alcohol withdrawal nursing case study

5 Alcohol Withdrawal Nursing Care Plans

Alcohol withdrawal syndrome (AWS) is a common clinical condition that occurs in individuals with alcohol use disorder who abruptly stop or reduce their alcohol intake. It is characterized by a range of symptoms that can vary from mild to severe and potentially life-threatening. Nursing care plans for alcohol withdrawal are an essential part of managing patients with AWS. This article aims to provide an overview of nursing care plans for alcohol withdrawal nursing assessment , nursing diagnosis , including their nursing interventions , and nursing management .

Table of Contents

What is alcohol withdrawal syndrome, nursing problem priorities, nursing assessment, nursing diagnosis, nursing goals, 1. managing signs of alcohol withdrawal syndrome, 2. promoting safety and preventing injury and seizures, 3. reducing fear and anxiety, 4. initiating patient education and health teachings, 5. administer medications and provide pharmacologic support, recommended resources.

Alcohol ,  a central nervous system depressant, is used socially in our society for many reasons: to enhance the flavor of food, to encourage relaxation and conviviality, for celebrations, and as a sacred ritual in some religious ceremonies. Therapeutically, it is the major ingredient in many OTC/prescription medications. It can be harmless, enjoyable, and sometimes beneficial when used responsibly and in moderation.

It is rapidly absorbed from the stomach and small intestine into the bloodstream. On the other hand, alcohol withdrawal refers to symptoms that may occur when a person who has been drinking too much alcohol every day suddenly stops drinking alcohol.

Alcohol withdrawal symptoms usually occur within 8 hours after the last drink but can occur days later. Symptoms usually peak in 24 – 72 hours but may persist for weeks. Common symptoms include anxiety or nervousness, depression , fatigue , irritability, jumpiness or shakiness, mood swings, nightmares and not thinking clearly.

Nursing Care Plans and Management

Nursing care plans for alcohol withdrawal are designed to support patients with AWS and ensure their safety and comfort during the withdrawal process. Nursing care planning for patients who are undergoing alcohol withdrawal includes: maintaining physiological stability during the acute withdrawal phase, promoting safety, providing appropriate referral and follow-up, and involvement of SO in the process.

The following are the nursing priorities for patients with alcohol withdrawal syndrome (AWS):

• Assessment and monitoring. Conducting a comprehensive assessment of the patient’s alcohol withdrawal symptoms and closely monitoring vital signs, including heart rate , blood pressure , and respiratory rate.
• Seizure prevention. Implementing preventive measures, such as the administration of appropriate medications (e.g., benzodiazepines), to prevent seizures , a potential complication of alcohol withdrawal syndrome (AWS).
• Delirium tremens (DT) prevention. Identifying patients at high risk for delirium tremens and implementing interventions, including pharmacological support, to manage symptoms and reduce the risk of severe complications.
• Fluid and electrolyte balance. Monitoring and maintaining adequate fluid intake and electrolyte balance to prevent dehydration and address any imbalances caused by AWS.
• Pharmacologic support. Administering medications, such as benzodiazepines or anticonvulsants, to manage alcohol withdrawal symptoms, including anxiety , agitation, insomnia , and tremors.
• Psychological support. Providing psychological support, counseling, and behavioral interventions to address the emotional and psychological challenges associated with AWS, including cravings, depression, anxiety, and mood disturbances.
• Nutritional support. Ensuring proper nutrition and addressing any nutritional deficiencies caused by alcohol abuse and poor dietary habits.
• Safety measures. Implementing safety protocols to prevent self-harm, falls, or accidents during the withdrawal process, including close observation and removing any potentially harmful objects from the patient’s environment.
• Education and relapse prevention. Providing education on the consequences of alcohol abuse, promoting awareness of triggers and coping strategies, and offering relapse prevention strategies to support long-term recovery.
• Discharge planning . Collaborating with the patient, family, and support networks to develop a comprehensive discharge plan that includes appropriate follow-up care, referrals to rehabilitation programs or support groups, and ongoing monitoring of the patient’s progress in managing AWS and maintaining sobriety.

Assess for the following subjective and objective data :

• See nursing assessment cues under Nursing Interventions and Actions.

Following a thorough assessment , a nursing diagnosis is formulated to specifically address the challenges associated with alcohol withdrawal syndrome (AWS) based on the nurse ’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Goals and expected outcomes may include:

• The patient will verbalize the reduction of fear and anxiety to an acceptable and manageable level.
• The patient will express a sense of regaining some control of the situation/life.
• The patient will demonstrate problem-solving skills and use resources effectively.
• The patient will regain/maintain the usual level of consciousness.
• The patient will report the absence of/reduced hallucinations .
• The patient will identify external factors that affect sensory-perceptual abilities.
• The patient will display vital signs within the patient’s normal range; absence of/reduced frequency of dysrhythmias.
• The patient will demonstrate an increase in activity tolerance .
• The patient will maintain an effective breathing pattern with a respiratory rate within normal range, lungs clear; be free of cyanosis and other signs/symptoms of hypoxia.
• The patient will demonstrate the absence of untoward effects of withdrawal.
• The patient will experience no physical injury .

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with alcohol withdrawal syndrome (AWS) may include:

Patients with alcohol withdrawal may experience sensory perceptual changes due to a combination of factors, including chronic alcohol consumption, sleep deprivation, and psychological stress. These factors can contribute to alterations in the patient’s perception of their surroundings, such as visual or auditory hallucinations, as well as difficulties in clear thinking and information processing. Additionally, patients with alcohol withdrawal are susceptible to decreased cardiac output , which may occur as a direct consequence of alcohol’s impact on the heart muscle , resulting in damage and impaired function. It can also cause changes in systemic vascular resistance, affecting blood flow and cardiac performance. In severe cases, reduced cardiac output can lead to complications like hypotension , shock, and organ failure. Moreover, patients with alcohol withdrawal are prone to impaired respiratory function caused by tracheobronchial obstruction, which can arise from incidents involving aspiration or choking. Furthermore, alcohol toxicity depresses the central nervous system and impairs respiratory function, which can contribute to various respiratory complications, including hypoxemia and respiratory failure.

Assess the level of consciousness; ability to speak, and respond to stimuli and commands. Speech may be garbled, confused, or slurred. Response to commands may reveal an inability to concentrate, impaired judgment, or muscle coordination deficits.

Observe behavioral responses such as hyperactivity , disorientation , confusion , sleeplessness, and irritability. Hyperactivity related to CNS disturbances may escalate rapidly. Sleeplessness is common due to the loss of the sedative effect gained from alcohol usually consumed before bedtime. Sleep deprivation may aggravate disorientation and confusion . Progression of symptoms may indicate impending hallucinations (stage II) or DTs (stage III).

Note the onset of hallucinations. Document as auditory, visual, and tactile. Auditory hallucinations are reported to be more frightening and threatening to the patient. Visual hallucinations occur more at night and often include insects, animals, or the faces of friends and enemies. Patients are frequently observed “picking the air.” Yelling may occur if the patient is calling for help from a perceived threat (usually seen in stage III AWS).

Monitor the patient for signs of depression. To avoid harming himself and attempts suicide .

Monitor laboratory studies: electrolytes , magnesium levels, liver function studies, ammonia, BUN, glucose , and ABGs . Changes in organ function may precipitate or potentiate sensory-perceptual deficits. Electrolyte imbalance is common. Liver function is often impaired in the chronic alcoholic, and ammonia intoxication can occur if the liver is unable to convert ammonia to urea. Ketoacidosis is sometimes present without glycosuria; however, hyperglycemia or hypoglycemia may occur, suggesting pancreatitis or impaired gluconeogenesis in the liver. Hypoxemia and hypercarbia are common manifestations in chronic alcoholics who are also heavy smokers.

Provide a calm environment, minimizing noise and shadows. To reduce the incidence of delusions and hallucinations.

Avoid restraining the patient unless necessary. To protect patients and others.

Provide a quiet environment. Speak in a calm, quiet voice. Regulate lighting as indicated. Turn off the radio and TV during sleep . Reduces external stimuli during the hyperactive stage. Patients may become more delirious when their surroundings cannot be seen, but some respond better to quiet, darkened rooms.

Provide care by the same staff whenever possible. Promotes recognition of caregivers and a sense of consistency, which may reduce fear .

Encourage SO to stay with the patient whenever possible. May have a calming effect, and may provide a reorienting influence.

Reorient frequently to person, place, time, and surrounding environment as indicated. May reduce confusion , and prevent and limit misinterpretation of external stimuli.

Avoid bedside discussion about the patient or topics unrelated to the patient that does not include the patient. Patients may hear and misinterpret conversation, which can aggravate hallucinations.

Provide environmental safety (place bed in a low position, leave doors in a fully open or closed position, observe frequently, place call light or bell within reach, remove articles that can harm the patient). Patients may have a distorted sense of reality or be fearful or suicidal, requiring protection from self.

Provide seclusion, and restraints as necessary. Patients with excessive psychomotor activity, severe hallucinations, violent behavior, and suicidal gestures may respond better to seclusion. Restraints are usually ineffective and add to the patient’s agitation, but occasionally may be required to prevent self-harm.

Orient the patient to reality. Patients may experience hallucinations and may try to harm themselves and others.

Administer medications as indicated: Antianxiety agents as indicated Reduces hyperactivity, promoting relaxation and sleep . Drugs that have little effect on dreaming may be desired to allow dream recovery (REM rebound) to occur, which has previously been suppressed by alcohol use.

Monitor vital signs frequently during acute withdrawal. Hypertension frequently occurs in the acute withdrawal phase. Extreme hyperexcitability, accompanied by catecholamine release and increased peripheral vascular resistance, raises BP and heart rate ; however, BP may become labile and progress to hypotension . Note: The patient may have underlying cardiovascular disease, which is compounded by alcohol withdrawal.

Monitor cardiac rate and rhythm. Document irregularities and dysrhythmias. Long-term alcohol abuse may result in cardiomyopathy or HF. Tachycardia is common because of the sympathetic response to increased circulating catecholamines. Irregularities and dysrhythmias may develop with electrolyte shifts and imbalance. All of these may have an adverse effect on cardiac function and output.

Monitor body temperature. Elevation may occur because of sympathetic stimulation, dehydration , and infections, causing vasodilation and compromising venous return and cardiac output.

Monitor I&O. Note 24-hr fluid balance . Preexisting dehydration , vomiting , fever , and diaphoresis may result in decreased circulating volume that can compromise cardiovascular function. Note: Hydration is difficult to assess in the alcoholic patient because the usual indicators are not reliable, and overhydration is a risk in the presence of compromised cardiac function.

Monitor laboratory studies: serum electrolyte levels. Electrolyte imbalance: potassium , and magnesium , potentiate the risk of cardiac dysrhythmias and CNS excitability.

Be prepared and assist in cardiopulmonary resuscitation. Causes of death during acute withdrawal stages include cardiac dysrhythmias, respiratory depression and arrest, oversedation, excessive psychomotor activity, severe dehydration or overhydration, and massive infections. Mortality for unrecognized and untreated delirium tremens (DTs) may be as high as 25%.

