Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

592 V. TREATMENTS FOR ADDICTIONS(1,000 mg daily in divided doses) in reducing the symptoms associated withalcohol withdrawal. Further double-blind studies are needed before routine useof this drug can be recommended in alcohol detoxification. Several studiesreported on the use of valproate, which appears to show good success when usedalone for alcohol detoxification (Hillbom et al., 1989; Roy-Byrne, Ward, &Donnelly, 1989). Sodium valproate should not be used in those with preexistinghepatic or hematological abnormalities. The extended release formulationof valproate now available may be superior for detoxification in order to haveonce daily dosing, less variation in blood levels, reduction in toxicity (peak levels),and reduced symptom breakthrough during dosing (trough levels).Carbamazepine, an anticonvulsant that has been widely used in alcoholwithdrawal, has been shown to be superior to placebo in the rapidity withwhich it relieves alcohol withdrawal symptoms, including tremor, sweating,palpitations, sleep disturbances, depression, anxiety, and anorexia (Bjorkquistet al., 1976). In outpatient randomized clinical trials comparing carbamazepineto tapering dosages of benzodiazepines, the patients receiving carbamazepinehad higher success rates and fewer withdrawal symptoms during alcohol detoxification(Agricola, 1982; Malcolm, Ballenger, Sturgis, & Anton, 1989). In astudy comparing carbamazepine to lorazepam for treatment of alcohol withdrawal,participants were treated over 5 days with a fixed-dose taper ofcarbamazepine 800 mg versus lorazepam 8 mg on day 1. Follow-up showedthat both drugs effectively suppress withdrawal symptoms, but carbamazepinetreatedindividuals showed less posttreatment drinking behavior, and those whoreported drinking stated that they drank less following carbamazepine treatment(Malcolm et al., 2002). This finding has yet to be replicated in additionalstudies. Carbamazepine has common side effects of dizziness, nausea, and vomiting.It may induce the metabolism of drugs that are substrates of hepaticcytochrome P450-3A4 and should not be used in persons with severe hepatic orhematological disease(s). Its efficacy has also not been established in severealcohol withdrawal. However, carbamazepine can be effective alone as a withdrawalmedication in mild to moderate alcohol withdrawal syndromes.The combination of anticonvulsants and moderate doses of benzodiazepinescan facilitate successful alcohol detoxification in those with a history ofprevious alcohol withdrawal seizures or head trauma (Kasser, Geller, Howell, &Wartenberg, 1997). In these cases, the anticonvulsant should be administeredconcomitantly with benzodiazepines in dosages that will provide therapeuticanticonvulsant blood levels. The anticonvulsant should be tapered within aweek of completion of the benzodiazepine taper. There is no indication for continuationof anticonvulsant therapy in individuals who have experienced generalized,nonfocal seizures secondary to alcohol withdrawal. It is, however,important to assess such patients carefully, because any focal neurological signsmay be indicative of an underlying neurological disorder requiring treatment.Two newer anticonvulsants, vigabatrin and gabapentin, have been exam-