- Medical Treatment
- Psychosocial Treatment
Detoxification:It is impossible to treat alcohol dependence in patients who continue to use alcohol. The patient must be detoxified before any meaningful therapy can begin for other emotional problems. Usually this detoxification can be done as an outpatient. However, the following are the indications for inpatient detoxification:
- Failure of outpatient detoxification
- Lack of motivation
- Strong denial
- Severe impairment
- Insufficient psychosocial supports
- Living situation encourages continued substance abuse
- Risk of medically dangerous withdrawal syndromes
- Coexisting medical or psychiatric illness requiring close observation
Because of the many medical complications of alcohol withdrawal, a complete physical examination with appropriate laboratory tests is mandatory, with special attention to the liver and nervous system.
Patients withdrawing from alcohol who exhibit any withdrawal phenomena should receive a benzodiazepine (such as chlordiazepoxide or diazepam). Anticonvulsant medication is not useful in preventing or treating alcohol withdrawal convulsions; the use of chlordiazepoxide or diazepam is generally effective.
A high-calorie, high-carbohydrate diet supplemented by multivitamins is important. Dehydration must be corrected with fluids by mouth or intravenously.
Alcoholic patients in severe withdrawal should never be physically restrained as they may fight the restraints to exhaustion. When patients are disorderly and uncontrollable, a seclusion room can be used. The need for warm verbal support is imperative in the treatment of severe alcohol withdrawal. Patients in severe withdrawal are very confused and frightened – yet can dramatically calm when given sufficient verbal support.
Restrict access to addicting substances:Following detoxification, alcohol should be removed from the patient’s home, and all prescriptions written by other physicians should be discontinued. Until the patient is stronger, all family or friends that drink heavily or use illicit drugs should be avoided.
Teach the disease model of addiction:The patient and the family should be educated that addiction is an medical illness – not a moral failing. An alcoholic can never go back to drinking. In general, controlled drinking (e.g., one drink per weekend) carries a high risk of relapse. Any treatment for alcoholism must be based on total abstinence. Likewise, ALL addictive drugs should be avoided (unless they are clearly indicated for acute pain or time-limited acute anxiety).
Addictions, like many other medical disorders, are relapsing conditions that require a long-term commitment to therapy. Thus progress in therapy is often “two-steps-forward-and-one-step-back”, but the patient should not be abandoned because of a temporary “slip” back into addiction. Relapses should be dealt with in a nonjudgmental manner, and detoxification should be arranged rapidly.
Treat associated psychiatric problems: Alcohol may have been a self-treatment for another psychiatric disorder. This is especially true of addicted patients who use alcohol to treat their Psychotic Disorder, Mood Disorder, Anxiety Disorder, or Personality Disorder. Many of these coexisting psychiatric disorders have effective medical treatments which should be given.
Do unscheduled alcohol blood tests: Periodic blood tests for alcohol can be essential in identifying relapse. It is essential that these blood tests be unscheduled (to minimize the risk of “cheating”).
Encourage exercise:It is important to stress the importance of regular exercise (lasting more than 20 minutes at a time) as an alternative to craving alcohol. It is hoped that the patient will develop a dependency on exercise to replace the former dependency on alcohol as a “stress reliever”.
The standard treatment regime for alcohol withdrawal is:
- Chlordiazepoxide:25-100 mg orally four times on the first day (with a 20% decrease in dose over a 5-7 day period). This dose may have to be doubled in severe alcohol withdrawal (if agitation, tremors, or change in vital signs develop). Should status epilepticus develop; diazepam, 10 mg intravenously, usually will abort the seizure. To prevent further status postwithdrawal seizures, magnesium sulfate may be given (1 g intramuscularly every 6 hours for 2 days).
- Multivitamin: one per day. For severe alcoholics, it is imperative to supplement this with thiamine 100 mg and folic acid 1 mg – both orally four times daily for at least two weeks. These vitamins prevent the dangerous progression of alcohol withdrawal into Korsakoff’s psychosis and Wernicke’s encephalopathy.
The chlordiazepoxide or diazepam may have to be prescribed for weeks or even months to control the anxiety, restlessness, and insomnia seen in the initial stage of abstinence. The physician must carefully monitor this antianxiety drug therapy to prevent over-medication or addiction. With careful monitoring, the risk of the alcoholic becoming addicted to an antianxiety drug is remote.
More on Alcohol Withdrawal Treatment
Overall, the medications discussed above, which fall into the class of benzodiazepines, have been found to be safe and effective in many clinical trials. Several studies are suggesting that anticonvulsant (i.e., anti-seizure) medications, such as sodium valproate, carbamazepine, gabapentin, and topiramate, may be of special utility in clinical settings for certain, more-severe patients.
Alcohol withdrawal requiring medication (i.e., severe) tends to occur in those with the most heavy, prolonged, and complex alcohol use histories. However, oftentimes those individuals who need medication are the very persons for whom medications are limited in effectiveness. This is because a person can become sensitized to these drugs with repeated receipt of them. As a result, after multiple treatments, a patient may become treatment-resistant and future withdrawal episodes become harder to treat.
Additionally, these drugs themselves have significant abuse risk and some are implicated as cross-tolerant with alcohol, limiting their utility in these patients. Furthermore, withdrawal can present through a wide array of symptom combinations, some of which pose a serious threat to the mortality of the individual (e.g., seizures).
Given the risks associated with both withdrawal itself and the mediations used to treat it, extensive research attention has been paid to evaluating the effectiveness and health effects of standard pharmacological agents, as well as to developing new drugs to treat alcohol withdrawal.
