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Medications for Alcohol Withdrawal and Dependence

In severe cases, acute alcohol withdrawal has the potential to be life-threatening. This is because someone struggling with alcoholism who abruptly quits drinking is at risk of experiencing severe symptoms, including delirium, hallucinations, seizures, and problems with blood pressure, temperature, and pulse. Without proper intervention, seizures can lead to death.

Although hallucinations and delusions aren’t inherently fatal, they may result in dangerous situations, such as accidents, injuries, or erratic or violent behaviors.1,2

Seizures, which typically appear within 24 hours of the last drink, occur in up to 25% of individuals withdrawing from alcohol, and delirium tremens occurs in approximately 5% of patients.3 The symptoms of delirium tremens generally appear between 2 and 4 days after discontinuation of alcohol consumption.3

Am I At Risk?

What withdrawal from alcohol feels like

Not everyone who struggles with alcohol abuse will experience severe or complicated withdrawal. The manifestation of the acute alcohol withdrawal syndrome varies greatly from person to person. Those who are at very high risk during alcohol withdrawal include:2,3

  • Those with a history of delirium tremens or withdrawal seizures.
  • Those who have consumed high amounts of alcohol in the weeks prior to withdrawal.
  • Those who have been regular drinkers for two decades or more.
  • Older adults.
  • People with co-occurring mental health or physical conditions.
  • Those in poor general health, such as those with nutritional deficiencies.
  • Those who've suffered head trauma in the past.

Where Should I Detox?

If you struggle with an addiction to alcohol, you’ll want to schedule an appointment with your doctor to receive a medical evaluation. Your physician will assess your risks by asking questions about a number of factors, including:2

  • Physical health.
  • Mental health.
  • Patterns of alcohol abuse.
  • Concurrent use of any other substances.
  • Past addiction treatment or detoxifications.
  • Risk of suicide or violence.

They will use this information to gauge your risk for experiencing a complicated withdrawal. If they feel you may be in danger of having a seizure or developing delirium tremens, they are likely to refer you to a medical inpatient detox facility. These programs provide you with 24-hour care, supervision, and monitoring, and medical staff can provide you with medications necessary to keep you safe during withdrawal.2

Who Should Receive Inpatient Detox?

Outpatient detox is reserved for people with little to no risk of dangerous withdrawal symptoms. There are several contraindications to outpatient detox. People who shouldn’t receive outpatient detox and instead should enroll in an inpatient program include those who:4

  • Have had multiple failed attempts at completing outpatient detox.
  • Have coronary artery disease or insulin-dependent diabetes.
  • Suffer from severe psychiatric disorders, such as suicidal thoughts or attempts, hallucinations, delusions, cognitive deficits, or psychosis.
  • Have a co-occurring sedative addiction.
  • Show signs of liver problems, such as jaundice.
  • Have a history of withdrawal delirium or seizures.
  • Fail to respond to medications with 1-2 days.
  • Are pregnant.
  • Don't have a secure home setting or support network.
  • Are in an advanced state of withdrawal (hallucinations, high fever, delirium, etc.).

Entering an inpatient detox program for alcohol withdrawal can save your life. Medical staff members, such as doctors and nurses, are available to administer medications and provide supportive care to help you eliminate alcohol from your system safely and achieve a physically and psychologically stable state.

What Medications Help Alcohol Withdrawal?

Some medications are useful in managing acute alcohol withdrawal. These medications include:2

  • Benzodiazepines: These sedatives are the most preferred class of medication for alcohol detox treatment. Benzos commonly employed in alcohol detox include diazepam and chlordiazepoxide. People may receive either loading doses of benzos every 1 to 2 hours or symptom-triggered treatment (in which medical personnel only administer the medication when they detect signs or symptoms of withdrawal). Since benzos can lead to physiological dependence, the drug will need to be gradually tapered once the patient has reached a stable state. This gradual tapering schedule will prevent the emergence of benzo withdrawal symptoms.
  • Phenobarbital: Although this type of barbiturate can be effective, it is not typically the medication of choice for alcohol withdrawal. Barbiturates are very addictive and an overdose from phenobarbital may be fatal, which is why it should only be administered in highly structured environments, such as inpatient medical detox.
  • Anticonvulsants: Seizures may be prevented with the use of anticonvulsants such as carbamazepine; however, they may not be as effective for cases of severe withdrawal as they are for mild or moderate cases.
  • Clonidine and beta-blockers: These drugs, which can help manage symptoms of autonomic arousal, such as hypertension and high body temperature, may be used in addition to benzodiazepines.
  • Antipsychotics: These drugs may be given to treat hallucinations, delusions, and agitation during alcohol withdrawal. However, they can occasionally lower the seizure threshold, meaning that the person is more susceptible to having a seizure, so close supervision is necessary.

Benzodiazepines are effective in managing alcohol withdrawal because they are cross-tolerant with alcohol. As a cross-tolerant substance, a benzodiazepine drug essentially serves as a substitute for alcohol during withdrawal and modulates excitatory brain signaling via its interaction with certain brain proteins known as GABA-A receptors. The benzos used to manage alcohol withdrawal have a relatively wide margin of safety, unlike older barbiturates (e.g., phenobarbital) that were used more commonly in the past.5

Can Medications Be Used After Detox?

