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 be 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 administered.
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 post-withdrawal 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 particular use in clinical settings for more severely-afflicted 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 use. 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 efficacy 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 medications used to treat it, extensive research has focused on evaluating the effectiveness and health effects of standard pharmacological agents, as well as 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.
For more on symptoms, please see symptoms of alcohol and substance abuse.
Psychosocial Treatments (following acute alcohol withdrawal)