Treatment of alcohol withdrawal.

Treatment of Alcohol Withdrawal Hugh Myrick, M.D., and Raymond F. Anton, M.D. Appropriate treatment of alcohol withdrawal (AW) can relieve the patient’s discomfort, prevent the development of more serious symptoms, and forestall cumulative effects that might worsen future withdrawals. Hospital admission provides the safest setting for the treatment of AW, although many patients with mild to moderate symptoms can be treated successfully on an outpatient basis. Severe AW requires pharmacological intervention. Although a wide variety of medications have been used for this purpose, clinicians disagree on the optimum medications and prescribing schedules. The treatment of specific withdrawal complications such as delirium tremens and seizures presents special problems and requires further research. KEY WORDS: AOD withdrawal syndrome; treatment method; inpatient care; outpatient care; symptom; disease severity; alcohol withdrawal agents; drug therapy; delirium tremens; AODR (alcohol and other drug related) seizure; patient assessment; cormorbidity; treatment cost; benzodiazepines; adrenergic receptors; special populations; literature review S ymptoms of alcohol withdrawal (AW) may range in severity from mild tremors to massive convulsions (e.g., withdrawal seizures). Mild AW can cause pain and suffering; severe AW can be life-threatening. The goals of AW treatment are to relieve the patient’s discomfort, prevent the occurrence of more serious symptoms, and forestall cumulative effects that might worsen future withdrawals. Withdrawal treatment also provides an opportunity to engage patients in long-term alcoholism treatment. This article explores the management of AW and co-occurring conditions, evaluates different treatment settings and medications, and addresses considerations in treating special populations. 38 Clinical Features of Alcohol Withdrawal The symptoms of AW reflect overactivity of the autonomic nervous system, a division of the nervous system that helps manage the body’s response to stress. The signs and symptoms of AW typically appear between 6 and 48 hours after heavy alcohol consumption decreases. Initial symptoms may include headache, tremor, sweating, agitation, anxiety and irritability, nausea and vomiting, heightened sensitivity to light and sound, disorientation, difficulty concentrating, and, in more serious cases, transient hallucinations. These initial symptoms of AW intensify and then diminish over 24 to 48 hours. Delirium tremens (DT’s), the most intense and serious syndrome associated with AW, is characterized by severe agitation; tremor; disorientation; persistent hallucinations; and large increases in heart rate, breathing rate, pulse, and blood pressure. DT’s occur in approximately 5 percent of patients undergoing withdrawal and usually appear 2 to 4 days after the patient’s last use of alcohol. HUGH MYRICK, M.D., is an assistant professor of psychiatry and RAYMOND F. ANTON, M.D., is a professor of psychiatry at the Medical University of South Carolina, Department of Psychiatry, Center for Drug and Alcohol Programs, Charleston, South Carolina. Alcohol Health & Research World Treatment of Alcohol Withdrawal Seizures occur in up to 25 percent of withdrawal episodes, usually beginning within the first 24 hours after cessation of alcohol use. For more detail on the signs and symptoms of AW, see the article by Trevisan et al., pp. 61–66. Supportive Care for Alcohol Withdrawal Certain medical disorders that commonly co-occur with alcoholism can exacerbate symptoms of AW or complicate its treatment. The purpose of supportive care is to treat such disorders and to remedy nutritional deficiencies. Patients with AW should be subject to a physical examination, with particular emphasis on detecting conditions such as irregular heartbeat (i.e., arrhythmia), inadequate heart function (i.e., congestive heart failure), liver disease (e.g., alcoholic hepatitis), pancreatic disease (i.e., alcoholic pancreatitis), infectious diseases (e.g., tuberculosis), bleeding within the digestive system, and nervous system impairment. Vital signs (e.g., heartbeat and blood pressure) should be stabilized and disturbances of water and nutritional balances corrected. The presence of water in the blood and within cells is essential for the performance of physiological processes and to maintain both heart and kidney function. Some patients undergoing AW may require intravenous fluids to correct severe dehydration resulting from vomiting, diarrhea, sweating, and fever. Conversely, many AW patients may retain excess water in their blood and tissues. In these patients, intravenous administration of liquid may overload the heart’s ability to pump blood, leading to heart failure. In most cases, water balance can be maintained by oral administration of fluids. Alcoholics are often deficient in electrolytes, or “minerals” (e.g., magnesium, phosphate, and sodium). Because these substances play a major 1 A dose of 100 mg thiamine is equivalent to that available in the highest potency nonprescription vitamin B complex supplements. By contrast, the daily requirement is approximately 1.5 mg. Vol. 22, No. 1, 1998 role in metabolism, electrolyte disturbances may lead to severe and even life-threatening metabolic abnormalities. A causal relationship has been postulated between low magnesium levels and the occurrence of seizures or delirium. Although such an association has not been verified, magnesium supplments may help improve general withdrawal symptoms. Some alcoholics exhibit vitamin deficiencies, presumably because of poor dietary habits as well as from alcohol-induced changes in the digestive tract that impair the absorption of nutrients into the bloodstream. Two dietary factors of particular importance in AW are folic acid and thiamine. Folic acid plays a role in the synthesis of the cell’s genetic material and maturation of certain blood cells. Folic acid deficiency can lead to changes in blood cells, including a form of anemia. Patients undergoing AW should be administered an oral multivitamin formula containing folic acid for a few weeks. Thiamine plays an essential role in the body’s energy metabolism. Thiamine deficiency in alcoholics is a factor in the development of Wernicke syn- The symptoms of AW reflect overactivity of the autonomic nervous system. drome, a condition characterized by severe confusion, abnormal gait, and paralysis of certain eye muscles. In addition, Wernicke syndrome can progress to an irreversible dementia. All patients being treated for AW should be given 100 milligrams (mg) of thiamine as soon as treatment begins and daily during the withdrawal period.1 Supplies of thiamine stored in the body are limited even in the absence of alcoholism. Therefore, thiamine should always be administered before giving an alcoholic patient glucose as an energy source to prevent precipitation of Wernicke syndrome by depletion of thiamine reserves. Treatment Set (...truncated)