Alcohol withdrawal treatment protocol is a set of guidelines sanctioned for use in District Withdrawal Management Units of Addiction Services.
It involves examining the history of the alcohol-dependent patient, evaluation of his/her alcohol withdrawal symptoms (AWS) and administration of medication, and other aspects of treatment.
Aim of treating alcohol withdrawal
How to detox from alcohol is an immediate concern when treating alcohol withdrawal. The aim of treating alcohol withdrawal syndrome is threefold:
- Treatment of withdrawal symptoms
- Prevent and treat the complications of alcohol withdrawal
- An extended therapy to help with abstinence from alcohol
Patients with very mild symptoms may need supportive care only, while patients with moderate-to-severe symptoms may require a more aggressive pharmacologic involvement.
Patients with AWS can be treated on an inpatient or outpatient basis. The choice rests with the treating psychiatrist and will depend on how severely the symptoms manifest.
Patients with mild to moderate symptoms can be treated effectively on an outpatient basis. The advantage is, it is cost-effective, safe, and allows the patient to attend his workplace.
Severely ill patients will have to be admitted to the rehab facility and treated with pharmaceutical intervention on an indoor basis.
About 90% of patients with AWS experience mild to moderate type of symptoms.
Outpatient treatment requires that the patient be able to take oral medication, attend follow-up visits regularly, and friendly home inmates who will administer his medication and show a caring attitude. Family members should show an encouraging attitude and this can be critical for recovery.
Oral medications are prescribed and include Benzodiazepines, anticonvulsants, and Beta-blockers.
Inpatient alcohol treatment
It becomes necessary to admit the serious alcohol withdrawal patient in a facility particularly one, which specializes in alcohol detoxification. Withdrawal symptoms can worsen rapidly and therefore, the patient is closely watched for the following:
- Body temperature
- Blood pressure
- Respiratory rate
- Heart rate and
- Fluid and electrolyte levels in the blood ( sodium, potassium, etc)
- Any onset of serious alcohol withdrawal signs and symptoms especially delirium tremens
Alcoholics suffer from dehydration and nutritional deficiencies due to poor food intake and nutrition depletion due to alcohol.
Staying hydrated is important because alcohol is known to dehydrate you. It is necessary to drink plenty of water daily during and after the treatment. Indoor patients are administered intravenous fluids in the required amounts.
During the initial stages of detox, drink soups and liquids. Your soups should contain plenty of vegetables, lean sources of protein, such as beans, poultry, and fish. You should also drink fruit juices to support your nutrition. Add milk to your everyday intake if you can tolerate it.
Eat a well-balanced diet to stay well-nourished and help you fight detox. Your diet should consist of plenty of healthy fruits and vegetables, fish and poultry, whole grains, nuts, beans, and low-fat dairy. It’s also important to use healthy oils, such as olive oil and coconut oil.
Nutritional support consists of routine administration of thiamine (100 mg daily) and folic acid (1 mg daily). This will help prevent Wernicke’s encephalopathy.
Where Wernicke’s encephalopathy is suspected, high potency vitamins with 500 mg of thiamine are administered intravenously three times daily for 3 days.
Serum magnesium levels are known to fall during the alcohol withdrawal period, which makes it necessary to give magnesium supplementation. This is especially helpful in patients with cardiac arrhythmias, electrolyte disturbances, or those with a previous history of AWS-related seizures.
Intravenous fluids are initiated to reverse fluid depletion, correct hypoglycemia, and restore electrolyte balance.
Benzodiazepines or Chlordiazepoxide form the basic choice and lay the foundation for a successful treatment regimen for AWS. They are the first line of treatment and the most commonly used drugs for alcohol withdrawal.
The ones most used are diazepam or lorazepam. They are tranquilizers and are safe and effective in suppressing the withdrawal symptoms including seizures and prevent their progression.
Both long- and intermediate-acting benzodiazepines are used to treat AWS. Chlordiazepoxide and diazepam have a long period of action, while Lorazepam, oxazepam, and alprazolam are short-acting. Both are equally effective.
Benzodiazepines are also given to treat delirium tremens and can be life-saving at times like these.
The success of BZDs in treating AWS lies in the fact that they stimulate GABA receptors and produce effects similar to those produced by alcohol.
Alcohol should never be taken when on these drugs because it can depress the person and can cause suicidal tendencies. Lorazepam is preferred in elderly persons above 70 years of age and in patients with liver disease.
To summarize, benzodiazepines form the main heart of treatment and they help to reduce agitation, prevent withdrawal seizures, and prevent the progression of withdrawal symptoms.
Anticonvulsants such as carbamazepine, oxcarbazepine, and Divalproex are useful in the treatment of alcohol dependence. They reduce alcohol craving and help in treating alcohol withdrawal symptoms through their antikindling effect.
Barbiturates are also effective and have a specific indication. In patients admitted to the ICU and requiring high doses of BZDs to control the AWS symptoms or delirium tremens (DT), barbiturates become useful.
Phenobarbital administered in combination with benzodiazepines, promotes the action of BZD and increases its efficacy. It helps control DT, reduces the need for mechanical ventilation, and helps reduce ICU admission.
Beta-blockers and the alpha-adrenergic agonist
Beta-blockers and the alpha-adrenergic agonist clonidine may be used as adjunctive therapy. They help to reduce adrenergic symptoms are useful by their action in lowering blood pressure and heart rate. They also help to reduce tremors.
Ethanol is also used but in weaning doses. It has a higher success rate and reduces the severity of the withdrawal symptoms.
As the alcohol detox becomes manageable, alcohol withdrawal therapy is extended to the following:
- Patient and family counseling
- Treatment of health conditions that may have developed as a result of alcohol complications due to excessive drinking of alcohol.
- Psychiatric evaluation and treatment, as psychiatric imbalance is common in such cases
- The patient of alcohol withdrawal is encouraged to join alcohol support groups, such as the alcoholic anonymous, to help him further abstain from alcohol.
- long-term medications to reduce the risk of relapse. This is to help and mentally gear up the patient to abstain from drinking alcohol for life.
Alcohol Withdrawal Recovery and Prognosis
Most patients recover fully after the treatment for alcohol withdrawal in an alcohol rehab center. A few patients succumb, especially those with severe delirium tremens.
Those who have developed complications of alcohol are treated for the same. Some complications, which turn out to be serious like liver cirrhosis, can turn out to be fatal.