The Patient Abusing Alcohol

Learning Objectives

• Identify factors that contribute to the etiology of alcoholism.
• Formulate appropriate nursing interventions for patients experiencing problems with alcohol abuse.
• Describe common nurse's reactions to the patient abusing alcohol.
• Describe the characteristics of codependency.

Glossary

Alcohol intoxication– Excessive alcohol use that leads to maladaptive behavior and at least one of the following: slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor.

Alcoholism – A complex progressive disease characterized by significant physical, social, or mental impairment directly related to alcohol dependence and addiction.

Binge drinking– Pattern of periodic intervals of heavy use of alcohol (usually defined as five or more drinks on one occasion) with intervals of no or little use.

Blackouts– Lapses of memory resulting from persistent heavy drinking. During blackouts the person may appear to function normally while drinking but cannot recall events afterward.

Codependency – Maladaptive coping behaviors that prevent individuals from taking care of their own needs because they are preoccupied with the thoughts and feelings of another. Also known as “enabling behavior.”

Detoxification– The process of withdrawal of alcohol from the body through supervised medical interventions to prevent complications.

Dual diagnosis – Diagnosis of both a substance dependency and a major psychiatric disorder. May also be called co-occurring or co-existing disorder.

Korsakoff's syndrome – Severe memory impairment related to thiamine defi- ciency from long-term alcohol use. Characterized by confabulation and inappropriate cheerfulness.

Tolerance – The need for increasing amounts of a substance to achieve desired effect.

Alcohol remains the most used and misused drug in America. Alcohol use is socially accepted throughout our culture, is included as part of celebrations, religious rituals, and social occasions, and is often used as a relaxant. Nearly 90% of all American adults have used alcohol at some time in their life (DSM-IV-TR, 2000).

The move from social use of alcohol to alcoholism can occur very quickly in some people and over many years in others. In the past, alcoholism was viewed as a defective character trait, a weakness, or a moral flaw. Since the 1950s, it has been realized that alcoholism is a complex disease that responds to proper treatment. Today, the role of brain dysfunction is viewed as key to etiology.

Studies indicate that about 8% of Americans are dependent on alcohol at any one time and 18% report an alcohol problem at some time in their lives (Kessler, et al, 2005). This includes daily or binge drinking that negatively affects the way one lives. Binge drinking is more common in young adults. Three times as many men as women are reported to have a drinking problem; however, it is suggested that women are more secretive in their drinking behaviors, and therefore, drinking by women may be underreported. Alcohol is often used along with other substances, especially in younger individuals, often to alleviate or enhance the effects of other drugs (e.g., to relax after using a stimulant). Heavy drinkers often have periods of enforced abstinence to try to control the problem.

Alcohol is a central nervous system depressant that produces mind-altering and mood-altering effects. Twenty percent of alcohol consumed is absorbed directly into the bloodstream through the stomach. The remainder moves through the digestive system and is absorbed more slowly. Drinking rapidly on an empty stomach or consuming drinks with higher alcohol content will lead to a more rapid rise in blood alcohol level. One ounce of distilled liquor, 5 ounces of wine, and 12 ounces of beer have equivalent amounts of alcohol. It is known that, given the same amount of alcohol, women have higher blood alcohol concentrations than men, even when size is taken into consideration. This is because of differences in fat and body water content, making women more prone to longterm-effects of alcohol. Problem drinking is identified by the National Institute of Alcohol Abuse and Alcoholism (2007) for men as having more than four drinks/day or greater than 14 drinks per week and in women and older men as greater than three drinks per day or more than seven drinks per week.

Alcoholism has a tremendous impact on the individual, the family, and society. Spouses and especially children are particularly vulnerable to become victims of alcohol-related abuse. They may experience violence or emotional and physical neglect, and they may blame themselves for the alcoholic's abusive state. Amazingly, 43% of U.S. adults have been exposed to alcoholism through a spouse or blood relative. Alcoholism is truly a family crisis (National Council on Alcoholism and Drug Dependence, 2002). The impact of alcohol abuse on society includes crime, traffic accidents and fatalities, suicide, industrial accidents, fires, and decreased workplace productivity.