Administer fluids and electrolytes , as indicated . Severe alcohol withdrawal causes the patient to be susceptible to fluid losses (associated with fever, diaphoresis, and vomiting ) and electrolyte imbalances, especially potassium , magnesium, and glucose .

Administer medications as indicated: Clonidine (Catapres), atenolol (Tenormin); Potassium. Although the use of benzodiazepines is often sufficient to control hypertension during initial withdrawal from alcohol, some patients may require more specific therapy. Note: Atenolol and other b-adrenergic blockers may speed up the withdrawal process and eliminate tremors, as well as lower the heart rate , blood pressure , and body temperature. Corrects deficits that can result in life-threatening dysrhythmias.

Monitor respiratory rate and depth and pattern as indicated. Note periods of apnea , and Cheyne-Stokes respirations. Frequent assessment is important because toxicity levels may change rapidly. Hyperventilation is common during the acute withdrawal phase. Kussmaul’s respirations are sometimes present because of an acidotic state associated with vomiting and malnutrition . However, marked respiratory depression can occur because of the CNS depressant effects of alcohol if acute intoxication is present. This may be compounded by drugs used to control alcohol withdrawal symptoms (AWS).

Auscultate breath sounds. Note the presence of adventitious sounds: rhonchi, wheezes. The patient is at risk for atelectasis related to hypoventilation and pneumonia . Right lower lobe pneumonia is common in alcohol-debilitated patients and is often due to chronic aspiration . Chronic lung diseases are also common: emphysema and bronchitis.

Review serial chest x-ray s, ABGs, and pulse oximetry as available and indicated Monitors the presence of secondary complications such as atelectasis and pneumonia ; evaluates the effectiveness of respiratory effort, identifies therapy needs.

Elevate the head of the bed. Decreases potential for aspiration ; lowers diaphragm , enhancing lung inflation.

Encourage cough and deep-breathing exercises and frequent position changes. Facilitates lung expansion and mobilization of secretions to reduce the risk of atelectasis and pneumonia.

Have suction equipment, and airway adjuncts available. The sedative effects of alcohol and drugs potentiate the risk of aspiration , relaxation of oropharyngeal muscles, and respiratory depression, requiring intervention to prevent respiratory arrest.

Administer supplemental oxygen if necessary. Hypoxia may occur with CNS and respiratory depression.

Patients with alcohol withdrawal are at risk for injury due to a variety of factors, including sudden cessation of alcohol, which can lead to severe physiological symptoms, such as seizures. Reduced hand and eye coordination , balancing difficulties, and confusion can also increase the risk of falls and other accidents, which can lead to serious injury. Additionally, some patients may engage in risky or impulsive behaviors as a result of their altered state of mind, further increasing the risk of injury .

Identify the stage of AWS (alcohol withdrawal syndrome); i.e., stage I is associated with signs and symptoms of hyperactivity (tremors, sleeplessness, nausea and vomiting , diaphoresis, tachycardia, hypertension ). Stage II is manifested by increased hyperactivity plus hallucinations and seizure activity. Stage III symptoms include DTs and extreme autonomic hyperactivity with profound confusion, anxiety, insomnia, and fever. Prompt recognition and intervention may halt the progression of symptoms and enhance recovery or improve prognosis. In addition, the recurrence or progression of symptoms indicates the need for changes in drug therapy and more intense treatment to prevent death.

Monitor and document seizure activity. Maintain patent airway . Provide environmental safety (padded side rails , bed in low position). Grand mal seizures are most common and may be related to decreased magnesium levels, hypoglycemia , elevated blood alcohol, or a history of head trauma and preexisting seizure disorder . Note: In absence of history and other pathology causing seizures, they usually stop spontaneously, requiring only symptomatic treatment. Note: Antiepileptic drugs are not indicated for alcohol withdrawal seizures.

Check deep-tendon reflexes. Assess gait, if possible. Reflexes may be depressed, absent, or hyperactive. Peripheral neuropathies are common, especially in malnourished patients. Ataxia (gait disturbance) is associated with Wernicke’s syndrome (thiamine deficiency) and cerebellar degeneration.

Assist with ambulation and self-care activities as needed. Prevents falls with resultant injury.

Provide for environmental safety when indicated. May be required when equilibrium , hand, and eye coordination problems exist.

Administer medications as indicated . See Pharmacologic Management

Patients with alcohol withdrawal are at risk for anxiety and fear related to the cessation of alcohol intake and physiological withdrawal symptoms. Hospitalization and the threat to self-concept can further exacerbate these feelings, as patients may feel a loss of control over their own lives and worry about the impact of their condition on their relationships and daily activities.

Determine the cause of anxiety, involving the patient in the process. Explain that alcohol withdrawal increases anxiety and uneasiness. Reassess the level of anxiety on an ongoing basis. A person in the acute phase of withdrawal may be unable to identify and accept what is happening. Anxiety may be physiologically or environmentally caused. Continued alcohol toxicity will be manifested by increased anxiety and agitation as the effects of the medication wear off.

Monitor the patient for signs of depression. To prevent suicidal attempts.

Develop a trusting relationship through frequent contact being honest and nonjudgmental. Project an accepting attitude about alcoholism. Provides patient with a sense of humanness, helping to decrease paranoia and distrust. Patients will be able to detect the biased or condescending attitudes of caregivers.

Maintain a calm environment, minimizing noise. Reduces stress.

Inform the patient about what you plan to do and why. Include patients in the planning process and provide choices when possible. Enhances a sense of trust, and explanation may increase cooperation and reduce anxiety. Provides a sense of control over self in circumstances where the loss of control is a significant factor. Note: Feelings of self-worth are intensified when one is treated as a worthwhile person.

Reorient frequently. The patient may experience periods of confusion, resulting in increased anxiety.

Orient the patient to reality. He may also experience hallucinations and may try to harm himself and others.

Arrange “Intervention” (confrontation) in a controlled setting. Process wherein SO and family members , supported by staff, provide information about how the patient’s drinking and behavior have affected each one of them, helps the patient acknowledge that drinking is a problem and has resulted in the current situational crisis.

Provide consultation for referral to detoxification and crisis center for ongoing treatment programs as soon as medically stable (oriented to reality). The patient is more likely to contract treatment while still hurting and experiencing fear and anxiety from the last drinking episode. Motivation decreases as well-being increases and the person again feel able to control the problem. Direct contact with available treatment resources provides a realistic picture of help. Decreases time for patients to “think about it,” change minds or restructure and strengthen denial systems.

These nursing interventions aim to empower patients with knowledge and skills to manage their alcohol withdrawal syndrome effectively and promote successful recovery.

Provide thorough education to patients with AWS regarding the physical and psychological effects of alcohol withdrawal, including symptoms, risks, and potential complications. Providing education about the physical and psychological effects of alcohol withdrawal helps patients understand what to expect during the process, reducing anxiety and increasing their motivation to stay committed to treatment.

Teach patients healthy coping mechanisms and stress management techniques, such as deep breathing exercises, mindfulness techniques, and engaging in activities that promote relaxation . Teaching patients healthy coping strategies and stress management techniques equips them with effective tools to manage triggers and cravings, reducing the likelihood of relapse and promoting long-term recovery.

Educate patients about available support systems, such as Alcoholics Anonymous (AA) or other support groups, counseling services, and community resources, and encourage their participation to enhance their recovery journey. Educating patients about available support systems and resources, such as support groups and counseling services, helps them establish a strong support network, providing encouragement, guidance, and a sense of belonging during their recovery journey.

Explain the importance of medication adherence in managing AWS and provide clear instructions on the prescribed medications, their purpose, potential side effects, and proper dosage . Emphasize the significance of following the prescribed medication regimen and attending scheduled medical appointments for monitoring and adjustment of treatment if necessary. Providing clear instructions on medication use and emphasizing the importance of adherence ensures that patients receive the full benefits of prescribed medications, reducing withdrawal symptoms and minimizing the risk of complications. Regular monitoring allows for adjustments to the treatment plan, ensuring its effectiveness.

Provide education on the importance of a balanced diet, adequate hydration, and regular physical activity to support overall health and recovery. Discuss the negative effects of alcohol on nutrition and encourage healthy habits, such as consuming nutritious meals, avoiding alcohol, and staying hydrated. Educating patients about the impact of alcohol on nutrition and overall health helps them recognize the importance of a balanced diet, hydration, and regular physical activity in supporting their recovery. This knowledge empowers patients to make healthier lifestyle choices and promotes overall well-being.

Benzodiazepines: chlordiazepoxide (Librium), diazepam (Valium) Antianxiety agents are given during acute withdrawal to help the patient relax, be less hyperactive, and feel more in control.

Barbiturates :  phenobarbital , or possibly secobarbital (Seconal), pentobarbital (Nembutal) These drugs suppress alcohol withdrawal but need to be used with caution because they are respiratory depressants and REM sleep cycle inhibitors.

Benzodiazepines (BZDs): chlordiazepoxide (Librium), diazepam (Valium), clonazepam ( Klonopin ), oxazepam (Serax), clorazepate (Tranxene) BZDs are commonly used to control neuronal hyperactivity because of their minimal respiratory and cardiac depression and anticonvulsant properties. Studies have also shown that these drugs can prevent progression to more severe states of withdrawal. IV and PO administration is the preferred route because IM absorption is unpredictable. Muscle-relaxant qualities are particularly helpful to patients in controlling “the shakes,” trembling, and ataxic quality of movements. Patients may initially require large doses to achieve the desired effect, and then drugs may be tapered and discontinued, usually within 96 hr. Note: These agents are used cautiously in patients with known hepatic disease because they are metabolized by the liver, although Serax has a shorter half-life.

Haloperidol ( Haldol ) May be used in conjunction with BZDs for patients experiencing hallucinations.

Thiamine Thiamine deficiency (common in alcohol abuse) may lead to neuritis, Wernecke’s syndrome, and Korsakoff’s psychosis.

Magnesium sulfate Reduces tremors and seizure activity by decreasing neuromuscular excitability.

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Other care plans for mental health and psychiatric nursing:

• Alcohol Withdrawal | 5 Care Plans
• Anxiety and Panic Disorders  | 7 Care Plans
• Bipolar Disorders  | 6 Care Plans
• Major Depression  | 9 Care Plans UPDATED!
• Personality Disorders  | 4 Care Plans
• Schizophrenia  | 6 Care Plans UPDATED!
• Sexual Assault  | 1 Care Plan
• Substance Dependence and Abuse | 8 Care Plans UPDATED!
• Suicide Behaviors  | 3 Care Plans

4 thoughts on “5 Alcohol Withdrawal Nursing Care Plans”

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Alcohol Withdrawal Nursing Diagnosis and Nursing Care Plan

Last updated on January 26th, 2024 at 05:18 pm

Alcohol Withdrawal Nursing Care Plans Diagnosis and Interventions

Alcohol consumption is pervasive in society; often, it is seen as a standard beverage in celebrations, fiestas, or special occasions, but it is also evident in ceremonial and religious customs.

With that said, alcohol withdrawal is the sudden discontinuance of chronic alcohol consumption after years of dependence. When alcohol is put on rapid halt, the body elicits excitatory indications—whereas signs and symptoms suggesting alcohol withdrawal manifest as delirium tremens, seizures, and mood changes.

