Management of Alcohol Withdrawal in the Outpatient Setting

Approximately 2% to 9% of patients seen in a family physician’s office have alcohol dependence. These patients are at risk of developing alcohol withdrawal syndrome (AWS) if they abruptly abstain from alcohol use.  Treatment goals for patients with AWS are to reduce withdrawal symptoms; prevent seizures, delirium tremens, and death; and prepare the patient for long-term abstinence from alcohol use. Adequate and prompt treatment diminishes the severity of future withdrawal episodes and the risk of the patient resuming alcohol use.

Patients with mild or moderate alcohol withdrawal syndrome can be treated as outpatients, which minimize expense and allows for less interruption of work and family life. Patients with severe symptoms or who are at high risk of complications should receive inpatient treatment.

Important Considerations:

  • Blood and breath alcohol concentration levels correlates more accurately to cognitive impairment than urine concentration levels
  • Intoxication itself is not a reason for psychiatric admission, but strongly consider it if the patient has other risk factors (current SI, no social contacts, history of depression, history of suicide attempts)
  • Consider medical admission if history of complicated withdrawal (i.e. seizures, DTs)

Withdrawal Symptoms: generally peak at 24-36 hours

  1. tremors
  2. nausea/vomiting
  3. anxiety/agitation
  4. tachycardia/hypertension
  5. diaphoresis
  6. insomnia
  7. hallucinations (in 5-10% of patients)
  8. grand mal seizures (less than 5% of patients, peaks 24-48 hours)
    1. highest risk: length of alcohol dependence, history of withdrawal seizures
  9. delirium tremens (less than 5% of patients, peaks 2-5 days)
    1. symptoms: disorientation, confusion, autonomic hyperactivity, can be lethal

Assessment: use a rating scale to help inform treatment: CIWA scale (link included)


  1. Include thiamine 100 mg qday, folate 1 mg qday, multivitamin qday to prevent Wernicke’s encephalopathy (triad: confusion, ataxia, opthalmoplegia)

Give thiamine before patient eats or receives an IV

  1. Include gabapentin 400mg tid for seizure prevention (as long as kidney function is fine). Also helpful for abstinence and relapse prevention, can be used past the acute phase of withdrawal
  2. Can provide benzodiazepine taper to minimize discomfort of alcohol withdrawal

Use Librium as default, but use Ativan if liver function is compromised (ALT/AST over 300) or if patient is over 60yo.

Librium sample taper:

Day 1: 50mg q4hr x 6 doses

Day 2: 50mg q6hr x 4 doses

Day 3: 50mg q8hr x 3 doses

Day 4: 25mg q6hr x 4 doses

Day 5: 25mg q12hr x 2 doses

Day 6: 25 mg x 1 dose then DC

Ativan sample taper:

Day 1: 2mg q6hr x 4 doses

Day 2: 2mg q8hr x 3 doses

Day 3: 1mg q6hr x 4 doses

Day 4: 1mg q8hr x 3 doses

Day 5: 0.5mg q6hr x 4 doses

Day 6: 0.5mg q8hr x 3 doses

Ideally have patient return to clinic daily for benzodiazepine prescription and to check vitals and breathalyzer. The patient should have a reliable family member or friend who can check on them daily or stay with them during the first 3-5 days of treatment.

Successful treatment of AWS is the initial step toward long-term abstinence. Abstinence is unlikely if the patient does not enroll in a long-term treatment program

Next week’s e-weekly will address on-going management of alcohol addiction and treatment.

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