Treating Alcohol Withdrawal With Benzodiazepines

Going through withdrawal is usually the hardest part of beating an alcohol addiction. This is because withdrawal symptoms can be uncomfortable, painful, and even prove fatal if not properly managed. To ensure a recovering alcoholic can go through detox with minimised withdrawal symptoms, medical professionals often prescribe a wide range of medication. A commonly used remedy that has proven to be highly effective in easing the pains of withdrawal during detox isbenzodiazepines.

Benzodiazepines (or benzos) are a class of synthetic drug. There are a wide variety of clinical drugs that fall under the category of benzodiazepines, and each is unique in its own way. Generally speaking, all benzos function by depressing the central nervous system and subsequently lead to feelings of drowsiness or sleepiness. This occurs due to the way in which benzodiazepines reduce brain activity by enhancing the effects of the neurotransmitter GABA (gamma-amino butyric acid).

When alcohol is abused, it affects the way the brain functions by changing its chemical structure. The impact on the brain tends to become more aggravated as alcohol abuse worsens. This eventually leads to a physical dependence on alcohol. If you’re an alcoholic who has developed dependence and suddenly cease abusing the substance, your brain functions will be thrown into disarray as your body struggles to function without the presence of alcohol in your system. This will lead to the manifestation of alcohol withdrawal symptoms – a condition referred to as Alcohol Withdrawal Syndrome (AWS).

Different types of benzodiazepines can be used to minimise the discomfort of AWS in a variety of ways. Some include treating the following alcohol withdrawal symptoms:

In alcohol addiction treatment facilities, your withdrawal symptoms could be treated with benzodiazepines such as diazepam (Valium), chlordiazepoxide (Librium), oxazepam, or lorazepam (Ativan).

As effective as benzodiazepines can be, using the medication can also lead to a range of side effects if not properly administered. This is why it is strongly recommended that a medically assisted alcohol detox be carried out in an inpatient addiction facility, rather than at home. One danger of using benzodiazepines incorrectly is developing an addiction to the drug itself. To avoid such an outcome or any other complications, only use the drug under the supervision and prescription of a licensed medical professional.

The type of benzodiazepine prescribed and the manner in which it is used will vary depending on a number of factors, including the setting of use, the severity of alcoholism, and the symptoms present during detox.

The most common benzodiazepines-related treatment procedure for alcohol withdrawal involves administering three days of long-acting benzodiazepines. This will be executed on a fixed schedule, and additional medication could be provided if the specialist in charge of your case deems it necessary.

What is Alcohol Withdrawal Syndrome (AWS)?

Alcohol withdrawal Syndrome (commonly abbreviated to AWS) usually occurs as a result of severe alcohol dependence. AWS can be described as a group of symptoms that alcohol-dependent people experience when they try to quit heavy alcohol abuse. The manifestation of AWS can vary from mild to severe in its intensity and the symptoms usually present themselves a few hours after your last drink. These symptoms are brought about by disturbances in various neurotransmitter circuits that are implicated in the alcohol pathway and reflect a homeostatic readjustment of your central nervous system.

If you are going through AWS, you’ll likely experience the following symptoms: restlessness, tremors, nightmares, insomnia, paroxysmal sweats, nausea, tachycardia, fever, vomiting, seizures, hallucinations, tremulousness, and increased agitation. People with especially severe AWS might experience more intense effects such as delirium tremens, a condition combining especially profound instances of the aforementioned symptoms.

Diagnosis of Alcohol Withdrawal Syndrome

In order to effectively determine if you are actually suffering from alcohol withdrawal syndrome, a medical professional will need to review your medical history, and ask about your symptoms. A physical exam might also be required.

Some of the physical symptoms the medical professional will ask about include:

This can be followed by a toxicology screen being performed to discover alcohol levels in your body.

Another approach to diagnosis is the CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol). It involves a series of questions, whose answers will be used to determine if you have AWS and to what degree. The test will measure if you have any of the following symptoms of AWS:

The questions used in performing CIWA-Ar could include:

What are Benzodiazepines?

Of all the benzodiazepines available, the two most commonly prescribed for alcohol withdrawal are chlordiazepoxide and diazepam. Chlordiazepoxide (marketed as Librium) is effective as an anticonvulsant, while diazepam (marketed as Valium) helps with preventing alcohol overdose Benzos that are short-acting (such as oxazepam and lorazepam) aren’t commonly used in the treatment of alcohol withdrawal, except in outpatient settings.

