1352 HOOVER: MANAGEMENT OF ALCOHOLIC INTOXICATION
83
psychological factors in the majority of alcohol
addicts.
3. Most alcohol addicts can be effectively treated
if the physician takes the trouble to feel secure witl
his knowledge of the condition and thereby conveys
his confidence to the patient who seeks help.
4. The first interview of an alcohol addict with a
physician is all-important. It should serve to dis-
prove the worn-out concept that "only an alcoholic
can understand an alcoholic". If the physician
appreciates that initial resistance to treatment is
an integral part of this self-perpetuating disability,
he can be mentally prepared to cope with resist-
ance and not become exasperated or discouraged
by relapses in the early stages of rehabilitation.
From the first interview the physician should think
in terms of periodic contact with his patient for at
least two years regardless of whether he is partici-
MANAGEMENT OF ACUTE
ALCOHOLIC INTOXICATION
MURRAY P. HOOVER, M.D.,' London, Ont.
MANAGEMENT OF the acute alcoholic patient is a
problem to most physicians. With this in mind, an
attempt will be made to offer suggestions that mav
help in the treatment of such patients. Management
includes specific treatment by drugs and admission
to hospital, where indicated, and also a type of
approach likely to promote co-operation and
adequate follow'-up care.
In general, acute intoxication is not a medical
emergency. While cases of death due directly to
excessive intake do occur, in over five years' experi-
ence the author has not encountered one such
death. However, severe hematemesis, hepatic
cirrhosis and inability to be roused, often do re-
quire immediate action. Most problem drinkers
have prolonged bouts of drinking, but do not get
into really serious trouble before seeking help.
Often the request comes from a relative or friend,
because of a desperate home situation, before the
patient wants help. If the doctor responds in this
situation, he has to treat the relatives as well as the
patient.
These observations suggest that not only may
time be wasted but greater hostility may be
created in the patient towards the family and
doctor if visited under these circumstances. The
patient who is "forced" to submit to therapy usually
resumes the drinking habit as soon as he is able.
Most patients who seek medical attention do so
because of some form of fear or pressure related
*Clinical Director, London Branch, Alcoholism Research
Foundation.
Dec. 24, 1960, vol.
pating in an Alcoholics Anonymous program or
not, and should retain his role of supervising
physician and counsellor.
5. If all physicians were adequately oriented to
the clinical problems of addiction, there would
be fewer mistakes in administering drugs to
patients who cannot tolerate them normally or who
could be started on addiction in another form.
6. The problems of addiction are too great to be
dealt with effectively by any one specialty. Until
physicians as a whole are willing to participate
in treating and counselling the addict, little im-
provement in the clinical management of addiction
can be expected.
REFERENCES
1. HAYMAN, M.: Am. J. Psychiat., 112: 485, 1956.
2. BELL, R. G.: Canad. M. A. J., 81: 929, 1959.
3. ISBELL, H. et al.: Quart. J. Stud. Alcohol, 16: 1, 1955.
to health, employment, economics, or the home
situation. But there are many more who do not seek
help at all, no matter how desperate their circum-
stances or those of their dependents. Unless the
patient himself decides to avail himself of treat-
ment, it will come about only after considerable
pressure is applied, which may ultimately and re-
luctantly have to be legal in character. Armstrong'
has recently reviewed the question of using earlier
legal pressure in the management of the "chronic
repeater".
The acutely intoxicated patient is best treated in
hospital, but obstacles are often encountered-a
bed shortage and the hospital's dislike of the
disturbing behaviour of these patients.
There are many and valid reasons why doctors
should take a more active interest in the treatment
of acute alcoholism. The number of patients suffer-
ing from this illness places it among the most im-
portant public health problems today. If it is as-
sumed that not more than 10%v of all alcoholics are
receiving treatment in any form, and at this figure
the available resources are taxed at present, more
help will be needed as education increases, as the
stigma is gradually lifted and more patients come
for or are compelled to take treatment. The family
doctor usually makes initial contact with the pa-
tient in the home and it is suggested that if he is
not interested in treating him after the acute
phase, then he should have him referred for further
help. In many respects the alcoholic is the same
type of dependent, anxious, hostile, symptom-laden
person as the neurotic or hypochondriac. Certainly
there is no magic formula anywhere for treatment,
but the results obtained by an all-out attack in a
small percentage of patients are encouraging and
suggest that this should be tried in all cases.
