Shakes... All about Alcohol withdrawal and what to do?

Alcohol is the most commonly used substance in the world. In small doses it works like a stimulant, people become "chatty" but in higher doses it has a calming effect on the brain and behavior. Effects can vary from happiness, increased sociability and euphoria to impairment of cognitive function and depression of central nervous system. Alcohol is addictive and can result in alcohol use disorder. Yearly about 5,3% of deaths are related to alcohol use.

Alcohol use disorder - "Alcoholism"

It is often grouped into three categories: mild - moderate - severe

Warning signs:

• Problems controlling the drinking

• Being unable to stop

• Craving alcohol

• Continuing to drink alcohol despite negative results

• Withdrawal symptoms

CAGE questions are practical to screen for alcohol use problems:

C = Cut down. Have you felt the need to CUT DOWN on your drinking?

A = Annoyance/Anger. Have you felt ANNOYED/ANGRY at people complaining about your drinking?

G = Guilt. Do you feel GUILTY about your drinking?

E = Eye opener. Have you ever had an EYE OPENER in the morning to relieve "the shakes"?

Withdrawal symptoms

Can be life threatening!

Common symptoms (many people have some or all of these when hungover):

• Nausea and vomiting

• Headaches

• Anxiety

• High temperature and/or chills

• Unpleasant, vivid dreams

• Fatigue

• Tremors - shakes

• Insomnia

Severe symptoms:

• Disorientation and confusion

• Extreme agitation

• Visual and/or auditory hallucinations

• Seizures

• Fever

• Tachycardia (rapid pulse) and hypertension (high blood pressure)

• Delirium tremens (DT)

  • Severe withdrawal - can be life threatening

  • Occurs 48-96 hours after the last drink

Treatment

We are gonna go over the moderate or severe alcohol disorder, when people are physically dependent upon alcohol, that is what I usually see and treat at work. Withdrawal symptoms usually start to show 6-12 hours after the last drink. The intensity of the symptoms depends on how much and what the patient has been drinking. It disrupts the brain activity when someone dependent on alcohol suddenly stops drinking and then we see withdrawal symptoms.

"Moderate" withdrawal symptoms:

What we usually first see is the elevated blood pressure, rapid pulse and the shaking/tremors. This is the time we want to start to treat the withdrawal so they don't increase and become severe and then possibly life-threatening.

"Severe" withdrawal symptoms:

Same symptoms as the moderate stage but more severe and in addition the patient can have hallucinations, disorientation and sometimes seizures.

This is an acute medical emergency and needs to be treated in a hospital setting.

Medication - what do we use?

Benzodiazepines (benzo) are used to control the symptoms and to prevent progression to more severe withdrawal.

First choice in my ward is chlordiazepoxide (Risolid/Librium).

It is a long-acting benzo and we feel it gets the patient more balanced compared to other benzos. It can lead to oversedation because of a long half-life, so it is important to monitor the patient and be aware that the liver is functioning okay.

If the patient is old, has advanced cirrhosis or acute alcoholic hepatitis we would prefer to use oxazepam (Sobril/Serax). It has a shorter half-life and less likely to cause oversedation. But is is more difficult to get the patient balanced/stable because of the short half-life.

Other benzos can be used such as lorazepam and diazepam. Sometimes it is required to use IV therapy if withdrawal symptoms are severe.

Dosing

When the patient is showing signs of withdrawal symptoms you give the first dose of medication. We usually use chlordiazepoxide and start with 25-50mg and repeat as needed for the first day or two. Most patients who come to our ward do well on 25-50mg every 4-6 hours some patients need much more medication, up to 400mg (or more) in the first day(s). How much medicine we give always depends on the symptoms that the patient is showing, symptom triggered approach.

We want to see the patient stable for a bit, the blood pressure and the pulse to go down and the tremors to slow and hopefully stop. Than we can start to lower the dose over the next days.

Important - B1/vitamin deficiency (thiamine)

The body cannot produce thiamine and when people drink alcohol it can reduce the body's ability to absorb vitamins through the stomach like it should. People who drink excessively also often don't eat very much and we must get thiamine from our foods and we can only store thiamine that lasts us for about 2 weeks. Thiamine deficiency can lead to serious problems, like Wernicke-Korsakoff syndrome (I plan to write a blog about that later).

Always give thiamine to patients who have been drinking and show signs of withdrawal symptoms.

For the first 2-3 days we give 200mg x2 IM (intra muscular) and then we keep on giving tablets after that. If we suspect the patient to have Wernicke's encephalopathy we give 500mg IV 3 times a day, then we give 200mg x2 IM for few more days and then we give tablets.

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In the ward when the patient is stable we recommend psychosocial interventions and look in to options and tell people about what is recommended:

• Treatment options with focus on CBT (cognitive-behavioral therapy)

• Motivational interviewing

• Mutual-support groups

• 12-step facilitation can be useful