Alcohol Withdrawal Management

Last updated December 18, 2021

Key Points

Key Points

  • Alcohol withdrawal can appear in a multitude of ways in every type of medical setting.
    • An estimated 32.5% of emergency department visits are alcohol related.a
    • An estimated 2–7% of patients with heavy alcohol use admitted to the hospital will develop moderate to severe alcohol withdrawal.
  • Alcohol withdrawal management alone is not an effective treatment for alcohol use disorder.
  • Withdrawal management should not be conceptualized as a discrete clinical service but rather as a component of the process of initiating and engaging patients in treatment for alcohol use disorder.
  • Since alcohol withdrawal is increasingly managed in outpatient settings, national guidance is needed on tailoring withdrawal management interventions to specific setting.
  • Agents other than the standard benzodiazepines are emerging as effective alternatives in certain situations.
                a MacLeod JBA, Hungerford DW. Injury. 2011;42(9):922-926.

Diagnosis

...Diagnosis...

...cohol Withdrawal Severity S...


...I. Identifi...

...A. Identificat...

....1Incorporate universal screening for...

...mendation I.2For patients known to be using alcoho...

...ation I.3For patients who have signs and sympt...

...dation I.4A biological test (blood, breath, o...

...B. Diagnosis...

...I.5To diagnose alcohol withdrawal and alcohol...

...ion I.6Alcohol withdrawal severity assessme...

...dation I.7Do not rule in or rule out the presenc...

...C. Different...

....8As part of differential diagnosis, assess the...

....9Do not rule in or rule out a co-o...

....10Conduct a neurological exam in patien...

...mmendation I.11For patients presenting wit...


...II. Initial Asse...

...mendation II.1First, determine whether a patient i...

...commendation II.2A history and physi...

...commendation II.3Additional information ab...

...ecommendation II.4Clinicians shoul...

...B....

...II.5Assess for the following factor...

Recommendation II.6The following individ...

...ecommendation II.7Patients' risk for complica...

...endation II.8In general, clinicians may consider...

...C. R...

...endation II.9Clinicians can consider the...

...I.10The following scales can be helpfu...

...on II.11A validated scale should be used to a...

...dation II.12Assess the risk for sco...

...endation II.13A validated withdrawal sever...

...E. Identify C...

...ation II.14When assessing for concu...

...ecommendation II.15A pregnancy tes...

...II.16In settings with access to labor...

...ng may also include laboratory tests...

...ecommendation II.17Assess patients for polysu...

...ndation II.18Do not delay the initiation of...

...dation II.19Assess patients for co...

...ation II.20Evaluate active suicide risk as part...


Treatment

...Treatment...

...III. Level...

A. General...

...n III.1Level of care determination...

...III.2Patients with active risk of...

...B. Level of...

...dation III.3The ASAM Criteria Risk Asse...

.... Ambulatory (Level 1-WM and Level 2-WM) an...


...IV. Ambulatory M...

...A. Monitoring...

...n IV.1In ambulatory settings, arrange for...

...IV.2Re-assessments should focus on the patie...

...V.3Alcohol withdrawal severity should be moni...

Recommendation IV.4In ambulatory settings, patient...

...ommendation IV.5For patients managed in an ambulat...

...B...

...dation IV.6Supportive care is a critical comp...

...dation IV.7When treating patients in ambula...

...V.8Patients should be advised to drink n...

...ommendation IV.9Patients can be offered or...

...ommendation IV.10Clinicians must explai...

...ommendation IV.11Communicate that safe alcoho...

...C. AUD Treatment Initi...

...n IV.12When feasible, alcohol use disorder (AUD)...

...D. Pharmacotherapy...

...(1)...

...IV.13Patients at risk of developing severe or co...

...on IV.14A front-loading regimen is recomm...

...tion IV.15Patients at risk of deve...

...(2) W...

...ion IV.16Patients experiencing mild al...

...endation IV.17Patients experiencing mo...

