Alcohol and nicotine withdrawal

Dr IM Joubert

Alcohol and nicotine are widely abused substances and are often used together

One study showed that 15% of patients visiting a primary care practice for any reason had either an “at-risk” pattern of alcohol use or an alcohol related health problem

It is important to note that alcohol contributes and leads to a wide range of medical problems and is also a significant contributor to trauma

Alcohol use history is important in all patients

In trauma patients exclude head injury before ascribing unusual behaviour to alcohol withdrawal but conversely keep alcohol withdrawal in mind for all patients with an altered mental status of unknown aetiology

High likelihood in following patients:◦ Alcohol-related reason for admission

◦ Regular use >80g/day in males, >60g/day in females

◦ >30 years of alcohol use

◦ <10 days since last drink

◦ History of alcohol dependence/previous withdrawal

Range from mild withdrawal to severe withdrawal and delirium tremens

Start within 6 to 24 hours of last drink, peak over 36 – 72 hours

Subside over a few days but mood and sleep disturbance may persist for weeks

Seizures can occur early in course –usually of short duration and self-limiting but may progress to status epilepticus

History of previous severe withdrawal

Use of >150mg alcohol per day

Presence of other illness/injury

History of head injury

Use of other psychotropic drugs

Patients at risk for severe withdrawal should be closely monitored and receive early and aggressive treatment ideally in high care setting

Agitation

Restlessness

Gross tremor

Disorientation and mental confusion

Fluctuating level of consciousness

Fluid and electrolyte imbalances

Sweating and pyrexia

Visual hallucinations

Paranoia

Identify and treat underlying medical conditions

Control behaviour

Prevent injuries

High dose benzodiazepines (not > 100mg/hour or 250mg in 8 hours)

Result of thiamine deficiency

Life threatening condition◦ Global confusional state

◦ Ocular disturbances: horizontal nystagmus, opthalmoplegia, CN VI palsy with diplopia

◦ Ataxia

Treatment:◦ Thiamine 300mg IVI for 3-5 days, then 100-300mg

po dly

All withdrawal patients should receive Thiamine 300mg IVI stat on presentation

Benzodiazepines

◦ Treatment of choice

◦ Reduce withdrawal severity and incidence of seizures and delirium

◦ Good safety profile

◦ Usually long-acting but can give short-acting in cases of liver disease

◦ Given for short period of time due to potential for abuse

◦ Dosing: Fixed dose, loading dose followed by fixed dose or symptom triggered therapy

Symptom-triggered therapy requires close monitoring, not ideal except in dedicated detoxification centre

Fixed dose in mild withdrawal◦ Day 1 – 5-15mg qid

◦ Day 2 – 5-10mg qid

◦ Day 3 – 5-10mg tds

◦ Day 4 – 10mg bd

◦ Day 5 – 5mg bd

Loading dose therapy is indicated in cases of a high level of dependency or a patient at high risk for severe withdrawal

Loading dose of 10-20mg diazepam every 2-4 hours until light sedation achieved, then then 10mg 4-6hourly, wean slowly over next 5 days

Anticonvulsants:◦ Phenytoin has no benefit

◦ Valproate and Carbamazepine increase seizure threshold

Thiamine:◦ 300mg IVI stat, then 100mg dly for 7 days

Antipsychotics/sedatives:◦ Phenothiazines/Haloperidol – decrease symptoms

but less effective than benzos – adjunct in severe withdrawal with perceptual disturbances, can decrease seizure threshold

ß-blockers and clonidine – reduce autonomic manifestations, ß-blockers may mask symptoms of early withdrawal or impending delirium

Symptomatic treatment ◦ Metoclopramide for nausea and vomiting

◦ Buscopan for abdominal cramps

◦ Immodium for diarrhoea

◦ Paracetamol for headaches and muscle pain if no liver damage

Nicotine and other tobacco components may interact with and affect action and metabolism of certain medication e.g. clozapine and olanzepine – upon cessation of smoking patients may develop drug side-effects - consider revising dosages

After smoking cessation caffeine is absorbed more readily – increased caffeine levels increase restlessness and sleep disturbance

Start hours after last cigarette, peak in 24 –72 hours, decline and resolve within 2 – 4 weeks

Dysphoric or depressed mood

Insomnia

Irritability, frustration or anger

Difficulty concentrating

Restlessness

Decreased heart rate

Increased appetite or weight gain

Nicotine replacement therapy

Available as patches, gum, inhalers and lozenges, gel

Dosage depends on amount of cigarettes smoked before stopping

Combinations may be used in patients with high nicotine tolerance

Schuckit MA. Alcohol and Alcoholism in Kasper BL, Braunwald E et al (eds), Harrison’s Principles of Internal Medicine, 16th ed, McGraw Hill, New York, 2006, p. 2562-2566

Burns DM. Nicotine Addiction in Kasper BL, Braunwald E et al (eds), Harrison’s Principles of Internal Medicine, 16th ed, McGraw Hill, New York, 2006, p. 2573-2576

Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Eng J Med 2003;348(18):1786-1795

Eyer F et al. Alcohol Alcohol 2011;46(4):427-433 McKeown N. Withdrawal Syndromes. Available from URL:

http://emedicine.medscape.com/article/819502-overview#showall

NorthWestern Mental Health. Alcohol and Other Drug Withdrawal Practice Guidelines.

Australian Alcohol and Drug Abuse Management Guidelines