Alcohol For alcohol detox we use a tranquillizer or sedative replacement. Benzodiazepines are tranquilizers. Any tranquilizer can be used for this purpose. I personally like to use Valium (diazepam) as do most doctors, but Librium (chlordiazepoxide), Ativan (lorazepam), or Serax (oxazepam) can be used as well. These are all tranquilizers. Previously, barbiturates (such as Phenobarbital) were commonly used. Although barbiturates work, they have significant disadvantages, including causing greater impairments in thinking and memory, along with acute depression that can bring with it a higher risk of suicide. It’s useful to keep in mind that alcohol and sedative withdrawal is potentially life-threatening because people can get DTs and have seizures and sometimes die. Delirium tremens is an acute episode of delirium precipitated by withdrawal from alcohol or sedative-hypnotics. The main symptoms of delirium tremens are nightmares, agitation, global confusion, disorientation, and visual and auditory hallucinations. DTs are sometimes associated with severe, uncontrollable tremors of the extremities, as well as secondary symptoms such as anxiety, panic attacks, and paranoia. There are four stages of alcohol withdrawal. Stages one and two can be treated in an outpatient setting, if necessary. People come in after they’ve stopped drinking and within a few hours they’re starting to get shaky, their pulse starts to go up, their blood pressure begins to rise, they get a fever, they’re sweating, they’re anxious, and they’re not feeling very good in general. In outpatient detox we check patients’ vital signs (temperature, blood pressure, pulse, and respiratory rate), perform a physical exam, run lab tests, and give them a prescription for Valium and some vitamins and tell them to go home, take the medication every four to six hours, and come back the next day to see the nurse. However, if the clinical situation continues to deteriorate and the tremulousness worsens, a patient may be at risk for a seizure. In most cases, we admit such patients to the detox unit of the hospital and treat them with intravenous (IV) medications. But as uncomfortable as it is physically, in stage one alcohol withdrawal people don’t get hallucinations or delusions. Hallucinations are false or distorted sensory experiences that appear to be real perceptions. These sensory impressions are generated by the mind rather than by any external stimuli, and may be seen, heard, felt, and even smelled or tasted. In alcohol withdrawal they are usually visual, tactile (touch), and auditory. Stage one alcohol withdrawal syndrome begins six to eight hours after the last drink. The reason this happens is there’s increased output from the sympathetic division of the autonomic nervous system. The action is like that of a spring. You’re holding a spring down, and if you let it go suddenly it flies all over the room, but if you let it out very slowly you have control over the spring. So when someone is drinking heavily it’s like having a hand on the spring and when he or she stops drinking, the hand comes off the spring and it goes boing! That’s what the brain is doing. All the neurons are firing; the sympathetic division of the autonomic nervous system is kicking in, reacting to the sudden withdrawal of alcohol. The blood pressure goes up, the pulse rate goes up, the temperature goes up, diaphoresis (sweating) occurs, there is an exaggerated startle reflex, nausea, restlessness, and distractibility. Now let’s look at stage two where patients are worsening and they’re experiencing some hallucinations along with other unusual sensory experiences. Hallucinations occur when someone sees things that aren’t there (visual), hears things that aren’t there (auditory), or feels things that aren’t there (tactile), such as insects crawling on the skin. In stage two, patients usually know that these experiences are not real but they can see shadows, flickering lights, and other funny things, but this is not a manifestation of DTs. These symptoms start twenty-four to seventy- two hours after the last drink and occur in 25 percent of untreated individuals. Patients are still cognitively intact. In other words they still can talk to you and they’re not having delirium. Sometimes we ask patients if they’ve ever had DTs and they’ll say yes, but when we ask them to describe what happened they’ll tell us that they felt weird things and got anxious, but that’s about it. Unfortunately, that’s what the public often thinks DTs are, but that is inaccurate. DTs is when you have all of the above symptoms coupled with delirium and