Alcohol Use Disorder

Claire Willman

Background 

  • 50% of hospitalized patients drink alcohol. At-risk alcohol use is >14 drinks/week or >5 drinks in a sitting for men. For women and men >65, 7 per week, >4 per sitting.
  • Alcohol withdrawal onset occurs 6-12 hours after last drink, with 90% having non-severe course. CIWA score <10 at 24-48 hours indicates low risk of worsening symptoms.
  • Risk of seizures greatest at 12-24 hrs, occurring in ~3% of patients.
  • Risk of delirium greatest at 48-72 hrs, occurring in ~5%
  • Risk Assessment:
    • Risk factors: Prior seizures/delirium tremons (most significant risk factor), co-substance use (especially benzodiazepines), no abstinent days in past month, presenting BAL >200, dysautonomia.
    • CIWA protocol is appropriate for patients at low risk of severe withdrawal.
    • For non-low risk patients, consider benzodiazepine/barbiturate load and standing taper.
    • Prediction of Alcohol Withdrawal Severity Scale (PAWSS) can be used to stratify risk of complicated alcohol withdrawal (seizure and DT risk); 1 point per question:
      • Intoxicated in the previous 30 days?
      • Previous episode of withdrawal from alcohol?
      • Previous withdrawal seizures?
      • Previous delirium tremens?
      • Previous detoxification from alcohol?
      • History of blackouts?
      • Concurrent use of benzodiazepines or barbiturates in last 90 days?
      • Concurrent use of other recreational substances within the last 90 days?
      • Positive BAL on admission?
      • Evidence of autonomic hyperactivity (tachycardia, diastolic HTN, diaphoresis, nausea)?
    • PAWSS score of 4 or greater is also considered high risk for complicated withdrawal.
    • Indications for admission: prior severe withdrawal (withdrawal seizures or delirium), PAWSS score of 4 or greater, comorbidities (medical and psychiatric illness), pregnancy, significant impairment in social/occupational functioning, communication barriers, social barriers.

Presentation

  • Acute intoxication: disinhibition, slurred speech, ataxia, nystagmus.
  • Acute withdrawal: nausea, vomiting, anxiety, agitation, audio-visual and tactile hallucinations, headache, diaphoresis, fine motor tremor while arms and fingers outstretched, autonomic hyperactivity.
  • Chronic heavy use: sequelae of chronic liver disease and malnutrition, including thiamine deficiency.
  • Caine criteria for Wernicke’s encephalopathy:
    • 2 or more: (1) malnutrition, (2) ataxia, (3) oculomotor abnormalities, (4) AMS.

Evaluation

  • Identify last use, quantity per day/week, other sedative-hypnotic use, history of withdrawal, social/occupational dysfunction, other toxic forms of alcohol compounds including methanol and ethylene glycol.
  • Acute alcohol withdrawal.
  • Labs: blood alcohol level, urine toxicology (+/- ethyl glucuronide to detect use in prior 3 days), BMP, CBC, LFTs (AST:ALT elevation 2:1), CK and β - hCG.
  • CIWA score quantifies severity, though subject to inflation by subjective symptoms.