Canad. M. A. J. HOOVER: MIANAGEMENT
2^.24, 1960, vol. 83
The commonest situation with which the phys-
ician is faced begins with a telephone call from
an intoxicated patient or his relative requesting
help. If the patient has one of the complicating
features mentioned above, then, if at all possible,
he should be admitted to hospital. If the physician
feels unable to cope with the aggressive, wild type
of patient, he should have him admitted to an
observation or psychiatric ward where such prob-
lems are commonly handled. If the patient is fairlv
rational but refuses hospitalization, even when
deemed essential, he cannot, in Ontario, be forced
to enter unles.s he is (a) certified as mentally7 ill,2
(b) certified for temporary admission as a habitue
or (c) committed on a warrant of habituation-up
to a maximum of two years. Certification as
mentally ill is not common, since the patient must
show evidence of a toxic psychosis and is usuallv
sent home as soon as his toxic state has disappeared.
This method of admission requires considerable
time and effort and results in too short a period
in hospital for the patient to be helped very much.
Certification for temporary admission of a habitue
can achieve retention of the patient in an Ontario
hospital for a maximum of 30 days. Thlis is a very
useful procedure but unforttunately can be used
only at the discretion of the hospital superintendent.
This procedure can be particularly useftul when
the patient refuses treatment and is a real menace
to his family and himself duiring a protracted
drinking bout. The third procedure hals little
practical value in the isolated acute situation.
The patient who has no obviouis complicating
features may not come to the office. If one
can be fairly certain that there is no real danger,
it may be better to tell the relatives that he
will be seen when he wants help. However, it
must be kept in mind that the jutdgment of the
toxic patient is warped and his ability to make a
decision is limited. Often the deciding factor is the
increasing discomfort which he experiences as the
bout continues, and his decision for help is based
on his desire to get relief from this: a discomfort
that can no longer be relieved by alcohol. The
frequency with which he repeats these experiences
strongly suggests that his suffering to the point of
intolerance does not facilitate his motivation over
a longer time.
If the call is from a relative of the patient or
from a patient who desires help and does not need
emergency treatment, an approach can often be
decided upon by knowing wlhether the patient is a
chronic repeater or this is a first request. The pa-
tient asking for attention for the first time should
be helped in every reasonable way to enter upon
treatment. Initial assessment at home, if the pa-
tient is too ill to come to the office, is indicated.
If it seems likely that the patient is unable to resist
further drinking, hospitalization may be necessary.
The patient should be approached with understand-
ing and told that he can be helped if he reallx'
wants it. As a test of motivation and as an added
OF ALCOHOLIC INTOXICATION 1353
crutch the patient can be offered, both at home
and at the clinic, the combination of disulfiramn
(Antabuse, one tablet) and chlorpromazine (four
25-mg. tablets) initially, as stuggested by Cummins
and Friend.3 Using this procedure in many cases,
the author has noted no reaction to Antabuse to
date, except when the patient resumed drinking the
next day. Antabuse may be continued indefinitely
and chlorpromazinie used in divided doses until
the acute phase is over. It is often preferable to
see this patient daily, either at the office or at
hiome, iuntil the acute phase is. over, as this is of
value to the dependent person and indicates
interest in him. Vitamin B complex injections,
tranquillizers and sedatives are commonly given,
but long-range dependence on these is not advis-
able. Anorexia, nausea and vomiting, dehydration
and electrolyte disturbances soon reverse them-
selves.
Btut management of the patient has only just
begun. If the physician is interested and has the
time, he may decide to see the patient on a
regular basis for an indefinite period, to give
him support and encouragement. Otherwise, he
should be referred to a private psychiatrist, a
mental health clinic, or some reputable group
specifically concerned with the treatment of alco-
holism, while his motivation is still satisfactory.