People with major psychiatric disorders may also have an abuse problem if they use alcohol to self-medicate for the psychiatric symptoms. The co-occurrence of a psychiatric diagnosis with alcohol or other substance abuse is very common in the mentally ill population. These patients are referred to as having a dual diagnosis or co-occurring disorder. These patients may use alcohol and other substances to self-medicate the distressing psychiatric symptoms of agitation, anxiety, or hallucinations. Alcohol or abuse of other substances may also trigger a psychotic episode leading to a dual diagnosis. Nearly half of all people with severe mental illness are affected by substance abuse, and 37% of alcoholics have at least one mental illness (NAMI, 2003). Goldsmith and Garlapati (2004) report that 47% of schizophrenics, 56% of bipolar patients, and 27% of patients with major depression have a dual diagnosis. The most common psychiatric diagnoses associated with substance abuse are mood and anxiety disorders, attention deficit disorders, and antisocial personality disorders (Miller & Grady, 2004). Patients with co-occurring disorders tend to have poorer outcomes with treatment of both diagnoses. Acute intoxication or withdrawal from alcohol and/or other substances can complicate accurate diagnosis of a primary psychiatric disorder. These patients require interventions specially geared to this population as they often do not fit in standard substance abuse treatment as Alcoholics Anonymous. Collaboration between the psychiatric treatment team and addiction specialists is essential.

Because alcoholism runs in families, there is current support for the genetic and biological theories as the cause of alcoholism. Alcoholism runs in families with a four-fold increase in close relatives of the alcoholic (Schuckit, 2006). The risk remains even if the children are not raised in the same home as the alcoholic parent.

The current biological theory for abuse of alcohol and other substances is that intrinsic reward pathways in the brain create a biological basis for craving the substance that induces a sense of well-being. The two main pathways are glutamatergic tracts in the prefrontal cortex and dopaminergic tracts. Each time a drink is taken for persons with altered brain function, an intense state of craving for the substance develops. This theory is the basis for the two pharmacological treatments of alcohol abuse: replacement therapy and neuromodulation. Replacement therapy substitutes the abused chemical with a safer alternative as in detoxification. Neuromodulators interact with the receptor system affected by the substance and eventually decrease the craving (e.g., Naltrexone or Acamprosate for alcohol).

A number of psychological factors are recognized as contributing to alcohol abuse. One of the most important looks at the link between depression and alcoholism. Alcoholics may have a higher incidence of depression and low self-esteem. Alcohol becomes a way to relieve those feelings. Each time a drink makes the person feel better, it reinforces this behavior. Difficulty managing anxiety and low self-esteem has led to identification of common coping styles (Table 13-1 Common Coping Styles of Alcoholics). Denial is the major defense mechanism used when the person is unable to acknowledge the role that alcohol plays in his or her life.

Alcohol use can severely affect the dynamics of the family relationship. Family members use protective behaviors, sometimes called codependent or enabling behaviors, to control or hide the alcoholic's behavior so that a sense of normalcy can be maintained. Affected family members care for and attempt to control the behavior of the alcoholic at the expense of their own needs. The family does not realize that this type of behavior reinforces the drinking patterns and dysfunctional behavior. Examples of these behaviors include minimizing the drinking, finding excuses for the drinker's alcohol use, attempting to control the drinking by diluting bottles or pouring out liquor, covering up for the drinker's unacceptable behavior, and self-blame for the drinking. Family members and friends of the person abusing alcohol are also at an increased risk of emotional or physical abuse.

Social and cultural factors may also contribute to the development of alcoholism. Certain cultural groups have higher incidences of drinking problems, which may represent genetic factors combined with an increased acceptance of heavy alcohol use. It may be part of socially expected behavior. One's social circle may play a role in how alcohol is used as one observes its use by friends or family to avoid problems, become a risk taker, and so on.

