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The Medical
Management of
ALCOHOL WITHDRAWAL
John J. Stasinos, M.D.
LTC(P), MC, USA
Chief, Chemical Addictions Treatment Services
Department of Psychiatry
Tripler Army Medical Center
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Disclosures
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I have no affiliation or financial relationship
with any pharmaceutical companies
The opinions stated herein are my own
Off-label use of medications will be
discussed
I am not on any medications or moodaltering substances...
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Outline
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Epidemiology
Definitions
Pathophysiology
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Diagnosis
Manifestations
Management
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Objectives
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By the end of this briefing, you will be able to…
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Identify, assess, & diagnose patients in acute EtOH
withdrawal
Determine the best setting for conducting management
of withdrawal symptoms
Manage patients with medically complicated EtOH
withdrawal
Grasp systemic & administrative issues that complicate
care & put patients at unnecessary risk
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Why Are We Even
Talking About This?...
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
Joint Commission standards & policies have
impacted our perceptions & decisions
regarding medical management of EtOH
withdrawal
Disagreement persists among health care
providers regarding how & where these
patients are best cared for
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What Standards?...
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Joint Commission recently
published new standards that
specifically apply to
procedure of “detoxification”
Standards require personnel,
training, & equipment that
represent considerable $
Some institutions sidestep the
issue by declaring:
“WE DON’T DO DETOX”
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What Disagreement?...
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The Good Patient
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Acknowledges illness & need for treatment
Seeks out medical care appropriately
Communicates clearly & transparently with health
care provider
Complies with treatment
Responds to treatment
Thanks the M.D. (& pays their medical bills)
Goes away
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But these patients…
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Deny their illness
Use up precious medical
resources
Can’t be reasoned with
Do not comply with
treatment
Are unruly, agitated,
uncooperative, &
ungrateful
Refuse potentially lifesaving care
And they keep coming
back!
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HOT POTATO!
=
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Clinical Vignette
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22 y/o SWM AD/MC E4 c hx of EtOH
Dependence
Brought to TAMC ER by Command escort after
found to be intoxicated with EtOH
ER assessment: BAL & UDS negative
House staff: “We don’t do detox [at TAMC].”
Pt has a grand mal seizure
ICU course: seizures, delirium tremens,
pneumonia, intubation & ventilation, management
with iv benzos
Discharged from hospital after 37 days
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Terminology

Withdrawal

Characteristic group of
signs & symptoms that
typically develop after
rapid, marked decrease or
discontinuation of a
substance of dependence,
which may or may not be
clinically significantly or
life threatening.
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Terminology

Detoxification:
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Interventions aimed at
managing acute intoxication
& withdrawal in order to
clear toxins from body &
minimize physical harm
from substance use.
Generic Marine (has he been drinking?...) 
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Terminology

Detoxification:
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Caveat #1: The acute medical management of
life-threatening intoxication & related medical
problems is NOT included within the term
detoxification.
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Caveat #2: Detox does NOT constitute
substance abuse treatment for dependence but
is only one part of a continuum of care for
substance use disorders.
Substance Abuse & Mental Health Services Administration (SAMHSA), TIP 45:
Detoxification & Substance Abuse Treatment
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Do we do inpatient detox?...
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Patients ARE NOT hospitalized on an elective
basis for detox purposes if…
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patient’s withdrawal symptoms can be managed in a
less restrictive setting;
patient has access to outpatient resources;
patient has the benefit of family or other supports to
monitor & provide support during detox process.
We DO hospitalize patients for the clinical
management of Medically Complicated
Withdrawal.
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Do we do inpatient detox?...

