Even though more than half a million patients are seen in U.S. emergency departments for alcohol withdrawal each year, this seemingly straightforward diagnosis is missed more often than we may believe.¹ Even when it is picked up, it is often mismanaged. Why?

We sometimes don’t suspect it in the first place. For example, we may not think about alcohol withdrawal in the older patient who presents with delirium.² Second, the differential diagnosis is enormous, and the presentation overlaps with other common ED diagnoses such as sympathomimetic drug intoxication and sepsis. There is no lab test to rule in the diagnosis, and we sometimes get sidetracked by other concurrent medical, psychiatric, and traumatic issues.

Mismanagement of these patients may stem from a lack of ED training on this topic and be due to little standardization in management. There is, unfortunately, still a stigma associated with alcoholism, which may contribute to indifference to these patients by ED staff, and the medications used to treat alcohol withdrawal are often dosed incorrectly.³ Mismanaged alcohol withdrawal can be fatal, and untreated severe withdrawal often ends up with your patient seizing and sometimes progressing to delirium tremens.⁴

Management of Alcohol Withdrawal Involves Four Steps

First, accurate diagnosis based on clinical features is paramount. Next, the use of a standardized, symptom-guided tool to assess symptom severity and guide treatment is important. Third, ensure that patients are fully treated prior to ED discharge, and fourth, provide a pathway to support for patients who are trying to quit.

1. Tremor is central to the diagnosis of alcohol withdrawal.

The diagnosis of alcohol withdrawal should be thought of as a clinical diagnosis of exclusion after infection, other toxidromes (ie, sympathomimetics, anticholinergics, toxic alcohols), serotonin syndrome, neuroleptic malignant syndrome, hypertensive crisis, acute pain, and thyrotoxicosis have been considered. There must be clear evidence of recent cessation or reduction of alcohol after high-dose regular use. Symptoms from alcohol withdrawal usually start within six to eight hours after the blood alcohol level decreases, peak at 72 hours, and diminish by days five to seven of abstinence. Delirium tremens can occur anytime from three to 12 days after abstinence.

The tremor of alcohol withdrawal is central to the diagnosis. It is important to understand the three key features of alcohol withdrawal tremor. It is an intention tremor (there is no tremor at rest, but when you ask the patient to extend their hands or arms, you will see a fine motor tremor) that is constant and does not fatigue with time. Other symptoms associated with alcohol withdrawal include gastrointestinal upset, anxiety, nausea/vomiting, diaphoresis, tachycardia, hypertension, and headache. If malingering is suspected, ask the patient to protrude their tongue. A tongue tremor is impossible to feign and is thought to be a more sensitive sign of alcohol withdrawal than hand tremor.

There are no lab tests that are diagnostic for alcohol withdrawal. A serum ethanol level should be considered only if you are unsure of the diagnosis. Even then, there is no single ethanol level at which withdrawal is impossible. Chronic alcohol users may experience alcohol withdrawal at serum ethanol levels that are intoxicating to the naive drinker. In mild cases of withdrawal, blood work is rarely helpful and is unlikely to change management. However, in patients with severe alcohol withdrawal, especially patients with delirium tremens, blood work can help rule out other causes of delirium.

There are no lab tests that are diagnostic for alcohol withdrawal. A serum ethanol level should be considered only if you are unsure of the diagnosis. Even then, there is no single ethanol level at which withdrawal is impossible.

2. Use a standardized, clinically guided approach to assess severity and guide treatment.

The Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar) protocol is a 10-item scale. It has been well validated in patients with alcohol withdrawal, improving the quality and consistency of care, but should not be used for patients with delirium tremens or as a diagnostic tool.⁵

The CIWA-Ar calls for patients to be assessed hourly and treated if the total score is 10 or greater. When two sequential scores are less than 10, discharge may be considered. Protocols using the CIWA-Ar help to standardize care, ensure clinicians identify the appropriate clinical features, and monitor treatment response. CIWA-Ar assesses 10 clinical features: nausea and vomiting, paroxysmal sweats, agitation, anxiety, visual disturbances, tremor, tactile disturbance, headache, auditory disturbances, and orientation and clouding of the sensorium.

Some clinicians find the CIWA-Ar protocol too labor-intensive. The SHOT (Sweating, Hallucinations, Orientation, and Tremor) protocol is a shorter one, which may be easier to implement in the emergency department. It is a four-item scale that correlates well with the CIWA-Ar score and takes about one minute to apply.⁶

3. Ensure that patients are fully treated prior to ED discharge.

If a patient has two sequential CIWA-Ar scores (two hours apart) less than 10 and there are no concerning risks for deterioration, consider discharging the patient from the emergency department. The patient’s tremor should be minimal or resolved before discharge, regardless of the CIWA-Ar score, as those with significant tremor are at risk of complications of alcohol withdrawal if discharged from the emergency department.

Benzodiazepines are first-line medications for treating patients with alcohol withdrawal. A Cochrane meta-analysis found that benzodiazepines are at least as effective as alpha-blockers and carbamazepine at preventing seizures and delirium tremens.⁷ The drug of choice is diazepam because it has a long half-life (100 hours) and carries a decreased risk of developing serious withdrawal symptoms once the patient is discharged. Diazepam also has a faster onset of action than lorazepam. Nonetheless, it is important to remember that diazepam should be avoided in patients with liver failure or a history of liver failure.

Use oral benzodiazepines in stable patients with mild withdrawal who are not vomiting (diazepam 5–10 mg by mouth for CIWA-Ar score 10–20). Use IV benzodiazepines allowing faster onset and easier titration in patients with severe withdrawal as these patients are at a higher risk of seizure (diazepam 10–20 mg IV for CIWA-Ar score greater than 20). Assess for response every five minutes in severe alcohol withdrawal, and repeat dosages as necessary. Some protocols suggest escalating dosages of diazepam by 10 mg every five minutes to a maximum of 40 mg per dose.⁸

There is no evidence that phenobarbital is superior to benzodiazepines for preventing complications of alcohol withdrawal.^9,10 While debate continues regarding the equivalency of phenobarbital and benzodiazepines, I do not recommend using phenobarbital alone for treatment of alcohol withdrawal, but consider its use as an adjunct with benzodiazepines after the patient has received the equivalent of 200 mg of diazepam and is still in severe withdrawal.

It is strongly discouraged that patients be provided a takeaway supply or prescription for benzodiazepines. The long half-life of diazepam will protect patients from developing serious symptoms of withdrawal, and if adequately treated in the emergency department, no additional medications will be required. Patients who are discharged from the emergency department with a prescription for benzodiazepines may be at increased risk for sedative overdose, drug-seeking behavior, and dependence.

4. Provide a pathway to support patients who are trying to quit.

Many patients in the emergency department with alcohol withdrawal are in a vulnerable state and may be ready to quit drinking. This is an opportune time for them to take the first steps on the pathway to recovery. I recommend counseling all ED patients whom you have treated for alcohol withdrawal by stating, “You need help for your serious alcohol problem. You can’t do it on your own. There are effective treatments available to you. With treatment, the way you feel, your mood, social relationships, and work will be profoundly better.”

Provide several options to patients and consider starting patients who are interested in quitting on anti-craving medications such as naltrexone. Naltrexone blocks the release of endogenous endorphins, which are thought to be released during alcohol consumption, leading to positive reinforcement effects. Naltrexone, 50 mg by mouth once daily, has been shown to significantly reduce the rate of relapse as well as heavy drinking days.¹¹

Thanks to Dr. Bjug Borgundvaag, Dr. Sarah Gray, and Dr. Meldon Kahan for their expert contributions to the podcast that inspired this article.

References

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