About 95 percent of people have mild to moderate withdrawal symptoms, including agitation, trembling, disturbed sleep, and lack of appetite. In 15 percent to 20 percent of people with moderate symptoms, brief seizures and hallucinations may occur, but they do not progress to full-blown delirium tremens. Such patients can nearly always be treated as outpatients.
After being examined and observed, the patient is usually sent home with a four-day supply of anti-anxiety medication, scheduled for follow-up and rehabilitation, and advised to return to the emergency room if withdrawal symptoms become severe. If possible, a family member or friend should support the patient through the next few days of withdrawal.
Benzodiazepines. Patients are usually given one of the anti-anxiety drugs known as benzodiazepines (tranquilizers such as Valium), which inhibit nerve-cell excitability in the brain. They are used to relieve withdrawal symptoms, help prevent progression to delirium tremens, and reduce the risk for seizures.
Diazepam has a longer duration of action than lorazepam or midazolam. Typically, the physician may give the patient an initial (or loading) intravenous dose of diazepam with additional doses given every one to two hours thereafter over the period of withdrawal. This regimen can cause very heavy sedation.
Problems With BenzodiazepinesBenzodiazepines are usually not prescribed for more than two weeks or administered for more than three nights per week. Problems with benzodiazepines include the following:
Side Effects. Common side effects of benzodiazepines are daytime drowsiness and a hung-over feeling. In rare cases, they actually cause agitation. Respiratory problems may be exacerbated. The drugs appear to stimulate eating and can cause weight gain. Benzodiazepines can interact with certain drugs, including cimetidine (Tagamet), antihistamines, and oral contraceptives. Benzodiazepines are potentially dangerous when used in combination with alcohol. Overdoses are serious, although very rarely fatal. Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people. Benzodiazepines are associated with birth defects, and should not be used by pregnant women or nursing mothers.
Loss of Effectiveness and Dependence. The primary problem with these drugs is their loss of effectiveness over time with continued use at the same dosage. As a result, patients may increase their dosage level to prevent anxiety. Patients then can become dependent.
Withdrawal Symptoms. People who discontinue benzodiazepines after taking them for even four weeks can experience mild rebound symptoms. The longer the agents are taken and the higher the dose the more severe the symptoms. They include sleep disturbance and anxiety, which can develop within hours or days after stopping the medication.
Other Drugs for Mild to Moderate WithdrawalThe following agents may also be given:
Anti-Seizure Medications. Anti-seizure agents, such as carbamazepine (Tegretol) or divalproex sodium (Depakote) may be useful for reducing the requirements of a benzodiazepine. When used by themselves, however, they do not appear to be effective in reducing seizures or delirium.
Specific Treatment for Severe SymptomsTreating Delirium Tremens. People with symptoms of delirium tremens must be treated immediately. Untreated delirium tremens has a fatality rate that can be as high as 20 percent. Symptomatic patients are usually given intravenous anti-anxiety medications. Lidocaine (Xylocaine) may be given to people with disturbed heart rhythms. It is extremely important that fluids be administered. Restraints may be necessary to prevent injury to themselves or others.
Treating Seizures. Seizures are usually self-limited and treated with a benzodiazepine. Intravenous phenytoin (Dilantin) along with a benzodiazepine may be used in patients who have a history of seizures, who have epilepsy, or in those whose seizures cannot be controlled. Because phenytoin may lower blood pressure, the patient's heart should be monitored during treatment. Chlormethiazole, a derivative of vitamin B1, is presently used in Europe in reducing agitation and seizures.
Psychosis. For hallucinations or extremely aggressive behavior, antipsychotic drugs, particularly haloperidol (Haldol), may be administered. Korsakoff's psychosis (Wernicke-Korsakoff-Syndrome) is very difficult to treat. It is caused by severe vitamin B1 (thiamine) deficiencies, which cannot be replaced orally. Rapid and immediate injection of the B vitamin thiamin is necessary.
Are your withdrawal symptoms mild or severe? Take the Alcohol Withdrawal Symptoms Quiz.