In this week’s pearl we will discuss how to decide which patients are candidates for ambulatory Alcohol Withdrawal Management (WM) and which patients should be treated as an inpatient (residential WM or hospitalization)
Introduction
Any one absolute contraindication indicates that a patient is at high risk for complicated withdrawal and as a result would benefit from inpatient care (hospitalization or residential WM)
There is more flexibility with relative contraindications. If a patient has two or more relative contraindications it is reasonable to consider inpatient care
Withdrawal Severity
Absolute contraindication: Any patient currently in severe AWS which can be defined as CIWA-AR> 18 is an absolute contraindication as these patients are at higher risk for seizure or DTs and will most likely require IV medication
Relative contraindication: Moderate AWS which can be defined as CIWA-AR between 1- and 18
Concurrent Dependence
Absolute contraindication: Concurrent benzodiazapine dependence or benzodiazepine use disorder
Relative contraindication: concurrent opioid dependence
Recent Alcohol Consumption
Absolute contraindication: More than 17 standard drinks per day
Relative contraindication: More than 8 standard drinks per day
Alcohol Withdrawal History
Absolute contraindication: Any history within the last year of complicated withdrawal, which is defined as seizure or delirium tremens.
Relative contraindication: Severe withdrawal (seizure or DTs) greater than 1 year ago.
Other Medical Conditions
Absolute contraindication: Unstable medical/surgical/psychiatric illnesses that are at high risk for exacerbation during physiologic stress of AWS. This includes moderate-severe cognitive impairment, pregnancy, and inability to take oral medications
Relative contraindication: older age (>65), history of seizure disorder and mild cognitive impairment
Recovery Environment
Absolute contraindication: Unable to participate in dialy clinic visit for 3-5 days or an unsupportive home environment
Relative contraindication: Absence of reliable support network or caregiver
Risk of Harm
Absolute contraindication: low level of cooperation, reliability, commitment
Adapted with permission from Dr. David Lawrence. Please send questions or suggestions to: David.Lawrence3@va.gov