The chronic use of alcohol causes abnormalities in the ways our body and brain work. Alcohol withdrawal refers to the physical and emotional symptoms we experience as alcohol leaves our body and these abnormalities reverse. Alcohol withdrawal usually begins 6-12 hours after the last drink, peaks at 1-2 days and then resolves in 3-5 days. Most people will experience tremulousness, anxiety, flushing, palpitations and high blood pressure. In severe cases, confusion can set in as well as hallucinations; these are serious complications that need to be discussed immediately with the doctor.
Seizures may also occur infrequently but are not a real problem unless they are multiple. A frequent problem, especially in people who are older and with long-term use, is ataxia. This refers to a worsening of coordination and balance that may take up to a week to resolve. In severe cases, this may not completely resolve. Certain medications may transiently worsen this condition.
A person undergoing withdrawal should not be alone for the first 48-72 hours. Liquid intake is to be strongly encouraged. . Small frequent bland meals are also appropriate.
Below are the medications I frequently use in treatment
1-Depakote (valproic acid) - This is an anti-seizure medication that has been shown to reduce the intensity of alcohol withdrawal. It is taken for five days. Some patients develop intestinal symptoms and a few others develop vague neurological symptoms but the majority of patients tolerate the medication well. At times, I may also substitute other similar medications such as gabapentin or carbamazepine
2-Lopressor (atenolol) - This is a blood pressure and heart medication that is able to reduce blood pressure, palpitations and tremulousness associated with the withdrawal. It is used for five days. It may be associated with excessive lowering of the pressure and lightheadedness.
3-Librium-This medicine is a central nervous system depressant that helps withdrawal; however, it can cause excessive sedation and worsen dis-coordination.
4-Vitamins- These are very important secondary to vitamin and mineral depletion that is often seen. Supplemental vitamin B1 (Thiamine) is most important to replenish (at least 100 mgs. daily during the detox process) as well as folate, and magnesium.
5-Clonidine-This medicine is occasionally used instead of Lopressor.
6-Immodeum-Many people note severe diarrhea (due to alcohol toxicity as well as withdrawal) This over the counter medication brings significant relief.
7-Zofran - This is an anti-nausea medication that is occasionally used.
In order to understand why we like to drink, we must understand what the drug does in our brain. It has three direct effects and one important indirect effect
Effect #1- Increase in GABA inhibition
GABA is a neurotransmitter that inhibits a target nerve; that is, it makes it less likely to fire. Inhibition will have a calming effect; this is how medicines like Valium work. In higher amounts it causes the dis-coordination, memory loss, dis-inhibition of behavior (which leads to impulsiveness). In dangerously high doses-people pass out and breathing can be reduced.
Increased GABA activity during withdrawal causes agitation and tremors and can lead to seizures, hallucinations and delerium tremens (DTss
Effect #2-Decrease in Glutamate Receptor Activity
Parallel to augmenting the inhibition of the GABA receptor; the drug also blocks excitatory neuro-transmitter glutamate. This is additive to the effects on GABA and contributes to the depressant effects of alcohol. During withdrawal excess activity of glutamate withdrawal also leads to agitation and is probably the major cause of hallucinations and delirium.
Due to the combined depressant effect of increased GABA and decreased glutamate- we see increasing dysfunction for the brain with increasing levels of alcohol The following are symptoms seen at different level of alcohol concentration:
.050%: (about two drinks for average weight male) Loss of emotional restraint, vivaciousness, feeling of warmth, flushing of skin, mild impairment of judgment. Of course this is the state that people are attempting to reach with occasional social use.
.100% (4 drinks) slurring of speech, loss of control of fine motor movements (such as writing), confusion, emotionally unstable,
200 mg%: (8 drinks) Very slurred speech, staggering gait. double vision, lethargic but able to be aroused by voice, difficulty sitting upright in a chair, memory loss.
