Bupropion and Alcohol Withdrawal: A Promising Path to Recovery?
In pharmacotherapy, certain medications wind up having unexpected treatment potentials. Bupropion is commonly recognized as an antidepressant and an Attention Deficit Hyperactive Disorder (ADHD) treatment. It is also used in smoking cessation. Bupropion has piqued the interest of researchers and medical practitioners on its potential to assist in alcohol withdrawal. Can it offer a unique contribution to help manage and reduce alcohol consumption?
Bupropion
Besides being used to treat depression, bupropion is also used to treat Seasonal Affective Disorder (SAD). This is a condition where a person gets depressed at the same time each year. It mostly occurs in the fall and winter, but on rare occasions, it occurs during summer and spring.
Bupropion Use in Treating Depressive Disorders
Bupropion hydrochloride is an antidepressant medication classified as an aminoketone. It was first introduced in 1985. Additionally, it has off-label uses, addressing concerns with sexual dysfunction, which is related to antidepressant use and generalized anxiety disorder. It is available in various formulations, including immediate-release (IR), sustained-release (SR), and extended-release (XL). Each formulation is released differently throughout the day.
At therapeutic doses, individuals may experience different side effects. These may include dry mouth, constipation, headache, nausea, agitation, insomnia, and weight loss. Notably, bupropion was temporarily withdrawn from the market in 1986 following reports of new-onset seizures in some bulimic clients. It was reintroduced in 1989 at lower dose ranges.
Contraindications include a history of seizures, eating disorders or individuals undergoing withdrawal from ethanol or CNS depressants. The risk of seizures is relatively low at 0.1% with daily doses below 300 mg. It rises to 0.4% with doses up to 450 mg daily. Careful consideration and monitoring should be done when using this medication.
Bupropion Use in Smoking Cessation in Alcohol-Dependent People
It is estimated that 80% of Alcohol-Dependent (AD) persons are smokers. About 70% of these individuals are dependent on nicotine. Alcohol and nicotine pose health risks independently. When used together, they increase the chances for health problems significantly. During or after treatment, most alcohol-dependent individuals choose to quit smoking. Furthermore, the study discovered that the use of tobacco-cessation components in AD treatment has no negative impact on recovery. It may help increase the chances of alcohol abstinence.
The safest and most common treatment method is Nicotine Replacement Therapy (NRT). It is, however, found to be less effective for alcohol-dependent people than for non-alcohol-dependent individuals. The alternative is sustained-release bupropion. It has been used as a monotherapy for non-alcohol-dependent smokers.
The safety and effectiveness of bupropion use are higher in people who have abstained from alcohol use for over 12 months. In a studies during early recovery, sustained-release bupropion did not help increase smoking-cessation outcomes in AD individuals. It was, however, well-tolerated. Bupropion is preferred for use due to its antidepressant effect. Most alcohol-dependent individuals have depression, anxiety, and insomnia.
Alcohol Withdrawal
After consuming alcohol heavily for an extended period, your body may become dependent on it. When you try to stop, you will have some unpleasant mental and physical side effects. These are called withdrawal symptoms. The symptoms start developing within hours of the last drink. They can range from mild tremors to delirium tremens. When the case is severe and results in seizures, death could occur if the problem is not identified and managed promptly. The reported mortality rate after delirium tremens attack is between 1% and 5%.
Causes of Alcohol Withdrawal
Most chronic alcohol users consume ethanol. It acts as a depressant for the Central Nervous System (CNS). Ethanol works by slowing down the excitatory part of the CNS (glutamate receptors). It also boosts the inhibitory part (GABA receptors). When the use of this depressant stops, the CNS experiences heightened activity because the inhibitory effects are removed. This leads to excessive excitation in the body, causing withdrawal symptoms.
Signs of Alcohol Withdrawal
Alcohol withdrawal can manifest in various ways, ranging from mild symptoms to severe conditions.
