CIWA

[Ewolly, BSN]

Hi guys, was just wondering on your thoughts of CIWA scoring patients with manipulative drug seeking behaviour.

I work in A&E/acute medicine and we have several regular alcoholics who come to A&E for free diazepam on CIWA. Obviously CIWA has its place in DTs, seizures, etc but they know which new nurses they are able to mislead to get a false high score, then when a more experienced nurse who knows them refuses to hand out the diazepam on grounds they are being manipulative they start kicking off, shouting, swearing, demanding a Dr, etc. We usually only have inexperienced junior drs on a night shift who do not know these regular patients so assess them as agitated because they are withdrawing and prescribe diazepam, rather than the patient is agitated because they can't score free diazepam. Usually they self discharge when the diazepam stops.

Sorry for the long post, how would you deal with these regulars who know how to play the system?

[Corey Narry, MSN, RN, NP]

It happens a lot here in the US too (I am assuming you're in either UK or Australia with your use of the term A&E).  In our area, we have a population of homeless indiviudals with substance abuse histories and they do present to the hospital in the Winter when they know they can find a warm bed to lay on.  It's an ongoing social problem and it can be hard to distinguish who's malingering or really at risk for withdrawal.  Sometimes it helps to know based on past admissions whether they had a history of a true DT.

[TheMoonisMyLantern, ADN, LPN, RN]

So, I have several thoughts on this. The good thing with CIWA is that it can help you keep folks out DT's when they require aggressive dosing during detox. The bad thing is that only a couple categories are objective and thus prone to manipulation by the patient. Having the provider order scheduled doses of Ativan/Valium with a PRN dose with blood pressure and Heart rate parameters, this takes the guess work out and is more clear cut and dry for both the nurse and the patient. CIWA's certainly have their place, but I think having scheduled round the clock dosing and PRN for breakthrough VS changes has its advantages. 

I will tell you this. When working with detoxers, we have to change our thinking sometimes. Withdraw from alcohol is physically dangerous and psychologically horrible to experience. Even with the abscense of physical withdraw symptoms and the patient is still freaking out, medicating them is not giving in to their demands, it is easing their suffering. Because they are suffering, it's self inflicted, but it is suffering nonetheless. When people are in detox, the chemical they've been using to cope with life and all the negative crap in their head is gone, and the medication you're giving is the only thing giving them relief. They haven't learned new coping skills, and most are too ill during detox to try. 

I used to get tired of the revolving door and felt like these folks were malingering. I learned though that many of them were just trying to survive, they'd drink until the money was gone then come in the hospital to keep from detoxing on the street, get clean, come into some money and go back to drinking. Month after month after month. And some of them can be real nasty about it too. Sadly until we get better at treating substance abuse and better at addressing homelessness, I don't see it getting better.