Practice recommendations
- Patients with mild to moderate alcohol withdrawal symptoms and no serious psychiatric or medical comorbidities can be safely treated in the outpatient setting (SOR:A).
- Patients with moderate withdrawal should receive pharmacotherapy to treat their symptoms and reduce their risk of seizures and delirium tremens during outpatient detoxification (SOR:A).
- Benzodiazepines are the treatment of choice for alcohol withdrawal (SOR:A).
- ln healthy individuals with mild-to-moderate alcohol withdrawal, carbamazepine has many advantages making it a first-line treatment for properly selected patients (SOR:A).
In our small community hospital—with limited financial and medical resources—we have designed and implemented an outpatient alcohol detoxification clinical practice guideline to provide cost-effective, evidence-based medical care to our patients, in support of their alcohol treatment.
Those patients with mild-to-moderate alcohol withdrawal symptoms and no serious psychiatric or medical comorbidities can be safely treated in the outpatient setting. Patients with history of severe withdrawal symptoms, seizures or delirium tremens, comorbid serious psychiatric or medical illnesses, or lack of reliable support network should be considered for detoxification in the inpatient setting.
The problem of alcohol withdrawal
Up to 71% of individuals presenting for alcohol detoxification manifest significant symptoms of alcohol withdrawal.4 Alcohol withdrawal is a clinical syndrome that affects people accustomed to regular alcohol intake who either decrease their alcohol consumption or stop drinking completely.
Physiology
Alcohol enhances gamma-aminobutyric acid’s (GABA) inhibitory effects on signal-receiving neurons, thereby lowering neuronal activity, leading to an increase in excitatory glutamate receptors. Over time, tolerance occurs as GABA receptors become less responsive to neurotransmitters, and more alcohol is required to produce the same inhibitory effect. When alcohol is removed acutely, the number of excitatory glutamate receptors remains, but without the suppressive GABA effect.5 This situation leads to the signs and symptoms of alcohol withdrawal.
Symptoms
Noticeable alcohol withdrawal symptoms may appear within hours of cessation or decreasing alcohol intake. The most common symptoms include tremor, craving for alcohol, insomnia, vivid dreams, anxiety, hypervigilance, agitation, irritability, loss of appetite, nausea, vomiting, headache, and sweating.5 Even without treatment, most of these relatively benign symptoms resolve within hours to days.
More concerning are hallucinations, delirium tremens (DTs), and seizures. Transient auditory or visual hallucinations may occur within the first 2 days of decreasing or discontinuing alcohol consumption, and can be separate from DTs. DTs, which present within 2 to 4 days of the last drink (and can last up to 3 to 4 days), are characterized by disorientation, persistent visual and auditory hallucinations, agitation and tremulousness, and autonomic signs resulting from the activation of stress-related hormones. These signs include tachycardia, hypertension, and fevers.
DTs are much more serious than the “alcohol shakes”—5% of patients who experience DTs die from metabolic complications.6 The occurrence of DTs is 5.3 times higher in men than in women;7 however, women may exhibit fewer autonomic symptoms, making DTs in women more difficult to diagnose.6
Grand mal seizures can occur in up to 25% of alcoholics undergoing withdrawal.4 If alcohol-related seizures do occur, they generally do so within 1 day of cessation of alcohol intake, but can occur up to 5 days later.
Risk factors for prolonged or complicated alcohol withdrawal include duration of alcohol consumption, the number of lifetime prior detoxifications, prior seizures, prior episodes of DTs, and current intense craving for alcohol.6-10
Before treatment: assess and stabilize
Initial assessment of the patient
Before initiating treatment for alcohol withdrawal, perform a thorough assessment of the patient’s medical condition. This evaluation should include an assessment of coexisting medical and psychiatric conditions, the severity of previous withdrawal symptoms, and the risk factors for withdrawal complications. The initial symptoms of alcohol withdrawal are not specific and may mimic other serious disease conditions; therefore, the initial assessment should exclude potentially serious medical and psychiatric comorbidities.
Initially, assessment of common alcohol-related medical problems should be conducted. These complications include gastritis, gastrointestinal bleeding, liver disease, cardiomyopathy, pancreatitis, neurological impairment, electrolyte imbalances, and nutritional deficiencies. A physical examination should be performed to assess for arrhythmias, congestive heart failure, hepatic or pancreatic disease, infectious conditions, bleeding, and nervous system impairment.
Initial alcohol level and urine drug screen should be assessed, as recent high levels of alcohol intake and substance abuse place the patient at higher risk for complications. Unstable mood disorders—delirium, psychosis, severe depression, suicidal or homicidal ideation—while potentially difficult to assess during intoxication, need to be considered and ruled out.
Stabilize the patient
After initial assessment, vital signs (eg, heart rate, blood pressure, and temperature) should be stabilized while fluid, electrolyte, and nutritional disturbances are corrected. Some patients undergoing alcohol withdrawal may require intravenous fluids to correct severe dehydration resulting from vomiting, diarrhea, sweating, and fever.