Pharmacological Management of Alcohol Withdrawal: A Meta-analysis and Evidence-Based Practice Guideline
Abstract
OBJECTIVE: To provide an evidence-based practice guideline on the pharmacological management of alcohol withdrawal. DATA SOURCES: English-language articles published before July 1, 1995, identified through MEDLINE search on "substance withdrawal--ethyl alcohol" and review of references from identified articles. STUDY SELECTION: Articles with original data on human subjects. DATA ABSTRACTION: Structured review to determine study design, sample size, interventions used, and outcomes of withdrawal severity, delirium, seizures, completion of withdrawal, entry into rehabilitation, adverse effects, and costs. Data from prospective controlled trials with methodologically sound end points corresponding to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were abstracted by 2 independent reviewers and underwent meta-analysis. DATA SYNTHESIS: Benzodiazepines reduce withdrawal severity, reduce incidence of delirium (-4.9 cases per 100 patients; 95% confidence interval, -9.0 to -0.7; P=.04), and reduce seizures (-7.7 seizures per 100 patients; 95% confidence interval, -12.0 to -3.5; P=.003). Individualizing therapy with withdrawal scales results in administration of significantly less medication and shorter treatment (P<.001). beta-Blockers, clonidine, and carbamazepine ameliorate withdrawal severity, but evidence is inadequate to determine their effect on delirium and seizures. Phenothiazines ameliorate withdrawal but are less effective than benzodiazepines in reducing delirium (P=.002) or seizures (P<.001). CONCLUSIONS: Benzodiazepines are suitable agents for alcohol withdrawal, with choice among different agents guided by duration of action, rapidity of onset, and cost. Dosage should be individualized, based on withdrawal severity measured by withdrawal scales, comorbid illness, and history of withdrawal seizures. beta-Blockers, clonidine, carbamazepine, and neuroleptics may be used as adjunctive therapy but are not recommended as monotherapy.
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The Clinical Institute Withdrawal Assessment Alcohol Scale Revised will be used to assess withdrawal symptoms to ensure safe progressive lorazepam discontinuation.
“The Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-AR; [80]) will be used to assess withdrawal symptoms to ensure safe progressive lorazepam discontinuation, in line with evidence-based practice guidelines recommending individualized tapering off schedules with withdrawal scales [81].”
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- Authors
- Mayo-Smith, M. F.
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 1997-07-09
- Volume
- 278
- Issue
- 2
- Pages
- 144
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2042931973
- Cited by
- 434
- References
- 0
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 9 · 2023: 9 · 2022: 6 · 2021: 6 · 2020: 20 · 2019: 10 · 2018: 18 · 2017: 11 · 2016: 16 · 2015: 15 · 2014: 18 · 2013: 13 · 2012: 18
- FWCI
- 7.37
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Neurology › Alcoholism and Thiamine Deficiency
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Health Sciences › Medicine › Pathology and Forensic Medicine › Alcohol Consumption and Health Effects
- Keywords
- alcohol withdrawal, pharmacological management, benzodiazepines, delirium, withdrawal seizures, beta-blockers, clonidine, carbamazepine, phenothiazines, withdrawal severity, personalized treatment, adjunctive therapy, alcoholism treatment
- MeSH terms
- Adrenergic beta-Antagonists, Alcohol Withdrawal Delirium, Ethanol, Benzodiazepines, Carbamazepine, Clinical Trials as Topic, Clonidine, Humans, Hypnotics and Sedatives, Magnesium, Severity of Illness Index, Substance Withdrawal Syndrome, Thiamine, Antipsychotic Agents, Treatment Outcome, Health Care Costs, Evidence-Based Medicine
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