300 mg/%: (12 drinks) Stuporous, able to be aroused only briefly by strong physical stimulus (such as a face slap or deep pinch),
400 %: (16 drinks) Comatose, not able to be aroused, incontinent (wets self), irregular breathing
500 %: Death possible,
Of course, with tolerance, alcoholics have less symptoms
Effect # 3- Serotonin Receptor Augmentation
The effect of alcohol is more difficult to characterize because of the myriad of different seratonin receptors. The main effect is that it increases seratonin activity at least in some of the key receptors being studied. This increases dopamine and reduces appetite. One of the characteristics of a person who is at increased risk for alcoholism is decreased seratonin levels; perhaps these decreased levels put them at risk for depression and otherwise not being satisfied. By increasing seratonin activity with alcohol, they may be self-medicating a chronic depressive or anxious state
Effect #4-Increase in B-endorphin Levels
This is a key effect to understanding the pleasurable effects of drinking. B-endorphin is the natural opiate in the brain. Alcohol seems to increase its' level which leads to a euphoric response. The endorphin in turns increases dopamine which leads us to repeat the behavior. When this effect is blocked with Naltrexone, alcoholics stop drinking
Depending on which study you choose to believe, the incidence of alcohol use disorders are over 20% of the population while alcoholism represents about half to two-thirds of these. The withdrawal from alcohol is well known and seen frequently by health professionals. There are widespread manifestations and potentially fatal complications. For this reason, no one should attempt withdrawal without medical supervision.
The first symptoms will usually begin 6-12 hours after a person’s last drink. This time frame is why patients may awake with mild withdrawal and why people may drink upon awakening. Early morning use is one of the main elements that we use to decide if a person is alcoholic. Tremors, anxiety and agitation develop as well as a significant craving for more alcohol. As time goes by, the tremors and agitation worsen. Many signs of brain and nervous system excitability begin to develop. The blood pressure and heart rate can increase. A fever can develop in severe cases. The person often appears flushed. As more time passes, hallucinations develop. Hallucinations involving the sense of touch are commonly seen. A person will often describe a crawling feeling and be deluded into thinking bugs are crawling on them. In addition, both visual and auditory (what we hear) hallucinations also occur.
Hallucinations are worrisome because they often predict the appearance of DELIRIUM TREMENS or DTs. This is a syndrome that is considered the most severe type of withdrawal and can be fatal, if untreated. It is fatal up to 10% of the time. I consider DTs to be occurring when two elements are present. First, there is a significant increase in the pulse and/or blood pressure AND second, the patient is confused or delirious. The person may not know where he is. He may not understand what is happening to him. He may not recognize familiar people. This symptoms will often not be seen until the second day of withdrawal. Many persons tell me they have experienced DTs; however, in actuality they have only experienced shakiness and agitation. When DTs occur, I place the person into a hospital intensive care unit, both to administer frequent medication as well as to give the person the attention and support they need. They are often intubated
Another serious complication of withdrawal is seizures. Again, this is an occurrence that people are often confused about. Shakes, even when severe, are not seizures and do they predict whether seizures will occur. The type of seizure mostly seen is called a Grand Mal seizure. During this occurrence, a person will often black out suddenly and be unconscious. There will then be alternating contractions and then relaxations of the body’s muscles that often lasts less than a minute. A person may bite their tongue and/or lose control of their bladders and/or bowels. They will eventually come around; but there will be a period of confusion that will last for several minutes to several hours. Because the person is unconscious, he will not remember the event; when a person tells me they remember being awake during a seizure, I know that it was probably not a seizure. The time frame for seizures is classically within 48 hours after a person stops drinking; but, it can occur up to 5 or 6 days after the last drink. If a seizure occurred after that time, I would be suspicious that there may be another problem responsible for the seizure. Also, seizures can occur without warning, even in the absence of any other symptoms of withdrawal. It can even occur while the person is drinking if there has been a decrease in the amount taken in.
By two or three days after the last drink, the severity of withdrawal begins to reverse and is mainly gone by the fourth or fifth day. Confusion caused by DTs can take a week or more to resolve. There may be other problems that take longer to resolve. Depression, which can be caused by the usage of alcohol and unmasked during withdrawal, may take up to two weeks to resolve. There is also ATAXIA. This is a problem of poor coordination and a feeling that the legs are weak. This is caused by the alcohols effect in certain areas of the brain. It may be made worse by the sedatives used for treatment of withdrawal. Ataxia can also take up to two weeks to resolve but may be permanent if the relevant parts of the brain have been seriously and permanently damaged.
