What should be done if a patient taking Acamprosate (Campral) experiences hallucinations?

Management of Hallucinations in Patients Taking Acamprosate

If a patient on acamprosate experiences hallucinations, immediately discontinue acamprosate and evaluate for alcohol withdrawal delirium, as acamprosate is not indicated during active withdrawal and hallucinations suggest either inadequate withdrawal management or an alternative diagnosis requiring urgent psychiatric or neurological evaluation.

Critical First Steps

Immediate Assessment Required

• Determine if the patient is in active alcohol withdrawal, as acamprosate should only be initiated 3-7 days after the last alcohol consumption and after withdrawal symptoms have resolved 1.
• Evaluate for delirium tremens or alcohol withdrawal delirium, which presents with hallucinations, agitation, and autonomic instability requiring immediate benzodiazepine therapy 1.
• Assess for other causes of hallucinations including medication side effects, psychiatric disease, Parkinson's disease, dementia with Lewy Bodies, or Alzheimer's disease 1.

Why This Matters

Acamprosate reduces withdrawal effects and craving but is specifically designed for maintaining abstinence in already-detoxified patients 1, 2. The drug has no role during active withdrawal 1. Hallucinations in this context suggest either:

1. Premature initiation of acamprosate before withdrawal resolution
2. Breakthrough withdrawal symptoms requiring benzodiazepines
3. An unrelated psychiatric or neurological condition

Pharmacological Management Algorithm

For Alcohol Withdrawal-Related Hallucinations

• First-line: Benzodiazepines are the primary treatment for alcohol withdrawal syndrome with psychotic symptoms 1:

  • Lorazepam 1-4 mg PO/IV/IM every 4-8 hours
  • Diazepam 5-10 mg PO/IV/IM every 6-8 hours
  • Chlordiazepoxide 25-100 mg PO every 4-6 hours

• Adjunctive therapy if benzodiazepines fail to control hallucinations: Haloperidol 0.5-5 mg PO every 8-12 hours or 2-5 mg IM, used carefully only when benzodiazepines alone are insufficient 1, 3.

For Non-Withdrawal Hallucinations

• If hallucinations persist despite adequate benzodiazepine therapy, consider haloperidol 0.5-2 mg IV in slow bolus for delirium with hallucinations 1.
• Monitor for extrapyramidal side effects and QT prolongation with haloperidol use 1, 4.

When to Resume Acamprosate

Only restart acamprosate after:

• Complete resolution of withdrawal symptoms (typically 3-7 days after last alcohol use) 1
• Confirmation that hallucinations were withdrawal-related and not due to acamprosate itself
• Psychiatric evaluation if any diagnostic uncertainty remains 1

The standard dosing is 1,998 mg/day for patients ≥60 kg (reduced by one-third for <60 kg) for 3-6 months 1.

Common Pitfalls to Avoid

• Do not continue acamprosate during active withdrawal or when hallucinations are present - this represents either misuse of the medication or an alternative diagnosis 1.
• Do not assume hallucinations are benign - atypical features including lack of insight into unreality of images, interactive hallucinations, or associated neurological signs require urgent medical or neuropsychiatric evaluation 1.
• Do not use haloperidol as monotherapy - benzodiazepines remain first-line for alcohol withdrawal, with haloperidol only as adjunctive therapy 1, 3.
• Do not forget thiamine supplementation - administer 100-300 mg/day before any IV glucose to prevent Wernicke encephalopathy 1, 3.

Alternative Considerations

If acamprosate is contraindicated or ineffective after resolution of acute issues, consider baclofen (30-80 mg/day) as an alternative abstinence-promoting agent, particularly in patients with liver disease where it has demonstrated safety and efficacy 3.