Causes of Alcohol Withdrawal

Signs and symptoms of alcohol withdrawal, related factors to alcohol withdrawal.

Alcohol withdrawal usually occurs in individuals with unhealthy drinking habits or who experience alcohol abuse. The risk factors include the following:

Diagnosis of Alcohol Withdrawal

Treatment of alcohol withdrawal.

Mild AWS may be treated with home care and nutritional supplements. For severe cases of alcohol withdrawal characterized by DT, these may be necessary for treatment:

Nursing Diagnosis for Alcohol Withdrawal

Nursing care plan for alcohol withdrawl 1.

Nursing Care Plan for Alcohol Withdrawl 2

Nursing Diagnosis: Anxiety / Fear related to a perceived threat of harm or death, secondary to alcohol withdrawal as evidenced by helplessness, feelings of remorse, panic attacks, increased BP, and heart rate. 

Nursing Care Plan for Alcohol Withdrawl 3

Desired Outcome: The patient’s vital signs will normalize with a marked decrease of dysrhythmias. 

Nursing Care Plan for Alcohol Withdrawl 4

Nursing Care Plan for Alcohol Withdrawl 5

Nursing Diagnosis: Risk for Injury related impaired motor and sensory function, secondary to alcohol withdrawal

Nursing References

Gulanick, M., & Myers, J. L. (2017).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

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Alcohol Withdrawal Case Study (45 min)

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The patient is a 45-year-old male who is a “frequent flyer” in the emergency room for abdominal pain. The patient always has a high ETOH level and demands to be given 3 macaroni and cheese dishes, 2 chicken sandwiches and 2 whole milk cartons. Vital signs are as follows:

Temp 98.6°F orally

Given that he will be admitted to the hospital for a few days without access to alcohol, what protocol medication needs to be ordered for this patient?

• Benzodiazepine (Librium, Ativan)

What question needs to be asked in regard to the patient’s alcohol intake?

• When the last drink was.

The patient reports he drank 2 pints of liquor and a 6-pack of beer tonight.  The patient is telling the nurse that he is serious this time and is going to quit drinking for the holidays so that his family will let him come over for Christmas. The patient is slurring his speech and has a history of trying to elope from the hospital.

What precautions does the nurse need to set up for this patient?

• Seizure precautions, fall precautions and elopement precautions.
• He should also be placed on CIWAA protocol

The patient has an IV line, labs are drawn and the patient has their meal. The blood alcohol level comes back 395 mg/dL. The nurse knows that the patient will metabolize 100 mg/dL every four hours and that the patient is no longer legally intoxicated once it falls to less than 80 mg/dL.

When will this patient likely be no longer legally intoxicated? What is the implication of this time period?

• In 12.6 hours.
• After this point, the patient is at risk for alcohol withdrawal symptoms

What medications will the doctor likely order for this patient to replace vitamins?

• IV fluids with folic acid, thiamine and magnesium sulfate added.
• This is also called a banana bag or rally pack.

The patient has been in the hospital for 14 hours now and is no longer legally intoxicated. The vital signs have stabilized and the patient is alert and oriented x4. The patient remains hopeful to stop drinking and is asking for additional help to stay sober.

What medication could be ordered for this patient to help keep him sober?

What education does this patient need in order to be successful on this medication.

• Avoiding mouthwash, cold medications, aftershaves or anything else that has alcohol in it to avoid having a reaction.
• As well as the reaction (they become immediately ill N/V/D) if they consume alcohol while on Antabuse.

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Activity steps, description, learning objectives.

After completing this continuing education activity you will be able to:

• outline a nursing care plan for an alcohol-dependent patient in acute alcohol withdrawal.
• list nursing interventions that are designed specifically for working with a patient in acute withdrawal for alcohol dependence, including hourly monitoring with the Clinical Institute Withdrawal Assessment for Alcohol, Revised Edition (CIWA-Ar) instrument and symptom-based pharmacologic management of withdrawal based on CIWA-Ar scores.
• identify discharge issues that can occur when working with a patient in acute withdrawal as well as interprofessional team members who can support the patient and family throughout the patient's recovery.

Learning Outcomes

Disclosures.

The authors and planners have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this learning activity.

• ANCC 1.0 CH
• DC - BON 1.0 CH
• GA - BON 1.0 CH
• FL - BON 1.0 CH

Accreditation Statement

SAMUEL M. TIGLAO, DO, ERICA S. MEISENHEIMER, MD, AND ROBERT C. OH, MD, MPH

This is a corrected version of the article that appeared in print.

Am Fam Physician. 2021;104(3):253-262

Author disclosure: No relevant financial affiliations.

Approximately one-half of patients with alcohol use disorder who abruptly stop or reduce their alcohol use will develop signs or symptoms of alcohol withdrawal syndrome. The syndrome is due to overactivity of the central and autonomic nervous systems, leading to tremors, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation. If untreated or inadequately treated, withdrawal can progress to generalized tonic-clonic seizures, delirium tremens, and death. The three-question Alcohol Use Disorders Identification Test–Consumption and the Single Alcohol Screening Question instrument have the best accuracy for assessing unhealthy alcohol use in adults 18 years and older. Two commonly used tools to assess withdrawal symptoms are the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale. Patients with mild to moderate withdrawal symptoms without additional risk factors for developing severe or complicated withdrawal should be treated as outpatients when possible. Ambulatory withdrawal treatment should include supportive care and pharmacotherapy as appropriate. Mild symptoms can be treated with carbamazepine or gabapentin. Benzodiazepines are first-line therapy for moderate to severe symptoms, with carbamazepine and gabapentin as potential adjunctive or alternative therapies. Physicians should monitor outpatients with alcohol withdrawal syndrome daily for up to five days after their last drink to verify symptom improvement and to evaluate the need for additional treatment. Primary care physicians should offer to initiate long-term treatment for alcohol use disorder, including pharmacotherapy, in addition to withdrawal management.

Alcohol-related disorders cause significant physical, psychological, and societal harm. Diagnostic criteria have integrated alcohol abuse and dependence into a single disorder: alcohol use disorder (AUD; Table 1 1 ) . AUD has an estimated 12-month and lifetime prevalence of 13.9% and 29.1%, respectively. 2 Key management principles include promptly recognizing and evaluating for alcohol withdrawal syndrome (AWS), establishing a treatment and monitoring plan, and providing medications and resources to support long-term abstinence.

Recognizing Patients at Risk for AUD

The U.S. Preventive Services Task Force recommends that primary care physicians screen patients 18 years and older for unhealthy alcohol use and offer appropriate behavioral counseling as indicated. 3 Several screening instruments can be used to identify hazardous and harmful drinking behaviors. The three-question Alcohol Use Disorders Identification Test–Consumption (AUDIT-C; https://www.mdcalc.com/audit-c-alcohol-use ) and the Single Alcohol Screening Question (SASQ) instrument have the best accuracy for assessing unhealthy alcohol use in adults 18 years and older. 3 Screening positive with either scale should prompt a longer evaluation with the full 10-question AUDIT ( https://auditscreen.org/ ). 3

The SASQ has a sensitivity of 73% to 88% and specificity of 74% to 100% for detecting unhealthy alcohol use. 3 The question, “How many times in the past year have you had X or more drinks in a day?” where X is five for men and four for women is used in the screening. Any response greater than one is considered positive. In comparison, the full AUDIT is less sensitive (73.9%) but more specific (82.8%) at detecting unhealthy alcohol use. 3 , 4

Despite the high prevalence of AUD, many patients are undertreated partly because of the stigma associated with the diagnosis. 5 For patients who are reluctant to tell their physician about their alcohol consumption, the National Institute on Alcohol Abuse and Alcoholism has a website, Rethinking Drinking ( https://www.rethinkingdrinking.niaaa.nih.gov/ ), that provides assessment and motivational tools for moderation and abstinence treatment resources.

Diagnostic Criteria

Approximately one-half of patients with AUD who abruptly reduce or abstain from alcohol use experience signs or symptoms of AWS. 6 When patients abruptly stop drinking or reduce their alcohol intake after a prolonged period (more than two weeks) of heavy use, withdrawal symptoms begin within six to 24 hours. 7 Withdrawal effects are primarily due to the unmasking of the adaptive responses to chronic alcohol use, 7 including decreased inhibitory activity of alpha-2 receptors, resulting in increased catecholamine levels on presynaptic neurons. Table 2 outlines the diagnostic criteria for alcohol withdrawal. 1

Assessing Severity

The patient's symptom severity should be evaluated using a validated scale to determine the risk of severe or complicated AWS. 8 The syndrome is classified as mild, moderate, severe, and complicated by the most recent guideline from the American Society of Addiction Medicine. 8 Patients with mild AWS tend to have mild to moderate anxiety, sweating, and insomnia, but tremor is absent. Moderately severe AWS causes moderate anxiety, sweating, insomnia, and mild tremor. Those with severe AWS experience severe anxiety and moderate to severe tremor, but they do not have confusion, hallucinations, or seizures. Complicated AWS is identified by seizures or signs and symptoms indicative of delirium, such as the inability to fully comprehend instructions, clouding of the sensorium, confusion, or new onset of hallucinations. 8 Correlating the patient's symptoms in relation to the time since their last drink is useful in anticipating the progression of symptoms. When not properly treated, AWS can progress to delirium tremens ( Table 3 8 – 10 ) .

The two most commonly used tools to assess withdrawal symptoms are the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar; https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal ) and the Short Alcohol Withdrawal Scale (SAWS). The CIWA-Ar is a 10-item questionnaire completed by a physician that assesses the signs, symptoms, and severity of alcohol withdrawal to guide benzodiazepine dosing as part of symptom-triggered dosing regimens ( Figure 1 ) . 11 The SAWS is a validated 10-item symptom checklist designed to be a self-assessment completed by the patient ( Figure 2 ) . 12 The initial assessment can help to determine appropriate treatment setting and to monitor symptom improvement.

Physicians may consider laboratory testing that includes a comprehensive metabolic panel (basic metabolic profile and hepatic panel), a complete blood count with differential, urine drug screen, and blood alcohol level. 8 These results also aid in identifying the risk of severe or complicated withdrawal and determining the appropriate disposition of care.

