Crush those 11 pm “STAT: Patient agitated” pages with this expert guide to assessing for and treating alcohol withdrawal! Dr. Joji Suzuki MD, addiction psychiatrist extraordinaire at the Brigham and Women’s Hospital, walks us through how to think about the risk of severe withdrawal, the different ways to manage it, and how to engage with patients as they’re leaving the hospital. In the course of this Car-Talk (well, not exactly the same as the critically acclaimed radio show, but he did record in his car….), Dr. Suzuki demystifies withdrawal and debunks some common myths: that we must manage withdrawal inpatient, that banana bags are the cure to a hangover and alcoholic malnutrition, and that we tend to under-medicate with benzos (actually, it’s the opposite!).
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Written and Produced by Nora Taranto MD
Infographic and Cover Art by: Nora Taranto MD
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
Editor: Cyrus Askin MD, Matthew Watto MD (written materials); Clair Morgan of nodderly.com
Guest: Joji Suzuki MD
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There are two types of useful screening: first, screening for alcohol use and at-risk drinking and second, screening for risk of severe withdrawal. Both are important.
The CAGE questionnaire has actually fallen out of favor (it is most useful to screen and triage heavy drinkers) in favor of AUDIT-C, which is more sensitive in that it identifies “at-risk drinkers,” or individuals along a broader spectrum of alcohol use, who may still be drinking heavily intermittently but may not meet criteria for alcohol-use disorder. AUDIT-C is a three question tool which sorts patients into a higher-risk vs lower-risk category based upon their response. Dr Suzuki recommends having a low threshold to place someone on a symptom-driven CIWA protocol if they score above 3-4 on the AUDIT-C (typically higher for men, lower for women Higgins-Bittle 2018). This approach ensures that individuals who need treatment get it, but that those who are at-risk drinkers don’t get medicated without symptoms (and avoids over-medication, which happens all too often).
Predicting who will go into severe withdrawal is the million dollar task. The best predictor (and the only good predictor we have so far) of having severe withdrawal is a history of prior severe withdrawal, including delirium tremens and withdrawal seizures (Wood 2018).
Kashlak Pearl: It is important to clarify what exactly happened to patients during their “severe withdrawal” episode, since many may think they had severe withdrawal but in fact have been over-medicated with benzos instead.
The PAWSS score for assessing severe withdrawal is another useful tool. It triages patients based upon history of alcohol use, whether the patient has a positive blood alcohol level, or is intoxicated at the time of exam. This JAMA 2018 Rational Clinical Exam paper walks through the data for screening tools and predicting withdrawal risk in depth (Wood 2018). But AUDIT-C may work just as well in terms of overall risk stratification; it’s shorter, well validated, and can be incorporated easily in workflow.
If we had the support and expertise to back it up, it would be great! In practice… it’s not as effective as we’d like it to be. Consider the task: You have no rapport with the patient but are expected to uncover evidence of alcohol use disorder, recommend a treatment and get buy-in…and do so without extensive addiction expertise to back your recommendations. While this may be changing, at present many hospitals do not have the addiction resources to provide the latter.
The hospital can be a traumatic place, especially for those with substance use. You CAN treat alcohol withdrawal (mild or moderate) as an outpatient, and in fact it may ultimately be preferable if the patient is low-risk and you have a low suspicion for severe complications. If you manage withdrawal at home, Dr Suzuki recommends gabapentin at daily doses of 1800-2400 mg, NOT benzos or barbs (expert opinion). Gabapentin has some evidence supporting its use for mild alcohol withdrawal and maintenance therapy for alcohol dependence (Leung 2015).
Absence of prior severe withdrawal history, CIWA score < 10, no concurrent sedative use disorder, a low blood alcohol level (an absolute cutoff of <400, per Dr Suzuki), a stable home environment without active drinking and ideally with a sober support person, and the ability to call the clinic or come in person daily (see figure).
You can use it for withdrawal management and maintenance after withdrawal for individuals with alcohol use disorder (though it’s not ideal if concomitant opioid use disorder). Dosing ranges from 1800 – 2400 mg total per day. Dr Suzuki notes that for mild to moderate withdrawal, a typical dosing regimen might involve starting at 1800 per day, and then tapering off over several days (with the large caveat that if sedation occurs, decrease the dose) –expert opinion. Additionally, there has been some interest in using gabapentin as adjuvant therapy to reduce benzodiazepine requirement in alcohol withdrawal, but this is not yet well established as beneficial (Wilming 2018).
