MANAGEMENT GUIDELINE FOR

ALCOHOL USE DISORDER

SPHMMC, DEPARTMENT OF PSYCHIATRY

Muluken Tesfaye
(MD, Ass. Professor of psychiatry)
 OUTLINE

• Introduction
– DEFINITION
– Epidemiology

• Pharmacologic Management

• Psychosocial Management
 DEFINITION

• A problematic pattern of alcohol use leading to

clinically significant impairment or distress, as
manifested by at ≥2 of the 11 criteria, occurring
within a 12-month period.
 EPIDEMIOLOGY

– United States:
(12-month prevalence)
– 4.6% : 12- to 17-year-olds
– 8.5% :  18 years
– 12.4%: men vs. 4.9%:
women
– Ethiopia: 5%
[National Mental Health Strategy]
 CONTINUED…

– Peaks in the late teens or early-to-mid 20s.

– An earlier onset of alcohol use disorder is observed in

adolescents with:
– preexisting conduct problems &

– earlier onset of intoxication

 TYPES OF PROBLEMS: THORLEY’S MODEL

Intoxication Regular / excessive

• Accidents / injury Use
• Poisoning / hangovers I R • Health
• Absenteeism • Finances
• High-risk behaviour • Relationships
• Child neglect
D
Dependence
• Impaired control
• Drug-centred behaviour
• Isolation / social problems
• Withdrawal symptoms and psychiatric
problems
• Health Problems
ALCOHOL USE DISORDER MANAGEMENT
PRINCIPLES

Intervention

Detoxification

Rehabilitation
TREATMENT PRINCIPLES
INITIAL PATIENT ASSESSMENT

TREATMENT SETTINGS

TREATMENT OF intoxication states

TREATMENT OF withdrawal syndromes

TREATMENT OF alcohol abuse and dependence

Aftercare
 1. INITIAL PATIENT ASSESSMENT

• Assess the need for alcohol detoxification.

– History
– Mental State Examination
– Physical Examination
– Investigation

• Determines the treatment setting

 2. TREATMENT SETTINGS

IN-PATIENT OUT-PATIENT
 A. IN-PATIENT
Criteria

history of withdrawal seizures or delirium tremens

documented history of very heavy alcohol use

high tolerance

concurrent abuse of other substances

severe comorbid general medical or psychiatric disorder

suicidaily

failed outpatient detoxification

psychiatrically or socially unstable individuals

CIWA-Ar Score: >20: Severe withdrawal

CIWA-Ar: CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT OF ALCOHOL SCALE-REVISED

 CONTINUED…

• Inpatient care should include medical detoxification

and a program of rehabilitation.

• Average treatment length = 28 days

B. OUTPATIENT

– Outpatient clinic

– Day hospital/partial
hospitalization
Criteria for Ambulatory Detoxification  
CONTINUED
Able to take oral medications …
Reliable family member/close contact

Able to commit to daily medical visits

No unstable medical condition

Not psychotic, suicidal, or significantly cognitively impaired

Not pregnant

No concurrent other substance abuse

No history of DTs or alcohol withdrawal seizures

CIWA scores of 8 -15 or in withdrawal stages 1 or 2

3. MANAGEMENT OF ALCOHOL
INTOXICATION
 TREATING INTOXICATION STATES

Assessment:-
– Reassurance & maintenance in a safe and
monitored environment.
– Decrease external stimulation & provide
orientation & reality testing.
– Adequate hydration & nutrition.
 CONTINUED…

Particular emphasis to:

– patient’s general medical & mental status

– substance use history
• history of prolonged or heavy drinking or a history of
withdrawal symptoms.
• possibility of recent use of other substances.
– associated social problems
 CONTINUED…

Rule out Unstable medical conditions:

– Gastrointestinal bleeding
– Electrolyte imbalance
– Infection
– Unstable cardiovascular status
– Pregnancy
 CONTINUED…

Risk factors for DT include :

– Age  30 years
– History of sustained drinking
– History of previous DT
– Significant alcohol withdrawal in the presence of
an elevated ethanol level
– A longer period since the last drink
– Concurrent illness
 AVOID
BENZODIAZEPINES
4. MANAGEMENT OF ALCOHOL
WITHDRAWAL
MANAGEMENT OF ALCOHOL WITHDRAWAL

Has two major goals:

1) help the patient achieve detoxification in a

manner that is as safe & comfortable as
possible.