Treatment goals include reducing withdrawal symptoms, preventing seizures, and preventing progression to delirium tremens, which has a 5% to 10% mortality rate. 8 – 10 In appropriate patients, outpatient treatment for AWS is safe and may be preferred. A randomized trial (n = 164) comparing outpatient and inpatient treatment of male veterans with mild to moderate withdrawal symptoms found the duration of therapy was shorter for outpatients. 13 The American Society of Addiction Medicine guidelines define two levels of outpatient care: Level 1 Withdrawal Management and Level 2 Withdrawal Management. 8 The two levels differ in their monitoring capabilities, with Level 1 Withdrawal Management being a typical outpatient clinic and Level 2 Withdrawal Management having extended on-site monitoring outside the scope of most primary care clinics. Level 2 Withdrawal Management facilities, including day hospitals, mental health facilities, and addiction treatment facilities, can monitor each patient for several hours each day and have greater access to psychological or psychiatric specialty treatments. Generally, patients experiencing mild symptoms (CIWA-Ar score less than 10) can be managed in Level 1 or Level 2 Withdrawal Management. For those with moderate symptoms, particularly those at increased risk of complicated withdrawal, a Level 2 Withdrawal Management facility may be more appropriate ( Figure 3 8 ) . Those with severe or complicated symptoms or additional risk factors should be treated in an inpatient facility ( Table 4 8 ) . [ corrected ]

MILD SYMPTOMS (CIWA-AR SCORE LESS THAN 10 OR SAWS SCORE LESS THAN 12)

For patients with mild symptoms who are at minimal risk of developing severe or complicated alcohol withdrawal, treatment options include supportive care with or without pharmacotherapy ( Table 5 8 , 14 ) . Patients at minimal risk have none of the following factors: history of alcohol withdrawal–related delirium or seizures, multiple prior withdrawal episodes, comorbid illness, age older than 65 years, long duration of alcohol consumption (e.g., heavy alcohol use five or more days in the past month 15 ), seizures during current withdrawal episode, marked autonomic hyperactivity on presentation, and physiologic dependence on GABAergic agents. 8

Supportive care includes educating patients on the course of withdrawal, monitoring for severe withdrawal, instructing them on how to maintain low-stimulation home environments, consuming noncaffeinated fluids, recommending a daily multivitamin containing 400 mcg of folic acid, and prescribing thiamine (typical dosage of 100 mg daily for three to five days). 16 , 17 If medications are used, carbamazepine (Tegretol) and gabapentin (Neurontin) are appropriate options for monotherapy but do not reliably prevent withdrawal seizures or delirium tremens. 18 Gabapentin is effective in treating AUD; patients already taking it should continue during treatment of AWS. 18 , 19

MODERATE SYMPTOMS (CIWA-AR SCORE OF 10 TO 18 OR SAWS SCORE GREATER THAN 12)

Benzodiazepines are a first-line therapy for patients experiencing moderate withdrawal symptoms, reducing the risk of seizure and the development of delirium tremens 20 , 21 ( Table 5 8 , 14 ) . Benzodiazepine dosing can be either fixed or symptom triggered. Fixed dosing sets a specific dose and time and is gradually tapered on a set schedule. Symptom-triggered dosing is given as needed based on specific CIWA-Ar or SAWS scores. Symptom-triggered use of benzodiazepines is preferred when the patient or caregiver can reliably assess symptoms and follow the dosing guidelines. 22

Long-acting benzodiazepines, such as chlordiazepoxide (Librium) and diazepam (Valium), can help control and minimize breakthrough symptoms and are preferred over short-acting benzodiazepines. 23 , 24 Patients should be monitored for oversedation and respiratory depression, especially if concomitant liver disease is present. 25 Physicians should consider benzodiazepines with less hepatic metabolism, such as lorazepam (Ativan) and oxazepam (Serax), in patients with liver disease. 8 If contraindications to benzodiazepines exist or if the risk of use outweighs the benefits, gabapentin, carbamazepine, and phenobarbital may be considered as alternative monotherapies. 8 , 18

SEVERE OR COMPLICATED SYMPTOMS (CIWA-AR SCORE OF 19 OR MORE)

Those with severe or complicated symptoms should be referred to the nearest emergency department for inpatient hospitalization.

OTHER MEDICATIONS

Gabapentin, carbamazepine, and valproate (Depacon) may be used adjunctively with benzodiazepines if symptoms persist despite adequate use. 18 Valproate is currently not recommended as monotherapy for the treatment of alcohol withdrawal. 26 Alpha-adrenergic agonists (e.g., clonidine) and beta-blocker agonists (e.g., atenolol, metoprolol) may also be used adjunctively with benzodiazepines for persistent hypertension or tachycardia. 27 , 28 Evidence does not support the use of oral or intravenous alcohol, baclofen (Lioresal), or magnesium in prophylaxis and treatment of AWS. 21 , 29 , 30 Table 5 provides a list of several medications used to treat moderate AWS. 8 , 14

Monitoring and Follow-up

The frequency and setting for outpatient monitoring of AWS should be guided by symptom severity, risk of complications, and social factors, including reliable social support and a safe home environment. Most patients will require daily evaluations for up to five days after their last drink, but evaluations may increase or decrease in frequency as necessitated by changes in symptom severity. 8 These visits can be with any health care professional. Face-to-face visits are preferred, but telemedicine appointments can alternate with in-person visits when necessary, for instance during treatment in a viral pandemic. 8 Evaluation should include multiple indicators of symptom severity and overall health, including mental status, hydration, sleep, mood, suicidality, and substance use. Blood pressure, pulse, and alcohol breath analysis should be obtained whenever possible. The assessment should also include a validated measure of withdrawal symptom severity, ideally with the same instrument as the initial assessment.

Continued symptoms despite multiple doses of the prescribed medication, worsening or severe symptoms (persistent vomiting, hallucinations, confusion, or seizure), signs of oversedation, worsening psychiatric symptoms, or unstable vital signs should prompt transfer to a higher level of care. Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.

Supporting Long-Term Abstinence

Long-term treatment of AUD should begin concurrently with the management of AWS. 8 Successful long-term treatment includes evidence-based community resources and pharmacotherapy. Primary care physicians should offer to initiate appropriate medications.

Currently, three medications are approved by the U.S. Food and Drug Administration for AUD treatment: acamprosate, naltrexone (Revia), and disulfiram (Ant-abuse). Acamprosate and naltrexone have the best evidence for use in AUD and should be initiated in patients who wish to reduce or abstain from alcohol use. 31 Neither of the medications has been shown consistently to be more effective than the other, and thus the choice should be individualized based on patient and physician preference. 31 Disulfiram should be considered for patients who have not responded to acamprosate or naltrexone. 32

Gabapentin and topiramate (Topamax), though not approved for this use, may be considered as second-line treatments. 33 In a randomized controlled trial, patients who started taking gabapentin after three days of abstinence had fewer heavy drinking days (defined as five or more drinks for men and four or more drinks for women) and greater rates of abstinence than those who received placebo. 34 These results were more pronounced in patients with higher self-reported scores on the Alcohol Withdrawal Severity Checklist than those with lower scores. 34 , 35 Antidepressants may be beneficial for concomitant mood disorders but are not used for the treatment of AUD. 33

Community-based support and formal therapeutic interventions should accompany pharmacotherapy. Motivational interviewing and cognitive behavior therapy are beneficial. 36 A recent Cochrane review found Alcoholics Anonymous and 12-step facilitation programs that follow a specific manual or syllabus to be more effective at increasing rates of abstinence at one-, two-, and three-year follow-up than motivational interviewing or cognitive behavior therapy, with substantial cost savings. 37 Regular monthly follow-up visits for at least one year can increase abstinence. 8

This article updates previous articles on this topic by Muncie, et al. 38 ; Blondell 14 ; and Bayard, et al. 10

Data Sources: A PubMed search was completed using the key terms alcohol use disorder (AUD), alcohol withdrawal, alcohol dependence, epidemiology, diagnosis, delirium tremens, screening, outpatient, and management. The search included meta-analyses, systematic reviews, practice guidelines, clinical trials, and original studies. Also searched were the Cochrane database, ECRI Guidelines Trust, Essential Evidence Plus, and the U.S. Preventive Services Task Force. Search dates: March 4 and 14, April 15 and 29, and June 15, 2020.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Uniformed Services University of the Health Sciences, the U.S. Army Medical Department, or the U.S. Army at large.

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Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757-766.

Curry SJ, Krist AH, Owens DK, et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(18):1899-1909.

Smith PC, Schmidt SM, Allensworth-Davies D, et al. Primary care validation of a single-question alcohol screening test [published correction appears in J Gen Intern Med . 2010;25(4):375]. J Gen Intern Med. 2009;24(7):783-788.

Carvalho AF, Heilig M, Perez A, et al. Alcohol use disorders. Lancet. 2019;394(10200):781-792.

Goodson CM, Clark BJ, Douglas IS. Predictors of severe alcohol withdrawal syndrome. Alcohol Clin Exp Res. 2014;38(10):2664-2677.

Turner RC, Lichstein PR, Peden JG, et al. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med. 1989;4(5):432-444.

The ASAM clinical practice guideline on alcohol withdrawal management [published correction appears in J Addict Med . 2020;14(5):e280]. J Addict Med. 2020;14(3S suppl 1):1-72.

Gortney JS, Raub JN, Patel P, et al. Alcohol withdrawal syndrome in medical patients. Cleve Clin J Med. 2016;83(1):67-79.

Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician. 2004;69(6):1443-1450. Accessed January 5, 2021. https://www.aafp.org/afp/2004/0315/p1443.html

Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). Br J Addict. 1989;84(11):1353-1357.

Elholm B, Larsen K, Hornnes N, et al. A psychometric validation of the Short Alcohol Withdrawal Scale (SAWS). Alcohol Alcohol. 2010;45(4):361-365.

Hayashida M, Alterman AI, McLellan AT, et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. N Engl J Med. 1989;320(6):358-365.

Blondell RD. Ambulatory detoxification of patients with alcohol dependence. Am Fam Physician. 2005;71(3):495-502. Accessed January 5, 2021. https://www.aafp.org/afp/2005/0201/p495.html

National Institute on Alcohol Abuse and Alcoholism. Drinking levels defined. Accessed April 28, 2021. https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking

British Columbia. BC guidelines. Problem drinking part 3—office based management of alcohol withdrawal and prescribing medications for alcohol dependence. Updated April 1, 2013. Accessed January 5, 2021. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/problem-drinking#part3

Rees E, Gowing LR. Supplementary thiamine is still important in alcohol dependence. Alcohol Alcohol. 2013;48(1):88-92.

Hammond CJ, Niciu MJ, Drew S, et al. Anticonvulsants for the treatment of alcohol withdrawal syndrome and alcohol use disorders. CNS Drugs. 2015;29(4):293-311.

Myrick H, Malcolm R, Randall PK, et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. 2009;33(9):1582-1588.

Department of Veterans Affairs, Department of Defense. VA/DoD Clinical practice guideline for the management of substance use disorders; 2015. Accessed January 5, 2021. https://www.healthquality.va.gov/guidelines/mh/sud/

Mayo-Smith MF American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. JAMA. 1997;278(2):144-151.

Holleck JL, Merchant N, Gunderson CG. Symptom-triggered therapy for alcohol withdrawal syndrome: a systematic review and meta-analysis of randomized controlled trials. J Gen Intern Med. 2019;34(6):1018-1024.

Sachdeva A, Choudhary M, Chandra M. Alcohol withdrawal syndrome: benzodiazepines and beyond. J Clin Diagn Res. 2015;9(9):VE01-VE07.

Amato L, Minozzi S, Vecchi S, et al. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010(3):CD005063.

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Soyka M, Kranzler HR, Hesselbrock V, et al.; WFSBP Task Force on Treatment Guidelines for Substance Use Disorders. Guidelines for biological treatment of substance use and related disorders, part 1: alcoholism, first revision. World J Biol Psychiatry. 2017;18(2):86-119.

Brotherton AL, Hamilton EP, Kloss HG, et al. Propofol for treatment of refractory alcohol withdrawal syndrome: a review of the literature. Pharmacotherapy. 2016;36(4):433-442.

