The Management of Alcohol
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
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.