Alcohol Withdrawal
An alcohol withdrawal syndrome (AWS) occurs when an individual who has alcohol dependence with physiologic dependence experiences a period of reduced dosage or abstinence from drinking. AWS is life-threatening as it poses a risk for seizures, hypertensive crisis, and autonomic instability (especially in patients with comorbid hypertension or diabetes) as well as delirium tremens, leading to death if not rapidly treated. AWS must be medically managed with close monitoring in either an outpatient or inpatient setting, depending on the patient risk profile.
Pathophysiology. Alcohol tolerance occurs with neuroadaptations
to chronic alcohol exposure. Alcohol is a sedative; chronic exposure leads to
compensatory changes with reduced neurotransmission at inhibitory type A
gamma-aminobutyric acid (GABA) receptors and enhanced neurotransmission
at excitatory N-methyl- d-aspartate (NMDA) glutamatergic
receptors. During abrupt abstinence episodes, the unopposed activity of these
compensatory changes results in central hyperexcitability responsible for
objective and subjective AWS symptoms.
Presentation. AWS onset typically peaks within 48 to 72 hours
of the last ethyl alcohol intake. Clinical signs of AWS include diaphoresis,
tachycardia, hypertension, fever, vomiting, insomnia, anxiety, tremor,
hyperreflexia, delirium, and grand mal seizures. Delirium tremens (“DTs”) is a
very severe withdrawal syndrome, with a fatal potential if not recognized or if
under- treated. This involves autonomic instability, agitation, altered mental
state, hallucinations, and tremor. Risk factors include advanced age, advanced
alcohol dependence, prior episodes of DTs, and medical illness. Clinical
symptoms of AWS include anxiety, irritability, dysphoria, nausea, anorexia,
alcohol craving, headache, fatigue, and auditory, visual and/or tactile
hallucinations. AWS is measured using a standardized instrument, the Clinical
Institute Withdrawal Assessment for Alcohol (CIWA). This measures 10 AWS
symptoms categories with a 0 to 7 scoring range for each. Moderate scores (8 to
15) reflect autonomic hyperactivity, and high scores (>15) predict seizures
and delirium; these scores warrant immediate initiation of medical treatment.
Persistent AWS may endure 1 to 6
months and consists of anxiety or dysphoria, insomnia, and restlessness as well
as frequent cravings for alcohol. Some medical treatments assisting recovery
and promoting abstinence are hypothesized to address persistent central hyper-excitability. These include acamprosate,
naltrexone, disulfiram, and topiramate (see Plate 4-14). These medications must
be combined with complete alcohol abstinence and active attendance at
Alcoholics Anonymous or similar support groups. This will reduce symptoms that
frequently lead to alcohol relapse.
Treatment. Benzodiazepines are the gold standard AWS
treatment due to their cross-reactivity with alcohol at type A GABA receptors.
Symptom-triggered detoxification protocols are used because these prevent
medical morbidity, and even a very occasional death, while minimizing dosing
requirements for benzodiazepines and thus adverse effects. Typical protocols
initiate treatment with either short-acting (lorazepam) or longer-acting
(diazepam, chlordiazepoxide) benzodiazepines once autonomic arousal is
recognized; this is followed by repeated dosing during the first 24 hours,
based on resolution of autonomic arousal and patient comfort. Chlordiazepoxide
may be administered at 25- to 50-mg doses every 2 hours PRN during the first 24 hours; subsequently, a continuing taper protocol
follows, reducing the total 24-hour requirement by not more than 25% per day.
These protocols are guidelines because ongoing clinical assessment is required
for safety; doses should be held if increasing sedation or gait instability
develops. Treatment must include nutritional repletion of thiamine, folate, and
multivitamins. Carbamazepine and valproate are anticonvulsants that may be
useful AWS therapeutic adjuncts. However, the very favorable efficacy and
safety of benzodiazepines does not support their use with their weaker evidence
for efficacy as primary treatments.
Medical stabilization of the acute AWS must always be paired with appropriate referral to maintenance treatment to prevent alcohol use relapse. This includes medication management per Plate 4-13, treatment of co-occurring psychiatric and medical illnesses, and referral to ongoing care for substance abuse. Level of care determinations may be assisted by evidence- based Patient Placement Criteria developed by clinical researchers in the American Society of Addiction Medicine. Six domains influencing probability of good outcome are assessed to help determine the appropriate level of care; these include (1) severity of intoxication and withdrawal, (2) medical comorbidity, (3) psychiatric illness and psychosocial stability, (4) patient readiness to participate actively in treatment, (5) history of past treatment outcomes, and (6) recovery environment. Levels of care range from least restrictive outpatient to increasing medical and psychiatric outpatient supervision (intensive outpatient, partial hospital) to residential treatment. The highest level of care is inpatient hospitalization with both intensive medical and psychiatric stabilization of life-threatening symptoms.
