Treatment of Alcohol

W'lthdrawal
HUGH MYRICK, M.D., AND RAYMOND F. ANTON, M.D.

Appropriate treatment of alcohol withdrawal (AW) can relieve the patient's discomfort,
prevent the development of more serious symptoms, and forestall cumulative effects that
might worsen future withdrawals. Hospital admission provides the safest setting for the
treatment of AW, although many patients with mild to moderate symptoms can be treated
successfully on an outpatient basis. Severe AW requires pharmacological intervention.
Although a wide variety of medications have been used for this purpose, clim-clans disagree
on the optimum medications and prescribing schedules. The treatment of specific withdrawal
complications such as delirium tremens and seizures presents special problems and requires
further research. KEY WORDS: ADD withdrawal syndrome; treatment method,- inpatient care,-

outpatient care,- symptom,- disease severity; alcohol withdrawal agents,- drug therapy;
delirium tremens,- AODR (alcohol and other drug related) seizure,- patient assessment,cormorbidity,- treatment cost,- benzodiazepines,- adrenergic receptors,- special populations,literature review

Symptoms of alcohol withdrawal

(AW) may range in severity from
mild tremors to massive convulsions
(e.g., withdrawal seizures). Mild AW
can cause pain and suffering; severe
AW can be life-threatening. The goals
of AW treatment are to relieve the
patients discomfort, prevent the occurrence of more serious symptoms, and
forestall cumulative effects that might
worsen future withdrawals. Withdrawal
treatment also provides an. opportunity to engage patients in long-term
alcoholism treatment.
This article explores the management of AW and co-occurring conditions, evaluates different treatment
settings and medications, and addresses
considerations in treating special
populations.

38

CLINICAL FEATURES OF
ALCOHOL WITHDRAWAL
The symptoms of AW reflect overactivity of the autonomic nervous system,
a division of the nervous system that
helps manage the bodys response to
stress. The signs and symptoms of
AW typically appear between 6 and
48 hours after heavy alcohol consumption decreases. Initial symptoms
may include headache, tremor, sweating, agitation, anxiety and irritability,
nausea and vomiting, heightened
sensitivity to light and sound, disorientation, difficulty concentrating,
and, in more serious cases, transient
hallucinations. These initial symptoms
of AW intensify and then diminish
over 24 to 48 hours.

Delirium tremens (DTs), the most

intense and serious syndrome associated
with AW, is characterized by severe
agitation; tremor; disorientation; persistent hallucinations; and large
increases in heart rate, breathing rate,
pulse, and blood pressure. DTs occur

in approximately 5 percent of patients

undergoing withdrawal and usually
appear 2 to 4 days after the patients
last use of alcohol.
HUGH MYRICK, M.D., is an assistant

professor ofpsychia and YMOND .F

ANTON, M. D., is aprofessor ofpsychia-

at the Medical Um'versity of South

Carolina, Department of Psychia
Centerfor Drug and Alcohol Programs,
Charleston, South Carolina.
ALCOHOL HEALTH & RESEARCH ORLD

