Clinical assessment and pharmacotherapy of the alcohol withdrawal syndrome

The Spectrum of Alcohol Use: Epidemiology, Diagnosis, and Treatment

In the United States, alcohol is the most common substance used and the spectrum of unhealthy alcohol use is highly prevalent. Complications of unhealthy alcohol use affect nearly every organ system. One of the most frequent and potentially life-threatening of these complications is alcohol withdrawal syndrome for which benzodiazepines remain first-line therapy. Pharmacologic treatment of alcohol use disorder, the most severe form of unhealthy alcohol use, is underutilized despite the availability of multiple effective medications. Although behavioral therapies are an important component of treatment, they are overemphasized at the expense of pharmacotherapy.

Increasing access to psychosocial interventions for alcohol use disorders: Home based interventions

Alcohol use disorders (AUD) are a significant and growing public health problem in India. However, health services for AUD remain largely confined to large institutions and a significant proportion of people with AUD do not having access to help for their alcohol related problems. One way of changing this status quo is making evidence based psychosocial interventions available in communities and closer to people's homes. There is extensive evidence supporting the effectiveness of a range of psychosocial interventions for AUDs. This is further augmented by the growing evidence for the effectiveness of contextually appropriate psychosocial interventions, such as Counselling for Alcohol Problems (CAP) from India, that are designed to increase access to care through delivery by non-specialist health workers. The effective implementation of such interventions integrated into collaborative care models will go a long way in reducing the treatment gap for AUDs in India.

Proposal of a comprehensive clinical typology of alcohol withdrawal--a cluster analysis approach

AIMS

To characterize the various courses of alcohol withdrawal.

METHODS

The Alcohol Withdrawal Scale (AWS) was applied to 217 alcohol-dependent patients every 4 h till the symptoms of withdrawal had passed (until each of four consecutive scores were <3). Patients were medicated by a standardized treatment scheme according to AWS-scores. Hierarchical cluster analysis and discriminant analysis were applied.

RESULTS

We found five clusters representing increasing severity of alcohol withdrawal. Each cluster is characterized by a combination of the two maximum subscores (vegetative and psychopathological subscore) and three additional psychopathological symptoms (anxiety, disorientation, and hallucination). In 18.4% of the patients, relevant symptoms were not observed (cluster 1), 18.9% developed mild or moderate vegetative symptoms only (cluster 2), and 40.6% additional anxiety (cluster 3). In cluster 4 (11.1%) the most frequent psychopathological symptoms were disorientation and anxiety but no hallucinations, which could be observed only in cluster 5 (11.1%). Discriminant analysis using the maximum subscores at the first day of treatment as independent variables correctly predicted 89.9% of the five clusters.

CONCLUSIONS

Our findings support a model of alcohol withdrawal clustering along the two dimensions of vegetative and psychopathological severity. Furthermore, the AWS may be useful to predict the course of alcohol withdrawal already at the first day of treatment.

Alcohol and public health

Alcoholic beverages, and the problems they engender, have been familiar fixtures in human societies since the beginning of recorded history. We review advances in alcohol science in terms of three topics: the epidemiology of alcohol's role in health and illness; the treatment of alcohol use disorders in a public health perspective; and policy research and options. Research has contributed substantially to our understanding of the relation of drinking to specific disorders, and has shown that the relation between alcohol consumption and health outcomes is complex and multidimensional. Alcohol is causally related to more than 60 different medical conditions. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco and hypertension. Treatment research shows that early intervention in primary care is feasible and effective, and a variety of behavioural and pharmacological interventions are available to treat alcohol dependence. This evidence suggests that treatment of alcohol-related problems should be incorporated into a public health response to alcohol problems. Additionally, evidence-based preventive measures are available at both the individual and population levels, with alcohol taxes, restrictions on alcohol availability, and drinking-driving countermeasures among the most effective policy options. Despite the scientific advances, alcohol problems continue to present a major challenge to medicine and public health, in part because population-based public health approaches have been neglected in favour of approaches oriented to the individual that tend to be more palliative than preventative.

