Introduction:
In our daily clinical practice, knowingly or unknowingly, we are affected by our surroundings, and all burning social issues seek our attention. In a developing country like India, there are many burning social issues like criminality, terrorism, unemployment, population explosion, poverty, socio-economic disparity and various addictions. If we study addiction, then we will find that it is largely associated with various burning social issues. This is especially seen in rural practice where in addition to the social problems associated with alcoholism, various difficulties are faced by the family members like battered wives/ babies. Alcoholism is an important unexplainable phenomenon behind the continued use of alcohol in alcoholics despite repeated health problems and social hazards. Alcohol has depressant action on C.N.S. in long term use and if an alcoholic stops it suddenly, then he faces many difficulties due to alcohol withdrawal symptoms. This again reinforces him to take alcohol and the vicious cycle continues and the patient is totally unable to withdraw alcohol even though who wants to withdraw. This indicates that alcohol withdrawal is the prominent obstacle for deaddiction.
Being homoeopathic physicians and what separate us from the other physicians belonging to different therapeutic systems are the concepts of holistic approach and individualization. There are many patients who withdraw alcohol suddenly but there were no withdrawal symptoms though they were binge drinkers and chronic alcoholic, and there were some cases where patients taking alcohol regularly in very controllable amounts and never having a history of binge drinking they undergo moderate to severe withdrawal. The particular one person is going into withdrawal and rest remains normal which needs to be defined with role individuality. The symptomatology of withdrawal also talks about individual susceptibility and end organ weakness. Allopathy has limited scope in dealing with the problem of withdrawal – sedatives and antipsychotics are chiefly prescribed.
Here we present three case of alcohol withdrawal managed by Homoeopathic medicine on basis of totality of symptoms
CASE-1
CASE PRESENTATION
Preliminary Data
Name- Mr. S K S IPD Reg no 2009-1565
Age 40 Yrs Date-8-12-09 2pm
Sex –Male Address- Palghar
Occupation- Tailor Marital status- Married since 20 yrs
Chief Complaints-
| LOCATION | SENSATION | MODALITY | CONCOMITANTS |
| GENERAL Since 2 days Onset- sudden Progress- mod | Trembling of whole body3 Restlessness2 Sleeplessness2 Appetite decreased2 | A.F. Alcohol withdrawal | Thirst increased 1 glass of water in 1 hr. Bitter taste + |
| STOMACH | Nausea2 with retching 2 episodes of vomiting , moderate quantity contained ingesta | < after eating and drinking+ | |
| ABDOMEN | Dull pain2 | .> after vomiting | |
| MIND Since 15 yrs Now since 2 months Since 20 yrs | Chronic alcoholic Gawati 1 quarter daily Increased 3 quarter daily h/o alcohol intoxication and arguments with wife after drinking ( abuse) Tobacco chewing 2 pack daily | a. f. ? |
Associated Complaints
| LOCATION | SENSATION | MODALITY | CONCOMITANTS |
| Chest, retrosternal region Since 15 yrs Increased since 2 months | Burning2 No pain No nausea/ vomiting | A.F.Alcohol drinking |
Presentation –
Patient brought by his wife who was constantly forcing him to leave alcohol . Patient also desired to stop alcohol completely but was unable to do it. Patient came with ataxic gait but well oriented in time, place and person.
Past and Family History
P/H Hepatitis 2 month back taken allopathic treatment. F/H; father chronic alcoholic
Physical Examination
Pallor+ , BP150/90, PR 110 min, RR-30/min Sclera muddy R.S. clear AB CVS- NAD
P/A Soft liver 1FP S0 mild tenderness at umbilical region CNS conscious oriented with time, place and person
Gait ataxic. Coarse tremors3 Romberg’s and tandem walking negative Reflexes normal
Mental Status Examination
Appearance– lean, thin whitish complexion, flushing of face
Behavior– trembling whole body, restless- continuously moving feet and hands, maintaining eye to eye contact, good rapport formed
Speech– pressured speech
Cognition– intact , oriented with time , place and person
Affect– anxious about trembling of the whole body and nausea vomiting. Thought– desire to cut down alcohol as it is causing a lot of financial problems.
