Assessment of Severity

Assessment of the severity of withdrawal is an important aspect of treatment. Most units that treat alcohol withdrawal assess symptoms in a semiquantitative manner. This approach avoids under or overtreatment of patients. This author prefers the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-r) scale. The scale employs semiquantitative estimation of 9 symptoms using a score of 1 to 7. The higher the score the greater the severity of the withdrawal. Disorientation is scored on a 1 to 4 scale (Table 37-3). Individuals with scores > 10 usually require pharmacotherapy.

Benzodiazepines

Benzodiazepines have been the primary category of drugs used in treating alcohol withdrawal for many years. They are safe and effective, but require monitoring of therapy to avoid unwanted effects such as oversedation. All drugs in this category are effective in both treating and preventing seizures. In recent years, short acting drugs such as lorazepam (Ativan) have been used more frequently. This drug does not accumulate in those patients with chronic liver disease, such as cirrhosis or severe alcoholic hepatitis, although it can precipitate hepatic encephalopathy as easily as other drugs in this category. Diazepam (Valium) and chlordiazepoxide (Librium) have a long track record of use for treating alcohol withdrawal. Both are metabolized to active metabolites, one of which is lorazepam, and have a longer effective half-life than lorazepam. Some protocols for managing withdrawal take advantage of the longer halflife by using a loading dose regimen, which will "self-taper" over several days as the drugs are metabolized. Lorazepam (Ativan) and oxazepam (Serax) both require continued administration to prevent rebound withdrawal and must be tapered to prevent relapse. The CIWA-r can also be used to monitor response to treatment, allowing more than one provider to follow the patient's recovery.

TABLE 37-3. Clinical Institute Withdrawal Assessment for Alcohol—Revised

Nausea and vomiting 0 to 7

Tremor 0 to 7

Paroxysmal sweating 0 to 7

Anxiety 0 to 7

Agitation 0 to 7

Tactile disturbances 0 to 7

Auditory disturbances 0 to 7

Visual disturbances 0 to 7

Headache 0 to 7

Disorientation 0 to 4

Minimal withdrawal 0 to 9

Mild-moderate withdrawal 10 to 19

Severe withdrawal > 20

Withdrawal Seizures

Withdrawal seizures occur most often within the first 24 hrs of abstinence but may continue for up to 72 hrs. Seizures are a more serious manifestation of withdrawal than other early signs and symptoms. The risk of DT is increased in patients who have had seizures or previous DT. Although withdrawal seizures are usually self-limited, most experts favor drug treatment to prevent "kindling." Kindling increases the risk of future seizures due to past withdrawal seizures. Withdrawal seizures are best treated with benzodiazepines. Because of the possibility of head trauma in alcoholics, the etiology of seizures should be evaluated at least once to be certain that a structural brain injury is not the cause. Focal seizures are usually not caused solely by alcohol withdrawal; however, alcohol withdrawal can lower the threshold for focal or generalized seizures in patients with preexisting brain lesions.

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