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Mental Health Nursing · Chapter 9

The Withdrawal Clock

The time and amount of the last use is the single most operationally important item in a substance history, because it sets the clock you will be nursing against for the next five days. Pick the substance, drag the hours, and read what should be happening, what you must be watching for, and what has to be escalated — plus, at the bottom, the one decision that most often goes wrong: when buprenorphine may be given.

Set the clock

10 hours

Buprenorphine go or no-go

Buprenorphine is a high-affinity partial agonist. Given while full agonists still occupy the receptors, it displaces them, drops intrinsic activity abruptly and causes sudden severe precipitated withdrawal. The teaching point never changes: do not give buprenorphine to a comfortable patient who used recently.
Phase
 
 
What you should be seeing
    What you do now

      Escalate now — do not wait for the next scheduled assessment

      Any one of these is a page, not a note. CIWA-Ar of 15 or more, or a rise of 5 or more between checks · a new withdrawal seizure · heart rate above 120 or systolic pressure above 180 with tremor and sweating · new disorientation or fluctuating consciousness · temperature above 38.3 degrees Celsius in withdrawal · respiratory rate below 10 or falling oxygen saturation after opioids or sedatives · return of sedation after naloxone · confusion with ataxia or eye findings · suicidal ideation with a plan · any pregnant patient in opioid or alcohol withdrawal.
      Thiamine before glucose. Thiamine is a cofactor for glucose metabolism, so a glucose load in a depleted patient burns the last of it and can precipitate Wernicke encephalopathy — confusion, ophthalmoplegia or nystagmus, ataxia. The full triad appears in only about one case in ten, so treat on suspicion. Untreated it becomes Korsakoff syndrome: irreversible amnesia with confabulation. Confabulation is not lying; the person is filling gaps without awareness, and correcting them harshly is both cruel and useless.
      Hallucinosis or delirium tremens? Orientation is the discriminator. In alcoholic hallucinosis at 12 to 24 hours the sensorium is intact — the patient knows the insects are not real. In delirium tremens at 48 to 96 hours consciousness is clouded and fluctuating, and the patient does not.
      Why alcohol and sedatives can kill and opioids usually do not. Chronic alcohol potentiates GABA-A and suppresses NMDA; the brain compensates by down-regulating GABA-A and up-regulating NMDA. Remove the alcohol and you unmask an unopposed glutamatergic storm — seizure and delirium. Opioid withdrawal is agonising, and it is not that. Be able to say that contrast in one sentence.