We are continuing our current theme of emergency psychiatry. Today we will discuss alcohol withdrawal. This post will include an introduction, signs and symptoms, and treatment.
Today's Content Level: All Levels (Beginner, Intermediate, Advanced)
•What is alcohol withdrawal? Alcohol withdrawal is a term used to described the cluster of signs and symptoms that occur when a heavy drinker suddenly stops or significantly reduces their alcohol intake.
•What are the symptoms? Symptoms are typically mild and include anxiety, tremor, headaches, sweating, and more. Around 20% of cases experience more serious symptoms (ex: hallucinosis, seizures, etc.) 1. At its most extreme, alcohol withdrawal can be life threatening. See next section for more details.
•What is the pathophysiology? Alcohol is a potent central nervous depressant (specific binding sites on the GABA receptor complex). Chronic and heavy use of alcohol leads to physiological tolerance and dependence. More specifically it enhances inhibitory tone (modulates/stimulates GABA receptors) and inhibits excitatory tone (modulates/inhibits glutamate receptors and other excitatory amino acids), which leads to increases in the number of glutamate receptors in an attempt to maintain a normal state of arousal. When these individuals stop or reduce their drinking and blood alcohol concentration is suddenly lowered, the brain is in an unregulated hyper-excited state, resulting in the withdrawal syndrome. Keep in mind that symptoms can start before blood alcohol level reaches zero.
•Who develops alcohol withdrawal? Roughly half of patients with alcohol use disorder experience some level of withdrawal symptoms if they abruptly stop drinking. Risk factors include history of complicated withdrawals, consumption of more drinks per occasion, the presence of more alcohol-related problems, and genetic differences 3. The PAWSS score or AUDIT-PC can be used to help assess risk. These tools in addition to their clinical picture (mental status, vital signs, physical exam) can also assist in determining the appropriate treatment setting for detox (outpatient vs inpatient vs ICU).
SIGNS AND SYMPTOMS
•Signs and symptoms of alcohol withdrawal are sometimes categorized as "uncomplicated" and "complicated".
Symptoms are non-specific and include general malaise, anxiety, tremor, headaches, diaphoresis, nausea/vomiting, hyperreflexia, hypertension, tachycardia.
Onset typically around 3-12 hours and symptoms peak at 24-48 hours.
Seizure: highest risk 12-48 hours after last drink, however may occur earlier or later. Recommend ruling out organic disease or idiopathic epilepsy during first seizure during medically assisted withdrawal 4. Treatment of withdrawal with longer-acting benzodiazepine (such as diazepam) significantly reduces risk of seizures.
Alcoholic hallucinosis: highest risk 12-24 hours after last drink and typically resolves within 48 hours. Typically visual and tactile hallucinations with preserved attention and orientation (contrast with DTs).
Delirium tremens (DTs): Also known as alcohol withdrawal delirium. Highest risk 48-96 hours (2-4 days) after last drink. Can last 5 or more days. Symptoms include disorientation, vivid hallucinations, marked tremor, and autonomic instability. Develops in 5% of withdrawal cases and associated with increased mortality (10-20% if untreated). This is a medical emergency and requires transfer to a general medical or ICU setting.
Symptom scales can be helpful in determining the level of alcohol withdrawal as well as determining when/how much pharmacological support that may be required. One of the most frequently used in the literature as well as my experience is the Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar). I have included the criteria categories here for ease of reference, however feel free to visit here for the full scoring system. Each criteria is scored 0-7 except orientation which is scored 0-4.
Tactile disturbances: assess by asking if they have any itching, pins and needles sensations, burning, numbness, or feel like bugs are crawling on or under their skin.
Visual disturbances: assess by asking if the light appears to be too bright, if the color is different, if it hurts their eyes, if they are seeing anything that is disturbing to them, and if they see things they know are not there.
Auditory disturbances: assess by asking if they are more aware of sounds around them, if the sounds are harsh/frightening/disturbing, and if they hear things they know are not there.
Headache/fullness in head: do not rate for lightheadedness/dizziness.
