Key Points
Diagnosis
Treatment
Flowcharts
Design and created by Guideline Central in participation with the American Society of Addiction Medicine.
Alcohol Withdrawal Management
American Society of Addiction Medicine
Publication Date: May 27, 2020
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
Table 1. Alcohol Withdrawal Severity
| Severity Category | Associated CIWA-Ara Range | Clinical Findings |
|---|---|---|
| Mild | CIWA-Ar <10 | Mild or moderate anxiety, sweating and insomnia, but no tremor |
| Moderate | CIWA-Ar 10–18 | Moderate anxiety, sweating, insomnia, and mild tremor |
| Severe | CIWA-Ar ≥19 | Severe anxiety and moderate to severe tremor, but not confusion, hallucinations, or seizure |
| Complicated | CIWA-Ar ≥19 | Seizure or signs and symptoms indicative of delirium – such as an inability to fully comprehend instructions, clouding of the sensorium or confusion – or new onset of hallucinations |
Throughout this document, we provide examples for withdrawal severity using the aCIWA-Ar, although other scales can be used. Regardless of the instrument used, there is a wide variety in the literature and in practice as to which scores best delineate mild, moderate and severe withdrawal. Classification of withdrawal severity is ultimately up to the judgment of clinicians and the choice of reference range may be based on their particular patient population or capabilities.
I. Identification and Diagnosis of Alcohol Withdrawal
A. Identification
Recommendation I.1
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.
Recommendation I.2
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).
Recommendation I.3
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
Recommendation I.4
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.
B. Diagnosis
Recommendation I.5
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.
Recommendation I.6
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.
Recommendation I.7
Do not rule in or rule out the presence of alcohol withdrawal for patients who have a positive blood alcohol concentration.
C. Differential Diagnosis
Recommendation I.8
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.
Recommendation I.9
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.
Recommendation I.10
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.
Recommendation I.11
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.
II. Initial Assessment of Alcohol Withdrawal
A. General Approach
Recommendation II.1
First, determine whether a patient is at risk of developing severe and/or complicated alcohol withdrawal, or complications from alcohol withdrawal. In addition to current signs and symptoms, a validated risk assessment scale and an assessment of individual risk factors should be utilized.
Recommendation II.2
A history and physical examination should be included as part of the comprehensive assessment process. Clinicians should conduct this examination themselves or ensure that a current physical examination is contained within the patient’s medical record.
Recommendation II.3
Additional information about risk factors can be gleaned by interviewing family, friends, and caregivers about a patient’s history of alcohol withdrawal, seizures, and delirium, as appropriate. Whenever possible in non-emergent situations, obtain written or verbal consent from the patient before speaking with or consulting with collateral sources.
Recommendation II.4
Clinicians should seek information about the time elapsed since the patient's cessation of (or reduction in) alcohol use. The timeline of symptom onset and severity helps determine the risk window for developing severe or complicated withdrawal.
B. Risk Factors for Severe or Complicated Withdrawal
Recommendation II.5
Assess for the following factors associated with increased patient risk for complicated withdrawal or complications of withdrawal:
- History of alcohol withdrawal delirium or alcohol withdrawal seizure
- Numerous prior withdrawal episodes in the patient’s lifetime
- Comorbid medical or surgical illness (especially traumatic brain injury
- Increased age (>65)
- Long duration of heavy and regular alcohol consumption
- Seizure(s) during the current withdrawal episode
- Marked autonomic hyperactivity on presentation
- Physiological dependence on GABAergic agents such as benzodiazepines or barbiturates
Recommendation II.6
The following individual factors may increase a patient’s risk for complicated withdrawal or complications of withdrawal:
- Concomitant use of other addictive substances
- Positive blood alcohol concentration in the presence of signs and symptoms of withdrawal
- Signs or symptoms of a co-occurring psychiatric disorder are active and reflect a moderate level of severity
Recommendation II.7
Patients' risk for complicated withdrawal or complications of withdrawal is increased by the presence of multiple risk factors.
Recommendation II.8
In general, clinicians may consider patients at risk of severe or complicated withdrawal if they are experiencing at least moderate alcohol withdrawal on presentation (e.g., CIWA-Ar score ≥10).
C. Risk Assessment Tools
Recommendation II.9
Clinicians can consider the use of a tool such as The ASAM Criteria Risk Assessment Matrix to assess a patient's risk of severe or complicated alcohol withdrawal as well as potential complications of withdrawal.
Recommendation II.10
The following scales can be helpful for assessing for the risk of severe alcohol withdrawal:
- Prediction of Alcohol Withdrawal Severity Scale (PAWSS)
- Luebeck Alcohol-Withdrawal Risk Scale (LARS)
D. Symptom Assessment Scales
Recommendation II.11
A validated scale should be used to assess alcohol withdrawal severity.
Recommendation II.12
Assess the risk for scores on an alcohol withdrawal severity assessment scale to be confounded by causes other than alcohol withdrawal. If risk factors are present, interpret the results of scales with caution. Use a scale that relies more on objective signs of withdrawal (autonomic activity) if a patient has difficulty communicating about their symptoms. See Alcohol Withdrawal Scales Table for the features of different scales.
Recommendation II.13
A validated withdrawal severity assessment scale can be used as part of risk assessment. A high initial score can indicate risk of developing severe or complicated withdrawal, although scores should not be the only information used to predict patient risk.
E. Identify Concurrent Conditions
Recommendation II.14
When assessing for concurrent medical conditions, screen patients for medical conditions that could affect the course of alcohol withdrawal or treatment of alcohol withdrawal, as well as common chronic conditions that are associated with alcohol use disorders.
Recommendation II.15
A pregnancy test should be obtained for women of childbearing potential. For managing pregnant patients, see VII.F. Patients who are pregnant.
Recommendation II.16
In settings with access to laboratory tests, clinicians should conduct and/or arrange for a comprehensive metabolic profile (CMP) or basic metabolic profile (BMP), a hepatic panel, and a complete blood count with differential to assess a patient’s electrolytes, liver functioning, renal functioning, and immune functioning. In a setting with limited access to laboratory testing, clinicians should obtain results when practical to assist with treatment planning decisions. Address any nutritional deficiencies detected.
Initial screening may also include laboratory tests for:
- Hepatitis
- Human immunodeficiency virus (HIV) (with consent)
- Tuberculosis
Recommendation II.17
Assess patients for polysubstance use and be prepared to treat other potential withdrawal syndromes. To assess a patient’s other substance use, it may be helpful to:
- Use a validated scale that addresses other substance use, such as the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)
- Conduct a urine or other toxicology test to detect other substance use
- Utilize information from collateral sources when possible (i.e., family and friends)
Recommendation II.18
Do not delay the initiation of treatment if alcohol withdrawal is suspected but laboratory test results are not available at the treatment setting or the results are pending.
Recommendation II.19
Assess patients for concurrent mental health conditions, including a review of their mental health history, to determine their mental health treatment needs. Consult with any mental health professionals caring for such patients. Obtain written or verbal consent before consultation whenever possible in non-emergent situations. The Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) scales can be helpful to screen for mental health disorders. Be cautious when diagnosing a new primary mental health disorder during acute withdrawal, as it can be difficult to differentiate between substance-induced signs and symptoms and primary psychiatric disorders.
Recommendation II.20
Evaluate active suicide risk as part of the initial patient assessment.
Treatment
III. Level of Care Determination
A. General Approach
Recommendation III.1
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.
Recommendation III.2
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.
B. Level of Care Determination Tools
Recommendation III.3
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.
