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Successful Use of Trazodone for Acute Alcohol Treatment

 

First published in Psychiatry Weekly, Volume 2, Issue 9, on February 26, 2007

David L. Ginsberg, MD

 

Director of Outpatient Services, Tisch Hospital’s Department of Psychiatry, New York University Medical Center

 

Many clinicians use trazodone, the second-generation antidepressant, in low doses as a sedative-hypnotic agent for antidepressant-induced insomnia. But over 25 years ago, it was shown to be effective in alcohol withdrawal treatment. Since then, few studies have been conducted. Of those that were, many focused on lasting post-withdrawal symptoms such as sustained alcohol craving, depression, and insomnia. In an open-label trial, adjuvant trazodone has been shown to be helpful to alcoholics in maintaining abstinence, significantly decreasing alcohol craving, as well as depressive and anxious symptoms in detoxified alcohol-dependent subjects after 3 months of treatment. A survey conducted among addiction medicine physicians showed that trazodone is the preferred therapy for sleep disturbance in alcohol recovery. Due to its serotonergic properties, it is also effective in the treatment of serotonin selective reuptake inhibitor (SSRI) discontinuation syndrome. Now comes a report on the successful treatment of acute alcohol withdrawal with trazodone.

The Case           

A 30 year-old married Caucasian man had a 10 year history of alcohol dependence. During the prior 2 years, he worked as a restaurant manager and increased his alcohol intake, with an average of 13 drinks—beer, wine, or spirits—per day. His alcohol use was characterized by several episodes of loss of control with legal and marital consequences as well as marked professional difficulties. At his own request, he was hospitalized for alcohol detoxification. There was no history of prior treatments. Upon admission he presented in severe withdrawal with symptoms of tremor, insomnia, marked anxiety, and autonomic hyperactivity associated with depressed mood and alcohol craving. Hepatic enzymes were significantly elevated. A specific anxiety disorder was ruled out. Despite introduction of diazepam 100 mg/day and the gamma-aminobutyric acid (GABA)-ergic agent clomethiazole 1500 mg/day, symptoms of tremor, insomnia, marked anxiety, and alcohol craving persisted over the next couple of days. Consequently, the dose of diazepam dose could not be decreased. On day 5, adjunctive trazodone was introduced, up to 600 mg/24 hour. Over the next 48 hours, withdrawal symptoms significantly decreased. By day 13 of trazodone treatment, mood and sleep disturbances as well as alcohol craving remitted. Concomitant pharmacological agents were progressively stopped without relapse. Three months after discharge, on a maintenance regimen of trazodone 300 mg/day, the patient showed no signs of depression and reported decreased anxiety, normal sleep, and sustained abstinence. Liver enzymes were normal.

Conclusion

The case described above suggests that trazodone may be an effective treatment for acute alcohol withdrawal symptoms, particularly with comorbid depression and insomnia.

As pointed out by the authors of this report, the sedative and anxiolytic effects of trazodone are likely due to 5HT2 and 5HT1 receptor blockade. Since it does not possess anticonvulsant properties, in patients in alcohol withdrawal, trazodone should only be used in association with a benzodiazepine. Placebo-controlled trials of adjuvant trazodone in acute alcohol withdrawal would be useful to confirm and extend these preliminary findings.

Disclosure: Dr. Ginsberg is a speaker for AstraZeneca, Cyberonics, Forest, and GlaxoSmithKline; and has received research support from Cyberonics.