Medical complications of substance withdrawal
may be benign or life-threatening, depending on…
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Substance used: e.g., EtOH, Benzodiazepines, etc.
Patient’s hx of prior withdrawals
Patient’s age: older  more severe
Number & severity of medical problems
Severe or high risk withdrawal requires inpatient
medical treatment
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Management of EtOH Withdrawal
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Consists of 3 essential components:
Clinical assessment
 Management of medical complications of
withdrawal
 Transition of patient into substance abuse
treatment (REHAB)
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Intervention that does not incorporate all 3
components is incomplete & inadequate
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EtOH Intoxication
Diagnostic Criteria
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Recent Ingestion of EtOH
Clinically significant maladaptive behavioral
or psychological changes
One or more of the following signs, following
EtOH use:
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Slurred speech
Incoordination
Unsteady gait
Nystagmus
Impairment in attention or memory
Stupor or coma
Symptoms are not due to a general medical
condition or another mental disorder
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Blood EtOH Levels
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BAL =
0.1%
 0.2%
 0.3%
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0.35%
 0.4%
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0.6%
effect on function
motor coordination is impaired
user is obviously intoxicated
physical & mental activity
decreases
anesthesia is present
respiratory drive is critically
affected; some die
most die
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EtOH Withdrawal
Diagnostic Criteria
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Cessation of (or reduction in) EtOH use that has been heavy &
prolonged
Two (or more) of the following, developing within several hours to a few
days later:
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Autonomic hyperactivity (sweating, tachycardia)
Increased hand tremor
Insomnia
Nausea or vomiting
Transient visual, tactile, or auditory hallucinations
Psychomotor agitation
Anxiety
Grand mal seizures
Symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
Symptoms are not due to a general medical condition or another mental
disorder
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Pathophysiology
of EtOH Withdrawal
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GABA (Gama amino butyric acid)
 Major inhibitory
neurotransmitter
 Chronic EtOH exposure 
decrease in GABA A alpha 1
receptor activity
NMDA (N-methyl-D-aspartate)
 Major excitatory
neurotransmitter
 Chronic EtOH exposure 
increase in NMDA receptor
concentration  neuron hyper
excitability
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Pathophysiology
of EtOH Withdrawal

