How should I assess and manage a patient with alcohol use disorder, including withdrawal treatment and long‑term pharmacologic and psychosocial interventions?

Management of Alcohol Use Disorder

Initial Assessment and Risk Stratification

All patients presenting with suspected alcohol use disorder should be systematically screened using the AUDIT questionnaire; a score ≥8 identifies hazardous drinking requiring intervention, and meeting ≥6 of the 11 DSM-5 criteria (tolerance, withdrawal, craving, failed quit attempts, continued use despite harm) establishes severe alcohol use disorder. 1

Immediate Hospitalization Criteria

Admit patients to inpatient care if any of the following are present:

• History of withdrawal seizures or delirium tremens 2, 1
• Consumption >80 g alcohol daily for ≥10 years 1
• Current significant withdrawal symptoms (tremor, tachycardia, hypertension, sweating, vomiting) 2, 1
• Co-existing serious medical illness (liver disease, gastrointestinal bleeding, pancreatitis, infection, cardiovascular disease) 2, 1
• Co-existing serious psychiatric illness or active suicide risk 2, 1
• Inadequate social support or prior outpatient treatment failure 2, 1

Essential Medical Evaluation

Assess for life-threatening complications including:

• Dehydration and electrolyte imbalances (especially magnesium depletion) 2, 1
• Infection (pneumonia, spontaneous bacterial peritonitis in cirrhotics) 2, 1
• Gastrointestinal bleeding 2, 1
• Hepatic encephalopathy (confusion, asterixis in patients with liver disease) 2, 1
• Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia—a medical emergency) 2

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Acute Withdrawal Management

Mandatory Thiamine Administration

Administer thiamine 100–500 mg IV immediately BEFORE any glucose-containing fluids to every patient with alcohol use disorder; failure to do so can precipitate acute Wernicke encephalopathy. 2, 1, 3

• Continue thiamine 100–300 mg daily throughout withdrawal and for 2–3 months after resolution 2, 1, 3
• For established Wernicke encephalopathy, escalate to 100–500 mg IV daily for 12–24 weeks 1

Benzodiazepine Therapy: The Gold Standard

Benzodiazepines are the only proven treatment that prevents alcohol withdrawal seizures and reduces mortality from delirium tremens; they are mandatory first-line therapy for moderate-to-severe withdrawal. 2, 1, 3

Agent Selection Algorithm

For most patients without liver disease:

• Diazepam 10 mg PO/IV every 3–4 hours or chlordiazepoxide 50–100 mg loading dose, then 25–100 mg every 4–6 hours 2, 1, 3
• Long-acting agents provide superior seizure protection due to self-tapering metabolites 2, 3

For patients with hepatic dysfunction, advanced age, respiratory compromise, or obesity:

• Switch to lorazepam 2–4 mg PO/IV every 4–6 hours (short half-life, minimal hepatic metabolism) 2, 1, 3
• Despite widespread belief, >70% of cirrhotic patients may not require benzodiazepines at all; use symptom-triggered dosing only when withdrawal signs are present 2, 1

Dosing Strategy

Use symptom-triggered dosing guided by CIWA-Ar scores:

• Initiate benzodiazepines when CIWA-Ar ≥8 2, 4
• Continue treatment until complete symptom resolution, not based on day of admission alone—withdrawal can persist beyond 72 hours 1
• Maximum treatment duration: 10–14 days to prevent iatrogenic dependence 2, 1

Benzodiazepine Tapering Protocol

• Begin taper after day 4 (96 hours) when acute symptoms improve 2
• Reduce daily dose by 25% every 2–3 days for long-acting agents 2
• Reduce by 10–25% every 2–4 days for short-acting agents 2
• Monitor for rebound anxiety, tremor, tachycardia, or altered mental status at each reduction 2
• Never discontinue abruptly—even short courses require gradual taper 2

Supportive Care Essentials

• Aggressive fluid and electrolyte replacement with magnesium supplementation 2, 1, 3
• Continuous vital sign monitoring for autonomic instability (tachycardia, hypertension, fever, sweating) 2, 1

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Management of Specific Withdrawal Complications

