[Treatment of alcohol withdrawal symptoms]. / Alkoholivieroitusoireiden hoito.

In the summer, alcohol consumption increases and the number of those requiring rehabilitation peaks at the end of the holiday season. Treatment of alcohol withdrawal symptoms early enough helps the patient to break the drinking cycle. Treatment of alcohol withdrawal symptoms will also prevent complications, such as convulsions and alcoholic delirium. Untreated alcoholic delirium is a life-threatening condition. Treatment aims to calm down the hyperactivity state of the autonomous nervous system, and correct electrolyte and fluid balance disturbances. Initiation of rehabilitation is determined by the severity of the patient's withdrawal symptoms. Benzodiazepines are the first-line drugs.

Alcohol-use disorders.

Alcohol dependence and alcohol abuse or harmful use cause substantial morbidity and mortality. Alcohol-use disorders are associated with depressive episodes, severe anxiety, insomnia, suicide, and abuse of other drugs. Continued heavy alcohol use also shortens the onset of heart disease, stroke, cancers, and liver cirrhosis, by affecting the cardiovascular, gastrointestinal, and immune systems. Heavy drinking can also cause mild anterograde amnesias, temporary cognitive deficits, sleep problems, and peripheral neuropathy; cause gastrointestinal problems; decrease bone density and production of blood cells; and cause fetal alcohol syndrome. Alcohol-use disorders complicate assessment and treatment of other medical and psychiatric problems. Standard criteria for alcohol dependence-the more severe disorder-can be used to reliably identify people for whom drinking causes major physiological consequences and persistent impairment of quality of life and ability to function. Clinicians should routinely screen for alcohol disorders, using clinical interviews, questionnaires, blood tests, or a combination of these methods. Causes include environmental factors and specific genes that affect the risk of alcohol-use disorders, including genes for enzymes that metabolise alcohol, such as alcohol dehydrogenase and aldehyde dehydrogenase; those associated with disinhibition; and those that confer a low sensitivity to alcohol. Treatment can include motivational interviewing to help people to evaluate their situations, brief interventions to facilitate more healthy behaviours, detoxification to address withdrawal symptoms, cognitive-behavioural therapies to avoid relapses, and judicious use of drugs to diminish cravings or discourage relapses.

[Levels of emotional awareness in alcohol-dependent patients and abstinent alcoholics]. / Niveaux de conscience émotionnelle chez les sujets alcoolodépendants et abstinents.

BACKGROUND: Deficits in the communication and identifying of feelings are usually observed in addiction disorders. These dysfunctions vary according to the type of addiction and are particularly marked for alcoholic subjects. The prevalence of alexithymia evolves in a nearly linear manner according to the severity and the duration of the disorder. As the duration of alcoholism and the quantity of alcohol that is consumed increase, so will the subjects' scores of alexithymia. In addition, certain authors have observed a decrease in alexithymia in abstinent subjects. Subjects having been abstinent for a long period of time were more alexithymic than those having been abstinent for a shorter period of time. However, other studies failed to confirm these findings and did not observe an increase in the levels of alexithymia in polydrug patients. It seems however that the measures of alexithymia obtained using self evaluation tools (TAS 20) lack in precision due to the fact that, even though the subject is supposed to have a deficit in the identifying and the verbalisation of his emotional states, he is asked to do his own evaluation of the said emotional states. Hence, other tools such as the level of emotional awareness scale (LEAS) offer another approach to the measuring of alexithymia, based on the everyday situations and integrated in a general model of the differentiation of emotional states (or of emotional awareness). DESIGN OF STUDY: The purpose of the study is to describe the level of emotional differentiation of alcoholic subjects, and to evaluate the development of the emotional processes following alcohol cessation. Our sample consists of 88 subjects distributed in three groups: a group of alcoholic participants who are in the process of quitting alcohol (33 subjects), a group of alcoholic participants that have been abstinent for more than 6 months (20 subjects) and a group of control participants (35 subjects). The prevalence of alexithymia is estimated by the Toronto alexithymia scale (TAS 20) which measures three factors: the difficulty to identify one's feelings (TAS 1), the difficulty to express one's feelings (TAS 2), and thoughts which are directed towards the outside world (TAS 3). The levels of emotional consciousness are estimated by the LEAS which establishes 20 scenarios in order to measure three scores: emotional consciousness "for oneself" (LEAS 1), emotional consciousness "for others" (LEAS 2) and a total score (total LEAS). RESULTS: The results show a different level of emotional awareness and alexithymia between the three groups of participants. The alcoholic participants are less conscious of their feelings and have more difficulties identifying and expressing their feelings than the control subjects. With regards to the evolution of the emotional deficit linked to alcohol withdrawal, the abstinent subjects obtain weaker scores of alexithymia than the alcoholic subjects. However, abstinent subjects continue to present more difficulties expressing their feelings than control subjects (TAS 2). On the other hand, abstinent subjects' levels of emotional awareness are once again comparable to those of control subjects. Finally, the analysis of the correlations does not show any link between the scores of alexithymia and the scores of emotional consciousness, and this for all of the groups studied. Our major result concerns the recovery of the emotional deficit of abstinent subjects (global score of TAS 20 and the score of emotional consciousness), which underlines the importance of the implementation of therapeutic protocols that focus on the emotional awareness of alcoholic subjects.

