Alcohol Withdrawal Syndrome

Pt with h/o chronic alcohol abuse presents s/p alcohol cessation. Reports insomnia, anxiety/agitation, H/A, photophobia, palpitations, N/V, decreased appetite, pins/needles sensation in extremities. H/o seizures, DT during previous withdrawal episodes; not currently pregnant. Alert by not oriented with tachycardia, sweating, hand tremor on exam.

  • Monitor for

    • Hallucinations at 12 to 24 hours

    • Generalized tonic-clonic seizures at 24 to 48 hours

    • Delirium tremens at 48 to 72 hours

  • Labs

    • EtOH 0.00 at admission

    • Obtain CMP, Mg level

  • Clinical Institute Withdrawal Assessment (CIWA) for Alcohol

    • Evaluate q4-8h until scoring < 10 x 24h, then evaluate CIWA score PRN

    • No h/o cirrhosis, normal CMP: Chlordiazepoxide (Librium) 50-100 mg for CIWA > 8

    • Elderly and/or h/o cirrhosis: Lorazepam (Ativan) 2-4 mg for CIWA > 8

  • Treatment

    • Dehydration with electrolyte abnormality on CMP: Administer 100 mg thiamine IV and start IV NS

    • Start standing thiamine 100 mg qd, multivitamin

    • Hypomagnesemia: Replete with magnesium sulfate

    • H/o CAD with persistent tachycardia: Metoprolol succinate 25 mg qd

    • Active hallucinations with no h/o seizure, QT prolongations: Haloperidol 2.5 mg IV loading dose followed by 0.5-2 mg/hr IV

  • Disposition

    • Start naltrexone 50 mg qd vs. topiramate (see below) at discharge for continued abstinence

    • Concern for kindling phenomenon

      • Pt and family counseled that h/o recurrent detoxifications may increase alcohol cravings and withdrawal symptoms

      • Consider discharge with topiramate 25mg qd followed by titration to 150 mg BID as outpatient to promote continued abstinence

    • Discharge to outpatient vs. inpatient rehabilitation program

Opioid Withdrawal Syndrome

Pt with h/o opioid abuse presents with acute on chronic anxiety, drug craving, and fear of withdrawal. Reports dysphoria, restlessness, insomnia, chills, myalgias, abdominal cramping, diarrhea. Tachycardia, HTN, dilated pupils, lacrimation, rinorrhea, yawning, N/V, diaphoresis, piloerection on exam. Naloxone administered in ED.

  • Obtain CBC, BMP, urine drug screen

  • Medications

    • Clonidine 0.1 mg PO QID x 4 days provided BP > 90/60

    • Trazadone 100 mg QHS x 4 days and then PRN for insomnia

    • Phenobarbitoal 30-60 mg BID as needed for anxiety/sedation

    • Gastrointestinal

      • Prochlorperazine 5-10 mg q4h PRN for N/V

      • Loperimide 4 mg q6h PRN for diarrhea

    • Pain

      • Acetminophen 650 mg q4h PRN

      • Naproxen 500mg BID PRN for myalgias

    • Hydroxyzine 50 mg TID PRN for anxiety/dysphoria, lacrimation, rinorrhea

  • Reassess COWS every 4 to 24 hours pending symptoms severity

  • Observe for 72 hours; monitor for suicidality

  • At discharge, start methadone 10mg TID for 3-4 days

    • Taper by 10 mg/day

    • Administer 5 mg x 1 on the final day of treatment

  • Monitor for relapse due to loss of opioid tolerance after 3-7 days

Notes

  • Physical withdrawal symptoms generally last 5-10 days

  • Methadone withdrawal occurs later than other opioids and lasts longer (2-3 weeks) due to its longer half-life

  • Psychological withdrawal symptoms may last weeks to months