As health professionals we must never underestimate the dangers of alcohol withdrawal. Alcohol is a central nervous system depressant and abrupt cessation can overstimulate the autonomic nervous system.

A respected doctor I had the pleasure of learning from once told me a story which highlights the importance of recognizing and treating alcohol withdrawal:
Imagine putting four people in a glass room that you can see and hear through and sit back and observe. One of these people is addicted to opiates, the second is addicted to amphetamines, the third is addicted to benzodiazepines and the fourth is an alcoholic. Over a period of time if deprived of their drug of choice they will experience withdrawal. The person who is addicted to opiates will sweat profusely, have severe stomach cramps and desperately beg you to help them with pain relief so that they can start to feel normal again. This is an important point that we must remember: it is not to get high anymore, it is to feel normal. The amphetamine addict will be very angry, probably hitting the walls and demanding medication while they scratch at their skin, causing abrasions. The person with a benzodiazepine addiction will be very frightened, shake, twitch and not be able to sleep. The alcoholic will probably sit in a corner, terrified and super sensitive to noise; have visual hallucinations; feel like things are crawling over them; slump over; and possibly have a fit and die.

It is important to remember that patients that go through alcohol withdrawal under our care will likely not have been admitted specifically for alcohol detoxification. Withdrawal is more likely to be inadvertent due to illness and lack of access to alcohol.

Withdrawal symptoms usually occur 6–24 hours after the last alcoholic drink (however this can vary depending on the patient and the nature and extent of their alcoholism). The signs of alcohol withdrawal include anxiety, agitation, sweating, tremor, nausea, vomiting, abdominal cramps, diarrhea, craving, insomnia, elevated blood pressure, elevated pulse and elevated temperature, headaches, seizures, confusion, perceptual distortions, disorientation, hallucinations, delirium tremens, arrhythmias and Wernicke’s Encephalopathy (WE). WE symptoms include: opthalmoplegia, ataxia and confusion.

The scales used to monitor withdrawal in Australia include:

• AWS,Alcohol Withdrawal Scale
• CIWA AR-Clinical Institute Withdrawal Assessment of Alcohol Scale (Ensure you use the scale that is recommended by your employer in their guidelines and policies and procedures.)

Medications that may be prescribed to assist patients suffering from alcohol detoxification symptoms include:

• Anti-anxiety medicines (benzodiazepines such as diazepam) which treat withdrawal symptoms such as delirium tremens (DTs).
• Seizure medicines to reduce or stop severe withdrawal symptoms during detoxification.
• Medicines for recovery include Disulfiram (Antabuse), which makes the person sick (vomit) if they consume alcohol. 
• Naltrexone (ReVia, Vivitrol), which interferes with the pleasure one gets from alcohol.
• Acamprosate (Campral), which may reduce cravings for alcohol.
• Thiamine supplements are recommended. Alcohol abuse can cause the body to become low in certain vitamins and minerals especially Thiamine (vitamin B1). Thiamine helps prevent Wernicke-Korsakoff syndrome which causes brain damage. (WE was first identified in 1881 by the German neurologist Carl Wernicke, although the link to Thiamine was not discovered until the 1930s. Russian psychiatrist SergiKorsakoff described a similar presentation in 1887-1891).

Patients and health professionals dealing with alcohol detoxification will also face systemic challenges, such as:

• Limited access to rehabilitation centres
• Significant distance between treatment and rehabilitation centres, particularly in regional and remote areas
• Navigating the rules and requirements that rehabilitation centres impose prior to admission (which ensure a patient’s level of readiness for change)
• Limited access to family support, as many patients suffering from severe alcoholism and requiring rehabilitation have often lost contact with friends and family.

The prevalence of alcohol abuse and dependence in our society means that as health professionals many of us will be confronted with alcohol withdrawal symptoms. It is vital that we are familiar with the warning signs and symptoms of alcohol withdrawal as mismanagement or the absence of appropriate care can have severe consequences.

References
Sydney Alcohol Treatment Group-http://www.alcpharm.med.usyd.edu.au/ accessed 2010 2/8/2014.