Table 2. Ambulatory (Level 1-WM and Level 2-WM) and Inpatient Placement Considerations
| Level 1-WM | |||
|---|---|---|---|
| Appropriate | Neutral/Uncertain | Inappropriate | |
| Withdrawal severity | Mild (e.g., CIWA-Ar <10). | Moderate (e.g., CIWA-Ar 10–18) | Severe or complicated (e.g., CIWA-Ar ≥19). |
| Concurrent withdrawal or physiological dependence | Withdrawing from other substance(s). Physiological dependence on opioids or OUD. | Physiological dependence on BZDs or BZD use disorder. | |
| Recent alcohol consumption | Consumes >8 standard drinks per day. | ||
| Alcohol withdrawal history | Previous severe withdrawal episode. Complicated withdrawal >1 year ago. | Recent complicated withdrawal episode. | |
| Treatment history | |||
| Other inpatient need | Medical or psychiatric condition that needs inpatient treatment. | ||
| Biomedical conditions and complications | Older age. History of epilepsy. History of nonalcohol related seizure. Clinically significant abnormal lab results. | Moderate, active, and potentially destabilizing medical problem. Moderate to severe active and potentially destabilizing medical problem, including unstable chronic condition. Suspected head injury. Unable to take oral medications. | |
| Emotional, behavioral, or cognitive conditions and complications | Mild/stable psychiatric symptoms. | Active psychiatric symptoms. Mild cognitive impairment. | Moderate or severe psychiatric symptoms. Moderate or severe cognitive impairment. |
| Symptom monitoring | Absence of reliable caregiver. Communication barrier (e.g., language, hearing, speech). | ||
| Recovery/living environment | Absence of reliable support network. Unable to come to treatment setting daily. | Unable to obtain transportation or housing. Family/friends not supportive of WM process. | |
| Risk of harm | Commitment not high, cooperation and reliability questionable. Imminent risk of harm—not cooperative or reliable. Significant risk of imminent relapse. | ||
| Level 2-WM | |||
|---|---|---|---|
| Appropriate | Neutral/Uncertain | Inappropriate | |
| Withdrawal severity | Mild or moderate (e.g., CIWA-Ar <0–18). | Severe but not complicated (e.g., CIWA-Ar ≥19). | Complicated (e.g., CIWA-Ar ≥19). |
| Concurrent withdrawal or physiological dependence | Physiological dependence on opioids or OUD. | Withdrawing from other substance(s). Physiological dependence on BZDs or BZD use disorder. | |
| Recent alcohol consumption | |||
| Alcohol withdrawal history | Severe withdrawal >1 year ago. | Previous complicated withdrawal episode. Recent severe withdrawal episode. | |
| Treatment history | Previous failure to benefit from Amb-WM. | ||
| Other inpatient need | Medical or psychiatric condition that needs inpatient treatment. | ||
| Biomedical conditions and complications | Older age. History of epilepsy. | Moderate, active, and potentially destabilizing medical problem. History of non-alcohol related seizure. Clinically significant abnormal lab results. Suspected head injury. | Moderate to severe active and potentially destabilizing medical problem including unstable chronic condition. Unable to take oral medications. |
| Emotional, behavioral, or cognitive conditions and complications | Mild/stable psychiatric sypmtoms. | Active or moderate psychiatric symptoms. Mild or moderate cognitive impairment. | Severe psychiatric symptoms. Severe cognitive impairment. |
| Symptom monitoring | Absence of reliable caregiver. Communication barrier (e.g., language, hearing, speech). | ||
| Recovery/living environment | Absence of reliable support network. Unable to come to treatment setting daily. Family/friends not supportive of WM process. | Unable to obtain transportation or housing. | |
| Risk of harm | Commitment not high, cooperation and reliability questionable. Significant risk of imminent relapse. | Imminent risk of harm — not cooperative or reliable. | |
The Guideline Committee rated each placement consideration on a benefit-to-harm ratio, comparing the potential harm that might result from the factor being considered to the expected benefit to the patient of being managed in a less restrictive setting. The rating was made in terms of the average patient in an average setting for both Level 1-WM and Level 2-WM. A consideration is Inappropriate for a given setting when the potential harm outweighs the expected benefit. A consideration is Appropriate for a given setting if the expected benefit outweighs the potential harm. Neutral/Uncertain considerations are ones where the harms and benefits are about equal or cannot be determined or where the Guideline Committee disagreed. If a consideration that is inappropriate for Level-2-WM is present, the patient should be managed in an inpatient setting.
IV. Ambulatory Management of Alcohol Withdrawal
A. Monitoring
Recommendation IV.1
In ambulatory settings, arrange for patients to check in with a qualified health provider (e.g., medical assistant, nurse) daily for up to five days following cessation of (or reduction in) alcohol use. For some patients who are unable to attend daily inperson check-ins, alternating in-person visits with remote check-ins via phone or video call is an appropriate alternative.
Recommendation IV.2
Re-assessments should focus on the patient’s health since the last checkup. Clinicians should assess general physical condition, vital signs, hydration, orientation, sleep and emotional status including suicidal thoughts at each visit. Ask about alcohol and other substance use and, if available, measure Blood Alcohol Content (BAC) with a breathalyzer to detect recent alcohol use.
Recommendation IV.3
Alcohol withdrawal severity should be monitored with a validated instrument (see Alcohol Withdrawal Scales Table for a summary of scale and their associated features). Patients who are able to monitor their own signs and symptoms may use an instrument designed for self-administration such as the Short Alcohol Withdrawal Scale (SAWS).
Recommendation IV.4
In ambulatory settings, patients with a current or past benzodiazepine use disorder need additional monitoring.
Recommendation IV.5
For patients managed in an ambulatory setting, the following indications would necessitate transfer to a more intensive level of care such as Level 2-WM (if in a Level 1-WM setting) or an inpatient setting:
- Agitation or severe tremor has not resolved despite having received multiple doses of medication, and the patient will not be continually monitored (e.g., treatment setting is closing
- More severe signs or symptoms develop such as persistent vomiting, marked agitation, hallucinations, confusion, or seizure
- Existing medical or psychiatric conditions worsen
- Patient appears over-sedated
- Patient returns to alcohol use
- Syncope, unstable vital signs (low/high blood pressure, low/high heart rate)
B. Supportive Care
Recommendation IV.6
Supportive care is a critical component of alcohol withdrawal management. Providers should ensure patients are educated about what to expect over the course of withdrawal, including common signs and symptoms and how they will be treated.
Recommendation IV.7
When treating patients in ambulatory settings, providers should ensure patients/caregivers are educated about monitoring for the development of more severe withdrawal and instructed to create a low-stimulation, reassuring environment at home to promote an effective outcome.
Recommendation IV.8
Patients should be advised to drink non-caffeinated fluids and that a daily multivitamin may be beneficial.
Recommendation IV.9
Patients can be offered oral thiamine. Typical dosing is 100 mg PO per day for 3–5 days.
Recommendation IV.10
Clinicians must explain the importance of taking medications as prescribed and confirm the patient’s understanding.
Recommendation IV.11
Communicate that safe alcohol withdrawal management may necessitate a transfer to a more intensive level of care including to an inpatient setting and secure the patient’s agreement to transfer if there are indications that management in the ambulatory setting is not safe or effective. See Recommendation IV.5 for indications for transfer to a more intensive level of care.
C. AUD Treatment Initiation and Engagement
Recommendation IV.12
When feasible, alcohol use disorder (AUD) treatment should be initiated concurrently with alcohol withdrawal management as cognitive status permits. If appropriate, clinicians should offer to initiate pharmacotherapy for AUD as cognitive status permits. If not initiating AUD treatment themselves, clinicians should explain the range of evidence-based treatment services available in the community and engage patients with these options. In addition, clinicians may offer information about local recovery support groups, including 12-step groups.
