Pharmacist Rounds: Alcohol Withdrawal: Recognizing Signs, Treating Symptoms

Dr. Zanni is a psychologist and health systems consultant based in Alexandria, Virginia.

Approximately 44% of American adults use alcohol on a regular basis; most do so responsibly with minimal or no impact on level of functioning, health, and interpersonal relationships. For 14 million Americans, however, problematic drinking leads to alcohol abuse and dependency, resulting in impaired behaviors and dysfunctional interpersonal relationships.¹

Alcohol dependency, commonly referred to as alcoholism, is a disease with 4 key symptoms:

• Craving: a strong or compulsive need to drink

• Loss of control: the inability to limit one's drinking

• Physical dependence: withdrawal symptoms pursuant to alcohol cessation

• Tolerance: the need to drink greater amounts of alcohol to experience its effects¹

Alcohol dependence differs from alcohol abuse, which is characterized by periodic irresponsible and/or binge drinking. Similar to other addictions, long-term alcohol use causes adaptive changes in the brain, resulting in increased tolerance and dependency. Alcohol enhances the effects of gamma-aminobutyric acid (GABA) on GABA-alpha (GABA-A) neuroreceptors, causing decreased brain excitability. Chronic alcohol exposure causes a compensatory decrease in GABA-A neuroreceptor response, leading to increased alcohol tolerance. Abrupt alcohol cessation results in brain hyperexcitability-otherwise known as alcohol withdrawal syndrome.^2,3 Up to 2 million Americans experience alcohol withdrawal each year.²

Withdrawal symptoms range from mild to severe and may include in--creased pulse and blood pressure, increased body temperature, restlessness, insomnia, fatigue, anxiety, nausea and vomiting, headache, tremors, seizures, hallucinations, and coma.^4,5 Up to 71% of patients in detoxification will manifest significant withdrawal symptoms.⁶ Although gradually tapering off alcohol use is less likely to lead to significant withdrawal effects, this strategy is often ineffective for those with dependency; effective treatment often requires detoxification in a supervised inpatient or outpatient medical setting.

Withdrawal typically begins 6 to 8 hours following a reduction in alcohol use, and it can begin even when the patient still has a measurable blood alcohol level. Symptoms peak 24 to 28 hours after the last drink and diminish in 24 to 48 hours, but can last up to 7 days. Seizures and delirium tremens (DT) may accompany severe alcohol withdrawal. Following withdrawal, symptoms like insomnia, mood changes, and fatigue may persist for 3 to 12 months.^3-5

DT is the harshest component of alcohol withdrawal syndrome and is characterized by agitation and tremulousness, autonomic instability, hyperpyrexia, visual and auditory hallucinations, and disorientation. DT occurs in approximately 5% of individuals with alcohol withdrawal and usually presents between 48 and 96 hours following final alcohol use.^3-5 In up to 25% of cases, seizures may occur within the first 24 hours, but in some cases, they may occur up to 5 days later.⁴ Seizures are typically grand mal in type, and the patient may experience a number of seizures over several hours.⁵

Alcohol Withdrawal Treatment

It is estimated that 10% to 20% of patients require inpatient hospitalization for alcohol withdrawal treatment syndrome; less severe dependency can be managed in outpatient settings.² Benzodiazepines, preferred agents in both settings, help counter the effects of abrupt alcohol cessation. Agents are selected based on their pharmacokinetics. The shorter-acting benzodiazepines are often preferred because of the lower risk of oversedation.⁵ The longer-acting benzodiazepines, however, allow for a smoother tapering period.²

Recommended medications include oxazepam (because its metabolism is not affected by alcohol-related liver disease), lorazepam, and chlordiazepoxide. Medication regimens are either fixed-dose (usually outpatient) or symptom-triggered; the latter results in less required medication and a shorter duration of treatment.² Doses should be individualized. Once withdrawal symptoms subside, the dose is usually tapered off by 20% during each 4- to 7-day period.⁵

Carbamazepine is an appropriate alternative to the benzodiazepines. Additionally, haloperidol, beta-blockers, clonidine, and phenytoin are adjunct medications to help treat other complications of withdrawal.²

Outpatient detoxification is reserved for patients who do not have complex comorbid conditions and/or present with less severe dependency and a lower risk for DT or seizures.

Continuity of care issues encompass 2 categories: patients who readily admit their present or former alcohol dependency, and patients with unreported alcohol dependency.

Many Americans harbor the prejudice that alcohol dependency signals personal weakness. Consequently, many sufferers do not disclose their true alcohol use, thereby increasing their risk for serious and/or life-threatening alcohol withdrawal symptoms when placed in supervised or restricted environments. When pharmacists encounter symptoms similar to alcohol withdrawal syndrome, they should probe further for alcohol use, regardless of patient self-reported information.

References

• US Department of Health and Human Services. Substance Abuse and Mental Health Administration. National Clearinghouse for Alcohol and Drug Information. General: Alcoholism. http://ncadistore.samhsa.gov/catalog/facts.aspx?topic=3. Accessed February 12, 2008.
• Bayard M, McIntyre J, Hill KR, Woodside J Jr. Alcohol withdrawal syndrome. Am Fam Physician. 2004;69(6):1443-1450.
• Withdrawal Syndromes. www.emedicine.com/emerg/TOPIC643.HTM. Accessed February 4, 2008.
• MedlinePlus Medical Encyclopedia: Alcohol withdrawal. www.nlm.nih.gov/medlineplus/ency/article/000764.htm. Accessed February 4, 2008.
• US Department of Health and Human Services. Center for Substance Abuse Prevention. At Any Age, It Does Matter: Substance Abuse and Older Adults. http://pathwayscourses.samhsa.gov/aaap/aaap_toc.htm. Accessed February 4, 2008.
• Saitz R, O'Malley SS. Pharmacotherapies for alcohol abuse. Withdrawal and treatment. Med Clin North Am. 1997;81(4):881-907.
• Kuehn BM. New therapies for alcohol dependence open options for office-based treatment. JAMA. 2007;298(21):2467-2468.
• Srisurapanont M, Jurusuraisin N. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2000;3:CD001867.
• US Department of Health and Human Services. National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert No. 49. http://pubs.niaaa.nih.gov/publications/aa49.htm. Accessed February 12, 2008.
• Johnson BA. Update on neuropharmacological treatments for alcoholism: Scientific basis and clinical findings. Biochem Pharmacol. 2008;75(1):34-56.