ASAM Pocket Guidelines and Patient Guide

Alcohol Withdrawal Management

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18 Treatment – Ambulatory (3) Benzodiazepine use Î Recommendation IV.20: While no particular benzodiazepine agent is more effective than another, longer-acting benzodiazepines are the preferred agents due to the clinical benefits of their longer duration of action. Î Recommendation IV.21: If waiting for lab test(s) results or if the test(s) are unavailable, if a patient has signs of significant liver disease, use a benzodiazepine with less hepatic metabolization. Î Recommendation IV.22: Clinicians should monitor patients taking benzodiazepines for signs of over-sedation and respiratory depression. Î Recommendation IV.23: A benzodiazepine prescription to treat alcohol withdrawal should be discontinued following treatment. Î Recommendation IV.24: Clinicians can manage benzodiazepine misuse or diversion risk in ambulatory settings by dispensing or prescribing the minimum amount necessary given patients' level of stability and timing of their next in-person clinic visit. Alternative medications can also be considered such as carbamazepine or gabapentin. Î Recommendation IV.25: In ambulatory settings, benzodiazepines should not be prescribed to patients with a history of even mild adverse events with benzodiazepine use because rapid intervention is not typically available. Benzodiazepines can be used with caution in patients with a high risk of benzodiazepine diversion including patients with a current or past benzodiazepine use disorder for the short period of acute alcohol withdrawal. Risk can be managed by dispensing or prescribing a small number of doses. Î Recommendation IV.26: Patients who are taking benzodiazepines, and their caregivers, should be educated regarding: • The danger of drug-drug interactions between benzodiazepines and other CNS depressants (impairment and respiratory depression) • The risks associated with combining alcohol and benzodiazepines and importance of abstinence from alcohol • The risks associated with driving or use of heavy machinery for the first few days of benzodiazepine administration • Instructions to reduce their benzodiazepine dose if drowsiness occurs

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