Suspected Substance Withdrawal in Adolescents — Management of Withdrawal Symptoms from Alcohol/Benzodiazepine — Clinical Pathway: Inpatient

Suspected Substance Withdrawal in Adolescents Clinical Pathway — Inpatient

Management of Withdrawal Symptoms from Alcohol/Benzodiazepine

Assessing Symptoms

  • Use CIWA-Ar, Clinical Institute Withdrawal Assessment for Alcohol, revised version
  • Scale with 10 items used to assess and manage alcohol withdrawal
  • Can be used to assess and manage benzodiazepine withdrawal symptoms
  • Can consider pausing CIWA-Ar assessments while asleep, depending on clinical condition
  • After 72 hrs of assessment with scores ≤ 9, can consider discontinuing CIWA-Ar assessments
  • General Signs, Symptoms of Withdrawal
  • Signs and Symptoms Specific to Alcohol Withdrawal

Pharmacologic Management

Benzodiazepines are effective in ameliorating symptoms of alcohol and benzodiazepine withdrawal.

Lorazepam

  • Dose adjustment may be required with significant liver disease
  • Consult Toxicology if benzodiazepine (BDZ) use disorder history to provide a BDZ
    equivalency chart
  • If lorazepam withdrawal is suspected, consult with PCC as efficacy of certain BDZ may be limited due to its unique receptor activity
  • Aggressive control of alcohol withdrawal symptoms is less risky than using subtherapeutic dosing and infrequent reassessment
  • If poor response with the following treatment dosing, CIWA-Ar > 10 during 2 subsequent treatment assessments, consult Psychiatry
  • If concern for overdose during induction, call Code
CIWA-Ar Score Lorazepam, PRN
Minimum Weight 20 kg		 Monitoring
≤ 5 None Perform CIWA-Ar every 4 hrs
6-9 0.5 mg PO/IM
  • RN notifies Ordering Provider for CIWA-Ar 6-9
  • Administer lorazepam dose per order
  • Monitor VS and reassess CIWA-Ar in 4 hrs
  • Obtain pulse oximetry with VS if sleeping, if patient prescribed benzodiazepines/opioid, and/or they appear sedated
  • Re-dose medication every 4 hrs, based on current CIWA-Ar
10-19 1 mg PO/IM
  • RN notifies Ordering Provider for CIWA-Ar 10-19
  • Administer lorazepam dose per order
  • Monitor VS and CIWA-Ar in 2 hrs
  • Obtain pulse oximetry with VS if sleeping, if patient prescribed benzodiazepines/opioid, and/or they appear sedated
  • Re-dose medication every 2 hrs, based on current CIWA-Ar
≥ 20 1 mg PO/IM
  • RN notifies Ordering Provider for CIWA-Ar ≥ 20
  • Administer lorazepam dose per order
  • Monitor VS and perform CIWA-Ar at least hourly or more frequently
  • Obtain pulse oximetry with VS if sleeping, if patient prescribed benzodiazepines/opioid, and/or they appear sedated
  • Notify ordering provider, consider higher level of monitoring and care

Lorazepam Taper

  • Discuss tapering plan with Psychiatry
  • Begin taper when symptoms are stable for 2 days on the same dosing
    • Convert to longer-acting benzodiazepine
    • Consult Toxicology for drug selection and dosing guidance
  • Taper lorazepam by 10% daily, but no greater than 25% daily
  • Generally advisable to continue hospitalization until taper is complete
  • Can consider continuing taper at home with outpatient supervision based on consultation with provider team/family

Vitamin Supplementation for Alcohol Withdrawal

Thiamine 100 mg daily
Folic Acid 1 mg daily
Multivitamin 1 tablet daily

Delirium Preventative Measures

Prevention and treatment strategies can manage or improve many of the contributing factors to delirium. See Delirium Preventive Measures.