Proof-of-concept human laboratory study for protracted abstinence in alcohol dependence: effects of gabapentin.

There is a need for safe medications that can effectively support recovery by treating symptoms of protracted abstinence that may precipitate relapse in alcoholics, e.g. craving and disturbances in sleep and mood. This proof-of-concept study reports on the effectiveness of gabapentin 1200 mg for attenuating these symptoms in a non-treatment-seeking sample of cue-reactive, alcohol-dependent individuals. Subjects were 33 paid volunteers with current Diagnostic and Statistical Manual of Mental Disorders-IV alcohol dependence and a strength of craving rating 1 SD or greater for alcohol than water cues. Subjects were randomly assigned to gabapentin or placebo for 1 week and then participated in a within-subjects trial where each was exposed to standardized sets of pleasant, neutral and unpleasant visual stimuli followed by alcohol or water cues. Gabapentin was associated with significantly greater reductions than placebo on several measures of subjective craving for alcohol as well as for affectively evoked craving. Gabapentin was also associated with significant improvement on several measures of sleep quality. Side effects were minimal, and gabapentin effects were not found to resemble any major classes of abused drugs. Results suggest that gabapentin may be effective for treating the protracted abstinence phase in alcohol dependence and that a randomized clinical trial would be an appropriate next step. The study also suggests the value of cue-reactivity studies as proof-of-concept screens for potential antirelapse drugs.

Twenty-Eight-Day-Long Delirium Tremens.

Refractory alcohol withdrawal delirium is uncommon in day-to-day clinical practice. This case report presents a rare case of delirium tremens of unusually long duration that was complicated by the difficulty in tapering down benzodiazepines despite adding midazolam drip as well as phenobarbitone to the management regimen and excluding other possible diagnoses.

Barbiturates for the treatment of alcohol withdrawal syndrome: A systematic review of clinical trials.

PURPOSE: To perform a systematic review of the clinical trials concerning the use of barbiturates for the treatment of acute alcohol withdrawal syndrome (AWS). MATERIALS AND METHODS: A literature search of MEDLINE, EMBASE, and the Cochrane Library, together with a manual citation review was conducted. We selected English-language clinical trials (controlled and observational studies) evaluating the efficacy and safety of barbiturates compared with benzodiazepine (BZD) therapy for the treatment of AWS in the acute care setting. Data extracted from the included trials were duration of delirium, number of seizures, length of intensive care unit and hospital stay, cumulated doses of barbiturates and BZDs, and respiratory or cardiac complications. RESULTS: Seven studies consisting of 4 prospective controlled and 3 retrospective trials were identified. Results from all the included studies suggest that barbiturates alone or in combination with BZDs are at least as effective as BZDs in the treatment of AWS. Furthermore, barbiturates appear to have acceptable tolerability and safety profiles, which were similar to those of BZDs in patients with AWS. CONCLUSIONS: Although the evidence is limited, based on our findings, adding phenobarbital to a BZD-based regimen is a reasonable option, particularly in patients with BZD-refractory AWS.

