Complicated Alcohol Withdrawal Research Articles

Use of Gabapentin for Alcohol Withdrawal Syndrome in the Hospital Setting: A Randomized Open-Label Controlled Trial

Background/objectives: Patients hospitalized with alcohol withdrawal syndrome (AWS) are typically treated with CIWA-directed benzodiazepines to prevent complications, such as seizures and delirium tremens. Gabapentin is an evidence-based alternative to benzodiazepines in the outpatient setting, but there is limited data for hospitalized patients with AWS. This study compared fixed-dose gabapentin to CIWA-directed benzodiazepines for AWS in the hospital setting. Methods: This open-label, randomized controlled trial enrolled 88 adults from February 1, 2017 to August 16, 2020 with a risk of complicated alcohol withdrawal as defined by the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) ≥4. Patients were randomized within 16 h of admission to either fixed-dose gabapentin taper or continued CIWA-directed benzodiazepine administration. The primary outcome was the length of stay (LOS). Secondary outcomes included seizure, delirium tremens, ICU transfer, and patient-reported symptoms (alcohol cravings, anxiety, sleepiness). Results: LOS was shorter, but not statistically different in the gabapentin group compared to the benzodiazepine group. Because benzodiazepines were received in both gabapentin and benzodiazepine groups before randomization, the mean amount of benzodiazepines received in each group was also not statistically different, although the amount received by the gabapentin group was less than half of that received by the benzodiazepine group (4.3 vs. 10.6 mg, p = 0.146 by per protocol analysis). There were no statistical differences in secondary measures. Conclusions: Fixed-dose gabapentin taper showed similar outcomes compared to CIWA-directed benzodiazepines for the treatment of hospitalized patients with mild/moderate AWS, but the interpretation of the results is limited due to under-enrollment and the use of benzodiazepines in both groups pre-enrollment. Clinical trial registration: NCT03012815.

Alcohol use disorder treatment delivered outside hepatology clinic.

Alcohol use disorder treatment delivered outside hepatology clinic.

A Hospital-based Managed Alcohol Program in a Canadian Setting.

A managed alcohol program (MAP) is a harm reduction strategy that provides regularly, witnessed alcohol to individuals with a severe alcohol use disorder. Although community MAPs have positive outcomes, applicability to hospital settings is unknown. This study describes a hospital-based MAP, characterizes its participants, and evaluates outcomes. A retrospective chart review of MAP participants was conducted at an academic hospital in Vancouver, Canada, between July 2016 and October 2017. Data included demographics, alcohol/substance use, alcohol withdrawal risk, and MAP indication. Outcomes after MAP initiation included the change in mean daily alcohol consumption and liver enzymes. Seventeen patients participated in 26 hospital admissions: 76% male, mean age of 54 years, daily consumption prehospitalization of a mean 14 alcohol standard drinks, 59% reported previous nonbeverage alcohol consumption, and 41% participated in a community MAP. Most participants were high risk for severe, complicated alcohol withdrawal and presented in moderate withdrawal. Continuation of community MAP was the most common indication for hospital-based MAP initiation (38%), followed by a history of leaving hospital against medical advice (35%) and hospital illicit alcohol use (15%). Hospital-based MAP resulted in a mean of 5 fewer alcohol standard drinks daily compared with preadmission ( P = 0.002; 95% confidence interval, 2-8) and improvement in liver enzymes, with few adverse events. Participation in a hospital-based MAP may be an effective safe approach to reduce harms for some individuals with severe alcohol use disorder. Further study is needed to understand who benefits most from hospital-MAP and potential benefits/harms following hospital discharge.