Related Clinical Concerns

Alcohol abuse plays a major role in a variety of health problems including gastritis, liver failure, heart disease, and pancreatitis. Twenty-five percent of admissions to general hospitals are related to an alcohol problem, including being treated for consequences of drinking (National Institute of Alcohol Abuse and Alcoholism, 2001). This statistic supports that need for all healthcare professionals incorporating some form of screening in their assessment. Assessing patients for alcoholism abuse can be helpful to prevent complications from withdrawal post-operatively (Sullivan, Sykora, Schneiderman, Narajo, & Sellers, 1989). Alcoholism is the third leading cause of preventable death in the United States (Kessler et al, 2005).

Alcohol is toxic to many major organs, especially the heart and liver. The patient with heart disease who abuses alcohol is at increased risk of complications, including hypertension. Liver metabolism may be compromised, and therefore, drugs metabolized by the liver may need dosage adjustments. Alcohol contributes to complications of diabetes.

Hingson (1993) noted that alcohol is a contributing factor in the following: 50% of trauma fatalities, 40% to 50% of falls, and 30% of motor vehicle accidents. If alcohol problems persist throughout a lifetime, the person will die 15 years earlier on average, with major causes being heart disease, cancer, accidents, and suicide (Rivara, Garrison, Ebel, McCarty, & Christakis 2004; Schuckit, 2006). Suicide assessment needs to be included in depressed patients abusing alcohol. Alcohol abuse also contributes to unwanted pregnancies, workplace accidents, and HIV exposure due to high-risk sexual activity.

Neonates

Fetal alcohol syndrome is recognized as being caused by alcohol abuse during pregnancy, when rapidly growing fetal brain cells are exposed to alcohol. The end result can be an infant born with mild to moderate developmental disabilities, hyperactivity, facial malformations, heart defects, and growth deficiencies.

Children and Adolescents

Alcohol use by children and adolescents has shown an alarming increase in recent years. Access to alcohol from the home or from friends can make it readily available. Seventy-seven percent of high school seniors have used alcohol (National Institute of Alcohol Abuse and Alcoholism, 2007). Teens who start drinking at age 15 years are four times more likely to develop alcoholism than those who start at age 21 (National Council of Alcoholism and Drug Dependence, 2001).

When teens are found to be drinking, they need to be evaluated for use of other substances as well as high-risk sexual activity and criminal behaviors (Schuckit & Tapert, 2004).

As with adults, children learn from parents, peers, or television and movie images suggesting that alcohol can be a defense against feelings of depression, low self-esteem, or anxiety. It may also represent an acting out against parental authority or enhance a sense of closeness with peers. Children who grow up in a home where one or both parents have an alcohol abuse problem may have an increased risk of abusing alcohol. However, even those children who intensely dislike their parents' drinking behavior may use alcohol as a coping mechanism because they have not learned more appropriate ones. Children and adolescents who become intoxicated are at increased risk of injury related to motor vehicle and bicycle accidents because they usually do not drink in the home. They are also at increased risk of alterations in growth and development because of nutritional deficiencies and because they often do not learn to deal effectively with normal anxiety and other uncomfortable emotions. Adolescents and young adults are more prone to binge drinking, which has been associated with life threatening effects from alcohol intoxication.

Older Adults

Alcohol abuse is often unrecognized and undertreated in the older-than-65 age group. Our society generally does not view the older population as an at-risk group. Because alcohol abuse is often a life-long pattern, elderly people may continue their earlier struggles with alcohol. Because of changes in metabolism with age, it may take less alcohol to begin to cause intoxication or other problems. Others may start drinking in later life because they face increasing problems, such as isolation, loss of spouse, and changes in health status. Alcohol may produce significant health problems in elderly persons, particularly if they have impaired liver function. Mental changes from alcohol use may be confused with dementia. It is a major factor in falls, burns, and suicide attempts. The brain in older adults is more susceptible to the depressant effect of alcohol, and therefore, depression may mask the signs of alcoholism. Other signs might be unexplained falls, poor nutrition, and self-neglect. Use of multiple medications with alcohol can exacerbate alcohol's effects. Withdrawal programs for this age group may require specialized care because of the increased health risks.

