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Alcohol Detox

Most alcohol-dependent individuals can be detoxified in a modified medical setting, provided assessment is comprehensive, medical backup is available, and staff know when to obtain a medical consultation.

As Gerstein and Harwood (1990) wrote:

Detoxification episodes are often hospital based and may begin with emergency treatment of an overdose. Much drug detoxification (an estimated 100,000 admissions annually) is now taking place in hospital beds. It is doubtful whether hospitalization (especially beyond a day or two) is necessary in most cases, except for the special problems of addicted neonates, severe sedative-hypnotic dependence, or concurrent medical or severe psychiatric problems. For clients with a documented history of complications or flight from detoxification, residential detoxification may be indicated. Detoxification may . . . be undertaken successfully in most cases on a nonhospital residential, partial day care, or ambulatory basis.

Patients who score higher than 20 on the Clinical Institute Withdrawal Assessment (CIWA-Ar) instrument should be admitted to a hospital. (A detailed description of the CIWA-Ar follows.)

Most patients can be detoxified from alcohol in 3 to 5 days. Providers should consider the withdrawal time frame in terms of when the patient will need the most support; for alcoholics, this occurs the second day after the last ingestion. Other factors that influence the length of the detoxification period include the severity of the dependency and the patient’s overall health status. Patients who are medically debilitated should detoxify more slowly.

Assessing Alcohol Withdrawal Symptoms

The signs and symptoms of acute alcohol abstinence syndrome generally begin 6 to 24 hours after the patient takes his or her last drink. The acute phase of alcohol abstinence syndrome may begin when the patient still has significant blood alcohol concentrations. Signs and symptoms may include:

  • Restlessness, irritability, anxiety, agitation
  • Anorexia, nausea, vomiting
  • Tremor, elevated heart rate, increased blood pressure
  • Insomnia, intense dreaming, nightmares
  • Impaired concentration, memory, and judgment
  • Increased sensitivity to sounds, alteration in tactile sensations
  • Delirium (disorientation to time, place, situation)
  • Hallucinations (auditory, visual, or tactile)
  • Delusions (usually paranoid)
  • Grand mal seizures
  • Elevated temperature.

Symptoms do not always progress from mild to severe in a predictable fashion. In some patients, a grand mal seizure may be the first manifestation of acute alcohol abstinence syndrome.

Although many programs devise their own methods of monitoring patients’ withdrawal signs and symptoms, there is considerable advantage to using a widely accepted validated instrument. The CIWA-Ar is commonly used in clinical and research settings for initial assessment and ongoing monitoring of alcohol withdrawal symptoms. It “takes 2 to 5 minutes to administer, helps make the decision to hospitalize the patient or to treat him or her as an outpatient, and is useful for monitoring and managing the patient during withdrawal” (Fuller and Gordis, 1994). It measures the severity of alcohol withdrawal by rating 10 signs and symptoms: nausea; tremor; autonomic hyperactivity; anxiety; agitation; tactile, visual, and auditory disturbances; headache; and disorientation. The maximum score is 67 (Saitz et al., 1994). The CIWA-Ar is not copyrighted, and the version in Exhibit 3-1 (Sullivan et al., 1989) may be used freely.

The CIWA-Ar should be repeated at regular intervals (initially every 1 or 2 hours) to monitor patients’ progress (Sullivan et al., 1989). Increasing scores on the CIWA-Ar signify the need for additional medication or a higher level of treatment; decreasing scores suggest therapeutic response to medication or treatment milieu. Patients scoring less than 10 on the CIWA-Ar do not usually need additional medication for withdrawal (Saitz et al, 1994.; Sullivan et al., 1989).

Benzodiazepine Treatment of Alcohol Withdrawal

Benzodiazepines, such as chlordiazepoxide (Librium), clonazepam (Klonopin), chlorazepate (Tranxene), and diazepam (Valium), are considered effective tools in ameliorating signs and symptoms of alcohol withdrawal because they decrease the likelihood and number of withdrawal seizures and episodes of delirium tremens. Chlordiazepoxide is “currently the most commonly administered medication for alcohol withdrawal in the United States” (Saitz et al., 1994). Oxazepam (Serax) or lorazepam (Ativan) are sometimes used with patients who have severe liver disease because neither is metabolized by the liver.