2) enhance the patient’s motivation for

abstinence & recovery
 CONTINUED…

The goal of alcohol detoxification is threefold:

1) to manage symptoms of alcohol withdrawal;

2) to prevent serious events
3) to bridge patients to treatment for maintaining
long-term recovery
 CONTINUED…

Development & course of acute alcohol

withdrawal:
– occurs as an episode usually lasting 4-5 days
– after extended periods of heavy drinking.
– Rare in individuals  30 years
– Risk & severity increase with increasing age
– “Kindling”
 CONTINUED…

ed Risk of Alcohol withdrawal in:

– ed quantity & frequency of alcohol consumption
– Prior withdrawals
– Family histories of alcohol withdrawal
– Concurrent use of sedative, hypnotic, or anxiolytic
drugs
– Concurrent medical conditions
 STAGES OF ALCOHOL WITHDRAWAL

Stage 1: Minor withdrawal  

– Agitation
– Anxiety, restlessness, insomnia,
– Tremor, diaphoresis, palpitations,
– Fluctuating tachycardia and hypertension, and
headache.
– Loss of appetite, nausea, and vomiting
– Generally coherent
 CONTINUED…

 Stage 2: Major withdrawal

– Marked agitation, restlessness, diaphoresis &
tremulousness
– Anorexia, nausea, vomiting, and diarrhea
– Sinus tachycardia (heart rates may 120
beats/min) & systolic hypertension
– Seizures
– Auditory or visual hallucinations
 CONTINUED…

Stage 3: Delirium tremens

– Autonomic hyperactivity, fever,
– Severe tachycardia & hypertension,
– Agitation, drenching sweats
– Hallucinations & disorientation.

Mortality rate
• Without treatment  20%;
• With treatment  1%.
 CONTINUED…

Consider using standardized alcohol

withdrawal scales:
– CIWA-Ar scale (out of 67)
• <10: Very mild withdrawal
• 10-15: Mild withdrawal
• 16-20: Moderate withdrawal
• >20: Severe withdrawal
 “MANAGEMENT PROPER”

I. SYMPTOM CONTROL AND SUPPORTIVE CARE

– Identifying & correcting metabolic

derangements
– IV fluids
– Nutritional supplementation
– Frequent clinical reassessment (e.g. vital signs)
 CONTINUED…

– Quiet, protective environment

– Reduce Mechanical restraint
– Thiamine (100mg BID or TID iv/po 1-2 weeks)
– Multivitamins containing or supplemented with
folate .
– Correct electrolyte disturbance (K+, Mg 2+, PO4+3)
– Glycemic control
 CONTINUED…

For 67% of the patients with mild-to-moderate

withdrawal symptoms:

 Generalized support
 Reassurance & sufficient
treatment
 Frequent monitoring
.
 CONTINUED…

• Moderate-to-severe Alcohol Withdrawal:

– Supportive management

– Pharmacotherapy:
– Restore physiological homeostasis
– Reduce CNS irritability with
benzodiazepines
CRITERIA FOR ICU ADMISSION OF PATIENTS
WITH ALCOHOL WITHDRAWAL

– Age >40
– Hemodynamic instability
– Marked acid-base disturbances
– Severe electrolyte defects
– Respiratory insufficiency
– Cardiac disease
 CONTINUED…

– Persistent hyperthermia (T >39°C [103°F])

– Potentially serious infections
– Signs of gastrointestinal pathology
– Evidence of rhabdomyolysis
– Renal insufficiency or increased fluid
requirements
 CONTINUED…

