{ "schemaVersion": 2, "eyebrow": "Addiction Medicine", "title": "Alcohol Withdrawal Syndrome", "summary": "Alcohol withdrawal syndrome requires early risk stratification, serial clinical assessment, benzodiazepine-based treatment for clinically significant withdrawal, supportive correction of nutritional and metabolic complications, and deliberate transition to treatment for alcohol use disorder.", "seoDescription": "Alcohol withdrawal syndrome: diagnosis, risk stratification, benzodiazepine treatment, supportive care, escalation, and transition to alcohol use disorder treatment.", "clinicalQuestion": "How should physicians identify, risk-stratify, treat, and safely disposition adults with alcohol withdrawal syndrome?", "specialty": "Addiction Medicine", "audience": "U.S. physicians and medical trainees", "tags": [ "alcohol withdrawal syndrome", "AWS", "CIWA-Ar", "PAWSS", "benzodiazepines", "phenobarbital", "delirium tremens" ], "keyTakeaways": [ "Alcohol withdrawal is a clinical diagnosis after cessation or substantial reduction of heavy, prolonged alcohol use plus at least 2 characteristic symptoms developing within hours to days; alternative causes of autonomic activation or delirium must be actively assessed.[12][21]", "A PAWSS score of 4 or greater identifies hospitalized patients at high risk for complicated withdrawal; prior withdrawal seizures or delirium, repeated detoxifications, medical instability, sedative co-exposure, and inability to participate in assessment lower the threshold for monitored inpatient care.[9][10]", "Use CIWA-Ar to quantify symptom burden only in alert, communicative patients. It is unreliable in delirium, intubation, severe medical illness, or impaired communication; do not use a low score to override a high-risk history.[9][10]", "Benzodiazepines are first-line therapy for clinically significant alcohol withdrawal and prevent seizures and delirium; symptom-triggered treatment is preferred when a validated scale can be applied reliably.[21][22]", "Acute withdrawal management is not treatment for alcohol use disorder. Initiate or arrange longitudinal AUD treatment and psychosocial support before discharge.[4][9]" ], "sections": [ { "id": "diagnosis-and-trajectory", "eyebrow": "Recognition", "heading": "Establish the diagnosis and anticipate progression", "intro": "Diagnosis is clinical; timing and trajectory guide monitoring intensity.", "paragraphs": [ "Alcohol withdrawal syndrome follows abrupt cessation or substantial reduction of heavy, prolonged alcohol use. Diagnostic features include autonomic hyperactivity, tremor, insomnia, nausea or vomiting, perceptual disturbances, agitation, anxiety, or generalized tonic-clonic seizures; at least 2 symptoms should develop within hours to several days, cause clinically meaningful distress or impairment, and not be better explained by another condition.[12][21]", "Symptoms may begin within 6 to 24 hours after the last drink, often peak over the next 2 to 3 days, and improve over several days. Withdrawal seizures usually occur within 6 to 48 hours, whereas delirium tremens generally begins after 48 to 72 hours.[9] Withdrawal may occur despite a measurable blood alcohol concentration, particularly when the serum concentration is falling in a patient with physiologic dependence.[21]", "Do not attribute fever, hypoxemia, focal neurologic findings, unexpected obtundation, severe metabolic abnormalities, or refractory agitation solely to withdrawal. Reassess for infection, trauma or intracranial injury, hypoglycemia, toxicologic syndromes, hepatic encephalopathy, pulmonary embolism, thyroid disease, medication toxicity, and non-alcohol delirium.[9]" ], "bullets": [ "History that changes management: time and pattern of last alcohol use; prior withdrawal seizure, delirium, ICU admission, or repeated withdrawal episodes; concurrent benzodiazepines, barbiturates, gabapentinoids, opioids, or stimulants; medical and psychiatric comorbidity; and capacity for safe observation after discharge.[9][10]", "Examination priorities: vital signs, tremor, diaphoresis, agitation, attention and orientation, volume status, trauma, focal deficits, respiratory status, and signs of infection or liver disease.[9]" ], "subsections": [], "table": { "caption": "Expected timing of major alcohol withdrawal manifestations.[9]", "columns": [ "Manifestation", "Typical timing after last drink", "Clinical consequence" ], "rows": [ [ "Early autonomic and neuropsychiatric symptoms", "6-24 hours", "Serial assessment; symptoms may evolve despite initially mild presentation.[9]" ], [ "Withdrawal seizures", "6-48 hours", "Treat and monitor as complicated withdrawal; investigate alternative seizure etiologies when presentation is atypical.[9]" ], [ "Delirium tremens", "Usually 48-72 hours", "Requires high-acuity monitoring and aggressive treatment of withdrawal plus competing causes of delirium.