Substance Dependence Nursing Care
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Direct answer
Substance dependence is a cluster of tolerance, withdrawal, craving and loss of control over use despite harm, and in India the commonest presentations are alcohol, opioids (prescribed and illicit), nicotine and cannabis. Alcohol withdrawal is the one that kills: tremors within 6 to 12 hours, seizures by 12 to 48, and delirium tremens at 48 to 72 hours with confusion, vivid hallucinations and autonomic storm. Nursing care combines safety and seizure precautions, benzodiazepine-tapered detoxification guided by the CIWA-Ar scale, thiamine given before any glucose infusion, maintenance drugs such as naltrexone or buprenorphine, and non-judgemental relapse-prevention counselling built on the stages of change.
What you must remember
- Alcohol withdrawal timeline: 6 to 12 hours tremor, sweating, anxiety; 12 to 48 hours withdrawal seizures; 48 to 72 hours delirium tremens — a medical emergency with significant untreated mortality.
- Wernicke encephalopathy is confusion, ataxia and ophthalmoplegia; thiamine 100 mg IM or IV precedes every glucose infusion, or the encephalopathy is precipitated and progresses to Korsakoff psychosis with anterograde amnesia and confabulation.
- CIWA-Ar scores the ten withdrawal features (tremor, sweats, anxiety, agitation, nausea, headache, orientation, hallucinations, and tactile and auditory disturbance) and guides chlordiazepoxide or diazepam dosing instead of fixed regimens.
- Opioid overdose triad: coma, pin-point pupils and respiratory depression; naloxone reverses it but is short-acting, so re-sedation occurs and repeat doses with monitoring are mandatory.
- Maintenance pharmacotherapy: methadone and buprenorphine for opioids; naltrexone blocks euphoria, acamprosate reduces craving, and disulfiram causes flushing, vomiting and hypotension if alcohol is consumed.
- Nicotine dependence is treated with replacement therapy plus behavioural support; bupropion and varenicline are prescription options.
- Stages of change (Prochaska and DiClemente): precontemplation, contemplation, preparation, action, maintenance — with relapse a common return loop, not a failure state; brief interventions match the stage, not the substance.
- Nursing stance: non-judgemental acceptance, pain treated like any patient's, observation for concealed use and drug interactions, and family included because denial and enabling are family phenomena.
Managing the first 48 hours of alcohol withdrawal
A 45-year-old man, admitted for a fractured femur after a fall, develops coarse tremor and sweating on day two since his last drink. The nurse institutes seizure precautions — padded side rails, suction at the bedside, bed low — orientates him with clock, calendar and familiar staff, and begins CIWA-Ar scoring, charting the score with pulse and blood pressure. Chlordiazepoxide is given per protocol and tapered over roughly a week as scores fall. Before the scheduled dextrose-containing fluids, thiamine 100 mg is administered, then a B-complex and folic acid supplement; hydration, electrolytes and glucose are monitored. On day three he becomes disoriented, muttering about snakes on the wall, with a pulse of 128 and blood pressure 170/100 — the recognisable onset of delirium tremens: the answer is urgent medical review, higher benzodiazepine dosing in a quiet lit environment with continuous observation, not a psychiatric label of psychosis. Once detoxified, the recovery phase begins: motivational interviewing to find his own reasons, teaching that craving waves last minutes and can be surfed, discharge planning with an alcohol-dependence support group, relapse-warning-sign identification, and treatment of the underlying fracture pain without undertreating it for fear of "addiction".
How the exam frames it
The order of thiamine-before-glucose is a fixed MCQ answer, tested through the stem "the nurse questions the order of dextrose before which medication". Delirium tremens timing at 48 to 72 hours separates it from early tremor and from alcoholic hallucinosis, which is perceptual without disorientation. The naloxone question always contains the trap of a single dose: re-sedation after 20 to 60 minutes is expected, so continued monitoring and repeat dosing is the correct option. Disulfiram education asks which drink to avoid completely — the answer is any alcohol, including mouthwash and cough syrup. Finally, which withdrawal can be fatal: alcohol and benzodiazepines yes, opioid withdrawal is miserable but rarely fatal — a discrimination examiners like.
Frequently asked questions
Why is thiamine given before glucose in alcohol dependence?
Because glucose metabolism consumes thiamine and precipitates or worsens Wernicke encephalopathy, which can progress to irreversible Korsakoff psychosis.
When does delirium tremens typically occur?
Forty-eight to 72 hours after the last drink, with confusion, vivid hallucinations, autonomic hyperactivity and significant mortality if untreated.
How is opioid overdose recognised and treated?
Coma, pin-point pupils and respiratory depression; naloxone is titrated to restore breathing, with repeat doses and monitoring because it wears off before the opioid.
What happens if a patient on disulfiram drinks alcohol?
A disulfiram-alcohol reaction of flushing, headache, nausea, vomiting, tachycardia and hypotension within minutes, which is why informed, motivated consent is essential.
What are the stages of change used in counselling?
Precontemplation, contemplation, preparation, action and maintenance, with relapse handled as a return to an earlier stage rather than treatment failure.
Which substance withdrawals can be life-threatening?
Alcohol and benzodiazepine withdrawal cause seizures and delirium; opioid withdrawal, though intensely distressing, is rarely fatal in otherwise healthy adults.