The major issues related to alcohol withdrawal, both acute and post-acute, involve the neurotransmitters GABA, glutamate, norepinephrine, and to a lesser degree dopamine and serotonin. Most alcohol withdrawal medications work either directly or indirectly on these neurotransmitter pathways, some more selectively than others.
The issues that arise in acute and post-acute alcohol withdrawal are discrete problems that require specific medications to treat each set of symptoms in turn. Additionally, there are quite a few alcohol detox medications that are used in special circumstances, such as refractory withdrawal and refractory delirium tremens. Refractory simply means that it is not responding to normal treatment methods. These medications are not used regularly, as refractory issues are by definition uncommon, but are considered first-line treatment for refractory complications.
Without withdrawal medications, the risk of serious health complications during detox increases substantially.
The acute phase of withdrawal is extremely dangerous because of the risk of seizure, heart problems, delirium, and death. Thankfully, there are a number of detox medications that effectively treat these issues, and provide a safe withdrawal experience when coupled with appropriate medical oversight.
The use of benzodiazepines for alcohol withdrawal is one of the most effective treatments to minimize the risks and discomfort. Since they work in a similar way to alcohol, these medications can make someone much more comfortable, while still allowing withdrawal to complete. That being said, using them still comes with a certain degree of risk. Some of the benzos most commonly used to treat alcohol withdrawal include:
The previous front-line treatment for withdrawal was the barbiturate class of medication. While these medications were effective, they posed very serious risks as well. They operate in a similar way to benzos but lead to greater central nervous system depression such as lowered breathing and heart rate. Additionally, barbiturate toxicity is extremely dangerous and there is currently no antidote for a barbiturate overdose.
While barbiturates are like blunt instruments that operate in a crude manner, using benzodiazepines for alcohol withdrawal has been proven to be much more precise and targeted. Since they work more subtly, there is much less unintentional CNS depression produced by benzos and there is more variety in strength and duration. Depending on the exact benzo used, the elimination rate can be between 2-100+ hours, leading to greater treatment customization. Finally, in the event of a benzo overdose, there are antidotes available to reverse the effects such as flumazenil. That being said, it is very dangerous to use a benzo antagonist during alcohol withdrawal, as it greatly increases the likelihood of a seizure occurring.
Benzodiazepine metabolism occurs primarily in the liver. While benzos themselves are unlikely to cause liver injury, their metabolism may be altered or slowed in patients with reduced liver function, leading to slower clearance and elimination. This has the result of producing stronger sedation at lower doses since the medications stay in the body longer. Using long-acting benzos can lead to unintentional overdose or dangerous levels of sedation. In patients with reduced liver function, such as cirrhosis or elderly patients, shorter-acting benzos such as lorazepam are preferred since they have a much lower risk of dangerous side effects.
While benzodiazepines are the first choice, there is a variety of other medications that may also be effective. Some of the other most commonly used alcohol withdrawal medications include:
The post-acute phase of alcohol withdrawal presents its own challenges, mainly in the realm of mental symptoms such as depression, cravings, and anxiety. Luckily, there are a variety of medications that are commonly used to treat these symptoms as well. The most widely used include:
Due to the large numbers of people seeking treatment for alcohol use disorder, there are several promising alcohol withdrawal medications that are currently being investigated for use in the United States and Europe. Since these medications are under development, these results are inconclusive at the present, and any attempt to try these treatments should be done only under the supervision of a doctor.
These medications are some of the most well-known, but there are many other options available. In addition to medications, therapeutic techniques and dietary supplements have been found helpful and effective for the treatment of alcohol withdrawal. Finding a professional alcohol detox center will give someone access to trained medical professionals who can help them discover the available medications and treatments which will be the most effective and applicable to them.
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