Do we have an obligation to keep this patient in the hospital and treat them for withdrawal? Not everything has to happen in the hospital. Hospitalization may make a patient feel distressed, judged and stripped of their social support mechanisms. We don’t have to get into battles with patients about needing to stay in the hospital. But, Dr Suzuki reminds us that it is important to use every encounter to motivate the patient.
Alcohol use disorder will never be treated in a single encounter. It is a constant struggle. While we so often think of alcohol use disorder in an abstinence-only framework, we ought to use a harm-reduction model, as is being used in opioid use disorder, to meet patients where they’re at and go from there. It is our job to support patients and motivate them on a daily basis, whether inside or outside the hospital. And we ideally ought to have a multidisciplinary outpatient team that can help with this journey, whether a patient is pre-contemplative or already maintaining sobriety.
“It is super hard to get sober in this country. There is alcohol at every street corner. Every social event is centered around alcohol. It’s everywhere”–Dr. Suzuki
If you can control symptoms and prevent complications within the first two days, the risk of developing delirium tremens or other severe withdrawal complications is extremely low. Once you’re behind, it can be difficult to catch up.
It may just be a question of protocol, says Dr. Suzuki. The loading strategy works well, and we use it with phenobarbital but much more rarely with benzodiazepines. Phenobarbital is given via a weight-based loading that’s split into 3 doses over the first 24 hours based on risk of respiratory depression. After this, an oral taper is unnecessary unless the patient is still showing symptoms of withdrawal. Phenobarbital is long-acting, and self-tapers. With fixed oral tapers after the initial loading dose, patients can be over-medicated. The loading strategy, if used correctly, would work well, whether with phenobarbital or diazepam (a benzo). But, our protocols don’t typically call for up-front loading with benzos.
The majority of patients do well on symptom-driven therapy (Daeppen 2002; Ismail 2019). It avoids the complications of overmedication (which is one of the most common complications of withdrawal treatment, far more common than undertreatment). But if a patient has a history of severe withdrawal or seizures, is already delirious, or has significant autonomic symptomatology (e.g. tachycardia), start a fixed-dose protocol –Dr Suzuki’s expert opinion.
Every hospital has its own protocol, and Dr. Suzuki recommends using your local protocol to create a standardized approach. Of course, once you have experience with it, you can adjust reasonably.
Dr. Suzuki’s benzo of choice is diazepam, which can provide the smoothest withdrawal and is faster onset (NOTE: therefore, has greater misuse potential; also beware if hepatic impairment). But lorazepam can also work well, especially if liver dysfunction. The bioavailability of most benzos is quite high, so these medications can be given IV or oral (though heavy drinkers can have gastric irritation which can impair absorption). Be wary of oxazepam, which can cause late onset seizures after completion of the medication taper (Mayo-Smith, 1995).
If a patient is already in delirium tremens or severe withdrawal, if they’re needing medications every one to two hours, if they’re scoring CIWAs of over twenty, or if they can’t maintain their airway, think about sending them straight to the ICU.
The banana bag has far too little thiamine in it (See this expert Mythbuster from ALiEM). The main nutritional deficiency to worry about is thiamine deficiency, which can cause Wernicke’s encephalopathy and which is pervasive among heavy drinkers. But note that the vast majority of thiamine deficient individuals won’t have the classic Wernicke’s triad of ataxia, ophthalmoplegia, and altered mental status. We should be treating all individuals empirically with high-dose IV thiamine (NOT oral, which is less bioavailable), typically 200 – 500 mg IV thiamine three times a day for several days (Flannery 2016).
Dr Suzuki points out that patients with severe alcohol use disorder often aren’t eating at all. So, encourage the patients to eat. They do not typically need to be on a multivitamin afterwards as long as they are eating. .
