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psych.alcohol_withdrawal.core.v1

Acute Alcohol Withdrawal — inpatient management

psychiatryacuteadult
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Detailed

Acute alcohol withdrawal — DSM-5-TR 2022 criteria (cessation/reduction + ≥2 of 8 symptoms within hours to days); typically inpatient management for moderate-severe; ICU for complicated withdrawal (ASAM 2020)

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Withdrawal diagnosis confirmed and admission decision made

Patient inputs (22)

Geriatric (>65) higher risk for complicated withdrawal + delirium (ASAM 2020); pediatric workflow distinct

Timeline predicts phase — tremor/anxiety 6–24h, seizures 12–48h, hallucinosis 12–24h, DT 48–96h (Mayo-Smith JAMA 1997)

Quantity (>150 g/d) + duration predict severity (ASAM 2020)

Prior DT or withdrawal seizure = strongest predictor (kindling) (ASAM 2020)

Cirrhosis changes BZD selection — avoid long-acting (diazepam, chlordiazepoxide) due to impaired clearance and active metabolites; use lorazepam or oxazepam (glucuronidation) (ASAM 2020; ACG 2018)

Polysubstance — benzodiazepine + opioid + stimulant complicates withdrawal management and monitoring (ASAM 2020)

CAD, COPD, head injury, pancreatitis, GI bleed all affect dosing and disposition (ASAM 2020)

Macrocytic anemia (chronic alcohol), thrombocytopenia (alcohol or cirrhosis) (ASAM 2020)

Hypokalemia, hyponatremia (psychogenic polydipsia, beer potomania), hypoglycemia, AKI (ASAM 2020)

Hypomagnesemia common and contributes to refractory hypokalemia + seizures (ASAM 2020)

Hypophosphatemia common — replete to prevent refeeding-like syndrome on glucose load (ASAM 2020)

AST/ALT, GGT, bilirubin, INR — cirrhosis severity affects BZD choice and disposition (ACG 2018)

Polysubstance (BZD, opioid, stimulant) common; affects regimen (ASAM 2020)

QTc baseline; rule out ischemia from sympathetic surge (ASAM 2020)

Subdural / intracranial hemorrhage in altered alcohol patient — low threshold for CT (ASAM 2020)

Fever >38.5 may indicate DT or concurrent infection (ASAM 2020)

HR >120 = autonomic hyperactivity, severe withdrawal trigger (Sullivan JClinPsychopharmacol 1989 CIWA-Ar)

SBP >180 = autonomic hyperactivity (Sullivan JClinPsychopharmacol 1989 CIWA-Ar)

If altered + trauma history OR focal neuro findings OR first-time seizure (ASAM 2020)

Sometimes surprisingly elevated while symptomatic if heavy chronic user (tolerance); also confirms recent intake (ASAM 2020)

Pancreatitis common in heavy alcohol use (ACG 2018)

Cirrhosis assessment; baseline for any neuraxial procedure (ACG 2018)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningwithdrawal seizure — Mayo-Smith 1997
    Witnessed or reported generalized tonic-clonic seizure within 24–48 h of alcohol cessation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdelirium tremens — Mayo-Smith 1997
    Delirium tremens — clouded sensorium + autonomic storm + hallucinations + disorientation, 48–96 h after cessation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbzd refractory withdrawal — Hack 2006
    Withdrawal refractory to escalating BZD doses (>40 mg lorazepam equiv. in 4 h without effect)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningwernicke triad — Cook 1998
    Ophthalmoplegia (nystagmus, lateral rectus palsy) + ataxia + confusion — Wernicke encephalopathy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdelirium_tremens_present
    Established delirium tremens with autonomic instability + clouded sensorium + visual hallucinations + disorientation, typically 48-96 h post-cessation; PAWSS ≥ 4 at admission predicts; mortality 5-15% untreated (Mayo-Smith JAMA 1997 PMID 9244334; Maldonado PAWSS 2014 NEEDS_SOURCE_REVIEW)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereciwa ge 20 — ASAM 2020
    CIWA-Ar ≥20 — severe withdrawal
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereautonomic storm — ASAM 2020
    HR >120 OR T >38.5 OR SBP >180 in alcohol withdrawal patient
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewithdrawal_seizure_first_episode
    First-episode uncomplicated generalized tonic-clonic seizure within 12-48 h of alcohol cessation; benzodiazepine load + observe for status (Mayo-Smith JAMA 1997 PMID 9244334)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverekindling_history_or_dt_history
    Prior history of delirium tremens OR prior alcohol-withdrawal seizure — strongest predictor of current-admission complication (kindling phenomenon: each subsequent withdrawal more severe due to GABA-A receptor down-regulation + NMDA receptor up-regulation cycling)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewernicke_features_present
    Any of the Wernicke triad features (confusion + ophthalmoplegia + ataxia) present — even incomplete-triad presentations (e.g., isolated confusion + ataxia or isolated confusion + nystagmus); LOW threshold for treatment (Cook 1998 / Royal College CR-185; EFNS 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