Abstract- Poster

Introduction:Alcohol dependence is a prevalent health problem in India with 12-month prevalence of 2.1%. Patients with alcohol withdrawal can present with symptoms ranging from mild to severe withdrawals including withdrawal seizures and delirium tremens with significant mortality. Thus it will be beneficial to identify patients at risk for severe withdrawals for appropriate management. Previous studies have correlated drinking pattern with withdrawal severity but there are limited studies comparing social factors to the severity of withdrawal symptoms. Studies correlating age with withdrawal severity showed conflicting results- with one study showing higher severity and prolonged withdrawals in younger patients while another study showing more severity in older patients. In another study bivariate analysis showed patients who were African-American, unemployed, and homeless were more likely to develop delirium tremens. Thus we propose this study to assess financial status, legal status, employment status and social relationships in patients with complicated and uncomplicated alcohol withdrawal.Aim:To assess financial status, legal status, employment status and social relationships in patients with complicated and uncomplicated alcohol withdrawal.Methodology:Study design:hospital-based cross-sectional study.Universe of Study:All adult patients admitted to any psychiatry unit for acute management of alcohol withdrawal.Study population:Adult patients admitted to Department of Psychiatry and Drug De-addiction Centre, LadyHardinge Medical College & Smt. S. K. Hospital, New Delhi for acute management of alcohol withdrawal.Study population comprised of three groups-1. Patients with Alcohol withdrawal seizures (AWS)2. Patients with Alcohol withdrawal delirium tremens (AWDT)3. Patients with alcohol withdrawal uncomplicated (AWU)Study Duration:18 Months (November 2017 to April 2019)Data collection period:12 months (November 2017 to December 2018)During the study period, all adult patients admitted for acute management of alcohol withdrawal were assessed for inclusion in study. Those fulfilling selection criteria and willing to give consent were recruited in the study. Participants were recruited only after they were conscious, oriented and had minimal alcohol withdrawal signs/symptoms (CIWAAr <10) to ensure that they are amenable for interview. Patients were assessed for various risk factors, the social factors concerned with this study were assessed using Alcohol severity Index(ASI). Alcohol Severity Index(ASI) assessed drug and alcohol use, psychiatry and medical comorbidity and effect of alcohol use on their medical status, employment status, legal status and family relationship.Results and conclusion:The following study reveals significant differences in the legal status, financial status, employment status and social relationships among patients of complicated and uncomplicated alcohol withdrawal. However, within the two groups of complicated alcohol withdrawal, that is, alcohol withdrawal delirium tremens (AWDT) and alcohol withdrawal seizures (AWS) there were not much significant differences in the given domains assessed. The data is large and detailed results along with conclusion will be part of final presentation.

P.0629 Prophylaxis and management of complicated Alcohol Withdrawal Syndromes- approaches beyond benzodiazepines

P.0629 Prophylaxis and management of complicated Alcohol Withdrawal Syndromes- approaches beyond benzodiazepines

Risk factors associated with complicated alcohol withdrawal syndrome

Risk factors associated with complicated alcohol withdrawal syndrome

Complicated Alcohol Withdrawal-An Unintended Consequence of COVID-19 Lockdown.

AimTo assess the impact of COVID-19-related lockdown in India on alcohol-dependent persons.MethodWe examined the change in the incidence of severe alcohol withdrawal syndrome presenting to hospitals in the city of Bangalore.ResultsA changepoint analysis of the time series data (between 01.01.20 to 11.04.20) showed an increase in the average number of cases from 4 to 8 per day (likelihood ratio test: χ2 = 72, df = 2, P < 0.001).ConclusionAn unintended consequence of the lockdown was serious illness in some patients with alcohol use disorders.

Alcohol Intoxication - a Psychiatric Emergency

Alcohol intoxication is the most common psychiatric cause of admission to German emergency rooms. Many of these patients refuse inpatient observation or treatment. Therefore, the physician in charge will have to decide on how to proceed. The capacity to consent has to be clarified, especially if the patient insists on being discharged. In this context, the risks of injuries, complicated alcohol withdrawal, and aggressive or suicidal behaviour have to be evaluated. In this article, the juridical aspects and the necessary mental and physical assessments, especially in case of discharge of the patient against medical advice, are presented. Essential aspects are summarized in checklists.

Alcohol intoxication in emergency medicine

Every year more than 100,000 people with an alcohol intoxication are admitted to German hospitals. Many of them refuse inpatient observation or treatment. Therefore the physician in charge at the emergency room has to decide, how to proceed. The capacity to consent has to be judged, especially if the patient insists on being discharged. In this context the risks of injuries, complicated alcohol withdrawal, aggressive and suicidal behavior must be evaluated. In this article the juridical aspects and the necessary mental and physical assessments especially in case of discharge of the patient against medical advice are presented. Essential aspects are summarized in checklists.