Mood- excited, congruent
Insight and judgment– good
Clinical Diagnosis: Mild alcohol withdrawal
Case Analysis
CAUSE– Alcohol withdrawal
GENERALS-
Restlessness Sleeplessness
Appetite decreased Thirst increased Trembling whole body
CHARACTERISTICS PARTICULARS-
Nausea retching with Vomiting < after eating Pain in abdomen – dull > after vomiting Bitter taste
I – SYMPTOM CLASSIFICATION OF ALCOHOL WITHDRAWAL-
Psychological– Restlessness2
Somatic- Sleeplessness2
Nausea 2 Vomiting2
Trembling3 Abdominal pain2
Thirst increased2 Appetite decreased2
Tachycardia Increased blood pressure
II- ACUTE TOTALITY
A.F. alcohol abstinence Restlessness Bitter taste Thirst increased Vomiting <eating and drinking
Pain in abdomen > after vomiting Retching
REPERTORIZATION
DIFFERENTIATION-
As there is no collapse or exhaustion stage, no much weakness hence China and Arsenic is omitted for further consideration. There is no burning usually associated with Phos and Sulph. The importance of this totality is revolving around alcoholism and nausea, retching with vomiting and pt is better after vomiting. The involvement of the GIT sector due to alcoholism hence Nux vomica was selected.
Imp- Nux vomica
PRINCIPLES OF MANAGEMENT
GENERAL MANAGEMENT As a patient is psychological and physiological dependent on alcohol he requires admission and close monitoring. And IVF, Injectable vitamins are necessary.
HOMOEOPATHIC MANAGEMENT SUSCEPTIBILITY ASSESSMENT-
- Sensitivity-Mind and nerves- moderate
- characteristics few
- physical particulars ++
- physical concomitants
- physiological dependence- structural ++
IMPRESSION-Susceptibility- moderate
Moderate susceptibility we have to give homoeopathic medicine on acute totality with frequent repetition in moderate potency.
CASE MANAGEMENT
Nux vomica 200 4hrly Inj Nervigen im daily IVF
Assurance was given about all withdrawal symptoms and tried to give psychological support. Patient’s wife was very anxious. We oriented her about withdrawal symptoms and later on she also supported him.
| FOLLOW UP CRITERIA | ||
| 1. Restlessness | 2. Appetite | 3. Sleep |
| 4. Taste-bitter | 5. Trembling | 6. Nausea |
| 7. Vomiting | 8. Abdominal pain | 9. Gait |
| 10. BP | 11. Pulse rate | |
| DATE AND TIME | 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. | 11. | TREATMENT |
| 8/12/09 8AM | >+ | + | N | SQ | >+ | >+ | 0 | >++ | >+ | 140/ 100 mm hg | 90/min | Nux vom 200 qds |
| 8/12/09 6pm | >++ | ++ | Disturbed slightly | N | >++ | 0 | 0 | 0 | >++ | 130/90 mm hg | 80/ min | Nux vom 200 qds |
| 9/12/09 4pm | >+++ | +++ | N | N | 0 | 0 | 0 | 0 | N | 110/70 mm hg | 70/min | Nux vom 200 qds |
9/12/09 5pm Pt discharged. Nux vomica 200 qds for 2 days given.
CASE DISCUSSION
In this case there are more somatic symptoms than psychological symptoms hence admission was required. After admission we are able to observe his general improvement in subjective and objective symptoms. As patient having withdrawal and GIT sector was predominant like nausea, retching and vomiting hence Nux Vom selected.
All information about the quantity of alcohol, time of the last drink, history of binge drinking which is very essential for determining the management strategy was obtained from the wife. The wife has also given important and reliable information which was crucial for erecting the totality of alcohol withdrawal. The observations of the patient in the ward during withdrawal are also important for the prescription. The wife of the patient was very caring, loving and cooperative which was the positive thing for us and the patient to help in the management.
CASE 2
Preliminary Data
IPD Reg no- 09/1542 Date- 06-12-09
Name- Mr K.M. Age- 35 yrs
Sex- male Marital status- Married since 15 yrs
Occupation- Farming Address- Kelva
Chief Complaint
| LOCATION | SENSATION | MODALITY | CONCOMITANTS |
| GENERAL Since- 3 days Onset- sudden Progress- gradual | Weakness3- can’t even walk , lying on bed continuously Appetite decreased3 Bodyache2 | A/F Alcohol withdrawal > warm2 | Thirst increased small quantity small interval2 |
| STOMACH ABDOMEN | Nausea2 Vomiting2 Fullness2 Stool-N Diagn- Acute alcohol withdrawal | <immediately after eating and drinking3 | |
| MIND Since 20 – 25 yrs Frequency- daily Quantity- 180 ml/day | Chronic alcoholic Alcohol dependence H/O Alcohol withdrawal No H/O alcohol abuse/ Intoxication | ||
| EXTREMITIES Right Foot Ball of big toe Since 6-7 months | Non healing ulcer No H/O DM/ HT/ Varicose veins Diagnosed as Trophic ulcer and taking antibiotic with daily dressing. |
PRESENTATION-
Patient was brought by relatives on wheelchair and came to camp. Patient had left alcohol since 3 days as he and all family members knew about alcohol camp. Patient was willing and convinced for stopping alcohol by his previous physician. Family members also well oriented for admission and very co-operative for patient as well as physician.
