Inpatient and Outpatient Management of Alcohol

Withdrawal

Devang Gandhi, MDRobert Joel Bush, MD

University of Maryland- Sheppard Pratt Addiction Medicine Fellowship Program

Summary of Module Contents Article text Slide Deck: N = 60 (+/-) Notes for lecturer: not available Handout materials: key article reprints/links to

PubMed Central Annotated bibliography: not available Test questions: 5 pretest; 5 posttest Other: Excel spreadsheet with summary of

major studies of symptom-triggered treatment

Inpatient and Outpatient Management of Alcohol Withdrawal

Alcohol Withdrawal Syndrome (AWS) is among the most common clinical problems in Addiction Medicine practice

Its management is a core competency for any Addiction Medicine specialist as AWS can be life-threatening if not adequately treated

Current practice in many centers follows tradition or personal preference rather than evidence base

This module will cover epidemiology, basic neurobiology, types of AWS, assessment, patient placement, management and monitoring.

Key Point: Alcohol Withdrawal Syndromes

Anxiety/tremor/autonomic overactivity

Hallucinations-auditory/visual/tactile

Delirium tremensSeizures

AWS severity

Several alcohol withdrawal syndromes are recognized, with delirium tremens and seizures being the most serious

Key Point: Criteria for Inpatient Management

Most AWS can be safely managed in an outpatient setting at a much lower cost provided the clinician knows how to assess the risk of serious withdrawal

Main criteria for inpatient management: Withdrawal risk- high Currently in severe withdrawal or delirium and/or prior history of delirium

or seizures during withdrawal Acute or chronic medical comorbidity requiring inpatient management Pregnant Significant psychiatric comorbidity requiring inpatient management Unstable living environment and unavailability of supportive others to monitor

• (Adapted from Blondell, 2005)

Inpatient and Outpatient Management of Alcohol Withdrawal

Main Recommendations: A symptom-triggered approach can reduce

medication use and duration of treatment, and is as efficacious as a fixed-dose approach.

Best available evidence supports the use of benzodiazepines as first line to manage AWS

Anticonvulsants may be used as alternatives to benzodiazepines, but the evidence for their use is limited

Recommendation #1 A symptom-triggered approach can reduce

medication use and duration of treatment, and is as efficacious as a fixed-dose approach.

SORT level = A References

Saitz, R, et al. JAMA 1994; 272(7):519-23. Daeppen, JB, et al. Arch Intern Med 2002; 162(10):1117-21. Elholm, B et al. Alcohol Alcohol 2011; 46(3):318-23

Recommendation #2 Benzodiazepines reduce withdrawal severity,

reduce incidence of delirium and seizures and should be considered first-line medications to treat AWS.

SORT level = A References:

Mayo-Smith, MF. JAMA 1997; 278(2):144-51. Mayo-Smith, MF, et al. Arch Intern Med 2004;

164(13):1405-12. Amato, L, et al. CDSR 2010; CD005063

Recommendation #3 Anticonvulsants (carbamazepine, valproate,

gabapentin) may be used as alternatives to benzodiazepines, though the evidence-base for their efficacy is limited.

SORT level = B References:

Minozzi, S, et al. CDSR, 2010; CD005064. Barrons, R, & Roberts, N. J Clin Pharm Ther

2010;35(2):153-67.

Dissemination strategy

Didactic classroom lecture Webinar Publication as an overview of the topic Module posted on ABAM website Standard instruments for assessment and sample

protocol that can be adapted for clinical use