Compared with other drugs, benzodiazepines are some of the most effective and safest medications for managing both severe and less severe cases of alcohol withdrawal. However, using the drug isn’t entirely risk-free, especially considering that a recovering alcoholic can develop a benzodiazepine addiction whilst receiving it for treatment. This is why it’s best to use the drug for only short-term treatment and to taper off dosage over a period of time,when ending treatment in order to avoid any serious withdrawal symptoms.

Side Effects of Benzodiazepines

The different types of benzodiazepines each bring about different side effects, which can range from mild to very severe. A challenge lies in the fact that the side effects of most benzodiazepines are very similar to that of abusing alcohol. This can make it difficult for your caregiver to determine if it’s benzos or alcohol that is negatively impacting your body. Commonly witnessed side effects include:

Benefits of Benzodiazepines

The variety of available benzodiazepines make it possible to offer personalised and appropriate treatment that best suits the unique needs of every alcoholic. Some of the ways in which benzodiazepines are used for the benefit of recovering alcoholics include:

• Counteractingalcohol withdrawal’s most severe and dangerous symptoms, such as pain and seizures
• Making it possible for alcoholics to get past the worst of withdrawal symptoms with greater ease and get them on the path to making a full recovery faster

Another benefit of benzodiazepine use- when compared to other drugs used for treating alcohol withdrawal -is it presents fewer and less severe side effects.

The drug is widely prescribed and evidence shows that a majority of individuals who are treated with benzodiazepines do not abuse them. However, when abused or improperly administered, benzodiazepines can lead to a variety of health complications.

Benzodiazepines are most commonly abused with other benzodiazepines, alcohol, and prescription pain medications (especially opiates). Most individuals who combine benzodiazepines with alcohol do it with the aim of intensifying the effect of the drug. Because alcohol is easily procurable and legal, it is a readily available option for using in combination with benzodiazepines.

There are great risks involved with combining drugs, especially alcohol and benzodiazepines. This is why every benzodiazepine warning label cautions against such forms of substance abuse. The risk of combining alcohol and benzodiazepines for recreational use – or by accident – far outweigh the risk of abusing either substance individually.

The greatest risks involved with mixing alcohol and benzodiazepines include:

• Because alcohol and benzodiazepines are both central nervous system depressants, there is an increased risk of overdose
• Increased reduction of cognition
• Slowed or reduced physical reaction
• Increased severity of side-effects of either substance
• Increased potential for unpredictable effects
• Increased likelihood of developing an acute physical or mental complication
• Increased risk of developing a physical dependence on one or both substances
• Increased risk of your relationships, professional goals, and finances suffering a negative impact from substance abuse

Simply put, abusing one drug is bad, but polydrug abuse (combining substances) is worse and can have more devastating consequences. Most people who combine benzodiazepines and alcohol often require long-term and intensivetreatment to help them make a full recovery from substance abuse.

Goals of Detoxification

• Accomplishing a safe withdrawal from dependence and enablingyou to become alcohol-free
• To achieve a withdrawal process that protects your dignity and is humane
• To prepare you for ongoing treatment of your alcohol addiction

Setting for Detoxification

Outpatient programmes are often not recommended for the treatment of severe cases of alcohol addiction, but they can be a good choice for cases of less severe addiction that does not require constant supervision or management from the treatment team. For recovering alcoholics who can’t leave their place of work, attending an outpatient detox programme regularly is a more affordable option that can still provide adequate treatment.

Inpatient programmes on the other hand are required for individuals with more severe cases of addiction, because they provide a conducive environment that guarantees patients are less prone to suffering a relapse. Inpatient detox programmes are often more costly, as they deliver round-the-clock care and treatment to patients, including boarding and feeding. The programme will provide all round treatment that cares for both the psychological and physical aspects of your alcohol addiction.

General Principles of Supportive Care

During alcohol detoxification, it’s very important that a patient is provided all necessary comforts so that they can remain focused on making a full recovery. In an addiction treatment clinic (especially an inpatient one), you should have access to a quiet environment with low lighting and minimal stimulation.

Because dehydration is a huge danger during the detox process, your hydration should be closely monitored and cared for. The same applies to your nutrition. Intravenous access should be made available for emergency situations, such as when low on body fluids or certain nutrients. Electrolyte imbalances should be corrected and Vitamin B1 (thiamine) can be administered to prevent Wernicke’s encephalopathy (WE), a kind of damage to the central nervous system.

Adequate sedation should also be made available to keep you calm in the event of aggression or seizures, but restraints should be avoided where possible to prevent injury.

Fixed-Schedule Doses vs. Symptom-Triggered Doses of Benzodiazepine for Alcohol Withdrawal

Symptom-triggered and fixed schedule/tapering doses are different approaches to using benzodiazepine to treat alcohol withdrawal.