It is this provision of long-range help and under-
standing that seems to make the difference between
success and failure. The family as a whole should
be encouraged in this direction.
As for the chronic repeater, he should be en-
couraged to see the doctor, rather than the reverse.
This enables him to realize sooner that he must
expend some energy in the direction of self-help.
Too often this patient is catered to and allowed to
contintie in his unhealthy dependency upon people
and alcohol until he has enslaved his environment.
The incorrigible alcoholic patient who will not or
cannot accept responsibility for his drinking and
other behaviour, and who is a chronic menace to
himself and others, must be considered a candidate
for an institution on a long-term basis. There mav
be sufficient brain damage to rtule out any thought
of responsible motivation on the part of the pa-
tient. Many of these patients do spend considerable
time in penal institutions and occasionally they are
able to reset their sights. In Ontario, committal to
an Ontario hospital on a warrant of habituation2
for a period not exceeding two years is the only
means of dealing with such a patient on a rela-
tively long-term basis. An important point here is
for the relative or friend to make the decision and
then follow through with it. Further legislation'
has been suggested in Ontario that would give
a wider measure of legal control over the alcoholic
patient and at an earlier stage in his illness.
A clinic, such as the Alcoholism Research
Foundation clinic in certain cities in Ontario.
and comparable clinics in some other provinces,
can be helpftul to the average doctor, especially in
 1354 HOOVER: MANAGEMENT OF ALCOHOLIC INTOXICATION Canad. M. A. J.
Dec. 24, 1960, vol. 83

continuing therapy at the outpatient level where almost always entered the psychiatric service. This,
the doctor's time, training and inclination do not it is felt, is preferable to a general ward for one
permit this. Where such a focal point for treatment reason only. The staff on such a service are more
does not exist, other professional help in the com- experienced with and tolerant of the agitated, rest-
munity can often be found-a psychiatrist, a mental less patient who may be aggressive at times. Should
health clinic, a social agency. a patient develop a toxic psychosis, again it is con-
In London, Ontario, the approach is essentially sidered that the facilities for managing this con-
as suggested above. Referrals come from Alcoholics dition are better. However, if no special service is
Anonymous, physicians, the patient, family and available to which these patients can be admitted,
friends, and other patients, in this order of fre- this should not deter admission.
quency. The "open door" policy has been adopted Treatment in the past has been more often
for repeaters as well as new referrals. The alcoholic empirical than physiological. The widely used
comes to know that even if rejected by all other "insulin cocktail", consisting of 50 c.c. of 50('r
sources of help, he is welcome at the clinic and will glucose with 15 to 50 units of regular insulin, given
find an understanding, non-judgmental atmos- intravenously, is an example of the former. As
phere. Many acute cases are referred. The more is being learned about the basic altered
acute alcoholic patient seen for the first time physiology and biochemistry, a more specific ap-
is managed occasionally at home or he may proach is possible. The malfunction of the organ-
be admitted to hospital if this seems warranted. ism as a whole, and underlying this of a wide
The chronic repeater is encouraged to come to variety of cellular structures, might be helped
the clinic no matter how miserable he feels, if alcohol could be eliminated more rapidly than
and by so doing his motivation for help on by natuLral metabolism. This is not yet possible.
our terms is tested. Repeated hospitalization is In any case, depending on the acuteness of the
usually not possible owing to a bed shortage, and problem, varying degrees of disturbed metabolism
is unnecessary and inadvisable because it mav are present which will take time or may need
foster a dependence on the hospital and even en- specific corrective treatment. KrystalF has presented
courage the patient to repeat this pattern. Many an excellent survey of the possible changes in
patients who, under a more lenient system, would fluids, electrolytes, enzyme systems and endocrine
be admitted and readmitted to hospital are brought function.