[9]" ] ] } }, { "id": "risk-stratification-and-setting", "eyebrow": "Disposition", "heading": "Choose the level of care using risk, not symptom score alone", "intro": "Current symptoms and future complication risk are separate decisions.", "paragraphs": [ "PAWSS is useful early in hospitalized patients before withdrawal fully declares itself. A score of 4 or greater indicates high risk for complicated withdrawal and may support pharmacologic prophylaxis and monitored treatment.[9][10] CIWA-Ar measures current symptom burden on a 0-to-67 scale; commonly used ranges are less than 8 for minimal to mild symptoms, 8 to 15 for moderate symptoms, and greater than 15 for severe symptoms, but protocols vary and thresholds should not be used as stand-alone disposition rules.[9]", "Outpatient management is limited to carefully selected patients with mild to moderate symptoms, stable vital signs, reliable follow-up and social support, stable housing and transportation, and no history of complicated withdrawal or major unstable medical or psychiatric comorbidity.[9] Moderate symptoms may be managed outside the hospital only when these conditions are met and reassessment is assured.[9]" ], "bullets": [ "Favor hospital-based care for delirium, withdrawal seizures, severe or escalating autonomic instability, respiratory compromise, uncontrolled agitation, significant diagnostic uncertainty, acute medical or surgical illness, or inability to maintain oral intake.[9]", "Favor monitored inpatient or higher-acuity care with prior delirium tremens or withdrawal seizures, PAWSS 4 or greater, repeated detoxifications, unreliable symptom reporting, pregnancy, advanced age, significant cardiopulmonary or liver disease, active infection or trauma, concurrent sedative or opioid exposure, suicide risk, severe electrolyte disturbance, polysubstance exposure, or an unsafe recovery environment.[9]", "Use CIWA-Ar only when the patient can reliably report subjective symptoms. In delirious, intubated, cognitively impaired, or medically complex patients, guide treatment by clinician assessment and objective findings rather than forcing a symptom-triggered CIWA-Ar protocol.[9]" ], "subsections": [], "table": { "caption": "Practical roles of common alcohol withdrawal instruments.[9][10]", "columns": [ "Instrument", "Best use", "Key limitation" ], "rows": [ [ "PAWSS", "Early prediction of complicated withdrawal in hospitalized patients; score 4 or greater indicates high risk.[9][10]", "Does not replace serial examination or determine the appropriate care setting by itself.[9]" ], [ "CIWA-Ar", "Serial measurement of symptom burden in alert, communicative patients.[9][21]", "Poor fit for delirium, intubation, severe medical illness, or impaired communication.[9]" ] ] } }, { "id": "initial-evaluation-and-supportive-care", "eyebrow": "First hours", "heading": "Correct reversible contributors while treating withdrawal", "intro": "Supportive care prevents complications but does not replace GABAergic treatment.", "paragraphs": [ "Obtain bedside glucose and evaluate volume status, electrolytes, liver injury, infection, and concurrent intoxication or withdrawal according to presentation. Repeated vital signs, mental-status assessments, and medication-response assessments are essential because oversedation, progression to complicated withdrawal, or an alternate diagnosis may become apparent during the first 24 to 48 hours.[9]", "Heavy alcohol use increases the risk of thiamine deficiency and Wernicke encephalopathy. Parenteral thiamine is preferred for hospitalized patients with malnutrition, vomiting, confusion, poor absorption, or severe or complicated withdrawal. In high-risk hospitalized patients, 100 mg IV or IM daily for 3 to 5 days is commonly used; suspected or manifest Wernicke encephalopathy warrants high-dose IV thiamine, commonly 200 to 500 mg IV 3 times daily for 3 to 5 days, followed by ongoing supplementation based on clinical response and local practice.[9]", "Correct hypoglycemia and clinically important potassium, magnesium, and phosphate abnormalities. Magnesium replacement is appropriate for hypomagnesemia, arrhythmia, electrolyte disturbance, or prior withdrawal seizures, but magnesium is not primary therapy for alcohol withdrawal itself.[9]" ], "bullets": [ "Give thiamine before glucose-containing fluids when feasible, but do not delay urgent hypoglycemia treatment.[9]", "Use oral hydration when safe; use isotonic IV fluids for clinically significant dehydration or inadequate oral intake, while individualizing volume management in heart failure, cirrhosis, and renal impairment.[9]", "Continue diagnostic reassessment if sedative requirements escalate unexpectedly or if fever, hypoxemia, focal findings, worsening metabolic derangement, or unexplained unresponsiveness develops.