Ayurvedic Management of Alcohol Withdrawal Syndrome - A Case Report

Introduction

Alcoholic beverages were an integral part of our ethnic cultures, religious ceremonies, celebrations etc. It is a transparent, colorless, mobile and volatile liquid, having a characteristics spirituous odour and a burning taste [1, 2, 3, 4, 5]. It has got tonic and poisonous effects depends on the amount of intake. On moderate use of alcohol it causes a feeling of livelier, easier and relaxed [6]. When a person consumes alcohol regularly, despite of the fact that it causes consequences in their life, it is termed as Alcohol abuse [7]. Alcohol dependency is a full-blown addiction to alcohol [8].

In DSM V, alcohol abuse and alcohol dependence integrated into single entity, ie. Alcohol Use Disorders [9]. The etiological factors of alcohol dependency are epigenetic, psychological, social, biological and environmental factors, along with genetic susceptibility, is paving increased susceptibility, to all sorts of alcoholism [10]. The basic cause of alcoholism is resulting from the maladaptive coping response due to lowered self-esteem, so as to face high risk situation [11].

The drug which takes away the discriminative power of an individual by the virtue of the enhancement in the property of “tamas” is called ‘madakari’ drug, in the ancient science [12]. If a person is administering ‘Madya’ by taking into account the desa, kala and matra and even kula or familial status, then it will acts in is a positive manner [13]. Madya possess various properties and actions such as bṛihmaṇa, balya, rocana, dīpana, hṛidya etc. It is effective in the management of dyssomnias. In reduced sleep, it improves the quality of nidra in fact by its action on providing clarity to the channels of the mind. It also provides bala as well [14].

Madya is explained to have qualities or guṇas similar to viṣha, but in a milder form and also opposite to qualities of ojas. The alteration of ojus results in the imbalance between the dhatus and also in immune-compromise in the individual. So, if it is not administered properly, results in harm to the body and is termed as slow poison, by many. In Ayurveda, several recipes for preparation of madya, its indication and use are explained in detail. The condition resulting from the unfavorable intake of madya is explained under the broad heading of ‘Madatyaya’. Madatyaya is of four types as per the distribution of dosha status involved in the pathogenesis as Vataja, Pittaja, Kaphaja and Sannipata [15]. The symptomatology as well as management protocol is explained in detail [16].

In Madatyaya, all the three doshas may be involved, but the permutation may vary as per the causative factors [17]. So, management should be aimed primarily at pacifying the most predominant dosha. The ama stage if identified may be managed initially and get rid of. If all the doshas are aggravated equally then, Kapha should be pacified first, followed by Pitta and Vata respectively. The chronic conditions are usually of Pitta and Vata aggravation and needs its management [18]. Even the judicious use of preparation of medicated madya eg. Sreekhandasava, is also mentioned in certain stages.

Acarya Vagbhata explains the madatyaya treatment to be performed up to 7 or 8 days so as to overcome the ill effects, which is quite correct in the case of AWS [19]. It has been explained that the symptoms due to localization of madya in improper channels will be exhibiting only for 7 or 8 days and treatment is needed for those days [19]. Mild to moderate symptoms on stoppage of consumption of alcohol subsides by 7 or 8 days, with treatment from our experience. But in the case of Alcohol dependence, one has to adopt sodhana procedures followed by appropriate rasayana such as medhya rasayana, so as to attain enhancement [20].

Alcohol withdrawal syndrome (AWS) occurs when a heavy drinker suddenly stops or significantly reduces their alcohol intake [21]. AWS consists of symptoms and signs arising in alcohol- dependent individuals, typically within 24 - 48 hours of consumption of their last drink. AWS occurs intentionally in those seeking abstinence, but in an alcohol dependent patient it may occurs quite unexpectedly, even after admission to hospital and is very common.

Nausea and vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, head ache and fullness in head and orientation and clouding of sensorium are the major symptoms of AWS. But in case of abrupt cessation of alcohol consumption by a patient with alcohol dependence, may cause delirium tremens and withdrawal seizures, which may even leads to death [22]. Alcohol symptoms are occurring because of enhanced N- methyl – D – asperate (NMDA) receptor function; reduced transmission and deregulation of the dopaminergic system etc. [23]. Intervention, detoxification and rehabilitation are the three steps of management available [24].

