17 SUBSTANCEABUSE 413
is the most common setting. Some psychiatric units
also admit clients for detoxification, but this is less
common.
Safe withdrawal usually is accomplished with the
administration of benzodiazepines such as lorazepam
(Ativan), chlordiazepoxide (Librium), or diazepam
(Valium) to suppress the withdrawal symptoms.
Withdrawal can be accomplished by fixed-schedule
dosing known as tapering or symptom-triggered dos-
ing in which the presence and severity of withdrawal
symptoms determine the amount of medication needed
and the frequency of administration. Often the proto-
col used is based on an assessment tool such as the
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar) in Box 17-2. Total scores
less than 8 indicate mild withdrawal; scores from 8 to
15 indicate moderate withdrawal (marked arousal);
and scores greater than 15 indicate severe with-
drawal. Clients on symptom-triggered dosing receive
medication based on CIWA scores alone, while clients
on fixed dose tapers also can receive additional doses
depending on the level of CIWA scores. Both methods
of medicating clients are safe and effective (Daeppen
et al., 2002).
Sedatives, Hypnotics, and Anxiolytics
INTOXICATION AND OVERDOSE
This class of drugs includes all central nervous system
depressants: barbiturates, nonbarbiturate hypnotics,
and anxiolytics particularly benzodiazepines. Benzo-
diazepines and barbiturates are the most frequently
abused drugs in this category (Ciraulo & Sarid-Segal,
2000). The intensity of the effect depends on the par-
ticular drug. The effects of the drugs, symptoms of in-
toxication, and withdrawal symptoms are similar to
those of alcohol. In the usual prescribed doses, these
drugs cause drowsiness and reduce anxiety, which is
the intended purpose. Intoxication symptoms include
slurred speech, lack of coordination, unsteady gait,
labile mood, impaired attention or memory, and even
stupor and coma.
Benzodiazepines alone, when taken orally in over-
dose, are rarely fatal but the person will be lethargic
and confused. Treatment includes gastric lavage fol-
lowed by ingestion of activated charcoal and a saline
cathartic; dialysis can be used if symptoms are severe
(Lehne, 2001). The client’s confusion and lethargy
will improve as the drug is excreted.
Barbiturates, in contrast, can be lethal when
taken in overdose. They can cause coma, respiratory
arrest, cardiac failure, and death. Treatment in an
intensive care unit is required using lavage or dialy-
sis to remove the drug from the system and to sup-
port respiratory and cardiovascular function.WITHDRAWAL AND DETOXIFICATION
The onset of withdrawal symptoms depends on the
half-life of the drug (see Chap. 2). Medications, such as
lorazepam, whose actions typically last about 10 hours
produce withdrawal symptoms in 6 to 8 hours; longer-
acting medications such as diazepam may not produce
withdrawal symptoms for 1 week (APA, 2000). The
withdrawal syndrome is characterized by symptoms
that are the opposite of the acute effects of the drug:
that is, autonomic hyperactivity (increased pulse,
blood pressure, respirations, and temperature), hand
tremor, insomnia, anxiety, nausea, and psychomotor
agitation. Seizures and hallucinations occur only
rarely in severe benzodiazepine withdrawal (Ciraulo
& Sarid-Segal, 2000).
Detoxification from sedatives, hypnotics, and
anxiolytics is often managed medically by tapering the
amount of the drug the client receives over a period of
days or weeks, depending on the drug and the amount
the client had been using. Tapering,or administer-
ing decreasing doses of a medication, is essential with
barbiturates to prevent coma and death that will
occur if the drug is stopped abruptly. For example,John, 62 years old, was admitted 5 AM this morning for
an elective knee replacement surgery. The surgical pro-
cedure including the anesthetic went smoothly. John
was stabilized in the recovery room in about 3 hours. His
blood pressure was 124/82, temperature 98.8°F, pulse
76, respirations 16. John was alert, oriented, and ver-
bally responsive, so he was transferred to a room on the
orthopedic unit.
By 10 PM, John is agitated, sweating, and saying, “I
have to get out of here!” His blood pressure is 164/98,CLINICALVIGNETTE: DETOXIFICATION
pulse 98, and respirations 28. His surgical dressing is dry
and intact, and he has no complaints of pain. The nurse
talks with John’s wife and asks about his usual habits of
alcohol consumption. John’s wife says he consumes
three or four drinks each evening after work and has
beer or wine with dinner. John did not report his alcohol
consumption to his doctor before surgery. John’s wife
says, “No one ever asked me about how much he drank,
so I didn’t think it was important.”