[Assessment of socio-demographic factors in alcohol-addicted patients recurrently treated in a detoxification unit]. / Ocena czynników socjodemograficznych u osób uzaleznionych od alkoholu wielokrotnie leczonych w oddziale detoksykacji.

The aim of the presented study was the assessment some socio-demographic factors of alcohol dependent patients more times hospitalized in Department of Toxicology in Kraków in the years 1999-2004. The repeatedly hospitalization of 334 patients (298 men and 36 women), aged from 17 to 71 years (mean 45.1 years) due the alcohol problem on the basis of clinic documentation were established. The following socio-demographics traits were taken in analysis: age, sex, marital status, place of living, education, kind of jobs, employment and others sources of money. The patients were admitted from 2 or more 29 times during 6 years. Medical history of addiction of mentioned patients was from 1 to 40 years, mean 25 years. 43.7% persons live single and 53.6% was married. The most patients live in Kraków (80%) and others near the town. The education of them: 15.0% ended high school, 28.7% "medium", 30.5% "low professional" and elementary school--13.8% of them. This factor was similar like regional data. Amount mentioned persons 25.8% worked for salary, 11.7% had own business, and 25.4% was retired, and 29.0% was unemployed. This last factor was worse liked similar from mentioned region. The kind of jobs of persons on the aspect of "social safety" was described. Among the mentioned chronic alcohol addicted persons about 18.8% of them with machines in traffic was worked (bus drivers i.e.) and 7.5% described persons in special jobs was worked (policemen, physician i.e.). The authors were suggested that mentioned factors due health services cost in Poland and propose integration of treatment of alcohol-addicted patients.

Alcohol detoxification and withdrawal seizures: clinical support for a kindling hypothesis.

There has been speculation that a kindling model may have applicability to alcohol withdrawal syndromes and seizures, suggesting that repeated alcohol withdrawals may lead to increased severity of subsequent withdrawals. We evaluated historical and clinical variables of a group of male alcoholics with (n = 25) and without (n = 25) alcohol withdrawal seizures. We found that the number of detoxifications appeared to be an important variable in the predisposition to withdrawal seizures. The withdrawal seizure group had 12 of 25 (48%) patients with 5 or more previous detoxifications, compared to only 3 of 25 (12%) of the control group. A relationship between alcohol use history and withdrawal seizures was not supported by the data. These findings support the concept that previous alcohol withdrawals may "kindle" more serious subsequent withdrawal symptomatology, ultimately culminating in withdrawal seizures.

Sleep and the cholinergic rapid eye movement sleep induction test in patients with primary alcohol dependence.

BACKGROUND: The present study investigated polysomnographically assessed sleep parameters in alcohol-dependent patients after withdrawal and in healthy control subjects during baseline and after a cholinergic stimulation paradigm. The aim of the study was to test whether sleep parameters, especially rapid eye movement (REM) sleep variables, may serve as predictors for relapse in alcohol-dependent patients. METHODS: Forty patients diagnosed with alcohol dependence were admitted to a specialized ward for alcohol withdrawal and were investigated by polysomnography at three time points: 2-3 weeks after withdrawal (T0) and at follow-up investigations 6 (T1) and 12 (T2) months after discharge from the hospital. A subgroup of patients (n = 17) was studied at T0 after challenge with galanthamine, a reversible cholinesterase inhibitor (cholinergic REM induction test, CRIT). Patients were compared with two control groups: a) 30 healthy control subjects (matched for age- and gender-distribution) for comparison at baseline conditions; and b) 17 age- and gender-matched control subjects for comparison with the CRIT. RESULTS: At baseline the patients showed significant disturbances of sleep continuity and sleep architecture (decreased slow-wave sleep, SWS) and exhibited an increase of "REM sleep pressure" (a combined index of REM latency, REM density, and REM sleep percent). Galanthamine provoked significant alterations of sleep continuity, sleep architecture (reduced SWS), and increased most of the components of REM pressure, taking patients and control subjects together. Apart from SWS %SPT (sleep period time) no significant drug-group interactions occurred. Patients who remained abstinent (n = 11) for at least 6 months at follow-up exhibited significantly less abnormalities of REM sleep at T0 compared to the group of patients that relapsed at 6 months follow-up. CONCLUSIONS: It is concluded that increased REM sleep pressure after alcohol withdrawal is a robust predictor of vulnerability to relapse. Thus, a subgroup of alcoholic patients appears to exhibit distinct neurobiological abnormalities assessable by polysomnography that are related to an increased vulnerability for alcoholism and early relapse.

