FPIN's Clinical Inquiries

Management of Alcohol Withdrawal Syndrome

Am Fam Physician. 2010 Aug 15;82(4):344-347.

Clinical Question

What is the most effective detoxification regimen for persons with alcohol withdrawal syndrome (AWS)?

Evidence-Based Answer

AWS may be managed with outpatient therapy if the patient has mild to moderate symptoms. (Strength of Recommendation [SOR]: B, based on one randomized, prospective trial). The Clinical Institute Withdrawal Assessment Scale for Alcohol, Revised (CIWA-Ar) may be used to assess symptom severity. (SOR: C, based on consistent reliability and validity from case series studies). The decision to prescribe medication is based on the severity of symptoms. High-quality randomized controlled trials and meta-analyses suggest that long-acting benzodiazepines are generally preferred for managing AWS in the inpatient setting. (SOR: A). However, there is also evidence that benzodiazepines are safe in the outpatient setting. (SOR: B, based on one randomized prospective trial).

Evidence Summary

The CIWA-Ar is a valid and reliable method of determining AWS severity based on 10 symptoms of withdrawal. This scale is easily incorporated into practice and can be used to monitor the success of therapy.1

Patients with mild AWS symptoms (CIWA-Ar score of less than 8 to 10) can be monitored on an outpatient basis and may not require medication. Patients with moderate symptoms (CIWA-Ar score of 8 to 15) may require medication to alleviate withdrawal symptoms and may be monitored on an outpatient basis. Patients with a CIWA-Ar score of 15 or higher or a history of alcoholic withdrawal seizure, suicidal ideation, or other comorbid conditions are not eligible for outpatient treatment.2,3 Patients may also require inpatient treatment if they develop seizures, delirium, or worsening of symptoms. Uncomplicated detoxification usually requires four to five days.4

Although there are data supporting the use of long-acting benzodiazepines for inpatient detoxification of patients with AWS,5 evidence for benzodiazepine use in the outpatient setting is limited. In a randomized prospective trial, 164 male veterans of low socioeconomic status were randomly assigned to inpatient (n = 77) or outpatient (n = 87) detoxification.3 Those in the outpatient group returned to the treatment facility each day, Monday through Friday, for evaluation. Patients in both groups usually received 30 mg of oxazepam. Those in the inpatient group were initially given four capsules per day, and dosages were adjusted daily based on patient progress. Persons in the outpatient group were instructed to take one capsule at bedtime and up to four capsules as needed during the day. There were no medical complications (i.e., seizures, delirium tremens, or death) in either cohort.

The mean treatment duration was significantly shorter for persons in the outpatient group than in the inpatient group (6.5 versus 9.2 days); however, significantly more persons in the inpatient group completed detoxification (95 versus 72 percent).3 Of the 24 persons in the outpatient group who did not complete detoxification, six were admitted to inpatient detoxification and 16 had stopped returning for daily evaluations by day 7 (eight patients did not return on day 2). The cost of inpatient therapy ranged from $3,319 to $3,665 per patient compared with $175 to $388 for outpatient therapy. The proportions of patients entering rehabilitation after inpatient or outpatient detoxification were 64 and 59 percent, respectively. At the six-month follow-up, no differences were found between groups, and there also were no differences in the use of subsequent alcoholism-treatment services. The authors concluded that outpatient detoxification for patients with mild to moderate symptoms is effective, safe, and less expensive than inpatient detoxification.

Long-acting benzodiazepines are generally preferred for managing AWS in persons receiving inpatient treatment, because of a decreased risk of delirium (number needed to treat [NNT] = 20.4) and seizure (NNT = 13.0).2  Short-acting benzodiazepines may be used in patients with comorbidities, such as liver disease. Table 1 outlines dosages that may be used for fixed-schedule detoxification.2,4

Table 1.

Benzodiazepine Dosages for Fixed-Schedule Detoxification in Patients with Alcohol Withdrawal Syndrome

Benzodiazepine Dosage

Long-acting

Diazepam(Valium)

10 mg every six hours for four doses, followed by 5 mg every six hours for eight doses

Chlordiazepoxide (Librium)

50 mg every six hours for four doses, followed by 25 mg every six hours for eight doses

Short-acting

Lorazepam (Ativan)

2 mg every six hours for four doses, followed by 1 mg every six hours for eight doses

Oxazepam

30 mg every six hours for four doses, followed by 15 mg every six hours for eight doses


Information from references 2 and 4.

Table 1.   Benzodiazepine Dosages for Fixed-Schedule Detoxification in Patients with Alcohol Withdrawal Syndrome

View Table

Table 1.

Benzodiazepine Dosages for Fixed-Schedule Detoxification in Patients with Alcohol Withdrawal Syndrome

Benzodiazepine Dosage

Long-acting

Diazepam(Valium)

10 mg every six hours for four doses, followed by 5 mg every six hours for eight doses

Chlordiazepoxide (Librium)

50 mg every six hours for four doses, followed by 25 mg every six hours for eight doses

Short-acting

Lorazepam (Ativan)

2 mg every six hours for four doses, followed by 1 mg every six hours for eight doses

Oxazepam

30 mg every six hours for four doses, followed by 15 mg every six hours for eight doses


Information from references 2 and 4.

Recommendations from Others

Recommendations from the Substance Abuse and Mental Health Services Administration consensus panel apply only to the management of acute intoxication and withdrawal, and are not appropriate for outpatient detoxification. 6 However, according to the American Society of Addiction Medicine, patients with mild AWS, no history of seizures or delirium tremens, and no concurrent comorbidities may be eligible for outpatient detoxification.7 Patients must have a responsible person to monitor them, must be evaluated by medical personnel on a daily basis until they have stabilized, and must have access to transportation to emergency medical services.7

Address correspondence to Janet Ricks, DO, at jricks2@umc.edu. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.


Copyright Family Physicians Inquiries Network. Used with permission.

REFERENCES

1. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353–1357.

2. Mayo-Smith MF; Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997;278(2):144–151.

3. Hayashida M, Alterman AI, McLellan AT, et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. N Engl J Med. 1989;320(6):358–365.

4. Blondell RD. Ambulatory detoxification of patients with alcohol dependence. Am Fam Physician. 2005;71(3):495–502.

5. Ntais C, Pakos E, Kyzas P, Ioannidis JP. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2005;(3):CD005063.

6. Center for Substance Abuse Treatment. Settings, levels of care, and patient placement. In: Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 45. Rockville, Md.: Substance Abuse and Mental Health Services Administration; 2006:9–18. DHHS publication no. (SMA) 06-4131.

7. Mayo-Smith MF. Management of alcohol intoxication and withdrawal. In: Ries RK, Fiellin DA, Miller SC, et al., eds. Principles of Addiction Medicine. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009: 559-572.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/?o=1025).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

A collection of FPIN's Clinical Inquiries published in AFP is available at http://www.aafp.org/afp/fpin.


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