Trends in the management of alcohol withdrawal syndrome

Approach and Management of Alcohol Withdrawal Syndrome in Operative Head and Neck Cancer Patients

Postoperative head and neck cancer patients are at increased risk for alcohol withdrawal syndrome. Literature has shown that in this patient population, alcohol withdrawal is associated with an increase in postoperative medical and surgical complications, length of hospitalization, and hospital-related costs. Harm reduction and addiction medicine philosophies can reduce morbidity and mortality, but have not been fully validated in perioperative surgical management for head and neck cancer. This commentary synthesizes key principles of addiction medicine and current strategies that Otolaryngology-Head and Neck Surgery surgeons can consider in their perioperative assessment and management of alcohol withdrawal syndrome in their patients.

Diazepam in the Treatment of Moderate to Severe Alcohol Withdrawal

Benzodiazepines ameliorate or prevent the symptoms and complications of moderate to severe alcohol withdrawal, which can include autonomic hyperactivity, agitation, combativeness, hallucinations, seizures, delirium, and death. The benzodiazepines most commonly used for this purpose are lorazepam, chlordiazepoxide, oxazepam, and diazepam. It is widely asserted that no member of this group is superior to the others for treatment of alcohol withdrawal. However, of these, diazepam has the shortest time to peak effect, which facilitates both rapid control of symptoms and accurate titration to avoid over-sedation. Furthermore, diazepam and its active metabolite, desmethyldiazepam, have the longest elimination half-lives, so their levels decrease in a gradual, self-tapering manner, resulting in a smoother withdrawal, i.e., a lower incidence and severity of both breakthrough symptoms and rebound phenomena, including a possibly decreased seizure risk. Importantly, the fear of increased risk of over-sedation with diazepam compared with other benzodiazepines is based on a misunderstanding of its pharmacokinetics and is unfounded. Similarly, the notion that diazepam should be avoided in patients with liver disease and elderly patients to avoid prolonged over-sedation is based on no more than conjecture. In fact, there is clinical evidence that diazepam is safe for the treatment of alcohol withdrawal in these patients when administered using a simple symptom-based approach. There is one instance in which diazepam should not be used: when intramuscular administration is the only option, the lipophilicity of diazepam can result in slow absorption-either lorazepam or, when rapid control of symptoms is required, midazolam should be used. The comparative pharmacokinetics of the benzodiazepines used in the treatment of alcohol withdrawal together with a comprehensive review of the literature on their use strongly suggest that diazepam should be the preferred benzodiazepine for the treatment of patients experiencing moderate to severe alcohol withdrawal under most circumstances.

Anticonvulsants for alcohol withdrawal

BACKGROUND

Alcohol abuse and dependence represents a most serious health problem worldwide with major social, interpersonal and legal interpolations. Besides benzodiazepines, anticonvulsants are often used for the treatment of alcohol withdrawal symptoms. Anticonvulsants drugs are indicated for the treatment of alcohol withdrawal syndrome, alone or in combination with benzodiazepine treatments. In spite of the wide use, the exact role of the anticonvulsants for the treatment of alcohol withdrawal has not yet bee adequately assessed.

OBJECTIVES

To evaluate the effectiveness and safety of anticonvulsants in the treatment of alcohol withdrawal.

SEARCH STRATEGY

We searched Cochrane Drugs and Alcohol Group' Register of Trials (December 2009), PubMed, EMBASE, CINAHL (1966 to December 2009), EconLIT (1969 to December 2009). Parallel searches on web sites of health technology assessment and related agencies, and their databases.

SELECTION CRITERIA

Randomized controlled trials (RCTs) examining the effectiveness, safety and overall risk-benefit of anticonvulsants in comparison with a placebo or other pharmacological treatment. All patients were included regardless of age, gender, nationality, and outpatient or inpatient therapy.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and extracted data from studies.

MAIN RESULTS

Fifty-six studies, with a total of 4076 participants, met the inclusion criteria. Comparing anticonvulsants with placebo, no statistically significant differences for the six outcomes considered.Comparing anticonvulsant versus other drug, 19 outcomes considered, results favour anticonvulsants only in the comparison carbamazepine versus benzodiazepine (oxazepam and lorazepam) for alcohol withdrawal symptoms (CIWA-Ar score): 3 studies, 262 participants, MD -1.04 (-1.89 to -0.20), none of the other comparisons reached statistical significance.Comparing different anticonvulsants no statistically significant differences in the two outcomes considered.Comparing anticonvulsants plus other drugs versus other drugs (3 outcomes considered), results from one study, 72 participants, favour paraldehyde plus chloral hydrate versus chlordiazepoxide, for the severe-life threatening side effects, RR 0.12 (0.03 to 0.44).

AUTHORS' CONCLUSIONS

Results of this review do not provide sufficient evidence in favour of anticonvulsants for the treatment of AWS. There are some suggestions that carbamazepine may actually be more effective in treating some aspects of alcohol withdrawal when compared to benzodiazepines, the current first-line regimen for alcohol withdrawal syndrome. Anticonvulsants seem to have limited side effects, although adverse effects are not rigorously reported in the analysed trials.

