Alcohol Withdrawal Management

Alcohol Withdrawal Management Chris Skinner

Aims of Session Introduction to concepts of physical dependency Introduction to three groups of drugs (including Alcohol) that cause physical dependency and withdrawal states Basic Overview of Treatment and Management Interventions Brief overview of signs and symptoms and side (or untoward) effects of each group Intervention Strategies that may assist in withdrawal from each group.

Alcohol - a drug of Dependence Like the opioids Alcohol causes Physical dependency when used chronically for long periods. When the drug is withdrawn a "withdrawal state" occurs - this is known as "Alcohol Withdrawal State" or previously, "Delirium Tremens" from the Latin "Shaking delirium"

Signs and Symptoms - Alcohol Withdrawal restlessness Raised Pulse (above 88 beats per minute) Raised lood Pressure (Diastolic above 95 mm/ Hg) Diaphoresis (Sweating) at rest Fine tremors of extremities (More Severe) Clouded sensorium Seizures, resembling epileptic fits Visual, Tactile and Auditory Hallucinations Delusional behaviour Patient feels restless, ill at ease or confused

Drug Management The drug of choice in managing Alcohol withdrawal state is Diazepam which is prescribed by the Medical Officer against a specific Alcohol withdrawal scale. Diazepam is generally only needed for 24 - 48 hours after commencement of extreme withdrawal status

Other treatments The person who has withdrawn from Alcohol needs a rehabilitation program which may comprise of Abstinence 12 steps program Education about the effects of Alcohol on Organ Systems Drinking at Safe Levels

Side effects of Alcohol Ataxia (poor gait) Social disinhibition and garrulousness Alcohol induced psychosis (previously known as Korsakoff's Psychosis) Encepalopathy Peripheral Neuritis (numbness of the fingers and toes, also known as Parasthesia) Alcohol induced hepatitis (inflammation of the liver) and Cirrhosis (replacement of healthy liver cells with fatty cells) Alcohol induced cardio-myo-pathy (disease of the heart muscle) Dementia Violent, irrational beahviour secondary to deformed thought processes

Safe Drinking - Responsible Drinking Safe levels are difficult to define but generally the following rules apply:3 standard drinks for men per day with at least two alcohol free days a week 2 standard drinks a day for women with at least two alcohol free days a week (Women have smaller livers than men so Alcohol has astronger effect in the woman) There is no level of safe drinking for pregnant women. Drinking when pregnant may lead to foetal alcohol syndrome where the foetus is born with skeletal deformities and intellectual disabilities

Side effects (continued) Portal Hypertension with back pressure to the oesophagus causing oesophageal varices Renal Disease  Pancreatic disease including Diabetes Skin Disease including alcohol induced psoriasis Morbid jealousy Depression and Suicide

Opiates Opiates (Syn opioids, narcotic analgesics) consist of the Prototype Codiene which is manaufactured from the Opium Poppy (Papaver somniferum) exudate commonly known as opium. Codiene is relatively weak and is more likely to cause Pruritis before it causes a Phsyical Dependency but its more distilled forms Morpine, DiacetylMorpine (Heroin) and Methadone, as well as the synthetic form Pethidine are extremely addictive at relatively low doses although they are all extremely effective analgesics (pain relievers) - all cause vomiting, pruritis and respiratory depression, even at low doses. As chronic users use Heroin, as an examples, the vomiting reflexlessens as tolerance to the drug develops,

Opiate Withdrawal Withdrawal of Opiates which cause a severe form of dpependency when used chronically is by way of Substitution with a Narcotic antagonist (such as Naltrexone) or with a substitute Narcotic Opiate with a lesser propensity to cause Euphoria - this is usually either Buprenorphine or Methadone. Dosage of the replacement is regulated downwards to prevent severe withdrawal symptoms such as Stomach Cramps and Diarrhoea

Benzodiazepines Benzodiazepines include anxiolytics (anxiety relieving agents), sedatives, hypnotics, short acting anaesthetic agents and anti-convulsants. They have been around since the late 1940's Examples are Diazepam, Lorazepam, Oxazepam, Alprazolam, Clonazepam and Midazolam They are classified as short acting (Midazolam, Lorazepam) or long acting (Diazepam) Alprazolam(Xanax) is often implicated in benzodiazepine dependency, it is a low dose Benzodiazepine and should only be prescribed for up to 2 weeks, to prevent dependency. It can be substituted with Oxazepam once

Diazepam Diazepam was made by Roche in the late 1950's through to the present, it is an anxiolytic, a sedative, an anticonvulsant and has been used pre and para operatively for small scale procedures not require general anaesthesia.   In the 1960's Diazepam was the world's most prescribed drug and was the subject of the song "Mother's Little Helper" by the Rolling Stones   Although extremely useful it can be habit formingand extremely damaging to the brain and central nervous system when used for long periods in high amounts.

Side effects of benzodiazepines Benzodiazepines can produce a physical dependence and withdrawal can be difficult and complicated by seizures Side effects include Dry Mouth, Taste Changes Increased Colour Awareness Short Term Memory Loss Mental Dullness Depression Somnolence (a desire to sleep all the time) Ataxia respiratory depression Peripheral Neuropathy  

Management of Benzodiazepine withdrawal Gradual decrease in the dose regimen over 10 -14 days blood tests to ensure compliance/adherence Cognitive behavioural therapy to decrease need for medication Psychiatrist Consultation to exclude co-morbid mental illness and to suggest adjunctive supportive pharmacotherapy if needed drug rehabilitation education