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. 1999 Mar 9;160(5):675–680.

Diagnosis and management of acute alcohol withdrawal

A M Holbrook 1, R Crowther 1, A Lotter 1, C Cheng 1, D King 1
PMCID: PMC1230114  PMID: 10102003

Abstract

Alcohol abuse produces a considerable burden of illness in the Canadian population. The diagnosis of alcohol dependence and withdrawal can be difficult, particularly in the setting of covert intake or comorbidity. Two validated scales, the CAGE questionnaire to screen for alcohol abuse and dependence and the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale to assess the severity of withdrawal, are valuable tools for clinicians to use on a regular basis. For the treatment of alcohol withdrawal, compelling anecdotal evidence supports the routine administration of thiamine, but not necessarily other vitamins. Phenytoin has not been shown to be superior to placebo for uncomplicated withdrawal seizures. Neuroleptics are not recommended for routine use. Sedation with benzodiazepines guided by the CIWA-Ar results is recommended. There is good evidence that the management of alcohol withdrawal can be improved with the routine use of the CIWA-Ar scale to assess severity, treatment with adequate doses of benzodiazepines and follow-up monitoring of patients in alcohol withdrawal.

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Selected References

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  1. Ahmed F. E. Toxicological effects of ethanol on human health. Crit Rev Toxicol. 1995;25(4):347–367. doi: 10.3109/10408449509021614. [DOI] [PubMed] [Google Scholar]
  2. Alldredge B. K., Lowenstein D. H., Simon R. P. Placebo-controlled trial of intravenous diphenylhydantoin for short-term treatment of alcohol withdrawal seizures. Am J Med. 1989 Dec;87(6):645–648. doi: 10.1016/s0002-9343(89)80397-3. [DOI] [PubMed] [Google Scholar]
  3. Anderson P., Cremona A., Paton A., Turner C., Wallace P. The risk of alcohol. Addiction. 1993 Nov;88(11):1493–1508. doi: 10.1111/j.1360-0443.1993.tb03135.x. [DOI] [PubMed] [Google Scholar]
  4. Chance J. F. Emergency department treatment of alcohol withdrawal seizures with phenytoin. Ann Emerg Med. 1991 May;20(5):520–522. doi: 10.1016/s0196-0644(05)81606-3. [DOI] [PubMed] [Google Scholar]
  5. Cold J. A., Wells B. G., Froemming J. H. Seizure activity associated with antipsychotic therapy. DICP. 1990 Jun;24(6):601–606. doi: 10.1177/106002809002400610. [DOI] [PubMed] [Google Scholar]
  6. Doll R., Peto R., Hall E., Wheatley K., Gray R. Mortality in relation to consumption of alcohol: 13 years' observations on male British doctors. BMJ. 1994 Oct 8;309(6959):911–918. doi: 10.1136/bmj.309.6959.911. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Foy A., March S., Drinkwater V. Use of an objective clinical scale in the assessment and management of alcohol withdrawal in a large general hospital. Alcohol Clin Exp Res. 1988 Jun;12(3):360–364. doi: 10.1111/j.1530-0277.1988.tb00208.x. [DOI] [PubMed] [Google Scholar]
  8. Guthrie S. K. The treatment of alcohol withdrawal. Pharmacotherapy. 1989;9(3):131–143. doi: 10.1002/j.1875-9114.1989.tb04119.x. [DOI] [PubMed] [Google Scholar]
  9. Holbrook A. M., Crowther R., Lotter A., Cheng C., King D. Meta-analysis of benzodiazepine use in the treatment of acute alcohol withdrawal. CMAJ. 1999 Mar 9;160(5):649–655. [PMC free article] [PubMed] [Google Scholar]
  10. Kahan M., Wilson L., Becker L. Effectiveness of physician-based interventions with problem drinkers: a review. CMAJ. 1995 Mar 15;152(6):851–859. [PMC free article] [PubMed] [Google Scholar]
  11. Kitchens J. M. Does this patient have an alcohol problem? JAMA. 1994 Dec 14;272(22):1782–1787. [PubMed] [Google Scholar]
  12. Leone M., Bottacchi E., Beghi E., Morgando E., Mutani R., Amedeo G., Cremo R., Gianelli M., Ravagli Ceroni L. Alcohol use is a risk factor for a first generalized tonic-clonic seizure. The ALC.E. (Alcohol and Epilepsy) Study Group. Neurology. 1997 Mar;48(3):614–620. doi: 10.1212/wnl.48.3.614. [DOI] [PubMed] [Google Scholar]
  13. Lerner W. D., Fallon H. J. The alcohol withdrawal syndrome. N Engl J Med. 1985 Oct 10;313(15):951–952. doi: 10.1056/NEJM198510103131509. [DOI] [PubMed] [Google Scholar]
  14. Markowitz J. C., Brown R. P. Seizures with neuroleptics and antidepressants. Gen Hosp Psychiatry. 1987 Mar;9(2):135–141. doi: 10.1016/0163-8343(87)90025-9. [DOI] [PubMed] [Google Scholar]