CIWA-Ar symptom-triggered benzodiazepine protocol + Wernicke prophylaxis + BZD-refractory adjuncts + AUD MAT bridge
axis: aw_ciwa_triggered_bzdstep 0 - Step 0 — universal Wernicke prophylaxis + electrolyte repletion (BEFORE glucose)
Selected step "Step 0 — universal Wernicke prophylaxis + electrolyte repletion (BEFORE glucose)" — All moderate-severe alcohol withdrawal; all chronic heavy drinkers regardless of CIWA
  • thiamine
    first line
    B-vitamin
    500 mg IV q8h × 3 days, then 100 mg PO daily • IV → PO • q8h × 3 days then daily (max: 1500 mg/day)
    triggers: universal_alcohol_withdrawal, high_risk_wernicke, before_glucose
    Royal College CR-185 / Cook 1998 — empiric high-dose IV thiamine for Wernicke prophylaxis; oral thiamine is poorly absorbed in alcohol misuse + malnutrition; rare anaphylaxis with IV — have epinephrine available; CRITICAL: give BEFORE any dextrose/glucose to avoid precipitating Wernicke
    rxcui 10454
  • folic_acid
    first line
    B-vitamin
    1 mg PO/IV daily • PO/IV • daily
    Folate deficiency common in chronic alcohol use — corrects macrocytic anemia (NICE 2010)
    rxcui 4511
  • multivitamin
    first line
    nutrition
    1 tablet PO daily • PO • daily
    Chronic alcohol use causes multiple micronutrient deficiencies (NICE 2010)
  • magnesium_sulfate
    first line
    electrolyte
    2–4 g IV over 2–4 h if Mg <1.6; oral magnesium oxide 200–400 mg BID if mild • IV/PO • per repletion
    triggers: Mg<1.6
    Hypomagnesemia common and refractory hypokalemia/seizures depend on it (ASAM 2020)
    rxcui 8591
  • potassium_chloride
    first line
    electrolyte
    40–80 mEq PO/IV per 0.1 mmol/L deficit • PO/IV • per repletion
    triggers: K<3.5
    Hypokalemia is common; replete Mg simultaneously (ASAM 2020)
    rxcui 8591
  • phosphorus_repletion
    first line
    electrolyte
    Sodium or potassium phosphate 15–30 mmol IV over 4–6 h if Phos <1.5; PO Neutra-Phos if mild • IV/PO • per repletion
    triggers: Phos<2.5
    Hypophosphatemia common; replete to prevent refeeding-syndrome physiology on glucose load (ASAM 2020)

outpatient playbook — drug actions (9)

