Managing alcohol withdrawal​

Clinical features of alcohol withdrawal

Time course

Withdrawal can begin as early as six to 12 hours after the last drink.

Symptoms peak at two to three days, although they can last up to seven days.

A subacute withdrawal syndrome may last for weeks, characterized by insomnia, irritability and craving.

Risk of withdrawal

The severity of withdrawal is partially dose-related. Alcohol withdrawal requiring treatment is rare in people consuming fewer than six drinks per day, except in older adults, who may develop significant withdrawal symptoms even if they were consuming only several drinks per day.

Withdrawal severity varies widely. Some people who drink very heavily experience few or no symptoms of withdrawal, whereas others experience severe symptoms.

Elderly patients have a more complicated withdrawal course because they often have concurrent health problems and may be frail.

Past withdrawal predicts future episodes. Patients with a history of delirium tremens and withdrawal seizures are at high risk of reoccurrence if they return to drinking and stop again.

Symptoms and signs

The most reliable sign of alcohol withdrawal is postural and intention tremor. Ask patients to hold their hands out in front of them, to reach for an object or to walk across the room. The tremor may not be visible when the patient is at rest.

Other signs include diaphoresis, tachycardia and hypertension. Anxiety, nausea and headache are common symptoms.

Distinguishing between withdrawal and anxiety

Patients with alcohol dependence sometimes attribute withdrawal symptoms to anxiety.

Withdrawal should be suspected if:

• the patient reports having six or more drinks per day (except for older adults, who can experience withdrawal at lower amounts)
• drinking begins at a predictable time in the morning or afternoon
• symptoms include sweating or tremor
• symptoms are quickly relieved by alcohol
• the patient has required medical treatment for withdrawal in the past, or has had withdrawal seizures.

Treatment settings for alcohol withdrawal

Alcohol withdrawal is managed in an inpatient or outpatient setting, depending on certain factors. The options include:

• office-based management
• withdrawal management services
• home-based management
• hospital-based management.

Office-based withdrawal management

Many patients can have their withdrawal managed in a primary care clinic. Office-based management is indicated in these situations:

• The patient does not have a history of severe withdrawal (seizures or delirium tremens).
• The patient does not have significant medical or mental health comorbidities and is under age 65.
• The patient is committed to abstinence and a treatment plan. (There is little value in planned treatment of withdrawal if the patient is likely to relapse immediately.)
• On completing treatment, the patient agrees to go home (if socially stable), to a withdrawal management service or, if necessary, to a hospital emergency room.
• You have a room in your clinic where the patient can spend several hours, and you or the office nurse has the time to assess the patient every one to two hours.

Office-based treatment protocol

• Agree on a date for the patient to come in to begin the withdrawal process. The patient should be prepared to spend at least four to six hours in your office.
• Have a plan for when the patient leaves the office: who, if anyone, is going to pick up the patient and where the patient will spend the night.
• Book the first appointment for the morning (8:00 or 9:00 a.m.). Advise the patient to have the last drink between 6:00 and 8:00 p.m. on the night before the appointment. The timing of the last drink may vary. Patients often know when their withdrawal symptoms begin and can time their last drink accordingly.
• When the patient arrives, the doctor or nurse should use the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar).

Give the patient diazepam (with the exceptions noted below), according to the diazepam loading protocol. Most patients require only one to three doses of diazepam at 20 mg.

Using the CIWA-Ar withdrawal scale

The CIWA-Ar is a validated instrument for monitoring the severity of withdrawal. It can be completed in a few minutes by a primary care provider.

The CIWA consists of 10 items that measure the severity of symptoms such as anxiety and hallucinations, and signs such as tremor and sweating. A score of 10 or more indicates the need for benzodiazepines. Treatment is completed when the patient scores less than 8 on two consecutive readings at least one hour apart.

Benzodiazepines for alcohol withdrawal

Benzodiazepines are the first-line treatment for withdrawal symptoms because they are effective and safe. Long-acting benzodiazepines such as diazepam may be more effective than short-acting in preventing complications such as seizures.

• If the CIWA score is 10 or more, give the patient 20 mg of diazepam orally every one to two hours until symptoms abate and the CIWA score is less than 8.
• Treatment is completed when the patient is comfortable, with minimal tremor, and the CIWA score is less than 8 on two consecutive readings.
• If take-home diazepam is necessary, give no more than two to three 10 mg tablets.
• Give thiamine orally. If the patient is at high risk of Wernickes encephalopathy (malnourished, in severe withdrawal), give three days of intravenous or intramuscular thiamine.

Indications for transferring patients to an emergency department

Patients in the following situations should be transferred to an emergency department to manage alcohol withdrawal:

• The patient arrives in severe withdrawal, with a CIWA score higher than 20, or with hallucinations or other concerning symptoms.
• The patient experiences a seizure and shows signs of impending delirium or psychosis (e.g., confusion, hallucinations).
• The patient shows any sign of acute medical illness (e.g., fever, dyspnea) or any other medical condition or complication requiring more investigations and management than a community clinic can provide.
• The patient's CIWA scores continue to climb despite following CIWA protocol.
• The patient's CIWA score is 10 or higher after four doses of diazepam at 80 mg.
• The patient has persistent tachycardia, with a heartrate higher than 120 beats per minute and irregular beats.
• The patients is suicidal.

