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
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Book Code: CA23CME
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