3/11/23, 12:18 AM Alcohol Misuse and Withdrawal - MRCEM Success

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Alcohol Misuse and

Withdrawal
Gastroenterology &
Hepatology
MRCEM Success

USEFUL LINKS
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CURRICULUM CODE
GC1 Alcohol Related Liver Disease
MHC1 Alcohol and Substance Misuse
NeuC16 Wernicke's Encephalopathy

KEYWORDS

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Alcohol Misuse Alcohol Withdrawal

Wernicke's Encephalopathy

RELATED TOPICS
Gastroenterology & Hepatology
Mental Health

Something wrong?
Alcohol Misuse and Withdrawal LAST UPDATED: 12TH
FEBRUARY 2021
GASTROENTEROLOGY & HEPATOLOGY / MENTAL HEALTH
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Definitions
Problem drinking is defined as regular consumption of alcohol above recommended
levels (14 units of alcohol per week).
Harmful drinking is defined as a pattern of alcohol consumption causing health
problems directly related to alcohol. This could include psychological problems such
as depression, alcohol-related accidents or physical illness such as acute
pancreatitis.
Alcohol dependence is characterised by craving, tolerance, a preoccupation with
alcohol and continued drinking in spite of harmful consequences (for example, liver
disease or depression caused by drinking).
One unit of alcohol in the UK is defined as 10 mL (8 g) of pure ethanol. The number of
units in a drink can be calculated by multiplying the total volume of the drink (mL) by
its percentage alcohol by volume (ABV) and dividing the result by 1,000. Therefore, A
small glass (125 mL) of average strength wine (11% ABV), or a standard pub measure
(35 mL) of spirits (40% ABV) each contain 1.4 units of alcohol.

Complications
Specific health complications relating to alcohol misuse include:
Short term harm:
Death and illness from accident and injury, drowning, alcohol poisoning, and
self-harm related to alcohol.
Long term harm:
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Cancer (such as mouth, throat, bowel, stomach, liver, and breast cancer).
Cardiovascular disease - cardiomyopathy, cardiac arrhythmia, hypertensive
disease, stroke, CHD.
Liver disease - fatty liver (steatosis), hepatitis (acute and chronic), and cirrhosis.
Gastrointestinal bleed.
Pancreatitis.
Gout.
Psychiatric illness.
Wernicke's encephalopathy.
Alcohol-use disorder is often associated with a thiamine deficiency
which, if severe, may lead to Wernicke's encephalopathy. This is
characterised by ocular motility disorders, ataxia, and confusion. When
people with Wernicke's encephalopathy are inappropriately treated,
mortality rates average about 20% and Korsakoff's psychosis develops in
about 85% of survivors. Korsakoff's psychosis is characterised by
anterograde and retrograde amnesia, disorientation, and confabulation.
Alcohol consumption during pregnancy can adversely affect the fetus:
Fetal alcohol exposure can cause miscarriage, stillbirth, and intrauterine growth
restriction.
Heavy drinking during pregnancy (repeatedly consuming more than around five
units per day), can result in fetal alcohol spectrum disorders (FASD). Some of
the features of FASD may not be obvious at birth and may only become
apparent when the child starts school, or later on in life. Features of FASD
include:
Malformations of the heart, skull, kidneys, limbs, bones, brain, and other
organs.
Dysmorphic facial features (small eyes, thin upper lip, poorly defined
philtrum).
Problems with eyesight and hearing.
Fetal growth restriction and poor growth throughout life.
Microcephaly, developmental problems which can range from mild to
severe.
Social complications relating to alcohol misuse include family conflict and domestic
violence and abuse.

Screening for alcohol misuse

Screening tools such as the Paddington Alcohol Test (PAT), the Fast Alcohol Screen Test
(FAST) and the Audit C are useful in EDs in the UK.
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The AUDIT-C questionnaire consists of the first three questions of AUDIT and can be used
where time is limited. The full AUDIT questionnaire should be administered to people with an
AUDIT-C score of ≥5 as this suggests a high likelihood of drinking at an increasing risk level.
The threshold score may be reduced to ≥3 in adults older than 65 years.
AUDIT-C questions:
How often do you have a drink that contains alcohol?
How many standard alcoholic drinks do you have on a typical day when you are
drinking?
How often do you have 6 or more standard drinks on one occasion?
Remaining AUDIT questions:
How often in the last year have you found you were not able to stop drinking once you
had started?
How often in the last year have you failed to do what was expected of you because of
drinking?
How often in the last year have you needed an alcoholic drink in the morning to get
you going?
How often in the last year have you had a feeling of guilt or regret after drinking?
How often in the last year have you not been able to remember what happened when
drinking the night before?
Have you or someone else been injured as a result of your drinking?
Has a relative/friend/doctor/health worker been concerned about your drinking or
advised you to cut down?
AUDIT scores are interpreted as:
Low-risk drinking: score of 1–7.
Hazardous drinking: score of 8–15.
Harmful drinking: score of 16–19.
Possible alcohol dependence: score of 20 or more.

