Learning Objectives
By the end of this section, you will be able to:
- Define and recognize how to diagnose alcohol use disorder
- Outline approaches to treating alcohol use disorder
- Plan nursing care for a client with alcohol use disorder
- Comprehend the risks a client in alcohol withdrawal might have to overcome
Alcohol is a legal drug that many people misuse. As of 2022, the lifetime statistics for alcohol use are that 221.3 million people aged twelve or older have used alcohol in their lifetime (SAMHSA, 2023a). Nurses provide care to individuals with alcohol use disorders, including performing assessments and offering treatment. Both alcohol and substance use have increased since the COVID-19 pandemic. Per the CDC, the number of Americans who reported either starting or increasing use of a substance to help them cope with the pandemic was at 13 percent (Chacon et al., 2021). Note that in the clinical setting, nurses may see the abbreviation ETOH. This stands for the chemical name for ethyl alcohol and is commonly used in documentation for alcohol and alcohol use.
Diagnosis and Definition of Alcohol Use Disorder
The DSM-5 recognizes alcohol use disorder (AUD) as a chronic medical condition that is categorized by difficulty stopping or controlling alcohol use, and by using alcohol to relieve or avoid withdrawal symptoms, even when it is causing negative social, occupational, or health-related consequences (SAMHSA, 2022c). Most people who have an alcohol use disorder will seek care from their primary care provider regarding an alcohol-related medical problem instead of for their drinking (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2023a).
An alcohol use disorder is considered a brain disorder that can be mild, moderate, or severe (National Institute on Alcohol Abuse and Alcoholism, 2023c). The misuse of alcohol causes many health concerns, including high blood pressure, gastroenteritis and pancreatitis, cirrhosis, cancer, and mental health problems. Violence and crime, fatal and nonfatal vehicle accidents, and death—more than 140,000 per year in the United States—are also connected to alcohol misuse (SAMHSA, 2022a).
Symptoms of Alcohol Use Disorder
The 2021 National Survey on Drug Use and Health reports that 47.5 percent (133.1 million) of Americans aged twelve or older use alcohol, 21.5 percent are binge drinkers, and 5.8 percent are heavy alcohol users (SAMHSA, 2022c). Consumption of eight or more drinks per week for women and fifteen or more drinks per week for men or binge drinking on five or more of the previous thirty days is considered heavy drinking. Consuming several standard drinks on one occasion in the past thirty days is considered binge drinking; for men, this refers to drinking five or more standard alcoholic drinks on one occasion, and for women, this refers to drinking four or more standard drinks on one occasion (SAMHSA, 2022c). Based on the 2015–2020 Dietary Guidelines for Americans, a standard drink is defined as 14 grams (0.6 ounces) of pure alcohol. Examples of a standard drink are one 12-ounce beer, 8 to 9 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of distilled spirits (Figure 19.3).
The term alcohol intoxication refers to problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, or impaired judgment) that develop during or shortly after alcohol ingestion. Signs and symptoms of alcohol intoxication are as follows: slurred speech, lack of coordination, unsteady gait, nystagmus, and impairment in attention or memory (American Psychiatric Association, 2013). The CDC’s recommendations on alcohol intake are limited to one to two drinks per day (Figure 19.4).
Symptoms of Alcohol Overdose
An alcohol overdose, also called alcohol poisoning, occurs when there is so much alcohol in the bloodstream that areas of the brain controlling autonomic nervous system functions (e.g., breathing, heart rate, and temperature control) begin to shut down. Signs of alcohol overdose include mental confusion, difficulty remaining conscious, vomiting, seizures, trouble breathing, slow heart rate, clammy skin, dulled gag reflex, and extremely low body temperature. Alcohol intoxication while also taking opioids or sedative-hypnotics (such as benzodiazepines or sleep medications) increases the risk of an overdose. Alcohol overdose can cause permanent brain damage or death (NIAAA & National Institutes of Health, 2021). Anyone who consumes too much alcohol too quickly is in danger of an alcohol overdose. As blood alcohol concentration (BAC) increases, so does the risk of harm. When BAC reaches high levels, blackouts (gaps in memory), loss of consciousness (passing out), and death can occur. BAC can continue to rise even when a person stops drinking or is unconscious because alcohol in the stomach and intestine continues to enter the bloodstream and circulate throughout the body.
Risk Factors in Developing Alcohol Use Disorder
Whether an individual ever uses alcohol or another substance and whether that initial use progresses to a substance use disorder of any severity depends on several factors, including the following:
- genetic and biological factors
- the age of substance use onset
- psychological factors related to a person’s unique history and personality
- environmental factors, such as the availability of alcohol, family and peer dynamics, financial resources, cultural norms, exposure to stress, and access to social support (Substance Abuse and Mental Health Services Administration (SAMHSA) & Office of the Surgeon General, 2016).
