Description

Alcohol withdrawal syndrome (AWS) is a spectrum of symptoms resulting from abrupt cessation or reduction in alcohol intake, after a period of prolonged use. It ranges from minor symptoms such as tremors, and insomnia, to major complications such as seizures, and delirium tremors. Symptoms generally start within a few hours of the last drink and peak at 24 to 48 hours.

Epidemiology

Incidence

• According to National Survey Drug Use and Health, in 2019, 14.5 million Americans met diagnostic criteria for alcohol use disorder (AUD). Approximately 50% of those with AUD have experienced AWS in their lifetime. <4% were offered FDA-approved medications to treat AUD.
• 2–7% of patients admitted to hospital with heavy alcohol use are at increased risk of AWS.
• 32% of emergency room visits are alcohol related.

Prevalence

• AUD are among the most prevalent mental disorders with 12-month and lifetime prevalence of 13.9% and 29.1%, respectively.
• Higher prevalence among men, younger and unmarried adults, and those with lower socioeconomic status

Etiology and Pathophysiology

• Consumption of alcohol stimulates the neurotransmitter γ-aminobutyric acid (GABA), resulting in decreased excitability, with chronic alcohol ingestion, this repeated stimulation downregulates GABA inhibitory effects.
• Concurrently, alcohol ingestion inhibits glutamate on the central nervous system (CNS), with chronic alcohol use upregulation of excitatory N-methyl-d-aspartate glutamate receptors.
• When alcohol is abruptly stopped, the joint effect of a downregulated inhibitory system (GABA modulated) and upregulated excitatory system (glutamate modulated) results in brain hyperexcitability no longer suppressed by alcohol; clinically seen as AWS

Genetics
Etiology of AUD is multifactorial; evidence suggests genetic predisposition is present in half of individuals with AUD.

Risk Factors

• Long duration of heavy alcohol consumption
• Prior history of alcohol withdrawal episodes, alcohol withdrawal seizures, and delirium tremens (DTs)
• Elevated blood pressure on presentation, comorbid medical conditions or surgical illness
• Physiologic dependence on benzodiazepines (BZDs) or barbiturates

Geriatric Considerations
Elderly with AUD are more susceptible to withdrawal, and chronic comorbid conditions place them at higher risk of complications from withdrawal.

Pregnancy Considerations
Inpatient hospitalization for acute alcohol withdrawal management is recommended in pregnancy.

General Prevention

• The U.S. Preventive Services Task Force recommends universal screening for all adults to reduce unhealthy alcohol use.
• The single screening question, “How many times in the past year have you had 5 or more (men) 4 or more (women) drinks in 1 day” is the most sensitive and specific question for detecting unhealthy alcohol use.
• Brief, standard assessment screening tools include CAGE, AUDIT, or AUDIT-C to detect unhealthy alcohol use.

Commonly Associated Conditions

• General: weight loss and poor nutrition, dehydration
• Renal: electrolyte abnormalities (hyponatremia, hypokalemia, hypomagnesemia, hypophosphatemia)
• GI: hepatitis, cirrhosis, esophageal varices, GI bleed, pancreatitis, portal hypertension
• Heme: thrombocytopenia, macrocytic anemia
• Cardiovascular: hypertension, atrial fibrillation, other arrhythmias, hyperlipidemia
• CNS: seizures, hallucinations, memory deficits, atrophy, Wernicke-Korsakoff syndrome
• Peripheral nervous system: neuropathy
• Pulmonary: aspiration pneumonitis or pneumonia; increased risk of anaerobic infections
• Psychiatric: depression, posttraumatic stress disorder, bipolar disease, polysubstance use disorder
• Reproductive: sexual dysfunction and amenorrhea