[9]" ], "subsections": [], "table": { "caption": "", "columns": [], "rows": [] } }, { "id": "pharmacologic-treatment", "eyebrow": "Acute treatment", "heading": "Use benzodiazepines as first-line therapy", "intro": "Select the regimen according to severity, monitoring capacity, and ability to assess symptoms.", "paragraphs": [ "Benzodiazepines are the standard first-line treatment for moderate to severe alcohol withdrawal because they relieve symptoms and reduce the risk of seizures and delirium.[9][22] Symptom-triggered treatment is preferred for most noncritically ill inpatients when trained staff can reliably perform serial CIWA-Ar assessment; compared with fixed schedules, it can reduce benzodiazepine exposure and may reduce length of stay.[21]", "Common initial symptom-triggered doses cited for medical inpatients are chlordiazepoxide 25 to 50 mg, lorazepam 1 to 2 mg, or oxazepam 15 mg, with repeat assessment and titration according to the institutional protocol and patient response.[21] Benzodiazepine selection should reflect pharmacokinetics, hepatic function, age, co-exposures, and the monitoring environment. Lorazepam or oxazepam may be preferred in significant hepatic dysfunction or older adults because they undergo glucuronidation and lack active metabolites.[9][21]", "Fixed-dose or front-loading approaches are appropriate when symptom scoring is unreliable or when there is a history of severe withdrawal. In severe, refractory, or delirious withdrawal, escalation should occur in a monitored setting that can manage respiratory compromise and airway intervention.[9][21]" ], "bullets": [ "Monitor for oversedation, hypoventilation, aspiration, and respiratory failure, especially in cirrhosis, advanced age, chronic lung disease, or concurrent opioid or sedative exposure.[9]", "Do not use antipsychotics as stand-alone treatment for alcohol withdrawal. Haloperidol may be used adjunctively for persistent agitation or delirium after adequate benzodiazepine treatment, with attention to seizure threshold, QT prolongation, electrolytes, and interacting drugs.[21][22]", "Alpha-2 agonists or beta-blockers can attenuate autonomic symptoms but do not replace benzodiazepines for seizure or delirium prevention.[10][21]" ], "subsections": [ { "heading": "Phenobarbital and ICU adjuncts", "paragraphs": [ "Phenobarbital is increasingly used within standardized, closely monitored hospital protocols, particularly for severe or benzodiazepine-refractory withdrawal, but requires clinician familiarity and monitoring for sedation and respiratory compromise.[9] Evidence and protocols remain heterogeneous; use should be matched to local expertise and monitoring capacity.[5][9]", "Dexmedetomidine can reduce adrenergic manifestations and benzodiazepine requirements in ICU-level care but does not correct the core GABAergic deficit and should not be used as sole therapy for seizure or delirium prevention.[11]" ], "bullets": [] } ], "table": { "caption": "Medication selection considerations for alcohol withdrawal.[9][21][22]", "columns": [ "Approach", "When it fits", "Important limitation" ], "rows": [ [ "Symptom-triggered benzodiazepine regimen", "Alert, communicative patient with reliable serial CIWA-Ar assessment and trained staff.[21]", "Do not apply when delirium or medical complexity makes CIWA-Ar unreliable.[9]" ], [ "Fixed-dose or front-loading benzodiazepine regimen", "History of withdrawal delirium or when symptom assessment cannot be performed reliably.[21]", "Requires close observation for accumulation and oversedation.[9][21]" ], [ "Phenobarbital protocol", "Severe or refractory withdrawal in a closely monitored setting with institutional expertise.[5][9]", "Risk of sedation and respiratory compromise; protocols and evidence are heterogeneous.[5][9]" ], [ "Adjunct haloperidol", "Agitation or delirium persisting despite adequate withdrawal treatment.[21][22]", "Not monotherapy; monitor QT-related risk and seizure threshold.[21][22]" ] ] } }, { "id": "seizure-delirium-and-refractory-withdrawal", "eyebrow": "Complicated withdrawal", "heading": "Escalate seizures, delirium, and refractory symptoms", "intro": "Complicated withdrawal is a high-acuity syndrome until alternative causes are excluded.", "paragraphs": [ "Alcohol withdrawal seizures and delirium tremens require urgent reassessment for competing etiologies, correction of metabolic abnormalities, and treatment in a setting capable of close respiratory and hemodynamic monitoring.[9] Benzodiazepines remain the pharmacologic foundation; antipsychotics and autonomic agents are adjuncts rather than substitutes for adequate GABAergic therapy.[21][22]", "For delirium tremens, serial CIWA-Ar is generally inappropriate because patient reporting is unreliable. Guide treatment by objective agitation, autonomic instability, attention, consciousness, airway safety, and response to sedatives, while repeatedly evaluating infection, trauma, intracranial pathology, hepatic encephalopathy, hypoxia, and toxidromes.[9]" ], "bullets": [ "Escalate to ICU or equivalent monitoring for refractory agitation, escalating sedative requirements, respiratory compromise, severe autonomic instability, need for continuous sedative infusions, or diagnostic uncertainty requiring intensive support.