Alcohol Withdrawal Syndrome: Answering the Unintended Consequence of COVID-19 Lockdown

By: Jill Mattingly, DHSc, MMSc, PA-C
Mercer University, Atlanta

As I listen to my patient’s heart sounds, I glance down at his hands. I see the tell-tale tremor as they are resting in his lap. There are other troubling signs surfacing as I continue my exam that point to alcohol withdrawal. Fortunately, this patient is here at the outpatient recovery clinic to start a medically supervised alcohol detoxification and intensive outpatient program.  

I saw many patients in this condition as a PA practicing outpatient addiction medicine, but now I am reading more and more about the unusual uptick in alcohol use disorder and withdrawal syndrome seen in primary care settings or by telemedicine. This is an unintended consequence of lockdowns and restrictions during the pandemic.

Ironically, one of the hidden effects of the COVID 19 pandemic has been the reduced accessibility of alcohol. Although liquor stores remain open, shelter-in-place restrictions have decreased on-premises (bar and restaurant) sales. Average sales remain 68% below rates in the previous non-COVID year. However, online sales of alcohol have skyrocketed, doubling from last year. In fact, the average online sales are up 234%. It is the fastest growing online sales division of consumer-packaged goods.  

When a person with a heavy drinking pattern suddenly stops all alcohol consumption, alcohol withdrawal can occur. Alcohol withdrawal is not a well-studied syndrome, even though significant symptoms occur in 13% to 71% of those needing withdrawal management. Up to 10% of individuals undergoing alcohol withdrawal require inpatient medical treatment, and it carries an estimated mortality of up to 2%.  

As a PA practicing outpatient addiction medicine, I was the clinician who screened and examined patients presenting with alcohol use disorder (AUD). The patients were able to go through medically supervised detoxification as outpatients if the screening and exam allowed for this setting.

Understanding that alcohol withdrawal syndrome (AWS) can be managed outside of the emergency department or inpatient hospitalization is valuable for the primary care clinician. 

Of course, this can be a medical emergency if the patient progresses to delirium tremens, and withdrawal seizure, but properly screening for AWS can prevent the development of this life-threatening stage. 

Using tools such as the Prediction of Alcohol Withdrawal Severity Scale can help with risk rating and care level. 

There are two outpatient settings: office-based or ASAM Level 1-WM (ambulatory withdrawal management without extended on-site monitoring, and structured program-based or ASAM Level 2-WM (ambulatory withdrawal management with extended on-site monitoring). Outpatient AWS management is still under-available despite being a well-established procedure for mild to moderate AWS severity. 

This could be, however, the solution to helping alcohol-dependent patients with decreased access and dwindling resources during a pandemic to safely stop alcohol use without hospitalization.  

Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard, DR, Calkins DR. JAMA. 1994;272:519-523.

 

See Jill Mattingly, DHSc, MMSc, PA-C speak at the GAPA 2021 CME Conference in Hilton Head Island, SC July 12-16, 2021.

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