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 (altered 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