Creditability and Appropriateness of Lorazepam and Gabapentin Studies for the Detoxification of the Alcohol-Dependent Patient
Although benzodiazepines such as lorazepam remain the intervention of choice for the treatment of alcohol withdrawal symptoms based on a growing body of evidence that confirms their efficacy and relative safety, there are some significant risks that are associated with the use of lorazepam for alcohol detoxification, including potential benzodiazepine-alcohol interactions as well as the psychomotor and cognitive impairments that can result. Furthermore, the potential for cross-tolerance with alcohol may restrict the efficacy of benzodiazepines such as lorazepam in treating withdrawal symptoms. Therefore, identifying the optimal intervention or mix of interventions represents a timely and important enterprise. To this end, this paper provides an analysis of two peer-reviewed studies concerning the use of lorazepam and gabapentin for the treatment of alcohol withdrawal. The first study, “Safer use of benzodiazepines for alcohol detoxification: To avoid excessive dosing, be alert for falsely elevated CIWA-Ar scores” by Spiegel, Kumari and Petri (2012) concerns lorazepam and the second study, “Alcohol Withdrawal: When to Choose an Adjunctive Anticonvulsant,” by Spiegel and Radac (2010) evaluates the appropriateness of gabapentin for alcohol withdrawal interventions. Finally, a summary of the research and important findings from these two studies are provided in the conclusion.
Review and Analysis
Study No. 1: Spiegel, D. R, Kumari, N. & Petri, J.D. (2012, October). Safer use of benzodiazepines for alcohol detoxification: To avoid excessive dosing, be alert for falsely elevated CIWA-Ar scores. Current Psychiatry, 11(10), 10-19.
The symptoms that are typically associated with alcohol withdrawal are primarily caused by the adverse effects of long-term alcohol exposure on brain gamma-aminobutyric acid (GABA) and glutamate systems and benzodiazepines such as lorazepam are the current standard of care. The research to date indicates that the use of lorazepam has been shown to be effective in limiting or even preventing morbidity and mortality in patients who are at risk of or are experiencing alcohol withdrawal (Spiegel, Kumari & Petri, 2012). These authors, though, also caution that falsely elevated scores can result from the administration of one of the screening instruments that is commonly used by clinicians for assessment of alcohol withdrawal systems, the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) (Spiegel et al., 2012). For instance, according to Spiegel et al., “The qualitative description of certain alcohol withdrawal symptoms is prone to subjective misinterpretation and can result, excessive benzodiazepine administration, and associated sequelae” (p. 12).
In sum, when used with the CIWA-Ar and other alcohol-withdrawal interventions such as nutrition and supportive care, lorazepam is an effective treatment for alcohol-withdrawal symptoms. As Spiegel et al. emphasize, though, “Although most patients with alcohol withdrawal respond to standard treatment that includes benzodiazepines, optimal nutrition, and good supportive care, a subgroup may resist therapy (resistant alcohol withdrawal)” (p. 17).
Study No. 2: Spiegel, D.R. & Radac, D. (2010, April). Alcohol withdrawal: When to choose an adjunctive anticonvulsant. Current Psychiatry, 9(4), 26-33.
Although a growing body of evidence supports the use of benzodiazepines including lorazepam as the intervention of choice for alcohol detoxification treatment, these pharmaceuticals are not without their risks. For instance, Spiegel and Radac (2010) advise that, “The risk of benzodiazepine-alcohol interaction, however, and psychomotor and cognitive impairments associated with benzodiazepine use may limit early rehabilitation efforts in hospitalized patients” (p. 26). In addition, the potential efficacy and appropriates of benzodiazepines as part of a multidisciplinary intervention in outpatient settings is limited by cross-tolerance with alcohol (Spiegel & Radac, 2010).
Because petit mal and grand mal seizures are always possible among alcohol-dependent patients during the withdrawal period, Spiegel and Racac suggest that including gabapentin to the pharmaceutical regimen can provide a synergistically beneficial effect. According to Spiegel and Radac, “Adding anticonvulsants to acute benzodiazepine therapy has been shown to decrease alcohol withdrawal symptom severity, reduce seizure risk, and support recovery, particularly in patients with multiple alcohol withdrawal episodes” (p. 27). Following detoxification, the long-term use of anticonvulsants such as gabapentin may also reduce recidivism rates by decreasing the cravings for alcohol during the post-cessation period (Spiegel & Radac, 2010).
An important point made by Spiegel and Radac, though, that while the evidence does not support the use of anticonvulsants such as gabapentin only for the treatment of alcohol withdrawal symptoms, but rather as an adjunctive therapy that is particularly efficacious when used in tandem with benzodiazepines such as lorazepam. In this regard, Spiegel and Radac emphasize that, “Although the literature does not support anticonvulsant use for monotherapy in alcohol withdrawal symptoms, anticonvulsants show potential as adjunctive therapy. Gabapentin offers unique mechanisms of action and demonstrates advantages over benzodiazepine monotherapy” (p. 29). In addition, the risk of relapse and delaying relapse has also been reduced through the adjunctive use of gabapentin in alcohol detoxification (Spiegel & Radac, 2010). In sum, these researchers conclude that, “[When used as an] adjunct to lorazepam, gabapentin offers advantages in acute and long-term therapy of alcohol dependence with efficacy in alcohol withdrawal symptoms, low abuse potential, benign safety profile, and mood-stabilizing properties” (Spiegel & Radac, 2010, p. 32).
The research showed that benzodiazepines including lorazepam are the current evidence-based practice that is used for the treatment of alcohol withdrawal symptoms. The research also showed that despite the benefits that can accrue to the use of lorazepam for alcohol detoxification, the intervention is not without it risks, which include benzodiazepine-alcohol interactions as well as psychomotor and cognitive impairments. In addition, cross-tolerance with alcohol can limit lorazepam’s effectiveness in treating alcohol withdrawal symptoms. Consequently, there is a need to integrate anticonvulsants such as gabapentin into the treatment regimen in some cases in order to achieve optimal clinical outcomes, including reduced relapse and delayed relapse rates.
Spiegel, D. R, Kumari, N. & Petri, J.D. (2012, October). Safer use of benzodiazepines for alcohol detoxification: To avoid excessive dosing, be alert for falsely elevated CIWA-Ar scores. Current Psychiatry, 11(10), 10-19.
Spiegel, D.R. & Radac, D. (2010, April). Alcohol withdrawal: When to choose an adjunctive anticonvulsant. Current Psychiatry, 9(4), 26-33.
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