"Outpatient Management of Alcohol Withdrawal Syndrome" (My Synopsis)

Outpatient Management of Alcohol Withdrawal Syndrome
HERBERT L. MUNCIE JR., MD, Louisiana State University School of Medicine, New Orleans, Louisiana YASMIN YASINIAN, MD, New Orleans, Louisiana LINDA OGE', MD, Louisiana State University School of Medicine, New Orleans, Louisiana
Am Fam Physician. 2013 Nov 1;88(9):589-595.

     Alcohol dependence is present in up to 9% of all family medicine patients. In women, alcohol dependence is defined as those who average more than one drink a day, seven drinks a week, or more than four drinks on one occasion. In men, dependence is defined as more than two drinks a day, 14 drinks a week, or five drinks on a single occasion. Alcohol withdrawal syndrome occurs from a sudden abstinence after a long period of drinking (two weeks or more). Treatment of AWS requires identification of the condition, assessing the complication risk, and symptom recognition. Screening for alcohol abuse can be done using the CAGE questionnaire (or the AUDIT or MAST test). The four CAGE questions are:
1. Have you ever felt the need to CUT DOWN on your drinking?
2. Do you feel that people ANNOY you about how much you drink?
3. Have you ever felt GUILTY about your drinking?
4. Do you ever need an EYE opener (a drink in the morning to feel better)?
     Alcohol use disorder can be diagnosed if the patient is positive for at least two of the following:
-drinking more than expected
-persistent desire or inability to quit
-spending a lot of time getting alcohol or drinking alcohol
-having a craving, desire or urge to drink
-having problems fulfilling work, home or school obligations
-continued use despite persistent problems due to drinking
-drinking during times that are hazardous
-altering activities because of drinking
-continuing to drink even though you know it is having a harmful effect
-gaining tolerance (drinking more to attain effect)
-having withdrawal symptoms
     Withdrawal symptoms will start with 6-24 hours after last drink. AWS is diagnosed if at least two of the following symptoms occur; sweating, tachycardia, hand tremor, insomnia, nausea/vomiting, hallucinations (visual, auditory, or tactile), anxiety, psychomotor agitation, or tonic-clonic seizures. If AWS is not treated, it could lead to delirium tremens (disorientation, impaired attention, hallucinations, hyperthermia, tachycardia, tachypnea, diaphoresis, and altered consciousness). There are three stages to AWS. Stage one is mild and will present with anxiety, tremors, headaches, palpitations and GI issues. Stage two moderate and presents with sweating, systolic hypertension, tachypnea, confusion, and hyperthermia. Stage three is severe and is includes delirium tremens. AWS severity is assessed with the CIWA-Ar scale seen here (http://www.aafp.org/afp/2013/1101/afp20131101p589-f1.gif). A score of 8 or less is considered mild withdrawal. Moderate withdrawal has a score of 9-14. A score of 15-20 is moderate. Above 20 is severe. Medication is not needed in patients with a score of less than 10.
     A patient with mild or moderate AWS can be treated as an outpatient if the patient can take oral medications, is committed to the treatment, is willing to follow up frequently, and has proper support at home to assist in medication compliance. Family support is critical in the outpatient setting. Patients with severe withdrawal, serious psychiatric problems, laboratory abnormalities, or poor support at home should be treated as an inpatient.
     Patients are given thiamine and folic acid to combat and deficiencies from heavy drinking. Thiamine can lower the risk of Wernicke encephalopathy. The medications used for reducing psychomotor agitation, seizures and convulsions in AWS are benzodiazepines and anticonvulsants. Long acting benzodiazepines are more effective than intermediate or short acting benzodiazepines. Shorter acting benzodiazepines are more addictive and have a higher potential for abuse. A "loading dose" is not needed. The benzodiazepine can be given as a fixed dose or a symptom-triggered dose (triggered with a CIWAS-Ar score above 9). Symptom-triggered doses end up giving the patient less medication over a shorter period of time. There is no difference in results between either schedule. Anticonvulsants, such as carbamazepine and valproic acid, is also effective in AWS treatment. Gabapentin has shown to be equally effective.
Most patients are evaluated on a daily basis until symptoms decrease and the medication dosage is decreased. Medication can be lowered when a CIWAS-Ar is less than 10. Symptoms should be gone within a week. Patients can then be referred to an long term outpatient treatment center. If they miss an appointment or resume drinking, then they should be referred to a specialist