In short…
GABA receptor is the brake
 NMDA receptor is the accelerator
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EtOH Withdrawal
is the brain
accelerating
without brakes...
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Factors affecting
Course of Withdrawal
Severity & duration of withdrawal depend on:
1.
2.
3.
4.
5.
6.
7.
Nature of substance
Half-life & duration of action
Length of time substance used
Amount used
Use of other substances
Presence of other medical & psychiatric
conditions
Individual biopsychosocial variables
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Blood EtOH Levels
during Withdrawal
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Course of EtOH Withdrawal
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Course of EtOH Withdrawal
Symptom
Tremulousness
Hallucinations
Seizures
Delirium Tremens
Onset after last drink
6 – 36 hours
12 – 48 hours
6 – 48 hours
48 - 96 hours
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Tremulousness
occurs within 6 – 36 hours
2ndary to autonomic hyperactivity
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Symptoms
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Tremor
Anxiety
Agitation
Insomnia
Anorexia
Nausea
Palpitations
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Signs
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Tachycardia
Hypertension
Hyper-reflexia
Hyperthermia
Diaphoresis
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Hallucinations
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Occurs within 12 – 48 hours of
last drink
3 – 10% of cases develop
hallucinations
Duration is variable
Usually visual (e.g., pink
elephants)
Occasionally auditory, tactile, or
olfactory
EtOH Hallucinosis: reality
testing is intact
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Seizures
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Occur within 6 – 48 hours of last drink
11-35% of patients develop seizures in hospital
setting
Risk correlates with duration EtOH use
Manifests as grand mal tonic-clonic activity
Always rule out other causes
40% are single episodes
30% of untreated patients go on to develop
delirium tremens
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Seizures
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EtOH is an independent risk factor for seizures
Retrospective study of 308 patients in a city
hospital with new onset of seizures during EtOH
withdrawal
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EtOH (gm/day)
51 – 100
101 – 200
201 – 300
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10 gm = 1 beer
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Risk
3x
8x
20x
Stephen KC. “Alcohol Consumption &
Withdrawal in New-Onset Seizures.”
NEJM, 1988
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Delirium Tremens
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Begins 3 to 5 days after last drink
Occurs in less than 5% of withdrawal patients
Not always predictable or preventable
Usually lasts 2-3 days, but can last up to 30 days
Delirium can occur with/without “tremens”
Risk factors
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Acute concurrent medical illness
History of seizures or delirium tremens
Heavier & longer EtOH history
Age > 60
Elevated BAL on admission (greater than 300 mg/dl)
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Delirium Tremens
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Symptoms
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Confusion &
disorientation
Hallucinations
Hyper-responsiveness
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Signs
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Hypertension
Tachycardia
Fever
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Delirium Tremens
Mortality
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Mortality:
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without treatment = 20%
with treatment = 2 – 10%
Temperature > 104  45%
mortality
Seizures & DTs  24%
mortality
Cause of death
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Pneumonia
Liver disease
Hypotension
Trauma
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Clinical Assessment
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History
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Presentation
Intake: amount, type, time of last drink, etc.?
Hx of complicated withdrawal?
Use of other substances?
Medical & psychiatric history
Mental Status Examination
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Cognitive impairment?
Hallucinations?
Impulsivity?
Suicide/homicide risk?
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Clinical Assessment
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Physical Examination
 Vital Signs
 Neurological exam
 Cardiovascular exam
 Abdominal exam
 Stigmata of liver
disease
 Evidence of trauma,
etc.
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Clinical Assessment
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Laboratory studies
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Blood EtOH level
Urine Drug Screen
Urinalysis
Blood chemistries
Complete Blood Count
Liver function tests &
GGT
PT/PTT
B12 & folate assays
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Laboratory studies
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Thyroid Function Tests
Beta-HCG
RPR, HIV, STD
screens
Other studies (if
clinically indicated)
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EKG
CXray
CT scan
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EtOH Withdrawal
Differential Diagnosis
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Acute stimulant intoxication
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cocaine, methamphetamine, caffeine
Sepsis
Thyrotoxicosis
Heat stroke
Hypoglycemia
Intracranial processes (e.g., trauma, CVA)
Encephalitis/encephalopathy
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EtOH Withdrawal
Treatment Setting
Severity of withdrawal dictates level of care:
Social Detoxification: 24 hour care, nonhospital/residential setting without professional
medical staff
 Medically Supported Detoxification: 24 hour
care, non-hospital/residential setting with
profession medical staff
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 Medical
Detoxification: 24-hour care,
hospital setting
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Treatment Setting
ASAM Criteria
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Level I-D: Ambulatory Detoxification Without Extended
Onsite Monitoring
Level II-D: Ambulatory Detoxification With Extended
Onsite Monitoring
Level II.2-D: Clinically Managed Residential
Detoxification
Level III.7-D: Medically Monitored
Inpatient Detoxification (hospital ward)
Level IV-D: Medically Managed Intensive
Inpatient Detoxification (ICU)
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Indications for Admission
(Level III)
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Hx of severe withdrawal symptoms
Hx of withdrawal seizures or delirium tremens
Hx of heavy prolonged EtOH use with a high
degree of tolerance
Abuse of multiple substances
Concomitant psychiatric
or medical illness
Pregnancy
Lack of reliable support
network
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Who goes to the ICU?...
(Level IV)
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Age > 65
Significant cardiac disease
Hemodynamic instability
Marked acid-base
disturbances
Severe respiratory disease
Serious infection
Active delirium tremens
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Who goes to the ICU?...
(Level IV)
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Serious GI pathology
Temp > 103 F
Rhabdomyolysis
Acute renal failure
Hx of recurrent
withdrawal seizures
Hx of delirium tremens
IV benzodiazepine drip
(Ativan 12+ mg/day)
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Treatment Strategy
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Reduce symptoms
Prevent seizures
Prevent delirium
tremens
Prevent &/or
manage medical
complications & comorbidities
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Supportive Care
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Ensure ABCs!...
Secure patient in safe
environment
Provide IV hydration
Correct electrolyte
imbalances
Provide nutritional support
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Supportive Care
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Nursing care: reassurance,
orientation
Monitor for signs &
symptoms of withdrawal
Involve Psychiatrist on Duty
(PsoD) if patient c/o
suicidal/ homicidal
ideation &/or psychotic
symptoms
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Role of Pharmacotherapy
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Stabilize psychological or physiological
withdrawal symptoms
Manage medical emergencies
Remediate non-life threatening, relapsetriggering symptoms
Stabilize co-morbid conditions
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Thiamine & Multivitamins
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30-80% of patients are deficient
Thiamine does not reduce risk of seizures or
delirium tremens
Thiamine does reduce risk of Wernicke’s
encephalopathy
Give thiamine 50 – 100 mg IV
or IM x 1, then po qd
Administer thiamine before
glucose
Add MV 1 tab po qd
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Benzodiazepines
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Ideal for management of EtOH withdrawal
symptoms
Cross-tolerance with EtOH
 Fairly wide therapeutic window (compared to
barbiturates)
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Short- vs. long-acting
Liver disease limits use to
short acting benzos
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Benzodiazepines
Short-acting
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Oxazepam & Lorazepam
Advantages
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They can be administered IM or IV (in monitored
settings)
They have no significant active metabolites
They are metabolized & excreted principally through
kidneys (& do not jeopardize already-damaged liver)
Disadvantages
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They need to be administered more frequently.
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Other Medications
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Beta-blockers & Clonidine
Reduce autonomic hyperarousal (tachycardia,
hypertension)
 May reduce total dosage of
benzos & result in less
sedation
 Do not reduce risk of seizures
or delirium tremens
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Other Medications
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Carbamazepine
Reduces risk of seizure
activity
 Does little for autonomic
hyper-arousal
 Requires monitoring of CBC,
LFTs, & serum levels
 Risks include liver & bone marrow toxicity
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Other Medications
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Antipsychotic agents
Can be used for management
of agitation, aggression, &
psychotic symptoms
 CAUTION: Can also lower
seizure threshold
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Bottom line: other medications are best used
as adjuncts instead of substitutes for benzos
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Play file: Roughmorning 2
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Routine vs. Symptom-driven
Protocols
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Study: 100 VA patients in EtOH
withdrawal
Outcomes
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Treatment time = 68 hrs vs. 9 hrs.
Total dose Librium = 425 mg vs. 100
mg
Advantages
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Reduced hospital length of stay
Reduced total dosage of medication
Reduced cost of care
Less sedation
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Symptom-driven Protocols
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Clinical Institute Withdrawal Assessment for
Alcohol Scale (CIWA)
10-item clinical rating system for EtOH
withdrawal assessment
 Patient is assessed q 4 hours (while awake)
 CIWA can be administered in under 2 minutes
 Each item (but one) is scored on a scale of 0 – 7
 Maximum score of 67 points
 Medicate for scores > 8-10