D. Pharmacotherapy
(1) Prophylaxis
Recommendation IV.13
Patients at risk of developing severe or complicated alcohol withdrawal or complications of alcohol withdrawal may be treated in ambulatory settings at the discretion of providers with extensive experience in management of alcohol withdrawal. Such patients should be provided with preventative pharmacotherapy. Benzodiazepines are first-line treatment because of their well-documented effectiveness in reducing the signs and symptoms of withdrawal including the incidence of seizure and delirium. Phenobarbital is an appropriate alternative in a Level 2-WM setting for providers experienced with its use. For patients with a contraindication for benzodiazepine use, phenobarbital (in Level 2-WM settings by providers experienced with its use) or transfer to a more intensive level of care are appropriate options.
Recommendation IV.14
A front-loading regimen is recommended for patients at high risk of severe withdrawal syndrome. Providing at least a single dose of preventative medication is appropriate for patients at lower levels of risk who have:
- A history of severe or complicated withdrawal
- An acute medical, psychiatric, or surgical illness
- Severe coronary artery disease
- Displaying signs or symptoms of withdrawal concurrent with a positive blood alcohol content
Recommendation IV.15
Patients at risk of developing new or worsening signs or symptoms of withdrawal while away from the ambulatory treatment setting should be provided with pharmacotherapy. Some indications of risk include a history of withdrawal episodes of at least moderate severity and being within the window for the development of symptoms in the time course of withdrawal. Benzodiazepines, carbamazepine, or gabapentin are all appropriate options for monotherapy. Providing at least a single dose of benzodiazepine followed by ongoing treatment according to symptom severity is also appropriate. If the risk of developing worse withdrawal is unknown, patients should be reassessed frequently over the next 24 hours to monitor their need for withdrawal medication.
(2) Withdrawal symptoms
Recommendation IV.16
Patients experiencing mild alcohol withdrawal (e.g., CIWA-Ar score <10) who are at minimal risk of developing severe or complicated alcohol withdrawal or complications of alcohol withdrawal may be provided pharmacotherapy or supportive care alone. If providing medication, carbamazepine or gabapentin are appropriate options. For patients who are at risk of developing new or worsening withdrawal while away from the treatment setting, benzodiazepines, carbamazepine, or gabapentin are appropriate.
Recommendation IV.17
Patients experiencing moderate alcohol withdrawal (e.g., CIWA-Ar scores 10–18) should receive pharmacotherapy. Benzodiazepines are first-line treatment. Carbamazepine or gabapentin are appropriate alternatives. For patients with a contraindication for benzodiazepine use, carbamazepine, gabapentin, or phenobarbital (in Level 2-WM settings for providers experienced with its use) are appropriate. Carbamazepine, gabapentin, or valproic acid (if no liver disease or childbearing potential) may be used as an adjunct to benzodiazepines.
Recommendation IV.18
Patients experiencing severe, but not complicated, alcohol withdrawal (e.g., CIWA-Ar ≥19) may be treated in ambulatory Level 2-WM settings at the discretion of providers with extensive experience in management of alcohol withdrawal. Such patients should receive pharmacotherapy. Benzodiazepines are first-line treatment. Phenobarbital is an appropriate alternative for providers experienced with its use. For patients with a contraindication for benzodiazepine use, phenobarbital, carbamazepine, or gabapentin are appropriate. The use of adjunct medications is also appropriate.
Recommendation IV.19
If a patient is taking medication as prescribed and symptoms are not controlled as expected:
- First, consider increasing the dose
- Reassess for appropriate level of care
- Consider switching medications
- If using benzodiazepines, consider adding an adjunct medication
(3) Benzodiazepine use
Recommendation IV.20
While no particular benzodiazepine agent is more effective than another, longer-acting benzodiazepines are the preferred agents due to the clinical benefits of their longer duration of action.
Recommendation IV.21
If waiting for lab test(s) results or if the test(s) are unavailable, if a patient has signs of significant liver disease, use a benzodiazepine with less hepatic metabolization.
Recommendation IV.22
Clinicians should monitor patients taking benzodiazepines for signs of over-sedation and respiratory depression.
Recommendation IV.23
A benzodiazepine prescription to treat alcohol withdrawal should be discontinued following treatment.
Recommendation IV.24
Clinicians can manage benzodiazepine misuse or diversion risk in ambulatory settings by dispensing or prescribing the minimum amount necessary given patients’ level of stability and timing of their next in-person clinic visit. Alternative medications can also be considered such as carbamazepine or gabapentin.
Recommendation IV.25
In ambulatory settings, benzodiazepines should not be prescribed to patients with a history of even mild adverse events with benzodiazepine use because rapid intervention is not typically available. Benzodiazepines can be used with caution in patients with a high risk of benzodiazepine diversion including patients with a current or past benzodiazepine use disorder for the short period of acute alcohol withdrawal. Risk can be managed by dispensing or prescribing a small number of doses.
Recommendation IV.26
Patients who are taking benzodiazepines, and their caregivers, should be educated regarding:
- The danger of drug-drug interactions between benzodiazepines and other CNS depressants (impairment and respiratory depression)
- The risks associated with combining alcohol and benzodiazepines and importance of abstinence from alcohol
- The risks associated with driving or use of heavy machinery for the first few days of benzodiazepine administration
- Instructions to reduce their benzodiazepine dose if drowsiness occurs
(4) Benzodiazepine dosing regimens
Recommendation IV.27
At short-term observational settings with continuous monitoring (e.g. Level 2-WM), symptom-triggered treatment conducted by trained staff is the preferred benzodiazepine dosing method. Front loading while under clinical supervision or fixed dosing with additional as-needed medication are also appropriate.
Recommendation IV.28
At settings without extended on-site monitoring (Level 1-WM), symptom-triggered dosing is appropriate if patients or a caregiver can reliably monitor signs and symptoms with a withdrawal severity scale and follow dosing guidance. Otherwise, front loading while under clinical supervision or fixed dosing with additional as-needed medication is appropriate.
Recommendation IV.29
Front loading is recommended for patients experiencing severe alcohol withdrawal (e.g., CIWA-Ar ≥19). Diazepam and chlordiazepoxide are preferred agents for front loading.
Recommendation IV.30
When using a fixed-dose schedule, patients’ signs and symptoms should still be monitored. A few additional take-home doses can be provided to take as needed. When initiating a fixed-dose regimen, arrange for the patient to be seen the following day to modify the dose if needed.
Recommendation IV.31
If prescribing a shorter-acting benzodiazepine, using a fixed-dose regimen with a gradual taper may be appropriate to reduce the likelihood of breakthrough and rebound signs and symptoms.
(5) Carbamazepine, gabapentin, valproic acid
Recommendation IV.32
Gabapentin is a favorable choice for treating alcohol withdrawal when a clinician also plans to use it for a patient’s ongoing treatment of alcohol use disorder.
Recommendation IV.33
Recommendation IV.34
Carbamazepine, gabapentin, or valproic acid may be used as an adjunct to benzodiazepine therapy to help control alcohol withdrawal. Before using as an adjunct, clinicians should ensure that an adequate dose of benzodiazepine has been administered.
Recommendation IV.35
Valproic acid should not be used in patients who have liver disease or women of childbearing potential.
Recommendation IV.36
There is insufficient evidence to support the use of valproic acid as monotherapy for the treatment of alcohol withdrawal.
(6) Phenobarbital
Recommendation IV.37
Phenobarbital can be used for some patients in Level 2-WM ambulatory settings. However, it should only be used by clinicians experienced with its use given its narrow therapeutic window and side effects.
Recommendation IV.38
In a Level 2-WM ambulatory setting (e.g., with extensive monitoring), phenobarbital monotherapy (managed by a clinician experienced with its use) is an appropriate alternative to benzodiazepines for patients who are experiencing severe alcohol withdrawal or who are at risk of developing severe or complicated alcohol withdrawal or complication of alcohol withdrawal.