Possible Nurses' Reactions

• May view alcohol abuse as a personality defect or weakness rather than a health problem.
• May avoid, criticize, or reject the patient. This may trigger guilt feelings, and the nurse may try to make up for these feelings by being overly sympathetic.
• May have feelings of disgust for the patient.
• May have unresolved feelings related to a past family or personal history of substance abuse.
• May feel helpless to facilitate change, especially in a patient with a long history of alcohol problems.

Behavior and Appearance

• Signs of intoxication include odor of alcohol, slurred speech, loud talking, loss of inhibition, loss of coordination, and poor judgment
• Sudden onset of signs of withdrawal
• Frequently talks or brags about alcohol use
• Exhibits extremes of behavior from euphoria to irritability
• Justifies drinking or the need to drink
• Refuses to discuss drinking or lies about drinking
• Drinks large quantities of alcohol
• Needs to drink increasingly more to get same effect
• Unable to stop drinking once he or she starts
• Overreacts when questioned about drinking pattern
• Reports drinking a much smaller amount than is accurate
• Suicide attempts
• Two or more affirmative responses to the CAGE questionnaire (Box 13-1 Cage Questionnaire) suggests dependence, further assessment required

Mood and Emotions

• Depression
• Remorse after a binge
• Low frustration tolerance
• Anxiety
• Low self-esteem

Thoughts, Beliefs, and Perceptions

• Evidence of defense mechanisms of denial, rationalization, projection, and minimizing
• Thinking about alcohol supply and plans to obtain it
• Blackouts
• Hallucinations

Relationships and Interactions

• Dependent
• Resentful of authority
• Manipulates others to avoid confrontation, conflict
• Blames others for drinking
• Argues with family about drinking

Physical Responses

• Blood alcohol level (0.08 to 0.10 is legal limit to define intoxication in most states) or positive polydrug panel (may be negative, depending on time since last consumption). Blood level is less useful in elderly people because of altered metabolism. Urine testing can be a less invasive approach.
• Amylase may be elevated if liver damage is present. Blood sugar measurement may indicate hyper- or hypoglycemia. Serum magnesium may be low from alcohol damage to the nervous system. Hemoglobin may be low if bleeding is present
• History of falls, burns, accidents
• May have signs of gastrointestinal bleeding, ascites, or jaundice
• May be underweight and show signs of malnutrition and dehydration
• Korsakoff's syndrome from prolonged thiamine deficiency creates a secondary dementia marked by ataxia, confabulation, and peripheral neuropathy
• Withdrawal symptoms may occur 8 to 24 hours after last alcohol use. Analgesics and recovery from anesthesia can precipitate an acute withdrawal reaction. This emphasizes the importance of quick diagnosis to institute detoxification. Assessment of alcohol use in the hospital can be helpful to reduce risk of complications. See Box 13-2 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) for Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-AR). A score of greater than 15 predicts a severe alcohol withdrawal.
• Withdrawal grand mal seizures can occur in a small group of chronic alcoholics
• Alcoholic hallucinosis when hallucinations develop during the withdrawal period. Most often these are visual hallucinations.
• Alcohol-related delirium (also known as delirium tremens) is a medical emergency with a 20 percent mortality rate if left untreated. Complications include pneumonia, dehydration, electrolyte imbalance, respiratory failure, and status epilepticus (Box 13-3 DSM-IV Criteria for Diagnosis of Alcohol-Related Syndrome).

Pertinent History

• Previous history of alcohol or polydrug use
• History of heart disease, liver disease, gastrointestinal bleeding or varices
• Psychotic, depressed, or manic behavior
• Suicide attempts
• Blackouts, seizures, or delirium
• Alcohol-related police record, possibly including motor vehicle violations or accidents, physical violence, or child or spouse abuse
• May have history of being abused as a child
• Erratic work record because of alcohol abuse
• One or both parents with history of alcohol problems

