I. Clinical course of withdrawal:

  1. "Common abstinence syndrome": hyperadrenergic with anxiety, tremor, diaphoresis, tachycardia, HTN, n/v, diarrhea, insomnia; usually self-limited. Starts hours after last drink; peak in 24-48h.
  2. Delirium tremens: (<50% have all 4): Onset 2-3d after last drink, though can be as much as 3wks; usually peaks 4th day and lasts 3-5d (except for nighttime relapses for 2-3 wks); often don't remember them afterward.
  1. Confusion/disorientation
  2. Hallucinations (us. visual)
  3. Motor/autonomic hyperactivity
  4. Fever
  1. "Rum fits": generalized tonic-clonic sz; occur 7-48 after last drink; peak at 24h; higher risk in pts with hypomagnesemia and resp. alkalosis.

II. Criteria for outpatient treatment of withdrawal:

  1. Minor withdrawal symptoms only
  2. No other illness, inc. head trauma
  3. Availability of daily f/u of some sort while withdrawing
  4. Committment to complete abstinence
  5. Good social support
  6. Pre-existing doc-pt relationship

III. Treatment

  1. For abstinence syndrome:
  1. Benzos are safe & effective; sx-triggered administration may work as well as routine scheduled dosing
  1. Serax: (oxazepam): good if pt has liver disease b/c excretion not liver-dependent. Use 15-30mg PO Q6-8h/ Equivalent dose = 60mg
  2. Ativan (lorazepam): Similarly to Serax, no sig. liver-dependent metabolism. 1-2mg PO Q6-8h
  3. Librium (chlordiazepoxide): longer t-1/2 gives smoother detox. Give 50-100mg test dose in office then observe 1-2h. Use 25mg Q4-6h for outpt detox. Equivalent dose = 50mg.
  4. Valium (diazepam). Rapid onset; some say euphoric f/x may be counter-productive. Equivalent dose = 20mg
  1. Beta-blockers may help but are probably not as good as benzo's for monotherapy
  2. Phenothiazines (adjunct to benzos but don't have cross-tolerance to EtOH and furthermore can decrease seizure threshold)
  3. Paraldehyde (obsolete), barbiturates (not as safe as benzo's)
  4. Principles of treatment
  1. Treat early, but not if still drunk!
  2. IV & PO are better than IM which has erratic absorption
  3. Taper dose of benzo's once pt stabilized
  1. For DT's:
  1. Valium 10mg IV x 1 then 5mg IV Q5min until see improvement
  2. Haldol 2-4mg Q2-6 PRN as an adjunct
  1. For rum fits:
  1. Check Mg; give prophylactic MgSO4 1g IM QID x 1-2d
  2. Treat with benzos if needed; DPH only if benzos no work
  1. For all pts with withdrawal (or all admitted alcoholics):
  1. MgSO4 (see above)
  2. Thiamine
  3. B12
  4. Folate

(source: a handout of obscure origin; also see JAMA 278:144, 1997--AFP; the latter is a practice guideline from Am. Soc. Add. Med.)