Alcohol Withdrawal

Keri Holmes-Maybank, MDCathryn Caton, MD, MSMUSCJune 21, 2012

ObjectivesDefine DependenceDefine WithdrawalDescribe symptoms and stages

of withdrawalDescribe goals of therapy Review management of

withdrawal◦Pharmacological and non-

pharmacological interventions

Alcohol Dependence DSM-IV Diagnostic Criteria A maladaptive pattern of alcohol use, leading to clinically

significant impairment or distress, as manifested by three or more of the following seven criteria, occurring at any time in the same 12-month period: ◦ 1. Tolerance, as defined by either of the following:

a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

b) Markedly diminished effect with continued use of the same amount of alcohol.

◦ 2. Withdrawal, as defined by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to DSM-IV for

further details). b) Alcohol is taken to relieve or avoid withdrawal symptoms.

◦ 3. Alcohol is often taken in larger amounts or over a longer period than was intended.

◦ 4. There is a persistent desire or there are unsuccessful efforts to cut down or control alcohol use.

◦ 5. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects.

◦ 6. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

◦ 7. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the alcohol (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

Alcohol WithdrawalDSM IV Criteria A. Cessation of (or reduction in) alcohol use that has been heavy and

prolonged. B. Two (or more) of the following, developing within several hours to

a few days after Criterion A: ◦ (1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100) ◦ (2) increased hand tremor ◦ (3) insomnia ◦ (4) nausea or vomiting ◦ (5) transient visual, tactile, or auditory hallucinations or illusions ◦ (6) psychomotor agitation ◦ (7) anxiety ◦ (8) grand mal seizures

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Specify if: With Perceptual Disturbances

KindlingIntensity of withdrawal symptoms

increases with successive episodes of withdrawal

3 Stages of WithdrawalStage 1

◦MinorStage 2

◦MajorStage 3

◦Delirium tremens

Minor SymptomsAppear between 6 and 48 hours after heavy

alcohol consumption decreasesMay occur with significant alcohol blood

levelsInitial symptoms intensify and then diminish

over 24 to 48 hours◦ Headache◦ Tremor◦ Diaphoresis◦ Anxiety and irritability◦ Nausea and vomiting◦ Heightened sensitivity to light and sound◦ Insomnia

Alcoholic HallucinosisNOT delirium tremens Occur within 12-24 hours of

cessationResolve within 24-48 hoursSpecific hallucinationsUsually visualNo globally clouded sensoriumVital signs normal

Delirium TremensMost intense and serious syndrome~ 5% of patients, 5% mortality rateOccurs 48-96 hours after cessationMay last 5 days

◦ Severe agitation◦ Tremor◦ Disorientation◦ Persistent hallucinations◦ Fever ◦ Tachycardia◦ Tachypnea◦ Hypertension◦ Diaphoresis

Risk Factors for DT’sHistory of sustained drinkingHistory of previous DT’s>30 years oldConcurrent illnesses (psych or

medical)Significant withdrawal symptoms

with elevated BALProlonged interval between

cessation and presentation to health care professional

Alcohol Withdrawal SeizuresOccur in up to 25% of withdrawal

episodesGeneralized tonic-clonic

convulsionsUsually occur 12-48 hours after

last drinkMore common after years of

drinking

Goals of TherapyReduce severity of withdrawal

symptomsPrevent seizuresPrevent DT’sReduce morbidity and mortality

associated with severe alcohol withdrawal

Indications for Outpatient TreatmentNo specific criteriaMild to moderate symptoms (Stage 1-2)No medical or psychiatric conditions

that may complicate withdrawalNo prior h/o AW seizures or DT’sSober support personCIWA-Ar score <15Able to take po medsNot psychotic, suicidal or significantly

cognitively impairedNo concurrent substance abuse

problems

Indications for Inpatient TreatmentHistory of

◦Severe withdrawal symptoms◦Alcohol withdrawal seizures◦Delirium tremens◦Multiple past detoxifications

Concomitant medical or psychiatric illness

Recent high levels of alcohol consumption

Lack of reliable support networkPregnancy

Admission

Blood alcohol levelEKGBMP, magnesium, phosphorusCDT %CIWA-A, modified

Nonpharmacological ManagementMild withdrawal symptoms

(Stage 1)Supportive care

Quiet environment, well-lit Limited interpersonal interaction Nutrition Fluids Reassurance and encouragement Reorientation – calendars, clocks

Pharmacological Management

Moderate to severe withdrawal (Stage 2-3)Clinicians disagree on the optimum

medications and prescribing schedulesSedative hypnotic drugs are recommended

as the primary agents for managing DT’s(grade A recommendation).

Benzodiazepines are the treatment of choice based on two major reviews ◦Reduce occurrence of seizures and delirium◦Reduce severity of withdrawal symptoms

BenzodiazepinesAct on GABA-A receptors,

similarly to alcoholCIWA-A, modified - symptom

triggered short acting lorazepamMany clinicians prefer long acting

diazepam or clonazepam to avoid symptoms and/or worsening of symptoms

Avoid use of long-acting benzos in elderly or liver disease

Benzodiazepines – Short vs. Long Acting

Agents with rapid onset control agitation more quickly, for example, oral or IV diazepam has a more rapid onset than other agents (level II evidence)

Agents with long duration of action (eg, diazepam) provide a smooth treatment course with less breakthrough symptoms

Agents with shorter duration of activity (eg, lorazepam) may have lower risk when there is concern about prolonged sedation, such as in patients who are elderly or who have substantial liver disease or other serious concomitant medical illness (level III evidence)

The cost of different benzodiazepines can vary considerably.

Benzodiazepines – Symptom Triggered vs. ScheduledSymptom triggered is as effective

as fixed dose therapy Requires significantly less

benzodiazepinesLeads to a more rapid

detoxificationHowever, patients with a CIWA

score of 15 or history of withdrawal seizures need scheduled benzos

CIWA-A, modifiedClinical Institute Withdrawal Assessment for

Alcohol Scale Measures severity of withdrawal Symptom-triggered therapyObjectively quantify severity of withdrawalWell documented reliability, reproducibility,

and validity High scores associated with alcohol

withdrawal seizures and DT’sAssesses need for medicationAssess appropriate site for detoxEvaluates status during treatment

CIWANausea and vomiting Paroxysmal sweatsAnxietyHeadacheAuditory disturbancesVisual disturbancesAgitationTremorTactile disturbancesOrientation and clouding of sensorium

CIWA-A, modified Includes heart rate, temperature, respiratory rate, blood

pressure Type A – CNS excitation

◦ Anxiety◦ Headache◦ Agitation

Type B – Adrenergic Hyperactivity◦ Tremor◦ Nausea and Vomiting◦ Paroxysmal Sweats◦ Heart rate◦ Blood pressure

Type C – Delirium◦ Auditory Disturbances◦ Visual Disturbance◦ Tactile disturbances◦ Orientation and clouding of sensorium

Medications for CIWA-A, modifiedType A – CNS excitation

◦LorazepamType B – Adrenergic Hyperactivity

◦Lorazepam◦Clonidine

Type C – Delirium◦Haloperidol

Additional MedicationThiamine –***give prior to any

glucose***Folic acidMultivitamin IVFElectrolyte replacement as

needed

GabapentinRecommended by MUSC PsychiatryConflicting trials for gabapentin300mg TID x 1 week, 200mg TID x

week, 100 mg x weekPro’s

◦Lack of drug-drug interactions◦Lack of cognitive impairment◦Lack of abuse potential◦Renal excretion

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