Why CIWA fails for alcoholics


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Unlike your typical drug user/seeker, patients admitted for alcohol detox are apparently there to STOP doing their drug of choice. But as anyone who is familiar with working with drug addicts of any kind, these patients LOVE drugs.

Most often it seems like alcoholics come in with an addiction to alcohol and leave with an addiction to alcohol and a new addiction to benzodiazepines… hooray!

CIWA is broken

The CIWA scale is kind of like a broken justice system. If it worked perfectly, we would safely detox a patient and send them on their sober way. In reality, it creates an opportunity to be easily exploited. If a patient legitimately wanted to be sober, this CIWA system would work, and work well. Ativan would probably be given on rare occasions, and never sought after by the patient.

What the CIWA creators forgot, is that this system is built for drug addicts. Drug addicts love drugs, remember? It’s because of this that I would say the CIWA scale fails the vast majority of the time. It is, unfortunately, the very rare exception to the rule that a patient actually benefits from the scale.

Any person with some type of IQ could figure out the CIWA grading scale, even if it wasn’t blatantly exposed to them. Babies can learn how to get their parents’ attention by crying the same way an alcoholic can figure out how to get Ativan from a nurse.

All it takes is a little practice auditioning various roles until one works. Shakes? Anxiety? Headache? Two of these are completely subjective and the patient can easily lie that they are extremely anxious and they have a splitting headache. Throw in some fake tremors and you’ve definitely pushed your score over 8 (usually the first threshold to get about 2mg of Ativan). What a joke!

It’s unbelievable how many times CIWA patients will say to the nurse, “I think I need some Ativan,” or “Is it time for my Ativan, yet?”

To the first, “No, you really don’t. The fact that you’re asking me for Ativan means that you don’t need it because you’re clearly with it, and just want to be sedated.” To the second, “Ativan is not something that’s scheduled, it’s supposed to be provided on an as-needed basis for emergencies!”

A huge problem is inconsistency. A patient will have at least 2 nurses per day, even 3 in some settings. Then you need to realize that a detox period could last 5-7 days which could be up to 21 different nurses.

I can guarantee that I’m going to hear about “the last nurse,” who gave Ativan all day. Here are a few retorts I’m definitely thinking:

“Congratulations?”

“I hope you were seizing all day, then.”

“Well, they were an idiot and a sucker, and now I’m here. Surprise!”

A case for phenobarbital

I’ve worked in an inpatient chemical dependency psych unit where Phenobarbital was scheduled for detox maintenance, and Ativan was only ordered for legitimate seizure activity. This is good because Phenobarbital will take the edge off, but not produce the euphoric high that Ativan does.

In 6 months we only had 1 seizure, and Ativan didn’t bring them out of it.

But I realize that Phenobarbital doesn’t always work for everyone, and sometimes patients need more powerful meds. So what can we do about the hardcore alcohol detox patients?

We’re talking about the patients with a high risk for DT’s and associated seizures, who report drinking at least a gallon of vodka a day for the last few weeks. We need to ask ourselves if we should even bother with an Ativan based CIWA protocol.

Most often these patients wreak havoc on the floor despite being doped up with significant quantities of Ativan until they are too much of a danger to themselves and others, and shipped off to the unit for Precedex.

Rather than having to go through this dangerous period, why not send them straight to the unit for Precedex and keep them safe and snoring until they’re through the worst of it? And when they wake up sober, then it’s straight off to a mandatory rehab program.

We also need some sort of strike policy. Patients should not be allowed to come into the hospital for detox, get loaded up with Ativan the whole time, get discharged, and then come right back a week later with the same story asking for more Ativan.

I’ve seen patients get admitted for alcohol detox 3 times in a month. They’ll literally be gone for 3 days, then show back up again asking for more drugs. Clearly, something’s not working.

Hope for gabapentin

It’s time for a detox revolution! We need to get rid of systems that allow for massive manipulation and create more drug habits then they cure.

There has been positive research using gabapentin for alcohol withdrawal and maintenance of sobriety. In fact, Gabapentin was shown to increase sobriety when compared with Ativan, while simultaneously being more efficacious in reducing withdrawal symptoms. This is hopeful because patients will not get high off of gabapentin, and probably won’t be easily addicted to the drug.

Gabapentin article: https://www.ncbi.nlm.nih.gov/pubmed/19485969

Note: This article does not apply to all detox patients. This is strictly directed towards the patients who use and abuse the system to feed their own personal drug addictions.

To all the patients who benefit from inpatient detox programs and actually obtain and maintain sobriety, a sincere congratulations to you!