marked physiological instability. If it’s severe you will witness frightening hallucinations and delirium. Stage three includes alcohol withdrawal seizures, and we see this in 5 to 15 percent of untreated individuals. It typically occurs within the first forty-eight hours after the last drink. These are always “grand mal,” which means major “motor” seizures, where patients are thrashing on the ground, biting their tongue, and urinating on themselves. It can be very scary to witness. I’ve watched as patients have seizures in our parking lot as soon as they get out of the car. They faint first, and 3 percent of these people will enter “status epilepticus,” which means they have a seizure that won’t stop. And we can’t stop it. we give them medications via injections, and we finally have to call in an anesthesiologist to put them to sleep. During a seizure, brain cells are being lost and the brain is effectively dying. The spring’s been released and now it’s bouncing all over the room. we see the more severe cases in people who have been drinking a long time and in older people, but I’ve seen younger people with alcohol withdrawal seizures, too. We all have different constitutions. When it happens in younger people, it’s usually due to the enormous quantities of alcohol they have been drinking. They may have been on a heavy drinking binge. Stage four alcohol withdrawal is DTs, delirium tremens. This is the highest acuity and worst-case scenario. It begins forty-eight hours to up to fourteen days after the last drink. Be aware that this can happen even after the person is sitting in your recovery group, seemingly appearing “normal.” It consists of profound clouding of the senses, and people become delirious and paranoid. DTs occur in about 5 to 10 percent of alcoholics, and there is 5 to 15 percent mortality with treatment, and up to 35 percent mortality without treatment. Obviously, it is very, very serious. As addiction to alcohol progresses, the so-called “kindling effect” kicks in, where each subsequent withdrawal episode is worse than the one that preceded it. Sometimes, this experience is bad enough that people will give up drinking. They’ll say, “The last time I almost died. I’m not doing this again because it keeps getting worse every time!” Of course, in spite of such declarations, driven by their addiction many people return to drinking. The kindling effect can also refer to the fact that when someone uses a little bit of drug he or she typically wants to use more and then winds up using more. It’s like using kindling wood when a fire is about to go out. Smaller pieces of wood that burn easily are inserted into the dying flames, and the fire flares up again. When an alcoholic tries to have just one drink, it provides kindling that ignites his or her whole nervous system, and starts a process where one drink is too many and five (or a thousand, as the twelve-step saying goes) is never enough. With proper detoxification, managing the withdrawal effectively seems to block the kindling phenomenon. So again, we replace the sedative alcohol with another medication, we prevent physiological deterioration, we treat any hallucinations with antipsychotic medications, and we consider other causes of seizures—especially after a falling-down episode involving alcohol or other drugs because maybe the patient hit his or her head when he or she was intoxicated. Before the patient came to the hospital, how do we know that he or she didn’t hit his or her head and have a brain injury? We don’t, so we have to do a CT scan. In detox settings, withdrawal-symptom management is a moving target. Some medications are symptom-triggered, so, for example, addiction doctors write the orders for the nurse to give the patient Valium every time the patient’s blood pressure is above a certain range or the pulse moves above a certain range and the person is trembling, or the patient is prescribed the medication every four hours unless asleep. That would be a standard procedure and these are typical of the standing orders that we give. If the nurses have any questions they call us. And we use benzos and vitamins as the basic medication for alcohol withdrawal. Addiction counselors should know what the CIwA (Clinical Institute withdrawal Assessment) Scale is. It’s a standardized assessment protocol used in North American hospitals to assess and treat alcohol withdrawal. This clinical tool assesses ten common withdrawal signs and symptoms: nausea and vomiting; tremor; paroxysmal sweats; anxiety; agitation; tactile disturbances; auditory disturbances; visual disturbances; headaches, feelings