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1. Management of Alcohol Intoxication and Withdrawal

Assess symptoms of intoxication and withdrawal.

  • Consider using standardized alcohol withdrawal scales such as the Clinical Institute Withdrawal Assessment of Alcohol Scale—Revised, to assess level and change in alcohol withdrawal symptoms.

  • Laboratory tests should be used to determine whether the presence of other substances is contributing to the clinical presentation.

  • Withdrawal symptoms generally begin within 4–12 hours after cessation or reduction of alcohol use, peak in intensity during the second day of abstinence, and generally resolve within 4–5 days.

  • Gastrointestinal distress, anxiety, irritability, elevated blood pressure, tachycardia, and autonomic hyperactivity occur in mild to moderate withdrawal.

  • Symptoms of severe withdrawal occur in fewer than 5% of patients and include delirium, hallucinations, grand mal seizures, respiratory alkalosis, and fever.

Determine whether risk factors for withdrawal are present.

Significant risk of withdrawal is associated with the presence of any of the following:

  • Prior history of delirium tremens and/or medicated alcohol withdrawals.

  • Documented history of very heavy alcohol use and high tolerance.

  • Concurrent abuse of other drugs.

  • Severe comorbid general medical condition or psychiatric disorder.

  • Repeated failures at outpatient detoxification.

Choose an appropriate setting for treatment (see section A.3).

  • For acute intoxication, monitor and maintain in a safe environment.

  • For mild to moderate withdrawal, provide generalized support, reassurance, and frequent monitoring. For most patients with mild to moderate withdrawal symptoms, this can occur in outpatient settings that provide for frequent clinical assessment and any needed clinical treatments.

  • For moderate to severe withdrawal, arrange for an appropriate setting based on the patient'€™s signs and symptoms, past history, co-occurring general medical and psychiatric conditions, and psychosocial support network. Residential treatment or hospitalization may be needed, particularly for patients with delirium tremens.

Treat moderate to severe alcohol withdrawal with pharmacotherapy.

  • Restore physiological homeostasis (e.g., glucose, thiamine, and fluids).

  • Reduce CNS irritability with benzodiazepines.

    • Administer a benzodiazepine orally, e.g., chlordiazepoxide 50 mg every 2–4 hours), diazepam (10–20 mg every 2–4 hours), oxazepam (60 mg every 2–4 hours), or lorazepam (1–4 mg every 2–4 hours), as needed for signs and symptoms of withdrawal.

    • Calculate the total number of milligrams of benzodiazepine required in the first 24 hours and use this value to determine subsequent daily doses.

    • Taper benzodiazepines over the next 2–5 days. (Patients in severe withdrawal and those with a history of withdrawal-related symptoms may require up to 10 days before benzodiazepines are completely withdrawn.)

  • Use an anticonvulsant agent (as an adjunct) for treating or preventing withdrawal seizures. Evidence is emerging for the use of anticonvulsants as a potential alternative to benzodiazepines, particularly for patients with preexisting alcohol withdrawal seizures or multiple previous medical detoxifications, and in outpatient detoxification settings.

  • Beta-blockers or clonidine may be used on a short-term basis in combination with benzodiazepines to decrease symptoms of withdrawal; however, such use may complicate dosing of benzodiazepines by masking withdrawal symptoms.

  • Use an adjunctive antipsychotic agent on a short-term basis for delirium or psychosis.

  • Observe for reemergence of withdrawal symptoms and alcohol relapse as medications are tapered.

  • Observe for emergence of signs and symptoms suggestive of a co-occurring psychiatric disorder.

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2. Management of Alcohol Dependence

Consider pharmacological treatment.

The following pharmacotherapies for alcohol-dependent patients have well-established efficacy and moderate effectiveness, particularly as part of a comprehensive program of treatment (see Table 7 for implementation guidelines):

  • Naltrexone can attenuate some of the reinforcing effects of alcohol and lead to reduced drinking and resolution of alcohol-related problems. A long-acting injectable preparation may promote adherence, but published research is limited and FDA approval is pending.

  • Disulfiram can help deter subsequent "slips" by causing a highly aversive reaction after a patient has even a single drink.

  • Acamprosate may decrease alcohol craving in recently abstinent individuals.

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Table Reference Number
TABLE 7. Implementation of Pharmacotherapies for Alcohol-Dependent Patients

Treat or prevent common neurological sequelae of chronic alcohol use by routinely giving thiamine if moderate to severe alcohol use is present.

  • Korsakoff'€™s syndrome (alcohol amnestic disorder) should be treated vigorously with B-complex vitamins (e.g., thiamine, 50–100 mg/day i.m. or i.v.), usually after adequate fluids and glucose levels are maintained.

Consider if pharmacotherapy is needed to treat comorbid psychiatric conditions.

  • For many patients, signs and symptoms of depression and anxiety may not require pharmacotherapy but instead are related to alcohol intoxication or withdrawal and remit in the first few weeks of abstinence. Treatment of nondepressed alcoholic patients with SSRIs appears to be ineffective.

  • For alcoholic hallucinosis during or after cessation of prolonged alcohol use, antipsychotic medication should be considered.

Consider providing psychosocial treatment.

Potentially helpful treatments include the following:

  • Cognitive-behavioral therapies aimed at improving self-control and social skills

  • Motivational enhancement therapy (MET)

  • 12-step facilitation therapy

  • Behavioral therapies

  • Marital and family therapy

  • Group therapies

  • Psychodynamic/interpersonal therapies

  • Brief interventions (i.e., abbreviated assessments of drinking severity and related problems and provision of motivational feedback and advice)

  • Aftercare, which may include partial hospitalization, outpatient care, or self-help group involvement and which may help maintain abstinence during the period following an intensive treatment intervention (e.g., hospital or residential care)

  • Self-help groups and 12-step–oriented groups, such as Alcoholics Anonymous

Table Reference Number
TABLE 7. Implementation of Pharmacotherapies for Alcohol-Dependent Patients

References

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