Clinical management of alcohol withdrawal: A systematic review

These substances pose additional risks due to their largely unknown safety profiles and potency and are frequently detected in counterfeit pills 22. The diagnosis requires adequate history of the amount and frequency of alcohol intake, the temporal relation between cessation (or reduction) of alcohol intake and the onset of symptoms that may resemble a withdrawal state. When the onset of withdrawal like symptoms or delirium is after 2 weeks of complete cessation of alcohol, the diagnosis of alcohol withdrawal syndrome or DT becomes untenable, regardless of frequent or heavy use of alcohol.

Clinical management of alcohol withdrawal: A systematic review

Behavioural changes were evident, consistent with research on the impact of drug checking results on behaviour modification 79. Behavioural modifications following drug checking intervention included disposal of adulterated samples, reduced benzodiazepine use, reduced injection frequency, and reduced solitary drug use 44, 51, 54. Three studies examined the impacts of the rescheduling of medications, including benzodiazepines 59,60,61. A 2021 review included five studies that explored the rescheduling of alprazolam in Australia from Schedule 4 to Schedule 8 in 2014 59. Four of the studies reported declines in alprazolam use, with reductions in prescribing, dispensing, overdose deaths, and calls to poison centres. Further restrictions in 2017, such as removing 2 mg pills from public subsidies and limiting pack sizes, had no substantial impact.

Alcoholic hallucinosis

A complicating factor in benzodiazepine consumption is the proliferation of counterfeit products on the illicit drug market. These counterfeits, often manufactured to mimic pharmaceutical branded products (e.g., ‘Xanax’), can be difficult for consumers to distinguish from legitimate pharmaceuticals 20, creating additional challenges for harm reduction efforts. Analyses of seized counterfeit tablets have been found to contain varying quantities of benzodiazepines, novel benzodiazepines, and other substances, including fentanyl and other synthetic opioids 21, presenting significant overdose risk. Benzodiazepines are a commonly prescribed class of depressant medications 1 and are considered essential medicines by the World Health Organisation 2. Primarily prescribed for anxiety, panic and sleep disorders, and substance withdrawal; these medications hold anxiolytic, hypnotic, muscle relaxant, and anticonvulsant properties 3. Drug checking emerged as the most widely reported harm reduction approach for benzodiazepine use, with consistent positive outcomes across studies.

• However, traditional dose equivalence tools prove challenging for novel and counterfeit benzodiazepines owing to their largely unknown composition and relative potencies, complicating treatment planning.
• Severe symptoms and reactions can occur, and working with a professional can help a person avoid or manage these symptoms.
• Clearly people taking one tablet a day for years require a different approach from the heavy user under discussion here.
• Future work should prioritise the development and evaluation of nonjudgmental, flexible interventions that meet people where they are.

TREATMENT OF ACUTE ALCOHOL WITHDRAWAL SYNDROME

Ordinarily, the excitatory (glutamate) and inhibitory (GABA) neurotransmitters are in a state of homeostasis Figure 1a. Alcohol facilitates GABA action, causing decreased CNS excitability Figure 1b. In the long-term, it causes a decrease in the number of GABA receptors (down regulation). This results in the requirement of increasingly larger doses of ethanol to achieve the same euphoric effect, a phenomenon known as tolerance.

Duplicate records were identified and removed using Zotero Reference Manager (v6.0.37). Titles, abstracts, and keywords were screened independently in duplicate by four reviewers (IN, CM, CH, RML) using Rayyan (Rayyan 2024) with blinded voting. An initial screening of 40 studies was conducted independently by all reviewers to pilot the inclusion criteria. The team then met to discuss the results, and any discrepancies were resolved through discussion to ensure consistency in the application of eligibility criteria. This calibration process was completed before continuing with the full screening of all identified records. All remaining discrepancies were resolved through discussion, with RML providing the final vote where required.

