Alcohol detoxification

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Table from the 2010 DrugScience study ranking various drugs (legal and illegal) based on statements by drug-harm experts. This study rated alcohol the most harmful drug overall, and the only drug more harmful to others than to the users themselves. HarmCausedByDrugsTable.svg
Table from the 2010 DrugScience study ranking various drugs (legal and illegal) based on statements by drug-harm experts. This study rated alcohol the most harmful drug overall, and the only drug more harmful to others than to the users themselves.

Alcohol detoxification (also known as detox) is the abrupt cessation of alcohol intake in individuals that have alcohol use disorder. This process is often coupled with substitution of drugs that have effects similar to the effects of alcohol in order to lessen the symptoms of alcohol withdrawal. When withdrawal does occur, it results in symptoms of varying severity.

Contents

As such, the term "detoxification" may be somewhat of a misnomer since the process need not refer exclusively to the removal of toxic substances from the body. Detoxification may or may not be indicated depending upon an individual's age, medical status, and history of alcohol intake. For example, a young man who binge drinks and seeks treatment one week after his last use of alcohol may not require detoxification before beginning treatment for alcohol use disorder.

Some addiction medicine practitioners use the term "withdrawal management" instead of "detoxification". [2] [3]

Withdrawal symptoms

The symptoms of alcohol withdrawal can range from mild to severe depending on the level of alcohol dependence a person has experienced. Symptoms can be behavioural (anxiety, agitation, irritability), neurological (tremor, hallucinations, increased risk of seizures), and physical (changes in heart rate, body temperature, blood pressure, nausea). Symptoms typically occur between 6 and 24 hours since cessation of drinking. In severe cases delirium tremens may occur, which is a medical emergency and could result in death. [4]

Management

Benzodiazepines are the most common family of drugs used for alcohol detoxification, [5] followed by barbiturates. [6]

Benzodiazepines

Benzodiazepines such as chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan) or oxazepam (Serax) are the most commonly used drugs used to reduce alcohol withdrawal symptoms. There are several treatment patterns in which it is used:[ medical citation needed ]

  1. The first option takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half-hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3 to 10 days.
  2. Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon.
  3. A third option is to defer treatment until symptoms occur. This method should not be used in patients with prior, alcohol-related seizures. This has been effective in randomized controlled trials. [7] [8] A non-randomized, before and after, observational study found that symptom-triggered therapy was advantageous. [9]

Dosing of the benzodiazepines can be guided by the CIWA scale. [10] The scale is available online. [11]

Regarding the choice of benzodiazepine:

Nitrous oxide

Nitrous oxide has been shown to be an effective and safe treatment for alcohol withdrawal. [13] Over 20,000 cases of the alcoholic withdrawal state have been successfully treated with psychotropic analgesic nitrous oxide (PAN) in South Africa and Finland. In 1992 it was officially approved for the treatment of addictive withdrawal states by the medical authorities in South Africa. Consequently, patients receiving it can claim a refund from their medical insurance. The gas therapy reduces the use of highly addictive sedative medications (like benzodiazepines and barbiturates) by over 90%. The technique thus reduces the danger of secondary addiction to benzodiazepines, which can be a real problem amongst alcoholics who have been treated with these agents. [14]

Other

Benzodiazepines remain first-line therapy for alcohol-withdrawal syndrome (AWS). Several non-benzodiazepine options may be used as adjuncts or, in selected cases, alternatives, but none replace benzodiazepines for preventing seizures or delirium unless otherwise specified. [15] [16]

Adjuncts for autonomic hyperactivity (α2-agonists and β-blockers)

Alpha-2 adrenergic agonists (e.g., clonidine; in intensive-care settings, dexmedetomidine) and β-blockers (e.g., atenolol, metoprolol) can be used as adjuncts to control tachycardia and hypertension when these persist despite adequate benzodiazepines. [15] They should not be used as monotherapy for AWS and do not prevent withdrawal-related seizures or delirium. Contemporary reviews similarly describe dexmedetomidine only as an adjunct in severe or benzodiazepine-resistant cases. [17]

Anticonvulsants (carbamazepine, gabapentin, valproate)

Non-benzodiazepine anticonvulsants have a limited but useful role. Carbamazepine or gabapentin may be used for mild–moderate AWS (including ambulatory care) or as adjuncts when benzodiazepines are contraindicated or insufficient; they can also serve as a bridge into longer-term AUD treatment in some patients. A Cochrane review found no clear overall advantage of anticonvulsants over benzodiazepines, though carbamazepine may improve some symptom scores; overall data quality is mixed and further trials are needed. [18] Valproate should not be used as monotherapy for AWS and is generally avoided in pregnancy and significant liver disease. [15] [16]

Phenobarbital

In monitored settings and when used by clinicians experienced with its dosing, phenobarbital can be an alternative to benzodiazepines (including monotherapy in selected settings) or an adjunct for severe/complicated or benzodiazepine-resistant withdrawal. Recent reviews support its usefulness within protocolized care, while emphasizing the need for close monitoring given its narrow therapeutic window. [19]

GHB sold in Italy for therapeutic use Alcover 17,5 - Gamma-Hydroxybutyric acid.JPG
GHB sold in Italy for therapeutic use

Sodium oxybate (gamma-hydroxybutyric acid)