– History of previous alcohol withdrawal

complications
– Need for frequent or high doses of sedatives or
an intravenous infusion to control symptoms
– Withdrawal despite an elevated ethanol
concentration
PHARMACOTHERAPYMODERATE-TO-SEVERE ALCOHOL
WITHDRAWAL

Criteria for an ideal pharmacological agent

selection:
– Effectiveness
– Benign side effect profile
– Limited interactions
– Tolerability
– Ability to suppress drinking
 CONTINUED…

BENZODIAZEPINES

CROSS TOLERACE SEIZURE

WITH ALCOHOL PREVENTION
 CONTINUED…

ADDITIONAL BENEFITS OF BENZODIAZEPINES:

– Treatment of psychomotor agitation.
– Prevention of progression from minor withdrawal
symptoms to major ones

N.B.
• Long-acting benzodiazepines with active metabolites
are preferred.
• Diazepam, lorazepam & chlordiazepoxide are used
most frequently.
 CONTINUED…

• Lorazepam or oxazepam preferred for the

treatment of for:
– Advanced cirrhosis.
– Elderly
– Delirium
– Dementia, or
– Another cognitive disorder.
 CONTINUED…

ROUTES

ORAL IV IM

NOT TAKING
NOT TAKING
OUTPATIENT PER OS PO

WITHDRAWAL
SEIZURE SEIZURE
PROPHYAXIS

DELIRIUM ERRATIC
TREMENS ABSORPTION
 CONTINUED…

DOSING
GENERAL PRINCIPLES:
– Dose titration should be based upon a given
patient's risk factors for & ability to tolerate
Delirium Tremens (DT).
– Light sedation to a degree that insures safety and
comfort
– Should not obscure the neurologic examination
 DOSING REGIMENS

FIXED-DOSE REGIMEN

SYMPTOM-TRIGGERED THERAPY

STABILIZING DOSE REGIMEN

 1. FIXED-DOSE REGIMEN

Detoxification in the community

– Diazepam 5-10mg BID
– Chlordiazepoxide 10–20 mg qds, reducing
gradually over 5–7 days.
 1. FIXED-DOSE REGIMEN

• Diazepam
• Day 1 and 2 10mg tid
• Day 3 and 4 10mgbid
• Day 5 and6 5mg bid
• Day 7 5mg at bed time
 2. SYMPTOM-TRIGGERED THERAPY

• For all patients with seizures or DT:

• give IV diazepam , 5 to 10 mg IV every 5 to 10
minutes, until the appropriate level of
sedation is achieved.
• Lorazepam , 2 to 4 mg IV every 15 to 20
minutes, can also be used.
 CONTINUED…

• In severe withdrawal, selected patients may

require massive doses (upto 500 mg
diazepam) to achieve initial control of
symptoms
• continued aggressive use of benzodiazepines
thereafter (upto 2000 mg diazepam over 48
hours.)
 CONTINUED…

Orally administered
– Diazepam (10 mg every 2–4 hours)
– chlordiazepoxide (50 mg every 2–4 hours),
– Oxazepam (60 mg q2h)
– Lorazepam (1 mg q2h) are commonly used.
 CONTINUED…

• Providing medication only when a patient has

symptoms.
• To use this approach, a regular systematic
assessment should be made.
• Use a validated instrument, such as CIWAS-Ar
 CONTINUED…

• Evaluation intervals as frequent as every 10 to

15 minutes .
• When the score is elevated, additional
medication is given.
• For acute withdrawal, we give diazepam 5 to
10 mg IV for any score of 8 or greater on the
CIWAS-Ar.
 CONTINUED…

• Once severe symptoms are controlled, hourly

reassessment of such patients is reasonable.
• an interval of four to six hours is reasonable
for stable patients with mild symptoms
receiving oral benzodiazepines.
• Multiple randomized and observational
studies support this therapy.
 CONTINUED…

