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
- Renal insufficiency (eGFR<60)
Step 3: Prescribe medication to reduce craving and relapse.
Oral: 25-50 mg daily
- Any opioid use (pills, heroin, methadone, buprenorphine)
- Acute liver injury with AST or ALT >250
- Alternative: Acamprosate 333mg TID PO
-Sub-Cutaneous Depot: "Vivitrol"
- For patients with >3 ED visits in last year for alcohol issues
- Discuss with SUN team first
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 SUN@alamedahealthsystem.org
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