Alcohol Withdrawal(291.81)

DSM-IV-TR criteria

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

B. Two (or more) of the following, developing within several hours to a few days after Criterion A:

1. Automatic hyperactivity (e.g., sweating or pulse rate greater than 100)
2. Increased hand tremor
3. Insomnia
4. Nausea or vomiting
5. Transient visual, tactile, or auditory hallucinations or illusions
6. Psychomotor agitation
7. Anxiety
8. Grand mal seizures

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Specify if:

With Perceptual Disturbances

Emperically supported treatment

• Many treatment with alcohol withdrawal syndroms can be managed with various pharmaceutical medications including barbituates, benzodiazepines, and clonidine, certain vitamins are also an important part of the management of alcohol withdrawal syndrome.
• Barbituates are superiors to diazepam in the treatment of severe alcohol withdrawal syndromes such as delirium tremens but equally effective in mildr cases of alcohol withdrawal.
• Clonidine has demonstrated superior clinical effects in the suppression of alcohol withdrawal symtpoms in a head to head comparison study with the benzodiazepine drug.
• Benzodiazepines are the most commonly used drug for the treatment of alcohol withdrawal and are generally safe and effective in suppressing alcohol withdrawal signs. Chlordiazepoxide and diazepam are the benzodiazepines most commonly used in alcohol detoxification. Benzodiazepines can be life saving, particularly if delerium tremens appears during alcohol withdrawal. Benzodiazepines should only be used short term in alcoholics who aren’t already dependent on benzodiazepines as benzodiazepines share cross tolerance with ethanol and there is a risk of replacing the addiction with a benzodiazepine dependence or worse still adding an additional addiction. Furthermore disrupted GABA benzodiazepine receptor function is part of alcohol dependence and chronic benzodiazepines may prevent full recovery from alcohol induced mental effects. Benzodiazepines have the problem of increasing cravings for alcohol in problem alcohol consumers and they also increase the volume of alcohol consumed by problem drinkers. The combination of benzodiazepines and alcohol can amplify the adverse psychological effects of each other causing enhanced depressive effects on mood and increase suicidal actions and are generally contraindicated except for alcohol withdrawal.
• Vitamins

• Alcoholics are often deficient in various nutrients which can cause severe complications during alcohol withdrawal such as the development of wernicke syndrome. The vitamins of most importance in alcohol withdrawal are thiamine and folic acid. To help to prevent wernicke syndrome alcoholics should be administered a multivitamin preparation with sufficient quantities of thiamine and folic acid. Vitamins should always be administered before any glucose is administered otherwise wernicke syndrome can be precipitaed.

Links:

• How long does withdrawal last? A discussion of the time course and symptoms associated with withdrawal at different stages in alcohol abuse and dependence (uploaded by ehowhealth, direct link http://www.youtube.com/watch?v=CWrp3YXMohQ)

DSM-V Proposed Changes: adding “Alcohol-Use Disorder”

DSM-V Alcohol-Use Disorder Criteria:

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:

1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

4. tolerance, as defined by either of the following:

• a need for markedly increased amounts of the substance to achieve intoxication or desired effect
• markedly diminished effect with continued use of the same amount of the substance

(Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)

5. withdrawal, as manifested by either of the following:

• the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
• the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

(Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)

6. the substance is often taken in larger amounts or over a longer period than was intended

7. there is a persistent desire or unsuccessful efforts to cut down or control substance use

8. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects

9. important social, occupational, or recreational activities are given up or reduced because of substance use

10. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

11. Craving or a strong desire or urge to use a specific substance.

Severity specifiers:

Moderate: 2-3 criteria positive

Severe: 4 or more criteria positive

Specify if:

With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)

Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)

Course specifiers (see text for definitions):

Early Full Remission

Early Partial Remission

Sustained Full Remission

Sustained Partial Remission

On Agonist Therapy

In a Controlled Environment