Orientation/clouding of sensorium
In addition to a thorough review of their history of drinking and withdrawals, mental status exam, physical exam, vital sign review, and CIWA scale, there are other tests that might be helpful in the acute setting.
Blood Alcohol Level (BAL) or Breathalyzer
Urine/Serum Tox Screen: rule out other confounding drugs.
Complete Metabolic Panel (CMP): assess liver function tests (LFTs). In chronic alcoholics the ratio of AST:ALT can be >2:1. Also pay attention to serum creatinine as binge drinking can lead to an acute kidney injury (AKI).
Complete Blood Count (CBC): observe for macrocytosis (elevated MCV), thrombocytopenia, and polycythemia vera.
+/- Creatinine Kinase (CK): rule out rhabdomyolysis in patients with alcohol intoxication leading to coma or immobilization with severe muscle pain and decreased urine output.
•The mainstay of pharmacological detox is benzodiazepines (BDZs) and are supported by large systematic reviews and clinical guidelines 5, 6. There is also some evidence for other medications to include phenobarbital and anticonvulsants (such as carbamazepine and gabapentin).
•Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are the most commonly used BDZs for alcohol withdrawal, but other benzodiazepines may be used.
•Dosing: Diazepam 5-20mg; chlordiazepoxide 25-100mg; lorazepam 1-4mg. Formulation: IV or PO formulations can be given but IV is required in seizures or DTs and preferred in severe withdrawal due to guaranteed absorption and rapid onset.
•Long-acting BDZs with active metabolizes (ex: diazepam or chlordiazepoxide) are preferred because they are better at "smoothing the ride".
•In patients with liver dysfunction (acute alcoholic hepatitis or advanced cirrhosis), lorazepam or oxazepam are preferred because they have no active metabolites and are liver friendly.
There are three main types of assisted withdrawal regimes of BDZs or other medications:
Scheduled dose reductions: patients are started on a dose of BDZ that is roughly equivalent to their number of drinks per day and then that dose is tapered over a period of 3-7 days. For example one common protocol is 50mg of chlordiazepoxide q6h x 1 day -> 25mg q6h x 1 day -> 25mg q12h x 1 day -> 25mg q24h x 1 day -> finish taper. CIWA-Ar or other scales are also performed to assess alcohol withdrawal symptoms and prns are available for elevated scores.
Symptom-triggered: medication is only given when withdrawal symptoms are observed using CIWA-Ar or other validated measures. The interval of assessments/medication varies depending on severity of withdrawals (can be as frequent as q15min up to q6h). Patients with elevated scores of ≥9 on the CIWA-Ar scale will receive a dose of benzodiazepine or other medication.
+-/Front-loading: a front-loading approach can be used prior to either a scheduled dose reduction or a symptom-triggered regime. This consists of administering higher initial doses of benzodiazepine to prevent or achieve more rapid control of alcohol withdrawal symptoms. It is typically titrated until an appropriate level of sedation occurs. This is most appropriate for patients at high risk of dangerous complications.
Where should treatment occur?
Outpatient detox: can be considered if there is a supervising carer throughout the duration of the detox process, treatment plan and contingency plan is agreed between provider and patient, and the patient is able to pick up medication daily and have regular check-ins.
Inpatient detox: should be considered if there is a history of complicated withdrawals (ex: seizures, DTs), regular consumption is very high (ex: >30 drinks/day), comorbid substance/benzodiazepine use, comorbid mental/physical illness, pregnancy, homelessness or no social support, or a history of failed outpatient detox.
Thiamine: chronic alcohol use puts patients at risk for thiamine deficiency and can lead to wernicke-korsakoff syndrome which is a neurological condition characterized by nystagmus, ataxia, and memory issues. Replete thiamine with high dose IV thiamine for 3-5 days (ex: 500mg IV q8h).
Fluid and electrolyte repletion: closely monitor vital signs +/- electrolytes. Patients may not have been adequately hydrating or eating meals. Encourage PO hydration but may need to replete with IV fluids during initial treatment. There has been some concern to screen for re-feeding syndrome, however it appears the risk in these patients is low.
Great work today. In our next post we will discuss opioid withdrawal.
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