1. Keri Holmes-Maybank, MD Cathryn Caton, MD, MS MUSC June 21, 2012
Alcohol Withdrawal
Keri Holmes-Maybank, MD
Cathryn Caton, MD, MS
MUSC
June 21, 2012

2. Objectives Define Dependence Define Withdrawal
Describe symptoms and stages of withdrawal
Describe goals of therapy
Review management of withdrawal
Pharmacological and non-pharmacological interventions

3. Alcohol Dependence DSM-IV Diagnostic Criteria
A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three or more of the following seven criteria, occurring at any time in the same 12-month period:
1. Tolerance, as defined by either of the following:
a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
b) Markedly diminished effect with continued use of the same amount of alcohol.
2. Withdrawal, as defined by either of the following:
a) The characteristic withdrawal syndrome for alcohol (refer to DSM-IV for further details).
b) Alcohol is taken to relieve or avoid withdrawal symptoms.
3. Alcohol is often taken in larger amounts or over a longer period than was intended.
4. There is a persistent desire or there are unsuccessful efforts to cut down or control alcohol use.
5. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects.
6. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
7. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the alcohol (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

4. Alcohol Withdrawal DSM IV Criteria
A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after Criterion A:
(1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
(2) increased hand tremor
(3) insomnia
(4) nausea or vomiting
(5) transient visual, tactile, or auditory hallucinations or illusions
(6) psychomotor agitation
(7) anxiety
(8) grand mal seizures
C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Specify if: With Perceptual Disturbances

5. Kindling
Intensity of withdrawal symptoms increases with successive episodes of withdrawal

6. 3 Stages of Withdrawal Stage 1 Stage 2 Stage 3 Minor Major
Delirium tremens

7. Minor Symptoms
Appear between 6 and 48 hours after heavy alcohol consumption decreases
May occur with significant alcohol blood levels
Initial symptoms intensify and then diminish over 24 to 48 hours
Headache
Tremor
Diaphoresis
Anxiety and irritability
Nausea and vomiting
Heightened sensitivity to light and sound
Insomnia

8. Alcoholic Hallucinosis
NOT delirium tremens
Occur within hours of cessation
Resolve within hours
Specific hallucinations
Usually visual
No globally clouded sensorium
Vital signs normal

9. Delirium Tremens Most intense and serious syndrome
~ 5% of patients, 5% mortality rate
Occurs hours after cessation
May last 5 days
Severe agitation
Tremor
Disorientation
Persistent hallucinations
Fever
Tachycardia
Tachypnea
Hypertension
Diaphoresis

10. Risk Factors for DT’s History of sustained drinking
History of previous DT’s
>30 years old
Concurrent illnesses (psych or medical)
Significant withdrawal symptoms with elevated BAL
Prolonged interval between cessation and presentation to health care professional

11. Alcohol Withdrawal Seizures
Occur in up to 25% of withdrawal episodes
Generalized tonic-clonic convulsions
Usually occur hours after last drink
More common after years of drinking

12. Goals of Therapy Reduce severity of withdrawal symptoms
Prevent seizures
Prevent DT’s
Reduce morbidity and mortality associated with severe alcohol withdrawal

13. Indications for Outpatient Treatment
No specific criteria
Mild to moderate symptoms (Stage 1-2)
No medical or psychiatric conditions that may complicate withdrawal
No prior h/o AW seizures or DT’s
Sober support person
CIWA-Ar score <15
Able to take po meds
Not psychotic, suicidal or significantly cognitively impaired
No concurrent substance abuse problems

14. Indications for Inpatient Treatment
History of
Severe withdrawal symptoms
Alcohol withdrawal seizures
Delirium tremens
Multiple past detoxifications
Concomitant medical or psychiatric illness
Recent high levels of alcohol consumption
Lack of reliable support network
Pregnancy

15. Admission Blood alcohol level EKG BMP, magnesium, phosphorus CDT %
CIWA-A, modified

16. Nonpharmacological Management
Mild withdrawal symptoms (Stage 1)
Supportive care
Quiet environment, well-lit
Limited interpersonal interaction
Nutrition
Fluids
Reassurance and encouragement
Reorientation – calendars, clocks

17. Pharmacological Management
Moderate to severe withdrawal (Stage 2-3)
Clinicians disagree on the optimum medications and prescribing schedules
Sedative hypnotic drugs are recommended as the primary agents for managing DT’s(grade A recommendation).
Benzodiazepines are the treatment of choice based on two major reviews
Reduce occurrence of seizures and delirium
Reduce severity of withdrawal symptoms

18. Benzodiazepines Act on GABA-A receptors, similarly to alcohol
CIWA-A, modified - symptom triggered short acting lorazepam
Many clinicians prefer long acting diazepam or clonazepam to avoid symptoms and/or worsening of symptoms
Avoid use of long-acting benzos in elderly or liver disease

19. Benzodiazepines – Short vs. Long Acting
Agents with rapid onset control agitation more quickly, for example, oral or IV diazepam has a more rapid onset than other agents (level II evidence)
Agents with long duration of action (eg, diazepam) provide a smooth treatment course with less breakthrough symptoms
Agents with shorter duration of activity (eg, lorazepam) may have lower risk when there is concern about prolonged sedation, such as in patients who are elderly or who have substantial liver disease or other serious concomitant medical illness (level III evidence)
The cost of different benzodiazepines can vary considerably.

20. Benzodiazepines – Symptom Triggered vs. Scheduled
Symptom triggered is as effective as fixed dose therapy
Requires significantly less benzodiazepines
Leads to a more rapid detoxification
However, patients with a CIWA score of 15 or history of withdrawal seizures need scheduled benzos

21. CIWA-A, modified
Clinical Institute Withdrawal Assessment for Alcohol Scale
Measures severity of withdrawal
Symptom-triggered therapy
Objectively quantify severity of withdrawal
Well documented reliability, reproducibility, and validity
High scores associated with alcohol withdrawal seizures and DT’s
Assesses need for medication
Assess appropriate site for detox
Evaluates status during treatment

22. CIWA Nausea and vomiting Paroxysmal sweats Anxiety Headache
Auditory disturbances
Visual disturbances
Agitation
Tremor
Tactile disturbances
Orientation and clouding of sensorium

23. CIWA-A, modified
Includes heart rate, temperature, respiratory rate, blood pressure
Type A – CNS excitation
Anxiety
Headache
Agitation
Type B – Adrenergic Hyperactivity
Tremor
Nausea and Vomiting
Paroxysmal Sweats
Heart rate
Blood pressure
Type C – Delirium
Auditory Disturbances
Visual Disturbance
Tactile disturbances
Orientation and clouding of sensorium

24. Medications for CIWA-A, modified
Type A – CNS excitation
Lorazepam
Type B – Adrenergic Hyperactivity
Clonidine
Type C – Delirium
Haloperidol

29. Additional Medication
Thiamine –***give prior to any glucose***
Folic acid
Multivitamin
IVF
Electrolyte replacement as needed

30. Gabapentin Recommended by MUSC Psychiatry
Conflicting trials for gabapentin
300mg TID x 1 week, 200mg TID x week, 100 mg x week
Pro’s
Lack of drug-drug interactions
Lack of cognitive impairment
Lack of abuse potential
Renal excretion

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