Step 1: Always, Always, Always treat acute withdrawal completely

     - Phenobarbital is preferred generally

- Dose empirically based on severity 

- Generally do not switch to benzodiazepines 

- For severe cases, consider adjuncts such as dexmedetomidine, valproate, and ketamine

- For mild cases, consider oral phenobarbital

Step 2: Prescribe medication for protracted withdrawal. 

     - Gabapentin 600 mg TID if severe may start at 1200 mg TID

     - Contraindications: 

          - Renal insufficiency (eGFR<60)

Step 3: Prescribe medication to reduce craving and relapse.

     - Naltrexone

Oral: 25-50 mg  daily 

     - Contraindications: 

- Any opioid use (pills, heroin, methadone, buprenorphine)

- Acute liver injury with AST or ALT >250

- Alternative: Acamprosate 333mg TID PO

-Intramuscular extended release Depot: "Vivitrol"

- For patients with >3 ED visits in last year for alcohol issues


Stay up and lateral (away from sitting pressure points), get into the butt muscle

It hardens fast; be ready to inject when you mix

- Discuss with SUN team for any advice or assistance

Step 4: Contact the Substance Use Navigator (SUN) 

    - (day hours) Call or text 510-545-2765, page 510-718-5604

    - route chart to AHS Bridge" or email   

Step 5: At Bridge Clinic follow up

*For pregnancy please contact the SUN for referral to treatment with addiction specialist, rather than starting algorithm above