Alcohol Withdrawal is a withdrawal syndrome that occurs within several hours to a few days of stopping heavy and prolonged alcohol use. The withdrawal syndrome includes autonomic hyperactivity, anxiety, and gastrointestinal symptoms.
Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
At least 2
of the following, developing within several hours
to a few days
after the cessation of (or reduction in) alcohol use described in Criterion A
:
The signs or symptoms in Criterion B
cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.
Specify if:
Stage 1 | Stage 2 | Stage 3 | Stage 4 | Stage 5 | |
---|---|---|---|---|---|
Time of last drink | 6-8 hours | 12-24 hours | 12-48 hours | 2-5 days | 1-6 months |
Definition | Mild withdrawal (in some cases can progress to DTs) | Alcoholic Hallucinosis (in some cases can progress to DTs) | Withdrawal Seizures | Delirium Tremens (DTs)[8], 5% mortality | Chronic Alcohol Use |
Symptoms | • Mild tremors • Anxiety • Nausea | • Stable Vitals • Tremors • Agitation • Insomnia • Hallucination (auditory, visual, tactile), but insight is maintained | • Same as Stage 2, but more severe • Seizures | • Unstable Vitals • Confusion • Agitation • Fever • Tachycardia • Hypertension • Diaphoresis | • Autonomic hyperactivity • Anxiety • Sleep disturbance |
Name | Rater | Description | Download |
---|---|---|---|
CIWA-Ar | Clinician | The CIWA–Ar (revised) measures 10 symptoms. Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal); and scores of 15 or more indicate severe withdrawal. It takes approximately 2 minutes to perform. | Download |
PAWSS | Clinician | The PAWSS is the first validated tool for the prediction of severe alcohol withdrawal syndrome in the medically ill and its use may aid in the early identification of patients at risk for complicated withdrawal, allowing for prophylaxis before severe alcohol withdrawal syndromes occur. | Download |
Uncomplicated withdrawal | Complicated withdrawal | |
---|---|---|
Definition | No history of siezures or delirium tremens | A history of withdrawal seizures, delirium tremens, pregnancy or geriatric |
Management | • Diazepam 20mg PO q1-2h until CIWA < 10 OR • Lorazepam 2mg q1-2h until CIWA < 10 | • Load with diazepam 20mg q1h x 3 = 60mg • Lorazepam 2mg q1h x 3 = 60mg total to start • Then administer CIWA based on symptoms |
Sample Taper: |
---|
Diazepam 10mg QID x 3 days (total 40mg daily) |
Diazepam 10mg BID x 3 days (total 20mg daily) |
Diazepam 10mg qHS x 3 days (total 10mg daily) |
Thiamine 300mg PO daily x 1 month |
LOT
benzodiazpines (L
orazepam, O
xazepam, and T
amazepam are metabolized via glucuronidation (Phase II metabolism), which is less dependent on global liver function. Thus, these benzodiazepines can be used in individuals with severe liver impairment.Guideline | Location | Year | Website | |
---|---|---|---|---|
Canadian Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder | Canada | 2023 | Link (see also: comment on sertraline use in AUD) | Link |
Canadian Guidelines on Alcohol Use Disorder Among Older Adults | Canada | 2020 | - | Link |
British Columbia Centre on Substance Use (BCCSU) | Canada | 2019 | Link | Link |
National Institute for Health and Care Excellence (NICE) | UK | 2011 | - | Link |
American Psychiatric Association (APA) | USA | 2018 | - | Link |
European Federation of Neurological Societies (EFNS) - Wernicke Encephalopathy | Europe | 2010 | - | Link |