alcohol withdrawal-Ativan

  1. Just wanted to pick you addiction nurses's brains on something...

    So patients can be ordered a ETOH withdrawal protocol, where they can get score-prompted PRN Ativan either q 4 or q 2. Essentially, if the pt's report anxiety and agitation, they can get this PRN b/c their score will be "high enough." As you can imagine, many of the pt's want the Ativan more for the psychological stress of detox even if physically their vitals are stable and they aren't having tremors, etc. Also, I know it is important to properly medicate to avoid DTs etc. But some of the pts you can see almost substituting ETOH dependence for ativan as a substance. So, in the case where a pt isnt exhibiting physical signs of withdrawal and vitals are stable, our nurses are giving the pts the Ativan if they request it but letting them know eventually the withdrawal protocol and Ativan will be d/c. If the pt has been taking the Ativan regularly, the Dr then decreases the frequency/dose of ativan ie-to q 8. This might be 1.5 weeks after the protocol started that the doctors change the order to q 8, but they leave the PRN indication as "withdrawal." It just seems off, b/c the pt isn't going to be going through withdrawal after 1 1/2 weeks.....it seems the PRN reason should be changed to anxiety or something. But they havent been changing the indication and nurses keep giving the PRn ativan for "withdrawal" well after the pt would/could be going thru withdrawal on the premise that "the doctor ordered it q 8 and knows they request it." If something where to happen it just seems it could be said that the med is being administered incorrectly bc the indication is for withdrawal but the pt is beyond the point that withdrawal could occur.....but then again the Drs are creating the q 8 order with withdrawal as an indication?
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  2. 10 Comments

  3. by   icuRNmaggie
    Is your facility using the CIWA protocol? I have it's pretty useful though cumbersome . My friend says it will drive you to drink
    In most hospitals a CIWA greater than 20 means transfer to the ICU. The danger of seizures from alcohol can last up to a month according to one of the psychiatrists I know. I would be generous with the po Lorazepam to someone recovering from severe dts. It is also useful as a sleep aid. I think giving it q 8 hours prn is the compassionate thing to do. Their body needs something for a while and if you had my family member in your care I would not want them to suffer from anxiety. Many alcoholics have untreated mental illnesses and we have to help them as best we can. If lorazepam helps them to function I would give it.

    I am not sure if you were referring to po or IV lorazepam. The upper limit of IV lorazepam is 24 mg in 24 hours due to the fact that a 2 mg per 1 cc lorazepam carpuject is 80% propylene glycol. Propylene glycol toxicity is very serious can wreak havoc on the kidneys.

    If you are not comfortable with giving the lorazepam after 10 to 12 days of detox why not ask the MD to clarify the order for anxiety or for sleep. You have my respect for taking on one of the tougher jobs in nursing.
    Last edit by icuRNmaggie on Jul 20, '14
  4. by   thekid
    Part of the challenge an addict faces is that even though they may be detoxing from a substance, the psychological component of addiction still exists. While Ativan may help with anxiety or sleep related symptoms, and I do agree it is the compassionate thing to do, I often wonder if we are enabling a patient to just substitute one addiction for another without really tackling the underlying addiction problem, and unfortunately that can be a long painful process. I work in case management, not a facility so I'm aware that there is outpatient support available when a patient "graduates" but what is their motivation to use the resources and support when it's much easier to "cope" by using a substance again? I've seen many patients successfully detox and be clean for some time only to fall prey to addiction again because of their environment whether it be their peers , lack of support etc. The most successful long term addiction recoveries I have witnessed have come about because the addiction and substance was painful and possibly life threatening, or the patient was at risk for losing something important due to addiction (like custody of a child, or cirrhosis, etc).

    I often question the logic of doctors prescribing prn ativan (or any benzo) since alcohol and benzos are the two substances most likely to cause the most harmful withdrawals. Even with short term use a person can build a tolerance to benzos so they may leave the facility alcohol free but then have a benzo problem.

    I do empathize with the hell the patient is going through during detox but I am sort of a tough love kind of person. If something is painful enough then maybe they will think twice about relapsing. I wouldn't want a patient to be in any kind of medical danger but it may change their approach to detox if it was a bit more uncomfortable.
  5. by   _firefly
    If the withdrawals are severe, there may be seizures and hallucinations. It becomes difficult to keep lines in. The ICU may switch to propofol with a vent and possibly a paralytic for the short term. It seemed to me that it would be easier on the body, cheaper and even safer to just administer etoh and wean them off slowly before switch to Ativan, etc. There must be studies, but I haven't found any.
  6. by   Gooselady
    The 'psychological' anxiety is just as real as the CNS abnormalities in alcohol withdrawal. Of course the detoxing addict will crave Ativan or whatever benzo is being used, because their neurochemistry remains deranged for at least three or four weeks. Anxiety will plague them, and having few or no coping skills except for alcohol, I don't see their requests for Ativan past the acute detox period to be manipulative or 'lazy' and not working hard enough on their recovery.

    They need BOTH, some kind of anti-anxiety medication and daily work with the counselor on developing normal coping skills.

