Medication to Treat Alcohol Withdrawal Symptoms

Alcohol is a big part of many socially acceptable occasions and celebrations, but like many drugs, it can be addictive, both physically and psychologically. 60% of people seeking treatment for substance abuse in the UK had a problem with alcohol, and on average only 60% completed treatment successfully and generally within 6 months. (https://www.gov.uk/)

Whilst quitting alcohol may seem daunting, there is help available, medication can be taken during and after your alcohol detox to help ease the withdrawal symptoms brought on by your dependence on alcohol.

Why are medications used to treat alcohol withdrawal?

therapy session

Drinking plays an important part in the life of an alcoholic, which could lead to a build-up of physical tolerance and experiencing withdrawal symptoms if they stop. A medically assisted detox is recommended even if you choose to detox at home.

Some of the withdrawal symptoms can start within 6 hours of your last drink and may include some or all of the following:

  • Headaches
  • Anxiety
  • Shaking
  • Nausea
  • Irritability
  • Disorientation
  • Hand tremors
  • Seizures
  • Your symptoms may intensify over the 1st week and depend on the severity of your alcohol use disorder, you may also experience acute alcohol withdrawal (PAWS) or Delirium Tremens (https://www.alcohol.org/detoxification/)
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What are delirium tremens?

Delirium Tremens is an acute and serious range of withdrawal symptoms that can occur as soon as 48 hours and can last up to 5 days and is known to occur in chronic alcohol abusers who abruptly cease using alcohol:

  • Tremors or shaking hands, feet
  • Chest pain
  • Dehydration
  • Excitability, anger, confusion
  • Fever
  • Easily startled
  • Hallucinations
  • Heavy sweating
  • High blood pressure
  • Nausea or vomiting
  • Nightmares
  • Pale skin
  • Passing out
  • Problems with eye muscle and movement
  • Sensitivity to light, sound, and touch
  • Severe hyperactivity
  • Sleepiness, stupor, or fatigue (this can include a deep sleep that lasts for a day or longer)

Management of DT should be in a hospital or residential detox treatment centre as intensive medical care may be required. (https://patient.info/doctor/acute-alcohol-withdrawal-and-delirium-tremens)

What is Post-Acute Withdrawal Syndrome (PAWS)?

Whilst PAWS is not an official diagnosis and is not found in the DSM-5 there have been regular enough occurrences of symptoms that come along after the initial withdrawal symptoms of early abstinence and are uncomfortable or aggravating enough to cause some to relapse merely to relieve those nagging symptoms.

There is a correlation between two factors: the amount of damage alcohol abuse did to the nervous system over the years and the amount of stress experienced during recovery. These factors contribute to a person experiencing ongoing symptoms including anxiety, low energy, trouble sleeping, and delayed reflexes, and can last from several months to a year. These persistent symptoms are generally minor and can be assisted with medication. (https://www.verywellmind.com/is-paws-real-or-another-relapse-excuse-4109902)
Some people who quit alcohol and drugs never experience post-acute withdrawal symptoms at all, while others can still face some symptoms years into abstinence.

Medications used to Treat Alcohol Withdrawal

Benzodiazepines:

As the recommended medication for use during alcohol detox, to help ease feelings of anxiety or panic and have been shown to reduce any seizures that may be experienced during withdrawal.

There are specifically FDA-approved benzodiazepines in both the long-acting and shorter-acting classes:

  • Chlordiazepoxide (Librium) – Chlordiazepoxide is the most prescribed during alcohol withdrawal, the dosage is generally reduced over the 5 – 7 days that a typical acute withdrawal lasts. You would be assessed daily to ensure that your withdrawal symptoms are being adequately eased.
  • Clorazepate (Tranxene) – Clorazepate is available only with a prescription and only when a fast-acting benzodiazepine is needed during acute alcohol withdrawal.
  • Diazepam (Valium) – Diazepam is an acceptable alternative to Chlordiazepoxide. It is effective in controlling muscle spasms and seizures during withdrawal.
  • Oxazepam (Serax) – Oxazepam is a short to intermediate-acting benzodiazepine, and is used to treat acute anxiety as well as acute alcohol withdrawal.

