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1. The Management of the Acute Withdrawal Phase in Alcoholism
- Cork University Press
- Chapter
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In Dublin in 1957–58, I wrote a paper on ‘The Acute Withdrawal Phase in Alcoholism’, which was published in The Lancet, 9 May 1959. This was a joint effort with the consultant under whom I was working at the time – Dr John Ryan. Psychoactive drugs were just coming in and we worked out a regime for helping to detoxify those who were in the acute phase of withdrawal from alcohol. THE alcoholic in an acute toxic state following prolonged excess is an unpleasantly familiar problem. We have been unfavourably impressed by the frequently vague and haphazard treatment of such cases in general hospitals, and even in specialized centres. Standard textbooks tend to dismiss the management of the acute toxic withdrawal phase with references to small doses of insulin, paraldehyde sedation, and the use of concentrated vitamins (MayerGross et al. 1954; Sargant and Slater 1954; Brain 1955; Cecil and Loeb 1955; Henderson and Gillespie 1955; Price 1956). The current literature of the subject varies widely in its approach, and there is what appears to us a mistaken preoccupation with single therapeutic agents such as chlorpromazine (Sainz 1957), promazine (Figurelli 1956), corticotrophin (Smith 1950), reserpine (Avol and Vogel 1955; Carey 1955) and vitamins (Armstrong and Gould 1955). Most alcoholics present themselves for treatment only when drinking has become a pressing problem through extreme excess, when trauma or infection has supervened, or when long-continued indulgence has dangerously undermined health. Any uncertainty or hesitation in instituting effective treatment at this critical point may result in dangerous or even fatal complications, such as delirium tremens, status epilepticus or pneumonia. It may be valuable, therefore , if we describe a regime that we have found effective. 1. The Management of the Acute Withdrawal Phase in Alcoholism IVOR W. BROWNE, JOHN P.A. RYAN AND S. DESMOND MCGRATH 1 The Writings of Ivor Browne 2 Development of Method This regime was first used in this hospital early in 1955. For withdrawal symptoms, preliminary American reports (Cummins and Friend 1954; Aivazien 1955; Mitchell 1955; Schultz et al. 1955) had emphasized the advantages of chlorpromazine over the more established forms of sedation. We were impressed by its effectiveness, but we found that it gave still more favourable results if combined with a barbiturate. The importance of vitamins in cerebral metabolism had become increasingly evident and Gould (Gould 1953, 1954; Armstrong and Gould 1955) had demonstrated that patients in toxic states responded to large doses of the B group with vitamin C. When a highly concentrated vitamin preparation for intravenous administration (parentrovite: 20ml. contains B1 500mg, B2 8mg, nicotinamide 380mg, pyridoxine 100mg, calcium pantothenate 10mg., dextrose 2g, and ascorbic acid 1000mg) became available, we tried it by itself and in conjunction with chlorpromazine and barbiturates. The results obtained with the combination were much better than those achieved using the vitamin preparation by itself. This tentative approach led to the evolution of a well-defined regime which has remained essentially unaltered for the past three years. As the use of chlorpromazine was followed by jaundice in two cases, and as there was often severe pain at the site of its injection, a more recent phenothiazine derivative (promazine, ‘Sparine’) has been used instead. This is apparently free of these disadvantages (Fazekas et al. 1956; Mitchell 1956). This method has now been employed in the management of 313 alcoholics suffering from severe withdrawal symptoms. Method A careful history is taken from a relative or friend and a physical examination of the patient is made. No alcohol is given after admission to hospital. First 24 hours An initial injection of 100mg promazine and 4g pentobarbitone is administered by the deep-intramuscular route into the buttock using separate syringes and needles (because mixture of these drugs causes [3.135.202.224] Project MUSE (2024-04-17 01:52 GMT) The Management of the Acute Withdrawal Phase in Alcoholism 3 precipitation). Following this, 20ml parentrovite is injected intravenously. These do not normally take effect for about 30 minutes, and during this period the patient is encouraged to eat a light meal with liberal fluids. In view of the deep sedation normally produced, antibiotic cover is given as a routine, usually as 500,000 units of crystalline penicillin intramuscularly. Injections of pentobarbitone, promazine and penicillin similar to the first are repeated after 8 and 16 hours, making three injections in all. The patient is kept propped up by pillows and is roused 4hourly . Fluids are encouraged, to achieve a total intake of 2.5 litres...