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American Society of Addiction MedicineAddiction Medicine2020advanced

Alcohol Withdrawal Management

Published by American Society of Addiction Medicine · RAND/UCLA Appropriateness Method (RAM)

185Recommendations

170References

3Tables

Summary

AI-generated

This guideline updates previous ASAM guidelines to address current practice concerns and provide clear guidance for consistent treatment practices in the field. It emphasizes risk assessment and proper level of care determination, detailing comprehensive management protocols for both ambulatory and inpatient settings.

alcohol withdrawalASAMaddiction medicinebenzodiazepinesphenobarbitalgabapentincarbamazepineguidelines

Key Takeaways

1
Alcohol withdrawal management is not a discrete treatment for AUD; it is a component of initiating and engaging patients in long-term treatment.
2
Universal screening for unhealthy alcohol use using validated scales should be incorporated into medical settings.
3
Clinicians should assess the risk of severe or complicated alcohol withdrawal using validated tools like PAWSS or LARS, alongside assessing current symptoms.
4
Benzodiazepines are the first-line pharmacological treatment across settings for preventing and treating severe or complicated alcohol withdrawal.
5
Ambulatory withdrawal management is safe and effective for patients with mild to moderate withdrawal who lack severe risk factors or complex comorbidities.
6
Symptom-triggered dosing is the preferred benzodiazepine dosing method when adequate clinical monitoring is available.
7
Phenobarbital, gabapentin, and carbamazepine are appropriate alternatives or adjuncts for specific clinical scenarios, such as benzodiazepine contraindications or low-risk outpatient settings.

What's New in This Version

This guideline replaces the 1997 'Pharmacological Management of Alcohol Withdrawal' and 2004 'Management of Alcohol Withdrawal Delirium' guidelines. It addresses current practice concerns including uncertainty regarding the CIWA-Ar scale, excessive caution about benzodiazepine use, the role of barbiturates, and inconsistent treatment practices in non-specialty and ambulatory settings.

Key Recommendations

Identification and Diagnosis of Alcohol Withdrawal

I.1
Incorporate universal screening for unhealthy alcohol use into medical settings using a validated scale to help identify patients with or at risk for alcohol use disorder and alcohol withdrawal.
Screening
I.5
To diagnose alcohol withdrawal and alcohol withdrawal delirium, use diagnostic criteria such as those provided by the Diagnostic and Statistical Manual 5 (DSM-5).
Diagnosis

Initial Assessment of Alcohol Withdrawal

II.1
First, determine whether a patient is at risk of developing severe and/or complicated alcohol withdrawal or complications from alcohol withdrawal. In addition to current signs and symptoms, a validated risk assessment scale and an assessment of individual risk factors should be utilized.
Assessment

Level of Care Determination

III.1
Level of care determination should be based on a patient’s current signs and symptoms; level of risk for developing severe or complicated withdrawal or complications of withdrawal; and other dimensions such as recovery capital and environment. Alcohol withdrawal can typically be safely managed in an ambulatory setting for those patients with limited or mitigated risk factors.
Management

Ambulatory Management of Alcohol Withdrawal

IV.12
When feasible, alcohol use disorder (AUD) treatment should be initiated concurrently with alcohol withdrawal management as cognitive status permits.
Treatment Initiation
IV.17
Patients experiencing moderate alcohol withdrawal (e.g., CIWA-Ar scores 10–18) should receive pharmacotherapy. Benzodiazepines are first-line treatment. Carbamazepine or gabapentin are appropriate alternatives.
Pharmacotherapy

Inpatient Management of Alcohol Withdrawal

V.13
For patients at risk of developing severe or complicated alcohol withdrawal or complications of alcohol withdrawal, preventative pharmacotherapy should be provided. Benzodiazepines are first-line treatment because of their well-documented effectiveness in reducing the signs and symptoms of withdrawal including the incidence of seizure and delirium.
Pharmacotherapy / Prophylaxis
V.23
Symptom-triggered treatment is the preferred benzodiazepine dosing method. Fixed dosing according to a scheduled taper is appropriate if symptom-triggered treatment cannot be used.
Pharmacotherapy / Dosing

Addressing Complicated Alcohol Withdrawal

VI.4
Following a withdrawal seizure, patients should be immediately treated with a medication effective at preventing another seizure. Benzodiazepines are first-line treatment, and a fast-acting agent such as lorazepam or diazepam is preferred.
Pharmacotherapy
VI.13
Patients with alcohol withdrawal delirium should be sedated to achieve and maintain a light somnolence. Benzodiazepines are recommended as the first-line agents for managing alcohol withdrawal delirium.
Pharmacotherapy

Specific Settings and Populations - Patients who are Pregnant

VII.27
Inpatient treatment should be considered for all pregnant patients with alcohol use disorder who require withdrawal management. Inpatient treatment should be offered to pregnant patients with at least moderate alcohol withdrawal (i.e., CIWA-Ar scores ≥ 10).
Management / Level of Care

Scope & Objectives

Clinical Topic

Alcohol Withdrawal Management

Objectives

Provide updated information on evidence-based strategies and standards of care for alcohol withdrawal management in both ambulatory and inpatient settings.