Sullivan, JT. British Journal of Addiction,
1989; 84: 1353-7
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Clinical Institute Withdrawal
Assessment for Alcohol Scale
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Nausea & vomiting
Tremor
Sweating
Anxiety
Agitation
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Tactile disturbances
Auditory
disturbances
Visual disturbances
Headache or head
fullness
Disorientation
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CIWA
64
FREE
EtOH
Detox
Guide!
Double Click
Document to Open
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Discharge Criteria
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Neurologically stable for last 24 hrs
No withdrawal symptoms; CIWA scores < 10 for
last 24 hrs
Vital signs are stable & within normal limits
No c/o of suicidal/homicidal thoughts or behavior
Detox protocol/taper must be completed; seizures
are controlled
Enrollment in rehab program, ideally within 24 hrs
of discharge
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P r o t r a c t e d
Withdrawal Syndrome

Duration
6
– 12 MONTHS
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Features
 Insomnia
 Depression
 Anxiety
 Irritability
 Mood
swings
 Cognitive deficits
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TAMC Process Action Team
EtOH Withdrawal Protocols
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Membership
Psychiatry
 Internal Medicine
 Family Medicine
 Emergency Medicine
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Process
Literature review
 Discussion &
collaboration
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Contact Information
John J. Stasinos, M.D.
LTC(P), MC, USA
Chief, Chemical Addictions
Treatment Services,
TAMC
Director, Addiction
Psychiatry Fellowship
Program
(808) 433-6566
[email protected]
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