• From 1996 to 2013, the number of people filling benzodiazepine prescriptions increased by 67%.
• This calibration process was completed before continuing with the full screening of all identified records.
• The Recovery Village exists to assist you through each step of the detoxification process, as well as help you acquire the skills needed to continue living in sobriety.Contact ustoday to learn more about treatment plans and programs that can work well for your needs.
• The inclusion of any studies that used the term ‘harm reduction’ has led to the inclusion of some approaches, such as abstinence-focused treatment, that may not align with most conceptualisations of harm reduction.

What is the most important information I should know about benzodiazepine withdrawal?

If you go into withdrawal without tapering, you also risk experiencing delirium and hallucinations that cause you to lose touch with reality—a terrifying and dangerous experience. While there is no FDA-approved medication to treat benzodiazepine withdrawal, your doctor may also prescribe other medications to help you manage withdrawal symptoms. The medication Romazicon (flumazenil) is sometimes used off-label for withdrawal symptoms. Depending on which benzodiazepine you are currently taking, your doctor may want to switch you to a different one before your taper begins. Short-acting benzodiazepines complicate withdrawal with too many ups and downs. Diazepam, a long-acting benzodiazepine, is the most common choice for dose tapering.

In performing a rigorous, systematic review of the evidence around tapering BZD, the guideline development committee was surprised by the paucity of research given that the need for BZD tapering is a relatively common clinical situation. One involved 100 people with long-term polydrug use in the UK, 61 where participants reported reduced injection of gel capsules but continued intravenous use with temazepam tablet formulations. The participants also reported increased criminal activity, higher drug prices, and substitution with riskier drugs such as flunitrazepam. Changes in the illicit drug market, such as the appearance of unfamiliar tablets and increased suspicion, desperation, and aggression, have been reported 61. Many providers across disciplines struggle with helping patients taper or even broaching the subject. One patient who has been taking BZDs for years may have little trouble tapering at a rate of 25% every 2-4 weeks.

Research showed that 40% of people taking benzos for longer than 6 months experienced moderate-to-severe withdrawal symptoms. Benzodiazepine, or benzo, withdrawal happens when a person suddenly stops taking benzodiazepine drugs, which doctors do not recommend. The withdrawal symptoms, which vary in severity, typically begin within 24 hours and may last from a few days to a few months.

We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider. The Recovery Village aims to improve the quality of life for people struggling with substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes.

The Drug Enforcement Agency (DEA) classify benzodiazepines as a Schedule IV controlled substance. According to the classification, these drugs have a low potential for abuse and low risk of dependence. Practices such as drug tapering or using other drugs to help ease withdrawal may make early withdrawal symptoms milder and more manageable. People looking to get off benzos should do so under the guidance of a healthcare professional, who may recommend coping strategies and other tools to make the withdrawal process more comfortable. The best resource in your quest to quit benzodiazepines is your prescribing doctor.

Coping strategies

This is particularly true if you are also giving up other substances, like alcohol or opioids. Some people, such as those with a history of complicated withdrawal, seizures, or severe mental illness, may be better suited for an inpatient setting. This can involve living at a detox facility or hospital for several weeks, where you can receive constant medical monitoring and psychological support. During your taper, you may still experience some of the symptoms of withdrawal.

There are some cases where BZD prescribing is appropriate to treat a severe anxiety disorder. Hence the patient needs a careful assessment including an evaluation of the reasons for and against use prior to embarking on the management outlined below. Research in the British Journal of Clinical Pharmacology notes that an estimated 10–25% of people who Benzodiazepine withdrawal use benzos for extended periods experience withdrawal symptoms that last for 12 months or longer. According to the American Psychiatric Association (APA), withdrawal symptoms from short-acting benzodiazepines peak on the second day and improve by the fourth or fifth. The onset of benzodiazepine withdrawal depends on the specific medication you are taking. Short-acting drugs like Xanax (alprazolam) and Ativan (lorazepam) leave the system quicker, which means withdrawal symptoms can appear in as little as eight to 12 hours.