[9][11]", "Alcohol withdrawal management does not eliminate coexisting alcohol use disorder or prevent future withdrawal; link the admission to longitudinal treatment planning.[4][9]" ], "subsections": [], "table": { "caption": "", "columns": [], "rows": [] } }, { "id": "transition-to-aud-treatment", "eyebrow": "After stabilization", "heading": "Use withdrawal care to initiate treatment for alcohol use disorder", "intro": "Detoxification alone has no durable relapse-prevention role.", "paragraphs": [ "Acute withdrawal treatment should be followed by assessment and treatment planning for alcohol use disorder, including psychosocial support and recovery services.[4][8][9] For patients in early recovery or after relapse, peer, network, or 12-step facilitation may be offered as part of ongoing care.[8]", "FDA-labeled pharmacotherapy may be considered once the acute withdrawal phase is addressed and patient-specific contraindications are reviewed. Acamprosate is indicated to maintain abstinence in alcohol-dependent patients who are abstinent when treatment begins and should be combined with psychosocial support.[4] Extended-release injectable naltrexone is indicated for alcohol dependence in patients able to abstain before initiation; patients should not be actively drinking at first administration and must be assessed for opioid exposure or dependence.[2]" ], "bullets": [ "Acamprosate: 666 mg orally 3 times daily; reduce to 333 mg 3 times daily for creatinine clearance 30 to 50 mL/min and avoid when creatinine clearance is 30 mL/min or less.[4]", "Extended-release naltrexone: 380 mg deep IM gluteal injection every 4 weeks; evaluate opioid exposure, require an opioid-free interval of at least 7 to 10 days to avoid precipitated withdrawal, and consider overdose-reversal access because opioid tolerance is reduced after antagonist treatment ends or doses are missed.[2]", "Acamprosate and extended-release naltrexone do not treat acute alcohol withdrawal symptoms.[2][4]" ], "subsections": [], "table": { "caption": "FDA-labeled relapse-prevention options supported by supplied prescribing information.[2][4]", "columns": [ "Medication", "Role after withdrawal", "Key selection constraint" ], "rows": [ [ "Acamprosate", "Maintenance of abstinence in patients abstinent at treatment initiation; use with psychosocial support.[4]", "Renal dose reduction for creatinine clearance 30-50 mL/min; contraindicated at 30 mL/min or less.[4]" ], [ "Extended-release naltrexone", "Alcohol dependence treatment in patients able to abstain before initiation; use with psychosocial support.[2]", "Avoid in current physiologic opioid dependence, acute opioid withdrawal, positive opioid screen, or failed naloxone challenge; opioid-free interval of at least 7-10 days is recommended.[2]" ] ] } } ], "faq": [ { "question": "Can alcohol withdrawal occur with a positive blood alcohol concentration?", "answer": "Yes. Withdrawal may begin while alcohol remains measurable when the concentration is falling in a physiologically dependent patient; a positive level should not defer risk assessment or treatment.[21]" }, { "question": "When should CIWA-Ar not be used to direct treatment?", "answer": "Do not rely on CIWA-Ar in delirium, intubation, cognitive impairment, severe medical illness, or any setting where the patient cannot reliably report subjective symptoms. Use clinician assessment and objective findings instead.[9]" }, { "question": "Who needs inpatient alcohol withdrawal management?", "answer": "Inpatient or higher-acuity care is favored for complicated withdrawal, PAWSS 4 or greater, prior seizures or delirium tremens, unstable comorbidity, concurrent sedative exposure, unreliable assessment, pregnancy, severe metabolic disturbance, or inadequate outpatient support.[9][10]" }, { "question": "Is phenobarbital first-line therapy for alcohol withdrawal?", "answer": "Benzodiazepines remain first-line. Phenobarbital is used increasingly in standardized, closely monitored protocols for severe or refractory withdrawal, but use depends on institutional expertise and monitoring capacity.[5][9]" }, { "question": "Do acamprosate or naltrexone treat acute alcohol withdrawal?", "answer": "No. Acamprosate is labeled for maintenance of abstinence and extended-release naltrexone for alcohol dependence treatment after appropriate abstinence and opioid assessment; neither replaces acute withdrawal treatment.[2][4]" } ], "references": [ { "number": 1, "title": "highlights of prescribing information", "detail": "dailymed.nlm.nih.gov", "url": "https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=74b52f61-c951-4b0e-bd22-2463cb518234&type=display", "authors": "dailymed.nlm.nih.gov", "host": "dailymed.nlm.nih.gov" }, { "number": 2, "title": "These highlights do not include all the information needed to use VIVITROL® safely and effectively. See full prescribing information for VIVITROL.