of “fullness” in the head; and orientation to person, place, and time. Patients’ symptoms in each of these areas are scored on a scale, and the cumulative score helps staff figure out what level of withdrawal an individual patient is in and informs the treatment approach. A score above a certain threshold is associated with increased risk of severe alcohol withdrawal effects such as seizures or DTs. We administer medications based on the CIwA scores; the higher the score, the more medication we give. In terms of determining dosages, we figure that five milligrams of Valium is equal to one drink. And one milligram of Ativan—which we usually prescribe for alcohol delirium—equals one drink. I use Phenobarbital as a detox agent if patients are also detoxing from benzos. If they say they’re alcoholic and have also been taking twenty-five xanax a day, I may put them on Phenobarbital because it is also useful for preventing seizures. We also use medications for hallucinations, and we use beta blockers to slow the heart rate if the patient’s pulse is too high. We administer medications in different ways: PO means by mouth, IM means intramuscular, IV means through an IV line into a vein. When making final judgments regarding medication administration, we always look at patient safety, early recognition of withdrawal signs and symptoms, standardized assessments, and established protocols. Sedative-Hypnotics As I mentioned, sedative-hypnotic withdrawal is dangerous and potentially life-threatening, similar to withdrawal from alcohol. Sedative-hypnotic is also similar to alcohol withdrawal in other ways. The symptoms of tranquilizer withdrawal include high blood pressure, rapid heartbeat, hyperactive reflexes, sweats, and, potentially, hallucinations, delirium, psychosis, and seizures. Such patients get anxious; they get nauseated; they get tremulous, and they are very difficult to manage. Not only is the withdrawal crappy, but these patients have a lot of anxiety to begin with, which is why they started taking these particular substances in the first place, so many of them have a psychiatric overlay which can make them an extremely complex group of patients to treat. Sometimes patients can present as manic or hypomanic. As is the case with other drugs of abuse, the severity and length of withdrawal that patients experience depend on the duration of use, the amount used, and the half-life of the specific hypnotic-sedatives used. Some people get hooked on xanax and they’re taking three or four a day. But I’ve also had patients taking thirty to forty a day! Treatment becomes challenging because different hypnotic-sedatives need to be managed differently. Different benzos have different half-lives. In the context of mind- and mood-altering substances, half-life means the time required for the body’s processes of metabolism and elimination to reduce the concentration of the drug to one half of what it was upon initial administration. xanax (alprazolam) is an example of a benzodiazepine with a very short half-life. Benzos with intermediate half-lives include temazepam (Restoril), oxazepam (Serax), and lorazepam (Ativan). Then there are those with long half-lives. we prefer to use Valium (diazepam), Librium (chlordiazepoxide), and Klonopin (clonazepam) for detox purposes due to their long half-life. With sedative-hypnotic withdrawal, the duration of detox lasts quite a long time—up to ten days for drugs with shorter half-lives and up to sixteen days for those with longer half-lives. Patients typically get really concerned toward the end of the detox process, when they’re going through withdrawal, and some cut their pills into pieces to have “just a little bit” to use each day because they are afraid to get off these drugs. When patients taper down themselves they have to go very slowly. we work with them to substitute a long-acting sedative-hypnotic and taper that down. So if someone comes in with xanax withdrawal, we try to treat it on an outpatient basis and switch him or her to Valium or Phenobarbital. Psychiatrists prefer to use Klonopin frequently due to its long half-life. So we’re not tapering the xanax, we’re tapering a substitute drug with a longer half-life. I give patients a calendar and I tell them to mark each day with the number they are taking so they can keep a record. The formulas we use in substituting medications during sedative-hypnotic detox are as follows:
- 30 milligrams of Phenobarbital is equal to about 10 milligrams of Valium,
- which is equal to about 25 milligrams of Librium,
- which is equal to about 2 milligrams of Klonopin.
