Identification and Treatment of Alcohol Withdrawal in the Correctional Setting

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The following course content

Introduction 

As of 2021, 11.2% of the U.S. adult population has alcohol use disorder (AUD), equating to 28.8 million people [6]. More than 140,000 people die annually as a result of excessive alcohol use (more than 380 deaths per day) [2]. Excessive drinking is a leading cause of preventable death in the U.S. [2]. 

In the correctional setting, nurses are faced with many obstacles to care delivery. It is imperative to understand the most common critical conditions with which our patients present. In the U.S., 58% of people in prisons and 63% of those in jails have a substance abuse disorder [12]. Alcohol use disorder (AUD) among this group is associated with suicide (inside prison) and violence and victimization (inside custody) [3]. 

Withdrawal from alcohol and drugs is a medical condition that needs prompt intervention from the nurse. Delivering quality, appropriate, and effective care to this population requires optimal assessment, treatment, referral, and communication between the multidisciplinary team (medical, mental health, and security staff). This course will walk learners through alcohol use, alcohol withdrawal, and the nurse’s role in the correctional setting in identifying and appropriately treating alcohol withdrawal. 

Alcohol Misuse 

Alcohol is toxic to the body if consumed in excess frequency and/or amount. The following are two definitions associated with alcohol misuse. 

• Alcohol Use Disorder (AUD): chronic relapsing brain disease characterized by impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences [6]. 
• Binge Drinking: drinking pattern that brings blood alcohol concentration (BAC) levels to 0.08g/dL. This is typically four drinks for a female and five drinks for a male within about two hours [7]. 

Alcohol can affect many organs. Damage to the heart can cause hypertension and lead to an increased risk of heart failure and strokes [8]. Alcohol can also increase the risk of certain cancers and change biochemical and hormonal physiology [8]. When performing a nursing assessment on a patient with a history of alcohol misuse, all body systems should be considered. 

Pathophysiology 

Once ingested, alcohol metabolism starts in the stomach. Gastric ADH (alcohol dehydrogenase) is the principal enzyme that breaks down alcohol to acetaldehyde (a toxin and carcinogenic) [3][5]. The most damaging effects are seen in the liver (the primary place of alcohol metabolism). Acetaldehyde is also metabolized in other areas of the body (although minimal), including the pancreas and brain, and causes damage to these areas as well. Less than 10% of alcohol is excreted in urine, sweat, or breath, leaving the remaining 90% to be circulated in the body and eventually transported to the liver. Eventually, acetaldehyde is broken down into acetate, which eventually breaks down into water and carbon dioxide for elimination. Over time, excessive alcohol use can damage tissues permanently.

Alcohol Withdrawal Syndrome 

Alcohol withdrawal syndrome is a condition that occurs in patients with AUD who abruptly stop drinking [11]. After drinking, most healthy people will be able to rid the system of alcohol within 72 hours. The following are time frames in which alcohol remains in various parts of the body [1]. 

• Blood: up to 12 hours 
• Breath: 12-24 hours 
• Urine: 12-24 hours (72 hours or more after heavier use) 
• Saliva: up to 12 hours 
• Hair: up to 90 days  

After binge drinking, the symptoms – commonly known as a “hangover” – can range from mild to severe (delirium) and are the manifestation of the body experiencing withdrawal from the alcohol. In general, a person without AUD can manage post-binge drinking symptoms over time with rest and hydration. However, alcohol withdrawal in patients that have AUD does not follow this pattern.  

Clinical Manifestations 

Alcohol withdrawal syndrome is characterized by overactivity of the central and autonomic nervous systems, causing a variety of troubling symptoms, including [11]: 

• 6 – 12 hours: weight loss, sweating, gastrointestinal upset, headache, insomnia, mild anxiety, palpitations, tremors
• 12 – 24 hours: alcoholic hallucinosis (auditory, visual, or tactile hallucinations)
• 24 – 48 hours: withdrawal seizures (generalized tonic-clonic seizures) 
• 48 – 72 hours: alcohol withdrawal delirium or “delirium tremens” (agitation, sweating, disorientation, hallucinations [mostly visual], high blood pressure, low-grade fever, elevated heart rate) 

Alcohol withdrawal syndrome can progress to “delirium tremens (DTs),” a serious medical condition that can occur in as little as 48 hours after cessation of drinking in patients with AUD [10]. DTs is a severe form of alcohol withdrawal characterized by altered mental status, and physiological changes. Patients with DTs can experience seizures, arrythmias, high blood pressure, and respiratory failure [10]. If left untreated, DTs is fatal in almost 15% of cases (some studies show up to 37%), compared to 1% when treated [9][10]. For patients in a correctional facility, clinical features of alcohol withdrawal syndrome can appear within hours of the last drink. However, each patient is unique and must be monitored closely for signs and symptoms. 

