Preparing for alcohol withdrawal

Chronic alcoholism in developed countries represents a major public health issue due to its medical (gastroenterological, cardiac, neurological, traumatic, etc.), social (social-professional disintegration, delinquency and crime, institutionalization, etc.), and financial consequences. Therefore, it is of significant importance. Unfortunately, it is still often poorly detected, and patients frequently receive medical care only at advanced stages.

Performing alcohol withdrawal under medical supervision in a chronic alcoholic is never an emergency in itself and is not comparable to the management of withdrawal done without medical supervision, which can lead to complications. It is therefore necessary to prepare in advance and consider possible hospitalization if necessary.

Detecting Alcoholism - "Problematic Consumption"

Alcohol consumption is common in our countries, and there is no clear medical criterion defining alcoholism, apart from the general definition of "dependence." Consumption and its impacts are often underestimated by the patients themselves, their relatives, or their doctors. As a result, many patients receive appropriate care only after medical or social complications occur, sometimes severe, and significant dependence has set in. Ideally, the issue should be raised with the patient as soon as "warning factors" appear.

However, there is a relative consensus on the signs that should suggest "problematic" alcohol consumption:

• Risk Factors:
  • Family history of alcoholism.
  • Precarious environment, social-family isolation, inactivity, poverty.
  • Social-professional stress, over-investment in work.
  • Other dependencies and psychiatric disorders.

• Warning Signs:
  • Daily alcohol consumption or very heavy, regular, occasional drinking.
  • Lack of control over consumption, describing consumption as a "need," intrusive thoughts about drinking.
  • Association of "well-being" with alcohol consumption.
  • Describing "discomfort" in the absence of drinking the day before, occurrence of "blackouts" after drinking.
  • Comments from third parties regarding the consumption.
  • Concerns or requests for help from relatives or the patient.
• Biological abnormalities compatible with chronic alcoholism without other explanations: macrocytic anemia, elevated GGT, chronic liver cytolysis, etc.
• Medical complications. They can be "discreet and non-specific" (gastroesophageal reflux, weight gain or loss, sleep disorders, etc.) or indicative of already advanced stages (withdrawal symptoms, organ failure, digestive hemorrhages, cognitive decline, etc.). In all cases, they require management.
• Social complications. Systematically consider this in cases of family, professional, or social problems.

Preparing for Withdrawal

In the case of problematic consumption, talk with the patient and assess their motivation.

If the patient is not motivated for withdrawal or is in denial:

• If the request for help came from relatives: support them, advise discussing calmly with the patient while sober, possibly in the presence of a doctor, recommend setting clear boundaries and warning of potential consequences if they are not upheld, guide them towards support groups for relatives.
• In all cases: support the patient, explain potential consequences without judgment, guide them towards support structures depending on the situation and the patient’s openness (psychiatrist-psychologist, "Alcoholics Anonymous," social services).
• If the patient seems "ambivalent," work with them on a "positive/negative" assessment on psychosocial, biological, clinical, and self-esteem aspects.
• Propose vitamin B1-B6 supplementation as long as consumption persists.
  • Ideally: Befact (contains vitamin B1 and B6) 1 tablet/day for 3 months/year and Benerva (contains vitamin B1) or equivalent 1 tablet/day the other months (vitamin B6 can have neurotoxic side effects if taken in excessive amounts).
• Regularly re-evaluate consumption and motivation over time.

If the patient is motivated for withdrawal:

• The same measures as in the "non-motivated" case.
• Ideally, act in consultation with a psychiatrist.
• Set objectives with the patient: reduction in consumption or abstinence? Favor choosing abstinence with a short period of gradual reduction to minimize the risk of withdrawal syndrome. Whatever the choice, develop an action and follow-up plan.
• Build or strengthen psychosocial support.
• Pre-withdrawal treatment for 2 weeks:
  • Befact Forte 2 tablets/day.
  • Gradual reduction of the consumed quantities.
  • Acamprosate (Campral) 3 x 2 tablets/day (no demonstrated effect on withdrawal success but effective in maintaining abstinence in the medium term).
  • Avoid, if possible, benzodiazepines, neuroleptics, and antidepressants.

The Withdrawal Process

• Continue Befact Forte and Campral.
• Introduce benzodiazepines (e.g., 40 to 120 mg/day of diazepam [Valium] in 4 to 6 doses for 5 days, to be adjusted, with a maximum of 60 mg/day on an outpatient basis, then reduce by 10 mg every 2 days).
• Prefer trazodone 50 to 200 mg in the evening in case of insomnia-anxiety. Other medications may be considered on psychiatric advice.
• Close monitoring, with particular vigilance during the first 24 hours.
• Consider hospitalization in case of clinical warning signs, patient desire, or social isolation. Never as an emergency but planned, always in consultation with a psychiatrist.
• Post-Withdrawal Maintenance and Follow-up:
  • Maintain Campral or disulfiram (Antabuse), potentially a post-cure center, regular follow-up with cognitive-behavioral therapy, and psychosocial rehabilitation. Provide social support if needed.

Bibliography

EMC, Traité de médecine AKOS, Elsevier, 2018

Hoffman, Management of moderate and severe alcohol withdrawal syndromes, Uptodate, 2022

Holt SR, Ambulatory management of alcohol withdrawal, Uptodate, 2022

Pace C, Alcohol withdrawal: Epidemiology, clinical manifestations, course, assessment, and diagnosis, Uptodate, 2022