Alcohol detoxification

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Alcohol detoxification, or 'detox', for individuals with alcohol dependence is the abrupt cessation of alcohol intake coupled with the substitution of alcohol with cross-tolerant drugs that have similar effects in order to prevent alcohol withdrawal. Detoxification may or may not be necessary depending upon an individual's age, medical status, and history of alcohol intake. For example, a young man who binge drinks and seeks treatment one week after his last use of alcohol may not require detoxification before beginning treatment for alcoholism. Benzodiazepines are the most common family of drugs used for this[1], followed by barbiturates[citation needed].

Benzodiazepines

Benzodiazepines such as diazepam (Valium), lorazepam (Ativan) or oxazepam (Serax) are the most commonly used drugs used to reduce alcohol withdrawal symptoms. There are several treatment patterns in which it is used.

  1. The first option takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3-10 days.
  2. Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon.
  3. A third option is to defer treatment until symptoms occur. This method should not be used in patients with prior alcohol related seizures. This has been effective in randomized controlled trials.[2][3] A non-randomized, before and after, observational study found that symptom triggered therapy was advantageous.[4]

Dosing of the benzodiazepines can be guided by the CIWA-Ar scale.[5] The scale is available online.[6]

Regarding the choice of benzodiazepine:

  • Chlordiazepoxide (Librium®) is the benzodiazepine of choice in uncomplicated alcohol withdrawal. [7]
  • Lorazepam or diazepam are available parenterally for patients who cannot safely take medications by mouth.
  • Lorazepam and oxazepam may be best in patients with cirrhosis (shorter half life).


Sympatholytics

Randomized controlled trials have found benefit from atenolol[8] and clonidine.[9]

Carbamazepine

A randomized controlled trial has found benefit from carbamazepine.[10]

Other drugs

Some hospitals administer alcohol to prevent alcohol withdrawal although there are potential problems with this practice.[11]

Various vitamins, especially from the B group, are often used during withdrawal treatment.

Sodium oxybate is the sodium salt of gamma-hydroxybutyric acid (GHB). It is used for both acute alcohol withdrawal and medium to long-term detoxification. This drug enhances GABA neurotransmission and reduces glutamate levels. It is used in Italy in small amounts under the trade name Alcover.

Baclofen has been shown in animal studies and in small human studies to enhance detoxification. This drug acts as a GABA B receptor agonist and this may be beneficial.


References

  1. Mayo-Smith MF (1997). "Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal". JAMA. 278 (2): 144–51. PMID 9214531. Full text at OVID
  2. Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR (1994). "Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial". JAMA. 272 (7): 519–23. PMID 8046805.
  3. Daeppen JB, Gache P, Landry U; et al. (2002). "Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial". Arch. Intern. Med. 162 (10): 1117–21. PMID 12020181.
  4. Jaeger TM, Lohr RH, Pankratz VS (2001). "Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients". Mayo Clin. Proc. 76 (7): 695–701. PMID 11444401.
  5. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM (1989). "Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar)". British journal of addiction. 84 (11): 1353–7. PMID 2597811.
  6. Holbrook AM, Crowther R, Lotter A, Cheng C, King D (1999). "Diagnosis and management of acute alcohol withdrawal". CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 160 (5): 675–80. PMID 10102003. (see appendix 2)
  7. Raistrick, D, Heather N & Godfrey C (2006) "Review of the Effectiveness of Treatment for Alcohol Problems" National Treatment Agency for Substance Misuse, London http://www.nta.nhs.uk/publications/documents/nta_review_of_the_effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf
  8. Kraus ML, Gottlieb LD, Horwitz RI, Anscher M (1985). "Randomized clinical trial of atenolol in patients with alcohol withdrawal". N. Engl. J. Med. 313 (15): 905–9. PMID 2863754.
  9. Baumgartner GR, Rowen RC (1987). "Clonidine vs chlordiazepoxide in the management of acute alcohol withdrawal syndrome". Arch. Intern. Med. 147 (7): 1223–6. PMID 3300587.
  10. Malcolm R, Ballenger JC, Sturgis ET, Anton R (1989). "Double-blind controlled trial comparing carbamazepine to oxazepam treatment of alcohol withdrawal". The American journal of psychiatry. 146 (5): 617–21. PMID 2653057.
  11. Blondell RD, Dodds HN, Blondell MN; et al. (2003). "Ethanol in formularies of US teaching hospitals". JAMA. 289 (5): 552. PMID 12578486.



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