Alcohol Detoxification
- Most alcohol-dependent individuals can be detoxified in a modified medical setting, provided assessment is comprehensive, medical backup is available, and staff know when to obtain a medical consultation. As Gerstein and Harwood (1990) wrote:Detoxification episodes are often hospital based and may begin with emergency treatment of an overdose. Much drug detoxification (an estimated 100,000 admissions annually) is now taking place in hospital beds. It is doubtful whether hospitalization (especially beyond a day or two) is necessary in most cases, except for the special problems of addicted neonates, severe sedative-hypnotic dependence, or concurrent medical or severe psychiatric problems. For clients with a documented history of complications or flight from detoxification, residential detoxification may be indicated. Detoxification may . . . be undertaken successfully in most cases on a nonhospital residential, partial day care, or ambulatory basis.
Patients who score higher than 20 on the Clinical Institute Withdrawal Assessment (CIWA-Ar) instrument should be admitted to a hospital. (A detailed description of the CIWA-Ar follows.)
Most patients can be detoxified from alcohol in 3 to 5 days. Providers should consider the withdrawal time frame in terms of when the patient will need the most support; for alcoholics, this occurs the second day after the last ingestion. Other factors that influence the length of the detoxification period include the severity of the dependency and the patients overall health status. Patients who are medically debilitated should detoxify more slowly.
Assessing Alcohol Withdrawal Symptoms
The signs and symptoms of acute alcohol abstinence syndrome generally begin 6 to 24 hours after the patient takes his or her last drink. The acute phase of alcohol abstinence syndrome may begin when the patient still has significant blood alcohol concentrations. Signs and symptoms may include
Restlessness, irritability, anxiety, agitation
Anorexia, nausea, vomiting
Tremor, elevated heart rate, increased blood pressure
Insomnia, intense dreaming, nightmares
Impaired concentration, memory, and judgment
Increased sensitivity to sounds, alteration in tactile sensations
Delirium (disorientation to time, place, situation)
Hallucinations (auditory, visual, or tactile)
Delusions (usually paranoid)
Grand mal seizures
Elevated temperature.
Symptoms do not always progress from mild to severe in a predictable fashion. In some patients, a grand mal seizure may be the first manifestation of acute alcohol abstinence syndrome.
Although many programs devise their own methods of monitoring patients withdrawal signs and symptoms, there is considerable advantage to using a widely accepted validated instrument. The CIWA-Ar is commonly used in clinical and research settings for initial assessment and ongoing monitoring of alcohol withdrawal symptoms. It takes 2 to 5 minutes to administer, helps make the decision to hospitalize the patient or to treat him or her as an outpatient, and is useful for monitoring and managing the patient during withdrawal (Fuller and Gordis, 1994). It measures the severity of alcohol withdrawal by rating 10 signs and symptoms: nausea; tremor; autonomic hyperactivity; anxiety; agitation; tactile, visual, and auditory disturbances; headache; and disorientation. The maximum score is 67 (Saitz et al., 1994). The CIWA-Ar is not copyrighted, and the version in Exhibit 3-1 (Sullivan et al., 1989) may be used freely.
Table
Exhibit 3-1 Addiction Research Foundation Clinical Institute for Withdrawal Assessment Alcohol (CIWA-Ar).
The CIWA-Ar should be repeated at regular intervals (initially every 1 or 2 hours) to monitor patients progress (Sullivan et al., 1989).Increasing scores on the CIWA-Ar signify the need for additional medication or a higher level of treatment; decreasing scores suggest therapeutic response to medication or treatment milieu. Patients scoring less than 10 on the CIWA-Ar do not usually need additional medication for withdrawal (Saitz et al, 1994.; Sullivan et al., 1989).