\n VIVITROL (naltrexone for extended-release injectable suspension), for intramuscular useInitial U.S. Approval: 1984", "detail": "dailymed.nlm.nih.gov", "url": "https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=cd11c435-b0f0-4bb9-ae78-60f101f3703f&type=display", "authors": "dailymed.nlm.nih.gov", "host": "dailymed.nlm.nih.gov" }, { "number": 3, "title": "These highlights do not include all the information needed to use ZOHYDRO® ER safely and effectively. See full prescribing information for ZOHYDRO® ER.  \n \n \n ZOHYDRO® ER (hydrocodone bitartrate) extended‑release capsules, for oral use, CII\n \n Initial U.S. Approval: 1943", "detail": "dailymed.nlm.nih.gov", "url": "https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=6ccfbd98-7750-4955-a654-ec104fb666f9&type=display", "authors": "dailymed.nlm.nih.gov", "host": "dailymed.nlm.nih.gov" }, { "number": 4, "title": "These highlights do not include all the information needed to use ACAMPROSATE CALCIUM DELAYED-RELEASE TABLETS safely and effectively. See full prescribing information for ACAMPROSATE CALCIUM DELAYED-RELEASE TABLETS.ACAMPROSATE CALCIUM delayed-release tablets, for oral useInitial U.S. Approval: 2004", "detail": "dailymed.nlm.nih.gov", "url": "https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=43e9ef60-2d85-4394-906b-93042fea099a", "authors": "dailymed.nlm.nih.gov", "host": "dailymed.nlm.nih.gov" }, { "number": 5, "title": "Use of Phenobarbital for Treating Alcohol Withdrawal", "detail": "jamanetwork.com", "url": "https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2837958", "authors": "jamanetwork.com", "host": "jamanetwork.com" }, { "number": 6, "title": "Management of Alcohol Withdrawal Delirium: An Evidence- ...", "detail": "jamanetwork.com", "url": "https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/217165", "authors": "jamanetwork.com", "host": "jamanetwork.com" }, { "number": 7, "title": "Diagnostic Criteria for Identifying Individuals at High Risk of ...", "detail": "jamanetwork.com", "url": "https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810438", "authors": "jamanetwork.com", "host": "jamanetwork.com" }, { "number": 8, "title": "The Management of Substance Use Disorders", "detail": "www.acpjournals.org", "url": "https://www.acpjournals.org/doi/10.7326/M21-4011", "authors": "www.acpjournals.org", "host": "www.acpjournals.org" }, { "number": 9, "title": "Alcohol withdrawal syndrome in hospitalized patients: a practical review", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0953620526004085", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 10, "title": "Alcohol Withdrawal Syndrome - an overview", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/alcohol-withdrawal-syndrome", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 11, "title": "A rational approach to the treatment of alcohol withdrawal in the ED", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S073567571300003X", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 12, "title": "Managing Alcohol Withdrawal Syndrome", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0196064424001057", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 13, "title": "The ASAM Clinical Practice Guideline on Alcohol... : Journal of Addiction Medicine", "detail": "journals.lww.com", "url": "https://journals.lww.com/journaladdictionmedicine/fulltext/2020/10000/the_asam_clinical_practice_guideline_on_alcohol.40.aspx", "authors": "journals.lww.com", "host": "journals.lww.com" }, { "number": 14, "title": "The ASAM National Practice Guideline for the... : Journal of Addiction Medicine", "detail": "journals.lww.com", "url": "https://journals.lww.com/journaladdictionmedicine/fulltext/2020/04001/the_asam_national_practice_guideline_for_the.1.aspx", "authors": "journals.lww.com", "host": "journals.lww.com" }, { "number": 15, "title": "Clinical management of the alcohol withdrawal syndrome", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1111/add.15647", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 16, "title": "Alcohol withdrawal syndrome: mechanisms, manifestations ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/full/10.1111/ane.12671", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 17, "title": "Severity and Treatment of Alcohol Withdrawal in Elderly ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1530-0277.1994.tb00903.x", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 18, "title": "A systematic review of the economic evidence surrounding ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1111/dar.14053", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 19, "title": "Management of Acute Alcohol Withdrawal Syndrome in ...", "detail": "accpjournals.onlinelibrary.wiley.com", "url": "https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.1770", "authors": "accpjournals.onlinelibrary.wiley.com", "host": "accpjournals.onlinelibrary.wiley.com" }, { "number": 