81: Ethanol Withdrawal

HISTORY AND EPIDEMIOLOGY

The medical problems associated with alcoholism and alcohol withdrawal were initially described by Pliny the Elder in the first century B.C. In his work Naturalis Historia, the alcoholic and alcohol withdrawal were described as follows: “…drunkenness brings pallor and sagging cheeks, sore eyes, and trembling hands that spill a full cup, of which the immediate punishment is a haunted sleep and unrestful nights. …”⁵⁴ Initial treatments as described by Osler at the turn of the 20th century were focused on supportive care, including confinement to bed, cold baths to reduce fever, and judicious use of potassium bromide, chloral hydrate, hyoscine, and, possibly, opium.²⁰

Some of the initial large series of alcohol related complications in the early 20th century describe alcohol use as a major public health concern. At Bellevue Hospital in New York City, there were 7000 to 10,000 admissions per year for alcohol-related problems from 1902 to 1935, with an estimated rate of 2.5 to 5 admissions per 1000 New York City residents.³⁸ Many of these patients were described as suffering from “alcoholomania” or “acute alcoholic delirium.”

A similar number of admissions to Boston City Hospital was also reported, with up to 10% of alcoholics admitted with evidence of delirium tremens (DTs).⁵¹ The mortality at the beginning of the study among patients with DTs was 52% (1912), and DTs was the leading cause of death among admitted alcoholics. Over the ensuing 20 years, this rate declined to approximately 10% to 12%, a decrease believed to be secondary to improved supportive care and nursing.

Although alcoholics were widely recognized as having a high incidence of delirium and psychomotor agitation, whether this was caused by ethanol use, ethanol abstinence, or coexisting psychological disorders remained controversial. Isbell and colleagues, in 1955, proved that abstinence from alcohol was responsible when they subjected 9 male prisoners to chronic alcohol ingestion for a period of 6 to 12 weeks followed by 2 weeks of abstinence.³⁶ Although they were ingesting alcohol daily, none of these prisoners developed signs and symptoms of DTs. However, during the abstinence phase, six of the nine men developed tremor, elevations in blood pressure and heart rate, diaphoresis, and varying degrees of either auditory or visual hallucinations, consistent with the diagnosis of DTs. In addition, two of the nine men developed convulsions, further linking alcohol abstinence to seizures. However, it should be noted that the high rate of development of DTs (67%) is atypical and does not represent the true prevalence found in later epidemiologic studies.

Alcoholism and the various manifestations of the alcohol withdrawal syndrome (AWS) still represent major problems in both the inpatient and outpatient setting. Ethanol is responsible for approximately 3.8% of all deaths worldwide (6.3% of men and 1.1% of women) and accounts for 4.6% of the global burden of disease (7.6% of men and 1.4% of women).^58...