...endation IV.18Patients experiencing severe, b...

...mmendation IV.19If a patient is taking medicatio...

...(3) Benzodi...

...ndation IV.20While no particular benzodiaze...

...ation IV.21If waiting for lab test(s) results o...

...IV.22Clinicians should monitor patient...

...IV.23A benzodiazepine prescription to tre...

...ion IV.24Clinicians can manage benzodiazep...

...mmendation IV.25In ambulatory settings, benzodiaze...

...tion IV.26Patients who are taking benzodiazepi...

...(4) Benzodiaz...

...ation IV.27At short-term observational...

...mmendation IV.28At settings without...

...n IV.29Front loading is recommended for pati...

...ommendation IV.30When using a fixed-dose schedul...

...V.31If prescribing a shorter-acting benzodiaz...

...(5) Carbam...

...ion IV.32Gabapentin is a favorable choice for t...

...on IV.33If benzodiazepines are cont...

...on IV.34Carbamazepine, gabapentin,...

...IV.35Valproic acid should not be used in...

...ecommendation IV.36There is insufficient evidence...

...(6) Phen...

...ation IV.37Phenobarbital can be used for some pati...

...dation IV.38In a Level 2-WM ambulatory sett...

...endation IV.39In a Level 2-WM ambulator...

...(7) A2AA an...

...V.40Alpha2-adrenergic agonists (A2AAs)...

...n IV.41Beta-adrenergic antagonists (beta-blo...

...(8) Inappropriate...

...ion IV.42Oral or intravenous alcohol shou...

...ecommendation IV.43There is insufficient evide...

...ndation IV.44Providing magnesium as a prophylaxis...


...V. Inpa...

...A. Monito...

...dation V.1The following monitoring schedule is a...

...n V.2Monitor patients’ vital signs, hyd...

...V.3Monitor patients receiving pharmaco...

...tion V.4Signs and symptoms of alcohol...

...B. Suppo...

...ndation V.5Supportive care is a critical c...

...V.6Supportive care for alcohol withdrawal...

...V.7Thiamine should be provided to...

...V.8Clinicians should administer thiamine to patie...

...V.9For patients with hypomagnesemia, car...

...ecommendation V.10If phosph...

...ation V.11In patients who are critic...

...C. AUD Treatment Ini...

...dation V.12The period of alcohol withdrawal...

...D. Pharmacothe...

...mmendation V.13For patients at risk of...

...V.14A front loading regimen is recommend...

...(2) Withdrawa...

...mendation V.15For patients experiencin...

...n V.16Patients experiencing moderate a...

...mmendation V.17Patients experiencing...

...ndation V.18If a patient’s symptoms are no...

...(3) Benzodi...

...ecommendation V.19While no particular benzodiazepi...

...ion V.20If waiting for lab test(s) r...

...mendation V.21Clinicians should monitor patie...

...ecommendation V.22A benzodiazepine prescripti...

...(4) Benzodiaz...

...ecommendation V.23Symptom-triggered tre...

Recommendation V.24Front loading is...

Recommendation V.25When using a fixed-dose...

Recommendation V.26If prescribing a shorter-act...

...(5) C...

...ion V.27Gabapentin is a favorable choice...

...V.28If benzodiazepines are contrai...

...dation V.29Carbamazepine, gabapentin,...

...ion V.30Valproic acid should not be used in pat...

...ommendation V.31There is insufficient eviden...

...commendation V.32Phenobarbital can be use...

...ndation V.33In an inpatient setting, phenobarbi...

....34In an inpatient setting, if close mo...

...mendation V.35Parenteral phenobarbi...

(7) A2AAs...

...on V.36Alpha2-adrenergic agonists (AA2s) such as...

...ndation V.37Beta-adrenergic antagonists (b...

...(...

...ion V.38Oral or intravenous alcohol should not b...

...ndation V.39There is insufficient evidence to sup...

...ion V.40Providing magnesium as a prophy...


...A. Alcohol W...