• The “kindling effect” in patients with AUD should be considered as well. The “kindling effect” occurs when a patient with AUD goes through episodes of withdrawal, experiencing symptoms that worsen with each episode [4]. For example, a patient may have one seizure during their last incarceration but may have three seizures the current incarceration. Knowing the patient’s history is crucial for assessing alcohol withdrawal. Obtaining an accurate history can also help determine what treatment level a patient may require while in your care. 

The Nurse’s Role and Treatment 

Research on alcohol withdrawal often focuses on the acute hospital setting. About 40% of patients in the emergency room (ER) have alcohol use disorder and of patients coming to the ER with trauma (who showed signs of withdrawal) 24% progress to DTs [9]. This reinforces the most important takeaway from this course: Alcohol withdrawal syndrome is a serious medical condition that can be fatal.  

The nurse’s role in monitoring and assessing patients who are going through alcohol withdrawal in the correctional setting is crucial. Safety is priority. Once a patient has been identified as at risk, some form of monitoring should be initiated immediately. Detoxification can start as early as a few hours after the last drink. The “Clinical Institute Withdrawal Assessment – Alcohol, Revised” (CIWA-Ar) is a monitoring tool that can be used. The tool uses a scoring system in relation to symptoms.  

Symptoms include:  

• Nausea/Vomiting 
• Tremors
• Paroxysmal Sweating
• Agitation
• Auditory, Visual, and Tactile Disturbances
• Anxiety 
• Headache/Fullness in Head 
• Orientation and Altered Perception 

Each symptom is scored and added together, with a maximum score of 67. Scores less than 10 are mild, 10 to 18 are moderate, and 19 and above are severe/complicated [11]. Nurses should follow facility protocols for actions to take when patients fall under a particular score. The patient’s vital signs should be monitored as well. Assessments and scoring should be performed at regular intervals (frequency is dependent on your facility’s protocol). If a score is greater than 19, the patient should be taken to an emergency room or seen by a provider right away. 

The gold standard for treatment of alcohol withdrawal is benzodiazepines [11]. If benzodiazepines alone do not address symptoms adequately, carbamazepine, gabapentin, and valproate may be added as adjunct therapy. Carbamazepine and gabapentin may also be used alone for mild withdrawal symptoms [11].

Case Studies 

The following case studies discuss the nurses’ role in advocating for patients in the correctional setting. 

Case Study 1 

Jimmy (55yr old male) is a regular visitor to your facility. You smell alcohol when he enters the room. During your assessment, his vital signs are as follows: 

• BP: 158/88 mmHg 
• P: 100 bpm 
• Temp: 98.6°F 
• RR: 12 bpm 
• SpO2: 97% 

His speech is slurred, and he is slow to respond to your questions. His answers are not always consistent with your questions. When you ask him if he knows where he is, he tells you it’s Tuesday night (it is Saturday), and he is in a bar. He is restless and when he tries to put his elbow on the table, he misses. When you try to weigh him, he is unable to stand without holding on to the wall. His mouth is dry, and his eyes are bloodshot. He tells you he has two beers every day and only had one today. 

The medical record history tells you that he had two seizures during his last incarceration eight weeks ago, had visual hallucinations, and had become very anxious. 

• What do you think should be done initially? 
• Are you concerned about Jimmy’s clinical condition now? 
• Can you name the physiological system(s) affected by the alcohol? 

For Jimmy, we need to use our clinical assessment skills, knowledge of alcohol withdrawal, and use every opportunity to ensure he will be cared for while he is inside of the facility. Jimmy may not be telling us the full story about his recent drinking habits. It is possible that Jimmy’s brain function may have been affected by his AUD. If you suspect a patient is not being truthful or able to be truthful (like Jimmy), you should use your clinical knowledge and complete your assessment independent of the patient’s story. 

To break it down: 

The first things to consider are his vital signs. 

• What do they tell us? 

The vitals do not tell much, other than he is hypertensive with mild tachycardia. His respiratory rate is on the low side as well. 

Next, assess his presentation. 

• What does that show us? 

Be careful not to assume – “He’s just drunk.”  

• Clinically, what is happening to him? What is the alcohol currently doing to him?  

Despite what he tells you about his “one beer,” his presentation shows you that his neuromuscular system is affected (imbalance) as well as his cognitive brain function (not answering questions appropriately). His mouth is also dry which may indicate dehydration. His electrolytes may be out of range as well. 

Even though Jimmy’s input does not aid your assessment, his vital signs and presentation are very telling. 

Consider his history. 

With some patients, a history is not always available. If you do have access to a patient’s history, review it carefully, particularly history of substance abuse and mental health conditions. Many patients may not give an accurate account of their recent history. For us to provide the best care, reviewing medically documented information is vital and may be the difference between life and death. 

Fortunately, there is a record of Jimmy’s medical history. 

• Remember the “kindling effect” – do you think it is applicable here? 

