Alcohol use Disorder (Intoxication, delirium tremens, detox)
The psychiatric diagnoses, alcohol abuse and alcohol dependence, in DSM-IV-TR were replaced by one
diagnosis, alcohol use disorder, in DSM-5.
Although the crosswalk between DSM-IV and DSM-5 disorders is imprecise, alcohol dependence is
approximately comparable to alcohol use disorder, moderate to severe subtype, while alcohol abuse is
similar to the mild subtype.
1. Screening & Evaluation
(a) Identify signs & symptoms
I. Signs of intoxication:
- slurred speech III. Signs of delirium tremens
- incoordination - Fluctuation in the level of consciousness
- unsteady gait - Confusion and disorientation
- nystagmus - Abnormal perceptions in the form of
- impairment in attention / memory illusions and hallucinations
- stupor - Seizure
- Autonomic instability
II. Signs of withdrawal: - usually occurs 3-4 days after cessation
- autonomic hyperactivity
- increased hand tremor IV. Other alcohol-induced disorders
- insomnia - alcohol-induced psychotic disorders
- nausea / vomiting - alcohol-induced mood disorders
- transient visual, tactile or auditory - other alcohol-induced disorders can be
hallucination / illusion referred as outpatient, e.g.
- psychomotor agitation - alcohol-induced sleep disorder, alcohol-
- anxiety induced neurocognitive disorder
- general tonic-clonic seizure
(b) Alcohol intake history / other substance (f) Physical examination
(c) Collaborative history
(d) History of alcohol/drug related cx; seizure,
delirium tremens, UGIB/LGIB, pancreatitis,
involves in MVA, blackouts
(e) Underlying medical condition
2. Investigations - Screening tools e.g.
CAGE/ASSISTS/AUDIT once patient alert
- Routine blood investigations including
and conscious
GGT
- Urine drug screening/ Urine drug lab
- ECG for high risk patient, e.g. age ≥ 40
test
years old
- Blood alcohol level (only for police
- Alcohol breath analyzer
cases)
3. Provisional Diagnosis
- Alcohol use disorder/intoxication/withdrawal
- Delirium Tremens
- Alcohol-induced disorder
- Poly-substance use disorder
- Dual diagnosis
4. Management
Placement of patient during management is based on early triaging process, and to be confirmed based
on the provisional diagnosis.
• If medico-legal issue involved --> please follow hospital policy
• If the patient having intoxication has other medical condition --> to stabilize in respective
department ward
• If underlying medical problem --> transfer to corresponding unit/ward
• If underlying psychiatric problem --> transfer to psychiatric ward, after intoxication and other
medical/surgical problem resolved.
4.1 Emergency and Trauma Department o Midazolam/Lorazepam/
Diazepam
• Controlled and safe environment.
• Route of administration:
• Monitor vital signs every 15 minutes;
o Oral : Olanzapine, Diazepam,
Blood sugar stat.
Lorazepam, Midazolam
• Check pupillary size,reaction to light,
o IV : Diazepam, Midazolam
especially for opioid-based substance.
o IM : Haloperidol, Midazolam
• IV Thiamine 100 mg stat if patient is
• Continuous monitoring every 15
high risk e.g. past history of delirium
minutes
tremens and alcohol withdrawal
• Admitted into medical ward
seizure.
(intoxication/overdose) because of the
• Evaluate hydration and start Normal
risk of respiratory depression/delirium
Saline IVD if poor oral intake.
tremens.
• Risk management i.e. suicidal risk.
• Transfer to medical ward ONLY if
• Symptomatic management (e.g. anti-
patient is stabilized and has been
emetic for vomiting)
observed as to give time for the
• Medical management of underlying co-
administered medication/treatment to
morbid medical problem.
take effects
• Options of medications for disturbed
• Transfer of patient: During the transfer,
patients:
patient should be stable or adequately
o Haloperidol (IM 5 mg stat for
sedated and may need to be restrained
naïve , may be repeated)
if necessary such as if patient is restless
o Olanzapine
or has high- risk behavior
(absconding/suicidal), this patient needs appropriate staff to accompany
him/her during the transfer.
