What is the management approach for alcohol intoxication?

Management of Alcohol Intoxication

Base management decisions on the patient's cognitive abilities and clinical presentation rather than waiting for specific blood alcohol levels, and proceed with psychiatric evaluation in alert, cooperative patients with normal vital signs regardless of elevated alcohol levels. 1

Initial Assessment and Stabilization

Cognitive Assessment Over Laboratory Values

• Evaluate mental status including alertness, orientation, memory, judgment, and decision-making capacity individually rather than relying on predetermined blood alcohol concentrations. 1
• Do not delay psychiatric evaluation waiting for blood alcohol results if the patient demonstrates adequate cognition, alertness, and normal vital signs—there is no evidence-based blood alcohol concentration threshold at which psychiatric assessment can accurately commence. 1
• Psychiatric evaluation can proceed in alert, cooperative patients with normal vital signs and noncontributory history/physical examination, regardless of elevated alcohol levels. 1

Observation Period

• Use a period of observation to determine if psychiatric symptoms resolve as intoxication resolves, as alcohol intoxication can mimic or alter psychiatric symptoms. 1
• Recognize that suicidality often diminishes as blood alcohol concentration decreases, and reassess as intoxication resolves. 1

Thiamine Administration

• Administer thiamine supplementation (oral or parenteral) to prevent Wernicke's encephalopathy in patients with severe intoxication. 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, 2

Management of Acute Alcohol Withdrawal

Benzodiazepine Therapy

• Benzodiazepines are the front-line medication for alcohol withdrawal to alleviate discomfort and prevent seizures and delirium. 1, 2
• For acute alcohol withdrawal, diazepam 10 mg intramuscular or intravenous initially, then 5-10 mg in 3-4 hours if necessary. 3
• Oral diazepam may be used for symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis. 4

Adjunctive Medications

• 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
• Naltrexone has no role in acute withdrawal management. 2

Avoiding Common Pitfalls

Laboratory Testing

• Do not routinely order toxicologic screening in alert, cooperative patients with noncontributory history/physical examination and normal vital signs—studies show no justified change in management plans and only 20% sensitivity for organic etiology. 1

Supportive Care Approach

• Treatment of acute alcohol intoxication depends on general clinical conditions, vital signs, hemodynamic stability, cognitive state, and alcohol-related complications. 5
• In mild-moderate intoxication (blood alcohol concentration <1 g/L), no drugs are necessary. 5
• In severe intoxication (blood alcohol concentration >1 g/L), support with intravenous fluids, treat hypoglycemia, hypotension, hypothermia and electrolyte imbalance, and administer complex B and C vitamins. 5

Disposition Decisions

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. 1
• Many patients with mild-moderate transitory symptoms can benefit from clinical observation in a Temporary Observation Unit, with clinical course often completed within 24 hours with favorable outcome. 5

Long-Term Management and Relapse Prevention

Pharmacotherapy

• Acamprosate, disulfiram, or naltrexone should be offered to reduce relapse in alcohol-dependent patients after acute withdrawal resolves. 1
• Medications such as naltrexone or disulfiram should be initiated after acute withdrawal resolves, not during the first 3 months when mortality is primarily related to hepatitis severity rather than relapse. 1
• Naltrexone must be part of a comprehensive treatment program combined with psychosocial support, motivational techniques, and community-based support groups. 2

Psychosocial Support

• Psychosocial support should be routinely offered to alcohol-dependent patients. 1
• Brief interventions, such as 15-minute personalized counseling, are effective in primary care for reducing excessive consumption in non-dependent drinkers. 1
• Encourage engagement with mutual help groups like Alcoholics Anonymous. 1

Critical Warnings

Benzodiazepine Duration

• Do not prescribe benzodiazepines for longer than necessary (beyond 7-14 days), as this increases dependence risk. 1

Naltrexone Contraindications

• Never use naltrexone in patients requiring opioids for pain control—it blocks pain relief from opioid agonists. 2
• Patients who discontinue naltrexone have increased risk of opioid overdose and death due to decreased opioid tolerance. 2

Concurrent Substance Use

• Do not overlook concurrent substance use disorders that may complicate recovery. 1