Addiction Medicine: Closing the Gap between Science and Practice

threatening.* 43 These withdrawal symptoms can
be more severe in persons who have undergone
prior multiple episodes of alcohol withdrawal, a
process known as the kindling effect.† 44

Benzodiazepines, which have calming, sedating
effects, have been shown to prevent the onset of
certain alcohol withdrawal symptoms and
acutely relieve such symptoms including
alcohol-induced seizures and DTs.^45 A large
review study found that whereas
benzodiazepines are more effective than
placebos at treating seizures in patients going
through alcohol withdrawal, there is no evidence
that they are more effective than other
medications used to treat alcohol withdrawal
syndrome or that particular benzodiazepines are
more effective than others.^46 Benzodiazepines
commonly used to treat the anxiety and agitation
symptoms associated with alcohol withdrawal
include diazepam,‡ 47 chlordiazepoxide,^48
lorazepam and oxazepam.^49

Because the combined effects of
benzodiazepines and alcohol can be life
threatening or even fatal,^50 patients must be
advised not to drink while on benzodiazepine
medications. This is particularly important since
benzodiazepines commonly are prescribed for
alcohol withdrawal on an outpatient basis where
patients’ drinking may not be monitored
adequately.^51 Another cautionary note is that
benzodiazepines have addictive potential in their
own right; therefore, their use must be
monitored carefully.^52

Carbamazepine, an anti-seizure medication, may
be an effective alternative to benzodiazepine
medications for treating alcohol withdrawal.^53
Carbamazepine also may be effective at

• Although DTs occur only in about five percent of

patients undergoing detoxification, mortality from
DTs historically has been as high as 18.5 percent.
Swift detection and proper treatment can lower this to
about five percent.
† Kindling is the increase in neuronal responses

produced by repeated stimulation. Kindling leads to
a worsening of withdrawal symptoms with each
attempt at alcohol detoxification.
‡ Diazepam also may relieve muscle spasms and

seizures associated with alcohol withdrawal.

addressing alcohol cravings.^54 The medication’s

ability to treat seizures, the minimal potential for

misuse, the significant potential to treat mood

disorder and the lack of sedating effects are

some of its advantages.^55

Opioid Detoxification. For patients with

addiction involving illicit or prescription

opioids, including heroin, hydrocodone or

oxycodone, withdrawal symptoms are not life

threatening, but they can be extremely

uncomfortable^56 and must be managed

effectively to prevent relapse.^57 Opioid

withdrawal symptoms can include abdominal

pain, muscle aches, agitation, diarrhea, dilated

pupils, insomnia, nausea, runny nose, sweating

and vomiting.^58 Withdrawal symptoms

generally last from seven days to several

weeks.^59 Because medical complications can

develop, patients must undergo regular

monitoring including physical examinations, a

complete review of the functioning of the body’s

organs and psychological status and, when

necessary, laboratory evaluations.^60

The goal of medical detoxification is a safe,

comfortable and complete withdrawal from

opioids. Abrupt discontinuation of opioids,

especially for a patient who has developed

physical dependence on the drug, typically is not

recommended; instead, in the case of such

dependence involving prescription opioids, the

patient is tapered or weaned off the opioid

medication.§ 61 However, for addiction

involving illicit opioids, it is not legal to

prescribe a tapering dose of the illicit drug so

another method must be used.

An alternative to tapering is management of

withdrawal symptoms using non-opioid

medications--such as clonidine^62 --to decrease the

agitation and discomfort associated with opioid

withdrawal, or other medications that can relieve

the symptoms of acute withdrawal such as

nonsteroidal anti-inflammatory drugs (NSAIDs)

to treat muscle pain, antiemetics for nausea and

non-addicting sleeping medications such as

§ The use of a tapering dose calculator can help in

this process and can be accessed online at:

http://www.agencymeddirectors.wa.gov/guidelines.asp