Summary

Alcohol dependence (alcohol use disorder, AUD) is a chronic relapsing condition characterised by compulsive alcohol use, loss of control over intake, and a negative emotional state when not drinking. Alcohol withdrawal syndrome (AWS) occurs when chronic heavy drinkers suddenly reduce or stop drinking, ranging from mild tremor and anxiety to life-threatening delirium tremens and seizures. Management of AWS requires careful assessment, thiamine replacement, and benzodiazepine-based detoxification. Long-term recovery requires pharmacotherapy, psychological support, and engagement with mutual aid groups.

Key Facts

• Prevalence: 5-10% of adults meet criteria for AUD; 20% of hospital inpatients
• Mortality: Delirium tremens has 5-15% mortality if untreated
• Wernicke's encephalopathy: Caused by thiamine (B1) deficiency; preventable with IV thiamine
• Withdrawal timeline: Tremor 6-12h → Seizures 12-48h → DTs 48-72h
• Key management: Thiamine BEFORE glucose; symptom-triggered benzodiazepines
• Prevention of relapse: Acamprosate, naltrexone, disulfiram, psychosocial support

Clinical Pearls

Thiamine Before Glucose: Always give IV thiamine before any glucose-containing fluids in at-risk patients. Glucose administration can precipitate or worsen Wernicke's encephalopathy.

The 48-72 Hour Window: Delirium tremens typically develops 48-72 hours after the last drink. Patients who appear stable at 24 hours may still deteriorate — maintain vigilance.

The Concealed Drinker: Hospital inpatients often underreport alcohol use. Any patient with unexplained tremor, confusion, or agitation 2-3 days into admission should be assessed for AWS.

Why This Matters Clinically

Alcohol withdrawal is common in hospital settings and frequently unrecognised until complications occur. Delirium tremens carries significant mortality and morbidity. Early recognition and treatment prevent seizures, aspiration, and death. Wernicke's encephalopathy is preventable but irreversible once Korsakoff's syndrome develops.

Structured Approach

General:

• Vital signs (HR, BP, temperature, RR)
• Level of consciousness and orientation
• Hydration status
• Signs of chronic liver disease (jaundice, spider naevi, hepatomegaly)

Neurological:

• Tremor assessment
• Eye movements (nystagmus, ophthalmoplegia)
• Gait (ataxia)
• Reflexes (hyperreflexia in withdrawal)
• Confusion/orientation (AMT, 4AT)

Cardiovascular:

• Heart rate and rhythm
• Blood pressure

Special Tests

Natural History

• Mild withdrawal: Self-limiting over 3-5 days
• Severe withdrawal: Progresses to DT if untreated
• Untreated DT: 5-15% mortality
• Wernicke's: 17% mortality; 80% develop Korsakoff's if untreated

Outcomes with Treatment

Prognostic Factors

Good Prognosis:

• Motivation to change
• Strong social support
• Engagement with addiction services
• No previous complicated withdrawal

Poor Prognosis:

• Previous DT or seizures
• Multiple relapses
• Concurrent mental health disorder
• Homelessness or lack of social support
• Advanced liver disease

Key Guidelines

1. NICE CG115 (2011) — Alcohol-use disorders: diagnosis and management. NICE CG115
2. NICE CG100 — Alcohol-use disorders: prevention.
3. SIGN 74 — The management of harmful drinking and alcohol dependence in primary care.

Landmark Trials

COMBINE Study (2006) — Combining medications and behavioural interventions

• 1383 patients randomised to naltrexone, acamprosate, behavioural intervention, combinations
• Key finding: Naltrexone and behavioural intervention both effective; no added benefit of combining all
• Clinical Impact: Supports pharmacotherapy plus psychosocial intervention

UKATT Trial (2005) — UK Alcohol Treatment Trial

• 742 patients randomised to motivational enhancement therapy vs social behaviour network therapy
• Key finding: Both equally effective; outcomes depend on engagement
• Clinical Impact: Emphasises importance of any structured intervention

Evidence Strength

What is Alcohol Dependence?

Alcohol dependence, also called alcoholism or alcohol use disorder, is when you find it very difficult to control your drinking even though it is causing problems in your life. Your body becomes used to alcohol, needing more to feel the same effect, and you feel unwell when you try to stop drinking.

What is Alcohol Withdrawal?

When someone who drinks heavily every day suddenly stops or cuts down, their body reacts. This is called withdrawal. Symptoms range from shaking, sweating, and feeling anxious to serious problems like fits (seizures) and confusion. The most severe form, called delirium tremens (DTs), can be life-threatening.

How is it treated?

1. In hospital or at home: Depending on severity, you may need to be in hospital or can sometimes be treated at home with regular nurse visits.
2. Vitamins: We give vitamin B1 (thiamine) through a drip to prevent brain damage.
3. Medication for withdrawal: Tablets (usually chlordiazepoxide) help calm the brain and prevent fits. The dose is gradually reduced over 5-7 days.
4. Preventing relapse: Medications like acamprosate or naltrexone reduce cravings. Counselling and support groups (like AA) help you stay alcohol-free.

What to expect

• Withdrawal symptoms usually peak at 24-72 hours and improve over 5-7 days
• You may feel tired, anxious, and have trouble sleeping for a few weeks
• Recovery is a long-term process — relapses are common but do not mean failure
• With the right support, many people achieve lasting recovery

When to seek help

Go to A&E or call 999 if you:

• Have a seizure (fit)
• Feel very confused or see/hear things that aren't there
• Have severe shaking that won't stop
• Feel your heart beating very fast or irregularly
• Have a high temperature with severe sweating