Chloral hydrate is also important to consider. It’s a powerful sleeping pill often used in hospital settings, especially when doing detox in the hospital. Remember that patients don’t always tell you the truth about their using. Sometimes patients try to justify or cover their actions; sometimes they are embarrassed about their drug-taking behavior; sometimes they also lie to try to get on your good side, and sometimes they exaggerate the extent of their using because they think they can get more drugs that way: “Doctor, you have to give me a lot of detox meds because I take a hundred Valiums a day.”Well, how do I really know that he or she is taking a hundred Valiums a day? I tend not to believe it, but I don’t know with certainty, so one of my little tricks in an inpatient or hospital setting is to give him or her a shot of pentobarbital (the brand name is Nembutal), and I observe, knowing that if you give 200 milligrams of Nembutal to a normal person, he or she is asleep in thirty minutes. If you give it to somebody who’s been taking 100 Valiums a day, it doesn’t touch him or her. It’s like a lie detector test. If a patient reports taking 100 Valiums a day and I give him pentobarbital and half an hour later he is asleep or even very groggy, I know that he’s lying and doesn’t really take that much. In the addiction medicine literature this is called a “pentobarbital challenge test.” Sadly, tests like this are necessary because, as a rule, addicts are devious. It can be challenging to get a reliable history from them. The sedatives that we often have to detox people from are barbiturates and sleeping pills. Sometimes these substances come in indirect forms. For example, Fiorinal, which people take for migraines, has barbiturates in it. It can be hard to believe how many different pills addicts can find to use. Among the twelve-step programs that include AA and NA, there is Pills Anonymous (PA). Anyone training to be an addiction therapist should visit a Pills Anonymous meeting to see what it’s like. The people who go there usually have problems with opioid pain pills like Vicodin and Norco, problems with benzodiazepine tranquilizers like xanax and Ativan, and problems with sleeping pills like Ambien (zolpidem), Lunesta (eszopiclone), and Sonata (zaleplon), the sleeping pills they advertise every night on TV. I sometimes treat people who are taking Ambien three or four times a day. As with other types of psychoactive substances, over time, using builds up a tolerance. This can result in episodes of sedative intoxication, even though the person may not feel intoxicated because his or her brain and body are so accustomed to its influence. Symptoms of intoxication include uncontrolled eye movement, which is why the police check the eyes of people they stop for suspicion of DUI. They are looking to see if the driver’s eyes are flickering (called nystagmus) or he or she appears drowsy. Since both alcohol and sedative-hypnotic withdrawal can precipitate delirium, addiction counselors need to know a bit about it. Delirium is an acute change in cognition. It’s like being demented but it happens acutely. The patient doesn’t know where she is, doesn’t know who she is, she’s terrified, doesn’t recognize her surroundings, and her awareness of where she is comes and goes. However, delirium can be caused by a number of different things. For example, delirium in an older person is often due to an underlying medical problem. Very often an acute change in consciousness or change in awareness in a nursing home resident is due to an infection, heart attack, a new medication, a stroke, or another medical cause, so until proven otherwise delirium is always attributed to a medical cause. In contrast, when a young or middle-aged person is doing fine and then seems totally confused and doesn’t know where he or she is, we can’t ignore drug intoxication or alcohol withdrawal syndrome in the differential assessment. A lot of intoxicated patients come to the emergency room and/or are admitted to the hospital related to a motor vehicle accident. Maybe they hit their head, maybe they didn’t, but when they come to the hospital they’re delirious and it may not be due to the auto accident. It’s important for addiction therapists to become familiar with the phenomenon of “protracted withdrawal.” Protracted withdrawal (sometimes referred to as post-acute withdrawal) is the period after the acute withdrawal ends but prior to the time when the patient actually starts to feel “normal” again. It can go on for many weeks or months after the patient stops using. It usually includes feelings of anxiety, depression,and irritability, along with anhedonia (lack of pleasure) and insomnia. The symptoms of protracted withdrawal can range in acuity from more mild to severe. It is not uncommon for these feelings to be sometimes misdiagnosed as a psychiatric condition. Due to the intense discomfort many people experience during the protracted withdrawal process, this is also a time when patients are at great risk to relapse. Many of the medications listed previously can also help to reduce the severity of these symptoms during this vulnerable period after detox. This blog post is an excerpt from The therapist’s Guide to Addiction Medicine – A Handbook for Addiction Counselors and Therapists – by Barry Solof, MD, FASAM; Published by Central Recovery Press (CRP).
