Alcohol Use: Treatment for alcohol withdrawal

Benzodiazepines for alcohol withdrawal

Benzodiazepines are the first-line treatment for alcohol withdrawal symptoms because they are effective and safe in the short-term and when used appropriately. Diazepam, a long-acting benzodiazepine, is the most studied and has been shown to be effective in preventing the complications of alcohol withdrawal.

Use the following as best practice guidelines:

• If the CIWA score (Clinical Institute Withdrawal Assessment) is 10 or more, give the patient 20 mg of diazepam orally every one to two hours until symptoms abate and the CIWA score is less than 8.
• Treatment is completed when the patient is comfortable, with minimal tremor, and the CIWA score is less than 8 on two consecutive readings
• If take-home diazepam is necessary, give no more than two to three 10 mg tablets.
• Give thiamine orally. If the patient is at high risk of Wernicke's encephalopathy (malnourished, in severe withdrawal), give three days of intravenous or intramuscular thiamine.

Transferring patients to an emergency department

Patients in the following situations should be transferred to an emergency department to manage alcohol withdrawal:

• The patient arrives in severe withdrawal, with a CIWA score higher than 20, or with hallucinations or other concerning symptoms.
• The patient experiences a seizure and shows signs of impending delirium or psychosis (e.g., confusion, hallucinations).
•  The patient shows any sign of acute medical illness (e.g., fever, dyspnea) or any other medical condition or complication requiring more investigations and management than a community clinic can provide.
• The patient's CIWA scores continue to climb despite following CIWA protocol.
• The patient's CIWA score is 10 or higher after four doses of diazepam at 80 mg.
• The patient has persistent tachycardia, with a heart rate higher than 120 beats per minute and irregular beats.
• The patient is suicidal.
• The patient has complicated polysubstance use.

The following guidelines can be used to determine when the patient is ready to leave the emergency department, and how to best support them after they leave:  

• Treatment is completed when the patient is comfortable and has minimal tremor, and the CIWA score is less than 8 on two consecutive readings.
• Send the patient home if an escort is available; otherwise, send the patient to a local withdrawal management service for admission.
• If the patient is still in some withdrawal, prescribe two or three 10 mg diazepam tablets, to be taken one tablet every four hours, preferably to be dispensed by a partner or friend. The patient should agree not to drink while taking benzodiazepines.
• Have the patient return for follow-up in one or two days.

Withdrawal management services

Most patients who do not need further medical interventions for withdrawal should be referred to withdrawal management services, which are non-medical and community-based.

These services provide a safe place for people who are attempting to withdraw from any substance. Patients can be admitted immediately if a bed is available, and they can stay for up to five days, or sometimes longer.

Withdrawal management services provide counselling and treatment referral. Some provide two- to three-week early recovery programs for outpatients.

You can phone a withdrawal management service to find out whether beds are available, but patients need to call or visit the service themselves to secure an assessment.

Home-based withdrawal management

Home-based treatment of withdrawal may be considered only for patients who meet certain criteria. For other patients, home-based treatment is unsafe.

Home-based withdrawal management may be a safe, effective option in the following situations:

• The patient has a history of mild withdrawal symptoms
• The patient has recently gone without drinking for five or more days and withdrawal symptoms did not progress to more severe withdrawal requiring medical management.
• The patient has no history of severe withdrawal (e.g., seizures, delirium, hospital admissions) or withdrawal requiring medical management.
• There is no history of polysubstance use, or polysubstance use is non-problematic.  The patient is not misusing sedatives.
• A support person (partner, family member or friend) agrees to dispense the medication.
• A treatment plan is in place (e.g., medications for alcohol use disorders, ongoing counselling, other treatment groups).
• The patient and the patient's support person agree to go to the emergency department if withdrawal symptoms become more severe.
• The patient is less than 65 years old and has no significant comorbidities or severe mental health problems.
• The patient agrees not to drink while taking medication.

The protocol for home-based withdrawal goes as follows:

• The patient has the last drink between 6:00 and 8:00 p.m. the night before.
• The patient takes 10 mg of diazepam, dispensed by the support person, starting the next morning, every four hours as needed for tremor.
• Prescribe no more than 40 mg of diazepam.
• Reassess the patient the next day (by phone or in person).
• The patient visits the clinic within two to three days.

Connect to community withdrawal management, if possible: In some communities, an addiction service worker from a withdrawal management service will visit patients in their homes to monitor home-based withdrawal and to arrange formal treatment. 

Emergency department or other hospital-based withdrawal management

Most patients in alcohol withdrawal can be managed as outpatients; however, some may require management in a hospital emergency department or inpatient medical detoxification program. These are patients who do not meet criteria for office management and/or check one or more of the following boxes:

• A history of severe withdrawal requiring hospitalization (e.g., delirium tremens, hallucinations, severe confusion)
• Heavy alcohol use (i.e., more than 12 to 15 drinks per day)
• A history of withdrawal seizures
• A significant medical or mental health comorbidity
• Problematic polysubstance use
• Aged 65 years or older
• Is experiencing suicidal thoughts
• Cannot be monitored appropriately in your office for reasons of time or space
• Unable to take oral diazepam.

Emergency department treatment for these patients often involves intravenous rehydration, psychiatric assessment and monitoring of electrolytes, vital signs and cardiac function.

Managing withdrawal in the emergency department or medical withdrawal unit is very similar to the outpatient clinic setting, but requires closer monitoring and more investigations. It involves the following practices:

• If the patient has a history of seizures, give diazepam 20 mg every hour for a minimum of three doses.
• If the patient is 65 or older, or has hepatic dysfunction, significant respiratory comorbidities such as COPD or pneumonia, or concurrent opioid use: Give lorazepam 1–2 mg sublingual or by mouth every two to four hours.
• Remember to give thiamine. If the patient is at high risk of Wernicke's encephalopathy (malnourished, in severe withdrawal), give three days of intravenous or intramuscular thiamine.
• Ideally, detoxification is integrated into the patient's treatment plan and the patient has a follow-up appointment with their regular care provider or an addiction medicine physician the day after discharge.

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