T)REATMENT OF ALCOHOL WITHDRAWAL

of becomes
BZ and adequate
control of
or thedoses
patient
excessively
adolescents
with
that indicates
BZs are that
"suitable
agents
forAW
alcominor
AWonly
symptoms
(Hersh
et al. 1997). hol withdrawal."
sedated.
Often
I to 2 days
of medrequire specialized
treatment.
For
All BZs appeared the
Antipsychotic
medications,
such as equally
ication are
required under
this regimen.
eldereffective
population,
cumulative
of
in treating
AWyears
symphaloperidol
have
may leadGroup
to morealso
severe
Other
studies (Haldol@),
have assessed
thebeen
needused toms.drinking
The Working
found
in administration
low doses to treat
DTs.on
These
for BZ
based
the agents that withdrawal
(Anton
and be
the dose ofsymptoms
medication
should
lackof
thethe
excessive
and low
severity
patientssedation
symptoms.
Becker
1995);
the
shorter
acting
BZs
individually tailored to suit the symppressure effects
of BZs while
Theseblood
assessments
have employed
a
may
be
preferable
in
treating
this
tom severity of each patient. The
providing
behavioral
However, authors
standard
AW scale
called control.
the Clinical
population,
given the increased
susceprecommended
that patients
antipsychotic
medications
can cause
Institute
of Withdrawal
Assessment
tibility
to
oversedation
in
the
elderly.
with moderate to severe AW symptoms
adverse effects,
as increased
sus- be treated
for Alcohol,
revised such
(CIWA-Ar)
(Saitz
Although
pregnancy does notPharmaappear
pharmacologically.
to seizures,
increased
et al.ceptibility
1994). Such
studies have
foundrestto
increase
the
occurrence
of
major
cological treatment should also be
lessness
agitation,
abnormal
withdrawal
such asymptoms
that when
theand
overall
dose and
of BZ
s is
administered
tosymptoms,
patients with
history
muscular
movements.
Clearly,
more
may
be
fatal
to
both
the
mother
reduced, patients suffer less unwanted
of withdrawal seizures or in
thoseand
with
specific
guidelines
areable
needed
in the
the fetus.
In addition,
medications
sedation
and are
therefore
to particcomorbid
medical
illnesses.
used to treat AW may have adverse
treatment
of DTs
ipate pharmacological
more readily in other
treatment
effects on the fetus (e.g., congenital
(SaitzClearly,
and O'Malley
1997).is a useactivities.
the CIWA-Ar
Adrenergic
Medications
malformation).
To prevent such risks,
ful instrument for quanng AW as well
treatment
with
BZs
should be limited
as for guiding the need for medication.
Adrenergic receptors are specialized
Alcohol Withdrawal Seizures
to the minimum amount needed to
No single BZ appears to be supeproteins on the surface of certain
major complications of AW.
AW
seizures
not treating
related to
DTs (i.e., nerveprevent
rior to
other
BZs for
AW
cells. These receptors play an
(For
a
discussion
of the fetal effects of
primary et
AW
usually
subside important role in the regulation
(Moskowitz
al. seizures)
1983). The
selection
of the
withdrawal
during
pregnancy, see the
with only
treatment.
of a specific
BZsupportive
for a specific
patient
autonomic nervous system and may
article by Thomas and Riley, pp. 47-53.)
However,been
because
one-third
has primarily
madeupontothe
basis
therefore be expected to influence the
The treatment of AW in the mediof patients
with
untreated
primary
of clinical
factors
such
as the patients
occurrence and severity of some withcally
ill can present a considerable
age; seizures
occurrence
of prior seizures;
subsequendy
developand
DTs, drawal symptoms.
Studies show that
challenge.
patients are at a
the functional
state
of theshould
liver, the
all primary
seizures
be treated. medications thatThese
alter the function of
higher
risk
of
developing
major withprimary
site forsuggests
the metabolism
of BZ .
Evidence
that for patients
adrenergic receptors significantly
drawal
symptoms
and
may
progress to
In patients
with
impaired
liver
funcwho do not have a history of AW
improve symptoms of AW, especially
more severe
forms
of AW,
such as DTs.
administration
BZs should by reducing
elevated
pulse
and blood
tion, seizures,
longer lasting
BZs may of
cause

