🍺 New Lesson 30
Substance Abuse & Withdrawal
Alcohol withdrawal timeline, DTs, opioid OD triad, Narcan, Antabuse, Librium, thiamine-before-glucose.
Alcohol Withdrawal
Alcohol Withdrawal Timeline
| Timeframe | What Happens | Priority Action |
|---|---|---|
| 6-24 hours | Tremors, anxiety, diaphoresis, tachycardia, hypertension, insomnia | Assess and medicate per orders |
| 24-48 hours | SEIZURES (rum fits) — grand mal type | Seizure precautions, benzodiazepines |
| 48-72 hours | DELIRIUM TREMENS (DTs): hallucinations, severe agitation, fever, autonomic instability — POTENTIALLY FATAL | Emergency response, ICU transfer |
🚨 Delirium Tremens (DTs) = Medical Emergency:
Visual hallucinations (seeing insects/bugs), severe tremors, extreme agitation, high fever, tachycardia, hypertension
Can be fatal from: MI, vascular collapse, electrolyte imbalance, aspiration pneumonia
Treatment: Benzodiazepines (Librium first-line), IV fluids, THIAMINE, seizure precautions
Visual hallucinations (seeing insects/bugs), severe tremors, extreme agitation, high fever, tachycardia, hypertension
Can be fatal from: MI, vascular collapse, electrolyte imbalance, aspiration pneumonia
Treatment: Benzodiazepines (Librium first-line), IV fluids, THIAMINE, seizure precautions
⭐ ALWAYS ask at admission: "When was your last alcoholic drink?"
This tells you exactly when withdrawal will peak and how dangerous it will be.
⭐ Chlordiazepoxide (Librium) = first-line benzodiazepine for alcohol withdrawal
This tells you exactly when withdrawal will peak and how dangerous it will be.
⭐ Chlordiazepoxide (Librium) = first-line benzodiazepine for alcohol withdrawal
Opioid Abuse
Opioid Overdose — The Triad
🚨 Opioid Overdose TRIAD:
1. MIOSIS — pinpoint pupils (very small, constricted)
2. RESPIRATORY DEPRESSION — slow, shallow breathing (CAUSE OF DEATH)
3. DECREASED LOC — stupor, unresponsive, coma
Also: hypotension, bradycardia, clammy skin
1. MIOSIS — pinpoint pupils (very small, constricted)
2. RESPIRATORY DEPRESSION — slow, shallow breathing (CAUSE OF DEATH)
3. DECREASED LOC — stupor, unresponsive, coma
Also: hypotension, bradycardia, clammy skin
Treatment: Naloxone (Narcan)
✅ Give IV, IM, or intranasal
✅ Works within minutes to reverse opioid effects
⚠️ Naloxone half-life (30-90 min) is SHORTER than most opioids (4-8 hrs)
⚠️ Watch for RE-NARCOTIZATION — patient can become sedated again after Narcan wears off
⚠️ Repeat doses or continuous infusion may be needed
⚠️ Fentanyl analogs may require MUCH higher Narcan doses
✅ Works within minutes to reverse opioid effects
⚠️ Naloxone half-life (30-90 min) is SHORTER than most opioids (4-8 hrs)
⚠️ Watch for RE-NARCOTIZATION — patient can become sedated again after Narcan wears off
⚠️ Repeat doses or continuous infusion may be needed
⚠️ Fentanyl analogs may require MUCH higher Narcan doses
| Substance | Intoxication Signs | Withdrawal Signs |
|---|---|---|
| Opioids | Miosis, respiratory depression, decreased LOC | Goosebumps, yawning, rhinorrhea, abdominal cramps, dilated pupils |
| Alcohol | CNS depression, slurred speech, ataxia | Tremors, seizures, DTs (48-72 hrs) |
| Stimulants | Dilated pupils, tachycardia, hypertension, euphoria | Lethargy, depression, hypersomnia |
Disulfiram & Thiamine
Disulfiram (Antabuse) Teaching
🚨 Disulfiram Reaction — happens with ANY alcohol:
Intense flushing, nausea, vomiting, palpitations, hypotension
Can be life-threatening
The aversion IS the therapy — teaches the body to associate alcohol with extreme discomfort
Intense flushing, nausea, vomiting, palpitations, hypotension
Can be life-threatening
The aversion IS the therapy — teaches the body to associate alcohol with extreme discomfort
Teach the client to AVOID ALL of these:
❌ Mouthwashes containing alcohol
❌ Cough syrups (many contain alcohol)
❌ Cold medicines
❌ Aftershave lotions and colognes
❌ Cooking wine and vinegars
❌ ANY alcoholic beverage
✅ READ ALL PRODUCT LABELS before using anything
❌ Mouthwashes containing alcohol
❌ Cough syrups (many contain alcohol)
❌ Cold medicines
❌ Aftershave lotions and colognes
❌ Cooking wine and vinegars
❌ ANY alcoholic beverage
✅ READ ALL PRODUCT LABELS before using anything
🧠 Thiamine BEFORE Glucose — Critical Rule!