There are several acceptable medication regimens for treating alcohol withdrawal:

  • Gradual, tapering doses. Oral benzodiazepines are administered on a predetermined dosing schedule for several days and gradually discontinued. This regimen is the one most commonly used. Dosing protocols vary widely among treatment facilities. As an example, patients may receive 50 mg of chlordiazepoxide (or 10 mg of diazepam) every 6 hours during the first day and 25 mg (or 5 mg of diazepam) every 6 hours on the second and third days(Saitz et al., 1994). Doses of withdrawal medication are usually omitted if the patient is sleeping soundly or showing signs of oversedation.
  • Signs and symptoms of the acute phase of alcohol abstinence syndrome may include:
    • Restlessness, irritability, anxiety, agitation
    • Anorexia, nausea, vomiting
    • Tremor, elevated heart rate, increased blood pressure
    • Insomnia, intense dreaming, nightmares
    • Impaired concentration, memory, and judgment
    • Increased sensitivity to sounds, alteration in tactile sensations
    • Delirium (disorientation to time, place, situation)
    • Hallucinations (auditory, visual, or tactile)
    • Delusions (usually paranoid)
    • Grand mal seizures
    • Elevated temperature
  • Symptom-triggered therapy. Using the CIWA-Ar, nurses are trained to recognize signs and symptoms of alcohol withdrawal and to give a benzodiazepine to their patients only when signs and symptoms of alcohol withdrawal appear. Studies have demonstrated that appropriate training of nurses in the application of the CIWA-Ar dramatically reduces the number of patients who receive symptom-triggered medication (from 75 percent to 13 percent)(Wartenberg et al., 1990).
  • Loading dose. Staff administer a slowly metabolized benzodiazepine for only the first day of treatment (Sellers et al., 1983). Patients in moderate-to-severe withdrawal receive 20 mg of diazepam (or 100 mg of chlordiazepoxide) every 1 to 2 hours until they show significant clinical improvement (such as a CIWA-Ar score of 10 or less) or become sedated. A 1985 study by Devenyi and Harrison indicates that “oral diazepam loading alone may be sufficient to prevent withdrawal seizures in patients who have had them previously and who have no other reason for having seizures” (Devenyi and Harrison, 1995). A randomized, double-blind controlled study conducted in an inpatient Veterans Administration hospital (Saitz et al., 1994) compared fixed-dose and symptom-triggered therapy and found that patients “treated with symptom-triggered therapy completed their treatment courses sooner and required less medication than patients treated using the standard fixed-schedule approach.” Specifically, they received less chlordiazepoxide (median 100 mg vs. 425 mg) and received treatment for a shorter period of time (9 hours vs. 68 hours). This indicates that symptom-triggered therapy is an approach that could individualize and improve the management of alcohol withdrawal. “Future studies should evaluate the effect of symptom-triggered therapy on the cost and duration of hospitalization for treatment of alcohol withdrawal and should identify the patient populations for whom symptom-triggered therapy is most effective” (Saitz et al., 1994).

Some patients can be withdrawn from alcohol without medication treatment; however, guidelines for identifying patients who can safely be treated without medication have not been validated in controlled clinical trials. Clinically, it is safer to provide treatment for patients who may not need it than to withhold medication until patients develop severe withdrawal signs and symptoms.

Symptom-triggered therapy is an approach that could individualize and improve the management of alcohol withdrawal.

Other Medications

Carbamazepine (Tegretol) – Carbamazepine, a medication used for treatment of seizures, has been reported as effective in treatment of alcohol withdrawal. A controlled study comparing carbamazepine 800 mg/day to oxazepam 120 mg/day for treatment of alcohol withdrawal found that the two drugs precipitated equivalent scores on the CIWA-Ar. The study’s authors concluded that “anticonvulsants with antikindling properties may be superior to traditional benzodiazepines in preventing alcohol withdrawal seizures and in potentially reducing long-term neurologic, behavioral, and psychiatric complications of alcoholism. To our knowledge, no double-blind, controlled studies have directly compared carbamazepine to a benzodiazepine in the treatment of alcohol withdrawal” (Malcolm et al., 1989).

Propranolol (Inderal) and Other Beta-Blockers – Some of the autonomic nervous system hyperactivity of alcohol withdrawal (such as rapid heartbeat, elevation of blood pressure, sweating, and tremors) is ameliorated by medications, such as propranolol (Inderal) and atenolol (Tenormin), that block beta adrenergic receptors. Although effective in decreasing autonomic symptoms, beta-blockers do not prevent hallucinations and confusion or withdrawal seizures. Propranolol may increase the risk of delirium and hallucinations during alcohol withdrawal (Jacob et al., 1983).

Treatment of Delirium and Seizures

Delirium tremens and seizures are two severe physiologic responses to withdrawal from sedative-hypnotics. Patients who develop delirium tremens with auditory, visual, or tactile hallucinations may need antipsychotic medications to ameliorate their hallucinations and to decrease agitation. Haloperidol, known by the trade name of Haldol, generally controls symptoms (0.5 to 2.0 mg every 4 hours by mouth or by intramuscular injection). Patients who are not vomiting may be given the medication by mouth; those who are severely agitated or vomiting may be administered Haldol intramuscularly. Patients should continue to receive benzodiazepines. Phenothiazines such as chlorpromazine (Thorazine) should not be used because of the increased risk of seizures.

Magnesium Sulfate – A controlled study has shown that magnesium sulfate does not reduce seizure frequency, even in patients with low serum magnesium levels (Wilson and Vulcano, 1984). More recent studies have affirmed the use of benzodiazepines to treat delirium tremens and seizures (Gorelick, 1993).

