Management of Alcoholism

Alcohol dependence is a major problem in UK.
Pharmacological therapy can help patients to abstain from alcohol and also reduce cravings.

Patients can belong to two broad groups

1. Patient wishing to abstain
2. Patient presents in acute alcohol withdrawal:
   • Detoxification may need to occur as an inpatient depending on severity of symptoms
   • If disorientation, agitation or seizures occur then refer for inpatient detoxification
   • However, the majority can be managed in the community and it is worth contacting the local community mental health team as they may have a setup for alcohol dependent patients.¹

Patients should ideally be nursed in quiet surroundings.

Benzodiazepines

Long acting forms are used to reduce tremor and agitation e.g. diazepam or chlordiazepoxide. Some hospitals have alcohol withdrawal assessment charts to determine how much to give e.g. clinical institute withdrawal assessment for alcohol scale.^1,2Short acting benzodiazepines are used for seizures e.g. lorazepam intravenously.
Be careful of possible dependence to benzodiazepines - advise short courses at lowest necessary dose.

Vitamin B complex

This is given as IV Pabrinex™ to inpatients for a couple of days and then patients are given oral thiamine and multivitamins.²
Intravenous therapy with vitamin B complex is the treatment of Wernicke-Korsakoff syndrome.

Beta blockers

These can be used to reduce autonomic hyperactivity but are rarely used in practice as the long-acting benzodiazepines are usually sufficient.

Disulfiram (Antabuse)

• Irreversibly and specifically blocks aldehyde dehydrogenase - a crucial enzyme involved in the metabolism of alcohol.
• This leads to a build up of acetaldehyde which results in an unpleasant reaction, thereby the patient will be unkeen to take alcohol.
• The unpleasant reaction includes: flushing, headaches, palpitations, nausea, vomiting.
• However, if a high dose of alcohol is taken then there is a risk of arrhythmias, MI, respiratory depression and hypotension and collapse - making its use less attractive.
• Thus its use should be restricted in patients who are well motivated and can be supervised e.g. colleague or partner.
• Patients also need to be aware of taking substances that inadvertently contain alcohol e.g. mouthwash.
• Furthermore, there is no clear evidence that disulfiram actually increases abstinence or relapse rates.^3,4,4,5
• Hepatotoxicity is a rare but fatal side-effect. Advise check LFTs at two weeks and then at three and six months.

Calcium acetyl-homotaurinate: (Acamprosate)

• Blocks GABA and reduces NMDA receptor glutamate related excitation
• Possible neuroprotective role in detoxification
• Does not interact with alcohol and reduces cravings
• Usually given post detoxification to maintain stabilisation³

Naltrexone

• See opioid dependence record.
• Alcohol causes pleasure by release of endogenous opioids.
• Naltrexone is a competitive antagonist of the opioid receptor which prevents the endogenous opioid from binding to the receptor therefore, reduction in the pleasurable effects from alcohol.
• Associated with lowers relapse rate, drinking days and length of abstinence.^4,5
• Therefore, patients are less likely to take large quantities in one go - thus used in binge drinkers.

The length of time spent in treatment of alcohol dependence appears not to be important when comparing brief or extended treatment conditions.⁶

Other more novel agents

• These agents are not currently licensed for use in alcohol dependence
• Include SSRIs such as fluoxetine and anticonvulsants (topiramate)

Psychosocial interventions

• All medications should be used in conjunction with psychological interventions.⁷
• This includes counselling, cognitive based therapy and self-help groups e.g. alcoholics anonymous.
• Social support is also important.⁸

• Early referral of patients with liver, cardiac or neurological dysfunction.
• Treatment and prevention of malnourished states.
• Treatment of depression which may co-exist.