Treating Alcohol Withdrawal

Detoxing from alcohol is often the first phase of the rehabilitation process for those in recovery from alcohol use disorder (AUD). When chronic and/or heavy alcohol use leads to significant physical dependence, symptoms of alcohol withdrawal may occur when that person decides to quit drinking.1 For those at risk of severe alcohol withdrawal, certain medications may be used to alleviate discomfort, decrease a worsening or progression of symptoms, and minimize the likelihood of withdrawal complications.2

Acute Alcohol Withdrawal Symptoms

Symptoms of acute alcohol withdrawal may range from mild to physically dangerous, with some relatively mild symptoms arising as soon as 8 hours after the last drink.1 Depending on the magnitude of physical dependence, additional symptoms may continue to arise beyond 24 hours, with some potentially severe effects emerging 2 to 4 days after abstinence.3 Symptoms of alcohol withdrawal may include irritability, anxiety, agitation, increased heart rate, high blood pressure, and seizures; in rarer cases, severe alcohol withdrawal is associated with a syndrome known as delirium tremens.3

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Alcohol Withdrawal Syndrome Treatments

Left unmanaged, heavy drinkers may experience a markedly uncomfortable and potentially life-threatening alcohol withdrawal syndrome when attempting to quit. In such instances, a supervised, medical detox may be needed to effectively minimize symptoms and manage any complications to best promote continued abstinence in early recovery.2 As a part of this process, medications may be given at the onset of symptoms and continued until they subside.4 Though more than 150 medications have been explored for the treatment of alcohol withdrawal,  there continues to be some disagreement regarding the best pharmacologic approaches to withdrawal management.2

What Are Delirium Tremens?

In some instances of pronounced alcohol dependence and severe accompanying withdrawal, a person may develop a neurologic syndrome called delirium tremens (DTs) that is marked by autonomic nervous system excitation and changes in mental status.5 DTs are most commonly seen in those with a history of alcohol withdrawal, who’ve abused alcohol for more than 10 years, or drink daily, for months on end.5 Typically, DTs are only present in around 5% of patients experiencing withdrawal.2

Delirium tremens symptoms may include hallucinations, body tremors, fever, agitation, severe confusion or disorientation, or seizures.5 If you suspect you or someone you know is experiencing this form of withdrawal, seek medical attention immediately.

Medications Used to Treat Alcohol Withdrawal Symptoms

In significantly severe cases of alcohol withdrawal, pharmacological treatment is often employed.2 The following include some of the more-commonly used medications used to treat symptoms of withdrawal. Although some withdrawal episodes may appear to not need pharmacological treatment, foregoing medications may, in some cases, have adverse consequences for any future withdrawal episodes.2 The failure to medicate may lead to alcohol-induced toxicity to nerve cells which, in a phenomenon known as kindling, could put patients at a greater risk of seizures following repeated withdrawals.2

Benzodiazepines for Alcohol Withdrawal

Used to treat panic, anxiety, and to control certain types of seizures, benzodiazepines are a class of sedative medications that are the agents of choice to manage some of the more problematic alcohol withdrawal symptoms.3,2 Frequently-used pharmaceutical agents include chlordiazepoxide (Librium) and Diazepam (Valium).6 Longer-acting benzodiazepines with active metabolites are common first-line medications since their use may result in a lower chance of recurrent withdrawal or seizures.

FDA-Approved Benzodiazepinesmedication to treat aws

Benzodiazepines that are specifically FDA-approved to manage acute alcohol withdrawal syndrome include:7

  • Chlordiazepoxide (e.g., Librium).
  • Clorazepate (e.g., Tranxene).
  • Diazepam (e.g., Valium).
  • Oxazepam (e.g., Serax).

Barbiturates for Alcohol Withdrawal

Barbiturates are another class of drug that may be used to treat alcohol withdrawal symptoms in benzodiazepine-resistant cases of alcohol withdrawal syndrome.8 In particular, their use in the emergency department and in the intensive care unit for severe cases of withdrawal has shown promise.8 However, to clarify the role of barbiturates in alcohol withdrawal syndrome, additional studies are needed.8

FDA-Approved Medications to Treat Alcoholism and Alcohol Dependencede

Aside from medications used for treating alcohol withdrawal syndrome, other meds may be used within recovery programming to treat alcoholism such as:

Disulfiram (Antabuse): Disulfiram inhibits an enzyme used to metabolize alcohol and causes very unpleasant effects when even small amounts of alcohol are consumed.9 When used as prescribed, to help a person stop drinking, these effects may begin to be felt as soon as 10 minutes after consuming alcohol and include anxiety, headache, flushing of the face, sweating, blurred vision, nausea, and vomiting.9 Typically, effects can last for 1 hour or more.9 Through its aversive reaction with alcohol, disulfiram is used to discourage continued drinking behavior.9,10

Naltrexone (Vivitrol, Revia): Originally used in treating individuals with opiate use disorders, naltrexone was approved in 1994 by the FDA as treatment for alcoholdependence.11 Although the precise way naltrexone works to decrease drinking behavior, reports from patient’s who’ve successfully been treated with the drug suggest that its effects include reducing the urge or desire to drink, helping them stay abstinent and interfering with their desire to continue drinking if they have a sip of alcohol.12 Naltrexone may cause liver damage when taken in large doses and should not be given to patients with hepatitis or liver disease.13

