Obtaining a Comprehensive Alcohol Use History and Managing Acute Alcohol Withdrawal
Obtaining an Accurate Alcohol History
Use the AUDIT (Alcohol Use Disorders Inventory Test) questionnaire as your primary screening tool, as it remains the gold standard with proven sensitivity and specificity across different clinical settings. 1
Key Historical Elements to Document
Quantify drinking in standard drinks per week using locally appropriate conversions (10g alcohol = 1 UK standard drink; 14g = 1 US standard drink), calculating average weekly consumption over the past year rather than relying solely on daily estimates 1
Document the "glass-year" history (average glasses consumed × years of drinking), similar to pack-years for smoking, to capture cumulative exposure 1
Record specific drinking patterns: daily amounts, weekly totals, binge episodes (≥5 drinks on one occasion), drinking settings, alcohol type, pace of consumption, and overall duration of heavy use 1
Identify high-risk features: chronic heavy drinking >80g/day for ≥10 years significantly increases risk of severe withdrawal 2
Obtain collateral information from family members or other providers when possible, as patients commonly underreport due to stigma, impaired recall, fear of consequences, or cognitive impairment including hepatic encephalopathy 1
DSM-5 Diagnostic Criteria Application
Apply the 11 DSM-5 criteria for Alcohol Use Disorder during your assessment: larger amounts/longer periods than intended; persistent desire to cut down; time spent obtaining/using/recovering; craving; failure to fulfill obligations; continued use despite social problems; activities given up; use in hazardous situations; continued use despite physical/psychological problems; tolerance; and withdrawal 1
Classify severity as mild (2-3 criteria), moderate (4-5 criteria), or severe (≥6 criteria) 1
Assessment of Acute Alcohol Withdrawal
Timeline and Clinical Presentation
Withdrawal symptoms typically begin 6-24 hours after the last drink, peak at days 3-5, and resolve spontaneously within one week. 2, 3
Early symptoms (6-24 hours): hand tremor, sweating, tachycardia, hypertension, nausea, vomiting, anxiety, agitation, irritability, headache, and hyperreflexia 2, 3
Withdrawal seizures (12-48 hours): occur in up to 15% of patients, typically generalized without focality, occurring singly or in brief clusters 3, 4
Alcoholic hallucinosis (12-24 hours): visual, auditory, or tactile hallucinations in 2-8% of patients 3
Delirium tremens (48-72 hours): occurs in 3-5% of patients, characterized by marked inattentiveness, agitation, hallucinations, fluctuating alertness, severe tremor, and autonomic hyperactivity; mortality reaches 50% without treatment 3, 4
Quantifying Withdrawal Severity
Use the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) to quantify withdrawal severity and guide treatment decisions. 2
- CIWA-Ar ≥8: indicates need for pharmacological treatment 2
- CIWA-Ar ≥15: indicates severe withdrawal requiring aggressive benzodiazepine therapy 2
Critical Physical Examination Findings
Assess vital signs continuously for autonomic instability: tachycardia, hypertension, fever, and diaphoresis 2
Evaluate for dangerous complications: dehydration, electrolyte imbalance (especially magnesium and phosphate), infection, gastrointestinal bleeding, pancreatitis, hepatic encephalopathy, and renal failure 2, 5
Screen for concurrent conditions: hypoglycemia, liver failure, sepsis, meningitis, intracranial hemorrhage, and Wernicke-Korsakoff syndrome 4
Immediate Pharmacological Management
Thiamine Administration (MANDATORY FIRST STEP)
Administer thiamine 100-500 mg IV immediately BEFORE any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy. 2, 5, 6
Continue thiamine 100-300 mg/day orally throughout withdrawal and for 2-3 months after resolution 2, 5
Never give glucose before thiamine, as this can precipitate acute Wernicke encephalopathy 2
Benzodiazepine Therapy (First-Line Treatment)
Benzodiazepines are the only proven treatment to prevent seizures and reduce mortality from delirium tremens, making them mandatory first-line therapy for moderate-to-severe alcohol withdrawal. 2, 6, 7
For Patients WITHOUT Hepatic Dysfunction
Initiate long-acting benzodiazepines (diazepam or chlordiazepoxide), which provide superior protection against seizures and delirium tremens 2, 6
Diazepam dosing: 10 mg IV or orally initially, then 5-10 mg every 3-4 hours as needed based on CIWA-Ar scores 2, 5
Chlordiazepoxide dosing: 50-100 mg orally as loading dose, then 25-100 mg every 4-6 hours as needed, maximum 300 mg in first 24 hours 2
For Patients WITH Hepatic Dysfunction, Elderly, or Respiratory Compromise
Switch to short-acting benzodiazepines (lorazepam 6-12 mg/day or oxazepam) to avoid drug accumulation and dose-stacking. 2, 5, 6
Special Consideration for Cirrhotic Patients
Over 70% of cirrhotic patients may not require benzodiazepines at all; use symptom-triggered dosing based on clinical assessment rather than routine prophylaxis 2, 5
