Alcohol Withdrawal Management

Incorporate universal screening for unhealthy alcohol use into medical settings using a validated scale to help identify patients with or at risk for alcohol use disorder and alcohol withdrawal.

For patients known to be using alcohol recently, regularly, and heavily, assess their risk of developing alcohol withdrawal even in the absence of signs and symptoms (see II. Initial Assessment for risk factors and risk assessment scale).

For patients who have signs and symptoms suggestive of alcohol withdrawal, assess the quantity, frequency, and time of day when alcohol was last consumed to determine whether the patient is experiencing or is at risk for developing alcohol withdrawal. For this assessment, it may be helpful to:

• Use a scale that screens for unhealthy alcohol use (e.g., Alcohol Use Disorders Identification Test-Piccinelli Consumption [AUDIT-PC])
• Use information from collateral sources (i.e., family and friends)
• Conduct a laboratory test that provides some measure of hepatic function

A biological test (blood, breath, or urine) for alcohol use may be helpful for identifying recent alcohol use, particularly in patients unable to communicate or otherwise give an alcohol use history. When conducting a biological test, consider the range of time (window of detection) in which the test can detect alcohol use. Do not rule out the risk of developing alcohol withdrawal if the result of a test is negative.

To diagnose alcohol withdrawal and alcohol withdrawal delirium, use diagnostic criteria such as those provided by the Diagnostic and Statistical Manual 5 (DSM-5). To diagnose alcohol use disorder, use diagnostic criteria such as those provided by the DSM-5.

Alcohol withdrawal severity assessment scales (including the Clinical Instrument Withdrawal Assessment for Alcohol, Revised [CIWA-Ar]) should not be used as a diagnostic tool because scores can be influenced by conditions other than alcohol withdrawal.

Do not rule in or rule out the presence of alcohol withdrawal for patients who have a positive blood alcohol concentration.

As part of differential diagnosis, assess the patient's signs, symptoms, and history. Rule out other serious illnesses that can mimic the signs and symptoms of alcohol withdrawal. Determine if patients take medications that can mask the signs and symptoms of alcohol withdrawal.

Do not rule in or rule out a co-occurring disease, co-occurring mental health disorder, co-occurring substance use disorder, or simultaneous withdrawal from other substances even in the presence of alcohol withdrawal.

Conduct a neurological exam in patients presenting with a seizure to determine etiology. A seizure should only be attributed to alcohol withdrawal if there was a recent cessation of (or reduction in) a patient’s alcohol consumption. For patients experiencing new onset seizures or for patients with a known history of alcohol withdrawal seizures showing a new pattern, an electroencephalogram and/or neuroimaging is recommended. For patients with a known history of withdrawal seizure who present with a seizure that can be attributed to alcohol withdrawal, additional neurological testing and a neurology consult may not be necessary. This includes if the seizure was generalized and without focal elements, if a careful neurological examination reveals no evidence of focal deficits, and if there is no suspicion of meningitis or other etiology.

For patients presenting with delirium, conduct a detailed neurological and medical examination with appropriate testing to rule out other common causes of delirium regardless of the apparent etiology. Attempt to distinguish between hallucinations associated with alcohol withdrawal delirium and alcohol hallucinosis/alcohol-induced psychotic disorder.

Level of care determination should be based on a patient's current signs and symptoms, level of risk for developing severe or complicated withdrawal or complications of withdrawal, and other dimensions such as recovery capital and environment. Alcohol withdrawal can typically be safely managed in an ambulatory setting for those patients with limited or mitigated risk factors. Patients with low levels of psychosocial support or an unsafe environment may benefit from a more intensive level of care than is otherwise indicated.

Patients with active risk of suicide should be treated in a setting equipped to manage patients at risk of suicide, which often necessitates admission to an inpatient psychiatric setting that also provides withdrawal management services.

The ASAM Criteria Risk Assessment Matrix and withdrawal severity scales can be helpful for determining the appropriate level of care for managing patients in alcohol withdrawal. Most withdrawal severity scales reflect current signs and symptoms and should not be used alone to determine level of care.