Clinical Presentation

A 48 years old Indian Muslim male patient hailing from Kottakkal, presented in Ayurvedic psychiatry OPD, with the complaints of tremulousness of hands, increased agitation and anxiety, nausea and vomiting, increased sweating and decreased sleep. He had got married at the age of 20. At the age of 25, he started the intake of alcohol due to peer group pressure. Initially there was only occasional use, but later it developed into frequent use of alcohol. On increased worries, he amplified the amount of alcohol intake. This caused familial conflicts and he got divorced due to this alcohol problem. He got married again to a younger lady, she has some psychological problems. Due to the familial issues, the intake of alcohol increased. Daily intake of alcohol was there, since last 2 years. By the time, he lost his job and financial crisis got worsened. He thought about to stop the alcohol, but he couldn’t stop by himself. So he was admitted in the IPD of our institution.

Clinical Observations

Patient presented with symptoms such as tremulousness of hands, increased agitation and anxiety, nausea and vomiting, increased sweating and decreased sleep. On examination the patient was found to be so anxious, the appetite was much reduced. He was of medium body built, avara in satwa, avara in rogi bala and of avara in abhyavaharanashakti and Jaranashakti (low food intake and digestive power). The case was diagnosed as AWS with the above mentioned diagnostic criteria [27].

On examination, the srotas involved was mainly the rasavaha, raktavaha and samjavaha srotuses based on their respective symptoms. On Mental Status Examination, attention and concentration were partially impaired. Baseline hematological investigations, Renal Function Test and Liver Function Tests were done, which revealed that Haemoglobin: 15.9gm%, ESR: 20/hr, Total Count: 6700cells/mm3, Fasting Blood Sugar: 78mg/dl, Total Cholesterol: 205mg/dl, Serum Creatinine: 0.4, SGOT - 92U/L, SGPT: 61U/L, Total bilirubin: 1.02mg/dl, direct bilirubin: 0.39mg/dl.

Management Protocol

Assessment

Assessment of effect of the therapy was done on the basis of changes observed at the clinical level. Numerical score was assigned for each of the signs and symptoms by using Clinical Institute Withdrawal Assessment of Alcohol revised scale (CIWA-Ar scale).

Discussion

The condition was approached and managed with the principles of management of madatyaya as already explained. The initial approach was Amapachana, Agnideepana and Srotorosodhana, which is ideal in madtyaya. On sudden abstinence of alcohol, agni which maintain the equilibrium of body gets altered, leading to to formation of ama. The ama causes srodhorodha and resulting deficit in bala. Hṛdaya which is the cetana stana and sthana of functions of the mind also gets affected. The anulomana property of Vata gets deranged and affects the functions of body as well as mind. These processes occur straight away and manifest as symptoms of AWS.

Snehana, Swedana, Sodhana ie. either Vamana or Virechana, followed by vasthi , nasya, moordhni taila ending with rasayana is the algorithm of management for Madatyaya. Before performing sodhananga snehapana, rookshana is crucial, which subsides the associative Kapha or ama and causes anulomana to Vatha, also enhances the agni. For the same, Ajamoda arka was administered upto 7 days. As Ajamoda arka which is kaţurasa and vipaka and of uṣnavirya helps to get rid of srotorodha. This drug is specially meant for koṣṭha rogas so possess site specific action in this regard. As it is a Vata Kaphahara drug along with this Vatanulomana also works. Because of its dīpana property it kindles agni. By this process, the channels in connection with the manovahasrotas will be clarified, leading to a pleasant mind.

Swedana karma was aimed for achieving vishyandana and vilayanao of doshas so as to bring them into koshta which is removed from the body by Virechana here, performed after 3 days of swedana [29]. Avipathy choorna was used here in this regard. Nasya and tala was followed by rasayana ie. Sankupushpi and yashti choorna use for 1 month. . Such a protocol seems safe as well as effective in the management of AWS.

Conclusion

Alcohol Withdrawal Syndrome and other disorders of alcohol abuse have been mentioned with details in the ancient texts of Ayurveda. Here a multidisciplinary approach including detoxification, management of associative conditions and rehabilitation are too adopted here. In severe presentations, sodhana chikitsa followed by rasayana is the best available option. There is need of further researches in this regard so as to enhance the available Ayurvedic management.