BACKGROUND: Outpatient management of symptoms from acute alcohol withdrawal usually includes a tapering regimen of a benzodiazepine such as lorazepam (Ativan). Benzodiazepine use is usually limited, however, by the potential for medication abuse and side effects such as central nervous system impairment. Because studies have demonstrated that carbamazepine can be effective for the treatment of alcohol withdrawal symptoms, this study compared the effectiveness of carbamazepine with that of lorazepam.
POPULATION STUDIED: The 136 patients were self-referred and fulfilled Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for alcohol dependence and alcohol withdrawal. Patients lived within 50 miles of the study site, and had an admission blood alcohol level < 0.1 g/dL, a Mini Mental State Examination score of 26, and an admission score on the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) 10 out of a possible score of 20. Patients were excluded if they had substance abuse syndromes other than alcohol dependence, nicotine dependence, or cannabis abuse; major Axis I psychiatric disorder; used benzodiazepines, beta-blockers, calcium channel blockers, or antipsychotic agents within the past 30 days; a history of head injury; neurologic illness; or grossly abnormal laboratory values.
STUDY DESIGN AND VALIDITY: This was a randomized double-blind trial comparing 2 different treatments for alcohol withdrawal. Allocation to treatment group was concealed from enrolling physicians. The patients received a 5-day taper of either lorazepam 6–8 mg tapered to 2 mg or carbamazepine 600–800 mg tapered to 200 mg. Withdrawal symptoms were measured using a validated CIWA-Ar tool. Patients also completed a daily drinking log to assess alcohol use prior to, during, and 7 days after study completion. The study evaluated 89 patients after the treatment period for number of drinks taken per day.
OUTCOMES MEASURED: Alcohol withdrawal symptoms and posttreatment alcohol use measured by the CIWA-Ar scale were the primary outcomes. Side effects were reported as a secondary outcome.
RESULTS: Both drugs were equally effective in reducing alcohol withdrawal symptoms. Over time, alcohol withdrawal symptoms were more likely to occur with lorazepam treatment (P = .007). After treatment, relapsing patients receiving carbamazepine had fewer drinks per day than those receiving lorazepam (1 vs 3; P = .003). Effectiveness varied based on whether patients had attempted alcohol detoxification in the past. Of the patients who reported prior multiple detoxifications, those receiving carbamazepine drank less than 1 drink per day as compared with 5 drinks per day in the lorazepam-treated group (P = .004). The overall frequency of side effects were the same for both groups; however, clinicians recorded dizziness and incoordination in more patients on lorazepam than carbamazepine (22.7% vs 6.9%; P = .02). Pruritus occurred more often in the carbamazepine group than the lorazepam group (18.9% vs 1.3%; P = .004).
Carbamazepine is an effective alternative to benzodiazepines for the outpatient treatment of alcoholic withdrawal symptoms. Carbamazepine appears to be particularly effective for patients in whom detoxification failed in the past.