been include
shown causing
to blockless
kindling
sedation,
in brain
exhibiting
interaction
with medications
alcohol if both
cells.less
Third,
antiseizure
areappear
used concomitantly,
producing
do not
to have abuseand
potential.
antianxiety
activity without
Fourth,
these medications
have abuse
been
Additional
information
is
used liability
to treat mood
and anxiety
disoruse of clinical
ders,needed
which concerning
share somethe
symptoms
to quantitate
drug effects
with scales
AW, including
depression,
irri-in
AWand
andanxiety
clearer specifications
on the
tability,
Fifth, antiseizure
utility ofare
supportive
care
treatmedications
generally
notinasthesedatAW.
Furthermore,
ing asment
BZsofand
therefore
allowconsiderable
the
research
is necessary
to further
patient
to engage
more quickly
in elucidate thetreatment
role of pharmacotherapy
in the
alcoholism
programs.
who medicahave experiIntreatment
Europe, of
thepatients
antiseizure
multiple withdrawal
episodes.
tionsenced
carbamazepine
(Tegretol@)
and .
valproic acid (Depakene@ and others)
have been used successfully to treat
REFERENCES
AW for
many years. However, these
medications
have rarely been used in
ABBOTT, J.A.; QUINN, D.; AND KNOX, L. Ambuclinical
settings
North America
for American
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detoxification
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Journal of Drug
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is 21(4):
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in part to the reluctance of
clinicians
to abandon
safe and
American
Psychiatric the
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Task Force.
Treatment
Pcbiatric
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because
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vant DC:
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ANTON, Rhas
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acolog)|: Volume 114. The Pbarmaco of Aoho[
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pp. 315-367.
Concurrent
medical
conditions
be sufficient
prevent
such seizures pressure
(Saitz and
O'Malley
1997). should
problems,
ranging to
from
oversedation
TREATMENT
OF COMPLICATED
not
only
be
aggressively
treated,
but
BALIENGER J.C., AND POST, R.M . Kindling as a
(Rothstein 1973).
No evidence indicates, however, that
to incoordination
(i.e., ataxia) and
WITHDRAWAL
should
also
be
anticipated
in
patients
model
for
alcohol
withdrawal syndromes. Brith
Controversy
surrounds
confusion.
Many alcoholics
have the
liveruse of these medications block delirium or
Journal of Pchia 133: 1-14, 1978.
undergoing
AW
who
have
been
admitthe
antiepileptic
medication
phenytoin
seizures.
Most
reviewers
have
concluded
damage and therefore require medicated to the medications
hospital for are
medical
in the
treatment of AW that adrenergic
of or
tions (Dilantin@)
that are rapidly
metabolized.
BROWN, M.E.; ANTON, R F.; MAI COLM, R ;
Delirium Tremens
surgical
treatment.
seizures.
Phenytoin
appear value largely as adjuncts to BZs in the
Recent
clinical
reviewsdoes
havenot
stressed
AND BALIENGER J.C. Alcohol detoxification and
to prevent
the occurrence
of primary management of AW These medications
withdrawal
Clinical
support
for a kindling
Because
DTs seizures:
are more
likely
to occur
the value
of short-acting
BZs, such
hypothesis. Rio al Pchin 23:507-514, 1988.
AW seizures.
However,
phenytoin
also may be useful in outpatient settings,
in
patients
who
have
co-occurring
as oxazepam
(SeraX@)
and lorazepam
may be(Gallant
useful 1989).
in combination
with a whereCONCLUSIONS
the abuse liability of BZs by
GALIANT,
D.M. Improvements
in treatment
(Ativan@)
Lorazepam
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illnesses,
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preventing
anisinitial
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alcohol withdrawal
Alcoho Clinical
is readily
metabolized
and
shorter
aggressive
treatmentsyndromes.
of such illnesses
The treatment of patients exhibiting
and Experimental Research 13:721-722, 1989.
who have
a history
actingpatients
than diazepam.
O'Brien
andof one or and where AW symptoms are generally
is paramount. The required treatment
AW
has
been
varied
and
at
times
more
seizures
in
their
adult
life,
irreless severe than among inpatient popcolleagues (1983) compared lorazepam
HAYASHIDA,
M.; ALTERMAN,
A.I.;
AND
MCLELLAN,
includes
maintaining
water
and
eleccontroversial.
clinicians genspective of
whetherwith
any moderate
of them were ulations
T. Comparative effectiveness and costs of inpa(Anton andAlthough
Becker 1995).
and diazepam
in patients
trolyte
balance, correcting metabolic
erally agree that severe AW requires tient and outpatient detoxification of patients
AWfound
seizures
and Becker
1995).
AW and
both(Anton
medications
to
disturbances,
and administering
med- synwith mild-to-moderate
alcohol withdrawal
pharmacological intervention, a wide
More effective
studies are
needed in AW
this area,
be equally
in alleviating
drome.
New
EngndJournal
of
Medici.ne
320(6):
ication
as
appropriate.
eizure of
Medications
medications have been used. 358-365, 1989.
particularly
focusing
on thelow
efficacy Anus'variety
symptoms,
although
excessively
The
optimum
pharmacological
Further
uncertainty
exists
among the
BZs and
antiseizure
HERSH, D.; RRANZIER, H.R.; AND MEYER, R E.
Although
in most
treatment
settings
bloodofpressure
occurred
moremedications,
commonly
therapy
for the
treatment
of DT
s is of heavy
treatment
community
when
considering
Persistent
delirium
following
cessation
such
as
carbamazepine
and
valproic
BZ's are the drugs of choice for uncomin the diazepam-treated patients.
somewhat
controversial.
Some
clinialcohol
consumption:
Diagnostic
and treatment
pharmacological
treatment
of
mild
to
acid, in new
the treatment
and prevention plicated AW, nonsedating antiseizure
Recently,
practice guidelines
implications.
Amen.can
Journal
of Phia
cians
have
used
BZ
s
to
decrease
moderate
AW
including
the
preferred
of
AW
seizures.
medications may represent desirable
were developed by the American Society
154(6):846-851, 1997.
autonomic hyperactivity, the risk of
treatment
setting
(i.e., potential
inpatient versus
alternatives.
There
are several
of Addiction Medicine Working Group
Institute
Medicine.
Prevention
and Treatment
outpatient).
While
extensive
research
AW seizures,of and
agitation.
Despite
advantages
to using
antiseizure
medion Pharmacological Management of
of Alcohol Problems. Washington, DC: National
hasFirst,
beenseizures
aimed are
at tackling
SPECIAL
POPULATION
these beneficial effects, BZs may
cations.
one of thesuch issues,
Alcohol
Withdrawal
(Mayo-SmithISSUES
Academy Press, 1990. pp. 268-269.
consensus
has not yetofbeen
contribute to the aggressive and impulmost aserious
complications
AW,reached.
1997). The Working Group reviewed
RAIM, S.C.;and
KLETT,
C.J.; ANDthat
POTHFELD,
Research in
has
notarticles
been conducted
to and the use
Directions
for futuremedicaresearch include
sive behavior
confusion
are B.
of an antiseizure
data presented
134
on the
Treatment of the acute alcohol withdrawal state:
determine
specific
AW
strategies
for
the
continued
search
for
non-BZ
elements
of
DT
s.
In
addition,
withti9n should decrease the probability
treatment of AW published between
A comparison of four drugs. Amen.can Journal of
geriatric,
pregnant,
treatments
for AW.
Desirable characof a patient
experiencing
a seizure.
drawal
may develop
and
1966 adolescent,
and 1995. Based
on the
review or
Pbindelirium
125:1640-1646,
1969.
medically
ill
populations.
No
evidence
teristics
of suchmedications
alternativeshave
would
Second,
antiseizure
persist despite administration of high
of data, the investigators concluded
42
ALCOHOL
&&RESEARCH
4oNo.
ALCOHOL
HEALTH
RESEARCHWORLD
WORLD
VOL. 22,
1,
1, 1998
1998HEALTH
41