• Simple concept of giving the patient what they

need, when they need it.
• Symptom-triggered therapy achieves
equivalent or superior clinical endpoints.
• Lower total doses of sedatives and shorter
periods of hospitalization.
 CONTINUED…

• In the landmark study of this approach, 101 patients

admitted to an inpatient alcohol detoxification unit
were randomly assigned to treatment with
chlordiazepoxide using a fixed schedule or a
symptom-triggered therapy.
RESULT
• Patients in the symptom-triggered group required
less medication (median 100 versus 425 mg) and a
shorter treatment period (median 9 versus 68 hours).
 3. STABILIZING-DOSE REGIMEN

• Take the total dose necessary to suppress CNS

irritability and autonomic hyperactivity in the
first 24 hours
• Give it in four divided doses the following day
• Tapered over 3–5 days
• Monitor for reemergence of symptoms
 CONTINUED…

• For most patients, the equivalent of 600

mg/day of chlordiazepoxide is the maximum
dosage
• Many patients require less
• A few may require substantially more(1000)
 DURATION OF TREATMENT

• Usual duration 5-7 days.

Up to 10 days

History of withdrawal-related
Severe withdrawal
symptoms
 Observations

– CIWA-Ar
– Vital sign
– Pulse oximeter
– The first 24 hours -every 1-2 hours.
– 2× daily observation from days 2–6
 Use adjunctively

Anticonvulsants
– Carbamazepine (600–800 mg/day for the first 48
hours; then tapered by 200 mg/day.
– Divalproex sodium at a dosage of 500 mg t.i.d
– Intramuscular magnesium sulfate.
– Phenobarbital?
– Phenytoin?
 Use adjunctively
Adrenergic agonists and antagonists:
– Beta-adrenergic antagonists (e.g., propranolol, 10
mg p.o. q6h)
– Have been used to reduce signs of autonomic
nervous system hyperactivity .
– Atenolol has been used for a similar purpose
 Adrenergic agonists and antagonists:

combination with benzodiazepines

– Allows the use of lower doses of benzodiazepines
– Reduce the sedation and
– Reduce cognitive impairment
 Adrenergic agonists and antagonists:

– Clonidine, an α-adrenergic agonist (0.5 mg

p.o,b.i.d. or t.i.d.)
– Shown to reduce tremor, heart rate, and
blood pressure
 Use adjunctively
Antipsychotic agents:
– For patients manifesting delirium, delusions, or
hallucinations
– Should be used as an adjunct to benzodiazepines.
– Haloperidol (0.5–2.0 mg i.m. q2h, as needed)
– Most patients will require <10 mg of haloperidol
every 24.
 Avoid
Intravenous ethanol:
– there is no clear evidence for the effectiveness of
ethanol.
– the use of IV ethanol is not supported by the
current published data.
 Refractory Delirium Tremens

• When >50 mg of diazepam or > 10 mg of

lorazepam is required to control the symptoms
of severe withdrawal during the first hour of
treatment or

• If doses >200 mg of diazepam or >40 mg of

lorazepam fail to adequately control symptoms
during the initial 3-4hrs of treatment.
 MANEGMENT
• Obtaining assistance from a medical
toxicologist or poison control center.

• Phenobarbital 130 to 260 mg IV, repeated

every 15 to 20 minutes, until symptoms are
controlled.

• Another reasonable alternative is propofol.

• Never forget !!