  1. 1. naltrexone (AUD MAT first-line)
    rxcui 7243
    50 mg PO daily OR XR-injection 380 mg IM every 4 weeks • PO/IM • daily PO or monthly IM
    trigger: AUD with cravings or recent heavy drinking days; no concurrent opioid use; LFTs < 5× ULN
    ASAM 2020 + COMBINE JAMA 2006 — first-line AUD MAT; reduces heavy drinking days + cravings; AVOID if active opioid use (precipitates withdrawal) OR liver enzymes > 5× ULN
  2. 2. acamprosate (AUD MAT first-line; renal-cleared)
    rxcui 82819
    666 mg PO TID (renal-dose 333 mg TID if eGFR 30-50; AVOID if eGFR < 30) • PO • TID
    trigger: AUD with renal function intact or mild impairment; liver disease present (preferred over naltrexone in significant hepatic impairment)
    ASAM 2020 + COMBINE JAMA 2006 — reduces relapse rates; safe in liver disease (renally cleared); 3× daily dosing limits adherence
  3. 3. disulfiram (AUD MAT second-line; aversive)
    rxcui 3554
    250 mg PO daily • PO • daily
    trigger: Highly motivated patient + supervised administration available (family/partner observed) + no CAD / severe cirrhosis / pregnancy
    ASAM 2020 — aversive disulfiram-ethanol reaction; informed consent + supervised administration ideal; AVOID active CAD, severe cirrhosis, pregnancy; second-line per ASAM hierarchy
  4. 4. gabapentin (off-label AUD MAT)
    rxcui 25480
    300 mg PO TID, titrate to 600 mg TID (max 1800 mg/day) • PO • TID
    trigger: AUD with residual anxiety / insomnia after withdrawal; naltrexone / acamprosate intolerance
    Mason JAMA Intern Med 2014 — off-label AUD evidence; covers post-acute withdrawal anxiety + insomnia; renal-dosed
  5. 5. topiramate (off-label AUD MAT)
    rxcui 38404
    25 mg PO daily, titrate over 8 weeks to 200-300 mg/day BID • PO • BID
    trigger: AUD with co-occurring obesity or seizure history or treatment-resistant
    ASAM 2020 off-label; cognitive side effects often dose-limiting; monitor bicarb (metabolic acidosis) and renal stones; not first-line
  6. 6. thiamine continuation
    rxcui 10454
    100 mg PO daily indefinitely while drinking risk persists • PO • daily
    trigger: Universal post-withdrawal — chronic alcohol-use micronutrient deficiency persists
    Cook 1998 / Royal College CR-185 — chronic thiamine deficiency persists beyond acute withdrawal; oral less effective than IV but adequate for prophylaxis once acute Wernicke risk has passed
  7. 7. folic acid + multivitamin continuation
    rxcui 4511
    Folate 1 mg PO daily + multivitamin daily • PO • daily
    trigger: Universal post-withdrawal
    Chronic alcohol-related deficiency; cheap and well-tolerated
  8. 8. taper antiseizure medication if seizure at presentation
    Continue levetiracetam (or equivalent) 500-1500 mg PO BID until 3-6 months seizure-free interval; neurology decision • PO • BID
    trigger: Withdrawal seizure at presentation
    No high-grade evidence for fixed duration; outpatient neurology + EEG guide taper; do NOT taper while still drinking heavily (kindling re-exposure risk)
  9. 9. depression / anxiety pharmacotherapy if PHQ-9 ≥ 10 or GAD-7 ≥ 10 sustained post-sobriety 4 weeks
    SSRI / SNRI per psych.depression.core.v1 / psych.anxiety hierarchy • PO • daily
    trigger: Persistent psychiatric symptoms after 4 weeks sobriety
    Re-assess after 4 weeks sobriety as alcohol-induced depression often resolves; if persistent, treat per affective-disorder dossier