T\REATMENT
TREATMENT OF
OFALCOHOL
ALCOHOLWITHDRAWAL
WITHDRAWAL

MALCOLM,
R.; BALLENGER,
J.C.;toSTURGIS,
E.T.;
abstinence
syndrome.
Current Therapeutic
Research:
occurrence
complications,
mild withdrawal
symptoms
may
Seizures
occurofinmedical
up
25 percent
role
inwith
metabolism,
electrolyte
disturbAND ANTON, R. Double-blind controlled trial

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and ongoing
treatment
effectiveness.
of withdrawal
episodes,
usually
beginning
ances
may
to severe
and evencare
benefit
from
supportive
alone. In
comparing carbamazepine to oxazepam treatment
within
the
first
24
hours
after
cessation
life-threatening
metabolic
abnormalities.
the
context
of
nonpharmacological
ROTHSTEIN,
L.
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of
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Inpatient
Treatment
chlordiazepoxide.
American
Journal
of enviPchia
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providing
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a
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MAYO-SMITH, M.F. Pharmacological management
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ronment,
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lighting,
limited
of alcohol withdrawal: A meta-analysis and evidence-

SELLERS,
E.M.;
NARANJO,
C.A.; HARRISON,of
M.;
PHARMACOLOGICAL
source
to
prevent
precipitation

DEVENYI,
P.; ROACH,
C.; AND
K. DiazeMANAGEMENT
Wernicke
syndrome
bySYKORA,
depletion
of

pam
loading:reserves.
Simplified treatment of alcohol
thiamine
withdrawal.
Clinical Pharmacological
Therapeutics
Pharmacological
treatment
is most

