A physician called after his first visit with a 48-year old HIV-positive female patient who expressed a desire to stop drinking alcohol. The patient has not consistently been engaged in medical care over the last year, and was hoping to establish care with a new HIV primary care provider. The patient reports drinking a half bottle of vodka daily over the last year since the death of her husband. She reports having tried to stop on her own, but experiences morning tremors and nausea which go away after her first drink. At this time, she is highly motivated to stop since alcohol use has strained her relationship with her daughter. The patient is reluctant to enter a residential detox program due to family care responsibilities. She has a history of hypertension, anxiety and depression, and denies any other substance use history.
The caller was concerned about: (1) safety of an outpatient detoxification program for this patient and (2) whether she is medically appropriate for such a program.
The consultant reviewed the DSM-5 11-point scale diagnostic criteria for alcohol use disorder as well as the Clinical Institute Withdrawal Assessment (CIWA) ten-item scale with the caller. Based on clinical assessment at today’s visit, the patient has a CIWA score of 13 which is on the border for being at increased risk of severe alcohol withdrawal (>15 represents significantly increased risk for higher morbidity with alcohol withdrawal). The patient is possibly a candidate for intensive outpatient alcohol detoxification using a benzodiazepine or gabapentin along with adjuvant nutritional support such as thiamine and folate. Her detoxification would need to dovetail with the use of consolidation therapy with continued gabapentin or naltrexone for the prolonged abstinence syndrome associated with recovery from alcohol dependence. Hypertension may also be affected by alcohol withdrawal as well as her anxiety and depression; namely, depression may deepen as she goes through withdrawal and through the early stages of recovery. If outpatient detoxification is pursued, the consultant recommended daily contact with the patient to assess symptoms, and proactively identifying home-based support to help monitor the patient’s physical and psychological status during acute withdrawal. Her medical and behavioral health teams should coordinate closely regardless of how detoxification is managed since close psychological support will be important to recovery.