Medically supervised alcohol withdrawal in the ambulatory setting
- Joseph R Volpicelli, MD, PhD
Joseph R Volpicelli, MD, PhD
- Executive Director
- Institute of Addiction Medicine
- Scott A Teitelbaum, MD
Scott A Teitelbaum, MD
- Professor of Psychiatry
- University of Florida
The goal of alcohol detoxification is threefold: to manage symptoms of alcohol withdrawal; to prevent serious events (seizures, delirium tremens, or death); and to bridge patients to treatment for maintaining long-term recovery.
The psychiatric diagnoses, alcohol abuse and alcohol dependence, in DSM-IV-TR were replaced by one diagnosis, alcohol use disorder, in DSM-5 . Although the crosswalk between DSM-IV and DSM-5 disorders is imprecise, alcohol dependence is approximately comparable to alcohol use disorder, moderate to severe subtype, while alcohol abuse is similar to the mild subtype.
Patients with alcohol use disorder can benefit from structured intervention to reduce drinking and/or achieve and maintain abstinence. Most patients with a moderate to severe disorder are physiologically dependent on alcohol and will first require a medically supervised withdrawal [2,3].
Medically supervised withdrawal from alcohol in the ambulatory setting will be reviewed here. Non-ambulatory treatment of more severe alcohol withdrawal is reviewed separately. Screening and treatment for alcohol use disorder is also discussed separately. (See "Management of moderate and severe alcohol withdrawal syndromes" and "Pharmacotherapy for alcohol use disorder" and "Psychosocial treatment of alcohol use disorder" and "Screening for unhealthy use of alcohol and other drugs in primary care" and "Brief intervention for unhealthy alcohol and other drug use".)
PATHOPHYSIOLOGY OF WITHDRAWAL
The alcohol withdrawal syndrome results from sudden reduction in chronic alcohol use. Excessive alcohol drinking for even one week can lead to mild withdrawal symptoms, and excessive drinking for over one month leads to significant withdrawal symptoms .
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
- Kaner EF, Beyer F, Dickinson HO, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2007; :CD004148.
- Fleming MF, Barry KL, Manwell LB, et al. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA 1997; 277:1039.
- ISBELL H, FRASER HF, WIKLER A, et al. An experimental study of the etiology of rum fits and delirium tremens. Q J Stud Alcohol 1955; 16:1.
- Grobin AC, Matthews DB, Devaud LL, Morrow AL. The role of GABA(A) receptors in the acute and chronic effects of ethanol. Psychopharmacology (Berl) 1998; 139:2.
- Freund G, Anderson KJ. Glutamate receptors in the frontal cortex of alcoholics. Alcohol Clin Exp Res 1996; 20:1165.
- Blondell RD. Ambulatory detoxification of patients with alcohol dependence. Am Fam Physician 2005; 71:495.
- Schuckit MA, Tipp JE, Reich T, et al. The histories of withdrawal convulsions and delirium tremens in 1648 alcohol dependent subjects. Addiction 1995; 90:1335.
- Yost DA. Alcohol withdrawal syndrome. Am Fam Physician 1996; 54:657.
- Brown ME, Anton RF, Malcolm R, Ballenger JC. Alcohol detoxification and withdrawal seizures: clinical support for a kindling hypothesis. Biol Psychiatry 1988; 23:507.
- Ferguson JA, Suelzer CJ, Eckert GJ, et al. Risk factors for delirium tremens development. J Gen Intern Med 1996; 11:410.
- Palmstierna T. A model for predicting alcohol withdrawal delirium. Psychiatr Serv 2001; 52:820.
- Ballenger JC, Post RM. Kindling as a model for alcohol withdrawal syndromes. Br J Psychiatry 1978; 133:1.
- Marchal C. [Alcohol and epilepsy]. Rev Prat 1999; 49:383.
- Limosin F, Loze JY, Boni C, et al. The A9 allele of the dopamine transporter gene increases the risk of visual hallucinations during alcohol withdrawal in alcohol-dependent women. Neurosci Lett 2004; 362:91.
- Holzbach E. Thiamine absorption in alcoholic delirium patients. J Stud Alcohol 1996; 57:581.
- Booth BM, Blow FC. The kindling hypothesis: further evidence from a U.S. national study of alcoholic men. Alcohol Alcohol 1993; 28:593.
- Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict 1989; 84:1353.
- Foy A, McKay S, Ling S, et al. Clinical use of a shortened alcohol withdrawal scale in a general hospital. Intern Med J 2006; 36:150.
- Saitz R, O'Malley SS. Pharmacotherapies for alcohol abuse. Withdrawal and treatment. Med Clin North Am 1997; 81:881.
- Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997; 278:144.
- Kaim SC, Klett CJ, Rothfeld B. Treatment of the acute alcohol withdrawal state: a comparison of four drugs. Am J Psychiatry 1969; 125:1640.
- Holbrook AM, Crowther R, Lotter A, et al. Meta-analysis of benzodiazepine use in the treatment of acute alcohol withdrawal. CMAJ 1999; 160:649.
- Ntais C, Pakos E, Kyzas P, Ioannidis JP. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev 2005; :CD005063.
- Erstad BL, Cotugno CL. Management of alcohol withdrawal. Am J Health Syst Pharm 1995; 52:697.
- Saitz R, Friedman LS, Mayo-Smith MF. Alcohol withdrawal: a nationwide survey of inpatient treatment practices. J Gen Intern Med 1995; 10:479.
- Ait-Daoud N, Malcolm RJ Jr, Johnson BA. An overview of medications for the treatment of alcohol withdrawal and alcohol dependence with an emphasis on the use of older and newer anticonvulsants. Addict Behav 2006; 31:1628.