20, "title": "Research Needs for Inpatient Management of Severe Alcohol ...", "detail": "academic.oup.com", "url": "https://academic.oup.com/ajrccm/article/204/7/e61/8492399", "authors": "academic.oup.com", "host": "academic.oup.com" }, { "number": 21, "title": "Alcohol withdrawal syndrome in medical patients", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/content/83/1/67", "authors": "www.ccjm.org", "host": "www.ccjm.org" }, { "number": 22, "title": "Mental Health, Brain Health and Substance Use", "detail": "www.who.int", "url": "https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme/evidence-centre/alcohol-use-disorders/management-of-alcohol-withdrawal", "authors": "www.who.int", "host": "www.who.int" }, { "number": 23, "title": "Study Details | NCT00229125 | Comparing the Treatment of Alcohol Withdrawal Syndrome Using Gabapentin Versus Lorazepam | ClinicalTrials.gov", "detail": "clinicaltrials.gov", "url": "https://clinicaltrials.gov/study/NCT00229125", "authors": "clinicaltrials.gov", "host": "clinicaltrials.gov" }, { "number": 24, "title": "Study Details | NCT00106106 | Acamprosate to Reduce Symptoms of Alcohol Withdrawal | ClinicalTrials.gov", "detail": "clinicaltrials.gov", "url": "https://clinicaltrials.gov/study/NCT00106106", "authors": "clinicaltrials.gov", "host": "clinicaltrials.gov" } ], "editorialNote": "Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.", "citations": [ { "number": 1, "title": "highlights of prescribing information", "detail": "dailymed.nlm.nih.gov", "url": "https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=74b52f61-c951-4b0e-bd22-2463cb518234&type=display", "authors": "dailymed.nlm.nih.gov", "host": "dailymed.nlm.nih.gov", "snippet": "... hepatic impairment and a dose adjustment is recommended for patients with severe hepatic impairment. ... Drug withdrawal syndrome; Decrease in sleep (insomnia)", "score": 0.5071046 }, { "number": 2, "title": "These highlights do not include all the information needed to use VIVITROL® safely and effectively. See full prescribing information for VIVITROL.\n VIVITROL (naltrexone for extended-release injectable suspension), for intramuscular useInitial U.S. Approval: 1984", "detail": "dailymed.nlm.nih.gov", "url": "https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=cd11c435-b0f0-4bb9-ae78-60f101f3703f&type=display", "authors": "dailymed.nlm.nih.gov", "host": "dailymed.nlm.nih.gov", "snippet": "Required for Pain Management5.7 Eosinophilic Pneumonia5.8 Hypersensitivity Reactions Including Anaphylaxis5.9 Intramuscular Injections5.10 Alcohol Withdrawal5.11 Interference with Laboratory Tests6 ADVERSE REACTIONS6.1 Clinical Trials Experience6.2 Postmarketing Experience7 DRUG INTERACTIONS8 USE IN", "score": 0.27610138 }, { "number": 3, "title": "These highlights do not include all the information needed to use ZOHYDRO® ER safely and effectively. See full prescribing information for ZOHYDRO® ER.  \n \n \n ZOHYDRO® ER (hydrocodone bitartrate) extended‑release capsules, for oral use, CII\n \n Initial U.S. Approval: 1943", "detail": "dailymed.nlm.nih.gov", "url": "https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=6ccfbd98-7750-4955-a654-ec104fb666f9&type=display", "authors": "dailymed.nlm.nih.gov", "host": "dailymed.nlm.nih.gov", "snippet": "| | FULL PRESCRIBING INFORMATION: CONTENTS\\WARNING: ADDICTION, ABUSE, AND MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; NEONATAL OPIOID WITHDRAWAL SYNDROME; INTERACTION WITH ALCOHOL; and CYTOCHROME P450 3A4 INTERACTION1 INDICATIONS AND USAGE 2 DOSAGE AND ADMINISTRATION 2.1 ", "score": 0.27159372 }, { "number": 4, "title": "These highlights do not include all the information needed to use ACAMPROSATE CALCIUM DELAYED-RELEASE TABLETS safely and effectively. See full prescribing information for ACAMPROSATE CALCIUM DELAYED-RELEASE TABLETS.ACAMPROSATE CALCIUM delayed-release tablets, for oral useInitial U.S. Approval: 2004", "detail": "dailymed.nlm.nih.gov", "url": "https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=43e9ef60-2d85-4394-906b-93042fea099a", "authors": "dailymed.nlm.nih.gov", "host": "dailymed.nlm.nih.gov", "snippet": "Although dosing may be done without regard to meals, dosing with meals was employed during clinical trials and is suggested in those patients who regularly eat three meals daily.\n\nTreatment with acamprosate calcium delayed-release tablets should be initiated as soon as possible after the period of a", "score": 0.25765342 }, { "number": 5, "title": "Use of Phenobarbital for Treating Alcohol Withdrawal", "detail": "jamanetwork.com", "url": "https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2837958", "authors": "jamanetwork.com", "host": "jamanetwork.com", "snippet": "by BJ Wolpaw · 2025 · Cited by 9 — The ASAM Clinical Practice Guideline on Alcohol Withdrawal.  