It’s reasonable to believe that for as long as humans have known alcohol, we’ve known both its ‘benefits’ and the dangers it represents. Some of the oldest surviving written documents refer to its effects on the body, soul, behaviour, and morals, and every major religion has strong views about (excessive) alcohol consumption. The Bible describes drinking as unwise and equates alcohol to the bite of a poisonous snake, the Quran as a defilement from the work of Satan, and the Torah predicts woe, sorrow, and contentions for those who tarry long at the wine.
What makes one of the earliest known intoxicants so insidious is that even if one decided to listen to their priest, imam, or rabbi’s advice and put the bottle down, intense alcohol withdrawal symptoms would often drive one right back to alcohol, cause severe pain and trauma, and in some cases, lead to death.
Before the advent of modern medicine, alcohol withdrawal symptoms would be treated with a combination of folk remedies such as herbal concoctions, tapering, and hydration and nutrition; institutionalised care at asylums or sanatoriums in the 19th century; and moral treatment and counselling from religious or community leaders.
Prior to the discovery of bromides and barbiturates in the early 20th century, the only medical solution that effectively dealt with many of the most severe withdrawal symptoms was opium and its derivatives. While naturally very good at alleviating pain, anxiety, and discomfort, it tended to cause its own set of addiction problems. By the 1960s, the discovery of benzodiazepines, including Librium, had set a new gold standard for drugs used to treat alcohol withdrawal symptoms. Today, benzodiazepines still form the backbone of the pharmacological treatment for alcohol withdrawal, with anticonvulsants, adrenergic medications, and medications used to address specific symptoms filling the gaps.
Examples: Chlordiazepoxide (Librium) | Diazepam (Valium) | Lorazepam (Ativan)
Legal Status in the UK: All three of these drugs are Class C drugs under the Misuse of Drugs Act 1971. This means that they have to be prescribed for legitimate medical use by a licensed physician and are subject to specific prescribing regulations.
Overview: Benzodiazepines were a true breakthrough in medically mitigating both the discomfort and danger of acute alcohol withdrawal and remain an integral part of medically assisted detox worldwide to this day.
Benzodiazepines are classified as sedative drugs. They increase the effect of GABA, a neurotransmitter that has a calming or sedative effect, making it more effective at calming the brain and nervous system. You can think of Benzos as improving your brain’s ability to brake itself, bringing relief from alcohol withdrawal symptoms such as anxiety, agitation, and muscle tension, and preventing seizures.
While Librium, Valium, and Ativan make up only a section of the Benzos used to treat alcohol withdrawal, they each have certain specific advantages: Librium, the most widely used for this purpose, is an intermediate- to long-acting sedative (5–30 hours) and can be effectively tapered for steady and predictable sedative effect; Valium is very similar but can act for up to 3 days; and short- to intermediate-term Ativan is preferred by patients with liver impairment as it is metabolised more quickly and predictably.
Examples: Carbamazepine (Tegretol) | Valproic Acid (Depakote) | Gabapentin (Neurontin)
Legal Status in the UK: Carbamazepine (Tegretol) and Valproic Acid (Depakote) are both classified as prescription-only medicines (POM), while Gabapentin (Neurontin) is a Class C controlled substance and subject to additional control and regulation measures.
Overview: Anticonvulsants have been used as an alternative to and alongside Benzodiazepines in the treatment of alcohol withdrawal symptoms since the 1960s. Although typically used to treat epilepsy and bipolar disorder patients, they reduce the risk of withdrawal-induced seizures and alleviate other withdrawal symptoms, such as anxiety and insomnia. Anticonvulsants have a reduced risk of dependency and offer additional benefits to patients with specific disorders, including seizures, nerve damage, and mood disorders (Zulino et al.).
Anticonvulsants have different workings. Tegretol stabilises the brain’s ‘electrical circuitry’ by inhibiting certain voltage-gated channels and preventing abnormal electrical discharges that can lead to seizures. This also leads to a reduction in anxiety and irritability. Depakote increases GABA synthesis, which has a sedative effect on the central nervous system, and also blocks hyperactive pathways for a calming effect. Neurontin limits the release of glutamate, an excitatory neurotransmitter, and boosts GABA production.
While anticonvulsants are effective in treating specific withdrawal symptoms, especially when benzodiazepines aren’t available as an option, they should only be taken after speaking to a physician. Anticonvulsants can have strong interactions with other drugs (Epilepsy Foundation) and might cause uncomfortable side effects such as dizziness, nausea, vomiting, and loss of coordination.
Examples: Clonidine (Catapres) | Propranolol (Inderal)
Legal Status in the UK: Both of these drugs are prescription-only medicines (POMs).
Overview: During alcohol withdrawal, our sympathetic nervous system, responsible for our response during dangerous or stressful situations, goes into overdrive. It increases one’s heart rate, leads to hypervigilance, and increases anxiety. Adrenergic medications affect the release and uptake of our ‘fight or flight’ hormones, epinephrine (adrenaline) and norepinephrine (noradrenaline), aiming to either decrease their production or slow down their uptake.