Collaborative Management

Pharmacological

Symptoms from alcohol withdrawal generally start within 4 to 12 hours of cessation of heavy drinking. Symptoms are the most intense on the second day. Protocols for detoxification from alcohol include pharmacologic treatment to prevent or reduce the development of alcohol-related delirium. Sedation with longer-acting central nervous system depressants is substituted for shorter-acting alcohol. Benzodiazepines such as diazepam (Valium) and chlordiazepoxide (Librium) are the drugs of choice because they have anticonvulsant actions and are relatively safe. The drugs are usually administered on a routine basis and then tapered down by 20% to 25% per day until withdrawal is complete—usually about 5 days. Shorter acting tranquilizers such as oxazepam and lorazepam (Ativan) may be used if patient has liver disease. Anticonvulsants may also be needed. Detoxification may be done in an alcohol treatment unit or hospital or at home, if adequate supervision is available. Fluid, vitamins, and electrolyte supplementation is also part of the treatment plan. The inpatient setting needs to be used if the patient is at risk for alcohol related delirium, has multiple comorbidities, or is elderly.

Disulfiram (Antabuse) has been used for chronic alcohol abuse. This drug inhibits impulsive drinking because it produces an extremely uncomfortable physical reaction when alcohol is ingested. The drug is taken daily and stays in the system for 5 days after the last dose. If the patient is exposed to alcohol while the drug remains active, he or she may experience headache, tachycardia, nausea, vomiting, flushing, sweating, and changes in blood pressure, as well as potentially serious reactions including shock and cardiac arrhythmias. Because of the risks involved with using this drug, the patient must have the ability to understand the reaction if alcohol is ingested and give informed consent. The patient must be instructed to avoid inhaling substances that could contain alcohol, such as paint or wood stains, and refrain from using any substances with alcohol, including those with hidden sources such as some mouthwashes, elixirs, skin preparations, or colognes. The drug metronidazole (Flagyl) may cause a disulfiram-like reaction when alcohol is also ingested. Antabuse is best used for the motivated patient who is less subject to impulsive behavior and does not have a psychiatric history.

Acamprosate and naltrexone are also being used to treat alcohol cravings and the physical signs associated with withdrawal. These work as neuromodulators to treat the brain dysfunction causing the addiction. These should be used in conjunction with psychological support. Other commonly used medications include beta blockers, clonidine, and haloperidol (for hallucinations).

Dual-diagnosis patients present a challenge because they usually need to continue to take their psychiatric medications during the detoxification process. These medications need to be closely monitored.

Alternative approaches for withdrawal may include herbs and plants such as chamomile for insomnia, valerian for anxiety (should not be taken with sedatives), and kava kava for anxiety (should not be used with sedatives or alcohol). Multivitamins, thiamine, and magnesium therapy are indicated in chronic alcoholics to prevent neurological complications. Patients must also maintain hydration.

Twelve-Step Program

The Twelve-Step Program of Alcoholics Anonymous (AA) is generally accepted as part of every alcoholic's treatment program. AA's philosophy mandates that the individual become sober and never drink or use mood-altering substances again. The person acknowledges that he or she is powerless over alcohol, is always considered recovering, and is never cured. One drink could cause a downward spiral to heavy drinking. The best outcomes occur when the AA group members are of similar age and cultural background.

AA uses sponsors who have been sober for longer periods to support new members. The alcoholic needs to attend regular, even daily group support meetings and work on the Twelve-Step Program. AA chapters are found in virtually every community in the United States. The only requirement for membership is the desire to stop drinking. AA has been the model for other self-help groups, including Gamblers Anonymous and Cocaine Anonymous. Family members of alcoholics can participate in self-help groups following the same model, including Al-Anon for spouses and friends, Al-a-Teen for adolescents, and Adult Children of Alcoholics (ACoA).

Additional approaches may include behavioral, group, and marital therapies.

Ineffective Denial

INEFFECTIVE DENIAL evidenced by lack of acknowledgment of alcohol abuse related to impaired ability to accept consequences of own behavior.