J Addict Med. 2020;14(3S suppl 1):1-72. doi:10.1097/ADM.0000000000000668PubMed ...Read more", "score": 0.459586 }, { "number": 6, "title": "Management of Alcohol Withdrawal Delirium: An Evidence- ...", "detail": "jamanetwork.com", "url": "https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/217165", "authors": "jamanetwork.com", "host": "jamanetwork.com", "snippet": "by MF Mayo-Smith · 2004 · Cited by 670 — Current diagnostic criteria for AWD include disturbance of consciousness, change in cognition or perceptual disturbance developing in a short ...Read more", "score": 0.1763029 }, { "number": 7, "title": "Diagnostic Criteria for Identifying Individuals at High Risk of ...", "detail": "jamanetwork.com", "url": "https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810438", "authors": "jamanetwork.com", "host": "jamanetwork.com", "snippet": "by AP Miller · 2023 · Cited by 24 — Recent US estimates indicate that 11% and 30% of adults meet criteria for past-year and lifetime AUD, respectively. This level of disordered", "score": 0.076112024 }, { "number": 8, "title": "The Management of Substance Use Disorders", "detail": "www.acpjournals.org", "url": "https://www.acpjournals.org/doi/10.7326/M21-4011", "authors": "www.acpjournals.org", "host": "www.acpjournals.org", "snippet": "by C Perry · 2022 · Cited by 80 — In addition, for patients with AUD in early recovery or after relapse, the CPG also recommends 12-step facilitation, network support, or peer", "score": 0.16289902 }, { "number": 9, "title": "Alcohol withdrawal syndrome in hospitalized patients: a practical review", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0953620526004085", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Alcohol withdrawal syndrome (AWS) develops in patients with alcohol use disorder (AUD) and physical dependence after abrupt cessation or substantial reduction of sustained heavy alcohol use. It is common and potentially life-threatening in general medical practice. Characteristic features include tr", "score": 0.7368747 }, { "number": 10, "title": "Alcohol Withdrawal Syndrome - an overview", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/alcohol-withdrawal-syndrome", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Alcohol withdrawal (AW) syndrome is one of the most severe complications of alcohol dependence for which patients often require treatment in an in-patient unit. It develops after cessation of heavy alcohol abuse in alcohol-dependent patients and it is characterized by increased anxiety, tremulousnes", "score": 0.6490677 }, { "number": 11, "title": "A rational approach to the treatment of alcohol withdrawal in the ED", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S073567571300003X", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Approximately 7% of the US population abuses or is dependent on alcohol. Patients with alcohol disorders often seek medical attention in Emergency Departments (EDs) for complications directly related to alcohol use or due to other medical issues associated with alcohol use. Because of increasing len", "score": 0.6485337 }, { "number": 12, "title": "Managing Alcohol Withdrawal Syndrome", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0196064424001057", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "### Br J Addict (1989) \n J.P. Reoux _et al._\n### Routine hospital alcohol detoxification practice compared to symptom triggered management with an Objective Withdrawal Scale (CIWA-Ar)\n\n### Am J Addict (2000) \n J.B. Daeppen _et al._\n### Symptom-triggered vs fixed-schedule doses of benzodiazepine ", "score": 0.56200886 }, { "number": 13, "title": "The ASAM Clinical Practice Guideline on Alcohol... : Journal of Addiction Medicine", "detail": "journals.lww.com", "url": "https://journals.lww.com/journaladdictionmedicine/fulltext/2020/10000/the_asam_clinical_practice_guideline_on_alcohol.40.aspx", "authors": "journals.lww.com", "host": "journals.lww.com", "snippet": "Ovid®\n\nOvid Logo\n\nSearch OvidSearch Ovid\n\nBrowseBrowse\n\nLoginLogin\n\nJournal of Addiction Medicine\n\nSearch JournalSearch Journal\n\nButton group.\n\nErratum\n\n# The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management: Erratum\n\nJournal of Addiction Medicine 14(5):p e280, September/October 202", "score": 0.49040702 }, { "number": 14, "title": "The ASAM National Practice Guideline for the... : Journal of Addiction Medicine", "detail": "journals.lww.com", "url": "https://journals.lww.com/journaladdictionmedicine/fulltext/2020/04001/the_asam_national_practice_guideline_for_the.1.aspx", "authors": "journals.lww.com", "host": "journals.lww.com", "snippet": "3. The physician holds an addiction certification or board certification from ASAM or the American Board of Addiction Medicine. (ASAM certification was taken over by the American Board of Addiction Medicine in 2007.)