- Myrick H, Malcolm R, Randall PK, et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res 2009; 33:1582.
- Myrick H, Taylor B, LaRowe S, et al. A retrospective chart review comparing tiagabine and benzodiazepines for the treatment of alcohol withdrawal. J Psychoactive Drugs 2005; 37:409.
- Rathlev NK, D'Onofrio G, Fish SS, et al. The lack of efficacy of phenytoin in the prevention of recurrent alcohol-related seizures. Ann Emerg Med 1994; 23:513.
- Chance JF. Emergency department treatment of alcohol withdrawal seizures with phenytoin. Ann Emerg Med 1991; 20:520.
- Polycarpou A, Papanikolaou P, Ioannidis JP, Contopoulos-Ioannidis DG. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev 2005; :CD005064.
- Colombo G, Agabio R, Carai MA, et al. Ability of baclofen in reducing alcohol intake and withdrawal severity: I--Preclinical evidence. Alcohol Clin Exp Res 2000; 24:58.
- Addolorato G, Leggio L, Abenavoli L, et al. Baclofen for outpatient treatment of alcohol withdrawal syndrome. J Fam Pract 2005; 54:24.
- Addolorato G, Leggio L, Agabio R, et al. Baclofen: a new drug for the treatment of alcohol dependence. Int J Clin Pract 2006; 60:1003.
- Adinoff B. Double-blind study of alprazolam, diazepam, clonidine, and placebo in the alcohol withdrawal syndrome: preliminary findings. Alcohol Clin Exp Res 1994; 18:873.
- Prater CD, Miller KE, Zylstra RG. Outpatient detoxification of the addicted or alcoholic patient. Am Fam Physician 1999; 60:1175.
- Krupitsky EM, Rudenko AA, Burakov AM, et al. Antiglutamatergic strategies for ethanol detoxification: comparison with placebo and diazepam. Alcohol Clin Exp Res 2007; 31:604.
- Stinnett JL. Outpatient detoxification of the alcoholic. Int J Addict 1982; 17:1031.
- Collins MN, Burns T, van den Berk PA, Tubman GF. A structured programme for out-patient alcohol detoxification. Br J Psychiatry 1990; 156:871.
- Ozdemir V, Bremner KE, Naranjo CA. Treatment of alcohol withdrawal syndrome. Ann Med 1994; 26:101.
- Wartenberg AA, Nirenberg TD, Liepman MR, et al. Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clin Exp Res 1990; 14:71.
- Ritvo JI, Park C. The psychiatric management of patients with alcohol dependence. Curr Treat Options Neurol 2007; 9:381.
- Lange-Asschenfeldt C, Müller MJ, Szegedi A, et al. Symptom-triggered versus standard chlormethiazole treatment of inpatient alcohol withdrawal: clinical implications from a chart analysis. Eur Addict Res 2003; 9:1.
- Reoux JP, Miller K. Routine hospital alcohol detoxification practice compared to symptom triggered management with an Objective Withdrawal Scale (CIWA-Ar). Am J Addict 2000; 9:135.
- Wiseman EJ, Henderson KL, Briggs MJ. Individualized treatment for outpatients withdrawing from alcohol. J Clin Psychiatry 1998; 59:289.
- Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med 2002; 162:1117.
- Sullivan JT, Swift RM, Lewis DC. Benzodiazepine requirements during alcohol withdrawal syndrome: clinical implications of using a standardized withdrawal scale. J Clin Psychopharmacol 1991; 11:291.
- Feldman DJ, Pattison EM, Sobell LC, et al. Outpatient alcohol detoxification: initial findings on 564 patients. Am J Psychiatry 1975; 132:407.
- Hayashida M, Alterman AI, McLellan AT, et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. N Engl J Med 1989; 320:358.
- Cook CC. Prevention and treatment of Wernicke-Korsakoff syndrome. Alcohol Alcohol Suppl 2000; 35:19.
- Charness ME, Simon RP, Greenberg DA. Ethanol and the nervous system. N Engl J Med 1989; 321:442.
- Cross GM, Hennessey PT. Principles and practice of detoxification. Prim Care 1993; 20:81.
- Moak DH. Assessing the efficacy of medical treatments for alcohol use disorders. Expert Opin Pharmacother 2004; 5:2075.
- Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA 2006; 295:2003.
- Sausser GJ, Fishburne SB Jr, Everett VD. Outpatient detoxification of the alcoholic. J Fam Pract 1982; 14:863.
- Blaho K, Merigian K, Winbery S. The Pharmacology of Alcohol Withdrawal Syndrome Treatment Reviewed: Efficacy, Cost, and Safety. Am J Ther 1996; 3:79.
- Soyka M, Horak M. Outpatient alcohol detoxification: implementation efficacy and outcome effectiveness of a model project. Eur Addict Res 2004; 10:180.
- Wiseman EJ, Henderson KL, Briggs MJ. Outcomes of patients in a VA ambulatory detoxification program. Psychiatr Serv 1997; 48:200.
- PATHOPHYSIOLOGY OF WITHDRAWAL
- CLINICAL PRESENTATION
- Delirium tremens
- Withdrawal seizures
- Alcohol hallucinosis
- INITIAL PATIENT ASSESSMENT
- CIWA-Ar scale
- CRITERIA FOR AMBULATORY DETOXIFICATION
- MEDICATIONS FOR AMBULATORY DETOXIFICATION
- Drug selection
- - Benzodiazepines
- - Anticonvulsants
- - Other medications
- Dosing schedules
- - Fixed schedule therapy
- - Loading dose
- - Symptom-triggered therapy
- Medication protocols
- SUPPORTIVE CARE
- Nutritional supplements
- BRIDGE TO MAINTENANCE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS