Alcohol Withdrawal

Alcohol Withdrawal is a withdrawal syndrome that occurs within several hours to a few days of stopping heavy and prolonged alcohol use. The withdrawal syndrome includes autonomic hyperactivity, anxiety, and gastrointestinal symptoms.

Epidemiology
  • Around 50% of middle-class, high functioning individuals with alcohol use disorder will meet criteria for alcohol withdrawal at some point in their lives.
    • In those who are homeless or hospitalized, this increases to 80%.[1]
Prognosis
  • Acute alcohol withdrawal usually lasts between 4 to 5 days and only after long periods of heavy drinking.[2]
  • During withdrawal, less than 10% will have severe autonomic hyperactivity, tremors, or alcohol withdrawal delirium.
    • Tonic-clonic seizures occurs in less than 3% of individuals.[3]
Comorbidity
  • Withdrawal is more likely in those with conduct disorder or antisocial personality disorder.
Risk Factors
  • Withdrawal is rare in those age 30 year and below, and the risk and severity of withdrawal increases with age.[4]
  • Individuals on other depressant drugs (sedative-hypnotics) are at increased risk.
  • Alcohol withdrawal delirium can often occur alongside another unrelated medical event, when an individual is admitted to hospital. For example, for liver failure, pneumonia, gastrointestinal bleeding, head trauma, hypoglycemia, electrolyte imbalances, or postoperative care. Thus, it is always important to ask about alcohol during a hospital admission.
Criterion A

Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

Criterion B

At least 2 of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A:

  1. Autonomic hyperactivity (e.g. - sweating or pulse rate greater than 100 beats per minute)
  2. Increased hand tremor
  3. Insomnia
  4. Nausea or vomiting
  5. Transient visual, tactile, or auditory hallucinations or illusions
  6. Psychomotor agitation
  7. Anxiety
  8. Generalized tonic-clonic seizures
Criterion C

The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion D

The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Specifier

Specify if:

  • With perceptual disturbances: This specifier applies in the rare instance when hallucinations (usually visual or tactile) occur with intact reality testing, or auditory, visual, or tactile illusions occur in the absence of a delirium.
  • Nausea, vomiting, gastritis, hematemesis, dry mouth, puffy blotchy complexion, and mild peripheral edema can occur during withdrawal.[5]
  • Withdrawal symptoms usually peak on the second day of abstinence and improve significantly by the fourth/fifth day.
  • However, symptoms of anxiety, insomnia, and autonomic dysfunction can remain for up to another 3 to 6 months.[6]
  • It is important to know the stages of alcohol withdrawal so that symptoms are properly identified and also treated for the correct length of time.
  • Alcoholic hallucinosis is not the same as hallucinations in delirium tremens. Alcoholic hallucinosis is self-resolving, and the patient has insight into these hallucinations (which can be auditory, visual, or tactile - most commonly visual).
  • The vast majority of individuals going through alcohol withdrawal will not experience complicated withdrawal (i.e. - withdrawal seizures or delirium tremens).
    • Generally speaking, between 10 to 30% of individuals with alcohol withdrawal will experience alcohol withdrawal seizures.[7]

Alcohol Withdrawal Classification by Stages

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Time of last drink 6-8 hours 12-24 hours 12-48 hours 2-5 days 1-6 months
Definition Mild withdrawal
(in some cases can progress to DTs)
Alcoholic Hallucinosis
(in some cases can progress to DTs)
Withdrawal Seizures Delirium Tremens (DTs)[8], 5% mortality Chronic Alcohol Use
Symptoms • Mild tremors
• Anxiety
• Nausea
• Stable Vitals
• Tremors
• Agitation
• Insomnia
• Hallucination (auditory, visual, tactile), but insight is maintained
• Same as Stage 2, but more severe
• Seizures
Unstable Vitals
• Confusion
• Agitation
• Fever
• Tachycardia
• Hypertension
• Diaphoresis
• Autonomic hyperactivity
• Anxiety
• Sleep disturbance

