Therapy goals
- Absolute, preferably lifelong abstinence
- If the achievement of abstinence is not possible or harmful or risky consumption is present, a reduction of consumption (amount, time, frequency) in the sense of harm reduction should be sought.
Therapy recommendations
Inpatient treatment (detoxification or better qualified withdrawal [QE]) is recommended for:
- When there is a risk of alcohol-related withdrawal seizure and/or withdrawal delirium, and/or [recommendation grade A]
- In the presence of underlying health or psychosocial conditions under which alcohol abstinence does not appear to be achievable in the outpatient setting [Grade of Recommendation A].
- In alcohol-dependent individuals and individuals with harmful use when at least one of the following criteria is met [clinical consensus point = PPP]:
- (expected) severe withdrawal symptoms,
- Severe and multiple concomitant or sequelae somatic or mental illnesses,
- Suicidality (suicide risk),
- Lack of social support,
- Failure in outpatient detoxification.
Outpatient withdrawal treatment (physical detoxification or qualified withdrawal treatment) may be offered if there are no severe withdrawal symptoms or complications, high adherence, and a supportive social environment [PPP]. Note: “Qualified withdrawal treatment” (QE) is addiction psychiatric or addiction medicine acute treatment that goes beyond physical detoxification. Severe and moderate alcohol withdrawal syndromes should be treated pharmacologically [recommendation grade A].
Treatment recommendations:
- Treatment recommended:
- For brief intervention in people with risky consumption (A recommendation).
- For binge drinkers (B recommendation).
- Treatment with medications designed to reduce alcohol consumption in patients with alcohol dependence:
- Acute phase: benzodiazepines and lomethiazole.
- In delirious symptoms (agitation, hallucinations and delusions) treatment with: Bezodiazepines with antisychotics (especially haloperidol and butyrophenone) in combination.
- For seizures: Anticonvulsants; carbamazepine, valproic acid, gabapentin, and oxcarbazepine may be used to treat mild to moderate alcohol withdrawal syndromes
- Acute phase: benzodiazepines and lomethiazole.
- Qualified withdrawal treatment (according to the guideline: 21 days) should always be followed by cognitive behavioral therapy (CBT) and motivational intervention.
- Post-acute treatment: abstinence as the overriding therapeutic goal.
- Concept of controlled drinking (KT) begins to establish itself more strongly alongside the goal of abstinence (treatment with: opioid antagonists)
- For relapse prophylaxis, acamprosate (glutamate modulator) and naltrexone (opioid antagonist) are used.
- Alcohol withdrawal delirium must always receive intensive medical care because of the risk of life-threatening complications(for details, see Delir):
- Monitoring of vital functions (cardiovascular functions).
- Control of water, electrolyte and glucose balance.
- In the presence of alcoholic ketoacidosis (metabolic derailment triggered by insulin deficiency): glucose infusion;
- Therapy with GABAergic substances such as benzodiazepines and clomethiazole.
- For prophylaxis of Wernicke’s encephalopathy (brain and nerve changes caused by vitamin B1 deficiency): infusion with vitamin B 1.
- See also under “Further therapy“.
Further notes
- According to a French network analysis, the “concept of pharmacologically assisted reduced drinking” may not meet current expectations, that is, there is very little evidence for the efficacy of the substances used,The primary endpoint was total alcohol consumption. Nalmefene, topiramate and baclofen each performed better than placebo. For the endpoint number of days without alcohol consumption, topiramate significantly increased the number of days without alcohol consumption compared to placebo.The study authors conclude that “The Concept of Pharmacologically Controlled Drinking” is based on the results of studies with a high risk of bias.