Management of Acute Alcohol Withdrawal 

  • Diazepam-based protocols:
  • Include hold parameters throughout the duration of the load and taper (sedation and hypopnea) and discontinue further doses for emergent toxicity (dysarthria, ataxia, nystagmus).
  • Low risk patients: CIWA-based symptom-triggered protocol, eg: diazepam 20 mg po q1h for CIWA greater than 20 or if 15-19 for 2 consecutive hours.
  • Non-low risk patients:
    • Load: Diazepam 20 mg q1h x3 doses followed by Diazepam 10 mg q4h PRN for first 24 hours to identify total diazepam requirement to achieve RASS score of 0
    • Taper: Schedule 20% taper per day from original 24-hour requirement divided into TID or QID dosing schedule.
  • Non-low risk patients with hepatic impairment
    • Substitute lorazepam (risk of long-acting accumulation).
    • Load: Lorazepam 2 mg q1h PO/IV x3 dose followed by Lorazepam 2 mg q4h + 1mg q4h PRN for the first 24 hours to identify total lorazepam requirement to achieve RASS score of 0.
    • Taper: Schedule 20% taper per day from original 24-hour requirement divided into QID dosing schedule.
    • DO NOT discontinue taper early (but do hold doses for toxicity) as abrupt discontinuation of a short acting agent can result in delayed lorazepam withdrawal seizure.
  • Phenobarbital-based protocols:
  • Benzodiazepine resistance: likely due to cross-tolerance between alcohol and benzodiazepines.
    • Considerations:
      • No reduction in CIWA after 60-80 mg of diazepam
      • No reduction of CIWA in 24 hours
      • Previous DTs or seizures
      • Concurrent use of benzodiazepines and alcohol
      • Phenobarbital load
      • 8-12 mg/kg (up to 15 mg/kg) divided into 3 doses 3 hours apart
      • Taper may or may not be necessary after initial weight-based load but may consider: 60-120 mg q4h on 2nd day, 30-60 mg q4h on 3rd day, and 30 mg on 4th day, then discontinue.
    • Special considerations:
      • Add folate, multivitamin, and electrolyte repletion.
      • If >2 Caine criteria, treat empirically for Wernicke’s encephalopathy with high-dose IV thiamine (500 mg TID IV x 3-5 days).
      • Consider Addiction Psychiatry consultation for complex presentations.

Long-term Management of Alcohol Use Disorder (AUD) 

  • After withdrawal stabilization, engage the patient in discussion around use and educate on connection between use and presenting medical problems.
  • Refer to Motivational Interviewing section for further guidance.
  • Pharmacotherapy (MAUD) should be discussed with all patients prior to discharge, and if interested, MAUD should be initiated regardless of abstinence goal.
  • If patient does not have abstinence goal, harm reduction may be achieved through reduction in quantity and/or frequency of drinking.
  • Naltrexone and topiramate have evidence for non-abstinence outcomes.
  • Pharmacologic interventions
    • Naltrexone (cannot be on opioid agonist):
      • Need 7-10 days since last opioid before starting.
      • 25 mg x1 day, then titrate up to 50 mg daily; also available in q30d IM.
      • Monitor liver enzymes; AST/ALT must be < 3-5x ULN.
    • Acamprosate
      • Head-to-head, inferior to naltrexone (see COMBINE trial).
      • Contraindicated with creatinine clearance less than 30 mL/min; dose reduced when 30- 60 mL/min.
      • Start with 333 mg TID, titrating to 666 mg TID dosing.
    • Disulfiram
      • Infrequently used outside of extreme motivation (e.g. professional under monitoring); would not use outside of specialist care.
      • Must abstain from alcohol ~2 weeks after last dose, given risk of disulfiram-ethanol reaction (DER), which can be fatal depending upon disulfiram and ethanol doses.
    • Topiramate
      • Not FDA-approved for AUD, but has significant supporting evidence.
      • Useful for individuals without abstinence goal.
      • Titrate slowly over 8 weeks to 200-300 mg/d.
    • Gabapentin
      • Not FDA-approved for AUD, but with some evidence and national guideline recommendations; however, continuation after discharge from acute care many be affected by controlled substance classification.
      • Useful for post-acute withdrawal anxiety, insomnia, or co-occurring neuropathy.
      • Titrate to 900-1800 mg/d divided into TID dosing, monitoring for sedation.
      • Risk of sedation/apnea if concomitant alcohol use, so recommend patient discontinue if alcohol relapse occurs.
  • Additional psychosocial treatments effective for AUD include 12-step groups (AA, SMART Recovery), cognitive behavioral therapy, sober living facilities, family therapy, contingency management, and IOP/residential treatment.
  • Consultation with Addiction Psychiatry or General Psychiatry is available to support management of AUD.
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