ASK DR. BAUGHAN                                             October 21, 1999

DETOX AIN’T WHAT IT USED TO BE

Although alcoholism remains one of the most widespread, expensive and deadly illnesses in the United States, the approaches to acute treatment of alcohol withdrawal and rehabilitation are changing dramatically.  Alcoholism still affects 6% of the population, or about 15 million Americans, and 100,000 deaths a year are attributed to alcohol.  As recently as five years ago, treatment typically consisted of in-patient treatment for 3-7 days, then transfer to a rehabilitation facility for 14 to 28 days.  As health insurers tightened the purse strings on health care expenditures, they stopped paying for rehab programs.  In 1999, almost all hospital or clinic based alcohol rehabilitation programs have closed in New England.  One reason was the expense.  Another reason was the effectiveness.  Unfortunately, one experience in a rehab center (at $5000 - $10,000 for 2-4 weeks) infrequently resulted in long term abstinence from alcohol.

The medical approach to alcohol detoxification is changing as well, and is well summarized in the September 15, 1999 article in American Family Physician, entitled “Outpatient Detoxification of the Addicted or Alcoholic Patient,” by C.D. Prater, K. Miller, and R. Zylstra.  It is no longer necessary to admit everyone for several days to sit around the hospital (usually at public expense) if there are not clear medical reasons, such as pancreatitis or a bleeding ulcer.  Not all alcohol withdrawal symptoms mean that the patient is developing “DTs,” or delirium tremens, a life-threatening neurologic and cardiovascular complication.  There are three stages of alcohol withdrawal.  In Stage 1, the person has shaking, a fast pulse, an elevated blood pressure, and feels agitated.  In Stage 2, the same symptoms are accompanied by “hallucinations with insight,” which means the person is seeing things, but he or she knows they are not real.  In Stage 3, all of the stage 1 symptoms occur, plus “hallucinations without insight” (the person is seeing things and thinks they are real) and a fever of 101 degrees or more.

If someone is able to monitor the patient, and they can follow daily with their health provider, stage 1 can be treated safely on an outpatient basis with medications to control symptoms and prevent seizures.  Stage  2 symptoms can be treated the same way if the hallucinations clear within 3 hours with medicine.  Stage 3 requires careful monitoring in the hospital.  Also important are vitamins, particularly thiamine, and lots of fluids.  Out-patient detoxification usually involves four days of daily visits.

Treating alcoholism involves much more than medical care.  A community must decide if “someone is able to monitor the patient,” who should that be?  Traditionally, it has been personnel in a hospital, even though skilled nursing or medical care may not be necessary.  If family or friends are fed up with someone’s drinking, do they still have an obligation to monitor detoxification when it is medically safe?  Or should the community bear the expense?  Equally difficult is the acutely intoxicated patient.  Someone cannot truly claim to want detox when they are intoxicated.  Their judgment is impaired; they by definition cannot make responsible decisions.  They are also not at risk for withdrawal when they are still drunk, but it is infrequent that someone presents to the hospital in the morning saying, “I have not had a drink since  yesterday, and I want help with detoxification.”

Wherever detoxification occurs, the true healing occurs when the alcoholic faces the rest of their life.  Long term sobriety is still best achieved with programs like Alcoholics Anonymous.  When I hear, “I don’t like AA,” my response is, “If you had cancer and needed chemotherapy, I wouldn’t expect you to like it.  But I would expect you to accept any therapy that had the best record of treating your disease.”  Rarely have I heard anyone say “I don’t like AA,” if they began to “work the steps.”  Working the steps is a challenging personal process, but it leads to remarkable growth and insight.  And it saves lives.  And it does not cost the community anything.