Catapres inhibits the release of norepinephrine, leading to a decrease in blood pressure and heart rate, sweating, and anxiety, all of which are typically elevated during alcohol withdrawal. Catapres, however, does nothing to address seizures or delirium tremens, the most dangerous and serious symptoms of alcohol withdrawal. Inderal, on the other hand, works by blocking adrenaline receptors in the body, slowing down the heart and decreasing blood pressure. This has a calming effect, helps reduce anxiety, and can help prevent tremors.
Adrenergic medication should always be used as directed, and in cases of serious withdrawal, is best used under medical supervision. Adrenergic medications may cause such a calming effect that they mask the symptoms of dangerous DTs and seizures. Their effect on the sympathetic nervous system could cause excessive sedation and respiratory depression, especially when combined with other medications such as benzodiazepines.
While the symptoms of alcohol withdrawal are largely predictable in broad strokes, there are certain cases where specific symptoms are exacerbated by co-occurring conditions, for example, respiratory conditions that preclude the use of certain benzodiazepines or adrenergic medications; unexpected reactions to commonly used drugs; and/or the interplay between different drugs.
In these cases, the attending physician might prescribe other types of medication to address specific symptoms.
Haloperidol (Haldol) | Prescription-only medicine in the UK
Used to treat severe agitation and hallucinations. There are no other antipsychotic medications recommended for this purpose (Faustmann et al.).
Ondansetron (Zofran) and Metoclopramide (Maxolon): Prescription-only medicines | Promethazine (Phenergan): Over the counter
All of these medications are used to treat nausea and vomiting caused by alcohol withdrawal. Other over the counter antiemetics in the UK include hyoscine and cinnarizine.
Trazodone (Molipaxin) and Hydroxyzine (Vistaril) | Both are prescription-only medicines
While Molipaxin is technically an antidepressant and Vistaril an antihistamine, both of these drugs are used to treat alcohol withdrawal-induced insomnia. It should be noted that in a 2009 double-blind, placebo-controlled study published in Alcoholism, Clinical and Experimental Research, patients treated with trazodone were more likely to start drinking again post-treatment (Friendmann et al.)
Loperamide (Imodium) | Available over the counter in the UK
Used to control diarrhoea during alcohol detox.
Examples: Thiamine (Vitamin B1), Folic Acid, Multivitamins
Legal Status in the UK: These are all available over the counter in the UK.
Long-term alcohol abuse affects the body’s nutritional status in several ways. It limits nutrient absorption and uses up the body’s stores of nutrients to metabolise the alcohol. The nutritional supplements mentioned above are commonly administered to patients in alcohol detox, with thiamine supplements playing an important role in warding off Wernicke-Korsakoff syndrome, a serious neurological disorder.
Folic acid and multivitamins both contribute to improving red blood cell production, neurological health, and psychiatric well-being, and even help reduce the severity of tremors and muscle cramps. Collectively, a healthy nutritional profile consisting of both nutritious food and supplements helps to facilitate a faster and more comfortable withdrawal, detox, and recovery (Kubala).
Gladstones Clinic has a 20-year history of helping individuals from all walks of life go through alcohol withdrawal and detox in a safe, comfortable, and relaxing residential setting. Our qualified and experienced team of physicians and recovery workers have years of firsthand experience in dealing with the discomfort of alcohol withdrawal and can provide a medically supervised environment where the right drugs are administered at the right time and in the right amount.
This guarantees a smooth and as-comfortable-as-can-be detox, setting the scene for a successful transition into primary care and long-term sobriety.
If you or a loved one are struggling with alcohol abuse and would like to know more about Gladstones Clinic’s facilities, treatment options, or pricing, please feel free to contact us for an obligation-free call at 0808 258 2350 or visit our online portal.
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Faustmann, T. J., et al. “Antipsychotic Treatment of Alcohol Withdrawal Syndrome with Focus on Delirium Tremens: a Systematic Review.” PubMed, Fortschritte der Neurologie-Psychiatrie, 23 March 2023, https://pubmed.ncbi.nlm.nih.gov/36958342/. Accessed 14 June 2024.
Friendmann, P. D., et al. “Trazodone For Sleep Disturbance After Alcohol Detoxification: A Double-Blind, Placebo-Controlled Trial.” NCBI, Alcoholism, Clinical and Experimental Research, 8 July 2008, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2567128/. Accessed 14 June 2024.
Kubala, Jillian. “Benefits of vitamin supplements for alcohol withdrawal syndrome.” MedicalNewsToday, Medical News Today, 31 March 2022, https://www.medicalnewstoday.com/articles/vitamins-for-alcohol-withdrawal. Accessed 14 June 2024.
Sachdeva, A., et al. “Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond – PMC.” NCBI, Journal of clinical and diagnostic research : JCDR, 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606320/. Accessed 14 June 2024.
Sirven, Joseph I. “Drug Interactions.” Epilepsy Foundation, 2014, https://www.epilepsy.com/treatment/medicines/drug-interactions. Accessed 14 June 2024.
Zulino, D. F., et al. “Anticonvulsant drugs in the treatment of substance withdrawal.” PubMed, Drugs of today, 2004, https://pubmed.ncbi.nlm.nih.gov/15510234/. Accessed 14 June 2024.
