Diagnostic Criteria for Alcohol Withdrawal Symptoms

Alcoholism, or alcohol use disorder, is defined, according to the diagnostic and statistical manual of mental disorders, 5th edition, as a problematic pattern of alcohol use leading to clinically significant impairment or psychological distress. Alcoholism results in an estimated 2.5 million death annually worldwide, representing 4%of all mortality. Alcohol consumption is the world’s third largest risk factor for disease and disability; in middle income countries it is the greatest risk. Harmful use of alcohol is particularly grave threat to men. It is the leading risk factor for death in males aged 15-59, mainly due to injuries, CVD and violence. Globally, 6.2% of all male deaths are attributable to alcohol, compared to 1.1% of female deaths. Lower socioeconomic status and educational levels result in a greater risk of alcohol-related deaths, disease and injury. Worldwide consumption in 2005 was equal to 6.133 litre of pure alcohol consumed per person aged 15 years or older. Alcohol consumption also affects society at large. Death, disease and injury caused by alcohol consumption have socioeconomic impacts, including medical costs borne by governments, financial and psychological burden to families. Harmful use of alcohol also impacts on workers’ productivity. The biggest social impact related to alcohol consumption is crime and violence. World health organization initiated the Global School Based Student Health Survey. In the WHO Global survey on alcohol and health, the five year trend of under-age drinking was assessed: out of 73 responding countries, 71% indicated an increase. The 5-year trend of drinking among 18-25 year olds indicated that, out of 82 responding countries, 80% showed an increase.

Alcohol is causally related to more than 60 different medical conditions. It accounts for about as much death and disability globally as tobacco and hypertension. Evidence suggests that treatment of alcohol related problems should be incorporated into public health response. An important intervention or many alcoholic patients is the management of alcohol withdrawal to relieve discomfort, prevent medical complications and prepare patient for rehabilitation.

Alcohol Withdrawal Symptoms (AWS) is a common reason for hospital admission. However a significant number of these patients have co-existence liver disease or other medical problems. More than 50% of AUD patients experience AWS after the discontinuation or abrupt decrease in alcohol consumption. Patients who have developed a biological dependence on alcohol are at a risk of developing AWS which is defined as a presents of two or more of the following symptoms after cessation of alcohol use:

• Tachycardia;
• Tremor;
• Insomnia;
• Nausea or vomiting;
• Transient, visual, tactile or auditory hallucination;
• Psychomotor agitation;
• Anxiety and tonic-clonic seizures;
• Hyperpyrexia;
• Hypertension;
• Diaphoresis.

Diagnostic criteria for AWD include disturbance consciousness, change in cognition or perpetual disturbance developing in a short period after stopping heavy alcohol intake.

Onset can occur 6-48 hours after last drink. Historically mortality from DT (delirium tremors) was about 40%, today with early recognition and prompt treatment it has dropped to 1-5%.

A reliable, brief, uncomplicated and clinically useful scale to assess the severity of alcohol withdrawal, to monitor response to treatment and to use in research. An earlier developed 15 item scale –the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A), was shortened to a 10 item scale for clinical quantification of the severity of alcohol withdrawal syndrome. This new alcohol withdrawal scale offers an increase in efficiency while at the same time retaining clinical usefulness, validity and reliability and can be incorporated into the usual clinical care of patients undergoing alcohol withdrawal in order that optimal pharmacotherapy can be instituted. CIWA-Arscores ≥8 but ≤15 indicate a potential need for a pharmacological treatment, An AWS with a CIWA-Ar score more than 15 must be treated pharmacologically.

Benzodiazepines are preferred for the treatment of alcohol withdrawal because of their favorable side effect profile. They form the gold standard for treatment of AWS and can prevent AWS progression to severe forms including delirium tremens. In alcoholic patients with liver involvement, Lorazepam or Oxazepam are preferred because they do not undergo phase 1 biotransformation, rather they undergo only glucuronidation. Lorazepam has a half -life of 10-20 hours. Benzodiazepines promote and enhance binding of the inhibitory neurotransmitter GABA to GABAA receptor in the central nervous system. Benzodiazepines are given in a symptom triggered fashion using CIWA-Ar as a measuring tool, most patients with CIWA-Ar score of 8 or higher benefit from benzodiazepine therapy. Thus pharmacotherapy with Lorazepam for alcohol withdrawal is a mainstay within alcoholic patients’ route to recovery. Here we plan to do the DUE of Lorazepam in AWS, to ensure rational drug use for optimal benefit of drug therapy in patient care.

Drug Utilization Evaluation (DUE) or Medication Use Evaluation (MUE), according to WHO is a marketing, distribution, prescription and use of drugs in society with special prominence on the resulting medical social and economic consequences. Purpose of DUE is to ensure drugs are used appropriately, safely and effectively to improve patient health.

Alcoholism being a substance abuse requires incessant intervention in the form of counseling. Brief interventions are a counseling strategy that can be delivered by a health care provider during a 5-10 minute medical office visit. It is aimed at educating the patient about problematic drinking, increasing motivation to change behavior, and reinforcing skills to address problematic drinking. In primary care settings, brief interventions are used to reduce drinking, particularly when repeated over time along with follow-up telephone consultations. This approach is typically referred to with the acronym SBIRT: screening, brief intervention, and referral to treatment. A Screening instrument for problematic drinking include Cut down – Annoyed-Guilty-Eye opener (CAGE), it is short and can be easily implemented in primary care setting and assess consequences of drinking. We are using this scale to address alcohol use disorder within alcoholic patients and provide them with a brief intervention.