What Is the Treatment for Alcohol Withdrawal?

What Is the Treatment for Alcohol Withdrawal?

Symptoms of Withdrawal.

When a person with alcoholism stops drinking, withdrawal symptoms begin within six to 48 hours and peak about 24 to 35 hours after the last drink. During this period the inhibition of brain activity caused by alcohol is abruptly reversed. Stress hormones are over-produced and the central nervous system becomes over-excited. About 5% of alcoholic patients experience delirium tremens, which usually develops two to four days after the last drink. Symptoms include fever, rapid heart beat, either high or low blood pressure, extremely aggressive behavior, hallucinations, and other mental disturbances.

Treatment of Withdrawal Symptoms.

Upon entering a hospital, patients should be given a physical examination for any injuries or medical conditions and should be treated for any potentially serious problems, such as high blood pressure or irregular heartbeat. The immediate goal of treatment is to calm the patient as quickly as possible. Patients are usually given one of the anti-anxiety drugs known as benzodiazepines, which relieve withdrawal symptoms and help prevent progression to delirium tremens. An injection of the B vitamin thiamine may be given to prevent Wernicke-Korsakoff syndrome. Patients should be observed for at least two hours to determine the severity of withdrawal symptoms. Physicians may use assessment tests, such as the Clinical Institute Withdrawal Assessment Scale (CIWA), to help determine treatment and whether the symptoms will progress in severity. Older people with alcoholism are not at higher risk for more severe symptoms than younger patients, but they may suffer more complications during withdrawal, including delirium, falls, and a decreased ability to perform normal activities.

Treatment for Mild to Moderate Withdrawal Symptoms.

About 95% of people have mild to moderate withdrawal symptoms, including agitation, trembling, disturbed sleep, and lack of appetite. In 15% to 20% of people with moderate symptoms, brief seizures and hallucinations may occur, but they do not progress to full-blown delirium tremens. Such patients can nearly always be treated as outpatients. After being examined and observed, the patient is usually sent home with a four-day supply of anti-anxiety medication, scheduled for follow-up and rehabilitation, and advised to return to the emergency room if withdrawal symptoms become severe. If possible, a family member or friend should support the patient through the next few days of withdrawal.

Treatment for Delirium Tremens, Seizures, and Other Severe Symptoms.

People with symptoms of delirium tremens must be treated immediately. Untreated delirium tremens has a fatality rate that can be as high as 20%. They are usually first given intravenous anti-anxiety medications and their physical condition is stabilized. It is extremely important that fluids be administered. Restraints may be necessary to prevent injury to themselves or others. Seizures are usually self-limited and treated only with a benzodiazepine. Intravenous phenytoin (Dilantin) along with a benzodiazepine may be used in patients who have a history of seizures, who have epilepsy, or whose seizures cannot be controlled. Because phenytoin may lower blood pressure, the patient's heart should be monitored during treatment. For hallucinations or extremely aggressive behavior, antipsychotic drugs, particularly haloperidol (Haldol), may be administered. Lidocaine (Xylocaine) may be given to people with disturbed heart rhythms.

Drugs Used for Mild to Moderate Withdrawal Symptoms.

Benzodiazepines. Benzodiazepines are anti-anxiety drugs that inhibit nerve-cell excitability in the brain. They relieve withdrawal symptoms and make it easier for patients to remain in treatment. The drugs may be administered intravenously or orally, depending on the severity of symptoms. For most adults with alcoholism, the longer-acting drugs, such as diazepam (Valium) or chlordiazepoxide (Librium), are usually prescribed. To prevent seizures, the physician may give the patient an initial, or loading, dose of the long-acting drug diazepam with additional doses given every one to two hours thereafter over the period of withdrawal. This regimen can cause very heavy sedation. People with serious medical problems, particularly respiratory disorders, may be given repeated doses of shorter-acting benzodiazepines, such as lorazepam (Ativan) and oxazepam (Serax); these drugs can be withdrawn immediately at any sign of trouble. Some physicians question the use of any anti-anxiety medication for mild withdrawal symptoms. Others believe that repeated withdrawal episodes, even mild forms, that are inadequately treated may result in increasingly severe episodes with seizures and possible brain damage. Benzodiazepines are usually not prescribed for more than two weeks or administered for more than three nights per week. Tolerance to these drugs may develop after as little as four weeks of daily use. Physical dependence may develop after just three months of normal dosage. People who discontinue benzodiazepines after taking them for long periods may experience rebound symptomssleep disturbance and anxietywhich can develop within hours or days after stopping the medication. Some patients experience withdrawal symptoms from the drugs, including stomach distress, sweating, and insomnia, that can last from one to three weeks. Common side effects are day-time drowsiness and a hung-over feeling. Respiratory problems may be exacerbated. Benzodiazepines are potentially dangerous when used in combination with alcohol. They should not be used by pregnant women or nursing mothers unless absolutely necessary.
Other Drugs for Mild to Moderate Withdrawal. Beta blockers, such as propranolol (Inderal) and atenolol (Tenormin), may sometimes be used in combination with a benzodiazepine. This class of drugs is effective in slowing heart rate and reducing tremor. Other drugs being tested are clonidine (Catapres) and carbamazepine (Tegretol). When used by themselves, they do not, however, appear to be effective in reducing seizures or delirium. Chlormethiazole, a derivative of vitamin B1, is presently used in Europe and is showing promise in reducing agitation and seizures.