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Tremor, diaphoresis, anxiety, autonomic hyperactivity after recent cessation/reduction of alcohol (DSM-5-TR 2022; ASAM 2020); Witnessed or reported generalized tonic-clonic seizure within 24–48 h of alcohol cessation (Mayo-Smith JAMA 1997); Delirium tremens — clouded sensorium + hallucinations + autonomic storm + disorientation (Mayo-Smith JAMA 1997).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Alcohol Withdrawal — inpatient management** (psych.alcohol_withdrawal.core.v1).
Phenotype framing: Sepsis vs thyroid storm vs sympathomimetic intoxication vs BZD/opioid withdrawal vs serotonin syndrome vs anticholinergic toxidrome vs encephalopathy (hepatic, Wernicke) vs CNS infection vs ICH (ASAM 2020)
Scope: Acute alcohol withdrawal — DSM-5-TR 2022 criteria (cessation/reduction + ≥2 of 8 symptoms within hours to days); typically inpatient management for moderate-severe; ICU for complicated withdrawal (ASAM 2020)

No severity triggers fired against current inputs.

Plan

Regimen axis: **CIWA-Ar symptom-triggered benzodiazepine protocol + Wernicke prophylaxis + BZD-refractory adjuncts + AUD MAT bridge** — step "Step 0 — universal Wernicke prophylaxis + electrolyte repletion (BEFORE glucose)".
1. thiamine 500 mg IV q8h × 3 days, then 100 mg PO daily IV → PO q8h × 3 days then daily (B-vitamin, first line) — Royal College CR-185 / Cook 1998 — empiric high-dose IV thiamine for Wernicke prophylaxis; oral thiamine is poorly absorbed in alcohol misuse + malnutrition; rare anaphylaxis with IV — have epinephrine available; CRITICAL: give BEFORE any dextrose/glucose to avoid precipitating Wernicke
2. folic_acid 1 mg PO/IV daily PO/IV daily (B-vitamin, first line) — Folate deficiency common in chronic alcohol use — corrects macrocytic anemia (NICE 2010)
3. multivitamin 1 tablet PO daily PO daily (nutrition, first line) — Chronic alcohol use causes multiple micronutrient deficiencies (NICE 2010)
4. magnesium_sulfate 2–4 g IV over 2–4 h if Mg <1.6; oral magnesium oxide 200–400 mg BID if mild IV/PO per repletion (electrolyte, first line) — Hypomagnesemia common and refractory hypokalemia/seizures depend on it (ASAM 2020)
5. potassium_chloride 40–80 mEq PO/IV per 0.1 mmol/L deficit PO/IV per repletion (electrolyte, first line) — Hypokalemia is common; replete Mg simultaneously (ASAM 2020)
6. phosphorus_repletion Sodium or potassium phosphate 15–30 mmol IV over 4–6 h if Phos <1.5; PO Neutra-Phos if mild IV/PO per repletion (electrolyte, first line) — Hypophosphatemia common; replete to prevent refeeding-syndrome physiology on glucose load (ASAM 2020)