Benzodiazepines and alcohol.

The frequency and quantity of alcohol consumption is a major consideration in patients who need treatment with benzodiazepines. Alcohol affects the GABA-benzodiazepine-chloride ionophore complex and has an agonist-like action. Thus, additive interactions should be expected from combining alcohol with benzodiazepines. Furthermore, alcohol has clinically meaningful anxiolytic efficacy, and many anxious patients may take advantage of that fact. Therefore, co-administration of alcohol and benzodiazepines is to be expected in an anxious patient receiving benzodiazepines who does not totally abstain from alcohol. This article reviews three clinically relevant issues concerning benzodiazepines and alcohol: (1) interactions of benzodiazepines with social drinking in patients taking benzodiazepines for indications unrelated to alcoholism; (2) use of benzodiazepines in treatment of alcohol withdrawal; and (3) use of benzodiazepines in patients with alcohol dependence.

Alcohol withdrawal: an adaptation to heavy drinking of no practical significance?

Markedly differing views can be found among both clinicians and researchers regarding whether alcohol withdrawal is a phenomenon of any practical or theoretical importance. Evidence has mounted that alcohol withdrawal, even in a severe form, is rarely life-threatening and the great majority of cases can be managed in non-medical settings, including the home. There is also a widely held view among clinicians that withdrawal symptoms have little motivational significance and may be best regarded as but epiphenomena of prolonged heavy drinking. There are also experimental data from both human and animal laboratory studies to the effect that withdrawal symptoms do not readily trigger further alcohol consumption. Against this most unpromising background a case is presented for alcohol withdrawal being but one manifestation of important biological and psychological adaptive processes which occur almost whenever alcohol is consumed with any regularity. It is proposed that understanding this more general phenomenon is critical to a better understanding of the factors which maintain heavy and problematic drinking. Recent evidence also suggests that minor alcohol withdrawal symptoms are far more common in the general population than had previously been realized, and that this has important implications for prevention policy.

Characteristics of men with alcoholic hallucinosis.

The goal of this study was to evaluate the characteristics of primary alcoholics with alcoholic hallucinosis. Six hundred and forty-three primary alcoholic men were recruited from a 28-day Alcohol and Drug Treatment Program at the San Diego VA Medical Center. Subjects only experiencing perceptual abnormalities during alcohol withdrawal, drug-related hallucinosis, as well as those having abnormal sensations that did not meet criteria for hallucinations were excluded from the present study. The remaining 532 subjects were divided into Group 1 (n = 48), which consisted of subjects with a DSM-IIIR and ICD-10 diagnosis of alcoholic hallucinosis, and Group 2 (n = 484) which consisted of those without any history of hallucinations. A comparison of the two groups revealed that Group 1 men were younger at the onset of alcohol problems, consumed more alcohol per occasion, developed more alcohol-related life problems, and had higher rates of drug experimentation as well as more different types of drugs used. This study suggests that primary alcoholics who consume more drugs and/or alcohol might be at an increased risk for developing alcoholic hallucinosis.

Alcoholism.