4.2 General Ward ◦ Patient without history alcohol-related
complications (use non-loading regime):
i. Advice to place in acute or close counter. • Follow regular regime of 10mg/20mg
oral diazepam 6-hourly
ii. If sedated or given Benzodiazepine; 15
minutes SPO2 and vital signs > hourly until • Daily dose reduction of 10 mg
stable > 4H-ly diazepam every 24 hours
iii. Maintain I/O charting and intravenous drip if ***In case of patient intoxicated/overdosed with alcohol,
neither this regime can be recommended. Needs to
dehydrated or not taking orally.
recover first from the intoxication. The regime will start
when withdrawal symptoms appear and in high-risk case,
iiii. If intoxicated/overdosed or has history of as long as no sign of drunkenness or intoxication or
delirium tremens, withdrawal seizures or overdose.
blackouts may continue IV Thiamine 100 mg OD
for another 2 days > oral Thiamine 300 mg daily ***This intervention does not apply to patients with
concurrent head injury.
if poor oral intake.
vii. Continue AWS scoring 4-hourly or if patient
v. 4-hourly monitoring of withdrawal symptoms
is restless. If AWS ≥ 10, the patient can be
based on Alcohol Withdrawal Scale (AWS).
served with an additional 10 mg of oral
vi. Once AWS is ≥ 10: Diazepam. This step can be maintained for at
least 2 days or it can be stopped once the
◦ History of alcohol-related complications: withdrawal symptom is persistently low.
• Start loading regime oral Diazepam 4.3 Psychiatry Ward
20 mg stat > 10 mg hourly until sedated
up to maximum of 60 mg (20 mg stat • Transfer from ED / general ward to
plus 10 mg hourly up to 4 consecutive psychiatric ward should only be
hours). 15 min monitoring considered if stabilized and not at risk
of respiratory depression and any
• Followed by oral Diazepam concurrent medical/surgical emergency.
10mg/20mg 6-hourly for the next 24 • Elective admission for alcohol
hours (adjust dose to maintain normal detoxification must be under the
sleep pattern) discretion of the addiction specialist.
• No patient with acute intoxication or
• daily dose reduction of 10 mg every emergency will be admitted for
24 hours detoxification.
• Patient is to be referred to Addiction
• Caution for patient with liver/renal
team. In case of Dual diagnosis, the
failure/impairment, head injury or
cardiac problems patient will be co-managed with general
psychiatry team.
• Similar monitoring as in general ward
• Follow diazepam regime as in general
ward once AWS ≥10
Delirium tremens is a diagnosis of exclusion, so consider other causes of agitated delirium
(hypoglycemia, infection, etc.).
Some clues that the patient doesn't have delirium tremens:
Patient becomes somnolent following moderate-low doses of benzodiazepine (patients with real
delirium tremens are benzodiazepine-resistant).
Patient remains agitated despite >15 mg/kg phenobarbital.
Delirium without other features of delirium tremens (e.g. absence of hypertension, absence of
tremors).
Candidates for benzodiazepine therapy
• Not usually preferred for patients with definite alcohol withdrawal (especially if severe).
• Benzodiazepines may be useful for patients admitted for another reason (e.g. pneumonia), who
are experiencing mild withdrawal symptoms.
• Benzodiazepines are most useful when you're not entirely sure that the patient has alcohol
withdrawal:
• Small doses of diazepam may be given to determine the patient's response.
• If the patient becomes sedated after a low dose of benzodiazepine, they probably don't have
delirium tremens (true delirium tremens causes at least a moderate tolerance of
benzodiazepines).
• IV diazepam is vastly superior to IV lorazepam
Advantages of diazepam over lorazepam:
• Faster onset (within 2-5 minutes) prevents dose stacking. In contrast, lorazepam can take a
while to work, which creates a risk of giving multiple doses before the initial doses have had a
full effect (eventually leading to over-sedation which requires intubation).
• Diazepam has a longer duration of action (slow terminal half-life), which diminishes rebound
symptoms.
• The choice of phenobarbital versus benzodiazepines remains controversial, with some
practitioners continuing to prefer benzodiazepine therapy initially. However, there is no real
controversy about the superiority of IV diazepam over IV lorazepam.
To use IV diazepam
• Diazepam is typically dosed with escalating doses as needed Q5-10 minutes (e.g. 10 mg, 10 mg,
20 mg, 20 mg, 20 mg, 40 mg, 40 mg, 40 mg).
• A subset of patients has benzodiazepine-resistant DTs. If your patient isn't responding well to
benzodiazepines, consider transitioning to phenobarbital.
Alcohol detoxification:
• psychological support
• medication to relieve withdrawal symptoms (via reducing BDZ regime)
• observation for the development of the features of complicated withdrawal
• nutritional supplementation
• integration with follow-up
Procedures:
• Decide setting as inpatient or outpatient
• Assess the need for a BDZ-reducing regime
• Consider the need for other medications
• Provide verbal and written advice
• Inform GP/Primary care about the plan (if not inpatient)
Disulfiram (deterrent agent)
Anti-craving:
• Acamprosate
• Naltrexone
