It appears that we won’t know what caused Amy Winehouse’s death for several months, but if the singer did die from alcohol withdrawal, as has been speculated, the tragedy of her loss will be compounded by the fact that such deaths are almost always preventable.
I spoke recently with Dr. Charles O’Brien, director of the University of Pennsylvania’s Center for Studies in Addiction about the the best ways to detox.
What’s the first thing that should be done when someone wants to quit drinking?
First of all, they need a complete medical evaluation. A lot depends on how high their alcohol intake has been. Sometimes, withdrawal can even occur when someone goes from high intake to a medium or low intake.
They also have to be treated in a medically sound place. There are some places where they detox people without medical treatment. That’s dangerous because alcohol withdrawal is a serious and potentially fatal condition.
[Detox] always requires a full physical examination. Very often people need intravenous fluids; they need electrolytes and high doses of B vitamins. Everyone needs that and the reason is that there’s brain damage from alcohol and lot of it involves deficiency of B vitamins, especially thiamine.
We typically give an injection of thiamine. That will reverse a lot of the brain changes if they get it early enough, so this is really important.
Before people are ready to stop drinking, should they take extra thiamine and B vitamins?
Sure. If people are drinking they should also recognize that alcohol has calories in it and tends to reduce your appetite. When you’re not hungry, you don’t eat a balanced diet and [people with alcoholism] often are malnourished. That’s damaging to the brain.
Alcohol is toxic to lot of organs in body, [not just the brain and liver].
So what is the best way to treat withdrawal itself?
You need to give a medication that suppresses the withdrawal. One way, theoretically, that that could be done is by giving alcohol, but obviously you don’t want to do that.
There was a recent Cochrane review that examined treatment for alcohol withdrawal, which moderately favored benzodiazepines but did not find that much evidence.. .
Yes, the best thing we find is benzodiazepines. We use Ativan (lorazepam) here because it has a very low abuse potential. We also use Serax (oxazepam) quite a lot because it doesn’t have to be metabolized by the liver. [Alcoholics] usually have compromised liver function. But you could also give Valium. You give a higher dose at first and gradually taper it over three to five days.
And that prevents seizures and other complications from withdrawal?
Unless, of course, they already have a seizure disorder. Then, they may need to be on continuous anticonvulsants. If they never had seizures before, you can generally assume that they won’t as long as you treat them adequately.
Some people are suggesting using baclofen, which is also being studied to fight craving.
It probably works, but not better than benzodiazepines. There are a lot of things that work, but the tried and true are the benzodiazepines.
Do all people with alcoholism need inpatient detox or can most be treated outpatient?
We actually instituted a program here in the ’70s for outpatient detox but it requires coming in every day. There’s so much alcohol out there that they often go back on it.
But we did a study that was published in the New England Journal of Medicine in 1980. We randomized people to either outpatient or inpatient detox and found that the results were essentially equal. [However,] we would never do outpatient with anyone who has previously had seizures or someone who has complications. The average patient is usually able to detox outpatient.
A lot of people seem to think that detox is all the treatment that is needed, that once the physical withdrawal is complete, they are done.
That’s a bad mistake that is often made because health insurance only covers detox. Even if you have a 30-day program, that’s nothing. They still have a high probability of relapse after they leave.
What I recommend is giving long-term treatment and anticraving medications to try to prevent people from relapsing. Our favorite is naltrexone (ReVia, Depade). Acamprosate (Campral) is also a possibility. New drugs are being studied, but in the U.S. we have naltrexone and acamprosate.
We encourage everyone to try naltrexone. First, we have to talk to them and see if they’re willing. We do think you should at least offer it to everyone, and if we give naltrexone and they don’t like it or can’t take it, we try acamprosate.
We find that [naltrexone] really significantly helps. Some people say, ‘I’m cured,’ [and don't have any craving when they take it]. Maybe 25% to 30% say that. But more that 50% do better with it.