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Alcohol Withdrawal (aka Delirium Tremens)

The brain will adapt to long-term, heavy alcohol use and compensate for the depressant effects of alcohol by decreasing its number of GABA receptors and increasing its number of Glutamate receptors [ref]. GABA is the major inhibitory neurotransmitter in the brain; like the breaks in a car, it serves to repress brain functions. Glutamate is the major excitatory neurotransmitter in the brain; it is like the gas pedal that stimulates many brain functions.

A combination of lowered GABA signaling and heightened Glutamate signaling means that the foot is off the breaks and pressing hard on the gas pedal, and the brain is now in a position to become over-active. The only thing preventing this is the individual's constant intake of alcohol, which serves to repress brain functions, thus creating an equilibrium. However, if the individual were to suddenly stop using alcohol, they would soon experience the effects of alcohol withdrawal as the brain is pushed into a state of hyperactivity that can be very dangerous and potentially life-threatening.

This syndrome is known as Delirium Tremens, and it can begin as soon as 6 hours after drinking cessation, but it can also appear anytime within the week following the last drink. Usually, the syndrome peaks within 24-72 hours after drinking cessation.

In the first stages of this syndrome, the individual will experience tremors, autonomic hyperactivity (sweating, fever, elevated blood pressure, rapid heart rate), anxiety, agitation, nausea, vomiting, and insomnia.

If left untreated, the next symptoms to appear are confusion and disorientation, hallucinations (mainly visual ones, but also auditory, tactile and olfactory) and delusions.

Seizures and cardiovascular collapse can then ensue, and are the most concerning symptoms.

If untreated, Delirium Tremens will result in death in over a third of all cases and is thus considered a medical emergency.

Treating alcohol withdrawal

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice.

The main treatment for alcohol withdrawal, and for preventing or treating Delirium Trements, is to use long-acting benzodiazepines [ref]. In medical settings where close observation (every 30 minutes) is possible, it is preferable to treat the alcohol withdrawal symptoms only as they appear, giving the equivalent of Diazepam 10mg for milder symptoms and 20mg for more severe symptoms, for this tends to reduce the amount and duration of medication required [ref]. However, it is also acceptable to start the individual on a fixed dose that is progressively tapered until discontinued a week after drinking cessation. The proper dose is one where the individual is not over-sedated but is also not having any of the first-stage symptoms described above, and is generally started at the equivalent of Diazepam 10-20mg every 6 hours. For individuals with liver impairment, Oxazepam or Lorazepam should be used.

Gabapentin used at doses of about 1200mg/day also seems to be effective when given for 4 days following alcohol cessation (and lowered to 800mg/day on the last day) [ref]. Other medications, such as other anticonvulsants, beta-blockers and antipsychotics may also be effective, but have less supporting evidence and no advantages over the benzodiazepines [ref, ref].

If an individual in the midst of alcohol withdrawal is unable or unwilling to seek medical treatment, then resuming alcohol use will also serve to stop the withdrawal symptoms. Obviously, this is not an ideal solution, but it is preferred to the alternative of going through withdrawal without treatment, which can be life-threatening.

 

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Long-term Heavy Use

Pregnancy & Fetal Alcohol Syndrome