Phenytoin (Dilantin) – The therapeutic or prophylactic value of a routine prescription of phenytoin to prevent alcohol withdrawal seizures is not established (American Society of Addiction Medicine, 1994b). The current consensus is that phenytoin or other anticonvulsant therapy appropriate for the seizure type should be used for patients with an established history of seizure disorder (seizures not caused solely by alcohol withdrawal). Expert opinion is mixed as to whether phenytoin (or other anticonvulsants) should be used in addition to adequate sedative-hypnotic medication in patients who are at an increased risk of alcohol withdrawal seizures because of previous withdrawal seizures, head injury, meningitis, encephalitis, or a family history of seizure disorder. Intravenous phenytoin is not beneficial for patients with isolated acute alcohol withdrawal seizures, but it may be indicated for patients who have multiple alcohol withdrawal seizures. Metabolism of phenytoin varies from patient to patient. It should be administered orally or intravenously because it is poorly absorbed when administered intramuscularly.

Phenobarbital – Phenobarbital can be used for alcohol detoxification when the patient is physically dependent on both sedative-hypnotics and alcohol.

Naltrexone – Naltrexone has been approved by the Food and Drug Administration (FDA) as a treatment adjunct to reduce relapse to alcohol dependence among detoxified alcohol-dependent patients. Naltrexone, previously marketed under the trade name of Trexan, is now marketed under the trade name of ReVia. The name change was made to prevent possible confusion with the benzodiazepine Tranxene.

Naltrexone is an opioid antagonist that has previously been used primarily to block the effects of heroin and thereby reduce the likelihood of relapse. Its mechanism of action in reducing alcohol consumption is not understood; however, clinical trials support its efficacy when it is used in conjunction with training in coping skills and/or supportive therapy (O’Malley et al., 1992; Volpicelli et al., 1992). It appears to reduce alcohol craving and thus is associated with less frequent and shorter relapses.

The National Institute on Alcohol Abuse and Alcoholism cautions that naltrexone should be administered only by doctors with knowledge of addiction treatment and as part of a structured treatment program. Researchers are still determining which populations are likely to respond best to naltrexone, and possible long-term side effects are under investigation.

Vitamins – Alcohol-dependent patients may have vitamin deficiencies, particularly of thiamine. Patients should receive thiamine in addition to high-potency multivitamins.

Special Problems With Medication Administration

Patients in alcohol withdrawal who are vomiting or who are in acute delirium may not be able to take oral medications. The absorption of diazepam or chlordiazepoxide after intramuscular administration is unpredictable. Intramuscular absorption of lorazepam (Ativan) is more reliable than that of diazepam or chlordiazepoxide. Lorazepam may be administered in doses of 2 mg every hour until signs and symptoms subside.

Outpatient Treatment Concerns

Increasingly, providers and patients are choosing the option of outpatient detoxification in part because of cost and in part because hospitalization (for other than serious sedative dependence) is considered unnecessary in most cases when there are no concurrent medical or severe psychiatric problems (Gerstein and Harwood, 1990). Providers must take into account some additional considerations when designing treatment plans for outpatients:

  • Patients may have ready access to AODs at home.
  • Patients may continue to use alcohol in addition to the prescribed detoxification medications. If they develop withdrawal symptoms, they may self-medicate with AODs. The combination of detoxification medications and other drugs may result in an overdose.
  • Patients may have difficulty getting from their homes to their programs each day.
  • Patients who are undergoing detoxification may experience side effects of withdrawal or breakthrough withdrawal.

Patients may continue to use alcohol in addition to the prescribed detoxification medications. If they develop withdrawal symptoms, they may self-medicate with AODs.

Medical Complications of Alcohol Withdrawal

Fluid and Electrolyte Imbalances

Maintaining the patient’s fluid and electrolyte balance is of key importance during detoxification. Most patents can be given fluids orally, beginning with juices and progressing to other liquids, such as soups. Solid foods should be added to the patient’s diet only after he or she can tolerate liquids. Patients who are vomiting or having severe diarrhea should first be treated with sips of liquids that contain electrolytes. The amount can be increased to patient tolerance. Patients who become dehydrated should receive intravenous fluids containing electrolytes, dextrose, and thiamine (100 mg/bottle).

Patients withdrawing from alcohol are not always dehydrated; in fact, many are overhydrated. Parenteral fluid therapy may be harmful in these cases. During detoxification from alcohol, patients generally tolerate a mild degree of dehydration better than they do overhydration.

Hypoglycemia – Hypoglycemia is a significant danger during detoxification. Oral fluids should contain carbohydrates; orange juice may be one option. Parenteral fluids should contain 5 percent dextrose.

Fever – Any elevation of temperature in an individual who is undergoing withdrawal should be investigated. If the elevated temperature is a result of withdrawal, there is a need for additional medication and reevaluation of the detoxification schedule. If a patient has no other signs or symptoms of withdrawal, the elevated temperature is probably caused by an infection, and early aggressive antibiotic therapy may be necessary.

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