Alcohol abuse withdrawal syndrome

Cessation of prolonged heavy alcohol abuse may be followed by alcohol withdrawal or life-threatening alcohol withdrawal delirium. Typical withdrawal symptoms are autonomic hyperactivity, increased hand tremor, insomnia and anxiety, and are treated with benzodizepines and thiamine. Alcoholism is the most common cause of thiamine deficiency and can lead in its extreme form to the Wernicke s syndrome that can be effectively treated by high doses of thiamine. 

Fadda F, Columbo G, Mosca E, et al Suppression by gamma-hydroxybutyric acid of ethanol withdrawal syndrome in rats. Alcohol Alcohol 24 447-451, 1989 Fine J, Finestone SC. Sensory disturbances following ketamine anesthesia recurrent hallucinations. Anesth Analg 52 428 30, 1973 Freese TE, Miotto K, Reback CJ The effects and consequences of selected club drugs. J Subst Abuse Treat 23 151—156, 2002... 

However, there are disadvantages to benzodiazepines. They prodnce sedation and can impair short-term memory and coordination (psychomotor fnnction such as driving). They can magnify the effects of alcohol and are snbject to abuse and withdrawal syndromes. Refer to Section 5.1 for a more extended discussion of benzodiazepines. 

A 33-year-old woman has a 15-year history of alcohol abuse. She comes to the emergency department for treatment of injuries received in a fall. She says she has been drinking heavily and almost continuously for 2 weeks, and she wants to stop. Which of the following drugs would most effectively and safely lessen the intensity of her withdrawal syndrome ... 

MacKinnon, G.L. and Parker, W.A. (1982) Benzodiazepine withdrawal syndrome a literature review and evaluation , American Journal of Drug and Alcohol Abuse, 9 (1) 19-33. 

Abrupt alcohol withdrawal leads to a characteristic syndrome of motor agitation, anxiety, insomnia, and reduction of seizure threshold. The severity of the syndrome is usually proportionate to the degree and duration of alcohol abuse. However, this can be greatly modified by the use of other sedatives as well as by associated factors (eg, diabetes, injury). In its mildest form, the alcohol withdrawal syndrome of tremor, anxiety, and insomnia occurs 6-8 hours after alcohol consumption is stopped (Figure 23-2). These effects usually abate in 1-2 days. In some patients, more severe withdrawal reactions occur, with patients at risk of hallucinations or generalized seizures during the first 1-3 days of withdrawal. Alcohol withdrawal is one of the most common causes of seizures in adults. Several days later, individuals can develop the syndrome of delirium tremens, which is characterized by total disorientation, hallucinations, and marked abnormalities of vital signs. 

Even normal people can be pushed to the limit of seizures through the abuse of drugs or alcohol. In these cases the seizures usually develop in the period of withdrawal, suggesting that they reflect alterations in the excitability of the brain that have taken place during the period of abuse but that are not expressed until the chemical that actually causes them is taken away. In order to maintain the desired alteration in consciousness afforded by the drug and to suppress the unpleasant effects of withdrawal, addicts typically increase their intake until the time of crisis inevitably occurs. It thus seems quite likely that the drug effectively quells the seizures that the withdrawal syndrome induces. 

A 69-year-old man developed acute benzodiazepine withdrawal delirium following a short course of flunitrazepam after an acute exacerbation of chronic obstructive pulmonary disease. He was not an alcohol-or drug-abuser and he had not previously taken benzodiazepines. Six days after withdrawal of flunitrazepam he became agitated and confused, and had visual hallucinations, disorganized thinking, insomnia, increased psychomotor activity, disorientation in time and place, and memory impairment. Tachycardia and significant anxiety were also noted. He fulfilled the DSM IV criteria for withdrawal syndrome and delirium, and had spontaneous remission of symptoms within 48 hours. 

A kind of (low-dose) dependence may also develop when alcohol is consumed daily, albeit in minor quantities. As a rule of thumb, alcohol always makes people dependent when consumed on a regular basis — no matter what the dose may be. Alcohol addiction comprises (1.) physical dependence including increased tolerance as well as the withdrawal syndrome and (2.) psychological dependence with an uncontrollable desire for permanent or intermittent alcohol consumption, reduced self-control as well as changes in behaviour, (s. tab. 28.1) Alcohol abuse includes addiction without actually being identical to it. Neither the brain s reward system (A. Herz et af, 1989) nor the addiction memory (X Boning, 1992) are stimulated by occasional alcohol consumption. Another explanation for this... 

Following detoxication, the use of naltrexone may decrease the craving for alcohol The most important goal in alcohol withdrawal is to prevent respiratory depression Wernicke-Korsakoff syndrome that occurs in alcohol abuse is due to a deficiency of folic acid... 

Sodium oxybate is effective and indicated for the treatment of cataplexy in patients with narcolepsy it could also be effective for general anesthesia, narcolepsy, fibromyalgia syndrome, insomnia, alcoholism and opiate withdrawal, but its potential for abuse is unacceptable... 

Tiapride appears to be useful in alcohol withdrawal as an alternative to the benzodiazepines (2). It facilitates the management of ethanol withdrawal, but its use in patients at risk of severe reactions in acute withdrawal should be accompanied by adjunctive therapy for hallucinosis and seizures. Since it may prove difficult to identify such patients and since there is also a small risk of the neuroleptic malignant syndrome (particularly with parenteral administration), the usefulness of tiapride in this setting is likely to be limited. The potential risk of tardive dyskinesia at the dosage used in alcoholic patients following detoxification (300 mg/day) requires evaluation and necessitates medical supervision. It is unlikely to produce problems of dependence or abuse. 

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