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SAMUEL M. TIGLAO, DO, ERICA S. MEISENHEIMER, MD, AND ROBERT C. OH, MD, MPH

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

 This clinical content conforms to AAFP criteria for CME.

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.

Clinical recommendation Evidence rating Comments
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

  1. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

    Alcohol is often taken in larger amounts or over a longer period than was intended.

    There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

    A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

    Craving, or a strong desire or urge to use alcohol.

    Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

    Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

    Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

    Recurrent alcohol use in situations in which it is physically hazardous.

    Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

    Tolerance, as defined by either of the following:

    A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

    A markedly diminished effect with continued use of the same amount of alcohol.

    Withdrawal, as manifested by either of the following:

    The characteristic withdrawal syndrome for alcohol.

    Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.


Specify if:
 In early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months (with exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met).
 In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met).
Specify if:
 In a controlled environment: This additional specifier is used if the individual is in an environment where access to alcohol is restricted.
Specify current severity:
 Mild: Presence of 2 to 3 symptoms
 Moderate: Presence of 4 to 5 symptoms
 Severe: Presence of 6 or more symptoms

Recognizing Patients at Risk for AUD

The U.S. Preventive Services Task Force recommends that primary care physicians screen patients 18 years and older for unhealthy alcohol use and offer appropriate behavioral counseling as indicated.3 Several screening instruments can be used to identify hazardous and harmful drinking behaviors. The three-question Alcohol Use Disorders Identification Test–Consumption (AUDIT-C; https://www.mdcalc.com/audit-c-alcohol-use) and the Single Alcohol Screening Question (SASQ) instrument have the best accuracy for assessing unhealthy alcohol use in adults 18 years and older.3 Screening positive with either scale should prompt a longer evaluation with the full 10-question AUDIT (https://auditscreen.org/).3

The SASQ has a sensitivity of 73% to 88% and specificity of 74% to 100% for detecting unhealthy alcohol use.3 The question, “How many times in the past year have you had X or more drinks in a day?” where X is five for men and four for women is used in the screening. Any response greater than one is considered positive. In comparison, the full AUDIT is less sensitive (73.9%) but more specific (82.8%) at detecting unhealthy alcohol use.3,4

Despite the high prevalence of AUD, many patients are undertreated partly because of the stigma associated with the diagnosis.5 For patients who are reluctant to tell their physician about their alcohol consumption, the National Institute on Alcohol Abuse and Alcoholism has a website, Rethinking Drinking (https://www.rethinkingdrinking.niaaa.nih.gov/), that provides assessment and motivational tools for moderation and abstinence treatment resources.

Diagnostic Criteria

Approximately one-half of patients with AUD who abruptly reduce or abstain from alcohol use experience signs or symptoms of AWS.6 When patients abruptly stop drinking or reduce their alcohol intake after a prolonged period (more than two weeks) of heavy use, withdrawal symptoms begin within six to 24 hours.7 Withdrawal effects are primarily due to the unmasking of the adaptive responses to chronic alcohol use,7 including decreased inhibitory activity of alpha-2 receptors, resulting in increased catecholamine levels on presynaptic neurons. Table 2 outlines the diagnostic criteria for alcohol withdrawal.1

  1. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

  2. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A:

    Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 beats per minute).

    Increased hand tremor.

    Insomnia.

    Nausea or vomiting.

    Transient visual, tactile, or auditory hallucinations or illusions.

    Psychomotor agitation.

    Anxiety.

    Generalized tonic-clonic seizures.

  3. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  4. 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:
With perceptual disturbances: This specifier applies in the rare instance when hallucinations (usually visual or tactile) occur with intact reality testing, or auditory, visual, or tactile illusions occur in the absence of a delirium.

Assessing Severity

The patient's symptom severity should be evaluated using a validated scale to determine the risk of severe or complicated AWS.8 The syndrome is classified as mild, moderate, severe, and complicated by the most recent guideline from the American Society of Addiction Medicine.8 Patients with mild AWS tend to have mild to moderate anxiety, sweating, and insomnia, but tremor is absent. Moderately severe AWS causes moderate anxiety, sweating, insomnia, and mild tremor. Those with severe AWS experience severe anxiety and moderate to severe tremor, but they do not have confusion, hallucinations, or seizures. Complicated AWS is identified by seizures or signs and symptoms indicative of delirium, such as the inability to fully comprehend instructions, clouding of the sensorium, confusion, or new onset of hallucinations.8 Correlating the patient's symptoms in relation to the time since their last drink is useful in anticipating the progression of symptoms. When not properly treated, AWS can progress to delirium tremens (Table 38–10).

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