If you work in a correctional facility, it is vitally important that you can appropriately recognize, assess and implement interventions for Alcohol Withdrawal Syndrome (AWS). It is the most dangerous type of substance withdrawal and the most prevalent. According to Criminal Justice DrugFacts, from the National Institute on Drug Abuse, 85% of all incarcerated persons could be classified as having a Substance Use Disorder at the time of their crime and arrest.   Over half of American incarcerated persons 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.

Thorough history

A thorough history and assessment at Intake can identify detainees who need close watching during the first few days of incarceration. Be sure your intake questioning gathers information about alcohol history (what, when, how often and for how long) and the timing of the patient’s last drink. Ask about any previous withdrawal episodes, and if they resulted in seizures, hallucinations or hospital visits. Although the mild to moderate withdrawal symptoms will peak and wane in the first two days, DT’s usually occur 48-72 hours after the last drink. Untreated DT’s can lead to cardiovascular collapse.

One of the most tested assessment tools 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 the patient. It is very important that staff are trained and can demonstrate how to assess the patient using the scale.  

Experts recommend two or three times daily CIWA-AR assessment for those determined to be at risk.  Your Withdrawal Protocol may require different timeframes, but all should have some level of monitoring that becomes more frequent if the patient exhibits worsening signs of withdrawal.

The Importance of Hydration

High on the list of non-pharmacologic interventions for AWS is hydration. Alcoholics are often dehydrated, which increases nervous system excitability. Thus, it is important to encourage patients at risk for, or in, alcohol withdrawal to increase oral fluids. Some facilities provide electrolyte replacement fluids, such as Gatorade and other sports drinks,  to withdrawing individuals, as alcohol-dependent individuals are often electrolyte depleted as well.

Nutritional Status

Individuals who are chronic drinkers are more likely to be glycogen-depleted and malnourished. These conditions may worsen AWS symptoms, so it is important that these patients get included on the meal roster; some may even require a higher calorie special diet, depending upon their nutritional status when  admitted. 

Medications

Reducing nervous system excitability will decrease the risk of life-threatening DTs. Providing a short-term (5 day) or longer-term (9 day) taper of Librium, Ativan, Valium or other benzodiazepine will decrease  the risk of respiratory and cardiovascular collapse. Remember that even if your facility has a Withdrawal Protocol that includes these medications, administering them requires a current provider order.  There are many sources of pharmacologic treatment plans, including the protocols developed by the American Society of Addiction  Medicine  and the Merck Manual.   It is important that the protocol medications the patient may need are available onsite,  and there is a process for calling the provider so that there is no delay in their initiation.  

Monitor and send to the Emergency Department 911

If the interventions implemented do not forestall seizures, hallucinations or hemodynamic instability, arrange for emergency transport to the nearest hospital. Correctional facilities are not equipped to monitor and manage life-threatening situations, and it is vitally important to the patient’s safety and well-being that your monitoring identifies these life-threatening emergencies and they are promptly addressed.  

One MOre Thing….

With the patient population entering your facility every day, you need to be ever vigilant for potential alcohol withdrawal. Sometimes newly incarcerated individuals do not tell us they are heavy drinkers, either because they are embarrassed, they are afraid that we will share the information with law enforcement, or they just think they will be released soon. Thus, it is very important that you are able to identify the signs and symptoms of alcohol withdrawal, and, even if your patient did not disclose a history of alcohol use, consider it as you conduct your patient evaluation for anyone presenting with those signs and symptoms.

What do you do at your facility to recognize and treat alcohol withdrawal? Share your thoughts in the comments section of this post.