Alcohol-induced tolerance and physical dependence in mice with ethanol insensitive alpha1 GABA A receptors

BACKGROUND

Although many people consume alcohol (ethanol), it remains unknown why some become addicted. Elucidating the molecular mechanisms of tolerance and physical dependence (withdrawal) may provide insight into alcohol addiction. While the exact molecular mechanisms of ethanol action are unclear, gamma-aminobutyric acid type A receptors (GABA(A)-Rs) have been extensively implicated in ethanol action. The alpha1 GABA(A)-R subunit is associated with tolerance and physical dependence, but its exact role remains unknown. In this report, we tested the hypothesis that alpha1-GABA(A)-Rs mediate in part these effects of ethanol.

METHODS

Ethanol-induced behavioral responses related to tolerance and physical dependence were investigated in knockin (KI) mice that have ethanol-insensitive alpha1 GABA(A)-Rs and wildtype (WT) controls. Acute functional tolerance (AFT) was assessed using the stationary dowel and loss of righting reflex (LORR) assays. Chronic tolerance was assessed on the LORR, fixed speed rotarod, hypothermia, and radiant tail-flick assays following 10 consecutive days of ethanol exposure. Withdrawal-related hyperexcitability was assessed by handling-induced convulsions following 3 cycles of ethanol vapor exposure/withdrawal. Immunoblots were used to assess alpha1 protein levels.

RESULTS

Compared with controls, KI mice displayed decreased AFT and chronic tolerance to ethanol-induced motor ataxia, and also displayed heightened ethanol-withdrawal hyperexcitability. No differences between WT and KI mice were seen in other ethanol-induced behavioral measures. Following chronic exposure to ethanol, control mice displayed reductions in alpha1 protein levels, but KIs did not.

CONCLUSIONS

We conclude that alpha1-GABA(A)-Rs play a role in tolerance to ethanol-induced motor ataxia and withdrawal-related hyperexcitability. However, other aspects of behavioral tolerance and physical dependence do not rely on alpha1-containing GABA(A)-Rs.

Symptom-driven lorazepam protocol for treatment of severe alcohol withdrawal delirium in the intensive care unit

STUDY OBJECTIVE

To compare outcomes of treating alcohol withdrawal delirium (AWD) with a symptom-driven benzodiazepine protocol versus nonprotocol benzodiazepine infusions in the intensive care unit (ICU).

DESIGN

Retrospective observational study of a quality improvement project.

SETTING

Medical intensive care unit at a Veterans Affairs medical center.

PATIENTS

Thirty-six patients who had 40 ICU admissions for AWD between January 1, 1994, and May 31, 2003. Sixteen episodes (15 patients [historical controls]) occurred before implementation of the symptom-driven protocol in 1998, and 24 episodes (21 patients) occurred after implementation.

MEASUREMENTS AND MAIN RESULTS

Outcomes evaluated were time to reach symptom control, total dose of benzodiazepine, amount of time receiving continuous benzodiazepine infusion, length of ICU and hospital stay, polypharmacy (use of multiple benzodiazepines), and complications of treatment. The historical control group was treated according to physician preference, which consisted of continuous-infusion midazolam without a protocol. The symptom-driven protocol used lorazepam administered initially as intermittent intravenous doses, progressing to a continuous intravenous infusion according to a locally developed symptom scale. The mean +/- SD values for the outcomes in the historical control group versus the protocol group were as follows: time to control symptoms 19.4 +/- 9.7 versus 7.7 +/- 4.9 hours (p=0.002), cumulative benzodiazepine dose in lorazepam equivalents 1677 +/- 937 versus 1044 +/- 534 mg (p=0.014), time receiving benzodiazepine continuous infusion 122.1 +/- 64.4 versus 52.0 +/- 35.1 hours (p=0.001), length of stay in the ICU 7.7 +/- 6.3 versus 5.6 +/- 1.7 days (p=0.21), and length of hospital stay 15.3 +/- 8.9 versus 11.2 +/- 3.4 days (p=0.43).

CONCLUSIONS

Use of a symptom-driven protocol was associated with significantly decreased time to symptom control, amount of sedative required, and time spent receiving benzodiazepine infusion compared with historical controls. The use of the protocol is effective but requires close monitoring to ensure protocol compliance and to avoid potential propylene glycol toxicity.

Alcohol and adult neurogenesis: Roles in neurodegeneration and recovery in chronic alcoholism

The concept of "structural plasticity" has emerged as a potential mechanism in neurodegenerative and psychiatric diseases such as drug abuse, depression, and dementia. Chronic alcoholism is a progressive neurodegenerative disease while the person continues to abuse alcohol, though clinical and imaging studies show that some recovery may occur with abstinence. The neural plasticity observed in chronic alcoholism coupled with conflicting reports on alcohol-induced hippocampal neuropathology make this disease ripe for reconsideration in terms of the phenomenon of adult neurogenesis. This review describes opposing neurogenic processes that occur with alcohol intoxication and abstinence following alcohol dependence and how these opposing events relate to neurodegeneration and recovery from chronic alcoholism.