...(1...

...endation VI.1Patients should be monitored fo...

...VI.2Following an alcohol withdrawal se...

...n VI.3If available and applicable, exis...

...(3) Pharmacoth...

...ommendation VI.4Following a withdrawal seizure, pa...

...mmendation VI.5Following a withdrawal seizure, par...

...commendation VI.6It is not recommended to use...

...B. Alcohol...

...(1) Monitoring...

...ecommendation VI.7Patients with al...

...mmendation VI.8Patients with alcohol withdrawal de...

...dation VI.9To monitor signs and symptom...

...(2) Sup...

...tion VI.10Provide immediate intraven...

...tion VI.11If available and applicab...

...mmendation VI.12Restraints should be used...

...(3) Pharmacot...

...n VI.13Patients with alcohol withdrawal delirium s...

...I.14When available, medication should be administ...

...ecommendation VI.15Patients receiving repeat...

...mmendation VI.16When treating alcohol withdraw...

...dation VI.17Very large doses of benzodiazepines ma...

...tion VI.18For patients who have been...

...commendation VI.19Barbiturates can be consid...

...mmendation VI.20Antipsychotic agents can b...

...ndation VI.21Alpha2-adrenergic agonists, bet...

...C. Alcoho...

...I.22If available and applicable, existing institu...

...mmendation VI.23The treatment of alcohol-i...

...I.24The treatment of alcohol-induced psychotic di...

...ndation VI.25For patients experienc...

...D. Resistant Alcohol Wi...

...ndation VI.26If available and applicable, existing...

...endation VI.27Phenobarbital may be used as...

...mendation VI.28Propofol may be used with patien...

...ation VI.29Dexmedetomidine may be used with p...


...VII....

...A. Primary Care...

...on VII.1If patients are experiencing...

...VII.2If withdrawal is mild (e.g., CIWA-Ar...

...commendation VII.3If withdrawal does not resolve...

...mmendation VII.4For patients treated in prima...

...B. Emergency Depart...

...II.5If patients are experiencing seve...

Recommendation VII.6Patients present...

Recommendation VII.7Patients in the Emergen...

...endation VII.8The following indicators should b...

...tion VII.9Patients with controlled...

...C. Hosp...

...(1) Identification...

...mmendation VII.10All patients admitted to the ho...

...mendation VII.11Patients undergoing ele...

...(2) Assessme...

...VII.12Among hospitalized patients,...

...dation VII.13For patients suspecte...

...n VII.14For patients who require more than standar...

...(3) Monitor...

...ion VII.15In patients who are hospita...

...ndation VII.16Signs and symptoms of alcohol withdr...

...dation VII.17Patients with a reduced...

...(4) Supportive care...

Recommendation VII.18Clinicians should ad...

(5) Pharma...

...endation VII.19Prophylactic treatment of alcohol...

...mendation VII.20Implementing an alcohol wit...

...D. Patients with M...

...endation VII.21For patients with me...

...ecommendation VII.22For patients wit...

...ecommendation VII.23Aggressive withdrawal...

...ommendation VII.24For patients with a medical cond...

E. Patient...

...VII.25Patients who are on chronic opioi...

...ndation VII.26For patients with concomit...

...F. Patient...

...endation VII.27Inpatient treatment sh...

...on VII.28The CIWA-Ar is an appropriate symptom a...

...VII.29During withdrawal management, consult wit...

...on VII.30Engagement in treatment for AUD i...

...on VII.31Before giving any medication...

Recommendation VII.32Benzodiazepines...

...ecommendation VII.33Due to the high tera...

...ommendation VII.34For patients at risk for...

...VII.35In cases of alcohol withdrawal treate...

...VII.36Inform pregnant patients of all wraparound s...

...ecommendation VII.37Licensed clinical staff h...


Flowcharts

...Flow...

...Protocol...


...armacotherapy


...Ambulatory...


I...


Sample Medication Regimens...


...al Scales Abbreviation...