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Medication in the Treatment of Alcohol Dependence Jonathan Chick

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Medication in the Treatment of Alcohol Dependence Jonathan Chick Advances in Psychiatric Treatment (1996), vol.2, pp. 249-257 Medication in the treatment of alcohol dependence Jonathan Chick Social,cultural, emotional and biologicalinfluences and certainly in the non-elective situation where determine whether people drink to excess and the drinker has suddenly been deprived of alcohol whether they then experience harm or cause harm because of an accident, illness or police arrest, all to others (Cook, 1994).Psychosocial treatments for care must be taken to prevent the life-threatening alcohol dependence are only modestly successful, complications of convulsions or delirium. Antici with most studies finding that at least 50% of pation is the key. patients return to harmful drinking in the following year. In the past decade there has been new evidence for the role of pharmacological treatments When and how in reducing harm from drinking and in preventing relapse. Some out-patients succeed in reducing their However, none of the treatments described here drinking in gradual steps. Benzodiazepines are is recommended as a solo therapy. Social and indicated if withdrawal symptoms promise to be psychological factors in treatment for alcohol too uncomfortable for the patient to control the urge dependence are crucial. Firstly, the chief patient to seek alcohol, or there is a risk of delirium or variables predicting good outcome are having a job convulsions indicated by past history, or recent and a supportive relationship. Secondly, the most consumption was more than 15 units per day for powerful therapy variable to date is therapist more than 10days. empathy. Finally, compliance with medication In-patient detoxification is indicated where there hinges on the patient's understanding and moti is a history of convulsions, incipient delirium or a vation, both of which are enhanced by family living situation inimical to abstinence. When support and attitudes, and the therapist-patient medication is not started until the day after the last relationship (Box1). drink in a severelydependent patient, as sometimes is the case in medical and surgical settings, large or frequent doses will be needed initially to titrate sedation against agitation with up to 200 mg Assisted withdrawal chlordiazepoxide or 80 mg diazepam being re quired in the first 24 hours. If the patient is vomiting, give metoclopropa- mide, 10mg intramuscularly 30minutes before the Aims first of the benzodiazepine tablets. Lorazepam 1 mg isabsorbed adequately from the intramuscular site, Electively,the psychiatrist and alcohol-dependent and diazepam 10mg can be given intravenously patient may decide to facilitate commencing (Shaw, 1995). abstinence by reducing the short-term discomfort A typical out-patient regime would be chlordi of withdrawal. This can be the beginning of azepoxide 20-30 mg q.i.d., or diazepam 10 mg restructuring thoughts and lifestyle towards long- q.i.d. in the first 36hours, reducing to nil over five term abstinence. Even in elective 'detoxification', days, giving the larger doses at night. Medication Jonathan Chick, FRCP Ed., FRCPsych, is Consultant Psychiatrist, Alcohol Problems Clinic, Royal Edinburgh Hospital, and Senior Lecturer, Department of Psychiatry, Edinburgh University. While working for the Medical Research Council he studied the evolution of alcohol problems in distillery and brewery workers and company directors. This led to research into early detection and brief intervention for drinking problems and later to the evaluation of treatments for severely dependent drinkers. APT (1996), vol. 2, p. 250 Chick More than three litres of fluid could be too much. Don't drink more than three cups of Box 1. Factors demonstrated to improve treatment outcome coffee or five cups of tea. These contain caffeine which disturbs sleep and causes Patient is employed and has a supportive nervousness. living arrangement (3) Aim to avoid stress. The important task is not Therapist empathy to give in to the urge to take alcohol. Help Coping skills and social skills training yourself relax by going for a walk, listening Supervised disulfiram to music or taking a bath. Naltrexone (4) Sleep. You may find that even with the cap Acamprosate sules, or as they are reduced, your sleep is (Alcoholics Anonymous: not shown in disturbed. You need not worry about this - controlled studies, but powerfully effec lack of sleep does not seriously harm you, tive for some) starting to drink again does. Your sleep pattern will return to normal in a month or so. It is better not to take sleeping pills so that your natural sleep rhythm returns. Try going is issued on the understanding that the patient does to bed later. Take a bedtime snack or milky not also take alcohol. If there is doubt that this drink. instruction will be followed, medication is issued (5) The capsules may make you drowsy so you daily and a check made that drinking has not been must not drive or