Recommendation IV.39
In a Level 2-WM ambulatory setting (e.g., with extensive monitoring), phenobarbital monotherapy (managed by a clinician experienced with its use) is appropriate for patients with a contraindication for benzodiazepine use who are experiencing moderate or severe alcohol withdrawal or who are at risk of developing severe or complicated alcohol withdrawal or complications of alcohol withdrawal.
(7) A2AA and beta-blockers
Recommendation IV.40
Alpha2-adrenergic agonists (A2AAs) such as clonidine can be used as an adjunct to benzodiazepine (A2AAs) such as clonidine can be used as an adjunct to benzodiazepine therapy to control autonomic hyperactivity and anxiety when symptoms are not controlled by benzodiazepines alone. They should not be used alone to prevent or treat withdrawal-related seizures or delirium.
Recommendation IV.41
Beta-adrenergic antagonists (beta-blockers) can be used as an adjunct to benzodiazepines in select patients for control of persistent hypertension or tachycardia when these signs are not controlled by benzodiazepines alone. They should not be used to prevent or treat alcohol withdrawal seizures.
(8) Inappropriate medications
Recommendation IV.42
Oral or intravenous alcohol should not be used for the prevention or treatment of alcohol withdrawal.
Recommendation IV.43
There is insufficient evidence to support the use of baclofen for the treatment of alcohol withdrawal.
Recommendation IV.44
Providing magnesium as a prophylaxis or treatment for alcohol withdrawal management has no supporting evidence.
V. Inpatient Management of Alcohol Withdrawal
A. Monitoring
Recommendation V.1
The following monitoring schedule is appropriate:
- In patients with moderate to severe withdrawal or those requiring pharmacotherapy, re-assess every 1–4 hours for 24 hours, as clinically indicated. Once stabilized (e.g., CIWA-Ar score <10 for 24 hours), monitoring can be extended to every 4–8 hours for 24 hours, as clinically indicated.
- Patients with mild withdrawal and low risk of complicated withdrawal may be observed for up to 36 hours, after which more severe withdrawal is unlikely to develop.
Recommendation V.2
Monitor patients’ vital signs, hydration, orientation, sleep, and emotional status including suicidal thoughts.
Recommendation V.3
Monitor patients receiving pharmacotherapy for alcohol withdrawal for signs of over-sedation and respiratory depression.
Recommendation V.4
Signs and symptoms of alcohol withdrawal should be monitored during withdrawal management with a validated assessment scale (see Alcohol Withdrawal Scales Table for a summary of scales and their associated features).
B. Supportive Care
Recommendation V.5
Supportive care is a critical component of alcohol withdrawal management. Frequent reassurance, re-orientation to time and place, and nursing care are recommended non-pharmacological interventions. Providers should ensure patients are educated about what to expect over the course of withdrawal, including common signs and symptoms and how they will be treated. Patients with severe alcohol withdrawal should be cared for in an evenly lit, quiet room. Patients should be offered hope and the expectation of recovery.
Recommendation V.6
Supportive care for alcohol withdrawal patients includes adherence to safety measures and protocols (e.g., assess risk for fall/syncope). If available and applicable, existing institutional/hospital-associated delirium protocols can be used for supportive care of patients with severe alcohol withdrawal.
Recommendation V.7
Thiamine should be provided to prevent Wernicke encephalopathy.
- Intravenous (IV) or intramuscular (IM) administration of thiamine is preferred, in particular for patients with poor nutritional status, malabsorption, or who are known to have severe complications of alcohol withdrawal.
- Typical dosing is 100 mg IV/IM per day for 3–5 days. Oral thiamine can also be offered.
- Patients also receiving glucose can be administered thiamine and glucose in any order or concurrently.
Recommendation V.8
Clinicians should administer thiamine to patients admitted to the Intensive Care Unit (ICU) to treat alcohol withdrawal.
Recommendation V.9
For patients with hypomagnesemia, cardiac arrhythmias, electrolyte disturbances, or a previous history of alcohol withdrawal seizures, magnesium should be administered.
Recommendation V.10
If phosphorus is <1 mg/dL, supplementation should be provided. Otherwise, in the case of moderate hypophosphatemia (1–2 mg/dL), correction through proper nutrition is recommended.
Recommendation V.11
In patients who are critically ill, folate supplementation may be considered, since chronic alcohol use is associated with hyperhomocysteinemia.
C. AUD Treatment Initiation and Engagement
Recommendation V.12
The period of alcohol withdrawal management should be used to engage patients with an alcohol use disorder (AUD) with comprehensive treatment. When feasible, AUD treatment should be initiated concurrently with alcohol withdrawal management as cognitive status permits. If appropriate, clinicians should also offer to initiate pharmacotherapy for AUD as cognitive status permits. Clinicians should explain the range of evidence-based treatment services available at the current site and in the community. Finally, clinicians should proactively connect patients to treatment services as seamlessly as possible, including initiating a warm handoff to treatment providers.
D. Pharmacotherapy
(1) Prophylaxis
Recommendation V.13
For patients at risk of developing severe or complicated alcohol withdrawal or complications of alcohol withdrawal, preventive pharmacotherapy should be provided. Benzodiazepines are first-line treatment because of their well-documented effectiveness in reducing the signs and symptoms of withdrawal including the incidence of seizure and delirium. For patients with a contraindication for benzodiazepine use, phenobarbital can be used by providers experienced with its use. In settings with close monitoring, phenobarbital adjunct to benzodiazepines is also appropriate.
Recommendation V.14
A front loading regimen is recommended for patients at high risk of severe withdrawal syndrome. Providing at least a single dose of preventive medication is appropriate for patients at lower levels of risk not experiencing significant signs or symptoms but have:
- A history of severe or complicated withdrawal
- An acute medical, psychiatric, or surgical illness
- Severe coronary artery disease
- Displaying signs or symptoms of withdrawal concurrent with a positive blood alcohol content
(2) Withdrawal symptoms
Recommendation V.15
For patients experiencing mild alcohol withdrawal (e.g., CIWA-Ar score <10) who are at minimal risk of developing severe or complicated alcohol withdrawal or complications of alcohol withdrawal, pharmacotherapy or supportive care alone may be provided. If providing medication, benzodiazepines, carbamazepine, or gabapentin are appropriate. For patients with a contraindication for benzodiazepine use, carbamazepine, gabapentin, or phenobarbital (for providers experienced with its use), are appropriate. Carbamazepine, gabapentin, or valproic acid (if no liver disease or childbearing potential) may be used as an adjunct to benzodiazepines.
Recommendation V.16
Patients experiencing moderate alcohol withdrawal (e.g., CIWA-Ar scores 10–18) should receive pharmacotherapy. Benzodiazepines are first-line treatment. Carbamazepine or gabapentin are appropriate alternatives. For patients with a contraindication for benzodiazepine use, carbamazepine, gabapentin, or phenobarbital (for providers experienced with its use) are appropriate. Carbamazepine, gabapentin, or valproic acid (if no liver disease or childbearing potential) may be used as an adjunct to benzodiazepines.
Recommendation V.17
Patients experiencing severe alcohol withdrawal (e.g., CIWA-Ar scores ≥19) should receive pharmacotherapy. Benzodiazepines are first-line treatment. For patients with a contraindication for benzodiazepine use, phenobarbital is appropriate for providers experienced with its use. If close monitoring is available, phenobarbital can be used as an adjunct to benzodiazepines. Other adjunct medications can be considered after a clinician ensures that an adequate dose of benzodiazepines has been administered.
Recommendation V.18
If a patient’s symptoms are not controlled as expected:
- First consider increasing the dose
- Reassess for appropriate level of care
- Consider switching medication
- If using benzodiazepines, consider adding an adjunct medication
(3) Benzodiazepine use
Recommendation V.19
While no particular benzodiazepine agent is more effective than another, longer-acting benzodiazepines are the preferred agents due to clinical benefits from their longer duration of action.
