1. Inpatient and Outpatient Management of Alcohol Withdrawal Devang Gandhi, MD Robert Joel Bush, MD University of Maryland- Sheppard Pratt Addiction Medicine Fellowship Program

2. Summary of Module Contents  Article text  Slide Deck: N = 60 (+/-)  Notes for lecturer: not available  Handout materials: key article reprints/links to PubMed Central  Annotated bibliography: not available  Test questions: 5 pretest; 5 posttest  Other: Excel spreadsheet with summary of major studies of symptom-triggered treatment

3. Inpatient and Outpatient Management of Alcohol Withdrawal  Alcohol Withdrawal Syndrome (AWS) is among the most common clinical problems in Addiction Medicine practice  Its management is a core competency for any Addiction Medicine specialist as AWS can be life-threatening if not adequately treated  Current practice in many centers follows tradition or personal preference rather than evidence base  This module will cover epidemiology, basic neurobiology, types of AWS, assessment, patient placement, management and monitoring.

4. Key Point: Alcohol Withdrawal Syndromes Anxiety/tremor/ autonomic overactivity Hallucinations- auditory/visual /tactile Delirium tremens Seizures AWS severity  Several alcohol withdrawal syndromes are recognized, with delirium tremens and seizures being the most serious

5. Key Point: Criteria for Inpatient Management  Most AWS can be safely managed in an outpatient setting at a much lower cost provided the clinician knows how to assess the risk of serious withdrawal  Main criteria for inpatient management:  Withdrawal risk- high  Currently in severe withdrawal or delirium and/or prior history of delirium or seizures during withdrawal  Acute or chronic medical comorbidity requiring inpatient management  Pregnant  Significant psychiatric comorbidity requiring inpatient management  Unstable living environment and unavailability of supportive others to monitor (Adapted from Blondell, 2005)

6. Inpatient and Outpatient Management of Alcohol Withdrawal  Main Recommendations:  A symptom-triggered approach can reduce medication use and duration of treatment, and is as efficacious as a fixed-dose approach.  Best available evidence supports the use of benzodiazepines as first line to manage AWS  Anticonvulsants may be used as alternatives to benzodiazepines, but the evidence for their use is limited

7. Recommendation #1  A symptom-triggered approach can reduce medication use and duration of treatment, and is as efficacious as a fixed-dose approach.  SORT level = A  References  Saitz, R, et al. JAMA 1994; 272(7):519-23.  Daeppen, JB, et al. Arch Intern Med 2002; 162(10):1117-21.  Elholm, B et al. Alcohol Alcohol 2011; 46(3):318-23

8. Recommendation #2  Benzodiazepines reduce withdrawal severity, reduce incidence of delirium and seizures and should be considered first-line medications to treat AWS.  SORT level = A  References:  Mayo-Smith, MF. JAMA 1997; 278(2):144-51.  Mayo-Smith, MF, et al. Arch Intern Med 2004; 164(13):1405-12.  Amato, L, et al. CDSR 2010; CD005063

9. Recommendation #3  Anticonvulsants (carbamazepine, valproate, gabapentin) may be used as alternatives to benzodiazepines, though the evidence-base for their efficacy is limited.  SORT level = B  References:  Minozzi, S, et al. CDSR, 2010; CD005064.  Barrons, R, & Roberts, N. J Clin Pharm Ther 2010;35(2):153-67.

10. Dissemination strategy  Didactic classroom lecture  Webinar  Publication as an overview of the topic  Module posted on ABAM website  Standard instruments for assessment and sample protocol that can be adapted for clinical use