Alcohol Cessation

Overview

Alcohol cessation support involves:

1. Managing acute withdrawal safely to prevent complications (e.g. seizures, delirium tremens).

2. Preventing relapse through maintenance pharmacotherapy and psychosocial interventions.

3. Ongoing monitoring for comorbid mental health conditions, nutritional deficiencies, and liver complications.

Acute Withdrawal Management

Timeline & Symptoms

• Onset: 6–24 hours after the last drink

• Peak: ~72 hours

• Duration: Up to 4–5 days; can be prolonged in severe cases

Common Withdrawal Symptoms:

• Anxiety, restlessness, irritability

• Tremors, nausea/vomiting

• Tachycardia, hypertension, sweating

• Hallucinations (auditory/visual)

• Seizures (withdrawal seizures typically occur 12–48 hours after last drink)

• Delirium Tremens (DTs): The most severe form, with confusion, disorientation, hallucinations, severe autonomic instability, and potential for seizures.

Medications for Acute Withdrawal

1. Benzodiazepines (e.g. diazepam, chlordiazepoxide, lorazepam)

   • Mechanism: Enhance GABA inhibitory neurotransmission, reducing excitatory overdrive.

   • Indications: Symptomatic relief, prevention of seizures and delirium tremens.

   • Contraindications: Severe respiratory insufficiency, obstructive sleep apnoea, benzodiazepine allergy.

   • Dosing Example:

     • Diazepam 20 mg orally 2-hourly as needed (max 100 mg/day), tapering according to symptom control.

2. Thiamine (Vitamin B1)

   • Rationale: Prevents Wernicke–Korsakoff syndrome (encephalopathy and potential permanent cognitive impairment).

   • Important: Give before any glucose-containing fluids or meals to avoid precipitating Wernicke’s.

   • Dosing Example: 300 mg IV/IM for 3–5 days, then 300 mg orally daily for several weeks.

3. Beta-blockers (e.g. propranolol)

   • Role: Can help control autonomic symptoms (tachycardia, tremor), but do not prevent seizures or DTs.

   • Should only be used as adjunctive therapy.

Supportive Care

• Nutritional support: Replace electrolytes, ensure adequate hydration.

• Monitoring: Regular vitals, sedation levels, mental state.

• Consultation: Involve drug and alcohol specialists if severe or complicated withdrawal is suspected.

Inpatient vs. Outpatient Withdrawal

• Outpatient is suitable for mild/moderate withdrawal with good social support, no significant medical or psychiatric comorbidities, and no history of seizures or DTs.

• Inpatient is indicated if there is:

  • History of withdrawal seizures or DTs

  • Unstable medical conditions (liver failure, arrhythmias)

  • High risk of self-harm or severe psychiatric issues

  • Inadequate social support or homelessness

Maintenance Pharmacotherapy

Acamprosate

• Mechanism: Modulates glutamate neurotransmission, reducing cravings and some withdrawal symptoms.

• Dosing: 666 mg orally TDS for individuals >60 kg.

• Best for: Patients with liver impairment (cirrhosis) as it is primarily excreted renally.

• Contraindication: Significant renal impairment (creatinine >120 µmol/L).

Naltrexone

• Mechanism: Opioid receptor antagonist, reducing the reward effect of alcohol.

• Dosing: 50 mg orally daily.

• Best for: Patients with binge drinking patterns; suitable in renal impairment (with caution).

• Contraindications:

  • Liver failure or acute hepatitis (risk of hepatocellular injury)

  • Current opioid dependence (will precipitate withdrawal)

Disulfiram

• Mechanism: Inhibits aldehyde dehydrogenase, causing unpleasant reactions (flushing, palpitations, nausea) upon alcohol ingestion.

• Dosing: Start with 100 mg orally daily for 1–2 weeks, may increase up to 300 mg daily.

• Contraindications:

  • Cardiovascular disease, severe renal or liver disease

  • High risk of non-adherence (risk of severe reactions if alcohol is consumed while on treatment)

• Monitoring: Requires close supervision and strict abstinence commitment.

Outpatient Withdrawal Criteria

• Mild to moderate symptoms only

• No history of complicated withdrawal (no seizures or delirium tremens)

• Adequate social support and a safe environment

• Capacity for close follow-up (e.g. daily check-ins)

Outpatient Contraindications

• Severe concurrent medical illness (e.g. unstable angina, severe COPD)

• Previous seizures or delirium tremens

• Unstable housing, lack of social supports

• Severe psychiatric issues (psychosis, active suicidal ideation)

• Current significant poly-drug use (except cannabis)

Psychosocial Interventions

• Motivational interviewing: Enhance readiness to change.

• Cognitive Behavioural Therapy (CBT): Identify triggers, develop coping strategies.

• Support groups: Alcoholics Anonymous (AA), SMART Recovery.

• Counselling: Address underlying stressors, relationship issues, or trauma.

• Relapse prevention plans: Identify high-risk situations, set goals, and ensure follow-up.

Key Points

1. Assess Severity: Use a validated withdrawal scale (e.g. CIWA-Ar) to guide benzodiazepine dosing.

2. Prevent Wernicke–Korsakoff: Always administer thiamine before glucose.

3. Medication Selection: Match maintenance therapy (acamprosate, naltrexone, disulfiram) to patient profile (e.g. comorbidities, drinking pattern, readiness to abstain).

4. Ongoing Support: Long-term psychosocial and medical follow-up is crucial to maintaining abstinence or reduced harm.