Alcohol Withdrawal (AWS)

Description:
- Spectrum of symptoms after abrupt cessation or reduction of prolonged alcohol use.
- Range: mild (tremors, insomnia) to severe (seizures, delirium tremens).
- Symptoms start within hours, peak at 24-48 hours.

Epidemiology

14.5 million Americans met AUD criteria in 2019; ~50% experienced AWS.
32% of ER visits alcohol related.

Etiology and Pathophysiology

Chronic alcohol stimulates GABA → decreased excitability; chronic use downregulates GABA effects.
Alcohol inhibits glutamate CNS receptors; chronic use upregulates NMDA receptors.
Abrupt cessation → downregulated inhibitory (GABA) and upregulated excitatory (glutamate) systems → brain hyperexcitability → AWS.

Risk Factors

Long duration heavy use
Prior withdrawal episodes
Elevated BP at presentation, comorbidities, surgical illness
Physiologic dependence on benzodiazepines/barbiturates

Geriatric Considerations

Elderly more susceptible to withdrawal.

Pregnancy Considerations

Hospitalization recommended for acute withdrawal.

General Prevention

USPSTF recommends universal screening.
Single screening question: “How many times in past year have you had 5 (men) or 4 (women) drinks in one day?”
Screening tools: CAGE, AUDIT, AUDIT-C.

Commonly Associated Conditions

Weight loss, poor nutrition
Electrolyte abnormalities (Na, K, Mg, PO4)
Hepatitis, cirrhosis, GI bleed, pancreatitis
Thrombocytopenia, macrocytic anemia
Hypertension, atrial fibrillation
Seizures, hallucinations, cognitive deficits, Wernicke-Korsakoff syndrome
Peripheral neuropathy
Aspiration pneumonitis, anaerobic infections
Psychiatric disorders (depression, PTSD, bipolar, polysubstance abuse)
Sexual dysfunction, amenorrhea

Diagnosis

DSM-5 Diagnostic Criteria for AWS (≥2 symptoms within hours of cessation):

Autonomic hyperactivity
Hand tremor
Insomnia
Psychomotor agitation
Anxiety
Nausea/vomiting
Generalized seizures
Transient hallucinations/illusions
Symptoms impair social/occupational function
Symptoms not due to other medical/mental conditions

Clinical Manifestations

Autonomic hyperactivity: onset within hours, peaks 24-48 hrs
Seizures: brief, 12-48 hrs after last drink
Delirium tremens: onset 48-72 hrs

History

Duration, quantity of alcohol, time since last drink
Prior withdrawal symptoms or admissions
Substance use, medical/psychiatric history
Social support, stressors, triggers

Physical Exam

Assess for exacerbated conditions: arrhythmias, HF, CAD, GI bleeding, liver disease, pancreatitis
Neuro: oculomotor dysfunction, gait ataxia, neuropathy
Psych: orientation, memory
Signs: hand tremor (6-8 Hz), infections

Differential Diagnosis

Intoxication/withdrawal from other substances
Anticholinergic toxicity
Neuroleptic malignant syndrome
Sepsis, CNS infection, hemorrhage
Mania, psychosis, anxiety, panic
Thyroid crisis

Diagnostic Tests & Interpretation

Blood alcohol level, urine drug screen
CBC, metabolic panel
Lipase, amylase, GGT
Head CT if altered mental status
First seizure workup: EEG, imaging, lumbar puncture
Amylase/lipase elevation → consider abdominal imaging
ECG for age >50 or cardiac history
Alcohol metabolism ~10-15 mg/dL/hr (faster in chronic use)

Treatment

Goals

Safe, humane withdrawal
Prepare for ongoing addiction treatment

Monitoring

Use CIWA-Ar scale (max 67 points) to rate severity:
Mild ≤8 (likely no meds)
Moderate 8-14 (often meds needed)
Severe ≥15 (high risk seizures/DTs)
Frequent reassessment required

Medications

First Line: Benzodiazepines (BZDs)
- Rapid onset (IV diazepam) controls agitation quickly
- Long-acting BZDs (diazepam, chlordiazepoxide) prevent seizures/rebound symptoms
- Short-acting BZDs (lorazepam, oxazepam) for elderly, hepatic impairment
- Symptom-triggered preferred (medicate when CIWA-Ar ≥8)
- Fixed schedule if nursing staff untrained, CAD, or past seizures
- Dose examples:
- Chlordiazepoxide 50-100 mg PO
- Diazepam 10-20 mg PO
- Oxazepam 30-60 mg PO
- Lorazepam 2-4 mg PO

Supplements
- Thiamine 50-100 mg/day (IV before glucose)
- Folic acid 1 mg/day
- Correct electrolyte imbalances

Second Line:
- Gabapentin (reduces cravings, mild withdrawal)
- β-Blockers (atenolol, propranolol), α2-agonists (clonidine) for BP and tachycardia (not monotherapy)
- Carbamazepine (reduces seizures, mild withdrawal; not monotherapy)
- Haloperidol for agitation/hallucinosis (monitor seizure risk)

Additional Therapies

Physical therapy for peripheral neuropathy, cerebellar dysfunction

Admission Criteria

CIWA-Ar >15 or severe withdrawal
Ataxia, nystagmus, confusion
Severe nausea/vomiting
Poor follow-up or social support
Pregnancy
History of seizures, DTs
Comorbid psychiatric or medical illness

Ongoing Care

Withdrawal management is first step in AUD treatment
Discharge includes outpatient counseling, peer support, residential treatment
Medication-assisted treatment (MAT): Acamprosate, Naltrexone, Disulfiram

Patient Education

Alcoholics Anonymous: https://www.aa.org/
SMART Recovery: https://www.smartrecovery.org/
NIAAA: https://www.niaaa.nih.gov/health-professionals-communities
FamilyDoctor.org (including Spanish resources)

Prognosis

Mortality of severe withdrawal (DTs) 1-5%.

References

Rastegar DA, Fingerhood MI. The American Society of Addiction Medicine Handbook of Addiction Medicine. 2nd ed. 2020.
Tiglao SM, Meisenheimer ES, Oh RC. Alcohol withdrawal syndrome: outpatient management. Am Fam Physician. 2021;104(3):253-262.

ICD10 Codes

F10.239 Alcohol dependence with withdrawal, unspecified
F10.230 Alcohol dependence with withdrawal, uncomplicated
F10.231 Alcohol dependence with withdrawal delirium

Clinical Pearls

BZD dose individualized to maintain light somnolence; taper carefully to prevent BZD withdrawal.
Administer thiamine before glucose to prevent Wernicke encephalopathy.
Avoid IM diazepam and lorazepam due to erratic absorption.
Managing AWS is first step in AUD treatment; ensure outpatient follow-up.