Recommendation V.20
If waiting for lab test(s) results or if the test(s) are unavailable, if a patient has signs of significant liver disease, use a benzodiazepine with less hepatic metabolization.
Recommendation V.21
Clinicians should monitor patients taking benzodiazepines for signs of over-sedation and respiratory depression.
Recommendation V.22
A benzodiazepine prescription to treat alcohol withdrawal should be discontinued following treatment.
(4) Benzodiazepine dosing regimens
Recommendation V.23
Symptom-triggered treatment is the preferred benzodiazepine dosing method. Fixed dosing according to a scheduled taper may be appropriate if symptom-triggered treatment cannot be used.
Recommendation V.24
Front loading is recommended for patients experiencing severe alcohol withdrawal (e.g., CIWA-Ar scores ≥19). Diazepam or chlordiazepoxide are preferred agents for front loading.
Recommendation V.25
When using a fixed-dose schedule, patients’ signs and symptoms should still be monitored, and additional doses of medication provided as needed.
Recommendation V.26
If prescribing a shorter-acting benzodiazepine, using a fixed-dose regimen with a gradual taper may be appropriate to reduce the likelihood of breakthrough and rebound signs and symptoms.
(5) Carbamazepine, gabapentin, valproic acid
Recommendation V.27
Gabapentin is a favorable choice for treating alcohol withdrawal when a clinician also plans to use it for a patient’s ongoing treatment of alcohol use disorder.
Recommendation V.28
If benzodiazepines are contraindicated, carbamazepine or gabapentin are appropriate alternatives for patients in mild or moderate withdrawal.
Recommendation V.29
Carbamazepine, gabapentin, or valproic acid may be used as an adjunct to benzodiazepine therapy to help control alcohol withdrawal. Before using as an adjunct, clinicians should ensure that an adequate dose of benzodiazepine has been administered.
Recommendation V.30
Valproic acid should not be used in patients who have liver disease or women of childbearing potential.
Recommendation V.31
There is insufficient evidence to support the use of valproic acid as monotherapy for the treatment of alcohol withdrawal.
(6) Phenobarbital
Recommendation V.32
Phenobarbital can be used for some patients in inpatient settings. However, it should be used only by clinicians experienced with its use, given its narrow therapeutic window and side effects.
Recommendation V.33
In an inpatient setting, phenobarbital monotherapy (managed by a clinician experienced with its use) is appropriate for patients with a contraindication for benzodiazepine use who are experiencing mild, moderate, or severe alcohol withdrawal or who are at risk of developing severe or complicated alcohol withdrawal or complications of alcohol withdrawal.
Recommendation V.34
In an inpatient setting, if close monitoring is available, phenobarbital (managed by a clinician experienced with its use) as an adjunct to benzodiazepines is an option for patients experiencing severe alcohol withdrawal or who are at risk of developing severe or complicated alcohol withdrawal or complications of alcohol withdrawal.
Recommendation V.35
Parenteral phenobarbital should be used only in highly supervised settings (e.g., ICU, CCU) because of risk of over-sedation and respiratory depression.
(7) A2AAs and beta-blockers
Recommendation V.36
Alpha2-adrenergic agonists (AA2s) such as clonidine and dexmedetomidine can be used as an adjunct to benzodiazepine (AA2s) such as clonidine and dexmedetomidine can be used as an adjunct to benzodiazepine therapy to control autonomic hyperactivity and anxiety when these signs are not controlled by benzodiazepines alone. They should not be used alone to prevent or treat withdrawal-related seizures or delirium.
Recommendation V.37
Beta-adrenergic antagonists (beta-blockers) can be used as an adjunct to benzodiazepines in select patients for control of persistent hypertension or tachycardia when these signs are not controlled by benzodiazepines alone. They should not be used to prevent or treat alcohol withdrawal seizures.
(8) Inappropriate medications
Recommendation V.38
Oral or intravenous alcohol should not be used for the prevention or treatment of alcohol withdrawal.
Recommendation V.39
There is insufficient evidence to support the use of baclofen for the treatment of alcohol withdrawal.
Recommendation V.40
Providing magnesium as a prophylaxis or treatment for alcohol withdrawal management has no supporting evidence.
VI. Addressing Complicated Alcohol Withdrawal
A. Alcohol Withdrawal Seizure
(1) Monitoring
Recommendation VI.1
Patients should be monitored for alcohol withdrawal seizures even in the absence of other clinically prominent alcohol withdrawal signs or symptoms.
Recommendation VI.2
Following an alcohol withdrawal seizure, patients should be admitted to a setting with close monitoring available and should be re-assessed every 1–2 hours for 6–24 hours. Patients should be closely monitored for delirium and the need to receive intravenous (IV) fluids, due to potential electrolyte imbalances.
(2) Supportive care
Recommendation VI.3
If available and applicable, existing institutional/hospital-associated delirium protocols can be used for supportive care of patients with an alcohol withdrawal seizure.
(3) Pharmacotherapy
Recommendation VI.4
Following a withdrawal seizure, patients should be immediately treated with a medication effective at preventing another seizure. Benzodiazepines are first-line treatment, and a fast-acting agent such as lorazepam or diazepam is preferred. Phenobarbital is also an option, but benzodiazepines are preferred.
Recommendation VI.5
Following a withdrawal seizure, parenteral administration of medications is preferred. If available, IV administration is preferred to intramuscular (IM), but IM administration is also effective. Parenteral phenobarbital should be used only in highly supervised settings (e.g., Intensive Care Unit [ICU], CCU) because of risk of over-sedation and respiratory depression.
Recommendation VI.6
It is not recommended to use alpha2-adrenergic agonists or beta-adrenergic antagonists to prevent or treat alcohol withdrawal seizures because they are ineffective for this purpose. Beta-adrenergic antagonists also can lower the seizure threshold. Phenytoin should not be used unless treating a concomitant underlying seizure disorder.
B. Alcohol Withdrawal Delirium
(1) Monitoring
Recommendation VI.7
Patients with alcohol withdrawal delirium should receive close nursing observation and supportive care, which often necessitates admission to an intensive or critical care unit. Agitated and disoriented patients should have continuous, one-to-one observation and monitoring.
Recommendation VI.8
Patients with alcohol withdrawal delirium should have their vital signs, oximetry and cardiac status monitored as frequently as required. Resuscitative equipment should be readily available when patients require high doses of benzodiazepines, when continuous infusion of medication is used, or when patients have significant concurrent medical conditions.
Recommendation VI.9
To monitor signs and symptoms of alcohol withdrawal delirium, use a structured assessment scale such as the Confusion Assessment Method for ICUTo monitor signs and symptoms of alcohol withdrawal delirium, use a structured assessment scale such as the Confusion Assessment Method for ICUTo monitor signs and symptoms of alcohol withdrawal delirium, use a structured assessment scale such as the Confusion Assessment Method for ICUTo monitor signs and symptoms of alcohol withdrawal delirium, use a structured assessment scale such as the Confusion Assessment Method for ICU Patients (CAM-ICU), Delirium Detection Score (DDS), Richmond Agitation-Sedation Scale (RASS), or Minnesota Detoxification Scale (MINDS). It is not recommended to use the CIWA-Ar in patients with delirium because it relies on patient-reported symptoms.
(2) Supportive care
Recommendation VI.10
Provide immediate intravenous access for administration of drugs and fluids to patients experiencing alcohol withdrawal delirium.
Recommendation VI.11
If available and applicable, existing institutional/hospital-associated delirium protocols can be used for supportive care of patients with alcohol withdrawal delirium.
Recommendation VI.12
Restraints should be used only when required to prevent injuries due to agitation or violence, and in compliance with state laws.
(3) Pharmacotherapy
Recommendation VI.13
Patients with alcohol withdrawal delirium should be sedated to achieve and maintain a light somnolence. Benzodiazepines are recommended as the first-line agents for managing alcohol withdrawal delirium.
