It’s common to imagine ‘detox’ as a place you stay for awhile, but most people in alcohol withdrawal can be managed as outpatients
The American Society of Addiction Medicine (ASAM) has released a new Alcohol Withdrawal Clinical Guideline. While currently in draft form, ASAM has made the document public because policy changes as the result of COVID-19 have heightened the risk of alcohol withdrawal, which–at its most severe–can cause seizures, delirium and even death.
IRETA helped develop this new clinical guideline and we too recognize the importance of providing accurate information about managing alcohol withdrawal at a time when some states have abruptly closed liquor stores; some treatment facilities are limiting admissions because they are concerned about infectious disease; and emergency departments may be overwhelmed by COVID-19 patients.
In short, this is a dangerous time to be physically dependent on alcohol.
Most Patients Can Be Treated as Outpatients
People often imagine “detox” as a place you go and stay for awhile. They envision either a hospital “detox unit” or “detoxing” as the first step of a residential addiction treatment program where you’d be expected to stay overnight for 2-4 weeks or longer.
The truth of the matter is that “detox” (or withdrawal management, as it now known) is a process that can take place in a number of settings. Many of us are aware that people often manage their own withdrawal without leaving home. What is less well-known (and especially important during the current pandemic) is that most patients with alcohol withdrawal can be safely and effectively managed in outpatient settings.
People benefit from outpatient treatment for obvious reasons: reduced disruptions to family life, housing, and employment. In other words, if you utilize outpatient treatment for withdrawal management, you don’t have to find someone to watch your kids for 28 days or figure out how to take time off from your job.
Known Risk Factors for Severe Symptoms
When considering where and how to treat alcohol withdrawal, the most important concern is whether alcohol withdrawal may be life-threatening.
The new ASAM clinical guideline lists a series of “risk factors for complicated withdrawal or complications of withdrawal.” What does that mean?
“Complicated withdrawal” refers to the development of seizures or delirium as the result of the alcohol withdrawal itself. These are the most severe symptoms of alcohol withdrawal and have been known to be fatal. “Complications of withdrawal” may also be fatal: this term refers to the exacerbation of existing medical or psychiatric conditions, such as schizophrenia or traumatic brain injury.
Patients who are at risk of complicated withdrawal or complications of withdrawal may be best served by inpatient treatment so that they can be monitored. The worst case scenario for some being treated on an outpatient basis is a seizure or the onset of delirium or other life-threatening symptoms while they are at home alone. Outpatient treatment is not appropriate if there is reason to believe that a worst case scenario might transpire.
The following factors indicate a higher risk of complicated withdrawal or complications of withdrawal:
– History of alcohol withdrawal delirium or alcohol withdrawal seizure
– Numerous prior withdrawal episodes in the patient’s lifetime
– Comorbid medical or surgical illness (especially traumatic brain injury)
– Increased age (>65)
– Long duration of heavy and regular alcohol consumption
– Seizure(s) during the current withdrawal episode
– Marked autonomic hyperactivity on presentation
– Physiological dependence on GABAergic agents such as benzodiazepines or barbiturates
The first factor–a history of delirium or seizure in prior alcohol withdrawal episodes–has particularly strong support in the research literature. If a patient has experienced severe symptoms in the past during alcohol withdrawal, they are more likely to experience them in the future. For the sake of safety, inpatient treatment may be best.
Two Broad Types of Outpatient Treatment Options
What does outpatient treatment for alcohol withdrawal look like? The clinical guideline discusses two broad types: Level 1 versus Level 2.
Level 1 care differs from Level 2 because it does not have “extended on-site monitoring.” What may be surprising is that a primary care office falls into the category of Level 1. That is to say: your current doctor may be able to treat you for alcohol withdrawal if you are not high-risk and you have reasonable support at home. A primary care provider can assess the severity of the withdrawal symptoms, prescribe medications if indicated, and monitor patients on a daily basis, either in-person or over the phone.
A Level 2 setting, on the other hand, has the capacity to conduct regular medical assessments and monitor alcohol withdrawal syndrome progression over time. It may also have access to psychological or psychiatric treatment. At a Level 2 setting, a provider could assess the patient’s symptom severity, offer medication to treat symptoms, and continue to monitor the patient’s symptoms over a series of hours.
Treatment for Alcohol Use Disorder in Conjunction with Withdrawal Management
Alcohol withdrawal management alone is not an effective treatment for alcohol use disorder. According to the guideline, “Withdrawal management should not be conceptualized as a discrete clinical service, but rather as a component of the process of initiating and engaging patients in treatment for alcohol use disorder.”
Not everyone who suffers from alcohol withdrawal is interested in treatment for alcohol use disorder, but everyone should be given a full picture of the options available to them.
This is important because just as the public imagination of “detox” does not reflect the actual available options for withdrawal management, there are misconceptions about what might be called “treatment for alcoholism.” At times, these misconceptions contribute to a reluctance to seek support for alcohol use disorder.
“Treatment” does not have to mean a 28-day rehab, a commitment to a 12-step program, or total abstinence from alcohol. There are FDA-approved medications for alcohol use disorder that your primary care provider can prescribe. One of these medications, oral naltrexone, is especially useful for patients who are not interested in total abstinence from alcohol.
And while people usually do benefit from social support when trying to change their drinking habits, 12-step certainly isn’t the only game in town. There are social media communities like Redditors in Recovery and explicitly secular support groups like SMART Recovery.
One of the benefits of this strange time during the COVID-19 outbreak is that all recovery support has moved online, which enables people to “shop the options” regardless of where they’re geographically located. National and international virtual support is available, as well as (probably) virtual support based in your city or town.