ALCOHOL WITHDRAWAL
Roger E. Thomas, MD, Ph.D, CCFP, FCFP, MRCGP
Emeritus Professor of Family Medicine, University of
Calgary
Article: Tiglao. Alcohol withdrawal syndrome: Outpatient management.
American Family Physician 2021;104(3): 253-262.
Diagnostic and Statistical Manual (DSM-5) Diagnostic Criteria
for Alcohol Use Disorder
DSM-5 Diagnostic Criteria for Alcohol Use Disorder.
A problematic pattern of alcohol use leading to clinically significant impairment or
distress, as manifested by at least two of the following, occurring within a 12-month
period:
1. Alcohol is often taken in larger amounts or over a longer period than was
intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol
use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use
alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at
work, school, or home.
Diagnostic and Statistical Manual (DSM-5) Diagnostic
Criteria for Alcohol Use Disorder
6. Continued alcohol use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or
reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been caused
or exacerbated by alcohol.
10. Tolerance, as defined by either of the following: a. A need for markedly
increased amounts of alcohol to achieve intoxication or desired effect. b. A
markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following: a. The characteristic
withdrawal syndrome for alcohol. b. Alcohol (or a closely related substance,
such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
Incidence of Alcohol Use Disorder
In USA 12 month 13% and lifetime
29%
Single Alcohol Screening Question
(SASQ) “How many times in the
past year have you had 5 or more
drinks in a day” [4 drinks for
females] Any response > 1 is
positive
DSM-5 Diagnostic Criteria for Alcohol Withdrawal
A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after
the cessation of (or reduction in) alcohol use described in Criterion A:
1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 beats per
minute).
2. Increased hand tremor.
3. Insomnia.
4. Nausea or vomiting.
5. Transient visual, tactile, or auditory hallucinations or illusions.
6. Psychomotor agitation.
7. Anxiety.
8. Generalized tonic-clonic seizures.
C. The signs or symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are
not better explained by another mental disorder, including intoxication or withdrawal
from another substance.
Clinical Institute Withdrawal Assessment of Alcohol
Scale Revised (CIWA-Ar) Max = 67 points
Nausea and vomiting
0 no nausea; 7. Constant nausea, frequent dry heaves, vomiting
Agitation
0 Normal; 7. Paces back and forth or thrashes about
Tremor
0 Not visible; 7. Severe, even with arms not extended
Paroxysmal sweats
0 No sweat; 7. Drenching sweats
Auditory disturbances
0 Not present; 7. Continuous hallucinations
Visual disturbances
0 Not present; 7. Continuous hallucinations
Anxiety
0 No anxiety, at ease; 7. Equivalent to acute panic states as in
severe delirium or acute schizophrenic reactions
Tactile disturbances
0 None; 7. Continuous hallucinations
Headache, fullness in head
0 Not present; 7. Extremely severe
Orientation and clouding of 0 Oriented and can do serial additions; 4 Disconnected with place
sensorium
or person
Treatment goals
Prevent withdrawal symptoms
Prevent seizures
Prevent delirium tremens (510% mortality rate)
Treatment based on the Clinical Institute Withdrawal Assessment
of Alcohol Scale Revised (CIWA-Ar)
MILD CIWA symptoms (< 10 points)
 Supportive care
 Monitor for severe withdrawal symptoms
 Low stimulation home environment
 Daily multivitamin with 400 mcg folic acid
 No caffeine
 Daily thiamine 100 mg x 5 days
 Gabapentin to prevent withdrawal seizures or delirium
tremens
Treatment based on the Clinical Institute
Withdrawal Assessment of Alcohol Scale
Revised (CIWA-Ar)
Moderate CIWA Score (10-18 points)
 Long-acting benzodiazepines (chlordiazepoxide or diazepam) to
reduce risk of seizures and delirium tremens
 Monitor patients for oversedation and respiratory depression
 In patients with liver disease change to diazepines with less
hepatic metabolism (lorazepam or oxazepam)
 If contraindications against benzodiazepines, consider
gabapentin, carbamazepine or phenobarbital
Severe CIWA Score (19 or more points)
 Hospitalisation