Benzodiazepines alcoholic withdrawal management

Benzodiazepines and other anxiolytics. Although benzodiazepines are widely used in the treatment of acute alcohol withdrawal, most nonmedical personnel involved in the treatment of alcoholism are opposed to the use of medications that can induce any variety of dependence to treat the anxiety, depression, and sleep disturbances that can persist for months following withdrawal. Researchers have debated the pros and cons of the use of benzodiazepines for the management of anxiety or insomnia in alcoholic patients and other substance abuse patients during the postwithdrawal period (Ciraulo and Nace 2000 Posternak and Mueller 2001). 

Historically, the treatment of alcohol use disorders with medication has focused on the management of withdrawal from the alcohol. In recent years, medication has also been used in an attempt to prevent relapse in alcohol-dependent patients. The treatment of alcohol withdrawal, known as detoxification, by definition uses replacement medications that, like alcohol, act on the GABA receptor. These medications (i.e., barbiturates and benzodiazepines) are cross-tolerant with alcohol and therefore are useful for detoxification. By contrast, a wide variety of theoretical approaches have been used to reduce the likelihood of relapse. This includes aversion therapy and anticraving therapies using reward substitutes and interference approaches. Finally, medications to treat comorbid psychiatric illness, in particular, depression, have also been used in attempts to reduce the likelihood of relapse. 

This fivefold clinical activity is possessed, to a greater or lesser extent, by all benzodiazepines in current clinical use. The properties of benzodiazepines make them ideally useful for managing anxiety (e.g. diazepam, chlordiazepoxide, lorazepam) insomnia (e.g. diazepam, temazepam, nitrazepam, loprazolam, flurazepam, lormetazepam) epilepsy (e.g. clobazam, diazepam, lorazepam) sports injuries where muscle relaxation is required (e.g. diazepam) and as premedications prior to surgery (e.g. midazolam, lorazepam). The benzodiazepines have a number of other uses, including management of alcohol withdrawal syndrome (chlordiazepoxide, diazepam) and restless legs (clonazepam). Short... 

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. 

Chlordiazepoxide, which has a long duration of action (t 2 = 10-25 hours), is useful for the management of alcohol withdrawal and is arguably better tolerated than other benzodiazepines when used for this indication. As with diazepam, loading doses are possible and simplify clinical management. 

Hoey, L.L. Nahum, A. Vance-Bryan, K. A prospective evaluation of benzodiazepine guidelines in the management of patients hospitalized for alcohol withdrawal. Pharmacotherapy 1994, 14, 579-585. 

Clorazepate is a benzodiazepine that potentiates action of GABA, an inhibitory neurotransmitter, resulting in increased neuronal inhibition and CNS depression, especially in limbic system and reticnlar formation. Clorazepate is indicated in the management of anxiety disorders relief of acnte alcohol withdrawal symptoms and adjunctive therapy in management of partial seizures. 

Chlordiazepoxide Diazepam Midazolam Phenobarbital 54. Benzodiazepines are LEAST effective in (A) Alcohol withdrawal syndromes Balanced anesthesia regimens Initial management of phencyclidine overdose Obsessive-compulsive disorders Social phobias... 

Sellers EM Alcohol, barbiturate and benzodiazepine withdrawal syndromes clinical management. CMAJ 139 113—120, 1988... 

Many alcohol-dependent patients manage their withdrawal outside of the hospital when they have only mild symptoms and are in generally good health. Very often these patients will visit their primary care physician, seeking a short course of benzodiazepines (such as diazepam or chlordiazepoxide) for a few days, as well as some prescription-strength vitamins and thiamine to assist in their withdrawal and recovery. It is critical that a responsible adult monitors these patients around the clock to be sure that they are not developing confusion, unstable blood pressure, or other vital signs and to provide essential support for the detoxification process. 

Alcohol also shows cross-dependence with CNS depressant drugs. This means that taking one drug can suppress withdrawal symptoms of the other. For example, alcohol and the benzodiazepine drugs such as Valium and Librium show cross-dependence. This phenomenon has proved valuable in managing withdrawal from alcohol in individuals who arc physically dependent on it. 

Off-label use Certain psychiatric disorders including bipolar disorders and post-traumatic stress disorder, non-neuritic pain syndromes, restless leg syndrome, management of alcohol, cocaine and benzodiazepine withdrawal, and chorea in children. ... 

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