Completion of treatment in the emergency department

• Treatment is completed when the patient is comfortable and has minimal tremor, and the CIWA score is less than 8 on two consecutive readings.
• Send the patient home if an escort is available; otherwise, send the patient to a local withdrawal management service for admission.
• If the patient is still in some withdrawal, prescribe two or three 10 mg diazepam tablets, to be taken one tablet every four hours, preferably to be dispensed by a partner or friend. The patient should agree not to drink while taking benzodiazepines.
• Have the patient return for follow-up in one or two days.

Withdrawal management services

Most patients who do not need further medical interventions for withdrawal should be referred to withdrawal management services, which are non-medical and community based.

These services provide a safe place for people who are attempting to withdraw from any substance. Patients can be admitted immediately if a bed is available, and they can stay for up to five days, or sometimes longer.

Withdrawal management services provide counselling and treatment referral. Some provide two- to three-week early recovery programs for outpatients.

You can phone a withdrawal management service to find out whether beds are available, but patients need to call or visit the service themselves to secure an assessment.

Home-based withdrawal management

Home-based treatment of withdrawal may be considered only for patients who meet certain criteria. For other patients, home-based treatment is unsafe.

Candidates for home-based withdrawal management

Home-based withdrawal management may be a safe, effective option in the following situations:

• The patient has a history of mild withdrawal symptoms: The patient has recently gone without drinking for five or more days and withdrawal symptoms did not progress to more severe withdrawal requiring medical management.
• The patient has no history of severe withdrawal (e.g., seizures, delirium, hospital admissions) or withdrawal requiring medical management.
• A support person (partner, family member or friend) agrees to dispense the medication.
• A treatment plan is in place (e.g., medications for alcohol use disorders, ongoing counselling, other treatment groups).
• The patient and the patient's support person agree to go to the emergency department if withdrawal symptoms become more severe.
• The patient is less than 65 years old and has no significant comorbidities or severe mental health problems.
• The patient agrees not to drink while taking medication.

Home-based withdrawal protocol

• The patient has the last drink between 6:00 and 8:00 p.m. the night before.
• The patient takes 10 mg of diazepam, dispensed by the support person, starting the next morning, every four hours as needed for tremor.
• Prescribe no more than 40 mg of diazepam.
• Reassess the patient the next day (by phone or in person).
• The patient visits the clinic within two to three days.

Connecting to community withdrawal management

In some communities, an addiction service worker from a withdrawal management service will visit patients in their homes to monitor home-based withdrawal and to arrange formal treatment. 

Emergency department or other hospital-based withdrawal management

Most patients in alcohol withdrawal can be managed as outpatients; however, some may require management in a hospital emergency department or inpatient medical detoxification program. These are patients who do not meet criteria for office management and who:

• have a history of severe withdrawal requiring hospitalization (e.g., delirium tremens)
• use alcohol very heavily (i.e., more than 12 to 15 drinks per day)
• have a history of withdrawal seizures
• have significant medical or mental health comorbidities
• are 65 years old or more
• are suicidal
• cannot be monitored appropriately in your office for reasons of time or space
• are unable to take oral diazepam.

Emergency department treatment for these patients often involves intravenous rehydration, psychiatric assessment and monitoring of electrolytes, vital signs and cardiac function.

Managing withdrawal in the emergency department or medical withdrawal unit

Inpatient management is very similar to the outpatient clinic setting, but requires closer monitoring and more investigations (see Table 1: Management of the complications of alcohol withdrawal and Table 2: Management of alcohol withdrawal in patients with other acute medical conditions). It involves the following practices:

• If the patient has a history of seizures, give diazepam 20 mg every hour for a minimum of three doses.
• If the patient is 65 or older, or has hepatic dysfunction, give lorazepam 1–2 mg sublingual or by mouth every two to four hours.
• Remember to give thiamine. If the patient is at high risk of Wernickes encephalopathy (malnourished, in severe withdrawal), give three days of intravenous or intramuscular thiamine.
• Ideally, detoxification is integrated into the patient's treatment plan and the patient has a follow-up appointment with their regular care provider or an addiction medicine physician the day after discharge.

Serious complications of alcohol withdrawal

Alcohol withdrawal can include serious complications, such as seizures, delirium tremens, hallucinations without delirium, electrolyte disturbances and arrhythmias. Wernicke-Korsakoff syndrome is not caused by withdrawal, but can accompany it.

Table 1: Management of complications of alcohol withdrawal describes these complications and how to manage them.

Alcohol withdrawal may also be complicated by other acute medical conditions, such as hepatic encephalopathy, depression and pancreatitis.

Table 2: Management of alcohol withdrawal in patients with other acute medical conditions describes how to manage alcohol withdrawal in patients with various medical conditions.