Alcohol Withdrawal in the YK Delta

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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 potentially important information for managing 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 restless, 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 leave restless, 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 treatments are indicated.


Hallucinations ≠ Delirium
Delirium involves clouding of consciousness, confusion, disorientation, agitation, etc. The alcohol withdrawing patient frequently has hallucinations without delirium. In the setting of recent alcohol cessation, hallucinations are usually due to:
  1. Uncomplicated withdrawal
  2. Delirium tremens
  3. Alcoholic hallucinosis (see below)


Alcoholic Hallucinosis
Alcoholic hallucinosis (AH), also known as Alcohol Induced Psychotic Disorder, is described as persistent hallucinations without other strong evidence of alcohol withdrawal or alcohol delirium. Hallucinations are predominantly auditory though can be visual and can be accompanied by delusions and suicidality. AH is a heterogeneous disorder with variable presentation and clinical course. Hallucinosis typically lasts 2-7 days, though persistent hallucinosis lasting weeks to months is possible.
As AH is a relatively rare phenomenon there is not consensus in the literature regarding treatment. Two approaches are generally utilized. The first approach considers alcoholic hallucinosis as a symptom of alcohol withdrawal, with treatment utilizing GABA agonists. The second approach considers alcoholic hallucinosis as a primary psychotic disorder treated with either first or second generation antipsychotics. Both approaches appear equally efficacious, though data is limited by a lack of single studies comparing treatments via a randomized approach.
A reasonable approach is to treat for alcohol withdrawal as long as symptoms of withdrawal persist, then adjunct treatment with a second generation antipsychotic if hallucinosis persists after other withdrawal symptoms have improved. Providers are cautioned against the use of anti-psychotics during DTs as these are associated with increased mortality, likely via QT prolongation and lowering of seizure threshold.[1]




Phenobarbital

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

Alcohol Withdrawal in Villages

The following resources are available for AWS treatment in the villages:

  1. GABA agonist: IM phenobarbital
  2. Anti-emetic: _
  3. IV fluid: NS and LR



Contributors

Authors

Andrew W. Swartz, MD
Travis Nelson, MD

Reviewers

Tara Lathrop, MD (Emergency Department Service Chief)



Resources

References

  1. Masood B, Lepping P, Romanov D, Poole R. Treatment of Alcohol-Induced Psychotic Disorder (Alcoholic Hallucinosis)-A Systematic Review. Alcohol Alcohol. 2018;53(3):259-267. DOI:10.1093/alcalc/agx090