A person who binge drinks or has heavy alcohol use has an increased risk of developing alcohol use disorder (AUD) (NIAAA, 2023c). Genetics influence development of AUD by approximately 50 percent, though environmental factors are also significant (Deak & Johnson, 2021). Parents’ drinking patterns can influence a child later in developing an alcohol use disorder. Drinking at an early age can increase the risk of developing an AUD. This risk is increased in females as compared to males. A person with mental illness or trauma history is also at higher risk for an AUD, as these factors are common comorbidities of AUDs. Continuing research in genetics and ancestry will further inform the science as to causation of all substance use disorders (Deak & Johnson, 2021).
Cultural Context
Alcohol Use among the Asian Community
Genetics are a component of alcohol use disorder (AUD). Genetics influence a person’s risk of developing AUD. Some individuals of Asian descent are affected by a gene variant that changes their ability to metabolize alcohol. When they drink, they have flushing, nausea, and a rapid heartbeat. These side effects cause many to abstain from drinking alcohol.
(American Addiction Centers, 2023b)
Approaches to Treatment of Alcohol Use Disorder
There are many approaches that can be used to treat alcohol use disorder. Keeping in mind that cravings will remain after an individual stops drinking, some of the things that the treatment team might offer are medications, behavioral therapies, and support groups. The care plan is individualized to meet the needs of the client.
Medications
The U.S. Food and Drug Administration (FDA) has approved three medications for treating alcohol dependence: naltrexone, acamprosate, and disulfiram. A health-care provider must first assess the client’s “motivation for treatment, potential for relapse, and severity of co-existing conditions” (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016, p. 4-24). Research has shown that most clients who are prescribed medication to treat their alcohol use disorders do see positive benefits.
Naltrexone is an opioid antagonist that blocks opioid receptors. Just as it counteracts the pleasurable parts of using opioids, it also blocks the pleasurable parts of drinking. Compliance with taking Naltrexone in the oral form is necessary to avoid relapse. For clients who have difficulty with adherence, there is an extended-release injectable, given once a month (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016).
Acamprosate reduces the cravings to drink. Research has shown that this medication works well when used with behavioral interventions. Acamprosate has been found to be effective for reducing instances of relapse and maintaining abstinence.
The third medication is Disulfiram. It works by stopping the metabolism of alcohol. When a client uses alcohol and takes Disulfiram, they feel nauseous, have flushed skin, and experience heart palpitations, sweat, dizziness, and headaches. Teach clients taking this medication to check labels of products or foods—such as fragrance, astringents, dyes, paints, cough syrup, vinegar, sauces, or flavorings—that may contain alcohol and could cause a reaction. This medication should only be used if the person wants to stop drinking, not just reduce their drinking (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016).
Behavioral Treatments
Behavioral treatments help the client identify the triggers for their drinking. These treatments take place in a variety of settings—individual, group, and family. Trained providers teach the client how to change their behaviors through various methods, such as CBT, motivational enhancement therapy (MET), and family therapy. Each of these treatments can work individually or in combination with one another to help the client develop the skills they need to decrease/stop drinking, work on goal-setting, and build a support system.
CBT is a short-term therapy approach that involves twelve to twenty-four weekly sessions. During these sessions, participants are taught techniques to help recognize the thoughts and emotions that lead to the behaviors they hope to change and implement better coping skills as a way of reducing/quitting their drinking habits (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). DBT is similar to CBT, though the approach is to accept and manage feelings of distress without engaging in high-risk behaviors (Brice, 2024). MET uses motivational interviewing to assist clients with determining any questions they have about stopping drinking/substance use. This therapy has been shown to have good results in combination with CBT in adolescents who use multiple substances (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016).
Family therapy helps the client by engaging the spouse, partner, and other family members to support reduction of the substance use and talk about other issues that may be occurring within the family unit. The family works together with the guidance of a therapist to learn better communication skills, bolster the individual’s recovery, and improve family relationships (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016).
Mutual Support Groups
Twelve-step groups are one type of mutual aid (support) group. Members reveal their substance use problem and value learning from each other’s experiences as they focus on personal-change goals. The groups are voluntary associations that charge no fees and are member-led.
