Alcohol withdrawal

Use validated screening tools to: (i) identify any patient with alcohol-use disorder and (ii) assess the level of alcohol dependence in those who have tested positive for alcohol misuse.

1. Screen the patient for alcohol-use disorder using a formal assessment tool such as AUDIT-C, FAST, PAT, or AUDIT.[2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital Decide which to use based on local protocols, the setting of care, and your preference. 

   • AUDIT-C ( Alcohol Use Disorders Identification Test - Consumption Opens in new window)[2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital

     • A total score of ≥5 is a positive screen.

   • FAST( Fast Alcohol Screening Test Opens in new window)

     • Conceived for use in emergency departments but can be used in a wide variety of settings.[3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf

   • PAT( Paddington Alcohol Test 2011 Opens in new window)

     • Takes less than a minute to perform and useful in busy clinical settings.[64]Patton R, Hilton C, Crawford MJ, et al. The Paddington Alcohol Test: a short report. Alcohol Alcohol. 2004 May-Jun;39(3):266-8. https://www.doi.org/10.1093/alcalc/agh049 http://www.ncbi.nlm.nih.gov/pubmed/15082467?tool=bestpractice.com

   • AUDIT ( Alcohol Use Disorders Identification Test Opens in new window)

     • The full version of AUDIT; takes longer to perform than the other screening tools and therefore may not be suitable in an acute hospital setting.[2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital

2. Identify patients who have tested positive for alcohol misuse and are at risk of alcohol withdrawal by assessing their level of alcohol dependence. AUDIT-C, FAST, PAT, and AUDIT only identify alcohol-use disorder and do not predict which patients are at risk of alcohol withdrawal. Decide which screening tool to use based on local protocols and your preference. Use either SAD-Q or the CAGE questionnaire.

   • SAD-Q  Severity of Alcohol Dependence Questionnaire Opens in new window[32]National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. February 2011 [internet publication]. https://www.nice.org.uk/guidance/cg115/chapter/1-Guidance

     • This can help guide drug doses for treatment as well as identifying those at risk of alcohol withdrawal delirium (also known as delirium tremens).

     • A chlordiazepoxide detoxification regimen is usually indicated for anyone who scores ≥16.

   • CAGE questionnaire[3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf [5]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018 Jan 1;175(1):86-90. https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969 http://www.ncbi.nlm.nih.gov/pubmed/29301420?tool=bestpractice.com

     • Ask four questions:[42]Fagbemi K. Q: What is the best questionnaire to screen for alcohol use disorder in an office practice? Cleve Clin J Med. 2011 Oct;78(10):649-51. http://www.ncbi.nlm.nih.gov/pubmed/21968471?tool=bestpractice.com

       • C: Have you felt the need to cut down on your drinking?

       • A: Have you ever felt annoyed by someone criticising your drinking?

       • G: Have you ever felt bad or guilty about your drinking?

       • E: Have you ever had an eye-opener - a drink first thing in the morning to steady your nerves?

     • The test is considered positive if score ≥2.

     • This is a brief and effective test for lifetime alcohol abuse or dependence. It is commonly used in clinical practice.

     • However, it fails to detect binge drinking and is less sensitive in screening for mild to moderate alcohol withdrawal than other screening tools. It also does not distinguish between active and past problem drinking.[3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf [5]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018 Jan 1;175(1):86-90. https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969 http://www.ncbi.nlm.nih.gov/pubmed/29301420?tool=bestpractice.com [76]Pilowsky DJ, Wu LT. Screening for alcohol and drug use disorders among adults in primary care: a review. Subst Abuse Rehabil. 2012 Apr;3(1):25-34. http://www.ncbi.nlm.nih.gov/pubmed/22553426?tool=bestpractice.com

Take account of the amount of alcohol that the patient reports drinking prior to admission/assessment as well as the result of SAD-Q/CAGE screening.[3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf

• Ask about changes in drinking patterns, at least during the previous 5 days, as well as the time of the patient’s last drink.[3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf

• Consider other diagnoses if the patient has consumed alcohol in the last 6 hours as alcohol withdrawal is unlikely within this timeframe. However, it is important to remember that patients can experience withdrawal symptoms even if their blood alcohol level has not reached zero.