Alcohol use disorder (AUD) is a leading risk factor for premature death and disability in the US and worldwide.1,2 In the US, nearly 15 million people aged 12 years and older had AUD in 2019 and excessive alcohol use is responsible for approximately 95,000 deaths per year.1,3

Previously described as separate disorders in the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV), the DSM-5 combines symptoms of both alcohol dependence and alcohol abuse into 1 disorder, AUD, and classifies the disorder as mild, moderate, or severe.2,4,5

Providing individualized care to patients with AUD who seek treatment is challenging. Patients with a history of heavy drinking for a prolonged period who significantly reduce their alcohol consumption or abruptly stop drinking can develop alcohol withdrawal syndrome. This typically occurs within 4 to 12 hours of the last drink with symptoms lasting for up to 5 days.2 More than 50% of patients with AUD develop alcohol withdrawal symptoms when discontinuing or decreasing alcohol use.6

Symptoms of alcohol withdrawal range from anxiety, agitation, tremor, insomnia, nausea, and hallucinations to potentially life-threatening seizures and delirium tremens (DTs; Table 1).2,5-8 In patients with unsuspected or untreated DTs, mortality rates are reported to be up to 37%.6


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Pathophysiology of Alcohol Withdrawal Syndrome

The effects of alcohol on the central nervous system are linked to the gamma-aminobutyric acid (GABA)-chloride channel receptor complex.9,10 GABA is the main inhibitory neurotransmitter and glutamate is the primary excitatory neurotransmitter in the brain.10,11 The GABA receptor is a pentameric protein, comprised of 5 subunits – 2 alpha, 2 beta, and 1 gamma (Figure).10 In between the alpha and beta subunits lies the binding site for GABA.9,10 Ethanol readily binds to the receptors on the GABA protein complex because of its high affinity for ethanol.12 As a positive allosteric modulator, alcohol acts as a central nervous system depressant because of its inhibitory effect on N-methyl-D-aspartate (NMDA) receptors leading to sedative and anxiolytic effects.9,11

Alcohol withdrawal causes a significant decrease in GABA levels, which subsequently causes a hyperactive response in the nervous system.11 Withdrawal also causes activation of glutamate, which enhances the function of the NMDA receptors.11,13,14

Figure. Subunits of the GABA receptor.10

Detecting Alcohol Withdrawal Syndrome

The American Society of Addiction Medicine (ASAM) recommends universal screening for unhealthy alcohol use in medical settings using validated scales to help identify patients with or at risk for AUD and alcohol withdrawal.8

Some of the screening questionnaires for AUD that can be used in both the inpatient and outpatient setting include the following11,15:

  • Alcohol Use Disorders Identification Test-Consumption (AUDIT-C)
  • Cut-Down, Annoyed, Guilty, and Eye-Opener (CAGE)
  • Munich Alcoholism Test (MALT)

Alcohol dependence should be considered in women who report more than 1 drink daily or more than 7 drinks per week, and in men who average more than 2 drinks daily or more than 14 drinks per week.16,17 Patients’ average daily and/or weekly alcohol intake, history of previous cessation attempts, history of previous alcohol withdrawals, presence of concurrent medical or psychiatric conditions, and concurrent drug abuse should be taken into consideration as clinicians assess for the presence of withdrawal symptoms.17

The Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) is a 10-item assessment tool that can evaluate the presence of withdrawal symptoms, quantify the severity of symptoms, and individualize treatment selection (Table 2).11,18 Each item is evaluated independently, with all components then aggregated to yield a score correlating with the severity of alcohol withdrawal.11 Each component is scored on a scale from 0 to 7, except for orientation and sensorium, which is scored from 0 to 4. In patients who score less than 8, the presence of alcohol withdrawal symptoms is suggested to be absent or minimal. Patients scoring 8 to 20 are noted to be in mild to moderate withdrawal, and those scoring greater than 20 are considered to be experiencing severe withdrawal symptoms. Patients with scores of 10 or less typically do not need pharmacologic treatment.18

Other scales that can be used to assess for the risk for severe alcohol withdrawal include8:

  • Luebeck Alcohol-Withdrawal Risk Scale (LARS)
  • Prediction of Alcohol Withdrawal Severity Scale (PAWSS)

Although data collected from these assessments are extremely helpful in detection of alcohol withdrawal symptoms, the screening tools should be used as supportive measures in combination with the clinical picture as provided by a detailed history and thorough physical examination. Additionally, laboratory investigations such as urine drug screening, liver functions tests, blood alcohol levels, electrolyte levels, and a complete blood count are mainstays for establishing a diagnosis.17

This article originally appeared on Clinical Advisor