Addiction Medicine, Article

Management of alcohol withdrawal and nicotine replacement therapy

alcohol withdrawal andnico”>American Journal of Emergency Medicine 35 (2017) 1956-1983

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Management of alcohol withdrawal and nicotine replacement therapy

Long et al.’s review of the emergency medicine management of alco- hol withdrawal deserved comments [1].

First all must be prevention, rather than early diagnosis. It relies on identification and treatment of pre-existing concomitant medical prob- lems (eg. pain, infection, dehydration …), organization for staff avail- ability (helping to reorient the patient to time, date and place; avoiding unnecessary wards change; taking time to provide reassur- ance). Among concomitant problems, nicotine withdrawal may rank first because alcohol users are frequently smokers. Indeed, ventilated critically ill smokers necessitate supplemental sedatives, neuroleptics, and physical restraints [2]. Nicotine replacement therapy prevents agi- tation in smokers with schizophrenia in the emergency setting [3].

Second, the claim “ketamine requires further study” is flying in the face of evidence. Ketamine produced hallucinations and nightmares. This relation between delirium and ketamine has been known since the beginning, fulfilling the simple dose-response principle of pharma- cology, without the least room for paradox: Severe delirium for more than 10 min was recorded in 10% of patients given total doses up to 2 mg/kg for minor surgery in non-vulnerable patients and up to 24% of those given 3 mg/kg [4,5]. Surprisingly, this did not preclude Avidan et al. to perform an international randomized controlled trial with keta- mine to prevent postoperative delirium after major surgery in older adults [6]. They observed no decrease in delirium but harm by inducing negative experiences.

Alain Braillon MD, PhD

Alcohol treatment unit, University hospital, 80000 Amiens, France

E-mail address: [email protected]


  1. Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. Am J Emerg Med 2017;35:1005-11.
  2. Lucidarme O, Seguin A, Daubin C, Ramakers M, Terzi N, Beck P, et al. Nicotine with-

    drawal and agitation in ventilated critically ill patients. Crit Care 2010;14:R58.

    Allen MH, Debanne M, Lazignac C, et al. Effect of nicotine replacement therapy on ag- itation in smokers with schizophrenia: a double-blind, randomized, placebo-con- trolled study. Am J Psychiatry 2011;168:395-9.

  3. Dundee JW, Knox JW, Black GW, et al. Ketamine as an Induction agent in anaesthetics.

    Lancet 1970;1:1370-1.

    Clarke HL. Ketamine. Lancet 1970;2:464.

  4. Avidan MS, Maybrier HR, Abdallah AB et al. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017. Online May 30.

    Author response to “management of alcohol

    withdrawal and nicotine replacement therapy” manuscript 16429?,??

    We appreciate the letter provided on our review, “The emergency medicine management of severe alcohol withdrawal.” [1] The letter ex- presses two primary concerns: 1) Need for prevention and management of concomitant problems, and 2) Ketamine’s use in alcohol withdrawal. We agree in that prevention of alcohol withdrawal is vital in improving patient outcomes. One of the most common complications of chronic al- cohol use is withdrawal, and the best treatment of withdrawal is to avoid its occurrence in the first place. The first step is to recognize the pa- tient at risk. Utilizing a standardized screening instrument for alcohol withdrawal identification can be helpful, as can important historical fac- tors such as prior episodes of alcohol withdrawal [2]. If a patient is deter- mined to be at risk, chlordiazepoxide 50-100 mg by mouth can be utilized, with referral to an outpatient rehabilitation program if the pa- tient desires cessation [2]. If appropriate for discharge, the patient should be discharged if he/she does not desire cessation. If a patient who is chronically inebriated presents intoxicated, these patients require close evaluation for complication (hypoglycemia, intracerebral hemorrhage, sepsis) and reassessment at regular periods (such as every hour) for clin- ical sobriety. If the chronically Intoxicated patient is ambulatory, commu- nicative, and displays clear thinking, he/she is likely at risk for withdrawal. As the letter states, these patients also commonly demonstrate concomitant issues such as nicotine addiction. Patients with nicotine withdrawal demonstrate higher rates of agitation and delirium, and ap- proximately 20-46% of admitted ICU patients are smokers [3,4]. Nico- tine addiction results in changes of nicotinic acetylcholine receptors, modulating neurotransmission [4-6]. Withdrawal disrupts neurotrans- mitter pathways, resulting in symptoms of anger, frustration, anxiety, sleep disruption, restlessness, and bradycardia, among others [4-7]. After abstinence, symptoms begin within 1-2 days and peak in the first week. Most patients admit if asked to nicotine use and dependence, though many Screening tools are available [8]. However, this may not be easy to assess in critically ill patients, such as in severe alcohol with- drawal. If nicotine dependence is known or suspected, nicotine replace- ment can be provided. However, the emergency physician’s primary goal must be management of alcohol withdrawal, which is life-threatening

    [1], rather than focusing on treatment of nicotine withdrawal.

    The next point of the letter expresses concern for the use of keta- mine, stating this medication produces hallucinations, nightmares, and delirium. However, the studies utilized in the letter are from 1970 eval- uating ketamine in anesthesia [9,10], followed by a 2017 study evaluat- ing ketamine intraoperatively for postoperative delirium or pain after

    ? Conflicts of interest: None.

    ?? DL, BL, and AK conceived the topic idea, completed the literature review, and drafted the manuscript. BL and AK assisted with editing and further refining the manuscript. References were confirmed by DL, BL, and AK.

    0735-6757/(C) 2017

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