When is it safe to discharge a patient in alcohol (etoh) withdrawal?

Safe Discharge Criteria for Alcohol Withdrawal Patients

A patient in alcohol withdrawal should only be discharged when they have been clinically stable for 24-48 hours with CIWA-Ar scores consistently <8-10, no autonomic instability, adequate social support, and arranged follow-up within 48 hours. 1, 2, 3

Clinical Stability Requirements

Before discharge, patients must demonstrate stability across multiple parameters:

• Vital signs must be stable for 24-48 hours without clinically significant fluctuations in heart rate, blood pressure, or temperature 2, 3
• CIWA-Ar scores should remain <8-10 consistently, indicating resolution of moderate-to-severe withdrawal symptoms 1, 3
• Patient must be fully alert and oriented with no confusion, hallucinations, or altered mental status 2
• No seizure activity during the observation period 1, 4
• Autonomic hyperactivity resolved, including normalization of tachycardia, hypertension, and diaphoresis 1, 2

The 24-48 hour stability window is critical because withdrawal symptoms typically peak within 24-72 hours after last drink, and premature discharge during this window significantly increases risk of progression to delirium tremens or seizures. 1, 5, 4

Laboratory and Medical Clearance

• Electrolyte abnormalities must be corrected, particularly magnesium, potassium, and phosphate 2, 3
• Liver function and metabolic derangements addressed if present 2
• Rhabdomyolysis ruled out or resolving if patient had prolonged immobility or seizures 2
• Thiamine supplementation initiated (100-300 mg daily) and continued for outpatient use 2, 3

Absolute Contraindications to Discharge

Patients should NOT be discharged if they have:

• History of delirium tremens or complicated withdrawal - these patients require inpatient monitoring as they have 10-fold higher risk of recurrence 3, 6, 4
• Active delirium or severe confusion - indicates progression requiring ICU-level care 6
• Seizures within the current withdrawal episode - risk of recurrent seizures remains elevated for 48-72 hours 1, 4
• CIWA-Ar scores ≥15 - indicates severe withdrawal requiring continued benzodiazepine therapy 1, 3, 6
• Concurrent serious medical conditions including cardiac disease, chronic pulmonary disease, or diabetes that increase mortality risk 3
• Inadequate social support or housing instability - outpatient management requires reliable environment 3

Benzodiazepine Tapering Before Discharge

• Benzodiazepines should be tapered gradually over several days to reduce withdrawal risk, not abruptly stopped 1, 7
• Symptom-triggered dosing is preferred over fixed-schedule to prevent drug accumulation 1, 3
• For elderly patients or those with hepatic dysfunction, use short-acting agents like lorazepam rather than diazepam 1, 3
• Avoid benzodiazepine use beyond 10-14 days due to abuse potential and dependence risk 1

The FDA label for diazepam specifically warns about withdrawal reactions and recommends gradual tapering rather than abrupt discontinuation. 7

Mandatory Discharge Planning Components

Follow-up must be arranged before discharge:

• Outpatient appointment within 48 hours with primary care or addiction medicine 2, 3
• Psychiatric consultation for long-term abstinence planning including consideration of acamprosate, naltrexone, or baclofen 3
• Substance abuse treatment referral with documented quit plan 3
• Medication reconciliation by pharmacist especially for patients on corticosteroid tapers or other medications 3
• Mental health screening completed as anxiety, depression, and ADHD are common comorbidities 3

Special Populations Requiring Admission

Elderly patients (>65 years) have increased complication risk and should generally be admitted even with mild-moderate withdrawal due to:

• Higher risk of falls and autonomic instability 3
• Increased sensitivity to benzodiazepines requiring careful titration 1, 3
• Greater likelihood of cardiac or pulmonary comorbidities 3

Patients with extremely high blood alcohol levels (>400-500 mg/dL) should never be discharged from the ED due to risk of respiratory depression and severe withdrawal progression. 2

Common Pitfalls to Avoid

• Discharging during the 24-72 hour peak withdrawal window - symptoms can rapidly progress to delirium tremens even if initially mild 1, 2, 4
• Failing to arrange close follow-up - patients without 48-hour follow-up have higher rates of relapse and re-presentation 2, 3
• Inadequate thiamine supplementation - can result in irreversible Wernicke encephalopathy 2, 3, 6
• Abrupt benzodiazepine discontinuation - increases seizure risk and rebound withdrawal 1, 7
• Missing underlying psychiatric comorbidities - unaddressed mental health issues increase relapse risk 3, 6

Outpatient Management Criteria

Outpatient management is ONLY appropriate for patients with:

• Mild withdrawal (CIWA-Ar <10) with no history of complicated withdrawals 3
• Adequate social support with reliable housing and supervision 3
• No concurrent serious medical or psychiatric conditions 3
• Ability to attend daily follow-up visits for first 3-5 days 3
• No history of seizures or delirium tremens 3, 4

Most hospitalized patients do not meet these criteria and require completion of inpatient withdrawal management before safe discharge.