Alcohol Withdrawal Seizures

If a seizure occurs:

• Administer diazepam 10 mg IV immediately, then 5–10 mg every 3–4 hours 3
• For hepatic dysfunction, use lorazepam 2 mg IV acutely, then 6–12 mg/day divided 3
• Do NOT use anticonvulsants (phenytoin, carbamazepine) for seizure prevention—they are ineffective and may worsen outcomes 2, 1, 3
• Benzodiazepines are the only effective seizure prophylaxis 2, 3

Delirium Tremens (48–72 Hours Post-Cessation)

For severe agitation or hallucinations refractory to adequate benzodiazepines:

• Add haloperidol 0.5–5 mg PO/IM as adjunctive therapy ONLY—never as monotherapy 2, 1
• Antipsychotics alone lower seizure threshold and worsen outcomes 2, 3
• For benzodiazepine-refractory cases in ICU, consider phenobarbital or propofol as second-line sedation 2

Adjunctive Agents to Avoid or Use Cautiously

• Beta-blockers (e.g., propranolol) may be added for persistent tachycardia despite adequate benzodiazepines, but never as monotherapy—they do not prevent seizures or delirium tremens 2
• Carbamazepine may be used as a benzodiazepine-sparing agent in patients with severe hepatic impairment or benzodiazepine abuse history, but only as adjunctive therapy and never if CIWA-Ar ≥15 2
• Dexmedetomidine is adjunctive only for ICU benzodiazepine-refractory cases; it does not prevent seizures 2

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Long-Term Relapse Prevention

After withdrawal stabilization, mandatory psychiatric consultation is required to assess alcohol use disorder severity and develop a comprehensive abstinence plan. 2, 1, 3

Evidence-Based Pharmacotherapy Options

Select based on patient characteristics and liver function:

Acamprosate (First-Line for Liver Disease)

• Dose: ≈2 g/day (666 mg three times daily) for patients ≥60 kg; reduce for lower body weight 1
• Mechanism: Reduces craving and maintains abstinence 1, 5
• Safe in liver disease 1, 5

Naltrexone (Contraindicated in Liver Disease)

• Dose: 25 mg daily for 1–3 days, then 50 mg daily for 3–12 months 1, 5
• Mechanism: Reduces heavy drinking days 5
• CONTRAINDICATED in alcoholic liver disease due to hepatotoxicity risk 2, 1

Baclofen (Only Medication Proven Safe in Cirrhosis)

• Dose: Up to 80 mg/day with gradual escalation 1, 5
• The only relapse-prevention medication with proven safety in cirrhotic patients 1

Disulfiram (Supervised Settings Only)

• Dose: 500 mg daily for 1–2 weeks, then 125–500 mg daily 1
• Induces unpleasant reactions if alcohol consumed 1
• CONTRAINDICATED in severe alcoholic liver disease 1
• Little evidence supports effectiveness outside supervised settings 5

Other Options

• Gabapentin: Strong evidence for reducing heavy-drinking days 5
• Topiramate: Moderate evidence for decreasing heavy-drinking days 5
• Varenicline: May reduce heavy alcohol use 5

Psychosocial Interventions

• Encourage engagement with mutual-help groups (e.g., Alcoholics Anonymous) 2, 1
• Combine pharmacotherapy with behavioral interventions 5

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Critical Pitfalls to Avoid

• Never administer glucose-containing IV fluids before thiamine—this precipitates Wernicke encephalopathy 2, 1
• Never use anticonvulsants for withdrawal seizure prophylaxis—only benzodiazepines prevent seizures 2, 1, 3
• Never use antipsychotics as monotherapy—they lower seizure threshold 2, 3
• Never extend benzodiazepines beyond 14 days—creates iatrogenic dependence 2, 1
• Never assume all cirrhotic patients need benzodiazepines—use symptom-triggered dosing 2, 1
• Never prescribe naltrexone in alcoholic liver disease—hepatotoxicity risk 2, 1
• Never discontinue benzodiazepines abruptly—taper gradually 2
• Dispense psychoactive medications in limited quantities or under supervision to minimize misuse 2