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Assessment
When you or a colleague suspect that a hospitalized patient may develop alcohol withdrawal, regularly assess the patient for signs of early withdrawal. Use a validated assessment scale to quantify the severity of the withdrawal syndrome, and initiate treatment decisions such as the dose of medication. If no withdrawal signs manifest after 48 hours, then it is usually safe to discontinue monitoring for withdrawal. Monitor patients for whom alcohol withdrawal is not considered but who then develop withdrawal signs using an assessment scale.
The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is commonly used to assess severity of withdrawal.4 Competent nurses can give it in less than five minutes. A CIWA-Ar score less than 5 indicates minimal withdrawal with no need for pharmacotherapy, whereas a score that falls in the range of 6-19 indicates mild withdrawal that may benefit from medical treatment. A score greater than 30 indicates severe withdrawal that requires close monitoring due to the risk for complications such as seizures and autonomic instability.5
The CIWA-Ar is just as useful for evaluating and treating withdrawal in hospitalized patients on general medical wards as it is for use in chemical dependency units. It can also be used to determine an appropriate pharmacotherapy dose for patients in withdrawal who also have other medical illnesses.6
Monitor patients every few hours, with the frequency of evaluation varying by severity of withdrawal signs. Every four hours is sufficient for most patients, but those who have developed late withdrawal or those with CIWA-Ar scores greater than 30 should be monitored hourly to prevent complications. Continue regular assessment until the withdrawal syndrome has been under control (CIWA-Ar score less than 6) for at least 24 hours.
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Treatment
Medications: Pharmacotherapy is indicated for the management of moderate to severe withdrawal. Any cross-tolerant medication may be used; benzodiazepines or barbiturates are most commonly prescribed. It is inappropriate to use beverage alcohol to prevent or treat alcohol withdrawal. Use of intravenous alcohol infusion is reserved for poisoning with methanol, isopropanol, or ethylene glycol. It should not be given for treatment of acute alcohol withdrawal due to potential complications such as intoxication with delirium and development of gastritis.
Both benzodiazepines and barbiturates, which are different classes of sedative-hypnotic medications, are cross-tolerant with alcohol and effectively treat alcohol withdrawal.7 Acute alcohol withdrawal in the United States is most often managed with benzodiazepines.8 There are a variety of benzodiazepines available, from ultra-short-acting to long-acting, as well as parenteral and oral forms. Diazepam has been used extensively due to rapid onset of action when given intravenously and long duration of action when given orally.
For similar reasons, chlordiazepoxide is also used widely. Lorazepam, an intermediate-acting benzodiazepine that can be given orally or parenterally, has been used extensively for treatment of acute alcohol withdrawal, especially in hospitalized patients, because it has fewer active metabolites than other benzodiazepines. This makes it safer to use in treating patients with severe liver disease, which is important when treating chronic alcoholics. Benzodiazepines have a relatively high therapeutic index when used to treat patients with illnesses in addition to acute withdrawal. This makes benzodiazepines an excellent choice for the treatment of acute withdrawal in patients on general medical wards.
Barbiturates have been used successfully to treat acute alcohol withdrawal syndrome in general medical inpatients, with phenobarbital the most common choice.9,10 Phenobarbital may be preferable to other sedative-hypnotics; with its longer half-life, patients rarely achieve a “high” as they do with other sedatives, and it is available in multiple dosage forms.11