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 ymptoms of alcohol withdrawal Clinical Features of Delirium tremens (DT’s), the most (AW) may range in severity from Alcohol Withdrawal intense and serious syndrome associated Smild tremors to massive convulsions with AW, is characterized by severe (e.g., withdrawal seizures). Mild AW The symptoms of AW reflect overac- agitation; tremor; disorientation; per- can cause pain and suffering; severe tivity of the autonomic nervous system, sistent hallucinations; and large AW can be life-threatening. The goals a division of the nervous system that increases in heart rate, breathing rate, of AW treatment are to relieve the helps manage the body’s response to pulse, and blood pressure. DT’s occur patient’s discomfort, prevent the occur- stress. The signs and symptoms of in approximately 5 percent of patients rence of more serious symptoms, and AW typically appear between 6 and undergoing withdrawal and usually forestall cumulative effects that might 48 hours after heavy alcohol con- appear 2 to 4 days after the patient’s worsen future withdrawals. Withdrawal sumption decreases. Initial symptoms last use of alcohol. treatment also provides an opportu- may include headache, tremor, sweat- nity to engage patients in long-term ing, agitation, anxiety and irritability, alcoholism treatment. nausea and vomiting, heightened HUGH MYRICK, M.D., is an assistant This article explores the manage- sensitivity to light and sound, disori- professor of psychiatry and RAYMOND F. ment of AW and co-occurring con- entation, difficulty concentrating, ANTON, M.D., is a professor of psychia- ditions, evaluates different treatment and, in more serious cases, transient try at the Medical University of South settings and medications, and addresses hallucinations. These initial symptoms Carolina, Department of Psychiatry, considerations in treating special of AW intensify and then diminish Center for Drug and Alcohol Programs, populations. over 24 to 48 hours. Charleston, South Carolina. 38 Alcohol Health & Research World Treatment of Alcohol Withdrawal Seizures occur in up to 25 percent role in metabolism, electrolyte disturb- source to prevent precipitation of of withdrawal episodes, usually beginning ances may lead to severe and even Wernicke syndrome by depletion of within the first 24 hours after cessation life-threatening metabolic abnormalities. thiamine reserves. of alcohol use. For more detail on the A causal relationship has been postu- signs and symptoms of AW, see the lated between low magnesium levels article by Trevisan et al., pp. 61–66. and the occurrence of seizures or delir- Treatment Settings for ium. Although such an association has Alcohol Detoxification not been verified, magnesium suppl- Supportive Care for ments may help improve general with- Patients with AW can be treated safely Alcohol Withdrawal drawal symptoms. and effectively either within a hospital Some alcoholics exhibit vitamin or clinic (i.e., inpatient treatment) or Certain medical disorders that com- deficiencies, presumably because of on an ambulatory basis (i.e., outpatient monly co-occur with alcoholism can poor dietary habits as well as from treatment). Although studies have exacerbate symptoms of AW or com- alcohol-induced changes in the digestive compared the effectiveness of outpa- plicate its treatment. The purpose of tract that impair the absorption of tient versus inpatient detoxification, supportive care is to treat such disorders nutrients into the bloodstream. Two no specific criteria have been rigor- and to remedy nutritional deficiencies. dietary factors of particular importance ously tested. Patients with AW should be subject to in AW are folic acid and thiamine. a physical examination, with particular Folic acid plays a role in the synthesis emphasis on detecting conditions such of the cell’s genetic material and mat- Outpatient Treatment as irregular heartbeat (i.e., arrhythmia), uration of certain blood cells. Folic acid Before the 1980’s, AW was generally inadequate heart function (i.e., con- deficiency can lead to changes in blood treated in an inpatient setting. Today, gestive heart failure), liver disease cells, including a form of anemia. Patients most detoxifications take place on an (e.g., alcoholic hepatitis), pancreatic undergoing AW should be adminis- outpatient basis. In a review of pub- disease (i.e., alcoholic pancreatitis), tered an oral multivitamin formula lished studies, Abbott and colleagues infectious diseases (e.g., tuberculosis), containing folic acid for a few weeks. (1995) concluded that fewer than 20 bleeding within the digestive system, Thiamine plays an essential role in percent of patients undergoing AW and nervous system impairment. the body’s energy metabolism. Thiamine require admission to an inpatient unit. Vital signs (e.g., heartbeat and blood deficiency in alcoholics is a factor in In addition, more than 70 percent of the development of Wernicke syn- pressure) should be stabilized and participants undergoing outpatient disturbances of water and nutritional detoxification complete the program. balances corrected. In most studies, 50 percent of the The presence of water in the blood The symptoms patients continued in alcoholism treat- and within cells is essential for the ment after outpatient detoxification. performance of physiological processes of AW reflect Most importantly, this review found and to maintain both heart and kidney overactivity of the no reports of serious medical compli- function. Some patients undergoing cations among AW outpatients except AW may require intravenous fluids to autonomic that one patient suffered a seizure correct severe dehydration resulting nervous system. after the start of detoxification. from vomiting, diarrhea, sweating, No specific criteria exist for deciding and fever. Conversely, many AW patients which patients could benefit from may retain excess water in their blood outpatient detoxification. Practical and tissues. In these patients, intra- drome, a condition characterized by considerations suggest that candidates venous administration of liquid may for outpatient treatment should exhibit overload the heart’s ability to pump severe confusion, abnormal gait, and paralysis of certain eye muscles. In addi- only mild to moderate AW symptoms, blood, leading to heart failure. In most no medical conditions or severe psy- cases, water balance can be maintained tion, Wernicke syndrome can progress to an irreversible dementia. All patients chiatric disorders that could complicate by oral administration of fluids. the withdrawal process, and no past Alcoholics are often deficient in being treated for AW should be given 100 milligrams (mg) of thiamine as history of AW seizures or DT’s. In electrolytes, or “minerals” (e.g., mag- soon as treatment begins and daily addition, candidates for outpatient nesium, phosphate, and sodium). during the withdrawal period.1 Supplies detoxification should have a sober Because these substances play a major of thiamine stored in the body are significant other to serve as a reliable support person. Ambulatory AW 1 limited even in the absence of alco- A dose of 100 mg thiamine is equivalent to that patients should report to their treatment available in the highest potency nonprescription holism. Therefore, thiamine should vitamin B complex supplements. By contrast, always be administered before giving center daily so that the clinician can the daily requirement is approximately 1.5 mg. an alcoholic patient glucose as an energy reassess the patient’s symptoms, the Vol. 22, No. 1, 1998 39 occurrence of medical complications, with mild withdrawal symptoms may Pharmacological and ongoing treatment effectiveness. benefit from supportive care alone. In Management the context of nonpharmacological Inpatient Treatment therapy, supportive care consists of Pharmacological treatment is most providing patients with a quiet envi- frequently employed in moderate to Inpatient detoxification provides the ronment, reduced lighting, limited severe AW. Although more than 150 safest setting for the treatment of AW, interpersonal interaction, nutrition medications have been investigated because it ensures that patients will be and fluids, reassurance, and positive for the treatment of AW, clinicians carefully monitored and appropriately encouragement. disagree on the optimum medications supported. Compared with outpatient Supportive care does