Several medications may help improve treatment of alcoholic patients. Medications that effectively and specifically reverse symptoms of alcohol intoxication or coma currently are lacking. Benzodiazepines remain the most effective medications for the treatment of alcohol withdrawal and for the prevention of withdrawal seizures and delirium, even though the adrenergic agents clonidine or atenolol may hasten resolution of withdrawal symptoms and facilitate outpatient detoxification. Psychosocial rehabilitation of alcoholics may be improved by judicious addition of the alcohol-sensitizing agents disulfiram and carbimide, the serotonergic drugs fluoxetine and buspirone, the opiate antagonist naltrexone, and, for primarily depressed alcoholics, tricyclic antidepressants. As in psychosocial alcohol rehabilitation, patient-treatment matching may improve results of pharmacotherapeutic intervention.

Alcohol withdrawal syndromes - prediction from detailed medical and drinking histories.

The predictability of the withdrawal syndrome on the basis of the drinking history immediately prior to detoxification was investigated in 43 patients admitted to an inpatient Alcoholism Service; a pilot study consisted of 17 patients and a subsequent definitive study of 26. After obtaining informed consent, blood alcohol concentrations were measured. Each subject was extensively interviewed to obtain a medical and dietary history and to determine alcohol and drug intake in the past week and months. The levels of intoxication and withdrawal signs/symptoms were assessed on admission and daily for at least 3 days. Urine and blood toxicology screens were also performed for 19 subjects. Contrary to widespread impressions, most of the patients were able to give a detailed account of their drinking and drinking-related behavior in the 3 days prior to admission and 73% could do this for the previous 7 days. Subjects were consistent in their reporting; 85% gave drinking histories consistent among interviews conducted independently by the medical, research and counseling staff. A significant correlation (r = 0.55; P less than 0.01) was found between the severity of withdrawal and the total alcohol intake in the days immediately prior to admission. No significant correlation was evident between withdrawal severity and the number of years of heavy drinking. Amounts of benzodiazepines (diazepam and flurazepam) administered by the medical staff during the first 3 days of withdrawal and for the total hospital stay were also found to be significantly correlated with withdrawal severity (r = 0.58; P less than 0.01 for both). Regression analyses of these data also confirmed the statistically significant relationships between alcohol intake and withdrawal severity and between withdrawal severity and amounts of benzodiazepines used for detoxication. Of special interest was the finding that 50% of the subjects reported no hangovers within he past year or more and 23% reported that they had never experienced a hangover, despite very heavy drinking. In addition, only 50% of the patients had regularly consumed coffee or any caffeine-containing substance; this low incidence of caffeine intake was statistically significantly less than that found in extensive surveys of the general population in which only 3-10% eschew caffeine-containing beverages. It is concluded that the severity of alcohol withdrawal can be related to a cluster of variables among which is recent alcohol intake. The present results are, at the same time, consistent with previous observations of the appreciable differences among individuals in the consequences of abrupt cessation of chronic alcohol consumption.

The growth of treatment research in alcohol and drug use disorders: a computerized literature search.

Index Medicus was searched to compare the number of articles on treatment trials for alcohol and for non-alcohol drug use disorders (abuse, dependence, withdrawal, intoxication, etc.) to that of two control conditions--anxiety and obesity--for the period 1967-1988. Over the entire 22 years, the number of articles for alcohol use disorders increased an average of 2.7 articles every 2 years and 5.8/2 years for drug use disorders compared to 5.7/2 years for obesity and 5.8/2 years for anxiety disorders. Over the most recent 8 years, articles for alcohol use disorders increased 7.7/2 years and for drug use disorders 7.9/2 years compared to--2.9/2 years and 12.0/2 years for obesity and anxiety disorders. The proportion of articles that cited using only pharmacotherapy decreased over time; however, studies of alcohol and drug withdrawal continue to almost exclusively use pharmacological therapies. We conclude that treatment research in alcohol and drug use disorders is growing as rapidly as that in similar psychological and psychiatric conditions and that such growth is not due to a focus on pharmacological treatments.

The impact of gender on clinical characteristics and outcome in alcohol withdrawal.