Anticonvulsants for alcohol withdrawal

BACKGROUND

Alcohol withdrawal syndrome is a cluster of symptoms that occurs in alcohol-dependent people after cessation or reduction in alcohol use. This systematic review focuses on the evidence of anticonvulsants' use in the treatment of alcohol withdrawal symptoms.

OBJECTIVES

To evaluate the effectiveness and safety of anticonvulsants in the treatment of alcohol withdrawal.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004); MEDLINE (1966 to October 2004); EMBASE (1988 to October 2004) and EU-PSI PSI-Tri database with no language and publication restrictions and references of articles.

SELECTION CRITERIA

All randomized controlled trials examining the effectiveness, safety and overall risk-benefit of an anticonvulsant in comparison with a placebo or other pharmacological treatment or another anticonvulsant were considered.

DATA COLLECTION AND ANALYSIS

The authors independently assessed trial quality extracted data.

MAIN RESULTS

Forty-eight studies, involving 3610 people were included. Despite the considerable number of randomized controlled trials, there was a variety of outcomes and of different rating scales that led to a limited quantitative synthesis of data. For the anticonvulsant versus placebo comparison, therapeutic success tended to be more common among the anticonvulsant-treated patients (relative risk (RR) 1.32; 95% confidence interval (CI) 0.92 to 1.91), and anticonvulsant tended to show a protective benefit against seizures (RR 0.57; 95% CI 0.27 to 1.19), but no effect reached formal statistical significance. For the anticonvulsant versus other drug comparison, CIWA-Ar score showed non-significant differences for the anticonvulsants compared to the other drugs at the end of treatment (weighted mean difference (WMD) -0.73; 95% CI -1.76 to 0.31). For the subgroup analysis of carbamazepine versus benzodiazepine, a statistically significant protective effect was found for the anticonvulsant (WMD -1.04; 95% CI -1.89 to -0.20), p = 0.02), but this was based on only 260 randomized participants. There was a non-significant decreased incidence of seizures (RR 0.50; 95% CI 0.18 to 1.34) favouring the patients that were treated with anticonvulsants than other drugs, and side-effects tended to be less common in the anticonvulsant-group (RR 0.56; 95% CI 0.31 to 1.02).

AUTHORS' CONCLUSIONS

It is not possible to draw definite conclusions about the effectiveness and safety of anticonvulsants in alcohol withdrawal, because of the heterogeneity of the trials both in interventions and the assessment of outcomes. The extremely small mortality rate in all these studies is reassuring, but data on other safety outcomes are sparse and fragmented.

Alcohol Withdrawal Prophylaxis in Patients Undergoing Surgical Treatment of Head and Neck Squamous Cell Carcinoma

OBJECTIVES

Alcohol abuse is common in patients with squamous cell cancer of the head and neck. Postoperative alcohol withdrawal is associated with increased morbidity and prolonged hospitalization and is commonly treated with benzodiazepines. We reviewed our experience with benzodiazepine prophylaxis in high-risk patients undergoing surgical treatment of head and neck cancer. We sought to determine whether benzodiazepine prophylaxis was successful in preventing complications from alcohol withdrawal.

STUDY DESIGN

Nonrandomized, retrospective patient analysis.

METHODS

The medical records of all patients diagnosed with squamous cell carcinoma of the head and neck from 1999 to 2004 were retrospectively reviewed. Patients who underwent surgical resection and who were considered high risk for postoperative alcohol withdrawal received benzodiazepine prophylaxis following an established institutional protocol and comprised the study group.

RESULTS

Of 96 patients who met study criteria, 13 (13.5%) patients developed alcohol withdrawal symptoms, and 9 (9.4%) patients developed delirium tremens. Patients who manifested alcohol withdrawal remained in the hospital an average of 10.8 days longer (19.0 vs. 8.2) and had an overall complication rate of 50% (11 of 22) versus a 17.6% (13 of 74) complication rate in patients that did not develop withdrawal (P < .05).

CONCLUSIONS

Alcohol withdrawal is associated with a significantly greater incidence of postoperative complications and duration of hospitalization. Benzodiazepine prophylaxis does not prevent postoperative alcohol withdrawal symptoms in all patients at risk. Alternate methods of prophylaxis should be explored.

Alcohol and cancer: a review for psycho-oncologists

Researchers have documented a link between alcohol consumption and the development of certain types of cancers. In addition, the prevalence of alcoholism and comorbid psychiatric disorders has been well-documented both the general population and medical settings. The role of the psycho-oncologist in the assessment and management of alcoholism and comorbid psychiatric disorders is crucial to improving both treatment adherence and the quality of life of the patient. This paper will provide psycho-oncologists with a review of: (1) the relationship of alcoholism to cancer; (2) psychiatric comorbidity frequently encountered in alcoholics, as a key to assessment and management; and (3) the goals and strategies of management of alcoholic cancer patient.