⚠️ RULE: Give THIAMINE (Vitamin B1) IV BEFORE any glucose-containing solution in known or suspected alcohol abuse!
WHY: Chronic alcohol use depletes thiamine (Vitamin B1). Giving glucose WITHOUT thiamine in a thiamine-deficient patient can PRECIPITATE WERNICKE ENCEPHALOPATHY — irreversible neurological damage.
Wernicke signs: ataxia, ophthalmoplegia (eye movement abnormalities), confusion
If untreated → Korsakoff syndrome (irreversible memory disorder)
Classic NCLEX scenario: Doctor orders D5W for a known alcohol abuser → GIVE THIAMINE FIRST
WHY: Chronic alcohol use depletes thiamine (Vitamin B1). Giving glucose WITHOUT thiamine in a thiamine-deficient patient can PRECIPITATE WERNICKE ENCEPHALOPATHY — irreversible neurological damage.
Wernicke signs: ataxia, ophthalmoplegia (eye movement abnormalities), confusion
If untreated → Korsakoff syndrome (irreversible memory disorder)
Classic NCLEX scenario: Doctor orders D5W for a known alcohol abuser → GIVE THIAMINE FIRST
📖 Notes for Dummies
📖 Substance Abuse Explained Simply
🍺 Alcohol Withdrawal in Plain English:
Alcohol calms the nervous system down. Take it away suddenly after years of use and the nervous system BOUNCES BACK with everything it had — anxiety, tremors, seizures, hallucinations. The timeline matters: seizures at 24-48 hours, DTs at 48-72 hours. DTs is like the nervous system in full-blown overdrive — fever, hallucinations, possibly a fatal heart attack. That's why we medicate with Librium from the start.
💉 Opioid Overdose in Plain English:
The classic picture: pinpoint pupils, barely breathing, passed out. The pupils are the giveaway — stimulants make pupils BIG (dilated), opioids make pupils TINY (pinpoint). Narcan is like a lock-pick for opioid receptors — it boots the opioid off fast. But Narcan is short-acting. The opioid is still in the body, just temporarily kicked off. When Narcan wears off (30-90 min), the opioid comes back. Watch the patient for hours.
🧪 Thiamine in Plain English:
Sugar burns in the body using Vitamin B1 (thiamine) as fuel. Alcoholics are almost always B1-deficient. Give them IV sugar without restocking the B1 first = brain damage. The brain cells try to burn the sugar but can't without B1. Always thiamine FIRST, then sugar. This is a classic NCLEX trap.
Alcohol calms the nervous system down. Take it away suddenly after years of use and the nervous system BOUNCES BACK with everything it had — anxiety, tremors, seizures, hallucinations. The timeline matters: seizures at 24-48 hours, DTs at 48-72 hours. DTs is like the nervous system in full-blown overdrive — fever, hallucinations, possibly a fatal heart attack. That's why we medicate with Librium from the start.
💉 Opioid Overdose in Plain English:
The classic picture: pinpoint pupils, barely breathing, passed out. The pupils are the giveaway — stimulants make pupils BIG (dilated), opioids make pupils TINY (pinpoint). Narcan is like a lock-pick for opioid receptors — it boots the opioid off fast. But Narcan is short-acting. The opioid is still in the body, just temporarily kicked off. When Narcan wears off (30-90 min), the opioid comes back. Watch the patient for hours.
🧪 Thiamine in Plain English:
Sugar burns in the body using Vitamin B1 (thiamine) as fuel. Alcoholics are almost always B1-deficient. Give them IV sugar without restocking the B1 first = brain damage. The brain cells try to burn the sugar but can't without B1. Always thiamine FIRST, then sugar. This is a classic NCLEX trap.