Hospital Use of Ethanol Survey (HUES): preliminary results

Little information exists about alcohol use within health facilities. We sought to determine alcohol use and control in acute-care hospitals by mailing a questionnaire to a convenience sample of Pharmacy Directors of 24 hospitals in two regions. Of 23 responders, in-patient alcohol was dispensed by 21 (91%) within the last 5 years. Of these 21, both beverage and intravenous alcohol were dispensed by 13 (62%), only beverage alcohol by seven (33%), and only intravenous alcohol by one (5%). No institutional policies regarding alcohol dispensing existed in 16 (70%) hospitals. Alcohol was frequently used as a patient courtesy (14/20, 70%), and to prevent withdrawal (7/20, 35%). All pharmacies procured intravenous alcohol in a formal process, but 60% (12/20) obtained beverage alcohol informally. Alcohol is widely dispensed with few guidelines in this sample of acute-care hospitals. Additional research on therapeutic efficacy, consequences, and institutional oversight of alcohol in hospitals is needed.

Effectiveness of propranolol for cocaine dependence treatment may depend on cocaine withdrawal symptom severity

Propranolol may reduce symptoms of autonomic arousal associated with early cocaine abstinence and improve treatment outcome. This trial was an 8-week, double-blind, placebo-controlled trial of propranolol in 108 cocaine dependent subjects. The primary outcome measure was quantitative urinary benzoylecgonine levels. Secondary outcome measures included treatment retention, addiction severity index results, cocaine craving, mood and anxiety symptoms, cocaine withdrawal symptoms, and adverse events. Propranolol treated subjects had lower cocaine withdrawal symptom severity but otherwise did not differ from placebo treated subjects in any outcome measure. However, in a secondary, exploratory analysis, subjects with more severe cocaine withdrawal symptoms responded better to propranolol in comparison to placebo. In these subjects, propranolol treatment was associated with better treatment retention and lower urinary benzoylecgonine levels as compared with the placebo treatment. Propranolol may be useful only for the treatment of cocaine dependent patients with severe cocaine withdrawal symptoms.

Monoaminergic changes associated with audiogenic seizures in ethanol-dependent rats

1. A previous report demonstrated the efficacy of combining dopaminergic and serotonergic agonists in suppressing audiogenic seizures induced in ethanol-dependent rats undergoing withdrawal. Moreover, an increase in dopamine and a reduction in serotonin levels in the striatum were associated with such seizures. 2. The present study was designed to examine neurochemical changes in the striatum associated with repeated episodes of ethanol withdrawal seizures in untreated ethanol-dependent rats as well as in those treated with amphetamine and fenfluramine in combination. 3. Ethanol-dependent rats undergoing audiogenic seizures exhibited an increase in striatal dopamine and a reduction in striatal serotonin as compared to control and ethanol-dependent rats not undergoing seizures. Amphetamine and fenfluramine in combination effectively suppressed the audiogenic seizures by reversing the neurochemical changes in the striatum in ethanol-dependent rats. However, increased dopamine but decreased serotonin levels in the striatum were observed in rats undergoing one episode of ethanol withdrawal, but not in those experiencing multiple episodes of ethanol withdrawal. 4. Thus, alterations in striatal dopamine and serotonin levels were, at best, necessary but not sufficient to predispose audiogenic seizure susceptibility in ethanol-dependent rats.

High amplitude contractions in the middle third of the oesophagus: a manometric marker of chronic alcoholism?

BACKGROUND

Oesophageal motor abnormalities have been reported in alcoholism.

AIM

To investigate the effects of chronic alcoholism and its withdrawal on oesophageal disease.

PATIENTS

23 chronic alcoholic patients (20 men and three women; mean age 43, range 23 to 54).

METHODS

Endoscopy, manometry, and 24 hour pH monitoring 7-10 days and six months after ethanol withdrawal. Tests for autonomic and peripheral neuropathy were also performed. Motility and pH tracings were compared with those of age and sex matched control groups: healthy volunteers, nutcracker oesophagus, and gastro-oesophageal reflux disease.

RESULTS

14 (61%) alcoholic patients had reflux symptoms, and endoscopy with biopsy showed oesophageal inflammation in 10 patients. One patient had an asymptomatic squamous cell carcinoma. Oesophageal motility studies in the alcoholic patients showed that peristaltic amplitude in the middle third was > 150 mm Hg (95th percentile (P95) of healthy controls) in 13 (57%), the ratio lower/ middle amplitude was < 0.9 in 15 (65%) (> 0.9 in all control groups), and the lower oesophageal sphincter was hypertensive (> 23.4 mm Hg, P95 of healthy controls) in 13 (57%). All three abnormalities were present in five (22%). Abnormal reflux (per cent reflux time > 2.9, P95 of healthy controls) was shown in 12 (52%) alcoholic patients, and was unrelated to peristaltic dysfunction. Subclinical neuropathy in 10 patients did not effect oesophageal abnormalities. Oesophageal motility abnormalities persisted at six months in six patients with ongoing alcoholism, whereas they reverted towards normal in 13 who remained abstinent; reflux, however, was unaffected.

