What is the treatment for alcohol intoxication?

Treatment of Alcohol Intoxication

Acute Intoxication Management

For mild-to-moderate acute alcohol intoxication (blood alcohol concentration <1 g/L), supportive care with clinical observation is sufficient without pharmacological intervention. 1, 2

Initial Stabilization and Assessment

• Management decisions should be based on clinical presentation (cognitive abilities, vital signs, mental status) rather than waiting for specific blood alcohol levels. 1
• Psychiatric evaluation can proceed immediately in alert, cooperative patients with normal vital signs, regardless of elevated alcohol levels. 1
• Stabilize vital functions first: monitor airway patency, breathing, circulation, and prevent aspiration. 2, 3
• Check for hypoglycemia, hypotension, hypothermia, and electrolyte imbalances—correct as needed. 2, 3

Thiamine Administration (Critical)

• Administer thiamine immediately to all patients with severe intoxication to prevent Wernicke's encephalopathy. 1, 4
• Oral thiamine 100-300 mg/day is adequate for standard cases. 4
• Parenteral thiamine is mandatory for high-risk patients (malnourished, severe withdrawal suspected, or signs of Wernicke's encephalopathy). 4
• Never delay thiamine when Wernicke's is suspected—irreversible neurological damage occurs rapidly. 4

Severe Intoxication (BAC >1 g/L)

For severe cases, additional interventions include:

• Intravenous fluid resuscitation for hemodynamic support. 2, 3
• Administer B-complex and vitamin C. 2
• Metadoxine can be used to accelerate ethanol metabolism and elimination. 2, 3, 5
• Continuous monitoring in observation unit or ICU depending on severity. 2

Critical Pitfalls to Avoid

• Do not order routine toxicologic screening in alert, cooperative patients with normal vital signs—it shows only 20% sensitivity for organic etiology and rarely changes management. 1
• Do not delay psychiatric evaluation waiting for blood alcohol results if the patient demonstrates adequate cognition. 1
• Avoid using intravenous ethanol—it has questionable efficacy, inconsistent pharmacokinetics, and a narrow therapeutic index. 6

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Alcohol Withdrawal Management

If the patient develops withdrawal symptoms, benzodiazepines are the first-line treatment to prevent seizures and delirium tremens. 1, 4, 7

Benzodiazepine Selection and Dosing

• Long-acting benzodiazepines (diazepam, chlordiazepoxide) are preferred for most patients due to better seizure and delirium prevention through gradual self-tapering. 4
• For acute alcohol withdrawal, diazepam 10 mg IV/IM initially, then 5-10 mg every 3-4 hours as needed. 7
• Use intermediate-acting benzodiazepines (lorazepam) in elderly patients, those with liver failure, respiratory compromise, or severe comorbidities. 4
• Start lorazepam at 6-12 mg/day and taper following resolution of withdrawal symptoms. 4
• Never prescribe benzodiazepines beyond 7-14 days to prevent iatrogenic dependence. 4

Adjunctive Medications

• Do not use antipsychotics as stand-alone treatment—only as adjuncts to benzodiazepines in severe delirium unresponsive to adequate benzodiazepine doses. 1, 4
• Do not use anticonvulsants for prevention of alcohol withdrawal seizures. 4

Inpatient vs. Outpatient Decision

• Admit patients with risk of severe withdrawal, concurrent serious physical/psychiatric disorders, or inadequate social support. 1, 4
• Discharge is safe when: stable vital signs, CIWA-Ar score <8, no complications requiring inpatient care, and comprehensive follow-up plan exists. 1

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Long-Term Management and Relapse Prevention

After stabilization, all patients should be screened for alcohol use disorder and referred to addiction services. 2, 3

Pharmacotherapy for Abstinence Maintenance

• Acamprosate is the only intervention with high-quality evidence showing superiority over placebo for maintaining abstinence in detoxified, alcohol-dependent patients. 8
• Naltrexone or disulfiram can also be offered, though evidence is less robust. 1
• These medications should be initiated after acute withdrawal resolves, not during the first 3 months when mortality is primarily related to hepatitis severity rather than relapse. 8

Psychosocial Support

• Psychosocial support and engagement with mutual help groups (e.g., Alcoholics Anonymous) should be routinely offered. 1
• Brief interventions (15-minute personalized counseling) are effective in primary care for reducing excessive consumption in non-dependent drinkers. 8

Common Long-Term Pitfalls

• Overlooking concurrent substance use disorders that complicate recovery. 1
• Failing to provide medium-to-long-term support after initial detoxification—abstinence maintenance requires ongoing care. 8
• Not addressing underlying alcohol use disorder when AAI represents a sentinel event of chronic abuse. 2, 3