Acamprosate (Campral): Used alongside counseling and social support, acamprosate is thought to restore  a balance in the central nervous system between the glutamate and gamma-aminobutyric acid (GABA), excitatory and inhibitory neurotransmitters, respectively.14 Acamprosate does not prevent symptoms of alcohol withdrawal and may not be effective in those who have not stopped drinking alcohol, drink it in large amounts, or abuse other substances.15 In contrast with other FDA-approved treatments for alcohol dependence (naltrexone and disulfiram), because acamprosate is not metabolized by the liver and does not adversely interact with alcohol, it can be used in patients with liver disease or hepatitis, as well as in those who continue to drink.14 However, according to several trials, it doesn’t appear to be more successful than naltrexone or disulfiram in reducing drinking behavior.14

Alternative and Contraindicated Agents

Along with benzodiazepines, other drugs are sometimes administered to reduce the frequency and intensity of minor withdrawal symptoms.6 More study on these agents is needed, as some of them may mask the hemodynamic signs of withdrawal (e.g., blood pressure changes), which can precede seizures.6 Such medications include:

  • Antipsychotics (e.g., haloperidol) — Individuals with a co-occurring thought disorder (e.g., schizophrenia) might be administered antipsychotic medications.6Caution will be used since certain antipsychotic agents may also lower the seizure threshold.6
  • Anticonvulsants (e.g., carbamazepine) — Anticonvulsant therapy should not be used with isolated alcohol withdrawal seizures; however, carbamazepine may have some utility in outpatient management of mild alcohol withdrawal.6
  • Centrally Acting Alpha-2 Agonists (e.g., clonidine) — Certain types of antihypertensive medications, such as clonidine, have been shown to reduce adrenergic symptoms, but don’t prevent seizures.16 These drugs may assist in controlling mild or non-complicated alcohol withdrawal symptoms such as high blood pressure, sweating, anxiety, irritability, and tremors.6
  • Beta Blockers (e.g., propranolol, atenolol) — Beta blockers reduce adrenergic symptoms of alcohol withdrawal, but do not prevent the development of seizures or delirium tremens.6,16
  • Baclofen — Baclofen is a skeletal muscle relaxant and selective agonist of the GABA-B receptor. It has been studied as a therapy for acute alcohol withdrawal and shows potential to rapidly reduce symptoms.6,17 However, its effectiveness in controlling severe symptoms remains unproven.6

Sources:

[1]. MedlinePlus (2016). Alcohol Withdrawal.

[2]. Hugh Myrick, M.D., and Raymond F. Anton, M.D. (1998). Treatment of Alcohol WithdrawalAlcohol Health & Research World; 22(1): 38-43.

[3]. National Clinical Guideline Centre. (2010). Alcohol Use Disorders: Diagnosis and Clinical Management of Alcohol-Related Physical Complications. NICE Clinical Guidelines, 100(2).

[4]. Kattimani, S. and Bharadwaj, B. (2013). Clinical Management of Alcohol Withdrawal: A Systematic ReviewInd Psychiatry; Jul-Dec 22 (2); 100-108.

[5]. U.S. National Library of Medicine. (2018). Delirium Tremens (DT).

[6]. UpToDate. (2019). Management of moderate and severe alcohol withdrawal syndromes.

[7]. Tarascon Publishing. (2019). Tarascon Pocket Pharmacopoeia, 2019 Deluxe Lab-Coat Edition.

[8]. Martin, K., Katz, A. U.S. National Library of Medicine. (2016). The Role of Barbiturates for Alcohol Withdrawal Syndrome. Psychosomatics; 57(4): 341-347.

[9]. MedlinePlus. (2017). Disulfiram.

[10]. U.S. National Library of Medicine. (1990). Disulfiram Treatment of Alcoholism. Am J Med.; 88(6): 647-55.

[11]. Substance Abuse and Mental Health Services Administration. (2009). Incorporating Alcohol Pharmacotherapies into Medical Practice. Treatment Improvement Protocol (TIP) Series, No. 49(4), 27-35.

[12]. National Institute on Alcohol Abuse and Alcoholism. (1995). Answers to Frequently Asked Medication Questions. Guidelines for the Use of Naltrexone in the Treatment of Alcoholism; 5(1).

[13]. MedlinePlus. (2017). Naltrexone.

[14]. U.S. National Library of Medicine. (2012). Acamprosate For Treatment of Alcohol Dependence: Mechanisms, Efficacy, and Clinical Utility. Therapeutics and clinical risk management; 8, 45-53.

[15]. MedlinePlus. (2016). Acamprosate.

[16]. Herbert L. Muncie Jr., MD; Yasmin Yasinian, MD; Linda Oge, MD. (2013). Outpatient Management of Alcohol Withdrawal Syndrome. Am Fam Physician; 88(9):589-595.

[17]. Liu  J, Wang  LN. (2017). Baclofen for alcohol withdrawal. Cochrane Systematic Reviews – Intervention.