The Clinical Institutes Withdrawal Assessment Scale for Alcohol (CIWA-AR), developed in the 1980s, is a standardized evaluation tool that can be used to assess the severity of withdrawal symptoms. It can help clinicians determine the need for medically supervised withdrawal and is commonly used to guide the treatment of alcohol withdrawal symptoms. It measures the severity of alcohol withdrawal symptoms, including the following: 171 • Nausea and vomiting. • Headache. • Paroxysmal sweats. • Auditory disturbances. • Anxiety. • Visual disturbances. • Agitation. • Tactile disturbances. • Tremor. • Orientation and clouded senses. Patients are scored based on symptom severity and classified as having mild withdrawal (less than 10 points), moderate withdrawal (10 to 18 points), and severe withdrawal (more than 19 points). 171 Diagnosis The Diagnostic and Statistical Manual of Mental Disorders, 5 th edition (DSM-5) created a new diagnosis of alcohol use disorder that replaced alcohol abuse and alcohol dependence, which were described in the DSM-4. Like substance use disorders, alcohol use disorder is diagnosed when patients experience a problematic pattern of alcohol use leading to clinically significant distress or impairment. 173 Alcohol withdrawal can be life threatening and may require intensive or inpatient care. Diagnostic criteria for alcohol withdrawal include the following: 173 • Reduction in or cessation of alcohol use that was prolonged and heavy. • Two or more of the following symptoms that develop within a few hours to a few days after alcohol reduction or cessation. ° Increased hand tremor. ° Nausea or vomiting. ° Autonomic hyperactivity. ° Insomnia. ° Anxiety. ° Generalized tonic-clonic seizures. ° Transient hallucinations that are visual, auditory, or tactile. ° Psychomotor agitation. • The above symptoms cause significant distress or impairment in important areas of functioning such as social or occupational. • The symptoms are not attributed to another medical condition, mental disorder, or intoxication or withdrawal from another substance. Treatment of Withdrawal Alcohol withdrawal treatment is typically dependent on the severity of withdrawal. Patients experiencing mild alcohol withdrawal, or those with a CIWA-Ar score of less than 10, can be treated
by addiction specialists in the outpatient setting with supportive care alone, or supportive care and pharmacotherapy. If providing medications, carbamazepine or gabapentin are appropriate options; benzodiazepines can be given if the patient is at risk of developing new or worsening symptoms while away from the treatment center. 171 Patients experiencing moderate alcohol withdrawal, or those with a CIWA-AR score between 10 and 18, can be treated in the outpatient setting and should receive pharmacotherapy. Benzodiazepines are considered first line treatment in these patients, though carbamazepine, gabapentin, or phenobarbital can be used as alternatives for patients with contraindications to benzodiazepines. If needed, benzodiazepines can be given with adjunctive carbamazepine, gabapentin, or valproic acid. 171 Severe, uncomplicated cases of alcohol withdrawal, or those with a CIWA-AR score greater than 19, should be treated with pharmacotherapy. These patients can be treated in a higher-level ambulatory setting, such as a treatment program, that has regular monitoring available in the event of escalation, or in higher levels of care if necessary. Benzodiazepines should be used as first line therapy in these patients; phenobarbital, carbamazepine or gabapentin may be used as an alternative. Adjunctive therapy with carbamazepine, gabapentin, or valproic acid is also appropriate. 171 For patients who have uncontrolled symptoms in the ambulatory setting, medication adherence should first be verified. If the patient is taking medication as prescribed, providers should consider increasing the dose. If providers are concerned about inadequate monitoring or oversedation, they can consider switching medications, adding an adjunctive medication, or reassess the level of care. 171 Providers should consider the patient’s risk for severe or complicated withdrawal when determining a treatment plan, as these patients may require closer management or inpatient hospitalization. Risk factors for severe or complicated withdrawal include: 171 • Prior history of alcohol withdrawal seizures or delirium • Medical or surgical comorbidities, especially traumatic brain injury • Numerous prior episodes of withdrawal • Age over 65 years • Long history of regular, heavy alcohol use • Seizures or significant autonomic hyperactivity during the current withdrawal episode • Dependence on medications that enhance GABA such as benzodiazepines or barbiturates • Use of other addictive substances in conjunction with alcohol • Signs and symptoms of withdrawal in conjunction with a positive blood alcohol concentration • Moderate to severe co-occurring psychiatric disorder
The risk of severe or complicated withdrawal is higher in patients with multiple risk factors. Providers can generally use CIWA-Ar scores to assess for the risk of severe or complicated withdrawal; patients with a CIWA-Ar score of 10 or greater, or those experiencing at least moderate alcohol withdrawal on presentation are at a higher risk of severe or complicated withdrawal. Other tools such as The ASAM Criteria Risk Assessment Matrix, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), or the Luebeck Alcohol-Withdrawal Risk Scale (LARS) can help assess a patient’s risk of severe or complicated alcohol withdrawal as well as potential complications of withdrawal. 171 Supportive Care and Nutrition Once comorbidities and alternative substance withdrawal have been excluded, the treatment of alcohol withdrawal is focused on alleviating symptoms and correcting metabolic abnormalities. Supportive care, such as IV fluids, nutritional supplementation, and frequent clinical reassessment, is a core component of withdrawal treatment. Patients should be educated on expectations over the course of withdrawal, including common symptoms and how they will be treated. In the outpatient setting, education should be provided on monitoring for more severe withdrawal, and that safe withdrawal treatment may require transfer to a higher level of care if the ambulatory setting is not safe or effective for the patient. 171 Patients experiencing withdrawal should be placed in a low-stimulation, reassuring environment that is calm and quiet. Dehydrated patients should receive IV fluids until they are euvolemic. Thiamine and glucose should be given to treat or prevent Wernicke’s encephalopathy. Multivitamins with folate should be initiated and electrolyte disturbances such as magnesium, potassium, glucose, and phosphate should be corrected. Depending on the severity, nutritional supplementation may need to be intravenous for at least the first day or two for aspiration prevention, as well as impaired gastrointestinal absorption in patients who chronically abuse alcohol. 171,212 Benzodiazepines are a mainstay of alcohol withdrawal treatment. They are useful in preventing withdrawal symptoms from becoming more severe, preventing seizures and delirium, and for treating psychomotor agitation. Longer acting agents such as diazepam and chlordiazepoxide are preferrable to reduce the chance of seizures or recurrent withdrawal. Patients with severe liver disease are at a higher risk of benzodiazepine accumulation due to reduced metabolism. These patients should be treated with lorazepam because of its shorter half-life, or oxazepam because of the lack of active metabolites, which prevents prolonged oversedation. IV administration is often required in patients in severe withdrawal, for those who cannot tolerate oral administration, or those who are unconscious. Medications Benzodiazepines
35
Powered by FlippingBook