Epidemiological and sociodemographic factors associated with complicated alcohol withdrawal syndrome

ObjectivesTo analyze the influence of epidemiological and sociodemographic factors in complicated alcohol withdrawal syndrome (AWS). Material and methodsA multicentre, observational prospective study was conducted on consecutively added patients with AWS hospitalised in internal medicine departments. We recorded sociodemographic, epidemiological, clinical and progression data. Complicated AWS was defined as that which progressed with seizures or delirium tremens. ResultsWe studied 228 episodes of AWS in 219 patients. The mean age was 54.5 years (SD, 11.5), and 90.8% were men. AWS was the cause for hospitalization in 39.9% of the patients. Some 27.1% of the cases presented seizures, and 32.4% presented delirium tremens. The daily quantity of alcohol ingested was 17.8 standard drink units (SD, 21.4), with 16.6 years of dependence (SD, 11.3). The pattern of alcohol abuse was regular in 82.8% of the patients. Some 38.4% of the patients were married or had a partner, and 45.6% had children. Some 72.7% of the patients were unemployed or retired. Some 68.5% had only completed primary studies. Some 4.8% consumed cannabis, 5.2% consumed cocaine and 3% consumed opioids. The independent variables related to complicated AWS were consumption of a drug other than alcohol (OR, 5.3; 95% CI 1.5–18.7), low education level (OR, 3.4; 95% CI 1.6–7.3) and hospitalization for AWS (OR, 2.9; 95% CI 1.5–5.6). The model's receiver operating characteristic area was 0.718 (95% CI 0.643–0.793). ConclusionsConcomitant drug abuse and a low educational level could help identify patients at risk of complicated AWS.

Factores epidemiológicos y sociodemográficos asociados al síndrome de abstinencia alcohólica complicado

ObjectivesTo analyse the influence of epidemiological and sociodemographic factors in complicated alcohol withdrawal syndrome (AWS). Material and methodsA multicentre, observational prospective study was conducted on consecutively added patients with AWS hospitalised in internal medicine departments. We recorded sociodemographic, epidemiological, clinical and progression data. Complicated AWS was defined as that which progressed with seizures or delirium tremens. ResultsWe studied 228 episodes of AWS in 219 patients. The mean age was 54.5 years (SD, 11.5), and 90.8% were men. AWS was the cause for hospitalisation in 39.9% of the patients. Some 27.1% of the cases presented seizures, and 32.4% presented delirium tremens. The daily quantity of alcohol ingested was 17.8 standard drink units (SD, 21.4), with 16.6 years of dependence (SD, 11.3). The pattern of alcohol abuse was regular in 82.8% of the patients. Some 38.4% of the patients were married or had a partner, and 45.6% had children. Some 72.7% of the patients were unemployed or retired. Some 68.5% had only completed primary studies. Some 4.8% consumed cannabis, 5.2% consumed cocaine and 3% consumed opioids. The independent variables related to complicated AWS were consumption of a drug other than alcohol (OR, 5.3; 95% CI 1.5-18.7), low education level (OR, 3.4; 95% CI 1.6-7.3) and hospitalisation for AWS (OR, 2.9; 95% CI 1.5-5.6). The model's receiver operating characteristic area was 0.718 (95% CI 0.643-0.793). ConclusionsConcomitant drug abuse and a low educational level could help identify patients at risk of complicated AWS.

Impact of Proactive Diazepam Loading Protocol on Clinical Outcomes Among Patients with History of Complicated Alcohol Withdrawal Syndrome

Impact of Proactive Diazepam Loading Protocol on Clinical Outcomes Among Patients with History of Complicated Alcohol Withdrawal Syndrome

Treatment Related Psycho-Social Needs Of Persons With Complicated Alcohol Withdrawal In Delirium Tremens: A Qualitative Enquiry From India

Treatment Related Psycho-Social Needs Of Persons With Complicated Alcohol Withdrawal In Delirium Tremens: A Qualitative Enquiry From India

T60 - Investigating The Role Of One-Carbon Metabolism Pathway In Complicated Alcohol Withdrawal States

