Remote Primary Health Care Manuals

Alcohol withdrawal ⚠️

  • If person who usually drinks 40–60g or more of alcohol a day (4–6 or more standard drinks) stops drinking there is a risk of alcohol withdrawal for the next 5 days
  • A standard drink Table 5.3 contains 10g of alcohol takes, a healthy liver about 1 hour to remove this alcohol from the body

  • If regular drinker unwell — they may be in withdrawal. More likely if

    • Drinks every day and often drinks a lot (4–6 or more standard drinks a day) OR has a regular binge pattern with more than 6 standard drinks per session every 2–3 days
    • Has past history of withdrawal or seizures

Table 5.3  

1 standard drink =

425mL light beer 285mL full-strength beer 60mL port
375mL mid-strength beer 100mL wine 30mL spirits
Red flags — Urgent Medical Consult
  • Withdrawal fits, DTs, severe withdrawal before, or many withdrawal episodes
  • Significant illness — cellulitis, pneumonia, diabetes, heart condition, severe liver disease, chronic kidney disease, respiratory disease, mental illness, epilepsy
  • Uses other drugs (eg opioids, benzodiazepines)
  • Drinking at high level over long time period 
  • If CIWA score more than 6
  • Signs of head injury

Severe alcohol withdrawal syndrome

  • Withdrawal seizures may happen in first 3 days after stopping alcohol
    • May be first feature of withdrawal
    • May happen if other illness at same time
  • Delirium tremens (DTs, 'horrors') can happen up to 6 days after stopping
    • Mix of anxiety, agitation, aggressive behaviour escalation, disorientation, hallucinations, dehydration, high heart rate, high BP, low-grade fever, tremors/shaking
    • Risk of death

Uncomplicated withdrawal

  • Usually starts 6–24 hours after last drink of alcohol
  • Any combination of anxiety, agitation, aggressive behaviour escalation, tremor, sweating, tachycardia (high heart rate), insomnia (can’t sleep) — may be mild, hard to detect

Alcohol withdrawal management

  • Assess and manage based on Clinical Institute Withdrawal Assessment (CIWA) score — see Table 5.4 AND red flags
    • Get advice from doctor or alcohol and drug service if not familiar with CIWA

Ask

  • When person had last drink
  • How they usually drink — regular or binge drinker
  • How much they usually drink
  • What time of the day do they start drinking alcohol
  • Any previous alcohol withdrawal
  • Taking any medicine or other drugs

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • U/A, pregnancy test
  • Head-to-toe exam
  • CIWA score

Table 5.4   Modified Clinical Institute Withdrawal Assessment (CIWA)

CIWA table Ed 2022

Observational assessment. Add up score for 10 criteria = score for person

Do

  • If CIWA score more than 6 — medical consult
  • Repeat CIWA every 30–60 minutes. If increasing despite treatment — consider evacuation
  • Look after person in quiet, dim room
  • Give medicines as needed
  • Monitor dehydration — give fluids as needed
  • Make sure responsible person is with them all the time

Follow-up

Medicines for alcohol withdrawal

  • Antiemetic for nausea or vomiting — see Nausea and vomiting
  • Loperamide oral — adult 4mg, single dose for diarrhoea

THEN loperamide oral — 2mg after each bowel action, up to 16mg/day

  • Thiamine IM into buttock — adult 300mg, once a day for 3 days, to correct common nutritional deficiency 

THEN thiamine oral — adult 100mg, once a day for at least 1 month

AND ​multivitamin oral — 1 tablet, once a day for at least 1 month

  • Paracetamol — adult 1g up to 4 times a day (qid) for pain — do not use if severe liver disease
  • Diazepam — see doses below

Diazepam doses

Diazepam lessens agitation and other symptoms (eg hallucinations), helps prevent fits and DTs

  • Medical consult before giving diazepam
  • After giving — recheck CIWA every 30 minutes for at least 2 hours
    • If CIWA increases — medical consult. May need to repeat or increase dose
    • If CIWA score still more than 10 after 2 hours — medical consult. May need to go to hospital
  • If older person, low body weight (less than 50kg), person with significant lung, liver or kidney disease (acute or chronic) — give half dose and watch closely for over-sedation
  • Do not exceed these diazepam doses and avoid using diazepam daily for more than 1 week — may lead to tolerance/dependence 
    • If 90kg or under — 40mg oral in first 24 hours
    • If over 90kg — 60mg oral in first 24 hours 

Table 5.5   Diazepam doses for alcohol withdrawal

Pattern of withdrawal Diazepam doses and what to do
Withdrawal fits or DTs in past
  • Give diazepam oral — 10mg every hour until CIWA less than 6 or mildly sedated
  • When CIWA stays at less than 6 for 2 hours
    • Give diazepam oral — 10mg, 4 times a day (qid) for 1 day
    • Then taper dose to nothing over 3 more days*
Very Severe
CIWA more than 16
  • Give diazepam oral — 20mg straight away
  • Put in IV cannula
  • Medical consult
Moderate to severe
CIWA 10–16
OR
CIWA 8
and other risk factors (see Red flags)
  • Give diazepam oral — 10–20mg every 2 hours until CIWA less than 6 or sedated
  • Base dose on how agitated person seems
    • If agitation score 4 — oral 10mg
    • If agitation score 7 — oral 20mg
  • When CIWA stays at less than 6 for 2 hours
    • Give diazepam oral — 10mg, 4 times a day (qid) for 1 day
    • Then taper dose to nothing over 3 more days*
  • Medical consult
Mild
CIWA 6–9
and no other risk factors
  • May not need diazepam
  • If agitation score 4 or more can give diazepam oral — 5–10mg, 3–4 times a day for 2 days
    • Taper dose to nothing over 3 more days*

*Taper dose to nothing — reduce total dose by 25% daily, eg initial dose — 4 times a day (qid), day 1 — 3 times a day (tds), day 2 — twice a day (bd), day 3 — once a day, day 4 — no dose