Alcohol Withdrawal

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Basics

Description

Alcohol withdrawal syndrome (AWS) is a spectrum of symptoms that results from abrupt cessation or reduction in alcohol intake, which has previously been heavy or prolonged. It ranges from minor symptoms such as anxiety, insomnia, and restlessness to major complications such as hallucinations, seizures, and delirium tremors. Symptoms generally start 6 to 24 hours after the last drink.

Epidemiology

Incidence
  • 15.1 million Americans meet diagnostic criteria for alcohol use disorder (AUD). Approximately 50% of those with AUD have experienced AWS in their lifetime.
  • 8% of those admitted to the hospital are at risk for AWS.

Prevalence
  • AUD is among the most prevalent mental disorder in the world with 12-month and lifetime prevalence of 13.9% and 29.1%, respectively
  • Higher prevalence among men, whites, Native Americans, younger and unmarried adults, and those with lower socioeconomic status

Etiology and Pathophysiology

  • Consumption of alcohol stimulates the effect of the inhibitory neurotransmitter γ-aminobutyric acid (GABA), which results in decreased excitability. With chronic alcohol ingestion, this repeated stimulation downregulates the inhibitory effects of GABA.
  • Concurrently, alcohol ingestion inhibits the stimulatory effect of glutamate on the central nervous system (CNS), with chronic alcohol use upregulating excitatory N-methyl-D-aspartate glutamate receptors.
  • When alcohol is abruptly stopped, the combined effect of a downregulated inhibitory neurotransmitter system (GABA modulated) and upregulated excitatory neurotransmitter system (glutamate modulated) results in brain hyperexcitability when no longer suppressed by alcohol; clinically seen as AWS

Genetics
Some evidence for a genetic basis of AUD

Risk Factors

  • High tolerance, prolonged use, high quantities
  • Previous alcohol withdrawal episodes, detoxifications, alcohol withdrawal seizures, and delirium tremens (DTs)
  • Serious medical problems
  • Concomitant benzodiazepine (BZD) use

Geriatric Considerations
Elderly with AUD are more susceptible to withdrawal, and chronic comorbid conditions place them at higher risk of complications from withdrawal; use of short-acting medications preferred for management

Pregnancy Considerations
Hospitalization or inpatient detoxification is usually required for treatment of acute alcohol withdrawal.

General Prevention

  • The U.S. Preventive Services Task Force recommends routinely screening all patients for alcohol misuse (1)[B].
  • Special attention should be paid to patient undergoing operative procedures, and elective surgeries should be postponed until 7 to 10 days after last drink.
  • Screen with the CAGE to detect problematic alcohol use; positive screen is ≥2 “yes” responses
    • Feeling the need to Cut down
    • Annoyed by criticism about alcohol use
    • Guilt about drinking/behaviors while intoxicated
    • Eye opener” to quell withdrawal symptoms
  • Three-question AUDIT-C screening test is also useful to identify patients with problematic drinking or active alcohol use disorder: positive screen is ≥4 in men and ≥3 in women
    • How often did you have a drink containing alcohol in the past year?
    • How many drinks did you have on a typical day when you were drinking in the past year?
    • How often did you have six or more drinks on one occasion in the past year?

Commonly Associated Conditions

  • General: poor nutrition, electrolyte abnormalities (hyponatremia, hypomagnesemia, hypophosphatemia), thiamine deficiency, dehydration
  • GI: hepatitis, cirrhosis, esophageal varices, GI bleed
  • Heme: splenomegaly, thrombocytopenia, macrocytic anemia
  • Cardiovascular: cardiomyopathy, hypertension, atrial fibrillation, other arrhythmias, stroke
  • CNS: trauma, seizure disorder, generalized atrophy, Wernicke-Korsakoff syndrome
  • Peripheral nervous system: neuropathy, myopathy
  • Pulmonary: aspiration pneumonitis or pneumonia; increased risk of anaerobic infections
  • Psychiatric: depression, posttraumatic stress disorder, bipolar disease, polysubstance use disorder

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Basics

Description

Alcohol withdrawal syndrome (AWS) is a spectrum of symptoms that results from abrupt cessation or reduction in alcohol intake, which has previously been heavy or prolonged. It ranges from minor symptoms such as anxiety, insomnia, and restlessness to major complications such as hallucinations, seizures, and delirium tremors. Symptoms generally start 6 to 24 hours after the last drink.

