Alcohol Withdrawal Syndrome: Outpatient Management

 

Am Fam Physician. 2021 Sep ;104(2):253-262.

  Patient information: Handouts on this topic are available at https://familydoctor.org/condition/alcohol-abuse and https://familydoctor.org/alcohol-withdrawal-syndrome.

Author disclosure: No relevant financial affiliations.

Approximately one-half of patients with alcohol use disorder who abruptly stop or reduce their alcohol use will develop signs or symptoms of alcohol withdrawal syndrome. The syndrome is due to overactivity of the central and autonomic nervous systems, leading to tremors, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation. If untreated or inadequately treated, withdrawal can progress to generalized tonic-clonic seizures, delirium tremens, and death. The three-question Alcohol Use Disorders Identification Test–Consumption and the Single Alcohol Screening Question instrument have the best accuracy for assessing unhealthy alcohol use in adults 18 years and older. Two commonly used tools to assess withdrawal symptoms are the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale. Patients with mild to moderate withdrawal symptoms without additional risk factors for developing severe or complicated withdrawal should be treated as outpatients when possible. Ambulatory withdrawal treatment should include supportive care and pharmacotherapy as appropriate. Mild symptoms can be treated with carbamazepine or gabapentin. Benzodiazepines are first-line therapy for moderate to severe symptoms, with carbamazepine and gabapentin as potential adjunctive or alternative therapies. Physicians should monitor outpatients with alcohol withdrawal syndrome daily for up to five days after their last drink to verify symptom improvement and to evaluate the need for additional treatment. Primary care physicians should offer to initiate long-term treatment for alcohol use disorder, including pharmacotherapy, in addition to withdrawal management.

Alcohol-related disorders cause significant physical, psychological, and societal harm. Diagnostic criteria have integrated alcohol abuse and dependence into a single disorder: alcohol use disorder (AUD; Table 11). AUD has an estimated 12-month and lifetime prevalence of 13.9% and 29.1%, respectively.2 Key management principles include promptly recognizing and evaluating for alcohol withdrawal syndrome (AWS), establishing a treatment and monitoring plan, and providing medications and resources to support long-term abstinence.

WHAT'S NEW ON THIS TOPIC

Alcohol Use Disorder and Withdrawal

In a randomized controlled trial, patients who started taking gabapentin (Neurontin) after 3 days of abstinence had fewer heavy drinking days (defined as 5 or more drinks for men and 4 or more drinks for women) and greater rates of abstinence than those who received placebo.

A Cochrane review found that Alcoholics Anonymous and other 12-step facilitation programs that follow a specific manual or syllabus are more effective at increasing rates of abstinence at 1, 2, and 3 years than motivational interviewing or cognitive behavior therapy, with substantial cost savings.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Adults should be screened for unhealthy alcohol use and counseled, if appropriate.3

B

U.S. Preventive Services Task Force recommendation

Patients with mild or moderate AWS can be treated safely in the outpatient setting.8

C

ASAM guideline

Carbamazepine (Tegretol) and gabapentin (Neurontin) are appropriate options for treating mild AWS.8,18,19

C

ASAM guideline recommendation, randomized controlled trial, and review

Benzodiazepines are the preferred medication for treating moderate AWS.20,21

A

Clinical practice guideline and ASAM meta-analysis

Gabapentin, carbamazepine, and valproate (Depacon) may be prescribed as adjuncts to benzodiazepines if symptoms persist despite adequate benzodiazepine use.18

C

Expert opinion

Patients successfully treated for AWS should be offered referral to a long-term treatment program to maintain abstinence and adjunctive use of an FDA-approved pharmacotherapy (i.e., acamprosate, naltrexone [Revia], and disulfiram [Antabuse]).31,32,37

B

Meta-analysis of FDA-approved pharmacotherapies and Cochrane review


ASAM = American Society of Addiction Medicine; AWS = alcohol withdrawal syndrome; FDA = U.S. Food and Drug Administration.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Adults should be screened for unhealthy alcohol use and counseled, if appropriate.3

B

U.S. Preventive Services Task Force recommendation

Patients with mild or moderate AWS can be treated safely in the outpatient setting.8

C

ASAM guideline

Carbamazepine (Tegretol) and gabapentin (Neurontin) are appropriate options for treating mild AWS.8,18,19

C

ASAM guideline recommendation, randomized controlled trial,

The Authors

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SAMUEL M. TIGLAO, DO, MBA, FAAFP, is a fellow in the Leader and Faculty Development Fellowship at Madigan Army Medical Center, Tacoma, Wash.; an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.; and a clinical instructor in the Department of Family Medicine at the University of Washington, Seattle....

ERICA S. MEISENHEIMER, MD, MBA, FAAFP, is a fellow in the Leader and Faculty Development Fellowship at Madigan Army Medical Center; an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences; and a clinical instructor in the Department of Family Medicine at the University of Washington.

ROBERT C. OH, MD, MPH, CAQSM, FAAFP, is associate Chief of Staff–Education at Veterans Affairs Puget Sound Health Care System, Seattle, and Madigan Army Medical Center and a clinical associate professor in the Department of Family Medicine at the University of Washington.

Address correspondence to Samuel M. Tiglao, DO, FAAFP, Madigan Army Medical Center, Department of Family Medicine, 9040A Jackson Ave., Joint Base Lewis-McChord, WA 98431 (email: samuel.m.tiglao.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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