CONCLUSIONS

Oesophageal peristaltic dysfunction and reflux are frequent in alcoholism. High amplitude contractions in the middle third of the oesophagus seem to be a marker of excessive alcohol consumption, and tend to improve with abstinence.

Trends in the management of alcohol withdrawal syndrome

Alcohol use among head and neck cancer patients is common. Alcohol withdrawal (especially delirium tremens) poses significant potential morbidity to postsurgical patients. Treatment with newer benzodiazepines (BZDs) such as lorazepam and midazolam has become more widespread, and mortality rates from severe alcohol withdrawal have decreased in recent years. The authors retrospectively studied 102 patients with a diagnosis of alcohol withdrawal, including 20 patients undergoing surgery for cancer of the head and neck. There were 81 men and 21 women, with a mean (+/- standard deviation [SD]) age of 52.3 (+/- 16.1) years. Many of these patients (46%) were treated with more than one BZD or other neuroleptic, while 49% received single agent therapy of either chlordiazepoxide (26%) or lorazepam (23%). Delirium tremens occurred in 12% of all patients undergoing withdrawal and in 10% of head and neck cancer patients, with a mortality rate of 9% and 0%, respectively. Single agent use was successful in greater than 95% when either lorazepam or chlordiazepoxide was used. Instances of combination treatment where older BZDs were used yielded a 69% success rate. The higher complication rate and lower treatment success with combination treatment was multifactorial. Optimal management of the alcohol withdrawal syndrome requires an understanding of its pathophysiology and the principles of its prevention along with a familiarity of BZD pharmacokinetic drug profiles. The authors present a treatment plan which is cost-effective, keeps morbidity low, and should allow a continued decreasing trend in mortality rates from delirium tremens.

Clinical predictors of alcohol withdrawal delirium

Up to now, clinical predictors for the course of the alcohol withdrawal syndrome, especially for the occurrence of a delirium, are lacking. Thus, this study was undertaken to examine whether clinical routine investigations at admission before the withdrawal syndrome can reveal factors indicating a higher risk for the development of a delirium. Our results showed that decreased serum electrolyte concentrations (i.e., chloride and potassium), elevated ALT, and gamma-glutamyltransferase serum levels, as well as ataxia and polyneuropathy at the neurological examination, indicate a higher risk for the development of an alcohol withdrawal delirium.

Treatment of alcohol withdrawal syndrome

Treatment of the alcohol withdrawal syndrome is the first step towards the rehabilitation of alcohol-dependent patients. The objectives of treatment are relief of symptoms, prevention of complications and a smooth transition into a long-term rehabilitation programme. Recently, progress has been made in the clinical management of the alcohol withdrawal syndrome through standardization of the assessment using the CIWA-A scale and frequent monitoring of clinical findings, recognition of the efficacy of non-pharmacological interventions (i.e. standardized supportive care) and simplification of pharmacotherapy by optimizing the use of long-acting benzodiadepines via a loading dose technique. Benzodiazepines, because of their cross-tolerance with ethanol, wide margin of safety and low potential for physical dependence and tolerance, are very effective and are the drugs of choice for the treatment of the alcohol withdrawal syndrome.

Fatal poisonings attributed to benzodiazepines in Britain during the 1980s

The fatal toxicity indices of benzodiazepines during the 1980s were calculated from national prescribing data and mortality statistics. The overall rate was 5.9 deaths per million prescriptions for benzodiazepines taken alone or with alcohol only, anxiolytics being less toxic than hypnotics. Diazepam appeared more toxic than average among anxiolytics (P < 0.05), and flurazepam and temazepam more toxic than average among hypnotics (both P < 0.001). It was shown that the finding for diazepam was probably explained by concurrent use of alcohol, which implies that other anxiolytics may be safer in cases where there is alcohol misuse; but the greater toxicity of flurazepam and temazepam remained unexplained. Benzodiazepines are indeed much less toxic than the barbiturates they superseded, but they are not innocuous and temazepam in particular requires further evaluation.

