# Management algorithm for alcohol withdrawal syndrome, alcohol dependence (AD) and AD with anxiety in the Indian population: a narrative review with expert opinion

## TL;DR

This paper provides a management algorithm for alcohol withdrawal, alcohol dependence, and co-occurring anxiety in India, based on expert opinions and literature.

## Contribution

A novel management algorithm for alcohol-related disorders in the Indian context, integrating expert consensus and literature.

## Key findings

- Physicians and psychiatrists should use distinct diagnostic tools to differentiate AWS, AD, and AD with anxiety.
- Benzodiazepines like chlordiazepoxide are recommended for detoxification in AWS and AD.
- Collaboration between physicians and psychiatrists is crucial for managing severe cases and preventing relapse.

## Abstract

Alcohol dependence (AD) is associated with several physical and psychiatric implications such as those observed in alcohol withdrawal syndrome (AWS) and AD with co-morbid anxiety. With the increasing burden of AD in India, both physicians and psychiatrists face unique challenges while managing patients with AWS, AD, and AD with anxiety. Physicians are often the first point of contact for patients presenting with alcohol use-related medical complications but lack clear management directives that distinguish their role from that of psychiatrists. To address this need gap, a series of five focus group discussions were conducted with a total of 57 expert physicians and psychiatrists. The expert opinions are presented along with supporting evidence from current literature based on a comprehensive literature review. This practice and policy review presents guidance for physicians and psychiatrists on the optimal screening, diagnosis, and treatment pathways to follow for patients presenting with each of the three indications. It highlights the importance of accurately diagnosing and distinguishing the three indications by using distinct inventories of presenting symptoms, questions to be asked as a part of comprehensive history-taking of the patient, screening questionnaires and tools, and laboratory investigations. It also discusses the roles of different classes of drugs in addressing the diverse presentations and comorbidities associated with each indication. Benzodiazepines, especially long-acting ones like chlordiazepoxide, remain the mainstay for detoxification protocols for both AWS and AD. Physicians need to work in conjunction with psychiatrists and refer the patient when required, based on distinct criteria such as severity of psychiatric comorbidities, complications of withdrawal, and behavioral issues leading to persistent alcohol use and relapses. The application of this holistic management approach that encompasses the multifaceted nature of alcohol-use related disorders will help reduce relapse rates and ensure optimal patient outcomes.