\n\n 4. The physician holds a subspecialty board certification in addiction medicine", "score": 0.3397405 }, { "number": 15, "title": "Clinical management of the alcohol withdrawal syndrome", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1111/add.15647", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "by E Day · 2022 · Cited by 124 — All 4 criteria must be present to diagnose alcohol withdrawal A. Cessation of (or reduction in) alcohol use that has been heavy and trigger", "score": 0.4272061 }, { "number": 16, "title": "Alcohol withdrawal syndrome: mechanisms, manifestations ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/full/10.1111/ane.12671", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "by S Jesse · 2017 · Cited by 377 — However, with early detection and appropriate treatment, the expected mortality is in the range of 1% or less.6 ・ last up to 4–48 h. They can", "score": 0.32614315 }, { "number": 17, "title": "Severity and Treatment of Alcohol Withdrawal in Elderly ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1530-0277.1994.tb00903.x", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "by KJ Brower · 1994 · Cited by 165 — All tests were two-tailed. For individual withdrawal symptoms, we predicted age differences for 3 of 17 symptoms (cognitive impairment, hallucinations, and", "score": 0.27189812 }, { "number": 18, "title": "A systematic review of the economic evidence surrounding ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1111/dar.14053", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "Alcohol withdrawal syndrome (AWS) is a medical emergency associated with lengthy hospital stays and an increased frequency of alcohol-related", "score": 0.25515383 }, { "number": 19, "title": "Management of Acute Alcohol Withdrawal Syndrome in ...", "detail": "accpjournals.onlinelibrary.wiley.com", "url": "https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.1770", "authors": "accpjournals.onlinelibrary.wiley.com", "host": "accpjournals.onlinelibrary.wiley.com", "snippet": "Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal", "score": 0.19576351 }, { "number": 20, "title": "Research Needs for Inpatient Management of Severe Alcohol ...", "detail": "academic.oup.com", "url": "https://academic.oup.com/ajrccm/article/204/7/e61/8492399", "authors": "academic.oup.com", "host": "academic.oup.com", "snippet": "by TL Steel · 2021 · Cited by 42 — Alcohol withdrawal syndrome (AWS) is common among hospitalized patients and can be fatal without appropriate pharmacologic management (3–5).", "score": 0.30557346 }, { "number": 21, "title": "Alcohol withdrawal syndrome in medical patients", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/content/83/1/67", "authors": "www.ccjm.org", "host": "www.ccjm.org", "snippet": "Other publications\n\n## Umbrella menu\n\nlogo\nlogo\n\n## Main navigation\n\nlogo\nlogo\n\n# Alcohol withdrawal syndrome in medical patients\n\n## ABSTRACT\n\nThe authors provide a critical review focusing on pharmacotherapy of alcohol withdrawal syndrome in hospitalized patients who are not critically ill. They o", "score": 0.60274047 }, { "number": 22, "title": "Mental Health, Brain Health and Substance Use", "detail": "www.who.int", "url": "https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme/evidence-centre/alcohol-use-disorders/management-of-alcohol-withdrawal", "authors": "www.who.int", "host": "www.who.int", "snippet": "Antipsychotic medications should not be used as stand alone medications for the management of alcohol withdrawal. \nStrength of recommendation: STRONG \nQuality of evidence: LOW\n\nBenzodiazepines, and not anticonvulsants, should be used following an alcohol withdrawal seizure for the prevention of fu", "score": 0.20977746 }, { "number": 23, "title": "Study Details | NCT00229125 | Comparing the Treatment of Alcohol Withdrawal Syndrome Using Gabapentin Versus Lorazepam | ClinicalTrials.gov", "detail": "clinicaltrials.gov", "url": "https://clinicaltrials.gov/study/NCT00229125", "authors": "clinicaltrials.gov", "host": "clinicaltrials.gov", "snippet": "Subjects with current (past month) DSM-IV diagnosis of any other substance dependence syndrome other than alcohol dependence (excluding nicotine, caffeine, cannabis and cocaine dependence).\n Use of pharmacological agents within a five half-life period that are known to lower the seizure threshold ", "score": 0.296451 }, { "number": 24, "title": "Study Details | NCT00106106 | Acamprosate to Reduce Symptoms of Alcohol Withdrawal | ClinicalTrials.gov", "detail": "clinicaltrials.gov", "url": "https://clinicaltrials.gov/study/NCT00106106", "authors": "clinicaltrials.gov", "host": "clinicaltrials.gov", "snippet": "1. Current or prior history of any disease, including cardiovascular, respiratory, gastrointestinal, hepatic, renal, endocrine, or reproductive disorders, or a positive hepatitis or HIV test at screening.\n2. Current Axis-I psychiatric illness.\n3. Current or prior history of any alcohol or drug", "score": 0.12632124 } ], "publishedAt": "2026-08-20T23:29:27.696755Z", "updatedAt": "2026-08-20T23:29:27.696755Z", "readingMinutes": 7, "slug": "alcohol-withdrawal-syndrome" }