PAST HISTORY– NAD FAMILY HISTORY– NAD PHYSICAL EXAMINATION-
Pallor2 Temp- 97.2 F P.R. 84/ min R.R. 22/ min B.P. 110/ 70 mmhg
R.S. AEBE, clear CVS. Haemic murmur P/A – soft non tender L0S0
C.N.S.Gait – ataxic, no tremors Oriented well in time, place and person Sensation/ Power – Normal Reflex –normal L/E- Right foot, ball of big toe Ulcer++ Mild pus offensive2 Peripheral pulses well felt
MENTAL STATUS EXAMINATION-
Appearance- dark complexion, stocky built Behavior- Calm, quiet Speech- monosyllabic, not talking much
Cognition- intact, well oriented with time, place and person Affect- flat Mood- low, incongruent Thinking- about withdrawal of alcohol Insight and judgment- good
Clinical Diagnosis-
Moderate Alcohol withdrawal somatic type Tropic ulcer on ball of right toe
Case Analysis-
CAUSE – alcohol abstinence General-
Weakness3 Appetite decreased3
Thirst increased2 Bodyache+ > warmth Particular-
Nausea2 < after eating and drinking immediately Vomiting2 < after eating and drinking immediately
Fullness in abdomen2
Symptom Classification of Alcohol Withdrawal SOMATIC
Weakness Bodyache
Appetite decreased Thirst increased
Nausea vomiting
Fullness in abdomen
PSYCHOLOGICAL SYMPTOM –Absent ACUTE TOTALITY-
A/f alcoholism Eating<
Drinking< Thirst increased small quantity small interval
REPERTORISATION-
FINAL SELECTION-
As it is very clear totality Ars alb was selected. Phosphorus and sulphur also comes close in the repertorization but burning which is present in these remedies is absent and patient is better by warmth is contraindicated in these remedies. Even weakness present in patient supports the Ars alb remedy.
Case Management-
General Management- Patient got admitted for alcohol withdrawal and trophic ulcer. Multivitamin and IVF were given as mentioned in our protocol.
Homoeopathic Management-
Susceptibility –
Sensitivity-Mind and nerves- Low Physical general- concomitants ++
Particular+ Characteristics- very few
Physiological dependence ++ Structural changes 3 -Irreversible-Trophic ulcer IMPRESSION- low
POTENCY- moderate potency with frequent repetition Arsenic Album 200 2 hrly started
FOLLOW UP CRITERIA –
| 1.General well being | 2.Weakness | 3.Bodyache |
| 4. Appetite | 5. Sleep | 6. Thirst |
| 7. Nausea | 8. Vomiting | 9. Fullness in abdomen |
| Date and time | 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | Treatment |
| 6/12/09 6pm | + | >+ | >+ | SQ | N | SQ | >+ | >++ | >++ | Ars alb 200 4 hrly |
| 7/12/09 8am | ++ | >++ | >++ | Improved | N | N | >++ | >+++ | >+++ | Ars alb 200 4 hrly |
| 7/12/09 6pm | +++ | 0 | 0 | Good | N | N | 0 | 0 | 0 | Ars alb 200 4 hrly |
| 8/12/09 8am | +++ | 0 | 0 | Good | N | N | 0 | 0 | 0 | Pt discharged on Ars alb 200 4 hrly |
CASE DISCUSSION-
This case was purely of physiological dependence of alcohol with somatic manifestations of alcohol withdrawal and psychological symptoms were absent. After consideration of totality and susceptibility of the patient, we had given Ars alb frequently as the patient has a lot of weakness, thirst increased and vomiting immediately after eating.. After giving Ars Alb withdrawal symptoms settled down. As compared to other cases of withdrawal this patient was not having psychological symptoms of alcohol withdrawal hence required frequent repetition.
