Alcohol Detox

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Alcohol Detox

Alcohol is a widely used substance that a large proportion of people throughout the UK regularly consume to gain positive benefits including a feeling of relaxation, improved social communication and a positive mood.

Drinking alcohol in low to moderate amounts is not seen as leading to harmful consequences, although the 14 unit per week level set as the benchmark for moderate alcohol intake is probably not recognised by the majority of people throughout the UK and if it is it is probably ignored to a large degree as people continue to consume alcohol in large amounts year upon year. (10,11)

Health Consequences of Heavy Alcohol Use

Unfortunately, many people are unable to limit their alcohol intake to a low or moderate level. Figures in recent years report that each year approximately 280,000 people are admitted to hospital with an alcohol-related problem.

Medical statisticians that analyse UK health data propose that alcohol leads to the development of several serious health conditions including several cancers, heart and liver disease and serious harm from hazardous accidents, risk of violence and self-harm.

The high levels of alcohol abuse throughout the UK cause a massive drain on NHS services throughout the country and this is seen no clearer than in the cultural practice referred to as binge drinking, where the danger is potentially sudden and life-threatening. (1a)

Alcohol Use Disorder (AUD)

Overall, there are 11 criteria used by medical professionals to help them diagnose a patient with alcohol use disorder (alcohol addiction).

Two of the most important criteria in determining whether a heavy drinker should be diagnosed with an AUD are, firstly, have they developed an increased tolerance to alcohol, and secondly do they experience withdrawal symptoms when they stop drinking alcohol for 1-2 days?

If tolerance and withdrawal are present, then it is likely the patient can be classed as having a physical dependence on alcohol. (1)

Detox Treatment Addresses Patients’ Physical (alcohol) Dependence

Alcohol detox treatment helps people eradicate their physical alcohol dependence and eliminate the poisonous chemical presence of alcohol in their bloodstream.

There are several stages to developing alcohol dependence:

1. Neuroadaptation

Alcohol is a psychoactive substance, which means it contains chemicals that can alter our internal brain biology and influence the way we think, feel and behave.

Because alcohol is a psychoactive substance the central nervous system and the body will try to process it as efficiently as possible so that the body is not so negatively affected by it in the future.

The more often a person drinks alcohol the more their body makes chemical and biological adjustments (adaptations) to help them function effectively each day so that the effect that alcohol has on them is minimised. (8,13)

2. Tolerance

Because the body becomes very efficient at processing alcohol regular drinkers will come to realise that over time they will need to consume more alcohol to feel its effects (i.e. getting drunk) compared with before. A person who has reached this stage can be said to have increased their tolerance to alcohol.

3. Withdrawal

If having built up a tolerance to alcohol, a moderate or heavy drinker stops drinking alcohol for 1-2 days (or even as little as 6 hours in severe cases) they may find that they will experience unpleasant withdrawal symptoms, often referred to as alcohol withdrawal syndrome.

The presence of withdrawal symptoms after a short period of abstinence (deliberate or accidental) confirms that the person is alcohol dependent and in need of detox treatment. (8,13)

Alcohol Withdrawal Syndrome

Alcohol is a very difficult substance to abstain from when you have become physically dependent on it, as a central characteristic of alcohol dependence is the presence of withdrawal symptoms when alcohol consumption is ceased.

Ironically the quickest way to eradicate these symptoms is to drink alcohol, which will only strengthen the drinker’s dependence.

The main withdrawal symptoms people will experience when they stop alcohol after heavy and prolonged use are;

• Autonomic hyperactivity is represented by increased sweating and a heart rate higher than 100 beats per minute.
• An increased likelihood of hand tremors.
• Insomnia/sleep disturbance.
• Nausea, vomiting and upset stomach.
• Headaches.
• Experiencing episodic visual, tactile, or auditory hallucinations.
• Psychomotor agitation.
• Anxiety and Hypertension.
• Brain seizures. (1)

Alcohol Detox – Timeline of Withdrawal Symptoms

Below, we outline the typical alcohol withdrawal timeline:

1. Between 6 and 12 hours after the last alcoholic intake

During this time window, minor withdrawal symptoms start to appear such as headaches, nausea, anxiety, insomnia, stomach upsets and hypertension.

