Alcohol (ethanol / ethyl alcohol) is a widely use and commonly abused substance throughout the world. Intoxication, misuse and dependence on alcohol is not a new social ill and mankind has a history with alcohol spanning thousands of years. Consumption of alcohol in limited quantities is known to produce a sense of well-being along with reduction of anxiety and some degree of disinhibition. This encourages individuals to consume alcohol repeatedly and more frequently. The repeated use of alcohol produces tolerance to the effects of alcohol on the brain. To overcome the effect of tolerance, individuals tend to consume more alcohol to reach the same level of intoxication. The regular intake of increased quantities of alcohol leads to alcohol abuse (addiction).
Initially the addiction is only psychological and discontinuation at this stage is not associated with any physical symptoms. Prolonged regular abuse of alcohol results in physical dependence and will experience withdrawal symptoms upon discontinuing alcohol. These individuals continue to consume alcohol despite experiencing the adverse medical and social effects. The health impact of chronic alcohol abuse includes drunkenness (inebriation), inaccurate judgment, chronic anxiety, irritability and insomnia. Alcohol exerts significant effects on the liver ranging from elevation of liver function tests to cirrhosis and liver failure. The extent of the health effects depends on the duration and degree of alcohol abuse. Following liver failure, the individual can develop encephalopathy as the body is unable to process toxins produced in the body. Alcohol consumption by pregnant women can result in some significant undesirable effects in the fetus. Children may be born with some functional or anatomic abnormalities.
Alcohol detoxification is important for overcoming both the medical and psychosocial of alcohol addiction. This extends beyond the addict and is of benefit to the family, friends and colleagues of the individual.Alcohol misuse has a broader impact even on society at large when one considers crimes committed under the influence of alcohol, road deaths with driving under the influence and anti-social behavior on the part of alcoholics and children raised in homes with alcoholic parents.
Alcohol detoxication is the cessation of alcohol use and is marked by a period of intense withdrawal (alcohol withdrawal syndrome) in some but not all alcohol abusers. The detoxification and subsequent rehabilitation period is also referred to as de-addiction. Recovery though is lifelong. The period of detoxification may require the use of certain medication to help control, minimize or prevent withdrawal symptoms. Medication may be continued during the rehabilitation period to counteract any mood disorders or treat alcohol-induced psychiatric illnesses. Psychotherapy is also necessary during these stages. For most individuals without the psychiatric illnesses, recovery is usually a drug-free journey but support and regular counseling is essential.
Alcohol Withdrawal Syndrome
Sudden stopping of alcohol intake by an alcohol addict can result in withdrawal symptoms. Withdrawal symptoms usually start 8 to10 hours after stopping alcohol intake. Sometimes just reducing, but not stoping alcohol consumption, can trigger these symptoms. The milder forms of withdrawal symptoms usually pass in 2 to 3 days time. The symptoms associated with alcohol withdrawal include :
- sleeplessness (insomnia)
The severity of withdrawal symptoms usually depends on the duration and extent of alcohol abuse. In some individuals it can also lead to serious and life threatening complications like seizures and delirium tremens. Seizures can develop in first couple of days following the stoppage. Delirium tremens usually appears several days after alcohol withdrawal. It is a type of delirium associated with alcohol withdrawal characterized by disorientation and hallucinations.
Alcohol withdrawal in chronic alcohol dependent individuals can also lead to a complication called as Wernicke’s encephalopathy which is characterized by ophthalmoplegia (eye paralysis), memory loss, ataxia (loss of movement co-ordination) and confusion. This complication results from deficiency of the vitamin thiamine which is common in chronic alcoholics. It is precipitated by intake of glucose or carbohydrates prior to administration of thiamine following alcohol withdrawal.
Medication for Withdrawal Symptoms
Alcohol withdrawal syndrome can be managed with a wide variety of drugs. The most important of these drugs are the benzodiazepines. Clonidine and barbiturates are other important drugs used for controlling alcohol withdrawal symptoms. Several other drugs may also be used including antipsychotics, trazodone and baclofen. Vitamin supplements like thiamine may be necessary for preventing Wernicke’s encephalopathy.
Benzodiazepines are popular sedative-hypnotic drugs. It is the most important group of drugs that is used for treating alcohol withdrawal syndrome during detoxification. Diazepam, lorazepam, and chlordiazepoxide are the commonly used benzodiazepines for this purpose. Benzodiazepines are safe and effectively reduce the symptoms of alcohol withdrawal. It also effectively prevents seizures associated with alcohol withdrawal. The treatment is generally confined to a short duration to avoid the development of any benzodiazepine dependence. Use of alcohol while on benzodiazepines can enhance the depressive effects of alcohol. It can even lead to suicidal thoughts or severe depression of the CNS functions. Individuals on benzodiazepines for detoxification are strictly cautioned about concurrent use of alcohol and its consequences.