CASE-3
PRELIMINARY DATA-
Name – Mr. S.d.
Age 35 yrs
Sex –male
Address- palghar
Occupation- salesman
Marital status- married since 10 yrs
Date- 06-12-09
Chief Complaints-
| LOCATION | SENSATION | MODALITY | CONCOMITANTS |
| MIND Since 2 days Onset- slow Progress- gradual Duration- continuous HEAD | Anger3 at trifles Sleeplessness2 No desire for work2 Lethargy2 Heaviness2 | A/F Alcohol withdrawal < contradiction3 <early morning | |
| MIND Since 8 yrs Increased since 6-7 months | Occasional whisky drinker 90ml Daily 180 ml whisky H/O withdrawal, 2-3 unsuccessful attempts to stop alcohol Quarrels with family members- Alcohol abuse | A/F ? |
Presentation – Patient came alone in the camp and having self motivation to stop alcohol and seeking help for the same.
Past History- Gastric ulcer- 1994 before taking alcohol Family History-Father- Cancer
Brother- alcoholic
Physical Examination
Pallor+ , BP120/80 mm hg , PR 88/ min, RR-20 /min
R.S. clear AEBE CVS- NAD P/A – Soft non tender LoSo CNS conscious oriented with time, place and person
Gait – Normal Tremor- absent
Romberg’s and tandem walking- negative Reflexes normal
MENTAL STATUS EXAMINATION
Appearance– Well dressed
Behavior– Co-operative, maintaining eye to eye contact rapport well formed
Speech– Normal
Cognition– intact, oriented with time, place and person Affect- Anxious about complaints, congruent Thought– Motivated and seeking help for deaddiction Mood- Normal
Insight and judgment– Good
CLINICAL DIAGNOSIS- Mild alcohol withdrawal
CASE ANALYSIS
FAMILY HISTORY– Cancer
PAST HISTORY– Gastric ulcer CAUSE– Alcohol withdrawal GENERALS–
Anger at trifles3 Sleeplessness2 < early morning Lethargy2
CHARACTERISTICS PARTICULARS-
Head- heaviness2
I – SYMPTOM CLASSIFICATION OF ALCOHOL WITHDRAWAL-
Psychological-
1. Anger at trifles
Somatic-
- Lethargy
- Sleeplessness
II- ACUTE TOTALITY
1. AF alcohol 2. Contradiction agg
3. Anger at trifles 4. Morning <
REPERTORIZATION
DIFFERENTIATION-
As the patient is having alcohol withdrawal and came with the presentation of anger and lethargy remedy selected Nux vom. The Ignatia and Aurum are coming close in repertorization but vexation and disappointment is missing in this case.
V- PRINCIPLES OF MANAGEMENT
GENERAL MANAGEMENT–
As this patient has mild withdrawal and also good insight about his complaints because he has self motivation to stop alcohol which also observed as he came alone. Hence this patient was managed on an OPD basis.
HOMOEOPATHIC MANAGEMENT-
SUSCEPTIBILITY ASSESSMENT-
Characteristic mentals with modality++ Physical general++ but not characteristics
Past history – Gastric ulcer- Structural changes++ Family history- Alcoholism and malignancy
IMPRESSION- Moderate, needs frequent repetition Nux vomica 200
CASE MANAGEMENT
FOLLOW UP CRITERIA-
| 1. | Anger | 2. Desire for work | 3. Sleep |
| 4. | Lethargy | 5. Head heaviness |
| DATE | 1. | 2. | 3. | 4. | 5. | TREATMENT |
| 10/12/09 | >+ | SQ | >++ | >+ | >+ | Nux vom 200 qds 5 days1 |
| 15/12/09 | >++ | Improved | Good | >++ | 0 | Placebo Stock Nux vom 200 SOS |
| 18/12/09 | >+++ | Normal | Good | >+++ | 0 | Placebo |
CASE DISCUSSION-
This was the first case of withdrawal which was managed on an OPD basis. The important learning from the case was if we have taken the history of alcoholism in detail and the patient has good insight and will and motivation to withdraw from alcohol then we can manage these cases on OPD basis only if they are of a mild type. The irritability agg contradiction is qualified mentally, obtained in this case and Nux Vom given good results.
Conclusion:
This is an attempt to demonstrate the role of homoeopathy in acute alcohol withdrawal through a small sample. It requires more sample with different research design for more clarity on role of homoeopathy in alcohol withdrawal.