Thiamine:

Due to poor diet or stomach issues, an alcohol abuser may have a deficiency in Thiamine (Vit B1), this deficiency can cause Wernicke’s Encephalopathy or Korsakoff Syndrome (https://medlineplus.gov/ency/article/000771.htm)
Due to this risk, you may need a prophylactic treatment of vitamin B1 either intravenously or orally for 3 to 5 days
A maintenance dose may be prescribed in a case where there is a chronic deficiency. (https://patient.info/doctor/acute-alcohol-withdrawal-and-delirium-tremens)

Anticonvulsants:

Prescribed in conjunction with benzodiazepines, anticonvulsants help manage acute alcohol withdrawal syndrome or delirium tremens:

  • Carbamazepine (Tegretol)
  • Gabapentin (Neurontin)
  • Oxcarbazepine (Trileptal)
  • Valproic Acid (Depakene)

Whilst anticonvulsants are not routinely prescribed, they are useful if there is a history of withdrawal seizures but doesn’t necessarily prevent Delirium Tremens & grand-mal seizures.

Barbiturates:

Although not as commonly used, Barbiturates may be used in benzodiazepine-resistant cases, their use has shown promise in the emergency department and ICU for extreme cases of withdrawal. However, their use in alcohol withdrawal is still being studied. (https://www.alcohol.org/medication/)

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Medications to treat alcohol dependence & prevent relapse

a man in therapy session

Close follow-up is needed after detoxification and acute alcohol withdrawal, if you have been discharged from secondary care, your doctor or treatment centre may recommend or prescribe the following medications to help minimise cravings, etc:

Disulfiram (Antabuse)

The use of Disulfiram as part of a maintenance programme is to discourage drinking alcohol, the adverse reactions induced by the intake of alcohol whilst taking Disulfiram can last up to an hour:-

  • anxiety
  • headache
  • flushing of the face
  • sweating
  • blurred vision
  • nausea/vomiting

Naltrexone (Vivitrol, Revia)

When Naltrexone is included in the maintenance part of recovery, craving of alcohol, urge, or desire to drink is believed to be reduced. Although initially used to treat opiate use disorder, the FDA approved its use in alcohol abuse recovery due to the positive results reported by patients.
The risk of liver disease unfortunately means this medication is contraindicated in patients that have pre-existing liver disease or hepatitis.

Acamprosate (Campral)

Acamprosate is not metabolized by the liver and does not adversely interact with alcohol, as such it can be used if you have liver disease or hepatitis.
The efficacy of Acamprosate is best felt when taken in conjunction with counselling, support, and other holistic treatments.

Other medications may also be used alternatively but their full effectiveness in alcohol withdrawal treatment may not have been studied enough, these include but are not limited to:

  • Antipsychotics
  • Antihypertensives
  • Beta-blockers
  • Muscle Relaxants

Multifaceted treatment approaches restore the balance in your central nervous system, as such counselling, self-help, and groups including Alcoholics Anonymous should be applied in conjunction with medications during recovery.

How can a medically assisted detox be requested?

Detox can be a very stressful time, the dependence your body has on alcohol will need to be assessed to find the correct mix of medication and support you may require, this can be done either through:

A GP:

Depending on your assessment, your GP may still refer you to a treatment centre, because, although he/she can prescribe any of the medications above, you may require a more supportive environment in which to detox

A Home Detox Programme

An at-home detox programme through a specialised service will include an assessment, ongoing support throughout your detox as well as any medications required. Your needs will be monitored by either a ‘support buddy’ or a private Sober Coach.

Residential Rehab

A private residential treatment centre will ensure that you are supervised 24/7 by a medical professional who will monitor your withdrawal symptoms and administer medication as needed, there is also often follow-up treatment available to you either within the residential rehab facility (alcohol rehab) or as an outpatient service.

 

How long will medication be necessary?

two women supporting each other

During the initial detox and withdrawal (first 5 -7 days) you will most likely be taking the full complement of medications prescribed (except for the maintenance or anti-craving medications) these meds will be reduced or adjusted depending on your needs.

If your alcohol use disorder is being treated in conjunction with another mental health issue (dual diagnosis) you may have other medications best suited to their treatment added and those may be taken for months or even years as needed.

Maintenance medications used to help ease cravings may also be part of long-term treatment as relapse can happen years after you have quit.