ALCOHOL WITHDRAWAL SYNDROME

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ALCOHOL WITHDRAWAL SYNDROME

• UNLOCKING THE MYTHS

Graham Fary Alcohol Other Drug Withdrawal
Nurse Maryborough Community Health Centre
Victoria Austrlia
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Alcohol Withdrawal Syndrome

• Is Usually Benign
• Occasionally Serious
• Lasts between 7 10 days

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Alcohol Withdrawal SyndromeMechanism

• Alcohol activates the GABA system in the brain
• Amino acid system of rapid nerve transmission
• Leads to inhibition of activity within the CNS
• Hyperpolarises the cell membranes
• Catecholamine system (adrenaline/nor adrenaline)
  inhibited
• With chronic use, both the GABA and Catecholamine
  systems become less responsive
• When alcohol is withdrawn there is no longer the
  inhibiting influences on the CNS
• Takes 2 4 days for these systems to return to
  normal
• During this time there is over activity of the
  catecolamine system leading to the manifestation
  of the Alcohol Withdrawal Syndrome
• Occurs after cessation or significant reduction
  of prolonged alcohol use
• Daily intake of 80 grammes or more (8 standard
  drinks) places a person at risk of developing
  Alcohol Withdrawal Syndrome

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Minor Withdrawal Syndrome

• Vast majority who withdraw experience only minor
  withdrawal syndrome
• Resolves in 2 3 days
• Tremor
• Perspiration
• Restlessness
• Hypersensitivity to stimulation
• Increased T. P. R. BP
• Nausea, vomiting diarrhoea
• Anxiety agitation
• Nightmares
• Insomnia
• Dysphoria

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Severe Withdrawal Syndrome

• In a minority of patients complications can occur
  which results in severe withdrawal syndrome
• Seizures
• Disorientation, Confusion, Delirium Tremens
• Hallucinosis

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Severe Withdrawal SyndromeSEIZURES

• Occur in about 5 of people withdrawing from
  significant amounts of alcohol
• Occur early, predominantly in the first 24 48
  hours
• Are Clonic/Tonic in type
• Usually one off and time limited
• Treat as per local protocols

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Severe Withdrawal SyndromeDelirium Tremens

• Infrequent, thought to be around 1-2 of people
  withdrawing from significant amounts of alcohol
• Generally preventable if patient is adequately
  assessed, monitored and treated
• Untreated DTs has a high mortality rate (around
  20) but is almost 100 avoidable
• Hard to pick the AT RISK patient. However
  patients demonstrating significant withdrawal
  symptoms around gt0.15 are good candidates.
• Typically arise 2 5 days after cessation of
  drinking
• Is thought to be due to an overactive
  catecholamine system which goes beyond a certain
  threshold
• This can be part of life threatening autonomic
  disturbance, Fluid balance and electrolyte
  disturbance, Hyperthermia, Vivid hallucinations
  and delirium.
• The hallucinations in this context are usually
  visual (classically small, colourful and animals)
  and tactile
• This group of patients usually require
  substantial doses of Diazepam to control their
  symptoms. WARNING these pts also tend to have
  significant liver disease and may need
  modification of their Diazepam to Oxazepam which
  doesnt rely on the liver so much for its
  elimination.

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Severe Withdrawal SyndromeAlcoholic Hallucinosis

• Uncommon though not rare
• Hallucinations which are auditory in content in
  the context of no delirium or evidence of
  psychiatric problems
• Patients are generally not too distressed as they
  are aware why they are experiencing them and that
  they will pass

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Severe Withdrawal SyndromePredictors

• Past Hx of severe withdrawal
• Duration, amount and tolerance to large doses of
  alcohol In general the longer, more frequent,
  more regular intake in greater amounts
  increased likelyhood of severe withdrawal (there
  is not a direct linear relationship with
  severity)
• Presence of concomitant illness, injury or recent
  surgery
• Use of other Psychotropic drugs

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Alcohol Withdrawal Key determinants to Treatment

• Amount, duration and tolerance to alcohol or
  Concurrent drug therapy especially
  Benzodiazepines
• PHx of Severe withdrawal syndrome
• Medical conditions ie Diabetes, Epilepsy
• Psychiatric problems inc. PHx of attempted
  suicide or suicide ideation
• Suitability of home environment ie significant
  others support

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Alcohol Withdrawal Syndrome Determinants to
treatment

