Overview
For patients with moderate to severe AUD, withdrawal management may support a goal of abstinence or substantially reducing their drinking—particularly if even reducing consumption will likely cause severe withdrawal symptoms.
Up to 50% of individuals with long-term AUD will experience withdrawal when they stop drinking. Symptoms of alcohol withdrawal typically begin 6–24 hours after the last intake of alcohol and reach peak intensity at 24–48 hours, with resolution of most symptoms within 5–7 days.
Following withdrawal management, all patients should be offered continuing care for AUD.
download flowchart
Assessing risk of severe complications
To assess the risk of severe alcohol withdrawal complications, use the Prediction of Alcohol Withdrawal Severity Scale (PAWSS). A history of past seizures or delirium tremens can be predictive of severe withdrawal symptoms.
The PAWSS should be used in conjunction with a comprehensive assessment of a patient’s medical history, current circumstances, needs and preferences. The PAWSS is not suitable for self-assessment. It should be administered by a clinician.*
Identifying the risk of severe withdrawal helps to determine the appropriate setting for withdrawal management: inpatient vs. outpatient.
PAWSS calculator
*Clinical judgment is important here, as the PAWSS has not been validated in outpatient care settings, or in youth or pregnant patient populations.
Notes for administering this tool:
Question —Withdrawal Seizures
- These are brief tonic-clonic seizures that occur 6–48 hours after stopping alcohol use and are distinct from tremor, epilepsy or other causes of seizure.
Question —Delirium Tremens (DTs)
- This is profound disorientation, confusion and agitation, accompanied by severe autonomic hyperactivity.
Question —Blood Alcohol Level (BAL)
- BAL is not likely available in primary care settings. As an alternative, you may ask the patient: “Have you consumed any alcohol in the past 24 hours?”
- You can use a Breathalyzer, if available.
Question —Blackouts
- Blackouts refer to transient retrograde amnesia without loss of consciousness (aka “passing out”).
SCORING AND INTERPRETATION
≥ 4 is HIGH RISK for severe complications from withdrawal:
- Inpatient care and management with benzodiazepines is recommended.
< 4 is LOW RISK for severe complications from withdrawal:
- Outpatient care and management with gabapentin, carbamazepine or clonidine is recommended.
Point of care assessments
These scales can be used to assess the severity of withdrawal symptoms.
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
calculator
Scoring and interpretation
| SCORE |
SEVERITY |
| 0 – 10 |
Mild withdrawal |
| 11 – 19 |
Moderate withdrawal |
| >20 |
Severe withdrawal |
Short Alcohol Withdrawal Scale (SAWS)
calculator
Scoring and interpretation
| SCORE |
SEVERITY |
| < 12 |
Mild withdrawal |
| 12 |
Moderate to severe withdrawal |
Outpatient considerations
Some patients may only experience mild symptoms of withdrawal and can be supported with over-the-counter pain relievers, antiemetics and anti-diarrheal medications, or may only need a supportive environment with encouragement, nutrition and hydration. Patients should be monitored frequently to look for worsening symptoms.
Outpatient management is preferred for patients who are at low risk of complications. Moderate symptoms can be managed with non-benzodiazepine medications such as gabapentin, carbamazepine or clonidine.
For outpatient withdrawal to be considered suitable for a patient, they should meet the following criteria:
Checklist
- PAWSS < 4
- Absence of serious medical comorbidity (e.g., COPD, heart disease, unstable psychiatric condition, severe concurrent substance use)
- Has a safe and stable setting
- Able to check in daily for 4–5 days and alternating days after
- Has a reliable person who can monitor symptoms for 4–5 days and help with medication adherenceSchedule the start day in consideration of the patient’s schedule and pharmacy availability and clinician availability (daily check-in for 4-5 days).
Here are the considerations involved in planning for an outpatient withdrawal:
- Daily monitoring should include:
- vital signs
- withdrawal symptoms
- hydration
- cognition
- physical and emotional condition
- Provide a phone number for the patient to call in the event of an emergency.
- Provide instructions for the patient if their symptoms worsen. Identify a reliable person who can support the patient.
- Provide advice on preventing relapse.
- Recommend vitamin supplements: thiamine 100-200 mg/day, folic acid 1 mg/day, B6 2 mg/day.
- Recommend increased fluids, mild foods and minimal exercise.
- Advise against driving until symptoms subside.
Inpatient considerations
Patients at high risk of developing severe withdrawal (e.g., PAWSS ≥ 4) should be referred to an inpatient setting where alcohol withdrawal can be medically supervised and closely monitored. Benzodiazepines remain the preferred option for the treatment of patients at risk of severe alcohol withdrawal.
The presence of any of these criteria should lead to referral for the patient to inpatient service (hospital or detox).
Checklist
- PAWSS ≥ 4 Previous unsuccessful attempts at withdrawal
- History of seizures or delirium tremens
- Presence of serious medical comorbidity (e.g., COPD, heart disease, unstable psychiatric condition, severe concurrent substance use)
- Current use of depressant substances (e.g., benzos, opioids, barbiturates)
- Any medical or social condition that could cause risk to the patient’s safety or health during withdrawal
For some patients, inpatient management is not an option due to lack of availability or patient preference. These patients should be accommodated through alternative strategies such as daily clinic visits, home visits, connection to a local pharmacist, or virtual care.