Recommendation VI.14
When available, medication should be administered intravenously. The use of intermittent IV administration of long- and short-acting medications is acceptable and effective. Continuous IV infusion is considerably more expensive and there is no evidence of therapeutic superiority.
Recommendation VI.16
When treating alcohol withdrawal delirium, use an established dosing protocol as a guide but individualize dosing regimens based on patient’s signs and symptoms. It is appropriate for patients with alcohol withdrawal delirium to receive intravenous symptom-triggered or fixed-dose front loading. Once light somnolence is achieved and patients are calm and cooperative, if on IV medication, shifting to oral symptom-triggered treatment is recommended.
Recommendation VI.17
Very large doses of benzodiazepines may be needed to control agitation in alcohol withdrawal delirium, including doses that are much higher than typically seen in other patient populations. Clinicians should not hesitate to provide such large doses to patients to control agitation but should keep in mind the possible risk of over-sedation and respiratory depression. Moreover, when large doses are used, there is risk of accumulation of long-acting benzodiazepine metabolites, especially in patients with impaired hepatic function or the elderly, and patients should be monitored closely.
Recommendation VI.18
For patients who have been delirious longer than 72 hours, assess for drug-induced delirium and withdrawal from another GABAergic agent (such as gabapentin or carisoprodol). When necessary, adjust the benzodiazepine dose.
Recommendation VI.19
Barbiturates can be considered an alternative option to benzodiazepines for the treatment of alcohol withdrawal delirium, but they are not preferred over benzodiazepines. Phenobarbital can be used as an adjunct to benzodiazepines in settings with close monitoring when alcohol withdrawal delirium is not adequately controlled by benzodiazepine therapy alone.
Recommendation VI.20
Antipsychotic agents can be used as an adjunct to benzodiazepines when alcohol withdrawal delirium and hallucinations are not adequately controlled by benzodiazepine therapy alone. They are not recommended as monotherapy for alcohol withdrawal delirium.s when alcohol withdrawal delirium and hallucinations are not adequately controlled by benzodiazepine therapy alone. They are not recommended as monotherapy for alcohol withdrawal delirium.
Recommendation VI.21
Alpha2-adrenergic agonists, beta-adrenergic antagonists and paraldehyde should not be used to treat alcohol withdrawal delirium.
C. Alcohol-Induced Psychotic Disorder
Recommendation VI.22
If available and applicable, existing institutional/hospital-associated delirium protocols can be used for supportive care of patients with an alcohol-induced psychotic disorder.
Recommendation VI.23
The treatment of alcohol-induced psychotic disorder may require consultation with a psychiatrist.
Recommendation VI.24
The treatment of alcohol-induced psychotic disorder may require addition of antipsychotics.
Recommendation VI.25
For patients experiencing hallucinations, diazepam may be considered a treatment option.
D. Resistant Alcohol Withdrawal
Recommendation VI.26
If available and applicable, existing institutional/hospital-associated delirium protocols can be used for supportive care of patients with resistant alcohol withdrawal.
Recommendation VI.27
Phenobarbital may be used as an adjunct to benzodiazepines to control resistant alcohol withdrawal syndrome in settings with close monitoring.
Recommendation VI.28
Propofol may be used with patients in the ICU experiencing resistant alcohol withdrawal who already require mechanical ventilation.
Recommendation VI.29
Dexmedetomidine may be used with patients in the ICU experiencing resistant alcohol withdrawal.
VII. Specific Settings and Populations
A. Primary Care
Recommendation VII.1
If patients are experiencing severe withdrawal (e.g., CIWA-Ar scores ≥19), refer them directly to the nearest Emergency Department.
Recommendation VII.2
If withdrawal is mild (e.g., CIWA-Ar <10), patients presenting to primary care can be prescribed a few doses of benzodiazepine. Whenever possible, medication can be supervised by a caregiver at home or staff at a nonmedical withdrawal management center. Do not prescribe medication to patients for ambulatory management of alcohol withdrawal without performing an adequate assessment or to patients without adequate support.
Recommendation VII.3
If withdrawal does not resolve (e.g., fall below a CIWA-Ar score of 10) after an adequate dose of medication (e.g., 80 mg diazepam), or patients appears sedated, transfer to an Emergency Department or other inpatient withdrawal management setting.
Recommendation VII.4
For patients treated in primary care settings, regular follow-up visits, at least monthly for one year, could increase the likelihood of sustained recovery.
B. Emergency Departments
Recommendation VII.5
If patients are experiencing severe alcohol withdrawal (e.g., CIWA-Ar ≥19), or are at risk of complicated withdrawal, administer medication immediately to treat withdrawal and reduce the risk of seizures and delirium.
Recommendation VII.6
Patients presenting with alcohol withdrawal syndrome in the Emergency Department should be evaluated for delirium as well as other conditions that mimic and/or accompany withdrawal. Patients presenting with delirium should be assessed for all potential etiologies including alcohol withdrawal.
Recommendation VII.7
Patients in the Emergency Department should receive a complete blood count and complete metabolic panel including liver enzyme and magnesium tests. Alcohol withdrawal treatment should not be delayed while waiting for results.
Recommendation VII.8
The following indicators should be present for discharge to an ambulatory alcohol withdrawal management setting from the Emergency Department:
- Mild alcohol withdrawal (e.g., CIWA-Ar score <10)
- Moderate alcohol withdrawal (e.g., CIWA-Ar score 10–18) with no other complicating factors
- Not currently intoxicated (including alcohol or other drugs)
- No history of complicated alcohol withdrawal (seizures, delirium)
- No significant medical or psychiatric comorbidities that would complicate withdrawal management
- Able to comply with ambulatory visits and therapy
Recommendation VII.9
Patients with controlled withdrawal syndrome being discharged from the Emergency Department may be offered a short term (e.g., 1–2 day) prescription for appropriate alcohol withdrawal medication to last until follow-up with their healthcare provider.
C. Hospitalized Patients
(1) Identification
Recommendation VII.10
All patients admitted to the hospital should be screened for risk of alcohol withdrawal. Among hospitalized patients, the Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test-Piccinelli Consumption (AUDIT-PC) can indicate risk of developing alcohol withdrawal.
Recommendation VII.11
Patients undergoing elective surgery should be screened for unhealthy alcohol use and the need to undergo alcohol withdrawal management before proceeding with surgery. Patients undergoing elective surgery who are at risk of alcohol withdrawal should undergo medically managed withdrawal before proceeding with surgery.
(2) Assessment
Recommendation VII.12
Among hospitalized patients, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) can be used for predicting risk of developing severe or complicated alcohol withdrawal in the medically ill.
Recommendation VII.13
For patients suspected of alcohol withdrawal for whom a complete medical history is not available, (i.e., are admitted from the Emergency Department or trauma unit, are in Intensive Care Unit [ICU]), or who are known to be at high risk of complicated alcohol withdrawal, medical decisions should be oriented toward a more aggressive treatment of alcohol withdrawal regardless of presenting signs and symptoms.
Recommendation VII.14
For patients who require more than standard amounts of medication to manage alcohol withdrawal, individualized assessment by clinicians experienced in the management of withdrawal is recommended. The medication and protocol used for treating other conditions and/or alcohol withdrawal syndrome may need to be modified.
(3) Monitoring
Recommendation VII.15
In patients who are hospitalized, monitor their vital signs. Fluid intake and output and serum electrolytes should be monitored as clinically indicated.
Recommendation VII.16
Signs and symptoms of alcohol withdrawal should be monitored during the course of withdrawal with a validated symptom assessment scale. Assess the risk for scores on a symptom assessment scale to be confounded by the use of certain medications, the presence of certain medical conditions (e.g., fever from infection), or a patient’s difficulty communicating. Among general medical/ surgical patients, low withdrawal scores can typically be interpreted with confidence, while high scores should be interpreted with caution. The use of alternative scales for patients with difficulty communicating is appropriate.
