What is the recommended management for alcohol intoxication?

Management of Alcohol Intoxication

Benzodiazepines are the gold standard treatment for alcohol withdrawal, with supportive care being the primary approach for acute alcohol intoxication. 1, 2

Assessment and Initial Management of Acute Alcohol Intoxication

• For mild-moderate intoxication (blood alcohol concentration < 1 g/L), supportive care without medications is sufficient 3
• For severe intoxication (blood alcohol concentration > 1 g/L), provide:
  • Intravenous fluids to correct dehydration 3
  • Treatment for hypoglycemia, hypotension, hypothermia, and electrolyte imbalances 3
  • Administration of complex B and C vitamins 3
  • Thiamine supplementation (oral or parenteral) to prevent Wernicke's encephalopathy 1

Management of Alcohol Withdrawal

• Benzodiazepines are the front-line medication for alcohol withdrawal to alleviate discomfort and prevent seizures and delirium 1, 2
• Diazepam dosing for alcohol withdrawal: 10 mg IV/IM initially, then 5-10 mg every 3-4 hours as needed 4
• Antipsychotics should not be used as stand-alone medications but may be used as adjuncts to benzodiazepines in severe withdrawal delirium that has not responded to adequate doses of benzodiazepines 1, 2
• Anticonvulsants should not be used following an alcohol withdrawal seizure for prevention of further seizures 1
• All patients should receive oral thiamine; high-risk patients (malnourished, severe withdrawal) or those with suspected Wernicke's encephalopathy should receive parenteral thiamine 1

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 1
• Patients can be safely discharged when they have stable vital signs, resolution of withdrawal symptoms (CIWA-Ar score <8), no complications requiring inpatient care, and a comprehensive follow-up plan 5
• Psychoactive medications used for withdrawal should be dispensed in small quantities or each dose supervised to reduce misuse risk 1

Long-term Management and Relapse Prevention

• Acamprosate, disulfiram, or naltrexone should be offered to reduce relapse in alcohol-dependent patients 1, 2
• Medication choice should consider patient preferences, motivation, and availability 1
• Naltrexone should only be started after complete detoxification from alcohol, not during active withdrawal 2
• Psychosocial support should be routinely offered to alcohol-dependent patients 1
• Non-specialist healthcare workers should encourage engagement with mutual help groups like Alcoholics Anonymous 1
• Family members should be involved in treatment when appropriate and encouraged to engage with mutual help groups 1, 2

Common Pitfalls and Special Considerations

• Overlooking concurrent substance use disorders that may complicate recovery 5
• Prescribing benzodiazepines for longer than necessary (beyond 7-14 days), increasing dependence risk 5
• Failing to monitor for and treat complications such as hypoglycemia, respiratory depression, and aspiration 6
• Not considering that adolescents are more vulnerable to alcohol's toxic effects due to immature hepatic alcohol dehydrogenase activity 3
• Missing the opportunity to refer patients to specialized alcohol treatment units for follow-up care 3

Medical Interventions Often Required

• 56% of intoxicated patients require at least one medical intervention that cannot be provided by detoxification facilities 6
• Common interventions include sedating medications (36%), physical restraints (34%), imaging studies (21%), laboratory testing (12%), and airway interventions (4%) 6