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Guideline on Alcohol Withdrawal Management

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Guideline on Alcohol Withdrawal Management Approved Draft 3/19/2020 1 ASAM Guideline on Alcohol Withdrawal Management 2 3 Guideline Committee Members (alpha order): 4 Anika Alvanzo, MD, MS, DFASAM, FACP 5 Kurt Kleinschmidt, MD, FASAM 6 Julie A. Kmiec, DO, FASAM 7 George Kolodner, MD, DLFAPA, FASAM 8 Gerald E. Marti, MD, PhD 9 Lorraine A. Milio, MD, FASAM 10 William F. Murphy, DO, MS, DFASAM 11 Carlos F. Tirado, MD, FASAM 12 Corey Waller, MD, MS, DFASAM, FACEP 13 Lewis S. Nelson, MD, FASAM (Moderator) 14 15 Clinical Champions (alpha order): 16 Stephen Holt, MD, MS, FACP 17 Darius Rastegar, MD, FASAM 18 Richard Saitz, MD, MPH, FACP, DFASAM 19 Michael F. Weaver, MD, DFASAM 20 21 ASAM Quality Improvement Council (alpha order): 22 John Femino, MD, DFASAM 23 Kenneth Freedman, MD, DFASAM (Chair) 24 R. Jeffrey Goldsmith, MD, DLFAPA, DFASAM 25 Barbara Herbert, MD, DFASAM 26 Margaret Jarvis, MD, DFASAM 27 Margaret Kotz, DO, DFASAM 28 P. Stephen Novack, DO 29 David R. Pating, MD 30 Sandrine Pirard, MD, PhD, MPH, FAPA, FASAM 31 32 ASAM Staff: 33 Maureen Boyle, PhD, Chief Quality and Science Officer 34 Leah White, MPH, Director of Quality Improvement 35 Taleen Safarian, Manager of Science and Dissemination 36 37 Institute for Research Education and Training in Addictions (IRETA) Team Members: 38 Dawn Lindsay, PhD, Project Director 39 Jessica Williams, MPH, Assistant Project Director 40 Piper Lincoln, MS, Senior Research Associate 1 AUTHORS Approved Draft 3/19/2020 1 Jackie Jones, MS, Research Associate 2 Peter F. Luongo, PhD, Executive Director 3 ASAM is honored that this guideline has been endorsed by: 4 5 American College of Preventive Medicine 6 American Osteopathic Academy of Addiction Medicine 7 Federation of State Physician Health Programs 8 National Association of Addiction Treatment Providers 9 National Association of Clinical Nurse Specialists 10 National Commission on Correctional Health Care 2 AUTHORS 1 2 Glossary of Terms 3 Below are terms that are used throughout the guideline. Note that some terms listed below are used to 4 convey a specific meaning for the purposes of this guideline (e.g., “clinicians”). 5 Abstinence: Intentional and consistent restraint from the pathological pursuit of reward and/or relief that 6 involves the use of substances and other behaviors. These behaviors may involve, but are not necessarily 7 limited to substance use, gambling, video gaming, or compulsive sexual behaviors. Use of FDA approved 8 medications for the treatment of substance use disorder is consistent with abstinence. 9 Addiction Specialist Physician: Addiction specialist physicians include addiction medicine physicians 10 and addiction psychiatrists who hold either a subspecialty board certification in addiction medicine by the 11 American Board of Preventative Medicine, a board certification in addiction medicine from the American 12 Board of Addiction Medicine, a subspecialty board certification in addiction psychiatry from the 13 American Board of Psychiatry and Neurology, a subspecialty board certification in addiction medicine 14 from the American Osteopathic Association, or certification in addiction medicine from the American 15 Society of Addiction Medicine. 16 Adjunct therapy (see also monotherapy): A pharmaceutical drug used together with a primary 17 pharmaceutical drug whose purpose is to assist the primary treatment.1 18 Alcohol Hallucinosis/Alcohol-induced Psychotic Disorder: See Special Terms. 19 ASAM Criteria dimensions: The ASAM Criteria use six dimensions to define a holistic biopsychosocial 20 assessment of an individual to be used for service and treatment planning including acute intoxication or 21 withdrawal potential; biomedical conditions and complications; emotional, behavioral, or cognitive 22 conditions or complications; readiness for change; continued use or continued problem potential; and 23 recovery/living environment. 24 CIWA-Ar: The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, is a reliable, valid, 25 and reproducible scale that measures the severity of alcohol withdrawal once a diagnosis has been made.2 26 Complicated alcohol withdrawal: See Special Terms. 27 Clinicians (Healthcare providers): Used throughout the guideline, this term is intentionally broad. It 28 encompasses anyone who participates in providing care to patients with substance use disorders, 29 including staff at specialty addiction treatment centers or other healthcare settings that provide substance 30 use disorder treatment.3 31 Fixed-dosing: See Special Terms. 32 Front loading: See Special Terms. 33 GABAergic agents: Drugs that affect the neurotransmitter GABA or its receptors. These include 34 agonists, antagonists, modulators, reuptake inhibitors and enzymes. Examples include benzodiazepines, 35 phenobarbital, and carbamazepine. 