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What is detoxification, and how do I know whether I need it?

The concept of detoxification or "detox" has multiple iterations. In this day and age of concern regarding a variety of potential toxins that we routinely ingest either wittingly or unwittingly, "detoxification centers" now exist as a cottage industry that often combines laxatives and purgatives. This treatment is not what is meant by alcohol detox. Alcohol detox requires medical management if the person is at risk for serious medical problems during the detoxification phase. Medical management includes monitoring signs and symptoms of alcohol withdrawal and the administration of medication to reduce or eliminate those signs and symptoms should they become too severe. The most serious medical problems include seizures and alcohol withdrawal delirium or DTs (see Questions 62 and 63 for a fuller explanation of DTs and alcohol withdrawal seizures). Seizures occur in less than 5% of individuals and DTs in about 5%. The good news is that most individuals with alcoholism do not require medication for their withdrawal symptoms. In fact, only about 8% of patients require it. That is not to say that one will not suffer from some kind of withdrawal symptoms. The bad news is that if DTs are not treated, the mortality rate is 15%.

Withdrawal symptoms from regular heavy alcohol use occur around 8 hours after the last drink. These symptoms include tachycardia or rapid heart rate, tremor, nausea, and insomnia. Over the next couple of days, anxiety, agitation, sensitivity to light and sound, sweating, headache, and high blood pressure will develop in conjunction with the other symptoms. Between days 2 and 4, symptoms may continue to get worse, including high blood pressure, a rapid pulse and fever, disorientation, hallucinations, and delusions. These last cognitive symptoms define the DTs. Seizures may occur anywhere from days 2 to 6.

There are specific risk factors that increase the probability that one may have serious withdrawal symptoms requiring detox medications. Risk factors that are associated with the development of seizures or DTs include the following: If you had either a previous history of DTs or seizures from any cause, this increases your risk. The higher the amount of daily alcohol use the greater your risk. The older you are the greater your risk. Being male increases your risk. Elevated liver enzymes associated with hepatitis increase your risk. Other medical problems such as pancreatitis, other gastrointestinal problems, and pulmonary or cardiovascular problems increase your risk.

What medications are used for detoxification?

Alcohol Withdrawal Syndrome

As discussed above, detox is medically necessary because of the possibility of developing alcohol withdrawal syndrome (discussed in greater detail in Question 61). The symptoms can be lessened or even prevented with appropriate medication, or the symptoms may progress (though not always) to the point where one suffers from DTs or has a withdrawal seizure. A rating scale known as the CIWA-A (Clinical Institute Withdrawal Assessment for Alcohol) is used to assess the symptoms and their severity in order to guide treatment (see Table 13). Treatment generally lasts approximately 5 days, although more complicated and severe symptoms may warrant more prolonged treatment.

Table 13 Clinical Institute Withdrawal Assessment Tool

Addiction Research Foundation Clinical Institute Withdrawal Assessment-Alcohol (CIWA-Ar)

This scale is not copyrighted and may be used freely.

Patient: Date: /_____/_____/_____ Time: _____ : ________________

(24 hour clock, midnight = 00:00)

NAUSEA AND VOMITING - Ask "Do you feel sick to your

TACTILE DISTURBANCES — Ask "Have you any itching, pins and

stomach? Have you vomited?"

needles sensations, any burning, any numbness, or do you feel bugs

Observation.

crawling on or under your skin?"

0 no nausea and no vomiting

Observation.

1 mild nausea with no vomiting

0 none

2

1 mild itching, pins and needles, burning or numbness

3

2 mild itching, pins and needles, burning or numbness

4 intermittent nausea with dry heaves

3 moderate itching, pins and needles, burning or numbness

5

4 moderately severe hallucinations

6

5 severe hallucinations

7 constant nausea, frequent dry heaves, and vomiting

6 extremely severe hallucinations

7 continuous hallucinations

TREMOR — Arms extended and fingers spread apart.

AUDITORY DISTURBANCES — Ask "Are you more aware of sounds

Observation.

around you? Are they harsh? Do they frighten you? Are you hearing

0 no tremor

anything that is disturbing to you? Are you hearing things you know are

1 not visible, but can be felt fingertip to fingertip

not there?"

2

Observation.

3

0 not present

4 moderate, with patient's arms extended

1 very mild harshness or ability to frighten

5

2 mild harshness or ability to frighten

6

3 moderate harshness or ability to frighten

7 severe, even with arms not extended

4 moderately severe hallucinations

5 severe hallucinations

6 extremely severe hallucinations

7 continuous hallucinations

PAROXYSMAL SWEATS - Observation.

visual DISTURBANCES - Ask "Does the light appear to be too

0 no sweat visible

bright? Is its color different? Does it hurt your eyes? Are you seeing

1 barely perceptible sweating, palms moist

anything that is disturbing to you? Are you seeing things you know are

2

not there?"

3

Observation.

4 beads of sweat obvious on forehead

0 not present

5

1 very mild sensitivity

6

2 mild sensitivity

7 drenching sweats

3 moderate sensitivity

4 moderately severe hallucinations

5 severe hallucinations

6 extremely severe hallucinations

7 continuous hallucinations

ANXIETY — Ask "Do you feel nervous?"

HEADACHE, FULLNESS IN HEAD - Ask "Does your head feel

Observation.

different? Does it feel like there is a band around your head?"

0 no anxiety, at ease

Do not rate for dizziness or lightheadedness. Otherwise, rate severity.

1 mildly anxious

0 not present

2

1 very mild

3

2 mild

4 moderately anxious, or guarded, so anxiety is inferred

3 moderate

5

4 moderately severe

6

7 equivalent to acute panic states as seen in severe

5 severe

delirium or acute schizophrenic reactions.

6 very severe

7 extremely severe

AGITATION — Observation.

ORIENTATION AND CLOUDING OF SENSORIUM - Ask "What day is

0 normal activity

this? Where are you? Who am I?"

1 somewhat more than normal activity

0 oriented and can do serial additions

2

1 cannot do serial additions or is uncertain about date

3

2 disoriented for date by no more than 2 calendar days

4 moderately fidgety and restless

3 disoriented for date by more than 2 calendar days

5

6

7 paces back and forth during most of the interview, or constantly thrashes about

4 disoriented for place and/or person

Total CIWA-A Score

The medication most commonly used to treat alcohol withdrawal is lorazépam (Ativan), although chlordiazepoxide (Librium) was historically used routinely.

Both of these medications are benzodiazepines, a class known as antianxiety medications. They act on the GABA receptor, modifying it to be more sensitive to the effects of GABA, the brain's major inhibitory neurotransmitter (discussed in greater detail in Question 6). This is identical to what alcohol does to the GABA receptor. Previously, alcohol itself was used to detox patients, but the development of benzodiazepines has led to safer management with greater control over dosing than alcohol allowed. Three differences distinguish benzodiazepines from one another.

 
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