Medications for withdrawal management
This section includes information on the use of benzodiazepines, gabapentin, carbamazepine and clonidine for withdrawal management, including contraindications, cautions, side effects and dosing.
Benzodiazepines
- Only medication known to prevent seizures and delirium tremens
- Recommended for managing severe withdrawal in the inpatient setting (e.g., hospital, inpatient detox).
Gabapentin and Carbamazepine
- Better safety profiles and less sedating than benzodiazepines
- Fewer drug-drug interactions
- Recommended for managing mild-moderate withdrawal and can be safely used in the outpatient setting (e.g., patient remains at home and checks in daily via phone, video or in-person clinic visit)
Carbamazepine
- Safe to use while consuming alcohol
- No reported risk of misuse or diversion
Gabapentin
- Ideal choice if patient opts to remain on gabapentin as a continuing treatment for AUD
- Potential for non-medical use, diversion and dependence
Thiamine
- Vitamin supplementation with thiamine recommended to prevent Wernicke-Korsakoff syndrome
Overview of Pharmacotherapy Options for Withdrawal Management
The following is a summary comparison of withdrawal management pharmacotherapies. Other medications with insufficient evidence for withdrawal management (e.g., valproic acid) were not included.
download comparison chart
Dosing protocols
Benzodiazepines
Benzodiazepines are best used for patients with a PAWSS score ≥ 4 and are high risk for severe withdrawal complications. Inpatient management at a detox facility or hospital is recommended. Benzodiazepines should be offered for a maximum of 7 days and should be tapered; shorter durations are preferred. Note that there is a risk for non-medical use, diversion, and dependence or benzodiazepine use disorder, when benzodiazepines are used in the long-term.
NOTE: Benzos should only be offered to outpatients if there is high risk of severe complications and inpatient services are not available. In this case, medication should be dispensed daily or blister-packed.
Example four-day fixed and flexible protocols for Diazepam (Valium)
| Schedule |
Day 1 |
Day 2 |
Day 3 |
Day 4 |
| Outpatient |
| Fixed |
5-10mg QID |
5-10mg TID |
5-10mg BID |
5-10mg q HS |
| Dose adjustments can be made following daily check-ins. Request support from a family member or other caregiver to assess symptoms and dispense medication. |
| Inpatient |
| flexible |
5-10mg prn based on symptoms |
5-10mg q4-6h prn based on symptoms |
5-10mg q4-6h prn based on symptoms |
5-10mg q4-6h prn based on symptoms |
| Dose adjustments can be made following daily check-ins. Request support from a family member or other caregiver to assess symptoms and dispense medication. |
Example four-day fixed protocol for lorazepam (Ativan)
| Day 1-2 |
Day 3-4 |
| 1-2mg q4h |
0.5-1mg q4h |
Carbamazepine
Carbamazepine can be used to manage mild to moderate withdrawal symptoms in the outpatient setting. This is appropriate for patients with a PAWSS score < 4.
Note: This protocol applies to immediate-release (IR) tablets.
| Schedule |
Day 1 |
Day 2 |
Day 3 |
Day 4-5 |
|
200mg QID |
200mg TID |
200mg BID |
200mg OD |
| For withdrawal management, most clinical trials have used a standard tapered 5-day regimen. There is no PRN regimen for this medication |
Gabapentin (for withdrawal management)
Gabapentin has a growing evidence base supporting its efficacy and safety for outpatient management of alcohol withdrawal in patients at low risk of complications. This is appropriate for patients with a PAWSS score < 4.
Note: This protocol applies to immediate-release (IR) tablets.
| Symptoms |
Regular Dose |
PRN |
HS |
If CIWA-Ar is 10–14
or SAWS ≥ 12 |
300mg TID. Titrate up to 600mg TID if symptoms are not responding. |
300mg PRN — Leave 2 hrs between regular and PRN doses. |
300–600mg HS PRN |
If CIWA-Ar is < 10
or SAWS < 12 |
|
300mg q4 h PRN |
300–600mg HS PRN |
| When acute symptoms resolve and CIWA is < 10 or SAWS < 12 consistently (e.g., 3 measurements), taper over 3–5 days, reducing dose by 600mg each day.
Max daily dose is 3600mg.
Do not provide doses if the patient shows drowsiness, ataxia or slurred speech. |
Clinical tip
Ask the patient to self-assess using Short Alcohol Withdrawal Scale (SAWS) to determine whether additional gabapentin is needed (PRN). Regardless of whether the patient is at 300mg or 600mg TID, additional doses of gabapentin 300mg PRN can be taken if SAWS scores are ≥ 12 or if the patient is experiencing cravings, insomnia or irritability.
Clonidine
Clonidine is a centrally acting α-adrenergic agonist that can suppress persistent noradrenergic symptoms (e.g., hypertension, tachycardia) associated with mild alcohol withdrawal that may be prescribed as a standalone or adjunct pharmacotherapy. When prescribed as a standalone treatment, clonidine should only be used for treating mild withdrawal symptoms in patients who are at low risk of developing severe complications of withdrawal (e.g., PAWSS < 4).
| Start |
Titrate |
Final Dose |
| 0.1–0.2mg BID |
Add 0.2mg OD PRN |
0.1–0.6mg TID |
| Note: The last dose of the day should always be taken at bedtime. |