Alcohol Withdrawal Tools and Scales

Name Rater Description Download
CIWA-Ar Clinician The CIWA–Ar (revised) measures 10 symptoms. Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal); and scores of 15 or more indicate severe withdrawal. It takes approximately 2 minutes to perform. Download
PAWSS Clinician The PAWSS is the first validated tool for the prediction of severe alcohol withdrawal syndrome in the medically ill and its use may aid in the early identification of patients at risk for complicated withdrawal, allowing for prophylaxis before severe alcohol withdrawal syndromes occur. Download
  • The Clinical Institute Withdrawal Assessment (CIWA) was developed in Toronto, Canada in the 1980s.[9] It is considered the gold-standard for measurement of alcohol withdrawal symptoms, and is used in the treatment of alcohol withdrawal in an inpatient setting. Whenever a patient scores > 10 on the CIWA, they should be given either lorazepam or diazepam.
  • The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) is a validated screening tool that uses a combination of symptoms and signs to identifying patients at risk of developing severe alcohol withdrawal syndrome (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens).[10][11]
  • The use of this tool is particularly important, as the CIWA does not indicate the probability that the patient will develop severe withdrawal syndrome, and only indicates whether the patient is experiencing withdrawal symptoms. This is particularly important for identifying high risk patients who may need more intensive medical management or prophylaxis.
  • Chronic exposure to alcohol is thought to cause an imbalance between GABA neurotransmission (decreased) and glutamate neurotransmission (increased).[12]
    • This is thought to cause a hyper-excitable brain state that can lead to seizures (if not adequately treated with benzodiazepines)
    • Overall, glutamate is thought to play a more important role than GABA.[13]
  • Additionally, there is also desensitization of the sympathetic nervous system, which results in autonomic disturbance including tachycardia, hypertension, diaphoresis, and orthostatic changes. In severe cases, this progresses to delirium tremens.
  • During alcohol withdrawal, the loss of GABA-A receptor stimulation from alcohol causes a reduction in chloride flux and is associated with tremors, diaphoresis, tachycardia, anxiety, and seizures.[14]
  • Other medical conditions
    • The symptoms of alcohol withdrawal can resemble other medical conditions (e.g. - hypoglycemia, diabetic ketoacidosis). Essential tremor may be mistaken for tremulousness associated with alcohol withdrawal.
    • Sedative, hypnotic, or anxiolytic withdrawal produces a syndrome similar to alcohol withdrawal.
  • If there is a clinical suspicion for other medical disease or conditions (e.g. - delirium, head injury), other relevant lab tests and investigations should be ordered.
  • Individuals may have tremors, difficulty with gait
  • Exam for stigmata of liver disease including hepatomegaly, spider angiomas
  • Esophageal varices and hemorrhoids may be present
  • Examine for asterixis if concerned about hepatic encephalopathy
  • Males with chronic alcohol use disorder may have decreased testicular size due to the feminizing effects associated with reduced testosterone levels.[15]
  • Alcohol and benzodiazepine withdrawal are treated the same way. Alcohol and benzodiazepine withdrawal are the two substance withdrawals that can be fatal!
  • Withdrawal seizures can be the initial clinical presentation; to prevent progression to more severe withdrawal symptoms.
  • Benzodiazepines must be used and are the first-line treatment; anti-epileptics do not work to prevent alcohol-related seizures.
    • Antipsychotics can lower the seizure threshold, and thus should only be used if there are severe psychotic symptoms that place the patient at risk for serious harms to self or others (e.g. - aggression/violence).

Should withdrawal be managed as an outpatient or inpatient?