Recognising alcohol withdrawal

The symptoms of alcohol withdrawal can vary in severity and include:
Mild — hypertension and tachycardia, anorexia, anxiety, emotional lability, insomnia,
irritability, diaphoresis, headache, and fine tremor.
Moderate — worsening mild symptoms plus agitation and coarse tremor.
Severe/delirium tremens — worsening moderate symptoms plus confusion/delirium,
generalised tonic-clonic seizures (this may be the first manifestation of alcohol

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withdrawal for some people), auditory, visual, or tactile hallucinations, hyperthermia

subsequent to psychomotor agitation.
Note: Mild to moderate withdrawal may start as early as 4 to 6 hours after the last drink, and
peak at 24 to 36 hours. Severe withdrawal symptoms occur after 24 hours and usually peak
at day 2. Delirium tremens generally occurs after 3 days of abstinence or decreased
drinking.

Managing alcohol withdrawal

Who to admit:
Offer admission to hospital for immediate (unplanned) medically assisted
alcohol withdrawal for people in acute alcohol withdrawal with, or who are likely
to be at high risk of developing, alcohol withdrawal seizures or delirium tremens.
Consider a lower threshold for admission for people who are frail, have cognitive
impairment or multiple comorbidities, lack social support, or have a learning
disability.
Urgently admit people with clinical features of Wernicke's encephalopathy (such
as confusion, ataxia, ophthalmoplegia, nystagmus, memory disturbance,
hypothermia, hypotension, and coma) for treatment with parenteral thiamine.
Offer referral to specialist alcohol services for people showing moderate or
severe signs of alcohol dependence so that they can enter a programme of
planned withdrawal. People in whom medically-assisted withdrawal is planned
should be advised to avoid a sudden, unsupervised reduction in alcohol intake,
and offered information about how to contact local alcohol support services.
Treatment:
Choice of agent
A long-acting benzodiazepine, such as chlordiazepoxide or diazepam, is
recommended to attenuate alcohol withdrawal symptoms; local clinical
protocols should be followed.
Carbamazepine [unlicensed indication] can be used as an alternative
treatment in acute alcohol withdrawal.
Clomethiazole may be considered as an alternative to a benzodiazepine or
carbamazepine. It should only be used in an inpatient setting and should
not be prescribed if the patient is liable to continue drinking alcohol.
Regimen
Follow a symptom-triggered regimen for drug treatment for people in
acute alcohol withdrawal who are in hospital or in other settings where
24-hour assessment and monitoring are available.

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The patient is regularly assessed and monitored, either using clinical

experience and questioning alone or with the help of a designated
questionnaire such as the CIWA–Ar. Drug treatment is provided if the
patient needs it and treatment is withheld if there are no symptoms of
withdrawal.
Withdrawal seizures
In people with alcohol withdrawal seizures, consider offering a quick-
acting benzodiazepine (such as lorazepam) to reduce the likelihood of
further seizures. If alcohol withdrawal seizures develop in a person during
treatment for acute alcohol withdrawal, review their withdrawal drug
regimen.
Delirium tremens
In people with delirium tremens (characterised by agitation, confusion,
paranoia, and visual and auditory hallucinations), offer oral lorazepam as
first-line treatment. If symptoms persist or oral medication is declined,
offer parenteral lorazepam or haloperidol. If delirium tremens develops
during treatment for acute alcohol withdrawal, the withdrawal drug
regimen should also be reviewed.
Wernicke’s encephalopathy
Parenteral thiamine, followed by oral thiamine, should be given to
patients with suspected Wernicke’s encephalopathy, those who are
malnourished or at risk of malnourishment, those who have
decompensated liver disease or who are attending hospital for acute
treatment.
Prophylactic oral thiamine should also be given to harmful or dependent
drinkers if they are in acute withdrawal, or before and during assisted
alcohol withdrawal.
Parenteral thiamine is available
 as part of a vitamin B substances with
ascorbic acid preparation.

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