  15. Mayo-Smith M. F. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997 Jul 9;278(2):144–151. doi: 10.1001/jama.278.2.144. [DOI] [PubMed] [Google Scholar]
  16. McIntosh M. C., Leigh G., Baldwin N. J., Marmulak J. Reducing alcohol consumption. Comparing three brief methods in family practice. Can Fam Physician. 1997 Nov;43:1959-62, 1965-7. [PMC free article] [PubMed] [Google Scholar]
  17. Millar W. A trend to a healthier lifestyle. Health Rep. 1991;3(4):363–370. [PubMed] [Google Scholar]
  18. Mäkelä P., Valkonen T., Martelin T. Contribution of deaths related to alcohol use to socioeconomic variation in mortality: register based follow up study. BMJ. 1997 Jul 26;315(7102):211–216. doi: 10.1136/bmj.315.7102.211. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Naranjo C. A., Sellers E. M., Chater K., Iversen P., Roach C., Sykora K. Nonpharmacologic intervention in acute alcohol withdrawal. Clin Pharmacol Ther. 1983 Aug;34(2):214–219. doi: 10.1038/clpt.1983.155. [DOI] [PubMed] [Google Scholar]
  20. Ng S. K., Hauser W. A., Brust J. C., Susser M. Alcohol consumption and withdrawal in new-onset seizures. N Engl J Med. 1988 Sep 15;319(11):666–673. doi: 10.1056/NEJM198809153191102. [DOI] [PubMed] [Google Scholar]
  21. Ozdemir V., Bremner K. E., Naranjo C. A. Treatment of alcohol withdrawal syndrome. Ann Med. 1994 Apr;26(2):101–105. doi: 10.3109/07853899409147336. [DOI] [PubMed] [Google Scholar]
  22. Peters C., Wilson D., Bruneau A., Butt P., Hart S., Mayhew J. Alcohol risk assessment and intervention for family physicians. Project of the College of Family Physicians of Canada. Can Fam Physician. 1996 Apr;42:681–689. [PMC free article] [PubMed] [Google Scholar]
  23. Poulin C., Webster I., Single E. Alcohol disorders in Canada as indicated by the CAGE questionnaire. CMAJ. 1997 Dec 1;157(11):1529–1535. [PMC free article] [PubMed] [Google Scholar]
  24. Rathlev N. K., D'Onofrio G., Fish S. S., Harrison P. M., Bernstein E., Hossack R. W., Pickens L. The lack of efficacy of phenytoin in the prevention of recurrent alcohol-related seizures. Ann Emerg Med. 1994 Mar;23(3):513–518. doi: 10.1016/s0196-0644(94)70070-2. [DOI] [PubMed] [Google Scholar]
  25. Rimm E. B., Klatsky A., Grobbee D., Stampfer M. J. Review of moderate alcohol consumption and reduced risk of coronary heart disease: is the effect due to beer, wine, or spirits. BMJ. 1996 Mar 23;312(7033):731–736. doi: 10.1136/bmj.312.7033.731. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Sackett D. L. The rational clinical examination. A primer on the precision and accuracy of the clinical examination. JAMA. 1992 May 20;267(19):2638–2644. [PubMed] [Google Scholar]
  27. Saitz R., Friedman L. S., Mayo-Smith M. F. Alcohol withdrawal: a nationwide survey of inpatient treatment practices. J Gen Intern Med. 1995 Sep;10(9):479–487. doi: 10.1007/BF02602395. [DOI] [PubMed] [Google Scholar]
  28. Saitz R., Mayo-Smith M. F., Roberts M. S., Redmond H. A., Bernard D. R., Calkins D. R. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA. 1994 Aug 17;272(7):519–523. [PubMed] [Google Scholar]
  29. Schwab R. A., Powers R. D. Prevalence of folate deficiency in emergency department patients with alcohol-related illness or injury. Am J Emerg Med. 1992 May;10(3):203–207. doi: 10.1016/0735-6757(92)90209-G. [DOI] [PubMed] [Google Scholar]
  30. Sellers E. M. Alcohol, barbiturate and benzodiazepine withdrawal syndromes: clinical management. CMAJ. 1988 Jul 15;139(2):113–120. [PMC free article] [PubMed] [Google Scholar]
  31. Sellers E. M., Naranjo C. A., Harrison M., Devenyi P., Roach C., Sykora K. Diazepam loading: simplified treatment of alcohol withdrawal. Clin Pharmacol Ther. 1983 Dec;34(6):822–826. doi: 10.1038/clpt.1983.256. [DOI] [PubMed] [Google Scholar]
  32. Shaw J. M., Kolesar G. S., Sellers E. M., Kaplan H. L., Sandor P. Development of optimal treatment tactics for alcohol withdrawal. I. Assessment and effectiveness of supportive care. J Clin Psychopharmacol. 1981 Nov;1(6):382–389. doi: 10.1097/00004714-198111000-00006. [DOI] [PubMed] [Google Scholar]
  33. Sullivan J. T., Sykora K., Schneiderman J., Naranjo C. A., Sellers E. M. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989 Nov;84(11):1353–1357. doi: 10.1111/j.1360-0443.1989.tb00737.x. [DOI] [PubMed] [Google Scholar]
  34. Turner R. C., Lichstein P. R., Peden J. G., Jr, Busher J. T., Waivers L. E. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med. 1989 Sep-Oct;4(5):432–444. doi: 10.1007/BF02599697. [DOI] [PubMed] [Google Scholar]

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