In this post I link to and excerpt from The Curbsiders‘ [Link is to the complete episode list] #212 Sober Talk: Managing Inpatient Alcohol Withdrawal
MAY 7, 2020 By NORA TARANTO:
ASSESSING ALCOHOL WITHDRAWAL RISK, CHOOSING A PROTOCOL (BENZOS OR BARBS?!), AND THE MYTH OF BANANA BAGS WITH JOJI SUZUKI MD
Dr. Joji Suzuki MD, addiction psychiatrist extraordinaire at the Brigham and Women’s Hospital, walks us through how to think about the risk of severe withdrawal, the different ways to manage it, and how to engage with patients as they’re leaving the hospital.
Dr. Suzuki demystifies withdrawal and debunks some common myths: that we must manage withdrawal inpatient, that banana bags are the cure to a hangover and alcoholic malnutrition, and that we tend to under-medicate with benzos (actually, it’s the opposite!).
Here is the podcast:
Here are excerpts:
Alcohol Withdrawal: Pearls
- The most predictive risk factor for having severe withdrawal is a history of having had severe withdrawal.
- If at all suspicious, screen patients with the AUDIT-C questionnaire to evaluate their alcohol use. Have a low threshold to initiate a symptoms driven protocol for alcohol withdrawal e.g. AUDIT-C score > 3-4 (Dr Suzuki’s expert opinion).
- The symptom-driven CIWA protocol is preferable, in general, to standing benzodiazepine protocols, since it minimizes the risk of over-treating and over-sedating.
- Some patients, who meet specific criteria (see below) can be treated at home for alcohol withdrawal. If you treat at home, use gabapentin, not benzos.
- The first two days of withdrawal are the golden period. If you can manage it well in those two days and maintain the patient without symptoms, you will likely avoid any of the severe withdrawal complications later on.
- Consider sending your patient to the ICU for withdrawal management if the patient is requiring medications every one to two hours, already in delirium tremens, has a CIWA >20 despite receiving medication, or if there are concerns about airway protection.
- Phenobarbital dosing is weight-based, is given via an IV load over one day, and often does not require an oral taper after that (unless the patient is still having withdrawal symptoms). Risk of over-medication is likely lower than with benzodiazepine protocols because of this standardization.
- In terms of benzos, diazepam is Dr. Suzuki’s favorite (rapid onset, easily absorbed, smooth withdrawal), but lorazepam also works well. Oral absorption typically high, but might favor IV > PO if the patient has alcoholic gastritis.
- Give IV thiamine…A lot, over several days. No other multivitamins needed in general.
- The transition home is key: use maintenance medications (see ep #194), motivational interviewing, and warm handoffs wherever possible to connect patients to a supportive outpatient treatment team, as soon as possible.