Epidemiology

Incidence
  • 15.1 million Americans meet diagnostic criteria for alcohol use disorder (AUD). Approximately 50% of those with AUD have experienced AWS in their lifetime.
  • 8% of those admitted to the hospital are at risk for AWS.

Prevalence
  • AUD is among the most prevalent mental disorder in the world with 12-month and lifetime prevalence of 13.9% and 29.1%, respectively
  • Higher prevalence among men, whites, Native Americans, younger and unmarried adults, and those with lower socioeconomic status

Etiology and Pathophysiology

  • Consumption of alcohol stimulates the effect of the inhibitory neurotransmitter γ-aminobutyric acid (GABA), which results in decreased excitability. With chronic alcohol ingestion, this repeated stimulation downregulates the inhibitory effects of GABA.
  • Concurrently, alcohol ingestion inhibits the stimulatory effect of glutamate on the central nervous system (CNS), with chronic alcohol use upregulating excitatory N-methyl-D-aspartate glutamate receptors.
  • When alcohol is abruptly stopped, the combined effect of a downregulated inhibitory neurotransmitter system (GABA modulated) and upregulated excitatory neurotransmitter system (glutamate modulated) results in brain hyperexcitability when no longer suppressed by alcohol; clinically seen as AWS

Genetics
Some evidence for a genetic basis of AUD

Risk Factors

  • High tolerance, prolonged use, high quantities
  • Previous alcohol withdrawal episodes, detoxifications, alcohol withdrawal seizures, and delirium tremens (DTs)
  • Serious medical problems
  • Concomitant benzodiazepine (BZD) use

Geriatric Considerations
Elderly with AUD are more susceptible to withdrawal, and chronic comorbid conditions place them at higher risk of complications from withdrawal; use of short-acting medications preferred for management

Pregnancy Considerations
Hospitalization or inpatient detoxification is usually required for treatment of acute alcohol withdrawal.

General Prevention

  • The U.S. Preventive Services Task Force recommends routinely screening all patients for alcohol misuse (1)[B].
  • Special attention should be paid to patient undergoing operative procedures, and elective surgeries should be postponed until 7 to 10 days after last drink.
  • Screen with the CAGE to detect problematic alcohol use; positive screen is ≥2 “yes” responses
    • Feeling the need to Cut down
    • Annoyed by criticism about alcohol use
    • Guilt about drinking/behaviors while intoxicated
    • Eye opener” to quell withdrawal symptoms
  • Three-question AUDIT-C screening test is also useful to identify patients with problematic drinking or active alcohol use disorder: positive screen is ≥4 in men and ≥3 in women
    • How often did you have a drink containing alcohol in the past year?
    • How many drinks did you have on a typical day when you were drinking in the past year?
    • How often did you have six or more drinks on one occasion in the past year?

Commonly Associated Conditions

  • General: poor nutrition, electrolyte abnormalities (hyponatremia, hypomagnesemia, hypophosphatemia), thiamine deficiency, dehydration
  • GI: hepatitis, cirrhosis, esophageal varices, GI bleed
  • Heme: splenomegaly, thrombocytopenia, macrocytic anemia
  • Cardiovascular: cardiomyopathy, hypertension, atrial fibrillation, other arrhythmias, stroke
  • CNS: trauma, seizure disorder, generalized atrophy, Wernicke-Korsakoff syndrome
  • Peripheral nervous system: neuropathy, myopathy
  • Pulmonary: aspiration pneumonitis or pneumonia; increased risk of anaerobic infections
  • Psychiatric: depression, posttraumatic stress disorder, bipolar disease, polysubstance use disorder

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