Target Patient Population

Adults 18 years or older with a diagnosis of alcohol withdrawal with or without other health conditions

Diagnostic Criteria

Diagnostic and Statistical Manual 5 (DSM-5)

Target Providers

PhysiciansNurse practitionersPhysician assistantsPharmacists

Patient Criteria & Setting

Therapeutic Area

Substance Use Disorders

Guideline Scope

ScreeningDiagnosisAssessmentManagementPharmacotherapy

Inclusion Criteria

Adults 18 years or older
Diagnosis of alcohol withdrawal
Immediate risk for developing alcohol withdrawal syndrome

Exclusion Criteria

Adolescents
Post-acute prolonged withdrawal or protracted withdrawal
Management of other conditions such as alcoholic liver disease and Wernicke encephalopathy (outside routine prophylaxis)
Home management outside the United States
Pharmacotherapies not widely available in the United States

Care Settings

Ambulatory settingsInpatient settingsPrimary careEmergency departmentsIntensive care unitsSurgery unitsHospitalsSpecialty addiction treatment settings

Special Populations

Pregnant patientsOlder adultsPatients with medical conditionsPatients who take opioidsHospitalized patientsCritically ill patients

Evidence Grading

System: RAND/UCLA Appropriateness Method (RAM)

Recommendation Strength

NecessaryProcedures that must be offered to patients fitting a particular clinical description, where it would be improper not to offer the procedure given the magnitude and likelihood of the expected benefit (Median rating 7-9 with agreement).

UncertainA statement with a median rating of 4-6 or with at least one-third of the experts rating the statement outside the median range.

AppropriateProcedures where the health benefits sufficiently outweigh potential harms such that the procedure is worth doing (Median rating 7-9 without disagreement).

InappropriateA statement where potential harms outweigh benefits (Median rating 1-3 without disagreement).

Safety & Contraindications

Contraindications

Valproic acid in patients with liver disease or women of childbearing potential
Benzodiazepines in ambulatory settings for patients with a history of adverse events with their use
Alpha2-adrenergic agonists and beta-blockers as monotherapy for withdrawal

Monitoring Guidance

Monitor alcohol withdrawal severity using validated instruments. Re-assess every 1-4 hours for 24 hours in moderate to severe cases, monitoring vital signs, hydration, orientation, sleep, emotional status, and signs of over-sedation.

Authors & Contributors

Anika AlvanzoKurt KleinschmidtJulie A. KmiecGeorge KolodnerGerald E. MartiWilliam F. MurphyCarlos F. TiradoCorey WallerLewis S. Nelson

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryDrug interactions discussed

Learning Context

Difficulty

advanced

Learning Paths

Alcohol Withdrawal ManagementAddiction MedicineSubstance Use DisordersPharmacotherapyRisk AssessmentBenzodiazepine ProtocolsDelirium TremensAmbulatory Care

AI Podcast

Deep-dive audio (~10 min)

Study Guide

Structured study document

Infographic

Visual overview of key points

Slide Deck

Presentation-ready slides

Navigating the Modern Standard of Care: Key Takeaways from the ASAM Alcohol Withdrawal Management Guidelines

Read the full blog article

Guideline Info

SocietyAmerican Society of Addiction Medicine

Full nameAmerican Society of Addiction Medicine

SpecialtyAddiction Medicine

Year2020

Evidence systemRAND/UCLA Appropriateness Method (RAM)

RegionUnited States

LanguageEnglish

Key Figures

Recommendations185

References170

Tables3

Clinical Areas

Addiction MedicinePrimary CareEmergency MedicineIntensive Care

American Society of Addiction Medicine

United States

American Society of Addiction Medicine

All American Society of Addiction Medicine guidelines

Alcohol Withdrawal Management

Summary

What's New in This Version

Key Recommendations

Identification and Diagnosis of Alcohol Withdrawal

Initial Assessment of Alcohol Withdrawal

Level of Care Determination

Ambulatory Management of Alcohol Withdrawal

Inpatient Management of Alcohol Withdrawal

Addressing Complicated Alcohol Withdrawal

Specific Settings and Populations - Patients who are Pregnant

Scope & Objectives

Patient Criteria & Setting

Evidence Grading

Safety & Contraindications

Authors & Contributors

Guideline Features

Related Guidelines

Learning Context