Liu J, Wang L-N. Baclofen for alcohol withdrawal. Cochrane Database Syst Rev. 2019(11):CD008502.

Sarai M, Tejani AM, Chan AHW, et al. Magnesium for alcohol withdrawal. Cochrane Database Syst Rev. 2013(6):CD008358.

Maisel NC, Blodgett JC, Wilbourne PL, et al. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful?. Addiction. 2013;108(2):275-293.

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Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018;175(1):86-90.

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Pittman B, Gueorguieva R, Krupitsky E, et al. Multidimensionality of the Alcohol Withdrawal Symptom Checklist: a factor analysis of the Alcohol Withdrawal Symptom Checklist and CIWA-Ar. Alcohol Clin Exp Res. 2007;31(4):612-618.

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Improving Nursing Knowledge of Alcohol Withdrawal

Second generation education strategies.

Berl, Kimberly MSN, RN, PCCN; Collins, Michelle L. MSN, RN-BC, ACNS-BC; Melson, Jo MSN, RN, FNP-BC; Mooney, Ruth PhD, MN, RN-BC; Muffley, Cheryl MSN, RN-BC; Wright-Glover, Angela MSN, RN-BC

Kimberly Berl, MSN, RN, PCCN, is a Staff Development Specialist for the Stepdown and Intensive Care Unit, Wilmington Hospital of Christiana Care Health System, Delaware.

Michelle L. Collins, MSN, RN-BC, ACNS-BC, is Director of Nursing Professional Development and Education, Christiana Hospital of Christiana Care Health System, Wilmington, Delaware.

Jo Melson, MSN, RN, FNP-BC, is a Nurse Practitioner, Wilmington Hospital of Christiana Care Health System, Delaware.

Ruth Mooney, PhD, MN, RN-BC, is a Nursing Research Facilitator, Christiana Care Health System, Wilmington, Delaware.

Cheryl Muffley, MSN, RN-BC, is a Staff Development Specialist for a Medical Stepdown Unit and the Express Admission Unit, Christiana Hospital of Christiana Care Health System, Wilmington, Delaware.

Angela Wright-Glover, MSN, RN-BC, is a Staff Development Specialist for two medical-telemetry units, Christiana Hospital of Christiana Care Health System, Wilmington, Delaware.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( www.jnpdonline.com ).

ADDRESS FOR CORRESPONDENCE: Kimberly Berl, MSN, RN, PCCN, Wilmington Hospital, 501 W. 14th Street, P.O. Box 1668, Wilmington, DE 19801 (e-mail: [email protected] ).

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0 .

Christiana Care Health System implemented a Care Management Guideline for Alcohol Withdrawal Symptom Management, which provided direction for inpatient screening for alcohol withdrawal risk, assessment, and treatment. Nurses educated on its use expressed confusion with the use of the assessment tools, pharmacokinetics, and pathophysiology of alcohol withdrawal and delirium tremens. Reeducation was provided by nursing professional development specialists. Pre- and postsurveys revealed that nurses were more confident in caring for patients with alcohol withdrawal.

The National Survey of Drug Use and Health, conducted from 2008 to 2012, reveals that 7.1% of Delawareans aged 12 or older describe themselves as dependent upon alcohol or abusive of alcohol in the previous year. In addition, 7.4% of these individuals considered themselves heavy users of alcohol, and yet only 3.8% received treatment—trends that are comparable to national averages ( Substance Abuse and Mental Health Services Administration, 2013 ). Throughout the nation, the number of adults admitted to a hospital with an alcohol use disorder increased significantly from 2006 to 2010 ( National Institute on Alcohol Abuse and Alcoholism, 2013 ), translating to approximately one in five admitted adult patients ( Elliott, Geyer, Lionetti, & Doty, 2013 ).

If untreated, up to 6% of patients with an alcohol use disorder will experience alcohol withdrawal when alcohol is withheld, with up to 10% of those progressing to delirium tremens (DT), a potentially life-threatening complication ( Melson, Kane, Mooney, McWilliams, & Horton, 2014 ). Screening and early management of alcohol withdrawal prevents progression of symptoms and further deterioration to DT ( Pecoraro et al., 2012 ). Before implementing the Care Management Guideline (CMG) for Alcohol Withdrawal Symptom Management, patients admitted to the largest healthcare system in Delaware were not evaluated for the potential of experiencing alcohol withdrawal, nor were they assessed or recognized until their behavior escalated to a crisis. The CMG for Alcohol Withdrawal Symptom Management is a hospital system tool developed by an interdisciplinary care team used to aid clinicians and providers in the management of this patient population. Prior to program implementation, severe symptoms arose before staff knew that patients were experiencing alcohol withdrawal. Delay in diagnosis and treatment resulted in suboptimal patient outcomes. Because of the absence of a protocol, patients experiencing escalating alcohol withdrawal were often transferred to an intensive care unit (ICU). Consequently, nurses and providers working outside of ICU were not prepared or educated to adequately manage the complexity of these patients.

The model of change that served as the framework of this process was Lewin’s change model. Kurt Lewin, a social psychologist, postulated a three-stage theory of change: unfreezing, change, and freezing or refreezing ( Lewin, 1947 ). For change to be successful, the driving forces for the change must be strengthened ( Shirey, 2013 ). For this project, such forces included safety considerations for nurses and patients, a desire on the part of the hospital to better manage patients with alcohol withdrawal, thus preventing DT and decreasing use of ICU and rapid response teams for this subset of patients. The nurses caring for patients experiencing alcohol withdrawal were unaware of the physiology of alcohol withdrawal and DT, and lacked confidence in caring for this patient population. They also felt that it would require more time to care for these patients, thus depriving other patients of their “share” of the nurse’s time. According to Lewin’s theory, these attitudes and beliefs are known as restraining forces, and these must be weakened in order for the change to occur successfully ( Shirey, 2013 ).

PHASE I: EDUCATION BEFORE IMPLEMENTATION OF THE CMG

Nursing professional development (NPD) specialists educated nurses and providers on the use of the new protocol before implementation. Education was provided by NPD specialists using small groups on individual patient care units, and larger groups of nurses from multiple units in a classroom setting.

There was much resistance to this initial education, both by NPD specialists and staff nurses. The short time frame designated for educating all of the nurses was challenging, and most NPD specialists had not previously used the Clinical Institutes Withdrawal Assessment-Alcohol revised (CIWA-Ar). The CIWA-Ar is a symptom-based assessment tool that quantifies the level of alcohol withdrawal symptoms, and helps determine appropriate Benzodiazepine dosing when the patient has a history of alcohol use. It is a freely distributed and widely used tool easily accessed via the Internet. The CIWA-Ar is widely used in both acute care and outpatient settings because of its high level of interrater reliability and ease of use. It is comprised of 10 questions and indicates the level of withdrawal the patient may be experiencing ( Sarff & Gold, 2010 ). Although relatively uncomplicated to administer, the CIWA-Ar does require instruction and a level of familiarity with its questions. Therefore, the NPD specialists needed instruction on how to properly perform the assessment and how to appropriately intervene. An educational slide presentation on risk assessment and the CIWA-Ar tool was reviewed with the NPD specialists by one of the advance practice nurses (APN) leading the project. Education included Nursing Grand Rounds and a No Harm Intended session. Nursing Grand Rounds is a presentation developed by nurses, and focuses on specific case studies and lessons learned. No Harm Intended sessions are presented by an interdisciplinary team for all healthcare team members, and cover actual or potential issues within the healthcare system. Providing education using an interdisciplinary approach allows a free exchange of ideas across fields, fosters an appreciation and understanding of others’ areas of expertise, and provides all those involved with an opportunity to learn from each other. Alcohol withdrawal served as a topic for both of these forums, and concentrated on situations where inpatients placed themselves or staff at high risk for injury. Nurses from inpatient units recounted difficult experiences with patients actively withdrawing from alcohol. Content experts provided information about the history of alcohol abuse management, basic pathophysiology of alcohol abuse, and current practice within our healthcare system. Key aspects of the new alcohol withdrawal CMG were introduced. The CMG included the Alcohol Withdrawal Risk Assessment (AWRA), the CIWA-Ar, order sheet, and algorithms. Completed on admission, the AWRA determines the risk for alcohol withdrawal. A score of 5 or greater prompts the nurse to complete the CIWA-Ar.

Many nurses felt the care of patients experiencing alcohol withdrawal was extremely difficult to manage and required increased nursing resources. Often times, these patients required high dosages of medication to alleviate their withdrawal symptoms, which many floor nurses were uncomfortable administering. In addition, there were several instances of patients attempting to harm themselves or harm others while withdrawing from alcohol, which contributed to nurses’ fear for patient and staff safety. Unfortunately, completing the AWRA and following the CMG were viewed as simply additional tasks for them to perform. The benefits of treating patients with alcohol withdrawal on the medical surgical units, rather than in the ICUs, were not clear to the nurses. These were some of the restraining forces that had to be addressed in order to successfully implement this new process.

INITIAL EVALUATION OF CMG IMPLEMENTATION

Documentation review.

Point prevalence assessment conducted via chart review hospital-wide one month after implementation helped to determine compliance. Nurses gathered data and were asked to determine if the AWRA was completed on admission. If the AWRA score was 5 or greater, nurses were instructed to complete a baseline CIWA-Ar. In addition, the provider was to be contacted to initiate the appropriate treatment plan and order set. In March of 2010, of the 184 charts that were reviewed, 96 (52%) had the AWRA completed. All of the patients who scored 5 or greater on the AWRA had the CIWA-Ar initiated. In April of 2010, charts for 224 patients were reviewed. Of those, 141 (63%) had the AWRA completed. Again, all of the patients who scored 5 or greater on the AWRA had the CIWA-Ar initiated. The results also showed that five patients scored 8 or greater on the CIWA-Ar; however, two of these patients did not have the CMG initiated. Moreover, these findings revealed opportunities for additional education regarding use of the AWRA and the CMG.

Focus Group

An APN involved in the alcohol withdrawal task force led a focus group to determine concerns or problems that staff nurses encountered related to implementation of the CMG. The format of the focus group included eight open-ended questions to solicit information and keep the discussion focused. Nurse managers sent staff from their units to provide representative opinions from their respective units. Two APNs with knowledge of the CMG and experience in leading focus groups facilitated, and two nurses not involved in the discussion documented the sessions.

The following themes emerged as listed in Table 1 :

• Reeducation needs,
• Effective use of CIWA-Ar scores,
• Increased burden of caring for patients on medical-surgical units,
• Limitations of the form used for documentation, and
• Ethical dilemmas.

An education subcommittee of the alcohol withdrawal team was formed in order to address knowledge gaps and assist in developing second-generation education for staff using information obtained from the focus group and other feedback. The purpose of this team was to facilitate understanding among nurses through reeducation. Units with the highest incidence of patients with the discharge diagnosis of alcohol withdrawal and/or DT were chosen to pilot this second generation of education.

