# Situation: A 52-year-old man is admitted to the surgical ward at 08:00 for an elective hernia repair scheduled in 3 days. His wife reports that he has drunk alcohol heavily every day for 10 years, and his last drink was at 22:00 the night before admission. He has no seizure disorder and takes no regular medicines. His wife adds that over the years he has needed much more alcohol than before to feel its effect. Which term describes this change?

> source: MyMerci (mymerci.kr)  
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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 52-year-old man is admitted to the surgical ward at 08:00 for an elective hernia repair scheduled in 3 days. His wife reports that he has drunk alcohol heavily every day for 10 years, and his last drink was at 22:00 the night before admission. He has no seizure disorder and takes no regular medicines.

His wife adds that over the years he has needed much more alcohol than before to feel its effect. Which term describes this change?

## 보기

1. Withdrawal
2. Craving
3. Cross-tolerance
4. Tolerance **✔ 정답**

**정답: 4**

## 해설

Tolerance is the need for markedly more of a substance to reach the desired effect, or a reduced effect from the same amount; it is one of the pharmacologic criteria of substance use disorder. Craving is a strong urge to use, withdrawal is the syndrome that follows stopping or cutting down, and cross-tolerance is tolerance that carries over to a related drug.

## 심화 해설

Core concept The wife is describing a change in the dose–response relationship: the same amount of alcohol no longer produces the effect it once did, and a larger amount is now required. In substance use terminology, this is tolerance, one of the pharmacologic criteria used in diagnosing alcohol use disorder. [1]

Why tolerance, not the other options The key phrase in the scenario is “needed much more alcohol than before to feel its effect.” That is the operational definition of tolerance. It is not about stopping alcohol, wanting alcohol, or transferring the effect to another substance.

| Term | Definition | Does it fit this patient? |
| --- | --- | --- |
| Tolerance | Reduced effect with repeated exposure, or need for a markedly higher dose to achieve the same effect [1] | Yes — he now requires more alcohol for the same subjective effect |
| Withdrawal | Syndrome that appears after stopping or reducing heavy, prolonged use | No — his last drink was 10 hours ago, but no withdrawal signs are described |
| Craving | Strong urge or desire to use the substance | No — the wife reports a dose change, not an urge |
| Cross-tolerance | Tolerance to one drug that extends to another drug of a similar class or mechanism | No — only alcohol is involved; no second substance is mentioned |

Pathophysiology and clinical relevance Alcohol tolerance reflects neuroadaptation. With repeated exposure, the brain adjusts so that the same blood alcohol concentration produces a smaller behavioral or subjective effect. [1] This can occur through changes in receptor systems, including glutamate and GABA pathways, and through modulation of ion channels such as large-conductance calcium- and voltage-activated potassium channels. [4] The result is that the person must drink more to reach the desired level of intoxication.

Tolerance can develop at different speeds. Acute behavioral tolerance refers to a rapid reduction in alcohol’s effect within the duration of a single drinking episode. [3] Chronic tolerance develops over weeks to years of regular heavy drinking, which matches this patient’s 10-year history. [1] A separate line of research suggests that people who perceive themselves as developing tolerance quickly after starting regular drinking may be at higher risk for problematic alcohol use later.

Watch out! Tolerance is not the same as dependence. A patient can develop tolerance without yet showing withdrawal, and tolerance alone does not confirm alcohol use disorder — it is one criterion among several. In this scenario, the wife’s report points specifically to tolerance, not to the full syndrome of withdrawal.

Key point! For licensure exams, link the phrase “needs more to get the same effect” directly to tolerance. If the question describes tremors, sweating, nausea, or seizures after stopping alcohol, that is withdrawal. If it describes a strong desire to drink, that is craving. If it involves a second sedative drug, consider cross-tolerance.

Perioperative nursing implication This patient is scheduled for elective hernia repair in 3 days. A history of heavy daily alcohol use for 10 years, with the last drink at 22:00 the night before admission, raises the risk for alcohol withdrawal during hospitalization. Tolerance itself does not cause vital sign instability, but it signals chronic heavy exposure, which can lead to withdrawal 24–72 hours after the last drink. The nurse should monitor for early signs such as tachycardia, hypertension, diaphoresis, tremor, and agitation, and should document the alcohol history accurately for the surgical and anesthesia teams.References (research sources)

- [1]Tolerance to alcohol: A critical yet understudied factor in alcohol addiction.Research articleElvig SK, McGinn MA, Smith C, Arends MA, Koob GF, Vendruscolo LF (2021) · DOI: 10.1016/j.pbb.2021.173155

- [3]Acute behavioral tolerance to alcohol.Research articleComley RE, Dry MJ (2020) · DOI: 10.1037/pha0000296

- [4]BK channels and alcohol tolerance: Insights from studies on <i>Drosophila</i>, nematodes, rodents and cell lines: A systematic review.Meta-analysis/systematic reviewIgnat LA, Tipa RO, Cehan AC, Bacârea VC. (2025) · DOI: 10.3892/mi.2025.232

## 임상 시나리오

Alcohol Tolerance in Preoperative AssessmentRecognizing neuroadaptation before elective surgery
A patient who needs markedly more alcohol than before to feel the same effect has developed tolerance, a pharmacologic criterion of alcohol use disorder. This reflects neuroadaptation: the brain adjusts so the same blood alcohol concentration produces a smaller response.

For surgical patients, tolerance matters because it often coexists with withdrawal risk. Even if no withdrawal signs are present at admission, a heavy daily drinker whose last drink was 10 hours ago may develop symptoms within the first 24–72 hours, overlapping with the planned procedure.

CautionDo not confuse tolerance with craving or withdrawal. Document the exact amount and timing of last alcohol use, and use a validated tool such as CIWA-Ar to monitor for emerging withdrawal during the preoperative period.

## 핵심 개념

- **Tolerance** — A reduced effect with repeated exposure to a substance, or the need for a markedly higher dose to achieve the same effect.
- **Withdrawal** — A syndrome that appears after stopping or reducing heavy, prolonged substance use.
- **Craving** — A strong urge or desire to use a substance.
- **Cross-tolerance** — Tolerance to one drug that extends to another drug of a similar class or mechanism.

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