● 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 Risk factors for alcohol use disorder Risk factors for alcohol use disorder in a person’s lifetime include the following (Tetrault & O’Connor, 2021):
○ Transient hallucinations that are visual, auditory, or tac- tile ○ Psychomotor agitation ● Significant distress or impairment in important areas of social or occupational functioning caused by the above symptoms ● Symptoms not attributable to another medical condition, mental disorder, intoxication, or withdrawal from another substance ● Significant disability ● Mood disorders, such as major depression or bipolar disorder ● Other substance use disorders ● Personality disorders such as antisocial or borderline personality disorder
● Age 18 to 29 ● Male gender ● White and Native American ethnicities
TREATMENT OF WITHDRAWAL
Alcohol withdrawal treatment is typically dependent on the sever- ity of withdrawal and should be tailored to the patient’s specific needs. Patients experiencing mild alcohol withdrawal, or those with a CIWA-Ar score of less than 10, can be treated in the out- patient setting with supportive care, or with supportive care and pharmacotherapy. Appropriate medications include carbamaze- pine or gabapentin. Benzodiazepines may be considered if the patient is at risk of developing new or worsening symptoms while away from the treatment center (American Society of Addiction Medicine, 2020). Patients experiencing moderate alcohol withdrawal, or those with a CIWA-Ar score between 10 and 18, can be treated in the outpa- tient setting and should receive pharmacotherapy. Benzodiazepines are considered first-line treatment in these pa - tients, though carbamazepine, gabapentin, or phenobarbital can be used as alternatives for patients with contraindications to ben- zodiazepines. If needed, benzodiazepines can be given with ad- junctive carbamazepine, gabapentin, or valproic acid (American Society of Addiction Medicine, 2020). Severe, uncomplicated cases of alcohol withdrawal, or those with a CIWA-Ar score greater than 19, should be treated with pharma- cotherapy. These patients can be treated in a higher- level am- bulatory 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 firs- line therapy for these patients. Phenobarbital, carbamazepine or ga- bapentin may be used as an alternative. Adjunctive therapy with carbamazepine, gabapentin, or valproic acid is also appropriate (American Society of Addiction Medicine, 2020). For patients who have uncontrolled symptoms in the ambulatory setting, medication adherence should first be verified. If the pa - tient is taking medication as prescribed, providers should con- sider increasing the dose. If providers are concerned about inad- equate monitoring or oversedation, they can consider switching 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 abnormali- ties. Supportive care, such as IV fluids, nutritional supplementa - tion, and frequent clinical reassessment, is a core component of withdrawal treatment. Patients should be educated on expecta- tions over the course of withdrawal, including common symptoms and how they will be treated. In the outpatient setting, education should be provided about monitoring for more severe withdrawal. Patients should also know that safe withdrawal treatment may re- quire transfer to a higher level of care if the ambulatory setting is not safe or effective for the patient (American Society of Addiction Medicine, 2020).
medications, adding an adjunctive medication, or reassessing the level of care (American Society of Addiction Medicine, 2020). 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 (American Society of Addiction Medicine, 2020): ● 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 cur - rent withdrawal episode ● Dependence on medications that enhance gamma-aminobu- tyric acid (GABA) such as benzodiazepines or barbiturates ● Use of other addictive substances in conjunction with alcohol ● Signs and symptoms of withdrawal in conjunction with a posi- tive 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 experi- encing 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 poten- tial complications of withdrawal (American Society of Addiction Medicine, 2020). Patients experiencing withdrawal should be placed in a low-stimu- lation, reassuring environment that is calm and quiet. Dehydrated patients should receive IV fluids until they are euvolemic. Thia - mine and glucose should be given to treat or prevent Wernicke’s encephalopathy, an acute neurological condition caused by thia- mine deficiency and characterized by ataxia, ocular abnormalities, and confusion. Multivitamins with folate should be initiated, and electrolyte disturbances such as magnesium, potassium, glucose, and phosphate should be corrected. Depending on the sever- ity, 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 (American Society of Addiction Medicine, 2020; Hoffman & Weinhouse, 2021).
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Book Code: RPUS3024
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