Some detoxification centers use lower dose of ethanol itself for controlling withdrawal symptoms. The dose of ethanol is then progressively lowered (weaning) and subsequently discontinued. This approach may be associated with minimal or milder withdrawal symptoms.
Barbiturates are a group of sedative-hypnotic drugs that has been replaced worldwide from clinical use by benzodiazepines. Barbiturates may be of use in some patients with severe alcohol withdrawal symptoms.
Clonidine is an alpha-2 adrenergic receptor agonist which acts on the central nervous system and has shown benefits similar to benzodiazepines in alcohol withdrawal symptoms. It is believed to act by reducing the enhanced transmitter release associated with alcohol withdrawal.
Drugs for Treating Alcohol Addiction
Three drugs are available for clinical use in the United States for treating alcohol addiction. Naltrexone, disulfiram and acamprosate are the drugs used for treatment of alcohol abuse. Success is dependent on strictly adhering to the drug regimen while simultaneously undergoing psychotherapy.
Naltrexone is an opioid-receptor blocker. It is primarily used for reversing the effects of opioid drugs (morphine and related drugs). Naltrexone is believed to block the alcohol-induced activation of dopaminergic neural pathways of the brain directly involved in the reward (pleasure) center. This can lead to the reduction in the pleasure effects obtained from the alcohol intake. As a result of this, naltrexone reduces the craving for alcohol and thereby reduces the alcohol intake.
Naltrexone treatment does not cure a person from alcoholism. It provides the individuals with stronger control to abstain from alcohol. The drug is administered typically after detoxification. Naltrexone is available for oral administration and intramuscular injection. Oral administration is usually done at a dose of 50 mg per day. The treatment usually lasts for several months. Intramuscular naltrexone is given at a monthly dose by a healthcare professional. The injections are usually taken in alternating buttocks for each subsequent monthly dose.
Treatment with naltrexone should be given only to patients who are not taking opioids and individuals on naltrexone treatment should not be given opioids. Concurrent use of naltrexone and opioids is likely to result in serious opioid intoxication which can even be life-threatening. Suicidal thoughts, depression, nausea, vomiting, sedation and decreased appetite are some of the adverse effects associated with naltrexone therapy. Naltrexone is also known to cause damage to the liver. Its use is contraindicated in individuals with liver failure and in patients suffering from hepatitis. Naltrexone may be combined with acamprosate but it is not combined with disulfiram due to the hepatotoxic potential of both the drugs.
Disulfiram is one of the oldest drugs available for treating alcohol addiction and commonly known as Antabuse or Antabus. It helps in the preventing a relapse of alcohol abuse by creating an extreme aversion (dislike) for alcohol. It exerts its effects by interfering with the normal metabolism of alcohol. Normally alcohol is converted first to acetaldehyde by the enzyme alcohol dehydrogenase. The acetaldehyde is then converted to acetic acid by the enzyme aldehyde dehydrogenase. Disulfiram inhibits the action of aldehyde dehydrogenase. It is results in accumulation of acetaldehyde which produces significant unpleasant effects creating an aversion for alcohol intake.
The individual then experiences unpleasant effects like feeling hot, throbbing headache, nausea, vomiting, sweating, thirst, hypotension, weakness, respiratory difficulties and blurred vision. These unpleasant effects usually subside within 30 minutes in mild cases but may take several hours in severe instances. The disulfiram treatment is only commenced after the person has abstained from alcohol use for a minimum of 12 hours. The treatment is started at a daily dose of up to 500 mg for about a couple of weeks. The individual is then maintained on a daily dose (125 to 500mg) that is well tolerated. The effect of the drug may continue for 1 or 2 weeks after discontinuation of the treatment.
Consuming alcohol during the treatment period and the couple of weeks after stopping it should be avoided. Alcohol content present in the cough syrups, sauces or other food items can result in similar reactions. Use of disulfiram is associated with a few adverse effects like a skin rash, metallic taste and abdominal discomfort. Some drugs unrelated to disulfiram are known to have disulfiram-like action like metronidazole and cefoperazone. Such drugs are always used cautiously bearing in mind possible reactions with concurrent alcohol intake.
Acamprosate is a weak antagonist of the NMDA (N-methyl-D-aspartate) receptor and a GABA receptor agonist. It is believed to normalize some of the chronic alcohol intake induced alterations in neurotransmission and possibly neutralizes some of the pathways that lead to relapse of alcohol abuse. Acamprosate may be used alone or in combination with naltrexone. Behavior therapy is usually needed to keep individuals motivated in treatment continuation and abstinence from alcohol.
Food interferes with the absorption of acamposate and therefore it is ideally administered before meals. Gastrointestinal problems like nausea, vomiting and diarrhoea are the most common side effects of acamprosate. It is not recommended for use in patients with renal failure.