36 Inpatient Withdrawal Management: See Special Terms. 3 GLOSSARY 1 Kindling: The relationship between repeated episodes of alcohol withdrawal which become progressively 2 more severe is referred to as the kindling effect or process.4 The effect is theorized to be the result of 3 increased neuronal excitability and sensitivity with repeated episodes of withdrawal and has been 4 demonstrated to result in increased craving for alcohol and decreased responsiveness to treatment with 5 benzodiazepines.5–7 6 Level of Care: See Special Terms. 7 Monotherapy (see also adjunct therapy): The use of a single drug to treat a disorder or disease. 8 Patients: Used throughout the guideline, this term is intentionally broad. It encompasses anyone who 9 receives care for a Substance Use Disorder (SUD) in a specialty SUD treatment center or other healthcare 10 setting.3 11 Pharmacotherapy: Therapy (medical treatment) using pharmaceutical drugs. 12 Recovery capital: The breadth and depth of internal and external resources that can be drawn upon to 13 initiate and sustain recovery from alcohol and other drug problems. It can be found at the personal, social, 14 community and cultural levels. Examples of recovery capital include physical health, financial assets, 15 supportive social relationships, visible local recovery role models, and accessible/affordable community 16 resources.8 17 Substance use: Used instead of “drug use” or “drug and alcohol use,” this term refers to the use of 18 psychotropic substances, which may include illegal drugs, medications or alcohol. This does not refer to 19 nicotine.3 20 Substance Use Disorder (SUD): Substance use disorder is marked by a cluster of cognitive, behavioral, 21 and physiological symptoms indicating that the individual continues to use alcohol, nicotine, and/or other 22 drugs despite significant related problems. Diagnostic criteria are given in the DSM-5. Substance use 23 disorder is the new nomenclature for what was included as substance dependence and substance abuse in 24 the DSM-4. 25 Supportive care: Treatment given to prevent, control, or relieve complications and side effects and to 26 improve the patient's comfort, quality of life and safety. This can include reassurance, orientation, general 27 nursing care, and adherence to safety measures and protocols (e.g., risk for fall/syncope). 28 Symptom-triggered dosing: See Special Terms. 29 Therapeutic window: Range of drug dose amount needed to maintain therapeutic effect yet avoid 30 adverse events. A drug with a narrower therapeutic window requires greater precision to be dosed 31 correctly and safely compared to a drug with a broader therapeutic window. A drug’s therapeutic window 32 is taken into account when modifying dose amount due to patient variability and exposure to other 33 substances including adjunt medications.9 34 Treatment plan: A therapeutic strategy that may incorporate patient education, drug therapy, and the 35 participation of health professionals. Treatment plans are especially important in the optimal management 36 of complex or chronic illnesses such as SUDs.3 37 Unhealthy alcohol use: Includes the following patterns of alcohol use: 1) Binge drinking (defined as 38 consuming 4 or more alcoholic beverages per occasion for women or 5 or more drinks per occasion for 39 men); 2) Heavy drinking (defined as consuming 8 or more alcoholic beverages per week for women or 15 4 GLOSSARY 1 or more alcoholic beverages per week for men); 3) Any drinking by pregnant women or those younger 2 than age 21.10 3 Withdrawal Management: This term has replaced the formerly used “detoxification.” Withdrawal 4 management refers to the medical and psychological care of patients who are experiencing withdrawal 5 symptoms as a result of ceasing or reducing their substance use.11 The process of withdrawal management 6 includes not only attenuation of the physiological and psychological features of withdrawal, but also 7 interrupting the momentum of habitual compulsive use in persons with SUD.12 5 GLOSSARY 1 Abbreviations and Acronyms 2 A2AA Alpha-2 adrenergic agonists 3 ALT Alanine aminotransferase 4 AUDIT-PC Alcohol Use Disorder Identification Test – Primary Care 5 ASAM American Society of Addiction Medicine 6 ASSIST Alcohol, Smoking and Substance Involvement Screening Test 7 AST Aspartate aminotransferase 8 AUD Alcohol Use Disorder 9 BAC Blood Alcohol Concentration or Content 10 BAWS Brief Alcohol Withdrawal Scale 11 CCU Cardiac/Coronary Care Unit 12 CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol, Revised 13 CNS Central Nervous System 14 DSM-5 Diagnostic and Statistical Manual – 5 15 ED Emergency Department 16 EEG Electroencephalogram 17 FAS Fetal Alcohol Syndrome 18 FASD Fetal Alcohol Spectrum Disorders 19 FDA Food and Drug
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