• Primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
• Characterized by 5 C's

1. Chronicity
2. impaired Control drug use
3. Compulsive use
4. Continued use despite harm
5. Craving

• State of adaptation manifested by a class of drugs
• Specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, administration of an antagonist

• Ventral tegmental area
• Nucleus accumbens
• Prefrontal cortex

• Drug administration/Drug-seeking behavior
• Drug euphoria/Positive reinforcement
• Neuroadaptations/Withdrawal and tolerance
• Drug craving/Negative reinforcement
• The cycle repeats itself

• Maintain vital functions
• Physical restraints if necessary
• AVOID drug therapy
• Obtain toxicology screen, liver function, CBC

Stage I

• Minor withdrawal symptoms
• Insomnia, tremulousness, mild anxiety, GI upset, headache, diaphoresis, palpitations, anorexia
• 6-12 hrs

Stage II

• Alcoholic hallucinosis: visual, auditory, or tactile hallucinations
• 12-24 hrs

Stage III

• Withdrawal seizures: generalized tonic-clonic seizures
• 24-48 hrs

Stage IV

• Alcohol withdrawal delirium (delirium tremens)
• Hallucinations, disorientation, tachycardia, HTN, low-grade fever, agitation, diaphoresis
• 48-72 hrs

AKA Delirium Tremens

• Disturbances of consciousness with reduced ability to focus, sustain, or shift attention
• A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia
• The disturbance develops in a short period and tends to fluctuate during the day
• There is evidence from the history, physical examination, or laboratory findings that the symptoms in criteria A and B developed during, or shortly after, a withdrawal syndrome

Pros

• perfect cross-tolerant drug
• alcoholic's drug of choice

Cons

• narrow therapeutic window
• many toxicities
• need to monitor and adjust levels
• reinforces acceptability and continued use
• more DTs/seizures compared with chlordiazepoxide
• no difference compared with BDZs + haloperidol or clonidine

1 st day q6h for 4-8 doses + PRN, 2nd day q6h for 4-8 doses + PRN

• chlordiazepoxide 50 mg 1st day/25 mg 2nd day
• diazepam 10 mg/5 mg
• Lorazepam 2 mg/1 mg

Underdosing is common, not preferred regimen

Preferred Schedule

q1h when CIWA > 8

• chlordiazepoxide 50-100 mg
• diazepam 10-20 mg
• lorazepam 2-4 mg

provides less total medication, because you only give it when you need to

requires shorter duration of treatment

Long Acting Benzodiazepines are most effective for preventing seizures and DTs

• chlordiazepoxide
• diazepam
• lorazepam

Diazepam

• 5 mg IV (2.5 mg/min) -- keep increasing if not effective
• Use 5-20 mg qh as needed to maintain light somnolence

Lorazepam

• 1-4 mg IV q5-15min OR 1-40 mg IM q30-60 min until calm, then qh as needed to maintain light somnolence

Older pts that can't metabolize well or have liver disease, use Lorazepam to decrease chance of prolonged sedation and it has lower duration than valium

AKA Thiamine Deficiency

• Mental confusion
• Ataxia
• Oculomotor dysfunction

• Last drink > 36hrs, symptoms unlikely to develop
• No other risk factors

• Older age (> 60 yrs)
• Concurrent acute illness
• Seizure
• Moderate to severe symptoms

• Past seizure
• Drug use
• Anxiety disorder
• Multiple Detoxs
• Alcohol > 150

MOA

• Blocks opioid receptors, resulting in reduced craving and reduced reward response to drinking

CI

• Currently using opioids or in acute opioid withdrawal
• Anticipated need for opioid analgesics
• Acute hepatitis
• Liver failure

MOA

• Affects glutamate and GABA neurotransmitter systems, but its alcohol-related action is unclear

CI

• Severe renal impairment (CrCl < 30 ml/min)

• For withdrawal, treat similar to alcohol treatment with a BZD taper to prevent seizures
• For overdose, give Flumazenil 0.2 mg/min IV, may repeat up to 30 mg

• Begins about 4-6 hrs
• By 8-12 hrs:

Autonomic symptoms (rhinorrhea, lacrimation, diarrhea)

Anxiousness, irritability

Excessive sweating, fever, chills

Stomach/muscle cramps

• Withdrawal lasts 1-3 days, as long as 7-10 days as well

Most popular: Clonidine -- controls autonomic symptoms