WITHDRAWAL FROM ALCOHOL USING MONITORED ALCOHOL CONSUMPTION: A CASE REPORT

Neil R. Wright,* and Caroline Thompson,1

Nottingham Alcohol and Drug Team, The Wells Road Centre, The Wells Road, Nottingham NG3 3AA and
1 Sneinton Hermitage, 35–37 Sneinton Hermitage, Sneinton, Nottingham NG2 4BT, UK

Received 5 November 2001; in revised form 13 December 2001; accepted 16 January 2002


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 CASE HISTORY
 DISCUSSION
 REFERENCES
 
Aims: A single case study of alcohol withdrawal through monitored alcohol consumption in a hostel resident. Method: A standard dose of cider was given when the client requested, and had a lower breath alcohol concentration than when he took his previous dose of cider. Results: Abstinence was uneventfully achieved on two separate occasions each taking only 2 days. Conclusions: Withdrawal from alcohol through monitored alcohol consumption is a potentially effective and rapid procedure, but the limits of its appropriate use have not been established.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 CASE HISTORY
 DISCUSSION
 REFERENCES
 
A variety of medications have been tested for alcohol detoxification (Mayo-Smith, 1997Go; Williams and McBride, 1998Go) and there are accounts of unmedicated detoxification (O'Briant, 1975Go; Whitfield et al., 1978Go; Shaw et al., 1981Go; McGovern, 1983Go). Whilst ‘gradual weaning’ from alcohol commanded support in the 18th and early 19th centuries (Porter, 1985Go), by the mid-19th century the Temperance movement had developed a strong influence on the conceptualization of habitual drunkenness and had widened its focus of condemnation from spirit drinking to demonizing all alcoholic beverages, thus making ‘gradual weaning’ increasingly difficult to advocate as a helpful or justifiable intervention. A search (MedLine, EmBase, Psycinfo, Cochrane, DARE) revealed only two recent reports in the addictions literature concerning the use of alcohol to detoxify people from alcohol (Faillace et al., 1972Go; Funderburk et al., 1978Go), although there are reports in other medical specialities (Hansbrough et al., 1984Go; Craft et al., 1994Go; Spies and Dubisz, 1995Go).

The 20th century construct of alcoholism, characterized by impaired control over drinking, has been challenged (Heather and Robertson, 1981Go), but still pervades the alcohol treatment field. It predicts that using alcohol for alcohol withdrawal is irresponsible and doomed to failure. In the present report, we demonstrate the successful withdrawal from alcohol of a subject by using monitored alcohol consumption.


    CASE HISTORY
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 CASE HISTORY
 DISCUSSION
 REFERENCES
 
A 28-year-old male living in a hostel for homeless people with alcohol problems asked staff for chlordiazepoxide. He had a 10-year history of extreme alcohol-related problems including withdrawal symptoms of morning tremulousness, sweating, nausea and vomiting, but not alcohol-induced seizures. Benzodiazepines for withdrawal had been prescribed for him on numerous occasions, but had not enabled him to achieve prolonged abstinence from alcohol.

At the time he presented, he was consuming up to 6 l of strong cider daily and experiencing withdrawal symptoms on waking-up. The hostel employs trained nursing staff, with close links to local specialist alcohol services. It supports sobriety, but is not a ‘dry house’, and encourages residents to restrict their levels of intoxication. The staff became aware that the resident had a large store of cider in his bedroom and suspected that he intended to drink heavily before medication could be arranged. Consistent with their restriction of levels of drunkenness, they suggested he drink his cider more slowly that day. He was receptive to this advice.

Procedures and results
He gave his supply of cider to the staff on the morning of the first day and without objective signs of alcohol withdrawal, at a breath alcohol concentration (BrAC) of 110 µg/100 ml, and was given 275 ml of 7.5% ABV cider. The staff judged that, to wait for the emergence of withdrawal symptoms, or even delay the first dose of cider at all, would probably result in demands for all the cider to be returned. Thereafter he repeatedly requested cider and 275 ml was given on occasions when his BrAC (Table 1Go) had declined by any measurable amount since his last drink (the breathalyser measured in 1 µg/100 ml increments). The interval between glasses of cider varied but averaged ~2 h, and the staff's efforts to build in some delays to rebreathalysing resulted in variable incremental falls in BrAC between drinks. To avoid onset of withdrawal symptoms during the night, the patient was given 1 l of cider before going to bed. He enjoyed being breathalysed and was interested to see if his BrAC had fallen. He breathalysed negative at the start of the third day, and was not exhibiting alcohol withdrawal symptoms. He was therefore given no further cider and congratulated on completing his detoxification. The staff noted his disappointment that the detoxification had finished and feared that he would immediately restart drinking cider. However, with support he remained abstinent from alcohol for 5 months.


View this table:
[in this window]
[in a new window]
 
Table 1. Alcohol detoxifications achieved with 275 ml doses of 7.5% ABV cider, given on request if breath alcohol concentration had fallen since the last dose
 
At 5 months, having relapsed into drinking up to 6 l of cider daily, for 1 week, he requested a further alcohol detoxification using alcohol. This time the detoxification was started on the basis that he willingly provided the alcohol, and was also completed successfully from a higher starting BrAC (205 µg/ 100 ml) in 2 days. He remained sober for the next 3 months.