Setting playbook (outpatient) — Post-withdrawal AUD MAT continuation + relapse prevention — MAT initiation/continuation (naltrexone, acamprosate, disulfiram per ASAM 2020 hierarchy), Brief Intervention + Motivational Interviewing, mutual-help referral (AA / SMART Recovery / LifeRing), structured follow-up at 1/2/4 weeks, lab monitoring, suicidal-ideation surveillance at every visit (kindling-driven post-withdrawal SI peaks 2-12 weeks per ASAM 2020 + Mayo-Smith JAMA 1997 long-term outcomes), lethal-means counseling for any SI history, family / support involvement
7. naltrexone (AUD MAT first-line) 50 mg PO daily OR XR-injection 380 mg IM every 4 weeks PO/IM daily PO or monthly IM — AUD with cravings or recent heavy drinking days; no concurrent opioid use; LFTs < 5× ULN (ASAM 2020 + COMBINE JAMA 2006 — first-line AUD MAT; reduces heavy drinking days + cravings; AVOID if active opioid use (precipitates withdrawal) OR liver enzymes > 5× ULN)
8. acamprosate (AUD MAT first-line; renal-cleared) 666 mg PO TID (renal-dose 333 mg TID if eGFR 30-50; AVOID if eGFR < 30) PO TID — AUD with renal function intact or mild impairment; liver disease present (preferred over naltrexone in significant hepatic impairment) (ASAM 2020 + COMBINE JAMA 2006 — reduces relapse rates; safe in liver disease (renally cleared); 3× daily dosing limits adherence)
9. disulfiram (AUD MAT second-line; aversive) 250 mg PO daily PO daily — Highly motivated patient + supervised administration available (family/partner observed) + no CAD / severe cirrhosis / pregnancy (ASAM 2020 — aversive disulfiram-ethanol reaction; informed consent + supervised administration ideal; AVOID active CAD, severe cirrhosis, pregnancy; second-line per ASAM hierarchy)
10. gabapentin (off-label AUD MAT) 300 mg PO TID, titrate to 600 mg TID (max 1800 mg/day) PO TID — AUD with residual anxiety / insomnia after withdrawal; naltrexone / acamprosate intolerance (Mason JAMA Intern Med 2014 — off-label AUD evidence; covers post-acute withdrawal anxiety + insomnia; renal-dosed)
11. topiramate (off-label AUD MAT) 25 mg PO daily, titrate over 8 weeks to 200-300 mg/day BID PO BID — AUD with co-occurring obesity or seizure history or treatment-resistant (ASAM 2020 off-label; cognitive side effects often dose-limiting; monitor bicarb (metabolic acidosis) and renal stones; not first-line)
12. thiamine continuation 100 mg PO daily indefinitely while drinking risk persists PO daily — Universal post-withdrawal — chronic alcohol-use micronutrient deficiency persists (Cook 1998 / Royal College CR-185 — chronic thiamine deficiency persists beyond acute withdrawal; oral less effective than IV but adequate for prophylaxis once acute Wernicke risk has passed)
13. folic acid + multivitamin continuation Folate 1 mg PO daily + multivitamin daily PO daily — Universal post-withdrawal (Chronic alcohol-related deficiency; cheap and well-tolerated)
14. taper antiseizure medication if seizure at presentation Continue levetiracetam (or equivalent) 500-1500 mg PO BID until 3-6 months seizure-free interval; neurology decision PO BID — Withdrawal seizure at presentation (No high-grade evidence for fixed duration; outpatient neurology + EEG guide taper; do NOT taper while still drinking heavily (kindling re-exposure risk))
15. depression / anxiety pharmacotherapy if PHQ-9 ≥ 10 or GAD-7 ≥ 10 sustained post-sobriety 4 weeks SSRI / SNRI per psych.depression.core.v1 / psych.anxiety hierarchy PO daily — Persistent psychiatric symptoms after 4 weeks sobriety (Re-assess after 4 weeks sobriety as alcohol-induced depression often resolves; if persistent, treat per affective-disorder dossier)

Non-pharmacologic actions:
- Brief Intervention + Motivational Interviewing at every visit — 5-15 min structured intervention proven to reduce drinking (USPSTF 2018)
- AA (Alcoholics Anonymous) / SMART Recovery / LifeRing / Refuge Recovery referral — patient-preference based (ASAM 2020)
- Cognitive Behavioral Therapy referral for AUD (CBT-AUD) — evidence-based ASAM 2020
- Family / partner / spouse engagement — Behavioral Couples Therapy if available; SMART Recovery Family & Friends; Al-Anon for family (ASAM 2020)
- Sober-living / IOP / PHP referral if outpatient adherence unstable or housing precarious (ASAM 2020)
- Lethal-means counseling (CALM protocol) at every visit if any SI history — firearm removal / safe storage, medication lockbox, alcohol-supply review (ASAM 2020; routes to psych.suicidality.ed.core.v1 if active SI)
- Naloxone co-prescription if any opioid co-use (concurrent ED-grade opioid risk; ASAM 2020)
- Driving restrictions if seizure at presentation per local jurisdiction; document and counsel
- Vaccinations catch-up: hepatitis A + B series (alcohol-use elevated hepatitis transmission risk), pneumococcal if aspiration history during withdrawal, influenza annual (ACIP 2024)
- Nutritional / dietitian referral if BMI < 18.5 or persistent micronutrient deficiencies (ASAM 2020)
- Patient + family education — kindling phenomenon (each subsequent withdrawal more severe); when to call PCP; when to return to ED; relapse-prevention triggers (ASAM 2020)