Background Complicated withdrawal states in alcohol dependence syndrome (ADS) include alcohol withdrawal seizures (AWS) and delirium tremens (DT) and are associated with significant medical and psychiatric morbidity. Existing evidence suggests that in patients with chronic ADS, the associated deficiency of vitamin B12 and folic acid could lead to hyperhomocysteinemia through the inhibition of methionine synthase (MS) and methylene tetrahydrofolate reductase (MTHFR) enzymes of the one-carbon metabolism pathway. Hyperhomocysteinemia has been found to be associated with complicated alcohol withdrawal especially withdrawal seizures (AWS). The common variant of the MS A2756G gene has been found to be associated with lower plasma homocysteine levels. The homozygote variant of the MTHFR A1298C gene results in partial loss of enzyme activity. Thus, it may be worthwhile to study the above SNPs in patients with complicated alcohol withdrawal states and correlate the findings with plasma homocysteine, vitamin B12 and folate levels. Methods In our study, we aimed to investigate the association of MTR A2756G (responsible for the MS enzyme) and MTHFR A1298C polymorphisms with complicated withdrawal states i.e. AWS and delirium tremens (DT). We also measured levels of plasma homocysteine, vitamin B12 and folate in these patients. The sample consisted of a total of 150 male patients with ADS of which 84 patients had simple withdrawal state (SWS), 30 patients had DT and 36 patients had AWS. Assessments included a general physical examination, biochemistry panel, a complete blood count, assays of plasma homocysteine, vitamin B12 and folate along with genotyping for the MTR A2756G and MTHFR A1298C polymorphisms. Results There was no difference in the mean age at onset of dependence (SWS - 28.2 ± 5.7; DT - 28.2 ± 4.6; AWS - 27.9 ± 5, F = 0.03, p = 0.9). However, there was a significant association between the mean daily units of alcohol consumed and complicated alcohol withdrawal states. (SWS - 13.6 ± 3.7; DT - 19.8 ± 3.9; AWS - 17.1 ± 4.9, F = 27.8, p The study also found no differences in the serum homocysteine levels (SWS – 0.91; DT – 0.91; AWS – 0.88 nmol/ml, t = 0.9, p = 0.6), vitamin B12 levels (SWS – 274; DT – 265; AWS – 230 pg/ml, t = 1.2, p = 0.5), and folate levels (SWS – 99.3; DT – 99.1; AWS – 98.2 pg/ml, t = 2.4, p = 0.1). Although vitamin B12 and folic acid levels fell in the lower end of the normal range, no deficiency states were observed. No association was found between levels of plasma homocysteine, vitamin B12 & folic acid levels and complicated alcohol withdrawal states. No significant differences were found between the groups with respect to haematological and biochemical parameters examined. The two groups did not differ significantly with respect to genotype frequency of the SNPs examined (MTHFR A1298C and MTR A2756G). Discussion Our study finds that it is the quantity of alcohol consumed in a day that is associated with complicated withdrawal states with frequent heavy drinkers more likely to have severe withdrawal. It would be worthwhile to explore this further as no clear genetic risk factors emerged. The study was limited by its sample size, the use of cross-sectional sampling method and the exclusion of female patients from the study. However, it is one of the first studies to examine these SNPs in a south Indian population. The role of the one-carbon metabolism pathway in these states remains an important area of research with numerous possible treatment implications.

Approach to the Complicated Alcohol Withdrawal Patient.

Alcohol withdrawal syndromes are common causes for admission to the intensive care unit. As many as one-fifth of the admitted patients have an alcohol-associated disorder. Identifying the benefit of the γ-aminobutyric acid (GABA) agonists has shifted toward methods to improve benzodiazepine (BZD) utilization. Literature validating this treatment approach in severe withdrawal, especially in the critical care setting, is limited, and extrapolation to this population may be dangerous. Multiple therapies have been suggested or utilized in the literature including continuous infusion of GABA agonists, ethanol, dexmedetomidine, antiepileptics, and antipsychotics, introducing a significant amount of variability into clinical practice. This variability in treatment approaches highlights the lack of uniformity and recommendations available for the treatment of severe refractory patients. In patients progressing to severe withdrawal, it may be warranted to escalate care with adjunctive or more aggressive therapies. Although multiple practices are commonly used, the evidence supporting their use after failing symptom-triggered or aggressive therapy with BZDs is virtually nonexistent. These patients commonly receive a multimodal approach, which varies substantially between providers and institutions. Further literature should be directed at the approach most likely to provide benefit when standard of care has failed.

Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients: A New Scale for the Prediction of Complicated Alcohol Withdrawal Syndrome.