    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 CASE HISTORY
 DISCUSSION
 REFERENCES
 
Patients who relapse into consistent heavy drinking associated with withdrawal symptoms sometimes believe that withdrawal from alcohol can only be achieved with medication. In practice, their drinking behaviour includes continual variation in rate and quantity of consumption which is reflected in varying levels of BrAC and degrees of intoxication or withdrawal. But whilst one day's drinking may represent a modest reduction, compared to the previous day, it is difficult to motivate such patients to reduce gradually on a day-by-day basis, and avoid severe discomfort until sobriety is achieved. When relapse occurs with the expectation that further medication will be prescribed on request, the experience of medicated detoxification may seem to be encouraging a repeated pattern of episodic binge drinking and medicating.

Alcohol withdrawal with alcohol empowers the client, because it achieves a desired goal through a process that makes obvious the importance of the client's own choice to stop drinking. It demystifies and demedicalizes the process of stopping drinking. The experience of the present case study is that the structure and monitoring were essential to the client's motivation and compliance. We doubt that similar levels of nursing supervision could be achieved in most hostels, so this probably does not represent a widely applicable therapeutic approach for this difficult-to-treat population. An alcohol detoxification ward could provide the environment and resources to best evaluate the use of alcohol as a detoxification agent, but this too presents problems, perhaps in particular the acceptability to other patients. Additionally, the dangers specific to the detoxification process remain scarcely evaluated, and drinkers with a variety of physical complications and behavioural disturbances may be unsuitable for an alcohol detoxification using alcohol.

Dolinsky and Babor (1997) concluded that there is no evidence of long-term harm from ‘ethanol administration research involving alcoholics as human subjects', and suggested an ethical framework for future clinical work. Their conclusions are based on a review of the administration of alcohol in a wide variety of research designs and treatments; but they make reference to only one study of alcohol withdrawal using alcohol. Nevertheless, their conclusions and our experience in the present study should help allay fears that administration of alcohol to such individuals might lead to more drinking in the future. This removes the major barrier to research into the use of monitored alcohol consumption to achieve withdrawal from alcohol.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 CASE HISTORY
 DISCUSSION
 REFERENCES
 
* Author to whom correspondence should be addressed. Back


    REFERENCES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 CASE HISTORY
 DISCUSSION
 REFERENCES
 
Craft, P. P., Foil, M. B., Cunningham, P. R. G., Patselas, P. C., Long-Snyder, B. M. and Collier, M. S. (1994) Intravenous ethanol for alcohol detoxification in trauma patients. Southern Medical Journal 87, 47–54.[ISI][Medline]

Dolinsky, Z. S. and Babor, T. F. (1997) Ethical, scientific and clinical issues in ethanol administration research involving alcoholics as human subjects. Addiction 92, 1087–1097.[ISI][Medline]

Faillace, L. A., Flamer, R. N., Imber, S. D. and Ward, R. G. (1972) Giving alcohol to alcoholics: An evaluation. Quarterly Journal of Studies on Alcohol 33, 85–90.[ISI][Medline]

Funderburk, F. R., Allen, R. P. and Wagman, A. M. I. (1978) Residual effects of ethanol and chlordiazepoxide treatments for alcohol withdrawal. Journal of Nervous and Mental Diseases 166, 195–203.

Hansbrough, J. F., Zapata-Sirvent, R. L., Carroll, W. J., Johnson, R., Saunders, C. E. and Barton, C. A. (1984) Administration of intravenous alcohol for prevention of withdrawal in alcoholic burn patients. American Journal of Surgery 148, 266–269.[ISI][Medline]

Heather, N. and Robertson, I. (1981) Controlled Drinking. Methuen, London.

Mayo-Smith, M. F. (1997) Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guidelines. Journal of the American Medical Association 278, 144–151.[Abstract]

McGovern, M. P. (1983) Comparative evaluation of medical vs social treatment of alcohol withdrawal syndrome. Journal of Clinical Psychology 39, 791–802.[ISI][Medline]

O'Briant, R. G. (1975) Proceedings of the 4th Annual Alcoholism Conference. A New Look in Non-medical Care for the Public Inebriate. Department of Health, Education and Welfare, National Institute on Alcohol Abuse and Alcoholism, Maryland.

Porter, R. (1985) The drinking man's disease: the ‘pre-history’ of alcoholism in Georgian Britain. British Journal of Addiction 80, 385–396.[ISI][Medline]

Shaw, J. M., Kolesar, G. S., Sellers, E. M., Kaplan, H. L. and Sandor, P. (1981) Development of optimal treatment tactics for alcohol withdrawal. 1. Assessment and effectiveness of supportive care. Journal of Clinical Psychopharmacology 1, 382–387.[ISI][Medline]

Spies, C. D. and Dubisz, N. (1995) Prophylaxis of alcohol withdrawal syndrome in alcohol-dependent patients admitted to the intensive care unit after tumour resection. British Journal of Anaesthesia 75, 734–739.[Abstract/Free Full Text]

Whitfield, C. L., Thompson, G., Lamb, A., Spencer, V., Pfeifer, M. and Browining-Farrandon, M. (1978) Detoxification of 1,024 alcoholic patients without psychoactive drugs. Journal of the American Medical Association 239, 1409–1410.[Abstract]

Williams, D. and McBride, A. J. (1998) The drug treatment of alcohol withdrawal symptoms: a systematic review. Alcohol and Alcoholism 33, 103–115.[Abstract]





This Article
Abstract
FREE Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Request Permissions
Google Scholar
Articles by Wright, N. R.
Articles by Thompson, C.
PubMed
PubMed Citation
Articles by Wright, N. R.
Articles by Thompson, C.