The Fixed Tapering Dose Regimen (FTDR)is applied by not adjustingthe benzodiazepine dose based on the severity of symptoms. It isideal for mild symptoms, as well as outpatient recovery programmes.

The Symptom Triggered Regimen (STR) alters dosage based on how much pain a patient is going through. That is, the higher degree of pain requires higher doses of benzodiazepine. The approach can be used to care for very severe or mild symptoms and is often applied only in inpatient facilities where it can be utilised under direct medical supervision.

The advantage of STR rests in the fact that it can be used to treat a patient regardless the severity of their symptoms. Because the treatment is administered via a standardised scale (which results in using less benzodiazepines for a significantly shorter duration), it will subsequently cost less.

Using Xanax to Detox From Alcohol

Xanax is the brand name of alprazolam and is a benzodiazepine used for treating anxiety. Since Xanax is available in various doses, with different degrees of potency, doctors often prescribe the drug based on the seriousness of a patient’s symptoms.

If you are going through alcohol withdrawal symptoms, Xanax can help minimise or altogether prevent the following symptoms:

Below are some things to take into consideration when using Xanax for alcohol withdrawal symptoms:

• Xanax should only be used according to prescription and under the supervision of a medical professional
• Xanax tablets are available as 0.25 or 0.5mg
• Xanax doses are typically distributed throughout the day
• Xanax has no standard dosage for alcohol withdrawal. Instead, your doctor will prescribe the drug according to the severity of your condition
• In order to avoid developing a physical dependence on Xanax, the drug shouldn’t be used for longer than needed

Using Lorazepam (Ativan) to Detox From Alcohol

Ativan is the brand name for the anti-anxiety drug lorazepam. Just like Xanax, Ativan is effective for treating alcohol withdrawal symptoms such as anxiety, convulsions, insomnia, nausea, delirious tremens, headache, tremors, restlessness, panic attacks, and high blood pressure.

Ativan should be used only under the supervision and prescription of a doctor. The drug is available in 0.5, 1, or 2mg tablets, but the first dose for alcohol withdrawal is usually 2-10 mg.Most individuals do not require the use of Ativan for alcohol withdrawal for more than a few days or a week.

What are Some Other Options for Benzodiazepine-Refractory Alcohol Withdrawal?

Asides from Librium, Xanax, Ativan, Oxazepam and Klonopin, there are other forms of medication available that are capable of delivering effective results for treating alcohol withdrawal. Examples include anticonvulsant drugs, adrenergic medications, barbiturates, and baclofen.

Anticonvulsant Drugs

Adrenergic Medications

Adrenergic medicines, which include antagonists like propranolol and centrally acting alpha-2 agonists like clonidine, can influence the operation of adrenergic receptors in the brain to improve the symptoms of AWS. This is accomplished by minimising increased blood pressure and pulse.

There is no proof that adrenergic medications treat or prevent delirium or seizures. The medication can be useful for outpatient treatment, especially in scenarios where a patient is likely to abuse benzodiazepines or if AWS symptoms are less severe in an inpatient setting.

Barbiturates

Barbiturates like phenobarbitone operate through GABA pathways. These type of drugs can ease withdrawal symptoms and are cross tolerance to alcohol. However, controlled studies have failed to deliver sufficient data to prove that barbiturates can preventdelirium tremens or seizures. Also, because barbiturates possess a narrow, therapeutic index (due to how a slight error in dosage can bring about a toxic effect instead of a therapeutic one), they are not commonly used in practice.

Baclofen

Baclofen is a GABA-B pathway agonist. A clinical case where five patients were treated with a single 10mg dose of baclofen indicated that the patients experienced significant relief from their severe withdrawal symptoms. Prior cases had shown that baclofen was capable of minimising the cravings of patients suffering from alcohol dependence. When properly administered, Baclofen can be just as effective as diazepam in treating uncomplicated AWS.

Newer Drugs

Many newly tried drugs for alcohol withdrawal are still being used to complement benzodiazepines in treatment. For example, ketamine (an N-methyl-d-aspartate antagonist also commonly available recreationally) makes it possible to reduce the dose of benzodiazepines and can itself be used in low doses. The drug for now seems promising, but there is still a shortage of data concerning its entire effectiveness.

Levetiracetam is a new drug that has been put through trials, but with unsatisfactory results. The medication was unable to significantly reduce the need of benzodiazepine in treating patients with AWS. On the other hand, sodium salt of γ-hydroxybutyric acid and sodium oxybate are proving effective in the treatment of alcohol withdrawal syndrome.

Dexmedetomidine is approved in the UK for treating AWS in emergency situations. The drug operates by influencing the noradrenergic system and can reduce the need for benzodiazepines.

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