Recommendation VII.17
Patients with a reduced level of consciousness who are at risk for the development of alcohol withdrawal should be monitored for the appearance of alcohol withdrawal signs. If a co-occurring clinical condition worsens, do not assume it is related to alcohol withdrawal among alcohol withdrawal patients. However, immediate treatment is required if alcohol withdrawal develops after surgery or trauma.
(4) Supportive care
Recommendation VII.18
Clinicians should administer thiamine to ICU patients with signs or symptoms that mimic or mask Wernicke encephalopathy.
(5) Pharmacotherapy
Recommendation VII.19
Prophylactic treatment of alcohol withdrawal should be provided in the ICU to patients who are suspected to be physiologically dependent on alcohol.
Recommendation VII.20
Implementing an alcohol withdrawal management protocol in the ICU is appropriate. When using a symptom-triggered dosing protocol, use a validated scale to monitor signs and symptoms. For patients being treated in ICU settings for alcohol withdrawal, existing scales that are appropriate to use for monitoring withdrawal include the Richmond Agitation-Sedation Scale (RASS). Administration of medications via the intravenous route is preferred because of the rapid onset of action and more predictable bioavailability.
D. Patients with Medical Conditions
Recommendation VII.21
For patients with medical comorbidities, modify the medication and/or protocol used for treating alcohol withdrawal syndrome as necessary in consultation with other specialists.
Recommendation VII.22
For patients with medical conditions that prevent the use of oral medication, provide intravenous or intramuscular medications as necessary.
Recommendation VII.23
Aggressive withdrawal treatment is indicated for patients with cardiovascular disorders due to risk of harm associated with autonomic hyperactivity.
Recommendation VII.24
For patients with a medical condition associated with impaired hepatic function, adjust medication dose or use medications with less dependence on hepatic metabolism.
E. Patients Who Take Opioids
Recommendation VII.25
Patients who are on chronic opioid medication (opioid agonist therapy for opioid use disorder or pain) should be monitored closely when benzodiazepines are prescribed, due to the increased risk of respiratory depression. Similarly, patients taking sedative-hypnotic medications exhibit tolerance to benzodiazepines and should be monitored closely for appropriate dose.
Recommendation VII.26
For patients with concomitant alcohol withdrawal and opioid use disorder, stabilize opioid use disorder (e.g., with methadone or buprenorphine) concomitantly with treating alcohol withdrawal.
F. Patients Who are Pregnant
(1) Level of care and monitoring
Recommendation VII.27
Inpatient treatment should be considered for all pregnant patients with alcohol use disorder who require withdrawal management. Inpatient treatment should be offered to pregnant patients with at least moderate alcohol withdrawal (i.e., CIWA-Ar scores ≥10).
Recommendation VII.28
The CIWA-Ar is an appropriate symptom assessment scale to use with pregnant patients. Clinicians should consider signs and symptoms such as nausea, headache, anxiety, and insomnia to be connected to alcohol withdrawal rather than pregnancy that will abate once the alcohol withdrawal has been effectively treated.
Recommendation VII.29
During withdrawal management, consult with an obstetrician.
(2) AUD treatment initiation and engagement
Recommendation VII.30
Engagement in treatment for AUD is particularly important for pregnant patients with alcohol withdrawal given the risk of Spectrum Disorder (FASD) including Fetal Alcohol Syndrome (FAS).
(3) Pharmacotherapy
Recommendation VII.31
Before giving any medications to pregnant patients, ensure that patients understand the risks and benefits of the medication, both for the patient and the developing fetus.
Recommendation VII.32
Benzodiazepines and barbiturates are the medications of choice in treatment of pregnant patients with alcohol withdrawal. While there is a risk of teratogenicity during the first trimester, the risks appear small, and they are balanced in view of the risk for fetal alcohol spectrum disorder and consequences to mother and fetus should severe maternal alcohol withdrawal develop.
Recommendation VII.33
Due to the high teratogenic risk, valproic acid is not recommended for pregnant patients.
Recommendation VII.34
For patients at risk for pre-term delivery or in the late third trimester, use of a short-acting benzodiazepine is recommended. This minimizes the risk for neonatal benzodiazepine intoxication given shorter onset and duration of action.
(4) Newborn considerations
Recommendation VII.35
In cases of alcohol withdrawal treated close to delivery, assess the newborn for benzodiazepine intoxication, sedative withdrawal, and Spectrum Disorder (FASD) including Fetal Alcohol Syndrome (FAS).
Recommendation VII.36
Inform pregnant patients of all wraparound services that will assist them in addressing newborn needs, including food, shelter, pediatric clinics for inoculations, as well as programs that will help with developmental or physical issues that the newborn may experience as a result of in-utero substance exposure.
Recommendation VII.37
Licensed clinical staff have an obligation to understand and follow their state laws regarding definitions of child abuse and neglect, reporting requirements, and plans for safe care of newborns with in-utero alcohol exposure.
Flowcharts
Full Protocol
Pharmacotherapy
Ambulatory Management
| Monitoring |
|---|
Frequency:
Worsening withdrawal severity Worsening medical or psychiatric problems Agitation or severe tremor despite multiple doses of medication Over-sedation Return to alcohol use Syncope, unstable vital signs (low/high blood pressure, low/high heart rate) |
| Supportive Care |
Advise patients and caregivers regarding:
|
| Pharmacotherapy |
| See Pharmacotherapy Protocol |
| AUD Treatment Engagement |
As cognitive status permits:
|
| Ongoing Care (Follow-up) |
AUD treatment:
|
Inpatient Management
| Monitoring |
|---|
Frequency:
|
| Supportive Care |
Assess need for:
Treat other conditions found during initial assessment or follow-up with Primary Care |
| Pharmacotherapy |
| See Pharmacotherapy Protocol |
| AUD Treatment Engagement |
As cognitive status permits:
|
| Ongoing Care (Follow-up) |
AUD treatment:
|
Sample Medication Regimens
| Regimen | Description, Examples |
|---|---|
| Benzodiazepines(doses in chlordiazepoxide) | |
| Typical single dose | Mild withdrawal (CIWA-Ar <10): 25–50 mg PO Moderate withdrawal (CIWA-Ar 10–18): 50–100 mg PO Severe withdrawal (CIWA-Ar ≥19): 75–100 mg PO |
| Symptom-triggered | 25–100 mg PO q4–6h when CIWA-Ar ≥10. Additional doses PRN. |
| Fixed-dose | Taper daily total dose by 25–50% per day over 3–5 days by reducing the dose amount and/or dose frequency. Additional doses PRN. Day 1: 25–100 mg PO q4–6h Day 2: 25–100 mg PO q6–8h Day 3: 25–100 mg PO q8–12h Day 4: 25–100 mg PO at bedtime (Optional) Day 5: 25–100 mg PO at bedtime |
| Front loading | Symptom-triggered: 50–100 mg PO q1–2h until CIWA-Ar <10. Fixed-dose: 50–100 mg PO q1–2h for 3 doses. |
| Phenobarbital | |
| Typical single dose | 10 mg/kg IV infused over 30 minutes or 60–260 mg PO/IM. |