Alcoholics Anonymous
Alcoholics Anonymous (AA) is a mutual aid support group that employs a twelve-step approach. It has been in existence since 1935 when two men, Bill W. and Dr. Bob S., met after both had been part of a nonalcoholic fellowship that shared the importance of living by spiritual values. Together they held the first AA meeting with a man they helped at Akron’s City Hospital (Alcoholics Anonymous, n.d.). Its philosophy, approach, and format have been adopted and adapted by groups focusing on recovery from other substances, such as Narcotic Anonymous, Cocaine Anonymous, Marijuana Anonymous, and Crystal Meth Anonymous. AA and derivative programs share two major components: social fellowship and a twelve-step program of action formulated based on members’ experiences of recovery from severe alcohol use disorders. These twelve steps are ordered in a logical progression, beginning with accepting that one cannot control one’s substance use, followed by abstaining from substances permanently, and transforming one’s spiritual outlook, character, and relationships with other people (SAMHSA & Office of the Surgeon General, 2016).
Research studying alcohol twelve-step mutual aid groups has shown that participation in the groups promotes an individual’s recovery by strengthening recovery-supportive social networks; increasing members’ abilities to cope with risky social contexts and negative emotions; augmenting motivation to recover; reducing depression, craving, and impulsivity; and enhancing psychological and spiritual well-being (SAMHSA & Office of the Surgeon General, 2016).
Al-Anon and Alateen
Friends and family members often suffer when a loved one has a substance use disorder. This can include worrying about their loved one or experiencing verbal or physical abuse, among other issues. Mutual aid groups provide emotional support to concerned significant others to help them systematically and strategically cope with the problems related to their loved one (SAHMSA & Office of the Surgeon General, 2016).
Al-Anon is a mutual aid group for family members dealing with substance misuse by a loved one. Like AA, Al-Anon is based on a twelve-step philosophy and provides support whether or not members’ loved ones seek help or achieve remission or recovery. More than 80 percent of Al-Anon members are women. The principal goal of Al-Anon is to foster emotional stability and “loving detachment” from the loved one rather than coaching members to “get their loved one into treatment or recovery.” Al-Anon includes Alateen, which focuses on the specific needs of adolescents affected by a parent’s or other family member’s substance use. Research studies regarding the effectiveness of Al-Anon show that participating family members experience reduced depression, anger, and relationship unhappiness at rates comparable to those of individuals receiving psychological therapies (SAMHSA & Office of the Surgeon General, 2016).
Screening/Assessment Tools for Withdrawal from Alcohol Use
Initial assessment of a client being seen for possible AUD should begin with an examination for withdrawal symptoms. There are scales to determine the amount of alcohol consumed by the client. The first is the Alcohol Use Disorders Identification Test (AUDIT-C). This test has three simple questions that are scored using a Likert scale. The higher the score, the more likely that the person will have negative health consequences due to their drinking habits (NIAAA, 2022). The second assessment tool is called CAGE, which stands for “Cut down, Annoyed, Guilty, Eye-opener.” It consists of four questions with yes/no answers. A score of two or more yes answers is considered significant (Ewing, 1984).
The Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) is the most widely used scale to determine the need for medically supervised withdrawal management. It is used in a variety of settings, including outpatient, emergency, psychiatric, and general medical-surgical units when there is a clinical concern regarding a client’s alcohol withdrawal. The CIWA-Ar scale is typically utilized in association with a protocol containing medications to guide symptom-triggered treatment. Clients with an alcohol use disorder who have a CIWA-Ar score of less than 10 do not typically require medical management (Pace, 2022). There are ten questions on the CIWA-Ar related to nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and level of orientation.
Clinical Judgment Measurement Model
Recognizing Cues: Using the CIWA-Ar for Alcohol Withdrawal
The CIWA-Ar assesses the withdrawal symptoms of a client with alcohol use disorder. The nurse has the client sit in a chair with their feet flat on the floor, then takes and records vital signs. The nurse proceeds to go down the form’s checklist choosing answers on a Likert scale based on the scale’s directions to either observe symptoms or ask the client a question about certain symptoms. The CIWA-Ar is a vital tool for gathering assessment data for the care of a person with alcohol use disorder.
(MDCalc, n.d.)
Treatment for Withdrawal from Alcohol Use
Benzodiazepines treat the psychomotor agitation many clients experience during alcohol withdrawal and prevent progression from minor symptoms to severe symptoms of seizures, hallucinations, or delirium tremens. Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are the drugs used most frequently to treat or prevent alcohol withdrawal symptoms (Hoffman, 2022). Anticonvulsants may be used concurrently or instead of benzodiazepines. Anticonvulsants decrease the probability of withdrawal seizures.
