Primary prevention

Prevention of alcohol withdrawal begins with screening and identification of patients who are deemed to be at risk by their level of alcohol consumption, history, and circumstances.[5] This risk assessment is done by assessing the frequency, duration, and volume of alcohol consumption; history of alcohol withdrawal syndrome (AWS) and its severity; as well as any recent reduction or cessation of intake.[5] Patients in both inpatient and outpatient settings should be screened for alcohol use disorder (AUD) or excessive use of alcohol using a formal assessment tool. Examples of appropriate screening tools include AUDIT-C (Alcohol Use Disorders Identification Test - Consumption), CAGE, or FAST (Fast Alcohol Screening Test).[3][5][9][43]​​ [ Alcohol Consumption Screening AUDIT Questionnaire Opens in new window ] Alcohol use disorders identification test consumption (AUDIT C) Opens in new window​​ CAGE questionnaire Opens in new window Fast Alcohol Screening Test (FAST) Opens in new window​ The full AUDIT (Alcohol Use Disorders Identification Test) is also an option, although this takes longer to perform than other screening tools and therefore may not be suitable in an acute hospital setting.[3][43]

An alternative approach (if time does not allow for a full assessment) is an initial one-question screen to identify potential alcohol use disorder: “How many times in the past year have you had X or more drinks in a day?” Recommended by the US National Institute on Alcohol Abuse and Alcoholism (NIAAA), X is 5 for men and 4 for women.[9][43][44] This test is positive if the patient’s response is >1, and a formal assessment tool such as AUDIT should then be used.[9][43][44]

Patients who screen positive for AUD and are at risk of alcohol withdrawal should have their degree of alcohol dependence assessed using a formal screening tool such as the Severity of Alcohol Dependence Questionnaire (SAD-Q) or the Leeds Dependence Questionnaire.[9][45][46][47][48] AUDIT-C, FAST, and AUDIT only identify alcohol use disorder and do not predict which patients are at risk of alcohol withdrawal.

The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) is another potentially useful tool to assess the risk of developing complex AWS among medically ill/hospitalized patients.[5][49][50]

When an at-risk patient is identified, prophylactic therapy with a benzodiazepine, such as chlordiazepoxide, should be initiated.[5] If the blood ethanol concentration is negative or if there is low suspicion for an elevated concentration, the patient may then be discharged with referral to a rehabilitation program or admitted to the hospital.[51]

Secondary prevention

Early recognition of alcohol withdrawal syndrome and prompt symptom-triggered administration of benzodiazepine (using a validated assessment tool such as the Clinical Institute Withdrawal Assessment for Alcohol scale, revised version [CIWA-Ar]) is required to prevent severe alcohol withdrawal, including alcohol withdrawal delirium (also known as delirium tremens). Optimization of supportive care, electrolyte repletion, and nutrition/vitamin administration is also essential to decrease the risk of alcohol-related complications during hospitalization.[15] The duration of ongoing treatment after the initial acute phase should be determined according to the severity of symptoms at the time of assessment. Once withdrawal is complete, benzodiazepines should be stopped, to prevent physiologic dependence, development of benzodiazepine use disorder, or withdrawal from benzodiazepines.[5] 

Ongoing follow-up, at a minimum every month for a year, improves the likelihood of maintained recovery. For patients treated in primary care, regular follow-up visits, at least once a month for one year, increase the likelihood of sustained recovery.[5]

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