As Alcohol Awareness Month unfolds, the imperative to address alcohol-related issues with informed strategies is a critical aspect often overlooked in discussions about alcohol abuse.
In this article, we dive into a comprehensive analysis of two major guidelines published by the American Society of Addiction Medicine (ASAM) and the American Psychiatric Association (APA). By comparing and contrasting their approaches, we aim to shed light on best practices for managing alcohol withdrawal, highlighting the importance of harmonized guidelines in ensuring effective and compassionate care for individuals grappling with alcohol dependency.
American Society of Addiction Medicine (ASAM)
- Clinical Practice Guideline on Alcohol Withdrawal Management
- Published May 2020
- Full Text
- Pocket Guide / Summary
American Psychiatric Association (APA)
- Practice Guideline for The Pharmacological Treatment of Patients With Alcohol Use Disorder
- Published January 2018
- Full Text
- Pocket Guide / Summary
Overview of Development
| Details | ASAM Guideline | APA Guideline |
|---|---|---|
| Authoring Organization | American Society of Addiction Medicine (ASAM) | American Psychiatric Society (APA) |
| Official Title | Clinical Practice Guideline on Alcohol Withdrawal Management | Practice Guideline for The Pharmacological Treatment of Patients with Alcohol Use Disorder |
| Publication Date | May 2020 | January 2018 |
| Journal | Journal of Addiction Medicine | American Journal of Psychiatry |
| Methodology | VA/DoD and RAND/UCLA Appropriateness Method (RAM) | GRADE |
| Grades Strength of Recommendation | No | Yes |
| Grades Level of Evidence | No | Yes |
| Based on Systematic Review | Yes | Yes |
| Goal | The goal is to provide updated information on evidence-based strategies and standards of care for alcohol withdrawal management in both ambulatory and inpatient settings | The goal is to improve the quality of care and treatment outcomes for patients with alcohol use disorder (AUD), as defined by DSM-5 (American Psychiatric Association 2013). The Guideline focuses specifically on evidence-based pharmacological treatments for AUD but also includes statements related to assessment and treatment planning that are an integral part of using pharmacotherapy to treat AUD |
| Literature Search Through | Through November 2017 | Through April 2016 |
| Population | Adults 18 years or older with a diagnosis of alcohol withdrawal with or without other health conditions | Adults (age 18 years or older) with AUD, including alcohol abuse or alcohol dependence as defined in DSM, who are eligible for treatment with medications for alcohol dependence |
| Included External Review | Yes | Yes |
| Discloses Funding Source and COIs | Yes | Yes |
Scope of Each Guideline
ASAM
- Diagnosis
- Alcohol Withdrawal Severity
- Identification of Alcohol Withdrawal
- Diagnosis of Alcohol Withdrawal
- Differential Diagnosis
- Initial Assessment of Alcohol Withdrawal
- Risk Factors for Severe or Complicated Withdrawal
- Risk Assessment Tools
- Symptom Assessment Scales
- Concurrent Conditions
- Level of Care Determination
- Ambulatory Management of Alcohol Withdrawal
- Ambulatory Monitoring
- Ambulatory Supportive Care
- Ambulatory AUD Treatment Initiation and Engagement
- Ambulatory Pharmacotherapy – Prophylaxis
- Ambulatory Pharmacotherapy – Withdrawal Symptoms
- Ambulatory Pharmacotherapy – Benzodiazepine
- Ambulatory Pharmacotherapy – Carbamazepine, Gabapentin, Valproic Acid
- Ambulatory Pharmacotherapy – Phenobarbital
- Inpatient Management of Alcohol Withdrawal
- Inpatient Monitoring
- Inpatient Supportive Care
- Inpatient AUD Treatment Initiation and Engagement
- Inpatient Pharmacotherapy – Prophylaxis
- Inpatient Pharmacotherapy – Withdrawal Symptoms
- Inpatient Pharmacotherapy – Benzodiazepine
- Inpatient Pharmacotherapy – Carbamazepine, Gabapentin, Valproic Acid
- Inpatient Pharmacotherapy – Phenobarbital
- Inpatient Pharmacotherapy – A2AAS and Beta Blockers
- Addressing Complicated Alcohol Withdrawal
- Seizure
- Delirium
- Alcohol-Induced Psychotic Disorder
- Specific Settings and Populations
- Primary Care
- Emergency Departments
- Hospitalized Patients
- Patients with Medical Conditions
- Patients Who Take Opioids
- Patients Who are Pregnant + with Newborns
APA
- Assessment and Determination of Treatment Goals in Alcohol Use Disorder
- Selection of Pharmacotherapy in Alcohol Use Disorder
- Co-Occurring Opioid Use Disorder
Specific Scope Overlap
- Assessment of AUD / Alcohol Withdrawal
- Pharmacotherapy of AUD
Background from ASAM
- Alcohol withdrawal can appear in a multitude of ways in every type of medical setting.