34:822-826, 1983.

frequendy employed in moderate to

AW. Although
more
than
150
SHAW,severe
J.M.; KOLESAR,
G.S.; SELLERS,
E.M.;
KAPLAN,
TREATMENT
SETTINGS
FOR
H.L.; AND
SANDORS,
P . Development
of optimal
medications
have been
investigated
ALCOHOL
DETOXIFICATION

ium.
Although
such aninteraction,
association
has
of AW,
interpersonal
nutrition
SAITZ,
R ; MAYO-SMITH,
M .F.; ROBERTS,
M.S.;
treatment
r alcohol withdrawal:
Assessment
fortactics
the treatment
of AW,Lclinicians
not
been
magnesium
will be
REDMOND,
H.A.; BERNARD,
D.R.; supplANDand
CALKINS,
andverified,
fluids,
reassurance,
positive
and effectiveness
ofon
supportive
care. Journalmedications
of
disagree
the
optimum
ments
may
help
improve
general
withSUPPORTIVE
CARE
FOR
D.R.
Individualized
treatment
for
alcohol
withcarefullyG.; CHALMER.s,
monitoredT.C.;
and
appropriately encouragement.
Patients with AW can be treated safely
MosKowrrz,
SACKS, H.S.;
Clinical
Pchopharmacolog)!
}:382-387, 1981.
drawal: symptoms.
A randomized double-blind controlled
and
prescribing
schedules.
The
drawal
ALCOHOL
WITHDRAWAL
supported.
Compared
with
outpatient
and effectively either within a hospitalfollowSupportive care does not prevent
FAGERSTROM, R.M.; AND SMITH, H. Deficiences
trial.Some
]ourna/ of the American
Medical
Association
ing (i.e.,
review
describes
some
medications
alcoholics
exhibit
vitamin
facilities,
inpatient
clinicsAlcoholism.'
may provide
WHITFIELD,
C.L.;inpatient
THOMPSON,
G.;
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A.;
of dinical
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or clinic
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or
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seizures. In fact,
272:519-523,
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that
have
been
recognized
as
potential
deficiencies,
presumably
of
Clinical
and en'mental
Research
7:42`46,
1983.
SPENCER,
V.;
PFEIFER,
M.;
AND
BROWNINGbetter
continuity
ofthat
care
for patients
Certain
medical
disorders
comon
an
ambulatory
basis
(i.e.,
outpatient
although more than two-thirds of a
treatments
for
AW.
FERRANDO,
M.
Detoxification
of
1,024
alcoholic
poor
dietary
habits
as
well
as
from
SAITZ,
R.,
AND
O
MALLEY,
S.S.
Pharmacotherapies
who
begin
treatment
monly
co-occur
withANDalcoholism
O'BRIEN,
J.E.;
MYER,alcoholism
R.E.;
THOMAS,
D.C. canwhile
group of outpatients experiencing mild treatment). Although studies have
patients without psychoactive drugs. ]ourna/ ofthe
of alcohol abuse: changes
Withdrawal
anddigestive
treatment. Medical
alcohol-induced
in the
in the
hospital.
Inoraddition,
Double-blind
comparison
lorazepam
exacerbate
symptoms
ofof
AW
com-and inpatient
compared the effectiveness of outpaAW
successfully
completed 1997.
detoxifica- American
MedicalAssociation 239:1409-1410, 1978.
Clinics
of impair
North America
81 (4):88l-907,
tract
that
the
absorption
of
diazepam
in
the
treatment
of
the
acute
alcohol
detoxification
separates
the
patient
plicate its treatment. The purpose of
tient Benzodiazepines
versus inpatient detoxification,
tion using social support alone, 8 pernutrients
into
the
bloodstream.
Two
from care
alcohol-related
socialdisorders
and envi- cent had to be referred to an emergency no specific criteria have been rigorsupportive
is to treat such
dietary factors of particular importance
(BZs) are a class of
that deficiencies.
might increase
and ronmental
to remedy stimuli
nutritional
ouslyBenzodiazepines
tested.
room and 2.5 percent required inpain
AW
are
folic
acid
and
thiamine.
sedative
medications
widely prescribed
the
risk
of
relapse.
Patients with AW should be subject to
tientplays
admission
(Whitfield
et al. 1978).
Folic
acid
a
role
in
the
synthesis
to
treat
anxiety
insomnia,
and seizures.
Despite
the
lack
of
research-based
a physical examination, with particular
andand
colleagues
(1981) Ounu'enc
Treatment
of theHowever,
celfs geneticShaw