Patient Outcomes

• Acknowledges own drinking problem
• Expresses feelings while under nurse's care
• Demonstrates problem-solving skills
• Abstains from alcohol and drug use or significantly reduces intake
• Asks for assistance with drinking problem

Interventions

• Help patient identify disturbing feelings by listening to concerns and helping him or her put labels on possible emotions. Patient may have used alcohol to deny feelings and needs assistance to identify them.
• Foster problem solving. Explore with the patient, the coping mechanisms that are more appropriate than alcohol to deal with the specific causes of stress and anxiety.
• Talk with patient about the normal range of personal emotions.
• Discuss behavioral inconsistencies.
• Maintain a positive attitude. Communicate the idea that patient can overcome his or her problems.
• Work with patient to set realistic small goals for abstaining from alcohol and managing his or her problems. This may require structured planning for how to get through the next day without a drink. Encourage use of readings and meditations.
• Reinforce the Alcoholics Anonymous philosophy of “one day at a time.” This means setting a goal of not drinking today rather than thinking about not drinking for the next year.
• Develop a trusting relationship. When the patient feels safe with a staff member, encourage examination of the negative consequences of his or her behavior. Recognize that this relationship could become too threatening to the patient and he or she may try to sabotage it or reject the nurse. This is all part of the struggle to face one's problems.
• If patient states, “I could stop drinking any time,” have him or her identify what could be done right now to stop. Look for windows in denial that might indicate the slightest insight and focus.
• Set limits on manipulative behavior. Some patients may have learned to be very charming. The goal of these behaviors is to avoid dealing with the real problems.

Risk for Injury

RISK FOR INJURY evidenced by disorientation, lack of coordination, or aggressive or disruptive behavior related to acute alcohol intoxication, withdrawal, and/or delirium.

Patient Outcomes

• Remains free from injury while under care of the nurse.
• Sleeps at least 6 hours at night.
• Has reduced incidence of medical complications.
• Exhibits appropriate behavior.

Interventions

• Monitor vital signs, seizures, and changes in mental status closely for 5 days after withdrawal from alcohol.
• Monitor closely for signs of withdrawal and report to physician to begin early treatment. With appropriate management, severe complications can be prevented. Recognize that the patient may be using several drugs, so the signs of alcohol withdrawal may be masked or delayed.
• Follow agency policy or protocol for detoxification for high-risk patients.
• Maintain a quiet, calm environment. Use a soft voice and calm, supportive approach to reassure patient.
• Make sure there is a night light in the room. Institute fall precautions. Encourage staff or family to stay with patient to ensure safety.
• Avoid restraints if at all possible by adequate use of medication.
• If the patient has pain from another medical condition, such as trauma or surgery, be sure to treat the pain. Do not withhold analgesia out of fear that it will reinforce addictive tendencies.
• Institute appropriate precautions if patient at risk for seizures, hallucinations, violent behavior.
• Promote use of relaxation techniques and herbal teas to reduce tension and help with possible insomnia.
• Monitor for complications, including cardiac arrhythmias or diabetes.
• Monitor food intake. Encourage fluids and a high-carbohydrate diet. Discourage use of dehydrating foods and fluids such as coffee, tea, and chocolate. Administer vitamins as ordered.
• Provide emotional support for patient and family.

Family Coping: Compromised

FAMILY COPING: COMPROMISED evidenced by over-responsible behavior to control the alcoholism related to anxiety in the family system.

Patient Family Outcomes

• Demonstrates assertive response when faced with abusive behavior
• Expresses feelings about the impact of alcohol on the family
• Demonstrates reduced number of behaviors that take responsibility for patient's drinking
• Attends support group meetings

