Alcohol withdrawal syndrome is a condition that can affect individuals who are heavy drinkers. With the increasing amount of alcohol consumption, the body adapts and becomes more tolerant. The brain eventually becomes dependent on it and when alcohol is cut off, the individual may experience withdrawal symptoms that can range from mild to severe. There are three stages of symptoms based on severity: mild, moderate and severe. Symptoms usually include anxiety, vomiting, increased heart rate, low grade fever, sweating, and sleep disturbances.  Alcohol withdrawal treatment can be a serious medical situation that requires close supervision. For those wanting to know how to detox from alcohol safely, it is important to note that this should usually not be attempted at home or without proper medical attention.

Initial Goals of Alcoholism Treatment [1]

According to the American Society of Addiction Medicine, there are three immediate goals for a patient undergoing the detoxification of alcohol. These three goals are:

  • Providing a safe detox and withdrawal from alcohol and to enable the patient to eliminate the substance from their system
  • Providing a humane alcohol withdrawal treatment regimen while protecting the dignity of the patient
  • Preparing the patient for long-term continuous treatment for dependence on alcohol

Treatment and Management of Alcohol Withdrawal

In patients with mild to moderate symptoms or those that do not require an intense detox regimen, they can opt to be treated as an outpatient (no overnight stays). This can be advantageous as it costs less [2-4]. Outpatients need to be assessed every day and instructions regarding the medication and its’ side effects must be given to the patient.  However, patients with a history of severe alcohol withdrawal symptoms, those with existing medical illness, pregnancy, poor support, and multiple past withdrawal episodes should be treated as an inpatient [5].

The patient should first be assessed. Abnormalities in electrolytes (the sodium, potassium, calcium, and other levels in the blood), nutrition, and fluid levels should first be corrected. In severe cases of withdrawal, these corrections may be needed as the excessive loss through the withdrawal symptoms such as sweating and vomiting can cause imbalance and dehydration. Multivitamins should be provided as patients with alcohol withdrawal tend to have thiamine deficiency.

Regimes – can be administered via fixed schedule or symptom-triggered regimens:

  1. Fixed schedule: doses of benzodiazepine administered at specific times with additional doses given as needed based on the severity of the symptoms
  2. Symptom-triggered regimen: medication is only given when needed, based on symptoms. Studies have found that this regimen can result in less medication being administered and a shorter treatment duration [6,7]. However, it requires the presence of trained staff. If not available, fixed scheduling should be used instead [8].

 Medication – there are several classes of medication that can be used in patients with alcohol withdrawal syndrome:

  1. Benzodiazepines: have been shown to be both effective and safe, especially when used in the prevention or treatment of seizures and delirium associated with alcohol withdrawal. It is the preferred class of medication for these patients [8]. High dosages of benzodiazepines are rarely needed. Examples of benzodiazepines include Diazepam, Chlordiazepoxide, Lorazepam and Oxazepam.
  2. Anti-epileptic drugs [9]: are also used in the treatment of alcohol withdrawal symptoms. Some studies have also shown that they are better than benzodiazepines in treating the anxiety and depression associated with alcohol withdrawal. One study has found that Carbamazepine is an excellent alternative to benzodiazepines in the treatment of mild to moderate symptoms. It has been shown to reduce alcohol cravings after withdrawal, be relatively non-sedating, and have low potential for abuse [10].
  3. Adjuncts: are medications that can be used to aid in the treatment of withdrawal symptoms. They should not be used on their own. For example, the use of Haloperidol (anti-psychotic) can help to reduce agitation and hallucinations. The use of beta blockers is helpful in patients who have an underlying heart condition. Topiramate can also be useful to reduce cravings and increase abstinence.

Follow-up [11] – is needed after the treatment of alcohol withdrawal. The patient should be treated for alcohol dependence to address the underlying issue of alcohol addiction. Some support groups such as Alcoholic Anonymous and Narcotics Anonymous have been found to be extremely effective. These groups and inpatient rehabilitation treatment centers may offer the 12-step model, cognitive behavioral therapy, group therapy, and more. These treatment plans should also be supplemented by a tailored individualized program for each patient to maximize the chances of long-term abstinence. This is important as relapses often result in more severe withdrawal symptoms.

 Conclusion

It is important to understand that alcohol addiction is a disease, not a choice. For many individuals, breaking an alcohol addiction is not possible without the proper medical supervision, a long-term outpatient/inpatient rehab program, and ongoing encouragement from friends, family, and support groups.

There are many ongoing studies and research for the treatment of alcohol withdrawal syndrome. Medications such as Baclofen, Gabapentin, and Vigabatrin have shown promising results. Early identification of drinking problems can be done using standardized screening questions and treatment and counseling services can be offered to these patients. Alcohol withdrawal and its accompanying symptoms should not be taken lightly.  With the right medication and treatment sobriety is a very real option.

References:
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  • Hayashida M, Alterman AI, McLellan AT, O’Brien CP, Purtill JJ, Volpicelli JR, et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome.N Engl J Med. 1989; 320:358–65.
  • Hayashida M, Alterman A, McLellan T, Mann S, Maany I, O’Brien C. Is inpatient medical alcohol detoxification justified: results of a randomized, controlled study.NIDA Res Monogr. 1988; 81:19–25.
  • Stockwell T, Bolt L, Milner I, Russell G, Bolderston H, Pugh P. Home detoxification from alcohol: its safety and efficacy in comparison with inpatient care.Alcohol Alcohol. 1991; 26:645–50.
  • Myrick H, Anton RF. Treatment of alcohol withdrawal.Alcohol Health Res World. 1998; 22:38–43.
  • Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial.JAMA. 1994; 272:519–23.
  • Daeppen JB, Gache P, Landry U, Sekera E, Schweizer V, Gloor S, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial.Arch Intern Med. 2002; 162:1117–21.
  • Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal.JAMA. 1997; 278:144–51.
  • McKeon A, Frye MA, Norman D. The alcohol withdrawal syndrome. J Neurol Neurosrg Psychiatry. 2008; 79:854-862.
  • Malcolm R, Myrick H, Roberts J, Wang W, Anton RF, Ballenger JC. The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an outpatient randomized trial.J Gen Intern Med. 2002; 17:349–55.
  • Bayard M, Mcintyre J, Hill KR, Woodside J. Alcohol Withdrawal Syndrome. Am Fam Physician. 2004; 69(6):1443-1450.
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