PHASE II: EDUCATION FOLLOWING IMPLEMENTATION OF THE CMG

Focus group feedback, staff comments, and discussion with the interdisciplinary team revealed confusion around the correct meaning of the AWRA and CIWA-Ar scores. Furthermore, the scores were being reported to the providers interchangeably. It was clear that there was a need to remedy and clarify this misunderstanding quickly. A Safety First Alert , a rapid communication process to disseminate key safety practices and education across the organization, was used in December 2009 to provide timely communication to the appropriate staff, and focused on clarifying the difference between the two assessment tools: the AWRA score as an initial screening tool and the CIWA-Ar score as a symptom-based assessment and management tool.

According to Lewin’s Theory of Planned Change, driving forces must be identified and presented to all involved to ensure a successful transition ( Shirey, 2013 ). In this case, these forces included increased patient safety and a decrease in the incidence of DT, ICU transfers, and rapid response teams. NPD specialists were now actively involved in the alcohol withdrawal committee, and their expertise in nursing development and education was utilized to address targeted learning needs. The educators were better able to understand nursing’s various concerns and determine the focus for our educational methods in order to focus on the driving forces and bring about positive change. The goal was to educate nurses to recognize alcohol withdrawal symptoms before patients advanced to DT, and initiate treatment before the onset of severe symptoms. Therefore, education focused on increasing nurses’ depth of knowledge about the differences between Alcohol Withdrawal Syndrome versus DT. On the basis of focus group results, small group discussions occurred with the alcohol withdrawal team and staff. NPD specialists presented second-generation education using educational slides and included content in the following areas:

• physiology of alcohol withdrawal and DT;
• mechanism of action of benzodiazepines, dosing, and frequency of administration for effective management of alcohol withdrawal;
• directions on how to complete the CIWA-Ar;
• correct use of the newly implemented electronic AWRA and CIWA-Ar forms; and
• mobilization of additional resources.

This second phase of education included greater sensitivity to environmental distraction, so educators used small group instruction in break rooms.

Electronic versions of the AWRA and the CIWA-Ar forms introduced a year after initial program implementation in October 2010 now sends an electronic reminder that alerts the nurse to complete the AWRA upon admission. This transformational change reminds nurses automatically to complete the CIWA-Ar and to intervene in a timely manner.

EVALUATION OF THE CMG IMPLEMENTATION AFTER PHASE II EDUCATION

For three consecutive quarters following completion of secondary education, charts of patients with a discharge diagnosis of alcohol withdrawal or DT were reviewed as delineated in Table 2 . Increases in the percentage of AWRA completed were seen (79% in the fourth quarter of 2010, 87% in the first quarter of 2011, and 90% in the second quarter of 2011). The CIWA-Ar was administered in 94%, 100%, and 98% of patients whose charts were reviewed. One reason more patients had a greater number of CIWA-Ar completed than AWRA is that AWRA is not always completed in critical care units. Often times in these units, patients are unable to communicate verbally during the admissions process, thereby preventing an accurate assessment. Families are requested to provide the information, but are often times unable to offer a thorough history. Patients may have been admitted to these units and then later transferred to noncritical care areas.

NPD specialists knew it was important to evaluate the effectiveness of the education. The survey instrument and education plan were developed by the NPD specialists and validated by the alcohol withdrawal team. The preeducation survey consisted of four questions with Likert scale responses from 1 to 4, with 1 being none and 4 being extensive . As shown in Table 3 , one additional question was added to the posteducation survey regarding the impact of the electronic version of the CIWA-Ar.

Surveys were conducted using Zoomerang and were distributed to approximately 250 nurses on five medical units. These units were selected based on the number of patients with a discharge diagnosis of alcohol withdrawal. Preeducation surveys were conducted in October 2010, and posteducation surveys were conducted in January 2011. Responses were obtained from 88 nurses in the preeducation survey and 92 in the posteducation survey.

As shown in Figure, Supplemental Digital Content 1, https://links.lww.com/JNPD/A6 , the preeducation survey revealed that many nurses rated their knowledge of the CIWA-Ar assessment tool as moderate, substantial, or extensive. This was unexpected based on the feedback from the focus group discussion, as we expected the ratings to be much lower. The posteducation survey showed that nurses’ ratings of their knowledge of the CIWA-Ar assessment tool increased. The greatest changes occurred in the moderate, substantial, and extensive categories with a decrease in the number of nurses rating their knowledge as moderate and an increase in the number of nurses rating their knowledge as either substantial or extensive. There were improvements in ratings for all questions despite the high preeducation ratings. The second-generation education was designed to overcome the lack of knowledge needed in order to adequately care for patients at risk for or experiencing alcohol withdrawal.

Nurses were asked to rate their comfort level in caring for alcohol withdrawal patients and in using the alcohol withdrawal algorithm before and after education. Nurses rated their comfort level as none, limited, moderate, substantial, or extensive. As shown in Figure, Supplemental Digital Content 2, https://links.lww.com/JNPD/A7 statistically significant differences were found in comfort level caring for alcohol withdrawal patients, with six nurses rating their comfort limited on the presurvey and choosing that rating on the postsurvey, a decrease in nurses rating their comfort level as moderate (45 pre; 32 post) and an increase in those rating their comfort level as substantial (38 pre; 47 post). There was no change in nurses rating their comfort level as extensive (11 pre and post). Mann–Whitney U test was performed, and differences from pre to post were statistically significant ( p = .051). Comfort level with the alcohol withdrawal algorithm showed a similar pattern of change; however, this was not statistically significant, with a Mann–Whitney U test of p = .073.

Additional analysis revealed the impact of electronic assessment on the nurses’ ability to manage patients experiencing alcohol withdrawal. Figure, Supplemental Digital Content 3, https://links.lww.com/JNPD/A8 illustrates the majority (68%) of nurses rated the electronic CIWA-Ar task as having substantially or extensively improved their ability to care for this patient population. Of the remaining nurses who responded to the survey, 24% indicated moderately, 7% limited, and only 1% rated the impact as none.

Several lessons were learned from this project related to implementing change across multiple patient care units. Initially, we did not emphasize the rationale for the practice change or the physiology of alcohol withdrawal and treatment modalities. Consequently, the initial education lacked several key components and was inhibited by hastened time line for implementation. In listening to staff, the need for additional education was noted. Recognizing the value of our nurse educators in the development and planning of learning content to address behavior change, their involvement was requested. Lastly, we failed to appreciate the benefit of conducting a pilot as a means of discovering the shortcomings of our practice change.

Lewin theorized that, in order to move through the stages of change successfully, there needs to be a comprehensive action plan to engage those experiencing the transition ( Shirey, 2013 ). Unfortunately because of the pressing nature of the issues at hand, this step was overlooked in the original education plan, and therefore, the project was set up to fail. When the second generation of education was implemented, the alcohol withdrawal team and NPD specialists made great efforts to ensure that frontline staff understood the necessity and benefit of the change. By utilizing the focus groups and surveys, nurses felt their voices had been heard and were now able to unfreeze their behaviors and successfully navigate the transition. Over the past year, members of the alcohol withdrawal task force and education committee have informally rounded with bedside nurses. The conversations they have had throughout the organization support these results. These discussions revealed that they now consider themselves experts in caring for patients with alcohol withdrawal. One nurse stated, “We are seasoned nurses and we know how to take care of patients with alcohol withdrawal.” These statements indicate that nurses have “refrozen” their beliefs and new behaviors. Because of these findings and our commitment to our change model, similar education was later provided to nurses throughout the health system.

Use of the CMG has changed the course for patients admitted to the hospital at risk for alcohol withdrawal and has also increased the confidence level of nurses caring for patients at risk for alcohol withdrawal. Successful education, planning, and proper execution of the CMG by nurses and providers had direct positive impact on this patient population.

PATH FORWARD

Results of the pre- and postsurveys revealed successful reeducation efforts, and education for the remainder of the medical, surgical, and stepdown units was based on these results. A simulation involving a standardized patient experiencing alcohol withdrawal and DT was part of a collaborative learning project for resident physicians and novice nurses. Currently, an additional alcohol withdrawal simulation scenario, coupled with didactic classroom content, is incorporated into nursing orientation. Future strategies will include incorporation of alcohol withdrawal into a Web-based education module for all nurses to complete on an annual basis, and development of a video about a patient experiencing alcohol withdrawal. Through the provision of nursing education regarding alcohol withdrawal, nurses’ comfort level in caring for alcohol withdrawal patients has improved. By increasing their knowledge, nurses are more confident in caring for patients suffering from alcohol withdrawal, potentially improving multidisciplinary communication and clinical outcomes.

Supplemental Digital Content

• JNPD_36_1_2015_11_04_BERL_14-458_SDC1.pdf; [PDF] (121 KB)
• JNPD_31_6_2015_11_04_BERL_14-458_SDC2.pdf; [PDF] (63 KB)
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Understanding Neonatal Abstinence Syndrome: Episode 263

Neonatal Abstinence Syndrome

Helping a Patient Through Alcohol Withdrawal

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• v.22(2); Jul-Dec 2013

Clinical management of alcohol withdrawal: A systematic review

Shivanand kattimani.

Department of Psychiatry, Regional Deaddiction Center, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Balaji Bharadwaj

Alcohol withdrawal is commonly encountered in general hospital settings. It forms a major part of referrals received by a consultation-liaison psychiatrist. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on pharmacological management of alcohol withdrawal in humans with no limit on the date of publication. Articles not relevant to clinical management were excluded based on the titles and abstract available. Full-text articles were obtained from this list and the cross-references. There were four meta-analyses, 9 systematic reviews, 26 review articles and other type of publications like textbooks. Alcohol withdrawal syndrome is a clinical diagnosis. It may vary in severity. Complicated alcohol withdrawal presents with hallucinations, seizures or delirium tremens. Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsants. Clinical institutes withdrawal assessment-alcohol revised is useful with pitfalls in patients with medical comorbidities. Evidence favors an approach of symptom-monitored loading for severe withdrawals where an initial dose is guided by risk factors for complicated withdrawals and further dosing may be guided by withdrawal severity. Supportive care and use of vitamins is also discussed.

Alcohol dependence is a severe form of alcohol use disorder and it may first manifest when a person develops withdrawal symptoms after stopping alcohol - either due to family pressure, self-motivation, physical ill health or difficulty in procuring alcohol. It is a common misconception among regular drinkers that stopping alcohol causes more problems than continuing it. This may be partly true in those who have developed dependence as they may experience withdrawal symptoms including autonomic arousal, hallucinations, seizures and delirium tremens (DT). Since many people underplay or minimize their drinking behavior, they tend to develop withdrawal symptoms when hospitalized for other physical problems and not for alcoholism forming a substantial part of consultation-liaison psychiatry.

Our aim was to review the evidence base for the appropriate management of the alcohol withdrawal syndrome using pharmacotherapy. This review informs readers about medications to be used for treating alcohol withdrawal, their dosing strategies to be used and managing specific complications arising during alcohol withdrawal such delirum trements (DT) and alcohol withdrawal seizures. We specifically sought articles relating to medications commonly used in India and those that can be recommended based on strong evidence.