| Monotherapy | Symptom-triggered in the ICU: 130 mg IV q30m to target a RASS score of 0–1. Fixed dose in the ED: Loading dose 260 mg IV, then 130 mg IV q30m at physician’s discretion. Fixed dose in ambulatory management: Loading dose 60–120 mg PO. Then 60 mg PO q4h until patient is stabilized. Then 30–60 mg PO q6h tapered over 3–7 days. Additional doses PRN. |
| Adjunct therapy | Single dose in the ED: 10 mg/kg IV infused over 30 minutes. Escalating dose in the ICU: After maximum diazepam dose (120 mg), if RASS ≥1, escalating dose of 60 mg ➔ 120 mg ➔ 240 mg IV q30m to target RASS score of 0 to -2. |
| Carbamazepine (Tegretol) | |
| Monotherapy | 600–800 mg total per day tapered to 200–400 mg/d over 4–9 days. |
| Adjunct therapy | 200 mg q8h or 400 mg q12h. |
| Gabapentin (Neurontin) | |
| Monotherapy | Loading dose 1200 mg, then 600 mg q6h on Day 1 or 1200 mg/d for 1–3 days, tapered to 300–600 mg/d up to 4–7 days. Additional doses PRN. |
| Adjunct therapy | 400 mg q6–8h. |
| Valproic acid (Depakene) | |
| Monotherapy | 1200 mg/d tapered to 600 mg/d over 4–7 days or 20 mg/kg/d. |
| Adjunct therapy | 300–500 mg q6–8h. |
Alcohol Withdrawal Scales
| Abbreviation | Scale Name | Brief Description | Primary Use | Appropriate Setting | Summary of Evidence | Reference |
|---|---|---|---|---|---|---|
| ASSIST | Alcohol, Smoking and Substance Involvement Screening Test | 8 items Interview format | Alcohol use screen | Any | Results of a study in 7 countries indicate that the ASSIST provides a valid measure of risk for individual substances and for total substance involvement. | WHO, 2002 |
| AUDIT | Alcohol Use Disorder Identification Test | 10 items | Alcohol use screen, Risk of alcohol withdrawal | Any | AUDIT is a useful alcohol screen in general medical settings and that its ability to correctly predict which patients will experience alcohol withdrawal is increased when used in combination with biological markers. | Dolman et al., 2005; Saunders et al., 1993 |
| AUDIT-PC | AUDIT-Picinelli Consumption | 10 items Range 0–19 | Alcohol use screen, Risk of alcohol withdrawal | Hospital | Admission AUDIT-PC score is an excellent discriminator of AWS (Sensitivity=91%, Specificity =98.7%). | Pecoraro et al., 2014 |
| AWS | Alcohol Withdrawal Scale | 11 items Based on CIWA-A In German | Risk of delirium | Hospital | AWS scale had good performance in predicting alcohol withdrawal delirium. | Wetterling et al., 1997a |
| AWS - Newcastle | Alcohol Withdrawal Scale | 10 items Based on CIWA | Withdrawal Severity | Hospital | Patients demonstrated shorter overall course of alcohol withdrawal using the AWS compared with WAS. | Foy et al., 2006 |
| BAWS | Brief Alcohol Withdrawal Scale | 5 items Scored 0–3 | Withdrawal severity | Hospital | BAWS patients received less diazepiam and had fewer assessments, but both groups had similar lengths of stay, treatment completion rate, no incidence of seizure or delirium. | Rastegar et al., 2017 |
| CAM-ICU | Confusion Assessment Method | XXX | Confusion | ICU | Excellent reliability and validity in identifying patients with delirium in ICU. | Ely et al., 2001 |
| Abbreviation | Scale Name | Brief Description | Primary Use | Appropriate Setting | Summary of Evidence | Reference |
|---|---|---|---|---|---|---|
| CIWA-Ar | Clinical Institute Withdrawal Assessment, Revised | 10 items | Symptom Assessment Scale | Any | Well established reliability and validity. | Sullivan et al., 1989 |
| DDS | Delirium Detection Scale | Delirium Detection Scale | Delirium | Hospital | Good reliability and validity specific to detection of delirium. | Otter et al., 2005 |
| GMAWS | Glasgow Modified Alcohol Withdrawal Scale | 5 items Scored 0–2 with max score of 10 | Withdrawal severity | Hospital | GMAWS score of ≥1 predicted CIWA-A ≥8, with a sensitivity of 100% and a specificity of 12%. GMAWS score of ≥2 predicted CIWA-A ≥8, with a sensitivity of 98% and a specificity of 39%. | Holzman et al., 2016b |
| LARS | Luebeck Alcohol Withdrawal Risk Scale | 11 items 10 items | Risk of severe withdrawal | Hospital | Predicted severe withdrawal among patients admitted for alcohol withdrawal management. | Wetterling et al., 2006 |
| MINDS | Minnesota Detoxification Scale | 9 items | Symptom Severity | Hospital; ICU | No formal validity study. | DeCarolis et al., 2007 |
| PAWSS | Prediction of Alcohol Withdrawal Severity Scale | 10 items | Risk of severe withdrawal | Hospital; ICU | Predicted complicated alcohol withdrawal among medically ill, hospitalized patients. | Maldonado et al., 2014; 2015 |
| RASS | Richmond Agitation-Sedation Scale | One item. Scored on a continuum with +4 (combative), 0 (alert and calm), and -5 (unarousable) | Sedation and agitation | Medical and surgical | Reliability and validity in medical and surgical patients, including patients who are sedated and/or ventilated. | Sessler et al., 2002 |
| Abbreviation | Scale Name | Brief Description | Primary Use | Appropriate Setting | Summary of Evidence | Reference |
|---|---|---|---|---|---|---|
| SAWS | Short Alcohol Withdrawal Scale | 10-items Scored 0–3 Designed to be self-administered | Withdrawal severity | Ambulatory and Inpatient | High internal consistency, good construct and concurrent validity. | Gossop et al., 2002 |
| SEWS | Severity of Ethanol Withdrawal Scale | 7 items Scored 0–3 | Withdrawal severity | ICU | SEWS-driven protocol led to shorter treatment episodes, possibly driven by high administration of medication in first 24 hours of treatment. | Beresford et al., 2017 |
| SHOT | Sweating, Hallucinations, Orientation, and Tremor | 4-items Range 0–10 | Withdrawal severity | Emergency Department | Showed potential for measuring pretreatment alcohol withdrawal severity in the emergency department. | Gray et al., 2010 |
| WAS | Withdrawal Assessment Scale | 18 Items Based on CIWA | Withdrawal severity | Hospital | Use of a shortened 10-item CIWA led to similar complication rates but reduced symptom duration compared to 18-item CIWA. | Foy et al., 2006 |
Abbreviations
- A2AA
- Alpha-2 adrenergic agonist
- ASAM
- American Society of Addiction Medicine
- ASSIST
- Alcohol, smoking and substance involvement screening test
- AUD
- Alcohol Use Disorder
- AUDIT-PC
- alcohol use disorder identification test - primary care
- BAC
- Blood alcohol concentration or content
- BAWS
- brief alcohol withdrawal scale
- BZD
- benzodiazepines
- CCU
- cardiac/coronary care unit
- CIWA-Ar
- Clinical institute withdrawal assessment for alcohol, revised
- CNS
- central nervous system
- DSM-5
- Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
- ED
- emergency department
- FAS
- Fetal alcohol syndrome
- FASD
- Fetal alcohol spectrum disorders
- FDA
- Food and Drug Administration
- GABA
- gamma-amino-butyric acid
- GAD-7
- generalized anxiety disorder test
- GBP
- gabapentin
- ICU
- intensive care unit
- IM
- intramuscular
- IPRAS
- interpercentile range adjusted for symmetry
- IV
- intravenously
- LARS
- Luebeck alcohol-withdrawal risk scale
- No Rx
- No medication
- PAWSS
- prediction of alcohol withdrawal severity scale
- PB
- phenobarbital
- PHQ - 9
- Patient Health Questionnaire - 9
- PO
- by mouth
- SAMHSA
- Substance Abuse and Mental Health Services Administration
- SAWS
- short alcohol withdrawal scale
- SUD
- substance use disorder
- WM
- withdrawal management
Source Citation
ASAM Guideline on Alcohol Withdrawal Management. Available at: https://www.asam.org/docs/default-source/quality-science/awg-3-20-20.pdf
Disclaimer
This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.
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