Emergency Management of Alcoholism
For patients with alcoholism presenting to the Emergency Room, the recommended treatment approach is to provide benzodiazepines for alcohol withdrawal management, administer parenteral thiamine before glucose, and initiate psychosocial interventions with appropriate medication for relapse prevention. 1
Initial Management in the ER
Assessment and Stabilization
- Assess for signs of alcohol withdrawal using the CIWA-Ar score:
- ≤7: Mild withdrawal - monitor, may not require medication
- 8-14: Moderate withdrawal - initiate benzodiazepine treatment
- ≥15: Severe withdrawal - aggressive benzodiazepine treatment, consider inpatient management 1
Pharmacological Management of Withdrawal
- Benzodiazepines are the front-line medication for alcohol withdrawal to alleviate discomfort and prevent seizures and delirium 2
- Use symptom-triggered dosing based on withdrawal rating scales to minimize total benzodiazepine dosage
- Long-acting benzodiazepines (e.g., chlordiazepoxide) are preferred in uncomplicated patients 3
- Antipsychotic medications should not be used as stand-alone treatment for alcohol withdrawal; only as adjuncts to benzodiazepines in severe withdrawal delirium unresponsive to adequate benzodiazepine doses 2
- Anticonvulsants should not be used following an alcohol withdrawal seizure 2
Critical Nutritional Support
- Administer thiamine before giving glucose to prevent Wernicke's encephalopathy 1, 3
- All patients should receive thiamine supplementation 2
- Parenteral thiamine (100-300 mg IV) should be given to high-risk patients (malnourished, severe withdrawal) or those with suspected Wernicke's encephalopathy 2, 1
- Despite recommendations, studies show low rates of thiamine prescribing (only 2.2% of alcohol-related ED visits) 4
- Provide IV normal saline with 5% glucose solution to address dehydration, hypoglycemia, and electrolyte imbalances 1
- Monitor and replace electrolytes, particularly potassium, phosphorus, and magnesium 1
Post-Stabilization Management
Pharmacotherapy for Relapse Prevention
- Initiate medication for relapse prevention based on patient's liver status:
- For patients with liver disease: Baclofen is the only medication with proven efficacy and safety, increasing abstinence days and decreasing relapse risk 2, 1
- For patients without liver disease: Naltrexone (50 mg daily oral or 380 mg monthly injection) or acamprosate (666 mg three times daily) 2, 1
- Disulfiram should not be used in patients with alcoholic liver disease 2
Psychosocial Interventions
- Provide brief intervention (5-30 minutes) incorporating individualized feedback and advice on reducing alcohol consumption 2
- Use the FRAMES model (Feedback, Responsibility, Advice, Menu of alternatives, Empathy, Self-efficacy) 1
- Encourage engagement with mutual help groups such as Alcoholics Anonymous 2, 1
- Consider involving family members in treatment when appropriate 2
Disposition Planning
Inpatient vs. Outpatient Management
- Patients at risk of severe withdrawal, with concurrent serious physical or psychiatric disorders, or lacking adequate support should be managed in an inpatient setting 2
- For outpatient management, ensure:
Referral for Continued Care
- Refer for structured psychological interventions such as Cognitive Behavioral Therapy or Motivational Enhancement Therapy 2, 1
- Arrange for integrated treatment that combines alcohol use disorder treatment with medical care 2, 1
Common Pitfalls to Avoid
- Failing to administer thiamine before glucose, risking Wernicke's encephalopathy 1, 4
- Using antipsychotics as primary treatment for withdrawal 2
- Prescribing addictive substances beyond the period of acute detoxification 3
- Discontinuing treatment prematurely (optimal duration is at least 3-12 months) 1
- Neglecting to address comorbid psychiatric conditions 3
By following this comprehensive approach that addresses both the acute withdrawal phase and long-term recovery needs, emergency physicians can significantly improve outcomes for patients with alcoholism.