material
matEspecially
in North America, BZs are
criteria,
factorsconditions
suggest thatsuch
a
emphasis
oncertain
detecting
supportive
careFolic
sufficient
urationfound
of certain
blood cells.
acid treatconsidered by research studies and
patient should
inpatient treatas irregular
heartbeatreceive
(i.e., arrhythmia),
Before. the 1980s, AW was generall. y
ment
for
75
percent
of
inpatients
with
deficiency can lead to changes in blood
consensus reports to be the medications
ment
(see
textbox).
These
factors
inadequate heart ftlnction (i.e., contreated in an inpatient setting. Today,
no psychiatric
oranemia.
medical
problems.
cells, induding
a form of
Patients
of choice to treat AW (American Psyinclude
a
history
of
significant
AW
gestive
heart
failure),
liver
disease
detoxifications take place on an
Although
these
studies suggest that most chiatric
undergoing
AW should
be adminisAssociation Task Force 1989;
symptoms,
high
levels
of
recent
drink(e.g., alcoholic hepatitis), pancreatic
outpatient
basis. In a review of puba nonpharmacological
approach to
tered an
oral multivitamin formula
Institute
of Medicine 1990; Anton and
ing, a(i.e.,
historyalcoholic
of withdrawal
seizures or
disease
pancreatitis),
studies,1995;
Abbott
and colleagues
treating
for most patients, lishedBecker
containing
folicAW
acidmay
for a work
few weeks.
Moskowitz
et al. 1983).
DT's,
and
the
co-occurrence
of
a
serious
infectious diseases (e.g., tuberculosis),
(1995)
concluded
that
fewer than 20
the
data
do
not
provide
specific
guidThiamine plays an essential role in
Early
controlled
trials
with BZs
medical
or
psychiatric
iHness
(Ballenger
bleeding within the digestive system,
of patients undergoing AW
anceenergy
on themetabolism.
selection Thiamine
of treatment types. percent
the bodys
and
Post
1978;
Brown
et
al.
1988).
emphasized
multiple
daily
dosing
and
nervous
system
impairment.
require admission to an inpatient unit.
In addition,
supportive
deficiency
in alcoholics
is a factorcare
in may be
according to a fixed schedule (m et
Vital signs (e.g., heartbeat and blood
more than 70 percent of
the development
more costly,
of Wernicke
because syna greater amount In addition,
al. 1969). For inpatients in severe AW,
pressure)
should
be
stabilized
and
Cost Comparison
participants
undergoing outpatient
of nursing care may be required dura loading procedure has been recomdisturbances of water and nutritional
detoxification
complete the program.
ing nonpharmacological
AW treatment.
mended (Sellers et al. 1983). In this
The
for
T choice of treatment setting
w manu
'rnary c
andInothe
balances
corrected.
most
studies,
50 percent of the
Until controlled studies of adequate
treatment strategy, 10 mg or more of
alcohol
detoxification
has
important
The
presence
of water in the
blood
patients continued in alcoholism treatduration
and
numbers
of
patients
are
diazepam (Valium@)
implications.
and
profes
with guidelines
use of screening
ief intervention
ures or another longand cost
within
cells is Hayashida
essential
for the
mentlasting
after outpatient
studied, the role of pharmacological
BZ is detoxification.
administered every hour
colleaguesof(1989)
found outpatient
performance
physiological
processes
Mostuntil
importantly,
review found
treatment
of patients
either
thethis
symptoms
are suppressed
detoxification
to beand
considerably
pati
risk
for
alcohol
ms. The
briefwith
int AW symption procedures
ar
gned compliand alcohol
to for
maintain
both theart
kidney
no
reports
of
serious
medical
less
costly
than
inpatient
treatment
toms
will
continue
to
be
debated.
function. Some patients undergoing
cations among AW outpatients except
$388
$3,319
to $3,665,
Theroutine
most disturbing
AW ($175
may
require
intravenous
fluids
to
for to
use
i versus
rimary
care
setting
ring
patie and perhaps
'sits. Alsothat
available
e
one patient suffered
a seizure
respectively).
To
some
