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Published July 10, 2019

Drug/Alcohol Use Disorder

Alcohol Use Disorder

About 9% of the adult U.S. population meets criteria for an alcohol use disorder. Alcohol use disorders can affect anyone, regardless of social status, age, race, or gender. More than 20% of patients in most medical settings are affected by alcohol use disorders (rates are higher in psychiatric wards, trauma wards, and burn services).

Diagnostic Criteria

The following table lists the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for diagnosing alcohol use disorders (note: the DSM-5 criteria differ significantly from DSM-IV, as shown by comparison):

Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5

Alcohol Withdrawal

It is important to obtain a thorough social history and a detailed history of alcohol consumption, because 50% of people with alcohol use disorders have symptoms of alcohol withdrawal and about 33% experience withdrawal seizures when alcohol consumption is reduced or discontinued. In 3% to 5% of such patients, delirium tremens (DTs) develop and can lead to death, usually resulting from hyperthermia, cardiac arrhythmias, complications of withdrawal seizures, or concomitant medical disorders. Withdrawal seizures may occur within 36 hours after cessation of alcohol use.

Diagnostic Criteria

The following table lists criteria for diagnosing alcohol withdrawal:

The Clinical Institute Withdrawal Assessment of Alcohol scale, revised (CIWA-Ar), shown in the following table, can be used to assess presence of alcohol withdrawal, need for medication, and risk for delirium tremens (DT):

Predictors of Delirium During Alcohol Withdrawal:

  • CIWA-Ar scores >15 (especially when accompanied by a systolic blood pressure >150 mm Hg or a pulse rate >100 beats per minute)

  • recent withdrawal seizures (in 20% of people with delirium)

  • prior withdrawal delirium or seizures

  • older age

  • recent misuse of other depressant agents

  • concomitant medical problems, including electrolyte abnormalities (e.g., low levels of potassium, magnesium, or both); low platelet counts; and respiratory, cardiac, or gastrointestinal disease

Treatment

Major treatment goals of alcohol withdrawal are:

  • control agitation

  • decrease the risk of seizures

  • decrease risk of injury or death

  • prevent relapse

Benzodiazepines (e.g., diazepam or lorazepam) are the mainstay of treatment. No single drug in this class has been shown to be superior to others. Required treatment doses vary widely by patient. Patients who don’t respond to high doses (and are intubated) may require propofol.

Alternative drugs for withdrawal include phenobarbital, clomethiazole, carbamazepine, oxcarbazepine, valproic acid, and gabapentin. Dexmedetomidine is used more often as an adjunctive agent for delirium. 

Note: Patients require high-dose, intravenous thiamine before receiving glucose-containing substances to prevent Wernicke’s encephalopathy. Be cautious when administering fluids, because some patients may also have thiamine- or alcohol-related cardiomyopathies.

The following table provides suggested treatments for alcohol withdrawal:

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Relapse Prevention

Treatment strategies to prevent relapse of alcohol misuse include behavioral interventions and pharmacotherapies. No evidence suggests the choice of one intervention over another.

Behavioral Interventions

Cognitive behavior therapy (CBT): CBT involves the use of education, relaxation techniques, and stress management aimed to address individual goals and problem-solving skills. CBT is used in the treatment of a variety of psychiatric disorders, ranging from depression to obsessive compulsive disorder and substance use disorders. This type of therapy is particularly useful in patients who are highly motivated.

Behavioral therapies based on conditioning: This form of psychotherapy applies classical conditioning techniques developed by Pavlov. In the context of alcohol misuse, patients think about cues that induce craving and they are exposed to cues in the absence of drinking and rewarded for their abstinence.  The evidence of efficacy for this particular intervention is not as strong as evidence of the efficacy of CBT.

Motivational enhancement therapy: This therapy uses patients’ insights to help reduce or abstain from drinking alcohol. The level of evidence for the efficacy of the type of therapy is high and similar to CBT.

12-step facilitation: Alcoholics Anonymous (AA) programs encourage a supportive environment and a buddy system to encourage abstinence. Although the evidence for this intervention is mixed, such programs can be substantially beneficial for many individuals. Other community based lay-led and professionally led group programs that have less of a spiritual focus are also available and can provide significant help.

Pharmacotherapy

Medications are underutilized in the treatment of alcohol use disorders. The FDA has approved three oral medications (naltrexone, disulfiram, and acamprosate) and a long-acting injectable formulation of naltrexone for the treatment of alcohol dependence.

Other options for patients who wish to pursue pharmacological interventions include disulfiram (for selected patients who wish to ensure enforced sobriety), and acamprosate. Studies have not established that one option is superior to another.

The following table describes medications used in the treatment of alcohol use disorder and associated adverse effects and mechanism of action:

Opioid Withdrawal

Withdrawal from any opioid, including heroin, resembles severe influenza and is accompanied by the following symptoms:

  • pupillary dilatation

  • lacrimation

  • rhinorrhea

  • piloerection (“goosebumps”)

  • yawning

  • sneezing

  • anorexia

  • nausea/vomiting

  • diarrhea

A clinical opiate withdrawal scale for measuring symptoms can be found here (Table 2).

Opioid withdrawal is extremely uncomfortable and distressing for the patient, but is usually not life-threatening (death rarely occurs, but when it does, it is most often due to dehydration or debilitation). In contrast, opioid intoxication, is much more likely to be life-threatening and both intoxication and withdrawal carry significant risks of death with alcohol. 

Treatment of Opioid Withdrawal

The treatment of opioid-withdrawal syndromes requires a long-acting opioid to relieve symptoms and then tapered over time as the patient adjusts to the absence of an opioid. Opioids such as methadone are oral drugs but require physicians with specific training in licensed addiction-treatment programs to administer to patients.

Treatment for Symptoms of Opioid Withdrawal with Long-Acting Opioid Agonists

Nonopioid therapy can be used to help treat anxiety, insomnia, and other withdrawal symptoms. However, some of these indications, such as the use of clonidine to control symptoms of autonomic overactivity, are off-label.

Opioid-Free Treatment of Opioid Withdrawal

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Maintenance Therapy

To prevent relapse, a combination of rehabilitation, supportive systems, and pharmacotherapies are required. Maintenance therapy may involve use of one of three agents: naltrexone, methadone, or buprenorphine. Naltrexone, a µ -opioid receptor antagonist is used in patients who are fully abstinent. In patients who may not be able to discontinue opioids, treatment options include methadone or buprenorphine. It is important to ensure that patients participating in these programs do not have cardiac dysfunction (patients who overdose on methadone may have prolongation of the QT interval).

Medications for Rehabilitation from an Opioid-Use Disorder

Stimulant Withdrawal

Stimulant withdrawal is also not life-threatening. Stimulant withdrawal from cocaine or amphetamines is associated with the following symptoms:

  • dysphoria

  • sleep disturbances

  • appetite disturbances

  • motor disturbances

Treatment

The following table indicates medication treatment for alcohol and drug withdrawal:

Note: It is important to remember that using a beta-blocker in someone who may be currently intoxicated with cocaine or someone who may relapse to cocaine can lead to dangerous unopposed alpha-adrenergic stimulation.

Some evidence suggests that topiramate might also be useful for prevention of cocaine cravings, but the study’s effect size is not large.

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