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The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management

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The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management CLINICAL PRACTICE GUIDELINE The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management Guideline Committee Members (alpha order): Table of Contents Anika Alvanzo, MD, MS, DFASAM, FACP Kurt Kleinschmidt, MD, FASAM Glossary of Terms 2 Abbreviations and Acronyms 3 Julie A. Kmiec, DO, FASAM Executive Summary 3 George Kolodner, MD, DLFAPA, FASAM Introduction 15 Gerald E. Marti, MD, PhD I. Purpose 15 06/04/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3RQIKUrpuF//+TLr8jGhDY87TpJTbZN0FK3a045zhsAU= by https://journals.lww.com/journaladdictionmedicine from Downloaded Downloaded William F. Murphy, DO, MS, DFASAM II. Background 15 Carlos F. Tirado, MD, FASAM III. Scope of Guideline 16 from IV. Intended Audience 16 Corey Waller, MD, MS, DFASAM, FACEP https://journals.lww.com/journaladdictionmedicine V. Qualifying Statement 16 Lewis S. Nelson, MD, FASAM, FACEP, FACMT (Chair) VI. Special Terms 16 Approach and Methodology 17 I. Overview of Approach 17 Clinical Champions (alpha order): II. Develop the Scope and Key Questions 18 Stephen Holt, MD, MS, FACP III. Conduct a Literature Review 18 Darius Rastegar, MD, FASAM IV. Develop Draft Guideline Statements 19 Richard Saitz, MD, MPH, FACP, DFASAM V. Conduct Panel Ratings 19 VI. Drafting the Guideline Document 20 Michael F. Weaver, MD, DFASAM Recommendations 20 by I. Identification and Diagnosis of Alcohol Withdrawal 20 BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3RQIKUrpuF//+TLr8jGhDY87TpJTbZN0FK3a045zhsAU= ASAM Quality Improvement Councilà (alpha order): A. Identification 20 B. Diagnosis 21 John Femino, MD, DFASAM C. Differential Diagnosis 21 Kenneth Freedman, MD, DFASAM (Chair) II. Initial Assessment of Alcohol Withdrawal 23 R. Jeffrey Goldsmith, MD, DLFAPA, DFASAM A. General Approach 23 Barbara Herbert, MD, DFASAM (Past- Chair) B. Risk Factors for Severe or Complicated Withdrawal 24 C. Risk Assessment Tools 25 Margaret Jarvis, MD, DFASAM D. Symptom Assessment Scales 26 Margaret M. Kotz, DO, DFASAM E. Identify Concurrent Conditions 27 P. Stephen Novack, DO III. Level of Care Determination 28 David R. Pating, MD A. General Approach 28 Sandrine Pirard, MD, PhD, MPH, FAPA, FASAM B. Level of Care Determination Tools 28 C. Considerations for Ambulatory vs Inpatient Management 29 IV. Ambulatory Management of Alcohol Withdrawal 33 ASAM Staff: A. Monitoring 33 Maureen Boyle, PhD, Chief Quality and Science Officer B. Supportive Care 35 Leah White, MPH, Director of Quality Improvement C. AUD Treatment Initiation and Engagement 36 D. Pharmacotherapy 36 Taleen Safarian, Manager of Science and Dissemination V. Inpatient Management of Alcohol Withdrawal 43 A. Monitoring 43 Institute for Research Education and Training in Addic- B. Supportive Care 44 C. AUD Treatment Initiation and Engagement 45 tions (IRETA) Team Members: D. Pharmacotherapy 45 Dawn Lindsay, PhD, Project Director VI. Addressing Complicated Alcohol Withdrawal 50 Jessica Williams, MPH, Assistant Project Director A. Alcohol Withdrawal Seizure 50 Piper Lincoln, MS, Senior Research Associate B. Alcohol Withdrawal Delirium 51 C. Alcohol-Induced Psychotic Disorder 53 Jackie Jones, MS, Research Associate D. Resistant Alcohol Withdrawal 53 on 06/04/2020 Rachael Vargo, BA, Research Associate VII. Specific Settings and Populations 54 Peter F. Luongo, PhD, Executive Director A. Primary Care 54 B. Emergency Departments 55 C. Hospitalized Patients 56 ASAM is honored that this clinical practice guideline has D. Patients with Medical Conditions 58 been endorsed by: E. Patients who Take Opioids 58 American College of Preventive Medicine F. Patients who are Pregnant 58 American Osteopathic Academy of Addiction Medicine Areas for Further Research 59 Appendices 61 Federation of State Physician Health Programs I. Cited References 61 National Association of Addiction Treatment Providers II. Literature Search Methods 66 National Association of Clinical Nurse Specialists A. Empirical Literature Search Terms 66 National Commission on Correctional Health Care B. Gray Literature Search 66 Adopted by the ASAM Board of Directors January 23, 2020 1 Copyright © 2020 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited. ASAM CPG on Alcohol Withdrawal Management Adopted by the ASAM Board of Directors January 23, 2020 C. PRISMA Flow Diagram 67 CIWA-Ar: The Clinical Institute Withdrawal Assess- D. Reasons for Exclusion 68 III. Alcohol Withdrawal Scales Table 68 ment of Alcohol Scale, Revised, is a reliable, valid, and IV. Flowcharts (Supplemental Digital Content, 70 reproducible severity of alcohol withdrawal in communicative http://links.lww.com/JAM/A192) patients once a diagnosis has been made.2 V. Sample