Alcohol withdrawal ⚠️

• If person who usually drinks 40–60g or more of alcohol a day (4–6 or more standard drinks) stops drinking there is a risk of alcohol withdrawal for the next 5 days
• A standard drink Table 5.3 contains 10g of alcohol takes, a healthy liver about 1 hour to remove this alcohol from the body

• If regular drinker unwell — they may be in withdrawal. More likely if

• Drinks every day and often drinks a lot (4–6 or more standard drinks a day) OR has a regular binge pattern with more than 6 standard drinks per session every 2–3 days
• Has past history of withdrawal or seizures

Severe alcohol withdrawal syndrome

• Withdrawal seizures may happen in first 3 days after stopping alcohol
• May be first feature of withdrawal
• May happen if other illness at same time
• Delirium tremens (DTs, 'horrors') can happen up to 6 days after stopping
• Mix of anxiety, agitation, aggressive behaviour escalation, disorientation, hallucinations, dehydration, high heart rate, high BP, low-grade fever, tremors/shaking
• Risk of death

Uncomplicated withdrawal

• Usually starts 6–24 hours after last drink of alcohol
• Any combination of anxiety, agitation, aggressive behaviour escalation, tremor, sweating, tachycardia (high heart rate), insomnia (can’t sleep) — may be mild, hard to detect

Alcohol withdrawal management

• Assess and manage based on Clinical Institute Withdrawal Assessment (CIWA) score — see Table 5.4 AND red flags
• Get advice from doctor or alcohol and drug service if not familiar with CIWA

Ask

• When person had last drink
• How they usually drink — regular or binge drinker
• How much they usually drink
• What time of the day do they start drinking alcohol
• Any previous alcohol withdrawal
• Taking any medicine or other drugs

Check

• U/A, pregnancy test
• Head-to-toe exam
• CIWA score

Observational assessment. Add up score for 10 criteria = score for person

Do

• If CIWA score more than 6 — medical consult
• Repeat CIWA every 30–60 minutes. If increasing despite treatment — consider evacuation
• Look after person in quiet, dim room
• Give medicines as needed
• Monitor dehydration — give fluids as needed
• Make sure responsible person is with them all the time

Follow-up

• Review daily until well
• Refer to alcohol and drug service, mental health service if needed
• Make management plan and  provide brief intervention

Medicines for alcohol withdrawal

• Antiemetic for nausea or vomiting — see Nausea and vomiting
• Loperamide oral — adult 4mg, single dose for diarrhoea

THEN loperamide oral — 2mg after each bowel action, up to 16mg/day

• Thiamine IM into buttock — adult 300mg, once a day for 3 days, to correct common nutritional deficiency 

THEN thiamine oral — adult 100mg, once a day for at least 1 month

AND ​multivitamin oral — 1 tablet, once a day for at least 1 month

• Paracetamol — adult 1g up to 4 times a day (qid) for pain — do not use if severe liver disease
• Diazepam — see doses below

Diazepam doses

Diazepam lessens agitation and other symptoms (eg hallucinations), helps prevent fits and DTs

• Medical consult before giving diazepam
• After giving — recheck CIWA every 30 minutes for at least 2 hours
• If CIWA increases — medical consult. May need to repeat or increase dose
• If CIWA score still more than 10 after 2 hours — medical consult. May need to go to hospital
• If older person, low body weight (less than 50kg), person with significant lung, liver or kidney disease (acute or chronic) — give half dose and watch closely for over-sedation
• Do not exceed these diazepam doses and avoid using diazepam daily for more than 1 week — may lead to tolerance/dependence 
• If 90kg or under — 40mg oral in first 24 hours
• If over 90kg — 60mg oral in first 24 hours