Sodium oxybate is approved in Italy and Austria for managing AWS and for relapse prevention in alcohol dependence. Randomized and observational studies suggest efficacy for AWS and maintenance of abstinence; however, concerns about misuse/abuse potential and regulatory variability limit its use outside specialized programs. [20] [21] In 2025, the European Medicines Agency began a safety and efficacy review of sodium-oxybate–containing products used for alcohol dependence, reflecting ongoing benefit–risk assessment. [22]

See also

References

  1. ↑ Nutt DJ, King LA, Phillips LD (November 2010). "Drug harms in the UK: a multicriteria decision analysis". Lancet. 376 (9752): 1558–1565. CiteSeerX   10.1.1.690.1283 . doi:10.1016/S0140-6736(10)61462-6. PMID   21036393. S2CID   5667719.
  2. ↑ "Adult Substance Use Withdrawal Management Services | Texas Health and Human Services".
  3. ↑ "The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management" (PDF). asam.org. 23 January 2020. Retrieved 17 July 2023.
  4. ↑ Bayard, Max (2004). "Alcohol Withdrawal Syndrome". American Family Physician. 69 (6): 1443–50. PMID   15053409.
  5. ↑ Mayo-Smith MF (1997). "Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal". JAMA. 278 (2): 144–51. doi:10.1001/jama.278.2.144. PMID   9214531. Full text at OVID
  6. ↑ Mohamed, Rashidi (2018). "Novel pharmacotherapeutic approaches in treatment of alcohol addiction". Current Drug Targets. 19 (12): 1378–4501. doi:10.2174/1389450119666180523092534. PMID   29788886. S2CID   46899136.
  7. ↑ Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR (1994). "Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial". JAMA. 272 (7): 519–23. doi:10.1001/jama.272.7.519. PMID   8046805.
  8. ↑ Daeppen JB, Gache P, Landry U, et al. (2002). "Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial". Arch. Intern. Med. 162 (10): 1117–21. doi:10.1001/archinte.162.10.1117. PMID   12020181.
  9. ↑ Jaeger TM, Lohr RH, Pankratz VS (2001). "Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients". Mayo Clin. Proc. 76 (7): 695–701. doi:10.4065/76.7.695. PMID   11444401.
  10. ↑ Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM (1989). "Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar)". British Journal of Addiction. 84 (11): 1353–7. CiteSeerX   10.1.1.489.341 . doi:10.1111/j.1360-0443.1989.tb00737.x. PMID   2597811.
  11. ↑ Holbrook AM, Crowther R, Lotter A, Cheng C, King D (1999). "Diagnosis and management of acute alcohol withdrawal". Canadian Medical Association Journal. 160 (5): 675–80. PMC   1230114 . PMID   10102003. (see appendix 2)
  12. ↑ Duncan Raistrick; Nick Heather & Christine Godfrey (November 2006). "Review of the Effectiveness of Treatment for Alcohol Problems" (PDF). National Treatment Agency for Substance Misuse, London. Archived from the original (PDF) on 2011-12-03. Retrieved 2011-11-29.
  13. ↑ Gillman M.A, Lichtigfeld, F.J. 2004 Enlarged double-blind randomised trial of benzodiazepines against psychotropic analgesic nitrous oxide for alcohol withdrawal, Addictive Behaviors, Volume 29, Issue 6, Pages 1183–1187
  14. ↑ "South African Brain Institute (SABRI) - profile". S A B R I.
  15. 1 2 3 "The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management". Journal of Addiction Medicine. 14 (3S Suppl 1): 1–72. 2020. doi:10.1097/ADM.0000000000000668. PMID   32511109.
  16. 1 2 Tiglao, Samuel M.; Meisenheimer, Erica S.; Oh, Robert C. (September 2021). "Alcohol Withdrawal Syndrome: Outpatient Management". American Family Physician. 104 (3): 253–262.
  17. ↑ Gottlieb, Michael (2024). "Managing Alcohol Withdrawal Syndrome". Annals of Emergency Medicine. 84 (1): 12–28. doi:10.1016/j.annemergmed.2024.05.003. PMID   38530674.
  18. ↑ Minozzi, S.; Amato, L.; Vecchi, S.; Davoli, M. (2022-04-01). "Anticonvulsants for alcohol withdrawal syndrome". Cochrane Database of Systematic Reviews (4): CD005064. doi:10.1002/14651858.CD005064.pub5 (inactive 30 August 2025).{{cite journal}}: CS1 maint: DOI inactive as of August 2025 (link)
  19. ↑ Umar, Zaryab; Haseeb Ul Rasool, Muhammad; Muhammad, Shoaib; Yousaf, Sara; Nassar, Mahmoud; Ilyas, Usman; Hosna, Asma U.; Parikh, Avish; Bhangal, Rubal; Ahmed, Nazaakat; Ariyaratnam, Jonathan; Trandafirescu, Theo (2023). "Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis". Cureus. 15 (1): e33695. doi: 10.7759/cureus.33695 . ISSN   2168-8184. PMC   9922035 . PMID   36788902.
  20. ↑ Nimmerrichter, A. A. (2002). "Double-Blind Controlled Trial of γ-Hydroxybutyrate in Alcohol Withdrawal". Alcohol and Alcoholism. 37 (1): 67–73. doi:10.1093/alcalc/37.1.67.
  21. ↑ "Alcover – Assessment Report (Article 29(4) referral)" (PDF). European Medicines Agency. 2017-10-12. Retrieved 2025-08-21.
  22. ↑ "EU reviews risk of abuse in some treatments for alcohol dependency". Reuters. 2025-06-23. Retrieved 2025-08-29.
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