Overview of alcohol withdrawal management
Alcohol withdrawal can be unplanned or planned.
Unplanned withdrawal occurs when a person is suddenly unable to drink alcohol for example, when admitted to hospital for an acute medical or surgical illness. The risk of complications is increased, particularly with delayed diagnosis of withdrawal. Concurrent conditions, particularly severe liver disease, are considerations that affect benzodiazepine prescribing for withdrawal.
Planned withdrawal can take place in a variety of settings; see Choice of setting for planned alcohol withdrawal. Involuntary planned withdrawal as an inpatient under urgent medical guardianship (or specific legislation on involuntary treatment in some states) is an intervention of last resort for a patient with dependence that poses serious risk to their life.
Mild alcohol withdrawal generally responds well to supportive care (eg calm low-stimulus environment, fluids, multivitamins, reassurance and symptomatic management of nausea and headache) and can be managed without benzodiazepines in the home setting (see Choice of setting for planned alcohol withdrawal), with support from someone close to the person (who does not have a disorder of substance use) and review by the clinician. Review may be undertaken by phone to provide support and assess progress; unless urgent issues arise (eg the patient or their support person feels they are not coping), in-person review can be undertaken after a few days when symptoms have improved. Psychological and behavioural interventions for insomnia may also be helpful; advice includes a printable patient handout on good sleep practices1.
Benzodiazepines are not required for all patients undergoing alcohol withdrawal. Evidence supports early use of benzodiazepines for alcohol withdrawal for people at risk of severe symptoms and complications; see Predictors of severe or complicated alcohol withdrawal for predictors of severe withdrawal. Benzodiazepines may also be used if mild to moderate withdrawal is predicted, because it can be difficult to predict severe withdrawalHaber, 2021. Treatment goals of benzodiazepine prescribing for managing planned or unplanned alcohol withdrawal are to reduce symptom severity and risk of complications, and improve outcomes, such as rates of withdrawal completion.
Thiamine supplementation is recommended for all patients undergoing withdrawal treatment to reduce risk of peripheral neuropathy and Wernicke encephalopathy.
Improvement in mood and re-establishment of normal physiological patterns (such as circadian rhythm) after alcohol withdrawal can take weeks. Because this takes time, some people relapse to drinking soon after withdrawal. To mitigate this risk, close follow-up in the weeks following withdrawal is essential; this comprises daily contact (eg by phone) and a plan for how to escalate care if needed.