Occurs when an individual is physically or psychologically dependent upon alcohol

Clinical features of alcohol withdrawal

• First symptoms occur within hours and peak at 24-48 hours
• Restlessness, tremor, sweating, anxiety, nausea and vomiting, loss of appetite and insomnia
• Tachycardia and systolic hypertension evident
• Generalised seizures usually in first 24 hours
• Can progress to the medical emergency Delirium Tremens
  • 5% of cases
  • Peak onset within 2 days of abstinence
  • Often presents insidiously with night time confusion
  • Confusion, disorientation, agitation, hypertension, fever, visual and auditory hallucinations, paranoid ideation
  • Mortality 2-5% (with medical support - higher without)
• In most cases symptoms resolve in 5-7 days

Investigations

Meet ICD-10 criteria of dependence:

• 3 or more present have been present together at some time during the use of previous year:
  • Strong desire or sense of compulsion to take drug
  • Difficulty in controlling use of substance in terms of onset, termination, or level of use
  • Physiological withdrawal state
  • Evidence of tolerance
  • Progressive neglect of other pleasures/interests because of use/effects of substance
  • Persistence with use despite clear evidence of harmful consequences

Management

• General support - reassurance, advice etc.
• Benzodiazepines - long acting agents, titrate against severity of symptoms, reduce gradually over 7 days
• Vitamin supplementation including thiamine as prophylaxis against Wenicke's encephalopathy
  • Must be parenteral
  • Increase dose if Wernicke's suspected
• Relapse prevention