Alcohol Use Disorder and Alcohol Withdrawal: Outpatient Management (Robledo 3/30/2022)

Thanks to Dr. Robledo for an excellent review of AUD and AWS at Grand Rounds this week. A link to a recording of the presentation is HERE.

Note: in place of male/female to discuss gender differences, Doctor Robledo used "assigned female at birth" (AFAB) and "assigned male at birth" (AMAB). These abbreviations are included in this summary.

Alcohol use

Appropriate alcohol use is considered no more than 1 standard drink/day (=7/week) for AFAB, 2/day (=14/week) for AMAB. Risky alcohol use is anything more than this amount. 

Risky alcohol use is drinking that can lead to health consequences and may develop into alcohol use disorder. 

Alcohol use disorder is a pattern of drinking that significantly impairs health and functioning. 

Binge drinking: drinking in a way that increases blood alcohol level >0.08 in 2 hours, generally >4 drinks at once for AFAB, >5 drinks at once for AMAB

Alcohol Use Disorder (by DSM-V Criteria)

https://creativecommons.org/licenses/by/4.0/

• mild 2-3 symptoms
• moderate 4-5 symptoms
• severe >6 symptoms

• early remission: abstinent between 3-12 months
• sustained remission: abstinent  >12 months

We all know that AUD is extremely prevalent in our society, but do you know how prevalent

29% lifetime prevalence

10.5% of children live with someone who has AUD

95K deaths/year

1/10 deaths in working age adults

$250 Billion/year in costs

COVID has been associated with alcohol use: 7.7x the odds ratio of getting COVID if you have AUD.

Screening tools for AUD 

The USPSTF recommends that all adults (>18) and all pregnant patients be screened annually for AUD. Here are some tools:

• SASQ: "How often in the past year have you had >4 drinks at one time (if AFAB), >5 drinks at home time (if AMAB)
• AUDIT-C: 3 questions, screening for at risk drinking (if +, should be followed by AUDIT-10)
• ADUIT-10: 10 questions
• CAGE questions: Cut down, Annoyed, Guilty, Eye opener (more looking at alcohol dependency)

https://www.aafp.org/afp/2013/1101/p596.html

https://www.aafp.org/afp/2002/0201/p441.html

Brief intervention for those who screen positive:

• be empathetic and caring
• state the medical findings in a non-judgemental way (e.g. signs of cirrhosis on exam, lab results, symptoms)
• educate patients regarding AUD
• advise patients to cut down/stop drinking
• assess their stage of change/readiness for change
• regular follow-up

Don't forget to use your motivational interviewing skills!

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Alcohol Withdrawal Syndrome requires that someone 1) stopped after heavy/prolonged use and 2) two or more of the symptomsm describes in table 1 below:

https://www.clinicaladvisor.com/home/topics/psychiatry-information-center/alcohol-withdrawal-individualized-care-and-pharmacologic-treatment/

80% of patients will have totally uncomplicated withdrawal and do not need to be hospitalized

Higher risk folks include: those with hx withdrawal seizure or DTs, those with hx of numerous withdrawals, those with medical comorbidities (e.g. CHF, cirrhosis, traumatic brain injury)

You can use the PAWSS score or the CIWA-Ar score to predict who can safely withdraw in the outpatient setting.

• PAWWS score available here
• CIWA-Ar score
• mild (<8 just need rest and hydration, 8-10 may need some PRN meds)
• moderate 10-18 should receive standing meds iwth a taper
• severe/complicated: >19, to hospital for monitored withdrwawa
• SAWS score: patient self-assessment (mild <12, severe >12)

PAWSS, Maldonado 2015

CIWA-AR https://www.aafp.org/afp/2013/1101/p589.html

SAWS: https://www.aafp.org/afp/2013/1101/p589.html

Treatment of AWS should be based on your scoring, classically using the CIWA score plus/minus the SAWSS score to determine treatment

• Level 1: CIWA<10, SAWS <12: supportive care, prn gabapentin, carbamazepine
• Level 2: CIWA 10-18, SAWS>12: close follow-up (daily in person, daily video), benzodiazepine (chlordiazepoxide vs. valium/lorazepam) in fixed vs. PRN dosing
• For more information on specific drug dosing, you can refer to this paper in AAFP from 2016https://www.aafp.org/afp/2013/1101/p589.html

Supportive care for AWS in addition to medication

• daily visits x at least 5 days
• education
• low stimulation home environment
• fluids
• 400mcg folic acid, 100mg Thiamine x 3 days

Treatment of AUD should involve CBT as well as  medication assisted therapy to help patients reduce and/or abstain from alcohol. The most commonly used option is Naltrexone (available in oral form 50-100 mg daily vs. injectable monthly form, aka Vivitrol). Additional medications to consider include acamprosate and disulfiram (less desirable, more punitive), as well as fluoxetine (if concomitant depression/anxiety and gabapentin, which has variable studies. More information in the chart below

https://www.aafp.org/afp/2016/0315/p457.html