Regular monitoring can be stopped after 24 hours if no withdrawal signs appear 5
Benzodiazepine Tapering Protocol
Begin tapering after approximately 96 hours (day 4) when acute symptoms are improving 2
For long-acting agents: reduce daily dose by 25% every 2-3 days 2
For short-acting agents: decrease daily dose by 10-25% every 2-4 days 2
Limit total benzodiazepine therapy to maximum 10-14 days to avoid iatrogenic dependence 2, 6
Never discontinue abruptly, even after short courses, as rebound withdrawal can occur 2
Supportive Care and Monitoring
Fluid and Electrolyte Replacement
Aggressively replace fluids and electrolytes with particular attention to magnesium and phosphate, which are commonly depleted in chronic alcohol use 2, 5
Avoid excessive water-sodium intake in patients with heart disease due to risk of pulmonary edema 7
Continuous Monitoring Requirements
Monitor vital signs continuously for autonomic instability before each benzodiazepine dose 2
Assess daily for up to 5 days after the last drink to verify symptom improvement and evaluate need for additional treatment 2
Watch for rebound symptoms during taper: increased anxiety, tremor, autonomic hyperactivity, new-onset seizures, or altered mental status 2
Management of Specific Complications
Withdrawal Seizures
Do NOT use anticonvulsants for alcohol withdrawal seizures, as these are rebound phenomena with lowered seizure threshold, not genuine epilepsy 2
Benzodiazepines are the only medication proven to prevent withdrawal seizures; chronic antiepileptic drugs are unnecessary after detoxification 2
Severe Withdrawal or Delirium Tremens
For benzodiazepine-refractory cases, add phenobarbital or propofol as second-line sedative agents 2
Antipsychotic agents (e.g., haloperidol) may be added ONLY as adjuncts to adequate benzodiazepine regimens in severe withdrawal-related delirium; they must never be used as monotherapy 2
Beta-blockers (e.g., propranolol) can be added for persistent tachycardia despite adequate benzodiazepines, but never as sole treatment because they do not prevent seizures or delirium tremens 2
Persistent Tachycardia
- Add intravenous beta-blockers only after ensuring adequate benzodiazepine therapy, as they lower heart rate and blood pressure but do not prevent life-threatening complications 2
Disposition and Admission Criteria
Indications for Inpatient Admission
Admit patients with any of the following: 2, 5
- Significant withdrawal symptoms (CIWA-Ar ≥8) with vomiting and tremor
- History of withdrawal seizures or delirium tremens
- Co-occurring serious medical illness (liver disease, infection, pancreatitis, gastrointestinal bleeding)
- Concurrent psychiatric illness or active suicide risk
- Failure of prior outpatient treatment
- High levels of recent drinking (>80g/day for ≥10 years)
- Insufficient social support or inability to attend daily monitoring
Outpatient Management Criteria
Outpatient treatment is appropriate for patients with mild-to-moderate withdrawal (CIWA-Ar <15) who lack serious complications 2
Require daily physician visits for 3-5 days after last drink to monitor vital signs and assess withdrawal severity 2
Post-Acute Management and Relapse Prevention
Mandatory Psychiatric Consultation
After withdrawal stabilization, psychiatric consultation is mandatory for evaluation of alcohol use disorder severity, ongoing treatment planning, and long-term abstinence strategies. 2, 5
Relapse Prevention Pharmacotherapy (After Withdrawal Completion)
Acamprosate (≈2g/day for patients ≥60kg): safe in liver disease, reduces alcohol craving 2
Baclofen (up to 80mg/day): the only medication with proven safety in cirrhotic patients 2
Disulfiram: useful if administration can be monitored and tied to meaningful contingencies 6
Topiramate: consider for relapse prevention after detoxification 2
AVOID naltrexone in patients with alcoholic liver disease due to hepatotoxicity risk 2
Psychosocial Support
Encourage engagement with mutual-help groups such as Alcoholics Anonymous to sustain recovery 2, 6
Complete abstinence is critical for improved outcomes, especially in patients with underlying liver disease 5
Persistent alcohol consumption >2 standard drinks/day significantly increases mortality in cirrhotic patients (RR 2.6 in males, 2.1 in females) 5
Critical Pitfalls to Avoid
Never give glucose-containing IV fluids before thiamine, as this precipitates acute Wernicke encephalopathy 2, 8
Never use benzodiazepines beyond 10-14 days for alcohol withdrawal, as this creates iatrogenic dependence requiring months-long taper 2, 6
Never use antipsychotics, anticonvulsants, or beta-blockers as monotherapy, as they do not prevent seizures or delirium tremens 2, 7
Never apply chronic benzodiazepine-dependence taper strategies to acute alcohol withdrawal patients; chronic dependence requires specialist referral and much longer taper 2
Dispense psychoactive medications in limited quantities or under supervised administration to minimize misuse risk 2