“The Latest and Greatest Strategies for Treatment of Alcohol Withdrawal and Alcohol Use Disorder” provided a practical, evidence-informed update highly relevant to hospitalists managing patients with unhealthy alcohol use. The session emphasized a shift toward patient-centered, non-stigmatizing care, improved risk stratification for alcohol withdrawal, and proactive initiation of medications for alcohol use disorder during hospitalization.
A key foundational principle discussed was the importance of language. Presenters strongly encouraged eliminating stigmatizing terminology such as “abuse” from documentation, replacing it with terms like “unhealthy alcohol use.” This subtle but important change can improve patient engagement, reduce bias, and align with modern standards of care.
Alcohol withdrawal remains a common inpatient issue, with approximately 50% of patients with unhealthy alcohol use experiencing some degree of withdrawal. Importantly, about 80% of these cases are uncomplicated and not life-threatening, while 5% to 20% are complicated. Complicated withdrawal includes seizures, hallucinations, and delirium tremens (“the DTs”), with each subtype associated with different risk factors such as duration and quantity of alcohol consumption. The concept of “kindling”—where repeated withdrawal episodes increase the likelihood of severe withdrawal—was highlighted as a critical pathophysiologic mechanism.
Given this variability, identifying patients at risk for severe or complicated withdrawal is essential. The Prediction of Alcohol Withdrawal Severity Scale, or PAWSS, was emphasized as a highly accurate tool, with a score of 4 or more demonstrating excellent sensitivity and specificity for predicting severe withdrawal. This tool enables hospitalists to triage patients appropriately and initiate early, aggressive treatment when indicated.
Monitoring withdrawal symptoms is another area undergoing evolution. While the Clinical Institute Withdrawal Assessment for Alcohol, or CIWA, has historically been the standard, it has significant limitations. More than half of hospitalized patients are evaluated with this protocol unnecessarily, and the tool is heavily subjective, requiring frequent nursing assessments. The modified Minnesota Detoxification Scale, or mMINDS, was presented as a more objective and efficient alternative, validated across emergency, intensive care, and general medicine settings. It reduces benzodiazepine exposure and may decrease rates of mechanical ventilation. However, clinicians must interpret scores carefully because vital sign abnormalities from unrelated conditions can inflate scores.
In terms of treatment, benzodiazepines remain the gold standard for alcohol withdrawal, acting on gamma-aminobutyric acid type A receptors to counteract the hyperexcitable state of withdrawal. Long-acting agents are generally preferred, with diazepam offering the fastest onset. Symptom-triggered therapy is favored over scheduled regimens in most cases, though front-loading strategies are recommended for patients with severe or high-risk withdrawal.
Phenobarbital is increasingly used as an adjunct or alternative in severe cases. Its dual mechanism—enhancing gamma-aminobutyric acid activity and inhibiting N-methyl-D-aspartate receptors—makes it particularly effective in refractory withdrawal. While evidence quality remains limited, studies suggest the use of phenobarbital helps reduce intensive care unit admissions and shortens hospital stays. However, its narrow therapeutic window and risk of toxicity require careful dosing and monitoring. Combination therapy with benzodiazepines may further improve outcomes in severe withdrawal.
Adjunctive therapies also play an important role. All patients should receive IV thiamine (100 mg daily for three to five days) to prevent Wernicke’s encephalopathy. Magnesium levels, liver function tests, and urine drug screens should be routinely assessed. Clinicians should also remain vigilant for coexisting conditions, including psychiatric disorders, other substance use disorders, and high suicide risk.
A major focus of the session was the underutilization of medication for alcohol use disorder (MAUD). Despite strong evidence demonstrating reductions in mortality, hospital readmissions, and alcohol consumption, fewer than 1% of eligible patients are discharged on these therapies. Hospitalization for alcohol withdrawal was framed as a “reachable moment” to initiate treatment.
Naltrexone was highlighted as the first-line agent with the strongest evidence base. It reduces cravings and drinking behavior and can be safely used in patients with mild to moderate liver disease (Child-Pugh classes A and B), even with moderately elevated transaminases. It should be initiated once the patient is no longer acutely withdrawing and has abstained from alcohol for at least 48 hours. Starting at a lower dose (25 mg daily) helps mitigate side effects such as nausea and insomnia, with titration to 50 mg or higher as tolerated. The main contraindication is concurrent opioid use, requiring an opioid-free period prior to initiation.
Acamprosate is another US Food and Drug Administration (FDA)-approved option, particularly useful for maintaining abstinence. However, its three-times-daily dosing and cost can limit adherence. Disulfiram, while also FDA-approved, does not treat underlying cravings and relies on aversive conditioning, making it less effective for many patients.
Off-label options include gabapentin and topiramate. Gabapentin is commonly used as an adjunct for withdrawal symptoms and protracted withdrawal, helping with insomnia, anxiety, and cravings. Topiramate has evidence for reducing heavy drinking days but requires slow titration and carries cognitive side effects. Emerging therapies such as glucagon-like peptide-1 receptor agonists are under investigation, with early data suggesting potential benefits in reducing alcohol intake.
The session also underscored the importance of harm reduction strategies. While abstinence remains an ideal goal for some patients, reducing alcohol consumption can still yield significant health benefits. Practical counseling points include measuring drinks, avoiding drinking on an empty stomach, alternating with water, and planning safe transportation. Encouragingly, the message that “every quit attempt counts” reinforces a nonjudgmental, supportive approach.
In summary, this session reinforced that hospitalists play a pivotal role not only in managing acute alcohol withdrawal but also in initiating long-term treatment for alcohol use disorder. By using validated risk stratification tools, optimizing withdrawal management strategies, and consistently offering MAUD, clinicians can significantly improve patient outcomes.
Key Takeaways
- Use the Prediction of Alcohol Withdrawal Severity Scale score to identify patients at high risk for severe alcohol withdrawal and initiate early, aggressive treatment in those with scores of 4 or higher.
- Benzodiazepines remain the gold standard for withdrawal management, but phenobarbital is an effective adjunct in severe or refractory cases when used carefully.
- Hospitalization is a critical opportunity to start MAUD—especially naltrexone—and this should be offered routinely to all eligible patients to reduce mortality and readmissions.
Dr. Beshay
Dr. Beshay is an assistant professor of medicine and assistant director of education at Emory St. Joseph’s Hospital in Atlanta.