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| PHARMACOLOGICAL MANAGEMENT OF ALCOHOL WITHDRAWAL |
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Alcohol dependence continues to be major public health problem, and among its many associated medical problems is a well characterized withdrawal syndrome. Withdrawal signs and symptoms are frequently minor but can develop into a severe, even fatal, condition. Because of its medical complications alcohol dependence is seen frequently by physicians, occurring in 15-20% of primary care and hospitalized patients. Physicians in all areas of medicine therefore frequently encounter the problem of managing withdrawal, particularly as medical encounters such as hospital admission or pregnancy, are often a precipitating event for cessation of alcohol. In recent decades there has been extensive research on pharmacologic interventions aimed at ameliorating withdrawal. However these studies are widely dispersed in the medical literature, generally involve few subjects and are often of uncertain methodologic quality. Uncertainty continues to exist about the role of pharmacotherapy and its effectiveness in reducing the rate of major complications such as seizures or delirium. Significant variation in physician management of withdrawal has been documented, even among specialists in the field, with a wide range in choice of medication, approaches to medication delivery and method of patient monitoring. Recommendations from authoritative sources such as medical and surgical textbooks vary even more widely, with recommendations for agents which have never been tested in clinical trials or for approaches that have been shown to result in administration of unnecessary medication. Given the frequency with which this condition is encountered by physicians, the wide variety of settings in which it occurs and the variation in the way it is managed, we felt an evidence-based guideline would have widespread utility.
The purpose of this review and guideline, therefore, is to aid physicians in providing the appropriate pharmacological management of alcohol withdrawal. This guideline does not address treatment of the patient who is examined after having an alcohol withdrawal seizure or who has already developed alcohol withdrawal delirium (delirium tremens), or the optimal setting for withdrawal management (inpatient or outpatient). These are important issues and will be addressed in separate guidelines. The role of phenytoin in alcohol withdrawal is the topic of a guideline already published.
Alcohol dependence continues to be major public health problem, and among its many associated medical problems is a well characterized withdrawal syndrome. Withdrawal signs and symptoms are frequently minor but can develop into a severe, even fatal, condition. Because of its medical complications alcohol dependence is seen frequently by physicians, occurring in 15-20% of primary care and hospitalized patients. Physicians in all areas of medicine therefore frequently encounter the problem of managing withdrawal, particularly as medical encounters such as hospital admission or pregnancy, are often a precipitating event for cessation of alcohol. In recent decades there has been extensive research on pharmacologic interventions aimed at ameliorating withdrawal. However these studies are widely dispersed in the medical literature, generally involve few subjects and are often of uncertain methodologic quality.
Uncertainty continues to exist about the role of pharmacotherapy and its effectiveness in reducing the rate of major complications such as seizures or delirium. Significant variation in physician management of withdrawal has been documented, even among specialists in the field, with a wide range in choice of medication, approaches to medication delivery and method of patient monitoring. Recommendations from authoritative sources such as medical and surgical textbooks vary even more widely, with recommendations for agents which have never been tested in clinical trials or for approaches that have been shown to result in administration of unnecessary medication. Given the frequency with which this condition is encountered by physicians, the wide variety of settings in which it occurs and the variation in the way it is managed, we felt an evidence-based guideline would have widespread utility.
The purpose of this review and guideline, therefore, is to aid physicians in providing the appropriate pharmacological management of alcohol withdrawal. This guideline does not address treatment of the patient who is examined after having an alcohol withdrawal seizure or who has already developed alcohol withdrawal delirium (delirium tremens), or the optimal setting for withdrawal management (inpatient or outpatient). These are important issues and will be addressed in separate guidelines. The role of phenytoin in alcohol withdrawal is the topic of a guideline already published.
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