There is increasing evidence that there is a persistent hyperactivity in the brain that contributes to a chronic irritability and increase in cravings. Glutamate receptors, which were inhibited in the presence of alcohol, became very hyper active during acute withdrawal. However, it is thought that these receptors remain mildly hyper active for weeks or months and this contributes to emotional issues and cravings. Opioid receptors may also be hyperactive weeks to months later which also contribute to cravings. Medication is available which is effective in treating the chronic symptoms.
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 subsequently be placed into various inpatient or outpatient rehabilitation programs.
More recently, 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 chlordiazepoxide (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 want them be with a companion for the first 48 hours, 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 receptors compensate by becoming less active. After alcohol is withdrawan, the is not inhibition of the brain so the brain become overactive during withdrawal. This over-activity is reduced when the anti-epileptics 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 with thiamine or B-1 is important. Alcohol may lead to to lack of thiamine especially in poorly nourished individuals. 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 is often not evident even when magnesium levels are checked
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.
The chronic use of alcohol causes abnormalities in the ways our body and brain work. Alcohol withdrawal refers to the physical and emotional symptoms we experience as alcohol leaves our body and these abnormalities reverse. Acute alcohol withdrawal usually begins 6-12 hours and resolves in 3-5 days. That issue is dealt with in another paper. Afterwards, chronic imbalances in brain biology as well as abnormally learned behaviors may result in prolonged cravings for alcohol whenever we are stressed, if we encounter alcohol, or if we are subjected to “triggers” that are meaningful to us as individuals. Theses cravings can be reduced with medication especially when coupled with quality counseling in a comprehensive treatment approach.
Below are the medications I frequently use in treatment. Often several drugs need to be used in combination:
Naltrexone (either as pills or as the Vivitrol shot) - This is the most effective drug. It is commonly advertised as blocking the euphoria caused by alcohol by blocking the results of an excessive b-endorphin release caused by alcohol. This is true; however, it is the lesser part of the story. After using alcohol chronically, our brain may develop hyper sensitive endorphin receptors in our prefrontal cortex- When these are stimulated we have increased cravings and impulsive behavior. Naltrexone reduces the activity of these receptors.
Topiramate- This is a mood stabilizer that reduces triggered cravings. It does this by reducing the activity of certain nerve impulses that underlie this activity (glutamate activity in the striate cortex). Cravings and drinking activity are reduced.
Campral – This is another drug that affects glutamate activity thereby reducing generalized irritability and triggered cravings. It helps, but I have found it less helpful than other agents.
Gabapentin – This is another mood stabilizer that reduces anxiety and irritability in a number of ways and has been found to be anti-craving for alcohol and variety of other substances.
N acetyl cysteine – This is an amino acid supplement available without a prescription that also stabilizes glutamate levels and reduces triggered cravings. Two pills (1200 mg) are taken twice daily.
Chantix- In those patients that are nicotine dependent, Chantix reduces both nicotine cravings & use and it reduces alcohol cravings and use.
Ultra-Low Dose Zofran- It needs to be compounded at a special pharmacy, but this has been shown to reduce alcohol use, especially in those with disease onset prior to age 25. It does this by reducing triggered dopamine release. The triggered dopamine release is one of the variables that contribute to strength of cravings.
Antabuse - This medicine is not really to help with cravings (it might do so since it slightly increases dopamine levels) However, it interferes with the breakdown of alcohol allowing for the accumulation of acetaldehyde. This will cause flushing, nausea and vomiting if more than ½ of a standard drink is consumed. Since it does not promote well-being by itself, I usually prefer to use it in combination with other medications.
Antidepressants- These have been shown to reduce drinking behaviors in those whose abuse began later in life; however, in those who began to use alcohol and/or substances in their teens and twenties, antidepressants can lead to increased use.