extent,
the
higher
controversial issue regarding nonpharRELATIVE INDICATIONS
correct severe dehydration resulting
after
the
start
of
detoxification.
cost
of
inpatient
treatment
reHects
the
treatment
of AW
the Drinking,"FOR
INPATIENT ALCOHOL
from companion
vomiting,
diarrhea,
brochuresweating,
for patients, macological
"How to Cut
Down
on isYour
presenting
No specific
criteria exist for deciding
occurrence
of moremany
severeAW
symptoms
DETOXIFICATION
concern that failure to medicate may
and fever.
Conversely,
patients
which
patients
could
benefit from
AW as
well aswater
more in
co-occurring
lead to alcohol-induced
toxicitytheir
to
may of
retain
excess
their blood
s for
thoseamong
who hospitalized
ors have advise
to reduce
consumption
outpatient
detoxification.
Practical
*
History
of
severe
withdrawal
medical
problems
nerve cells (i.e., neurotoxicity), which
and tissues. In these patients, intradrome, a condition characterized by
considerations
suggest that candidates
symptoms
patients
compared
with
ambulatory
may
increase the patients susceptibilvenous administration
ofsteliquid may
d are
taking
oHowsevere
that
advice.
confusion, abnormal gait, and for outpatient treatment should exhibit
patients.
However,
thepump
safety, efficacy,
ity
to
repeated
of alcohol withdrawal
overload
the hearts
ability to
paralysis ofseizures
certainfollowing
eye muscles.
In addi- only mild* toHistory
moderate AW symptoms,
and cost-effectiveness of outpatient
(i.e.,
kindling)
(for
furseizures
tremens
blood, leading to heart failure. In most tion, withdrawals
Wernicke syndrome can progress no medical conditionsorordelirium
severe psydetoxification suggest an important
discussiondementia.
of kindling,
seepatients
the
cases, water balance can be maintained to anther
*
Multiple
past
detoxifications
irreversible
All
chiatric disorders that could complicate
role for this setting in the treatment
by Becker,
25-33)be
(Ballby oral administration of fluids.
beingarticle
treated
for AWpp.should
given the withdrawal
process, and
no pastor
of mild to moderate AW.
* Concomitant
medical
Alcoholics are often deficient in 100 milligrams
enger and Post
Therefore,
(mg)1978).
of thiamine
as
history of AW
seizures or
DT
s. In
psychiatric
illness
electrolytes, or "minerals" (e.g., magsome withdrawal
episodes
soon although
as fretreatment
beginsus'and
our
Gu daily
chore,
addition,
candidates
for
outpatient
nesium,
phosphate,
and
sodium). during
* Recent high levels of alcohol
may appear
to be mild
enoughSupplies
to
period.I
'oual Institute onthe
Alc withdrawal
se and Alcoholism,
us Distribution
Ceuteshould have a sober
NONPHARMACOLOGICAL
detoxification
Because these substances play a major
consumption
be treated
without
medications,
of
thiamine
stored
in
the
body
are
MANAGEMENT
significant
P.0. Box
e, MD 20849-0686.
02) 842-0418. other to serve as a reliable
this10686,
approach
long-term
limited
even
in may
the have
absence
of alco- support person.
* of reliable
supportAW
network
Ambulatory
IA dose of 100 mg thiamine is equivalent
Full t to that
both publications
is ava' consequences
u NIAAA's
World
Wi
site at http://www.uiaa
ov
deleterious
for patients
holism.
Therefore,
thiamine
should
While
most
clinicians
agree that severe
patients *should
report to their treatment
Pregnancy
available
in the
highest
potency nonprescription
whobe
experience
future withdrawal
always
administered
before giving center daily so that the clinician can
AW
requires
pharmacological
vitamin
B complex
supplements.
By contrast, treatment,
episodes.
an alcoholic
patient glucose as an energy
the daily
requirement
is approximately
1.5 mg.
studies
suggest
that some patients

safest guideline.
settingJournal
for the
based practice
of thetreatment
American

Medical
Association
278(2):144-151,
1997.
because
it ensures
that patients

reassess the patients symptoms, the

VOL. 22, No. 1, 1998 9