MATERIALS AND METHODS

We searched Pubmed for articles published in English on pharmacological management of alcohol withdrawal in humans without any restriction on the publication date. We used the following medical subject heading (MeSH) terms: “Alcoholism”, “alcohol withdrawal seizures” and “alcohol withdrawal delirium” and “drug therapy”. Although “alcoholism” alone yielded 43921 articles, “alcohol withdrawal seizures” returned 103 results, “alcohol withdrawal delirium” 911 results; combining these terms with the MeSH term “drug therapy” yielded 1037, 10 and 102 articles respectively. Articles not relevant to the topic were excluded based on the titles and abstract available. Full text articles were obtained for the 24 articles relevant to clinical practice at this stage. Cross-references mentioned in the full text articles were checked for other relevant articles. Further search for books, monographs and articles relating to thiamine supplementation, neurobiology of alcohol withdrawal state were done by hand-search and other convenient means. A total of 100 full text-articles, books and monographs were identified. There were four meta-analyses, nine systematic reviews and 26 review articles. Other publications were randomized controlled trials, observational studies, case reports, manuals and monographs. By exclusion of articles relating to drugs with poor quality of evidence and inclusion of the latest version of Cochrane reviews, we were left with 35 published studies for our review focused on the clinical management and the rest are reports, books and monographs.

The literature was reviewed independently by the two authors. We tabulated the major recommendations from each source as regards the management of alcohol withdrawal with respect to severity of withdrawal, doses and regimen used in each study and the outcomes.

THE ACUTE ALCOHOL WITHDRAWAL SYNDROME

Alcohol is a central nervous system (CNS) depressant, influencing the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). Ordinarily, the excitatory (glutamate) and inhibitory (GABA) neurotransmitters are in a state of homeostasis [ Figure 1a ]. Alcohol facilitates GABA action, causing decreased CNS excitability [ Figure 1b ]. In the long-term, it causes a decrease in the number of GABA receptors (down regulation). This results in the requirement of increasingly larger doses of ethanol to achieve the same euphoric effect, a phenomenon known as tolerance. Alcohol acts as an N-methyl-D-aspartate (NMDA) receptor antagonist, thereby reducing the CNS excitatory tone. Chronic use of alcohol leads to an increase in the number of NMDA receptors (up regulation) and production of more glutamate to maintain CNS homeostasis [ Figure 1c ].

Neurochemistry of alcohol withdrawal

With the sudden cessation of alcohol in the chronic user, the alcohol mediated CNS inhibition is reduced and the glutamate mediated CNS excitation is left unopposed, resulting in a net CNS excitation [ Figure 1d ]. This CNS excitation results in the clinical symptoms of alcohol withdrawal in the form of autonomic over activity such as tachycardia, tremors, sweating and neuropsychiatric complications such as delirium and seizures.[ 1 ]

Dopamine is another neurotransmitter involved in alcohol withdrawal states. During alcohol use and withdrawal the increase in CNS dopamine levels contribute to the clinical manifestations of autonomic hyper arousal and hallucinations.

Repeated episodes of withdrawal and neuroexcitation results in a lowered seizure threshold as a result of kindling[ 2 ] predisposing to withdrawal seizures.

Making a diagnosis of alcohol withdrawal syndrome

The alcohol withdrawal syndrome is diagnosed when the following two conditions are met

• A clear evidence of recent cessation or reduction of alcohol after repeated and usually prolonged and/or high-dose use.

Common signs and symptoms of alcohol withdrawal syndrome[ 3 ]

The diagnosis requires adequate history of the amount and frequency of alcohol intake, the temporal relation between cessation (or reduction) of alcohol intake and the onset of symptoms that may resemble a withdrawal state. When the onset of withdrawal like symptoms or delirium is after 2 weeks of complete cessation of alcohol, the diagnosis of alcohol withdrawal syndrome or DT becomes untenable, regardless of frequent or heavy use of alcohol. Table 2 gives a clinical description of alcohol withdrawal syndrome by severity and syndromes.[ 4 , 5 , 6 ] Figure 2 depicts the time course of symptom evolution.

Clinical descriptions of alcohol withdrawal syndromes by severity[ 4 , 5 , 6 ]

Graph depicting the time course of alcohol withdrawal symptoms (based on clinical information gathered in Table 2; adaptation from Haber et al .[ 7 ])

Once a clinical diagnosis of alcohol withdrawal is made, we must review the patient's condition from time to time for the appearance of signs of medical or neurological illness which may not have been evident at admission but may develop subsequently.

Objective assessment of the severity of alcohol withdrawal – the Clinical Institutes Withdrawal Assessment-Alcohol Revised (CIWA-Ar) scale

In a patient diagnosed to have alcohol withdrawal syndrome, the CIWA-Ar[ 8 ] can be used to measure its severity. The scale is not a diagnostic tool as it has not been found to be useful in differentiating between DT and delirium due to medical illnesses.[ 9 ] The scale includes 10 common signs and symptoms of alcohol withdrawal with the notable exceptions of pulse rate and blood pressure, which must be a part of the assessment of alcohol withdrawal states. It has also been found useful in Indian setting.[ 10 ] It can be administered bedside in about 5 min. Scores of 0-9 indicate absent to minimal withdrawal, scores of 10-19 indicate mild to moderate withdrawal (marked autonomic arousal) and scores of 20 or more indicate severe withdrawal (impending DT).[ 8 ] It can be used to monitor the severity of withdrawal and in titrating pharmacotherapy. The score on CIWA-Ar remains high even after adequate dosing with benzodiazepines in cases with comorbid medical illness (“DT plus" condition).[ 11 ]

Differential diagnosis of DT

Delirium is a clinical syndrome of acute onset, characterized by altered sensorium with disorientation, perceptual abnormalities in the form of illusions and hallucinations and confused or disordered thinking, psychomotor agitation (or retardation) with disturbed (usually reversed) sleep-wake cycle. In most cases, it is secondary to a general medical condition causing disturbance in the basic functions of the brain. It could be due to infection, toxic, metabolic, traumatic or endocrine disturbances.

DT is a specific type of delirium occurring in patients who are in alcohol withdrawal states. Alcohol withdrawal delirium is typically associated with psychomotor agitation (hyperactive delirium) and in cases of hypoactive delirium comorbid hepatic encephalopathy, hyponatremia or other medical illnesses [ Table 3 ] must be ruled out. This is especially important in a patient who has not had previous history of DT.

Differential diagnosis for alcohol withdrawal delirium

Alcohol withdrawal delirium has a high mortality of about 8%. Hence, it is important for clinicians to be able to predict it. The risk factors for DT were analyzed by Ferguson et al .[ 12 ] and further factors are tabulated in Table 4 .

Predictors of severe alcohol withdrawal (withdrawal seizure or DT)[ 6 , 11 , 13 ]

TREATMENT OF ACUTE ALCOHOL WITHDRAWAL SYNDROME

Detoxification.

Detoxification is the process of weaning a person from a psychoactive substance in a safe and effective manner by gradually tapering the dependence producing substance or by substituting it with a cross-tolerant pharmacological agent and tapering it.[ 14 ] This process minimizes the withdrawal symptoms, prevents complications and hastens the process of abstinence from the substance in a more humane way.

General supportive care

Patients in alcohol withdrawal should preferably be treated in a quiet room with low lighting and minimal stimulation. All patients with seizures or DT should have immediate intravenous access for administration of drugs and fluids. Intramuscular lorazepam may be given to prevent further seizures. Adequate sedation should be provided to calm the patient as early as possible and physical restraints may be used as required in order to prevent injuries due to agitation. Fluid and electrolyte imbalances must be promptly corrected. Adequate nutrition must be ensured with care to prevent aspiration in over-sedated patients. Vitamin B supplementation helps to prevent Wernicke's encephalopathy (WE).

Medication of choice for detoxification

In 1969, a landmark study by Kaim et al ., proved beyond doubt that chlordiazepoxide (a benzodiazepine) was far better in preventing seizures and DT in patients with alcohol withdrawal compared to chlorpromazine, hydroxyzine, thiamine or placebo.[ 15 ] Evidence is strongly in favor of the use of benzodiazepines to treat alcohol withdrawal states.[ 13 , 16 ] They unequivocally reduce the risk of severe alcohol withdrawals like seizures or DT.[ 17 ] Among the benzodiazepines, chlordiazepoxide has a slight advantage over the other benzodiazepines or anticonvulsants.[ 18 ] Anticonvulsants have not been proven to be better than benzodiazepines. They may be considered in mild withdrawal states due to their advantages of lower sedation and lower chances of dependence or abuse potential. However, they may not have the expected advantage of preventing seizures or DT in alcohol withdrawal states[ 18 ] and their use is not recommended in severe withdrawal states.

The dose of benzodiazepine required per day is calculated according to the average daily alcohol intake. An estimate of the amount of alcohol consumption is given by the following formula:[ 19 ]

Alcohol (in g) = Volume of liquor (ml) × 0.008 × (%) ethanol content in the liquor (w/v).

The percentage of alcohol in various liquors[ 20 ] is: Beer (standard) – 3-4%, Beer (strong) – 8-11%, Wines – 5-13%, Fortified wines – 14-20%, Spirits/Indian Made Foreign Liquor like (rum/whiskey/gin/vodka/brandy) – 40%, arrack – 33%. One standard drink contains about 10 g of absolute alcohol or ethanol.

Treatment regimens used in alcohol withdrawal states

Fixed dose regimen.

A fixed daily dose of benzodiazepines is administered in four divided doses. The daily dose is calculated by using the aforementioned formula. Approximately 5 mg of diazepam equivalents [ Table 5 ] is prescribed for every standard drink consumed. However, it needs to be based upon the severity of withdrawals and time since last drink. For example, a person presenting after 5 days of abstinence, whose peak of withdrawal symptoms have passed, may need a lower dose of benzodiazepines than a patient who has come on the second day of his withdrawal syndrome. Chlordiazepoxide and diazepam remain the agents of choice. However, in the presence of co-morbidities shorter acting drugs such as oxazepam and lorazepam are used. A ceiling dose of 60 mg of diazepam or 125 mg of chlordiazepoxide is advised per day.[ 18 ] After 2-3 days of stabilization of the withdrawal syndrome, the benzodiazepine is gradually tapered off over a period of 7-10 days. This is best suited for out-patient setting. Patients need to be advised about the risks and to reduce the dose, in case of excessive drowsiness. In in-patient settings where intense monitoring is not possible due to lack of trained staff, a fixed dose regimen is preferred.

Comparison of the four most commonly used benzodiazepines in treatment of alcohol withdrawal[ 21 , 22 ]

Loading dose regimen

In studies by Sellers et al .[ 23 ] and Manikant et al .[ 24 ] the efficacy of an oral loading dose of 20 mg of diazepam given every 2 h was established to be of use in treating alcohol withdrawal. The withdrawal severity CIWA-Ar and the clinical condition needs to be monitored before each dose. This has been shown to reduce the risk of complications, reduces the total dose of benzodiazepines needed and the duration of withdrawal symptoms. Loading dose strategies use long acting benzodiazepines as they provide a self-tapering effect due to their pharmacokinetic properties.[ 25 ]

Symptom-triggered treatment (STT)

The STT was proposed by Saitz et al . in 1994[ 26 ] where in chlordiazepoxide was given when CIWA-Ar ratings were eight or more. The STT requires close monitoring as in-patient. Patients who are non-verbal (e.g. stupor due to head injury) may not be suited for this regimen as they may not be able to inform the nursing personnel if they were to experience any withdrawal symptoms. This protocol is not safe in patients with a past history of withdrawal seizures because they can occur even in a patient without overt autonomic arousal or symptoms of alcohol withdrawal.[ 6 ] STT decreases the duration of detoxification and dose of benzodiazepine required compared with fixed dose regimen and may be useful in patients who have never had complicated withdrawals.