Few studies have compared the social and clinical features of alcoholism for women and men, and none has focused on patients entering treatment for withdrawal. We investigated the role of gender by analyzing the data for 179 patients (34 women, 145 men) who underwent outpatient withdrawal. Our analysis focused on two questions: 1) How do women and men compare in terms of baseline social and clinical features? and 2) Do women and men have similar treatment outcomes in alcohol withdrawal? Baseline sociodemographic features revealed that women were more likely to be poor (90% vs. 71%, p = .03) but less likely to be uninsured (32% vs. 51%, p = .05), homeless (6% vs. 20%, p = .05), or have legal problems (29% vs. 54%, p = .02). Surprisingly, women and men reported a similar mean daily alcohol intake (240 g vs. 243 g). Women reported a shorter duration of alcohol abuse prior to entering treatment (16.1 y vs. 19.1 y). Although women experienced a higher treatment failure rate (53% vs. 43%), this difference is not significant. Our analysis highlights gender similarities and differences among patients entering treatment for withdrawal. We conclude that women and men have similar treatment outcomes in the management of alcohol withdrawal.

Treatment response and safety of ambulatory medical detoxication.

An ambulatory medical detoxication program for alcoholics with limited social and environmental supports is described. The treatment response of all 49 patients who underwent treatment and the short-term outcome and safety of 15 patients (31%) who failed to complete treatment are reviewed. Treatment completers were found to attend over 90% of their scheduled daily appointments and drinking during the treatment term was infrequent. The average duration for completed treatments was approximately 5 appointment days. Treatment noncompleters also attended their scheduled appointments regularly prior to discontinuation and, except for several patients who were transferred to inpatient treatment because of continued drinking, drinking during detoxication was relatively infrequent. The short-term outcome and safety of treatment noncompleters was reviewed. No instance of serious medical or psychiatric consequences following discontinuation from treatment was revealed. It was concluded that discontinuation of treatment by a patient is not in all cases indicative of a poor outcome. It was further concluded that ambulatory medical detoxication is a relatively successful treatment for mild to moderate alcohol withdrawal symptomatology and for patients not requiring immediate medical or psychiatric attention.

Alcohol withdrawal in the elderly.

The phenomenon of alcohol withdrawal has seldom been studied in subgroups of patients in withdrawal. We developed a rating scale for measuring alcohol withdrawal that we found to be reliable and valid. The scale, when applied to young (ages 21-33, N = 24) and elderly (ages 58-77, N = 26) groups of patients in alcohol withdrawal, indicated that the elderly group initially had a more severe withdrawal for which they received higher doses of chlordiazepoxide.

Delirium tremens: a prospective long-term follow-up study.

A follow-up by health insurance records of 716 male hospital-treated alcoholics revealed a tendency to a more favorable long-term adjustment in patients with delirium tremens at first admission compared with others. Standardized ratings at first admission indicated that the delirium patients had lower frequencies of depressive symptomatology, personality disturbance and social complications. Slight cerebral impairment at first admission was more frequent in the delirium patients, perhaps indicating a more severe abuse. In a subsample of 105 personally followed-up patients it was found that subjects with delirium later during the course of their illness were characterized by a lower level of social stability at first admission, compared with those with an initial delirium or with no history of delirium tremens. Contrary to initial delirium, later delirium was related to an unfavorable course. Six subjects with a history of delirium tremens were found to have taken up social drinking. Patterns and processes of improvement were found to be related more to background characteristics in terms of personality disturbance and social stability than to the severity of withdrawal symptoms.

Alcoholism treatment in general hospitals.

This article examines recent developments in the role of general hospitals in providing treatment for alcoholism. It employs data on 5,000 U.S. short-term general hospitals and on all patients discharged from a subsample of 400 of these hospitals in the years 1980 through 1985. The article describes the growth in alcoholism treatment resources in short-term hospitals (1980-85) and examines linked hospital and patient data for the 400 hospitals in the subsample to describe patient diagnoses and resource use (1980 and 1985). Patients are classified by the stage of their alcohol problem, and hospital use is examined for patients in different stages.