Interventions

• Recognize that alcoholism is a health problem that affects all family members. Monitor response of all family members to patient's behavior.
• Give feedback to individuals about over-responsible behavior. Encourage them to recognize the signs and feelings associated with it. Explain how efforts to contain the patient's drinking merely delay the needed confrontation.
• Assist family members to set limits on the urge to “rescue” the patient. Give suggestions on coping mechanisms to reduce the stress. They need support to accept the idea that they are not responsible for patient's drinking or behavior.
• Educate family members about availability and purpose of group support programs. Talk to them about meeting with a chemical dependency specialist for assistance. Participate in a planned intervention technique under the supervision of the specialist when the patient is confronted by family and friends about his or her drinking problem.
• Give person permission to take care of own needs first.
• Teach the family assertive responses to abuse or criticism from others, especially the patient.
• Encourage them to express emotions, both positive and negative.
• Reinforce the idea that ultimately the individual with the drinking problem is the only one who can control his or her own behavior.
• Recognize the fact that family members may unconsciously sabotage patient's recovery in order to maintain the security of the status quo. Remain as objective as possible and avoid becoming involved in family conflicts.
• Prepare patient for changes in relationships with family and friends that may occur once he or she has stopped drinking. There may be some individuals who no longer like the patient when he or she is sober. Patient needs to reexamine these relationships.

Alternate Nursing Diagnoses

• Noncompliance
• Nutrition, Imbalanced: Less Than Body Requirements
• Sleep Pattern, Disturbed
• Thought Processes, Disturbed
• Violence, Risk for

When to Call for Help

• Escalation of aggressive, belligerent behavior to violence
• Need to apply restraints
• Intoxication
• Complications including seizures, cardiac arrhythmias, bleeding, high temperature
• Inadequate staff available to manage behavior
• Presence of increase in psychotic behavior
• Sudden change in mental status

Who to Call for Help

• Addiction specialists
• AA sponsor
• Social Worker
• Security
• Psychiatric Team

Patient & Family Education

• Reinforce strategies to avoid exposure to alcohol. For example, caution patient to avoid contact with drinking friends. Teach patient to avoid his or her old habits that included drinking, and remove all alcohol from the home. Teach patient and family to read labels of products purchased. Avoid products with alcohol in them such as mouthwashes and cough syrup. Avoid any mood-altering substance that could be used as a substitute for alcohol.
• Provide information about the addictive process and how it affects all aspects of one's life. Review “one-day-at-a-time” philosophy.
• Provide information on any medications being used to treat withdrawal and/or alcoholism.
• Provide information on nutrition and how to address possible vitamin and mineral deficiencies.
• Provide information on side effects of medications used to treat alcoholism
• Provide information to patient and family on managing potential seizures.
• Provide health teaching on the potential of gastrointestinal bleeding and liver disease. Encourage patient to avoid using products containing aspirin.
• Educate patient and family on the hazards of drinking in pregnancy and the effects of alcohol on driving and working.
• Teach strategies to replace alcohol with more healthy activities such as sports, hobbies, and journal keeping.
• Reinforce relaxation measures.
• Prepare patient for need to develop social contacts who do not drink.
• Reinforce education to family on avoiding overresponsible responses.
• Prepare the patient for the fact that intense emotions may be more painful without alcohol. He or she may need extra help at these times.
• Remind patient to tell every physician seen about his or her history to ensure that doctor will prescribe medications appropriately.
• Useful Web sites for patients and families include ncadd.org (National Council on Alcoholism and Drug Dependence) and samhsa.gov (Substance Abuse and Mental Health Services Administration).

• Document vital signs and any evidence of symptoms of withdrawal and delirium.
• Describe in detail the patient's level of consciousness and mental status.
• Document the patient's response to the medications being used for withdrawal.
• Document the family's response to patient's behavior.
• Document any observations of continued alcohol use.
• Document any actions taken to prevent violent behavior.
• If restraints are necessary, document the type, the time the patient was in restraints, the reason why they were applied, the patient's response to treatment, when limbs were released, and the care given to the patient while in restraints.

Community-Based Care

• Provide information to patient and family on location and phone numbers for local chapters of AA, Al-Anon, and Al-a-Teen, as needed.
• Encourage the patient and family to begin or continue counseling or provide referral to alcohol counseling programs.
• Communicate information on all medications prescribed for alcohol withdrawal and alcoholism
• Encourage the patient to follow up with medical appointments
• Arrange for follow-up home health visits for patients being discharged from detoxification treatment to home.
• Provide information to referring agencies, such as home health agencies or nursing homes, on patient's drinking patterns and the treatment program.