Pearls of Wisdom: Managing Alcohol Withdrawal
A 46-year-old alcoholic male comes to your office stating his intention to quit drinking. He typically drinks 12-16 glasses of whisky per day and had his last drink about an hour prior to his visit this morning.
This scenario has played out several times over the last 3 years. Due to his uninsured status and hefty hospital bills from the last detoxification admission, he is unwilling to go to the hospital again. He intends to “tough it out on his own.”
Unfortunately, he has previously had some problems with drug diversion and has been known to sell benzodiazepines when prescribed for him.
Are there any alternatives that might help smooth the process?
A. Venlafaxine 75 mg bid x 30 days
B. Baclofen 10 mg q8h x 30 days
C. Cetirizine 10 mg q12h x 30 days
D. Methyl-alcohol inhaler titrated over 14 days
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.
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Answer: Baclofen 10 mg q8h x 30 days
When managing alcohol withdrawal in the outpatient setting, it is important to remember that the goals of successful withdrawal are relief of symptoms, prevention of seizures, and enhancement of smooth transition from excessive drinking to abstinence.
Managing Alcohol Withdrawal in an Outpatient Setting1
Animal studies provide some support for the potential of baclofen as an alcohol withdrawal tool. In this research, alcohol-habituated rates voluntarily decrease alcohol consumption, appear to have less craving and intake during a cessation program, and have suppressed withdrawal symptoms when physically dependent.
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In the pilot trial, 5 alcohol-dependent patients (average number of drinks = 16-35 per day for 3-9 years) were enrolled with the understanding that they would administer baclofen 10 q8h around the clock for 30 days. To ensure compliance, subjects had to present with a teammate who would agree to ensure that the medication was appropriately administered.
Alcohol Withdrawal with Baclofen1
The first baclofen dose was administered in the clinic. At baseline, the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWAAS) was performed. (Note: A score of 20 or greater is considered severe.) Monitoring at the clinic was performed every hour for 4-8 hours, and then if the patient was stable, he/she was sent home, with a request to record CIWAAS scores every 7 days to follow and return in 30 days.
According to the authors, “a single administration of 10 mg baclofen…resulted in rapid disappearance of alcohol withdrawal symptoms in all patients. Throughout the 30 day follow-up, all patients were asymptomatic and abstained from alcohol.”
Let’s look at a few of the patients individually:
At baseline, his CIWAAS score was 34. He had paroxysmal sweats, tremor, anxiety, agitation, tactile disturbances, and headache. His pulse was 108 beats per minute, and blood pressure was 185/90 mm Hg.
Thirty minutes after the first dose, symptoms had improved. By 1 hour, all symptoms were gone (CIWAAS score = 0), pulse was 85 beats per minute, and blood pressure was measured at 150/70 mm Hg. Subsequently, he was sent home. Follow-up for the next 30 days indicated maintenance of no withdrawal symptoms for 30 days.
His immediate pre-treatment CIWAAS score was 23. He reported nausea, paroxysmal sweats, vomiting, tremor, anxiety, agitation, tactile disturbances, and visual disturbances. His pulse was 95 beats per minute and blood pressure was 140/90 mm Hg.
At 1 hour, his CIWAAS score was minimally reduced to 21 (from 23). At 2 hours, his score had dropped to 8, pulse was 80 beats per minute and blood pressure was 130/70 mm Hg. At 3 hours, his CIWAAS score was 0 and he was sent home. Subsequent follow-up indicated a CIWAAS score of 0 at each measurement point for 30 days.
In follow-up of this trial a 100-participant trial was also performed but doesn’t give the hour-by-hour patient-by-patient content.
What’s the “Take Home”?
Especially in a patient in whom we consider the risk of drug diversion to be substantial, and one who refuses hospitalization for alcohol withdrawal, baclofen is a reasonable choice. To mimic the structure of the trial, it is probably wise to include a partner in the treatment process to make sure the patient maintains regular baclofen administration.
1. Addolorato G, Caputo F, Capristo E, et al. Rapid suppression of alcohol withdrawal syndrome by baclofen. Am J Med. 2002;112(2):226-229.