Clinical assessment and pharmacotherapy of the alcohol withdrawal syndrome

All patients in alcohol withdrawal should have a full assessment for detecting medical complications. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) scale permits a quantitative assessment for following the clinical course and therapeutic response in patients in withdrawal. Most patients with mild withdrawal symptoms do not require hospitalization and respond to non-pharmacologic supportive care. Early initiation of treatment with supportive nursing care and, if necessary, benzodiazepines usually will prevent progression to serious withdrawal reactions and provide the patient with sufficient symptomatic relief. Pharmacotherapy can be considerably simplified by using the loading dose technique, i.e., giving diazepam every 1-2 hr initially until the patient shows signs of clinical improvement and/or mild sedation. If long half-life drugs (e.g., diazepam) are used, further therapy is rarely needed and complications are prevented. Short-acting benzodiazepines can also be given in a similar fashion in the milder clinical syndrome. Phenytoin should only be given to patients with a preexisting seizure disorder. Phenothiazines, barbiturates, paraldehyde, and antihistamines have no role in the treatment of withdrawal because of their toxicity or lack of efficacy. Haloperidol is effective in the control of hallucinations in patients also treated with a benzodiazepine. The treatment of alcoholic intoxication and withdrawal is only the first step toward full rehabilitation.