• Psychotherapy
– Warm, supportive psychotherapy in the treatment
of DTs is essential.
 PROPHYLAXIS

For admitted Patients to the hospital for other

reasons
– Patients with a history of:
• seizures, delirium tremens
• prolonged, heavy alcohol consumption
– who are minimally symptomatic
 CONTINUED…

Chlordiazepoxide 50-100 mg PO Q 6hrs for 1 day

Chlordiazepoxide 25 -50 mg Q 6hrs for an additional 2

days

Additional 25-50 mg hourly if a CIWAS-Ar score ≥8

5. TREATMENT OF ALCOHOL ABUSE
AND DEPENDENCE
5. TREATMENT FOR MAINTENANCE OF
ABSTINENCE
 TREATMENT

PHARMACOLOGIC PSYCHOSOCIAL
 PHARMACOLOGICAL MANAGEMENT

1. NALTREXONE
PREPARATIONS:
– an opioid receptor antagonist – ORAL
– INJECTABLE (long-acting): may
– recommended for relapse promote adherence
prevention by: – IMPLANT (not yet FDA approved)
• attenuating some of the
reinforcing effects of
DOSING:
alcohol
– It can be started after
• Suppressing the urge to
withdrawal from alcohol at a
drink alcohol.
dose of 50 mg/day.
– Limited data on its long-term – It is then maintained w/in the 50
efficacy – 100 mg range for 12 months.
 CONTINUED…

NOTE:
– Importantly, the person must not have taken any opioid drugs for the previous
7 days.
– The person must be warned that naltrexone will block opioid drugs in case
they need opioid analgesia in the near future.

ADVERSE REACTIONS

– In 20% of patients:
– Nausea, Vomiting, Abdominal pain,
– Anxiety, sleeping difficulties, headache, reduced energy,
– Joint &muscle pain.

– Liver toxicity can occur with higher doses and,

– Liver function tests should be routinely carried out.
 CONTINUED…

2. ACAMPROSATE:
PREPARATIONS:
– a γ-aminobutyric acid (GABA) – ORAL
analogue
DOSING:
– decreases alcohol craving in – It is best started immediately
abstinent individuals after withdrawal.

– may also be an effective adjunctive – Starting dose: dose of (each

medication in motivated patients containing 333 mg 2 tablets TID
who are concomitantly receiving
psychosocial treatment. – It is then maintained w/in the 50
– 100 mg range for 12 months.
 CONTINUED…

ADVERSE REACTIONS

• In 20% of patients
– diarrhoea, nausea, vomiting, abdominal pain
– pruritus, occasionally maculopapular rash & rarely bullous
skin reactions.
3. DISULFIRAM (ANTABUSE):

– for reliable, motivated patients

DOSING:
whose drinking may be triggered by
• The dose is typically
events that suddenly increase
alcohol craving. 200 mg/day.
• Not to be used for 
6 months
– “Feared/aversive effects ” include:
• facial flushing,
• nausea, vomiting and fainting

Other adverse effects:

• drowsiness, fatigue, reduced libido,
rarely psychotic reactions, allergic
dermatitis, peripheral neuritis or
hepatic cell damage
 CONTINUED…

CONTRAINDICATION
– with coronary heart disease,
– cardiac failure,
– history of cerebrovascular accidents,
– hypertension,
– psychosis,
– severe personality disorders
– suicide risk.
 PSYCHOSOCIAL MANAGEMENT

• Psychosocial treatments found effective for some

patients with an alcohol use disorder include:

– Motivational Enhancement Therapy

– Cognitive Behavioral Therapy
– Behavioral Therapies
– Marital & Family Therapies
– Group Therapies
– Psychodynamic Therapy/Interpersonal Therapy
– Self-help Groups (e.g. Alcoholics Anonymous , AA)
 BIBLIOGRAPHY
American Psychiatric Association. Practice guideline for the treatment of
patients with substance use disorders, 2nd ed. Virginia: American
Psychiatric Association, 2006.

American Psychiatric Association. Diagnostic and Statistical Manual, 5th ed.

Virginia: American Psychiatric Publishing, 2013.

FMOH, National Mental Health Strategy 2012/2013-2013/2014. Addis

Ababa, 2012.

Sadock, Benjamin James et al. Kaplan & Sadock’s Synopsis of Psychiatry:

Behavioral Sciences/ Clinical Psychiatry. 11th ed. Philadelphia:
Lippincott Williams & Wilkins, 2015.

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