Intravenous flunitrazepam in the treatment of alcohol withdrawal delirium

Alcohol withdrawal delirium (AWD) requires treatment with an adequate sedative, anticonvulsant, and antipsychotic agent next to general intensive care measures. Optimal medication should have a rapid onset of action and the possibility of parenteral application. A specific antagonist should be available. Flunitrazepam is a benzodiazepine that fulfills all these criteria. Twenty five patients suffering from AWD (mean age 45 years) took part in an open trial and underwent treatment with infusions of flunitrazepam (concentration: 8 mg/250 ml NaCl; speed, 250 ml/hr). Psychopathological, vegetative, and vital parameters were assessed every hour. All patients survived. They were treated with a mean total dose (SD) of 83.9 (45.4) mg of flunitrazepam (1.3 mg/kg body weight), which induced sedation 13.2 (5.3) min after the initiation of intravenous treatment. The mean duration of AWD (85.1 +/- 39.4 hr) corresponded to other studies, whereas the frequency of preexisting and concomitant diseases was higher (92%) in our patients. A patient who suffered from bronchitis and had a nasopharyngeal tamponade showed severe respiratory depression after having received 4 mg of flunitrazepam. This complication remitted immediately when 0.5 mg of flumazenil was given intravenously. No epileptic manifestation was observed during the treatment or after discontinuation of flunitrazepam. Vegetative and psychopathological symptoms (tremor, sweating, hallucinations, confusion, and restlessness) remitted rapidly. Our data suggest that intravenous flunitrazepam can be an efficacious and safe alternative to traditional treatment strategies of AWD.

Pharmacotherapies for alcoholism: promising agents and clinical issues

The past 10 years have witnessed important advances in research on pharmacotherapy for alcoholism. Promising drugs are discussed under six headings: agents to treat alcohol withdrawal; anticraving agents; agents that make drinking an aversive experience; agents to alleviate concomitant psychiatric problems; agents to treat concurrent drug abuse; and amethystic ("sobering-up") agents. Research on the drug classes is summarized and clinical issues surrounding specific agents and alcoholism pharmacotherapy in general are discussed. Finally, long-range therapeutic implications of recent findings on the actions of alcohol on basic mechanisms of the brain are offered.

A structured programme for out-patient alcohol detoxification

An out-patient alcohol detoxification service based in a psychiatric emergency clinic is described. Of 173 patients referred during the first year, 76 (44%) were accepted for the programme; 60 (79%) of these successfully completed detoxification with no medical complications. Compared with previous years, during the year of operation of the service there was a 50% fall in the number of in-patient admissions for detoxification to the local hospital. We conclude that a structured out-patient detoxification programme is safe and effective, and may obviate the need for many patients to be admitted, freeing psychiatric beds for other uses.

Benzodiazepines and alcohol

The frequency and quantity of alcohol consumption is a major consideration in patients who need treatment with benzodiazepines. Alcohol affects the GABA-benzodiazepine-chloride ionophore complex and has an agonist-like action. Thus, additive interactions should be expected from combining alcohol with benzodiazepines. Furthermore, alcohol has clinically meaningful anxiolytic efficacy, and many anxious patients may take advantage of that fact. Therefore, co-administration of alcohol and benzodiazepines is to be expected in an anxious patient receiving benzodiazepines who does not totally abstain from alcohol. This article reviews three clinically relevant issues concerning benzodiazepines and alcohol: (1) interactions of benzodiazepines with social drinking in patients taking benzodiazepines for indications unrelated to alcoholism; (2) use of benzodiazepines in treatment of alcohol withdrawal; and (3) use of benzodiazepines in patients with alcohol dependence.

The treatment of alcohol withdrawal

Abrupt cessation of regular use of alcohol in a dependent person causes a withdrawal syndrome that may range from mild to extremely severe. Most patients require pharmacologic intervention, especially those with severe symptoms. Historically, the pharmacotherapy of alcohol withdrawal has involved a wide variety of agents. Benzodiazepines are currently preferred due to their consistently high degree of efficacy and laudable record of safety. In addition, beta blockers and clonidine are useful, as both effectively combat the hypertension and tachycardia commonly associated with withdrawal. They are ineffective as anticonvulsants; however. Opinions differ concerning the best treatment for withdrawal seizures. Prophylaxis with benzodiazepines may be all that is required, although some authors advocate the use of phenytoin for 5 days, especially in persons with a history of prior seizures during alcohol withdrawal. Once established, delirium tremens are difficult to treat. Benzodiazepines are most commonly used to provide sedation, and extremely large doses may be required. Careful clinical assessment is essential to the proper treatment of patients undergoing alcohol withdrawal since the coexistence of medical problems may complicate the condition.