The prevalence of alcohol use disorders (AUDs) among hospitalized medically ill patients exceeds 40%. Most AUD patients experience uncomplicated alcohol withdrawal syndrome (AWS), requiring only supportive medical intervention, while complicated AWS occurs in up to 20% of cases (i.e. seizures, delirium tremens). We aimed to prospectively test and validate the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), a new tool to identify patients at risk for developing complicated AWS, in medically ill hospitalized patients. We prospectively considered all subjects hospitalized to selected general medicine and surgery units over a 12-month period. Participants were assessed independently and blindly on a daily basis with PAWSS, Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) and clinical monitoring throughout their admission to determine the presence and severity of AWS. Four hundred and three patients were enrolled in the study. Patients were grouped by PAWSS score: Group A (PAWSS < 4; considered at low risk for complicated AWS); Group B (PAWSS ≥ 4; considered at high risk for complicated AWS). The results of this study suggest that, using a PAWSS cutoff of 4, the tool's sensitivity for identifying complicated AWS is 93.1% (95%CI[77.2, 99.2%]), specificity is 99.5% (95%CI[98.1, 99.9%]), positive predictive value is 93.1% and negative predictive value is 99.5%; and has excellent inter-rater reliability with Lin's concordance coefficient of 0.963 (95% CI [0.936, 0.979]). PAWSS has excellent psychometric characteristics and predictive value among medically ill hospitalized patients, helping clinicians identify those at risk for complicated AWS and allowing for prevention and timely treatment of complicated AWS.

Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond.

Alcohol dependence is an increasing and pervasive problem. Alcohol withdrawal symptoms are a part of alcohol dependence syndrome and are commonly encountered in general hospital settings, in most of the departments. Alcohol withdrawal syndrome ranges from mild to severe. The severe complicated alcohol withdrawal may present with hallucinations, seizures or delirium tremens. Benzodiazepines have the largest and the best evidence base in the treatment of alcohol withdrawal, and are considered the gold standard. Others, such as anticonvulsants, barbiturates, adrenergic drugs, and GABA agonists have been tried and have evidence. Supportive care and use of vitamins is essential in the management. Symptom triggered regime is favoured over fixed tapering dose regime, although monitoring through scales is cumbersome. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on 'Alcohol withdrawal syndrome' in humans during the last 10 years. A total of 1182 articles came up. Articles not relevant to clinical utility and management were excluded based on the titles and abstract available. Full text articles, meta-analyses, systematic reviews and randomized controlled trials were obtained from this list and were considered for review.

Alcohol Withdrawal Treatment in the Medically Hospitalized Patient: A Pilot Study Assessing Predictors for Medical or Psychiatric Complications

Optimizing alcohol withdrawal treatment is a clinical priority, yet it is difficult to predict on presentation which patients would require benzodiazepines or in which patients withdrawal would be complicated. Detoxification studies typically exclude patients with medical comorbidities, psychiatric comorbidities, or multiple substance use disorders; therefore, it is difficult to generalize their conclusions to all types of patients. This retrospective study with no exclusion criteria identifies the risk factors for complicated withdrawal. A retrospective medical record review of 47 veterans admitted to a tertiary veteran's medical hospital for alcohol detoxification. Demographics, blood alcohol level, Charlson Comorbidity Index, drinks per drinking day, pre-psychiatry consult benzodiazepine administration, and length of stay were compared for veterans with complications vs those without. Overall, 21% patients experienced significant complications during their medically-managed detoxification, including behavioral disruptions and delirium tremens. Of the patients, 79% were initially assessed using the Clinical Institute Withdrawal Assessment for Alcohol-Revised scale, and 34% continued to be monitored with the Clinical Institute Withdrawal Assessment for Alcohol-Revised scale during their hospital stay. A Clinical Institute Withdrawal Assessment for Alcohol-Revised scale score ≥15 at presentation was significantly associated with increased odds of complications (p = 0.005). There was a trend toward significance of association of complications with tachycardia, history of delirium tremens, and benzodiazepines being administered before psychiatric consultation. The groups did not significantly differ with respect to age, admission blood alcohol level, Charlson Comorbidity Index, comorbid recent substance abuse, or length of stay. Clinical Institute Withdrawal Assessment for Alcohol-Revised scale scores ≥15 at presentation was significantly associated with increased odds of complicated alcohol withdrawal (odds ratio = 28, 95% CI: 2.5-317.6, p = 0.005), which supports findings from previous studies.

The “Prediction of Alcohol Withdrawal Severity Scale” (PAWSS): Systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome

BackgroundTo date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill. ObjectivesOur goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool. MethodsFor the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS.A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS. ResultsThe search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4. DiscussionThe results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.

Complicated alcohol withdrawal presenting as self mutilation

Self-mutilation has been defined as deliberate self injury to body tissue without the intent to die. There has been an association between substance abuse and self mutilation. Alcoholic hallucinosis is usually in auditory modality and regarded as harmless. But patients can indulge in self harm behavior when the hallucinosis is commanding type. We are presenting a case in which the patient inflicted multiple stab injury to his own abdomen in response to alcoholic hallucinosis. This has clinical implication to enquire about substance abuse in patients presenting to emergency setting.