• Home based treatment-
• - If no risk of severe withdrawal and there
  are no other adverse key determinants
• Non medical Residential Care-
• - If home not supportive but no medical
  intervention is needed, then a non medical
  residential care facility is appropriate

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Alcohol Withdrawal Syndrome Determinants to
treatment

• Where there is a need for medical intervention or
  the likelihood of severe withdrawal syndrome
  occurring, a medical residential unit/hospital is
  appropriate

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Alcohol Withdrawal SyndromeGeneral Nursing Care

• Where Possible
• Limit external stimuli Noise, visitors, other
  pts especially if distressed
• At night light on if possible to limit
  potential for disorientation
• Regular orientation to day, date , time, place
• Explanation of symptoms to reassure pt
• If risk of injury may need to be nursed with
  mattress on the floor
• Keep patient secure especially when severe
  symptoms are experienced

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Withdrawal Scales

• An Alcohol Withdrawal Scale should be used
• Used to measure patients condition
• Used to measure trends
• High Scores are Predictors of development of
  delirium
• Seizures are only predicitive in patients who
  have a Past Hx of them
• Scores on-
• Perspiration
• Tremors
• Anxiety
• Agitation
• Nausea Vomiting
• Hallucinations
• Orientation
• Headaches
• Facial Flushing
• Seizures

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Scoring of Alcohol Withdrawal Signs
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Alcohol Withdrawal ScaleScores

• Score lt 5 Mild Withdrawal Severity
• Score 5 14 Moderate Withdrawal Severity
• Score gt 15 Severe Withdrawal Severity
• NB Rate of change between readings, look for
  trends

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Alcohol Withdrawal ScaleIn Hospital
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Alcohol Withdrawal SyndromePharmocotherapy

• Benzodiazepine - Diazepam
• Thiamine
• Magnesium
• Haloperidol

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Alcohol Withdrawal SyndromeBenzodiazepines

• Diazepam is generally the only BZD used due to
  its cross tolerance with alcohol which allows the
  withdrawal symptoms to be wiped out.
• If loading dose used then 20mg every 1 2 hours
  for three to four doses (i.e. 60 80 mgs) for
  first 24 48 hrs MAXIMUM daily dose of 120 mgs
  is generally advocated. (Alcohol dependent
  patients usually have higher doses due to cross
  tolerance)
• No further dosing is required to treat
  withdrawal, but occasionally diazepam is given in
  accordance to the AWS and can be continued for a
  few days to manage pts anxiety
• Dose Tapering is generally not recommended unless
  concurrently Benzodiazepine dependent Consult AD
  Specialist

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Alcohol Withdrawal SyndromeThiamine

• Thiamine should always be given - Alcohol reduces
  the bowels capacity to absorb Vitaman B1. It
  takes the bowel some days to weeks post
  withdrawal to resume its capacity to absorb B1
• Has shown to reduce incidence of Wernickes
  Korsakoffs syndrome
• Dose 50 100 mgs Daily I.M. for at least 3 days

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Alcohol Withdrawal SyndromeMagnesium

• Still controversial if to give routinely
• Consider in cases of more severe withdrawal
• If Low Serum Magnesium on presenting to hospital
  - appears to be increased risk for Severe
  Withdrawal Syndrome (i.e Delirium Tremens)

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Alcohol Withdrawal SyndromeHaloperidol

• Used where hallucinations and agitation are
  present and distressing despite repeated Diazepam
  dosing
• Small doses 2 5 mgs Orally
• Phenothiazines avoided as they can lower seizure
  threshold

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Alcohol Withdrawal Syndrome

• REMEMBER
• Multidisciplinary approach, G.P. AD Specialist
  A D Nurse, AD Counsellor, Welfare, District
  Nurse, Social Worker, EMS etc all SHOULD be
  involved
• Withdrawal small part not an end but a start to
  improving the patients life and changes
• Withdrawal DOES NOT deal with the drug problem IT
  IS NOT A CURE it allows assessment of the
  patients situation in the best intellectual
  situation for that patient
• Ongoing counselling and life changes required
• Regular Medical checkups required

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Alcohol Withdrawal Syndrome

• IF EVER IN DOUBT CONTACT
• Your Local
• Alcohol Drug Specialist for advice

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References

• Dr Rodger Brough, Director, Western Region
  Alcohol Drug Withdrawal Service, Warrnambool,
  Victoria, Australia
• Detoxification from Alcohol, Dr Tony Gill, GP
  Drug Alcohol Supplement No.7, Central Coast
  Area Health Service NSW, Australia, May 1997.