Monitoring alcohol withdrawal in the ambulatory setting*^¶

CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol, Revised.

* Refer to UpToDate content for initial treatment decisions including choice of medication and tapering doses.

¶ This algorithm assumes that the individual is appropriate for treatment in the ambulatory setting. Refer to UpToDate content for treatment-setting considerations.

Δ In-person visits with a clinician are preferred. In cases where in-person visits are a hardship but the individual or support are reliable, we agree to every other day in-person visits alternating with remote visits. In cases where the individual cannot attend any visits, we consider seeing them in real-time remote visits on a case-by-case basis if they are reliable or have a reliable support system. This is less preferred. We treat individuals who may not be able to self-monitor and have no supports in the inpatient setting. Additionally, we treat individuals unable to make any in-person or remote visits in the inpatient setting. Refer to UpToDate content for treatment-setting considerations.

◊ In addition to referral to a higher level of care for CIWA-Ar >15, delirium, seizure, worsening medical or psychiatric condition, or use of >1 symptom-triggered dose in a 24-hour period, we refer for inpatient or other level of care (ie, substance treatment center) individuals that are nonadherent to treatment, those that divert or misuse medication, or return to use of substances.

§ Refer to UpToDate content for diagnosis of alcohol withdrawal.

¥ Length of time for symptom-triggered medication to work depends on many factors. Typically, effects are seen within one hour. Refer to UpToDate content for information on time of medication onset.

‡ We allow for one symptom-triggered medication dose every 24 hours. If more than one dose is needed, we refer for inpatient treatment.

† We provide a four-day fixed-dose taper schedule with a limited amount of symptom-triggered doses. For all individuals, we arrange for maintenance treatment of alcohol use disorder to begin immediately after completion of supervised taper.