Author: James Anderson

Alcohol Withdrawal: Symptoms, Treatment & Timeline – In-Depth Analysis

The production of these neurotransmitters is affected when a person stops or significantly reduces alcohol intake. Intravenous ethanol infusions have been used in the past, especially in surgical ICUs, as prophylaxis against alcohol withdrawal among patients with suspected or proven alcohol dependence. Retrospective, uncontrolled, noncomparative case series have reported the successful and unsuccessful use of IV ethanol in trauma and burn patients. Persons with alcoholism frequently have large total body deficits of magnesium.

Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsants. Clinical institutes withdrawal assessment-alcohol revised is useful with pitfalls in patients with medical comorbidities. Evidence favors an approach of symptom-monitored loading for severe withdrawals where an initial dose is guided by risk factors for complicated withdrawals and further dosing may be guided by withdrawal severity.

Treatment Setting

Heavy alcohol use also depletes the body of vital electrolytes and vitamins, such as folate, magnesium, and thiamine. So, treatment may also include electrolyte corrections and multivitamin fluids. In most cases, it is secondary to a general medical condition causing disturbance in the basic functions of the brain. It could be due to infection, toxic, metabolic, traumatic or endocrine disturbances. Dopamine is another neurotransmitter involved in alcohol withdrawal states.

Withdrawal treatment also provides an opportunity to engage patients in long-term alcoholism treatment. Less frequently, people can develop severe symptoms of alcohol withdrawal syndrome. Continued symptoms despite multiple doses of the prescribed medication, worsening or severe symptoms (persistent vomiting, hallucinations, confusion, or seizure), signs of oversedation, worsening psychiatric symptoms, or unstable vital signs should prompt transfer to a higher level of care. Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.

The issue of alcohol dependence should be addressed prior to hospital discharge, because detoxification from alcohol in the hospital is not sufficient to prevent a patient’s return to hazardous alcohol use. Treatment to prevent relapse frequently requires extended management over long periods of time. Alcohol cessation programs and support groups, such as Alcoholics Anonymous, should be recommended. The main management for severe symptoms is long-acting benzodiazepines — typically IV diazepam or IV lorazepam. Alcohol withdrawal can range from very mild symptoms to a severe form, known as delirium tremens.

Some people experience prolonged withdrawal symptoms, like insomnia and mood changes, that can last for weeks or months. Motivational interviewing is a type of counseling that helps people identify their reasons for wanting to change their behavior. It can be helpful for people struggling to remain motivated to quit alcohol or who are resistant to treatment for alcohol withdrawal. Generally, there are few risk factors in receiving cognitive behavioral therapy.

Management of moderate to severe alcohol withdrawal syndrome

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.

Severe and complicated alcohol withdrawal requires treatment in a hospital — sometimes in the ICU. While receiving treatment, healthcare providers will want to monitor you continuously to make sure you don’t develop life-threatening complications. Other studies have assessed the need for BZ administration based on the severity of the patient’s symptoms. These assessments have employed a standard AW scale called the Clinical Institute of Withdrawal Assessment for Alcohol, revised (CIWA-Ar) (Saitz et al. 1994). Such studies have found that when the overall dose of BZ’s is reduced, patients suffer less unwanted sedation and are therefore able to participate more readily in other treatment activities. Clearly, the CIWA-Ar is a useful instrument for quantifying AW as well as for guiding the need for medication.

1. Patients who are non-verbal (e.g. stupor due to head injury) may not be suited for this regimen as they may not be able to inform the nursing personnel if they were to experience any withdrawal symptoms.
2. Repeated episodes of withdrawal and neuroexcitation results in a lowered seizure threshold as a result of kindling[2] predisposing to withdrawal seizures.
3. In Europe, the antiseizure medications carbamazepine (Tegretol®) and valproic acid (Depakene® and others) have been used successfully to treat AW for many years.
4. Chronic use of alcohol leads to an increase in the number of NMDA receptors (up regulation) and production of more glutamate to maintain CNS homeostasis [Figure 1c].
5. Treatment of alcohol withdrawal usually involves a combination of pharmacological and supportive therapies.
6. This article explores the management of AW and co-occurring conditions, evaluates different treatment settings and medications, and addresses considerations in treating special populations.

The authors recommended that patients with moderate to severe AW symptoms be treated pharmacologically. Pharmacological treatment should also be administered to patients with a history of withdrawal seizures or in those with comorbid medical illnesses. 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.

Second, antiseizure medications have been shown to block kindling in brain cells. Fourth, these medications have been used to treat mood and anxiety disorders, which share some symptoms with AW, including depression, irritability, and anxiety. Fifth, antiseizure medications are generally not as sedating as BZ’s and therefore allow the patient to engage more quickly in alcoholism treatment programs.

What Is Alcohol Withdrawal Syndrome?

As the alcohol wears off, these effects lead to common hangover symptoms, such as headache, nausea, and fatigue. Drastic changes in blood pressure and heart rate can also develop, which may lead to a stroke or heart attack. Alcohol use disorder or drinking heavily over an extended period can change a person’s brain chemistry due to the continued exposure to the chemicals in alcohol. Frequent boluses of diazepam are given intravenously until the patient is calm and sedated. Cognitive behavioral therapy and motivational enhancement therapy (which are sometimes combined with pharmacologic therapy) have been used successfully to prevent relapse. Many involve a combination of group psychotherapy (talk therapy) and medications.

Recently, new practice guidelines were developed by the American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal (Mayo-Smith 1997). The Working Group reviewed data presented in 134 articles on the treatment of AW published between 1966 and 1995. Based on the review of data, the investigators concluded that BZ’s are “suitable agents for alcohol withdrawal.” All BZ’s appeared equally effective in treating AW symptoms. The Working Group also found that the dose of medication should be individually tailored to suit the symptom severity of each patient.

Most people with mild to moderate alcohol withdrawal don’t need treatment in a hospital. But severe or complicated alcohol withdrawal can result in lengthy hospital stays and even time in the intensive care unit (ICU). Alcohol withdrawal (alcohol withdrawal syndrome) is a range of symptoms that can happen if you stop or significantly reduce alcohol intake after long-term use.

Inpatient Treatment

Benzodiazepines are the mainstay of management of alcohol withdrawal states. STT regimen reduces dose and duration of detoxification compared with traditional fixed dose regimen in mild to moderate alcohol withdrawal. However, it is feasible only in relatively stable patients and requires periodic monitoring of the withdrawal severity by trained personnel. For management of severe withdrawals, inpatient care and SML dose is advised. Though rapid loading is advised in DT, the few trials and retrospective chart reviews in DT have used a loading dose regimen. Refractory DT can be managed with phenobarbital or adjuvant antipsychotics.