- An estimated 32.5% of emergency department visits are alcohol-related.
- An estimated 2–7% of patients with heavy alcohol use admitted to the hospital will develop moderate to severe alcohol withdrawal.
- Alcohol withdrawal management alone is not an effective treatment for alcohol use disorder.
- Withdrawal management should not be conceptualized as a discrete clinical service but rather as a component of the process of initiating and engaging patients in treatment for alcohol use disorder.
Background from APA
- Alcohol use disorder (AUD) is a major public health problem in the United States.
- The estimated 12-month and lifetime prevalence values for AUD are 13.9% and 29.1%, respectively, with approximately half of individuals with lifetime AUD having a severe disorder.
- AUD and its sequelae also account for significant excess mortality and cost the United States more than $200 billion annually.
- Despite its high prevalence and numerous negative consequences, AUD remains undertreated.
- In fact, fewer than 1 in 10 individuals in the United States with a 12-month diagnosis of AUD receive any treatment.
- Nevertheless, effective and evidence-based interventions are available, and treatment is associated with reductions in the risk of relapse and AUD-associated mortality.
Guideline Similarities
- Both organizations recommend screening for tobacco, opioids, and other substance use
- Both organizations recommend screening for other potential co-occurring disorders or medical conditions
- Both organizations recommend screening for alcohol use with quantitative behavior measures
- Both organizations recommend physiological biomarkers to screen for alcohol use
- Both organizations recommend using the DSM-5 as a basis for diagnosis
- Both organizations recommend naltrexone, acamprosate, and disulfiram for AUD
- Both organizations limited their scope to adults 18 years of age and older
- Both organizations included a systematic review and offered an external review period
Guideline Differences
- ASAM is focused on Alcohol Withdrawal, and APA is focused on Alcohol Use Disorder as a whole
- ASAM includes differing recommendations depending on specific treatment setting, including ambulatory, hospital/emergency care, and inpatient treatment
- Both organizations recommend screening for alcohol use with quantitative behavior measures, but ASAM favors AUDIT-PC, while APA mentions AUDIT and AUDIT-C
- ASAM focuses on levels of care, risk factors for complications, and withdrawal severity, while APA does not cover these
- ASAM covers concurrent AUD and alcohol withdrawal management, while APA does not
- ASAM includes specific recommendations for complications from withdrawal, including delirium and alcohol-induced psychotic disorder
- While both organizations recommend naltrexone, acamprosate, and disulfiram for AUD, APA also recommends topiramate and gabapentin as additional options.
- APA recommends no medications for pregnant individuals, while ASAM permits it in some cases after an assessment of risks vs. benefits
- APA offers specific recommendations for individuals with hepatitis or renal impairment
Potential Reasons for Differences
- While both organizations considered a systematic review, the organizations followed different methodologies to develop their guideline recommendations
- The literature review cut-off periods differed by over a year and a half
- The scopes of each guideline are slightly difference – ASAM focused specifically on Alcohol Withdrawal, while APA focused on AUD as a whole
Specific Medication Recommendations for Alcohol Use Disorder
| Medication | ASAM | APA |
|---|---|---|
| naltrexone | Initiate AUD treatment, including medications for AUD (e.g., acamprosate, disulfiram, or naltrexone) if appropriate, or refer to a qualified provider | APA recommends that naltrexone be offered to patients with moderate to severe alcohol use disorder who: have a goal of reducing alcohol consumption or achieving abstinence; prefer pharmacotherapy or have not responded to nonpharmacological treatments alone; and have no contraindications to the use of these medications. (1, B) |
| acamprosate | Initiate AUD treatment, including medications for AUD (e.g., acamprosate, disulfiram, or naltrexone) if appropriate, or refer to a qualified provider | APA recommends that acamprosate be offered to patients with moderate to severe alcohol use disorder who: have a goal of reducing alcohol consumption or achieving abstinence; prefer pharmacotherapy or have not responded to nonpharmacological treatments alone; and have no contraindications to the use of these medications. (1, B) |
| disulfiram | Initiate AUD treatment, including medications for AUD (e.g., acamprosate, disulfiram, or naltrexone) if appropriate, or refer to a qualified provider | APA suggests that disulfiram be offered to patients with moderate to severe alcohol use disorder who: have a goal of achieving abstinence; prefer disulfiram or are intolerant to or have not responded to naltrexone and acamprosate; are capable of understanding the risks of alcohol consumption while taking disulfiram; and have no contraindications to the use of this medication. (2, C) |