    A motivated addict will self-regulate the use of benzos if they are receiving adequate treatment, supportive care and education. The OP's question is understandable, but it's just not that cut and dried. Addicts may even do better when 'eased' into sobriety, rather than thrown in the cold lake and being expected to swim. It's not a moral issue, it's a neurochemical issue.
  7. by   Mandychelle79
    Quote from thekid
    I do empathize with the hell the patient is going through during detox but I am sort of a tough love kind of person. If something is painful enough then maybe they will think twice about relapsing. I wouldn't want a patient to be in any kind of medical danger but it may change their approach to detox if it was a bit more uncomfortable.
    I used to think something similar until I took the time to talk to my cousin who was dealing with his own addiction issues. He put it in perspective for me and I have never forgotten it. They forget what the pain of w/d is like, just like a woman forgets what the pain of childbirth is like. The benefit is worth it. Kinda like me with my gallbladder and my love of chicken wings and other fried foods. I know the pain that is going to happen, but at that moment I dont care.
  8. by   DWillaman72
    I definitely agree with you, but one can argue detox can last up to 14 days esp the fifth a dayers. However, it should be determined off of a CIWA score and the orders should conicide with a CIWA scale. If pt. is not >8 they should not be given it PRN (or however the doc writes the order). If the doctor is writing it for withdrawal only then bring it to the attention of your superiors and maybe request at next staff meeting more restrictive orders be placed on the use of PRN ativan after the customary 5 day detox. However, remember that you are the nurse and you have to bring all concerns to the doc. If a pt is abusing it tell the doctor your concerns and tell him what you want, why it will benefit the pt, and why it is more appropriate than the alternative.
  9. by   hppygr8ful
    Quote from thekid
    Part of the challenge an addict faces is that even though they may be detoxing from a substance, the psychological component of addiction still exists. While Ativan may help with anxiety or sleep related symptoms, and I do agree it is the compassionate thing to do, I often wonder if we are enabling a patient to just substitute one addiction for another without really tackling the underlying addiction problem, and unfortunately that can be a long painful process. I work in case management, not a facility so I'm aware that there is outpatient support available when a patient "graduates" but what is their motivation to use the resources and support when it's much easier to "cope" by using a substance again? I've seen many patients successfully detox and be clean for some time only to fall prey to addiction again because of their environment whether it be their peers , lack of support etc. The most successful long term addiction recoveries I have witnessed have come about because the addiction and substance was painful and possibly life threatening, or the patient was at risk for losing something important due to addiction (like custody of a child, or cirrhosis, etc).

    I often question the logic of doctors prescribing prn ativan (or any benzo) since alcohol and benzos are the two substances most likely to cause the most harmful withdrawals. Even with short term use a person can build a tolerance to benzos so they may leave the facility alcohol free but then have a benzo problem.

    I do empathize with the hell the patient is going through during detox but I am sort of a tough love kind of person. If something is painful enough then maybe they will think twice about relapsing. I wouldn't want a patient to be in any kind of medical danger but it may change their approach to detox if it was a bit more uncomfortable.

    Trust me Detox with or without Ativan Librium etc is painful and uncomfortable (Been there/done that) the time to treat addiction is not during the acute detox phase. Once I got sober I went to work in a mental health detox setting and saw several people go into seizures during detox from ETOH. We did not use Ativan though we used Librium in gradually tapered doses.
  10. by   Meriwhen
    Quote from hppygr8ful
    Trust me Detox with or without Ativan Librium etc is painful and uncomfortable (Been there/done that) the time to treat addiction is not during the acute detox phase. Once I got sober I went to work in a mental health detox setting and saw several people go into seizures during detox from ETOH. We did not use Ativan though we used Librium in gradually tapered doses.
    I agree to a point. The groundwork for treating the addiction should start being laid down during acute detox (e.g., suggesting group participation, 1:1s). However, the focus should be to medically stabilize the patient.

    Librium is used because it has a much longer half-life than Ativan. Ativan may be used in lieu of Librium if the patient has hepatic problems, if the withdrawal is expected to be mild, and/or if Librium/Valium/other long-actings benzos aren't available.
  11. by   RNingaround
    I'm in the med-surg setting and we cared for a patient who tried to detox at home and ended up finishing out his detox with us due to the seizures/vomiting at home. I had him on day 3 of detox CIWA 2 No tremors, headaches, nausea, ect. His only issue was anxiety and being fuzzy on what day it was. I asked him what he was feeling anxious about if it was generalized feeling or specific and he said it was specific about his body/illness, his life, ect. and that he had anxiety even before the detox.

    I think this is a similar situation as you have. I told him to talk with the provider when she rounded about ordering a oral/scheduled anti-anxiety, but that I couldn't give him the IV ativan because this was no longer a detox agitation symptom but a general life psych symptom and it wouldn't be appropriate for me to give him this IV medication when it was indicated for this specific use. It would be like giving benadryl for sleep when it was ordered for hives. The purpose of the med is part of the order and I can't give it for an "unordered" reason. Lucky for me he was understanding about this, I was proud of how mature he was about it.
  12. by   SICUmurseCCRN
    i do not really like the CIWA protocol. in the ICU I've seen pts given 30mg of lorazepam and still be wild. maxed out on lorazapam and precedex drips and still wild. i believe these meds are metabolized by the liver and I'm sure an alcoholics liver is not the best so the pts tend to be very tough to control. the best thing to do is get beer TID ordered, it really calms the pt the best (although the docs rarely order it). this is what i see in the ICU but does not really pertain to people who are trying to get sober.
    Last edit by SICUmurseCCRN on Nov 11 : Reason: update

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