May 18, 2026

Advanced Management of Alcohol Withdrawal

26 minutes

EP 02

🎙 Special Series: ASAM's 57th Annual Conference

This episode is part of a special three-part series spotlighting key sessions from ASAM’s 57th Annual Conference.

In this episode of ASAM Practice Pearls, In this episode of ASAM Practice Pearls, Dr. Stephen Taylor is joined by Drs. Tessa Steel and Melissa Weimer to discuss highlights from their Annual Conference session, Advanced Management of Alcohol Withdrawal: Case-Based, Evidence-Informed Solutions. Together, they explore the challenges of managing severe and resistant alcohol withdrawal syndrome (AWS), effective assessment tools, escalation strategies, and care considerations for high-risk or medically complex patients.

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Host

Stephen M. Taylor, MD, MPH, DFAPA, DFASAM

Dr. Stephen M. Taylor is ASAM's President and is board-certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states.

Expert

Melissa Weimer, DO, MCR, DFASAM

Dr. Melissa Weimer is board-certified in Internal Medicine and Addiction Medicine, focusing on substance use disorders in hospital settings. She is an Associate Professor of Medicine at Yale School of Medicine and currently the Medical Director of the Yale Addiction Medicine Consult Service (YAMCS) at Yale New Haven Hospital. Dr. Weimer has worked on local, state, and national levels to enhance access to evidence-based treatments for substance use disorders. As an educator, she teaches healthcare students and professionals about substance use disorders and serves as the Associate Program Director of the Yale Addiction Medicine Fellowship program. She is also the Medical Director/Lead Trainer for the SAMHSA-funded Providers Clinical Support System-Medications for Alcohol Use Disorder.

Expert

Tessa Steel, MD, MPH

Dr. Tessa Steel is an Assistant Professor, physician-scientist, and Pulmonary Critical Care Medicine doctor at Harborview Medical Center, a county safety-net hospital operated by the University of Washington in Seattle. She is board-certified in Internal Medicine, Pulmonary Medicine, and Critical Care Medicine. Her clinical and research interests include improving hospital-based treatments for alcohol withdrawal syndrome and using hospitalizations to help people with addiction launch their process of recovery.

📖 Show Segments

00:05 - Introduction

01:39  - Prevalence and Risk

02:54 - Assessment Tools and Common Pitfalls

08:41 - Escalating Pharmacological Strategy

17:02 - Intubation Decisions and ICU Considerations

21:57 - Key Takeaways

25:37 - Conclusion and Additional Learning Opportunity 

📋 Key Takeaways

Use the right tools to assess alcohol withdrawal: There are several tools that can be used to monitor alcohol withdrawal symptoms and severity, including CIWA-Ar, mMINDS, and RASS; however, it's important to note that CIWA-Ar is not appropriate for patients with altered mental status or inability to self-report. Instead, use mMINDS, RASS, or other objective tools.

Treating alcohol withdrawal is about preventing brain injury, not just controlling agitation: Each withdrawal episode progressively upregulates NMDA receptors and worsens the risk of future brain hyperexcitation through a process called “kindling”. Inadequately treated brain hyperexcitation leads to neuron cell death, resulting in permanent brain damage. Therefore, effective management of alcohol withdrawal presents an opportunity to limit and prevent brain injury.

Match your pharmacology to the physiology and know what each drug is actually doing: Benzodiazepines give you GABA agonism only. Phenobarbital addresses the GABA agonism and glutamate antagonism and is much longer acting, hitting both sides of the main imbalance in the brain caused by alcohol. Dexmedetomidine helps control autonomic instability related to norepinephrine signaling but won't prevent seizures. Ketamine can directly antagonize NMDA-driven hyperexcitation when GABA-directed therapy isn't enough. Propofol gives you titratable cortical suppression once a patient requires intubation.

Front-load benzodiazepines early and monitor closely: When using benzodiazepines for severe alcohol withdrawal, give enough of the medication up-front. Falling behind is very hard to recover from; do not give a dose and walk away for hours without re-evaluation.

Always broaden your differential diagnosis: Severe alcohol withdrawal rarely occurs in isolation. Comorbid illnesses, such as infection, sepsis, trauma, or hepatitis, amplify the neurobiologic stress response and can make withdrawal look refractory when the real driver is something else.

Intubation is a high-stakes decision in this population: Intubation is a trade-off. In complex patients, such as those with advanced liver disease, active infection, or malnutrition, mechanical ventilation risks include secondary ventilator-associated pneumonia and prolonged sedation due to impaired drug clearance. The decision to ventilate should be deliberate, but once made, it should utilize titratable continuous sedation to reliably quiet brain excitation.

Hospitalization is an opportunity for engagement: AWS stabilization is not alcohol use disorder (AUD) treatment, and getting a patient safely through withdrawal is necessary but not sufficient. Withdrawal management should be a bridge to longitudinal AUD care, including shared decision-making, addiction consultation, and medications for AUD.

🔗 Resources

Advanced Management of Alcohol Withdrawal: Case-Based, Evidence-Informed Solutions Annual Conference Session: Register HERE

Handouts from session:

Yale New Haven Health System Phenobarbital Guidance

Supplemental Content from Wolpaw et al, 2025

PCSS MAUD Education: Free, comprehensive training, guidance, resources, and mentoringon the prevention, diagnosis, and treatment of AUD.

Assessment and Management of Alcohol Withdrawal – Online Course

Medication Matters: Selecting the Right MAUD and Optimizing Outpatient Medically Managed Withdrawal – Online Course

Who is at Risk of Alcohol Withdrawal? Management in Ambulatory Care – Online Course

Medications for Alcohol Use Disorder: Considerations for Patients with Comorbid Conditions – Digital Resource

Outpatient Management of Alcohol Withdrawal – Digital Resource

Treatment of Severe and Complicated Alcohol Withdrawal Syndrome – Digital Resource

Alcohol Withdrawal Syndrome in the Emergency Department – Mini Video

Hospital-wide Implementation, Clinical Outcomes, and Safety of Phenobarbital for Alcohol Withdrawal. Wolpaw BJ, Oren HO, Quinnan-Hostein et al. JAMA Netw Open. 2025;8(8):e2528694. doi:10.1001/jamanetworkopen.2025.28694 2025

Phenobarbital for Alcohol Withdrawal Syndrome Dosing Guidelines - Yale New Haven Health; 2020. Accessed April 28, 2026. PDF

The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management - American Society of Addiction Medicine. J Addict Med. 2020;14(3S Suppl 1):1-72. doi:10.1097/ADM.0000000000000668

CIWA-Ar – The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is a validated, 10-question tool used to objectify the severity of alcohol withdrawal.

mMINDS - The Modified Minnesota Detoxification Scale (mMINDS) is a 9-item tool to objectively score symptoms for patients with alcohol withdrawal.

RASS - The Richmond Agitation-Sedation Scale (RASS) is a 10-point scale used to objectively assess agitation and sedation levels in patients who cannot communicate.

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In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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