Alcohol Withdrawal in the YK Delta

Alcohol withdrawal is a frequently encountered condition in the delta. The clinical challenge is to relieve the suffering of the patient (and by proxy, their housemates) while not indulging in interventions which promote further alcohol abuse and/or misuse of health care resources.

Most alcohol withdrawal in the delta is secondary to relatively short-term binges of 3 to 14 days.

Treatment Principles and Pearls

Breath alcohol level

All patients complaining of alcohol withdrawal should have a breath alcohol level measured. This is truly the "fifth vital sign" in such patients. The presence of a measurable alcohol level does not rule-out withdrawal, but it does provide important information for management during this and/or future visits.

Intoxicated or sick patients

Patients suffering alcohol withdrawal do not fall asleep while waiting to be seen. Alcohol withdrawal is a state of autonomic hyper-activity and hyper-alertness. Consequently, most withdrawing patients have an inability to sleep. The patient who is drowsy or falling asleep is almost certainly intoxicated and pursuing some type of secondary gain (i.e. hangover prevention, a place to sleep, prescription medication abuse, etc.) or suffering from some other medical problem. The clinician should be alert to the co-existence of other medical problems which require treatment, but providing the desired secondary gain should be avoided.

Reasons to treat

Prevention of seizing is an inadequate clinical endpoint. If the pacing, tremulous patient is driving you and/or the staff crazy, then they are almost certainly doing the same to their housemates. The patient's access to a bed or couch to sleep on frequently depends upon adequate treatment of their withdrawal symptoms. If a patient is so irritating that everyone kicks them out, they will almost certainly bounce back to the ED. This alone is a reason to treat alcohol withdrawal. Patients who can sit still, keep down oral intake, and sleep are MUCH less likely to bounce back; and patients who are pacing, tremulous, and vomiting are almost guaranteed to bounce back.

Etiology of vomiting

Alaska Natives have a very high rate of both chronic gastritis and/or H. pylori infection, and binge drinking frequently exacerbates or unmasks this condition. Yet nausea and vomiting are common symptoms of alcohol withdrawal in patients without any appreciable degree of gastritis. To efficiently treat the nausea and vomiting, the astute clinician’s task is to assess whether the nausea and vomiting are mostly attributable to gastritis, withdrawal, or a combination. The best indicator is the history. If the patient is in withdrawal because they stopped drinking because of abdominal pain and vomiting, then gastritis is the likely etiology, and an anti-emetic and a GI cocktail are high yield. But if the patient stopped drinking due to lack of access to alcohol and the vomiting subsequently started with the withdrawal symptoms, then withdrawal is the likely etiology of the vomiting, and GABA agonist treatment will likely fix the vomiting. When the etiology is mixed, both treatment regimens are required.

Phenobarbital

IV/IM phenobarbital is the preferred outpatient treatment of alcohol withdrawal at our facility. See Phenobarbital for Alcohol Withdrawal for details.