Alcohol Use Disorder

Ben Johnson

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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 o 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 o 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 2^nd day, 30-60 mg q4h on 3^rd day, and 30 mg on 4^th 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
    • 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 relaps 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