2. Between 12 and 24 hours after the last alcohol intake

Existing symptoms increase in intensity with patients becoming more uncomfortable, it is also likely that patients may begin to experience hallucinations which can be auditory, visual or tactile in nature.

Patients experiencing tactile hallucinations will feel like something is crawling on their skin.

3. Between 24 and 48 hours after the last alcohol intake

During this time period, patients are at risk of developing withdrawal-related seizures which can be life-threatening.

4. Between 2 and 3 days after the last alcohol intake

After the 48-hour mark, prolonged heavy drinkers are vulnerable to developing alcohol withdrawal delirium (otherwise known as delirium tremens) which is evident in their confused and disorientated state, their hallucinations may become more pronounced, particularly visual hallucinations.

This will be accompanied by agitation and heavy sweating. (8,9,12)

Severe Alcohol Withdrawal – Delirium Tremens

A small percentage of patients diagnosed with alcohol use disorder will have severe alcohol withdrawal when they stop drinking alcohol for 1-2 days. This can result in them being at risk of developing life-threatening conditions such as delirium tremens.

Delirium tremens, also known as late-stage withdrawal usually occurs on the third day after alcohol was last consumed and is a very serious and dangerous condition if not treated quickly as it is classed as a medical emergency and should result in an immediate hospital visit. (15)

The two main criteria associated with the condition are a state of mental confusion (delirium) reflected in a deterioration in consciousness and aspects of their cognition. For example, patients may not be aware of who they are and they will not talk coherently.

Also, they will need to exhibit the main physical symptoms associated with alcohol withdrawal. (8,12)

Other symptoms of DT include:

• Agitation.
• Appear frightened/terrified.
• Perceptual disturbances (hallucinations).
• Severe tremors.
• They appear delusional.
• Fast heart rate (Tachycardia).
• Hypertension.

Heavy drinkers who experience the symptoms of alcohol withdrawal syndrome need to book into rehab treatment very quickly to deal with their condition before it becomes much worse and places their life in danger.

The Main Aims of Detox Treatment

The main aims of alcohol detox as set down by the American Society of Addiction Medicine (ASAM) is to:

• Ensure the patient withdrawals from their alcohol safely and eliminate their alcohol dependence.
• To ensure the patient is treated respectfully and not subject to distress, or humiliation whilst undergoing treatment and any discomfort they may experience is minimised.
• To prepare the client to engage with ongoing assistance and care for their alcohol dependence. (7)

Where Does Alcohol Detox Take Place?

As withdrawing from alcohol can be a very precarious activity, it is preferable that clients are monitored regularly during the time they are receiving detox treatment in case there are unforeseen complications with their treatment.

Most clients who attend residential rehab stay at a treatment centre for 4-6 weeks to help overcome their addiction.

Usually, the treatment team initially focus on organising detox treatment so that the client is stabilised before they start their programme of psychosocial therapies.

Alcohol Detox Procedures

There are several protocols that medical staff can use to help clients withdraw from alcohol, these include:

1. Fixed tapering dose regime (FTDR)

This approach is predominantly used for treating mild alcohol withdrawal and involves providing patients with a fixed dose of a benzodiazepine throughout the duration of their detox programme to treat the uncomfortable withdrawal symptoms they are experiencing. (2,14)

This detox approach is more suitable for patients on outpatient programmes as they will tend to have mild alcohol withdrawal symptoms.

2. Loading dose regime (LDR)

The loading dose regime prescribes patients with longer-acting benzodiazepines that are slowly absorbed into the body over 3-4 days. This approach is very effective for protecting patients from seizures and is used only in residential detox programmes.

This is because it is imperative to monitor patients consistently to check they come to no harm, particularly those who have moderate to severe alcohol withdrawal syndrome.

3. Symptom-triggered regime (STR)

This method is commonly used in residential centres and involves medical staff obtaining feedback from the patient on the intensity of their withdrawal symptoms.

Patients are then given an appropriate dose to satisfy the intensity of their symptoms. It is important that the dose given is the minimum amount to satisfy withdrawal only so it must be measured carefully and accurately.

