Alcohol detoxification

Alcohol detoxification, or "detox", for individuals with alcohol dependence, is the abrupt cessation of alcohol intake coupled with the substitution of alcohol with cross-tolerant drugs that have similar effects in order to prevent alcohol withdrawal. Detoxification may or may not be necessary depending upon an individual's age, medical status, and history of alcohol intake. For example, a young man who binge drinks and seeks treatment one week after his last use of alcohol may not require detoxification before beginning treatment for alcoholism. Benzodiazepines are the most common family of drugs used for thiscite journal |author=Mayo-Smith MF |title=Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal |journal=JAMA |volume=278 |issue=2 |pages=144–51 |year=1997 |pmid=9214531 |doi= [http://gateway.ovid.com/ovidweb.cgi?T=JS&PAGE=linkout&SEARCH=9214531.ui Full text] at OVID] , followed by barbituratesFact|date=August 2007.

Benzodiazepines

"Benzodiazepines" such as chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan) or oxazepam (Serax) are the most commonly used drugs used to reduce alcohol withdrawal symptoms. There are several treatment patterns in which it is used.

# The first option takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3–10 days.
# Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon.
# A third option is to defer treatment until symptoms occur. This method should not be used in patients with prior alcohol related seizures. This has been effective in randomized controlled trials.cite journal |author=Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR |title=Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial |journal=JAMA |volume=272 |issue=7 |pages=519–23 |year=1994 |pmid=8046805 |doi=] cite journal |author=Daeppen JB, Gache P, Landry U, "et al" |title=Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial |journal=Arch. Intern. Med. |volume=162 |issue=10 |pages=1117–21 |year=2002 |pmid=12020181 |doi=] A non-randomized, before and after, observational study found that symptom triggered therapy was advantageous.cite journal |author=Jaeger TM, Lohr RH, Pankratz VS |title=Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients |journal=Mayo Clin. Proc. |volume=76 |issue=7 |pages=695–701 |year=2001 |pmid=11444401 |doi=]

Dosing of the benzodiazepines can be guided by the CIWA-Ar scale.cite journal |author=Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM |title=Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar) |journal=British journal of addiction |volume=84 |issue=11 |pages=1353–7 |year=1989 |pmid=2597811 |doi=] The scale is available online.cite journal |author=Holbrook AM, Crowther R, Lotter A, Cheng C, King D |title=Diagnosis and management of acute alcohol withdrawal |journal=CMAJ : Canadian Medical Association journal journal de l'Association medicale canadienne |volume=160 |issue=5 |pages=675–80 |year=1999 |pmid=10102003 |doi= ( [http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1230114 see appendix 2] )]

Regarding the choice of benzodiazepine:
* Chlordiazepoxide (Librium) is the benzodiazepine of choice in uncomplicated alcohol withdrawal. [ Raistrick, D, Heather N & Godfrey C (2006) "Review of the Effectiveness of Treatment for Alcohol Problems" National Treatment Agency for Substance Misuse, London http://www.nta.nhs.uk/publications/documents/nta_review_of_the_effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf]
* Lorazepam or diazepam are available as an injection for patients who cannot safely take medications by mouth.
* Lorazepam and oxazepam may be best in patients with cirrhosis (shorter half life).

ympatholytics

Randomized controlled trials have found benefit from atenololcite journal |author=Kraus ML, Gottlieb LD, Horwitz RI, Anscher M |title=Randomized clinical trial of atenolol in patients with alcohol withdrawal |journal=N. Engl. J. Med. |volume=313 |issue=15 |pages=905–9 |year=1985 |pmid=2863754 |doi=] and clonidine.cite journal |author=Baumgartner GR, Rowen RC |title=Clonidine vs chlordiazepoxide in the management of acute alcohol withdrawal syndrome |journal=Arch. Intern. Med. |volume=147 |issue=7 |pages=1223–6 |year=1987 |pmid=3300587 |doi=]

Carbamazepine

A randomized controlled trial has found benefit from carbamazepine.cite journal |author=Malcolm R, Ballenger JC, Sturgis ET, Anton R |title=Double-blind controlled trial comparing carbamazepine to oxazepam treatment of alcohol withdrawal |journal=The American journal of psychiatry |volume=146 |issue=5 |pages=617–21 |year=1989 |pmid=2653057 |doi=]

Other drugs

Some hospitals administer alcohol to prevent alcohol withdrawal although there are potential problems with this practice.cite journal |author=Blondell RD, Dodds HN, Blondell MN, "et al" |title=Ethanol in formularies of US teaching hospitals |journal=JAMA |volume=289 |issue=5 |pages=552 |year=2003 |pmid=12578486 |doi=]

Various vitamins, especially from the B group, are often used during withdrawal treatment.

Sodium oxybate is the sodium salt of gamma-hydroxybutyric acid (GHB). It is used for both acute alcohol withdrawal and medium to long-term detoxification. This drug enhances GABA neurotransmission and reduces glutamate levels. It is used in Italy in small amounts under the trade name Alcover.

Baclofen has been shown in animal studies and in small human studies to enhance detoxification. This drug acts as a GABA B receptor agonist and this may be beneficial.

References