The Management of Alcohol Withdrawal
An important initial intervention for a substantial number of alcohol-dependent patients is the management of alcohol with-drawal through detoxification. The objectives in treating alcohol withdrawal are the relief of discomfort, prevention or treatment of complications, and preparation for rehabilitation. Successful management of the alcohol withdrawal syndrome provides a ba-sis for subsequent efforts at rehabilitation.
Careful screening for concurrent medical problems is an important element in detoxification. Administration of thiamine (50–100 mg by mouth or IM) and multivitamins is a low-cost, low-risk intervention for the prophylaxis and treatment of alco-hol-related neurological disturbances. Good supportive care and treatment of concurrent illness, including fluid and electrolyte repletion, are essential.
Social detoxification, which involves the nonpharmaco-logical treatment of alcohol withdrawal, has been shown to be effective. It consists of frequent reassurance, reality orientation, monitoring of vital signs, personal attention and general nurs-ing care. Social detoxification is most appropriate for patients in mild-to-moderate withdrawal. Increasingly, detoxification is be-ing done on an ambulatory basis, which is much less costly than inpatient detoxification Inpatient detoxification is indicated for serious medical or surgical illness, and for those individuals with a past history of adverse withdrawal reactions or with current evidence of more serious withdrawal (e.g., delirium tremens).
A variety of medications have been used for the treat-ment of alcohol withdrawal. However, due to their favorable side-effect profile, the benzodiazepines have largely sup-planted all other medications. Although any benzodiazepine will suppress alcohol withdrawal symptoms, diazepam and chlordiazepoxide are often used, since they are metabolized to long-acting compounds, which in effect are self-tapering. Because metabolism of these drugs is hepatic, impaired liver function may complicate their use. Oxazepam and lorazepam are not oxidized to long-acting metabolites and thus carry less risk of accumulation.
Although carbamazepine appears useful as a primary treatment of withdrawal the liver dysfunction that is common in alcoholics may affect its metabolism, which makes careful blood level monitoring necessary. Antipsychotics are not indicated for the treatment of withdrawal except in those instances where hal-lucinations or severe agitation are present, in which case they should be added to a benzodiazepine. In addition to their poten-tial to produce extrapyramidal side effects, antipsychotics lower seizure threshold, which may be particularly problematic during alcohol withdrawal.