The regime deemed suitable for each patient will depend on the personal situation of each patient and the severity of their alcohol use and the medical staff will have the health and safety of the patient utmost in their minds when making the decision. (2,14)

4. Symptom-triggered regime utilises the CIWA tool

To help the treatment team understand the severity of a patient’s withdrawal symptoms they utilise the Clinical Institute Withdrawal Assessment (CIWA) Scale, which is a 10-item clinical tool and ask patients to report how uncomfortable their withdrawal symptoms are every 4-5 hours. (2,14)

The CIWA or the updated CIWA-AR version focuses on several specific symptoms that are consistently associated with alcohol withdrawal.

Clients under the care of rehab medical staff are asked to rate each symptom on a scale of 0-7 depending on how severe the symptom is for them at the time of asking (with 0 being not at all severe and 7 being extremely severe).

The main symptoms of interest are:

• Agitation or irritation
• Anxiety levels
• Auditory disturbances
• Clouding of the sensorium, which relates to brain and sensory functioning
• Prevalence of headaches
• Nausea
• The intensity of sweating
• Tactile disturbances
• Hand tremors
• If there are any visual disturbances present.

If after completing the clinical assessment a patient returns a score of 8-10 they will be assessed as suffering from mild withdrawal, a score of 10-15 would indicate the patient is experiencing moderate withdrawal.

A score of over 15 would indicate severe withdrawal which means the patient may be vulnerable to being diagnosed with delirium tremens. (14)

Alcohol Detox Treatment FAQs

Below, we provide answers to common questions about the alcohol detox treatment process:

1. Is there medication used for alcohol detox?

Medication from the benzodiazepine drug class is used to help relieve the withdrawal symptoms associated with alcohol withdrawal.

2. Why are benzodiazepines used for alcohol rehab?

Benzodiazepine drugs are able to settle down GABA neurotransmitters, and they are also slow-acting drugs so they only need to be taken once every 24 hours to alleviate unpleasant symptoms.

Benzodiazepines are able to satisfy withdrawal symptoms as they are central nervous system depressants just like alcohol, but they are safe to use in a controlled setting.

Taking benzodiazepines as part of a detox programme does not lead to physical dependence nor increased tolerance as they are only used for a short time frame (1-2 weeks) and the dose measure used is only the necessary amount required to keep withdrawal symptoms at bay

It usually takes one month to develop a dependence on benzodiazepines and detox treatment only lasts half that time.

The benzodiazepine drugs usually prescribed include:

• Diazepam (Valium) and Chlordiazepoxide (Librium) are slow-acting substitute drugs that can replicate the effect of alcohol but do not lead to any dependence, they also drastically reduce the risk for patients experiencing seizures.
• Lorazepam is also an option, however, this benzodiazepine drug is faster acting than diazepam and chlordiazepoxide but it is only preferable to use when treating patients with significant liver and lung disease as Lorazepam is not processed in the liver. (14)

3. Why are benzodiazepines so effective in treating alcohol dependence?

An abundance of research over the years has established that benzodiazepines are the preferred substitute drug of choice used by medical practitioners carrying out detox treatment.

Benzodiazepine-based substitute drugs have very similar effects to alcohol as they are also central nervous system depressants so will act on GABA neurotransmitters to prevent seizures, they also have the following characteristics that make them ideal for treating alcohol withdrawal:

• Rapid onset – Benzodiazepines start to work quickly when taken.
• Long duration of action – They can be absorbed slowly into the body and central nervous system meaning withdrawal symptoms are kept at bay for longer which means patients will experience fewer cravings. This will help to slowly reduce their levels of alcohol dependence and the dose size of benzodiazepine can be gradually reduced over 7-10 days.
• A wide margin of safety – The time that the benzodiazepines are taken does not a pose threat to the patient. Even though benzodiazepines are highly addictive drugs it usually takes one month to develop a dependence on them. Alcohol detox lasts no more than 2 weeks so detox patients are comfortably outside of the vulnerable time period for drug dependence. Therefore, benzodiazepines have very limited abuse potential. (2,14)
• Not necessarily metabolised in the liver – There are some benzodiazepines that can be taken that are not processed in the liver which can be beneficial for some patients with poor liver functioning due to heavy alcohol use.
• Eliminates key withdrawal symptoms – Benzodiazepines are very effective at treating extreme agitation which is a common alcohol withdrawal symptom. Benzodiazepines contain chemicals that can prevent seizures as they can affect GABA neurotransmitters and calm the body down. They are also able to treat the symptoms of the life-threatening condition delirium tremens. (2,8,14)

4. How long does detox treatment take?

The detox treatment element of a patient’s alcohol rehab will typically last between 7-10 days for the majority of patients.

