TREATMENT OF ACUTE ALCOHOL WITHDRAWAL

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Traditionally, alcohol withdrawal has been treated in a hospital or another inpatient detoxification setting.  The length of admission had been about 5 days and a person would be placed into various rehabilitation programs.  With the advent of managed care, two things have happened.  The hospital stays have been reduced so that most are now two to four days in length.  Secondly, detoxification as an outpatient has been studied with good success.
          Traditionally, alcohol withdrawal has been treated in a hospital or another inpatient detoxification setting.The length of admission had been about 5 days and a person would be placed into various rehabilitation programs.With the advent of managed care, two things have happened.The hospital stays have been reduced so that most are now two to four days in length.Secondly, detoxification as an outpatient has been studied with good success.

          Traditionally, alcohol withdrawal has been treated in a hospital or another inpatient detoxification setting.The length of admission had been about 5 days and a person would be placed into various rehabilitation programs.With the advent of managed care, two things have happened.The hospital stays have been reduced so that most are now two to four days in length.Secondly, detoxification as an outpatient has been studied with good success.

Because alcohol is a nervous system depressant, the brain becomes irritable during withdrawal leading to the typical withdrawal syndrome. (See Alcohol Withdrawal Syndrome)  For this reason, the mainstay of treatment has been the use of various tranquilizers.  Tranquilizers are central nervous system depressants that have similar effects to alcohol at certain receptors in the brain.  Typically, these drugs have been chosen because they have the longest half-life and remain in the body the longest.  The result is that one can give them less frequently.  The withdrawal is more even and easier to manage.  

The most commonly used pills are chlordiazepam (Librium), diazepam (Valium), and phenobarbital. Typically 25-50 milligrams of Librium are given 4-6 times daily.  In severe cases, I have used 200 milligrams four times a day and sometimes more. 

The benefits include the reduction of anxiety, tremors, blood pressure and pulse and protection from seizures.  There are side effects.   The person could become very sedated which can lead to confusion and falling.  They could also worsen muscle coordination, a problem otherwise known as ataxia. 

Over the years this approach to treatment has resulted in physician discomfort with outpatient detoxification.  Not only did the physicians worry about medical complications and potential legal liability (What if the patient gets into an accident?), but there was a concern that the patients might abuse the tranquilizers as well.

I have performed hundreds of detoxes at home.  I find the alcohol patients are usually trustworthy.  I still insist that they be with a companion but I rarely see major problems.  One reason for this is I have an approach that minimizes the sedation, confusion and ataxia inherent in the use of tranquilizers. 

Over the past decade, there have been many studies looking at the use of certain anti-epileptic medication such as carbamazepam (Tegretol), valproic acid (Depakote) and gabapentin (Neurontin).  These drugs have been found to completely treat mild or moderate withdrawal.  In fact, several years ago Tegretol was compared head to head against Librium in mild to moderate withdrawal.  It was found to be just as effective in reducing symptoms of withdrawal while avoiding excess sedation and ataxia. In the setting of severe withdrawal, tranquilizers will still be necessary but the use of anti-epileptics will allow lower doses of tranquilizers.  When withdrawal is severe, the patient should be hospitalized.

Alcohol works by stimulating GABA receptors, which has an inhibitory effect on the brain.  These become overactive during withdrawal.  This over-activity is reduced when the tranquilizers are used.  Alcohol also has the ability to reduce activity at the NMDA-type glutamate receptors. The NMDA receptors become more active during withdrawal leading to seizures and irritability.  The anti-epileptics are believed to reduce this over-activity as well. 

The anti-epileptic drugs may cause nausea, sedation and other symptoms but usually they are tolerated during withdrawal.  They have no euphoric effects so they are not abused.  In fact, their lack of abuse makes them good drugs to consider for suppression of long-term mood disturbances that often occur after withdrawal and can lead to relapse.

In addition, certain blood pressure medications have found a role as secondary medications.  They will reduce blood pressure and pulse, tremors and agitation.  However, they offer no protection against seizures.  Therefore, they are never used alone. The drugs include Inderal, Tenormin, Lopressor and Catapres (clonidine).

Certain patients are at increased risk for seizures.  Traditionally, Dilantin was given.  However, Dilantin has never been found to be particularly good at preventing alcohol seizures. The anti-epileptics mentioned above do help with alcohol related seizures.  However, the tranquilizers have a better track record of preventing seizures that they have become the treatment of choice when there is a significant history of seizures.  When there is a significant history of seizures, I usually want a person in a hospital for a few days.

Vitamin supplementation, especially with thiamine or B-1, is important.  Lack of thiamine is known to cause significant neurological problems.  I also like to make sure folate is supplemented as well.  Other minerals may need to be given as well.  Magnesium may get depleted and such depletion may not be routinely checked for.

In addition, there are a myriad of other symptoms during withdrawal and I prescribe medications for symptomatic relief.  Nausea and vomiting are treated with appropriate medications; I usually use Zofran, which is potentially safer than other types of anti-nausea medicine.  Diarrhea can be treated with Imodium.  Stomach upset can be treated with antacids and medications like Zantac or Prilosec.   

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