Take note of the care that Jimmy received during his last incarceration. He was given no treatment until day 3. He had his second seizure on day 8 and started new medication on day 9. 

• Do you think the care team was proactive with his treatment plan? 
• Do you think the treatment was adequate? 

Jimmy has suffered from withdrawals in his last incarceration, so we can expect that he will have at least the same severity of withdrawal symptoms (possibly more) due to the kindling effect on this occasion. 

Physiologically, he is compromised. In a correctional setting, Jimmy is at risk of being harmed by others due to his incapacitated state. He is also at risk of harming others due to his potential mood swings and poor decision making. Lastly, he is at risk of self-harm due to mood changes and alcohol withdrawal syndrome. 

• How should you proceed with Jimmy? 

Jimmy’s plan of care at this point will depend on what level of care your facility is able to manage. If you have a hospital unit or a close observation/detox unit staffed with clinical personnel, he may be able to be assisted there. However, if your facility lacks the ability to closely monitor him, then he will likely need to be sent to the local ER. 

As the nurse assessing Jimmy, the conversation you have with the provider will determine Jimmy’s outcome. Ensure that the information provided is given in a clear, concise, and comprehensive way as Jimmy could become very ill quickly. 

Case Study 2 

The next patient after Jimmy comes in with vomit stains down the front of her shirt and make-up running down her face. Poppy is 22 years old. This is her first arrest and first time in jail. She is crying and tells you that she was in a club, drank too much, and vomited on the way to the restroom. The security guard came to get her, and she tried to fight with him because she wanted to stay and continue having a “good time.” She scratched the security guard’s face and bit his arm. She tells you that the last time she had a drink was six weeks ago at her boyfriend’s birthday party. She has a full-time job and doesn’t drink on a typical day. Her vitals are as follows: 

• BP: 126/80 mmHg 
• P: 86 bpm 
• Temp: 98.1°F 
• RR: 18 bpm 
• SpO2: 99% 

She denies any health issues, and is alert, oriented, and coherent. However, she is visibly upset. She denies suicidal ideation. Her only complaint is that she claims to be getting a bit of a headache and feels very thirsty.  

• What else do we need to know about Poppy before we do anything? 
• Is she of reproductive age? 

It is best practice to conduct a pregnancy test on every female of child-bearing age who comes into the facility. After conducting a pregnancy test, you find that Poppy is not pregnant. 

There are a few important points to consider when you think about Poppy and what kind of care she may need. It may be easy to assume that she will be fine. However, nurses have a responsibility to ensure that all patients are safe.  

A difficult part of correctional nursing is caring for patients with very little information on medical/social history. Additionally, it may be difficult to verify the patient’s story. Further, in the correctional setting, there may be no easy way to closely monitor patients as is possible in a hospital setting. In Poppy’s case, without a detailed history, it may be hard to know what is really going on with her. 

• What if she had been drinking for three days in a row up until today?  
• What if she has a neurological disorder or congenital liver disorder? 
• What if she was taking medication for depression and had scars on her wrist from previous self-harm? 

This information will change how you manage Poppy’s care while she is incarcerated. When assessing patients who are intoxicated at the correctional facility’s intake area, try to gather as much information as possible. If the patient is too intoxicated and their story is inconsistent and incomplete, this alone should raise a red flag. A higher level of care may be required. Performing an assessment and obtaining information from a patient who is intoxicated may be difficult, but alcohol is a toxin that can be fatal if not appropriately managed. 

Upon further examination, you are able to gather a better history from Poppy. Now, it’s time to think about other considerations for care. 

• Are there any clinical indicators that need to be monitored closely? 
• Are there any other factors to consider for Poppy’s safety? 

Poppy, like Jimmy, is physiologically compromised. She is detoxing from alcohol and may fall victim to mood swings. 

• How should you proceed with Poppy? 

Poppy’s plan of care will require a discussion with the provider. For Poppy’s safety, it would also be helpful to discuss her case and needs with the security staff.  

Consider the staff’s ability to monitor Poppy at your facility as this will guide you and the provider to determine the best plan of care for her. In this case, Poppy should be safely managed onsite without further intervention – this is assuming she has no other compromising medical or mental health needs. 

Always follow your facility’s protocol concerning patients who have consumed alcohol in excess.

Conclusion

As with the general population, many incarcerated patients have substance abuse and/or alcohol problems. It is important to consider the full picture: signs, symptoms, presentation, behaviors, patient story, and history. By avoiding assumptions and completing a thorough assessment, you can ensure that your patient is receiving the best care possible. 

Key aspects to your role: 

• Assessing the patient to get a good history, obtaining vital signs, using the CIWA-Ar tool, observing, and documenting behaviors associated with physiological compromise due to intoxication. 
• Determining what level of care your patient needs and using the multidisciplinary medical and mental health teams’ input to help support your decision. 
• Communicating with security staff and implementing observation plans or protective elements to ensure the patient is kept safe in this environment. 

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