Delirium Although confusion and changes in the level of consciousness are not criteria for alcohol withdrawal, delirium may occur. Individuals with delirium are dangerous to themselves and others (Boland & Verduin, 2022). Delirium tremens occurs on the third day after reduction or cessation of alcohol and has a mortality of 20% if left untreated. Individuals demonstrate confusion, disorientation, hallucinations, delusions along with autonomic hyperactivity, anxiety, and fluctuating levels of psychomotor activity (Boland & Verduin, 2022). Alcohol induced disorders Wernicke encephalopathy (alcoholic encephalopathy) is characterized by ataxic gait, vestibular dysfunction, confusion, horizontal nystagmus, lateral orbital palsy, and gaze palsy (Boland & Verduin, 2022). The condition is reversible but may progress to Korsakoff syndrome (Boland & Verduin, 2022). Korsakoff syndrome is a chronic amnestic syndrome that follows Wernicke encephalopathy (Boland & Verduin, 2022). The main feature is anterograde amnesia, with possible confabulation (Boland & Verduin, 2022). Thiamine deficiency is the pathophysiologic between these two syndromes (Wernicke- Korsakoff syndrome) (Boland & Verduin, 2022). Thiamine is involved in the conduction of axon potential and synaptic transmission (Boland & Verduin, 2022). Antidipsotropic medications ● Acamprosate is the most effective medication for maintaining abstinence in alcohol use disorder (France, 2022). Acamprosate is thought to target GABA and N-methyl-D-aspartate glutamatergic receptor activity, thereby decreasing cravings and relapse (France, 2022). The individual must be alcohol-free at initiation and is contraindicated in severe renal disease. Side effects include diarrhea and nausea. Dosing is weight based, and titration is not required (Mariani, 2014). ● Disulfiram is a second-line treatment to treat individuals who are dependent on alcohol but are motivated to discontinue use (Stokes & Abdijadid, 2022). Alcohol consumption increases serum acetaldehyde causing diaphoresis, palpitations, facial flushing, nausea, vertigo, hypotension, and tachycardia. These symptoms are known as disulfiram- alcohol reaction and discourage alcohol intake (Stokes & Abdijadid, 2022). Side effects include headache, skin rash, drowsiness, and metallic aftertaste; adverse reactions include hepatitis and peripheral neuropathy. ● Naltrexone is a first-line treatment for alcohol and opioid dependence by blocking the µu receptor (Singh & Saadabadi, 2022). Additionally, naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress alcohol consumption (Singh & Saadabadi, 2022). Absorption is almost complete after administration but has an extensive first pass effect. Nausea and abdominal pain are common. Caution is needed in hepatic and renal impairment. Healthcare Considerations: Delirium tremons should be considered a medical emergency and can be fatal if not managed. The best-validated tool to assess the severity of alcohol withdrawal is the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar). The main treatment objectives for alcohol withdrawal are controlling agitation, lowering seizure risk, and reducing morbidity and mortality. Benzodiazepines are the first-line treatment for all alcohol withdrawals. Barbiturates are used for those patients who are refractory to benzodiazepines. Propofol in conjunction with benzodiazepines could be used in patients refractory to barbiturates; however, this would require mechanical ventilation (Hoffman & Weinhouse, 2023).
Blood Alcohol Concentrations (BAC) with Impairment 20-30 mg/dL Slowed motor impairment with decreased thinking ability. 30-80 mg/dL Increased motor and cognitive problems. 80-200 mg/dL Incoordination and judgment errors with deterioration in cognition. 200-300 mg/dL Nystagmus, slurred speech, and blackouts. >300 mg/dL Impaired vital signs and possible death. If an individual lacks significant impairment at 150 mg/dL pharmacodynamic tolerance may be present (Boland & Verduin, 2022). Repeated alcohol intoxication can predispose individuals to depressed immune function leading to repeated infections and some cancers (APA, 2013). Blackouts Blackouts are identified as anterograde amnesia (the inability to form new memories while under the influence of alcohol) occurring with alcohol intoxication. During blackouts, individuals’ remote memory remains intact but short-term memory is deficient. Likely, the hippocampus and temporal lobe structures are affected. Intellectual faculties remain intact, and the individual can perform complicated tasks. It's important to note that blackouts are not the same as passing out, which occurs when a person loses consciousness due to alcohol intoxication. Alcohol withdrawal The decision to stop drinking is usually in response to a crisis followed by weeks of abstinence and then controlled nonproblematic drinking (APA, 2013). However, consumption escalates rapidly, and severe problems likely occur (APA, 2013). Individuals will often continue consumption to decrease the unpleasant side effects of withdrawal. A repetitive and intense use pattern develops, and individuals spend time consuming alcohol (APA, 2013). Alcohol withdrawal can be severe, including seizures and autonomic hyperactivity (diaphoresis, tachycardia). The classic sign of alcohol withdrawal is tremulousness (Boland & Verduin, 2022). Other withdrawal symptoms include nausea; vomiting; insomnia; transient visual, tactile, and auditory hallucination or illusions; psychomotor agitation; anxiety; and seizure (APA, 2013). The estimated progression of alcohol withdrawal symptoms is presented here:
Time to Presentation
Progression
Symptoms
Mild
Tremulousness.
6-8 hours.
Moderate
Perceptual disturbances. 8-12 hours.
Severe
Seizures.
12-24 hours.
Life Threatening Delirium tremens.
Within 72 hours.
Note . Boland & Verduin, 2022. Withdrawal seizures
Alcohol withdrawal produces generalized tonic-clonic seizures, but status epilepticus is rare (Boland & Verduin, 2022). Long- term alcohol use can produce hypoglycemia, hyponatremia, and hypomagnesemia, which also produces seizures (Boland & Verduin, 2022).
ANXIOLYTICS OR SEDATIVE-HYPNOTIC RELATED DISORDERS
Sedative hypnotics are among the most commonly prescribed psychoactive drugs by clinicians in primary care (Ehrlich, 2022). These drugs are frequently taken orally to obtain a steady
intoxicated state. Individuals with sedative-hypnotic or anxiolytic use disorders are frequently treated in the outpatient setting, as the overall stability requires less monitoring. Sedative
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