AVOID / contraindication checks:
- Thiamine before glucose universal (Cook 1998)
- Long acting BZD avoid in significant cirrhosis use lorazepam (ASAM 2020; ACG 2018)
- Phenobarbital BZD combined respiratory depression intubate if needed (Hack 2006; ASAM 2020)
- Disulfiram avoid CAD cirrhosis pregnancy (ASAM 2020)
- Naltrexone block if active opioid or LFTs above 5x ULN (ASAM 2020)
- Acamprosate renal dose avoid eGFR below 30 (ASAM 2020)
- Haloperidol QTc seizure threshold caution (Mayo Smith 1997)
- Phenytoin not first line for alcohol withdrawal seizure (Mayo Smith 1997)
- Flumazenil AVOID in BZD assisted alcohol withdrawal (ASAM 2020)

Monitoring

Regimen monitoring:
- CIWA Ar q1-2h while GTE 10 (Sullivan 1989; ASAM 2020)
- CIWA Ar q4-8h once below 10 x 24h (Sullivan 1989; ASAM 2020)
- Vitals q1-2h x 24h then q4h (ASAM 2020)
- BMP Mg Phos q12-24h until stable (ASAM 2020)
- LFTs q24h in cirrhosis (ACG 2018)
- Mental status q2-4h to detect DT (ASAM 2020)
- Seizure precautions active (ASAM 2020)
- ECG telemetry while autonomic storm (ASAM 2020)
- Glucose q1h x 4 post insulin if used (ASAM 2020)
- Continuous EEG if status or focal seizures (ASAM 2020)
- PHQ9 C-SSRS during admission AUD suicide comorbidity (ASAM 2020)
- AUDIT AUDIT-C at discharge for MAT planning (USPSTF 2018)

Setting (outpatient) monitoring:
- Follow-up at 1 week, 2 weeks, 4 weeks post-discharge — then monthly × 3 months — then q3 months for ≥ 12 months (ASAM 2020)
- PHQ-9 + C-SSRS at EVERY visit — SI risk peaks 2-12 weeks post-withdrawal (post-acute withdrawal anhedonia + protracted GABA dysregulation) (ASAM 2020)
- AUDIT / AUDIT-C at each visit to track sobriety progress (USPSTF 2018)
- LFTs at 2-4 weeks then q3 months × 1 year — naltrexone hepatic monitoring + AUD-liver-disease surveillance (ASAM 2020)
- CBC at 2-4 weeks then q3 months — macrocytic anemia recovery (ASAM 2020)
- BMP + Mg + Phos at 2-4 weeks — confirm repletion sustained (ASAM 2020)
- Naltrexone XR injection adherence tracking if XR formulation (ASAM 2020)
- BP + weight + lipid surveillance per cardiovascular risk (USPSTF 2018)
- Family / partner / support engagement assessment at each visit

Follow-up plan: Outpatient addiction medicine within 1 week; AUD MAT (naltrexone, acamprosate, disulfiram, gabapentin off-label) (ASAM 2020); counseling; mutual-help (AA, SMART, LifeRing); thiamine continued PO; nutritional supplementation; primary care follow-up for liver, BP, cardiac
- Close-out criterion: Outpatient handoff complete with appointment confirmed

Monitoring phase: CIWA-Ar q1–2h while ≥10; then q4–8h once <10 × 24h (Sullivan JClinPsychopharmacol 1989); vitals q1–2h × 24h; BMP/Mg/Phos q12–24h; mental status q2–4h to detect DT progression; seizure precautions; ECG telemetry while autonomic storm (ASAM 2020)