through the hangover phase by drugs (many by the Recently the trend has been away from intra-
combination of Antabuse and chlorpromazine) and venous
daily attendance over a few days. By adopting inducingglucose and insulin as a relaxing and sleep-
procedure, because it is a more involved
this policy, which we consider realistic within the procedure and demands greater nursing care. This
framework of available facilities for treatment, we has been supplanted by use of tranquillizing agents,
have been able to reduce admissions to hospital which are usually effective when given intra-
and house calls considerably (3 house calls in 10 muscularly or even
orally. They
months in 1959). Drugs are used liberally only often after a sleep the patient startsact rapidly, and
during the immediate recovery phase. Vitamin B quantities of fluid, soon graduating to taking copious
complex, intramuscularly or by mouth, is com- within 24 hours). As soon as improvement food (ofteii
monly used but not always considered necessary. intramuscular administration can be begins,
Barbiturates and paraldehyde are not used. The oral. Paraldehyde is not used because changed it acts in
to
a
common tranquillizers, promazine and chlor- similar manner to alcohol
promazine, are very helpful in reducing irritabilitv by producing acetal-
and restlessness, but are not mandatory. We have dehydetinue the
during metabolism, thus tending to con-
same state; it is clear how habituation can
made extensive use of a capsule containing change from alcohol to the other. Use of bar-
mephenesin, acetylcarbromal and reserpine (Anai- biturates is usually avoided. Dehydration is cor-
tenson Forte), and have found it effective and more
economical than most tranquillizers. Sedatives have rected as soon as the gastritis, nausea and vomiting
subside sufficiently to allow intake and retention
been restricted to chloral hydrate up to 45 grains of fluids. Very occasionally intravenous fluids are
per night, and glutethimide (Doriden) 0.5-1.0 g. per
night. A "total push" program is used after the necessary, owing to the rapid improvement in
acute stage. This includes physical examination, A gastrointestinal function when alcohol is avoided.
attending to the patient's specific physical prob- small dose of regular insulin (15-25 units) before
lems, by referral if necessary, psychotherapy, co- breakfast
intake
has been found helpful in restoring food
operation with Alcoholics Anonymous, administra- vitamin B rapidly. Supplementary intramuscular
tion of disulfiram (Antabuse) and citrated calciunm complex therapy is often recommended
and widely
carbimide (Temposil) where indicated, and the is considered the most used. Thiamine chloride (vitamin B,)
use of social and welfare agencies. essential one because of its
place in the Krebs metabolic cycle and its known
Treatment of the acutely toxic patient in hos- value in reversing an
pital is rarely difficult. In London, the patients chosis. Most vitamin Bearly acute Korsakoff's psy-
complex preparations con-
admitted to hospital from the Alcoholism Research tain small amounts of vitamin B1 and therefore
Foundation, by consent of Victoria Hospital, have are inadequate if larger amounts (50-100 mg.) are
Canad. M. A. J. HOOVER: MANAGEMENT
needed. Patients who respond slowly or in whom
one suspects impending delirium tremens are given
extra vitamin B1 as well as vitamin B complex
intramuscularly. Many patients. respond well with-
out added vitamins.
Night-time sedation is usually required initially.
Non-barbiturates, such as chloral hydrate and
glutethimide, are sufficient, especially when added
to the tranquillizers used by day.
The most severe and lethal complication of acute
intoxication is, delirium tremens, with the ensuing
confusion, extreme aggressiveness, lack of co-
operation, hallucinosis, and occasional epileptic
seizure. In the author's experience, the number
who develop this range from 5 to 10%, and they
usually develop it two to four days after beginning
withdrawal. Isbell and his co-workers6 produced
this condition experimentally in humans and found
that adequate food and vitamin intake was not
prophylactic. Krystal5 suggests, that any or all of
the following may be etiological factors: dehydra-
tion generally, brain swelling, salt depletion,
potassium excess, magnesium depletion, infection
and a panic state.
When a patient presents, with this picture, it is
a definite emergency. Electrolyte estimations
should be performed as soon as possible. Con-
vulsions should be treated by sodium luminal intra-
muscularly. For the difficult problem of restless-
ness, which tends to exhaust both patient and staff
and prevent the intravenous fluid from running
continuously, many approaches may be necessary.
