Alcohol detoxification (also known as ''detox'') is the abrupt cessation of alcohol intake in individuals that have

alcohol dependence Alcohol dependence is a previous (DSM-IV and ICD-10) psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol (also chemically known as ethanol). In 2013, it was reclassified as alcohol use disorder ...

. This process is often coupled with substitution of drugs that have effects similar to the effects of alcohol in order to prevent

alcohol withdrawal Alcohol withdrawal syndrome (AWS) is a set of symptoms that can occur following a reduction in alcohol use after a period of excessive use. Symptoms typically include anxiety, shakiness, sweating, vomiting, fast heart rate, and a mild fever. M ...

. When withdrawal does occur, it results in symptoms of varying severity. As such, the term "detoxification" may be somewhat of a misnomer since the process need not refer exclusively to the removal of toxic substances from the body. Detoxification may or may not be indicated depending upon an individual's age, medical status, and history of alcohol intake. For example, a young man who binge drinks and seeks treatment one week after his last use of alcohol may not require detoxification before beginning treatment for alcohol use disorder.

Withdrawal symptoms

The symptoms of alcohol withdrawal can range from mild to severe depending on the level of alcohol dependence a person has experienced. Symptoms can be behavioural (anxiety, agitation, irritability), neurological (tremor, hallucinations, increased risk of seizures), and physical (changes in heart rate, body temperature, blood pressure, nausea). Symptoms typically occur between 6 and 24 hours since cessation of drinking. In severe cases

delirium tremens Delirium tremens (DTs) is a rapid onset of confusion usually caused by withdrawal from alcohol. When it occurs, it is often three days into the withdrawal symptoms and lasts for two to three days. Physical effects may include shaking, shiver ...

may occur, which is a medical emergency and could result in death.

Management

Benzodiazepine Benzodiazepines (BZD, BDZ, BZs), sometimes called "benzos", are a class of depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat conditions such as anxiety disorders, ...

s are the most common family of drugs used for alcohol detoxification,Full text
at OVID followed by

barbiturate Barbiturates are a class of depressant drugs that are chemically derived from barbituric acid. They are effective when used medically as anxiolytics, hypnotics, and anticonvulsants, but have physical and psychological addiction potential a ...

Benzodiazepines

s such as chlordiazepoxide (Librium),

diazepam Diazepam, first marketed as Valium, is a medicine of the benzodiazepine family that acts as an anxiolytic. It is commonly used to treat a range of conditions, including anxiety, seizures, alcohol withdrawal syndrome, muscle spasms, insomnia, ...

(Valium),

lorazepam Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety disorders, trouble sleeping, severe agitation, active seizures including status epilepticus, alcohol withdrawal, and che ...

(Ativan) or oxazepam (Serax) are the most commonly used drugs used to reduce alcohol withdrawal symptoms. There are several treatment patterns in which it is used. # The first option takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half-hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3 to 10 days. # Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon # A third option is to defer treatment until symptoms occur. This method should not be used in patients with prior, alcohol-related seizures. This has been effective in

randomized controlled trials A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical t ...

. A non-randomized, before and after, observational study found that symptom-triggered therapy was advantageous. Dosing of the benzodiazepines can be guided by the CIWA scale. The scale is available online.
see appendix 2
Regarding the choice of benzodiazepine: * Chlordiazepoxide (Librium) is the benzodiazepine of choice in uncomplicated alcohol withdrawal due to its long half-life. * Lorazepam or diazepam is available as an injection for patients who cannot safely take medications by mouth. * Lorazepam and oxazepam are indicated in patients with impaired liver function because they are metabolised outside of the liver.

Nitrous oxide

Nitrous oxide Nitrous oxide (dinitrogen oxide or dinitrogen monoxide), commonly known as laughing gas, nitrous, or nos, is a chemical compound, an oxide of nitrogen with the formula . At room temperature, it is a colourless non-flammable gas, and ha ...

has been shown to be an effective and safe treatment for alcohol withdrawal. Over 20,000 cases of the alcoholic withdrawal state have been successfully treated with psychotropic analgesic nitrous oxide (PAN) in South Africa and Finland. In 1992 it was officially approved for the treatment of

addictive Addiction is a neuropsychological disorder characterized by a persistent and intense urge to engage in certain behaviors, one of which is the usage of a drug, despite substantial harm and other negative consequences. Repetitive drug use oft ...

withdrawal states by the medical authorities in South Africa. Consequently, patients receiving it can claim a refund from their medical insurance. The gas therapy reduces the use of highly addictive sedative medications (like benzodiazepines and barbiturates) by over 90%. The technique thus reduces the danger of secondary addiction to benzodiazepines, which can be a real problem amongst alcoholics who have been treated with these agents.South African Brain Research Institute
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Other

Randomized controlled trials A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical t ...

have found benefit from

atenolol Atenolol is a beta blocker medication primarily used to treat high blood pressure and heart-associated chest pain. Atenolol, however, does not seem to improve mortality in those with high blood pressure. Other uses include the prevention of mi ...

and

clonidine Clonidine, sold under the brand name Catapres among others, is an α2-adrenergic agonist medication used to treat high blood pressure, ADHD, drug withdrawal ( alcohol, opioids, or nicotine), menopausal flushing, diarrhea, spasticity, and c ...

. A

randomized controlled trial A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical t ...

has found benefit from

carbamazepine Carbamazepine (CBZ), sold under the trade name Tegretol among others, is an anticonvulsant medication used primarily in the treatment of epilepsy and neuropathic pain. It is used as an adjunctive treatment in schizophrenia along with other m ...

Alcover 17,5 - Gamma-Hydroxybutyric acid

Some hospitals administer alcohol to prevent alcohol withdrawal although there are potential problems with this practice. Various vitamins, especially from the B group, are often used during alcohol withdrawal treatment.

Sodium oxybate Sodium oxybate, sold under the brand name Xyrem among others, is a medication used to treat two symptoms of narcolepsy: sudden muscle weakness and excessive daytime sleepiness. It is used sometimes in France and Italy as an anesthetic given i ...

is the sodium salt of

gamma-hydroxybutyric acid ''gamma''-Hydroxybutyric acid (or γ-hydroxybutyric acid (GHB), also known as 4-hydroxybutanoic acid) is a naturally occurring neurotransmitter and a depressant drug. It is a precursor to GABA, glutamate, and glycine in certain brain areas ...

(GHB). It is used for both acute alcohol withdrawal and medium-to-long-term detoxification. This drug enhances GABA neurotransmission and reduces glutamate levels. It is used in

Italy Italy ( it, Italia ), officially the Italian Republic, ) or the Republic of Italy, is a country in Southern Europe. It is located in the middle of the Mediterranean Sea, and its territory largely coincides with the homonymous geographical ...

in small amounts under the trade name Alcover. Baclofen has been shown in animal studies and in small human studies to enhance detoxification. This drug acts as a GABA B receptor agonist and this may be beneficial.

Phenibut Phenibut, sold under the brand names Anvifen, Fenibut, and Noofen among others, is a central nervous system depressant with anxiolytic effects, and is used to treat anxiety, insomnia, and for a variety of other indications. It is usually take ...

is used in Eastern Europe for alcohol detoxification as it has sedative and anxiolytic effects.

References