Chlormethiazole and alcohol: a lethal cocktail

Chlormethiazole or chlordiazepoxide in alcohol detoxification

The alcohol withdrawal syndrome is characterised by symptoms such as anxiety, insomnia, anorexia, nausea, tremor, sweating and disturbances in coordination. These symptoms tend to occur within 6 to 12 hours of alcohol-dependent patients stopping or reducing their alcohol intake. Less frequently, convulsions, hallucinosis and delirium tremens can occur. Delirium tremens (disturbed orientation, visual and auditory hallucinations, paranoid ideation and tremulousness) is the most serious complication of alcohol withdrawal and occurs in up to 5% of patients withdrawing from alcohol. If it is severe or poorly treated, death can occur. In the UK some clinicians use chlormethiazole while others favour chlordiazepoxide. This article will examine and compare the use of these two drugs.

Comparing general practitioners and specialist alcohol services in the management of alcohol withdrawal

Aims and Method

A postal questionnaire was used to compare the pharmacological management of alcohol withdrawal as carried out by a group of general practitioners and specialist alcohol services.

Results

General practitioners were significantly more likely to prescribe chlormethiazole, less likely to use B vitamins and less likely to admit patients with a history of withdrawal complications.

Clinical Implications

General practitioners need training in order to improve their management of alcohol withdrawal.

Alcohol and drugs in epilepsy: pathophysiology, presentation, possibilities, and prevention

The potentially serious outcomes from ingestion of and dependence on toxins make this an important topic for epileptologists. We must be aware of the potential for harm from compounds that may be freely available, yet patients may try to conceal their use. Problematic compounds may cause seizures either acutely or on withdrawal: Their use may reduce effectiveness of antiepileptic drugs, or may simply promote and enhance chaotic lifestyles. Any or all of these factors may worsen seizure control or even directly cause seizures. This article highlights the pathophysiology behind provoked seizures, provides clues to diagnosis, and then outlines the steps that clinicians should take to reduce the deleterious effects of toxic compounds.

How do general practitioners manage alcohol-misusing patients? Results from a national survey of GPs in England and Wales

The appropriateness of the primary care setting to undertake health promotional activities has been emphasized, but little is known about the clinical work of GPs with patients misusing alcohol. This study examines how GPs managed alcohol-misusing patients. A 20% random sample of all general practitioners in England and Wales were surveyed using a postal questionnaire. A 44% response rate was achieved. GPs reported managing different levels of severity of drinking problems differently. Basic interventions, such as reporting the alcohol misuse diagnosis and the provision of advice and information, were routine. Health promotion leaflets were not used uniformly, even with the less severe problem drinkers. Detoxification, prescribing of drugs and the management of medical complications were undertaken mainly with dependent patients. Dependent drinkers were the most likely group to be referred to specialist services, while internal practice referrals occurred with all drinking status categories. Anti-depressants were the drugs most usually prescribed to alcohol-misusing patients. The data point to a need for basic guidelines, not only on how to manage and refer dependent drinkers, but also on how to detect and manage those who are not yet manifesting problems but are drinking above recommended guidelines. One of the most evident areas in which there appears to be a need for guidelines is that of prescribing within primary care.

Treatment of psychiatric aspects of alcohol misuse

Psychiatric disorders and alcohol misuse often coexist. This article outlines the clinical management of these comorbid disorders. It discusses and suggests therapeutic recommendations.

Assessment and management of individuals under the influence of alcohol in police custody

Individuals taken into police custody are commonly under the influence of alcohol. Some of these individuals are dependent on alcohol and suffer from withdrawal symptoms. Morbidity and mortality in this group is high, and deaths have been recorded in police custody. There are no specific guidelines on the assessment and management of individuals under the influence of alcohol taken into police custody. This article outlines the clinical features, assessment, investigations and management of these individuals based on a review of the literature.

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.

Home detoxification for problem drinkers: acceptability to clients, relatives, general practitioners and outcome after 60 days

The value of a new Home Detoxification service was assessed in a variety of ways employing data collected from 41 clients of the service, their family and GP's. By 60 days from the start of treatment, 11 clients were abstinent, two were controlling their drinking with relatively few problems, 13 had 'improved', 14 were not 'improved' and one had an unknown outcome. Subsequent involvement in treatment by both clients and their partners was high in comparison with other studies. Significant predictors of 'Good' outcome included attendance for after-care by client and by spouse/partner and a low Alcohol Problems Inventory score. High levels of satisfaction were expressed with the HD service by clients, their carers and GP's. The great majority of clients gave 'home' as their preferred place of treatment and nearly half claimed they would have been unwilling to accept hospital care. There was evidence of significant, though modest, shifts in GP's management practices towards less use of hospitals and greater use of the patient's home after 15 months of the programme.

Is clonidine useful in the treatment of alcohol withdrawal?

The comparative efficacy of clonidine and chlormethiazole has been examined in the management of acute alcohol withdrawal. A double blind randomized study was conducted in consecutive patients admitted to a hospital detoxification unit. Patients were assessed regularly by a standard alcohol withdrawal rating-scale. Thirty-two patients received either clonidine or chlormethiazole in reducing dosages over 96 hr. All the patients receiving chlormethiazole had uneventful withdrawals. However, eight patients treated with clonidine were withdrawn from the trial due to hallucinations (two), seizures (two), symptomatic orthostatic hypotension (three) or drowsiness (one), indicating that clonidine is less effective than chlormethiazole in the prevention of the major manifestations of alcohol withdrawal.

Drug interactions that matter. A critical reappraisal

Drug interactions are ubiquitous but those with proven clinical relevance are much less common. Only when the combined effects of the interacting drugs are greater or less than the arithmetic sum of their individual actions can the event be considered a true interaction. This eliminates many candidate 'interactions' which in reality merely describe the summation of similar or opposing, but independent, drug effects. An appreciation of those drug interactions that really do matter can be best achieved by combining a practical knowledge of the pharmacological mechanisms involved with awareness of the most vulnerable patients (those with little reserve capacity) and the drugs associated with the greatest risk (those with a narrow therapeutic index). This review follows these guidelines and provides an account of well documented drug interactions categorised according to mechanism.