There will be some patients however that may face several complications during their detox treatment which can vary between patients and depends on several factors, such as:

• The severity of their dependence (how long have they been drinking heavily and how much do they tend to drink).
• If they are a dual-diagnosis patient.
• If they are addicted to other substances as well as alcohol.
• Underlying health (especially liver).
• Age.
• Sex.

5. What happens after alcohol detox treatment has finished?

Detox is not a cure for alcohol use disorder, it is only one component of a treatment plan. There is therefore a great deal of work still left for the client to do once the detox phase of the treatment has been completed.

Detox treatment may successfully address a person’s physical dependence on alcohol but they are still psychologically dependent on alcohol and will be unable to resist strong urges and cravings to drink alcohol again unless they engage in several weeks of psychological treatments.

Rehab centres have developed an effective programme of psychological therapies to help clients come to terms with the strong emotions they may feel after going through traumatic events and difficult life experiences.

These treatments tend to include group therapy sessions, attending AA meetings and several one-to-one therapies depending on the recommendations made by senior rehab practitioners after they conducted an assessment of the patient. (13)

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References

(1) Black, D., Grant, J. (2013) DSM5 Guidebook: The Essential Companion to Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition. APP. London.

(1a) Digital NHS (2022) Statistics on Alcohol. available@ Statistics on Alcohol, England 2021

(2) Ewin- NHS (2022) Alcohol withdrawal assessment scoring guidelines available@ Alcohol Withdrawal Assessment Scoring Guidelines (CIWA – Ar) (ewin.nhs.uk)

(3) Ghodse, H. (2002) Drugs and Addictive Behaviour: A guide to treatment Cambridge University Press.

(4) Herie, M. & Skinner, W. (2014) The Fundamentals of Addiction: A Practical Guide for Counsellors. CAMH. Canada.

(5) Kahan, M. (2014) Physical Effects of Alcohol and Other Drugs. In Herie, M. & Skinner, W. (ed) Fundamentals of Addiction: A Practical Guide for Counsellors. CAMH. Canada

(6) Mack, A.H., Harrington, A.L. & Frances, R.J. (2010) Clinical Manual for Treatment of Alcoholism and Addictions. APP. London.

(7) Mee-Lee, D. (2013) The ASAM Criteria: Treatment Criteria for Addictive, Substance Related and Co-occurring Conditions. American Society for Addiction Medicine.

(8) Moss, A, Dyer, K (2010) The Psychology of Addictive Behaviour. Palgrave McMillan. Basingstoke.

(9) National Institute for Clinical Care Excellence (2022) Management of Acute Alcohol withdrawal available@Alcohol Care Bundle A4 guide (nice.org.uk)

(10) National Health Service (2021) Alcohol Misuse available @ Alcohol misuse – NHS (www.nhs.uk)

(11) National Health Service (2022) Alcohol. available@NHS Long Term Plan » Alcohol

(12) Raistrick, D. (2004) Alcohol Withdrawal and Detoxification in Heather, N., & Stockwell, T. (ed) The Essential Handbook of Treatment and Prevention of Alcohol Problems by (2004). John Wiley & Sons. Chichester.

(13) Rassool, G.H. (2011) Understanding Addictive Behaviours. Palgrave MacMillan. New York.

(14) Sachdeva, A. et al (2015) Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. Journal of Clinical Diagnostic Research. 9 (9). available@Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond – PMC (nih.gov)

(15) Stern, TA; Gross, AF; Stern, TW; Nejad, SH; Maldonado, JR (2010). . Primary Care Companion to the Journal of Clinical Psychiatry. 12 (3). available@Current Approaches to the Recognition and Treatment of Alcohol Withdrawal and Delirium Tremens: “Old Wine in New Bottles” or “New Wine in Old Bottles” – PMC (nih.gov)