Psych / Mental Health · Substance Use
Substance Use Disorders & Withdrawal: Alcohol, Opioids, Benzodiazepines
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.
If you or someone you know is in crisis: call or text 988 (Suicide & Crisis Lifeline, U.S.) or call 911 for immediate danger. This guide is for exam study, not for diagnosing or treating anyone.
1. Overview
A substance use disorder (SUD) is a treatable medical condition involving loss of control over use, continued use despite harm, cravings, and — often — tolerance (needing more for the same effect) and withdrawal (symptoms when stopping). It changes brain reward, stress, and self-control circuits. Use person-first, nonstigmatizing language (“person with an opioid use disorder,” not “addict”).
Screening: SBIRT (Screening, Brief Intervention, Referral to Treatment), AUDIT-C, CAGE (Cut down, Annoyed, Guilty, Eye-opener).
Stages of change (motivational interviewing): precontemplation → contemplation → preparation → action → maintenance (relapse can occur at any point).
2. Alcohol
Intoxication: slurred speech, ataxia, nystagmus, impaired judgment → respiratory depression and aspiration at high levels.
Withdrawal timeline (from last drink; varies):
| Time | Findings |
|---|---|
| 6–24 hr | Tremor, anxiety, tachycardia, HTN, sweating, nausea, insomnia |
| 12–48 hr | Alcoholic hallucinosis (usually visual/tactile, with clear sensorium) |
| 24–48 hr | Withdrawal seizures (generalized) |
| 48–96 hr | : disorientation, hallucinations, fever, severe autonomic instability — medical emergency, can be fatal |
Nursing priorities:
- Assess with regularly; benzodiazepines (e.g., lorazepam, chlordiazepoxide, diazepam) per symptom-triggered or scheduled protocol; phenobarbital in some protocols
- Seizure precautions, fall precautions, quiet, well-lit room (reduce misperceptions)
- Thiamine before glucose — give thiamine (B1) to prevent/treat (confusion, ataxia, eye-movement abnormalities); untreated it can progress to Korsakoff syndrome (memory loss, confabulation)
- Monitor vitals, fluids, electrolytes (low Mg, K, phosphate), glucose; folate and multivitamin
- Long-term meds: naltrexone (reduces cravings; not with opioids — precipitates withdrawal; liver monitoring), acamprosate (adjust in kidney disease), disulfiram (severe reaction with any alcohol, including mouthwash, hand sanitizer, cough syrups)
3. Opioids
Overdose triad: pinpoint pupils, respiratory depression, decreased consciousness. Fentanyl and analogs are highly potent.
- (intranasal or IM/IV) — support breathing; may need repeat doses (naloxone may wear off before the opioid); monitor for recurrence and for precipitated withdrawal
- Withdrawal (uncomfortable, rarely life-threatening in healthy adults): yawning, runny nose, tearing, dilated pupils, gooseflesh, muscle aches, abdominal cramps, nausea/vomiting/diarrhea, anxiety, tachycardia. Assess with
- Medications for opioid use disorder (MOUD):
- Buprenorphine (partial agonist; often with naloxone) — start when in mild–moderate withdrawal (to avoid precipitated withdrawal)
- Methadone (full agonist; certified opioid treatment programs) — QT prolongation, respiratory depression
- Naltrexone (antagonist; extended-release IM) — must be opioid-free ~7–10 days first
- Clonidine/lofexidine for withdrawal symptoms
- Harm reduction: naloxone kits for patients and families, fentanyl test strips where permitted, never use alone
4. Benzodiazepines & Sedatives
- Overdose: sedation, respiratory depression (much worse combined with alcohol or opioids). Flumazenil reverses but can trigger seizures in dependent patients — use with caution per provider
- Withdrawal is potentially life-threatening (like alcohol): anxiety, insomnia, tremor, seizures, delirium. Never stop abruptly — gradual taper
5. Other Substances (quick hits)
| Substance | Intoxication | Withdrawal |
|---|---|---|
| Stimulants (cocaine, methamphetamine) | Tachycardia, HTN, hyperthermia, dilated pupils, paranoia, chest pain/MI, stroke | “Crash”: fatigue, hypersomnia, depression, suicidal thoughts |
| Cannabis | Red eyes, increased appetite, impaired coordination; possible psychosis | Irritability, sleep problems; cannabinoid hyperemesis with heavy use |
| Nicotine | — | Irritability, cravings; treat with NRT, varenicline, bupropion |
6. Patient Education
- SUD is treatable; relapse is not failure — adjust the plan
- Support: 12-step groups, SMART Recovery, counseling; SAMHSA National Helpline 1-800-662-HELP (4357); 988 for crisis
- Carry naloxone; teach family to use it
- Don’t combine alcohol with sedatives or opioids
7. Memory Aids
- Alcohol & benzo withdrawal can kill; opioid withdrawal makes you wish you’d die (but rarely kills)
- “Thiamine before glucose”
- Opioids: Pinpoint pupils → Pupils go big in withdrawal
- Buprenorphine: “wait for withdrawal”
8. NCLEX-Style Practice Questions
1. A patient admitted 60 hours after their last drink is confused, febrile, tachycardic, diaphoretic, and picking at the air. What does the nurse suspect?
A. Alcoholic hallucinosis
B. Delirium tremens
C. Wernicke encephalopathy only
D. Opioid withdrawal
Answer: B. DTs typically appear 48–96 hours after the last drink, with delirium and autonomic instability — an emergency.
2. A patient with alcohol use disorder is malnourished and confused. Which order should the nurse carry out first?
A. IV dextrose 50%
B. IV thiamine
C. Oral naltrexone
D. Disulfiram
Answer: B. Thiamine is given before glucose to prevent precipitating or worsening Wernicke encephalopathy.
3. A patient is found unresponsive with respirations of 6/min and pinpoint pupils. After calling for help and supporting breathing, what does the nurse give?
A. Flumazenil
B. Naloxone
C. Lorazepam
D. Atropine
Answer: B. This is an opioid overdose picture.
4. A patient taking disulfiram asks about products to avoid. Which should the nurse include? Select all that apply.
A. Alcohol-based mouthwash
B. Cough syrups containing alcohol
C. Alcohol-based hand sanitizer
D. Cooking with wine or vinegar marinades containing alcohol
E. Plain water
Answer: A, B, C, D. Any alcohol can trigger a disulfiram reaction (flushing, vomiting, tachycardia, hypotension).
5. A patient on long-term alprazolam wants to stop “cold turkey.” What does the nurse teach?
A. “That’s safe since benzodiazepines aren’t addictive.”
B. “Stopping suddenly can cause seizures; your provider will plan a gradual taper.”
C. “Take naloxone if you feel shaky.”
D. “Switch to drinking alcohol at night instead.”
Answer: B.
References
Canver, B. R., & Gomez, A. E. (2024). Alcohol withdrawal. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441882/
Substance Abuse and Mental Health Services Administration. (n.d.). SAMHSA’s National Helpline. Retrieved October 15, 2026, from https://www.samhsa.gov/find-help/helplines/national-helpline
Substance Abuse and Mental Health Services Administration. (n.d.). Medications for substance use disorders. Retrieved October 15, 2026, from https://www.samhsa.gov/substance-use/treatment/options
National Institute on Drug Abuse. (n.d.). Drug topics. Retrieved October 15, 2026, from https://nida.nih.gov/research-topics
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page