Disposition

Current setting: outpatient — Post-withdrawal AUD MAT continuation + relapse prevention — MAT initiation/continuation (naltrexone, acamprosate, disulfiram per ASAM 2020 hierarchy), Brief Intervention + Motivational Interviewing, mutual-help referral (AA / SMART Recovery / LifeRing), structured follow-up at 1/2/4 weeks, lab monitoring, suicidal-ideation surveillance at every visit (kindling-driven post-withdrawal SI peaks 2-12 weeks per ASAM 2020 + Mayo-Smith JAMA 1997 long-term outcomes), lethal-means counseling for any SI history, family / support involvement

Disposition criteria:
- Sustained sobriety ≥ 12 months + stable mental health + outpatient MAT continued = continue MAT ≥ 12 months total then shared-decision-making gradual discontinuation (ASAM 2020)
- Step-up to PHP / IOP if outpatient adherence uncertain or relapse occurring (ASAM 2020)
- Sober-living / residential treatment referral if homeless or housing precarious (ASAM 2020)
- Re-admit for stabilization if relapse with severe complications (CIWA-Ar ≥ 15 OR kindling-driven complicated withdrawal OR SI emergency) (ASAM 2020)

Escalation triggers (move to higher acuity):
- Relapse with new withdrawal symptoms (CIWA-Ar rising) → urgent re-evaluation; admit if CIWA ≥ 10 or kindling history (ASAM 2020)
- PHQ-9 ≥ 15 OR C-SSRS active SI OR new SI history → urgent mental-health referral; routes to psych.suicidality.ed.core.v1 (ASAM 2020)
- New seizure post-discharge → ED for workup + neurology referral; reassess antiseizure medication taper (Mayo-Smith JAMA 1997)
- LFTs > 5× ULN → discontinue naltrexone (or do not start) + hepatology referral (ASAM 2020)
- Disulfiram-ethanol reaction (flushing + headache + nausea + tachycardia + hypotension) → ED if hemodynamic compromise (ASAM 2020)
- Wernicke features (any) → ED for IV thiamine + neurology (Cook 1998 NEEDS_SOURCE_REVIEW)
- Housing instability / loss of supports / IPV → social-work referral + sober-living / IOP / PHP escalation (ASAM 2020)
- New cardiovascular event in patient on disulfiram → discontinue disulfiram + cardiology (ASAM 2020)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Witnessed or reported generalized tonic-clonic seizure within 24–48 h of alcohol cessation
- [LIFE_THREATENING] Delirium tremens — clouded sensorium + autonomic storm + hallucinations + disorientation, 48–96 h after cessation
- [LIFE_THREATENING] Withdrawal refractory to escalating BZD doses (>40 mg lorazepam equiv. in 4 h without effect)

Citations

- ASAM 2020 Alcohol Withdrawal Management + Sullivan CIWA-Ar 1989 + Mayo-Smith JAMA 1997 benzodiazepine guideline + Rosenson 2013 phenobarbital ED RCT + Maldonado PAWSS 2014 [PMID:31909543](https://pubmed.ncbi.nlm.nih.gov/31909543/)
- Cited evidence (PMID 2597811) [PMID:2597811](https://pubmed.ncbi.nlm.nih.gov/2597811/)
- Cited evidence (PMID 9244334) [PMID:9244334](https://pubmed.ncbi.nlm.nih.gov/9244334/)
- Cited evidence (PMID 22834916) [PMID:22834916](https://pubmed.ncbi.nlm.nih.gov/22834916/)

Last reconciled with current guidelines: 2026-05-14.
References
  • ASAM 2020 Alcohol Withdrawal Management + Sullivan CIWA-Ar 1989 + Mayo-Smith JAMA 1997 benzodiazepine guideline + Rosenson 2013 phenobarbital ED RCT + Maldonado PAWSS 2014 — PMID:31909543
  • Cited evidence (PMID 2597811) — PMID:2597811
  • Cited evidence (PMID 9244334) — PMID:9244334
  • Cited evidence (PMID 22834916) — PMID:22834916