operate machinery. If you resumed using an alcohol breath test, if a get drowsy, miss out a dose. breathalyser is available. As required, additional (6) Meals. Even when you are not hungry, try to doses may be needed in the first 48 hours (Table 1). eat something. Your appetite will return. Advice to a patient withdrawing from alcohol at home Complications (1) If you have been chemically dependent on alcohol, stopping drinking causes you to get Wernicke-Korsakoff syndrome tense, edgy, perhaps shaky or sweaty, and unable to sleep. There can be vomiting or Wernicke-Korsakoff syndrome seems often to be diarrhoea. This 'rebound' of the nervous precipitated by hospital admission and withdrawal system can be severe. Medication controls the from alcohol. The physiological stress of with symptoms while the body adjusts to being drawal may contribute; as may resuming intake without alcohol. This usually takes three to of carbohydrates, breakdown of which requires seven days from the time of your last alcoholic enzymes dependent on thiamine and uses up drink. If you didn't take medication, the remaining stores of that essential component of symptoms would be worst in the first 48 neuronal metabolism. It is good preventive hours, and then gradually disappear. This is practice to prescribe thiamine 200 mg orally daily why the dose starts high and then reduces. during the withdrawal phase. If the patient is ataxic (2) YOU HAVE AGREED NOT TO DRINK or obviously malnourished, give thiamine paren- ALCOHOL. You may get thirsty. Drink fruit terally. The currently available vitamin B injection, juices and water but do not overdo it. You Tabrinex', has not acquired a reputation for allergic do not have to 'flush' alcohol out of the body. reactions, but administration should be in a setting where resuscitation facilities are available in case of anaphylactic shock. Anaphylaxis is less likely Table 1. Example of dose regime for alcohol with intramuscular than intravenous injection, and withdrawal using capsules of chlordiazepoxide of the intravenous routes perhaps slow infusion 10 mg saline drip is preferable to slow bolus injection. First thing 12 noon 6 p.m. Bedtime Treating Wernicke-Korsakoff syndrome. If confusion, incontinence, ataxia or strabismus are noted in a Day! 3 3 patient withdrawing from alcohol, intravenous Day 2 2 2 3 thiamine must be given immediately and hypogly- Day3 2 1 2 caemia considered. Then, consideration may given Day 4 1 1 2 to other potential causes, such as subdural haema- Day5 1 1 toma or hepatic encephalopathy. Alcohol dependence APT (1996), vol. 2, p. 251 Convulsions of delirium tremens resolve. Abstinence plus chlor- promazine (e.g. 50-100 mg b.d.) or other major Deaths have occurred in hospital, prison and police cells from bursts of alcohol withdrawal fits. Elective tranquilliser usually results in complete recovery withdrawal from alcohol in patients with a history over the coming months, permitting withdrawal of fits of any cause can be made safer by commen of the medication. However, a proportion of such cing an anticonvulsant (e.g. phenytoin or carba- illnesses persist and are later diagnosed as mazepine) four days before cessation of drinking. schizophrenia or affective psychosis (Cutting, 1978). This permits a therapeutic serum level to be achieved in good time. Alternatively, larger than Which sedative? normal doses of long-acting benzodiazepines are given in the first 36 hours, and should be started The longer-acting benzodiazepines, diazepam and not after the blood alcohol level has fallen to zero chlordiazepoxide, are the most successful in but before. If the patient is sober enough to reducing anxiety and the risk of convulsions. Both cooperate appropriately with admission, the have active metabolites, which themselves require psychiatrist should commence benzodiazepines excretion by the liver and so may cause a cumula while the patient still smells of alcohol. tive over-sedation in the elderly or those with liver A patient died at 6 p.m. in a convulsion having been failure, unless progressive reduction is made admitted at 12 noon to a psychiatric ward. The nurses, appropriately. Lorazepam and oxazepam have adhering to the prescribed 6 hourly regime, had waited intermediate half-lives and do not produce active until 6 p.m. to give him his first dose of sedative. metabolites, being inactivated and eliminated by Treating convulsions. With the aim of preventing simple glucuronidation. Dosage may be harder to further convulsions, the patient is given 10 mg titrate than for diazepam or chlordiazepoxide. diazepam intravenously or rectally. Give double Withdrawal symptoms can be controlled with the dose in a patient who has been taking benzo chlormethiazole. It has the disadvantage that it is diazepines regularly prior to this event, or is much relatively short-acting (elimination half-life 3-6 above average weight. A convulsion may presage hours). It should not be given to out-patients a severe withdrawal syndrome, and parenteral because of the risk of respiratory depression, if thiamine should be given.
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