Rapid Clinical Updates: Inpatient AUD Pearls and Adulterants in the Unregulated Supply-Handout

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This clinical update from the Society of Hospital Medicine focuses on advances in understanding and managing Alcohol Use Disorder (AUD) and emerging issues in addiction medicine.<br /><br />AUD is defined as any drinking pattern causing impairment or distress. The 3Cs model—Craving, Consequences, and loss of Control—helps identify and stratify acutely ill patients. Importantly, clinicians are urged to avoid stigmatizing language like “dependence” or “alcoholic,” favoring terms related to recovery or symptom recurrence to reduce stigma.<br /><br />Regarding withdrawal, most hospitalized patients with AUD experience mild or no withdrawal. The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) is validated for medically ill patients and has high sensitivity (93.1%) and specificity (99.5%) for identifying those at risk of complicated withdrawal. A cutting-edge concept is “kindling,” where repeated withdrawal episodes trigger escalating brain excitability and increase risks of seizures, delirium tremens, and hallucinations.<br /><br />Xylazine, an α-2 adrenergic and kappa opioid agonist causing central nervous system depression, is an emerging threat in the U.S. illicit opioid supply. Not approved for humans, it may appear unknowingly in street drugs. Management should include clinical suspicion-based treatment of xylazine withdrawal, while naloxone remains essential for opioid overdose reversal along with rescue breathing. Patients should be screened for characteristic xylazine-associated wounds, linked to harm reduction resources, offered xylazine test strips, and provided early wound care to promote healing.<br /><br />Overall, this update emphasizes non-stigmatizing approaches to AUD, advances in withdrawal risk prediction, and preparedness for emerging substances like xylazine within hospital addiction management.

Keywords

Alcohol Use Disorder

AUD

3Cs model

Craving

Consequences

Loss of Control

Alcohol Withdrawal

PAWSS

Kindling

Xylazine