Delirium tremens (DT), a rapid-onset, fluctuating disturbance of attention and cognition, can include hallucinations and autonomic hyperactivity, with fever, tachycardia, hypertension, and diaphoresis. DTs typically begin between forty-eight and ninety-six hours after the client’s last drink, reinforcing the necessity for accurate assessment data.
Chronic alcohol use depletes thiamine and magnesium. Clients receiving alcohol withdrawal treatment typically receive intravenous thiamine, along with dextrose, to prevent Wernicke’s encephalopathy. Wernicke’s encephalopathy is an acute, life-threatening neurological condition characterized by nystagmus, ataxia, and confusion caused by thiamine (B1) deficiency associated with alcohol use disorder. If untreated, Wernicke’s encephalopathy can progress to Korsakoff’s syndrome, a chronic, irreversible memory disorder resulting from thiamine deficiency (National Institute of Neurological Disorders and Stroke, 2023). Other electrolyte deficiencies may require treatment during alcohol withdrawal.
Unfolding Case Study
Substance Misuse: Part 2
See Substance Misuse: Part 1 for a review of the client data.
| Nursing Notes | 1240 Ongoing Assessment The client is seen in the dayroom, pacing near the windows. She appears to be anxious and has tremors that are visible in her extremities. You complete a CIWA-Ar and her score is 12, scoring for anxiety, tremors, headache, and mild sweating. She denies hallucinations and appears oriented, but increasingly anxious and difficult to redirect. 1255 Intervention MD notified of increased CIWA-Ar scoring and client symptoms. |
| Flow Chart | 1245 Ongoing Assessment Blood pressure: 154/97 mmHg Heart rate: 110 beats/minute Respiratory rate: 20 breaths/minute Temperature: 99.1°F (37.2°C) Oxygen saturation: 98% on room air Pain 6/10 (head) |
| Lab Results | No additional labs |
| Diagnostic Tests/Imaging Results | No additional diagnostic tests |
| Provider’s Orders | CIWA-Ar with protocol Close observation Seizure precautions |
Planning Nursing Care for a Client with Alcohol Use Disorder
Considering that only one in six people ever talks to their health-care professional about their drinking, nurses need to know how to start the conversation; after all, this important step can reduce drinking by 25 percent (CDC, 2020). Nurses and other health-care professionals must collaborate to help these clients.
Every facility should have a policy to ask all clients, including pregnant clients, about their drinking. Talking with the client about their drinking by asking for their thoughts on the good and bad of drinking is the first step toward beginning screening and counseling. Determine if the client is interested in making changes to their drinking—cutting back or quitting—or planning to continue their current drinking. Then begin to work with the client on a treatment plan (CDC, 2020). This type of screening and counseling can happen anywhere that health-care professionals are seeing clients. Screening will identify potential concerns while providing the opportunity to begin talking about the treatment resources available. It is important for health-care professionals to know that the federal Affordable Care Act (2010) mandates that insurance policies cover this service and to share this information with clients. The treatment plan must be individualized and person-centered, keeping in mind age, race, religion/spirituality, culture, sexual orientation, trauma history, any co-occurring physical or mental health problems, language, and health literacy (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). The development of an individualized treatment plan increases client engagement and retention.
Nurses can educate clients about the dangers of drinking excessive amounts of alcohol and advise all women not to drink alcohol if they are pregnant. Treatment options are based on the severity of the client’s drinking (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). If the client’s alcohol use is mild, then counseling services of one to two visits per week may be appropriate. A client with a more severe alcohol use disorder may require inpatient treatment. The nurse caring for a client in an inpatient setting would use evidence-based practice to determine the client’s motivation for change, triggers, help the client to increase their belief in themselves, and educate on changing thinking patterns (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016).
Link to Learning
The CDC (2017) produced this one-minute public service announcement to share the importance of screening and counseling clients on alcohol use.
Overcoming Risks of Developing AUD
Many factors influence the development of substance use disorders, including growth and development, environment, social, genetics, and co-occurring mental health disorders. Genetics play a 60 percent role in a person developing an AUD, and a child who sees their parents drinking may also be influenced to begin drinking. Mental health and trauma histories can have an effect on the likelihood that an individual will develop an AUD (NIAAA, 2023a).
Other conditions called protective factors shield people from developing a substance use disorder or addiction. Protective factors are things like cultural or religious beliefs, having supportive friends and family, and having healthy coping mechanisms. The relative influence of these factors varies across individuals and the lifespan.
Educating the public about the significance of AUD by providing programs in schools, community centers, and media public service announcements decreases the risks of people developing AUDs. Nurses have the potential to effect positive change through their educational endeavors.