.
Get ‘em Mellow
Reducing nervous system excitability will decrease chances of life-threatening DTs. Providing a short-term (5 day) taper of Librium, valium or other barbiturate will decrease the chances for respiratory and cardiovascular collapse. Of course, a physician order is needed for this intervention. Examples of pharmacologic treatment can be found in many sources, including the Merck Manual. A standard protocol for barbiturate treatment with stock medication available can smooth the initiation of effective treatment on hectic, high-load weekend nights. Encourage your facility to have a treatment system set up for AWS.
Don’t be Afraid to Package and Ship
If you are unable to forestall seizures, hallucinations or hemodynamic instability, arrange for emergency transport to the nearest emergency room. Jails are not equipped to monitor and manage life-threatening situations. Pack them up and send them to the next level of care.
With the patient population entering your jail every day, you need to be ever vigilant for potential alcohol withdrawal. With solid assessment tool, close observation and early intervention, you will be ready before trouble strikes.
What do you do at your facility to recognize and treat alcohol withdrawal? Share your thoughts in the comments section of this post.
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My spouse died 2 days ago while incarcerated on a bench warrant. He died of Alcohol Withdrawal Syndrome. He was 58 years old. He was also medically fragile and weighed barely 100 pounds and was nearly 6 feet tall. Skin and Bones. It is incredibly painful to think of the torture he endured with no medical treatment due to the negligence of the jail staff. This has to be stopped. Jail staff need to be educated and supported to move inmates in this condition to the next level of care. My grief cannot be expressed in words. I would like to hear from anyone who also lost a loved one in this tragic way.
I am sorry for your loss, Mary Jo.