Applied Evidence N EW R ESEARCH F INDINGS T HAT A RE C HANGING C LINICAL P RACTICE 3 Regimens for alcohol withdrawal and detoxification Chad A. Asplund, MD, Jacob W. Aaronson, DO, and Hadassah E. Aaronson, DO Department of Family Practice, DeWitt Army Community Hospital, Fort Belvoir, Va Practice recommendations withdrawal symptoms and no serious psychiatric or medical comorbidities can be safely treated in ■ Patients with mild to moderate alcohol with- the outpatient setting. Patients with history of drawal symptoms and no serious psychi- severe withdrawal symptoms, seizures or deliri- atric or medical comorbidities can be safely um tremens, comorbid serious psychiatric or med- treated in the outpatient setting (SOR: A). ical illnesses, or lack of reliable support network should be considered for detoxification in the ■ Patients with moderate withdrawal should inpatient setting. receive pharmacotherapy to treat their symptoms and reduce their risk of seizures ■ THE PROBLEM OF ALCOHOL and delirium tremens during outpatient WITHDRAWAL detoxification (SOR: A). Up to 71% of individuals presenting for alcohol ■ Benzodiazepines are the treatment of detoxification manifest significant symptoms of choice for alcohol withdrawal (SOR: A). alcohol withdrawal.4 Alcohol withdrawal is a clinical syndrome that affects people accus- ■ ln healthy individuals with mild-to-moderate tomed to regular alcohol intake who either alcohol withdrawal, carbamazepine has decrease their alcohol consumption or stop many advantages making it a first-line drinking completely. treatment for properly selected patients (SOR: A). Physiology Alcohol enhances gamma-aminobutyric acid’s n our small community hospital—with limited (GABA) inhibitory effects on signal-receiving financial and medical resources—we have neurons, thereby lowering neuronal activity, Idesigned and implemented an outpatient alco- leading to an increase in excitatory glutamate hol detoxification clinical practice guideline to pro- receptors. Over time, tolerance occurs as GABA vide cost-effective, evidence-based medical care to receptors become less responsive to neurotrans- our patients, in support of their alcohol treatment. mitters, and more alcohol is required to produce Those patients with mild-to-moderate alcohol the same inhibitory effect. When alcohol is removed acutely, the number of excitatory glu- tamate receptors remains, but without the sup- Corresponding author: Chad Asplund, MD, 5663 5 Marshall Road, Fort Belvoir, VA 22060. E-mail: pressive GABA effect. This situation leads to [email protected]. the signs and symptoms of alcohol withdrawal. JULY 2004 / VOL 53, NO 7 · The Journal of Family Practice 545 3 REGIMENS FOR ALCOHOL WITHDRAWAL AND DETOXIFICATION Symptoms medical condition. This evaluation should include Noticeable alcohol withdrawal symptoms may an assessment of coexisting medical and psychi- appear within hours of cessation or decreasing atric conditions, the severity of previous with- alcohol intake. The most common symptoms drawal symptoms, and the risk factors for with- include tremor, craving for alcohol, insomnia, drawal complications. The initial symptoms of vivid dreams, anxiety, hypervigilance, agitation, alcohol withdrawal are not specific and may irritability, loss of appetite, nausea, vomiting, mimic other serious disease conditions; therefore, headache, and sweating.5 Even without treat- the initial assessment should exclude potentially ment, most of these relatively benign symptoms serious medical and psychiatric comorbidities. resolve within hours to days. Initially, assessment of common alcohol-relat- More concerning are hallucinations, delirium ed medical problems should be conducted. These tremens (DTs), and seizures. Transient auditory complications include gastritis, gastrointestinal or visual hallucinations may occur within the first bleeding, liver disease, cardiomyopathy, pancre- 2 days of decreasing or discontinuing alcohol con- atitis, neurological impairment, electrolyte imbal- sumption, and can be separate from DTs. DTs, ances, and nutritional deficiencies. A physical which present within 2 to 4 days of the last drink examination should be performed to assess for (and can last up to 3 to 4 days), are characterized arrhythmias, congestive heart failure, hepatic or by disorientation, persistent visual and auditory pancreatic disease, infectious conditions, bleed- hallucinations, agitation and tremulousness, and ing, and nervous system impairment. autonomic signs resulting from the activation of Initial alcohol level and urine drug screen stress-related hormones. These signs include should be assessed, as recent high levels of alco- tachycardia, hypertension, and fevers. hol