Mild symptoms can emerge within six hours of stopping alcohol consumption. If they do not worsen within 24 to 48 hours, recovery is likely. The presentation time and symptom severity vary based on factors like the client’s history of alcohol dependence and normal alcohol intake, so it is important to assess the severity of the symptoms instead of focusing only on the time since the last drink. Monitoring the time of the last drink is important for clients with a history of alcohol dependence. It is essential if they are presenting other symptoms.
According to clinical studies, the percentage of people who experience significant withdrawal symptoms ranges from 13% to 71%. This variation is because some people are more prone to the symptoms than others. Factors that make this possible include a history of delirium tremens, low blood platelets (thrombocytopenia), or low potassium levels (hypokalemia).
Mild Symptoms
- Feel restless and nervous and will have a sense of unease during the withdrawal period and may have difficulty falling/staying asleep.
- Profuse sweating even in cool temperatures (diaphoresis)
- Feelings of nausea and possible vomiting
- Persistent or throbbing headaches
- Mood swings, irritability, and depression may also occur.
Severe Symptoms
- Difficulty concentrating and confusion
- Rapid heartbeat (tachycardia)
- High blood pressure (hypertension)
- Extremely high body temperature (hyperthermia)
- Visual or auditory hallucinations
- Seizures, often within the first 48 hours
- Delirium tremens.
Some symptoms, such as visual hallucinations, tachycardia, hypertension, hyperthermia, and diaphoresis, can persist for up to seven days after alcohol cessation. These symptoms are often similar to withdrawal due to benzodiazepine or barbiturate use. It is thus crucial to consider medication history and social factors. It is to be noted that 40% of clients in the emergency departments have AUD, according to DSM-IV. Of those with trauma and showing alcohol withdrawal symptoms, about 52% had a Clinical Institute Withdrawal Assessment for alcohol score of more than 20. Twenty-four percent of the cases developed into delirium tremens. If untreated, delirium tremens account for 15% of deaths. When treated, the mortality rate reduces to 1%.
Diagnosing Alcohol Withdrawal
Recognizing alcohol withdrawal requires skillful physical examination based on the severity of the symptoms. People who are suspected to be suffering from alcohol withdrawal symptoms are also evaluated for other underlying health issues. The medical examiner will check for dehydration, infections, cardiac problems, gastrointestinal bleeding, and body injuries.
Lab tests, like electrolyte checks and blood counts, may be done. It is, however, unlikely to diagnose the problem. Persons with Alcohol Use Disorder (AUD) are likely to have baseline ketoacidosis due to poor nutrition. The lab tests may show acidemia with ketone production, which is common in people with diabetes. However, it may show euglycemia because of the absence of glycogen in the liver. The Clinical Institute for Withdrawal Assessment for Alcohol revised scale (CIWA-Ar) is used. It is a tool that is used to gauge the signs of withdrawal. The clinicians then decide who needs medical therapy.
Alcohol Withdrawal Treatment and Management
Treatment will vary, depending on the severity of the symptoms. The client should be kept calm to prevent escalation of mild symptoms to severe cases.
Supportive Therapy
This is also known as supportive care. The individual undergoing withdrawal symptoms is given comfort, encouragement, and assistance. Healthcare professionals provide emotional support to their clients who are experiencing anxiety, irritability, or mood swings. They are also educated about the withdrawal process, potential symptoms, and why adhering to the treatment plan is important. When clients understand what to expect during the withdrawal period, they are less likely to fear the process.
Supportive therapy also helps alcohol-dependent individuals develop coping mechanisms and strategies to prevent relapse. They are taught how to identify and avoid triggers. They understand stress-management techniques and can explore healthier ways of dealing with life’s challenges. Communication between AD individuals and the healthcare provider fosters trust. It becomes easy to identify emerging problems during the withdrawal process. However, there is a risk of a comorbid condition called Wernicke-Korsakoff syndrome. The healthcare provider should provide a mixture of folate, thiamine, dextrose, and a multivitamin to prevent this condition.
