Distill the management of inpatient alcohol withdrawal down to its core with Dr. Shawn Cohen (@ShawnCohen_MD, Yale University). This episode is full of practical pearls, and we discuss the ins and outs of managing alcohol withdrawal in the hospital setting. Learn how to triage patients in the hospital, which benzodiazepines to select, the pathophysiology of alcohol withdrawal, and phenobarbital for the management of alcohol withdrawal.
Claim free CME for this episode at curbsiders.vcuhealth.org!
By listening to this episode and completing CME, this can be used to count towards the new DEA 8-hr requirement on substance use disorders education.
The Curbsiders Addiction Medicine are proud to partner with The American College of Addiction Medicine (ACAAM) to bring you this mini-series. ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Visit their website at acaam.org to learn more about their organization.
Alcohol is a CNS depressant. Chronic alcohol use requires more of the inhibitory neurotransmitter GABA to be needed in the body to maintain inhibitory tone. Over time the body compensates by upregulating the excitatory neurotransmitter glutamate to compensate. When someone is using enough alcohol (around 4 drinks) consistently (over at least two weeks), their brain may make these changes.
Alcohol withdrawal occurs, if chronic alcohol use has been removed or decreased. This causes there to be an excess of the excitatory glutamate signals that have been up-regulated leading to the clinical signs of alcohol withdrawal we associate with tremors, agitation, nausea/vomiting, hallucinosis, seizure, and delirium tremens.
Alcohol withdrawal syndrome is a clinical diagnosis – one based on the correct clinical scenario and symptoms we attribute to alcohol withdrawal. DSM 5 criteria include
Mild to moderate withdrawal symptoms may include tremors, agitation, diaphoresis, nausea, and tongue fasciculations. More severe symptoms include seizures and delirium tremens.
The timeline below is a general picture of when to expect specific symptoms of alcohol withdrawal, although these observed patterns and certain symptoms may appear at different time points than below (Kattimani, 2013).
The kindling effect is the idea that the more often a person experiences alcohol withdrawal syndrome, the more severe their alcohol withdrawal symptoms are likely to be (Becker 1998). This is the basis for the idea that if someone has had severe alcohol withdrawal in the past, they are likely to experience this again and so may need more aggressive treatment.
There are various clinical scales used, not to diagnose alcohol withdrawal, but instead to measure severity and guide therapy. Examples of these clinical withdrawal scales include:
The use of these clinical scales is institutionally dependent. Dr. Cohen recommends using the scale that one’s clinical staff are familiar with to direct treatment.
The severity of alcohol withdrawal is often defined and understood using these clinical withdrawal scales. CIWA-Ar scores of <10 constitute mild alcohol withdrawal, 10-18 moderate, and >18 severe (ASAM Clinical Practice Guideline on Alcohol Withdrawal Management). Dr. Cohen notes that there is a lack of consensus on what CIWA cutoff represents severe withdrawal, as different cutoffs have been used in a variety of studies.
Not all patients experiencing alcohol withdrawal need to be admitted. Considerations include a history of severe alcohol withdrawal, support system at home, mild severity of current symptoms, and comorbidities (as discussed in Curbsiders Addition Medicine Episode #2).
Once the decision has been made to admit a patient, Dr. Cohen recommends utilizing a patient’s history to help guide the triage decision as to where the patient should be admitted. Consider the following:
Thinking about the underlying pathophysiology of alcohol withdrawal (too little GABA in comparison to glutamate signaling), the mainstay of therapy is giving GABA-ergic medications. The therapy with the most evidence base is benzodiazepines which act on GABA receptors (Amato, 2010).
Dr. Cohen recommends long-acting benzodiazepines over short-acting ones, as this may help prevent breakthrough symptoms of withdrawal. There is mixed evidence in the research of one benzodiazepine over the other, with some studies pointing to long-acting (diazepam, chlordiazepoxide etc.) options being more effective at preventing seizures than shorter-acting options (Mayo-Smith, 1997). In Dr. Cohen’s expert opinion, he often uses diazepam, given it is available in PO, IV, and IM formulations and has a rapid time to onset, making it ideal for acute withdrawal settings. As with clinical withdrawal scales, the types of benzodiazepines available vary from institution to institution – he recommends using the protocol in place at your institution for consistency.
A common question is what benzodiazepines to choose in patients with liver dysfunction. Benzodiazepines that are safer to use in patients with liver dysfunction can be remembered with the pneumonic “L.O.T” – lorazepam, oxazepam, and temazepam. All three of these benzodiazepines undergo hepatic metabolism via conjugation instead of CYP-mediated oxidation and do not result in active metabolites, making them safer to utilize in patients with significant liver dysfunction. The other benzodiazepines have active metabolites and thus can have a higher risk of causing sedation in patients with liver dysfunction. In the US, lorazepam is typically the most available of the three options. Dr. Cohen is only switching to lorazepam if someone has severe liver dysfunction, otherwise, he recommends continuing to use diazepam.
Often hospitals will have the option for symptom-triggered vs. fixed-dosing protocols to manage alcohol withdrawal. Making this decision between these two protocol options is often related to the severity of a patient’s alcohol withdrawal.
Evidence indicates that symptom-triggered protocols may have improved patient outcomes, resulting in shorter hospital stays with fewer benzodiazepine doses needed for patients without significant adverse effects (Mayo-Smith, 1997) (Duby, 2014) (Saitz, 1994). Generally, these protocols are driven by a clinical withdrawal scale such as CIWA or MINDS, and depending on a patient’s score, they are given certain doses of benzodiazepines. This is a good option for patients who are at low risk for severe alcohol withdrawal.
Dr. Cohen also discusses a few options for patients who are at higher risk for severe withdrawal:
A small cohort of patients may not respond as well to benzodiazepines for the treatment of alcohol withdrawal (Hack 2006). For Dr. Cohen, if someone isn’t responding to high doses [variable definition of benzo resistant alcohol withdrawal, some studies consider this threshold to be 50mg of intravenous diazepam in 1 hour (Hack 2006) of benzodiazepine]), this is when he thinks about switching them over to Phenobarbital.
It is also vitally important to offer treatment for the underlying cause of all someone’s alcohol withdrawal – Alcohol Use Disorder. It is not always appropriate to discuss this when someone is acutely ill early in their withdrawal syndrome, but as they are nearing the end of their course, it is important to discuss medication options for AUD treatment. (Curbsiders Addiction Medicine Episode #4).
Listeners will be able to diagnose and manage inpatient alcohol withdrawal with evidence-based medications.
After listening to this episode listeners will…
Dr. Cohen reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Huxley-Reicher, Z, Cohen, S, Roy P, Chan, CA. “#16 Distilling Inpatient Alcohol Withdrawal with Dr. Shawn Cohen”. The Curbsiders Addiction Medicine Podcast. https://thecurbsiders.com/addiction August 3rd, 2023
Producer, writer, show notes, cover art, and infographic: Zina Huxley-Reicher, MD
Hosts: Carolyn Chan, MD and Zina Huxley-Reicher, MD
Reviewer: Payel Jhoom Roy, MD, MSc
Showrunner: Carolyn Chan, MD
Technical Production: Podpaste
Guest: Dr. Shawn Cohen
Got feedback? Suggest an Addiction Medicine topic. Recommend a guest. Tell us what you think.
We love hearing from you.
Yes, you can now join our exclusive community of core faculty at Kashlak Memorial Hospital along with all the perks:
Close this notice to consent.