Medication Regimens 70 Complicated alcohol withdrawal: See Special Terms VI. Statement Rating Table (Supplemental Digital Content, 70 http://links.lww.com/JAM/A193) on page 16. VII. Disclosures and Conflicts of Interest 70 Clinicians (Healthcare providers): Used throughout A. 2019 Guideline Committee Member Relationships 70 the guideline, this term is intentionally broad. It encompasses with Industry and Other Entities anyone who participates in providing care to patients with B. 2019 ASAM Board of Directors Relationships 71 with Industry and Other Entities (Supplemental Digital substance use disorders, including staff at specialty addiction Content, http://links.lww.com/JAM/A194) treatment centers or other healthcare settings that provide C. 2019 ASAM Quality Improvement Council 71 substance use disorder treatment.3 (Oversight Committee) Relationships with Industry Fixed-dosing: See Special Terms on page 16. and Other Entities (Supplemental Digital Content, http://links.lww.com/JAM/A194) Front loading: See Special Terms on page 16. D. 2019 Clinical Champions Relationships with Industry 72 GABAergic agents: Drugs that affect the neurotrans- and Other Entities mitter GABA or its receptors. These include agonists, antag- E. 2020 External Reviewers Relationships with Industry and 72 onists, modulators, reuptake inhibitors and enzymes. Other Entities (Supplemental Digital Content, http://links.lww.com/JAM/A194) Examples include benzodiazepines, phenobarbital, and car- bamazepine. Inpatient Withdrawal Management: See Special Terms on page 16. GLOSSARY OF TERMS Kindling: The relationship between repeated episodes of alcohol withdrawal which become progressively more Below are terms that are used throughout the guideline. severe is referred to as the kindling effect or process.4 The Note that some terms listed below are used to convey a effect is theorized to be the result of increased neuronal specific meaning for the purposes of this guideline (e.g., excitability and sensitivity with repeated episodes of with- ‘‘clinicians’’). drawal and has been demonstrated to result in increased Abstinence: Intentional and consistent restraint from craving for alcohol and decreased responsiveness to treatment the pathological pursuit of reward and/or relief that involves with benzodiazepines.5–7 the use of substances and other behaviors. These behaviors may involve, but are not necessarily limited to substance use, Level of Care: See Special Terms on page 16. gambling, video gaming, or compulsive sexual behaviors. Use Monotherapy (see also adjunct therapy): The use of a of FDA approved medications for the treatment of substance single drug to treat a disorder or disease. use disorder is consistent with abstinence. Patients: Used throughout the guideline, this term is Addiction Specialist Physician: Addiction specialist intentionally broad. It encompasses anyone who receives care for a Substance Use Disorder (SUD) in a specialty SUD physicians include addiction medicine physicians and addic- 3 tion psychiatrists who hold either a subspecialty board certi- treatment center or other healthcare setting. fication in addiction medicine by the American Board of Pharmacotherapy: Therapy (medical treatment) using Preventative Medicine, a board certification in addiction pharmaceutical drugs. medicine from the American Board of Addiction Medicine, Recovery capital: The breadth and depth of internal a subspecialty board certification in addiction psychiatry and external resources that can be drawn upon to initiate and from the American Board of Psychiatry and Neurology, a sustain recovery from alcohol and other drug problems. It can subspecialty board certification in addiction medicine be found at the personal, social, community and cultural from the American Osteopathic Association, or certification levels. Examples of recovery capital include physical health, in addiction medicine from the American Society of Addic- financial assets, supportive social relationships, visible local tion Medicine. recovery role models, and accessible/affordable community 8 Adjunct therapy (see also monotherapy): A pharma- resources. ceutical drug used together with a primary pharmaceutical Substance use: Used instead of ‘‘drug use’’ or ‘‘drug drug whose purpose is to assist the primary treatment.1 and alcohol use,’’ this term refers to the use of psychotropic Alcohol Hallucinosis/Alcohol-induced Psychotic Dis- substances, which may include illegal drugs, medications or order: See Special Terms on page 16. alcohol. This does not refer to nicotine.3 ASAM Criteria dimensions: The ASAM Criteria use Substance Use Disorder (SUD): Substance use disor- six dimensions to define a holistic biopsychosocial assess- der is marked by a cluster of cognitive, behavioral, and ment of an individual to be used for service and treatment
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