The vast majority of patients will be fine, whether or not you treat them for withdrawal. They will experience two to four days of discomfort and mild withdrawal symptoms (headache, anxiety, n/v restlessness, mild perceptual disturbances, lots of cravings). But for some, especially those with prior severe withdrawal, the course will be more complex, some with seizures in the first two days and with development of delirium tremens (delirium, autonomic instability, seizures) if left untreated that can last upwards of five to ten days and carry a high mortality rate (Stat Pearls DT Summary 2019).
Of note, Dr. Suzuki points out that alcoholic hallucinosis, or the phenomenon of having specific, persisting perceptual disturbances (“I hear a voice when I stop drinking”) with otherwise normal cognition, is NOT a withdrawal symptom. It tends to begin during withdrawal, but it typically persists past the withdrawal. Moreover, the treatment is not benzos, but antipsychotics. Wow, mind blown! (Pookala 2012)
Start these medications in the hospital, and close to the time of discharge (see Curbsiders #194 Alcohol Use Disorder with Marlene Martin). With a lot of things, we often defer to the outpatient setting, but it’s critical to start these sorts of medications in the hospital. Dr Suzuki has noticed that PCPs may be hesitant to start a medication like naltrexone themselves, but they will very rarely stop it if it was started in the hospital. Regarding timing, start these medications at the end of the withdrawal protocol, close to discharge. Studies have found that 4 days of abstinence after the last drink prior to starting naltrexone and other abstinence-aiding medications improves outcomes (O’Malley 2007).
Kashlak Pearl: Extended-Release naltrexone is a great, well-tolerated medication, and the manufacturer offers a free shot per person per calendar year!
Providing early access to ongoing treatment and support (meetings, support, recovery coaches, intensive treatment) is essential. The sooner you can connect them to this, the better: ideally the day of discharge and via warm handoff, in which you physically walk patients down to the clinic to meet their provider (who may be a recovery coach, a psychiatrist, a social worker, or a resource specialist depending on their need). As this March 2020 Cochrane review of Alcoholics Anonymous and other 12-step programs for alcoholism has begun to show, recovery programs may be more effective than other treatments for increasing abstinence (Kelly 2020).
(Dr. Suzuki’s profound parting words): Finally, using motivational interviewing is key, to demonstrate empathy and compassion while respecting autonomy. This compassion and connection guides patients, over time, towards change and health. Our medical system has failed these patients for far too long. The educational system around substance use disorder in medical training is fairly limited. Generations of physicians, meanwhile, were exposed to the hidden curriculum (attendings treat these patients in a particular way, these topics pushed away, stigmatized, treated poorly). Addiction treatment was always viewed as someone else’s problem. Now that it’s coming back into mainstream medicine, there will be more responsibility taken for this patient population. But there is still a long way to go.
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Listeners will be able to screen patients for risk of alcohol withdrawal and decide on management strategies that are individualized to the patient.
After listening to this episode listeners will…
Dr Suzuki reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Suzuki J, Taranto NT, Williams PN, Askin C, Watto MF. “#212 Sober Talk: Managing Alcohol Withdrawal with Joji Suzuki, MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list May 7, 2020.
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Do you have resources on how to do the weight based dosing of phenobarbital with the divided doses over the first 24 hrs?
I enjoyed the episode and learned several things. I did take issue with a couple of the comments, however. First, the speaker's comments about Gallup, NM were inaccurate. It is not true that there are no opportunities for outpatient treatment of alcohol abuse and dependence. I worked for Gallup Indian Medical Center for 3 years and often treated patients with naltrexone as did other providers. We also had a psychology department which provided counseling. NCI (the center the speaker was referring to) also offers outpatient 12 step programs. Also, it isn't true that only a few patients per year have withdrawal severe enough to warrant transfer to the ER from NCI. When I was in Gallup (2003-2006), this happened quite frequently. There were people in the ER experiencing withdrawal every day, and our ICU routinely had 1 to 3 people in severe withdrawal / DT's. (Right now that ICU is a Covid19 unit). One other thing, I'm surprised at how hesitant the speaker is to treat outpatients with Librium. Chlordiazepoxide can be a safe and inexpensive treatment for patients who have a history of alcohol withdrawal, but no history of delirium tremens or other severe sequelae. People with addiction tend to have a lot of experience titrating medications and I have not had a problem treating patients who I know well with outpatient chlordiazepoxide. I have done this many times both in Gallup and the FQHC where I work now.