By itself, the supportive care approach is not effective for severe cases and may need supporting medical intervention. Tough issues have a CIWA-Ar score of eight to 15 or higher.
Medical Treatment
Medical management of withdrawal symptoms includes administration of benzodiazepines. These psychoactive medicines target the benzodiazepine receptors (BZ-R) in the central nervous system. They are used to manage seizures. In the emergency department, seizures constitute 1% to 2% of all annual visits in the United States.
Benzodiazepine is used in several scenarios, including anxiety disorders, insomnia, acute status epilepticus (a severe and prolonged seizure state), induction of amnesia (loss of memory), spastic disorders (muscle stiffness and spasms), seizure disorders, and agitation. The comprehensive nature of benzodiazepine usage requires a thorough understanding of its indications, mechanisms of action, safe administration practices, potential adverse effects, contraindications (conditions where their use is not recommended), toxicology, and the need for vigilant monitoring.
When used to manage withdrawal symptoms, intravenous diazepam or intravenous lorazepam is used. In cases where the individual shows severe withdrawal symptoms, there may be a need for escalating benzodiazepine doses. Close monitoring at an intensive care level might also be necessary. Early consultation with a toxicologist is recommended since there is potential for complex cases. For instances where there might be a need for a higher dosage of benzodiazepine than what the practitioner administers, toxicologists provide management strategies.
Inpatient Services
Normally, clients with mild withdrawal symptoms can be treated without admission. However, when no support systems are available, the individual has suicidal intentions or has a history of withdrawal seizures, admission is necessary. Clients with a high risk of delirium tremens, other substance use disorders, and concomitant psychiatric problems should also be admitted.
Bupropion Use in Alcohol Withdrawal
A research study about the coadministration of low-dose naltrexone and bupropion for the reduction of alcohol drinking was done. By itself, neither bupropion nor naltrexone is able to reduce alcohol intake in the subjects. When naltrexone (10.0 mg/kg BW) and bupropion (10.0 mg/kg BW) were combined and given as a single dose, there was a reduction in alcohol consumption after continued treatment.
The research concluded that when used together, modest doses of both Bupropion and Naltrexone, two ineffective drugs, now enhance the effectiveness of the total medication. Using low drug doses helps avoid potential negative side effects associated with higher amounts of either drug. This reduction in side effects can enhance client compliance. It helps contribute to better clinical outcomes for individuals with alcohol use disorder (AUD) or heavy drinkers aiming to decrease their alcohol intake. These findings and insights from their earlier studies underscore the robustness of a combined pharmacotherapeutic strategy in treating AUD.
According to this PubMed Central research article, the neurobiological processes that explain how bupropion affects ethanol intake are presently not understood. However, one potential explanation is that bupropion may activate melanocortin (MC) signaling. Previous research has demonstrated that MC signaling can affect how much alcohol a person consumes. It is influenced by two important brain chemicals: dopamine (DA) and norepinephrine (NE).
It is also possible that bupropion works by preventing the breakdown of dopamine in the brain. This aligns with the well-known role of dopamine in pleasure and reward. By preserving higher levels of dopamine, bupropion could help reduce alcohol cravings and ease withdrawal symptoms.
Dealing with alcohol withdrawal is complex, and everyone responds differently to medications. Seeking professional advice is vital to understand how bupropion may work for you, the right dosage and any possible interactions. Trying to manage withdrawal on your own can lead to unexpected outcomes. Remember, 25% of people with alcohol use disorder get back to an alcohol-free life after they use professional services, according to studies.
So, seek the help of professional healthcare to get personalized and safe support during this process. Your well-being matters, and getting the right guidance ensures a safer and more effective approach to addressing alcohol-related concerns. Joining support groups and meeting people with similar issues may also help, or give us at a call at Alcohol Awareness so that we can help you get back on your feet.