mechanism,signs, symptoms and treatment of alcohol and nicotine withdrawal

1. Dr IM Joubert

2. Alcohol and nicotine are widely
abused substances and are often used
together
 One study showed that 15% of
patients visiting a primary care
practice for any reason had either an
“at-risk” pattern of alcohol use or an
alcohol related health problem


4. 
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It is important to note that alcohol
contributes and leads to a wide range of
medical problems and is also a significant
contributor to trauma
Alcohol use history is important in all
patients
In trauma patients exclude head injury
before ascribing unusual behaviour to
alcohol withdrawal but conversely keep
alcohol withdrawal in mind for all patients
with an altered mental status of unknown
aetiology

5.  High
likelihood in following
patients:
◦ Alcohol-related reason for admission
◦ Regular use >80g/day in males, >60g/day
in females
◦ >30 years of alcohol use
◦ <10 days since last drink
◦ History of alcohol dependence/previous
withdrawal

6. 
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Range from mild withdrawal to severe
withdrawal and delirium tremens
Start within 6 to 24 hours of last drink,
peak over 36 – 72 hours
Subside over a few days but mood and
sleep disturbance may persist for weeks
Seizures can occur early in course –
usually of short duration and self-limiting
but may progress to status epilepticus

8. 
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History of previous severe withdrawal
Use of >150mg alcohol per day
Presence of other illness/injury
History of head injury
Use of other psychotropic drugs
Patients at risk for severe withdrawal should
be closely monitored and receive early and
aggressive treatment ideally in high care
setting

9. 
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Agitation
Restlessness
Gross tremor
Disorientation and mental confusion
Fluctuating level of consciousness
Fluid and electrolyte imbalances
Sweating and pyrexia
Visual hallucinations
Paranoia

10. Identify and treat underlying medical
conditions
 Control behaviour
 Prevent injuries
 High dose benzodiazepines (not >
100mg/hour or 250mg in 8 hours)


11. 
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Result of thiamine deficiency
Life threatening condition
◦ Global confusional state
◦ Ocular disturbances: horizontal nystagmus,
opthalmoplegia, CN VI palsy with diplopia
◦ Ataxia

Treatment:
◦ Thiamine 300mg IVI for 3-5 days, then 100-300mg
po dly

All withdrawal patients should receive
Thiamine 300mg IVI stat on presentation

12. 
Benzodiazepines
◦ Treatment of choice
◦ Reduce withdrawal severity and incidence of
seizures and delirium
◦ Good safety profile
◦ Usually long-acting but can give short-acting
in cases of liver disease
◦ Given for short period of time due to
potential for abuse
◦ Dosing: Fixed dose, loading dose followed by
fixed dose or symptom triggered therapy

13. 
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Symptom-triggered therapy requires close
monitoring, not ideal except in dedicated
detoxification centre
Fixed dose in mild withdrawal
◦
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Day
Day
Day
Day
Day
1
2
3
4
5
–
–
–
–
–
5-15mg qid
5-10mg qid
5-10mg tds
10mg bd
5mg bd

14. Loading dose therapy is indicated in
cases of a high level of dependency or
a patient at high risk for severe
withdrawal
 Loading dose of 10-20mg diazepam
every 2-4 hours until light sedation
achieved, then then 10mg 4-6hourly,
wean slowly over next 5 days


15. 
Anticonvulsants:
◦ Phenytoin has no benefit
◦ Valproate and Carbamazepine increase seizure
threshold

Thiamine:
◦ 300mg IVI stat, then 100mg dly for 7 days

Antipsychotics/sedatives:
◦ Phenothiazines/Haloperidol – decrease symptoms
but less effective than benzos – adjunct in severe
withdrawal with perceptual disturbances, can
decrease seizure threshold

16. 
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ß-blockers and clonidine – reduce
autonomic manifestations, ß-blockers may
mask symptoms of early withdrawal or
impending delirium
Symptomatic treatment
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Metoclopramide for nausea and vomiting
Buscopan for abdominal cramps
Immodium for diarrhoea
Paracetamol for headaches and muscle pain if no
liver damage

18. 
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Nicotine and other tobacco components
may interact with and affect action and
metabolism of certain medication e.g.
clozapine and olanzepine – upon cessation
of smoking patients may develop drug
side-effects - consider revising dosages
After smoking cessation caffeine is
absorbed more readily – increased caffeine
levels increase restlessness and sleep
disturbance

19. 
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Start hours after last cigarette, peak in 24 –
72 hours, decline and resolve within 2 – 4
weeks
Dysphoric or depressed mood
Insomnia
Irritability, frustration or anger
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain

20. 
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Nicotine replacement therapy
Available as patches, gum, inhalers and
lozenges, gel
Dosage depends on amount of cigarettes
smoked before stopping
Combinations may be used in patients
with high nicotine tolerance

22. 
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Schuckit MA. Alcohol and Alcoholism in Kasper BL,
Braunwald E et al (eds), Harrison’s Principles of Internal
Medicine, 16th ed, McGraw Hill, New York, 2006, p. 25622566
Burns DM. Nicotine Addiction in Kasper BL, Braunwald E et
al (eds), Harrison’s Principles of Internal Medicine, 16th ed,
McGraw Hill, New York, 2006, p. 2573-2576
Kosten TR, O’Connor PG. Management of drug and alcohol
withdrawal. N Eng J Med 2003;348(18):1786-1795
Eyer F et al. Alcohol Alcohol 2011;46(4):427-433
McKeown N. Withdrawal Syndromes. Available from URL:
http://emedicine.medscape.com/article/819502overview#showall
NorthWestern Mental Health. Alcohol and Other Drug
Withdrawal Practice Guidelines.
Australian Alcohol and Drug Abuse Management
Guidelines