The Alcohol Withdrawal Syndrome

Once the brain has been repeatedly exposed to high doses of alcohol, any sudden decrease in intake can produce withdrawal symptoms, many of which are the opposite of those produced by intoxication. Features include tremor of the hands (shakes or jitters); agitation and anxiety; autonomic nervous system overactivity including an increase in pulse, respiratory rate, and body temperature; insomnia, possibly accompanied by bad dreams; and gastrointestinal upset. These withdrawal symptoms generally begin within 5 to 10 h of decreasing ethanol intake, peak in intensity on day 2 or 3, and improve by day 4 or 5. Anxiety, insomnia, and mild levels of autonomic dysfunction may persist to some degree for 6 months as a protracted abstinence syndrome, which may contribute to the tendency to return to drinking.

At some point in their lives, between 2 and 5% of alcoholics experience withdrawal seizures, often within 48 h of stopping drinking. These rare events usually involve a single generalized seizure, and electroencephalographic abnormalities generally return to normal within several days.

The term delirium tremens (DTs) refers to delirium (mental confusion, agitation, and fluctuating levels of consciousness) associated with a tremor and autonomic overactivity (e.g., marked increases in pulse, blood pressure, and respirations).

Fortunately, this serious and potentially life-threatening complication of alcohol withdrawal is seen in <5% of alcohol-dependent individuals, with the result that the chance of DTs during any single withdrawal is <1%. DTs are most likely to develop in patients with concomitant severe medical disorders and can usually be avoided by identifying and treating medical conditions.

Treatment

Acute Intoxication

The first priority is to be certain that the vital signs are relatively stable without evidence of respiratory depression, cardiac arrhythmia, or potentially dangerous changes in blood pressure. The possibility of intoxication with other drugs should be considered, and a blood or urine sample is indicated to screen for opioids or other CNS depressants such as benzodiazepines or barbiturates. Other medical conditions that must be evaluated include hypoglycemia, hepatic failure, or diabetic ketoacidosis.

Patients who are medically stable should be placed in a quiet environment and asked to lie on their side if fatigued in order to minimize the risk of aspiration. When the behavior indicates an increased likelihood of violence, hospital procedures should be followed, including planning for the possibility of a show of force with an intervention team. In the context of aggressiveness, patients should be clearly reminded in a nonthreatening way that it is the goal of the staff to help them to feel better and to avoid problems. If the aggressive behavior continues, relatively low doses of a short-acting benzodiazepine such as lorazepam (e.g., 1 mg orally) may be used and can be repeated as needed, but care must be taken so that the addition of this second CNS depressant does not destabilize vital signs or worsen confusion. An alternative approach is to use an antipsychotic medication (e.g., 5 mg of haloperidol), but this has the potential danger of lowering the seizure threshold. If aggression escalates, the patient might require a short-term admission to a locked ward, where medications can be used more safely and vital signs more closely monitored.