One of the phenothiazines, in repeated doses intra-
venously, may be sufficient. If not, sodium luminal
or paraldehyde intramuscularly may be tried.
Sodium thiopental intravenously has occasionally
been required. The salt depletion is treated by
giving adequate amounts of normal saline intra-
venously. Potassium excess corrects itself. We have
not added magnesium to the therapy, but it can be
THE FINE ART OF INCONGRUITY
We have read in Chemical and Engineering News, a
journal of no small discernment, the harsh comment that
"basic research is starvin-' that the money spent last year
"for research on all diseases just equals the suim we spend
yearly for dog food"; that the salaries paid "make it nearly
impossible for a man in pure science to raise and educate
a family."
The occasion for their criticism is a review of J. H.
Heller's book, "Of Mice, Men and Molecules", which warns
against the neglect of basic research and describes the
work of the New England Institute of Medical Research
and its generalistic approach to disease. Such pointed ques-
tions arise as, What's the good of mastering space or seeing
the other side of the moon? How much will it add to
human well-being and happiness?
OF ALCOHOLIC INTOXICATION 1.355
given intramuscularly as a 20-50% solution of
MgSO4 up to 8 g. per day in divided doses. Vitamin
B complex, especially vitamin B1, is given intr.a-
muscularly every 12 hours. Desoxycorticosterone
acetate appears to be the hormone of choice, Al-
though ACTH has been widely used. Most com-
monly we have used long-acting ACTH (Duracton),
40 units intramuscularly every 12 hours, and then
gradually tapered the dosage off to allow restora-
tion of normal adrenal function. Last, but not least,
a quiet, patient, understanding atmosphere is. most
helpful in bringing the patient back to the reality
situation.
SUMMARY
An attempt has been made to presenit a practical
approach, from the standpoint of the average practi-
tioner, to the over-all management, whether at the
home, the office, or in hospital, of the acuitely alcoholic
intoxicated patient. It hals been suggested that certain
limits should be set, especially for the chronic repeater,
primarily with the view that he may be motivated in
the direction of accepting some responsibility and
treatment for his problem. The necessity for using any
technique or agency available has beeni stressed. If a
special clinic exists in an area, this service should be
used when necessary.
The specific medications employed in the manage-
ment of the acute withdrawal phase are mentioned, ancl
the fact that paraldehyde and barbiturates are not
used is commented upon. The emergency aspect of
delirium tremens is emphasized and measures for in-
vestigation and management are outlinied.
REFERENCES
1. ARMISTRONG, J. D.: J. Social Thlerapy, 5: No. 3, 1959.
2. Mental Hospitals Act, Revised Statutes of Ontatio, 1950,
Chapter 229.
3. CT MAnINS, J. F. AND FRIEND, D. G.: Am. J. MI. SC., 227:
561, 1954.
4. Medico-Legal Society of Toronto: Report of Committee
on Alcoholism, 1958.
5. KRYSTAL, H.: Am. J. IP'sychliat., 116: 137, 1960.
6. ISBELL, H. et al.: Quart. J. Staid. Alcohiol, 16: 1, 1955.
Not very much, it is suggested; and yet in fear that we
might fall behind the U.S.S.R. in missile and space tech-
nology, the Congress had advanced abundant funds for
those purposes. The journal goes on to explain that basic
research, on which all real progress must depend, commands
higher salaries in the U.S.S.R. than in the U.S., where
"love of science" has to make up the difference. They go
on to mention the unmentionable nightmare, too, in which
a new basic discovery renders obsolete the most ambitious
and extravagant ventures.
There is an implacable natural law that says you get what
you pay for; and it was some time ago (July 25) we
expressed happiness that the American people were now
spending more for medical research than for chewing gium,
though not nearly so much as for greeting cards. But even
so, dog food . . . that ain't hay.-Editorial, Medical Tribune,
November 7, 1960.