Alcohol Withdrawal: Individualized Care and Pharmacologic Treatment

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 ofAlcohol 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 Treatment Setting The treatment setting is primarily determined by the severity of the withdrawal symptoms present.11 In patients presenting with mild to moderate withdrawal, outpatient detoxification is considered safe and effective.11'17 Although outpatient followup recommendations include seeing the patient daily until symptoms subside, treatment in this environment is cost effective, less burdensome on acute care hospitals, and minimizes interruptions on the patients personal life.11,17 An inpatient setting is warranted for patients who experience seizures or DTs or have severe withdrawal symptoms, abnormal laboratory results, or chronic medical or psychiatric conditions.8,17 Management of Alcohol Withdrawal Syndrome Patients at risk of developing alcohol withdrawal syndrome (AWS) may be provided with preventative pharmacotherapy with benzodiazepines when attempting to reduce or stop alcohol intake, according to the 2020 ASAM guidelines on AWS. Adjunctive agents may be used (eg, carbamazepine, gabapentin, and valproic acid).8 Risk for prolonged benzodiazepine use and misuse include memory impairment, psychomotor retardation, depression, and emotional anesthesia in addition to physiologic dependence.17 Because of the high addiction risk, alternative agents such as carbamazepine and gabapentin have less abuse potential, less toxicity, less sedation, and have demonstrated efficacy in the treatment of alcohol withdrawal syndrome.8 For ongoing management of AUD, the Department of Veterans Affairs and the Department of Defense recommends use of acamprosate, disulfiram, naltrexone (extended release), and/or topiramate (off-label) for the initial management of AUD.19 The American Psychiatric Association