Symptom-monitored loading dose (SML)

We recommend that clinicians take into account the past history of seizures or DT as well as the current clinical status while deciding upon medications for a patient. In the presence of an acute medical illness at present or a past history of severe withdrawals, a single loading dose of 20 mg diazepam should preferably be given immediately and the patient be monitored for further signs of alcohol withdrawal.[ 13 ] Further doses of diazepam (20 mg) should be given orally every 2 h until CIWA-Ar scores are less than ten. Up to three doses are required in most patients,[ 23 ] which helps in reliably preventing the occurrence of withdrawal seizures.[ 27 ] This strategy, which could aptly be called SML combines the principles and advantages of a STT, whereas at the same time takes into account a past history of severe withdrawals and gives a loading dose regardless of the appearance of symptoms.

Rapid loading with close monitoring

This method is recommended only in patients with DT. Frequent boluses of diazepam are given intravenously until the patient is calm and sedated. It is described under management of DT below.

MANAGEMENT OF MINOR ALCOHOL WITHDRAWAL SYNDROME

Minor alcohol withdrawal syndrome may not need pharmacotherapy in all cases. The patient needs supportive care in a calm and quiet environment and observation for a period of up to 36 h, after which he is unlikely to develop withdrawal symptoms.[ 13 ]

In the presence of risk factors like an acute medical illness or a past history of severe withdrawals, a single dose of 20 mg of diazepam should be given immediately as a loading dose and the patient be monitored for further signs of alcohol withdrawal,[ 13 ] further doses being guided by the appearance of withdrawal symptoms.

Out-patient treatment can be started for patients without these risk factors and is based on the clinical withdrawal signs. Pharmacotherapy is started when the systolic blood pressure exceeds 150 mmHg, diastolic blood pressure exceeds 90 mmHg, body temperature greater than 37.7°C, pulse exceeds 100/min or other withdrawal symptoms such as agitation, insomnia, tremulousness are present without other medical or neurological illness.[ 3 ]

Management of moderate to severe alcohol withdrawal syndrome

Without seizures or dt.

In these cases, we recommend that patients should be started immediately on a SML dose regimen, while monitoring the withdrawal severity (CIWA-Ar ratings) and clinical signs of tachycardia and hypertension. A fixed dose regimen can be safely used in such patients in case adequate trained personnel are not available or if outpatient treatment is advised.

Severe alcohol withdrawal with alcohol withdrawal seizures

Regardless of the CIWA-Ar score, the occurrence of seizures during the alcohol withdrawal period is indicative of severe alcohol withdrawal.[ 19 ] Seizure prophylaxis with lorazepam 2 mg intravenously must be given to all patients with seizures in the current withdrawal period at presentation and also in those with past history of withdrawal seizure.[ 28 ] Lorazepam is more effective than diazepam in preventing seizure recurrence. Unlike diazepam brain tissue levels of lorazepam don’t fall rapidly owing to its poor lipid solubility and poor redistribution. Although, a single lorazepam dose given is likely to prevent further seizure recurrences, it may still be required to give SML dose of diazepam of at least 20[ 13 ]-60 mg[ 27 ] or at times even 80 mg diazepam[ 7 ] in such patients. This strategy helps to prevent the development of DT. All patients who presenting with seizures after cessation of alcohol, regardless of previous episodes, must ideally be monitored as inpatients for at least 36-48 h to watch for further seizures or DT.[ 19 ]

In patients who present with seizures, a thorough neurological and general medical evaluation is a must to detect alternative cause of seizures. Patients with new onset seizures should preferably undergo brain imaging. Neurological work-up and consultation is essential in patients with more than six seizures during alcohol withdrawal, seizures persisting for more than 6 h or despite adequate dose of benzodiazepines treatment,[ 6 ] presence of focal seizures/change in seizure type, history of traumatic brain injury, family history of seizures in relatives who do not use alcohol, status epilepticus, focal neurological deficits, presence of meningeal irritation or patients with worsening sensorium despite at least 8 h of loading dose diazepam (60 to 80 mg).

Severe alcohol withdrawal with DT

Treatment of alcohol withdrawal delirium DT is defined by the goal of achieving a calm, but awake state[ 13 ] or light somnolence defined as a sleep from which the patient is easily aroused.[ 29 ] This goal is best achieved by the use of intravenous diazepam administered at frequent intervals while closely monitoring the patient during the procedure. Intravenous or intramuscular lorazepam may be used in patients with hepatic disease, pulmonary disease or in the elderly where there is risk of over-sedation and respiratory depression with diazepam.

An initial dose of 10 mg diazepam is given intravenously. Further doses of 10 mg can be repeated every 5-20 min interval.[ 13 , 14 ] Others recommend increasing the dose to 20 mg per bolus for the subsequent boluses if the first two boluses do not calm the patient down.[ 29 ] Once the goal of light somnolence is achieved, the patient is shifted to a SML dose regimen. Though experts advice the use of rapid loading doses of diazepam for management of DT, no trials of rapid loading with diazepam has been conducted in patients with DT. There have been trials comparing loading doses of barbiturates (versus diazepam loading), where the drug is given at 2 h intervals[ 30 ] and a trial of diazepam (loading dose versus fixed doses)[ 31 ] for the management of DT. In practice, loading dose strategy (20 mg diazepam every 2 h) can be safely administered in DT. Vital signs should be used to guide treatment in “DT-plus” condition (DT in presence of medical comorbidities) as these patients have been noted to have failure of loading-dose regimen with falsely high CIWA-Ar scores.[ 11 ]

Refractory DT

A review by Hack et al .[ 32 ] suggests that a high requirement of intravenous diazepam (more than 50 mg in the 1 st h, or 200 mg or more within the first 3 h) with poor control of withdrawal symptoms is a marker of non-response of DT to benzodiazepines.

Such patients can be diagnosed to have refractory DT after a review of the clinical condition to rule out medical or neurological causes of delirium. They can be given oral (or intravenous) loading with phenobarbital 100-200 mg/h, which has been shown to as effective as or better than diazepam front-loading for patients in DT in a more recent retrospective chart review.[ 33 ] The use of barbiturates is justified by the fact that they are also GABA-enhancing drugs that have a different receptor profile than benzodiazepines and have been tested in a double-blind protocol against diazepam for DT.[ 30 ] However, it carries the risk of over-sedation, especially in the elderly or in presence of hepatic disease and a risk of respiratory depression in patients with pulmonary disease. There is no antidote to barbiturate toxicity. For these reasons, barbiturates have fallen out of favor.

An alternative adjunctive medication useful in patients with refractory DT is haloperidol given in doses of 0.5-5 mg by intramuscular route every 30-60 min[ 29 ] or 2-20 mg/h[ 34 ] while continuing to give diazepam 10-20 mg every 1-2 h. Newer antipsychotics like risperidone (1-5 mg/day) or olanzapine (5-10 mg/day) may have a better safety profile than haloperidol (2, 5-10 mg/day)[ 7 ] and are preferred as adjuncts to benzodiazepine treatment.

In patients who do not respond to benzodiazepines and haloperidol, propofol infusion (0.3-1.25 mg/kg/h) in an intensive care setting has been used in a few cases.[ 34 ] The risks of propofol infusion include bradycardia, hypotension, metabolic acidosis, acute pancreatitis and lipid abnormalities.[ 29 ] Moreover, propofol may not treat the underlying withdrawal syndrome because patients are often noted to exhibit withdrawal symptoms soon after stopping propofol infusion.

Alcoholic hallucinosis

This is a unique form of withdrawal related psychosis which can begin even while the person is continuing to use alcohol or begins after he stops alcohol. Hallucinations occurring in clear sensorium are the hallmark of this disorder. A cluster analysis of alcohol withdrawal symptoms by Driessen et al .[ 35 ] showed that hallucinosis is a severe form of alcohol withdrawal and is often associated with DT. However, it is one of the conditions that may cause apparent failure of the loading dose regimen[ 11 ] and we recommend a fixed dose strategy to cover the period of alcoholic hallucinosis. The patient may be given low doses of antipsychotics like chlorpromazine 100-200 mg/day or risperidone 1-3 mg/day to control severe agitation due to hallucinations. The hallucinations last about a week in most cases, but may last up to 1 month in some patients after which the antipsychotic can be stopped.

Importance of adjunctive supplements (Vitamin B and magnesium)

Wernicke's Encephalopathy (WE) results from cell damage due to chronic thiamine deficiency. It rarely presents with the classic triad of confusion, ataxia and ophthalmoplegia and therefore goes undiagnosed in nearly 90% of the cases.[ 36 ] It is difficult to diagnose in the presence of alcohol withdrawal symptoms. The presence of small mammillary bodies and thalami on magnetic resonance imaging brain may be helpful in diagnosis, but confirmation is by postmortem examination. WE has an associated mortality of 20%, with 75% developing a permanent severe amnestic syndrome (Korsokoff's encephalopathy).[ 37 ] This can be prevented by administering parenteral thiamine which achieves adequate blood thiamine level much earlier than the oral route.[ 38 ] Allergic reactions are rare. All patients in alcohol withdrawal should receive at least 250 mg thiamine by the parenteral route once a day for the first 3-5 days,[ 39 ] whereas for those with suspected WE, thiamine 500 mg/day for 3-5 days is advised. If there is clinical improvement the supplementation is continued for total of 2 weeks.[ 39 ] Concurrent administration of parenteral thiamine with glucose is advised traditionally. However, this is only to ensure that thiamine supplementation is not forgotten. Administration of glucose containing fluids before thiamine may not precipitate WE.[ 40 ] Due to chronic malnutrition and gastric malabsorption that follows chronic alcohol abuse, many clinicians advise multivitamin supplements (B1 + B2 + B6 + nicotinamide + Vitamin C) in parenteral form for the initial 3-5 days.[ 36 ]

Chronic alcohol use is associated with abnormal magnesium metabolism. Those with neuropathy and presenting with severe withdrawal symptoms are more likely to show low serum magnesium level.[ 41 ] Oral or parenteral magnesium supplementation may benefit such patients by reducing the severity and duration of alcohol withdrawal. Routine use is not advised[ 29 ] [ Table 6 ].

Summary of recommendations

CONCLUSIONS

Benzodiazepines are the mainstay of management of alcohol withdrawal states. STT regimen reduces dose and duration of detoxification compared with traditional fixed dose regimen in mild to moderate alcohol withdrawal. However, it is feasible only in relatively stable patients and requires periodic monitoring of the withdrawal severity by trained personnel. For management of severe withdrawals, inpatient care and SML dose is advised. Though rapid loading is advised in DT, the few trials and retrospective chart reviews in DT have used a loading dose regimen. Refractory DT can be managed with phenobarbital or adjuvant antipsychotics. Thiamine supplementation should be routinely prescribed to prevent WE.

Source of Support: Nil

Conflict of Interest: None declared.