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Alcohol Use Disorder

Barrington Hwang, Kristopher Kast


  • 50% of hospitalized pts 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 pts; risk of delirium greatest at 48-72 hrs, occurring in ~5%

  • Risk assessment

  • RF: prior seizures/delirium, co-substance use (especially benzodiazepines), no abstinent days in past month, presenting BAL >200, dysautonomia

  • CIWA symptom-triggered protocol appropriate for pts at low risk of severe withdrawal

  • For non-low risk pts, consider benzodiazepine/barbiturate load and standing taper;

  • Indications for admission: prior severe withdrawal (withdrawal seizures or delirium), comorbidities (medical and psychiatric illness), pregnancy, significant impairment in social/occupational functioning, communication barriers, social barriers


  • 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 & malnutrition, including thiamine deficiency

  • Caine criteria for Wernicke’s encephalopathy:

    • 2 or more: (1) malnutrition, (2) ataxia, (3) oculomotor abnormalities, (4) AMS


  • 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, ethylene glycol

  • Acute Alcohol Withdrawal

    • Labs: Blood alcohol level, urine toxicology (± ethyl glucuronide to detect use in prior 3 days), BMP, CBC, HFTs (AST:ALT elevation 2:1), CK and β - hCG

    • CIWA score quantifies severity, though subject to inflation by subjective symptoms


Acute Alcohol Withdrawal

  • Most patients are appropriate for diazepam-based protocols:

  • CIWA-based symptom-triggered for low-risk patients

  • Diazepam load + standing taper for non-low risk patients

  • Substitute lorazepam for pts with hepatic impairment (risk of long-acting accumulation)

  • Benzodiazepine resistance: likely due to poor cross-tolerance, these pts require phenobarbital load ( 8-12 mg/kg (up to 15 mg/kg) divided into 3 doses 3 hours apart)

  • 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

Alcohol Use Disorder

  • After withdrawal stabilization, engage pt in discussion around use and educate on connection between use and presenting medical problems

  • All patients with AUD should be initiated on pharmacotherapy (MAUD) prior to discharge to mitigate risk of relapse, if consistent with patient’s goals

  • 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 facilities

  • If patient does not have abstinence goal, reduced or controlled drinking may allow for harm reduction; 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 (cannot be used in severe renal impairment)

      • Head-to-head, inferior to naltrexone (see COMBINE trial)

      • 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 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

      • 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

Last update: 2022-06-26 15:53:24