| topiramate | Not covered | APA suggests that topiramate be offered to patients with moderate to severe alcohol use disorder who: have a goal of reducing alcohol consumption or achieving abstinence; prefer topiramate or gabapentin or are intolerant to or have not responded to naltrexone and acamprosate; and have no contraindications to the use of these medications. (2, C) |
| gabapentin | Covered with withdrawal, but not AUD | APA suggests that gabapentin be offered to patients with moderate to severe alcohol use disorder who: have a goal of reducing alcohol consumption or achieving abstinence; prefer topiramate or gabapentin or are intolerant to or have not responded to naltrexone and acamprosate; and have no contraindications to the use of these medications. (2, C) |
| antidepressants | Not covered | No – should not be used for treatment of alcohol use disorder unless there is evidence of a co-occurring disorder for which an antidepressant is an indicated treatment. (1, B) |
| benzodiazepines | Covered with withdrawal, but not AUD | No – should not be used unless treating acute alcohol withdrawal or unless a co-occurring disorder exists for which a benzodiazepine is an indicated treatment. (1, C) |
General Comparison of Key Components in Each Guideline
| Details | ASAM Guideline | APA Guideline |
|---|---|---|
| Assessment of Current and Past Alcohol Use | Yes, during initial evaluation | Yes, during initial evaluation |
| Assessment of Current and Past Tobacco Use | Yes, during initial evaluation | Yes, during initial evaluation |
| Assessment of Opioid Use | Yes, during initial evaluation | Yes, during initial evaluation |
| Assessment of Other Substance Use | Yes, during initial evaluation | Yes, during initial evaluation |
| Assessment of Co-Occurring Conditions | Yes, during initial evaluation | Yes, during initial evaluation |
| Suggested Quantitative Behavior Measures | Yes, specifically AUDIT-PC | Yes, specifically AUDIT; AUDIT-C |
| Physiological Biomarkers | Yes, specifically mentioning blood, breath, or urine | Yes, but no specific biomarkers are recommended over others |
| Establish Treatment Goals | Not covered | Yes, during initial evaluation |
| Establish Comprehensive Treatment Plan | Mentioned, but not among formal recommendations | Yes, during initial evaluation |
| Discuss Legal Obligations | Not covered | Yes, during initial evaluation |
| Review Risk to Self or Others | Not covered | Yes, during initial evaluation |
| Diagnosis Using | DSM-5 | DSM-5 |
| Neurological Examination | Yes, for select patients (e.g. those with seizures or delirium) | Not covered |
| Establish Rusk Factors for Complications | Yes, with ASAM Criteria | Not covered |
| Establish Withdrawal Severity | Yes, with CIWA-Ar | Not covered |
| Establish Level of Care Determination | Yes, with ASAM Criteria | Not covered |
| Concurrent AUD and alcohol withdrawal treatment | Yes, as cognitive status permits | Not covered |
| Specific withdrawal management recommendations | Yes, various | Not covered |
| Naltrexone as an AUD Medication | Yes, recommended | Yes, recommended |
| Acamprosate as an AUD Medication | Yes, recommended | Yes, recommended |
| Disulfiram as an AUD Medication | Yes, recommended | Yes, recommended |
| Topiramate as an AUD Medication | Not covered | Yes, recommended |
| Gabapentin as an AUD Medication | Not covered for AUD, but is covered for withdrawal | Yes, recommended |
| Medications for Pregnant Individuals | Only after reviewing risks vs. benefits | Nor recommended |
| Recommendations for Hepatitis or Renal Impairment | Not covered | Yes, various |
Key Takeaways
- Screening and assessment should consist of:
- screening for alcohol use with quantitative behavior measures, such as AUDIT, AUDIT-C, and/or AUDIT-PC
- physiological biomarkers to screen for alcohol use
- screening for tobacco, opioids, and other substance use
- screening for other potential co-occurring disorders or medical conditions
- Diagnosis of alcohol use disorder should be made using the DSM-5 as a basis for diagnosis
- Three key recommended medications for alcohol use disorder include: naltrexone, acamprosate, and disulfiram
- Exercise extreme caution before prescribing any medications to pregnant individuals with alcohol use disorder symptoms
- For establishing withdrawal severity, utilize CIWA-Ar
- When determining risk factors for complications, as well as for determining appropriate levels of care, utilize the ASAM Criteria
Additional Guidelines
| Guideline Title | Society | Publication Date |
|---|---|---|
| Diagnosis and Treatment of Alcohol‐Associated Liver Diseases | American Association for the Study of Liver Diseases (AASLD) | July 1, 2019 |
| Alcoholic Liver Disease | American Gastroenterological Association (AGA) | February 1, 2018 |
| Mental, Neurological and Substance Use Disorders | World Health Organization (WHO) | November 20, 2023 |
| Alcohol-Associated Liver Disease | American College of Gastroenterology (ACG) | January 4, 2024 |
| Alcohol Use Disorder Among Older Adults | Canadian Coalition for Seniors’ Mental Health (CCSMH) | January 1, 2020 |
By continuously educating ourselves and aligning with evidence-based practices, we can better support those in need and contribute to a healthier, safer society. Sign up for alerts to stay updated on the latest guidelines and advancements to address alcohol misuse and promote wellness for all.
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