intake and substance abuse place the patient DTs are much more serious than the “alcohol at higher risk for complications. Unstable mood shakes”—5% of patients who experience DTs die disorders—delirium, psychosis, severe depres- from metabolic complications.6 The occurrence of sion, suicidal or homicidal ideation—while poten- DTs is 5.3 times higher in men than in women;7 tially difficult to assess during intoxication, need however, women may exhibit fewer autonomic to be considered and ruled out. symptoms, making DTs in women more difficult to diagnose.6 Stabilize the patient Grand mal seizures can occur in up to 25% of After initial assessment, vital signs (eg, heart alcoholics undergoing withdrawal.4 If alcohol- rate, blood pressure, and temperature) should be related seizures do occur, they generally do so stabilized while fluid, electrolyte, and nutritional within 1 day of cessation of alcohol intake, but disturbances are corrected. Some patients under- can occur up to 5 days later. going alcohol withdrawal may require intravenous Risk factors for prolonged or complicated fluids to correct severe dehydration resulting from alcohol withdrawal include duration of alcohol vomiting, diarrhea, sweating, and fever. consumption, the number of lifetime prior detoxi- Alcoholics are often deficient in electrolytes or fications, prior seizures, prior episodes of DTs, minerals, including thiamine, folate, and magne- and current intense craving for alcohol.6–10 sium (although replacing magnesium makes no difference in clinically meaningful outcomes) ■ BEFORE TREATMENT: (level of evidence [LOE]: 1, double-blind random- ASSESS AND STABILIZE ized controlled trial).11 All patients being treated Initial assessment of the patient for alcohol withdrawal should be given 100 mg of Before initiating treatment for alcohol withdraw- thiamine immediately and daily (LOE: 3; insuffi- al, perform a thorough assessment of the patient’s cient evidence from randomized controlled trials 546 JULY 2004 / VOL 53, NO 7 · The Journal of Family Practice THE JOURNAL OF FAMILY PRACTICE FIGURE 1 The Clinical Institute Withdrawal Assessment for Alcohol—Revised Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) Patient _____________________________________________ Date |—|—|—| Time ____:____ Y m d (24-hour clock, midnight=00:00) Pulse or heart rate, taken for one minute: _________ Blood pressure: ______ / ______ NAUSEA AND VOMITING—Ask “Do you feel sick to your TACTILE DISTURBANCES—Ask “Have you any itching, stomach? Have you vomited?” Observation. pins and needles sensations, any burning, any numbness, 0 no nausea and no vomiting or do you feel bugs crawling on or under your skin?” 1 mild nausea with no vomiting Observation. 2 0 none 1 very mild itching, pins and needles, burning or numbness 3 2 mild itching, pins and needles, burning or numbness 4 intermittent nausea with dry heaves 3 moderate itching, pins and needles, burning or numbness 5 4 moderately severe hallucinations 6 5 severe hallucinations 7 constant nausea, frequent dry heaves and vomiting 6 extremely severe hallucinations 7 continuous hallucinations TREMOR—Arms extended and fingers spread apart. Observation. AUDITORY DISTURBANCES—Ask “Are you more aware of 0 no tremor sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are 1 not visible, but can be felt fingertip to fingertip you hearing things you know are not there?” Observation. 2 0 not present 3 1 very mild harshness or ability to frighten 4 moderate, with patient’s arm extended 2 mild harshness or ability to frighten 5 3 moderate harshness or ability to frighten 6 4 moderately severe hallucinations 7 severe, even with arms not extended 5 severe hallucinations 6 extremely severe hallucinations PAROXYSMAL SWEATS—Observation. 7 continuous hallucinations 0 no sweat visible VISUAL DISTURBANCES—Ask “Does the light appear to be 1 barely perceptible sweating, palms moist too bright? Is its color different? Does it hurt your eyes? 2 Are you seeing anything that is disturbing to you? Are you 3 seeing things you know are not there?” Observation. 4 beads of sweat obvious on forehead 0 not present 5 1 very mild sensitivity 6 2 mild sensitivity 7 drenching sweats 3 moderate sensitivity 4 moderately severe hallucinations ANXIETY—Ask “Do you feel nervous?” Observation. 5 severe hallucinations 0 no anxiety, at ease 6 extremely severe hallucinations 1 mildly anxious 7 continuous hallucinations 2 HEADACHE, FULLNESS IN HEAD—Ask “Does your head 3 feel different? Does it feel like there is a band around your 4 moderately anxious, or guarded, so anxiety is inferred head?” Do not rate for dizziness or lightheadedness. 5 Otherwise, rate severity. 6 0 not present 7 equivalent to acute panic states as