Certain medications can be used once detox has been completed. These medications, which are approved by the Food and Drug Administration (FDA) for the treatment of alcohol dependence, function in different ways to help a person abstain from abusing alcohol. Common relapse prevention drugs include:6

  • Naltrexone: This medication is available as an oral tablet or a once-a-month intramuscular injection (Vivitrol). It blocks opioid receptors in the brain, which blunts the rewarding effects of continued drinking and reduces alcohol cravings.
  • Acamprosate: This medication interacts with the glutamate and gamma-aminobutyric acid (GABA) neurotransmitter systems to mitigate protracted withdrawal symptoms, such as anxiety, dysphoria, restlessness, and anxiety. Because it is taken orally 3 times each day, it requires more vigilance on the part of the patient to keep up with treatment.
  • Disulfiram: This medication is available as a once-a-day pill. If a person drinks alcohol while taking disulfiram, they will experience very unpleasant effects, such as heart palpitations, nausea, and flushing.

The risk for relapse is extremely high in the first 6 to 12 months after quitting drinking and then the risk slowly decreases over the years following. It is often recommended that people who are newly abstinent receive at least 3 months of medication, although it can be beneficial to continue taking medication for a year or longer. Medications address just one facet of alcohol addiction, though, and should be combined with professional counseling or therapy to instill lasting behavioral changes.6

When Can I Start Taking Medications for Alcohol Addiction?

naltrexone withdrawalIt’s important to understand that some of the alcohol addiction medications cannot be taken during acute withdrawal and require a waiting period before initiation.

For example, the FDA recommends that naltrexone should not be used until alcohol withdrawal symptoms have dissipated. On average, this involves waiting at least 3 days after quitting drinking, with as many as 7 if at all possible. This recommendation is due to the potential side effects of naltrexone, such as nausea, which may be heightened by the presence of alcohol. That being said, taking naltrexone during medical detox or while drinking is not dangerous.7 Taking naltrexone within 7-10 days of quitting opioids, however, could cause precipitated opioid withdrawal, so patients detoxing from both alcohol and opioids may need to wait longer to initiate therapy.7

The FDA also approved acamprosate for relapse prevention maintenance once the person is already abstinent from alcohol. Acamprosate is not effective in decreasing or managing alcohol withdrawal symptoms. The FDA doesn’t indicate a specific time period that the individual must wait before initiating acamprosate use, but since alcohol detox may last several days, it is likely that at least a few days are necessary before introducing the medication.8

Because disulfiram interferes with alcohol metabolism, it should not be taken when the person has alcohol in their system. Disulfiram use should be initiated in patients who have been abstinent for at least 12 hours and their blood alcohol level is at 0.9

Can I Join AA if I Use Medications?

Traditionally, Alcoholics Anonymous (AA) has held the viewpoint that sobriety means you should be taking no substances at all. This includes the use of relapse prevention medications. This can present a challenge for recovering individuals undergoing medication-assisted treatment (MAT) who wish to receive support, encouragement, and guidance in the form of a 12-step group. That being said, viewpoints are changing and many chapters of AA have looser interpretations of their rules than others, including those involving MAT. With the ever-evolving attitudes of AA members and chapters, it is likely that you’ll be able to find a chapter that welcomes you and won't condemn your medication use. When in doubt, you can always reach out to specific chapters and inquire about their viewpoints on relapse prevention drugs. That way you’ll be able to avoid feeling stigmatized during meetings.

In 2000, a study was conducted to evaluate the attitudes of AA members toward alcohol addiction medications, such as naltrexone. More than 50% of those surveyed expressed the belief that the use of these medications was a good idea, or at the very least, may be a good idea. About 17% said that people should not take one of these drugs, and 12% responded that they would instruct a fellow member to quit taking it. Nearly 29% of responders reported that they’d experienced some level of pressure to stop taking (any) medication.10

If you’d prefer to avoid the risk of experiencing pressure to quit taking naltrexone, acamprosate, disulfiram, or any other medications that have been prescribed to you, there are alternatives to AA that may be more open on the subject. For example, SMART Recovery is a secular, evidence-based approach to addiction recovery. SMART Recovery focuses on empowering members, instilling and maintaining motivation, coping with cravings, and managing behaviors, feelings, and thoughts. Their approach evolves as scientific research surrounding addiction treatment changes, and they advocate for the appropriate use of medications that can help people remain abstinent.11

If you are looking to stay sober with the use of medications, you will be able to find the support and guidance that is right for you and your individual journey towards lasting sobriety.

References

  1. U.S. National Library of Medicine. (2018). Alcohol withdrawal.
  2. Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment (Treatment Improvement Protocol (TIP) Series, No. 45.).
  3. Myrick, H. & Anton, R.F. (1998). Treatment of Alcohol Withdrawal. Alcohol Health & Research World, 22 (1), 38-43.
  4. British Columbia Medical Association. (2013). Problem Drinking Part 3-Office Based Management of Alcohol Withdrawal and Prescribing Medications for Alcohol Dependence.
  5. Sachdeva, A., Choudhary, M., & Chandra, M. (2015). Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. Journal of Clinical and Diagnostic Research, 9(9), VE01-VE07.
  6. National Institute on Alcohol Abuse and Alcoholism. (2008). Helping Patients Who Drink Too Much: A Clinician’s Guide (excerpt).
  7. Substance Abuse and Mental Health Services Administration. (2009). Incorporating Alcohol Pharmacotherapies Into Medical Practice: Chapter 4—Oral Naltrexone.
  8. Food and Drug Administration. (n.d.). CAMPRAL (acamprosate calcium) Delayed-Release Tablet.
  9. Substance Abuse and Mental Health Services Administration. (2009). Incorporating Alcohol Pharmacotherapies Into Medical Practice: Chapter 3—Disulfiram.
  10. Rychtarik, R.G., Connors, G.J., Dermen, K.H., & Stasiewicz, P.R. (2000). Alcoholics Anonymous and the use of medications to prevent relapse; an anonymous survey of member attitudes. Journal of studies on alcohol, 61(1), 134-138.
  11. SMART Recovery. (2018). Introduction to SMART Recovery.
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