Table 1. Alcohol Withdrawal Severity

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.

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