In most cases, alcohol withdrawal can be managed in an outpatient setting. However, there are several contraindications to this, including:
  • Severe psychiatric/medical comorbidity, or coexisting illness that requires inpatient treatment
  • Electrolyte disturbances/dehydration
  • Current severe alcohol withdrawal, especially with delirium
  • No possibility for follow-up
  • No reliable contact person to monitor the patient
  • Pregnancy
  • Seizure disorder or history of alcohol withdrawal seizures
  • Suicide risk
  • History of delirium tremens or seizures

Inpatient Alcohol Withdrawal Management

Uncomplicated withdrawal Complicated withdrawal
Definition No history of siezures or delirium tremens A history of withdrawal seizures, delirium tremens, pregnancy or geriatric
Management • Diazepam 20mg PO q1-2h until CIWA < 10
OR
• Lorazepam 2mg q1-2h until CIWA < 10
• Load with diazepam 20mg q1h x 3 = 60mg
• Lorazepam 2mg q1h x 3 = 60mg total to start
• Then administer CIWA based on symptoms

Think about the specific symptoms scored on the CIWA!

Think about the patient's scores: are they showing objective signs of autonomic instability in the score? A delirious person might score on AH/VH/agitation and have a “positive” CIWA!

Outpatient Alcohol Withdrawal Management

Sample Taper:
Diazepam 10mg QID x 3 days (total 40mg daily)
Diazepam 10mg BID x 3 days (total 20mg daily)
Diazepam 10mg qHS x 3 days (total 10mg daily)
Thiamine 300mg PO daily x 1 month
  • One may want to switch patients to lorazepam instead if blood work shows significantly elevated liver enzymes or if there are signs of acute liver failure (e.g. - jaundice).

Diazepam or Lorazepam?

The LOT benzodiazpines (Lorazepam, Oxazepam, and Tamazepam are metabolized via glucuronidation (Phase II metabolism), which is less dependent on global liver function. Thus, these benzodiazepines can be used in individuals with severe liver impairment.
  • Diazepam has a long half-life, multiple active metabolites, and should only be used in healthy patients with no signs of liver disease.
  • Lorazepam can be used in patients with hepatic impairment. It has an intermediate length half-life, and no metabolites. This makes it more suitable for use in the elderly, those with severe liver disease, respiratory distress, or if they already on existing opioids (to reduce the risk of respiratory depression). It can also be given in IM form reliably.
  • Thiamine deficiency (vitamin B1) is common in patients with alcohol dependence. Cognitive impairments may be an early consequence of thiamine deficiency and Wernicke's encephalopathy is under-diagnosed and under-treated.[16]
  • It is important to supplement patients with PO or IV thiamine.
  • Thiamine 100mg TID should be prescribed as ongoing supplementary therapy in alcohol use disorder patients identified as at risk for thiamine deficiency. [17]
  • For more severe cases, 200mg IV thiamine x 3 days, followed by oral supplementation is appropriate. Those with suspected Wernicke’s encephalopathy should receive thiamine 100mg IM/IV x 3 days, then 300mg PO x 3-12 months. Don’t forget to give fluids as well!
  • When managing alcohol withdrawal, drug-drug interactions should be considered.
  • If patients are on mood stabilizer like lithium or valproic acid, ensure that appropriate levels are drawn to make sure they are not suffering from medication-related toxicity.
    • Lithium levels may increase due to increased diuresis from alcohol, and lithium toxicity can cause tremulousness and nausea (mimicking alcohol withdrawal)
    • Valproic acid combined with with alcohol use increases risk of liver damage, and this can increase valproic acid levels due to decreased metabolism from the liver.
  • Folate deficiency is also common in chronic alcohol use.[18]

Alcohol Use Disorder Guidelines

Guideline Location Year PDF Website
Canadian Guidelines on Alcohol Use Disorder Among Older Adults Canada 2020 - Link
British Columbia Centre on Substance Use (BCCSU) Canada 2019 Link Link
National Institute for Health and Care Excellence (NICE) UK 2011 - Link
American Psychiatric Association (APA) USA 2018 - Link
1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
15) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.