Disulfiram (Antabuse) competitively inhibits the enzyme aldehyde dehydrogenase, so that even a single drink usually causes a toxic reaction due to acetaldehyde accumulation in the blood. Administration of the drug should not begin until 24 hours after the patient’s last drink. The physician must warn the patient about the drug or for as long as 2 weeks thereafter. Those who drink while taking disulfiram turn purple, become severely ill for 30 to 60 minutes (or longer) and often vomit. Patients on disulfiram may also have this same response to alcohol ingested in mouthwash, wine sauces or vinegars, or even to inhaled alcohol vapors from aftershave lotions. Disulfiram may also exacerbate psychotic symptoms in schizophrenic patients (but this is uncommon).
Disulfiram can be of critical importance in helping the alcoholic to make the essential decision to stop drinking. There should be nothing surreptitious about the use of disulfiram (i.e., no slipping the drug into the coffee by the spouse). It should be discussed with the patient, with full disclosure of its side effects and dangers. The initial dosage (after a minimum of 24 hours’ abstention from alcohol) is 500 mg/d in a single dose in the morning. This can be decreased to a maintenance dose of 250 mg/d, continued indefinitely.
Disulfiram frees the alcoholic from ruminating as to whether he should or should not have a drink and prevents the relapses that usually follow a sudden and impulsive first drink.
Studies of alcoholic patients indicated that as many as 30 percent may suffer from a Major Depression beyond the detoxification period. These patients often benefit from antidepressant medication (in doses similar to those prescribed for other clinically depressed patients). The antidepressants can be used without difficulty in patients taking disulfiram. Lithium has also been used with some success.
Hospitalization is not usually necessary or even desirable unless there are serious medical complications during alcohol withdrawal. Most alcoholics can be safely withdrawn from alcohol at home or at a detoxification center.
Antipsychotic drugs are best avoided because they may increase the risk of alcohol withdrawal seizures. Antipsychotic drugs are only used for the rare cases of alcoholic hallucinosis that fail to respond to treatment with benzodiazepines.
Arrange follow-up treatment: If an alcoholic is to remain alcohol-free, follow-up treatment, usually with psychiatric help and resort to community resources, is often vital. The patient must be seen regularly to monitor continued abstinence and adjustment.
Research is showing that patient factors such as having a stable family, stable job, less sociopathy, less psychopathology, and a negative family history for alcoholism are more powerful predictors of positive outcome that is the type of treatment (Frances et al. 1984). This research could be interpreted to mean that follow-up treatment is most needed for alcoholic patients with an unstable family, unstable job, more sociopathy, more psychopathology, and a positive family history for alcoholism.
Confront denial gradually: Aggressive confrontation too early in treatment may increase, rather than decrease, the patient’s denial of having a problem. Initially, all that the patient has to agree to is detoxification (usually done to placate the family or the physician).
The best way to confront the patient’s denial of addiction is to challenge him to “prove” that he’s not addicted by going on a one month trial period of abstinence. A successful trial period of abstinence may help the patient feel so much better that continued abstinence becomes easier. An unsuccessful trail period of abstinence proves that the alcohol use is out of control, and the therapist must then confront the patient’s denial more vigorously.
Focus psychotherapy on the patient’s addiction: Psychotherapy is most successful when it focuses on the alcoholic’s drinking. The drinking itself – past, present, and future consequences – must be given firm emphasis. Patients who insist that they need to solve their emotional problems before they stop using alcohol must be told that the alcohol is the main problem, and that other emotional problems can not be adequately treated until they first stop using alcohol.
Involve family and friends: The therapist must involve the patient’s family or friends as allies in the patient’s treatment. Family and friends are often aware of relapses that are concealed by the patient. Research has shown that patients that are encouraged or even coerced into treatment by family or friends are more likely to remain in treatment and have a better outcome than those who are not so pressured.
Therapists should routinely refer alcoholics to A.A. as part of a multiple treatment approach. Although Alcoholics Anonymous does not appeal to all alcoholics, it is obvious that the AA approach has been extremely successful with many.
A.A. meetings provide members with acceptance, understanding, forgiveness, confrontation, and a means for positive identification. New A.A. members are asked to admit to a problem, give up a sense of personal control over the disease, do a personal assessment, make amends, and help others. Telephone numbers are exchanged, and new members pick “sponsors” (more experienced members who guide them through their recovery).
Al-Anon is an organization for the spouses of alcoholics that is organized along the same lines as Alcoholic Anonymous. Alateen has been developed for the children of alcoholics so that they may better understand their parents’ alcoholism.
A residential center or halfway house is an important treatment resource for the alcoholic newly discharged from inpatient care. The halfway house provides emotional support, counselling and progressive entry into society.
Behavior therapy teaches the alcoholic other ways to reduce anxiety. Relaxation training, assertiveness training, self-control skills, and new strategies to master the environment are emphasized.
Trials of aversive conditioning – apomorphine and emetine to induce vomiting, electrical stimulation to produce pain – are no longer widely used in the treatment of alcoholism.
Psych Central. (2014). Alcohol Use Disorder Treatment. Psych Central. Retrieved on November 26, 2014, from http://psychcentral.com/disorders/alcohol-abuse-dependence-treatment/
Symptom criteria summarized from:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC: American Psychiatric Association.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
Last reviewed: By John M. Grohol, Psy.D. on 9 Jul 2014
Published on PsychCentral.com. All rights reserved.