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 abuse, and on average only 60% completed treatment of alcohol 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 alcohol dependence. They cannot completely cure alcohol addiction, but they can make the process of detoxification more comfortable and shorten the time it takes to recover.
Why are medications used to treat alcohol withdrawal?
Drinking plays an important part in the life of an alcoholic, which could lead to a build-up of physical tolerance and experiencing alcohol withdrawal symptoms if they stop. A medically assisted detox is recommended for the treatment of alcohol withdrawal even if you choose to detox at home.
Some of the alcohol withdrawal symptoms can start within 6 hours of your last drink and may include some or all of the following:
- Hand tremors
- Your alcohol withdrawal 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/)
Medications are not intended to cure alcoholism or help people quit drinking. The goal of medications for the treatment of alcohol withdrawal is to relieve symptoms and help the person remain as comfortable as possible. They are used only during the acute phase of withdrawal, which usually lasts one to two weeks.
Although studies have not yet established precisely how these drugs work, they believe they reduce alcohol withdrawal symptoms by blocking receptors in the central nervous system.
Medications in pill form may be used alone or in combination with other treatments for substance abuse. For example, they can be given in combination with behavioural therapy and medical care while a patient is in an inpatient treatment centre. The medications may also be used after you are discharged from an alcohol detox program or given on an outpatient basis by a primary care provider.
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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. These alcohol withdrawal symptoms are known to occur in chronic alcohol abusers who abruptly stop drinking alcohol. These severe symptoms may include:
- Tremors or shaking hands, feet
- Chest pain
- Excitability, anger, confusion
- Easily startled
- Heavy sweating
- High blood pressure
- Nausea or vomiting
- 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)
The DTs are a medical emergency and can be life-threatening if not treated properly. 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). To treat withdrawal symptoms, your GP provides a personalised treatment program to prevent severe reactions during the detoxification process.
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 from alcohol intake. These severe alcohol withdrawal symptoms 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 alcohol withdrawal symptoms, low energy, trouble sleeping, and delayed reflexes, and can last from several months to a year. These are persistent yet mild withdrawal symptoms and can be assisted with medication during the treatment process. (https://www.verywellmind.com/is-paws-real-or-another-relapse-excuse-4109902)
Post-acute withdrawal syndrome (PAWS) can last for months or years, although it usually lasts for less than six months in most people. 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.
PAWS is more common in people who have been alcoholics for years and have stopped drinking independently. If you’ve been diagnosed with alcohol addiction, you must seek help from your doctor to treat the symptoms of PAWS as soon as possible.
Medications used to Treat Alcohol Withdrawal
Alcohol detox medications are often prescribed by a GP who specialises in substance abuse disorders. These medications can reduce the severe reactions associated with acute alcohol withdrawal syndrome. They are typically taken as part of an overall alcohol health and treatment plan for alcohol addiction or other substance use disorders.
There are several types of drugs used to treat alcohol dependence. They work by reducing alcohol cravings, helping you cope with urges to drink and preventing withdrawal symptoms. Medications also can make it easier for you to stay in treatment.
Benzodiazepines are medications that can be used to treat alcohol withdrawal symptoms experienced during alcohol addiction treatment. As the recommended medication for use during alcohol detox, it helps to treat anxiety or panic and have been shown to reduce any alcohol withdrawal seizures that may be experienced during substance abuse treatment.
There are specifically FDA-approved benzodiazepines in both the long-acting and shorter-acting classes that can be prescribed for treating alcohol withdrawal:
- 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 treatment.
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. Thiamine is an effective treatment for alcohol withdrawal syndrome, even when used alone with no other medications. It can reduce the severity and frequency of symptoms such as hallucinations and delirium tremens (DTs).
A maintenance dose may be prescribed during the addiction treatment process in a case where there is a chronic deficiency. (https://patient.info/doctor/acute-alcohol-withdrawal-and-delirium-tremens)
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 for alcohol treatment, they are useful if there is a history of withdrawal seizures but doesn’t necessarily prevent Delirium Tremens & grand-mal seizures.
These drugs can be habit-forming and have side effects such as nausea, dizziness and headache, so they’re usually only used for a short time to manage acute withdrawal symptoms. The goal is to discontinue use as soon as possible because they can be addictive when taken over long periods of time.
Although not as commonly used for drug abuse treatment, Barbiturates may be used in benzodiazepine-resistant cases, their use has shown promise in the medical emergency department and ICU for extreme cases of withdrawal. However, their use in alcohol withdrawal is still being studied. (https://www.alcohol.org/medication/)
Side effects may include fatigue, nausea, vomiting, dry mouth, and drowsiness. Benzodiazepines aren’t recommended for long-term use because they can cause dependence in those who abuse other drugs or have a history of substance abuse.
Medications to treat alcohol dependence & prevent relapse
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 to drink alcohol, adverse consequences, etc:
The use of Disulfiram as part of addiction treatment maintenance programme is to discourage drinking alcohol, the adverse reactions induced alcohol consumption whilst taking Disulfiram can last up to an hour:-
- flushing of the face
- blurred vision
Naltrexone (Vivitrol, Revia)
When Naltrexone is included in the maintenance part of recovery from alcohol use disorders. It is believed to reduce the craving, the urge, or the desire. 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 is not metabolized by the liver and does not adversely interact with alcohol, as such it can be used alcohol addiction treatment if you have liver disease or hepatitis.
The efficacy of Acamprosate is best felt when taken in conjunction with counselling, support, and other holistic substance abuse treatments.
Other drugs may also be used alternatively but their full effectiveness in treatment of alcohol withdrawal may not have been studied enough, these include but are not limited to:
- Muscle Relaxants
It is important to take these medications exactly as directed by your GP so you do not become dependent on them. If you have been using alcohol for a long time, it may take several weeks before all of the alcohol withdrawal symptoms have resolved.
Additionally, multifaceted alcohol 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 alcohol detox and recovery.
How can a medically assisted detox be requested?
Medically assisted detox is a treatment programme that uses medications to ease the symptoms of alcohol withdrawal. Alcohol Detox can be a very stressful time, the physical dependence your body has on alcohol will need to be assessed to find the correct mix of medication and support you may require, for the treatment of alcohol. It can be done in either an inpatient or outpatient setting, depending on your needs and situation. This can be done either through:
Depending on your assessment, your GP may still refer you to a treatment centre, because, although he/she can prescribe and administer 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 a medical 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.
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 alcohol rehab facility (alcohol rehab) or as an outpatient service.
How long will medication be necessary?
During the initial detox and withdrawal process (first 5 -7 days) you will most likely be taking the full complement of medications prescribed (except for the maintenance or anti-craving medications) to prevent serious complications. 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 such as mood disorders or major depressive disorder (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 for relapse prevention.
Maintenance medications used to help ease cravings may also be part of long-term treatment as relapse can happen years after you have quit drinking.