Alcohol Use Disorder and Withdrawal

General Overview

  • Canada’s Low-Risk Alcohol Drinking Guidelines (* standard drink = 1 bottle of beer/cider/cooler OR 5 oz wine OR 1.5 oz shot)

    • Men: 0-3 standard drinks* per day; < 15 per week

    • Women: 0-2 standard drinks* per day; < 10 per week

  • Screening

    • Consider annual universal screening of ALL adult and youth patients

      • Adults: CAGE, AUDIT, SASQ (single question: in past year, how often consumed more than 4 [women] or 5 [men] drinks in any one occasion? SE 84% SP 78%)

      • Adolescents: CRAFFT (car, relax, alone, forget, friends, trouble), NIAAA (Friends consumed EtOH in past year? You consumed EtOH in past year?)

        • Drugs and alcohol are also discussed as part of the HEEADSSS exam (see In Children)

  • Brief Intervention (See 5 A's on substance use page)

💡 Multiple reviews have demonstrated that even a single, 5-minute session is likely to be effective in reducing alcohol consumption among higher risk individuals (BCCSU 2019).

Treatment

  • Psychosocial intervention

    • Motivational interviewing

    • Cognitive behavioral therapy

    • Family-based therapy

    • Residential programs (e.g., treatment, rehabilitation, or detoxification programs)

    • Mutual help groups (e.g., Alcoholics Anonymous, “12-step” programs) *less evidence than CBT and FBT

  • Pharmacotherapy

    • 1st line: Naltrexone 25mg PO daily x 3d, then 50mg PO daily (Competitive mu-antagonist)

      • Goal: Reduction or abstinence in alcohol consuption

      • Safe with active drinking

      • Avoid in liver disease (ALT > 3x normal) or if on opioids

      • Consider depot injections if poor adherence

      • Eligible for full cost coverage in BC

    • Acamprosate 666mg PO TID (Glutamate antagonist/GABA-agonist)

      • Goal: Complete abstinence

      • Ideally abstinent from alcohol at treatment initiation (increased effectiveness)

      • Eligible for full cost coverage in BC

    • Consider topiramate (25mg PO daily up to 100mg PO BID) or gabapentin (100mg-300mg PO TID) if active drinking and failed first line

Nutritional deficiency in sustained heavy alcohol use

  • Consider nutritional supplements in patients with AUD with sustained heavy alcohol use or evidence of malnutrition (weight loss, poor healing, lack of coordination, alcohol liver disease):

      • Thiamine (B1) 100mg PO daily supplementation (IV/IM x 3-5d if inpatient)

      • Magnesium if confirmed hypomagnesemia

      • Folic acid 1mg PO daily

      • Pyridoxine (Vitamin B6) 2mg PO daily

      • An alternative is to prescribe a daily multivitamin

  • WerNICke’s encephalopathy (acute, reversible): Nystagmus/ophthalmoplegia, Incoordination/ataxia, Confusion (alterned mental status

    • Thiamine 500 mg IV q8h x 2d, then 250mg IV daily x 5d

    • Wernicke-Korsakoff Syndrome (chronic, irreversible): presence of Wernicke's Encephalopathy + Korsakoff's Psychosis (amnesia, confusion, confabulation)

Alcohol Withdrawal

Definition

  • DSM-5: Cessation or reduction in alcohol use that has been heavy and prolonged with two or more of the following

    1. Autonomic hyperactivity

    2. Increased hand tremor

      • Tongue tremor may be more reliable

    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

Stages

    • Symptoms begin within 6-24h of last drink or acute reduction in chronic alcohol

    • 12-48h Alcohol hallucinosis (typically insects/animals in room)

    • 6-48h Withdrawal seizures (typically tonic-clonic convulsions)

      • Occur in 10-30% of patients with alcohol withdrawal

    • 3-7d (up to 14d) Withdrawal delirium (aka. delirium tremens)

      • Sudden-onset fluctuating attention/cognition, agitation, autonomic hyperactiviity (fever, tachycardia, hypertension, diaphoresis)

      • Mortality from cardiovascular complications, hyperthermia, aspiration, fluid/electrolytes disorders

      • Risk: Previous DT, age>30, sustatined drinking, concurrent illness, longer period between last dirnk and onset of withdrawl (>2 days)

Evaluation

  • Rule out acute medical problem (head trauma, gastritis, pancreatitis, hepatitis, pneumonia)

    • Rule out concurrent Wernicke encephalopathy (altered mental status, oculomotor function, gait ataxia)

      • Consider Thiamine prior to glucose

  • Determine outpatient vs. inpatient management

    • Chronic/acute conditions, medications, social support

    • Substance use disorder history (alcohol, drugs, amount, last used, previous withdrawals/seizures/delirium tremens/hospitalizations)

    • If Prediction of Alcohol Withdrawal Severity Scale (PAWSS) < 4 consider outpatient treatment

Consider Labs

  • CBC

  • Electrolytes (K, Mg, PO4, glucose, creatinine)

  • LFTs

  • Amylase/Lipase

  • Blood alcohol level

  • Urine drug testing

  • bhCG

  • Consider EKG

  • Consider CT Head of suspect trauma, or atypical clinical presentation)

Management

  • Treat aggressively in first few hours, then taper

    • CIWA <10 if patient can communicate symptoms

    • RASS target -1 to 0 may be simpler

  • Benzodiazepines

    • Diazepam 10-20mg PO/IV q5mins (96h half-life) if no liver dysfunction

      • May gradually increase 20mg, 20mg, 30mg, 30mg, 40mg, 40mg, etc..

    • Lorazepam 2-4mg PO/IV q15mins(<12h half-life) if liver dysfunction

  • Second-Line Drugs (eg. >200mg diazepam or >40mg lorazepam)

    • Phenobarbitol 130mg IV q15 minutes (80h half-life) care in liver dysfunction

      • Note: Phenobabital may be considered first-line

    • Propofol 5-25mcg/kg/min IV

  • Consider nutritional supplements in patients with AUD with sustained heavy alcohol use or evidence of malnutrition (weight loss, poor healing, lack of coordination, alcohol liver disease):

      • Thiamine (B1) 100mg PO daily supplementation (IV/IM x 3-5d if inpatient)

        • If suspect Wernicke's Encephalopathy, consider higher dose IV (eg. 500mg IV q8h)

      • Magnesium if confirmed hypomagnesemia

      • Folic acid 1mg PO daily

      • Pyridoxine (Vitamin B6) 2mg PO daily

      • An alternative is to prescribe a daily multivitamin

  • Consider fluids (and glucose with Thiamine)

  • Discharge

    • Discharge when fully treated, consider avoiding prescription benzodiazepines

    • Follow-up care

      • Psychosocial support or treatment program (Detox centers, AA meetings, social worker)

      • Pharmacotherapy (Naltrexone/Acamprosate), see Substance Use